I. Background

  1. Right hemisphere is nondominant in most patients
  2. Left Hemiplegia differs from Right Hemiplegia
    1. Cortical function only
    2. Subcortical, Brainstem and spinal cord are the same

II. Symptoms

  1. Left sided weakness or paralysis

III. Signs: Right Cortical (nondominant)

  1. Inattention
    1. Left sided neglect (body, room, picture)
    2. Bilateral simultaneous sensory testing
    3. Bilateral simultaneous visual field testing
  2. Denial
    1. Patient denies that anything is wrong
    2. Patient is not concerned that he is paralyzed
  3. Constructional Apraxias
    1. Draw a clock and fill in the numbers
    2. Copy a diagram of a cube
  4. Difficulty dressing (Dressing Apraxia)
  5. Spatial Disorientation
    1. Navigate a hallway from waiting room to exam room
    2. Picture analysis
    3. Local travel
  6. Task impersistence
    1. Protrude Tongue and maintain phonation ("ahhh")
  7. Acute confusional state
  8. Distribution of deficit
    1. Left face and arm most affected
      1. Middle Cerebral Artery CVA
    2. Left leg more involved
      1. Anterior Cerebral Artery CVA
  9. Eye Deviation look right in cortical Left Hemiplegia
    1. Eyes look at involved hemisphere
    2. Eyes look away from the Hemiparesis
  10. Visual Field deficit (also seen in subcortical lesion)

IV. Signs: Right Subcortical Lesion

  1. Involved regions
    1. Internal Capsule
    2. Basal ganglia (Globus pallidus, putamen)
    3. Thalamus
  2. Left face, arm and leg equally affected
    1. Suggests internal capsule lesion
  3. Dystonic Postures
    1. Suggests basal ganglia lesions
  4. Dense sensory loss on left side
    1. Pain and Touch Sensation lost in face and extremities
    2. Suggests thalamic lesion
  5. Visual field deficit (also seen in cortical lesions)

V. Signs: Right Brainstem

  1. Crossed Hemiplegia
    1. Right-sided dysmetria
    2. Right Cranial Nerve palsy at level of lesion
  2. Cerebellar signs
    1. Right Finger to nose ataxia
    2. Difficult rapid alternating movements of Right hand
    3. Difficult heel-toe walking (tandem walking)
      1. Foot clumsy
  3. Nystagmus on looking toward the lesion (right)
  4. Right ear Hearing Loss
  5. Sensory loss
    1. Right face sensory loss (descending CN 5)
      1. Loss of right pain and Temperature sensation
      2. Loss of right Corneal reflex
    2. Left body sensory loss
      1. Loss of Left extremity pain and Temperature sense
    3. Dysarthria and Dysphagia
      1. Distinguish from Pseudobulbar palsy (higher lesion)
  6. Abnormal eye movements
    1. Difficulty gazing right
    2. Right eye difficulty crossing midline to look left
  7. Tongue deviation to right past midline (right CN 12)
    1. Left hypoglossus muscle overpowers weak right muscle

VI. Signs: Right Spinal cord lesion

  1. Face is not involved
  2. Cranial Nerves are not involved
  3. Left sided paralysis
  4. Right Temperature and pain sense loss
    1. Brown-Sequard Syndrome
    2. Sensory Level may be identified
  5. Bladder or bowel dysfunction

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