Blunt trauma to the carotid artery

Non-penetrating trauma to the internal carotid artery presenting as an immediate or delayed neurological deficit is an uncommon clinical entity. It has a high reported morbidity and mortality. Three cases are presented with long-term clinical and radiological follow-up. The mechanisms of injury, clinical features and possible treatment modalities are discussed.

Thalamic bleeding: clinico-computed tomographic correlations

A series of 22 patients with thalamic bleeding with CT confirmation is reported. Sixteen patients had hypertension and 7 experienced headaches and vomiting. Twenty patients had hemiparesis, and 14 had hemianesthesia. More than half the cases had hematomas in the posterior thalamus. Twenty-one had hematomas less than 3 cm. No patient displayed the characteristic pupil signs. One patient died and mortality rate was 4.5% (died from respiratory arrest). None of the 7 patients who had ventricular rupture died, indicating that the prognosis of the patients may not be affected by the ventricular extension.

Chronic focal encephalitis (Rasmussen syndrome): six cases

Six of 81 (7.4%) patients with medically intractable epilepsy treated by selective cortical excision at The Hospital for Sick Children, Toronto, Canada, since 1974 were found to have inflammatory changes in the excised specimens of cerebral cortex. The clinical and histopathological findings in these cases resemble the chronic encephalitic syndrome described by Rasmussen. We confirm the unsatisfactory seizure control and the guarded neurological and intellectual prognosis that has been associated with Rasmussen syndrome.

Bobath axillary support for adults with hemiplegia. A biomechanical analysis

The purpose of this article is to report on a simple biomechanical analysis of the effects of an axillary support on shoulder subluxation. The underlying postulate was that an axillary support always is accompanied by an increase in shoulder abduction. The immediate effect of axillary support, as confirmed by roentgenograms, was a partial reduction of inferior subluxation and a decrease in the magnitude of the vertical component of the internal resultant force on the shoulder. After the axillary support was applied, the total force acting on the shoulder tissues increased with the abduction angle. The results of this study indicate that the axillary roll size and position and the stabilizing strap tension should be adjusted to the patient's specific problem or problems. This article provides a simple method to estimate, in a given patient, the magnitude and the direction of the forces involved in axillary support.

Parietal ataxic hemiparesis

Ataxia in the parietal lobe is rarely described. A case of ataxia hemiparesis due to a parietal lobe infarction is described and pathophysiology is discussed.

A multi-centre, double-blind trial of tizanidine, a new antispastic agent, in spasticity associated with hemiplegia

A double-blind study was carried out in 105 patients with chronic spasticity associated with hemiplegia in order to compare the efficacy and tolerability of tizanidine with that of diazepam. Dosage was increased progressively, if tolerated, to a maximum of 24 mg tizanidine or 30 mg diazepam per day at the end of 2 weeks. The optimum dosage was then maintained for 6 weeks. Efficacy and tolerability parameters were assessed after 2 and 8-weeks' therapy. Patients on tizanidine but not those on diazepam showed a statistically significant improvement in functional status, as assessed by walking distance on flat ground. Analysis of the stretch reflex in four groups of muscles showed that both tizanidine and diazepam reduced the duration of contractions and increased the angle at which contraction occurred, but there were no significant differences between the two drugs. Clonus of the triceps surae resolved in 48% of tizanidine and 40% of diazepam patients. Evaluation of the effect of therapy revealed an improvement with each drug in approximately 83% of patients, with the overall evaluation being slightly (but non-significantly) in favour of tizanidine. There were fewer discontinuations of treatment in the tizanidine group as a result of side-effects. It would appear, therefore, that tizanidine is an effective and well-tolerated drug in the treatment of cerebral spasticity.

Rotation of the scapula and shoulder subluxation in hemiplegia

Inferior subluxation of the shoulder in hemiplegia was measured using a tridimensional (3-D) x-ray technique. This technique gave the true vertical distance separating the apex of the humeral head and the inferior margin of the glenoid cavity. Both shoulders of each subject were evaluated and the difference used as a measure of subluxation. This measure was then compared to the orientation of the scapula relative to the vertical, to the abduction, and to the relative abduction of the arm. Relative abduction is defined as the angle between the humerus and the glenoid fossa. It has been suggested that these factors are associated with inferior subluxation in hemiplegia. Results of this study of 50 volunteer stroke patients indicated that the affected and nonaffected shoulders were different (subluxed) in terms of the vertical position of the humerus vis-à-vis the scapula. The orientation of the glenoid cavities was also different, the subluxed one facing less downward. The angle of abduction of the arm of the affected side was significantly greater than on the nonaffected side, but the relative abduction of the arm was on the same order of magnitude for both sides. There was no significant relationship between the orientation of the scapula and the severity of the subluxation. The abduction of the humerus was weakly (r = .24) related to the subluxation, which partly explained the weak association found between the relative abduction of the arm and the subluxation. It was concluded that the position of the scapula and the relative abduction of the arm cannot be considered important factors in the occurrence of inferior subluxation in hemiplegia.

Shoulder subluxation in hemiplegia: a radiologic correlational study

A tridimensional (3-D) x-ray method of evaluation of the shoulder was contrasted with six clinical and radiologic techniques used to evaluate shoulder subluxation, in 50 hemiplegic subjects. The 3-D evaluation is obtained through a mathematical computation associating two x-rays of the same shoulder, one taken at 0 degree (anteroposterior) and the other at a 45 degrees oblique view. A vector is thus obtained quantifying the separation from the apex of the humeral head to the inferior border of the glenoid fossa. The Y component (cephalocaudal) of this vector is used to represent the inferior displacement of the humeral head. The six other techniques of evaluation were: a) palpation, or the number of finger breadths inserted between the acromial process and the head of the humerus; b) anthropometry, or the distance between the acromial process and the lateral epicondyle of the humerus; c) templates, or the use of four schemas representing different degrees of separation of the humeral head from the glenoid fossa; d) a measure of the relation of the center of the humeral head to the center of the glenoid fossa; e) the vertical distance between the center of the humeral head and the center of the glenoid fossa; and f) the vertical distance between the apex of the humeral head and the inferior border of the glenoid fossa. Correlation coefficients contrasting the 3-D x-ray technique and the six other measures ranged from .738 to .995. The high level of precision and reliability of the 3-D measure indirectly validated the other measurement techniques.

Mechanical energy patterns in gait of cerebral palsied children with hemiplegia

The mechanical energy costs of walking were studied in 10 cerebral palsied children with hemiplegia to determine whether their values were substantially different from normal and, if so, to discover the movements that were responsible. A two-dimensional, sagittal-plane cinematographic analysis of the subjects' normal walking was undertaken. This technique provided continuous information about the mechanical energy costs of the whole body and each of its parts, the energy types involved, and the amounts of energy conserved. In most cases, the energy costs were above normal and were attributable to poor patterns of exchange between the potential and kinetic energy types of the head, arms, and trunk segment; to very low levels of kinetic energy that precluded exchange; or to both. We concluded that attention should be directed to restoring the sinusoidal pattern of motion and to the fluctuating speeds during each gait cycle when energy costs are a therapeutic consideration.

Focal ischaemia caused by instability of cerebrovascular tone during attacks of hemiplegic migraine. A regional cerebral blood flow study

During the course of hemiplegic migraine in 3 patients, changes in regional cerebral blood flow (rCBF) were recorded by the intracarotid 133Xe method and a 254 multidetector camera covering one hemisphere. The rCBF measurements were performed in conjunction with cerebral angiography. During repeated rCBF measurements all 3 patients developed focal hypoperfusion originating in the frontal lobe, subsequently spreading posteriorly to involve the precentral and postcentral regions. In 2 cases focal hyperperfusion appeared to precede the hypoperfusion. In association with the rCBF changes the patients developed transient motor and/or sensory deficits and subsequently severe headache. No signs of arterial occlusion were found. In the over and underperfused regions blood flow fluctuated rapidly because of instability of cerebrovascular tone, defined as transient constriction of the smallest cerebral vessels (arterioles) alternating with a normal calibre for these vessels and/or short periods of vasodilatation. It is considered to be a primary pathological condition of the vessels. When vasoconstriction was present the blood flow decreased to values consistent with ischaemia, which was probably the cause of the neurological deficits. On the basis of these observations and previous work from our laboratory we conclude that instability of cerebrovascular tone may cause focal ischaemia during the course of attacks of classical and hemiplegic migraine.

Functional electric stimulation to enhance systemic fibrinolytic activity in spinal cord injury patients

Functional electric stimulation (FES) of muscle has been used to decrease the incidence of postoperative deep vein thrombosis (DVT) in neurologically intact individuals. This study was undertaken in order to determine whether a large-scale trial should be initiated using FES to prevent DVT in spinal cord injury (SCI) patients. The goals of this pilot study were to demonstrate the value of FES of calf musculature in (1) increasing plasma fibrinolytic activity and (2) promoting venous blood flow in the lower extremities. Plasma fibrinolytic activity was monitored in ten SCI patients before, immediately after, and 100 minutes after 60 minutes of calf FES. A significant increase in plasma fibrinolytic activity was noted using whole blood and platelet-rich plasma clot lysis assays. Continuous photoplethysmographic and Doppler ultrasound monitoring of venous flow was attempted during FES in four spinal cord patients, and a mild to moderate increase in flow was achieved. FES was not as successful as manual compression in promoting venous emptying of the lower extremity. FES may be a useful tool in the prevention of DVT in SCI patients due to a significant increase in fibrinolytic activity and a mild to moderate increase in venous blood flow. FES merits full-scale clinical evaluation for this purpose.

Rapidly destructive hip disease following ipsilateral hemiparesis: report of two cases

Two patients who developed rapidly destructive arthropathy of the hip following ipsilateral hemiparesis are described. The possible significance of this association is discussed.

Hemiplegia and lower extremity amputation: double disability

A retrospective study of 52 consecutive patients was conducted to determine the influence of certain factors on the ambulatory rehabilitation of patients with hemiplegia and lower extremity amputation. Factors studied included side of hemiplegia, laterality of disability, level of amputation, order of disability (amputation first or hemiplegia first), neuromuscular status, mental status, sex, age. The level of function was defined as independent, limited, or nonambulatory. Of 52 double-disability patients, thirty were fitted with a prosthesis. Eight patients attained independent prosthetic function while 16 patients were limited and six were nonambulatory. Factors such as ipsilateral BK amputation preceding hemiplegia, a good-to-fair neuromuscular status, and an intact mental status have been associated with better functional results. Although producing higher fitting rates, none of these factors has been found in the present study to be associated with statistically higher levels of ambulatory function. A good-to-fair neuromuscular status seemed to be the prime requisite for good ambulation with a prosthesis in a patient with the double disability of amputation and hemiplegia.

Heterotopic ossification in hemiplegia following stroke

Heterotopic ossification is a recognized complication in patients with head injury, burns, paraplegia, or direct trauma to muscle tissue. Heterotopic ossification with hemiplegia following stroke is considered rare. A case of a 53-year-old patient with right hemiplegia who developed painful right hip, limiting range of movement and progress in ambulation, is presented. X-ray and laboratory tests confirmed the presence of heterotopic ossification, suggesting that this condition may not be so rare in patients with a cerebrovascular accident, but may escape recognition, with pain being considered to stem from soft-tissue strain, premorbid arthritis, or altered sensation commonly associated with stroke.

Eales' disease with hemiplegia

A case of Eales' disease with hemiplegia is reported. The patient had a right hemiparesis and a left hemiplegia occurring after a sudden loss of vision in the left eye two years earlier. The diagnosis was based on fluorescein angiography showing neovascularisation, fluorescein leakage, perivascular sheating and hemorrhages and on CT scan showing multiple hypodense lesions in right and left hemispheres and on IDSA showing bilateral occlusion of anterior cerebral arteries. The patient did not have further relapses.

Neuromuscular electrical stimulation of the muscles surrounding the shoulder

Neuromuscular electrical stimulation (NMES) can be used to augment range-of-motion, strengthening, and facilitation treatment programs of the muscles surrounding the shoulder. The purposes of this article are 1) to describe the uses of NMES around the shoulder joint as developed through our clinical use and 2) to detail the effects of an NMES program on chronic shoulder subluxation as determined by a clinical study. Because of the complexities of this multiarticular joint, NMES is most useful in the initial phase of the ROM, and stimulated contractions are compromised, relatively, as the humerus moves above the 90-degree horizontal plane. The use of NMES to provide scapular stabilization often entails unwanted alteration of the pressures on the spinal column, occasionally making the treatment program unusable. Electrical stimulation to prevent or correct shoulder subluxation, especially in the neurologically involved patient, provides the therapist with a powerful new treatment technique. In a group of stroke patients, shoulder subluxation was reduced significantly (p less than .05) at the completion of a six-week NMES program. Some of the problems, and possible solutions, unique to the development of electrical stimulation programs for the shoulder muscles are discussed.

Hemiplegic shoulder pain

This article reviews the literature relevant to the possible causes, prevention, and treatment of hemiplegic shoulder pain. Shoulder pain and stiffness impede the rehabilitation of patients with hemiplegia. The cause of this complication is unknown, but it may be related to the severity of neurological deficits, preexisting or posthemiplegic soft tissue injury, subluxation, brachial plexus injury, or shoulder-hand syndrome. Shoulder pain may be preventable if risk factors can be identified and appropriate prophylaxis applied. Resolution of the condition depends on diagnosis and effective treatment at the onset of the symptoms. More clinical research is needed to clarify the cause of hemiplegic shoulder pain and to document the efficacy of prophylactic and treatment methods.