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Proximal paresis of the upper extremity in patients with stroke

From the Neurorehabilitation Research Institute, Morinomiya Hospital, Osaka, Japan (M.H., I.M.); Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan (M.H., S.S.); and Osaka Neurological Research Institute, Osaka, Japan (T.Y.).

Address correspondence and reprint requests to Dr. Megumi Hatakenaka, Neurorehabilitation Research Institute, Morinomiya Hospital, 2-1-88, Morinomiya, Joto-ku, Osaka, 536-0025, Japan megmy{at}leto.eonet.ne.jp

Objective: To characterize the physiologic and neuroanatomical features and functional outcome of proximal dominant paresis of the upper extremity (UE) in poststroke patients.

Methods: The authors studied 34 hemiparetic patients after the first subcortical stroke (mean age 65 years; males/females = 21/13; mean 45 days after stroke; right/left hemiparesis = 20/14). They were divided into proximal and distal paresis groups according to the distribution of UE paresis. Transcranial magnetic stimulation (TMS) was used to assess residual function of the descending pathways to the UE muscles. The location and size of lesions were assessed by MRI.

Results: The lesion density maps revealed damages in the posterior putamen, posterior limb of the internal capsule, and posterior half of the corona radiata in the distal group (n = 19), whereas lesions in the proximal group (n = 15) uniformly encompassed the middle part of the corona radiata, usually sparing the posterior half of the posterior limb of the internal capsule. TMS indicated that the descending pathways to proximal muscles were disrupted in patients with proximal UE paresis, whereas innervation to distal muscles was spared. Functional outcome of the affected UE after inpatient rehabilitation was better in the proximal group. It depended on the initial severity of UE paresis, but not on TMS findings, age, or the size of the lesions.

Conclusion: Although the distribution of upper extremity (UE) paresis was associated with distinct MRI and transcranial magnetic stimulation (TMS) findings, the clinical examination of UE paresis was more sensitive than MRI or TMS findings in predicting functional outcome of the paretic UE.

Supplemental data at www.neurology.org

Supported by a Grant-in-Aid for "the Research Committee for Ataxic Diseases" of the Research on Measures for Intractable Diseases and Funds for Comprehensive Research on Aging and Health from the Ministry of Health, Labor and Welfare, Japan, and a Grant from Japan Cardiovascular Research Foundation.

Disclosure: The authors report no conflicts of interest.

Received November 30, 2006. Accepted in final form February 26, 2007.