10/11 - CVA Pathology and Medical Management Flashcards
More common side for CVA
Left (possibly due to fluid dynamics of L vs R branch from aortic arch); MCA most common
Transient Ischemic Attack (TIA)
Transient episode of neurological dysfunction
Temporary disturbance in blood supply to the brain spinal cord or retina without permanent death of tissue.
Symptoms usually last ? 1 hour.
3-17% 90-day risk of a completed stroke.
Up to 50% occur within 48 hours of the TIA
Stroke
Disruption of the vascular supply to the brain brainstem or spinal cord that leads to infarction (death) of CNS tissue.
Symptomatic or silent.
Symptomatic strokes manifest by cerebral or spinal dysfunction caused by CNS infarction.
Silent strokes are documented CNS infarction that was asymptomatic
Stroke epidemiology
?795 000 strokes per year in the United States
?610 000 are first strokes
> 5 000 000 stroke survivors in the US
#1 cause of disability in the US
4th leading cause of death in the US (#2 worldwide)
4-8% recurrence in 1st 3 months
Overall 7-10% recurrence/year
Highest in first year
Survival*
~50% at 3 years
~33% at 10 years
*comorbidities common
Ischemic stroke
61-87%; Thrombotic Vs Embolic; Large Vs Small vessel; Arterial Vs Venous
Hemorrhagic
Intraparenchymal Vs Subarachnoid
Primary Vs Secondary (conversion)
Higher proportion of hemorrhage in children
Large vessel thrombotic stroke
Slow stuttering onset due to gradual occlusion +/- collateral circulation
Possibly preceded by TIA
Small vessel thrombotic ?lacunar? stroke
Associated with longstanding hypertension and diabetes
Basal ganglia internal capsule and brainstem
Cardioembolic Etiologies in Ischemic Stroke
Valvular atrial fibrillation Nonvalvular atrial fibrillation Acute myocardial infarction Bacterial endocarditis DVT with a patent foramen ovale Mitral valve prolapse Prosthetic mechanical heart valves Possible injury in multiple vascular distributions
Cerebral venous thrombosis
Relatively rare
Higher risk in peripartum period OCPs + smoking coagulopathies
Hemorrhagic Stroke facts
Intraparenchymal (75%) vs. subarachnoid (25%) Fast large volumes of blood Increased mortality If survived decreased morbidity BP and ICP control MAP = 1/3 (SBP-DBP) + DBP MAP-ICP=CPP Vomiting systolic BP >220 mm HG severe headache coma decreased level of consciousness and progression over minutes-hours suggest hemorrhage.
Rapid deterioration in neurological status is common
Intraparenchymal Hemorrhagic Stroke
75% of hemorrhagic strokes
Hypertensive hemorrhages
Rupture of micro-aneurysms
Putamen»thalamus pons cerebellum and cerebral hemispheres.
Non-hypertensive hemorrhages
Sympathomimetic agents
Cavernous angiomas amyloid angiopathy intracranial tumors bleeding disorders trauma vasculitis hemorrhagic conversion infection
Subarachnoid Hemorrhagic Stroke
25% of hemorrhagic strokes Progressive deficits over minutes to hours Headache and decreasing consciousness Etiologies: Saccular aneurysms Most common cause of SAH 45 % risk of death in the 1st 30 days Most within a few days Arteriovenous malformations (AVMs)
EMS Management of stroke
Airway breathing and circulation (ABC) Cardiac monitoring Intravenous access Oxygen if needed Rapid identification of stroke/time of onset Rule out (and treat) stroke mimics Keep NPO (no food or drink) Alert receiving ED Rapid transport to closest appropriate facility
ED Evaluation
General medical examination Identify contributing factors: Drug exposures trauma cardiac conditions NIH Stroke Scale Glasgow Coma Scale Dysphagia screen Airway breathing and circulation (ABC) Adequate hydration Treat elevated temperatures Glucose control Cardiac monitoring for 1st 24 hours Cautious initial approach to HTN
Non-enhanced brain CT scan (NECT) (Medical Diagnosis)
The acute study of choice
Quick and affordable
Blood and bone visible
Radiation exposure
Does not show brain tissue changes such as hypoxia/anoxia
Helps identify nonvascular etiologies
E.g. brain tumor
Certain findings may predict hemorrhage with TPA
Early infarct signs including edema and mass effect
Poor visualization of small cortical and subcortical acute infarcts
Not as useful for imaging the ?posterior fossa? because of bone artifacts
Vascular Evaluation
Conventional angiogram Still appears to be gold standard Magnetic Resonance Angiogram (MRA) CT angiogram Carotid ultrasound Transcranial doppler ultrasound
Magnetic Resonance Imaging
Better than CT Identifies: Acute small cortical strokes Posterior fossa lesions Acute vs. chronic lesions Subclinical satellite lesions May be preferable when TPA is not considered No radiation exposure
Considerations: More time consuming and less available Patient contraindications Claustrophobia Internal devices Metal implants
AHA/ASA Guidelines for Ischemic Stroke - Medical Treatment
Airway breathing and circulation (ABC) Airway protection in dysphagia or decreased LOC/NPO Adequate hydration Treat elevated temperatures Glucose control Cardiac monitoring for 1st 24 hours Cautious initial approach to HTN Oxygen only if hypoxic Identify etiology of hypovolemia or hypotension
AHA/ASA Guidelines for Ischemic Stroke - Medical Treatment
Intravenous (IV) TPA given in ? 3 hours of stroke onset in appropriate patients
Possible expansion of window to 4.5 hours in selected patients
SBP <120
PT implications?
AHA/ASA Guidelines for Hemorrhagic Stroke ? Medical Treatment
ABCs Rapid transport Immediate imaging Careful blood pressure management Normalize fluid balance and electrolytes Control seizures Normalize body temperature Correct any bleeding disorders (specific to the problem) DVT prophylaxis Clot evacuation and ventricular drainage as required
Pressure Monitors
Control intracranial pressure (ICP)
Elevate head osmotherapy (mannitol) hyperventilation barbiturate coma sedatives ventricular monitors lasix
Risk of decreasing cerebral perfusion pressure
Cerebral perfusion pressure = mean arterial pressure ? intracerebral pressure (CPP=MAP-ICP)
Pressure Management
20-30% develop acute hydrocephalus Most require shunting Clip ligation or coiling for aneurysm Prevent and treat vasospasm (peak day 5-7) Seizure prophylaxis may be indicated
ASA Clinical Practice Guideline for Stroke
Algorithm A B C Key points of ?prevention of complications minimize impairments and maximize function.? Secondary prevention of another stroke Early assessment and intervention Standardized evaluation and tools EBP ? based interventions Multidisciplinary team Pt and family ed and team Community resources
Physical Therapy Examination - Review
History and systems review
Identify problem areas
individual
therapist
Make hypotheses
Test your hypotheses with your examination
task analysis
tests and measures
Clinical Impression
Link participation difficulties with activities and impairments
Combined with the history what is the prognosis for change?
How do you prioritize your interventions?
Set goals that address impairments in body structure and function AND activities
Stroke Examination
History Age and living situation Participation and Activity level Type and location of stroke How long since stroke Medications Blood pressure parameters Co-morbid pre-morbid conditions
Systems Review Neuromuscular Musculoskeletal Cardiopulmonary/Vascular Cognition/Communication Integumentary Genitourinary Gastrointestinal Endocrine
Neuromuscular Impairments of Body Structure/function
Lack of adequate force production Lack of adequate timing Abnormal synergistic movement patterns Muscle imbalance Lack of adequate motor planning Decreased postural control Sensory-Perceptual visual deficits
Risk of falls: <30 days post CVA
<30 Berg Balance Score Apraxia Cognitive deficits Low Functional Independence Measure (FIM) scores Predictive of increased fall rates
Risk of falls: >6 months post CVA community dwelling
Self-reported persistent balance problems while dressing is predictive of falls
Fall predictors in older adults
Incontinence
Medications
History of falls
These factors are not predictive of falls post CVA
Apraxia
Loss of ability to execute skilled or learned movement patterns on command in the absence of weakness sensory loss comprehension difficulty abnormality of tone or posture or intellectual deterioration.
Ideational apraxia
Planning of a movement fails
Patient is unable to conceptualize how a movement pattern must be organized.
Ideomotor Apraxia
Plan for the movement is intact but the execution fails.
Damage within pathways connecting the areas in which the plan is conceived to those responsible for innervating the motor plan
Aphasia
Impairment of language associated with damage to the language dominant hemisphere.
Nearly always involves damage to the left fronto-temporal and/or temporo-parietal regions.
May affect verbal expressive output fluency comprehension naming reading writing and repeating.
Global aphasia
commonly associated with a large lesion in the frontal temporal and parietal lobes of the brain causing an almost total reduction of all aspects of spoken and written language
Broca’s (expressive motor) aphasia
loss of the ability to produce language (spoken or written)
Receptive aphasia also known as Wernicke?s aphasia fluent aphasia or sensory aphasia
loss of ability to understand language (spoken or written)
Hemi-Neglect
Failure to attend to respond to and/or report stimulation that is introduced contralateral to the lesion.
Most often seen with non-dominant parietal association area lesions.
Affects contralesional side.
Persistent neglect is a negative functional outcome predictor.
Intrapersonal Hemi-Neglect
Contralateral hemineglect of patient?s own body associated with anosagnosia (denial of deficit)
Peripersonal hemi neglect
Hemispatial neglect of contralateral stimuli within reaching distance.
Extrapersonal hemi neglect
Hemispatial neglect of contalateral stimuli beyond reaching distance.
Dysarthria
Difficulty producing speech
Dysphagia
Difficulty swallowing
Difficulty eating
Dealing with secretions
Stroke Tests and Measures
6MWT 10 m walk Modified Ashworth Scale Berg Balance Test Functional Reach Test Dynamic Gait Index Fugl-Meyer (Motor ) Orpington Prognostic Scale Postural Assessment Scale for Stroke Stroke Impact Scale Tardieu Spasticity Scale Action Research Arm Test (ARAT) Chedoke-McMasters
Fugl-Meyer Motor scale
100 point motor domain is reliable valid and responsive to clinical change
Chedoke-McMaster Stroke Assessment
Measure of impairments and disability level
Impairments in 6 dimensions: shoulder pain postural control arm hand leg foot
measured on a 7 point scale following Brunnstrom stages
Disability measured by gross motor function and walking
measured on same 7 point scale as FIM
Postural Assessment Scale for Stroke Patients (PASS)
Maintaining a Posture (0-3) Sitting without support with feet on floor Standing with support Standing without support Standing on non-paretic leg Standing on paretic leg Changing Posture (0-3) Supine to affected side lateral Supine to non-affected side lateral Supine to sitting EOT Sitting on edge of table to supine Sitting to standing Standing to sitting Standing picking up pencil from floor
Stroke Impact Scale (SIS)
Questionnaire
5 point scale - Not Difficult at all to Extremely Difficult
Physical problems
Memory and thinking
Mood and emotions
Communication
Activities in a typical day
Mobility in home and community
Hand function
Ability to participate in usual meaningful activities
On a scale of 0=100 how much have you recovered?
Action Research Arm Test (ARAT)
Total score 0-57
Scored 0-3 on each item
Minimal clinical important difference (MCID) 5.7 points
Additional Tests and Measures
Glasgow Coma Scale (GCS) NIH Stroke Scale (NIHSS) Montreal Cognitive Assessment (MOCA) Modified Tardieu Scale Functional Independence Measure(FIM)
Glasgow Coma Scale (GCS)
EYE OPENING
None = 1 Even to supra-orbital pressure
To pain = 2 Pain from sternum/limb/supra-orbital pressure
To speech = 3 Non-specific response not necessarily to command
Spontaneous = 4 Eyes open not necessarily aware
MOTOR RESPONSE
None = 1 To any pain; limbs remain flaccid
Extension = 2 Shoulder adducted and shoulder and forearm internally rotated
Flexor response = 3 Withdrawal response or assumption of hemiplegic posture
Withdrawal = 4 Arm withdraws to pain shoulder abducts
Localizes pain = 5 Arm attempts to remove supra-orbital/chest pressure
Obeys commands = 6 Follows simple commands
VERBAL RESPONSE
None = 1 No verbalization of any type
Incomprehensible = 2 Moans/groans no speech
Inappropriate = 3 Intelligible no sustained sentences
Confused = 4 Converses but confused disoriented
Oriented = 5 Converses and oriented
TOTAL (3?15): _______
NIH Stroke Scale (NIHSS)
Time Intervals: Baseline 2 hours post treatment 24 hours post onset 7-10 days 3 months other Scored 0 1 2 scale with 0 = normal Level of Consciousness Best Gaze Visual Facial Palsy Motor Arm Motor Leg Limb ataxia Sensory Best Language Dysarthria Extinction and Inattention (neglect)
Montreal Cognitive Assessment (MOCA)
MOCA
Scale 0-30
Consider language difficulties
Modified Tardieu Scale
Velocity One = V1
Slow movement
Goniometric measurement at this joint angle
Velocity Two = V2
Fast movement
Goniometric measurement at this joint angle
May provide more precision in documenting amount of spasticity and amount of contracture
Functional Independence Measure (FIM)
20 functional items measured on 7 point scale: 7 = Independence 6= Modified Independence 5= Supervision (subject does 100%) 4= Minimal Assist (subject does 75%) 3= Moderate Assist (subject does 50%) 2= Maximal Assist (subject does 25%) 1= Total Assistance (subject does < 25%)
