Approach to hemiplegia

This presentation looks at some of the common conditions that can present with hemiplegia. Stroke is the commonest, however, there are several other causes that need to be considered in a patient presenting with hemiplegia.

1. APPROACH TO HEMIPLEGIA DR SUDHIR KUMAR MD DM (NEUROLOGY) SENIOR CONSULTANT NEUROLOGIST APOLLO HOSPITALS, HYDERABAD

2. OVERVIEW Brain stroke is the commonest cause of hemiplegia, Stroke is among the three most common causes of death and disability (heart attack and cancer are the other two), It is important to correctly and quickly diagnose stroke, as treatment (thrombolysis) is time-bound, Missed or delayed diagnosis can deny thrombolytic therapy, On the other hand, thrombolysis of a “stroke-mimic” may be harmful We look at some of the common stroke mimics, which can present with acute onset hemiplegia

3. CASE 1 60-year old man, One hour duration of drowsiness, headache and vomiting, BP: 220/110 mmHg Left-sided weakness

4. CT BRAIN

5. DIAGNOSIS Brain hemorrhage Contraindication to thrombolysis, About one-third of all strokes, Management includes control of BP and lowering of ICP (mannitol, mechanical ventilation); surgery in some cases.

6. CASE 2 55-year old lady, Known diabetic, Right hemiplegia of 45 minutes duration On admission, power grade 0/5 in right UL, LL CT brain- normal 30 min later, complete recovery. Power-grade 5/5 all 4 limbs

7. DIAGNOSIS TIA- transient ischemic attack No need to thrombolyse in cases of TIA However, if the recovery is incomplete, thrombolysis should be considered All patients with TIA should be started on anti-platelets and statins, as they have a high risk of stroke in future, esp in the first 30 days after TIA.

8. CASE 3 70-year old man, Sudden onset left hemiplegia of two hours duration, History of fall at home present, Mild drowsiness, power grade 3/5 left UL, LL

9. CT BRAIN

10. DIAGNOSIS Acute subdural hematoma (SDH) Treatment is urgent surgery- Burr hole evacuation of hematoma.

11. CASE 4 25-year old lady, Acute onset weakness of right side of body of three hours duration, Preceded by headache for three days, One episode of seizure while in ER, Drowsy, arousable, obeys a few commands Power grade 3/5 right UL, LL

12. CT BRAIN

13. DIAGNOSIS CVST (Cerebral venous sinus thrombosis) Common in post-partum period, after OCP use, head injury, thrombogenic states such as nephrotic syndrome, malignancy, protein C/S deficiency Confirm by MRI/MRV brain Treatment- anticoagulation with heparin Intra-sinus thrombolysis in selected cases.

14. CASE 5 21-year old man presented with weakness of right arm and leg of three hours duration, He had a GTCS at the onset of weakness, He had history of epilepsy in childhood, and was treated with valproate for three years. Conscious, alert, power grade 3/5 in right UL, LL

15. CT BRAIN CT brain- normal Diagnosis- Todd’s paresis Todd’s paralysis can last from 30 min to 36 hours (average duration is 15 hours) Resolves on own and no treatment is necessary.

16. CASE 6 55-year old lady, Known diabetic on metformin and glimepiride, Brought to ER with sudden onset left hemiplegia and drowsiness of one hour duration Drowsy, not obeying commands, left hemiplegia, CT brain- normal

17. RBS- 30 mg% Diagnosis- hypoglycemic hemiparesis Hemiparesis occurs in 4.2% cases of hypoglycemia, at an average glucose of 32 mg% or less, Mostly right hemiparesis (in 66% of cases) Internal capsule or splenium of corpus callosum lesion may be seen on MRI brain, Rapidly improves with dextrose infusion

18. CASE 7 19-year old girl Presented with acute onset right hemiplegia and aphasia of two hours duration, History of fever and cough two weeks ago, subsided in 3 days on own

19. MRI Brain

20. DIAGNOSIS Acute disseminated encephalo -myelitis (ADEM) An auto-immune condition, affecting white matter of brain, Treated with IV methylprednisolone for 3-5 days Good recovery is seen.

21. OTHER CAUSES of hemiplegia Hyperglycemia, Hyponatremia, Brain tumor with bleed, Brain abscess, Encephalitis, meningitis

22. COMMENTS/QUERIES Whatsapp: [phone] Email: [email protected] Facebook: www.facebook.com/bestneurologist /