CVA impairments 2 (more sensory/perception) Flashcards
How many people who have had a stroke have visual deficits? What type of recovery is possible?
about 65% of stroke survivors may have vision problems
full recovery is uncommon
some recovery is possible
vision structures span entire brain so vision tends to be heavily involved in strokes
What is some visual dysfunction patient history we can ask to gather a baseline of vision function even prior to stroke?
-Do you wear glasses? Contact lenses?
For distance, near, bifocals, or monovision? Does your correction (glasses, contact lenses) work as well now as before the (stroke, accident, etc.)?
-Do you notice anything different about vision?
Blurry vision, loss of vision? If blurry, near or far?
-Do you ever see double?
More than double? Near or far?
What are some potential clinical observations we can make regarding visual dysfunction post-stroke?
-Head turn or tilts to tasks, or postural adjustments made to tasks
-Avoidance of near tasks
-One eye appears to go in, out, up, or down
-Seems to look past observer
-Closes or covers one eye, or squints
-During movement, bumps into walls or objects (either walking or in a wheelchair )
-Appears to misjudge distance, underreaches or overreaches for objects
-Has difficulty finding things
What visual dysfunctions are associated with CN II nuclei and associated CNS areas?
Refractive errors
-Myopia (nearsightnedness), hyperopia (farsightedness), astigmatism,
Blurry vision, headaches, dizziness
What visual dysfunctions are associated with CN II and various regions of visual tract, visual cortex?
Impaired accommodation
-blurry vision, dizziness, headaches
Visual field losses
What visual dysfunctions are associated with cerebellum?
Impaired pursuits and saccades
-Dizziness, nausea, balance difficulties
Diplopia without conjugate gaze dysfunction
-Nausea, balance difficulties
What visual dysfunctions are associated with CN III, IV, VI, II nuclei, and associated CNS areas?
Ptosis
Ocular motility disturbance
Diplopia, Visual distortions, dysconjugate gaze, impaired vergence
Dizziness, nausea, balance difficulties
Go study visual field loss slide ( slide 8)
:)
What is ocular misalignment?
When eyes are not aligned with each other
very common impairment
What are the types of ocular misalignment and which is the worst?
Tropia- overt deviation of the eye (this is the worst of the two)
Exo-outward(laterally)
Eso-inward (medially)
Hyper- upward
Hypo- downward
Phoria- Ocular deviation occurs when disassociation occurs
Eso- damage to abducens nerve and loss of abduction
Exo, hypo, and hyper all can be seen with oculomotor dysfunction
Hyper- more so with loss of depression/trochlear nerve dysfunction
If there is severe ocular misalignment, what might we see?
Diplopia, head tilt, noticeable eye turn
If the ocular misalignment is subtle, what might we see?
Difficulty maintaining focus, cosmetically normal, ocular soreness, headaches, mental dullness
What is a very common complaint related to vestibular function following a stroke?
Dizziness
In what areas would a stroke typically cause vestibular symptoms, what areas would it not usually cause vestibular symptoms?
Typically see vestibular symptoms: Brainstem and cerebellar CVAs : PICA stroke (wallenberg’s syndrome)
AICA strokes
Transient ischemic attacks- most common site - vertebrobasilar artery - vertigo, vision symptoms typically tend to be very intense
Typically don’t:
MCA/PCA territory infarcts
Vertigo is typically not present, and vestibular symptoms tend to be milder (disequalibrium, vertical disorientation)
Damage to what would manifest in VOR dysfunction?
Brain stem strokes
Vestibular nuclei in midbrain (oculomotor nucleus) and pons (abducens nucleus)
What systems are we evaluating when looking at sensory deficits post stroke?
Medial lemniscus pathway, dorsal column, anterolateral system and seeing if it can properly ascend with information
Why will thalamic lesions have diffuse involvement in sensory systems?
Thalamus is the grand central station for all of our ascending information
What is sensory dysfunction linked to?
reduced functional return, longer rehabilitation, learned non-use, safety, distal UE recovery
Proprioception in particular linked to poorer functional recovery
What are the most common predictors of fall risk post stroke?
Functional impairment
Cognitive deficits
Impaired balance
Falls and related fractures are very common in the time following a stroke
How is balanced typically examined post CVA?
Typically though outcome measures
What is perception?
Integration of sensory impressions into info that is meaningful to us
Which hemisphere will perceptual deficits most often occur with?
Right sided hemispheric damage
What are some signs of right hemisphere lesions?
Body scheme impairments
Unilateral neglect, Pusher’s Syndrome, Anosognosia, Somatognosia, R-L discrimination
Difficulties in general with spatial relationships
Hand-eye coordination, Figure-ground discrimination, Position-in-space, depth and distance, Topographical disorientation
Agnosias
Visual, auditory, sensory
Some exceptions…
What are some typical signs of left sided hemisphere lesions?
Apraxia common (very commonly seen with aphasia!!)
Ideational
Ideomotor
What is unilateral inattention?
Failure to orient toward, respond to, or report stimuli on the side contralateral to the lesion
Despite normal sensory, motor, and visual systems
Which side inattention is most common and due to what structures being damaged?
left inattention is most common due to right hemispheric damage
Mostly occurs with R temporoparietal junction, posterior parietal lesions
Also: dorsolateral frontal, cingulate gyrus, thalamic, putamen lesions
How can unilateral inattention be classified?
Modality
-Sensory -Auditory, Visual or Tactile -Motor -Representational
Distribution
-Personal
-Spatial
-Peri-personal
-Extra-personal
What are some tests we can use to examine inattention?
Observation
Double Simultaneous Stimulation test
Clock drawing, picture copying, cross-out tasks, line bisection
These tests are far from perfect, but all we have
What type of infarct typically causes inattention and what is the most common manifestation of this inattention?
MCA infarct and visuospatial
True or false: Inattention is a poor prognostic indicator for functional recovery
True
What is vertical disorientation and what are the types? Also, what are typical infarcts these are seen with?
The brain believes it is standing upright, even if it is not
Lateropulsion
Lateral lean
Lean towards side of lesion/away from involved side of body
Retropulsion (also commonly seen in Parkinson’s disease)
Posterior lean
Anteropulsion
Anterior lean
and this is especially seen with cerebellar or brain stem infarcts
What is pusher’s syndrome?
Lesion: R hemisphere centered in area of posterolateral thalamus
- Contralateral tilted posture with severe imbalance
Head can orient to vertical with cues
- Tendency to push strongly towards paretic side with nonaffected limbs
- Resistance to external corrections
This is different than lateropulsion in the fact that the patient is pushing away from the lesion, towards the side of affected body
What is post stroke fatigue defined as?
“lack of physical and mental energy”
occurs without specific exertion
Can manifest as problems related to self-control, emotional instability, reduced mental capacity, perceived reduction in energy
What is post stroke fatigue most closely associated with?
Post CVA depression
correlates also found with sleep disturbances, anxiety, and pain
What is central post-stroke pain/thalamic syndrome?
-Present in 10% of CVAs
-Pain arising as a direct consequence of lesion to central somatosensory system
-Cortex, thalamus, medulla
-Thalamus = “Thalamic Syndrome” – most common site of involvement (VPL)
-“Neuropathic pain”
this is most associated with damage to VPL of thalamus
Does thalamic/neuropathic pain respond to analgesic?
no
What type of pain does central post-stroke pain/thalamic syndrome feel like?
severe, burning type pain
Which medication has been found to be helpful with neuropathic pain and neuroplasticity?
fluoxetine
What is the most common site of orthopedic pain post stroke?
shoulder
second most common is low back pain
What are some common causes of orthopedic pain post stroke?
Weakness
Rotator cuff
Impaired motor control
Inappropriate muscle activation
Chronic: muscle shortening and contractures
Acute hypotonicity
Spasticity
Direct versus indirect pain
Positioning
Effects of gravity on UE
Severe UE hemiplegia and/or shoulder subluxation within 72 hours post-CVA = significantly higher risk of developing shoulder pain within first 8-10 weeks of CVA
How do you examine hemiplegic shoulder subluxation?
Fingerbreadth method*
Subluxation = 1⁄2 fingerbreadth or more
Radiographs
Ultrasound
