C H A P T E R

Approach to a Patient with

27 Hemiplegia and Monoplegia

Sudhir Kumar, Subhash Kaul

INTRODUCTION 4. Injury to multiple cervical nerve roots.

Monoplegia and hemiplegia are common neurological 5. Functional or psychogenic.
symptoms in patients presenting to the emergency
department as well as outpatient department. Insidious onset, gradually progressive monoplegia
affecting lower limb can be caused by the following
Monoplegia refers to weakness of one limb (either arm or conditions:
leg) and hemiplegia refers to weakness of one arm and leg
on the same side of body (either left or right side). 1. Tumor of the contralateral frontal lobe.

There are a variety of underlying causes for monoplegia 2. Tumor of spinal cord at thoracic or lumbar level.
and hemiplegia. The causes differ in different age groups. 3. Chronic infection of brain (frontal lobe) or spinal
The causes also differ depending on the onset, progression cord (thoracic or lumbar level), such as tuberculous.
and duration of weakness. Therefore, one needs to
adopt a systematic approach during history taking and 4. Lumbosacral-plexopathy, due to diabetes mellitus.
examination in order to arrive at the correct diagnosis. Insidious onset, gradually progressive monoplegia,
Appropriate investigations after these would confirm the affecting upper limb, can be caused by one of the following
diagnosis. conditions:
The aim of this chapter is to systematically look at the 1. Tumor of the contralateral parietal lobe.
differential diagnosis of monoplegia and hemiplegia
and outline the approach needed to pinpoint the exact 2. Compressive lesion (tumor, large disc, etc) in
underlying cause. cervical cord region.
3. Chronic infection of the brain (parietal lobe) or
APPROACH TO THE DIAGNOSIS OF MONOPLEGIA spinal cord (cervical region), such as tuberculous.
Causes of Monoplegia
The causes can be classified on the basis of onset- acute 4. Tumor of the brachial plexus.
or chronic; and involvement of the limb (lower or upper). Causes of hemiplegia
Acute onset monoplegia affecting the lower limb can be Acute onset hemiplegia can be caused by one of the
caused by one of the following conditions: following conditions:
1. Stroke- affecting anterior cerebral artery territory. 1. Ischemic or hemorrhagic stroke, affecting
contralateral cerebral hemisphere, internal capsule,
2. Cerebral venous sinus thrombosis, affecting brainstem or ipsilateral upper cervical cord.
superior sagittal sinus.
2. Cerebral venous sinus thrombosis with venous
3. Trauma-head injury, with contusion in the frontal infarction of contralateral cerebral hemisphere.
lobe.
3. Acute central nervous system infection, such
4. Infection, such as granuloma affecting frontal lobe. as meningitis or encephalitis, brain abscess,
5. Trauma to the lumbo-sacral plexus, diabetic lumbo- granulomatous infections.
sacral plexopathy. 4. Head injury, causing contusion/bleeding in the
6. Functional or psychogenic. contralateral cerebral hemisphere, internal capsule,
basal ganglia, or brainstem.
Acute onset monoplegia affecting upper limb can be
caused by the following conditions: 5. Bleeding into a brain tumor on the contralateral
side.
1. Stroke, affecting superior division of contralateral
middle cerebral artery territory, affecting parietal 6. Demyelinating illness, such as ADEM (acute
lobe, or unpaired anterior cerebral artery. disseminated encephalomyelitis) or MS (multiple
sclerosis).
2. Head injury, with contusion in the parietal lobe.
7. Todd’s paresis.
3. Trauma to the brachial plexus.
 142 8. Metabolic derangements, such as hypoglycemia, The clue towards a likely vascular cause is the sudden
hyperglycemia or hyponatremia. onset of weakness, and the exact time of onset of
weakness can be obtained from the history. The exception
9. Functional or psychogenic.
includes “wake up strokes”, where the patient goes to
Insidious onset, gradually progressive hemiplegia can be sleep without any deficits and wakes up with a new onset
caused by one of the following conditions: weakness of the leg.
1. Brain tumor, affecting cerebral hemisphere, internal The diagnosis of stroke can be confirmed by doing a
capsule, basal ganglia or brainstem. computerized tomography (CT) scan. Hemorrhage
or bleeding is easily picked up on the CT scan. Acute
2. Tumor of the spinal cord in cervical region.
infarction may be missed on the CT scan during initial
3. Chronic infections of the brain, such as tuberculosis, few hours. Therefore, magnetic resonance imaging (MRI)
hydatid cysts, etc. with diffusion-weighted imaging is the modality of choice
NEUROLOGY

4. Mill’s hemiplegic variant of motor neuron disease for diagnosis of acute ischemic stroke causing isolated
(MND). monoparesis.[4]

Above, we have seen the list of differential diagnosis for Acute onset weakness of contralateral leg can also
acute onset as well as insidious onset, gradually progressive occur with cerebral venous sinus thrombosis (CVST)
conditions causing monoplegia and hemiplegia. The with venous infarction affecting medial frontal lobe.
list mentions the most common causes encountered in Weakness of contralateral leg can also rarely occur due
routine clinical practice, and rare conditions have not to granulomatous infections affecting the medial frontal
been listed. Still, there are a lot of conditions/diseases lobe and head injury causing contusion/hemorrhage of
to be considered while evaluating a case. Therefore, it is the precentral gyrus.[5]
important to tailor the history and clinical examination to In peripheral nervous system, involvement of lumbosacral
arrive at the correct diagnosis. A thorough history taking plexus (lumbo-sacral plexopathy) is the commonest cause
and examination would also lead us to order appropriate of acute onset unilateral lower limb weakness. The most
investigations, in order to clinch the diagnosis. characteristic feature of lumbo-sacral plexopathy is the
In the subsequent sections, we would discuss in detail presence of pain along with weakness of the lower limb.
about the approach to monoplegia and hemiplegia. For Pain may be severe and poorly localized. It is described
ease of discussion, we would separately consider the as lancinating, aching or burning pain. It may involve
acute onset and chronic conditions. thigh, leg and gluteal regions. There is predominant
involvement of proximal group of muscles, as compared
Acute onset monoplegia affecting lower limb to the distal group of muscles. In addition, there may be
In this section, we would consider the conditions that loss of sensations too. Weight loss is noted in most patients.
cause acute onset weakness of the lower limb, evolving Clinical examination would confirm the weakness of
over hours to days. The site of lesion in a patient with proximal group of muscles. If patients present after a few
lower limb weakness can vary from peripheral to central weeks, there may be wasting of thigh and leg muscles.
nervous system. Knee jerk is absent. Ankle jerk may be present, however
it may be sluggish or absent, if the patient has associated
Lesions in the central nervous system more often cause
peripheral neuropathy. The diagnosis of lumbo-sacral
acute onset monoplegia affecting the lower limb. Among
plexopathy can be confirmed by nerve conduction
these, the most common are the vascular syndromes. Leg-
studies and needle electromyography. A clinical clue for
predominant weakness with stroke is due to contralateral
a plexus lesion (as against multiple peripheral nerves
anterior cerebral artery (ACA) infarction in only 25% of
and nerve roots) is the motor and sensory involvement
cases. More often, it is related to lesions in the contralateral
in the distribution of two or more peripheral nerves and
corona radiata or internal capsule, in the territory of the
two or more nerve root territories in the same limb. The
anterior choroidal artery or perforators (30%), or in the
common causes for acute onset lumbo-sacral plexopathy
brainstem (25%) and can occur with lesions in the middle
are diabetes mellitus (also called as Bruns Garland
cerebral artery territory or with thalamic hemorrhage.[1]
syndrome), viral infections, hemorrhage, vasculitis and
Regarding lesions of the medial aspect of the frontal lobe,
trauma. In diabetic lumbo-sacral plexopathy, both lower
those restricted to precentral gyrus of the paracentral
limbs may be affected, however, one side is more affected
lobule cause contralateral leg weakness. In rare cases,
than the other side.
lacunar infarction of the corona radiata can cause
ipsilateral weakness of the leg.[2] This can happen due to Acute onset monoplegia affecting upper limb
anomalous pyramidal fibers with ipsilateral innervation Lesions in the central as well as peripheral nervous system
or due to reorganization of pyramidal fibers due to old can cause acute onset monoplegia affecting upper limb.
stroke. Ipsilateral pure motor monoparesis of the leg
can also rarely occur with lateral medullary infarction. The most common cause of acute onset isolated arm
[3]
This occurs due to involvement of corticospinal tract weakness on one side is stroke. However, it should
fibers innervating the lower limb caudal to pyramidal be noted that it is uncommon for stroke to present
decussation. with isolated arm weakness without associated face
or leg weakness. Stroke presenting with isolated arm evaluating such a case in order to correctly localize and 143
monoparesis may be misdiagnosed as a peripheral nerve diagnose.
disorder, because of absence of pyramidal tract signs or
Tumors of the brain or spinal cord are the common causes
the involvement of the speech, face or lower limbs. Distal
of slowly progressive isolated monoparesis of lower limb.
arm monoparesis is an unusual form of cortical infarct,
The person presents with weakness of one leg, which often
which occurs in the parietal lobe or central sulcus region,
starts distally in the foot, and over a few weeks to months,
comprising less than 1% of stroke cases.[6]
spreads to involve the proximal group of muscles. This is
Again, the acute onset is the key to suspicion of stroke. because the lower limb fibers are located laterally in the
The diagnosis can be confirmed by diffusion-weighted spinal cord. Presence of back pain and radicular pain may
imaging on MRI brain. point towards a spinal cord lesion, most probably a tumor.
Examination, in addition to motor weakness, may reveal
Acute onset monoplegia of upper limb can also occur
loss of sensations in the affected leg. Bladder symptoms
due to peripheral nervous system involvement. The most

CHAPTER 27
are unusual with unilateral leg weakness. Diagnosis is
common cause in this category is brachial plexopathy.
almost always delayed in a case of neoplastic spinal cord
Brachial plexus lesions that can result in acute onset
compression, when the patient presents with unilateral
weakness include injury/trauma, infections, hemorrhage,
leg weakness.[8] However, we need to suspect a spinal
etc. The classical features include arm and shoulder pain,
cord compression even in the absence of sensory level, as
weakness and sensory disturbances. Weakness affects
23% of cases may present with unilateral weakness.[9] An
proximal group of muscles more than the distal group.
MRI of the spine with contrast is valuable in confirming
Most patients also have wasting of muscles. Deep tendon
the diagnosis of spinal cord tumor. The common spinal
reflexes of the affected upper limb may be sluggish or
cord tumors include meningioma & schwannoma (benign
absent. A clinical involvement in the distribution of more
tumors) and metastases & glioma (malignant tumors).
than two spinal nerves and more than two peripheral
nerves is a strong indicator of brachial plexus lesion. Tumors of the brain affecting precentral gyrus, medial
The diagnosis of brachial plexopathy can be confirmed frontal lobe and paracentral lobule may present with
by doing nerve conduction studies with Erb’s point monoparesis of contralateral leg.
stimulation and needle EMG. MRI is also valuable
Tuberculosis of spine and tuberculous meningitis (TBM)
in diagnosing brachial plexus lesion. An abnormal
can also present with subacute or chronic weakness of
hyperintense signal on MRI suggestive of inflammation
one leg. A case of 37-year old woman is reported where
may be seen in brachial neuritis caused by varicella zoster
she presented with spastic weakness of right leg of six
virus.[7]
years duration.[10] The cause was found to be tuberculous
While evaluating a case of acute onset weakness of leg or syringomyelia, as she had a past history of TBM and had
arm, we must also consider a diagnosis of psychogenic received anti-tuberculous therapy for that.
or functional basis for the same. Psychogenic monoplegia
Among the peripheral nervous system causes, the most
is common in younger people, and is more common in
common cause for unilateral leg weakness would be
women. Detailed history may reveal stress factors related
lumbo-sacral plexopathy. The clinical features of lumbo-
to personal relationships, job or studies in the affected
sacral plexopathy have already been discussed above.
individual. Psychogenic weakness may be associated
The underlying etiology for slowly progressive lumbo-
with primary gain (deriving attention towards illness) and
sacral plexopathy could be metastases, neurofibroma &
secondary gain (avoidance of stress factor). Examination
nerve sheath tumors, infections and diabetes mellitus.
of a patient with psychogenic monoplegia may reveal
inconsistent findings. Power of the affected limb may Slowly progressive monoplegia affecting upper limb
change, when repeatedly tested. Also, if a person with The causes for slowly progressive weakness affecting
psychogenic weakness of leg were made to stand by self, upper limb would be similar to that of lower limb. This
she would avoid injury while falling. Hoover’s sign is would include spinal cord tumors affecting the cervical
very important while examining a person suspected to cord region, and tumors affecting the parietal lobe of
have psychogenic leg weakness. Palm of the examiner’s brain. Similarly, infections such as tuberculosis of these
hand is placed under the heel of patient’s normal leg; and areas could also result in unilateral arm weakness.
the patient is asked to raise the weak leg. In a person with
Among the peripheral nervous system causes, involvement
true weakness, pressure on the palm would be felt due to
of brachial plexus would present with unilateral arm
downward movement of the normal leg, however, in a
weakness. Causes of slowly progressive brachial
person with psychogenic weakness, no such mechanical
plexopathy include tumors, metastases, infections, etc.
pressure is felt on the palm.
Diabetes could also cause brachial plexopathy, though
Slowly progressive monoplegia affecting lower limb the involvement of lumbo-sacral plexus is more common
A variety of conditions can cause insidious onset, slowly with diabetes.[11] In this condition, patients complain of
progressive weakness of one leg. The site of lesion shoulder and arm pain, and there is weakness of hand
causing such isolated progressive weakness of one leg and forearm muscles.
can extend from brain, spinal cord to nerve roots and
Another cause to be considered in a patient presenting
plexus. Therefore, a systematic approach is needed while
 144 with slowly progressive weakness of one limb (upper In the initial period after stroke, upper motor neuron
or lower limb) associated with wasting is monomelic signs are absent. There is hypotonia of affected limbs
amyotrophy.12 The characteristic clinical features and deep tendon reflexes are absent. This state is called
are insidious onset in the second and third decades, as cerebral shock. This state should not be confused with
male preponderance, sporadic occurrence, wasting a lower motor neuron lesion. Presence of aphasia, visual
and weakness confined to one limb, and absence of field defects, cortical sensory loss and extensor plantar
involvement of the cranial nerves, cerebrum, brain stem, response may help in localizing the lesion to cerebral
and sensory system. The electromyographic features, cortex. The typical upper motor neuron signs develop
along with histologic features of neurogenic atrophy, after a few days of stroke onset.
are suggestive of an anterior horn cell lesion. The slow
A note should be made of the cranial nerve involvement.
progression of illness for two to four years followed by a
Cranial nerve involvement on the same side of hemiplegia
stationary phase is observed. There is no clinical evidence
localizes the lesion to the cerebral cortex or internal
of involvement of the other three limbs even in patients
NEUROLOGY

capsule. Whereas, involvement of cranial nerves on the

with long-standing illness of ten to 15 years’ duration.
side opposite to that of hemiplegia (crossed hemiplegia),
Monomelic amyotrophy affecting upper limb is also
localizes the lesion to the brainstem.[14] In brainstem, the
called as Hirayama disease. MRI cervical spine in these
localization depends on the cranial nerve involvement.
cases show asymmetrical lower cervical cord atrophy in
Third cranial nerve involvement along with contralateral
about half the cases.[13]
hemiplegia localizes the lesion to the midbrain (Weber’s
Acute onset hemiplegia syndrome). Involvement of sixth and seventh cranial
Acute onset hemiplegia is among the commonest nerves along with contralateral hemiplegia localizes
presentations in the emergency department. The the lesion to pons. Ipsilateral hypoglossal palsy and
underlying cause of acute hemiplegia can be varied, contralateral hemiplegia localizes the lesion to medial
however, brain stroke remains the commonest cause. medulla.[15]
Also, it is of utmost importance to make a quick diagnosis Acute onset hemiplegia may also occur due to spinal cord
of acute ischemic stroke, as the only approved therapy small infarctions in the upper cervical cord. Hemiplegia
for acute stroke (thrombolytic therapy with tissue in these cases is on the side of lesion. Sensory examination
plasminogen activator) can be given only within the first may also reveal ipsilateral loss of joint position and
four and half hours after stroke onset. vibratory sensations, and pain and temperature
The most important consideration in the diagnosis of impairment on the contralateral side.[16] The artery
stroke is the abruptness of onset of symptoms. The affected is usually anterior spinal artery.
typical history of a patient with stroke could be as per In a patient suspected to have stroke, MRI brain or
the described case here: “Mr KS went for a morning walk spinal cord (as per the clinical findings) is the imaging
as usual and returned in half an hour. He sat down in modality of choice for confirming the diagnosis. Diffusion
balcony reading a newspaper and having a cup of tea. All weighted sequences are the most preferred and valuable
of a sudden, the newspaper fell off his right hand, and he in detecting acute infarcts.
could not hold the cup of tea. He slumped off the chair
to the ground. He could not use his right hand or leg. He Bleeding into a tumor in brain is another cause of acute
tried calling for his wife but could not.” This is the typical hemiplegia. History of headache for a few weeks to
history of a patient with stroke in left middle cerebral months may point towards a neoplastic etiology. The
artery (MCA) territory. In fact, the commonest site of tumor may be located in cerebral cortex, basal ganglia,
arterial occlusion in a patient with hemiplegia is MCA thalamus or brainstem. CT or MRI scan of brain would
territory. It is also important to enquire about the history confirm the diagnosis.
of transient ischemic attacks (TIAs), as several patients In addition, we also need to consider demyelinating
would have had one or more TIA in previous 30 days. illnesses and infections as the alternative possible causes
The risk factors for stroke such as diabetes, hypertension, for acute onset hemiplegia. Among demyelinating
dyslipidemia, hyperhomocystinemia, cardiac disease and illnesses, acute disseminated encephalomyelitis (ADEM)
smoking should also be looked into. An enquiry about is more common. ADEM is known to present as acute
any accompanying symptoms should also be made. For onset hemiplegia, and may mimic stroke.[17] Patients
example, presence of aphasia localizes the site of occlusion with ADEM are relatively younger & healthy, and may
to left MCA territory. give a history of fever two weeks prior to the onset of
When upper and lower limbs are equally affected, it is hemiplegia. MRI brain is helpful in differentiating ADEM
called as dense hemiplegia, and is typical of infarcts in from MS and brain stroke.
internal capsule. Motor power is usually grade 0 or 1. On In our country, cerebral venous sinus thrombosis (CVST)
the other hand, unequal involvement of limbs point to a is another important diagnostic consideration in patients
lesion in cerebral cortex. Upper limbs are more affected with acute onset hemiplegia. Almost always, patients
than the lower limbs in a MCA territory infarction, complain of headache for a few days preceding the
whereas lower limbs are more affected than the upper hemiplegia. Most patients are young and the risk factors
limbs in ACA territory infarction. may be present. These include pregnancy, post-partum
period, use of hormonal pills, nephrotic syndrome, Slowly progressive hemiplegia 145
hypercoagulable states, etc. MRI with MR venogram of In a patient presenting with insidious onset and slowly
brain would confirm the diagnosis. Hemiplegia in CVST progressive hemiplegia, brain tumors are the most
usually occurs due to hemorrhagic infarctions in the important consideration. In a series on brain tumors
cerebral cortex. presenting to ER, about 25% of them had hemiparesis.[23]
Infections such as herpes encephalitis and tuberculous Patients may complain of headache of raised intracranial
meningitis (TBM) can also rarely cause acute-onset tension type. Headaches are worse on awakening and are
hemiplegia mimicking stroke. In patients with herpes associated with projectile vomiting. There may be visual
encephalitis, sudden onset stroke-like hemiparesis has obscuration at the peak of headaches. CT or MRI brain
been reported.[18] In suspected case of TBM, patient may scan with contrast should be performed in suspected cases
complain of sudden onset hemiplegia, often due to to confirm the diagnosis. The commonest brain tumors
vasculitis affecting TBM. The commonest artery affected are metastases and gliomas. Other tumors that can cause
hemiparesis are lymphoma, meningioma, neurofibroma,

CHAPTER 27
in TBM is MCA. Hemiplegia has also been reported
with dengue and falciparum malaria. An infective cause etc. The location of tumor can be in cerebral cortex, basal
should be suspected when the patient with hemiplegia ganglia, thalamus, and brainstem.
has a fever. Appropriate investigations should be done to We must also consider infections such as tuberculoma in a
confirm or exclude these infections in a patient presenting patient with slowly progressive hemiplegia. Hemiplegia
with hemiplegia. may also be an initial manifestation of CNS tuberculosis.
Enquiry should be made about any episode of seizure
[24]
It is important to suspect a diagnosis of tuberculosis,
prior to the onset of hemiplegia. The most common cause if the patient has fever, headache and weight loss as the
of hemiplegia after a seizure could be Todd’s paresis. symptoms. Institution of anti-tuberculous treatment
Todd’s paresis may occur after a generalized or partial may reverse the hemiparesis. Neurosarcoidosis can
seizure, however, it is more common after a generalized also present with various neurological manifestations,
seizure. The weakness usually lasts for a few hours, including hemiparesis.[25]
however, it may last for upto 36 hours in some cases.[19] We should also consider a diagnosis of Mill’s variant of
Weakness may occur after the first seizure or after many amyotrophic lateral sclerosis in a person presenting with
years of seizures and does not appear after every seizure. slowly progressive hemiplegia.[26] Pure motor system
It should be noted that seizure might also occur in the is affected, with sparing of sensory and autonomic
setting of brain stroke, where it is more common with symptoms. Clinical examination would reveal a
embolic strokes and venous sinus thrombosis. combination of lower and upper motor neuron signs.
Metabolic derangements should also be kept in mind Needle EMG would confirm the diagnosis.
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