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Approach to a patient with Hemiplegia Definitions Hemiplegia Quadriplegia Monoplegia Paraplegia Definitions Stroke Pathogenesis of Stroke Weakness over

one side of the body Weakness of all 4 limbs Weakness of 1 limb Weakness of both lower limbs Hypertension Atherosclerosis Thrombosis Emboli Arterial spasm Ischemia/ Infarction Necrosis of brain tissue Hypertension Aneurysm Bleeding diathesis AV Malformations Intracerebral Haemorrhage Destruction of brain tissue Expanding mass from arterial haemorrhage

Cerebral ischaemia Transient Ischemic Attack (TIA) Infarction (death of brain tissue)

Abrupt onset of neurologic deficit Due to a focal vascular cause Symptoms & signs lasts for > 24h Blood flow (lasts for longer than several seconds) Transient reduction of blood flow Usually last for 5-15 minutes Must last less than 24h (by definition) Cessation of blood Lasts for more than few minutes

Reactive edema of surrounding brain Localizing signs due to destruction of brain tissue (permanent) Edema of surrounding brain (temporary) History Onset of symptoms y Sudden y Slow/ insidious y Chronic Progression of symptoms y Maximum deficit at onset y Progressing within hours/ days Symptoms (along with weakness pertaining to CNS) y LOC (loss of consciousness) y Speech difficulty y Seizures y Difficulty in breathing y Symptoms of ICP (headache/ vomiting/ blurring of vision) y Double vision/ difficulty in opening eye y Squint y Facial numbness/ weakness y Difficulty in swallowing/ choking y Nasal regurgitation Systemic symptoms y Chest pain y Palpitation y Neck pain y Fever y Loss of weight/ appetite y Joint pain/ rash y Chronic cough Past history y Stroke y TIA (transient ischemic attack) y MI (myocardial infarction) y DM (diabetes mellitus) y Hyperlipidemia y Migrane Social history y Smoking y Alcohol y Drugs contraceptive pills/ HRT/ recreational drugs/ IVDU Family history (similar illness in family) Steps Structures involved? Site of lesion? Etiology? Management? Tests? Treatment?

Classification of Stroke Ischemic (85%) Atherosclerosis y Thrombosis y Hemodynamic insufficiency y Arterio-arterial emboli Cardiogenic/ Aortogenic Lacunar Non-atherosclerotic y Vasculopathies y Coagulopathies Idiopathic Common Causes of Ischemic Stroke Thrombosis Lacunar stroke Large vessel thrombosis Dehydration

Hemorrhagic (15%) Intracranial aneurysm AVM

Embolic occlusion Artery-artery y Carotid bifurcation y Aortic arch y Aortic dissection Cardioembolic y Atrial fibrillation y Mural thrombus y Myocardial infarction y Dilated cardiomyopathy Valvular lesion y Mitral stenosis y Mechanical valve y Bacterial endocarditis ASD PDA

Other Causes of Hemiplegia Infective encephalitis, meningitis, brain abscess Neoplastic glioma/ meningioma Demyelination multiple sclerosis, lesions to internal capsule Traumatic cerebral lacerations, subdural hematoma Congenital cerebral palsy Uncommon Causes of Ischemic Stroke Hypercoagulable disorders Venous sinus thrombosis Vasculitis Drugs cocaine/ amphetamine Moyamoya disease Eclampsia Psychological

Structures involved If right upper & lower limb weakness y Right hemiplegia y Left corticospinal (Pyramidal) tract Site of lesion If patient present with hemiplegia Determine if lower part of face involved with sparing of upper face th y UMN 7 CN palsy y Lesion above pons o Motor cortex o Corona radiata o Internal capsule Hemiparesis is proportionate (similar degree of weakness) y Upper limb y Lower limb Degree of weakness Face & Arm Leg > Arm Arm = Leg Faciobrachial Paracentral Dense hemiplegia (lesion is corticoInternal capsule subcortical) Neighbouring signs/ symptoms y Aphasia y Ipsilateral hemisensory loss y Homonymous hemianopia y Anosognosia y Partial motor seizures Lesions Internal capsule Thalamus Brain stem Pure motor hemiplegia Contralateral Midbrain hemisensory loss Pons (including face) Medulla Crossed hemiplegia (ipsilateral cranial nerve & contralateral hemiplegia) Midbrain lesion Webers syndrome Benedikt s syndrome Millard Gubler CN 3rd Weber s + red nucleus CN 6 Contralateral CN 3 palsy CN 7 hemiparesis Contralateral Contralateral hemiparesis hemiplegia Contralateral hyperkinesis Ataxia Intention tremor Medullary Syndrome Lateral Medullary Syndrome Medial Medullary Syndrome (PICA + Vertebral) (Occlusion of basilar (Wallenberg s syndrome) paramedian branches) Hoarseness, dysphagia Ipsilateral hemiparalysis of tongue Ipsilateral vocal cord paralysis Contralateral arm & leg hemiparesis Loss of gag reflex (CN 9 is afferent limb of gag reflex) (CN 10 is efferent limb) Vertigo Oscillopsia (swaying side to side) Facial analgesia Horner s Ipsilateral loss of taste Ipsilateral arm, trunk, leg numbness Contralateral pain, temperature loss (No weakness in contralateral arm or leg) Dysarthria (clumsy hand syndrome) y Lacunar infarct of basis pontis (supplied by basilar artery) y Facial weakness y Severe dysarthria y Severe dysphagia y Occur in conjunction with a clumsy or paretic hand Site of lesion based on vascular territory Anterior cerebral artery Middle cerebral artery Posterior cerebral artery

Etiology Example Experienced 4 similar episodes in last 3 weeks Long history of hypertension, diabetes mellitus Answer Ischemic stroke of lacunar type involving lenticulostriate branch of left MCA

Site of lesion (based on vascular territory) Anterior Cerebral Artery Motor cortex (lower limb) Controls movement of contralateral lower limb Sensory Cortex (lower limb) Receives sensory input from contralateral lower limb Prefrontal Cortex Functions in volition, motivation, planning, organizing of complex behaviour Supplemental Motor Cortex (Dominant Hemisphere) Functions with Broca s area in initiation of speech Middle Cerebral Artery (Superficial division) Broca s area Expressive speech area Integration with other language areas Wernicke s area Receptive speech area Integration with other language areas Motor cortex Movement of contralateral head, neck, arm Sensory cortex Sensation from contralateral head, neck, arm Middle Cerebral Artery (Lenticulostriate (deep) branches) Striatum (Caudate, Putamen) Receives cortical inputs to basal ganglia Globus pallidus Site of origin of output from basal ganglia to substantia nigra & thalamus Internal capsule (Anterior limb) Contains corticopontine, thalamocortical fibers Internal capsule (Genu) Contains descending fibers of corticobulbar tract MCA Clinical Syndromes Contralateral face, arm (due to damage to motor cortex) Nonfluent (Broca s), fluent (Wernicke s) aphasia Contralateral cortical type sensory loss Hemineglect (damage to non-dominant association areas) Posterior Cerebral Artery (Superficial & deep branches) Occipital lobe Primary & secondary visual areas Splenium of Corpus Collosum Carries commissural fibers connecting right & left visual association cortices Thalamus Relay center for descending & ascending information Functions in integration between cerebral cortex & rest of CNS Internal Capsule (Posterior limb) Contains descending fibers of lateral & ventral corticospinal tracts

ACA Clinical Syndromes Paralysis/ weakness of contralateral foot, leg Sensory loss in contralateral foot, leg Left sided stroke develop transcortical motor aphasia Gait apraxia Urinary incontinence (occur with bilateral damage in acute phase) If stroke occur prior to anterior communicating artery, it is well tolerated (secondary to collateral circulation)

PCA Clinical Syndromes Homonymous hemianopsia (due to damage to visual cortex in occipital lobe) Alexia without agraphia (interference with communication between 2 visual association through splenium of corpus collusom) Contralateral hemisensory loss & hemiparesis (disruption of ascending & descending information)

Examination General Vital signs BP, Pulse Temperature Carotid bruit Peripheral pulses Neurological Conscious level Higher mental function Speech Cranial nerve Motor system Cerebellar Gait

Risk Factor Modification Hypertension Diabetes Mellitus Obesity Hyperlipidaemia Cardiac disease AF Smoking Alcohol, drug abuse Sedentary life style

Examination of Motor System Tone y Hypertonia/ spasticity (predominant in antigravity muscles) o Flexors in upper limb o Extensors of lower limb Power y Medical research council grading (0-5) Hyperreflexia Extensor plantar response (Babinski sign) Clonus Superficial reflexes (absent) Investigations Blood studies y FBC y ESR y Cardiac enzyme levels y Electrolyte values (urea, creatinine, Na+ , K+) y Serum glucose values y Liver function tests y Coagulation Electrocardiography (ECG) Chest radiography Oxygen saturation & blood gas determination Urinalysis, blood culture (if fever) Imaging y CT scan y MRI Treatment Ischemic Stroke Depend on timing st 1 3-6 hours of onset of symptoms IV/ IA Thrombolysis Aspirin Heparin Aspirin (if thrombolysis is contraindicated) Statins Surgery decompression (large MCA infarct) Prognosis Disability affects 75% of stroke survivors Hemorrhagic Stroke Factor VII Frozen plasma Anti-edema measures Mannitol Surgery Hematoma evacuation (>3cm) lobar bleeds

> 6 hours

Prognosis Death rate 34-50% by 30 days after insult