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Rehabilitation Practice and Science

Translated Title

蜘蛛網膜下腔出血併缺血性腦中風續發膈神經功能異常造成單側橫膈肌麻痺：病例報告

Abstract

Background: Cerebrovascular accident may lead to neurological symptoms and functional defects. Impaired respiratory and swallowing function as well as limited mobility make pneumonia a common complication after stroke. The diaphragm is innervated by the phrenic nerve and is a major respiratory muscle. Phrenic nerve dysfunction can lead to diaphragm paralysis and result in abnormal respiratory function. Cerebrovascular accident of cerebral hemisphere is one of the etiologies of phrenic nerve dysfunction and can lead to respiratory symptoms. There are few discussions in current literature regarding secondary diaphragm paralysis after cerebrovascular accident of cerebral hemisphere. This casereport presents the clinical signs of unilateral diaphragm paralysis after cerebrovascular accident of cerebral hemisphere and discusses about the possible pathophysiology, symptoms, complications, diagnosis, treatment, and prognosis. Case: The patient is a 61-year-old man diagnosed with subarachnoid hemorrhage and left middle cerebral infarction. Due to persistent right limb weakness, Wernicke's aphasia and dysphagia, he was admitted to our ward for further rehabilitation. His respiratory pattern was smooth and normal at rest. However, he suffered from intermittent exertional dyspnea during rehabilitation with a blood O_2 saturation level of 88%-90%. Dyspnea improved with supplemental oxygen by nasal cannula. His body temperature was normal. Physical examination showed no limb edema, cyanosis, or orthopnea. Auscultation of the chest showed decreased breath sounds of right lower lung and bilateral basal crackle without wheezing. Blood test showed normal renal and liver functions, no electrolyte alterations and no leukocytosis. The resting electrocardiogram was normal. Due to the suspicion of pneumonia, diaphragm paralysis, and pleural effusion, we arranged chest X-ray and Computed tomography (CT) for further information. The chest X-ray and CT showed new onset right diaphragm elevation with mild bilateral pleural effusion and no abnormal mass or lymph node enlargement. Due to the suspicion of right diaphragm paralysis, phrenic nerve conduction study was performed to evaluate phrenic nerve function. This study revealed the absence of right phrenic compound motor action potential, but intact on the left side. The patient was diagnosed with right phrenic nerve axonal neuropathy. The chest echo showed absence of right diaphragm movement during inspiration. The patient could not complete pulmonary function test because of Wernicke's aphasia and impaired cognitive function. According to previous examination, the diagnosis was subarachnoid hemorrhage and left middle cerebral artery infarction with secondary right phrenic nerve injury and right diaphragm paralysis. After receiving rehabilitation, the patient could complete the training program smoothly and less supplemental oxygen therapy was needed during rehabilitation. Conclusion: Cerebrovascular accident of cerebral hemisphere can lead to phrenic nerve dysfunction and secondary diaphragm paralysis, which may further impair pulmonary function. The possible pathophysiology after stroke is the corticospinal tract disturbance and phrenic nerve motor neuron damage. The diaphragm paralysis may lead to exertional dyspnea and impaired cough ability. If a patient with stroke has exertional dyspnea and difficulty coughing, further examination include chest image study, pulmonary function test, diaphragm electromyography and phrenic nerve conduction study are suggested to confirm diaphragm paralysis or phrenic neuropathy and arrange further rehabilitation program.

Language

Traditional Chinese

First Page

193

Last Page

203

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