CVA impairments Part 2 Flashcards
List common CVA neurological impairments
- altered consciousness
- cognitive and perceptual deficits
- visual deficits
- vestibular deficits
- somatosensory deficits
- postural and balance deficits
- fatigue
- pain
what are the levels of consciousness
- full consciousness
- lethargy → general slowing of cognitive and motor processes
- Obtundation → dulled or blunted sensitivity, difficult to arouse
- Stupor → state of semi-consciousness, only arouses w/intense stimulation
- coma → unconsciousness
how do we measure level of consciousness?
Glasgow coma scale → measures 3 areas of consciousness: eye opening, motor response, verbal response
scores 3-15
what are some post stroke considerations with the GCS?
total GCS score found to predict acute mortality w/88% validity
Cognition and communication deficits common post CVA, concern for impacting verbal scores
arousal levels will often fluctuate and levels of consciousness have many potential causes and influences such as:
- course of injury/neuroanatomy injured
- medical interventions
- medications
- autonomic system dysfunction
- sleep/wake cycle disruption
- Patient positioning
what are the basic components of the cognitive eval?
- orientation (person, place, time, situation)
- attention
- sustained, selective, divided, alternating
- memory
- immediate recall, short-term, long-term
- executive function
- abstract thinking, problem-solving, judgement, reasoning, insight
- communication
- spontaneous speech, command following, repetitive and naming, articulation
- behavior
how does a CVA impact orientation and what brain regions are involved?
- orientation deficits:
- disorientation denotes general intellectual dysfunction but can reflect difficulties w/attention, memory
- often requries increased cues, redirection encouragement
- brain regions:
- multiple cortical regions involved
how does a CVA impact attention and what brain regions are involved?
- attention deficits:
- most common cognitive deficit post stroke
- difficulty in processing and assimilating new info and tech, motor learning, dual task
- dysfunction correlated w/balance impairments, falls
- brain regions involved:
- prefrontal cortex
- reticular formation
how does a CVA impact memory and what brain regions are involved?
- memory deficits:
- difficulty w/carry-over of newly learned or retained tasks
- long-term memory typically remains intact
- brain regions involved:
- Short term:
- prefrontal cortex
- limbic system
- Long term:
- hippocampus
- temporal lobe
- Short term:
how does a CVA impact executive function and what brain regions are involved?
- executive function deficits:
- inappropriate interactions, poor self-monitoring and self-correcting
- impulsive, inflexible thinking, decreased insight, impaired organization, sequencing and planning abilities, impaired judgement
- brain regions involved
- prefrontal cortex
list some broad CVA behavioral considerations
Emotional changes → lesions affecting frontal lobe, hypothalamus, and limbic system can produce notable emotional changes such as:
- apathy
- euphoria
- pseudobulbar affect
- depression
what is the pseudobulbar affect?
state of emotional liability due to neurologic insult
- correlated w/inferior frontal and inferior parietal lobe damage (R or L)
- emotional outbursts of uncontrolled or exaggerated laughing or crying
- inconsient with actual mood
a right hemispheric lesion will have what behavioral considerations?
- difficulty percieving emotions
- difficulty w/expression of negative emotions
- irritability, confusion
- impulsive, quick movement
- poor judgment
- rigidity of thought
- absent or poor insight, awareness of impairments, may completely deny disability
- high safety risk
a left hemispheric lesion will have what behavioral considerations?
- difficulty w/expression of positive emotions
- slow, anxious, cautious
- disorganized and distracted when attempting to complete a task
- compulsive behavior
- typically very aware of impairments and extent of disability; more realistic
- may need extra coaxing to participate
- high safety risk
summarize the big themes for right vs left hemispheric lesions’ impact on behavior
- Right → impulsive, quick = big fallers
- left → more guarded and cautious, compulsive = more tense and have a higher fear of falling
what are some perceptual deficits that may be present with a R hemispheric lesion?
- Body scheme impairments
- unilateral neglect, pusher’s syndrome
- anosognosia, somatagnosia, R-L discrimination
- Difficulties in general w/spatial relationships
- hand-eye coordination
- figure-ground discrimination
- position-in-space depth and distance
- topographical disorientation
- agnosias
- visual, auditory, sensory
what are some perceptual deficits that may occur with left hemispheric lesions?
Apraxia
both ideational and ideomotor
Where does unilateral neglect mostly occur?
R temproparietal junction, posterior parietal lesions
also: dorsolateral frontal lobe, cingulate gyrus, thalamic, putamen lesions
How is neglect classified?
- modality
- sensory (auditory, visual, tactile)
- motor
- representational
- distribution
- person
- spatial (peri-personal, extra-personal)
A stroke impacting what artery most commonly results in neglect?
MCA
T/F: neglect is a poor prognostic indicator for functional recovery
TRUE
the examination for neglect includes what?
- observation
- double simultaneous stimulation test
- clock drawing, picture copying, cross-out task, line bisection
list the types of vertical disorientation that can present following a CVA. What brain regions are invovled?
- lateropulsion → commonly seen w/brainstem and cerebellar strokes and often Wallenberg syndrome
- retropulsion → very common w/PD
- Pusher’s syndrome → R hemisphere centered in area of posterolateral thalamus
how does R vs L hemispheric involvement impact Pusher’s syndrome?
- Right
- majority (50-65%) of cases
- commonly seen w/left hemiplegia
- high association w/left spatial and sensory neglect
- Left
- commonly seeen w/right hemiplegia
- high association w/aphasia
what questions should be included in the pt history when checking for visual dysfunction?
- do you wear glasses/contact lens?
- do you notice anything different about vision?
- do you ever see double?
List some common visual dysfunctions following a CVA. List the brain regions involved with each
- CN II nuclei and associated CNS area
- refractive errors
- impaired accommodation
- CN II and various regions of visual tract, visual cortex
- visual field loss
- Cerebellum
- impaired pursuits and saccades
- diplopia
- CN III, IV, VI, II nuclei and associated CNS areas
- ptosis
- ocular motility disturbance
- diplopia
- visual distortions
- dysconjugate gaze
- impaired vergence
What are some potential clinical observations with visual dysfunction post stroke?
- head turn/tilt during near tasks, or postural adjustments to task
- avoidance of near tasks
- one eye appears to go in, out, up, or down
- vision shifts from eye to eye as indicated by head tilting
- seems to look past observer
- closes or covers one eye
- squints
- during movement, bump into walls or objects
- appears to misjudge distance, under-reaches or overreaches for objects
- has difficulty finding things
central vestibular dysfunction can occur with injury to what brain regions?
- cortical vestibular regions (PIVC, MST, VIR)
- brainstem vestibular regions (midbrain, pons)
- flocculonodular lobe
what is the most common complaint with vestibular dysfunction?
dizziness
List the types of strokes that can result in vestibular dysfunction as well as the brain regions invovled
- TIA → most common site = vertebrobasilar artery
- Brainstem and cerebellar CVAs
- PICA strokes (Wallenberg syndrome)
- AICA strokes
- Cortical CVAs → MCA/PCA territory infarcts
what vestibular dysfunction symptom differentiates between PICA and AICA strokes
the presence of hearing deficits are unique to AICA strokes
somatosensory dysfunction post stroke is linked to _____________
- reduced functional return
- longer rehab
- learned non-use
- distal UE recovery
define hypoesthesia
decreased sensitivity to sensory stimuli
define paresthesia
abnormal sensation such as numbness, prickling, or tingling
define dysesthesia
touch sensation experienced as pain
define allodynia
pain produced by non-noxious stimulus
define atopognosia
inability to localise sensation
T/F: stroke is considered one of the greatest risk factors for falls among elderly people
TRUE
14-29% of individuals hospitalized for a stroke experience a fall during their hospitalization
75% of individuals with stroke fall within 6 months of D/C
what are the most common predictors of fall risk post stroke (acute/subacutely)?
- functional impairment
- cognitive deficits
- impaired balance
what are some stroke specific outcome measures to assess balance?
- postural assessment scale for stroke patients (PASS)
- trunk impairment scale (TIS)
- function in sitting test (FIST)
define post stroke fatigue
lack of physical and mental energy
occurs w/o specific exertion
can manifest as problems related to self-control, emotional instability, reduced mental capacity, perceived reduction in energy
T/F: post stroke fatigue has no correlation with depression
FALSE
most closely assocaited with depression post CVA
also correlates with sleep disturbances, pain, anxiety
List the 2 major scales that can be used to assess post stroke fatigue
- fatigue severity scale
- fatigue impact scale
define thalamic pain
also called neuropathic pain/central post-stroke pain
pain arising as a direct consequence of lesion to central somatosensory system
describe neuropathic pain
often beings week-months post initial insult
severe, burning-like pain
can be intermittent or persistent
may have triggers (mechanical stim, changes in temp, stress, etc.)
what type of meds have been found to be useful in the treatment of neuropathic pain?
Antidepressants
specifically Fluoxetine
what is the most common site of orthopedic pain in post stroke patients?
the shoulder
main causes:
- weakness (rotator cuff)
- impaired motor control
- chronic: muscle shortening and contractures
- acute hypotonicity
- spasticity
- positioning
what can weakness at the shoulder post stroke progress to?
hemiplegic shoulder subluxation
due to changes in mechanical integrity of GH joint from gravity pulling it down
what are some examination methods for hemiplegic shoulder subluxation?
- fingerbreadth method
- radiographs
- potentially ultrasound
define and describe complex regional pain syndrome
“shoulder-hand syndrome”
painful shoulder + painful and edematous hand/wrist with elbow spared
onset correlated w/stroke etiology, the severity and recovery of motor deficit, spasiticity and sensory distrubances, GH subluxation
