HNNS Case 2: Stroke Flashcards
Anatomy of brainstem and its vascular supply
See lecture
Describe the anatomy of motor and somatic sensory pathways between cerebral cortex and spinal cord
See lecture
Sensory
1. Spinothalamic pathway
2. Dorsal column-Medial lemniscus pathway
Motor
- Lateral corticospinal tract
- Ventral corticospinal tract
- Extrapyramidal tracts
- Rubrospinal tract
- Tectospinal tract
- Reticulospinal tract
- Vestibulospinal tract
Major pathways and structures in the Cerebral hemisphere and Brainstem and S/S related to their disruption
See lecture
Different types of cerebral vascular diseases and underlying causes
- Ischaemic stroke
- **Atherosclerosis (Occlusive) - large / small vessels
—> small vessel disease: **Lipohyalinosis
- ***Emboli (Occlusive) - from mural thrombi of heart / bifurcation of common carotid artery
- Hypotension - watershed areas (boundary zone infarct)
- Vasculitis (prudent meningitis e.g. TB meningitis / Haemophilus influenzae) - Haemorrhagic stroke
- Abnormalities of blood vessels
—> **Microaneurysm in hypertension (located in **deep penetrating artery)
—> **Saccular aneurysm (located in **big cerebral artery, in **subarachnoid space)
—> **Arteriovenous (vascular) malformation
- Blood disorders
—> thrombocytopenia (multifocal, lobar)
—> coagulopathies (bleed into subdural space)
—> anti-coagulants - Trauma
—> Extradural / Subdural haemorrhage
Pathological change in blood vessels underlying different types of cerebrovascular diseases and their implications to treatment
Ischaemic stroke - Acute therapy: —> Intravenous ***Alteplase therapy within 3 to 4.5 hours —> after 4.5 hours: ***Intracerebral haemorrhage outweighs benefit of Thrombolysis —> Endovascular thrombectomy (only in some forms of ischaemic stroke) - Antithrombotic therapy within 48 hours - Prophylaxis for DVT and pulmonary embolism - Mannitol to reduce cerebral edema - Aspirin at discharge - Lipid-lowering therapy - Anti-hypertensive - Management of metabolic syndrome - Smoking cessation
Haemorrhagic stroke
- Discontinuation of anticoagulant and antiplatelet
- Maintain body temp
- Normal saline
- Treat hyperglycaemia, avoid hypoglycaemia
- Prevention of aspiration due to dysphagia
- Prevnetion of DVT and Venous thromboembolism
Principles of rehabilitation in stroke patient
Rehabilitation program
- Assessment + Management plan + Progress measurement + Discharge planning
- achieve highest possible functional level + re-integration into community
- Mobility training
- ADL training
- Cognitive training
- Dysphagia management
- Bladder / Bowel function management
- Psychosocial intervention
- Vocational training
- Prevention + Management of complications
Emotional impact and depression in stroke patient
- Feeling of loss of control
- Feeling of loss of independence
- Poor self-esteem
- Helplessness
Use of Glasgow Coma Scale in monitoring the neurological state of patients
Maximum 15
- Motor (1-6)
- Verbal (1-5)
- Eye (1-4)
Brain injury:
Mild: >=13
Moderate: 9-12
Severe: <9
Eye opening response —> Determine **Arousal level —> controlled by **Subcortical ascending reticular formation
Verbal / Motor response —> Determine **Awareness level —> controlled by **Cerebral cortex
Risk factors for a changing epidemiology of cerebrovascular disease
Risk factors
- Hypertension
- Ischaemic heart disease
- Hyperlipidaemia
- DM
- Smoking
- Age
- Gender
Changing epidemiology
- Crude mortality rate ↑
- Age-specific mortality ↓ due to hypertension treatment
Impact of cultural and socioeconomic factors on the neurologically disabled
- Discrimination due to impairment
- Disadvantage in job seeking
- Deprivation of sense of self-worth
- Patients with chronic illness need to adapt to life-long treatment
- Disruption of family and social life
- Uncertainty (Trajectory, Symptomatic)
- Biographical disruption
Multi-disciplinary approach in treatment of stroke patients
- Physicians
- Stroke unit nurse
- Allied health professionals (Physiotherapy, Occupational therapist, Speech therapist)
- Dietician
- Social worker
