Hemiplegia

1. Hemiplegia
Dr. V.S.Nandakumar

2. History
• Goals
• 1. Etiology
• 2.Localization

3. Etiology
• Non – CVA
– Neoplasm
– Infection
– Demyelination
– Trauma (SDH)
• CVA
– Thrombosis
– Embolism
– Hemorrhage

4. Non- CVA
• Onset- More gradual
• Progression –gradual
• Recovery
• Fever - infection

5. CVA
• Sudden onset
• Progression
• Recovery
• Deficit explainable by a vascular territory
lesion

6. CVA - Thrombosis
• Most common
• Slowest – Hours
• Wakes up in the morning with weakness
• History of TIA
• Old age

7. Embolism
• Fastest onset - Seconds
• No progression {Max. deficit at onset}
• History of heart disease
• Younger age group
• Major deficit ( heart to vessel )

8. Hemorrhage
• H/o Prolonged hypertension
• Awake – stress
• Head ache
• Vomiting
• Altered consciousness
• Convulsion

9. Localization
• Internal capsule
• Cortex
• Subcortex - Corona radiata
• Brainstem
– Midbrain, Pons, Medulla
• Spinal cord

10. Internal capsule
• Dense&uniform hemiplegia ( UMN Facial )
• Hemisensory blunting
• Homonymous Hemianopia

11. Cortex
• Non dense nonuniform weakness
• Monoplegias
• Cortical signs
– Dysphasia
– Apraxia
– Cortical ssensory loss
– Convulsions

12. Subcortex
• Pattern of weakness similar to cortical
– Non dense non-uniform weakness
• No cortical signs

13. Brainstem
• Crossed hemiplegia
• Ipsilateral LMN CN palsy & contralateral
hemiplegia
• Cerebellar signs

14. 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

15. Clinical examination
• General
– Pulse, BP,LN,Clubbing.neurocutaneous markers
• Other systems - CVS
– Valvular heart disease,CAD,Hypertensive heart
disease
• NS

16. Neurological examination
• Higher functions
• Cranial nerves
• Tone
• Weakness
– Grade,symmetry
• Reflexes
• Sensory – +Cortical
• Cerabellar
• Meningeal irritaion

17. Localization
• Internal capsule
• Cortex
• Subcortex - Corona radiata
• Brainstem
– Midbrain, Pons, Medulla
• Spinal cord

18. Internal capsule
• Dense&uniform hemiplegia ( UMN Facial )
• Hemisensory blunting
• Homonymous Hemianopia

19. Cortex
• Non dense nonuniform weakness
• Monoplegias
• Cortical signs
– Dysphasia
– Apraxia
– Cortical ssensory loss
– Convulsions

20. Subcortex
• Pattern of weakness similar to cortical
– Non dense non-uniform weakness
• No cortical signs

21. Brainstem
• Crossed hemiplegia
• Ipsilateral LMN CN palsy & contralateral
hemiplegia
• Cerebellar signs

22. 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):

23. Pons
• LMN Facial + contralateral hemiplegia
• +VI th Nerve + cotralateral hemiplegia
• + Lateral Gaze palsy + cotralateral
hemiplegia

24. 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

25. Medial Medullary syndrome
• Same side
• Wasting and weakness of the tongue
• Opposite side
• Hemiplegia without facial palsy

26. Spinal cord
• Rare
• No facial
• Brown sequard Syndrome

27. Hemiparesis without Facial palsy
• Cortex
• Subcortex
• Medial medulla
• Spinal cord

28. 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

29. Hemiplegia & coma
• Intra cerebral hemorrhage
• Large infarctions
• Brainstem lesions

30. 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

31. 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,

32. When not sure, What?
• Localization – Internal capsule
• Vessel - Middle cerebral
• Cause - Thrombosis

33. Commonly asked questions
• Etiology?
• Localization?
• Investigations?
• Treatment?
• Demonstrate
– Tone, Power, Neck stiffness, Kernig’s, Plantar,
DTR, Cerebellar, Clonus

34. Commonly forgotten points
• Proper examination of CVS
• Careful GE
• Meningeal signs
• Skull & Spine
• Carotid Bruit
• Case sheet - write Diagnosis properly

35. THE END