Hemiparesis 2018-01-30T16:37:17+00:00

Relevant clinical signs

  • Inspection
    • Walking aids
    • Facial droop
    • Feeding tubes, nil by mouth signs (dysphagia)
    • Flexor posturing of the upper limbs, extensor of the lower limbs
  • Limbs
    • Positive pronator drift on affected side
    • Increased tone, velocity-dependent
    • Reflexes
      • Brisk reflexes on the affected side
      • Positive Hoffman’s sign on the affected side
      • Extensor plantar response on the affected side
      • Ankle clonus on the affected side
    • Pyramidal weakness
      • Flexors stronger than extensors in upper limb on the affected side
      • Extensors stronger than flexors in lower limb on the affected side
      • Severe hemiparesis may affect all muscle groups equally
    • Sensation
      • Brainstem syndromes
        • Weber’s: ipsilateral III, contralateral hemiparesis
        • Millard-Gubler: ipsilateral VI, VII, contralateral hemiparesis, dorsal column loss
      • Cord syndromes
        • Brown-Séquard: ipsilateral hemiparesis and dorsal column loss, contralateral spinothalamic loss
      • May have cortical sensory loss: astereognosis, agraphesthesia rather than modality loss
  • Cortical function
    • Hemineglect
    • Homonymous hemianopia
    • Gaze preference (towards the side of the lesion)
    • Expressive dysphasia
    • Anomia
    • Cortical sensory loss
    • Reduced Glasgow Coma Scale (cerebral oedema)
  • Underlying cause
    • Pulse (atrial fibrillation)
    • Carotid bruit (internal carotid artery stenosis)
    • Finger prick marks, diabetic dermopathic changes (diabetes mellitus)
    • Bruising, metallic heart sounds (anticoagulation)

Differential diagnosis

  • Ischaemic stroke
    • Cardioembolic
    • Internal carotid artery stenosis
    • Hypertensive disease
    • Cerebral vasculitis
  • Haemorrhagic stroke
  • Brain abscess
  • Brain tumour
  • Post-ictal (Todd’s paresis)

 Investigations

  • Confirm diagnosis:
    • Computed tomography scan of the brain (established infarcts) ± CT angiography (thrombolysis)
    • Magnetic resonance imaging ± magnetic resonance angiography
  • Look for an underlying cause
    • Electrocardiogram, consider Holter looking for tachyarrhythmia
    • Trans-cranial Doppler looking for stenosis
    • Doppler of the carotid arteries looking for stenosis (>70%)
    • Trans-thoracic echocardiogram looking for intramural thrombus
  • Blood tests (pre-thrombolysis and before starting antiplatelets)
    • Full blood count
    • Renal function
    • Liver function
    • Coagulation screen
  • Cardiovascular risk factors
    • Fasting glucose level, HbA1c
    • Lipid monitoring
  • Young stroke work-up
    • ANA, dsDNA, ESR
    • Anti-phospholipid antibodies
      • Lupus anticoagulant
      • Anti-cardiolipin IgG and IgM
      • Anti-β2 glycoprotein IgG and IgM
    • Thrombophilia screen
      • Protein C and protein S (deficiency)
      • Anti-thrombin III (deficiency)
      • Homocysteine (high)
    • Syphilis screen

Management

  • Multidisciplinary team approach
  • Speech therapy for swallowing, communication
  • Physiotherapy and occupational therapy to preserve and maximize function
  • Acute management
    • Stabilize, intubate if unable to protect airway
    • Within thrombolytic window (4½ hours of clear symptom onset)
      • No established infarct on CT brain
      • National Institutes of Health Stroke Scale > 5
      • Contraindications: recent stroke, age ≥ 80, bleeding diathesis, NIHSS ≥ 25, BP > 185/110
      • Complications: haemorrhagic conversion (BP must be < 180/105 for 24h post-thrombolysis)
    • Out of window
      • Load antiplatelet, or change from aspirin to clopidogrel if already on aspirin
      • Statin
      • Gastric protection if starting aspirin
      • If cardioembolic – anticoagulate
  • Manage cardiovascular risk factors
    • Smoking cessation
    • Weight loss
    • Diabetic control
    • Hypertension control
  • Consider neurosurgical referral for decompression if haemorrhagic conversion / cerebral oedema

Hemiparesis

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