Acute hemiplegia in children

Introduction to acute hemiplegia in children Acute hemiplegia (acutehemiplegia infantandchildhood) is called cerebralart erythrocsis, which is a group of clinical syndromes. It is now named after its pathology, ie cerebral arterial thrombosis, due to the involvement of pyramidal tracts in cerebral arterial thrombosis. Blood supply, so acute hemiplegia is its main clinical symptom. The main pathogenesis is due to the lack of cerebral blood flow and the function of one side of the pyramidal tract. The acute hemiplegia in children can be seen in various diseases that can cause occlusive cerebral artery disease. In addition to acute hemiplegia, clinical symptoms may include convulsions, disturbance of consciousness, and increased intracranial pressure. basic knowledge Sickness ratio: 0.0001% Susceptible people: children Mode of infection: non-infectious Complications: disturbance of consciousness, ataxia, difficulty swallowing

Acute hemiplegia in children

Infection (25%):

Cerebral vasculitis caused by various infections can narrow the arterial lumen, thrombosis, occlusion, cause local cerebral blood flow reduction, insufficient blood flow perfusion of the brain tissue, resulting in degeneration and necrosis of nerve cells, and viruses or bacteria may directly invade the cerebral blood vessels. Causes cerebral vasculitis; may also cause immune cerebrovascular inflammation or demyelinating around the cerebral vessels after infection or after vaccination, the original disease of infection: 1 virus: such as herpes simplex, chickenpox, measles, mumps Acute hemiplegia syndrome can occur in infections such as adenovirus and enterovirus. In recent years, human immunodeficiency virus (HIV) infection has also been found to cause typical acute hemiplegia and has been shown to have cerebral infarction or intracranial arteritis. 2 bacteria: such as meningococcus, influenza bacillus, pneumococci, tuberculosis, etc. caused by purulent meningitis, pneumonia, sinusitis, otitis media, endocarditis, tuberculous meningitis, etc., can be due to cerebral arteritis Or venous thrombosis causes acute hemiplegia. 3 parasites, fungal diseases: such as cerebral paragonimiasis, leptospirosis, new cryptococcosis and other infections. 4 Others: Cases of acute hemiplegia in children such as Kawasaki disease have also been reported. The cause of this disease is still unclear and may be related to retroviral infection and immune mechanisms.

Traumatic brain injury (5%):

Brain contusion, subdural or epidural hematoma, parenchymal hemorrhage and associated cerebral edema can cause hemiplegia, carotid artery injury caused by posterior pharyngeal wall injury can not be ignored, blunt pharyngeal wall injury can make the neck Arterial thrombosis or tearing of blood vessels, formation of dissecting aneurysms, mild head injury in the head, neck injury, or soft palate in the mouth, can cause internal carotid artery thrombosis, the symptoms of internal carotid artery dissection aneurysm Hours after trauma, a few days later (or later), manifested as acute hemiplegia, headache, vascular murmur and Horner's disease, cervical spine trauma, cervical hyperextension or atlantoaxial subluxation, can cause vertebral artery dissection aneurysm, Can cause double hemiplegia.

Heart disease (5%):

Cyanotic congenital heart disease can cause cerebral thrombosis due to infection and increased blood viscosity during dehydration. When diverted from right to left, emboli can enter cerebral blood circulation and form cerebral embolism, which occurs in children under 2 years old. Due to hemiplegia caused by concurrent brain abscess, arrhythmia such as atrial fibrillation, can be accompanied by a wall thrombus and cause cerebral infarction, rare cardiac tumors can also occur hemiplegia, rheumatic heart disease or endocarditis, sputum exfoliation, can form Embolism can cause cerebral embolism, aseptic emboli of mitral valve prolapse can also cause cerebral ischemic attack. Iatrogenic emboli can come from cardiac catheter, heart surgery, fat embolus of parenteral nutrition.

Pathogenesis

(1) intracranial lesions: intracranial aneurysms, arteriovenous malformations, moyamoya disease, brain occupying lesions, etc., due to hemorrhage, vascular occlusion or oppression caused by hemiplegia.

(2) Blood diseases: leukemia, thrombotic thrombocytopenic purpura, hemophilia, etc. may cause local blood supply disorders, abnormal blood coagulation can cause venous and arterial thrombosis, and some genetic diseases can cause thrombosis, such as protein C and Protein S deficiency, activated protein C resistance, antithrombin deficiency, etc., protein C is an important anticoagulant factor, protein S is a cofactor of protein C, when it is lacking, it is easy to coagulate, protein C The gene is located on the long arm of chromosome 2, and can cause a variety of point mutations or deletions, causing thrombosis. Mutation of factor V can cause another dominant genetic disease called activated protein C resistance (APC-R). It is the most common genetic cause of spontaneous cerebral thrombosis in children. In APC-R, the inactivation rate of coagulation factor V is slowed down, which leads to "coagulative state". Acquired coagulation abnormality can also cause cerebral embolism, which is seen in nephropathy. , liver disease, fever, protein S and protein C deficiency during dehydration, and antiphospholipid antibody syndrome (APLS), in APLS patients, 25% to 30% have thrombocytopenia, the latter can be benign, can also be cited Cerebral venous sinus thrombosis (Alper et al., 1999), other blood diseases that can cause cerebral thrombosis, thrombocytosis, iron deficiency anemia, sickle cell anemia, etc., the latter 25% have cerebrovascular complications, rare in China .

(3) connective tissue disease: nodular periarthritis, systemic lupus erythematosus, multiple arteritis and other diseases when the lesion invades the cerebral artery or its branches, hemiplegia can occur, systemic lupus erythematosus about 20% There is vasculitis, mainly small arteries, causing microthrombus in the brain, TIA occurs, nodular polyarteritis is involved, small blood vessels, angiography is not easy to find, arterial fibromuscular dysplasia is a systemic disease, when it involves the neck Cerebral aneurysms, thrombosis, embolism, dermatomyositis, Wegener granulomatosis, juvenile temporal arteritis, avascular disease, and Behcet's disease may occur in the internal arteries.

(4) Hereditary diseases and metabolic disorders: In recent years, due to the development of neuroimaging techniques (CT, MRI) and the application of dynamic cerebral blood flow distribution and brain metabolism testing (SPECT, PET), some genetic diseases and metabolic disorders have been discovered. Can be complicated by cerebrovascular abnormalities, cerebral blood flow changes or abnormal regional brain metabolism, such as cystineuria, organic acidemia, hyperammonemia, lactic acidosis, mitochondrial disease (mitochondrial myopathy - lactic acidosis - Stroke-like episodes, etc., some demyelinating degeneration, hemoglobinopathy, neurocutaneous syndrome (neurofibromatosis type I, tuberous sclerosis) can cause acute hemiplegia, in addition, water and electrolyte disorders, especially severe dehydration The intracranial venous sinus thrombosis can also cause hemiplegia. Cases of acute hemiplegia caused by intracranial hemorrhage caused by vitamin K deficiency have been reported in China. Diabetic children may have a short episode of hemiparesis when their blood sugar is low. The hour is naturally relieved, or it is alternating hemiparesis, which may be cerebral vasospasm.

(5) paroxysmal disorder: seizures or migraine attacks may occur with acute hemiplegia.

Pathological change

The pathological changes of acute hemiplegia in children are mainly thrombosis of cerebral arteries, embolism and vasculitis, which cause occlusive lesions of cerebral vessels. Among them, cerebral thrombosis is the most common, and the blocked parts are different in each case, which can occur in the brain. The large blood vessels can also occur in small blood vessels. The incidence of thrombosis in children, large blood vessels and small blood vessels is roughly equal. Large blood vessel thrombosis can be seen in the extracranial part of the internal carotid artery, but it occurs mostly in the branch of the internal carotid artery. That is, the proximal end of the middle cerebral artery or anterior artery, a small number of visible vertebral-basal artery thrombosis, the small arterial thrombosis of the brain is often multiple, occurs in the deep perforating branch of the cerebral artery, and the blood supply to the deep structure of the brain (basal ganglia, inner The sac, thalamus, and brainstem), because the small arteries are the terminal arteries, lack the anastomotic branch and collateral circulation, and the nerve path and function are dense in this area, so often cause permanent functional damage.

Causes

30% to 50% of cases can not find the cause of the disease, belonging to idiopathic pediatric acute hemiplegia, the remaining cases can find the primary disease, called symptomatic (secondary) children with acute hemiplegia, secondary pediatric acute Hemiplegia is common in infections, immune diseases, intracranial vascular malformations, craniocerebral trauma, heart disease, blood diseases, metabolic diseases, etc. These diseases can cause occlusive lesions of the cerebral blood vessels, which may cause hemiplegia.

Acute hemiplegia prevention in children

The cause of this disease is clear infection, intracranial vascular malformation, craniocerebral trauma, heart disease, blood disease, metabolic diseases are more common, the focus should be actively prevention and treatment of the above causes caused by this disease.

Acute hemiplegia complications in children Complications, disturbance of consciousness, ataxia, dysphagia

Often combined with seizures and disturbance of consciousness, muscle contracture often occurs after 2 to 3 months, and most cases have sequelae, partial sensory disturbance, hemianopia, dyskinesia, ataxia, dysphagia, and dysarthria.

Acute hemiplegic symptoms in children Common symptoms Awareness disorder Sensory disorder Spastic hemiplegia Gait Ataxia Convulsion Cranial nerve palsy Dizziness Double vision Visual impairment Dyskinesia

Acute hemiplegia in children can be seen in any age of children, but it is more common in children under 6 years old. According to the symptoms and course of disease at the beginning of onset, the following types can be classified:

Fulminant onset

More common, the symptoms immediately reach the peak, the child suddenly hemiplegia, often combined with seizures and disturbance of consciousness, convulsions are limited to one side, even can be extended to the whole body, hemiplegia develops rapidly, can be seen after convulsions stop, culminate within 1-2 days Upper limbs and hemifacial spasm are predominant, lower limbs are lighter, initially flaccid paralysis, low muscle tone, sputum reflex can not be induced, but may have pathological reflexes, become spasmodic sputum after 2 to 3 weeks, increased muscle tone Pathological reflex is obvious. If it is not treated in time, muscle contracture often occurs after 2 to 3 months. The recovery of motor function is more than 6 months, but most cases have sequelae. In addition, partial sensory disturbance and hemianopia can be seen.

2. Acute onset

Hemiplegia develops to the apex within 3 to 7 days (up to 10 days), generally without seizures, consciousness disorder is not obvious or only transient, motor function recovery is more complete, and some have light dyskinesia.

3. Lightweight

Only a temporary limb is weak and can recover within a few days.

4. Recurrent hemiplegia

After the recovery of the paralysis of one limb, multiple paralysis occurred on the side. The interval between the two hemiplegia was different, and the motor function of most cases recovered completely.

The first symptoms of acute hemiplegia in children often vary with age. Most of the older children start with hemiplegia, and some have convulsions. Infants often start with convulsions and then have hemiplegia. Most of the sick children are aware of the onset, only a few have Different levels of consciousness disorder, vital signs have no significant changes.

5. Lacunar cerebral infarcts

It is an ischemic microembolism caused by deep occlusion of the cerebral artery, often multiple, and the late necrotic tissue is cleared to form multiple small cysts. The cause is mainly arteriosclerosis in adults, and no specific cause can be found in children. Can be seen in moyamoya disease, viral infection (especially after varicella), infarcts are more common in the cerebral cortex, such as basal ganglia, internal capsule, thalamus, brain stem, cerebellum, etc., clinical manifestations vary depending on the infarction site, and some have no obvious symptoms Some are simple hemiplegia, or are ataxia with hemiparesis, or may be a partial dance of the hand and foot, or appear to be paralyzed, unclear, poorly swallowed.

6. Transient ischemic attack (TIA)

It refers to temporary brain dysfunction caused by insufficient blood supply in the brain. Children's TIA is getting more and more attention because it can develop into a typical cerebral infarction. The clinical features of TIA are sudden hemiplegia and short duration (minutes to several Hour), complete recovery within 24h, imaging examination can not see the lesion, easy to relapse, children's carotid system TIA is more common, manifested as hemiplegia, aphasia, partial sensation abnormalities, visual impairment, etc., vertebral-basal artery system in children TIA is mainly characterized by dizziness, vomiting, diplopia, vision or visual field symptoms, ataxia, dysphagia, dysarthria, etc., cross-paralysis (one-sided cranial nerve paralysis with contralateral hemiplegia), is one side of brain stem ischemia Performance.

Examination of acute hemiplegia in children

According to age, clinical manifestations, medical history, physical examination, choose a method that benefits less damage.

Laboratory inspection

Cerebrospinal fluid examination

In patients with idiopathic pediatric acute hemiplegia, lumbar puncture is generally not performed, because there is no specific change in cerebrospinal fluid, and cerebrospinal fluid is not checked unless meningitis or subarachnoid hemorrhage is confirmed.

2. Hematology examination

Whole blood count, blood gas, erythrocyte sedimentation rate, prothrombin time, fibrinogen, etc., if necessary, hemoglobin electrophoresis, when there is a suspected hypercoagulable state, check whether the protein C, S, antithrombin III is lacking.

3. Metabolic disease examination

Blood electrolytes, blood or urine amino acids, lactic acid, urine sugar, organic acids, blood lipids, urea, liver function, etc. can be checked according to the characteristics of each case.

4. Other

When an autoimmune disease is suspected, lupus antibodies, antiphospholipid antibodies, etc. are measured.

Film degree exam

1. Neurophysiological examination

Epileptic discharge can be seen on the EEG with convulsions.

2. Neuroimaging

It can show the location, extent and nature of vascular lesions. The infarction and hemorrhage should be clearly distinguished. The CT scan shows a low-density lesion in the ischemic area, and the hemorrhage area is a high-density shadow. CT examination shows hemiplegia in the early stage of cerebral infarction and cerebral edema. There is a non-uniform low-density area in the contralateral cerebral hemisphere. In severe cases, the midline shift is visible. After about 1 week, the low-density area becomes uniform, the edge is clearer than before, and the distribution area of an artery is consistent. Multiple infarction It is often suggested that there is embolism, or there is a wide range of vasculitis. After hemiplegia lasts for a long time, CT can see the contralateral cerebral hemisphere atrophy. CT can also see the calcification of intracranial arteriovenous malformation. The disadvantage of CT is that it cannot be critical after onset. The lesions are displayed within a few hours, but the ischemic lesions are displayed after 12 to 24 hours. The most obvious is 5 to 7 days. The resolution of MRI is high. The ischemic changes can be seen as early as 6 to 12 hours after infarction (T2 phase is the signal). Enhanced, T1 phase signal reduction), can also show basal ganglia, brain stem, posterior cranial fossa lesions, new MRI, such as perfusion imaging, can show small blood vessel lesions and brain blood flow dynamic changes; diffusion weighted imaging can be on the number of onset Within minutes Cerebral ischemia, magnetic resonance angiography (MRA) can show blood flow, can clearly identify large blood vessel stenosis or occlusion, can show cerebral aneurysms and deformities, but not enough for small blood vessels or vasculitis, magnetic resonance spectroscopy (MRS) Specific biochemical values can be measured to assess metabolic abnormalities in focal cerebral ischemia. A series of tests can detect the progress of infarction, neuronal loss and myelin disintegration. Conventional cerebral angiography is still important for cerebral infarction in children. The examination means, especially to help detect cerebrovascular abnormalities that can be treated, such as vasculitis (uneven lumen, bead-like stenosis), dissecting aneurysm (dual lumen), collateral circulation (smog disease, etc.), SPECT And PET examination can find blood perfusion and metabolic changes, which is helpful for diagnosis and follow-up. Brain ultrasound examination is suitable for infants, especially for detecting brain parenchyma and intraventricular hemorrhage, but is not satisfied with the examination of subarachnoid hemorrhage. Doppler ultrasound can measure the condition of the skull base artery, and a series of examinations can detect changes in arterial blood flow.

3. Cardiac examination

Suspected cardiac embolism or thrombosis, can be found in heart ultrasound, Doppler, ECG and so on.

Diagnosis and diagnosis of acute hemiplegia in children

diagnosis

The diagnosis of cerebral arterial thrombosis in children mainly depends on detailed medical history, physical examination and laboratory and auxiliary examination. Firstly, the type of cerebral infarction should be distinguished, whether it is ischemic or hemorrhagic. At the same time, the cause should be diagnosed as much as possible. To understand developmental history, family history (cardio-cerebral vascular disease, lipid metabolism, coagulopathy, migraine, epilepsy, etc.), whether the disease has convulsions, disturbance of consciousness, trauma, medication, with or without metabolic diseases, blood diseases, intelligence Developmental disorders, general examination should pay attention to cardiovascular symptoms (heart murmur, blood pressure, skull and neck vascular murmur), skin with or without hemangioma, pigment abnormalities (neurofibromatosis), nodular sclerosis, other rash (Fabry disease), The neurological examination should include fundus examination (bleeding, edema, pigment abnormalities), and the infarct site should be distinguished according to neurological symptoms, whether it is the internal carotid artery system or the vertebrobasilar artery, whether it is a trunk or a branch. Based on the above preliminary results, a further examination method is selected.

Differential diagnosis

1. Identification of the cause of acute hemiplegia in children

There are many reasons for acute hemiplegia in children. The cause should be determined according to medical history, physical signs, seizure characteristics, increased intracranial pressure, cardiovascular signs, EEG and imaging examinations and other auxiliary examinations. First, consider whether there is special treatment available. Disease, so as to deal with early, such as bacterial meningitis, abscess, tumor, epidural or subdural hematoma, intracerebral hematoma, etc., if cerebral infarction symptoms with heart and kidney vascular disease, encephalopathy, recurrence tendency and immune inflammation mark Should consider autoimmune cerebrovascular disease, such as history of trauma, head and neck pain, pupillary Horna disease, may consider carotid dissection aneurysm, hemiplegia recurrence, progressive cognitive impairment, should be excluded from moyamoya disease, fever, full Brain symptoms, meningeal irritation, bacterial or viral infection should be considered. Todd paralysis after partial seizures should be short-lived, and should be differentiated from acute hemiplegia in children. Acute cerebral infarction caused by hereditary metabolic diseases can be family history. Diagnosis by biochemical examination, late onset of stroke after varicella virus infection, the first symptom of HIV infection may be expressed as brain Stroke.

2. alternating hemiplegia

Is left, right hemiplegia alternately, often suggesting diffuse vascular disease, such as moyamoya disease, vasculitis, etc., also seen in hemiplegia type migraine, hemiplegia type seizures, brain demyelinating disease, etc., hemiplegia type migraine attack There is a local reduction in cerebral blood flow, which may have transient vasospasm. There are two different situations of convulsions and hemiplegia. One is the transient paralysis of the limbs twitching after seizures. At this time, the corresponding regional cerebral blood flow is reduced. After a few minutes to a few days, it is completely recovered, called Todd's palsy. The nature of the other case is still controversial. Some people think it is a "hemiplegic seizure". When the attack occurs, the EEG shows a contralateral slow wave in the contralateral cerebral hemisphere. The cerebral blood flow in this area was increased by SPECT, and the CT examination was normal. Therefore, hemiplegia was considered to be a manifestation of seizure. In addition, there was an idiopathic alternating hemiplegia of childhood. The cause was unknown and sporadic. Or hereditary, some related to migraine, onset in infancy, repeated hemiplegia, alternating left and right side, the course of the disease is mostly chronic, but The case can be naturally relieved after several years. In addition to hemiplegia, idiopathic alternating hemiplegia may also have dystonia, dance hand and foot, ataxia, nystagmus, autonomic symptoms, seizures, etc. With mental retardation, treatment with calcium channel blockers (flunarizine) has a certain effect.

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