Hemiparesis & Hemiplegia
Hemiplegia (complete lack of motor function) and hemiparesis (decreased motor function) are almost always the result of a problem with the brain. The tempo of onset, past history, and associated findings on examination are usually helpful in localizing the problem and suggesting an etiology. Emergent stabilization and treatment are essential to save lives and decrease disability, but correct diagnosis is necessary to limit untoward risks of treatment, such as that of hemorrhagic stroke in a patient who receives thrombolytic therapy.
Differential Diagnosis
- 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
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Chronic subdural hematoma
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Demyelinating disease (e.g., multiple sclerosis, Guillain-Barré syndrome)
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Trauma
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Congenital (e.g., cerebral palsy, congenital structural anomalies)
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Brain tumors (primary or metastatic)
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Cerebral abscess
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Complicated migraine
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Inflammatory conditions (e.g., cerebral vasculitis)
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Postictal (Todd's) paralysis
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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
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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
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Meningitis
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Syphilis
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Transverse myelitis
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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)
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Initial laboratory studies may include CBC, electrolytes, calcium, glucose, BUN/creatinine, and PT/PTT
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MRI and/or CT scan are the imaging modalities of choice
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CSF examination is useful in suspected cases of multiple sclerosis (reveals oligoclonal bands and elevated IgG index)
Treatment
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Hemiplegia and hemiparesis are best managed by identifying and treating the underlying cause
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General measures, such as physical and occupational therapy, assistive devices, and orthotics, may be beneficial in improving the functioning of patients with hemiplegia or paresis
- Cerebral infarction is best managed medically
–Thrombolytics within 3 hours of onset of symptoms in carefully selected patients improves the outcome of ischemic stroke patients
–General measures include careful management of blood pressure, blood sugar, and avoiding infectious complications (e.g., pneumonia due to bedrest)
–Identify underlying cause to direct long-term therapy (usually antiplatelet or anticoagulant therapy with risk factor management) to prevent recurrence
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Mass lesions affecting the brain, including tumors and hematomas, may require surgical management
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Multiple sclerosis: Steroids for acute exacerbations
Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hemiparesis
Read excerpts from these other book chapters related to Hemiparesis:
Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Hemiparesis
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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Hemiplegia (Hemiparesis) (A Pocket Manual of Differential Diagnosis)
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