A clinical approach to Hemiparesis and quadriparesis

1. Approach to
Hemiparesis & Quadriparesis
Momen Ali Khan
Neurosurgery Resident
Department Of Neurosurgery
Dhaka Medical College Hospital

2. Grade Description
0 No muscle contraction visible
1 Flicker of contraction but no movement
2 Joint movement when effect of gravity eliminated
3 Movement against gravity but not against resistance
4 Movement against resistance but weaker than normal
5 Normal power
Medical Research Council grading of muscle power

3. Paresis: Partial paralysis
Plegia: Complete paralysis
Paresis & Plegia

4.  Hemiplegia is a paralysis of one side of the body and includes the upper limb, one
side of the trunk, and the lower limb.
 Monoplegia is paralysis of one limb only.
 Diplegia is paralysis of two corresponding limbs (i.e., arms or legs).
 Paraplegia is paralysis of the two lower limbs.
 Quadriplegia is paralysis of all four limbs.
[Snell Clinical Neuroanatomy 8th 166]
Types of Paralysis

5. Approach to hemiparesis

6. Vascular Stroke
Infective Encephalitis, meningitis, brain abscess
Neoplastic Glioma-meningioma
Demyelination Disseminated sclerosis, lesions to the internal capsule
Congenital Cerebral palsy
Spinal cord diseases Brown-Séquard syndrome
Traumatic
Causes of hemiplegia

7. Site of lesion
1. Cerebral hemisphere in the region of the contralateral motor strip.
2. Contralateral internal capsule.
3. Brainstem.
4. Cervicomedullary junction.
5. Unilateral spinal cord lesions. Above ≈ C5
Produced by anything that interrupts the corticospinal tract from its origin in the
pyramidal cells of betz in the motor strip down to the cervical spine.

8. History taking in hemiplegia
1. When did the event started?
2. What is the total duration of the illness? If multiple, ask about each episode.
3. What according to the patient or relatives were the initial presenting symptoms?
4. What was the exact mode of onset: was it abrupt, sudden, sub-acute, or gradual?
5. When was the maximum deficit noted: in the beginning or later?
6. Time course of the initial symptoms? Static or progress

9. Assessing the CNS function
1. GCS
2. Was there any loss of consciousness/ in the beginning or later; did he recover from it?
3. And for how long he stays unconsciousness?
4. What is the emotional status of the patient; memory and intelligence?
5. Is speech affecting and if so in what way? Motor, sensory, conductive aphasia?
6. Which of the cranial nerve is affected and what are the symptoms related?
7. What is the degree of motor weakness?

10. 1. GCS, pupil
2. Speech
3. Paralysis site identification
4. Plantar response
5. Facial Palsy: UMN or LMN type
6. Cranial nerve palsy
7. Vital sign: Pulse, BP, Lung
8. RBS by Glucometer
Rapid assessment in emergency room

11. UMN or LMN facial paralysis
UMN facial paralysis:
1. Upper half of face is spared
2. Lower half affected
3. No Bell’s phenomena
4. Taste not affected
LMN facial paralysis:
1. Entire half of the face affected
2. Bell’s phenomena present
3. Taste affected

13. Details Examination In Hemiparesis

14. General appearance Conscious level, Gaze deviation, Facial symmetry
Pulse Rate, Rhythm
BP Blood pressure, carotid bruits and cardiac auscultation
Higher cerebral
function
Dysphasia or dysarthria, Attention and neglect, Abbreviated
mental test
Cranial nerve
function
Swallow, Horner syndrome, Internuclear ophthalmoplegia,
Cranial nerve palsy, Visual field loss
Motor system Tone, Strength, including pronator drift, Co-ordination, Tendon
reflexes, Plantar reflexes
Sensory system Touch sensation, Cortical sensory function: sensory inattention
or neglect, Joint position sense
Gait Sitting balance, Standing balance, Ataxic gait pattern,
Hemiparetic gait pattern

15. Investigation
1. CT scan of Brain (Gold Standard)
2. MRI of Brain
3. ECG, Echocardiogram
4. MRA
5. CTA
6. Ultrasound of carotids with Doppler
7. Routine: CBC, RBS, S. Creatinine, Lipid Profile

16. Case Discussion

17. CASE 1
60-year old man,
One-hour duration of drowsiness, headache and vomiting
BP: 220/110 mmHg
Left-sided weakness

18. CASE 2
70-year old man,
Sudden onset left hemiplegia of two hours duration
History of fall at home present,
Mild drowsiness, power grade 3/5 left UL, LL

19. Approach to Quadriparesis

20. Site of Lesion
Cervical Spine ( Commonest)
Cerebrum
Bilateral brainstem lesion

21. Cause of Quadriparesis
1. Compressive Cervical Myelopathy
a. Cervical spondylosis
b. Traumatic cervical spine injury
c. Spinal Tumor in cervical region
d. Tuberculosis of cervical spine
2. Cranio-vertebral junction anomalies
3. Cerebral Palsy
4. Bilateral ventral pontine damage (Locked in Syndrome)
5. Non-compressive cervical myelopathy

22. HISTORY
Age
Onset and Duration
Progression of weakness: constant/progressing/intermittent
Is it acute- within minutes or hours?
Is it subacute- within days or weeks?
Is it chronic- within months or years?

23. HISTORY
Trauma to cervical spine
Pain in neck
Any loss of sensations?
Any sphincter disturbances( bladder and bowel involvement) ?
History regarding infections/fever(Viral illness/Tuberculosis)
Any comorbid illness: Diabetes, Hypothyroidism, HIV
Recent history of vaccination (Rabies, H1N1, COVID)

24. Past History
Enquire about Malignancy
Swellings or bone tenderness?
Surgery for tumors?
Chemotherapy or radiation?
Personal History
Diet (veg/non-veg, vitamins deficiencies, excess alcohol intake)
Drugs intake
Occupational exposure (regarding toxins(OP), heavy metals)

25. Rapid Assessment in emergency room
• Sudden or Gradual
• Muscle tone: Spastic or Flaccid
• Hoffman sign
• Plantar response
• Jerk
• Sensory level
• Vital sign
• Any history of Diarrhoea, Vomiting Dehydration

28. Signs of upper motor neuron (UMN) lesion:
1. Spastic paralysis
2. Increased tone (hypertonia, spastic, may be clasp knife).
3. Exaggerated tendon reflex, may be clonus and absent abdominal reflex.
4. Plantar response: Extensor.
5. No wasting (occasionally due to disuse).
6. Upper limb drift: Present
Signs of lower motor neuron (LMN) lesion:
1. flaccid paralysis
2. Hypotonia.
3. Loss of all reflexes.
4. Wasting of involved muscles.
5. Fasciculation of affected muscles.
6. Plantar: Normal or absent.

29. Cause of non-compressive cervical myelopathy
1. MND (e.g., amyotrophic lateral sclerosis).
2. Subacute combined degeneration.
3. Acute transverse myelitis.
4. Multiple sclerosis.
5. Friedreich’s ataxia.
6. Syringomyelia.
7. Vascular disease of the cord.
8. Post-vaccination.
9. Infective: Syphilitic amyotrophy, HIV, Herpes zoster, Herpes simplex.
10.Non-metastatic manifestation of malignancy.
11.Others: Radiation myelopathy, functional, lathyrism.

30. Cause of Flaccid Quadriparesis
1. Guillain-Barre syndrome
2. Hypokalemia
3. Paraneoplastic syndrome
4. Thyrotoxic periodic paralysis
5. Myasthenia gravis
6. Botulism
7. Venom: snake, sea urchin

31. Investigation
1. X-ray cervical spine
2. MRI cervical spine with screening of whole spine
3. Serum electrolyte
4. S.TSH
5. CBC, RBS, S. Creatinine
6. Work up in suspected metastatic lesion- CXR, USG W/A

32. Case Discussion

33. 36 yr.
Male
Neck pain
radiating to
both upper
limbs for 6
months
Tingling
and
numbness
for same
duration
Weakness of
all four
limbs for last
2 months
Hoffman
positive
bilatreally
Spastic
Quadripa
resis

37. A case of Spastic quadriparesis due to Compressive cervical
myeloradiculopathy due to Prolapsed Intervertebral Disc at C4-5 level

38. 40 yr.
Female
Neck pain
for 9
months
Progressive
weakness of
all four
limbs for 3
month
Hoffman
Positive
bilaterally
All jerk UL
LL
exaggerated
Spastic
Quadripa
resis

45. Cervical Intradural extramedullary Space
Occupying lesion at the level of C2 partly C1

46. Thanks