Stroke case study

Question 1

Hypertension

Answer 1

• Hypertension = abnormally high BP which puts the body under physiological stress
o Increases risk of heart attack, failure, kidney disease, stroke and dementia
o Biggest RF for stroke
o HBP has no symptoms -

Question 2

Smoking

Answer 2

o Smokers 3 times more likely to have a stroke – proportional relationship between stroke risk and number of cigarettes smoked
o Chemicals in cigarette smoke are damaging (CO) – chemicals transfer from the lungs to the blood stream, and this causes damage around the body (chemicals increase risk)
o Damage to artery walls and increased blood viscosity – more likely clot formation = increased risk of atherosclerosis
o Smoking can also increase LDL cholesterol and reduces HDL – increased risk

Question 3

Brain areas

Answer 3

• Varying signs and symptoms as this is because different parts of the brain control different parts of your body – dependent on the part of the brain affected and extent of the damage
o Cerebrum – Right and left hemispheres, performs higher functions like touch, vision and hearing as well as speech, reasoning, emotions, learning and fine control of movement
o Injuries to either side effects the opposite side
o Frontal, parietal, temporal and occipital lobes
• Skeletal muscle movement
o Primary motor cortex
o Motor association area (premotor cortex and supplementary motor cortex)

Question 4

Reasoning skills

Answer 4

o Frontal lobe – smell, speech, concentration, planning, problem solving and motor control
♣ Problem solving and selective attention – PFC controls personality and various higher cognitive functions such as behavior and emotions, back of frontal lobe consists of pre-motor and motor areas, which produce and modify movement

Question 5

Sensory info from skin, MS, viscera and taste buds

Answer 5

o Primary somatic sensory cortex
o Sensory association areas
o Parietal lobe – touch, pressure, taste and body awareness

Question 6

Vision

Answer 6

o Occipital lobe – vision
o Visual association area
o Visual cortex

Question 7

Hearing

Answer 7

o Auditory association cortex

o Auditory cortex

Question 8

Cerebellum

Answer 8

• Cerebellum – coordination

o Controls reflexes, balance and certain aspects of movement and coordination

Question 9

Taste and smell

Answer 9

• Taste – gustatory cortex

* Smell – olfactory cortex

Question 10

Signs

Answer 10

• Signs – FACE
o Face – may have dropped on one smile, not able to smile, mouth or eye may have dropped
o Arms – may not be able to life both arms and hold above head because of arm weakness or numbness in one arm
o Speech – might be slurred or garbled, or person may not be able to talk despite appearing awake
o Time – dial 999

Question 11

Other symptoms

Answer 11

• Other symptoms
o Complete paralysis of one side of the body
o Sudden loss of vision
o Dizziness
o Confusion
o Difficulty understanding what others are saying
o Problems with balance and coordination
o Difficulty swallowing (dysphagia)
o A sudden and severe headache resulting in blinding pain unlike anything experienced before
o Loss of consciousness

Question 12

STROKE LOCATION IMPORTANT

Answer 12

o Stroke in right hemisphere of cerebrum left paralysis, difficulty reasoning or thinking out solutions
o Left hem right paralysis and may disrupt the ability to speak
o Cerebellum Lack of coordination (ataxia), clumsiness and balance problems, shaking, or other muscular difficulties – interfere with ability to walk, talk, eat and perform other self-care tasks
o Brain stem most devastating and life threatening as they disrupt involuntary functions essential to life – people who survive may remain in a vegetative state or severe impairments

Question 13

Watershed infarct

Answer 13

• Watershed infarct (border zone infarcts) – occur at the border between cerebral vasicular territories (5-10% of all cerebral infarctions). An area of necrosis in the brain caused by an insufficiency of blood where the distributions of cerebral arteries overlap (resembles agricultural field irrigation system – most distant regions not irrigated if pressure falls).
o Often haemorrhagic, as restoration of circulation allows blood to flow into damaged capillaries and ‘leak’ into ischaemic tissue
o Post-intial carotid artery occlusion, causing vascular ‘steal’ phenomena, or between the anterior and middle cerebral arteries, which may be compromised in circle of Willis occlusions, often in a background of generalized atherosclerosis and as a possible complication of direction therapeutic embolization

Question 14

ACA and MCA territory

Answer 14

o ACA supplies the medial part of the frontal and the parietal lobe and the anterior portion of the corpus callosum, basal ganglia and internal capsule
o MCA corticol branches supply the lateral surface of the hemisphere, expect for the medial part of the frontal and the parietal lobe (anterior cerebral artery), and the inferior part of the temporal lobe (posterior cerebral artery)

Question 15

Right frontal lobe

Answer 15

• Role of the right frontal lobe? – what is the impact of the infarct
o Controls important cognitive skills in humans, such as emotional, problem solving, memory, language, judgement and sexual behavior – in essence the ‘control panel’ of our personality and our ability to communicate
o Damage affects most aspects of behavior, mood, and personality, during recovery, you will have to adapt what was previously basic human behavour, such as relationship with oneself and others.
o Right damage affects non-verbal communication and negative emotions, degree of dysfunction caused by damage dependent on your abilities before the TBI, as well as the extent, location, and nature of the damage as a result of the TBI.

Question 16

Circle of WIllis

Answer 16

o Blood supplied to brain, face, and scalp via two major sets of vessels: right and left common carotid arteries and right and left vertebral arteries
o Carotid arteries – 2 divisions – external (supply face and scalp with blood) and internal (supply blood to anterior 3/5ths of cerebrum, except for temporal and occipital lobe parts), vertebrobailar arteries supply posterior 2/5ths of cerebrum, cerebellum parts, and brain stem.
o Any decrease in BF through carotid arteries = some impairment in function of frontal lobes – impairment may result in numbness, weakness, or paralysis on side of body opposite to artery obstruction, occlusion of one of vertebral arteries may cause blindness or paralysis.
o Circle of Willis – Base of brain, carotid and vertebrobasilar arteries form a circle of communicating arteries known as the Circle of Willis. From the circle, other arteries ACA, MCA and PCA arise and travel to all parts of brain. Because carotid and vertebrobasilar arteries form a circle, if one of main arteries is occluded, distal smaller arteries that it supplies can receive blood from other arteries (collateral circulation).

Question 17

Types of stroke

Answer 17

o Ischaemic – result of an obstruction with a blood vessel supplying blood to the brain, typically form in areas where ateries have been narrowed or blocked over time by fatty deposits known as plaques (atherosclerosis) – 87%
o Haemorrhagic – weakened BV ruptures, two types of weakened BV usually cause stroke (aneurysms and atriovenous melformations), most common cause is uncontrolled hypertension (high BP)
o TIA – temporary clot, often known as a mini stroke, blockage often caused by a blood clot that has formed elsewhere in your body and travelled to the blood vessel supplying the brain
♣ Increased risk – Smoking, HBP, obese, high cholesterol, regular drinker, diabetic, irregular HB

Question 18

Phases of stroke

Answer 18

• Acute (few days) surgery and drug treatments, neuropreservation, pernumbria (area of neurons potentially saved with early treatment – increase function)
• Sub-acute (first months/3 weeks) prevent disuse – early rehabilitation is essential as brain is changing (therapeutic FES)
• Chronic (3m-6m) Becomes a lot harder to change, not permanent (compensatory), permanent if too much damage, not always Taub (2002) learned non-use, mental process of treatment
• John Kraukower reviews

Question 19

Sensitivity tests

Answer 19

• It is estimated that 60% of patients with stroke have impaired sensory abilities (Carey, 1995). It is therefore important to measure severity of this as it could affect several walks of life, including safety (burns etc.). Self reported scales - patients often report whether they can fully feel a stimulus or whether there is absent sensory feedback. Patients also score areas of the body on hypersensitivity and temperature.

Question 20

Immediate treatment

Answer 20

• Immediate
o Key in preventing long term damage
o Golden hour post-stroke
o Treatment dependent on type of stroke experienced, some meds given to those having an ischaemic stroke would negatively affect some experiencing a haemorrhagic stroke
o Alteplase – dissolve blood clots and to restore BF to brain via thrombolysis – if given to haemorrhagic patient = increased bleeding not good
o Drugs and Surgical Treatment
♣ Initial treatment for stroke concerns preventing further damage to neuronal cells
♣ Tissue Plasminogen Activator (Thrombolytic agent) is usually given to dissolve the clot and prevent further cells death (also promotes penumbral recovery)
♣ Converts plasminogen to plasmin, which dissolves fibrin (protein that forms clots)
♣ An endarterectomy can also be performed to remove material from the inside of the artery
♣ In order to correct stenosis (>70% occlusion)

Question 21

Preventative

Answer 21

o Ischaemic patients often given meds to prevent a clot re-occuring
o Anti-platelets – Aspirin given to dull pain, make platelets less sticky and prevent clots
o Anti-coagulants – Prevent future clotting, change chemical composition of the blood to prevent clots (e.g. warfarin)
o Antihypertensives – Lower HBP (i.e. b-blockers, calcium channel blockers)
o Statins and carotid endarterectomy both linked to patient displaying certain risk factors

Question 22

Recovery

Answer 22

o rTMS useful treatment to compliment post-stroke rehab and enhance motor control (Massie et al. 2013)
♣ Either by enhacing cortical excitation of ipsilesional hemisphere (LTP) or by inhibiting contralesional activity (Takeuchi et al. 2009) to reduce transllocal inhibition
♣ Provides trains of ES to cortical areas at different frequencies (1, 3, 10 and 20 Hz)
o FES
♣ Functional Electrical Stimulation provides external innervation (surface or implanted) to the stroke affected muscles to allow for movement and commonly used to aid walking
♣ However, thought to be more effective as a way to assist with voluntary movement (what good does it do to the patients recovery without voluntary cortical drive?)
♣ Yan et al (2004) showed how FES improved motor function after first incidences of acute stroke and assisted walking ability beyond that of a control group – perhaps importantly increasing ‘return to home’ rates
♣ Programmed so that it mimics typical muscle synergies and can be triggered at different times (e.g for drop foot it is triggered when weight is taken off the foot)
♣ Benefits of FES include: More natural walking patterns, reduced falls, improved confidence, walking becomes less tiring
♣ Early onset of treatment, alongside traditional physiotherapy is thought to have more affective effects than just physiotherapy, in acute stages of stroke (Popovic et al 2002
o Constraint therapy
♣ Involves making patients place more reliance upon the stroke affected limbs
♣ Found to induce better rehab outcomes (Taub 2002) and maintaining cortical representations of the affected limbs (Sawaki 2009)
♣ Can be done in creative manners art therapy
♣ Patients encouraged to create art work with the stroke affected limbs in order to overcome learned disuse and retrain movements
o Traditional physio
♣ The other treatments work in addition to physio (complimentary)
♣ Typically focuses on:
• Prevent joint stiffness and reduce muscle tightness (passive treatments)
• Encourage muscle use of stroke affected limbs
• Assist relearning of motor tasks
• Get the patient back up and moving

Question 23

Psych impact

Answer 23

• Sudden shock but varies on severity and area stroke affects
• Certain areas of brain associated with mood and emotion control, if stroke occurred in these areas, will cause changes in mood and behavior
• May cause impairment in communication (vision and speech), cognition which can be also be a factor for psychological ill-being
• Shock, denial, anger, grief, guilt, loss of confidence all common
• Emotionalism – problems controlling
• Less likely to adhere to rehab process
• Depression – common, estimated that ½ who suffer from stroke will get sig depression in first year – often develops when patient becomes aware of the lasting disability and life changes
o Underlying chronic pain and social isolation
o Symptoms – loss of energy, inability to concentrate, lose interest in daily activities, sadness, sleep changes, anxiety
o Develop into suicidal feelings
• Apathy – lack of motivation or enthusiasm, loss of interest in thing (hobbies and socializing)
o Arise from post-depression of changes in brain functioning
o Frontal area key for energy, enthusiasm, productivity and initiative – damage to this area could be cause
o Might be prompted and encouraged to do activities – join stroke group and counselling
• Personality changes
o Stroke causes behavioural change – irritable/impatient or alternatively withdrawn – reversed? Exisitin traits exaggerated?
o More easily upset, more responsive, mood swings
o Loss of identity – struggle with idea of disability
• Treatments
o Talking/counselling
o Occupational therapist
o Cog behavioural therapy
o Medication – anti-depressants
o Support groups
o Regular gentle exercise
o Healthy diet
o Pick up hobbies and interests

Question 24

Exercises

Answer 24

• Encourage movement with strength and control exercises
• Spasticity – ROM and stretching
• Walking, bending, stretching, swimming etc.
• Avoid overexertion to avoid fatigue and don’t allow too much discomfort
• Mildly affected by stroke
o Strengthen shoulder stabilisers – lie on back and lift arm against resistance band
o Strengthen elbow straighteners – bend and straighten
o Improve hip control for walking activities – crossing and uncrossing legs over the other
o Enhance hip and knee control – legs bent to straight
o On side leg straightening and bending, stretch hip extensors
o Hip raises
o Crawling
o Weight shifting
• More so affected by stroke - Passive
o Enhance shoulder motion
o Shoulder lifting of floor (good for rolling over in bed)
o Pelvis, hip and knee rolling
o Knees up to chest
o Sitting twisting exercises for trunk rotation
o Small squats – weight hovering over chair
o Calf stretching
• Large muscle activities (walking, treadmill, stationary cycle, ergometry, seated stepper) Increased independence, walking speed/efficiency, tolerance for prolonged PA
• Strength – circuit training, weight machines, free weights increase independence
• Flexibility – stretching increase ROM, prevent contractures
• Neuromuscular – Coordination and balance activities improve level of safety
• A single bout of walking exercise enhances endogenous fibrinolysis in stroke patients by stimulation short-term increases in plasma tissue plasminogen activator, thought to potentially protect again atherosclerotic events (Ivey et al. 2003).