Journal ofNeurology, Neurosurgery, and Psychiatry 1990;53:675-680 675 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.8.675 on 1 August 1990. Downloaded from Hemiparetic multiple sclerosis J Cowan, I E C Ormerod, P Rudge Abstract right cerebral hemisphere, thought to Eight patients are described who presen- represent a mature infarct. Routine blood ted with hemiparesis which involved the tests, erythrocyte sedimentation rate (ESR), face in seven. Six of the eight subsequen- serology for syphilis and autoantibodies were tly developed clinically definite multiple normal or negative. Further investigations sclerosis and in the remaining two were unremarkable including echocar- patients multiple sclerosis was the likely diogram, arch aortogram, carotid ultrasound diagnosis. Magnetic resonance imaging scan and visual evoked potentials (VEPs). gave useful information about the site of In 1984 (aged 48 years) there was another the lesions responsible for the presenting episode of hemiparesis involving the right face syndrome and provided ailditional and limbs which was associated with dys- information in support of a diagnosis of phasia. She was admitted to the National multiple sclerosis. Hospital at which time the weakness had lar- gely resolved and the physical signs were limited to ataxia of all limbs. A further CT Hemiparesis which involves the face is scan showed two areas of low attenuation, the uncommon as the presenting feature of multi- first in the white matter adjacent to the right ple sclerosis (MS), and may lead to diagnostic trigone and the second in the left centrum confusion, particularly when the syndrome is semiovale. MRI at that time showed wide- progressive or stuttering in onset. In recent spread periventricular lesions and other years various investigations have enabled the lesions within the cerebral white matter with diagnosis of MS to be pursued in patients lesions bilaterally in the corona radiata who, because of their unusual clinical picture, immediately superior to the internal capsule previously might not have been suspected of (fig 1). The cerebrospinal fluid (CSF) was suffering from the disease. Of these inves- acellular but showed oligoclonal banding of tigative techniques magnetic resonance imag- the immunoglobulins. VEPs and somatosen- ing (MRI) of the brain and spinal cord is the sory evoked potentials (SEPs) were normal. most sensitive. In this article patients with Case 2 This right handed man developed hemiparetic MS are described in whom MRI a mild left hemiparesis, involving the face, scanning gives useful information about the when aged 34 years. This resolved completely http://jnnp.bmj.com/ probable sites of the lesions responsible for over a period of two weeks. He remained well the hemiparetic episodes. Other patients with until the age of 51 when he became impotent. an acute hemiparetic syndrome are described At the age of 56 years he had an episode of in whom MS is the most likely diagnosis. unsteadiness of gait with veering to the right. This lasted a week but did not resolve com- pletely and was followed by a progressive Patients unsteadiness of gait and dragging of the right on September 27, 2021 by guest. Protected copyright. Case 1 In 1975, when 39 years old, this right leg, and later he developed slurring of his handed woman experienced an episode of tin- speech and clumsiness of the hands. He was gling affecting the whole of the left side of her admitted to the National Hospital in 1985 body and over the next three years she had when aged 59 years. On examination he had a five further episodes all precipitated by exer- slurring dysarthria and there were pyramidal tion. The symptoms lasted for up to three signs in all limbs with extensor plantar res- weeks and were accompanied by mild weak- ponses and ataxia of limbs and trunk. Routine The National Hospital ness on the left side. Between episodes she blood tests including ESR and serology for for Nervous Diseases, was free of either symptoms or signs. At the syphilis were normal; the anti-nuclear anti- Queen Square, age of 45 years she had another similar body (ANF) was not sought. VEP latency was London was brain stem J Cowan episode of sensory disturbance and admit- increased bilaterally and SEPs and I E C Ormerod ted to hospital where within a few hours she auditory evoked potentials (AEPs) were both P Rudge developed a left hemiparesis involving the face abnormal. The CSF was acellular with Correspondence to: and limbs. Computerised tomography (CT) of negative syphilis serology but showed oligo- Dr Ormerod, to near was normal. MRI The National Hospital the head was normal. She recovered clonal banding. Cranial CT for Nervous Diseases, normal over a period of six months. She then in 1985 showed several lesions in the white Queen Square, London and and in WC1N 3BG, started to have intermittent headaches matter of both cerebral hemispheres United Kingdom over the following eight months she had an the right internal capsule (fig 2). Received 20 June 1989 episode of weakness of the right leg followed Case 3 This left handed man had two and in revised form A CT between the 21 November 1989. by an episode of left hemiparesis. repeat attacks of right sided weakness Accepted 29 November 1989 scan showed an area of low attenuation in the ages of 13 and 15 years. When sixteen years 676 Cowan, Ormerod, Rudge J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.8.675 on 1 August 1990. Downloaded from Figure I MRI scans at two levels (a, b) in patient I (SE2000160). There are periventricular lesions and also discrete white matter lesions. The lesions involve the white matter immediately above the internal capsules. Figure 2 MRI scan in in which he had experienced an apparently patient 2 (SE 2000140). minor head injury. He also noticed tingling There is a lesion in the right internal capsule down the spine and legs on neck flexion. On (arrowed). examination he had some restriction of abduc- tion of both eyes, nystagmus on upgaze and first degree horizontal nystagmus in both directions. There was sensory loss involving all three divisions of the right trigeminal nerve, and both taste and hearing were im- paired on the right. In the limbs there was weakness of the right leg with right sided hyperreflexia. The CSF contained six lym- phocytes/mm3 and 0-5 g/l of protein. Bilateral vertebral and right carotid arteriograms were normal. When he was 46 years he had an episode of tinnitus with right hemisensory loss and diplopia on looking to the right. These symp- http://jnnp.bmj.com/ toms lasted for two weeks. Two years later he developed a right sided weakness over a few hours and three days later he became dys- phasic. He was admitted to the National Hos- pital and found to have a nominal dysphasia and a dense right hemiparesis involving the face with right hemisensory loss. The CSF contained five lymphocytes/mm3 and a protein on September 27, 2021 by guest. Protected copyright. old he developed, over a period of 24 hours, a of 0-69 g/l and oligoclonal bands were present; right hemiparesis involving the face which the syphilis serology was negative. Routine was associated with a right hemisensory im- blood tests were normal including the ESR pairment, headache and intermittent diplopia. and autoantibody screen. The CT showed Two weeks later he was admitted to the mild cerebral atrophy, cerebellar atrophy and National Hospital. On examination he had a an area of low attenuation in the left corona slurring dysarthria. He had incomplete ab- radiata. The VEP was delayed on the right. duction of the left eye and some nystagmus on MRI scanning was performed in 1985 (aged lateral gaze to right or left. He had a severe 52 years) which revealed lesions in the deep right hemiparesis with an extensor plantar cerebral white matter of both hemispheres response on the right. The CSF had a normal and in the left cerebral peduncle. There were protein content with six white cells/mm3. A also lesions in the posterior limbs of both left carotid angiogram was normal. He re- internal capsules (fig 3). Examination at this covered within two weeks. At the age of 22 time revealed a right hemiparesis and ataxia in years he had a left hemiparesis and hemi- both arms. The plantar responses were flexor. sensory disturbance which recovered over Case 4 In 1979, aged 23 years, this man eight weeks. A few months later he had an suddenly developed a sensation of pins and episode of right sided weakness with bilateral needles down his right side followed by a visual impairment and intermittent diplopia. dense right hemiparesis. These symptoms This came on within days of a bicycle accident passed off within minutes but he had nine Hemiparetic multiple sclerosis 677 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.8.675 on 1 August 1990. Downloaded from Figure 3 MRI scans in patient 3. The SE 2000/ 40 (a) image shows lesions in both internal capsules (arrowed) confirmed on the IR 2000/500 image (b). similar episodes over the next 24 hours each the cerebral white matter. In particular there lasting about 10 minutes. He was transferred were lesions in the posterior limb of the inter- to the National Hospital the following day and nal capsule on the right and there was a lesion had another three similar episodes affecting involving the posterior aspect of the left the right side the longest of which lasted for lentiform nucleus and pallidum which in- two hours and during which examination re- volved the posterior limb of the internal cap- vealed a right hemiparesis involving the face sule on the left (fig 4).