L9 Stroke Flashcards
Modifiable RF for Stroke
HTN
Smoking
Diabetes
Diet high in saturated, trans, and cholesterol
physical inactivity
obesity
high LDL
CAD and PAD
A-fib
Stroke Epidemiology
5 cause of death in US
leading cause of disability
up to 80% of strokes are preventable
Non-modifiable RF for strokes
age
family history
race (black has higher risk)
gender (female)
prior stroke, heart attack, TIA
rural area
Transient Ischemic Attack
sometimes called a mini-stroke
temporary blockage of blood flow to brain
often precede a full stroke
Acute Ischemic Stroke
blood vessel supplying blood to the brain is obstructed
accounts for 87% of all strokes
Hemorrhagic Stroke
weakened blood vessel ruptures causing bleeding into the brain
accounts for 13% of stroke cases
aneurysms and AVMs two most common causes of HS
most common cause of HS is uncontrolled HBP
BEFAST
balance
eyes (visiual field loss, double vision, blurry)
Face
Arm
Speech
Time
FAST
Face drooping or numbness
Arm weakness or numbness
Speech difficulty, slurred speech, seem confused
Time to call 911
FAST SPIN/SNOUT
SNOUT = 77%
SPIN = 60%
fails to recognize 40% of those with post circulation events and 14% of AIS are missed
BEFAST SPIN/SNOUT
SPIN = 85%
SNOUT = 68%
BEFAST helps to reduce the number of patients with AIS
Comprehensive Stroke Center
most demanding certification, can receive all stroke cases
Primary Stroke Center
hospitals that provide critical elements of stroke care to achieve long-term success in improving outcomes
Thrombectomy-Capable Stroke Center
hospitals that are primary stroke center and provide endovascular procedures and post-procedural care
Acute stroke ready hospital
hospitals or emergency centers that have dedicated stroke-focused program
ER Tx for AIS
-MRI with DWI most sensitivity and specificity
-tissue plasminogen activator, alteplase, within three hours
-Thrombectomy to remove clot within 6 hours
ER Tx of HS
Correct imaging, non contrast CT is gold standard
craniotomy to surgically evacuate hematoma and relieve cranial pressure
neurosurgery to perform AVM removal or clip vessel at the base of aneurysm
Medical Treatment for TIA
full medical work up to identify cause
brain imaging, ECG, ultrasound of carotid artery, assess and treat risk factors
goal to prevent future stroke
Post ER Care for AIS
BP less than 180/105 for first 24 hours
should provide early rehab that is organized and interprofessional
should NOT provide high does very early mob within 24 hours
R MCA Syndrome
R gaze deviation
L sided weakness
L neglect
ACA Syndrome
contralateral leg weakness
executive dysfunction
(blue in picture)
L MCA Syndrome
L gaze deviation
R sided weakness
Aphasia
(yellow in picture)
PCA Syndrome
contralateral hemianopsia
confusion, amnesia, disorders of consciousness
(red in picture)
Cerebellar Stroke
ipsilateral ataxia
nausea, vertigo, nystagmus, imbalance
Mid-basilar stroke
locked-in state
crossed symptoms
ocular palsies
Top of basilar Stroke
acute disorders of consciousness or coma
Middle Cerebral Artery Stroke
more common than ACA or PCA
will have unique presentation depending on R/L
occlusion of proximal stem will have CP of all 3 divisions
L MCA Clinical Syndrome, Superior Divison
R face and arm weakness, nonfluent broca’s aphasia
L MCA Inferior Division
fluent or wernicke’s aphasia, R visual field deficit, R cortical sensory loss, some R side weakness
Broca’s aphasia
non-fluent aphasia
spontaneous speech is diminished
loss of normal grammatic structure, word salad
source fo frustration for patient
Wernicke’s Aphasia
fluent aphasia
impaired language comphrension
speech has normal rate, rhythm, and grammar
R MCA Superior Division
left face and arm weakness, L hemineglect, sometimes L face/arm sensory loss
R MCA Inferior Divison
profound L hemineglect but normal L side strength with spontaneous movements
R MCA Deep Territory
left pure motor hemiparesis
L MCA Deep Territory
right pure motor hemiparesis
Unilateral Spatial Neglect
inattention to the side of body opposite of brain lesion
L inattention in most common, R attention is less severe
usually safety concern because patient could harm self
Hemianopsia S/S
-difficulty seeing items or finding them
-miss details in one visual field
-locate lost items once cued
-attempt to make eye contact no matter where PT stands
-spontaneously use both UE
-Spontaneously turn head to compensate for vision loss
Spatial Neglect S/S
-Miss details in one visual field
-walk into things on one side without noticing
-lose track of limbs, doesn’t reposition limbs
-sees to forget position of limbs, drop or spill items
Test for unilateral spatial neglect
extinction on double simultaneous stimulation
normal sensory function but ignores one side of environment
Pusher Syndrome
perceptual deficit after some strokes, with active pushing toward hemiplegic side
displayed in 5% of all pts post stroke, impedes functional outcomes
most common in pts with R hemispheric lesions in thalamus
Presentation of pusher syndrome
patients misbelieve body orientation in space, believing that upright is approx 18° tilted toward hemiplegic side
patient will try to correct by pushing towards their impaired side
Anterior Cerebral Artery Stroke
presents as UMN weakness and cortical sensory loss affecting contralateral leg more than the arm or face
sometimes motor aphasia is present or frontal lobe dysfunction
Frontal lobe dysfunction
grasp reflex, impaired judgement, flat affect, apraxia/dyspraxia, abulia, incontinence, perseveration, impaired judgement/logic/abstraction, lacks a filter
Perservation
difficulty in changing from one task to the next
they will continue the former task continuously
Abulia
changes to drive, personality and judgement
Apraxia
inability to perform tasks or naturalistic actions
difficulty with motor conceptualization, planning, and execution
Apraxia is found in patients with
diffuse lesions of the cortex
focal lesions affecting the frontal or L parietal lobe
pts will present with language comphrension, gross motor, and sensation still intact
Apraxia Screen of Tulia
MDC = 1.79 points
has a 100% positive predictive value and 92% negative predictive value
Cut-off scores of Apraxia Screen of Tulia
10-12 = no praxis errors
6-9 = abnormal praxis or mild
5 or less = severe apraxia
Posterior Cerebral Artery Stroke
causes a contralateral homonymous hemianopia
small branches occluded causes thalamus or posterior limb of IC to be affected
also known as alexia without agraphia
S/S of thalamus/post limb of IC stroke
contralateral sensory loss
contralateral hemiparesis
dominant hemisphere can cause thalamic aphasia
Contralateral homonymous Hemianopia
Losing both L visual fields of both L/R eyes
impact on the optic tract, optic radiation, primary visual cortex
Alexia
inability to read or comprehend written language
remains capable of spelling and writing words, unable to comprehend
seen after stroke affecting dominant hemisphere
Agraphia
loss of previous ability to write
often occurs concurrently with alexia, apraxia, or hemispatial neglect
Stage 1 of Brunnstrom’s Stages of Stroke Recovery
Flaccid tone
no motor control/active movement
Stage 2 of Brunnstrom’s Stages of Stroke Recovery
Mild spasticity
weak synergies and weak associated reactions
Stage 3 of Brunnstrom’s Stages of Stroke Recovery
Increasing spasticity, may be severe
voluntary movement within basic synergies, demonstrates small determinable joint movement
Stage 4 of Brunnstrom’s Stages of Stroke Recovery
Spasticity begins to decrease
active movement begins to occur outside of basic limb synergies
Stage 5 of Brunnstrom’s Stages of Stroke Recovery
Spasticity decreasing
able to perform more difficult isolated movement patterns
Stage 6 of Brunnstrom’s Stages of Stroke Recovery
no spasticity
movements are generally selective, but may require performance at decreased velocities with diminished coordination
Stage 7 of Brunnstrom’s Stages of Stroke Recovery
not universally recognized
normal tone returns
normal isolated movements
Brunnstrom’s Stages of Stroke Recovery
pts may progress through all stages or remain in a stage
severity and length of time in each stage varies on stroke severity and the age of patient
Fugl Meyer Assessment
motor score
helps to quantify the patient’s recovery through Brunnstrom stages
Contemporary PT
focusing on neuroplasticity, like repetition and intensity and that it is ok to allow movement synergies during training
with enough repetitions of practice, neuroplasticity and motor learning principles will drive improvements in movement quality
Traditional PT
focuses on movement quality as primary focus
patients should only practice with movements out of synergistic patterns
UE Flexor Synergy
Scapula = elevation and retraction
Shoulder = abduction/ER or adduction/IR
Elbow = flexion
Forearm = supination
Wrist/Digits = flexion
LE Flexion Synergy
Pelvic = Elevation
Hip = Flexion
Knee = Flexion
Ankle = DF
Forefoot = Eversion
unusual pattern to observe after stroke
UE Extension Synergy
Scapula = downward rotation and protraction
Shoulder = IR and adduction
Elbow = extension
Forearm = pronation
Wrist/hand/digits = position varies
occurs with intentional elevation of arm
LE Extension Synergy
Pelvic = elevation and. retraction
Hip = adduction and extension
Knee = extension
Ankle = PF
Forefoot = inversion
occurs in late swing with extension
Are synergies good or bad?
it depends
some people use their synergies to be able to perform functional tasks
but synergies impede ability to perform necessary mobility tasks or ADLs
