Lecture 2: Sequelae of TBI 1 Flashcards
Other names for Stroke
brain attack, CVA, mini-stroke, pin stroke, TIA (transient ischemic attack)
Stroke Statistics
19% unaware that CVA is preventable; 38% don’t know where in body CVA occurs; 42% can’t identify most common s/s of stroke; 92% don’t know what TIA represents
Most common s/s of stroke
weakness/numbness
Stroke Defined
clinical consequences of focal or diffuse disruption of brain circulation secondary to ischemic or hemorrhagic event; interruption of blood flow to brain
Who is at risk, generally?
50% of general population; >50% of healthcare workers
____ leading cause of death in USA
3rd
Heart disease is _____ leading cause of death; cancer is _____ leading cause of death
1; 2
How many new stroke cases each year?
750,000 (500,000 are preventable)
Roughly 1 every 45 seconds
Every ____ minutes, a person dies from stroke
3
What is the leading cause of disability
Stroke
What % of stroke survivors have deficits?
90
Goal is for functional lifestyle
% of strokes that are ischemic
80
% of strokes that are hemorrhagic
20
Stroke Epidemiology: Age
risk doubles each decade after 55yo
Stroke Epidemiology: Race
African Americans: 233/100,000
Hispanics: 196/100,000
Whites: 93/100,000
Stroke Epidemiology: Heredity
Paternal Stroke: 2 times as likely
Maternal Stroke: 1.4 times as likely
How many brain cells die each minute during stroke
2 millions
How many strokes are preventable
80% Decrease heavy alcohol use: 34K Decrease/quit smoking: 90K Decrease cholesterol: 145K Decrease HTN: 360K
Hypertension
130/85
Atrial Fibrillation
risk factor for stroke; type of irregular heartbeat resulting in ineffective pumping of 1 of the heart chambers/heart palpitations; impacts 2 million Americans; 9% of people 65yo+ have it
S/s of Atrial Fibrillation (AF)
rapid heartbeat, irregular heartbeat
Tachycardia
fast heartbeat
Bradycardia
slow heartbeat
Treatment of AF
blood thinners; proper tx can prevent stroke
Heart palpitation effects
quivering in one of the chambers which facilitates a clot; clot can go to brain, etc.; blood can pool in upper chambers of heart; can be easily treated if identified; causes ischemic stroke
General Stroke Risk Factors
diabetes, physical inactivity, obesity/ metabolic syndrome, oral contraceptives, alcohol abuse, illicit drug use, hypercoagulable states, dietary factors, infection/inflammation, hyperhomocysteinemia, vascular inflammation
Hypercoagulable state
clotting factor in blood–>tends to overclot
Hypocoagulable states
hemophilia, aspirin overuse
Modifiable risk factors
DM, HTN, smoking, alcohol consumption, obesity/overweight, AF, high cholesterol
Non-modifiable risk factors
age, race, gender, previous CVA/TIA, family history
Primary 5 Stroke Symptoms
sudden numbness/weakness; sudden confusion/trouble speaking; trouble seeing in 1 eye; sudden trouble walking, dizziness, etc.; sudden severe headache
FAST acronym & Stroke
Face: ask pt. to smile, any drooping?
Arm: ask pt. to raise both arms, any drifting?
Speech: ask pt. to repeat simple sentences, any dysarthria?
Time: Observe any signs, call 911
(keep in mind hypoglycemia)
Stroke Classifications
Ischemic & Hemorrhagic (includes SAH, ICH, IVH)
SAH
subarachnoid hemorrhage
ICH
intracerebral hemorrhage
IVH
intraventricular hemorrhage (lots of preemies)
Ischemic Strokes
occur when arteries are blocked by clots or by build up of plaque & other fatty deposits; blood supply insufficient to given area (80%); 2 subtypes: thrombotic, embolic
Thrombotic Ischemic Stroke
blood clot forms within blood vessel in brain
Embolic Ischemic Stroke
clot forms in heart or elsewhere, dislodges, travels, & becomes lodged in brain
At some point, embolus will become thrombus; thrombus can become embolus
DVT
Deep vein thrombosis; usually in calf muscle (gastroc(nemius)); have trouble walking, limp, leg hurts really bad, calf muscle will feel very warm to touch, hurt for them to dorsi-flex (point) foot; at risk for thrombosis to travel as embolis to lungs, heart, brain; can also cause redness in leg
PE
pulmonary embolism; may cause SOA, sudden pain over area affected; In more severe cases, can cause death
Penumbra & Therapists
Therapists are protectors of the penumbra; area around affected vessel will start to die (penumbra); hypoprofused area: profusion is ability of blood to get where it needs to go; supply cut off
Lacunar Infarct
Obstruction of blood flow in the small, deep brain arteries; occur frequently in basal ganglia, internal capsule, thalamus, brainstem; damage isn’t usually as diffuse; often occur in subcortical regions
Ischemic Penumbra
area of dysfunctional ischemic tissue; suggests a possible lacunar state
tPA
used only in individuals who have a known ischemic stroke; never used in hemorrhagic type, will make pt. bleed more
Hemorrhagic Stroke
occurs when blood vessel in brain breaks, leaking blood into brain; accounts for ~15-17% of strokes but are responsible for more than 30% of deaths
3 types of hemorrhagic strokes
intracerebral (inside cerebral cortex)
subarachnoid (subarachnoid space)
intraventricular (in ventricles)
Intracerebral Hemorrhage
bleeding inside the brain; results from chronic HTN; often coincides with severe headaches; risk of brain herniation
Subarachnoid Hemorrhage
Bleeding that occurs within the meninges; (can suck blood out or let body reabsorb); possible rupture of an aneurysm; sudden headaches with LOC; women more than men
Intraventricular Hemorrhage
Extension of both intracerebral hemorrhages &/or the subarachnoid hemorrhages into the ventricular spaces
Aneurysm
localized, blood-filled dilation of a blood vessel caused by disease or weakening of vessel wall; Blood circulates within aneurysm before it cycles out; may eventually burst; will resut in hemorrhagic stroke; commonly occur in arteries at the Circle of Willis or aorta (bifurcation of vessel); most common complaint is pain behind the eyes
HTN
more pressure on blood vessels due to heart having to pump harder to move blood
2 Methods of Aneurysm Management
Clipping & Coiling
Arteriovenous Malformation
AVM/ AV Malformations; majority of cases involve congenital disorder comprised of snarled tangles of arteries & veins (@ capillary level); impacts ~300K Americans occurring in males/females of all racial/ethnic backgrounds at equal rates
AVMs damage brain &/or spinal cord through 3 basic mechanisms:
- reducing amt. of oxygen reaching neurological tissue
- causing bleeding (hemorrhaging) into surrounding brain tissues
- compressing/displacing parts of the brain or spinal cord (violation of Monroe-Kellie Hypothesis)
Brainstem Stroke
especially devastating; BS controls all involuntary, life-support functions: breathing rate, BP, heartbeat; eye movement, speech, audition, deglutition; pts. may incur paralysis on unilateral or bilateral paralysis of the UE/LE due to cortical pathways; hemorrhagic here particularly devastating
Locked-In Syndrome
neurological disorder characterized by paralysis of voluntary movements in all body parts except those that control eye movements; may result from TBI, diseases of circulatory system, demyelinating diseases, or meds overdose; pts. conscious w/ intact cognition but are unable to speak or move; leaves pt. completely paralyzed/ mute
Cerebellum Jobs
Aids in control of our reflexes & assists in maintaining balance & coordination
Cerebellar Strokes
May cause abnormal reflexes of head & torso Coordination & balance problems Vertigo Nausea/vomiting Ataxia (ataxic dysarthria)
Medical Management of Hemorrhagic Stroke
Prevention is paramount thru reducing modifiable risk factors
Identify s/s early: “Time is Brain”
Control BP
(remember hypoglycemia mimics stroke)
Frequent neurological checks by nurse, neurologist, therapists, etc
Sudden Mental Status changes should be taken to ER
Medical Management of Ischemic Stroke
Prevention paramount through reducing modifiable risk factors Identify s/s early Identify etiology & reverse if able Frequent neurological checks Thrombolytic therapies (tPA)
tPA
clot buster; tissue plasminogen activator
Extreme criteria must be met before administration
tPA administration criteria
Must be given (if IV) 180 minutes post onset s/s of stroke
May be given w/in 6hrs if administered via intraarterial catheter
CONTRAINDICATED for hemorrhagic stroke
Infarct
where tissue has died as result of ischemic stroke; can technically grow without treatment
tPA contraindications
evidence of intracranial hemorrhage; suspicion of subarachnoid hemorrhage; recent ABI/TBI; history of CVA; history of intracranial hemorrhage; uncontrolled HTN; seizure @ onset of CVA; active internal bleeding; AVM; aneurysm
Other Ischemic Therapies
Catheter directed tPA
Endovascular retrieval: MERCI System
MERCI system
endovascular retrieval method; thread thru femoral artery, thread to clot, corkscrew in then suck clot out thru tube
Prognostic Indicators related to Stroke
Young w/ outgoing personality; tx programs started early; expressive aphasia; pt’s that don’t have perceptual or sensory impairments; ability to self-correct; single lesions; pt whose tx program was initiated before 6mos post stroke; higher intelligence; mild-mod impairments; ability to point to pictures when named; good comprehension; go w/ the flow personality; pt not dependent on SLP
When research says most gains will be made
within 1st 6 months, but can still make gains after but not as fast
Brodmann’s Areas
done by Korbinian Brodmann; references #s 1-52 w/ some subdivided areas
Brodmann’s area 4 (frontal lobe)
primary motor cortex
Brodmann’s area 6 (frontal lobe)
premotor cortex (supplementary motor cortex)
Brodmann’s areas 44 and 45 (frontal lobe)
Broca’s area
BA 3, 1, 2 (parietal lobe)
primary somatosensory cortex
BA 39 (parietal lobe)
angular gyrus
BA 40 (parietal lobe)
supramarginal gyrus
BA 41 (temporal lobe)
primary auditory cortex
BA 21 & 22 (temporal lobe)
middle & superior temporal gyri; Wernicke’s area
BA 17 (occipital lobe)
primary visual cortex
BA 18-19 (occipital lobe)
visual association areas
Functional Pathways: connection between Wernicke’s & Broca’s areas mediates:
expression of language utterances in speech
Functional Pathways: connection b/t Broca’s area & Primary Motor Strip mediates:
speech sound production
Functional Pathways: connection b/t primary auditory cortex & Wernicke’s area mediates:
language comprehension
Functional Pathways: connection b/t Wernicke’s area & visual areas mediates:
reading ability
Functional Pathways: connection between somatosensory perception area & Wernicke’s area would mediate:
language reception via tracing letters on skin or reading braille, interpreting sign language, etc.
