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A case of acute infantile hemiplegia, probably in co-occurrence with intracranial fibromuscular dysplasia, is reported. A review of the literature is given and some remarks are made concerning the management of this disease.
In addition to regulating sensory and motor function, the human brain is also involved in the coordination of complex mental processes. In some cerebrovascular accidents, hemiplegia may be completely absent and deficits of language, behavior, and memory may dominate the clinical picture.
Contralateral hemiplegia may develop a few weeks after the onset of an ophthalmic herpes zoster. This complication, which is not part of the herpetic encephalopathy, generally coexists with lesions of arteritis demonstrable by arteriography, affecting in most cases the proximal segments of the middle and anterior cerebral arteries and resulting in infarcts. The pathophysiology of these lesions is uncertain, but the vessels appear to be invaded by contiguity.
In 19 children with acute infantile hemiplegia an ischemic cerebral infarct was found clinically and by serial computertomography. In 11 patients an angiography has been performed in addition. 9 of the children had chronic diseases which are known as predisposing factors for cerebrovascular disease (congenital heart disease in 7 and chronic renal failure with hypertension in 2). One child had a severe hypernatremic dehydration due to infantile diarrhea and in 1 child thrombosis of the internal carotid artery occurred 3 days after a perforating trauma of the soft palate. No obvious reason for the ischemic stroke could be evaluated in 8 children. The onset of symptoms was either acute or slowly progressive. An altered state of consciousness was present in 11 children. Hemiparesis was found in 18 patients (13 right, 5 left) accompanied by facial palsy in 12 and aphasia in 6. Seizures occurred in 6 patients. One patient with incomplete occlusion of a vertebral artery showed acute cerebellar ataxia. In children without predisposing factors the prevalence of girls was higher (2 : 6) and there was a history of a preceding acute febrile illness in 5 of 8 patients. Laboratory investigations showed polycythemia in 4 children with cyanotic heart disease and additional hypochromia in two. Blood sedimentation rate was increased in 6 out of 8 patients without a known predisposing factor. Cerebrospinal fluid (CSF) showed a slight increase of erythrocytes (36-88/cmm) in 4 children, in two others purulent CSF was obtained after the infarct had developed into a brain abscess. The etiology of ischemic stroke in childhood and the possibility of an inflammatory vascular disease are discussed.
The oxygen 15 non invasive continuous inhalation technique coupled with positron emission tomography (P.E.T.) allows the local study of cerebral blood flow and oxygen metabolism. Recent P.E.T. studies have demonstrated the frequent occurrence of widespread metabolic depression remote from the site of middle cerebral artery territory infarct per se, especially over the cortical mantle and thalamus ipsilaterally, and over the cerebellar hemisphere contralaterally. These phenomena have been taken as indicative of transneural depression (i.e. diaschisis). We thought it interesting to study the possible occurrence of such abnormalities in patients with lacunar syndromes. We have applied the (15)0 technique to six patients (2 with pure motor hemiplegia, 4 with ataxic hemiparesis) for whom no large causal ischemic lesion could be demonstrated on CT scans; in only one patient was a lacunar lesion, presumably responsible for the clinical deficit demonstrated. Compared to a set of 19 patients without brain disease, the semi-quantitative results (analyzed in terms of asymmetry indices between homologous brain regions) in our patients did not disclose any pathophysiologically significant abnormality. More specifically, no evidence of physiological dysfunction similar to that reported in internal carotid artery territory infarcts, was detected over the cerebral or cerebellar cortices. These findings are commented upon in view of the presumably small size and the uncertain topography of the causal lesion.
Electromyographic feedback was compared with physical therapy for its relative effectiveness in training motor activity in patients with hemiplegia. A cross over design was used, so that each patient served as his own control. Strong reinforcement for attentional direction and for successful response to established criteria was used with both modalities. Electromyography through auditory and visual display was found effective in improving electromyographic activity, but more limited in training effective function as measured by active range of motion. In some cases it was counterproductive. Using an instrumental modality permits attention to only a limited number of motor elements involved in a motion, and is even more limited with respect to the interplay of activation and inhibition of those components. The activity of physical therapy, using tactile, proprioceptive, visual and communicative modalities, has the capacity for attending and drawing attention to many motor elements, as well as to the complexities of activation of some components concomitantly with the inhibition of others during the training process. Electromyographic feedback was felt to be especially useful in its ability to enhance figure-background discrimination and bypass possible areas of sensory obtundation.
Rheumatoid arthritis is generally a symmetrical polyarthritis characteristically involving small joints. Unilateral disease may occur when limbs are protected by a neurologic defect. Unilateral rheumatoid arthritis occurring in a patient with hemiplegia is here described.
Two young drug abusers with nontraumatic hemiplegia have been observed. Onset of symptoms occurred within minutes after intravenous administration of heroin. One case had cerebral infarction and the other cerebral hemorrhage. Hypersensitivity to heroin or an unknown adulterant may play a role.
Neuro-orthopedic and electrophysiological studies in 122 patients with post-insult hemiplegia underlie the authors' conclusion of shoulder pains peripheral origin. According to the authors' data these patients have humeroscapular periarthrosis formed as a result of cerebral and peripheral damages, including neck osteochondrosis. Fixing shoulder adductors are shown to become originally "numb" because of constant tonic impulsation damages. The mechanisms of this state are supposed to be connected with trophic changes and demand further study.
The relationship between motor and sensory functions has been studied in sixteen patients with hemiplegia due to brain infarct. Somatosensory evoked potentials (SEP) were recorded in the subacute phase after the vascular accident. Clinical ratings of the reduction of motor and sensory functions were repeatedly performed during a period of six months. The study demonstrates that a relationship exists between the results of the early SEP recording and the degree of motor recovery in the upper limb and, to a lesser extent, in the lower limb.
The purpose of this study was to determine the correlation, if any, between the status of the somatosensory evoked potential (SEP) and functional change in the right upper extremity of patients with right hemiplegia following stroke. Sixty-eight such patients were admitted to a rehabilitation hospital for intensive treatment from 3 to 8 weeks after onset. All had SEP studies by stimulation of the median nerves of the upper extremities and had complete medical, neurologic and functional evaluations. Forty-two patients had an absent SEP; of these only one showed some functional gain in the right upper extremity (RUE) at discharge. Of 14 patients having diminished SEP, 5 (36%) had some functional gain in RUE at discharge. Of 8 having normal SEP, 3 (38%) showed some functional gain on discharge. None of these 64 patients had any function in RUE on admission. Four patients had a normal SEP and some function on admission, with an increase of function on discharge. Of right hemiplegic patients who showed absence of SEP and nonfunction of RUE on admission, 98% gained no functional return in RUE during hospitalization. These data suggest that SEP studies in stroke patients offer useful information for prognosis and rehabilitation programming.
Over a 25-year period, 1855 patients have been subjected to a variety of common orthopaedic procedures for correction of disabling postures resulting from spastic hemiplegia. A widely applicable rationale for surgical correction of these postures has been slowly established over these years of clinical research. These methods are submitted in this review article with the hope that others will espouse, criticize and modify them, towards a better understanding of this complex kinetic disorder.
Following a minimum period of 11 weeks after cerebrovascular accident and resulting hemiplegia, 100 adult patients were assessed, over a period of 3 years, for sensory-motor deficits affecting the function of the paralyzed upper extremity. This paper presents only the assessment of voluntary control, the disturbances of voluntary motion, and the interrelationship between the components of voluntary motion and other clinical manifestations. Kendall rank order correlations were computed for this purpose. In the voluntary control of gross arm motions, forearm supination and spontaneity of arm usage appeared to be most significant in predicting the presence of other synergistic components. The isolated muscle function revealed during execution of functional tasks showed the ability to grasp an object as the least affected task and dropping a coin in a slot as the most difficult. Inability to perform voluntary motion was primarily related to the limitation of active and passive motion of the shoulders, elbow, wrist, and hand.
The author treated 50 cases of hemiplegia with acupuncture of needling points of the head. The results showed that 7 cases were basically cured, 12 cases markedly effective, 31 cases improved. The total effective rate was 100%.
By needling chiefly an empirical point Shengen with the penetration method, a total effective rate of 96.04% was obtained in 101 cases of apoplectic hemiplegia. In comparison with 38 controls, either the therapeutic effects and courses or other indices observed in the needling group were shown to be encouraging.
Moyamoya disease is one of the cerebrovascular disorders and is characterized by bilateral stenosis or occlusion of the distal internal carotid arteries and their main branches. Repeated ischemic episodes in children and intracranial hemorrhage in adults with moyamoya disease is usually noted. In this report, we describe two children with moyamoya disease who presented with alternating hemiplegia. The final diagnosis was made by cerebral angiography and cranial computed tomography in these patients. Other neurological and radiological features of the patients were described.
We present a 93-year old female who abruptly developed left hemiplegia on the way to the wash room. She was admitted to another hospital where her consciousness deteriorated and artificial respiration was necessary. She was transferred to our hospital 20 days after the onset of her stroke. On admission, her BP was 60/40 mmHg, and wheezing râle was heard in both lung fields. No heart murmur was present. She was in comatose state, but a small amount of spontaneous movements were present in her eyelids and the jaw. Neurologic examination revealed no papilledema, small non-reactive pupils with the right side being slightly larger than the left, absence of ocular movements, and loss of oculocephalic response and corneal reflex. An intratracheal tube was in situ, and the observation of the pharynx was impossible. No stiff neck was present. No spontaneous movement was observed in her limbs which were flaccid, and all the deep reflexes were lost except for jaw jerk which was weakly positive. Cranial CT scans revealed low density areas in the right anterior and middle cerebral artery territories with patchy areas of high density being consistent with a hemorrhagic infarction. In addition, a small high density mass lesion was noted in the left frontal lobe adjacent to the falx, which was thought to be a small meningioma. Her clinical course was complicated by pneumonia, hypotension and cardiac failure. She expired 2 months after the onset of her stroke. Postmortem examination revealed an extensive hemorrhagic infarction involving the territory of the right internal carotid artery.(ABSTRACT TRUNCATED AT 250 WORDS)
A 59-year-old male patient presented in 1991 with left-sided hemiplegia and hemihypesthesia and left homonymous hemianopsia, which had developed for the preceding 12 months. The cerebrospinal fluid (CSF) level of protein was mildly elevated, oligoclonal IgG band was initially negative, but finally positive and myelin basic protein was absent. Magnetic resonance imaging and X-ray computed tomography (CT) of the brain revealed a unilateral demarcated lesion extending around the posterior horn and triagular part of the right lateral ventricle, apparently capped by remarkably gadolinium enhancement at its front, which had no mass effect, and several small isolated plaques were also observed in other areas of the brain. All lesions appeared as high intensity areas on T2 weighted images and hypodense areas on CT. The JC virus hemagglutination-inhibition antibody titers were 1:32 in serum and 1:8 in CSF; the antibody titer ratio and index both suggested an intrathecal antibody production. Pathological examination of brain biopsy specimen taken from the large lesion demonstrated profound demyelination with preservation of axons, a large number of macrophages and spotted perivascular lymphocyte cuffings. Based on this experience, we discussed the features in this case which differentiated it from multiple sclerosis, leukodystrophy and typical progressive multifocal leukoencephalopathy (PML). Diffuse-disseminated sclerosis or transitional sclerosis was most likely so far as the clinical picture, imaging and histology were concerned. However, we implicated the possible involvement of JC virus infection to the etio-pathogenesis of the demyelinating lesions in view of the intrathecal JC virus antibody production in CSF observed in this case.(ABSTRACT TRUNCATED AT 250 WORDS)