To approach a child with sudden onset of weakness The task is not just to identify the hemiplegia, but to ascertain the level of the problem and the etiology. The examination can assess these factors sequentially as outlined here. The plan is as follows: • Demonstrate the physical signs of hemiplegia in the lower and upper limbs. • Demonstrate the level by assessing, as a minimum, the seventh cranial nerve (lower motor neuron involvement implies pathology in the region of the pons; upper motor neuron involvement implies a lesion above the pons) and the visual fields (involvement implies site of lesion at internal capsule or above), and look for parietal lobe signs (cortical lesion). • Look for the cause.

1. Approach to
a child with
sudden onset
of weakness

2. 1.GENERAL
OBSERVATIONS
•Introduce yourself to the child and parent.
•Ask the child simple things, such as name, age and school. Note any
dysphasia (dominant hemisphere) and note any obvious intellectual
impairment (secondary to meningitis, HSE, NAI, MVA, homocystinuria).
•Have the child adequately exposed, being sensitive to their modesty.
•Note the posture and describe it carefully.
•Note any asymmetry of the limbs (growth arrest).

3. •Assess the growth parameters. If
tall or Marfanoid habitus, think of
homocystinuria.
Comment on whether the child is
well or unwell, as she or he may
be recovering from recent insults
(e.g. encephalitis) or may be in
distress from acute problems
(SBE, CHD with cardiac failure).
•Check whether the child is
cyanosed (CHD).
•Examine the skin for the
following:
1.Bruising/purpura (NAI, ANLL,
ALL).
2.Pallor (SCA, ANLL, ALL).
3.Neurocutaneous stigmata (SWS,
NF1).
4.Cigarette or electric heater
burns (NAI).

4. ASK IF CHILD
CAN WALK?

5. 2.GAIT
(OLDER
CHILD) OR
GROSS
MOTOR
ASSESSMENT
(INFANT)
•Now, after thorough inspection,
take the child through a full gait
examination.
•Remember to check for sensory
neglect when the child is standing
up (when testing for Romberg’s
sign).

6. •In infants too young to walk, where the introduction will obviously not be
‘gait’ but perhaps ‘not using one side’ or ‘6 months old and prefers the left
hand’, a gross motor developmental assessment replaces the gait maneuvers.
•use the ‘cover’ test, where the child’s face is covered with a cloth, and each
handheld in turn to see if the cloth can be removed equally well using either
one.
•Also check the primitive reflexes for signs such as asymmetric Moro or
parachute reflexes.

7. 3.LOWER
LIMBS
•Check tone, power, and reflexes.
•Remember to test for clonus at both ankle and
knee, crossed adductor response (abnormal after
9 months of age) and spread of reflexes.
•In view of time constraints, it is reasonable to
omit sensory testing, or postpone it until later, if
the examiners agree when you suggest this.

8. 4.ABDOMINAL REFLEXES
For a complete assessment of pyramidal tract function, these
should be included. They correspond to spinal segments T7–T12.
5.UPPER LIMBS
As with lower limbs, just test tone, power and reflexes, and omit or
postpone sensory testing.

9. 6.HEAD
Inspect and describe facial features; there may be obvious facial asymmetry (e g.
seventh cranial nerve lesion).
In this case, it is best to examine the motor cranial nerves, starting with the twelfth
nerve and working up.
•Check for tongue deviation (twelfth),
•asymmetry of shoulder shrugging (eleventh),
•asymmetry of palate elevation (ninth),
•eyebrow raising, tight closing of eyes, showing teeth and puffing out cheeks (all
seventh)
•external eye movements (third, fourth and sixth; note that the third cranial nerve
nucleus is in them midbrain, and the fourth is in the pons).

10. At completion of
motor cranial nerves
check the visual fields for field defects and for
parietal visual neglect. A field defect implies a
lesion at or above the internal capsule.

11. Now examine the
higher centers for
parietal lobe signs.
In older children, test for receptive dysphasia, agraphia
(‘write your name for me’), astereognosis (e.g. unable to
recognize key in hand), ideomotor apraxia (e.g. ‘show
me how you brush your teeth’) and left/right confusion.
These occur when the dominant side is involved. Also
test for constructional apraxia (e.g. ask the child to
draw a clock), which occurs when the non-dominant side
is involved

12. In younger children, the ‘higher centers’ part of
the examination is more general, and works best
if simple things are asked first, such as name,
address age, sex (‘Are you a boy or a girl’), and
naming parts of the body (e.g. pointing at nose,
eyes, ears, arm and asking ‘What’s this?’). If the
child is unable to succeed at the latter, point to
something such as your watch, ask ‘Is this a dog?
A cat? A watch?’ and note the responses.

13. finally examine for sensory extinction, which can occur with either side
involved.
Note that if there is no involvement of any cranial nerves or higher
centers, then a spinal cord lesion is possible, and warrants a sensory
examination being performed, as well as assessment of the spine itself.

14. By this stage, the level
will have been
ascertained, and the
cause can be sought.

15. Inspect and palpate the head for the ‘S’ signs:
• Size: head circumference may be increased with subdural haematoma, or intracranial
tumour.
• Scars (e.g. craniotomy for repair of AVM, evacuation of subdural haematoma).
• Sutures and fontanelles (widened sutures, full fontanelle with raised intracranial
pressure: e.g. with intracranial tumour, hydrocephalus).
• Shunts (e.g. hydrocephalus, chronic subdural collection).
Auscultate the skull for bruits (AVM). Inspect conjunctivae for pallor
(SCA).
Examine the retinae for retinal haemorrhage (NAI), papilloedema
(raised intracranial pressure).
Inspect the oral cavity for haemorrhage from oral trauma.

16. CARDIOVASCULAR
Perform a full cardiovascular examination, looking for clubbing
(cyanotic CHD), hypertension, central cyanosis (CHD), murmurs
(CHD, SLE), carotid pulsation (decreased in arteritis), carotid bruits,
ABDOMEN hepatomegaly (SCA, ALL) and splenomegaly (SCA).
Genitalia for urinary fecal incontinence

17. SPINE
•This is an essential part of the examination if there is no involvement of any cranial nerves or higher
centres. If this is the case, the above head and cardiovascular assessments should be postponed.
•Inspect for scoliosis (e.g. NF1, spinal tumour) and scars (e.g. excised spinal tumour).
•Palpate for tenderness and masses. Auscultate for arteriovenous malformations or vascular
tumours.
Take BP (for hypertensive encephalopathy)

18. The causes can also be grouped as systems.
Cardiovascular causes
1. Hypertension.
2. Cyanotic congenital heart disease (CHD): before 2 years of age, usually cerebral
thrombosis; after 2, cerebral abscess.
3. Subacute bacterial endocarditis (SBE).
4. Cerebral arteriovenous malformations (AVM).
5. Cerebral vaso-occlusive disease; for example, moyamoya disease.
6. Sturge-Weber syndrome (SWS): cerebral vessel anomalies.
Traumatic causes
1. Non-accidental injury (NAI).
2. Brain trauma; for example, motor vehicle accidents (MVA).
3. Intraoral trauma.
Infective causes
1. Herpes simplex encephalitis (HSE).
2. Bacterial meningitis.
3. Cerebral abscess.
Systemic disorders
1. Systemic lupus erythematosus (SLE).
2. Sickle cell anaemia (SCA).
3. Homocystinuria.
4. Neurofibromatosis type 1 (NF1).
5. Acute leukaemia, non-lymphocytic (ANLL) or lymphocytic (ALL).
In practice, there is a significant percentage of children with acute hemiplegia in
which the cause is not yet known. A suggested approach is as follows.