Hemiplegia

FileList Convert a pdf file!INDIA N PEDI ATRICS VOLUME 34- JANUARY 1 997
Acute infantile hemipleg ia is character - ized by the sudden onset of hemiplegi a in inf ancy or childhood usu ally pr ior to 6 years of age(l). In adult life, arterial occlu - sion is most frequently the consequence of arteriosclerosis of cerebral vasculature. In childhood, arterial occlusion us ually results from congenital dsyplasia of the vessels, cerebral arteritis, or trauma. Since the ante- rior cerebral circulation is usually affected, acute hemiplegia results. This clinical study was undertaken to revi ew the cases of childhood hemiplegia especially with refer- ence to the clinical presentation and radio - logical findings, and establish the possible etiology.
,
every child, deta iled history including on- set and progress of the disease, associated symptoma tolog y, antenatal, natal history and diagnosti c and therapeut ic interven - tions undergone was recorded. A careful and detailed clinica l examinat ion was con- ducted. Apart from routine investiga tions like complete blood counts, blood culture, serum electrolytes, CSF studies, EEG, CT scan, and MRI were done on individual ba- sis and affordability. Angiographic studies were not perfo rmed. If permitted, autopsy studies were done.
The cases of hemiplegia were catego- rized under three groups, namely,
Associa ted with convulsions at the on- set; not associated with convul- sions at onset; and congenital hemiplegia. The following definition were adopted: delayed initia- tion of breathing historically or document - ed by Apgar score of <6 at 1 min;
avoidable and unavoidable trauma susta ined dur ing the proces s of birth. On the basis of clinical features, EEG record- ings and CT scan findings, an attempt was made to determi ne the cause o f hemiplegia. Follow up of individual cases was not in- cluded in the study.
Forty chi ldren (21 boys and 19 girls) with hemiplegia formed the study material. Twenty eight cases were right handed. Nineteen chi ldren belonged to Group A, 9 to Group B, and 12 to Gr oup C. Majority o f the children in Group A were below 2 years of age (10/19) while all 9 cases in Group B were above 2 years. Majority of chi ldren had acute onset of hem iplegia (15/19 in Group A and 2/9 in Group B). Other important symptomatolog y included unconsciousness, fever, vomiting and headache. Past history of convulsions was elicited in 13 cases (Group A-10, Group C- 3). Delayed developmental history was ob-
Hemiplegia
T.S. Raghu Raman K.K. Surendran R.K. Gupta A.K. Gupta Ravichander S.L. Sood
Subj ects and Methods Results
From the Department of Pediatrics, Armed Forces Medical College, Pune 411 040.
Reprint requests: Wg. Cdr. T.S. Raghu Raman, As- sociate Professor, Department of Pediatrics, AFMC,Piu ie4U040.
Manuscript re ceived: Oct ober 14,19 95; Initial review com pleted: February 6 1996; Revision accepted: July 10 1996
(i) Group A:
(i) Birth asphyxia:
(ii) Birth injuries:
BRIEF REPORTS
tained in 10 children (Gr oup A-7, Group C - 3). There was a single case of head injury. As a group, in congenital hem iplegia the illness was not suspected earlier by the par- ents. The time period between the onset of hemiparesis and adm ission varied fro m one day to mo nths.
There were almo st equ al num ber of right and left sided hemiplegia. An impor - tant and dis tinctive feature of congeni tal hemiplegia cases was hypoplasia of limbs including the nails on the affec ted side. However, none of these children had de- monstrable sensory loss. There were two children who had cardiovascular disease resulting in hemiplegia. One of them was a 10 years old male child with features of Marfan's syndrome and associated congen- ital bicuspid aortic valve and aortic regur - gitation. The othe r was a 6 years old femal e child with features of polyangit is overlap syndrome and assoc iated cardiomyopa thy
Based on CSF examination, 10 children were diagnosed to have mening itis (7 tu- bercular and 3 pyo genic) and one child in -
tracranial hemor rhage. Abnormal EEG re- cordings were documented in 7 out of 11 cases. CT scan done in 23 cases revealed significant findings. 1 & 2 highlight t w o im p o r t an t CT s can f in d in g s .
summarizes the etiological classifi- cation based on the clinical features and investigative profile.
Infantile hemiplegia is not a disease, but rather is the non specific response of the central nervous system to multiple and var - ied conditions. These morbid processes, primary or secondary usual ly involve the blood vesse ls of the bra in. Hemiplegia is the only consistent clinical feature of this ischemic o r necrotic state. The mode o f on- set, subsequent clinica l course, prognosi s and the mod ality of man agement are in large p art d ependent upon spe cific etiolo-
56
INDIA N PEDI ATRICS VOLUME 34 -JANUAR Y 19 97
gic delineation. With improved diagnostic techniques man y more chi ldren are now given a s pecific diagnosis.
Hemiplegia in childhood is not rare. Ford recalled observing some 200 patients with this cond ition at the Harriet Lane home in Baltimore(l) . Parlauis report- ed the annual incidence of cerebrovascular disease in children to be 2.5 cases per 100,000 populat ion every year(2). Ther e was no gender differ ence in the pre sen t study, though a sex ratio of 1.5 in favor of males has been reported(3).
Acquired hemip legia in an apparentl y healthy child by i tself is not a com mon dis- ease. Case s of acquired hemiplegia i n
Group A had associat ed seizures at onset. Seizures are often an ischemic symptom in an infant brain whic h probably explains the prepo nderance of children upto 2 years of age in Group A(4). Onset of hemiplegia in the present study was acute in majority of Group A chi ldren (15/19), while only 2/9 children in Group B had acu te onset. This differen ce has also been observed earli- er(5). Loss of consciousness was a constant feature in those children with seizure at on- set. Presence of fever, either before or at the onset of hemiplegia, seen more commonly in Group A cases, might have been due to the high frequ ency of infection in the younger age group. A unilateral growth ar- rest of the thumb hail, hand o r extremity in a child with focal seizure disorder and hemiple gia suggests a chronic condit ion such as porencephalic cyst, arterio -venous malformation or cortical atrophy in the op- posit e cort ex(6). In the pre sen t study , all the 12 cases of congenital hemipleg ia had these features which could be correlated with CT scan findings. Associated facial p ares is, d iso rders of sp eech and contracture s have been reported earl ier also(7). The important investi gations in- clude CSF studies, EEG, CT scan and MRI. Analysis of CSF can identify subarachnoid hemorr hage and meningi tis. CT scan was done in 23 of 40 cases. Significant findings were o bserved in 20 of these cases correlat- ed with clinical diagnos is. In an earlier study on the relationshi p of CT scan and clinical findings in children with congenital hemiplegia, four types of changes were observed. The scan can be normal or show unilat eral ventricu lar enlar gement with involveme nt of the periventricular white matter, or a wedge shaped cavitation of the cortex, or it can de monstrate major involve- ment of both th e cortex and white matter(8). The value of CT scan in estab- lishing the diagnosis of hemiplegia is well established(9).
et al
BRIEF REPORTS
Included in congenital hemipl egia are prenatal and perinatal disorders which may not be recognized until several months after bir th, although the insu lt to the developing brain was sustained earlier. Ther commonest cause is probably a vascu - lar lesion occu rring during birth. Less often the condit ion may be due to a congen ital deformity, such as true porencephaly or in- tracran ial angioma( 10). In acqu ired hemiplegia, viral and bacterial infect ions, trauma, immuniza tions, systemi c diseases, cerebral arterio-venous malformations, car- diac abnormali ties, status epi lepticus and neoplasms and their ensuing complications are recognized etiologic factors. One im- portant survey meri ts ment ion in this con- text. Of the 86 children with acute hemip legia seen during a 21 year interva l at the Colombian Presby terian Medical Center, 11 were secondary to trauma, 11 had infection of CNS, 10 had miscellaneous conditions while in the remaining 25 cases, neither a specific etiology nor radiologic diagnosis could be establishe d(8). Solomon
11 in a review of 86 infants and children presenting 6 months to 20 years after becoming acutely hemiple gic, concluded that the on set of hemip legia assoc iated with seizures in children with occlusive vascular disease portended subsequent epilepsy and a persistent motor deficit. In the present study also, epilepsy and persistent hem iplegic motor def icit was seen most ly in cases pres ent ing with seizures and subjects with congenital hemiplegia.
It is concluded that hemiplegia of child- hood in our setting occurs due to diverse etiologies, ma ny of which can be a ccurately identified with the use of newer non invasive diagn ostic modalities.
1. Ford FR, Schaffer AJ. The etiology of in- fantile (acquired) hemiplegia. Arch Neurol Psychiatry 1927,18: 323-347.
2. Parlauis SG, Gould JR, Zito ZL. Stroke in children. Adv Pediatr 1991, 38:151-171.
3. Marie-Th Abena Obama, Dongmo L,
et al.( )
INDIAN PEDIATRICS VOLUME 34 -JANUAR Y 19 97
Nkemayim, Mbede J, Hagbe P. Stroke in children in Yaiunde, Cameroon. Indian Pediatr 1994, 31:791-794.
4. Bickerstaff ER. Cerebrovascular disease in infancy and childhood. Hand Book of Clinic al Neurolog y, Part II, Vol 12. Eds. Vinken PJ, Bru yn GW. Oxford, North Holland Publishi ng Com pany, 1972, p 341.
5. Malik GK, Sharma B, Misra PK, Chhabra DK, Tandon SC. A study of acute hemiplegia in children. Indian Pediat r 1979,16: 867-872.
6. Behrm an RE, Klieg man RM. Seizures in childhood. Nelson Textbook of Pediat - rics, 14th edn. Eds Behrman RE, Kliegman RM. Philadelphia, W.B. Saunders Compa- ny 1992, pp 1491-1503.
7. Gold AP, Car eter S. Acute hemiplegia of
infancy and childhood. Pediatr Clin North Am 1976, 23: 413-433.
8. Molteni B. Relationship between CT pat- terns, clinical findings and etiological fac- tors in children born at term, affected by congenital hemiparesis. Neurope diatri cs 1987,18: 75-80.
9. Ramsa y RG. Congenital disorders of brain. Neuror adiolo gy 3rd edn. Ed. Ramsay RG Philadelphia, W.B. Saunders, 1994 pp 137-173, 431-494.
10. Waljon JN. Congenital and infantile hemiplegia. Brai n's Diseases of Ner- vous System, 8th edn. Ed. Waljon JN. Ox - ford, Oxford Universit y Press, 1977, pp 632-636.
11. Solomon GE, Hilal SK, Gold AP, Carter S. Natu ral histor y of acut e hemiplegia in childhood. Brain 1970, 93:107-120.
59
In:
In:
In :
In;