Unilateral Hemiplegia Research Articles

Feasibility of Simultaneous Anodal Transcranial Direct Current Stimulation During Gait Training in Chronic Stroke Patients: A Randomized Double-Blind Pilot Clinical Trial.

Transcranial direct current stimulation (tDCS) is a therapeutic tool for improving post-stroke gait disturbances, with ongoing research focusing on specific protocols for its application. We evaluated the feasibility of a rehabilitation protocol that combines tDCS with conventional gait training. This was a randomized, double-blind, single-center pilot clinical trial. Patients with unilateral hemiplegia due to ischemic stroke were randomly assigned to either the tDCS with gait training group or the sham stimulation group. The anodal tDCS electrode was placed on the tibialis anterior area of the precentral gyrus while gait training proceeded. Interventions were administered 3 times weekly for 4 weeks. Outcome assessments, using the 10-meter walk test, Timed Up and Go test, Berg Balance Scale, Functional Ambulatory Scale, Modified Barthel Index, and European Quality of Life 5 Dimensions 3 Level Version, were conducted before and after the intervention and again at the 8-week mark following its completion. Repeated-measures analysis of variance (ANOVA) was used for comparisons between and within groups. Twenty-six patients were assessed for eligibility, and 20 were enrolled and randomized. No significant differences were observed between the tDCS with gait training group and the sham stimulation group in gait speed after the intervention. However, the tDCS with gait training group showed significant improvement in balance performance in both within-group and between-group comparisons. In the subgroup analysis of patients with elicited motor-evoked potentials, comfortable pace gait speed improved in the tDCS with gait training group. No serious adverse events occurred throughout the study. Simultaneous anodal tDCS during gait training is a feasible rehabilitation protocol for chronic stroke patients with gait disturbances. URL: https://cris.nih.go.kr; Registration number: KCT0007601; Date of registration: 11 July 2022.

Comparative Study of Vestibular Rehabilitation and Dual Task Training on Balance and Quality of Life in Young Stroke Patients

Question: Is there any impact of vestibular rehabilitation and dual task training alongside conventional therapy on balance and quality of life in young stroke patients.  Design: Quasi-experimental study with treatment duration of 8 weeks. Simple random sampling was used to divide patients into 3 groups.  Participants: 30 subjects in the age group 18-45 years both males and females with diagnoses of unilateral hemiplegia within the previous six months.  Intervention: Group A received vestibular rehabilitation along with conventional therapy; Group B received dual task training alongside conventional therapy and Group C received only conventional therapy. Outcome measures: Assessment using Berg Balance Scale and Stroke Specific Quality of Life was conducted pre- and post-treatment.  Results: The results revealed a significant improvement (p<0.05) in balance and quality of life scores in Group A as compared to Groups B and Group C.  Conclusion: Hence, it was concluded that vestibular rehabilitation along with conventional therapy is more effective in enhancing balance among young stroke patients compared to dual task training along with conventional therapy or conventional therapy alone.  Registration: BFUHS/2K23p-TH/11527.

Effectiveness of Modified Constraint Induced Movement Therapy in Improving Functional Activities of Hand in Sub Acute Stroke Subjects

BACKGROUND: In stroke, upper limb hemi paresis is a commonly seen impairment and challenging for activities of daily living that have a significant impact on one's quality of life. The majority of studies used both occupational therapy and physiotherapy to improve hand functions in subjects who had chronic strokes. Stroke patients often under-utilizes their paretic limb despite sufficient residual motor function. We hypothesize that acquired non-use can be overcome by reinforcement-based training strategies. The goal of this study is to analyze the efficacy of modified constraint induced movement therapy (m CIMT), to improve functional activities of hand in sub acute Stroke subjects. AIM: The Objective of this study was to analyze the effectiveness of Modified constraint induced movement therapy in improving hand functions in Sub acute stroke subjects. Methodology: This study was an Experimental study and the type of sampling was convenient sampling. The sample size was 30 subjects with unilateral hemiplegia with duration of more than 3 months and the study was conducted in outpatient PT Department. Results: The results were obtained using FMA and MAL on the basis of Pre and Post treatment data and comparing the Control and experimental groups. The statistical analysis showed significant difference between the experimental group and the control group. This shows that subjects in the experimental group who received Modified Constraint induced movement therapy have shown significant improvement than control Group who received only Conventional Physiotherapy. Conclusion: Modified constraint induced movement therapy can be added in stroke rehabilitation for improvement of activities of daily living and functional independence of stroke patients. Keywords: Hemi paresis, CIMT, m CIMT

An Instrumented Glove-Controlled Portable Hand-Exoskeleton for Bilateral Hand Rehabilitation.

Effective bilateral hand training is desired in rehabilitation programs to restore hand function for people with unilateral hemiplegia, so that they can perform daily activities independently. However, owing to limited human resources, the hand function training available in current clinical settings is significantly less than the adequate amount needed to drive optimal neural reorganization. In this study, we designed a lightweight and portable hand exoskeleton with a hand-sensing glove for bilateral hand training and home-based rehabilitation. The hand-sensing glove measures the hand movement of the less-affected hand using a flex sensor. Thereafter, the affected hand is driven by the hand exoskeleton using the measured hand movements. Compared with the existing hand exoskeletons, our hand exoskeleton improves the flexible mechanism for the back of the hand for better wearing experience and the thumb mechanism to make the pinch gesture possible. We designed a virtual reality game to increase the willingness of repeated movement practice for rehabilitation. Our system not only facilitates bilateral hand training but also assists in activities of daily living. This system could be beneficial for patients with hemiplegia for starting correct and sufficient hand function training in the early stages to optimize their recovery.

Asymmetric atrophy of the multifidus in persons with hemiplegic presentation post-stroke

ABSTRACT Objective: To identify the asymmetry of fatty infiltration and cross-sectional areas (CSAs) of individual paravertebral muscles in persons with hemiplegic presentation post-stroke. Methods: We retrospectively reviewed 26 patients with unilateral hemiplegia who underwent lumbar magnetic resonance imaging post-stroke. CSAs and functional CSAs (FCSAs) of individual paraspinal muscles (multifidus, erector spinae, quadratus lumborum, and psoas major) at the mid-disc level were bilaterally measured from L1-L2 to L5-S1 on T2-weighted lumbar axial images. The FCSA-to-total CSA ratio of each paraspinal muscle was also calculated. These parameters were compared between the more-affected and less-affected sides, and between the less chronic and chronic phases. Results: FCSA (p = .049) and FCSA-to-total CSA ratio (p = .044) were significantly smaller at the L5-S1 multifidus on the more-affected side than on the less-affected side in the chronic phase. Other muscles showed no meaningful changes. The erector spinae on the more-affected side and the multifidus on the less-affected side significantly increased in size in the chronic phase compared with the less chronic phase. Conclusions: Persons with hemiplegic presentation may have unilateral atrophy and fatty infiltration of the multifidus on the more-affected side during the chronic phase. The comparison between the less chronic and chronic phases suggested that the recovery pattern of the trunk muscles could differ between sides in unilateral hemiplegia: increased size of the multifidus, a tonic stabilizer, on the less-affected side and of the erector spinae, a phasic muscle, on the more-affected side. This finding could be applied to trunk rehabilitation strategies for persons post-stroke.

Clinical aspects, neuroimaging, and electroencephalography of 35 cases of hemiconvulsion-hemiplegia syndrome

IntroductionThe hemiconvulsion-hemiplegia-epilepsy (HHE) syndrome is a rare consequence of febrile seizures during childhood. It is characterized by the presence of prolonged unilateral clonic seizures occurring during febrile illness in a child less than 4years of age. Then, a flaccid unilateral hemiplegia with variable duration occurs. ObjectivesThe objective of the study was to describe the clinical, electroencephalogram (EEG), and neuroimaging treatment and outcome of series of cases of HHE syndrome followed for 10years in our clinical neurophysiology department of the specialty hospital of Rabat. Patients and methodsWe report a retrospective study of 35 patients followed up for HHE syndrome from January 2005 to December 2015. All patients included in the study met the definition criteria for HHE syndrome. ResultsThe age of onset ranged from 1 to 10years. Hemiplegia or spastic hemiparesis of the ipsilateral side to the convulsion was present in all patients. Abnormal brain magnetic resonance imaging (MRI) was found in all patients. All patients developed drug-resistant focal epilepsy during the course of the disease. ConclusionsThe management of HHE syndrome constitutes a real public health problem in developing countries like Morocco. The neurological morbidity and the severe sequels are of high impact in these young kids. On the one hand, authors highlight the need for improving emergency care of status epilepticus. On the other hand, in our context, the prophylaxis of febrile seizures seems to be the corner stone of the prevention of HHE Syndrome.

Cutaneous temperature sensitivity alteration in subjects with chronic stroke sequelae - pharmacological perspectives.

Stroke can result in body temperature sensitivity changes. This study analyzed abnormal temperature perception of patients with stroke and the use of vasoactive drugs. A cross-sectional retrospective study was carried out consisting of 100 patients (55.6±12.9 years old), from both genres, with either hemorrhagic or ischemic stroke, with unilateral hemiplegia or hemiparesis. Subjects had axillary temperature and different temperature sensitivities of the limbs measured using a visual analog scale (VAS). Information on the use of medical drugs was collected in clinical records. In total, 64 patients reported body temperature alterations, and 62 patients stated they feel cold in the affected side. They reported 6.12±2.44 cm alteration for the upper limb and 6.72±2.44 cm for the lower limb in the VAS. Some 86 different drugs were identified in the 85 medical records available. There was a prevalence of a group of drugs formed by the β-blockers, dopamine agonists, dopamine reuptake Inhibitors, tricyclic antidepressants (TCAs) and another group formed by the selective serotonin reuptake inhibitors. Most of the subjects reported a sensation of cold in the affected limbs. The β-blockers, dopamine agonists, dopamine reuptake inhibitors, and TCAs seem to be related to this sensation, however, due to the number of uncontrolled variables that may be related to these drugs and the possible role of nitric oxide, it was not possible to establish precise relations regarding the use of a specific group of drugs and the cold sensation in the affected limbs, as reported by the patients.

Ultrasonographic measurements of the metacarpal and talar cartilage thicknesses in hemiplegic patients after stroke

Background: Immobilization of the extremities after stroke is known to be the foremost reason of articular cartilage degeneration and musculoskeletal ultrasound (US) has become increasingly important in the assessment of joint cartilage. To the best of our knowledge, US measurements of the metacarpal and talar cartilage thicknesses in hemiplegic patients after stroke have not been performed before.Objectives: The aim of the study was to explore whether metacarpal and talar cartilage thicknesses were affected after stroke using US.Methods: Fifty-eight patients (33 M and 25 F) with unilateral hemiplegia after stroke were enrolled between April and June 2015. Age, sex, body mass index, paretic side, and underlying etiology (ischemic or hemorrhagic) were noted. Modified Ashworth scale, Brunnstrom motor recovery stage (BMRS), motor functional independence measure and functional ambulation category were recorded. A 5–12 MHz linear array probe was used for ultrasonographic cartilage measurements at 2nd, 3rd, and 4th metacarpal heads and talus.Results: When compared with the non-paretic side, metacarpal (but not talar) cartilage thicknesses were found to be less on the paretic side (significant for the 3rd and 4th ones) (both p < 0.05). Subgroup analysis yielded thinner 3rd and 4th metacarpal cartilage thicknesses between the groups in patients with BMRS 1–3 (p = 0.009 and 0.054, respectively) but not in patients with BMRS 4–6 (p = 0.416 and 0.571, respectively).Conclusions: We may conclude that metacarpal (but not talar) cartilage is thinner on the paretic side of stroke patients that seems to be less with better motor functioning.

Who May Benefit From Armeo Power Treatment? A Neurophysiological Approach to Predict Neurorehabilitation Outcomes

BackgroundThe Armeo Power, a rehabilitation exoskeleton that allows early treatment of motor disabilities, provides intelligent arm support in a large 3-dimensional work space, thus enabling patients to perform intensive, repetitive, and goal-oriented exercises. This device could efficiently induce new connections and facilitate plasticity phenomena potentiation. Knowledge of the potential brain plasticity reservoir after brain damage constitutes a prerequisite for an optimal rehabilitation strategy. ObjectiveTo identify potential neurophysiologic markers predicting the responsiveness of stroke patients to upper limb robotic treatment. DesignProspective cohort study. SettingBehavioral and Robotic Neurorehabilitation Laboratory of IRCCS Centro Neurolesi Bonino-Pulejo, Messina, Italy. PatientsWe enrolled 35 patients who had sustained a first-ever ischemic supratentorial stroke at least 2 months before enrollment and had unilateral hemiplegia. MethodsAll patients underwent 40 Armeo Power training sessions that lasted 1 hour each (ie, 5 times a week for 8 weeks). Main Outcome MeasurementsWe assessed the spasticity and motor function of the upper limb by means of the Modified Ashworth scale and Fugl-Meyer assessment, respectively. Moreover, we evaluated the cortical excitability and plasticity potential of the bilateral primary motor areas in response to the repetitive paired associative stimulation paradigm using transcranial magnetic stimulation and Armeo Power kinematic parameters. ResultsThe patients who showed significant repetitive paired associative stimulation aftereffects at baseline exhibited an evident increase of cortical plasticity in the affected hemisphere (motor evoked potential amplitude increase, P = .03), a decrease of interhemispheric inhibition (affected hemisphere cortical silent period duration decrease, P = .01; unaffected hemisphere cortical silent period duration increase, P = .004; repetitive paired associative stimulation aftereffect increase, P = .008). Such findings were paralleled by clinical improvements (Fugl-Meyer, P = .04) and Armeo Power kinematic improvements (elbow flexion/extension, P = .02; shoulder range of movement, P = .002). ConclusionsOur data suggest that use of Armeo Power may improve upper limb motor function recovery as predicted by reshaping of cortical and transcallosal plasticity, according to the baseline cortical excitability. Level of EvidenceIV

The Effect of Body Weight Support Treadmill Training on Gait Recovery, Proximal Lower Limb Motor Pattern, and Balance in Patients with Subacute Stroke.

Objective. Gait performance is an indicator of mobility impairment after stroke. This study evaluated changes in balance, lower extremity motor function, and spatiotemporal gait parameters after receiving body weight supported treadmill training (BWSTT) and conventional overground walking training (CT) in patients with subacute stroke using 3D motion analysis. Setting. Inpatient department of rehabilitation medicine at a university-affiliated hospital. Participants. 24 subjects with unilateral hemiplegia in the subacute stage were randomized to the BWSTT (n = 12) and CT (n = 12) groups. Parameters were compared between the two groups. Data from twelve age matched healthy subjects were recorded as reference. Interventions. Patients received gait training with BWSTT or CT for an average of 30 minutes/day, 5 days/week, for 3 weeks. Main Outcome Measures. Balance was measured by the Brunel balance assessment. Lower extremity motor function was evaluated by the Fugl-Meyer assessment scale. Kinematic data were collected and analyzed using a gait capture system before and after the interventions. Results. Both groups improved on balance and lower extremity motor function measures (P < 0.05), with no significant difference between the two groups after intervention. However, kinematic data were significantly improved (P < 0.05) after BWSTT but not after CT. Maximum hip extension and flexion angles were significantly improved (P < 0.05) for the BWSTT group during the stance and swing phases compared to baseline. Conclusion. In subacute patients with stroke, BWSTT can lead to improved gait quality when compared with conventional gait training. Both methods can improve balance and motor function.

Effects of repetitive transcranial magnetic stimulation of the unaffected hemisphere leg motor area in patients with subacute stroke and substantial leg impairment: A pilot study.

To evaluate the effects of repetitive transcranial magnetic stimulation (rTMS) on mobility among patients with substantial leg impairment after subacute stroke. Double-blinded, stratified, randomized trial involving a sham control group. Patients who developed unilateral hemiplegia after first-ever subacute stroke and underwent inpatient stroke rehabilitation. The 15-day intervention programme used in the present study included the application of rTMS (1 Hz, 15 min) over the leg motor area of the unaffected hemisphere, followed by 45 min physical therapy. Overall, 32 participants were randomly assigned to receive either real rTMS or sham stimulation. Clinical assessments, including the Postural Assessment Scale for Stroke Patients (PASS), balance subscale of the Performance Oriented Mobility Assessment (POMA-b), Fugl-Meyer Assessment, Barthel Index (BI), and Timed Up and Go test, were performed immediately before and after the intervention. Both groups demonstrated significant improvements in all the test results over time. At the post-test assessment, the patients in the real rTMS group demonstrated greater improvements in the PASS, POMA, and BI scores than did the patients in the sham rTMS group. In addition, a significantly higher number of patients in the real rTMS group regained mobility at the post-test assessment compared with the corresponding number of patients in the sham rTMS group. Application of 1-Hz rTMS may improve mobility among patients with substantial leg impairment after subacute stroke.

Can Motor Evoked Potentials Be an Objective Parameter to Assess Extremity Function at the Acute or Subacute Stroke Stage?

ObjectiveTo investigate whether motor evoked potential (MEP) amplitude ratio measurements are sufficiently objective to assess functional activities of the extremities. We also delineated the distribution between the presence or absence of MEPs and the Medical Research Council (MRC) scale for muscle strength of the extremities.MethodsWe enrolled 183 patients with first-ever unilateral hemiplegia after stroke. The MEP parameters were amplitude ratio (amplitude of affected side/amplitude of unaffected side) recorded at the first dorsal interosseous (FDI) and tibialis anterior (TA) muscles. We performed frequency analyses using the MRC scale for muscle strength and the presence or absence of evoked MEPs. Change on the MRC scale, hand function tests (HFTs), and the Modified Barthel Index (MBI) subscore were compared between the evoked MEP and absent MEP groups using the independent t-test. Receiver operating characteristic curves were used to determine the optimal cutoff scores for the MEP amplitude ratio using the HFT results and MBI subscores. Correlations between the MEP amplitude ratio and the MRC scale, HFTs, and MBI subscore were analyzed.ResultsAbout 10% of patients with MRC scale grades 0-2 showed evoked MEPs at the FDI muscle, and 4% of patients with MRC scale grades 3-5 did not show MEPs. About 18% of patients with MRC scale grades 0-2 showed evoked MEPs at the TA muscle, and 4% of patients with MRC scale grades 3-5 did not show MEPs. MEP amplitude increased with increasing MRC scale grade. The evoked MEP group had more significant changes on the MRC scale, HFT, and the climbing stair score on the MBI than those in the group without MEPs. Larger MEP amplitude ratios were observed in patients who had more difficulty with the HFTs and ambulation. The MEP amplitude ratio was significantly correlated with the MRC scale, HFT, and MBI subscore.ConclusionWe conclude that the MEP amplitude ratio may be useful to predict functional status of the extremities in patients who suffered stroke.

Corticospinal Integrity and Motor Impairment Predict Outcomes After Excitatory Repetitive Transcranial Magnetic Stimulation: A Preliminary Study

ObjectiveTo identify the effective predictors for therapeutic outcomes based on intermittent theta-burst stimulation (iTBS). DesignA sham-controlled, double-blind parallel study design. SettingA tertiary hospital. ParticipantsPeople with stroke (N=72) who presented with unilateral hemiplegia. InterventionsTen consecutive sessions of real or sham iTBS were implemented with the aim of enhancing hand function. Patients were categorized into 4 groups according to the presence (MEP+) or absence (MEP−) of motor-evoked potentials (MEPs) and grip strength according to the Medical Research Council (MRC) scale. Main Outcome MeasuresCortical excitability, Wolf Motor Function Test (WMFT), finger-tapping task (FT), and simple reaction time were performed before and after the sessions. ResultsMEPs and the MRC scale were predictive of iTBS therapeutic outcomes. Group A (MEP+, MRC>1) exhibited the greatest WMFT change (7.6±2.3, P<.001), followed by group B (MEP−, MRC>1; 5.2±2.2 score change) and group C (MEP−, MRC=0; 2.3±1.5 score change). These improvements were correlated significantly with baseline motor function and ipsilesional maximum MEP amplitude. ConclusionsThe effectiveness of iTBS modulation for poststroke motor enhancement depends on baseline hand grip strength and the presence of MEPs. Our findings indicate that establishing neurostimulation strategies based on the proposed electrophysiological and clinical criteria can allow iTBS to be executed with substantial precision. Effective neuromodulatory strategies can be formulated by using electrophysiological features and clinical presentation information as guidelines.

Unilateral hemiplegia: a unique complication of septoplasty

Septoplasty is one of the most common otolaryngological operations. It is often dismissed as a simple procedure, despite the wide range of potential complications. We describe the first reported case of unilateral hemiplegia as a complication of septoplasty. A 51-year-old man presented with right hemiplegia following a septoplasty and turbinoplasty procedure carried out elsewhere. Cranial imaging showed a breakthrough fracture of the left sphenoid sinus anterior wall and clivus, with a haemorrhagic area in the left paramedian pons, which was responsible for the patient's right hemiplegia. Despite neurological and physiotherapeutic rehabilitation, the patient gained only partial recovery from his right hemiplegia. Good intra-operative visualisation and appropriate surgical technique are essential to prevent complications and achieve a functional nasal airway. The importance of the presented case to the pre-operative informed consent process is underlined.

Analysis of F response in upper motoneurone lesions

The F response can provide a measure of motoneurone excitability (MNE) and so it may be used to investigate upper motoneurone disorders. This report studies the F-wave configuration in patients with stroke to evaluate the changes of the central excitability of the motoneurones at different times after an acute cerebral insult. Various parameters of the F response, including amplitude (absolute and F%/M), duration, and persistence have been determined in 26 patients with unilateral hemiplegia and in 32 healthy subjects of both sexes in the same age range. The investigation was carried out applying a series of 20 supramaximal stimuli at 0.5 Hz on tibial and ulnar nerves bilaterally. In all patients a detailed clinical examination and a CT scan were performed. Our results indicate that an initial stage of reduced spinal motoneuron excitability evidenced by a decreased F amplitude and persistence was present in the early phases after a stroke, followed within 90 days by an enhanced MNE. Moreover, F-wave amplitude shows a positive correlation with weakness and increased tone.

Hemispherectomy for intractable epilepsy in adults: The first reported series

Hemispherectomy for intractable unihemispheric epilepsy (IUE) has long been established in pediatric patients. This study reports the first series examining hemispherectomy exclusively in adult patients (>18 years old). Nine adults with IUE underwent hemispherectomy at the University of Minnesota. All patients had unilateral hemiplegia and visual field loss. Seven patients (77.8%) were Engel class I/II at last follow-up. Five (83.3%) of the six patients with >30 years of follow-up were seizure free. No surgery-related mortality, hydrocephalus, or superficial cerebral hemosiderosis occurred. Hemispherectomy is an effective procedure in appropriately selected adult patients, resulting in excellent long-term seizure control and no mortality.

Cerebral and Systemic Embolization During Left Ventricular Support With the Novacor N100 Device

Background. Patients undergoing implantation of left ventricular assist systems (LVAS) are prone to thromboembolic complications. We analyzed the incidence, clinical findings, and outcome of neurologic and systemic thromboembolic events (TE) in patients with the Novacor N100 LVAS. In a subset of patients, transcranial Doppler sonography was used to detect microembolic signals. Methods. Thirty-six patients underwent implantation of a Novacor N100 LVAS for various reasons. The surgical procedure was elective in 18 patients and scheduled on an urgent or emergency basis in another 18 patients. The assist period lasted from 17 to 336 days (109 ± 88 days); 22 patients were forwarded to heart transplantation after being supported for 140 ± 87 days. Results. Clinical cerebral embolism was evident in 17 patients (47%). Thromboembolic events were singular in 8 and multiple in 9 patients; in the latter up to 10 TE occurred (mean ± SD, 1.4 ± 2 TE). Leading neurologic symptoms were unilateral hemiplegia in 11, as well as ocular symptoms and aphasia in 12 patients each. Noncerebral TE were detected in 4 patients, 2 of whom underwent an emergency operation for intestinal and iliac artery occlusion. The incidence of TE did not correlate strongly with the interval of LVAS support. Cerebral computed tomography confirmed lesions in 58% of patients. Transcranial Doppler sonography detected microembolic signals on 67% of all recordings, with the microembolic signals being more frequent on days with clinically manifest TE. The outcomes were good, as only 2 patients suffer from neurologic sequelae. Conclusions. Thromboembolism is still a major threat for patients with LVAS implantation. Neurologic sequelae are frequent but have a favorable prognosis, and systemic complications occur considerably less often. Patient selection, adequate anticoagulation, and transcranial Doppler sonography may help to reduce the incidence of TE.

Spinal epidural hematoma progressing to brown-sequard syndrome: Report of a case

A 51-yr-old woman was transferred to the emergency department with nonspecific interscapular pain and a progressive right-sided hemiparesis. Physical examination and laboratory examination revealed moderate right-sided hemiparesis, with no other fecal neurologic deficits. A computed axial tomography scan of the brain was negative. Emergency arteriography revealed bilateral highgrade fibromuscular dysplasia involving the origins of the left and right common carotid arteries. The patient was admitted with the presumptive diagnosis of embolic cerebrovascular accident. Subsequently, the patient developed a left-sided sensory deficit, and magnetic resonance imaging of the cervical spine revealed a C5-T2 epidural hemorrhage. The patient underwent emergent surgical evacuation of the clot and recovered without incident. Spinal epidural hematomas are rare and typically present as cord compressions with or without pain rather than as unilateral hemiplegia.

Factors affecting the incidence of hip dislocation in cerebral palsy.

We have studied the natural history of spontaneous dislocation of the hip in cerebral palsy, with particular reference to the pattern of neurological involvement. In patients with bilateral hemiplegia and severe involvement of the upper limbs the incidence of dislocation was very high (59%), while in those with diplegia and little involvement of the upper limbs, only 6.5% were affected. There was no evidence of dysplasia or instability of the hip in any of the patients with unilateral hemiplegia. A strong correlation was found between the stability of the hip and the patients' ability to walk. These findings have a bearing on clinical surveillance and also on the indications for prophylactic surgery.