Intro Stroke (1a) Flashcards
What was stroke previously called?
CVA
What is the most common cause of neurological disability in adults?
Stroke
Correct way to refer to someone who has had a stroke
Stroke survivor
What is the definition of a stroke?
Acute onset of neurological deficit lasting greater than 24 hours or leading to death with no apparent cause other than a vascular cause
What is the definition of a TIA
Transient Ischaemic Attack - neurological defecit lasting less than 24 hours with a vascular aetiology
What are the 2 major groups of stroke? (and their prevalence)
Ischaemic (85%)
Haemorrhagic (15%)
What are the types of ischaemic stroke and their prevalence (of all strokes)?
Artherothrombosis - 30%
Embolism - 25%
Small vessel disease - 20%
Watershed infarction - 10%
What is a watershed infarction?
Ischaemic infarct where 2 major supplies are intersecting.
What are the types of haemorrhagic stroke and their prevalence (of all strokes)?
Subarachnoid - 5%
Intracerbral - 10%
What is an intracerebral stroke?
Bleed inside the cerebral tissue
What is the ischaemic penumbra?
An area of vulnerable brain tissue surrounding the ischaemic brain tissue
Why is timely medical intervention important when considering an ischaemic penumbra?
If blood flow can be restored
- The exten of the damage caused by secondary and delayed mechanisms can be limited
- The ischaemic penumbra may be salvaged
What are the risk factors for stroke?
Hypertension Diabetes melitis Heart disease Increased blood lipid levels Obesity Smoking
Acronym for stroke first aid/potential stroke
F -face
A - arms
S- speech
T- time
What supplies the anterior circulation?
Internal carotid artery system
What supplies the posterior circulation?
Vertebro-basilar system
What are the primary impairments after a stroke?
Hemiplegia or hemiparesis Spasticity Sensory impairments Visual impairments Impairments of higher cortical function
What is hemiplegia/hemiparesis
unilateral paralysis/paresis on the side of the body conntralateral to the brain lesion
What are the prominent motor impairments following a stroje?
loss of strength (weakness)
loss of dexterity
How can loss of movement vary after a stroke and why?
Varies with size and site of lesions
Ranges from total paralysis to loss of selectivity of distal movements
Describe steps to loss of strength and dexterity after a stroke
Lesions of cortical motor areas and their projections > Decreased descending input to spinal motor neurons > Reduced activation of motor units > Impaired muscle activation > Loss of strength and dexterity
( If inactive also get disuse atrophy)
Effect of stroke on ipsilateral body
General also weakness on the side of the body ipsilateral to the brain lesion
Strength ipsilateral side: 65% - 89% of normal
How does MCA stroke affect movement?
Worse in UL than LL
How does ACA stroke affect movement?
Worse in LL than UL
What is spasticity?
A velocity dependent increase in the tonic stretch reflex?
When may spasticity become evident after a stroke?
4-6 weeks
Which side is affected by sensory impairments after a stroke?
Typical stroke:
anterior circulation = contralateral
posterior = ipsilateral and contralateral
What are the different sensory impairments after a stroke?
Tactile (light touch localisation, pressure, texture)
Proprioception (/joint position sense, passive movement sense, vibration)
Pain
Temperature
Visual impairments
What is hemianopia?
loss of visual field on the side of the hemiplegia
What is the loss of a quadrant of the visual field?
Quadrantanopia
What is loss of conjugate gaze?
Loss of ability to move eyes together
What do impairments of higher cortical function affefct?
Language Motor planning Perception Cognition Emotion and behaviour
What is aphasia/dysphasia?
Difficulty with the spoken word (NOT related to weakness of the mouth)
- Receptive
- Expressive
- Global (both)
What is dyslexia
Difficulty with reading
What is dysgraphia?
Difficulty with writing
What are motor planning impairmentss?
Dyspraxia/Apraxia
What are some of the cognitive impairments after a stroke?
General intellectual function
Memory
Attention
Executive functions: problem solving motivation planning organisation
Emotional problems after a stroke
Lability
Depression
Anxiety
What are some behavioural changes after a stroke?
Impulsivity
Disinhibition
Personality changes (agressive or passive behaviour)
Decreased insight (unrealistic goals, failure to see the relevance)
What is dysarthria
Physical production of speech, difficulty with articulation
What is dysphagia?
Difficulty with swallowings
What are secondary impairments that affect the muscle after a stroke?
Disuse weakness
Length changes
Atrophy
Increased muscle stiffness
What are some general secondary impairments after a stroke?
Adaptive motor patterns (overactivity) Changes in joint mobility (Stiffness) Decreased neural length Decreased bone density (decreased WB/load) Decreased cardiorespiratory endurace Pain Learned non use
what is a TAC
Total anterior circulation stroke
What is a PAC?
Partial anterior circulation stroke
What is a POC?
Posterior circulation stroke
What is a LAC?
Lacunar stroke
What does S mean in bamford/oxfordshire classification?
Syndrome- inderterminate pathogenesis, prior to imaging eg TACS
What does I mean in bamford/oxfordshire classification?
Infarct eg TACI (most often)
What does H mean in bamford/oxfordshire classification?
Haemorrhage
In the Bamford 0r Oxfordshire Classification, what must be present to be classifed as Total anterior circulation syndrome (TACS)?
All of the following three features:
- Hemiplegia involving at least two thirds of face, arm and leg +/- hemisensory loss contralaterally
- Homonymous Hemianopia contralaterally
- Cortical signs (dysphasia, neglect etc)
Bamford or Oxfordshire classification for posterior anterior circulation syndrome (PACS)
2 out of 3 features present in a TACS or
Isolated cortical dysfunction such as dysphasia or;
Pure motor/sensory signs less sever thanin lacunar syndromes (eg monoparesis)
The Bamford or Oxfordshire classicfcation for Lacunar Syndromes (LACS)
Features include motor +/- sensory deficits adffecting at least two thirds of the face, arm, leg and ataxic hemiparesis in the absence of visual field deficits and cortical signs
Bamford or Oxfordshire classification Posterior Syndromes (POCS)
Heterogenous group of strokes
Brainstem or cerebellar dysfucntion:
- Cranial nerve palsies with contralateral moto and/or sensory deficits
Biolaterral motor and/or sensory deficits
Conjugate eye movement disorders
Isolated homonymous hemianopia
Cortical blindness ( can see things but not interpret)
Cerebellar deficits without ipsilateral motore/sensory signs.
Bamford or Oxfordshire classification Posterior Syndromes (POCS)
Heterogenous group of strokes
Brainstem or cerebellar dysfucntion:
- Cranial nerve palsies with contralateral moto and/or sensory deficits
Biolaterral motor and/or sensory deficits
Conjugate eye movement disorders
Isolated homonymous hemianopia
Cortical blindness ( can see things but not interpret)
Cerebellar deficits without ipsilateral motore/sensory signs.
What is the frequency of subtypes of infarct (most to least)
PACS
LACS & POCS
TACS
Which type of stroke has the worst prognosis?
TACS - 60 dead one year later, ~35 dependent, ~ 5 independent
What is the left hemisphere mainly responsible for?
Langauge and analytical activity
What is the right hemisphere mainly responsible for?
visuo-spatial functions and attetnion
What side of the brain is usually dominant?
Left
What is typical of a dominant sided stroke?
Aphasia Dysgraphia Dyscalculia Apraxia: - ideomotor - ideational - constructional Preservation (motor and speech)
What is typical of a non dominant stroke?
Unilateral neglect
Inattention/extinction
Agnosis (trouble remembering faces)
Body image impairment
Other impairments of visuo-spatial awareness
Motor impersistance (inability to sustain a movement)
Left sided stroke: Concentration: Movement time: Performance: Carryover effect Attitude: Mood:
Concentration: good Movement time: slow Performance: correct Carryover effect: good Attitude: realistic Mood: depressed, anxious, frustrated, can be labile
Right side stroke: Concentration: Movement time: Performance: Carryover effect Attitude: Mood:
Concentration: poor/distractible Movement time: Impulsive Performance: Erratic Carryover effect: poor Attitude: Unrealistic Mood: May appear unmotivated. Can be labile
What type of treatment environment and professionals has shown the best results?
People treated in a dedicated stroke unit - brings togehter in one geographically located ward an interdisciplinary team of professionals with an interest and expertisein stroke care
who is part of the treatment team for stroke?
Physicians Nurses Physios OT speech pathologists
Often also includes:
dieticians
social worker
orthoptists
referral may be appropriate
eg psychiatry/psychology or optometry
Roles and responsibilites of stroke management team
- immediate management of stroke and secondary complications
- physical, psychosocial, spiritual and bereavement needs of both the patient and the carer/family
- meeting information needs of pt/family
- Coordinated discharge home/rehab
- End of life care
What are the different levels of stroke care?
Acute care
Rehab
Community-based rehab
Where could acute care of stroke occur?
Neurological ward
Acute stroke unit
Mixed medical ward
Neurological unit
Where could rehab of a stroke occur?
Mixed rehab unit
Stroke unit
Slow stream rehabilitation
Where could community based rehab occur?
Hospital outpatient/day therapy Community centre Private practice Home based Residential care.
Where to look for evidence on stroke treatmnet
Australian Clinical Guidelines for Stroke Management
What is the evidence for physio after a stroke
Strong evidence: Early rehab Task related practice Increased intensity of practice potential for improvement may exist for many years
What are the key aspects of physio management of stroke?
Address primary impairments
Increase strength and train dexterity in context of everyday acticvites
Prevent and manage secondary impairments
