Stroke Flashcards
Circle of Willis Arteries
a. anterior cerebral artery
b. internal carotid artery
c. posterior communicating artery
d. posterior cerebral artery
e. basilar artery
f. middle cerebral artery
g. anterior communicating artery (minute connection between the left and right anterior cerebral arteries)
Middle cerebral artery
- Most common for stroke b/c connected to artery of the heart - supplies a lot of areas!
- Supplies almost the entire lateral surface of the frontal, parietal, and temporal lobes as well as white matter and basal ganglia
- Largest of the terminal branches of the internal carotid and the direct continuation of this vessel
- Lateral convexity of Hemisphere; Broca’s, Wernicke’s speech areas, face, arm
Left hemisphere
Contralateral hemiplegia (primary motor area)
Contralateral hemiparesthesia (primary sensory area)
Aphasia (Broca’s, Wernicke’s or combination or connections)
Cognitive (frontal lobe, prefrontal)
Affective (emotional labiliity and depression)
Right Hemisphere:
Contralateral hemplegia
Contralateral hemiparesthesia
Perceptual deficits (posterior multimodal association area) (left sided neglect)
Apraxia (anterior multimodal association area, premotor area and/or primary motor cortex
Cognitive
Affective (euphoria or lack of awareness)
Anterior cerebral artery
- Superior, lateral, and medial aspects of frontal and parietal lobes
- Basal ganglia, corpus callosum
- ACA: Leg, feet
Lesion: Contralateral hemiplegia Contralateral hemiparesthesia Cognitive Apraxia Affective (same as MCA)
Posterior Cerebral Artery
- Medial and inferior surfaces of temporal and occipital lobes
- Thalamus, hypothalamus (however not usually affected by lesion in this area)
Lesion
Memory loss
Visual Perceptual Deficits (occipital lobe and posterior multimodal association area)
Visual Field Cuts (optic chiasm)
Brainstem and Cerebellar Arteries
- Superior or anterior inferior cerebellar
- May also affect medulla
- Posterior Inferior cerebellar
- Basilar
- Vertebral
Brainstem and Cerebellar Arteries:
Superior or anterior inferior cerebellar
Ipsilateral ataxia Ipsilateral hypotonicity and hyporeflexia Dysmetria Adiadochokinesia Movement decomposition Asthenia Rebound phenomenon Staccato voice Ataxic gait Intention tremors Incoordination
Brainstem and Cerebellar Arteries
-May also affect medulla
Vestibular signs (nystagmus, vertigo nausea) Facial Sensory Impairment Dysphagia Dysarthria Bell’s palsy
Brainstem and Cerebellar Arteries:
-Posterior Inferior cerebellar
- Ipsilateral hypertonicity and hypoeractive reflexes (posterior and anterior spinocerebellar tracts
- Vertigo, nausea, nystagmus (vestibular nuclei junction pons and medulla)
- Supplies lateral medulla and back/ undersurface of brain
Brainstem and Cerebellar Arteries:
-Basilar
- Formed by the vertebral arteries joining at the medulla/pons level
- Pons, corticospinal tracts, abducens, trigeminal, and facial nerve nuclei
- Contralateral hemiplegia (corticospinal)
- Medial or internal strabismus (abducens)
- Ipsilateral sensory loss of the face (trigeminal)
- Loss of the masseter reflex and the corneal reflex (trigeminal)
- Bells’ Paly and Hyperacusis (facial)
Brainstem and Cerebellar Arteries:
-Vertebral
Dysphagia (accessory)
Anterior Spinal Artery
Anterior spinal:
- Medulla (pyramids, vestibular, hypoglossal, glossopharyngeal, and vagus)
- Contralateral hemiplegia (corticospinal – pyramids)
- Deviation of tongue to the affected side
- Dysphagia and loss of the gag reflex (glossopharyngeal and vagus)
- Nystagmus and balance disturbances (vestibular)
Cerebral Cortex
Functions:
- Initiates voluntary movements of face & limbs on contralateral side.
- Interprets sensation on contralateral side.
- Initiates voluntary eye movements to opposite direction.
- Interprets vision in the opposite field of both eyes.
- Dominant hemisphere (mostly L) initiates & interprets language.
Subcortical Areas
Functions:
- Connect cerebral cortex & brainstem.
- Consists of:
- deep WM, motor & sensory pathways for contralateral body
- basal ganglia, GM motor modifier, makes movements faster & smoother.
- 2 thalami, GM sensory relay station.
Deficits:
- Contralateral hemiparesis
- Contralateral hemisensory loss
- Sensorimotor deficit – combination of above 2
- Motor problems: incoordination, timing
Brainstem
Functions:
- Contains motor & sensory pathways for contralateral body.
- Relay station for the cerebellum to the ipsilateral body.
- Contains cranial nerves to ipsilateral face & head.
- Contains centers of consciousness & cardiopulmonary function
Deficits:
- Hemiparesis or quadriparesis
- Hemisensory loss or sensory loss in all four limbs
- Crossed signs – ipsilateral face & contralateral body involvement
- Eye mvmt abnormalities – diplopia, dysconjugate gaze, gaze palsy, eyes deviate to opposite direction
- Tinnitus, vertigo, nausea, vomiting
- Dysarthria, dysphagia, hiccups, abnormal respirations, breathing disturbances
- Decreased consciousness, sleep disturbances
Cerebellum
Functions:
- Coordination/motor learning center.
- Vermis
- Controls the trunk and gait balance.
- Cerebellar hemispheres:
- Coordination of the ipsilateral limbs.
Hemorrhage
Headache. Neck stiffness. Neck pain. Light intolerance. Nausea, vomiting. Decreased consciousness/coma/stupor
Somatognosia
Lack of awareness of body structure and relationship of body parts
Difficulty to transfer
Anosognoisa
- Denial & lack of awareness of the presence or severity of one’s paralysis.
- Disown the limb
- Testing: talking to client
Ideomotor
breakdown between concept & performance
- cannot perform task on command
Ideational
failure in conceptualization of task
- put toothpaste in mouth than applying on toothbrush
Broca’s
- expressive aphasia
- Difficulty expressing oneself using language
- Can understand
- Can chew and swallow
- May have:
- no language
- habitual phrases (How’re you doin?)
- curses when emotional
- Usually writing also impaired
- Usually aware of problem and frustrated
Wernicke’s
- receptive aphasia
- Difficulty understanding language
- Are able to speak but it is meaningless (gibberish)
- Difficulty interpreting sign language
- Alexia – inability to read
- Inability to write meaningful words
- Less aware of their problem than Broca’s
- Milder form ‘severe word finding’ so describe but not find the word
Conduction Aphasia
- Damage to neurons connecting Broca’s and Wernicke’s
- Severe cases client’s speech and writing is meaningless, however can understand spoken and written language
Globa Aphasia
- Inability to use language in any form
- Not able to speak, understand, read, or write
- Usually due to large lesion in the lateral side of the left hemisphere
Right Hemisphere
- Sensory & motor left side
- Perceptual interpretation of environment and relationship of self to environment
- Interpretation abstract & creative info. & language
Left Hemisphere
- Sensory & motor right side
- Interpretation concrete meaning words / literal interpretation stories
- Symbols (numbers & letters)
- Categorizing & sequencing
Left Hemisphere disorders
- Wernicke’s aphasia
- Broca’s aphasia
- Agraphia
- Alexia
- Right side motor and sensory problems
Right Hemisphere disorders
- Visual-spatial
- Body schema perception
- Apraxias (motor planning)
- Perceptual language
- Left side motor and sensory problems
Lacunar Strokes
- Caused by occlusion of a single deep penetrating artery that arises directly from the constituents of the COW, or cerebellar and basilar arteries
- May result from carotid artery pathology or microemboli from the heart as in atrial fib
Glasgow Coma Scale
-Useful for depressed consciousness & ICH.
-Sudden, spontaneous onset of decreased consciousness suggests:
-Large ICH.
-Large SAH.
-Basilar artery occlusion.
-Use is limited in acute ischemic stroke.
Score range, 3 (coma) to 15 (normal): motor response, verbal response, eye opening
Hunt & Hess Scale.
- For Non-traumatic SAH.
- Scale, 1 to 5.
- Grades 1 -3 have better prognosis & are candidates for early aneurysmal intervention.
- Any change in consciousness or focal neurologic deficit puts patient in grade 3 or worse.
- Grades 4 & 5 are generally not candidates for early surgery.
NIH Stroke Scale
- Quantifies severity of stroke.
- Scores, 0 – 42; 11 items
- Requires safety pin for sensory testing & special cards for speech & language testing.
- AHA & AAN require all involved in stroke care learn the NIHSS.
- Somewhat complex & requires training.
- Untestable items do not contribute to total score.
- Modified version available, better organized.
Glasgow Outcome Scale
1 DEAD
2 VEGETATIVE STATE Unable to interact with environment; unresponsive
3 SEVERE DISABILITY Able to follow commands/ unable to live independently
4 MODERATE DISABILITY Able to live independently; unable to return to work or school
5 GOOD RECOVERY Able to return to work or school
Barthel Index
Evaluation of Function (ADL) (0-100)
Motor Assessments Used with Stroke
- Motor Assessment Scale (MAS)
- Wolf Motor Function Test
- Fugl Meyer
- Box and Block
- 9 Hole Peg Test
- Motor Activity Log (MAL)
- Action Research Arm Test
Thrombolytic therapy
- tPA: Tissue Plasminogen Activator
- extreme clot-buster
- 3 hours
- Need to complete evaluation of patient and treat within 1 hour
FAST
Face – drooping
Arms – weakness
Speech – slurred
Time – quickness
STR – Speak, Tongue, Raise arms
Give Me 5:
Walk, talk, reach, see, feel
