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Acute onset hemiplegiaAcute onset hemiplegia
Dr Surya KumarDr Surya Kumar
 Paralysis of one half of the bodyParalysis of one half of the body
CompleteComplete
IncompleteIncomplete
CrossedCrossed
Anatomy of brainAnatomy of brain
PhysiologyPhysiology
 CMRoCMRo22 is 3.5ml/100mgis 3.5ml/100mg
 Glucose storage upto 90 minGlucose storage upto 90 min
 ...
 2.5-2.7/100,000 population2.5-2.7/100,000 population
IncidenceIncidence
EtiologyEtiology
 Cardiac ---CCHD, IE, RHD, MyxomaCardiac ---CCHD, IE, RHD, Myxoma
 Blood dyscrasia---Blood dyscrasia---...
 Metabolic DiseaseMetabolic Disease
Homocystinuria,MELAsHomocystinuria,MELAs
 TraumaTrauma
Carotid Dissection, Air Embol...
 IschemicIschemic
 HemorragicHemorragic
 Share equal proportion of incidenceShare equal proportion of incidence
Ischemic strokeIschemic stroke
 Cardiac disease 19%Cardiac disease 19%
 Coagulation Disorder 14%Coagulation Disorder 14%...
AISAIS
Vulnerable sitesVulnerable sites
 DiencephalonDiencephalon
 Watershed aresWatershed ares
SymptomsSymptoms
 Focal neurological deficitFocal neurological deficit
 SeizureSeizure
 MigraineMigraine
 FeverFever
...
Cadiac disorderCadiac disorder
 CHDCHD
 RHDRHD
 Prosthetic ValveProsthetic Valve
 Shunts,Shunts,
 Patent foramen oval...
causescauses
 PolycythemiaPolycythemia
 AnemiaAnemia
 ArrythmiaArrythmia
 EndocarditisEndocarditis
IncidenceIncidence
 Exact Data is not availableExact Data is not available
 Upto 9% undergoing fontan surgeryUpto 9% und...
Hematological and hypercoagubleHematological and hypercoaguble
statesstates
 22ndnd
most important causemost important ca...
Sickle cell anemiaSickle cell anemia
 300per 100,000 sickle cell patient300per 100,000 sickle cell patient
 Above 5 yrAb...
 Keep good hydrationKeep good hydration
 Transfusion to keep HbS <30%Transfusion to keep HbS <30%
InfectionInfection
 5 to 12 % of meningitis5 to 12 % of meningitis
 Systemic infectionSystemic infection
post varicella ...
Moya moyaMoya moya
 Chronic,prgrssive,stenotic disease ofChronic,prgrssive,stenotic disease of
arteryartery
 Mainly fema...
vasculitisvasculitis
 Takayasu, SLE, MCTD,PANTakayasu, SLE, MCTD,PAN
 Present with associated symptomsPresent with assoc...
MetabolicMetabolic
 Homocystenemia, MELA, FamilialHomocystenemia, MELA, Familial
HypercholesteremiaHypercholesteremia
 F...
MigraineMigraine
 More common in femalesMore common in females
 FamilialFamilial
 Occasionaly permanent deficitOccasion...
TraumaTrauma
 Dissecting aneurysm in arteryDissecting aneurysm in artery
 Barbershop,fall on pencil in mouth,Barbershop,...
Sinovenous thrombosisSinovenous thrombosis
Risk factorsRisk factors
 Prothrombotic disorder 30%Prothrombotic disorder 30%
 Dehydration 30%Dehydration 30%
 Sysyste...
featuresfeatures
 Seizures, lethargy,jitterySeizures, lethargy,jittery
 Dilated scalp veins, anterior fontanel,Dilated s...
OutcomeOutcome
 53% normal53% normal
 25% neurological deficit and seizure25% neurological deficit and seizure
 5% seiz...
hemorrhagehemorrhage
 Congenital vascular anamolyCongenital vascular anamoly
 VasculopathiesVasculopathies
 Systemic di...
Intracerebral hemorrhageIntracerebral hemorrhage
 At the entry point of brainAt the entry point of brain
 Hematoma and c...
FeaturesFeatures
 Severe headache,Severe headache,
 SeizuresSeizures
 Focal signsFocal signs
 Decrease in conciousness...
Risk factorRisk factor
 Trauma most commonTrauma most common
 Vascular malformationVascular malformation
 Degenerative ...
Subarachnoid hemoorrhageSubarachnoid hemoorrhage
 Ateries forming circle of willis andAteries forming circle of willis an...
 Erythrocytes in subarachnoid spaceErythrocytes in subarachnoid space
can cause severe spasm leading tocan cause severe s...
FeatureFeature
 Severe headache, neck rigidity,Severe headache, neck rigidity,
 Low grade feverLow grade fever
 Leckocy...
Malformation of vein of galenMalformation of vein of galen
ApporachApporach
 Through examinationThrough examination
 HeaHea
 FaceFace
 EyesEyes
 EarsEars
 Paranasal sinusesPar...
 SkinSkin
 Bone and jointsBone and joints
 ExtremitiesExtremities
 AnthropometryAnthropometry
 vitalsvitals
 Per abdomenPer abdomen
 CVSCVS
 Suppurative lung diseaseSuppurative lung disease
InvestigationInvestigation
 CBC,Platelet,ESRCBC,Platelet,ESR
 LFTLFT
 CholesterolCholesterol
 Coagulation profileCoagu...
 Ana,RA, anti cardiolipinAna,RA, anti cardiolipin
 Lumbar puntureLumbar punture
 CTCT
 MRIMRI
 AngiographyAngiography
TherapyTherapy
 Absence of RCTAbsence of RCT
 Adapted from adultsAdapted from adults
 Treat underlying risk factorTreat...
Consensus on……Consensus on……
 Sickle cell diseaseSickle cell disease
 Acute therapyAcute therapy
• Exchange transfusionE...
Current recommendations……Current recommendations……
 Neonatal AIS – no therapyNeonatal AIS – no therapy
 Dissecting vascu...
HeparinHeparin
 For rapid anticoagulationFor rapid anticoagulation
 Bolus heparin 75-100u/kgBolus heparin 75-100u/kg
 M...
LMW heparinLMW heparin
 LovenexLovenex
 1mg/kg in >1yr every 12 hr1mg/kg in >1yr every 12 hr
 1.5mg/kg in neonate1.5mg/...
AspirinAspirin
 3-5 mg/kg3-5 mg/kg
 Dose in less then 10% of antipyreticDose in less then 10% of antipyretic
dosedose
WarfarinWarfarin
 Used if secondary prevention withUsed if secondary prevention with
ASA failsASA fails
 Maintain INR of...
Supportive treatmentSupportive treatment
 Manage ICTManage ICT
 Blood presureBlood presure
 Blood sugarBlood sugar
 Bo...
OutcomeOutcome
 Mortality 20 to 30%Mortality 20 to 30%
 Residual neurological deficit in >50%Residual neurological defic...
Differential DiagnosisDifferential Diagnosis
 MigraineMigraine
 Todds paralysisTodds paralysis
Hemiplegia stroke
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Hemiplegia stroke

  1. 1. Acute onset hemiplegiaAcute onset hemiplegia Dr Surya KumarDr Surya Kumar
  2. 2.  Paralysis of one half of the bodyParalysis of one half of the body CompleteComplete IncompleteIncomplete CrossedCrossed
  3. 3. Anatomy of brainAnatomy of brain
  4. 4. 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
  5. 5.  2.5-2.7/100,000 population2.5-2.7/100,000 population IncidenceIncidence
  6. 6. 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 
  7. 7.  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
  8. 8.  IschemicIschemic  HemorragicHemorragic  Share equal proportion of incidenceShare equal proportion of incidence
  9. 9. 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%
  10. 10. AISAIS Vulnerable sitesVulnerable sites  DiencephalonDiencephalon  Watershed aresWatershed ares
  11. 11. SymptomsSymptoms  Focal neurological deficitFocal neurological deficit  SeizureSeizure  MigraineMigraine  FeverFever  LethargyLethargy  HeadacheHeadache  DYstoniaDYstonia  Age relate and associted conditionsAge relate and associted conditions
  12. 12. Cadiac disorderCadiac disorder  CHDCHD  RHDRHD  Prosthetic ValveProsthetic Valve  Shunts,Shunts,  Patent foramen ovalePatent foramen ovale
  13. 13. causescauses  PolycythemiaPolycythemia  AnemiaAnemia  ArrythmiaArrythmia  EndocarditisEndocarditis
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17.  Keep good hydrationKeep good hydration  Transfusion to keep HbS <30%Transfusion to keep HbS <30%
  18. 18. 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
  19. 19. 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
  20. 20. vasculitisvasculitis  Takayasu, SLE, MCTD,PANTakayasu, SLE, MCTD,PAN  Present with associated symptomsPresent with associated symptoms  Steroid and immunotherapySteroid and immunotherapy
  21. 21. MetabolicMetabolic  Homocystenemia, MELA, FamilialHomocystenemia, MELA, Familial HypercholesteremiaHypercholesteremia  Family history, and charactersticsFamily history, and characterstics featurefeature
  22. 22. MigraineMigraine  More common in femalesMore common in females  FamilialFamilial  Occasionaly permanent deficitOccasionaly permanent deficit
  23. 23. 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
  24. 24. Sinovenous thrombosisSinovenous thrombosis
  25. 25. 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
  26. 26. featuresfeatures  Seizures, lethargy,jitterySeizures, lethargy,jittery  Dilated scalp veins, anterior fontanel,Dilated scalp veins, anterior fontanel, eyelid swellingeyelid swelling  Headche,Headche,
  27. 27. 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
  28. 28. hemorrhagehemorrhage  Congenital vascular anamolyCongenital vascular anamoly  VasculopathiesVasculopathies  Systemic diseaseSystemic disease  TraumaTrauma  Hematological disodersHematological disoders
  29. 29. 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
  30. 30. FeaturesFeatures  Severe headache,Severe headache,  SeizuresSeizures  Focal signsFocal signs  Decrease in conciousnessDecrease in conciousness  AtaxiaAtaxia  Dysconjugate gaitDysconjugate gait  comacoma
  31. 31. Risk factorRisk factor  Trauma most commonTrauma most common  Vascular malformationVascular malformation  Degenerative vasculopathyDegenerative vasculopathy  Hemophilic disorderHemophilic disorder
  32. 32. 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
  33. 33.  Erythrocytes in subarachnoid spaceErythrocytes in subarachnoid space can cause severe spasm leading tocan cause severe spasm leading to secondary ishemic infarctionsecondary ishemic infarction
  34. 34. FeatureFeature  Severe headache, neck rigidity,Severe headache, neck rigidity,  Low grade feverLow grade fever  LeckocytosisLeckocytosis  Raised ICTRaised ICT
  35. 35. Malformation of vein of galenMalformation of vein of galen
  36. 36. ApporachApporach  Through examinationThrough examination  HeaHea  FaceFace  EyesEyes  EarsEars  Paranasal sinusesParanasal sinuses  Oral cavityOral cavity  neckneck
  37. 37.  SkinSkin  Bone and jointsBone and joints  ExtremitiesExtremities  AnthropometryAnthropometry  vitalsvitals
  38. 38.  Per abdomenPer abdomen  CVSCVS  Suppurative lung diseaseSuppurative lung disease
  39. 39. 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
  40. 40.  Ana,RA, anti cardiolipinAna,RA, anti cardiolipin  Lumbar puntureLumbar punture  CTCT  MRIMRI  AngiographyAngiography
  41. 41. TherapyTherapy  Absence of RCTAbsence of RCT  Adapted from adultsAdapted from adults  Treat underlying risk factorTreat underlying risk factor  Prevent recurrencePrevent recurrence
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. AspirinAspirin  3-5 mg/kg3-5 mg/kg  Dose in less then 10% of antipyreticDose in less then 10% of antipyretic dosedose
  47. 47. 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
  48. 48. 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
  49. 49. 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%
  50. 50. Differential DiagnosisDifferential Diagnosis  MigraineMigraine  Todds paralysisTodds paralysis
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