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  • Updated 11.08.2020
  • Released 06.19.1995
  • Expires For CME 11.08.2023

Acute hemiplegia in childhood

Introduction

Overview

Acute hemiplegia in childhood is a diagnostic and management challenge for the clinician. Hemiplegia is a total paralysis of arm, leg, and sometimes the face 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 variety of insults. Underlying etiologies are more diverse in children than in adults. This review is a clinical approach to the child with acute hemiplegia. It includes a staged approach towards clinical assessment, diagnostic workup, and management of specific causes of hemiplegia.

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 (40). Todd described a post-epileptic hemiplegia in 1865 (91), and in 1887 Freud described acute childhood hemiplegia associated with epilepsy (73). In 1916, Higier described hemiplegic seizures (45). Seminal papers by Bickerstaff (11), Aicardi and colleagues (02), and Carter (84; 46) 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 (58). 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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