1) A 60-year-old man presented with sudden onset right-sided hemiplegia upon waking.
2) On examination, he had right-sided weakness and sensory loss consistent with involvement of the left middle cerebral artery territory.
3) Brain imaging revealed an acute ischemic stroke in the left middle cerebral artery distribution, likely due to thrombotic occlusion of that vessel.
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Approach to a_patient_presenting_with_hemiplegia
1.
2. OUTLINE
Brief anatomy and physiology of brain lobes and
their blood supply
Different terminology
Causes of hemiplegia:
Stroke in details
Approach to a patient presenting with hemiplegia
History taking
Physical examination
Investigation
A case: brain storming
3.
4. Brain
blood
supply
ICA
Vertebr
al.a
•Hypophyseal.
a
•Ophthalmic. a
•Antrerior
choroidal.a
•Supply:optic tract,
coridal plexus, internal
capsule, globus pallidus
•ACA
•Supply medial aspect
of frontal and parital
lobe
•Upper lateral part of
cortex of both lobes
•MCA
•Supply the whole
lateral surface of
parietal, temporal ,and
frontal lobe
Anterior and
posterior
spinal. a
•Supply spinal
cord•Ant & post
inferior
cerebellar.a
•Sperior
cerebellar. a
•Supply
cerebellum
•PCA
•Occipital lobe
•Inferomedial
aspect of temporal
Basil
ar. a
7. Anterior Limb -Frontopontine fibres, Thalamocortical fibres to frontal lobe
Genu - Corticonuclear/ corticobulbar fibres and Corticospinal fibres to head and
neck
Posterior Limb - Corticospinal fibres to trunk, upper and lower limbs,
corticorubral fibres, temporopontine, parietopontine and occipitopontine fibres,
thalamocortical fibres to temporal, parietal and occipital lobes
Retrolentiform part -Optic radiations from lateral geniculate body (thalamus) to
Visual cortex in occipital lobe
Sublentiform part -Auditory radiations from Medial geniculate body (thalamus) to
8.
9. DIFFERENTTERMIMOLOGIES
Paresis: partial or incomplete paralysis
Plegia: complete paralysis
Monoplegia is a paralysis of a single limb, usually an arm
Hemiplegia: total paralysis of the arm, leg, and trunk on the
same side of the body.
Paraplegia: an impairment in motor or sensory function of the
lower extremities.
Triplegia : is paralysis of three limbs.
Quadriplegia : is paralysis of all limbs, paraplegia is similar
but does not affect the arms
12. Definitions
Stroke:
Clinical syndrome of rapid onset of focal deficits of
brain function lasting more than 24 hours or leading
to death
Transient Ischemic attack (TIA):
Clinical syndrome of rapid onset of focal deficits of
brain function which resolves within 24 hours
Amaurosis fugax
13. DefinitioNS
Progressive Stroke:
A stroke in which the focal neurological deficits
worsen with time
Also called stroke in evolution
Completed Stroke:
A stroke in which the focal neurological deficits
persist and do not worsen with time
14. Epidemiology
Third most common cause of death after cancer
and ischeamic heart disease
Most common cause of severe physical
disability
Incidence and prevalence of stroke is on the rise
due to increasing adoption of unhealthy lifestyle
& an increasing life expectancy
17. IschemicStroke
80% of strokes
Arterial occlusion of an intracranial vessel leads
to hypoperfusion of the brain region it supplies
three etiological types:
Thrombotic
Embolic
Systemic hypoperfusion
19. ATP depletion
Hypoperfusion
Failure of Na+/K+ ATPase membrane ionic pump
Calcium entryGlutamate release
Activation of lipid peroxidases, proteases & NO synthase
Destruction of intracellular organelles, cell
membrane & release of free radicals
Free fatty acid release
Activation of pro-coagulant
pathways
Liquefactive
necrosis
Thrombus/embolus
Membrane depolarization & cytotoxic cellular
edema
20. Hemorrhagic Stroke
Four types:
Epidural
Subdural
Subarachnoid √
Intraparenchymal √
Higher mortality rates
when compared to
ischemic stroke
21. Intracerebral Hemorrhage
• Result of chronic hypertension
• Small arteries are damaged due to hypertension
• In advanced stages vessel wall is disrupted and
leads to leakage
• Other causes: amyloid angiopathy, anticoagulant
therapy, cavernous hemangioma, cocaine,
amphetamines
22. SubarachnoidHemorrhage
Most common cause is rupture of saccular or Berry
aneurysms
Other causes include arteriovenous malformations,
angiomas, mycotic aneurysmal rupture etc.
Associated with extremely severe headache
23.
24.
25. History taking
The history and physical examination should be used to
distinguish between other disorders in the differential
diagnosis of brain ischemia .
As examples, seizures, syncope, migraine, and
hypoglycemia can mimic acute ischemia.
It is important to ask the patient or a relative whether the
patient takes insulin or oral hypoglycemic agents, has a
history of a seizure disorder or drug overdose or
abuse, medications on admission, recent trauma, or
hysteria.
The history is also important in separating ischemia
from hemorrhage and distinguishing between subtypes
of ischemia and hemorrhage.
26. History taking in hemiplegia
When did the event started?
What is the total duration of the illness? If
multiple, ask about each episodes.
What according to the patient or relatives were
the initial presenting symptoms?
What was the exact mode of onset: was it abrupt,
sudden, sub-acute, or gradual?
When was the maximum deficit noted: in the
beginning or later.
Time course of the initial symptoms? Static or
progress
Any associated symptoms: CVS,RS,or GIT?
27. assessing the CNS
function?
Was there any loss of consciousness/ in the beginning or later;did he
recover from it? And for how long he stays unconsciousness?
What is the emotional status of the patient; memory and
intellegance?
Is speech affect and if so in what way? Motor, sensory, conductive
aphasia?
Which of the cranial nerve is affected and what are the symptoms
related?
What is the degree of motor weakness?
Are you able to wear your cloths? put button of your clothes? eat?
Open the door?
Are you able to stand? Walk? Move your limbs?
28. 1- Is the patient having
neurological problem?
Yes or no?
Is it a medical condition simulating
hemiplegia?
Post icteal Todd’s paralysis, or episode of MS
If yes, what are the neurological deficits:
Hemiplegia, UMN facial weakness, hemianesthesia,
homonymous hemianopia
Dysphasia in right hemiplegia and dysarthria in a
left hemiplegia
Crossed hemiplegia
Cervical cord lesion
30. 3- Is it a UMN lesion or a
LMN lesion?
UMN Disease LMN Disease
Suprasegmental Segmental
1. Weakness of the functional group of muscles
(depending on the site of lesion).
1. Weakness in one or more muscles, depending the
segmental involvement.
2. Spastic paralysis. 2. Flaccid paralysis.
3. Hypertonia. 3. Hypotonia (may be atonia if the destruction is
complete).
4. Hyperreflxia (Exaggerated Deep Tendon
Reflexes “DTRs”).
4. Deep Tendon Reflexes (DTRs) are lost in sever
cases (decreased otherwise).
5. Positive Babinski’s sign (Extensor plantar reflex:
dorsiflexion of foot). Triple Flexion: dorsiflexion of foot,
leg and thigh).
5. Babinski’s sign is absent.
6. Disuse atrophy. 6. Neurogenic atrophy (denervation atrophy) about
70% - 80%.
7. Nerve conduction is normal. 7. Nerve conduction is abnormal.
8. No fibrillations or fasciculations. 8. Fibrillations and fasciculations may be present.
9. Clonus is present. 9. No clonus seen.
10. Bilateral movements such as eyes, jaws, pharynx,
larynx and neck are little affected or not at all.
32. 5- is there a UMN or LMN
facial paralysis?
UMN facial paralysis:
Upper half of face is spared
Lower half affected
no Bell’s phenomena
Taste not affected
LMN facial paralysis:
Entire half of the face affected
Bell’s phenomena present
Taste affected
33. 6- what is the site of
localization of lesion?
• Partial deficit, speech involvement, cortical
sensory, focal sezure
• Brain lobs deficit
cortex
• Full hemiplegia
Sub-cortical
lesion
• Dense hemiplegia, sparing of speech
• Absence of speech deficit and sizuresInternal capsule
• Hemiparalysis, hemianopia, hemisensory
loss, and emerging hyperpathiaThalamic lesion
• Crossed hemiplegiaBrain stem
34. 7- is it an ischemic stroke or
Hemorrhagic stroke??
Ischemic stroke Hemorrhagic stroke
•Start suddenly
•Over seconds or
minutes
•Most cases do not
progress (Complete
stroke)
•Classically detected by
patient in the morning
when waking up
•May or may not be
preceded by episodes of
TIAs
•Mainly in HTN patients
•55-75 years of age
• smooth onset
•Over minutes or hours
•Steady progress despite
treatment
•Signs of increase ICT
•Usually associated with
severe headache and
vomiting
35. 8-IF IT ISCHEMIC WHICH
ARTERY INVOLVED??
carotid
• Contralateral weakness
• Contralateral numbness
• Dysphasia
• dysarthria
• ipsilatera;l mono-ocular
• Contralateral
homonymous
vertebral
• Bilateral or shifting
weakness
• Bilateral or shifting
numbness
• diplopia
• Dysarthria
• Inco-ordination of upper
limbs
• Ataxia/ imbalance/
disequilibrium
• Visual loss in both
homonymous fields
36. 9- is it internal carotid artery
syndrome?
Often asymptomatic
Due to collaterals circulations
Ext. carotid and ophthalmic anastamosis
• Warning
symptoms:
•Episode of
confusion
•Speech
dysfunction
•Amouriosis fugax
(transient mono-
ocular blindness)
•Fleeting
parasthesia
•Neurological deficits:
•Same as that of
MCA territory infract
•Contralateral
Hemiplegia
•Contralateral
sensory symptoms
•Local carotid
examination:
•Feeble carotide
pulsation
•Feeble temporal. a
pulsation
•Cervical bruit over
carotid
•Carotid doppler
angiography
37. 10- which cerebral artery
syndrome?
MCA
• Contra-lateral weakness face, UL, & LL
• Contralateral hemisensory loss
• Broca’s, wernecke’s, conduction, global aphasia
• contralateral homonymous hemianopia
ACA
• Contralateral paralysis of leg and foot
• Sensory loss in the contralateral leg and foot
• Gait apraxia
PCA
• Thalamic syndrome: hemiplagia ,and hemisensory loss, followed
with searing pain (thalamic hyperpathia)
• Up regulation of threshold for pain
• The pain aggrevated by: heat, cold, emotion of listening to music,
39. Physical Examination
Level of consciousness, mental status, speech, &
gait.
Cranial nerves, motor function, sensory function,
and superficial and deep tendon reflexes.
Special reference:
Optic fundus: papilledema
Signs of meningeal irritation: Kernig's Signs, and
Brudzinski's Sign
Signs of head injury
42. MOTOR FUNCTION
BODY POSTURE
INSPECTION- MUSCLE BULK
TONE
POWER
REFLEXES
CO-ORDINATION
43. SENSORY FUNCTION
Pain and temperature
Pressure and touch
Proprioception, vibration, and fine touch
44. Examination of a stroke
patient
Skin:
• Xanthalasma
• rash(arteritis,
splinter
hemorrhage)
• color and
temperature
changes
Eye:
• Diabetic changes
• retinal emboli
• HTN changes
CVS:
• Heart rhythme
(AF)
• BP (HTN
,hypoBP)
• JVP(HF,
hypovolemia)
• Murmurs
• Peripheral pulse &
bruits
RS:
• Signs of
pulmonary
embolism
• Signs of
respiratory
infection
Abdomen:
• Palpable bladder
(urinary retention)
45. Investigation
All patients with suspected stroke should have the
following studies immediately upon admission to the
emergency department:
Noncontrast brain CT or brain MRI
Electrocardiogram
Complete blood count including platelets
Cardiac enzymes and troponin
Electrolytes, urea nitrogen, creatinine
Serum glucose
Prothrombin time and international normalized ratio
(INR)
Partial thromboplastin time
Oxygen saturation
Lipid profile
46. Investigations
•For diagnosing ischemic
stroke in the emergency
setting:
•CT scans (without
contrast):
•Sensitivity: 16%
•Specificity: 96%
•MRI scan:
•Sensitivity: 83%
•specificity :98%
•For diagnosing hemorrhagic
stroke in the emergency setting:
•CT scans (without
contrast):
•Sensitivity: 89%
•Specificity: 100%
•MRI scan:
•Sensitivity: 81%
•specificity :100%
•For detecting chronic hemorrhages, MRI scan is more sensitive
47. Case1
A right handed 60 years old man was admitted with
weakness involving the right side of the body. He
woke up from sleep unable to move his right arm or
leg. The family noted that he had right sided facial
drooping. He was also noted to have difficulty
speaking.
No fever, headache, vomiting, seizure or loss of
consciousness. He denied any chest pain or
palpitation.
He have an episode of weakness affecting his right
arm that resolved within a few hours a few months
prior to this episode.
Past HX of DM and HTN for 6 years. Also diagnosed
with IHD previously. On medication
No history of smoking or alcohol consumption.
48. case1
On examination:
Alert oriented and attentive
Vitals: BP(180/100), RR (22), temp(36.8), O2
saturation (98%)
He have:
Expressive aphasia
Right sided UMN seventh cranial nerve palsy
Homonymous hemianopsia
Dense right sided hemiplagia and hemianesthesia.
Irrigulare heart sound. No murmur
Destended urinary bladder
49. Case 1
What is the cause of his symptoms?
What are the risk factors?
What type of stroke he have?
Which are the CNS structures involved?
Which cerebral artery most likely involved?
What investigation you will order?