Severe Hemiplegia Research Articles

Pituitary Apoplexy Producing Internal Carotid Artery Compression: A Case Report

We report a case of pituitary apoplexy resulting in right internal carotid artery occlusion accompanied by hemiplegia and lethargy. A 43-yr-old man presented with a sudden onset of severe headache, visual disturbance and left hemiplegia. Investigations revealed a nodular mass, located in the sella and suprasellar portion and accompanied by compression of the optic chiasm. The mass compressed the bilateral cavernous sinuses, resulting in the obliteration of the cavernous portion of the right internal carotid artery. A border zone infarct in the right fronto-parietal region was found. Transsphenoidal tumor decompression following conservative therapy with fluid replacement and steroids was performed. Pathological examination revealed an almost completely infarcted pituitary adenoma. The patient's vision improved immediately after the decompression, and the motor weakness improved to grade IV+ within six months after the operation. Pituitary apoplexy resulting in internal carotid artery occlusion is rare. However, clinicians should be aware of the possibility and the appropriate management of such an occurrence.

Presentation of Hemiplegic Migraine—Hemiplegia and Hemi-Sensory Loss following General Anaesthesia

We report a case of a 15-year-old male who developed severe left-sided hemiplegia and hemi-sensory loss 20 minutes after arrival in post anaesthetic care unit following an uneventful general anaesthesia for removal of a cannulated screw of left hip. Initial CT and MRI/MRA with diffusion-weighted imaging were unremarkable. The patient was transferred to The Royal Children's Hospital Melbourne and was commenced on heparin infusion pending investigation results. Complete recovery occurred within 36 hours. Eventually, hemiplegic migraine was diagnosed on the basis of negative investigations and a retrospective history of the patient's migraine. This case demonstrates that the management of peri-operative neurological deficits must be approached in a systematic fashion. Hemiplegic migraine is a well-defined clinical syndrome. It is not merely a diagnosis of exclusion.

Kongenitale Hemiplegie

Congenital hemiplegia, defined as unilateral motor disability, is the hemiplegic type of cerebral palsy. The prevalence of congenital hemiplegia is estimated to be about 0.41-0.79/1000 live births. We examined 223 children (122 boys and 101 girls) suffering from congenital hemiplegia at the age of 3 months to 12 years. Mild hemiplegia was found in 31%, a moderate form in 48%, and a severe form in 21%. The upper limb was affected in more than half of the patients, only the lower extremity in one third, and both upper and lower limbs in 20%. Electroencephalographic abnormalities were found in 75.8% of the patients. The most frequent type of epilepsy was complex partial seizures (33%). Severity of the motor handicap, grade of EEG abnormalities, and the prevalence of epilepsy showed a significant correlation. The magnitude of the lesions in neuroimaging directly correlated with these three clinical variables, particularly in children with cortical and subcortical defects (84.2%). Strabismus was the most common visual impairment (17%), while hearing impairment was found in 8% of the patients. Of them, 38.3% showed no cognitive deficits, while those with severe congenital hemiplegia were found to have a lower intelligence quotient.

Oxygen Consumption During Machine-Assisted and Unassisted Walking: A Pilot Study in Hemiplegic and Healthy Humans

David D, Regnaux J-P, Lejaille M, Louis A, Bussel B, Lofaso F. Oxygen consumption during machine-assisted and unassisted walking: a pilot study in hemiplegic and healthy humans. Objective To determine whether a gait-training (GT) machine influenced walking time duration and oxygen consumption in hemiplegic patients. Design Repeated measures with comparison of 2 groups. Setting Physiology laboratories in a rehabilitation hospital. Participants Seven patients with stroke-related hemiplegia (2 men, 5 women; age, 46±11y; time since stroke, 12±9wk) and 7 healthy subjects (3 men, 4 women; age, 30±7y). Interventions Floor walking (FW) and GT-assisted walking with and without 50% body-weight support (BWS). Main Outcome Measures Walking time duration, oxygen consumption (V̇ o 2), minute ventilation (V̇ e), and heart rate. Results When the condition effect was analyzed independently from the group, mean V̇ o 2 was higher during FW than during the GT tests (post hoc analysis: FW vs GT, P=.017; FW vs GT+BWS, P<.002). When the groups were compared independently of the condition, the group with hemiplegia had a significantly shorter walking time duration (analysis of variance [ANOVA], P<.001) and a significantly higher V̇ o 2 as a percentage of baseline (ANOVA, P=.03), compared with the controls. Walking time duration was influenced by walking condition (ANOVA, P<.001; post hoc analysis: FW vs GT, P<.001; FW vs GT+BWS, P<.001). V̇ e was influenced by walking condition (ANOVA, P=.043; not significant in the post hoc analysis) and was higher in the group with hemiplegia (ANOVA, P=.02). Heart rate was not influenced by walking condition ( P=.11). A group effect was found with heart rate in cycles per minute ( P=.035) but not as a percentage of baseline. No interaction was found between the ANOVA group-effect factor and the ANOVA walking-condition effect factor. Conclusions Compared with FW, GT assistance increased walking time duration and reduced V̇ o 2 in patients with severe hemiplegia.

Does motor lateralization have implications for stroke rehabilitation?

Recent findings on motor lateralization have revealed consistent differences in the control strategies of the dominant and nondominant hemisphere/limb systems that could have implications for hemiplegic stroke patients. Studies in stroke patients have demonstrated deficiencies in the ipsilesional arm that reflect these distinctions; patients with right-hemisphere damage tend to show deficits in positional accuracy, and patients with left-hemisphere damage show deficits in trajectory control. Such deficits have been shown to impede functional performance; yet patients with severe dominant-side hemiplegia must often use the nondominant arm as the primary manipulator for activities of daily living. Nevertheless, the nondominant arm may not spontaneously become efficient as a dominant manipulator, as indicated by the persistence of deficits in chronic stroke patients. More research is necessary to determine whether motor therapy can facilitate a more effective transition of this arm from a nondominant to a dominant controller.

Middle Cerebral Arterial Thrombosis in a Patient with Hypofibrinogenemia, 5 Days After rFVIIa and FFP Infusion

A 13-year-old female patient is presented who had hypofibrinogenemia diagnosed as von Willebrand disease at 5 years of age at another hospital. She was admitted to the department of pediatric hematology with a severe headache, vomiting, and progressive right flaccid hemiplegia and lethargy. Contrast-enhanced computed tomography scan showed subdural hematoma in posterior parietal region of the brain and impending cerebellar herniation. She was given fresh-frozen plasma (FFP) and then activated factor VII (rFVIIa), 80 microg/kg was infused for replacement of von Willebrand factor. The subdural hematoma was emergently drained. The results of coagulation tests before infusion of FFP and rFVIIa revealed hypofibrinogenemia, and FFP was given every 48 hours. The patient recovered dramatically in a few days. Five days after rFVIIa infusion, a magnetic resonance angiography-proven right middle cerebral arterial thrombosis developed. It is an interesting point of discussion whether the middle cerebral arterial thrombosis was provoked as a consequence of rFVIIa and FFP infusion.

Late development of A false aneurysm of the common carotid artery

Abstract A case is presented of false aneurysm formationo f the common carotid artery occurring in a young soldier 8 months after his original injury, and immediately preceded by a severe hemiplegia. The relative frequency of such aneurysms is given, and also an account of the frequency of neurological complications from carotid arterial injuries. A possible explanation is given of the timing of events in this particular case, and the problem of follow-up is discussed.

Postural visual dependence after recent stroke: Assessment by optokinetic stimulation

This study was conducted to assess visual dependence of postural control early after stroke. Case control study. A Physical Medicine and Rehabilitation Department. Twenty-five patients impaired by severe hemiplegia due to a recent first stroke, were examined. Fourteen had a right and 11 a left hemispheric lesion. There were aged 52+/-13 years, time since stroke was 30+/-12 days. Patients' data were compared to data for 25 healthy subjects. Sitting posture was assessed on a dynamic balance, using two parameters: frontal plane displacement of the centre of pressure under optokinetic stimulation (OKS), and the total length of centre of pressure displacement for the stability reaction. On the basis of 90th percentile control data, patients' behaviour was classified as totally visuo independent (VI), totally visuo dependent (VD) or mixed. Body tilt under OKS was greater in patients than controls. No control subject was totally VD, 19 subjects were totally VI. Four patients were totally VD and only six were VI. The only clinical parameter linked to the effect of OKS was the sensitivity impairment. Overall patients with visuospatial neglect were the most perturbed, but two were totally visuo independent. Assessment of postural variations in sitting under OKS is proposed for estimating visual dependence early after stroke. Individual reactions are more important than mean group reactions. Visual dependence is not solely due to neurological impairment, implying that previous physiological behaviour may be involved. Knowledge of these characteristics may affect rehabilitation programmes.

Poster 37: Functional and Neuromuscular Recovery After a Cerebrovascular Accident From a Seatbelt Injury

Setting: Freestanding rehabilitation hospital. Patient: A 43-year-old woman who suffered a stroke as a result of a seatbelt injury. Case Description: The patient was involved in a motor vehicle collision in which she was a restrained front-seat passenger. On physical exam, she had severe left hemiplegia with loss of sensation and right-sided preferential gaze. Workup revealed a right middle cerebral artery infarct. Apparently, the patient had suffered an occlusion of the right carotid artery from the seatbelt, as a diagonal abrasion was found across the neck.

MRI characteristics of suspected acute spinal cord infarction in two cats, and a review of the literature

A 10-year-old neutered male Persian cat and a 4-year-old spayed female domestic shorthair (DSH) cat were evaluated for acute-onset severe lateralising tetraparesis and hemiplegia, respectively. Both cats also had left-sided Horner's syndrome. Neurological examination of the cats localised the lesion to cranial to C5 in the Persian and the left cervical intumescence (C6-T2) in the DSH. Physical examinations were otherwise generally unremarkable. Routine laboratory tests and spinal radiography were normal for the Persian cat and were not performed for the DSH cat. A cerebrospinal fluid (CSF) tap was attempted for the Persian cat but aborted because of gross blood contamination, and was not performed for the DSH cat. Magnetic resonance imaging (MRI) of the Persian cat revealed a lesion within the spinal parenchyma at segments C1 to C3 (slightly more left-sided) which was iso- to hypointense on T1-weighted scans and hyperintense on T2-weighted scans, and which enhanced slightly with gadolinium. MRI of the DSH cat revealed a lesion within the spinal parenchyma at segment C7 (predominantly left-sided) which was hypointense on T1-weighted scans and hyperintense on T2-weighted gradient echo scans. Contrast was not administered. The MRI findings in both cases were highly suggestive of acute spinal cord infarction, based upon comparison to human cases. Both cats made full neurological recoveries with supportive treatment only. This paper describes two cases of suspected acute spinal cord infarction in the cat, demonstrates the potential diagnostic value of MRI, and discusses the clinical syndrome of this condition with a brief review of published cases.

脳卒中患者における下肢静脈血栓症の予防―超音波検査法による予防効果の評価―

Although elastic stockings are used to reduce the risk of deep vein thrombosis (DVT) after stroke, their efficacy has not been evaluated. We evaluated the effect of elastic stockings in preventing DVT after stroke using ultrasonography. Methods: Among 101 patients with severe hemiplegia after stroke who were enrolled, 30 were given no prophylaxis (controls) and 71 were prescribed elastic stockings. We evaluated DVT in the paralytic lower extremities using ultrasonography for more than seven days after stroke onset. Ultrasonographically, DVT was visualized as an intraluminal thrombus, lack of venous compressibility and lack of signal on colour flow images. Results: In the control group, 9 patients (30%) had DVT and 6 (20%) had moyamoya echo an average of 19. 1days after onset. In the prophylaxis group, 4 patients (5.6%) had DVT and 16 (22.5%) had moyamoya echo an average of 14.4 days after onset. There was a significant reduction in the incidence of DVT in the patients who used elastic stockings (odds ratio 0.139,95% CI 0.039-0.499). Conclusion: Elastic stockings are useful for preventing DVT in patients after stroke.

Median SSEP changes in hemiplegic stroke: Long-term predictive values regarding ADL recovery

To assess the predictive value of median somatosensory evoked potentials (SSEP) in the acute phase of brain infarction or hemorrhage regarding long-term prognosis. Ninety-four stroke patients mean age 61.2, SD 11.8) were included. CT confirmed diagnoses were: cortical middle cerebral artery (MCA) infarction in 35; subcortical MCA 11; mixed 25. By size, infarctions were: massive, 29; restricted, 33; and lacunar, 9. The number of patients with thalamic hemorrhage was 8; putamenal hemorrhage, 7; other, 8. All patients presented with severe hemiparesis (54) or hemiplegia (40) with hemihipoesthesia in 89 patients. Median SSEP were recorded early (up to 7th day, mean 5.2 days, SD 0.72). SSEP parameters (presence/absence of SSEP, absolute and relative latency, amplitude of early waveforms) were compared to motor (Medical Research Council scale) and functional ability (Barthel index) at 3 and 12 months after stroke. Absolute N20 amplitudes and amplitude ratio evidenced almost similar predictive values that reached 66.4% at 12 months. Combined application of N20 and MRC gains provided significantly stronger prognostic information which reached 72%. Median SSEP parameters may serve as independent predictors of outcome. Most informative in prognosis in the early stage of stroke was the combined assessment of MRC and N20-P25 amplitude ratio.

Application of Constraint-Induced Movement Therapy for an Individual With Severe Chronic Upper-Extremity Hemiplegia

Constraint-induced movement therapy (CIMT) has been documented to improve motor function in the upper extremity of people with mild hemiparesis. The use of CIMT has not been documented for people with severe hemiparesis. This case report describes a CIMT program for an individual with severe upper-extremity deficits as a result of stroke. The client was a 53-year-old woman who had a stroke 15 years previously and had no isolated movement in her right upper extremity. The client completed a 3-week CIMT program during which she restrained her left upper extremity and participated in intensive training of her right upper extremity. Task practice and shaping were the primary techniques used for training. Increased scores were noted from pretreatment to posttreatment on the Motor Activity Log, Graded Wolf Motor Function Test (GWMFT), and Fugl-Meyer Evaluation of Physical Performance. Further progress on the GWMFT was noted at the 6-month follow-up. Fugl-Meyer test scores remained higher than at pretreatment, but Motor Activity Log scores returned to near baseline by the 6-month follow-up. The speed of performance on the GWFMT did not change. Although some scores increased, the client reported and demonstrated no progress in functional use of the involved upper extremity at the end of the program. This case report describes the use of CIMT with an individual who had severe chronic motor deficits as a result of stroke. Further investigation of CIMT, as well as investigation of CIMT in combination with other motor recovery interventions, is warranted.

Epilepsy in children with congenital hemiplegia: correlation between clinical, EEG and neuroimaging findings

ABSTRACT Objectives the aim of this retrospective, multicentre study was to investigate the relationship between epilepsy, clinical, electroencephalographic (EEG) and neuroimaging findings in children with congenital hemiplegia (CH). Patients and methods two hundred and three children with CH were assessed by history, neurological and developmental examination. Electroencephalogram (EEG) and CT/MRI brain imaging were performed in 150 of them (81/150 had an MRI and 69/150 had a CT scan). Patients were re‐evaluated every six months for, at least, a two‐year follow‐up period (range 2‐14 yrs). Results the EEG was abnormal in 76% of patients; epileptic seizures developed in 38.9% of them. The frequency of epilepsy paralleled the degree of EEG abnormality, approaching 85% in patients with severe EEG abnormalities and was also closely related to the extent of neuroimaging findings (up to 79% in patients with cerebral malformations). The prevalence of epilepsy in 12/62 patients (19.4%) with mild hemiplegia was significantly lower as compared to 67/141 (47.5%) of patients with moderate or severe hemiplegia. 36.7% of the children had their first seizure between the 1st and the 5th year of life, and 26.5% during the first year of life. Conclusions epileptic seizures developed in more than one third of patients with CH, although EEG abnormalities were evident in the majority of them. The prevalence of epilepsy is closely related to the severity of hemiparesis, the extent of neuroimaging findings and the degree of EEG abnormalities. The absence of EEG abnormalities and/or normal (or minor) neuroimaging findings was negatively related to the occurrence of epilepsy.

Masticatory force and function in patients with hemispheric brain infarction and hemiplegia.

Recent functional animal studies have reported that the motor control of masticatory muscle function is bilaterally guided by both hemispheres, which may fundamentally differ from the cortical control of limb muscle function. In this study, we investigated whether unilateral cortical brain infarction induces different impairments in masticatory and upper limb motor performance. Evidence of the importance of both hemispheres in controlling masticatory movements would be greater if the masticatory function were shown to be unimpaired in patients with severe hemiplegia. The masticatory function of 16 patients with severe hemiparesis caused by brain infarction in the region of the middle cerebral artery was studied by means of interview, clinical examination, and bite-force measurements. Finger-thumb grip-force measurements and clinical examination of the upper limbs were also performed for evaluation of the effect of infarction on upper limb motor function. Localization of the infarction was confirmed with computer tomography and magnetic resonance imaging. The Scandinavian Stroke Scale demonstrated that each patient had a major unilateral cortical infarction which had caused a marked handicap with a serious impairment of upper limb function on the contralateral side. The clinical examination revealed no major signs of temporomandibular disorders, and the masticatory muscles, when examined by palpation, contracted symmetrically. None of the patients with unilateral brain infarction showed any differences in bite forces between the healthy and paralyzed sides. These results indicate that, in hemiparetic patients, great differences may exist between the motor performances of the masticatory and upper limb muscles. The present investigation clinically illustrates the importance of both hemispheres in the control of masticatory function and movements.

The influence of non-paretic leg movement on muscle action in the paretic leg of hemiplegic patients.

The aim of this investigation was to study the effect of non-involved-side exercise on the involved (paretic) leg-muscle of patients with stroke. Each of the ten adults studied attempted to perform, while seated, a predetermined sequence of the following actions : (1) a voluntary knee extension on the involved side; (2) a maximal, isometric knee-flexion on the non-involved side; (3) a maximal, isometric knee-flexion on the non-involved side with counter-resistance (in front of the ankle joint) on the involved side. The root-mean-square voltage was measured across the rectus femoris, the medial hamstring, the tibialis anterior, and the medial gastrocnemius muscles (on the involved side) with surface electrodes. The root-mean-square voltages of the involved-side rectus femoris and the tibialis anterior muscles were found to increase substantially during non-involved-side knee flexion relative to that detected for voluntary knee extension on the involved side. The voltage of the rectus femoris muscle increased substantially also when counter-resistance was present. There was no similar substantial increase of muscular activity, in the medial hamstring and medial gastrocnemius, induced by contralateral isometric knee-flexion. This study suggests that, among patients with severe hemiplegia, isometric knee flexion in the non-involved side may be useful for facilitating the paretic rectus femoris and tibialis anterior muscular activities.

Bilateral Dissection of the Internal Carotid Artery at the Base of the Skull due to Blunt Trauma: Incidence and Severity

Between January 1, 1992 and December 31, 1996, a total of 1095 head trauma vicims were admitted in our intensive care unit. If CT scans demonstrated ischemic brain lesions, arteriography to visualize supraaortic vessels was performed. Carotid artery dissection was observed in ten patients (0.91%) and was bilateral in eight patients (0.73%). In the bilateral carotid artery dissection (BCAD) group, there were five women and three men, with a mean age of 35.2 years (range: 17 to 54 years). Injuries resulted from traffic accidents in seven patients and a fall in one patient. Upon admission, six patients presented with alteration of consciousness and three with hemiplegia or hemiparesia, associated with aphasia in two cases. In two other cases, hemiplegia occurred 24 hr and 13 days after the accident. All patients had brain infarction, which was unilateral in five cases and bilateral in three cases. The severity of lesions was graded on the basis of arteriographic findings as follows: Type I, wall involvement without significant stenosis or dilation; Type II, arterial dissection with stenosis >70% (Type IIA) or dilatation >50% (Type IIB) and the normal diameter of the proximal or distal internal carotid artery; and Type III, thrombosis of the internal carotid artery. Lesions were asymmetrical in six patients, including two with Type II and III lesions and four with Type I and II lesions, and symmetrical in two patients, including one with bilateral Type III lesions and one with bilateral Type II lesions. Surgery was performed in two patients with Type II lesions, including one case associated with contralateral carotid thrombosis. The intrapetrous carotid artery was exposed by an ear-nose-throat (ENT) surgeon and repaired by interposition grafting. Follow-up in these two surgical cases was 28 and 31 months. In the remaining six cases, medical treatment was performed. Outcome in nonsurgical cases was variable: death in two cases at 31 and 43 days after the accident, severe permanent hemiplegia in two cases, and minimal or no sequels in two cases. Following blunt trauma, arteriography of supraaortic vessels should be performed to detect BCAD in any patient with immediate or delayed neurologic symptoms that cannot be explained by CT-scan findings. To better understand the natural course of these lesions and define the indications for surgery, we propose a three-grade classification according to arteriographic findings. If surgery is undertaken, vein grafting should be performed following resection of the carotid artery lesions.

急性期脳虚血病巣の拡大と脳循環代謝 Ｄｉｆｆｕｓｉｏｎ ＭＲＩ，ＰＥＴによる検討

Evolution of ischemic lesion volume in echo-planar diffusion weighted MRI (EP-DWI) was investigat-ed in 17 patients with acute ischemic stroke. Comparing to the follow-up MRI studies, lesion volume expansion up to 317 ml was observed in patients whose initial EP-DWI performed within 17 hours after the onset. Misery perfusion was not observed by PET in patients without significant expansion (>10 ml), but in 2 of 5 patients with such an expansion. Significant lesion volume expansion occurred in patients with 1) acute hemispheric symptoms and signs, such as consciousness disturbance, conjugate deviation of eyes, mild to severe hemiplegia, and cortical signs, 2) vascular occlusion of the internal carotid or the middle cerebral arteries, either embolic or thrombotic in nature, and 3) small ischemic lesion volume in the initial EP-DWI study. Patients exhibiting these clinical features at early stage of ischemia should be regarded as a high risk group for the lesion volume expansion and they might have a substantially large volume of potentially salvageable tissue.

Upper Motor Neuron Lesions in Stroke Patients Do Not Induce Anterograde Transneuronal Degeneration in Spinal Anterior Horn Cells

To determine whether upper motor neuron lesions in stroke can cause transneuronal degeneration of lower motor neurons, we assessed spinal anterior horn cells in patients dying with poststroke hemiplegia. Subjects were four stroke patients with severe left hemiplegia and four age-matched control subjects who died of nonneurological disease. After histological processing and staining, cytoarchitectonic assessment was made of all neurons in the ventral horns of the 4th lumbar segment of the spinal cord according to cell diameter and topography. In the four stroke patients, no differences were seen in anterior horn cell populations or diameter and size distribution patterns between affected and unaffected sides or between these patients and the control subjects. The present quantitative analysis provides no evidence of anterograde transneuronal degeneration of lower motor neurons after upper motor neuron damage in stroke patients.

Use of electrical stimulation in brain injured patients: a case report

After failure of other therapeutic measures, electrical stimulation was applied to promote gait rehabi litation in a patient with severe brain injury and complete left hemiplegia. The favourable results reported in the literature were confirmed. Despite the long interval between injury and institution of electrical stimulation, independent ambulation was quickly restored.