This document discusses acute onset hemiplegia, including its etiology, symptoms, risk factors, investigation, and treatment. The main causes of acute onset hemiplegia are ischemic stroke and hemorrhagic stroke, which have various underlying etiologies like cardiac disorders, blood disorders, infections, and vascular malformations. Evaluation involves a neurological exam and imaging tests. Treatment depends on the underlying cause but may include medications like anticoagulants, antiplatelets, or immunosuppressants, as well as procedures like neurosurgery or interventional radiology. Outcomes range from full recovery to neurological deficits or mortality in 20-30% of cases.

1. Acute onset hemiplegiaAcute onset hemiplegia
Dr Surya KumarDr Surya Kumar

2.  Paralysis of one half of the bodyParalysis of one half of the body
CompleteComplete
IncompleteIncomplete
CrossedCrossed

3. Anatomy of brainAnatomy of brain

5. PhysiologyPhysiology
 CMRoCMRo22 is 3.5ml/100mgis 3.5ml/100mg
 Glucose storage upto 90 minGlucose storage upto 90 min
 CBF 30-60ml/100mg <3yrCBF 30-60ml/100mg <3yr
 105-100ml/100mg in 3 -10 yr105-100ml/100mg in 3 -10 yr

6.  2.5-2.7/100,000 population2.5-2.7/100,000 population
IncidenceIncidence

7. EtiologyEtiology
 Cardiac ---CCHD, IE, RHD, MyxomaCardiac ---CCHD, IE, RHD, Myxoma
 Blood dyscrasia---Blood dyscrasia---
 Primary vascular disease AcutePrimary vascular disease Acute
infantile hemiplegia, MoyaMoya, Takayasu,infantile hemiplegia, MoyaMoya, Takayasu,
hemiplegic Migraine, fibromuscularhemiplegic Migraine, fibromuscular
Dysplasia,Dysplasia,
 Collagen Vascular Disease PAN,Collagen Vascular Disease PAN,
SLESLE
 Infectious DiseaseInfectious Disease


8.  Metabolic DiseaseMetabolic Disease
Homocystinuria,MELAsHomocystinuria,MELAs
 TraumaTrauma
Carotid Dissection, Air Embolism, FatCarotid Dissection, Air Embolism, Fat
Embolism, Vertebral occlusionEmbolism, Vertebral occlusion
 Vascular MalformationVascular Malformation
Aneurysm, arteriovenous Malformation,Aneurysm, arteriovenous Malformation,
Vein of galen malformation,Vein of galen malformation,
 Neurocutaneous syndromeNeurocutaneous syndrome
Sturge WeberSturge Weber

9.  IschemicIschemic
 HemorragicHemorragic
 Share equal proportion of incidenceShare equal proportion of incidence

10. Ischemic strokeIschemic stroke
 Cardiac disease 19%Cardiac disease 19%
 Coagulation Disorder 14%Coagulation Disorder 14%
 Dehydration 11%Dehydration 11%
 Infection 6%Infection 6%
 Vasculitis 7%Vasculitis 7%
 Dissection 5%Dissection 5%
 Cancer 4%Cancer 4%
 Metabolic disorder 3%Metabolic disorder 3%
 Moyamoya ,SCA, 2%Moyamoya ,SCA, 2%
 MISC 4%MISC 4%
 No risk factor 21%No risk factor 21%

11. AISAIS
Vulnerable sitesVulnerable sites
 DiencephalonDiencephalon
 Watershed aresWatershed ares

12. SymptomsSymptoms
 Focal neurological deficitFocal neurological deficit
 SeizureSeizure
 MigraineMigraine
 FeverFever
 LethargyLethargy
 HeadacheHeadache
 DYstoniaDYstonia
 Age relate and associted conditionsAge relate and associted conditions

13. Cadiac disorderCadiac disorder
 CHDCHD
 RHDRHD
 Prosthetic ValveProsthetic Valve
 Shunts,Shunts,
 Patent foramen ovalePatent foramen ovale

14. causescauses
 PolycythemiaPolycythemia
 AnemiaAnemia
 ArrythmiaArrythmia
 EndocarditisEndocarditis

15. IncidenceIncidence
 Exact Data is not availableExact Data is not available
 Upto 9% undergoing fontan surgeryUpto 9% undergoing fontan surgery
 50% occurred within 72 hr of50% occurred within 72 hr of
surgerysurgery

16. Hematological and hypercoagubleHematological and hypercoaguble
statesstates
 22ndnd
most important causemost important cause
 2 to 7% of young patient2 to 7% of young patient
 Factor v leiden mutation,Factor v leiden mutation,
homocystinemia, deficiency ofhomocystinemia, deficiency of
protein c and protein sprotein c and protein s

17. Sickle cell anemiaSickle cell anemia
 300per 100,000 sickle cell patient300per 100,000 sickle cell patient
 Above 5 yrAbove 5 yr
Silent infarcts are presentSilent infarcts are present
 Associated with seizures, cranialAssociated with seizures, cranial
nerves ,cognitive declinenerves ,cognitive decline
 Prone for recuurences, chronicProne for recuurences, chronic
seizure disorderseizure disorder

18.  Keep good hydrationKeep good hydration
 Transfusion to keep HbS <30%Transfusion to keep HbS <30%

19. InfectionInfection
 5 to 12 % of meningitis5 to 12 % of meningitis
 Systemic infectionSystemic infection
post varicella angiopathy,post varicella angiopathy,
pneumonia, borrelia, HIV,pneumonia, borrelia, HIV,
helicobacter,helicobacter,
 May occur after weeks to months ofMay occur after weeks to months of
infectioninfection
 Post varicellea and herpes isPost varicellea and herpes is
commoncommon

20. Moya moyaMoya moya
 Chronic,prgrssive,stenotic disease ofChronic,prgrssive,stenotic disease of
arteryartery
 Mainly females are involved. 6 timesMainly females are involved. 6 times
 Multiple telengtesia seen in brainMultiple telengtesia seen in brain
mainly in basal ganglonmainly in basal ganglon
 seizure seen in 335 of patientsseizure seen in 335 of patients
 Recurrent ischemic attack, mentalRecurrent ischemic attack, mental
retardation,,infarction on CTretardation,,infarction on CT
 Treatment is surgeryTreatment is surgery

21. vasculitisvasculitis
 Takayasu, SLE, MCTD,PANTakayasu, SLE, MCTD,PAN
 Present with associated symptomsPresent with associated symptoms
 Steroid and immunotherapySteroid and immunotherapy

22. MetabolicMetabolic
 Homocystenemia, MELA, FamilialHomocystenemia, MELA, Familial
HypercholesteremiaHypercholesteremia
 Family history, and charactersticsFamily history, and characterstics
featurefeature

23. MigraineMigraine
 More common in femalesMore common in females
 FamilialFamilial
 Occasionaly permanent deficitOccasionaly permanent deficit

24. TraumaTrauma
 Dissecting aneurysm in arteryDissecting aneurysm in artery
 Barbershop,fall on pencil in mouth,Barbershop,fall on pencil in mouth,
popstick,barbershoppopstick,barbershop
 Symtoms come after 1 to 2 daysSymtoms come after 1 to 2 days

25. Sinovenous thrombosisSinovenous thrombosis

26. Risk factorsRisk factors
 Prothrombotic disorder 30%Prothrombotic disorder 30%
 Dehydration 30%Dehydration 30%
 Sysystemic infection 8-10%Sysystemic infection 8-10%
 Head and neck infection 9%Head and neck infection 9%
 Rest by cardiac, leukemia,perinatalRest by cardiac, leukemia,perinatal
complication, Drugscomplication, Drugs

27. featuresfeatures
 Seizures, lethargy,jitterySeizures, lethargy,jittery
 Dilated scalp veins, anterior fontanel,Dilated scalp veins, anterior fontanel,
eyelid swellingeyelid swelling
 Headche,Headche,

28. OutcomeOutcome
 53% normal53% normal
 25% neurological deficit and seizure25% neurological deficit and seizure
 5% seizure alone5% seizure alone
 9% died9% died
 Perspective study of 80 infantsPerspective study of 80 infants

29. hemorrhagehemorrhage
 Congenital vascular anamolyCongenital vascular anamoly
 VasculopathiesVasculopathies
 Systemic diseaseSystemic disease
 TraumaTrauma
 Hematological disodersHematological disoders

30. Intracerebral hemorrhageIntracerebral hemorrhage
 At the entry point of brainAt the entry point of brain
 Hematoma and cerebral edemaHematoma and cerebral edema
produces mass like lesionproduces mass like lesion

31. FeaturesFeatures
 Severe headache,Severe headache,
 SeizuresSeizures
 Focal signsFocal signs
 Decrease in conciousnessDecrease in conciousness
 AtaxiaAtaxia
 Dysconjugate gaitDysconjugate gait
 comacoma

32. Risk factorRisk factor
 Trauma most commonTrauma most common
 Vascular malformationVascular malformation
 Degenerative vasculopathyDegenerative vasculopathy
 Hemophilic disorderHemophilic disorder

33. Subarachnoid hemoorrhageSubarachnoid hemoorrhage
 Ateries forming circle of willis andAteries forming circle of willis and
surrounding itsurrounding it
 Circle of willis seen more in adulutCircle of willis seen more in adulut

34.  Erythrocytes in subarachnoid spaceErythrocytes in subarachnoid space
can cause severe spasm leading tocan cause severe spasm leading to
secondary ishemic infarctionsecondary ishemic infarction

35. FeatureFeature
 Severe headache, neck rigidity,Severe headache, neck rigidity,
 Low grade feverLow grade fever
 LeckocytosisLeckocytosis
 Raised ICTRaised ICT

36. Malformation of vein of galenMalformation of vein of galen

37. ApporachApporach
 Through examinationThrough examination
 HeaHea
 FaceFace
 EyesEyes
 EarsEars
 Paranasal sinusesParanasal sinuses
 Oral cavityOral cavity
 neckneck

38.  SkinSkin
 Bone and jointsBone and joints
 ExtremitiesExtremities
 AnthropometryAnthropometry
 vitalsvitals

39.  Per abdomenPer abdomen
 CVSCVS
 Suppurative lung diseaseSuppurative lung disease

40. InvestigationInvestigation
 CBC,Platelet,ESRCBC,Platelet,ESR
 LFTLFT
 CholesterolCholesterol
 Coagulation profileCoagulation profile
 ECG, chest X xay,ECG, chest X xay,
 USG abdomenUSG abdomen
 VDRL/HIVVDRL/HIV
 UrinanalysisUrinanalysis
 Lactate/pyruvateLactate/pyruvate

41.  Ana,RA, anti cardiolipinAna,RA, anti cardiolipin
 Lumbar puntureLumbar punture
 CTCT
 MRIMRI
 AngiographyAngiography

42. TherapyTherapy
 Absence of RCTAbsence of RCT
 Adapted from adultsAdapted from adults
 Treat underlying risk factorTreat underlying risk factor
 Prevent recurrencePrevent recurrence

43. Consensus on……Consensus on……
 Sickle cell diseaseSickle cell disease
 Acute therapyAcute therapy
• Exchange transfusionExchange transfusion
 Preventive therapyPreventive therapy
• Blood transfusion every 3-6 weeks toBlood transfusion every 3-6 weeks to
maintain HbS<30%maintain HbS<30%
• ?HU, stem cell transplant?HU, stem cell transplant
• Transcranial dopplersTranscranial dopplers

44. Current recommendations……Current recommendations……
 Neonatal AIS – no therapyNeonatal AIS – no therapy
 Dissecting vasculopathy –Dissecting vasculopathy –
anticoagulation 3-6 monthsanticoagulation 3-6 months
 Cardiogenic embolism –Cardiogenic embolism –
anticoagulation but no consensus onanticoagulation but no consensus on
length of timelength of time
 Vasculopathy – ASA (no consensusVasculopathy – ASA (no consensus
on dose 1-5mg/kg/day)on dose 1-5mg/kg/day)
 Recurrent stroke – considerRecurrent stroke – consider
anticoagulationanticoagulation

45. HeparinHeparin
 For rapid anticoagulationFor rapid anticoagulation
 Bolus heparin 75-100u/kgBolus heparin 75-100u/kg
 Maintainence at 28 unit/kg/hr forMaintainence at 28 unit/kg/hr for
infantinfant
 20u/hr for >1 yr20u/hr for >1 yr
 Adjust APTT to 1.5 to 2Adjust APTT to 1.5 to 2
 Check APTT 4 hr after bolusCheck APTT 4 hr after bolus
 Daily APTT and CBCDaily APTT and CBC

46. LMW heparinLMW heparin
 LovenexLovenex
 1mg/kg in >1yr every 12 hr1mg/kg in >1yr every 12 hr
 1.5mg/kg in neonate1.5mg/kg in neonate
 Monitor by antifactorXa weeklyMonitor by antifactorXa weekly

47. AspirinAspirin
 3-5 mg/kg3-5 mg/kg
 Dose in less then 10% of antipyreticDose in less then 10% of antipyretic
dosedose

48. WarfarinWarfarin
 Used if secondary prevention withUsed if secondary prevention with
ASA failsASA fails
 Maintain INR of 2 to 3Maintain INR of 2 to 3
 In case of mechanical valve 2.5 toIn case of mechanical valve 2.5 to
3.53.5

49. Supportive treatmentSupportive treatment
 Manage ICTManage ICT
 Blood presureBlood presure
 Blood sugarBlood sugar
 Body temperatureBody temperature
 AntiepilepticAntiepileptic
 ImmunosuppresantImmunosuppresant
 TransfusionTransfusion
 NeurosurgeryNeurosurgery
 Interventional neuroradiological techniqueInterventional neuroradiological technique
 RehabilitationRehabilitation
 Acute stroke careAcute stroke care

50. OutcomeOutcome
 Mortality 20 to 30%Mortality 20 to 30%
 Residual neurological deficit in >50%Residual neurological deficit in >50%
 Risk of stroke recurrence is as highRisk of stroke recurrence is as high
as 20%as 20%

51. Differential DiagnosisDifferential Diagnosis
 MigraineMigraine
 Todds paralysisTodds paralysis