Chapter 023. Weakness and Paralysis (Part 5)

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Quadriparesis or Generalized Weakness Generalized weakness may be due to disorders of the CNS or of the motor unit. Although the terms quadriparesis and generalized weakness are often used interchangeably, quadriparesis is commonly used when an upper motor neuron cause is suspected, and generalized weakness when a disease of the motor unit is likely. Weakness from CNS disorders is usually associated with changes in consciousness or cognition, with spasticity and brisk stretch reflexes, and with alterations of sensation. Most neuromuscular causes of generalized weakness are associated with normal mental function, hypotonia, and hypoactive muscle stretch reflexes. The major causes of intermittent weakness...

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Chapter 023. Weakness and Paralysis (Part 5) Quadriparesis or Generalized Weakness Generalized weakness may be due to disorders of the CNS or of the motor unit. Although the terms quadriparesis and generalized weakness are often used interchangeably, quadriparesis is commonly used when an upper motor neuron cause is suspected, and generalized weakness when a disease of the motor unit is likely. Weakness from CNS disorders is usually associated with changes in consciousness or cognition, with spasticity and brisk stretch reflexes, and with alterations of sensation. Most neuromuscular causes of generalized weakness are associated with normal mental function, hypotonia, and hypoactive muscle stretch reflexes.
The major causes of intermittent weakness are listed in Table 23-2. A patient with generalized fatigability without objective weakness may have the chronic fatigue syndrome (Chap. 384). Table 23-2 Causes of Episodic Generalized Weakness 1. Electrolyte disturbances, e.g., hypokalemia, hyperkalemia, hypercalcemia, hypernatremia, hyponatremia, hypophosphatemia, hypermagnesemia 2. Muscle disorders a. Channelopathies (periodic paralyses) b. Metabolic defects of muscle (impaired carbohydrate or fatty acid utilization; abnormal mitochondrial function) 3. Neuromuscular junction disorders
a. Myasthenia gravis b. Lambert-Eaton myasthenic syndrome 4. Central nervous system disorders a. Transient ischemic attacks of the brainstem b. Transient global cerebral ischemia c. Multiple sclerosis Acute Quadriparesis Acute quadriparesis with onset over minutes may result from disorders of upper motor neurons (e.g., anoxia, hypotension, brainstem or cervical cord ischemia, trauma, and systemic metabolic abnormalities) or muscle (electrolyte disturbances, certain inborn errors of muscle energy metabolism, toxins, or periodic paralyses). Onset over hours to weeks may, in addition to the above, be due to lower motor neuron disorders. Guillain-Barré syndrome (Chap. 380) is the most common lower motor neuron weakness that progresses over days to 4 weeks;
the finding of an elevated protein level in the cerebrospinal fluid is helpful but may be absent early in the course. In obtunded patients, evaluation begins with a CT scan of the brain. If upper motor neuron signs are present but the patient is alert, the initial test is usually an MRI of the cervical cord. If weakness is lower motor neuron, myopathic, or uncertain in origin, the clinical approach begins with blood studies to determine the level of muscle enzymes and electrolytes and an EMG and nerve conduction study. Subacute or Chronic Quadriparesis When quadriparesis due to upper motor neuron disease develops over weeks, months, or years, the distinction between disorders of the cerebral hemispheres, brainstem, and cervical spinal cord is usually possible clinically. An MRI is obtained of the clinically suspected site of pathology. EMG and nerve conduction studies help to distinguish lower motor neuron disease (which usually presents with weakness that is most profound distally) from myopathic weakness, which is typically proximal. Monoparesis This is usually due to lower motor neuron disease, with or without associated sensory involvement. Upper motor neuron weakness occasionally
presents as a monoparesis of distal and nonantigravity muscles. Myopathic weakness is rarely limited to one limb.