3 Stroke Flashcards
Stroke statistics
- 5th leading cause of death in US
- leading cause of disability in adults
- 795,000 Americans each year, 75% first stroke, 25% recurrent
- in US, stroke every 40 seconds and someone dies every 4 minutes due to stroke
- 87% ischemic strokes, 13% hemorrhagic
ABCD2 prediction rule
- age >60 years = 1 point
- BP >140 or >90 = 1
- unilateral weakness with or without speech impairment = 2
- speech impairment without weakness = 1
- > 60 minutes = 2, 10-59 minutes = 1
- diabetes = 1
Higher score = higher 30 and 90 day stroke risk
CT for stroke
- primary imaging for initial evaluation
- rule out hemorrhagic stroke and may identify ischemic lesion, but may not see in early hours
- aids in decision whether to administer tPA
Computed Tomography Angiogram
- inject IV contrast followed by radiography
- clear images of cerebral blood vessels to see stenosis, occlusion, aneurysms, and vascular abnormalities
MRI
- detect edema in sub-acute phase that may not be visible on CT
- can’t use with pacemakers, some metallic implants
Magnetic Resonance Angiogram
-detect high grade atherosclerotic lesions and less common causes of ischemic stroke (carotid and vertebral artery dissection, venous thrombosis, etc.)
Positron emission tomography
- imaging of regional blood flow and cerebral metabolism
- determine areas of tissue where ischemia is reversible
Anticoagulation meds
- Heparin (Lovenox)
- Warfarin (Coumadin)
MCA stroke
- most common location
- primary motor and sensory cortices, Broca’s, Wernicke’s
- contralateral weakness (UE and face), sensory impairment
- aphasia if L
- neglect if R
Lacunar strokes
- deep branches of MCA (lenticulostriate arteries)
- high incidence in those with HTN and elderly
- supplies BG, internal capsule
- contralateral weakness
PCA stroke
- supplies occipital lobe, inferior part of temporal lobe, deep structures (diencephalon)
- contralateral homonymous hemianopsia
- contralateral sensory impairment, weakness
ACA stroke
- rare due to collateral circulation provided by anterior communicating artery
- supplies motor and sensory cortices (LE), SMA, prefrontal cortex
- contralateral weakness, sensory impairment (LE)
- frontal lobe behavioral abnormalities- poor judgment, decreased attention and motivation, difficulty regulating emotions
Watershed strokes
- affect areas of brain supplies by most distal branches of major cerebral arteries
- results from hypoperfusion (heart disease, cardiac arrest, shock, etc.)
- proximal arm and leg weakness with preservation of distal strength (“man in a barrel”
PICA stroke
- Lateral medullary syndrome or Wallenberg syndrome
- supplies cerebellum and medulla
- loss of pain and temperature on contralateral side of body and ipsilateral face
- dizziness/vertigo
- ataxia, diplopia, dysphagia, dysarthria
- Horner’s syndrome- caused by damage of sympathetic trunk to vertebral bodies. Ipsilateral miosis (pupil constriction), ptosis, decreased sweating
AICA stroke
- lateral pontine syndrome
- supplies cerebellum, CN VII and VIII
- ipsilateral ataxia
- contralateral weakness, sensory impairment (pain and temperature)
- dizziness/vertigo
Cranial nerve signs opposite long tract signs
Brainstem disorder
Loss of pain and temp, vibration, touch, position on different sides of body
SCI
Impairment of all sensory modalities on one side of body plus UMN signs
Cortical injury
Impairment of all sensory modalities on one side of body plus LMN signs
Peripheral nerve injury
Supratentorial
- damage to cerebral cortex or diencephalon
- cognitive, judgment, affect, and/or language deficits
Infratentorial
- damage to brainstem or cerebellum
- abnormal vitals, automatic movement adjustments, posture/gait, and/or breathing patterns
Thalamic pain syndrome
- initially presents as numbness that turns into debilitating burning
- may be accompanied by allodynia- pain from stimulus that would not normally be painful
Right optic nerve lesion
Blindness in R eye
Optic chiasm lesion
- loss of temporal fields in both eyes
- bitemporal hemianopsia
Lesion to uncrossed fibers from R eye
- loss of nasal field of R eye
- R nasal hemianopsia
Right optic tract lesion
- loss of L visual field
- L homonymous hemianopsia
Lesion to R optic radiation projecting directly to occipital lobe
Loss of inferior quadrant of L visual field
Lesion to R optic radiation in Meyer’s loop
-loss of superior quadrant of L visual field
Lesion to entire R optic radiation
- loss of left visual field
- L homonymous hemianopsia
Lesion to medial surface of R visual cortex
- loss of left visual field with macular sparing
- macular (foveal) representation extends beyond medial surface onto posterolateral surface of hemisphere
UE flexion synergy
-scapular retraction/elevation, shoulder abduction, shoulder ER, elbow flexion, forearm supination, wrist and finger flexion
LE flexion synergy
-hip flexion, abduction, ER, knee flexion, ankle dorsiflexion, ankle inversion, toe extension
UE extension synergy
-scapular protraction, shoulder adduction, shoulder IR, elbow extension, forearm pronation, wrist and finger flexion
LE extension synergy
-hip extension, adduction, IR, knee extension, ankle plantarflexion, ankle inversion, toe flexion
Muscles not involved in synergies
-latissimus dorsi, teres major, serratus anterior, finger extensors, ankle evertors
Modified Ashworth Scale
0- no increase
1- slight increase, catch or min resistance at end ROM
1+- slight increase, catch with minimal resistance through less than half ROM
2- more marked increase through most of ROM, but can easily move
3- considerable increase in tone, passive movement difficult
4- affected parts rigid
Decorticate rigidity
- LE extended, UE flexed
- lesions superior to red nucleus of midbrain
Decerebrate rigidity
- UE and LE extended
- lesions inferior to red nucleus of midbrain
Sogue’s phenomenon
-finger extension and abduction when arm is elevated above horizontal
Raimste’s phenomenon
-resisted hip abduction or abduction elicits abduction or abduction in contralateral limb
Unilateral neglect-lesion where?
Right posterior inferior parietal lobe
Anosagnosia- lesion where?
-right posterior insula
Somatotopagnosia- lesion where?
- AKA body-image agnosia, lack of awareness of body structure and relationship of body parts to one another in self or others
- lesion left parietal or posterior temporal lobe
Gerstmann syndrome
- damage to parietal lobe in region of angular gyrus
- R/L discrimination disorder
- finger agnosia
- agraphia (writing)
- acalculia (calculating)
Ideomotor apraxia
-difficulty planning and completing actions on command, but can do automatically
Ideational apraxia
-inability to conceptualize and perform tasks, either on command or automatically
Spastic vs flaccid dysarthria
- spastic- loud bursts, UMN
- flaccid- soft, breathy, LMN
Requirements of CIMT
- 20 degrees wrist extension
- 10 degrees finger extension
- no sensory or cognitive deficits
Core Outcome Measures CPG
- FTSTS
- 10MWT
- 6MWT
- ABC
- BBS
- FGA
10MWT
- distance walked 3 trials, average of 2nd and 3rd recorded
- <0.4 m/s = household ambulatory
- 0.4-0.8 m/s = limited community ambulator
- > 0.8 m/s = community ambulator
FGA
-<23/30 = fall risk
ABC
-<67% indicates increased fall risk
FTSTS
-measured from 17-18 inch chair
Orpington Prognostic Scale
- scores 1.6-6.8
- mild to mod deficit <3.2
- mod to severe deficit 3.2-5.2
- severe or major deficit >5.2
Functional Reach Test
-<15 cm = fall risk
TUG
->14 seconds = falls risk
Fugl-Meyer assessment of motor performance
- 5 domains- motor function, sensory function, balance, joint ROM, joint pain
- max score 226 points
FIM
-18 (dependent) to 126 (independent)
Stroke impact scale
- 59 items in 8 domains (strength, hand function, ADL/IADL, mobility, communication, emotion, memory and thinking, participation/role function)
- 0 (high impact of stroke, more impairment) to 100 (low impact, less impairment)
Goal attainment scale
- 2+ = goal achieved much more than expected
- 1+ = more than expected
- 0 = goal achieved
- 1- = less than expected
- 2- = much less than expected
Motor activity log
- interview to assess arm function
- score from 0 (never used) to 5 (PLOF)
Dorsolateral prefrontal damage
Dysexecutive function
Orbitofrontal damage
Distractible
Labile
Disinhibited
Perseverates
Medial prefrontal damage
Apathetic
Passive
Brainstem damage presentation
Axial rigidity
Early falls
Early FOG
Similar to PSP
Inferior shoulder dislocation stimulation
Supraspinatus
Posterior deltoid
