Hemiparesis

Routine for examination:

 

Inspect (facial droop, flexed arm, extended leg, wheelchair/walking aid, wasting, contractures)

Gait (and Rhombergs test)

Tone

Power

Reflexes

Sensation

Coordination

 

If time allows and suspect hemiparesis proceed as follows:

Assess cranial nerve VII and V

Assess visual fields and eye movements

Assess speech

Examine the hands for diabetic fingerprick marks, tar staining and feel the pulse (? AF) and look for bruising (?anticoagulated)

Listen for a carotid bruit and listen to the heart sounds

Assess for complications such as look at legs for DVT, inspect for presence of catheter/NG tube/PEG, pressure sores.

Assess function: ask patient to do a button, hold a pen etc

 

Present to the examiner:

 

This patient has a left hemiparesis as evidenced by:

 

• Increased tone
• Pronator drift
• Pyramidal weakness
• Increased reflexes
• Clonus
• Upgoing plantar
• Hemiparetic gait
• The upper limb was held in a flexed position and the lower limb was extended
• There was a wheelchair/walking aid by the bedside
• There were (no) cerebellar signs/coordination was in proportion to the weakness
• There was left sided sensory loss
• There was left UMN facial weakness (forehead spared)
• There was a left homonymous hemianopia/no obvious visual field defect
• There was (no) dysphasia/dysarthria

 

With regards to aetiology:

 

The pulse was regular, there was (no) carotid bruit or cardiac murmur/prosthetic sounds or evidence of diabetic fingerprick marks or tar staining.

 

With regards to complications:

 

There was (no) DVT, pressure sores, catheter, NG tube

 

The patient had good/reduced function of the left hand.

 

My differential diagnosis is:

 

1. Anterior circulation vascular event affecting the right cortex (either ischaemic or haemorrhagic stroke) or lacunar infarct (if no visual field defect and no higher cortical dysfunction)
2. Space-occupying lesion eg. tumour, subdural haemorrhage, abscess
3. Hemiplegic cerebral palsy
4. Less likely causes: Todd’s paresis post-seizure, hemiplegic migraine, stroke mimic such as sepsis, hypoglycaemia, demyelination

 

To complete I would like to:

 

Perform fundoscopy (diabetes, hypertension)

Perform a full cranial nerve examination and lower limb examination (if not already done) and cardiovascular examination (if not already done)

Perform a speech and swallow assessment

Check the BP, CBG

Perform an AMTS

 

 

Investigations for stroke:

 

• Level 1
  • Bloods: FBC, U+E, LFT, CRP/PV/ESR, lipids, fasting glucose/Hba1c, clotting
  • 12 lead ECG (?atrial fibrillation), CXR, urine dipstick (for blood and protein)
  • Immediate CT head: infarct versus haemorrhage, exclude tumour/subdural, assess for complications e.g. hydrocephalus
    • NB: CT head is often normal in acute phase of ischaemic stroke. Early CT signs include: loss of grey-white differentiation, insular ribbon sign, sulcal asymmetry, hyperdense MCA sign
  • Level 2
    • Carotid dopplers if anterior circulation stroke suspected
    • 24 hour tape/48/72 hour tape or 7 day tape
    • Echo
    • MRI with diffusion weighted imaging +/- MRA (dissection, aneurysm, AVM, venous sinus thrombosis, posterior fossa lesion suspected)
  • Level 3
    • Vasculitic and thrombophilia screen to include ANA, ANCA, antiphospholipid antibodies, lupus anticoagulant, factor V leiden, protein C and S, antithrombin III etc
    • HIV and syphilis serology
    • Bubble echo

 

Management of stroke:

 

1. ABCDE assessment, exclude hypoglycaemia. Bloods, ECG, CT head as above. Discuss with brain attack team.
2. If < 4.5 hours since symptom onset and no contraindications such as haemorrhage on CT head: thrombolysis with alteplase (NIHSS 5-20)
3. Admit to hyperacute stroke unit (MDT approach)
   1. Regular neuro obs (dropping GCS may mean haemorrhagic transformation)
   2. Post thrombolysis CT head at 24 hours
   3. Aspirin 300mg PO (or PR/ by enteral tube if dysphagic) +PPI for 2 weeks then clopidogrel 75mg PO for life NB: hold off aspirin until 24 hours after thrombolysis
   4. Atorvastatin 80mg OD
   5. Sip test, NBM, SALT assessment, dietician +/- NG feeding
   6. IPCs (intermittent pneumatic compression) for VTE prophylaxis
   7. Rehab: Physiotherapy, Occupational therapy, neuropsych
   8. Level 2 investigations as above +/- referral for carotid endarterectomy within 1 week if stable neurological symptoms from acute non-disabling stroke and symptomatic carotid stenosis of 50–99% according to the NASCET (North American Symptomatic Carotid Endarterectomy Trial) criteria or 70–99% according to the ECST (European Carotid Surgery Trialists’ Collaborative Group) criteria. Surgery within a maximum of 2 weeks of onset of stroke is the target.
   9. Secondary prevention: lifestyle advice (e.g. stop smoking), control diabetes, hypertension, cholesterol
   10. Driving advice (no driving for at least 4 weeks)
   11. Anticoagulation after 2 weeks if atrial fibrillation NB: CHA2DS2VASC and HASBLED scores
   12. Monitor for complications:
       1. Acute
          1. Haemorrhagic transformation of ischaemic stroke
          2. Aspiration pneumonia
       2. Subacute
          1. Pressure sores
          2. DVT and PE
          3. Pneumonia
          4. Constipation
          5. UTI

• Later
  1. Depression
  2. Seizures
  3. Contractures

 

 

Be familiar with the NICE stroke algorithm (https://www.nice.org.uk/guidance/CG68) and the Bamford classification of stroke and the CHA2DS2Vasc and HASBLED scoring systems and the National Institutes of Health Stroke Scale.

 

Written by Dr Sarah Kennedy

 

Resources used to write this document include those listed in the references section of this webpage and also:

 

https://www.nice.org.uk/guidance/CG68)