Hemiparesis (hemiplegia)

Hemiparesis ("central") - paralysis of the muscles of one half of the body as a result of the injury of the corresponding upper motoneurons and their axons, that is, motor neurons in the anterior central gyrus or corticospinal (pyramidal) pathway usually above the level of the cervical thickening of the spinal cord. Hemiparesis, as a rule, has a cerebral, rarely - a spinal origin.

The neurological differential diagnosis, as a rule, begins to be built taking into account the cardinal clinical features facilitating the diagnosis. Among the latter it is useful to pay attention to the course of the disease and, in particular, to the peculiarities of its debut.

The rapid development of hemiparesis is an important clinical sign that allows accelerating diagnostic search.

Suddenly developed or very rapidly progressing hemiparesis:

1. Stroke (the most common cause).
2. Volumetric education in the brain with a pseudo-abscess flow.
3. Craniocerebral injury.
4. Encephalitis.
5. Postictal condition.
6. Migraine with aura (hemiplegic migraine).
7. Diabetic encephalopathy.
8. Multiple sclerosis.
9. Pseudoparesis.

Subacute or slowly developing hemiparesis:

1. Stroke.
2. Brain tumor.
3. Encephalitis.
4. Multiple sclerosis.
5. Atrophic cortical process (Mills syndrome).
6. Hemiparesis of stem or spinal (rarely) origin: trauma, tumor, abscess, epidural hematoma, demyelinating processes, radiation myelopathy, in the picture of the Brown-Sekar syndrome).

[1], [2], [3], [4], [5], [6],

Suddenly developed or very rapidly progressive hemiparesis

Stroke

Meeting a patient with acute hemiplegia, the doctor usually presumes a stroke. There are strokes, of course, not only in elderly patients with arteriopathy, but also in young patients. In these rarer cases, it is necessary to exclude cardiogenic embolism or one of the rare diseases such as fibromuscular dysplasia, rheumatic or syphilitic angiitis, Sneddon's syndrome or other diseases.

But first it is necessary to establish whether the stroke is ischemic or hemorrhagic (arterial hypertension, arteriovenous malformation, aneurysm, angioma), or there is venous thrombosis. It should be remembered that sometimes a hemorrhage into a tumor is possible.

Unfortunately, so far there are no other reliable methods of differentiating the ischemic and hemorrhagic nature of lesions in stroke, except for neuroimaging. All other indirect evidence mentioned in the textbooks is not sufficiently reliable. In addition, a subgroup of ischemic stroke, which seems to be single, can be caused by hemodynamic disturbances due to extracranial arterial stenoses, as well as cardiogenic embolism, or arterio-arterial embolism due to plaque ulceration in extra- or intracerebral vessels, or local thrombosis of a small arterial vessel. These different types of stroke require differentiated treatment.

Volumetric educations in the brain with pseudo-abscess flow

Acute hemiplegia can be the first symptom of a brain tumor, and the cause, as a rule, is a hemorrhage into the tumor or surrounding tissues from rapidly forming internal vessels of the tumor with an inferior arterial wall. The increase in the neurological deficit and the decrease in the level of consciousness, together with the symptoms of generalized hemispheric dysfunction, are quite typical for the "apoplectic glioma." In the diagnosis of a tumor with a pseudo-abscess current, methods of neuroimaging are invaluable.

[7], [8], [9], [10], [11], [12], [13]

Craniocerebral injury (CCI)

TBI is accompanied by external manifestations of trauma and usually the situation that caused the trauma is clear. It is desirable to interview eyewitnesses to clarify the circumstances of the injury, since the latter is possible when the patient falls during an epileptic fit, subarachnoid hemorrhage and falls from other causes.

Encephalitis

According to some publications, in about 10% of cases, the onset of encephalitis resembles stroke. Usually rapid deterioration of the patient's condition with impaired consciousness, grasping reflexes and additional symptoms that can not be attributed to the basin of a large artery or its branches, requires an urgent examination. EEGs often reveal diffuse disorders; neuroimaging methods may not show pathology within the first few days; in the analysis of cerebrospinal fluid there is often a slight pleocytosis and a slight increase in the level of protein at a normal or elevated level of lactate.

Clinical diagnosis of encephalitis is facilitated if there is meningoencephalitis or encephalomyelitis, and the disease manifests itself as a typical combination of general infectious, meningeal, cerebral and focal (including hemiparesis or tetraparesis, cranial nerve damage, speech disorders, atactic or sensitive disorders, epileptic seizures) of neurological symptoms.

In about 50% of cases, the etiology of acute encephalitis remains unclear.

[14], [15], [16], [17]

Postictal condition

Sometimes epileptic seizures remain unnoticed by others, and the patient may be in a coma or in a confused state having hemiplegia (with some types of epileptic seizures). It is useful to pay attention to the bite of the tongue, the presence of involuntary urination, but these symptoms are not always present. It is also useful to interview eyewitnesses, examine the patient's things (for the purpose of searching for antiepileptic drugs), if possible, phone call home or to the district clinic at the patient's place of residence to confirm epilepsy according to the outpatient card. In the EEG, made after an attack, "epileptic" activity is often detected. Partial seizures that leave after transient hemiparesis (Todd's paralysis) can develop without aphasia.

Migraine with aura (hemiplegic migraine)

In young patients, a complicated migraine is an important alternative. This is a variant of migraine, in which transient focal symptoms such as hemiplegia or aphasia appear before a one-sided headache, and, like other migraine symptoms, periodically recur in the anamnesis.

The diagnosis is established relatively easily if there is a family and (or) personal history of recurring headaches. If there is no such anamnesis, the examination will reveal a pathognomonic combination of symptoms that constitute a severe neurological deficit, and focal abnormalities on the EEG in the presence of normal results of neuroimaging.

You can rely on this symptom only if it is known that they are due to hemispheric dysfunction. If there is a basilar migraine (vertebrobasilar pool), the normal results of neuroimaging do not exclude a more serious brain injury, in which violations on the EEG may also be absent or minimal and bilateral. In this case, ultrasound dopplerography of vertebral arteries is most valuable, since severe stenosis or occlusion in the vertebrobasilar system is extremely rare in the presence of normal ultrasound data. In case of doubt, it is better to perform an angiographic study than to miss a curable vascular lesion.

Diabetic metabolic disorders (diabetic encephalopathy)

Diabetes mellitus can be the cause of acute hemiplegia in two cases. Hemiplegia is often observed in non-ketone hyperosmolarity. On the EEG, focal and generalized disturbances are recorded, but the neuroimaging and ultrasound data are normal. Diagnosis is based on laboratory tests that should be widely used in hemiplegia of unknown etiology. Adequate therapy leads to a rapid regression of symptoms. The second possible cause is hypoglycemia, which can lead not only to convulsions and confusion, but sometimes to hemiplegia.

Multiple sclerosis

Multiple sclerosis should be suspected in young patients, especially when there is acute sensory-motor hemiplegia with ataxia, and when consciousness is fully preserved. On the EEG, minor violations are often detected. In neuroimaging, a region of reduced density is found that does not correspond to the vascular pool, and is not, as a rule, a volumetric process. The evoked potentials (especially visual and somatosensory) can significantly help in the diagnosis of multifocal lesion of the central nervous system. CSF data also help diagnosis if IgG parameters are changed, but, unfortunately, cerebrospinal fluid can be normal during the first exacerbation (s). In these cases, an accurate diagnosis is established only after further investigation.

[18], [19], [20], [21], [22],

Pseudoparesis

Psychogenic hemiparesis (pseudoparesis), which develops sharply, usually appears in an emotiogenic situation and is accompanied by affective and autonomic activation, demonstrative behavioral reactions and other functional neurological signs and stigmata that facilitate diagnosis.

Subacute or slow developing hemiparesis

Most often, these disorders are caused by cerebral lesion.

The reasons for this type of weakness are the following:

Strokes

Vascular processes, such as stroke in development. Most often there is a gradual progression. This reason can be suspected based on the patient's age, gradual progression, the presence of risk factors, noise over arteries due to stenosis, previous vascular episodes.

Tumors of the brain and other voluminous processes

Intracranial volumetric processes, such as tumors or abscesses (most often progression for several weeks or months) are usually accompanied by epileptic seizures. In meniomas, there may be a long-term epileptic anamnesis; as a result, the voluminous process leads to an increase in intracranial pressure, headache, and growing mental disorders. Chronic subdural hematoma (mainly traumatic, sometimes confirmed by mild trauma in the anamnesis) is always accompanied by headache, mental disorders; relatively non-violent neurologic symptoms are possible. There are pathological changes in cerebrospinal fluid. Suspicion of the abscess occurs when there is a source of infection, inflammatory changes in the blood, such as acceleration of ESR, rapid progression. Because of a hemorrhage, tumors can suddenly appear in the symptoms, rapidly growing to the hemisyndrome, but not resembling a stroke. This is especially characteristic of metastases.

Encephalitis

In rare cases, acute hemorrhagic herpetic encephalitis can cause a relatively rapidly increasing (subacute) hemisindrom (with severe cerebral disorders, epileptic attacks, changes in cerebrospinal fluid), which soon leads to a coma.

Multiple sclerosis

Hemiparesis can develop within 1-2 days and be very severe. This pattern sometimes develops in young patients and is accompanied by visual symptoms, such as retrobulbar neuritis and episodes of double vision. These symptoms are accompanied by urination disorders; often pallor of the optic disc, pathological changes in visual evoked potentials, nystagmus, pyramidal signs; remittent current. In cerebrospinal fluid, an increase in the number of plasma cells and IgG. Such a rare form of demyelination, like Balo's concentric sclerosis, can cause subacute hemisindrome.

[23], [24], [25], [26], [27]

Atrophic cortical processes

Local one-sided or asymmetric cortical atrophy of the precentral area: impaired motor function can be slowly increasing, sometimes years are needed for the development of hemiparesis (Mills paralysis). The atrophic process is confirmed by computed tomography. The nosological independence of Mills syndrome has been questioned in recent years.

[28], [29], [30], [31], [32]

Processes in the field of the brain stem and spinal cord

The lesions of the brain stem in rare cases are manifested by an increasing hemi-syndrome; processes in the spinal cord, accompanied by hemiparesis, are even less common. The presence of cross-symptom is a proof of this localization. In both cases, the most common cause is volumetric lesions (tumor, aneurysm, spinal spondylosis, epidural hematoma, abscess). In these cases, hemiparesis is possible in the picture of the Brown-Sekar syndrome.

Diagnosis with hemiparesis

A general-purpose examination (general and biochemical), a blood test; hemorheological and hemocoagulation characteristics; Analysis of urine; ECG; with indications - search for hematological, metabolic and other visceral disorders), CT or (better) MRI of the brain and cervical spinal cord; investigation of cerebrospinal fluid; EEG; evoked potentials of different modalities; ultrasound dopplerography of the main arteries of the head.

[33], [34], [35], [36], [37], [38]