Hemiplegia

Hemiparesis is unilateral paresis, that is, weakness of the entire left or right side of the body (hemi- means "half"). Hemiplegia is, in its most severe form, complete paralysis of half of the body. Hemiparesis and hemiplegia can be caused by different medical conditions, including congenital causes, trauma, tumors, or stroke
 Hypenension: Commonest cause of intracerebral haemorrhage.
 Rupture of an intracranial aneurysm, angioma or A-V malformation: commonest cause of subarachnoid haemorrhage.
 Haemorrhagic blood diseases: purpura, haemophilia.
 Anticoagulants.
 Trauma to the head: commonest of subdural haematoma.
II. Infective: ;
 Encephalitis
 Meningitis – Brain abscess.
III. Neoplastic: e.g. Meningioma.
IV. Demyelination: multiple sclerosis may present with hemiplegia.
V. Traumatic: e.g. Cerebral laceration and subdural haematoma.
VI. Hysterical: patient suffering from paralysis in the absence of organic lesion.

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Amr Hassan, M.D.
Associate professor of Neurology - Cairo
University

HEMIPLEGIA

3. Definition: Paralysis of one side of the body
due to pyramidal tract lesion at any point
from its origin in the cerebral cortex down to
the 5th cervical segment (beginning of origin
of brachial plexus).

5. Vascular
causes
Thrombotic
Vessel wall
Atherosclerosis
Vasculitis
Blood diseases
Polycythemia
Thrombocytosis
Hyper
gammaglobuline
mia
Circulation
defect
Heart failure
Systemic
hypotension
Embolic
Heart
MI
AF
PROSETHTIC
VALVE
Distal vesseles
Crotid
venous
Other sources
Lung
Bone
Tumour
Haemorrhagic
Hypertension
Aneurysm
Blood diseases
Anticoagulatio
trauma

8. Acute or subacute onset:
Infective: viral, brain abcess
Traumatic :
Demyelinating:
Hysterical
Gradual onset:
neoplastic

9. 1. Intracerebral: the bleeding is in the brain
substance & may leak into the ventricles; The
commonest artery causing intracerebral hge is
the lenticulo-stnate branch of the middle
cerebral artery.
2. Subarachnoid: the bleeding is in the
subarachnoid space

10. Onset & course:
Acute onset & regressive course (vascular,
infective & traumatic lesions).
Gradual onset & progressive course
(neoplastic lesions).
Relapsing remitting course (M.S.).

11. Symptoms & signs: Vary according to the
onset:
Acute lesions: the clinical picture passes
through 2 stages:
Stage of flaccidity due to neuronal shock.
Stage of spasticity which is the stage of
established hemiplegia.
Gradual lesions: the hemiplegia passes directly
to the stage of spasticity.

12. Stage of flaccid paralysis (shock stage):
It lasts from 2-6 weeks.
It is characterized by ↓tone (flaccidity), ↓ or
lost deep reflexes and absent plantar
response.
During recovery from the shock stage, the
muscle tone & deep reflexes reappear &
gradually increase, Babinski sign becomes
+vethen, stage of spasticity sets in.

13. Spastic stage
▪Paralysis
▪Hypertonia
▪Exaggerated deep reflexes
▪Lost superficial reflexes
▪+ve Babiniski sign
▪gait

14. Think about where
the lesion could be!

15. Cerebral
Brainstem
Spinal

16. Brown-sequard syndrome

17. Cerebral
Brainstem
Spinal

19. Hemiplegia &
hemiataxia
Oculomotor
palsy
Red nucleus
Benedikt
Hemiparesis Oculomotor
palsy
Weber
(hemiparesis
alternans
oculomotoria)
Contralateral side
Ipsilateral
side
Site of
lesion
Syndrome

22. Hemiparesis 6
th

7th
Millard-
Gubler
(hemiparesis
alternans
facialis)
Contralateral side Ipsilateral side Site of lesion Syndrome
1.CN VI and/or VII
2.Corticospinal
tract

23. Contralateral hemiplegia
Ipsilateral 6 & / or
LMN 7

24. Hemiparesis
1.Abducent
paresis
2.Horizontal gaze
paralysis
Foville
Contralateral side Ipsilateral side
Site of
lesion
Syndrome
Contra.

25. Hemiparesis 9
th
, 10
th

Avellis

Hemiparesis 11
th
, 12
th

Jackson

Contralateral side
Ipsilateral
side
Site of
lesion
Syndrome

26. Cerebral
Brainstem
Spinal

27. Contralateral hemiplegia
Cortical sensory loss
Coma
Convulsions at onset

Aphasia

29. 3/9/2017 29

30. H
H
H
NO
NO
NO

31. Fibres descending from the cortex
are called the ‘corona radiata’
cortex
C.R.
I.C.
To
LMN
Brainstem

Reticular
formation
Subcortical
•In-between

نينبلا نيب

32. In which vascular syndrome
is the facial nerve affected:
1. Dejerine
2. Avellis
3. Millard-Gubler
4. Brown-Sequard

33. Labs: blood glucose, liver and kidney functions,
lipid profile, CBC.

Imaging:
CT brain: to detect presence of infarction,
haemorrhage , brain tumor.
MRI brain: to detect presence of infarction,
haemorrhage, brain tumor, encephalitis, M.S.
plaques.

37. Vascular imaging
Doppler ultrasonic imaging: for carotid and
vertebrobasilar arteries.
Transcranial Doppler (TCD), CT Angiography, MR
Angiography.
Digital subtraction angiography: It visualises the
intracerebral vessels. It is non-invasive as it requires a
contrast medium given I.V.
Cerebral angiography: It is the most precise method,
showing any occlusion or stenosis in the cerebral
vascular tree.
Other investigations according to the cause:
echocardiography and ECG in cardiac cases.

39. General
Care of the skin:
Frequent change of the patient's position
(every 2 hours), and of the bed sheets.
Frequent wash of the skin of the back and
pressure points.
Suction of nasal and pharyngeal secretions.
O2 inhalation via catheter or mask specially
in cases of coma.
Tracheostomy in urgent cases.

40. Care of nutrition and fluid balance:Tube feeding
giving fruit juices, milk and pureed food,
besides I.V. fluids, in comatosed patients.
Care of the urinary bladder:Foley's self-
retaining catheter in case of retention.
Guarding against D.V.T.: by subcutaneous
injection of anticoagulant and wearing elastic
stocks.

41. II. Specific: It is the treatment of the cause.
A) If the cause is cerebral thrombosis:
Control of vascular risk factors: such as
hypertension and D.M. and dyslipidaemia
Antiplatelets: because platelet aggregation is
increased after thrombosis e.g. aspirin,
dipyridamole,clopidogril.
Nootropic drugs: e.g. piracetam and pentoxifylline.

42. B) If the cause is cerebral embolism:
Treatment of the source of emboli.
Anticoagulants are given in cardiac cases to
prevent further embolisation specially in
cases of A.F.

43. C) If the cause is cerebral haemorrhage:
General care
Control of vascular risk factors: such as
hypertension and D.M. and dyslipidaemia
Surgical evacuation: of the haematoma in
certain conditions.

44. D) If the cause is cerebral inflammation:
Treatment of meningitis and encephalitis
E) If the cause is brain tumors: Surgical
removal.
E) If the cause is M.S.: Pulse steroid therapy.

45. III. Physiotherapy:
Proper positioning of the hemiplegic side.
Passive and active exercises (after stabilisation
of the neurological condition) to minimise
contractures & to strengthen the muscles.
NO MASSAGE

46. Thank you