Stroke symposium Flashcards
How many people have a stroke each year?
Over 100000 people in the UK
What is the lifetime risk for males of a stroke?
1 in 6
What is the lifetime risk for females of a stroke?
1 in 5
What is the cost of stroke to society?
£26billion
List some impacts of having a stoke
Lack in confidence Fear of another stroke Difficult to talk about the stroke Feel friends and family treat them differently Unable to care for family Considered breaking up with partner
What are the symptoms of stroke?
Face
Arms
Speech
How many neurons die a minute in stroke?
1.9 million neurons
What is found in the clinical assessment of stroke?
Sudden onset of focal neurological or monocular symptoms
Symptoms and signs should fit within a vascular territory
Negative symptoms rather than positive symptoms
What examination is used in stroke?
Quick assessment of systems
Standardised score
Describe the classic presentation of an ACA stroke
Colateral lower limb
Describe the classic presentation of a left MCA infarct
Dysphasia, right sided weakness/numbness
Describe the classic presentation of a right MCA infarct
Neglect, left sided weakness/numbness
Describe the classic presentation of a brainstem infarct
May involve diplopia, visual field defect, facial weakness, colateral limb weakness/numbness, incoordination
What are the causes of a hemorrhagic stroke?
Anomalies in vessel arrangement - aneurysm
Arteriovenous anomaly
What are the causes of an ischaemic stroke?
Thrombosis
Emboli
How is an ischaemic stroke diagnosed?
CT scan
If there is an infarct what is shown on CT?
Attenuation
Different colours of the brain matter
Where is the characteristic hypertensive haemorrhage found?
In the centre of the brain
Describe critical ischaemia
High metabolic demand of the brain - no glucose stores
Physiological blood flow 50ml/100g/min
<20ml/100g/min - electrical function stops - neurons still alive potentially salvageable - reversible ischemia - limited time
<10ml/100g/min - neuronal death within minutes, irreversible ischaemia - cerebral infarction
What is CT perfusion imaging used for?
Tells which areas are salvageable and determine the timing of the stroke
What does the length of the clot tell you?
Efficacy of thrombolysis
What is stent retrieval?
Way of regaining blood supply
Mechanical thrombectomy
Why is an MRI useful?
Determines cerebral oedma and sites of infarction quicker
What drug is used?
Clopidogrel
What are the risk factors of stroke?
Smoking Diabetes High blood pressure Obesity Stress Hyperlipidemia LDL
What tests are done to determine what caused the clot?
Heart - echo (PFO), ECG (AF), ultrasound bifurcation (carotid stenosis)
What is used to prevent the carotid stenosis causing more problems?
Stent and remove the atherosclerotic plaque
Describe stroke pathophysiology
Endothelial injury - Increased vascular permeability, leukocyte adhesion
Accumulation of lipoproteins - Including LDL and its oxidised forms
Monocyte adhesion to the endothelium - Followed by migration into the intima and
transformation into macrophages and foam cells.
Platelet adhesion
Factor release - From activated platelets, macrophages inducing smooth muscle cell recruitment.
Smooth muscle cell proliferation
Lipid accumulation
List the 5 types of ischaemic stroke
●Large artery atherosclerosis ●Cardioembolism ●Small vessel occlusion ●Stroke of other determined etiology ●Stroke of undetermined etiology
What is vital in care after a stroke?
Nursing and medical staff Functional and movement disability – OT/physiotherapy Communication and swallowing function – S&LT Nutritional support – Dieticians Social service
What is the role of the speech therapist in acute stroke management
Initial screen of swallow on admission - NG/NBM/PEG
Swallow therapy
Initial language/speech screen
Follow up language therapy
MDT working and support
Discharge planning and hand over to rehab or community teams
What happens in the community by the speech therapist?
Follow up on communication and swallow Usually at patients home Therapy Link to community support 6 month review Getting them back to hobbies
What is dysphagia?
Difficulty swallowing
An impairment at any of the 4 stages of swallowing:
(pre-oral, oral, pharyngeal ,Oesophageal)
Can lead to aspiration pneumonia, malnutrition, dehydration, choking and death.
Assessed at bedside via observation and palpation and/or through instrumental techniques such as Videofluroscopy or Fiberoptic Endoscopic Evaluation of Swallow (FEES).
Can have a negative impact on mood and social participation
What is aphasia?
Difficulty talking
List some motor speech disorders
Dysarthria
Apraxia of speech
How can we help with complications of post stroke symptoms?
- Adaptation of posture
- Environmental changes e.g. reducing distractions
- Modifying diet and fluids e.g. use of thickener in drinks
- Educating family/carers e.g. feeding techniques
- Compensatory strategies e.g. head turn, chin tuck- Swallow rehab exercises such as Massako manoeuvre for weak soft palate.
- Adaptive equipment e.g. cutlery with large handles, plate guards, bolus limiting cups- Feeding at risk decisions
What do you look out for in dysphagia?
Coughing whilst eating or drinking
Eyes watering, shortness of breath, choking episodes, reduced sats just after swallowing
New and/or recurrent chest infections (predominantly right sided consolidation, may indicate aspiration pneumonia)
What are the risk factors for dysphagia?
dependent on feeding and oral care, poor positioning, reduced dentition, comorbidities e.g. COPD, frailty, alertness, cognition
What is aphasia?
An acquired language impairment
Can affect any of the 4 modalities of language:
- speech/ auditory comprehension
- reading/ writing
Can have a devastating impact on the individual’s Quality of Life (QoL) and wellbeing
Which part of the brain is involved in aphasia?
Usually associated with damage to the left cerebral hemisphere
People with communication impairments may find it difficult to …
take part in a conversation talk in a group or noisy environment read a book or magazine or road sign understand or tell jokes follow the television or radio write a letter or fill in a form use the telephone use the internet use numbers and money say their own name or the names of their family unable to express their immediate needs or ideas or words go out.
Describe aphasia expressive difficulties
word finding difficulties non-fluent output short, staggered sentences difficulty with past/present, he/she may miss words out
Describe aphasia receptive difficulties
Long muddled sentences
Use of non-words e.g. ‘ploof’ for ‘dog’
Unable to understand what others are saying
May not be aware of impairment
What does aphasia therapy focus on?
Specific impairments (usually 1:1) e.g. use of past tense
- Functional communication e.g. practising how to order a coffee and then completing the task or learning compensatory strategies e.g. gesture and writing
- Social participation e.g. developing communication techniques in group settings with family and friends or training carers to support communication.
What is dysarthria?
Difficulty in speaking resulting from a weakness or loss of control
of the muscles used to make the sounds of speech, e.g. lips,
tongue, soft palate, larynx
Speech can sound slurred or unintelligible
Varies from individual to individual – some people may not be able
to form any words at all and other people may have only slightly
imprecise articulation
What is apraxia of speech?
An inability to control the muscles used to form words. When themessages from the brain tothe mouth are disrupted, the person cannot move his or her lips or tongue in the correctmanner to make lettersounds.
Speech is uncoordinated and effortful.
Many sound and word errors e.g. ‘kitchen’ for ‘chicken’
Often very frustrating for the person
What is cognitive communication disorder?
Result from damage to frontal regions of the brain (predominantly right-sided)
The frontal lobes are particularly important for cognitive communication skills because of their role in the brain’s ‘executive functions’, including planning, organisation, flexible thinking and social behaviour.
People with CCD may:
- talk too much or not enough
- interrupt conversation
- jump from topic to topic
- give too much or not enough eye contact
- Over or under-share
- Show impulsive behaviours such as spending lots of money online in one go
- Have reduced facial expression
List some tips for communicating with people with communication difficulties
Don’t pretend you understand Write down key words Say one thing at a time Relax – be natural Recap – check you both understand Don’t rush – slow down, be patient Draw diagrams or pictures Reduce background noise Ask what helps, e.g. some people would prefer that others don’t finish their sentences for them Use pen and paper
What is post stroke rehabilitation
EARLY INDIVIDUALISED FOCUSED and SPECIFIC COMPLEX ONGOING
List some post stroke problems that impact of therapy
Joint/muscle stiffness Loss of muscle length Contractures Tissue Breakdown/Pressure Sores Unstable Shoulder Respiratory Complications Urinary Problems Pain Circulatory Problems Depression and Anxiety Osteoporosis CV Deconditioning Hygiene difficulties Oedema Constipation
What is hypertonia?
Made up of 1. Neural component
2. Biomechanical component
CNS Damage
- Direct result of blood alteration, ischaemia/haemorrhage, causing neuronal change and disordered information to be sent via corticospinal pathways.
- Biomechanical
- Muscle shortening and lengthening for cross bridges in muscle fibres depending on direction of pull
What is spasticity?
Resistance in 1 direction
Characteristic posture changes
Sensitive to sensory input
What is rigidity?
Resistance in all directions
No static postural changes
Not Sensitive to sensory input
Cogwheel = rigidity plus tremor
