Hemiplegia

Dr. V.S.Nandakumar

History

• Goals

• 1. Etiology

• 2.Localization

Etiology• Non – CVA

– Neoplasm

– Infection

– Demyelination

– Trauma (SDH)

• CVA

– Thrombosis

– Embolism

– Hemorrhage

Non- CVA

• Onset- More gradual

• Progression –gradual

• Recovery

• Fever - infection

CVA

• Sudden onset

• Progression

• Recovery

• Deficit explainable by a vascular territory

lesion

CVA - Thrombosis

• Most common

• Slowest – Hours

• Wakes up in the morning with weakness

• History of TIA

• Old age

Embolism

• Fastest onset - Seconds

• No progression {Max. deficit at onset}

• History of heart disease

• Younger age group

• Major deficit ( heart to vessel )

Hemorrhage

• H/o Prolonged hypertension

• Awake – stress

• Head ache

• Vomiting

• Altered consciousness

• Convulsion

Localization

• Internal capsule

• Cortex

• Subcortex - Corona radiata

• Brainstem

– Midbrain, Pons, Medulla

• Spinal cord

Internal capsule

• Dense&uniform hemiplegia ( UMN Facial )

• Hemisensory blunting

• Homonymous Hemianopia

Cortex

• Non dense nonuniform weakness

• Monoplegias

• Cortical signs

– Dysphasia

– Apraxia

– Cortical ssensory loss

– Convulsions

Subcortex

• Pattern of weakness similar to cortical

– Non dense non-uniform weakness

• No cortical signs

Brainstem

• Crossed hemiplegia

• Ipsilateral LMN CN palsy & contralateral

hemiplegia

• Cerebellar signs

Points in history helping

localization

• Grade of weakness – dense or not

• Uniformity of weakness –

• UMN facial palsy - present or not

• Cortical symptoms

– Focal seizures;Dysphasia;Apraxia

• Cranial nerve palsies, gaze palsies

• Level of consciousness

• Recovery

Clinical examination

• General – Pulse, BP,LN,Clubbing.neurocutaneous markers

• Other systems - CVS – Valvular heart disease,CAD,Hypertensive heart

disease

• NS

Neurological examination

• Higher functions

• Cranial nerves

• Tone

• Weakness

– Grade,symmetry

• Reflexes

• Sensory – +Cortical

• Cerabellar

• Meningeal irritaion

Localization

• Internal capsule

• Cortex

• Subcortex - Corona radiata

• Brainstem

– Midbrain, Pons, Medulla

• Spinal cord

Internal capsule

• Dense&uniform hemiplegia ( UMN Facial )

• Hemisensory blunting

• Homonymous Hemianopia

Cortex

• Non dense nonuniform weakness

• Monoplegias

• Cortical signs

– Dysphasia

– Apraxia

– Cortical ssensory loss

– Convulsions

Subcortex

• Pattern of weakness similar to cortical

– Non dense non-uniform weakness

• No cortical signs

Brainstem

• Crossed hemiplegia

• Ipsilateral LMN CN palsy & contralateral

hemiplegia

• Cerebellar signs

Midbrain

• crossed cerebellar ataxia with ipsilateral third

nerve palsy (Claude's syndrome):

• Weber's syndrome: third nerve palsy and

contralateral hemiplegia:

• Contralateral hemiplegia: Cerebral peduncle

• Contralateral rhythmic, ataxic action tremor;

rhythmic postural or "holding" tremor (rubral

tremor):

Pons

• LMN Facial + contralateral hemiplegia

• +VI th Nerve + cotralateral hemiplegia

• + Lateral Gaze palsy + cotralateral

hemiplegia

Medulla – lateral Medullary syndrome

• Same side

– Horner’s syndrome

– Loss of pain & touch on the face

– Cerebellar signs

– Palate weakness

• Opposite side

– Loss of pain and temperature sensation on the body and limbs

Medial Medullary syndrome

• Same side

• Wasting and weakness of the tongue

• Opposite side

• Hemiplegia without facial palsy

Spinal cord

• Rare

• No facial

• Brown sequard Syndrome

Hemiparesis without Facial palsy

• Cortex

• Subcortex

• Medial medulla

• Spinal cord

Hemiparesis with cranial N palsy

• Brain stem lesions – LMN CN palsy

• UMN Facial palsy

• Transient UMN weakness in the initial

stages of Higher lesions

– Palate. Jaw.Tongue

Hemiplegia & coma

• Intra cerebral hemorrhage

• Large infarctions

• Brainstem lesions

Hemiplegia & coma Problems in examination

• Higher functions - assess grade of coma

• Cranial nerves

– II- menace, light reflex

– III, IV, VI - Doll’s eye

– VII – bulge with breathing, NL fold, Pain effect

– IX , X – Gag reflex

• Motor system

– Tone, Posture,(grab,lift &drop)Movement on pain

• Sensory system- assessment not possible

• Cerebelar – not possible

Hemiplegia & Aphasia Problems in examination

• Higher functions – level of consciousness

• Cranial nerves

– II-Watch Gaze & Fixation, menace, light reflex

– III, IV, VI – Watch eyemovements, Squint, ptosis

– VII – Watch expressions, NL fold, Pain effect

– IX , X – Nasal regurgitation, aspiration, Gag reflex

• Motor system - Watch movements

– Tone, Posture,(grab,lift &drop)Movement on pain

• Sensory system- assess pain

• Cerebelar– Watch coordination, Gait, Intention tremour,

When not sure, What?

• Localization – Internal capsule

• Vessel - Middle cerebral

• Cause - Thrombosis

Commonly asked questions

• Etiology?

• Localization?

• Investigations?

• Treatment?

• Demonstrate

– Tone, Power, Neck stiffness, Kernig’s, Plantar,

DTR, Cerebellar, Clonus

Commonly forgotten points

• Proper examination of CVS

• Careful GE

• Meningeal signs

• Skull & Spine

• Carotid Bruit

• Case sheet - write Diagnosis properly

THE END