APPROACH TO HEMIPLEGIA

DR SUDHIR KUMAR MD DM (NEUROLOGY)SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, HYDERABAD

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

CASE 1 • 60-year old man,• One hour duration of drowsiness, headache

and vomiting,• BP: 220/110 mmHg• Left-sided weakness

CT BRAIN

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.

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

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.

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

CT BRAIN

DIAGNOSIS• Acute subdural hematoma (SDH)• Treatment is urgent surgery- Burr hole

evacuation of hematoma.

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

CT BRAIN

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.

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

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.

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

• 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

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

MRI Brain

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.

OTHER CAUSES of hemiplegia

• Hyperglycemia,• Hyponatremia,• Brain tumor with bleed,• Brain abscess,• Encephalitis, meningitis

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Email: drsudhirkumar@yahoo.com

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