Hemiparesis/Hemiplegia
Examination
“This man has a left hemiparesis, please examine him”
 For this, examine the UL and LL
 Locate
o Brainstem
 Weber’s syndrome (III and contralateral hemiplegia)
 Millard-Gubler (VI and VII and contralateral hemiplegia; usually
a/w contralateral loss of proprioception and light touch as the
medial lemniscal damage)
o Subcortical – lacunar; a/w UMN VII
 Pure motor (50%)
 Pure sensory (5%)
 Mixed motor and sensory (35%)
 Ataxic hemiparesis (10%)
 Dysarthria clumsy hand syndrome (rare)
o Cortical signs
 Do abbreviated version
 Gaze preference, sensory and visual neglect, hemianopia and
dysphasia if dominant lobe involved
 Causes or risk factors
o Pulse, Carotid bruit, murmur
o Dyslipidaemia stigmata (xanthelasma, xanthomas, thickened TA)
o DM dermopathy
o Tar stains
o Bruising, telangiectasia
 Function and complications
o Upper limb
o Gait
o Pressure sores, NG, urinary catheter
 Request
o BP
o Urine dipstick
o Fundoscopy for papilledema (to rule out SOL which is a possible
differential)
Presentation
Sir, this patient has got a left hemiparesis as evidenced by
 State the UL and LL findings
 State the level of the lesion and justify as above
 Mentioned the causes as above
 Mention the functional status and complications
Questions
What are your differential diagnoses?
 Vascular
o Ischaemic (80%)
 Intracranial thrombosis
 Extracranial embolism – heart, extracranial arteries, paradoxical
 Lacunar strokes – small vessel disease from DM or hypt as a result
of lipohyalinosis
 Dissection
o Haemorrhagic (Intracerebral, SDH, SAH)
 Space occupying lesion
 Infective – abscess, meningoencephalitis
 Seizures
 Toxic-metabolic – Hypoglycaemia, HypoNa
What are the 4 neuroanatomic stroke syndromes?
 Anterior cerebral artery - affect frontal lobe function, producing altered mental
status, impaired judgment, contralateral lower extremity weakness and
hypoesthesia, and gait apraxia.
 Middle cerebral artery (MCA) - contralateral hemiparesis, contralateral
hypoesthesia, ipsilateral hemianopsia (blindness in one half of the visual field),
and gaze preference toward the side of the lesion. Agnosia is common, and
receptive or expressive aphasia may result if the lesion occurs in the dominant
hemisphere. Since the MCA supplies the upper extremity motor strip, weakness
of the arm and face is usually worse than that of the lower limb.
 Posterior cerebral artery occlusions affect vision and thought, producing
homonymous hemianopsia, cortical blindness, visual agnosia, altered mental
status, and impaired memory.
 Vertebrobasilar artery occlusions are notoriously difficult to detect because they
cause a wide variety of cranial nerve, cerebellar, and brainstem deficits. These
include vertigo, nystagmus, diplopia, visual field deficits, dysphagia, dysarthria,
facial hypoesthesia, syncope, and ataxia. Loss of pain and temperature sensation
occurs on the ipsilateral face and contralateral body. In contrast, anterior strokes
produce findings on one side of the body only.
How would you investigate?
 Confirm the diagnosis
o Imaging – CT or MRI if posterior stroke (Diffusion-weighted imaging)
 For diagnosis and type
 For complications eg hydrocephalus
 Blood Ix
o FBC – polycythemia
o Coagulation profile
o Biochemical – HypoNa
 ECG – AF, MI (60% a/w with AF or MI)
 CXR – Enlarged mediastinum suspicious of a dissection
 2D echo (cardioembolic course)
 Carotid ultrasound scan (significant stenosis - >70%) and transcranial doppler
 Young patient – young stroke work up (10)
o ANA, dsDNA, ESR
o Protein C, S
o Anti Thrombin III
o Factor V leiden or APC resistance
o Anticardiolopin IgM/IgG
o Homocystine
o VDRL
What are the limitations of CT brain?
 Unable to visualise the posterior fossa structures such as the brainstem and the
cerebellum
 Maybe normal up to 6 hours of onset
o After 6 hours – hypodense area
o Early signs on CT (5) – loss of grey-white differentiation, insular
ribbon sign, sulcal asymmetry, hyperdense MCA sign and obscuration
of the LN
 MRI – Diffusion weighted imaging which has a high sensitivity – looked for
hyperintense signal
How would you manage?
 Multidisciplinary approach
 Education and counselling
 PT/OT and ST – speech and swallowing, caregiver training, prevention of bed
sores
 Medications
o Antiplatelets (Aspirin, persantin, Clopidogrel, Ticlid)
o Anticoagulation
 Correct risk factors
o Hypertension
o Hyperlipidaemia
o Diabetes mellitus

Surgical
o Intracranial bleeds
o Hydrocephalus
How would you manage the patient acutely?
 Airway, breathing and circulation
 Control BP if bleed otherwise allow high BP in ischaemic stroke up to 220/120
 Treat fever
 Control of blood sugar
 Determine if bleed or ischemic
 If ischaemic stroke, assess for possibility of reperfusion therapy ie National
Institute of Health Stroke Scale (NIHSS) using alteplase ie recombinant tissue
plasminogen activator; within 3 hours and important to note inclusion and
exclusion criteria.
 Treat complications
o Seizures
o Raised intracranial pressure (Hyperventilation, elevate the head, mannitol)