37 Hemiplegia
Salient features
History
• Obtain history of headache, seizures and loss of consciousness (more common in subarachnoid haemorrhage or intracerebral bleeds than in cerebral infarction)
• History of speech defects, sensory loss and weakness of face and limbs
• Risk factors: hypertension, smoking, diabetes mellitus
• History of functional status: swallowing, mobility, pressure sores, independence in activities of daily living, visual difficulties (for visual field defects).
Examination
• Unilateral upper motor neuron seventh nerve palsy.
• The arm is held to the side, the elbow is flexed and the fingers and wrist are flexed on to the chest.
• The leg is extended at both the hip and knee, while the foot is plantar flexed and inverted.
• Weakness of the upper and lower limbs on the same side with upper motor neuron signs: increased tone, hyper-reflexia and upgoing plantar response.
• Hemiplegic weakness of the upper limbs affects the shoulder abductor, elbow extensors, wrist and finger extensors, and small hand muscles.
• Hemiplegic weakness of the lower limbs affects hip flexors, knee flexors and dorsiflexors and evertors of the foot.
• Do not forget sensory signs, in particular joint sensation which is important in rehabilitation.
• Tell the examiner that you would like to check the patient’s BP and check the urine for sugar.
Questions
How would you manage such a patient?
• Early hospital admission preferably to a dedicated stroke unit, which has been shown to produce long-term reductions in death, dependency and need for institutional care (BMJ 1997;314:1151–9)
• Aspirin given within 48 h of ischaemic stroke reduces the risk of death and recurrent stroke. The International Stroke Trial (Lancet 1997;349:1569–81) and the Chinese Stroke Trial (Lancet 1997;349:1641–9), each involved 20 000 patients and found that aspirin was associated with about 10 fewer deaths or recurrent strokes, but with slightly more haemorrhagic strokes. The International Stroke Trial reported no benefit from subcutaneous heparin given with or without aspirin
• Echocardiography (looking for source of emboli), CT and carotid digital subtraction angiography (DSA) in selected patients
• Carotid Doppler: prior to endartrectomy, presurgical evaluation of saccular aneurysm
• MRI: diffusion-weighted sequences allow early detection. MRI has a much higher sensitivity than CT for acute ischaemic changes, especially in the posterior fossa and in the first hours after an ischaemic stroke
• Physiotherapy, speech therapy and occupational therapy
• Control of risk factors: hypertension, hyperlipidaemia and diabetes; stop smoking and oral contraceptives.
Advanced-level questions
What are the measures used to determine the outcome after an acute stroke?
Some of the standard measures include:
• Barthel index: reliable and valid measure of the ability to perform activities of daily living such as eating, bathing, walking and using the toilet.
• Modified Rankin Scale: simplified overall assessment of function in which a score of 0 indicates the absence of symptoms and a score of 5 shows severe disability.
• Glasgow Outcome Scale: global assessment of function in which a score of 1 indicates good recovery, a score of 2 moderate disability, a score of 3 severe disability, a score of 4 survival but in a vegetative state, and a score of 5 death.
• NIH Stroke Scale: a serial measure of neurological deficit using a 42-point scale that quantifies neurological deficits in 11 categories. For example, a mild facial paralysis is given a score of 1 and complete right hemiplegia with aphasia, gaze deviation, visual field deficit, dysarthria and sensory loss is given a score of 25. Normal function without neurological deficit is scored as 0.
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