Neuromuscular Stroke and PD Flashcards
What is the Epidemiology of Stoke?
- Stroke is the leading cause of long-term disability and the leading preventable cause of disability
- More women than men have strokes
- Majority >65 y.o; 28% <65 y.o
- African Americans are more impacted by stoke than any other racial group within the American population
What are the 2 main types of stroke?
Type 1 - Ischemic Stroke (occlusive)
Type 2 - Hemorrhagic Stroke (Abnormal bleeding)
Describe Type - Ischemic Stroke.
- Account for approx. 80% of all strokes, and associated with a higher survival rate
- Commonly linked to atherosclerosis of the cerebral arteries, which can lead to the formation of a Thrombus (Platelet aggregation within vessel wall) or an embolus.
What are Types of Ischemic Strokes?
- Thrombus: This is platelet aggregation within vessel wall. This clot disrupts or blocks distal blood flow to the brain and it causes neuronal cell death and injury due to lack of O2 and glucose, this can break off and become a traveling embolism.
- Embolus is a traveling clot or a bit of matter the forms elsewhere in the body and finds itself in the cerebral circulation, which then gets lodged in the vessel and blocks distal blood flow to the brain causing cell death and injury lack of O2 and glucose; Emboli are thrown from the heart and are related to types of Cardiovascular disease, can be caused by trauma
- Atherosclerosis is that paste or plaque buildup that occurs in the arteries and the hardening of the BV wall, these plaque consist of fatty substances of calcium and cellular waste as well as cholesterol, over time these plaque can build up and can rupture the body then uses platelet aggregation and blood clot formation resulting in a thrombus
Describe Type 2 - Hemorrhagic Stroke. What happens if the bleeding is sudden and severe?
- Referred to as Abnormal bleeding
- Hemorrhagic stroke accounts for approximately 20% of all strokes, and is associated with a much higher mortality rate
- A hemorrhagic stroke is bleeding in the brain due to a ruptured blood vessel, most often due to an aneurysm or trauma. The blood leaks into or around the brain and the loose blood clot is an irritant to the nervous system tissue and it leads to neuronal death.
- In addition, when a hemorrhagic stroke is occurring there is lack of blood flow or ischemia distal to the ruptured vessel which further causes neuronal cell death
- If the bleeding is sudden and severe it can cause a rise in intracranial pressure, and cortical tissue will shift or become compressed, or your brain matter can herniate resulting in secondary brain damage
What are 2 types of Hemorrhagic Stroke?
- Intracerebral Hemorrhage: Bleeding within the brain that occurs from smaller ruptured arteries that penetrate the brain, usually from small aneurysms related to things like chronic hypertension and atherosclerosis. This is also the more deadly type of stroke and those that survive often have very significant impairments and activity limitations.
- Subarachnoid Hemorrhage: Bleeding occurs from much larger vessels that travel in the subarachnoid space. This is usually due to a berry aneurysm, which is defined as a congenital defect of an artery which causes weakness of the arterial wall and ballooning at bifurcation. This hemorrhage is typically easier in terms of medical treatment.
What is the Pathophysiology of Stoke? What is the area around the core area? What is the cascade of events that occurs in terms of deprivation of O2 to the cerebral tissue?
MUST KNOW
Complete occlusion of blood flow leads to a core area of neuronal cell death
- Around the core area is what’s referred to as the ischemic penumbra (area where neurons are lethargic, but remain viable)
- Firstly we have ischemia causing the neurons to release excessive glutamate, then we have altered Ca ion channels causing influx of Ca into neuron, because of this you have high levels of intracellular Ca it then activates a series of destructive Ca sensitive enzymes leading further neuronal cell death in ischemic penumbra area.
What are the risk factors and early signs for stroke? What are the 5 “sudden” warnings?
Balance
Eyes
Face
Arm
Speech
Time: Huge in terms of getting medical intervention
Warning signs:
- Sudden numbness or weakness of the face, arm or leg especially one side of the body.
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden sever headache with no known cause
What are Stoke Vasculature Syndromes?
Typically involve the large cerebral vessels, which are:
- Anterior Cerebral
- Middle Cerebral
- Posterior Cerebral
- Vertebrobasilar Artery
What is the role of the Anterior Cerebral Artery? What are common problems with this artery?
- Supports the medial aspect of the Frontal and Parietal lobes, the anterior limb of the internal capsule, the caudate nucleus, the putamen and the Corpus callosum.
Common Problems with ACA stroke are:
- Contralateral Hemiparesis or Hemiplegia
- Contralateral Sensory loss (mostly in LE)
- Mental confusion because of frontal lobe involvement
What is the role of the Middle Cerebral Artery? What are some common problems with this artery?
- Supplies the lateral aspect of the Frontal Temporoparietal and Occipital lobes, as well as the head of the caudate nucleus and putamen, or basal ganglia structures, the external capsule, colostrum and the anterior internal capsule
Common Problems with MCA stroke are:
- Contralateral hemiparesis or Hemiplegia
- Contralateral Sensory loss (mostly in UE)
Can include:
- Homonymous Hemianopia or other visual and spatial perceptual deficits, that being neglect if its the non-dominant hemisphere and apraxia if its the dominant hemisphere
The MCA is the most common site for Infarct
What is the role of the Posterior Cerebral Artery (5)? What are some common problems with this artery?
- Supports the medial aspect of the occipital lobe and the medial and inferior aspects of the temporal lobe, as well as the corpus callosum, the posterior diencephalon (involving both thalamus and hypothalamus) as well as midbrain
Common problems with PCA Stoke are:
- Visual Changes (Pt. may exhibit homonymous hemianopsia
- May have very transient contralateral hemiparesis or hemiplegia
- Transient contralateral sensory loss (mainly because of thalamus and diencephalon involvement)
What is the role of the Vertebrobasilar Artery? What happens if there is Vertebrobasilar Artery insufficiency?
What are common problems with is artery?
- Supports the medulla, the pons, the midbrain, the cerebellum as well as the labyrinth
- If there is Vertebrobasilar Artery insufficiency death may occur because of the life function that are housed in within the brainstem
Common problems with Vertebrobasilar Artery are:
- Ipsilesional or ipsilaterally taction coordination. Pt. could be in a coma, have diplopia, tetraplegia and bulbar paralysis
What is a specific syndrome related to Vertebrobasilar Artery? How does this syndrome occur?
“Locked-In” Syndrome
- Tetraplegia with preserved consciousness, preserved sensation and vertical gaze
This occurs with a basilar artery occlusion and typically with bilateral infarction of the ventral aspect of the pons
*This can be very devastating because an individual is completely dependent and the only type of communication and/or mobility that they have would be to blink their eyes
With Motor impairments, what are abnormal synergy patterns?
When joint movement cannot be isolated, due to an inability to activate or coordinate muscle contractions, an abnormal mass pattern of movement occurs
What is the Medical Management of stoke in the acute setting?
Neuroimaging
- CT scan: used to figure out whether the patient has had a Hemorrhagic stroke. Its not available to delineate in acute setting an ischemic stroke or cerebral edema until three to five days after the neurological event.
- MRI:
- Angiography: (Invasive test where dye is injected to give specific info about the BVs prior to injury; dye allows vasculature to be shown on x-ray or CT)
What are different Interventions for Stoke?
Pharmacological
- tPA
- Glutamate and Ca antagonists:
Surgical
- Clot evacuation
With Pharmacological management of stroke, What is tPA? When is this drug most optimal? When should it not be used?
- Tissue Plasminogen Activase: A clot busting drug, with optimal effectiveness when the drug is administered within a 3hr window of the onset of symptoms
- This can dramatically improve recovery and decrease the long-term participation restrictions.
- Should not be used with Pt. that have hemorrhagic stroke, this would cause more bleeding and a worsening of symptoms
With Pharmacological management of stroke, How can Glutamate and Ca antagonist be beneficial for a patient?
This drug is given as Neuroprotectant-type agents, may be administered to help prevent further neuronal cell death in the area of the ischemic penumbra
