Stroke and Vascular Disorders Flashcards
What kind of recovery occurs in the first few days after a stroke?
natural recovery
Resolution of oedema
Reperfusion of ischemic penumbra
What kind of recovery occurs weeks/months after a stroke?
Neuronal plasticity
cortical remodelling
Dendrite sprouting
synaptic remodelling
What disabilities/conditions can occur after a stroke?
Post stroke pain Incontinence Depression Visual loss Neglect Agnosias Dyspraxia Gait Spasticity
What is neglect?
Can be visual or somatosensory
Feature of RIGHT parietal lobe stroke only
Problem of attention - failure to attend to/ monitor left side
(Think of picture of the one sided clock)
What is agnosias?
“Modality-specific inability to access semantic knowledge of an object”
Can apply to any sensory modality
E.g. visual agnosia = unable to recognise object by just looking at it, needs to use other senses too e.g. touch
What is dyspraxia?
loss of ability to conceptualise, plan, and execute complex sequence of motor actions - Loss of cortical pathways
Difficulty in: Identifying and knowing how to use objects, copying drawings etc
Lesion can be in left inferior parietal lobe or supplementary motor area
What are meant by ‘transfers’?
Devices to move patients from one place to another safely e.g. hoist, banana board
Method chosen depends on: Balance, alertness and cognition
What is taken into consideration when producing a discharge plan for a patient after a stroke?
The patient’s abilities: what assistance do they need?
Are any family or friends willing to provide care?
Any foreseeable and modifiable risks?
The environment they will be discharged to? - check accessibility, need for adaptations, hazards
What is a spastic hemiparetic gait?
Stiff legged due to spasticity of ankle plantar flexors and knee flexors
Short, slow steps
Risk of falls
Ankle weak, unable to dorsiflex - difficulty on uneven surfaces
Loss of “righting reflexes”
What is the management for gait?
Splints to correct foot drop
physiotherapy
manage spasticity
walking aides
What is spasticity?
Hyperexcitability of the stretch reflex
May be co-existent tendon or soft tissue shortening
Can lead to:
Loss of function - impaired balance, manual dexterity
Unable to maintain skin hygiene in flexures
Pain
What is the management of spasticity?
Physiotherapy and splinting to maintain joint range of movement
Drugs: botulinum toxin injections (local), baclofen (systemic)
What is the impact on family members who have had stroke?
Depression and anxiety common in family
Specifically ask about carer strain
Provide information about diagnosis and plan
Ask about arrangements for respite care?
Refer for benefits advice: many carers do not claim benefits they are entitled to
Voluntary organisations e.g. Stroke Association
On what side does weakness occur in comparison to the side of the stroke? And what can weakness of muscles cause?
Contralateral
Weakness and incoordination of oropharyngeal muscles
Dysarthria: slurred, indistinct speech
Incoordination of swallowing
Where is Broca’s and what can damage to Broca’s cause?
In right handed patient: infero-lateral frontal lobe
EXPRESSIVE DYSPHASIA
Flow of speech: stilted, difficult
Difficulty finding words, e.g. “spoot” for “spoon”
Reading, writing and comprehension relatively intact
Where is Wernicke’s and what can damage to Wernicke’s cause?
In right handed individuals: left posterior superior temporal lobe
Flow of speech is fluent, but:
Neologisms (“made up” words)
Mistake closely related words: up/ down, yes/ no,
Comprehension, reading and writing impaired
What physiological variables should be controlled after a stroke?
Blood pressure - Anti-hypertensive treatment is not recommended after acute stroke, apart from in certain circumstances
Oxygenation
Capillary blood glucose
What is used to set goals for rehabilitation?
Specific Measurable Achievable Relevant Time-limited
What is post stroke pain?
Damage to sensory cortex leads to contralateral sensory disturbance
Can be a negative phenomena - decreased sensation OR
positive phenomena - Paraesthesia, burning, shooting pains
May respond to:
Pregabalin or Gabapentin (anti-epileptic agents)
Amitriptyline (antidepressant) but not paracetamol, opiates or NSAIDs
What is the definition of a TIA?
Neurological Deficit lasting less than 24 hours attributable to
cerebral or retinal ischaemia
What are the risk factors of TIA’s and strokes?
Family history age sex smoking diabetes sickle cell race previous TIA's
How does a TIA occur pathologically?
Causes: vascular i.e. large/small artery disease, cardiac embolism
What are the signs and symptoms of TIA’s that can mimic other conditions?
Seizures Syncope Hypoglycaemia Migraine Acute confusional states
How do you classify TIA’s?
Anterior or posterior circulation
How does having a TIA affect the risk of having a stroke?
calculated via the ABCD(2) score Age BP Clinical features Duration symptoms Diabetes above 5 = high risk
What investigations are conducted when a patient is suspected of a TIA?
History
Exam
Blood glucose
What treatments are available for TIA’s?
Polypill - Combination of statin, aspirin, antihypertensives, folic acid
Carotid Endarterectomy - surgical procedure to unblock a carotid artery
What are the signs and symptoms of a anterior circulation stroke?
Amarausis fugax - transient monocular or binocular visual loss
Dysphasia - cannot generate speech
Apraxia - inability to perform particular purposive actions
Inattention
What are the signs and symptoms of a posterior circulation stroke?
Ataxia - the loss of full control of bodily movements
Diplopia - double vision
Vertigo
Bilateral Symptoms
What are the signs and symptoms of a either anterior or posterior circulation stroke?
Visual field disturbance (e.g. hemianopia)
Hemiparesis - weakness of the entire left or right side of the body
Hemisensory loss
Dysarthria
What is the definition of stroke?
Sudden onset
Focal neurological deficit
Of presumed vascular origin
Symptoms lasting more than 24 hours or leading to death
What are the two types of stroke?
Ischemic - more common
Haemorrhagic
What causes ischemic stroke?
Initial reduction in cerebral blood flow
Alterations in cellular chemistry caused by the ischaemia
Cellular necrosis
Thrombosis (large/small vessel)
Embolism (cardioembolism) - AF
What causes haemorrhagic stroke?
Bleeding e.g. Berry Aneurysm
What is the treatment for stroke?
Aspirin Anticoagulation Surgery e.g. endarterectomy (surgical removal of part of the inner lining of an artery), stent Thrombolysis e.g. tPA Recanalisation
