Lecture 2 Flashcards
Stroke
Brain Attack, CVA, Mini-Stroke, Pin Stroke, and TIA (transient ischemic attack- brief and passing)
- Strokes are preventable
- Strokes in the right hemisphere affect the left side of the body
- TIA- indicative of larger stroke (coming)
Stroke Awareness
- 19% are unaware that stroke is preventable
- 38% do not know where in the body a stroke occurs
- 42% cannot identify the most common s/s of stroke is weakness/numbness
- 92% do not realize what a TIA represents
Stroke Defined
- Describes the clinical consequences of a focal or diffuse disruption of brain circulation secondary to an ischemic or hemorrhagic event
- Interruption of blood flow in the brain
50% of the general population is at risk
> 50% of healthcare workers are at risk (stress)
-90% of stroke suvivors has chronic deficits (such as dysarthria)
Stroke Statistics
- 3rd leading cause of death in the USA
- Heart Disease is #1; Cancer is #2
- 750K new cases each year; 500K are preventable
- Roughly 1 every 45s
- Every 3m a person dies from stroke
- Leading cause of disability; 90% of survivors have deficits
80%of strokes are Ischemic
20% of strokes are hemorrhagic
Stroke Epidemiology
Age-
Risk of stroke doubles each decade after 55y
Race-
African Americans: 233/100K
Hispanics: 196/100K
Whites: 93/100K
Heredity-
Paternal Stroke: 2x as likely for stroke
Maternal Stroke: 1.4x as likely for stroke
Time is brain
- 2 million brain cells die every minute during a stroke
- 80% of strokes are preventable
- Based on ~730K strokes annually
- Decrease heavy alcohol use: 34K
- Decrease smoking: 90K
- Decrease cholesterol: 145K
- Decrease Hypertension: 360K; 130/85 is HTN
- Every minute you wait during a stroke is neurons dying
Atrial Fibrillation
- AF- irregular heart beat
- Risk factor for stroke. Rapid heartbeat (tacacardia)
- AF is a type of irregular heartbeat resulting in ineffective pumping of one of the chambers of the heart (causes ischemic strokes)
- Impacts 2 million Americans
- 9% of persons age 65y+ have AF
- s/s: rapid heartbeat, irregular heartbeat
- tx: blood thinners; proper tx prevents stroke
- 4 chambers in the heart. Quivering in the heart causes a clot and the clot can be sent to the brain
Risk Factors for Stroke
- Diabetes
- Physical Inactivity
- Obesity
- Metabolic Syndrome)
- Oral Contraceptives
- Alcohol Abuse
- Illicit Drug Use
- Hypercoagulable States
- Dietary Factors
- Infection/Inflammation
- Hyperhomocysteinemia- leads to vascular inflammation
- Vascular Inflammation
Modifiable Risk Factors for Stroke
- DM- diabetes mellitus
- HTN- hypertension
- Smoking
- Alcohol Consumption
- Obesity/Overweight
- AF
- High Cholesterol
Non-Modifiable Risk Factors for Stroke
- Age
- Race
- Gender
- Previous TIA/CVA
- Family Hx
Common Stroke Symptoms
- Weakness: Sudden numbness or weakness of face, arm or leg, especially on one side of the body.
- Speech/Language Disturbances: Sudden confusion or trouble in speaking or understanding speech.
- Visual symptoms: Sudden trouble seeing in one or both eyes
- Motor symptoms: Sudden trouble in walking, feeling dizzy or loss of balance and coordination
- Severe Headache: Sudden and severe headache with unknown cause
Have these: go to the hospital
Rapid Detection of Stroke
- Acronym FAST
[F] FACE: Ask the Patient to smile; Any drooping?
[A] ARM: Ask the Person to raise both arms; Any drifting?
[S] SPEECH: Ask the Person to repeat simple sentences; Any dysarthria?
[T] TIME: Observe any signs; Call 911!
make sure patient is not hypoglycemic- low sugar can mimic stroke signs
Stroke Classifications
- Ischemic- 80%
- Hemorrhagic- 20% (more deadly- blood should never interact with the brain) violation of MKH
- —-SAH- subarachnoid hemorrhage
- —-ICH- Intracerebral hemorrhage
- —-IVH- Intraventricular hemorrhage
Ischemic Strokes
Occur when arteries are blocked by blood clots or by the build up of plaque and other fatty deposits
As such, blood flow is insufficient to a given area
80%+ of strokes are ischemic in nature
•Ministroke, pin stroke, TIA- brief occlusion of a vessel.
large and small vessels
2 Types of Ischemic Strokes
Thrombotic: blood clot forms within a blood vessel in the brain; vessel supplying blood to the brain (Stationary)
Embolic: blood clot forms with in the heart or elsewhere, dislodges, and becomes lodged in the brain (moves)
Lacunar Infarct (Ischemia)
Obstruction of blood flow in the small, deep brain arteries; occur frequently in the Basal Ganglia, Internal Capsule, Thalamus, Brain Stem!
o Lacunar- stoke occurs in small, deep brain arteries. Causes focal damage. Often occur in subcortical areas (basal ganglia, internal capsule, brainstem)
Ischemic Penumbra
The penumbra is an area of dysfunctional ischemic tissue; suggests a possible lacunar state. Can use tPA with ischemic strokes
o Penumbra- tissue around the blood clot (hypoprofused- blood cannot reach area)
Hemorrhagic Strokes
- Occurs when a blood vessel in the brain breaks leaking blood into the brain; accounts for ~15-17% of all stroke but are responsible for more than 30% of deaths
- Intracerebral Hemorrhage
- Subarachnoid Hemorrhage
- Intraventricular Hemorrhage
•A small bleed in the brain (the body will absorb the blood) Astrocytes will help clean up the bleed.
Intracerebral Hemorrhage
- Bleeding inside the brain
- Results from chronic HTN
- Often coincides w/severe headaches
blood is moving faster and puts strain on the blood vessels
Subarachnoid Hemorrhage
- Bleeding that occurs within the meninges
- Possible rupture of an aneurysm
- Sudden headaches with LOC
- Women>Men
in the subarachnoid space- can suck the blood out at times or the brain may be able to reabsorb the blood
Intraventricular Hemorrhage
-Extension of both intracerebral hemorrhages and/or subarachnoid hemorrhages into the ventricular spaces
Aneurysm
- Localized, blood-filled dilation of a blood vessel caused by disease or weakening of a vessel wall
- Commonly occur in arteries at the Circle of Willis or the aorta; bifurcation of vessel
- Most common complaint is “pain behind the eyes”
Violation of MKH
Clipping an Aneurysm
•Clipping- clip off the aneurysm, leave it in place because it will eventually congeal over (let it clot).
Coiling an Aneurysm
•Coiling- go through phremral artery in groin and use a tube and they snake it into the ballooned aneurysm to reinforce it so it doesn’t burst.
Arteriovenous Malformation
- AVMs or AV Malformations
- The majority of cases involve a congenital disorder comprised of snarled tangles of arteries and veins
- Impacts ~300K Americans occurring in males/females of all racial or ethnic backgrounds at equal rates
Arteriovenous Malformation 2
***Know the three mechanisms
-AVMs damage the brain and/or spinal cord through three basic mechanisms:
——-Reducing the amount of oxygen reaching neurological tissue
——-Causing bleeding (hemorrhaging) into surrounding brain tissues
——-Compressing/Displacing parts of the brain or spinal cord
Brainstem Stroke
- Brainstem strokes are especially devastating
- has CN and pathways CST & CBT
- The brainstem controls all of our involuntary, life-support functions:
Breathing rate, BP, and heartbeat
Eye movements, Speech, Audition, and Deglutition
-Patients may incur paralysis on unilateral or bilateral paralysis of the UE/LE due to cortical pathways
Locked-In Syndrome
- Neurological disorder characterized by paralysis of voluntary muscles in all parts of the body except for those that control eye movements
- May result from TBI, diseases of the circulatory system, demyelinating diseases, or medication overdose
- Persons are conscious with intact cognition but are unable to speak or move
- Disorder leaves the patient completely mute/paralyzed
Cerebellar Stroke
- The cerebellum aids in control of our reflexes and assists in maintaining balance and coordination
- A stroke that occurs at the cerebellar level may:
- Abnormal reflexes of the head and torso
- Coordination and balance problems
- Vertigo
- Nausea/Vomiting
Medical Management of Hemorrhagic Strokes
- Prevention is paramount through reducing modifiable risk factors
- Identify s/s of CVA early: “Time is Brain”
- GLUCOSE: Hypoglycemia mimics stroke
- Control BP
- Frequent neuro checks via NSG, MDs, Therapists
Medical Management of Ischemic Strokes
- Prevention is paramount through reducing modifiable risk factors
- Identify s/s of CVA early: “Time is Brain”
- GLUCOSE: Hypoglycemia mimics stroke
- Identify etiology and reverse if able.
- Frequent neuro checks via NSG, MDs, Therapists
- Thrombolytic therapies (tPA)
tPA
- Tissue plasminogen activator
- Extreme criteria must be met before administration
- Must be given (if IV) 180m post onset s/s of stroke
- For some patients, tPA can be given at 4.5h
- May be given within 6h if administered via intra-arterial catheter
- tPA IS CONTRAINDICATED FOR HEMORRHAGIC STROKES
• tPA-clot buster- there is a window of time that it can be given (strict criteria)
o intra-arterial catheter (put in the clot)
o contraindicated for hemorrhagic stroke
o Fibrin-protein that forms the clot
used only in individuals with a known ischemic attack (never in a hemorrhagic attack- makes the bleed worse) Thins the blood (injected through a shot and direct app)
tPA Contraindications
- Evidence of intracranial hemorrhage
- Suspicion of subarachnoid hemorrhage
- Recent ABI/TBI
- Hx of CVA
- Hx of intracranial hemorrhage
- Uncontrolled HTN
- Seizure at onset of CVA
- Active internal bleeding
- AVM
- Aneurysm
Other Ischemic Therapies
- Catheter directed tPA
- Endovascular retrieval
- ——–MERCI system
MERCI System
MERCI system- blood clot retrieval system (endovascular retrieval). Essentially coiling, they snake through the vessels until they find the clot and then they attach to it and sneak it back out and suck it into the tube.
Prognostic Indicators I of good recovery
- Young with outgoing personalities
- Treatment programs that were started Early
- Expressive aphasia (because they can understand, receptive skills are intact)
- Patient’s that Do Not have perceptual or sensory impairments (more functional in therapy)
- Ability to self-correct- if they can fix they can understand
- Single lesions
Prognostic Indicators II
- Patients whose treatment program was initiated Before six month window (post stroke)
- Higher intelligence- more previously learned skills
- Mild-Moderate Impairments
- Ability to point to pictures when named (comprehension is intact)
- Good comprehension
- Go-With-The-Flow personality
- Patient is Independent upon the SLP- more generalization
Brodmann’s Areas
- Korbinian Brodmann
- References #s 1-52 with some areas subdivided
Frontal Lobe
- Area 4- Primary Motor Cortex
- Area 6- Pre-motor and Supplementary motor cortex
- Areas 44- pars opercularis, part of Broca’s area
- Area 45- pars triangularis, part of Broca’s area
Parietal Lobe
- Area 3,1,2- Primary somatosensory cortex
- Area 39- Angular gyrus (part of wernicke’s area)
- Area 40- Supramarginal gyrus (part of wernicke’s area)
Temporal Lobe
Area 41- Primary Auditory Cortex- Heschl’s Gyrus
Areas 21- Middle temporal gyrus
Area 22- Wernicke’s area, posterior 2/3 of superior temporal gyrus
Occipital Lobe
Area 17- Primary visual cortex
Area 18 and 19- Visual association cortex
Interconnecting Functional Pathways
- Primary Visual Preception
- Wernicke’s area
- auditory perception
- somatosensory perception
- primary motor function
- broca’s area
Wernicke’s–>Broca’s Pathway
-mediates expression of language utterances in speech
Broca’s–> Primary Motor Strip Pathway
- mediates speech and sound production
Primary Auditory Cortex–> Wernicke’s Pathway
- mediates language comprehension
Wernicke’s–>Visual Areas Pathway
- mediates reading ability
Somatosensory Perception Area–> Wernicke’s
- mediates language reception via tracing letters on the skin or reading braille
Deep vein thrombosis
• DVT- Deep vein thrombosis (need to watch because it can become an embolism and break off and travel to the lungs, brain, or heart)- typically occurs in the leg (calf muscle) gastrocnemius muscle. Way to determine a DVT- pain in the back of the leg, difficulty walking, the calf will feel very warm to the touch. It will hurt for the patient to flex and point their foot.
Pulmonary Embolism
- PE- can cause a sharp pain, shortness of breath (SOA-short of air) – can also be a sign of a heart attack
- Referred pain- heart attack can cause pain to radiate down a patients arm
Varicose veins are not a risk factor for PE
Possible Aneurysm Sites:
1. Anterior cerebral artery
- Internal Carotid
- Middle Cerebral
- Basilar
- 40%
- 20%
- 34%
- 4%
