1. Hemiplegia is defined as weakness or paralysis of one side of the body caused by an upper motor neuron lesion above C5 in the pyramidal motor pathway. 2. Common causes of hemiplegia include vascular (85% ischemic, 15% hemorrhagic), tumors, head injuries, demyelinating diseases like multiple sclerosis, and metabolic disorders. 3. The clinical presentation depends on the cause and location of the lesion. Lesions in the internal capsule typically cause contralateral hemiplegia and hemisensory loss with facial and hypoglossal weakness on the same side.

1. Approach to a case of
Hemiplegia
By Mohamed A. Tarek
Assistant lecturer of Neurology
Fellow of European board of Neurology
FEBN

2. Defintion
• Weakness or paralysis of one side of the body (one upper and lower
limb ).
• Due to UMNL ( pyramidal tract lesion )
• Above the level of C5

3. Pyramidal
motor
pathway

5. Localization
• Sites of lesions of pyramidal tract causing hemiplegia :
1- Cerebral cortex & Subcortex
2- internal Capsule
3- Brain stem
4- Cervical spinal cord above C5

6. Causes of
Hemiplegia
1- Vascular Causes:

7. • Ischemic (85%) Hemorrhagic (15%)
Acute stroke
Thrombotic
55%
Embolic
30%
SAH Intracerebral Subdural & Extradural
-Lacunar 20%
-Large vessel 35%
-Cardioembolic
-Artery to Artery

9. Other causes of Stroke (stroke mimics)
• Intracranial Neoplasm
• Head injury ( brain contusion )
• Subdural Hematoma
• Demyleinating dis ex MS
• Hyper/Hypoglycemia
• Encephalitis
• Migraine
• HTN encephalopathy
• Metabolic Encephalopthy
• Psychogenic ( conversion disorder )

10. Clinical Picture
• Acute onset & regressive course : Vascular – infective- traumatic .
• Gradual onset & progressive course : Neoplastic
• Relapsing remitting course : MS

11. Clinical Picture
• Symptoms & signs :
Acute lesions : C.P passes through 2 stages :
Stage of Flaccidity ( Shock stage ).
Stage of Spasticity
Gradual lesions : the hemiplegia passes directly to the stage of Spasticity
.

12. Where is the Lesion ?
•Cerebral Cortical Lesion :
Contralateral hemiplegia
Cortical Sensory loss
Coma
Convulsions at onset
Aphasia

13. Where is the
lesion ?
•Internal Capsule lesion:

14. Internal Capsule

15. •Internal
Capsule

16. Where is the Lesion?
• Internal Capsule Lesion :
Contralateral Hemiplegia
Contralateral hemisensory loss
Contralateral UMN facial weakness
Contralateral Hypoglossal weakness
Contralateral homonymous hemianopia
N.B: All cranial nerve nuceli have bilateral
motor supply from corticonuclear fibers
except lower half of the facial nucleus and
hypoglossal nucleus having motor supply
from contralateral fibers.

17. Where is the lesion
?
•Brain stem lesion :
Crossed Hemiplegia

20. Where is the Lesion ?
• Spinal hemiplegia

26. Investigations :
• Exclude stroke mimics : Random blood sugar , LFTs , Urea , Creatinine ,
Electrolytes.
• CT brain
• MRI , MRA , MRV .
• If ischemic stroke :
ECG &Echocardiography.
Carotid and vertebrobasilar Doppler .

27. Management :
• If ischemic stroke :
Acute management :

28. Prevention
• Primary prevention :
Healthy lifestyle , Healthy food , Exercise .
Secondary Prevention :
Control of Risk Factors of ischemic stroke.
Antiplatelets or Anticoagulation According to the Cause

29. Management
• If hemorrhagic stroke :
Control of Risk factors :
HTN is the most important cause of intra
Cerebral hemorrhage .
CT angio or MRA :
In case of SAH or any suspicion of
intracranial Aneurysm or AVM.

30. Awareness
Campaigns:

31. m.a.tarek91@gmail.com