Acute hemiplegia in childhood

Kimon Bekelis MD (Dr. Bekelis of Dartmouth-Hitchcock Medical Center has no relevant financial relationships to disclose.)
Robert J Singer MD (Dr. Singer of Dartmouth-Hitchcock Medical Center/Geisel School of Medicine at Dartmouth has no relevant financial relationships to disclose.)
Nina Schor MD PhD, editor. (Dr. Schor of the University of Rochester Medical Center and Chair of the Department of Pediatrics at Golisano Children’s Hospital at Strong has no relevant financial relationships to disclose.)
Originally released June 19, 1995; last updated September 12, 2016; expires September 12, 2019

Overview

Acute hemiplegia in childhood poses a diagnostic and management challenge for the clinician. Seizure and migraine are common etiologies. However, pediatric stroke is also a common cause of acute hemiplegia and needs to be promptly differentiated from other causes. In this recently updated article, the authors discuss recent advances in understanding the risk factors for and the etiology of stroke.

Key points

 

• Acute hemiplegia in children is often accompanied by headache. Tingling paresthesias as well as visual, sensory, or dysphasic auras are more common with headache associated with hemiplegic migraine than with acute hemiplegia due to stroke, where negative symptoms predominate.

 

• Acute hemiplegia after seizures is most frequently a Todd postictal paralysis, but stroke still needs to be considered when the paralysis is prolonged because children have seizures with stroke relatively frequently.

 

• Acute hemiplegia after a sports injury can be the result of trauma (hemorrhage or contusion), seizure with a Todd paralysis, hemiplegic migraine, or an arterial dissection. Appropriate imaging including MRA is required to evaluate for dissection because anticoagulation may be necessary to avoid progression.

 

• Focal cerebral arteriopathy is the most common cause of hemiplegia due to stroke in childhood. Onset of the hemiplegia is often subacute; preceding infections are relatively common especially in younger children; and recurrence risk is higher than with many other stroke types.

 

• Acute hemiplegia in childhood resulting from arterial ischemic stroke may eventually be regularly treated with thrombolytic therapy. This can currently be considered in children older than 12 years at institutions with stroke teams who are experienced in treating adult stroke in this manner. Clinical trials are in progress to determine the efficacy of thrombolytic therapy in children.

Historical note and terminology

The occurrence of unilateral weakness related to contralateral brain injury was already familiar to ancient physicians like Hippocrates and Aretaeus. Jusepe Ribera, a 17th century Spanish artist, painted a portrait of young soldier with hemiplegia. Early observations of acute hemiplegia were based on experience with penetrating head injury, intracranial hemorrhage, and epileptic seizures. In the late 18th century, Darwin experimented with electrical therapy for children with hemiplegia (Gardner-Thorpe and Pearn 2006). Todd described a post-epileptic hemiplegia in 1865 (Todd 1865), and in 1887 Freud described acute childhood hemiplegia associated with epilepsy (Pearce 2003). In 1916, Higier described hemiplegic seizures (Higier 1916). Seminal papers by Bickerstaff (Bickerstaff 1964), Aicardi and colleagues (Aicardi et al 1969), and Carter (Solomon et al 1970; Hilal et al 1971) focused mainly on childhood stroke and heralded the modern approach to evaluating acute childhood hemiplegia, caused by stroke. Our knowledge of the causes and treatment of both transient and permanent acute childhood hemiplegia have increased exponentially in the past decade due in no small measure to the International Pediatric Stroke Study (IPSS) initiative (Lynch et al 2002). In addition, structural and functional brain MRI, as well as traditional and MR angiography, have contributed to our understanding of the multiple causes and pathophysiology of acute hemiplegia in childhood.

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