Hemiplegia

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