DIFFERENTIAL

DIAGNOSIS
OF LIMB
WEAKNESS

Prepared by : Onieee @study_with_Onieee

Causes of Limb weakness
Causes of Limb weakness
Weakness
Syndrome
 1.UNILATERAL WEAKNESS, IPSILATERAL
FACE DEMYELINATION (TRANSVERSE
MYELITIS)
Lesion: Contralateral cortex, internal capsule.
Causes:
Stroke(sudden onset),
demyelination/mass (gradual onset).
Symptoms: Neglect, visual field cut, aphasia.
Findings: UMN signs.
Key features: Association with headache suggests
hemorrhage or mass.
 2.UNILATERAL WEAKNESS,
CONTRALATERAL FACE

Lesion: Brainstem.

Causes:
Vertebrobasilar insufficiency, demyelination.

Symptoms:
Dysphagia, dysarthria, diplopia, vertigo nausea/vomiting.

Findings: CN involvement, cerebellar abnormalities.

 3.UNILATERAL WEAKNESS, NO FACIAL
INVOLVEMENT

Lesion: Contralateral medial cerebral cortex, discrete internal capsule

Causes: Stroke

Rare Cause: Brown-Sequard if contralateral hemi body pain and

temperature sensory disturbance
 4.UNILATERAL WEAKNESS SINGLE LIMB
(MONO PARESIS/PLEGIA)

Lesion: Spinal cord, peripheral nerve, NMJ

UMN signs:
Brown-Sequard if contralateral pain and temperature sensory disturbance

LMN signs:
Radiculopathy if associated sensory disturbance
Normal reflexes, normal sensation: Consider NMJ disorder
 5.BILATERAL WEAKNESS OF LOWER
EXTREMITIES (PARAPARESIS/PLEGIA)

Lesion: Spinal cord, peripheral nerve

UMN signs: Anterior cord syndrome (compression,

ischemia, demyelination) if contralateral pain and
temperature sensory disturbance

Cauda equina: Loss of perianal sensation, loss of rectal

tone, or urinary retention

Guillain-Barre syndrome: If no signs of cauda equina

and sensory disturbances paralleling ascending
weakness (with hyporeflexia)
 6.BILATERAL WEAKNESS OF UPPER
EXTREMITIES

Lesion: Central cord syndrome

Causes: Syringomyelia, hyperextension injury

Findings:
Pain and temperature sensory disturbances in upper
extremities (intact proprioception)
 7.BILATERAL WEAKNESS OF ALL FOUR
EXTREMITIES (QUADRIPARESIS/PLEGIA)

Lesion: Cervical spinal cord

Findings:
UMN signs below level of injury,
strength/sensory testing identifies level
 8.BILATERAL WEAKNESS, PROXIMAL
GROUPS

Lesion: Muscle

Causes:
Rhabdomyolysis, polymyositis, dermatomyositis, myopathies

Findings:
Muscle tenderness to palpation, no UMN signs, no sensory disturbances
 9.FACIAL WEAKNESS, UPPER AND LOWER
FACE

Lesion: CNVII (Facial nerve)

Causes:
Bell’s palsy, mastoiditis, parotitis

Other CN involvement suggests:

- brainstem lesion, multiple cranial neuropathies, or NMJ
disease
03
STROKE
 DEFINITION
 CLASSIFICATION
 CAUSES & PATHOPHYSIOLOGY
 INVESTIGATION
 DEFINITION OF STROKE

Stroke is defined as a clinical

syndrome characterized by rapidly
developing clinical symptoms and/or
signs of focal, and at times global, loss
of cerebral function, with symptoms
lasting more than 24 hours or leading
to death, with no apparent cause other
than that of a vascular origin.
 EPIDEMIOLOGY
Stroke is a major cause of mortality and disability in many countries, including Malaysia.
Global stroke estimates study reported that, in 2013, there were approximately 25.7 million stroke
survivors, 6.5 million deaths, 113 million disability-adjusted life-years (DALYs) lost, and 10.3
million new cases of stroke.1

Statistics from the Department of Statistics,

Malaysia showed that stroke emerged as one
of the top five leading causes of mortality
since 2000. Data in 2017 showed that
cerebrovascular diseases contributed to 7.1%
of all mortalities recorded in the Malaysian
population (Table 1.1).

Table 1.1
 Transient Ischaemic Attack
(TIA)
TIA originally had a time-based definition characterized
by an acute loss of focal cerebral or monocular
functions with symptoms lasting less than 24 hours and
which is thought to be due to inadequate cerebral and
ocular blood supply as a result of arterial thrombosis
or embolism. However, a time-based definition is
inadequate because there is risk of permanent tissue
injury (i.e. infarction) even when focal transient
neurologic symptoms last less than one hour.
 CAUSES OF STROKE

\
 1. Atherothrombosis
Atherothrombosis is defined as atherosclerosis with superimposed
thrombosis. Atherosclerosis affects large and medium-sized arteries.

The process begins in childhood as fatty streaks and progresses over

years with gradual build-up of fibrolipid plaque and infiltration of
inflammatory cells. Thrombosis occurs when this atherosclerotic
plaque is disrupted resulting in platelet aggregation.
Atherothrombosis leads to local arterial occlusion with intraluminal
propagation of the thrombus proximally or distally or it can result in
distal embolism.
 2. Intracranial Small Vessel Disease
Intracranial small vessel disease is thought to be due
to lipohyalinosis, microatheroma and fibrinoid
necrosis. The clinical syndrome caused by this
phenomenon is lacunar infarction due to occlusion of
small perforating arteries. Table (2.1) exhibits the
vascular risk factors associated with increased risk of
stroke.

Table 2.1
 3. Embolism
Cardioembolism causes approximately 20% of all ischaemic strokes. Embolic material formed within the heart or large
arteries travels through the arterial system, lodging in a vessel and partially or completely occluding it.

The most common causes are atrial fibrillation and valvular heart disease. Rare causes of embolism include air, fat,
cholesterol, bacteria, and tumour tissues.
 4. Cryptogenic Infarctions
Cryptogenic infarctions or stroke of undetermined etiology are infarctions without a defined cause despite a
complete work up and account for 20-40% of all ischemic stroke.

Possible mechanisms of cryptogenic stroke are :

 Embolism secondary to occult paroxysmal atrial fibrillation

 Paradoxical embolism originating from the systemic venous circulation that enters the arterial circulation
through a patent foramen ovale (PFO)

 Atrial septal defect

 Ventricular septal defect

 Pulmonary arteriovenous malformation

 Sub-stenotic atherosclerosis disease.

 5. Other Causes
Other causes include non-atherosclerotic abnormalities of the cerebral vasculature such as:

• Arterial Dissection

• Fibromuscular Dysplasia

• Vasculitis

• Moyamoya Disease

• Hypercoagulable States

• Metabolic Disorder

• Inherited Conditions - Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts &
Leukoencephalopathy (CADASIL)
INVESTIGATION
S
of Stroke
OBJECTIVES

 TO CONFIRM DIAGNOSIS.
 TO DETERMINE THE MECHANISM
FOR LIMB WEAKNESS / DIAGNOSIS.
 PROGNOSIS.
 HOW TO MANAGE/TREAT PATIENT.
INVESTIGATION OF STROKE
INVESTIGATION OF STROKE
A) DOPPLER ULTRASOUND
– measures speed of blood flow
through an artery.

B) CT ANGIOGRAPHY
– cerebral circulation & areas of
ischemia.

C) MR ANGIOGRAM
– detect blood flow.

D) INTRA-ARTERIAL
ANGIOGRAPHY
– shows arteriovenous
malformation
CARDIAC INVESTIGATIONS
Identification of a cardioembolic source of
stroke, principally atrial fibrillation, is
achieved with electrocardiography (ECG) or
24-hour ECG.
Other causes, such as valve disease, patent
foramen ovale or mural thrombus, require
transthoracic echocardiography.

TRANSTHORACIC ECHOCARDIOGRAPHY
(TTE)
Non-invasive type of echocardiogram.
Probe is placed on abdomen or chest to get
various views of the hearts.
Can visualize heart valves.
REFEREN
CES
1. Davidson’s Principles & Practice of Medicine,
23rd Edition
2. Kumar & Clark’s Clinical Medicine, 10th
Edition
3. CPG : Management of Ischaemic Stroke
CPG_Management_of_Ischaemic_Stroke_3rd
_Edition_2020_28.02_.2021_.pdf (moh.gov.m
y)
4. Limb Weakness Differential Diagnosis - WEA
KNESS UNILATERAL LMN Signs UMN Sig
ns Intracranial -
StuDocu
THANKYO
U