Background
1. Left hemisphere usually dominant for speech
  1. Nearly all right hand dominant patients
  2. Most left hand dominant patients
2. Right Hemiplegia differs from Left Hemiplegia
  1. Cortical function only
  2. Subcortical, brainstem and spinal cord are the same
Symptoms
1. Right sided weakness or paralysis
2. Seizure in distribution of weakness
Signs: Left Cortical Lesion
1. Aphasia
  1. Object Naming (pen, watch, tie)
  2. Repeat sentence ("no ifs ands or buts")
  3. Reading and comprehension of a magazine article
  4. Aphasic errors on spontaneous speech
2. Cortical sensory loss
  1. Position sense
  2. Point localization
  3. Stereognosis
  4. Graphesthesia
3. Distribution of deficit
  1. Right face and arm most affected
    1. Middle Cerebral Artery CVA
  2. Right leg more involved
    1. Anterior Cerebral Artery CVA
4. Eye deviation look left in cortical right Hemiplegia
  1. Eyes look at involved hemisphere
  2. Eyes look away from the Hemiparesis
5. Visual Field deficit (also seen in subcortical lesion)
Signs: Left Subcortical Lesion
1. Involved regions
  1. Internal Capsule
  2. Basal ganglia (Globus pallidus, putamen)
  3. Thalamus
2. Right face, arm and leg equally affected
  1. Suggests internal capsule lesion
3. Dystonic postures
  1. Suggests basal ganglia lesions
4. Dense sensory loss on right side
  1. Pain and touch sensation lost in face and extremities
  2. Suggests thalamic lesion
5. Visual field deficit (also seen in cortical lesions)
Signs: Left Brainstem
1. Crossed Hemiplegia
  1. Left-sided dysmetria
  2. Left Cranial Nerve palsy at level of lesion
2. Cerebellar signs
  1. Left Finger to nose ataxia
  2. Difficult rapid alternating movements of left hand
  3. Difficult heel-toe walking (tandem walking)
    1. Left foot clumsy
3. Nystagmus on looking toward the lesion (left)
4. Left ear Hearing Loss
5. Sensory loss
  1. Left face sensory loss (descending CN 5)
    1. Loss of left pain and temperature sensation
    2. Loss of left Corneal reflex
  2. Right body sensory loss
    1. Loss of right extremity pain and temperature sense
  3. Dysarthria and Dysphagia
    1. Distinguish from Pseudobulbar palsy (higher lesion)
6. Abnormal eye movements
  1. Difficulty gazing left
  2. Left eye difficulty crossing midline to look right
7. Tongue deviation to left past midline (Left CN 12)
  1. Right hypoglossus muscle overpowers weak left muscle
Signs: Right Spinal cord lesion
1. Face is not involved
2. Cranial Nerves are not involved
3. Right sided paralysis
4. Left temperature and pain sense loss
  1. Brown-Sequard Syndrome
  2. Sensory level may be identified
5. Bladder or bowel dysfunction

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This page was written by Scott Moses, MD. This page was last revised before 5/10/08, prior to consistent tracking of revision date. This page was last published on 5/10/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 6.0.