Stroke Flashcards
BE FAST
Balance: LOB or coordination loss
Eyes: vision changes
Face: drooping, asymmetries
Arm: raise both simultaneously and check for differences
Speech: ask person to repeat a statement, check for Dysarthria: slurring
Time: get to ER, 3 hour window after seen “normal” to get tPA to dissolve the clot
Motor Impairments of Stroke
-interference with smooth and purposeful movement
-hypotonia/faccidity
-hypertonia/spasticity
-tonal changes will result in impaired joint alignment
Normal Postural Tone
-tone sufficient to hold us upright against gravity
Pyramid of Postural Reflex Mechanism
-Normal Postural tone
-Primitive movement patterns
-Righting reactions
-Protective Extension Reactions
-Equilibrium Reactions
Primitive Movement Patterns/Reflexes
-provide basis for mocement paptterns that progressively shoow more coordination
Righting Reactions
-provide orientation of the head and alignment of other body parts
-critical for development as upright individuals
ex: inability to lift head in supine, keeping head rotated away from weaker side
Protective Extension Reactions
-1st line of defense against chanfes in our postural balance, CoG over BoS changes
-parachute reactions or protective stepping
ex: client does not extend arm when falling, client doesn’t move impaired leg to prevent falling
Equilibrium Reactions
-extension of protective reaction allows us to maintain balance by adjusting the location of CoG
-cocontracting muscles or making adjustments
ex: clinent doesnt lengthen weight bearing side of trunk when shifting, clien does not increase muscular stability when shifting
Atypical Synergies
-predictable movement patterns occurring during voluntary attempts
-result of loss of selective mmt strategies
-tone changes or neuro disorganization
-impaired timing
UE Flexion Synergy
-Scapular Elevation
-Scapular Retraction*
-Shoulder Abd & ER
-Elbow flexion*
-Forearm Supination
-Wrist flexion*
-Finger Flexion*
UE Extension Synergy
-Scapular Depression*
-Scapular Protraction
-Shoulder extension*
-Shoulder add*
-Shoulder IR*
-Elbow Extension
-Forearm Pronation*
-Wrist Extension
-Finger flexion*
UE Resting Synergy
-Scapular Depression
-Scapular Retraction
-Shoulder extension
-Shoulder add
-Shoulder IR
-Elbow flexion
-Forearm Pronation
-Wrist flexion
-Finger Flexion
LE Flexion Synergy
-Pelvic elevation*
-Pelvic retraction*
-Hip Flexion*
-Hip Abd
-Hip ER
-Knee Flexion
-Ankle DF
-Foot Inversion*
LE Extension Synergy
-Pelvic depression
-Pelvic protraction
-Hip extension
-Hip Add*
-Hip IR*
-Knee Extension*
-Ankle PF*
-Foot Inversion*
LE Resting Synergy
-Pelvic elevation
-Pelvic retraction
-Hip Flexion
-Hip Add
-Hip IR
-Knee Extension
-Ankle PF
-Foot Inversion
Sensory Impairments of Stroke
-disorders of tactile, proprioception, complex sensory systems
-disorders of movement secondary to sensory (lack of feedback and proprioception)
Visual/Perceptual Impairments
-Disorders of body image: neglect, no longer mirror images
-visual disorders
-Disorders of spatial thought (awareness of surroundings)
Cognitive/Communication Impairments of Stroke
-imaired memoory
-disorientation
-Impaired judgement, problem solving
-decreased concentration span
-personality changes
-aphasia
Predictors of Poor Rehab Outcome
-Dementia
-Global Aphasia
-Previous Stroke
-Older age
-incontinence
-severe visuospatial deficits
-Persistent sensory
Goals of Rehabilitation
-maximize functional independence
-Return to most optimal living environment
-Improve Quality of life
Functional Independence
ability to handle one’s needs without assistance
Quality of Life
-one’s ability to pursue pleasureable activites
Neurorehabiliation
-interventions useful for assisting the recovery of pt with neuro lesions
Neurophysiological Approaches
-PNF: proprioception neuromuscular facilitation
-Brunnstrom: Movement therapy for hemiplegia
-NDT: neurodevelopmental techniques
-Neuro-IFRAH: Neuro-integrative Rehab and habilitation
-Rood: sensorimotor retraining
Cerebrovascular Disease
-abnormality of the brain from pathologic processes of blood vessels
Ischemia
-decreased blood flow
Infarction
-death of tissue due to lack of blood flow
Thrombosis
-clot in vessel
Embolism
-blood clot from elsewhere travels to the brain
Hemorrhage
-bleeding
Ischemic Stroke
-clot or disturbance to blood flow
-87%
-large vessels-50% have warning TIA
Hemorrhagic Stroke
-burst of bloodvessel leading to lack of blood to tissues
-13%
Intracerebral: inside of parenchyma (cortical or subcortical)-10%
Subarachnoid-3%
Stroke
-acute event related to inturruption of blood supply or bleeding of a blood vessel
-last more than 24h
-5th leading COD in US
-2nd in world
-most common in older poppulations
Transient Ischemic Attack
-mini stroke
-brief episode of neuro dysfunction froom brain or retinal ischemia
-usually <1 hours
-not more than 24h
-most are 15-20 mins
-90 day risk after TIA is 3-17%
-highest risk in first 30d
-18% risk in the next 10 years
Mimickers of Stroke
-hypoglycemia
-Hypoxia
-seizure
-migraines (Todd’s Paralysis: weak on side of attack)
-MS Attack (more slow)
-Brain Tumor swelling
NOT a Stroke
-loss of consciousness
-syncope/fainting
-Numbness in both feet
-waxing and waning confusion
-Diffuse weakness
-Numbness in one hand or foot (usually too small an area)
-Pain
Modifiable RK for Strokes
-HTN
-Diabetes
-High cholesterol
-smoking
-OCP
-pregnancy
ACA Stroke
-rare
-hemiparesis contra leg weakness
-urinary incontinence
-slowness, delay
-akinetic mutism: no motivation to speak
-longer term
MCA Stroke
-common
-hemiparesis contra face and arm weakness
-global aphasia if on dominant side (initially)
-neglect (non-dominant worse than >dominant)
-sensory loss
-Cortical sensory loss
-Gaze deviation: look away from weak side
Dominant Hemisphere
-pays attention to both sides
Non-Dominant Hemisphere
-looks only on the contra side
PCA Stroke
-homonymous hemianopsia
-visual hallucination, color abnormalities
-cortical blindness
-contra sensory
-alexia: inability to read
-basilar syndrome
Veterbobasilar Stroke
-inpsi cranial nerve/face, contra body
-sensory
-vertigo
-diplopia, dysarthria, dysphagia
-nausea
-hearring loss
Cardioembolic Infarction
-most cerebral emboli come from heart
-atrial fibrillation
-heart attack
-usualy in multiple areas in brain
Atrial Fibrillation
-5x increase stroke risk
-2x increased risk of death
Treat:
-warfarin, anticoagulants
Embolic Infarction
-aorta
-large intracranial arteries
-patent foramen ovale
Embolic Stroke of Uncertain Source
-don’t know location
Small Artery Occlusion (Lacune)
-BC within brain
-<1.5cm
-penetrating vessles of putamen, caudate, internal capsule, thalamus
-face, arm, leg equally
Lacunar Infarction Syndrome
-small stroke
-better prognosis
-affects thalamus and has bigger symptoms
Lacunar Infarction: Pure Motor Stroke
-hemiparesis of face, arm, leg
-internal capsule or base of pons
Lacunar Infarction: Pure Sensory Stroke
-face, arm, leg
-posteriorlateral thalamus
Lacunar Infarction: Sensorimotor Stroke
-thalamus and internal capsule
Lacunar Infarction: Dysarthria
-clumsy hand syndrome
-base of pons
Lacunar Infarction: Ataxia: Hemiparesis
-pons/internal capsule or subcortex
Thalamic Stroke
-contra sensory loss to all modalities
-spontaneous pain and dysethesias
-mild hemiparesis
Rare Causes of Strokes
-inherited, inflammatory disorders, hematologic disorders, radiation, cocaine
Approach for Acute Ischemic Stroke
- Stabilize Patient
- Ischemic vs. Hemorrhagic
- Last known normal
- NIHSS Score
- Candidate for acute thrombolytics
- Candidate for endovascular intervention
Door to Needle Time
-time from entering hospital to when TPA is given
-usually 60, goal is 45m
-every 30 min, 10% decrease in probability
tPA/tNK
-Tissue plasminogen activator
-clot busting medication
-for acute strokes
-doesn’t change death, but function in 3 months
0-90m: need 5
91-180m: need 9
181-270m: need 15
Contraindications:
->4.5 hours last known normal (risk of hemorrhage goes up)
-hemorrhage
-Head trauma in last 3m
-high BP 185/110
-endocarditis or aortic dissection
-bleeding disorder
-glucose <50
Endovascular Intervention
-if area of clot is not completely dead (Perfusion>diffusion)
-clot can be pulled out
-24h
BP Management with tPA
-in ICU for 24h (no PT possible bleeding)
-check BP frequently
-maintain BP of 180/105
Post-Stroke Management
-want BP high to increase blood flow post tPA to get through swelling (180/105)
-no tPA BP goal 220/110
-sugar control
-antiplatelet/anticoagulants
if worse: head down (reverse trtendelenburg)
Secondary prevention
Post Stroke Complications
-edema
-hemorrhagic conversion: blood pools in the brain, inschemic to hemorrhagic stroke
-infection
-aspiration
-MI
-DVT
Carotid Endarterectomy
-remove plaque from carotid
Old vs. New Stroke Imaging
DWI:
-New: white
-Old: holes
T2:
-New: grey
-Old: white
Recovery from Stroke/Outcomes
-best recovery in 3-6m
-motor recovers better than language and spatial attention
-proximally better first
-prevent contractures
Limitations to Recovery: Stroke
-size
-limited therapy
-depression
-aphasia, neglect, apathy
-spasticity/contractures
-medications
-recurrent stroke
Hemorrhagic Conversion
blood pools in the brain, inschemic to hemorrhagic stroke
Intracerebral Hemorrhagic Stroke
-subcortical
-cortical: avms, tumors
Subarachnoid Hemorrhagic Stroke Causes
-aneurysms, avms, venous, trauma
Signs of Intracranial Hemorrhagic Stroke
-neuro deficits onset
-headache, vomitting, decreased consciousness
-CT shows blood fast
-only way to differentiate hemorrhagic or ischemic
Causes of Intracranial Hemorrhagic Stroke
-HTN
-trauma
-avm: rupture of arteriovenous malformation
-aneruysm
-brain tumor bleeding
-hemorrhagic conversion
-bleeding disorders
-amyloid angiopathy
Intracranial Hemorrhagic Stroke due to HTN
-putamen
-hemiphere
-thalamus
-cerbellum
-pons
Intracranial Hemorrhagic Stroke Prognosis
-more likely to kill you, but better outcomes than ischemic
Intracranial Hemorrhagic Stroke: Treatment
-treat increased pressure
-intubate
-surgery
-BP management
Subarachnoid Hemorrhagic Stroke (stats)
-80% of SAH caused by aneurysm burst (effects of inittial, recurrent hemorrhage, vasopasm)
-10% die before medical attention
-40% die within 3 m
-50% have disabilites
Aneurysm Rupture s/s
-sudden explosive headache
-los of consicousness
-photophobia
-stiff neck
-seizure
-nausea
-half have sentinel hemorrhage: warning leaking
Venous Stroke
-thrombosis of venous sys
-can be ischemic or hemorrhagic
-pregnancy
Signs:
-headache
-focal neuro signs
-hemorrhage
-altered mental status
