Acute hemiplegia in childhood

Uluc Yis MD (

Dr. Yis of Dokuz Eylül University has no relevant financial relationships to disclose.

)
Haluk Topaloglu MD (

Dr. Topaloglu of Hacettepe Children's Hospital in Ankara, Turkey, has no relevant financial relationships to disclose.

)
Nina Schor MD PhD, editor. (

Dr. Schor of the National Institutes of Health and Deputy Director of the National Institute of Neurological Disorders and Stroke has no relevant financial relationships to disclose.

)
Originally released June 19, 1995; last updated February 12, 2020; expires February 12, 2023

This article includes discussion of acute hemiplegia in childhood, stroke, intracranial hemorrhage, intracranial infection, acute demyelinating conditions, posterior reversible encephalopathy, bleeding or edema associated with central nervous system tumor, metabolic disease, reversible vasoconstriction syndrome, postictal state (synonym of Todd paralysis), conversion disorder, alternating hemiplegia, asthmatic amyotrophy (synonym of Hopkins syndrome), and acute hemiparesis in diabetes mellitus. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Acute hemiplegia in childhood is a diagnostic and management challenge for the clinician. Hemiplegia is a total paralysis of arm, leg, and trunk on 1 side of the body whereas hemiparesis is partial paralysis on 1 side of the body. Hemiplegia/hemiparesis is not a disease but a response of the central nervous system to a range of results. Underlying etiologies in childhood are more diverse when compared to adults. This review is a clinical approach to a child with acute hemiplegia with a staged approach towards clinical assessment, investigations to reach a diagnosis, and management of each related disorder.

Key points

 

• Acute hemiplegia in children is a clinical syndrome with various causes.

 

• The immediate priority is to exclude a neurosurgical condition like intracranial hemorrhage, brain tumor, hydrocephalus, and massive ischemic stroke.

 

• Acute hemiplegia in children is the most common presentation of vascular stroke syndromes.

 

• About 20% to 30% of children with acute hemiplegia have “stroke mimics” like hemiplegic migraine, alternating hemiplegia, Todd paralysis, reversible vasoconstriction syndrome, posterior reversible encephalopathy, and conversion disorder.

 

• Clinical data and neuroimaging help to establish the diagnosis in most of the cases.

 

• Management and prognosis of acute hemiplegia in children depend on the etiology.

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 initiative (Lynch and Han 2005). 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. Advances in genetics have enabled us to understand the pathophysiology of familial hemiplegic migraine and alternating hemiplegia of childhood.

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