Diagnosis of Alternating Hemiplegia
Alternating Hemiplegia Diagnosis: Book Excerpts
Diagnostic Tests for Alternating Hemiplegia: Online Medical Books
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HEMIPARESIS/HEMIPLEGIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it intermittent? Intermittent hemiparesis or hemiplegia would suggest migraine or transient ischemic attacks from basilar artery or carotid artery disease.
- Is it sudden or gradual in onset? Sudden onset of hemiparesis would suggest a cerebral thrombosis, hemorrhage, or embolism. However, contusion or concussion of the spinal cord can occasionally produce a sudden onset of hemiparesis or hemiplegia. If there is a history of trauma, a subdural or epidural hematoma must be suspected. Gradual onset of hemiparesis or hemiplegia would suggest a space-occupying lesion.
- Is there facial paralysis or other cranial nerve signs? If there is a central facial palsy or other cranial nerve signs, one would look for a lesion above the foramen magnum (i.e., in the brain). If there are no cranial nerve signs, a spinal cord lesion should be suspected.
- Is there a fever? The presence of fever should suggest a cerebral abscess, venous sinus thrombosis, or encephalitis.
- Is there a history of trauma? The history of trauma with hemiparesis or hemiplegia would suggest a subdural
or
epidural hematoma or a hemorrhage in the brain itself.
- Is there a history of hypertension? The history of hypertension along with hemiparesis or hemiplegia suggests a cerebral hemorrhage. However, a cerebral thrombosis or cerebral aneurysm may also occur with a history of hypertension.
- Is there auricular fibrillation or another embolic source? The presence of auricular fibrillation, cardiac murmur, or other signs of an embolic source would suggest a cerebral embolism.
DIAGNOSTIC WORKUP
A neurologist should be consulted at the outset because he can best determine what type of imaging study should be done. A spinal tap is no longer done without first doing an imaging study. Carotid scans can be done to rule out carotid artery insufficiency. Four-vessel cerebral angiography may be indicated, especially in transient ischemic attacks. Magnetic resonance angiography has become an acceptable noninvasive technique for evaluating the cerebral blood flow, especially in the vertebral-basilar arteries. EKG, echocardiography, and blood cultures will help identify an embolic source, but a cardiologist should be consulted to investigate this further. SSEP, BSEP, and VEP studies along with a spinal tap will help diagnose multiple sclerosis.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hemiparesis & Hemiplegia:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Cerebrovascular disease is the most common cause of acute hemiparesis or hemiplegia
–Infarction (thromboembolic)
–Intracerebral hemorrhage
–Transient ischemic attacks may produce a transient hemiplegia or paresis (though they are defined as cerebrovascular deficits that resolve within 24 hours, most TIAs last only minutes)
–RINDs last 24–72 hours
-
Chronic subdural hematoma
-
Demyelinating disease (e.g., multiple sclerosis, Guillain-Barré syndrome)
-
Trauma
-
Congenital (e.g., cerebral palsy, congenital structural anomalies)
-
Brain tumors (primary or metastatic)
-
Cerebral abscess
-
Complicated migraine
-
Inflammatory conditions (e.g., cerebral vasculitis)
-
Postictal (Todd's) paralysis
-
Psychogenic or hysterical weakness
–These patients usually lack associated physical findings such as hyperreflexia or Babinski's signs, and may also exhibit inconsistent or nonphysiologic patterns of weakness
-
Amyotrophic lateral sclerosis
–May present initially with asymmetric weakness, but more diffuse involvement develops over time
- Brown-Séquard syndrome (spinal cord hemisection)
–Leads to weakness, upper motor neuron signs, and impaired proprioception and vibratory sensation ipsilateral to the lesion
–Impaired pain and temperature sensation contralateral to the lesion
-
Meningitis
-
Syphilis
-
Transverse myelitis
-
Periodic paralysis
Workup and Diagnosis
- History and physical examination
–Acute onset of hemiparesis or hemiplegia suggests a vascular cause until proven otherwise (although an exacerbation of multiple sclerosis may present relatively acutely)
–More gradual onset of hemiparesis suggests a more slowly evolving process, such as a tumor
–The pattern of weakness noted on exam and the associated deficits will help to localize the problem (e.g., right hemiparesis with greater weakness of the face and arm than the leg and associated aphasia suggest a cerebral infarction in the territory of the left middle cerebral artery; equal weakness of the face, arm, and leg without associated cortical deficits suggests a subcortical lesion (e.g., internal capsule); cranial nerve abnormalities and weakness of the contralateral limbs suggests a brainstem lesion)
-
Initial laboratory studies may include CBC, electrolytes, calcium, glucose, BUN/creatinine, and PT/PTT
-
MRI and/or CT scan are the imaging modalities of choice
-
CSF examination is useful in suspected cases of multiple sclerosis (reveals oligoclonal bands and elevated IgG index)
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
HEMIPLEGIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The history is very important in determining the diagnosis of
hemiplegia. An acute onset without a history of trauma would suggest a
cerebral embolism, hemorrhage, or thrombosis, whereas a gradual onset would
indicate a possible neoplasm or other space-occupying lesion. Intermittent
occurrence of hemiplegia might suggest migraine, multiple sclerosis, or
carotid artery insufficiency. A history of fever may indicate a cerebral
abscess or subacute bacterial endocarditis. The physical examination may
also be helpful. A carotid bruit points to carotid stenosis. A cardiac
arrhythmia suggests cerebral embolism. Hypertension points to cerebral
hemorrhage. A central facial palsy or other cranial nerve signs indicate a
brain or brainstem lesion as opposed to a cervical cord insult. The initial
diagnostic workup would include a CBC, sedimentation rate, VDRL, ANA, and
chemistry panel.
More definitive studies such as a CT scan or MRI will almost certainly be
necessary, but a neurologist should be consulted first. If a vascular lesion
is suspected, MRI, a carotid duplex scan, and four-vessel cerebral
angiography may be indicated. Blood cultures would be helpful in ruling out
bacterial endocarditis. Spinal fluid analysis should be done if multiple
sclerosis or neurosyphilis is suspected.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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