Spastic hemiplegia is a form of cerebral palsy (cerebral palsy), in which there is a lesion of half of the body. The condition is manifested by paralysis of the arm and leg on the one hand, severe cognitive impairment, pathological motor stereotype. Less often, the injuries are bilateral, and hemiplegia is double. The disease is diagnosed by the results of neurological examination, neuroimaging by ultrasound, MRI and CT, electrophysiological examination. Complex treatment includes taking medications, methods of physical rehabilitation. orthopedic correction.
ICD 10
G81.1 Spastic hemiplegia
General information
The hemiplegic (hemiparetic) variant of cerebral palsy accounts for about 30% of all cases of the disease, second only to spastic diplegia, which occupies up to 40% in the structure of morbidity. In a separate form, double spastic hemiplegia is distinguished — the most severe variant of the disease, which in fact is tetraparesis. The overall incidence of cerebral palsy in the United States is 2.2-3.3 cases per 1,000 live-born newborns without a downward trend.
Causes
Spastic hemiplegia is a polyetiological disease that occurs with the combined action of negative prenatal, intranatal and postnatal factors, and intrauterine brain damage accounts for up to 80% of the causes of cerebral palsy. The disease is caused by unilateral (sometimes bilateral, that is, double) cerebral damage. In modern neurology, more than 400 causes of cerebral palsy have been described, among which the following types are the most significant:
- Premature birth. The condition is determined in 1% of premature babies, whereas in full-term babies it is 3-10 times less common. The weight of the baby at birth is of great importance: with a body weight of 1.5-2.5 kg, pathology is diagnosed in 5-15% of patients, and with a weight below 1.5 kg — in 25-30% of cases.
- Head injuries. Intracranial injuries sustained during childbirth are a typical cause of cerebral palsy in children. A high risk of spastic-plegic disorders exists with postpartum asphyxia due to the complicated course of labor. However, up to 75% of patients with birth trauma in the past have other risk factors for cerebral palsy.
- Pathology of pregnancy. The risk of developing spastic, including double, hemiplegia increases if there is a history of abnormalities of placental circulation, presentation or placental abruption, immunological conflict of mother and fetus. Extragenital diseases of the mother, taking neurotoxic drugs during pregnancy also have a negative impact.
- Burdened heredity. Progressive spastic forms of cerebral palsy, especially double hemiplegia, may be a manifestation of undifferentiated genetic syndromes. The doctor should be alerted by the presence in the family history of cases of miscarriage, infant deaths, the birth of children with congenital anomalies.
- Postnatal factors. The causes of spastic hemiparesis can be strokes, baby shaking syndrome, severe forms of encephalitis and meningitis. More rare provoking factors include intoxication, episodes of brain hypoxia, nuclear jaundice.
Pathogenesis
The pathomorphological basis of the condition in premature newborns is periventricular hemorrhagic infarction of the brain or congenital cerebral anomalies (schizencephaly). In full-term infants, the direct cause of the disease is ischemic heart attacks, intracerebral hemorrhages due to birth trauma. Double hemiplegia occurs with bilateral damage to brain tissues.
As a result of an organic cerebral defect, muscle tone increases, which leads to violations of the formation of rectifying reflexes. With unilateral injuries, changes affect only the contralateral (opposite to the lesion) side of the body, which is due to the structural features of the motor pathways. Spastic double hemiplegia is usually accompanied by signs of cranial nerve pathology.
Symptoms
With the disease, as a rule, paresis or paralysis of the upper and lower extremities on one side are noted. More often, with cerebral palsy, the muscles of the arm are involved in the process, the leg partially retains its functionality. Double hemiplegia is manifested by total paresis of all limbs, which is why patients from an early age are unable to move independently, are extremely limited in arbitrary movements.
Signs of a hemiplegic variant of cerebral palsy appear mainly in the first year of a child’s life. There is a noticeable lag in physical development, lack of skills characteristic of a certain age (holding the head, sitting, crawling, walking). When parents try to put the child on his feet, he relies only on his fingers, not on a full foot, and transfers weight to a healthy leg. The lag of paretic limbs in growth is gradually getting worse.
The motor stereotype in patients with cerebral palsy with spastic hemiplegic disorders has a number of features. Pathological tonic reflexes that increase in an upright position, synkinetic activity with arbitrary movements, disorders of the coordination interaction of antagonist muscles are determined. Also typical is increased reflex excitability — the startle reflex.
Many patients have cognitive impairment: mental retardation of varying severity, learning disabilities, general mental retardation. Intellectual decline is aggravated by speech disorders, hearing loss, visual impairments, which together causes significant social maladaptation. Often, convulsive syndrome is detected in patients with spastic cerebral palsy.
Complications
Constant muscle tension and disproportionate development of the limbs results in severe joint contractures, lateral deformation of the spine, and a change in the shape of the chest. Pathological processes aggravate motor deficits, therefore, over time, patients lose the ability to move independently, they cannot perform purposeful movements. Cerebral palsy is often combined with chronic pain syndrome.
With cerebral palsy, gastrointestinal pathologies are often bothered: dysphagia, gastroesophageal reflux disease, intestinal motility disorders. Patients often face dental problems: enamel hypoplasia, malocclusion, bruxism. The condition is accompanied by hypotrophy, which leads to a lag in bone age, false microcephaly, calciopenia.
Diagnostics
A clinical assessment of the neurological status reveals pathological muscular dystonia, a decrease in the volume of voluntary motor activity on half of the body. When a total paresis is detected, a double form of lesion is diagnosed. At an appointment with a neurologist, the state of mental development and the level of cognitive skills are examined. Instrumental and laboratory methods are used to confirm the diagnosis:
- Neuroimaging. In children of the first year of life, neurosonography is prescribed for the study of brain matter, in older age CT or MRI is mainly used. Neuroimaging helps to determine a possible organic defect of the cerebral tissue, which has become the direct root cause of the disease, including bilateral disorders with a double (tetraplegic) variant of pathology.
- Electrophysiological methods. EEG is recommended in all cases of cerebral palsy accompanied by epileptic seizures. For a detailed study of the state of the musculature and neuromuscular transmission, electromyography and electroneurography are performed.
- Analyzes. With hemiplegia and signs of stroke, an extended study of the parameters of the blood coagulation system is shown on MRI. To exclude hereditary metabolic diseases that may occur with a similar clinical picture, the results of biochemical tests and genetic studies are indicative.
Treatment
The therapeutic approach is based on compliance with the principles of complex multidisciplinary treatment, which involves a team of specialists: neurologists, psychologists, defectologists, kinesiotherapists. Taking into account the numerous complications of cerebral palsy, patients need the help of an orthopedist, an otolaryngologist, an ophthalmologist. The most difficult is the treatment of double paralysis. There are the following areas of therapy:
- Non-drug methods. Dietary therapy is prescribed to correct energy deficiency and hypotrophy, vitamin and mineral complexes are selected according to indications. To improve mobility, normalize muscle tone, special kinesiotherapy programs, therapeutic massage courses are conducted.
- Drug therapy. In the spastic form of paralysis, a good effect is observed from taking oral muscle relaxants, GABA derivatives, benzodiazepine tranquilizers. Botulinum therapy is performed to relieve local spasticity.
- Orthopedic correction. Individually selected orthoses are recommended to ensure independent movement. Double hemiplegia requires the use of multifunctional wheelchairs, special beds. Atlant and Gravistat suits are used for dynamic proprioceptive posture correction.
- Defectological correction. An individual program of classes is assigned to stimulate the mental development of the patient, increase his social adaptation, develop ways to compensate for existing disorders (deafness, blindness).
- Alternative methods. Acupuncture, acupuncture, manual therapy and osteopathy are practiced as auxiliary therapy. In some cases, a positive effect is noted during dolphin therapy, hippotherapy.
Prognosis and prevention
A comprehensive approach to the treatment of unilateral spastic hemiparesis shows a good result in compensating for neurological deficits and socialization of patients, but double hemiplegia has an unfavorable prognosis. Prevention of pathology consists in proper preparation and management of pregnancy, prevention of obstetric injuries, regular supervision of the baby by a pediatrician to monitor physical and mental development.