Hemiplegia Flashcards
What histories are important in hemiplegia?
Headache, seizures, LOC
Speech deficits, sensory loss and weakness of face/limbs
Risk factors for stroke (HTN, smoking, DM)
What classic upper limb posture will be adopted in hemiplegia?
Arm held to the side, elbow flexed and fingers and wrist flexed on to the chest
What classic lower limb posture will be adopted in hemiplegia?
Limb extended at both hip and knee
Foot plantar flexed and inverted
What will be the muscular symptoms in hemiplegia?
Unilateral weakness
Increased tone, hyper-reflexia and upgoing plantar response (UMN deficit)
Which upper limb muscle groups are most affected by hemiplegia?
Shoulder abducters
Elbow extensors
Wrist and finger extensors
Small hand muscles
Which lower limb muscle groups are most affected by hemiplegia?
Hip flexors
Knee flexors
Dorsiflexors and evertors of the foot
What are some special things that you should look for on examination in hemiplegia?
Homonymous hemianopia and sensory inattention
Horners syndrome
Carotid bruits
Speech defects
AF/murmurs
If the patient had horner’s syndrome contralateral to the hemiplegia what does that suggest?
Carotid dissection
What are some geriatric causes of hemiplegia?
Vascular event (thrombosis, embolism, haemorrhage)
Tumour
Subdural haematoma
Syphilis
What are some paediatric causes of hemiplegia?
MS
Sickle cell disease (most common?)
Neoplasm
Trauma
Neurosyphilis
Intrarcanial infection
If you have a patient that has hemiplegia secondary to an intracranial infection, what else should you look for?
Underlying AIDS
Otitis media
Cyanotic heart disease
What is first line therapy for a suspected stroke?
Aspirin as soon as possible
What is a possible complication of aspirin therapy for stroke?
Increased risk of haemorrhagic stroke
For ischaemic stroke, what early changes can you sometimes see on CTB?
Loss of white/grey matter differentiation
What investigations should you perform in a patient with hemiplegia?
CTB/MRI
FBE, BSL, INR/aPTT
ECG, pO2
What are some adult causes of hemiplegia?
Seizures and postictal deficits
Migraine
Systemic infection
Neoplasm
Why is it important to measure BSL in acute stroke patients?
Hyperglycaemia associated with stress response of the stroke associated with poor prognosis
Hyperglycaemia worsens ischaemic damage
Hyperglycaemia worsens penumbra salvage
Hyperglycaemia worsens results of re-canalisation and increases chance of intracerebral haemorrhage
T/F BSL monitoring is important in acute stroke management, but intensive serum glucose control is not
T
No difference found in morbidity or mortality with intense glucose control vs normal therapy
Intense control only associated with higher risk of iatrogenic hypoglycaemia
Is it important to assess if the person can swallow correctly?
Yes
Dysphagia is a common complication but important for preventing aspiration pneumonia
Should tPA (alteplase) be given in the setting of acute ischaemic stroke, and if so, how much?
It should, and within 3 hours (but asap after CT/MRI)
0.9mg/kg, 10% of which should be given as a bolus and 90% of which should be infused over 1/24
Maximum dose of 90mg, thus maximum bolus of 9mg
How should a TIA patient be managed?
Aspirin
Advise re risk factors
Ultrasound/digital subtraction angiography of carotid arteries
MRI
Why Is it important to differentiate a carotid TIA from a vertebrobasilar TIA?
Carotid TIA more amenable to surgery
TIA in anterior circulation is usually more serious prognostically than one in posterior circulation
What features are classically present in an carotid TIA?
hemiparesis
Aphasia
Amaurosis fugax
What features are classically present in a vertebrobasilar TIA?
Two of vertigo, dysphagia, ataxia and drop attacks
Bilateral or alternating weakness or sensory symptoms
Sudden bilateral blindness in patients aged >40
When is carotid endarterectomy indicated in the case of TIAs?
When carotid stenosis is close to 99% (not 100%, and not much below 80%)
Carotid angioplasty (stenting) vs endarterectomy for carotid TIAs?
Possibly better results with angioplasty
What is RIND?
Reversible ischaemic neurological disease
Like a TIA, but resolves within 1/52 rather than 1/7
What is the major risk factor for the development of lacunar infarcts?
HTN
Where can lacunar infarcts occur in the brain?
Internal capsule
Pons
Basal ganglia
Thalamus
What deficit would a lacunar infarct in the internal capsule produce on examination?
Partial hemiparesis or hemisensory impairment
What deficit would a lacunar infarct in the pons produce on examination?
Ataxia of cerebellar type
Partial hemiparesis
What is the pathogenesis of lacunar infarcts?
Hyaline arteriolosclerosis causing occlusion of small arteries in the brain
Or
Rupture of Charcot-Bouchard microaneurysms that produce a haematoma, which resolves leaving an area of infarct
