NEUROLOGY Acute Hemiplegia in Children Complicating Upper RespiratoryInfections Report of Three Cases with Angiographic Findings Albert Zilkha, M.D.,* Frederic Mendelsohn, M.D.,** Leatrice G. Borofsky, M.D.† Three children presented with acute onset of hemiplegia following an upper respiratory infection. Angiography revealed irregularities, beading, and slow flow of a peripheral branch of a middle cerebral artery. In addition, one child had narrowing of the cervical segment of the internal carotid artery. An inflammatory arteritis of the cervical internal carotid artery is presumably the site of the formation of cerebral emboli. ACUTE ONSET OF HEMIPLEGIA in children associated with upper respiratory infection, followed by angiographic demonstration of cerebral artery involverment, seems worthy of being reported. We here present three children, all under (8) years of age, who were hospitalized at the Nassau County Meclical Center with acute hen3iple~ia which began during an upper respiratory infection. Angiographic studies were performed two to 18 days after admission. Case Reports Case 1 This seven-~~ear-old boy was well until six days earlier when he developed malaise, cough, and tow fever. He was given erythromycin and aspirin. On the next day. he had a generalized tonic-donic * Division of Neuroradioiogy. Nassau County Medical Center. East Meadow, N.Y. (11554) and the State of New York at Stony Brook. N.Y. University ** Division of Pediatric Neurology. t Division of Pediatric Neurology. seizure and was given phenobarbital and dilantin. Over the next two days, he complained of occipital headache and became progressive!}’ more lethargic before having a second generalized convulsion. He was taken to the emergency room of a local hospital where a lumbar puncture was performed and the findings interpreted as normal. He remained lethargic and two days later was admitted to the Nassau County Medical Center. On arrival, he was lethargic but awake and f~ull3oriented. He had left hemiparesis and some decrease of position sensation on the left. side ot the body. Funduscopv revealed blurring of the tempera! margin of the right optic disc. The reflexes were normal,. There was no evidence of’ pharyngitis or (atltls. Blood pressure was 1 1 ()/ i Cl mm: pulse 110 per minute: respirations 20 per minute: temperature 101 F. His white blood cell count was 1 ‘?,10(I with 74 per cent PM0is. Lumbar puncture after intravenous mannitol revealed an opening pressure of 160 mm of- water, protein 14 rng/1 00 m!, glucose 140 mg/100 ml, 8 red l~l(a(acl cells per cu nun. and numerous lymphocytes. Cultures caf~ cereh~-(aspin4rl fluicl (C5F), throat, nasopharynx. and rectum were negative. An EEti revealed generalized stowing. with high-voltage delta waves predominantly on the right side and posteriorly. Brain scans were normal on admission and on the fifth and 17th 1137 Downloaded from cpj.sagepub.com at UCSF LIBRARY & CKM on March 23, 2015 FiG. 1. Case l. Right retrograde t~rachial angiogram, lateral view. Early arterial phase demonstrating irregularities and beading invc~lvin~ a small parietal branch of the middle cerebral artery (arrows). Earlier view showed a normal internal carotid artery. days. ~n~pic~illin, mannitoi, and dilantin were started. In 24 hours, his consciousness improved as did his hemiparesis. The ampicillin was continued for ten days. A right 3~rachial angiogram, on the !8th day of hnsiraiing irregularities and straightening involving a small opercular branch of ¡he middle cerebral artery (arrows). white blood cells. Cultures «f’ CSf~, ear canais, urine and rectum were negative. A myxovirus (Influenza A) was grown from the nasopharynx, associated v.iili a significant rise in serum titers. On EEG he showed excess right-sidecl slowing with phase reversals in the posterior temporal derivations. Brain scans were normal on the second and seventh days of hospitalization. Right carotid angiogram on the tenth day of hospitalization revealed irregular narrowing with decrease in the caliber of a posterior frontal aper~ular branch of the middle cerebral artery. There was no associated mass or displacement of the midline structures (Fig. 3). He was treated irlitially- with penicillin and chlc~rarnphenicc~l. These antibiotics were replaced by ampicillin on the tenth day when the white blood cell count dropped. The left hemiparesis improved gradually. On discharge four weeks after admission, anly mild weakness remained. Discussion The neurologic symptoms in these three children began acutely, three to six days after the onset of an upper respiratory infection. Hemiptegia was present in all three children and seizures were seen in two. The upper respiratory infection was associated with en!arged tonsils in two children, cervical lymphactenopathy in two, and otitis rnedia in two. In none of our cases was any evidence found of bacterial meningitis, brain abscess, intracranial space-occupying lesion, congenital or acquired heart disease, collagen vascular disease or blood dyscrasia. Radioisotope brain scanning was repeatedly negative. With each child, angiography revealed irregularities, beading, and slow now in a peripheral branch of a middle cerebral artery. In addition, one child had irregular narrowing of the clistal portion of the cervical internal carotid artery, but repeat angiography 5V2 weeks later revealed that this arterial segment had returned to normal. From case 3, the influenza A virus was isolated. The etiology in cases 1 and 2 was undetermined. Some degree of encephalitis was present in the three cases, accounting for 1140 Downloaded from cpj.sagepub.com at UCSF LIBRARY & CKM on March 23, 2015 FIG. 3. Case 3. Right carotid angiogram. L