10/21 CVA Exam, eval Flashcards
Transient Ischemic Attack
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 definition
Disruption of the vascular supply to the brain, brainstem or spinal cord that leads to infarction (death) of CNS tissue.
Stroke Classification
Ischemic (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 of 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
Fast, large volumes of blood
Increased mortality
If survived, decreased morbidity
Signs of hemorrhagic stroke
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 or Non-hypertensive hemorrhages
Hypertensive hemorrhage
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
Subarachnoid Hemorrhagic Stroke Etiology
Saccular aneurysms
Most common cause of SAH
45 % risk of death in the 1st 30 days - Most within a few days
Arteriovenous malformations (AVMs)
Emergency Medical Services 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 During/Following Stroke
General medical examination Identify contributing factors: NIH Stroke Scale Glasgow Coma Scale Dysphagia screen Glucose Cardiac monitoring for 1st 24 hours
Medical Diagnosis of Stroke
Non-enhanced brain CT scan (NECT)
What is the gold standard for vascular evaluation during stroke?
Conventional angiogram
When is MRI better than NECT better for diagnosing stroke?
Acute small cortical strokes
Posterior fossa lesions
Acute vs. chronic lesions
Subclinical satellite lesions
Medical Treatment of Ischemic Stroke
Airway, breathing and circulation (ABC) 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
BP targets following stroke
If given TPA, < 185/110
If no TPA, < 220/120
Medical Treatment of Hemorrhagic Stroke
Airway, breathing and circulation (ABC) 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
Name the likely type and location (if applicable) of stroke:
A 60-year-old woman was brought to the ED leg motor weakness.
Right MCA
Name the likely type and location (if applicable) of stroke:
33 year old man complains of headache and then loses consciousness at work. Onset of symptoms accompanied by a seizure.
Patient requires intubation in the field and is brought to the ED unresponsive.
Hemorrhagic
Intraparenchymal – progressing very quickly, very severe
Name the likely type and location (if applicable) of stroke:
A 52-year-old man complained of severe headache prior to loss of consciousness
Hemohhragic, subarachnoid - No seizure
Name the likely type and location (if applicable) of stroke:
The patient was treated with TPA.
Approximately 10 hours after the TPA, the patient was noted to be much more drowsy
Hemorrhagic conversion
PT Stroke Exam: 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
Common impairments of body structure/function following stroke
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
Assessing fall risk: less than one month post-CVA
<30 Berg Balance Score
Apraxia
Cognitive deficits
Low Functional Independence Measure (FIM) scores
Assessing fall risk: Community-dwelling stroke survivors > 6 months after CVA
Self-reported persistent balance problems while dressing is predictive of falls
Fall predictors in typical older adults vs. post-CVA
While incontinence, medications, and history of falls are predictive of falls in older adults, they are not predictive post-CVA
What is 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.
What is ideational apraxia?
Planning of a movement fails
Patient is unable to conceptualize how a movement pattern must be organized.
What is 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
What is 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.
Broca’s vs. Wernicke’s Aphasia
Broca’s tends to be more expressive, Wernicke’s receptive
Keys to communicating with someone with aphasia
Give them time to speak
Reduce environmental noise
Try other, non-verbal means of communication
Confirm that the pt uses yes and no correctly
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.
Hemi-neglect as a prognostic factor
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
StrokEDGE Task Force Top PT Tests and Measures following Stroke
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
Glasgow Coma Scale (GCS)
Assesses EYE OPENING, MOTOR RESPONSE,
VERBAL RESPONSE
TOTAL (3–15): _______
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
Glasgow Coma Scale (GCS) 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
Glasgow Coma Scale (GCS) 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
NIH Stroke Scale (NIHSS)
Level of Consciousness Best Gaze Visual Facial Palsy Motor Arm Motor Leg Limb ataxia Sensory Best Language Dysarthria Extinction and Inattention (neglect)
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%)
