Infantile hemiplegia
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Infantile hemiplegia
26/05/2009
26/05/2009
Dr Ira Shah
https://www.pediatriconcall.com/Journal/images/journal_cover.jpg
Dr Ira Shah.
Medical Sciences Department, Pediatric Oncall, Mumbai.
ADDRESS FOR CORRESPONDENCE
Medical Sciences Department, Pediatric Oncall, Mumbai |
Clinical Problem
Case Report:- An 8 month old boy born of non consanguineous marriage presented with multiple episodes of generalized tonic clonic convulsions since 15 days. He was admitted for pneumonia 4 months back when mother had noticed decreased movement of the right side of the body. His birth history and milestones are normal. On examination, he had 2 café au lait spots on the back. On systemic examination he had hypertonia on the right side with decreased power and extensor planter on the right side. Cranial nerves and other systemic examination were normal. He was diagnosed as a case of infantile hemiplegia with epilepsy.
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What is the cause of the hemiplegia and where is the CNS lesion?
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Discussion
Expert's opinion: Dr Ira Shah
This child had a sudden onset of hemiplegia without loss of consciousness or speech involvement which has remained the same.
Common causes of hemiplegia at this age are thromboembolic phenomenon, arterial malformations and CNS bleed. CNS bleed is usually catastrophic and patients have usually loss of sensorium and if bleed is in the subarachnoid space then there would be neck stiffness. Commonest cause of bleed would be hypertension or rupture of AV malformation. Hence, it is always necessary to check for hypertension in any child with hemiplegia or seizures. Due to the clinical presentation, bleed seems unlikely.
This child has a right sided hemiparesis without any altered sensorium or cranial nerve involvement but has seizures. Thus, the lesion seems to be in the cortical area. Cortical lesions lead to seizures and altered sensorium. Lesion in the inferior capsule leads to dense hemiplegia and facial nerve involvement. Lesion in the brainstem would lead to multiple cranial nerve involvement. Hence, it seems to be most likely involvement of left sided cortical lesion. Also, since it was sudden onset with no marked improvement, it is highly suggestive of thrombo-embolic phenomenon.
In this child, preliminary investigation would be MRI brain (to locate the lesion as well as determine whether it is a bleed or infarct) and EEG for the seizures. If MRI brain shows a bleed, then MRI angiography should be done simultaneously to look for AV malformations. (If the child had recurrent hemiplegia episodes, MRI angiography would be required irrespective whether the child had a bleed or infarct to rule out Moya Moya disease).
Once the MRI is suggestive of an infarct, then investigations to determine why the child developed a thrombus would be required. Sudden factors may predispose a child to form a thrombus and include :
Sickle cell anemia
Hyperlipidemia
Autoantibodies and autoimmune disease such as SLE and Antiphospholipid antibodies
Deficiency of anti coagulants such as Protein C, Protein S, Anti thrombin III
Homocystinuria
Cyanotic congenital heart disease
Mastoiditis
In this child, MRI brain showed infarct in right temporal region with old gliotic areas and this workup for thromboembolic phenomenon revealed Protein S deficiency.
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| Compliance with ethical standards |
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Funding: None
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Conflict of Interest: None
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Cite this article as:
Shah I. Infantile Hemiplegia. Pediatr Oncall J. 2007;4.
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