Download CASE STUDY

Stroke
• Stroke or cerebrovascular
acciden(CVA) is defined as sudden,
focal neurological deficit resulting
from ischemia or hemorrhage in the
brain
• Stroke = CVA = infarction or hemorrhage +
sudden onset focal neurological deficit
• Rt. CVA with Lt. Hemiparesis(hemiplegia)
• Accompany
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Motor paralysis
Sensory disturbances
Perception dysfunction
Visual disturbances
Personality and intellectual changes
Language disorders
• The neurological deficits persist
longer than 24hours.
Causes of CVA
• Essentially a disease of the cerebral
vasculature in which failure to supply
oxygen to the brain cells.
• Ischemic stroke 80%
• Hemorrhagic stroke 20%
Ischemia
• Embolisms to the brain from cardiac or
arterial sources.
– Cardiac sources
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Atrial fibrillation
Sino-atrial disorders
Acute myocardiac infarction
Endocarditis
Cardiac tumors
Valvular disorders
– Arterial sources
• Carotid and basilar arteries severe stenosis
High risk factors
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Hypertension
Cardiac disease
Diabetes and glucose metabolism
Smoking
Excessive use of alcohol
Use of illegal drugs
Lifestyle factors
Risk factor
Hyperlipidemia
Ischemic heart disease
대한뇌졸중학회, 추계학술대회, 배희준
Brain infarction
• Infarcts: when an embolus or thrombus
lodges in a vessel, obstructing blood flow
– Embolus: abruptly deprives an area of blood,
resulting in almost immediate onset of deficits
– Thrombus : abrupt or may worsen over several
days
• Lacunar infarcts : obstructions of blood flow
in small, deep arteries(20%)
– Slowly develop, either purely motor or purely
sensory, and good recovery is the norm
• Hemorrhage:
– deprives the downstream vessels of
blood(10%)
- Exerts pressure on the surrounding brain
by extravascular blood
- Worst deficits within hours of onset
• Subarchnoid hemorrhage:
– sudden, excruciating headache with a brief
loss of consciousness
- Progressive because of continued bleeding
or secondary hydrocephalus
Transient ischemic attacks
• TIA
– Symptoms that develop suddenly, last from a
few minutes to several hours but not longer
than 24 hours, and clear completely.
– Is seen as a sign of impending CVA
– Estimate
• One third will sustain a completed stroke
• Another third will continue to have additional TIAs
without stroke
• One third will experience no further incident.
Effects of CVA
• CT, MRI, PET, SPECT
• Medical chart
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C.C.
PMH
Surgical history
DX
Current pharmacological
• OT develop hypothesis identify pt.
Internal Carotid Artery
• Occlusion of ICA
– Contralateral hemiplegia
– Hemianesthesia
– Homonymous hemianopsia
• Involvement of the dominant hemisphere
– Aphasia, agraphia, dysgraphia, acalculia, dyscalculia,
right-left confusion, finger agnosia
• Involvement of the nondominant hemisphere
– Visual perceptual dysfunction, unilateral neglect,
anosognosia, contructional or dressing apraxia, attention
deficts, and loss of topographic memory.
Blood supply1
• Ant. Circulation(=carotid system)
– Internal Carotid Artery(ICA)
• Opthalmic artery
• MCA
– Ant. Choroidal artery
– Lenticulostriate artery
• ACA
– A-com
• PCA
– P-com
Blood supply2
• Post. Circulation(=vertebrobasilar sys)
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PCA
Superior Cerebellar Artery(SCA)
Basilar artery
Pontine artery
AICA
PICA
• Spinal artery
Middle cerebral artery
• Dominant hemisphere.
– Contralateral hemiplegia with greater
involvement of the arm, face and tongue
– Sensory deficits
– Contralateral homonymous hemianopsia
– Aphasia
• Nondominant hemisphere.
– Perceptual deficits Anosognosia, unilateral
neglect, impaired vertical perception, visual
spatial deficits, perseveration
MCA
• M1
– Anterior choroidal artery.
– BG
• Middle cerebral a.(lateral striate branch)
• Anterior cerebral a.(medial striate branch, of
Huebner)
– Thalamus
MCA
Basal Ganglia
MCA
Caudate nucleaus
Head
Body
Tail
Putamen
Rostral
Caudal
Globus pallidus
Lateral
Medial
ACA
anterior chor..
BG ICH & IVH
• Physical state
– U/E; flaccide / shoulder(subluxation)
• Sensation
– NT(observation-proprioception;absent)
• Cognitive & perception
– Unilateral visual neglect severe
– Cognition ↓(drowsy)
• ADL
– Total dependent
Putamen ICH
• Physical state
– U/E; flaccide
• Sensation
– Intact
• Cognitive-intact
• ADL
– maximal assist(sitting balance↓)
Choroidal artery
• Anterior choroidal (a branch of the
internal carotid) :
– optic tract, choroid plexus in the lateral
ventricles, part of the optic radiations,
putamen, thalamus, internal capsule,
hippocampus
• Posterior choroidal ( a branch of the
posterior cerebral artery) :
– choroid plexus of the third ventricles and
parts of the thalamus and hippocampus
Ant. Choroidal artery
• Contralateral hemiplegia
• Hemianesthesia(hypesthesia)
• Homonymous hemianopsia
Ant. Choroidal inf.
• Physical state
– U/E; functional use
• Sensation
– Intact
• Cognitive & perception
– hemianopsia
• ADL
– moderate assist
Thalamus
thalamus
• Thalamic syndrome:
– Sensory loss, intention tremor,spasm of hand,
mild hemiparesis
– Posteroventral nu.
• Thalamoperforate syndrome:
– Crossed cbll ataxia with ipsilateral 3rd palsy
– Dentatothalamic tract
• Weber’s syndrome:
– 3rd palsy, contralateral hemiplegia
– Paralysis or paresis of vertical eye move
– Cbll peduncle
Thalamic ICH & IVH
• Physical state
– U/E; movement-clumsy/non functional
• Sensation
– Intact
• Cognitive and perception-good
• ADL
– maximal assist(sitting balance↓)
MCA
• M2
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Insular
IC
CR
SC
• M3
– Superior
– Inferior
Internal Capsula infarct
• Physical state
– U/E; proximal(poor)/distal(mass grip&release)
• Sensation
– Intact
• Cognitive
• ADL
– Feeding-independent
– Other-moderate assist
Corona Radiate infarct
• Physical state
– U/E; shoulder(fair-)/distal(grip&release)
• Sensation
– Intact
• Cognitive-good
• ADL
– Feeding-independent
– Other-maximal assist(sitting balance↓)
Striate-Capsular infact
• Physical state
– U/E; shoulder(subluxation)/distal(flaccide)
• Sensation
– Intact
• Cognitive-good
• ADL
– Feeding&grooming-independent
– Other-moderate assist
MCA infarct
• Physical state
– U/E; Proximal(poor)/distal(flaccide)
• Sensation
– Proprioception loss
• Cognitive & perception-good
• ADL
– Feeding and grooming-independent
– Other-moderate assist
MCA inferior division inf.
• Physical state
– U/E; fine motor coordination↓/clumsy
• Sensation
– Intact
– Aphasia
• Cognitive-impaired &
• ADL
– Feeding & grooming-supervision
– Other-minimal assist
Anterior cerebral artery
• Occlusion of the ACA
– Contralateral LE >> UE
– Apraxia, mental changes, primitive reflexes, and bowel
and bladder incontinence
• Total occlusion of ACA
– Contralateral hemiplegia with severe weakness of the
face, tongue, and proximal arm muscles and marked
spastic paralysis of the distal LE.
– LE cortical sensory loss
– Intellectual change
• Confusion, disorientation, abulia, whispering, slowness,
distractibility, limited verbal output, perseveration, and
amnesia may be seen.
ACA
• A1
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Anterior limb of the IC
Anterior perforate substance
Amygdala
Anterior hypothalamus
Inferior part of the head of the caudate nu.
• A2
– Abulia(a delay in verbal and motor response)
– Urinary incontienence
ACA infarct
• Physical state
– U/E; movement good/Arian hand syndrome
• Sensation
– Intact
• Cognitive & perception
– Sequence↓
– Constructional apraxia
• ADL
– Minimal assist
Posterior cerebral artery
• Symptoms is potentially broad & varied
– Artery supplies the upper brainstem
– Temporal and occipital lobes.
• Some possible outcome
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Sensory and motor deficits
Involuntary movement disorders
Memory loss
Alexia
Astereognosis
Dysesthesia
Cnotralateral homonymous hemianopsia
Anomia
Topographic disorientation
Visual agnosia
PCA
• P1 syndromes
– Thalamic Dejerine-Roussy syndrome
• P2 syndromes
– Anton’s syndrome
– Balint’s syndrome
• Post choroidal a.
Thalamic Dejerine-Roussy
syndrome
• Penetrating branches of thalamic &
thalamogeniculate a, thalamocapsular
lacunar syndrome
• Contralateral hemisensory loss
– By agonizing, searing or burning pain
– Motor; hemiparesis, intention tremor,
incoordination
P2
• Anton’s syndrome
– Blindness
• Balint’s syndrome
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Visual association area lesion
Optic ataxia
Ocular ataxia
Sumultagnosia
Post choroidal a. inf.
• Physical state
– U/E; shoulder(fair-)/distal(grip&release)
• Sensation
– Intact
• Cognitive-good
• ADL
– Feeding-independent
– Other-maximal assist(sitting balance↓)
Vertebrobailar artery system
• Combination of bilateral or crossed
sensory and motor abnormalities
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Cerebellar dysfunction
Loss of proprioception
Hemiplegia
Quadriplegia
Sensory disturbances
With unilateral or bilateral cranial nerve
involvement of nerves 3 to 12.
VA/Basilar a.
• SCA
• AICA
• PICA
Vascular supply to brain stem
and cerebellum
• Brain stem and cerebellum : by branches of the
vertebral arteries and branches of the basilar
artery
• Each vertebral artery : three main branches: the
anterior and posterior spinal arteries and the
posterior inferior cerebellar artery
• Medulla : receives blood from all three branches
of the vertebral arteries
• Cerebellum : posterior inferior cerebellar artery
• Pons and most of the cerebellum : basilar artery
and its branches(anterior inferior cerebellar,
superior cerebellar)
• Midbrain : posterior cerebral artery
Cerebellar artery system
• Cerebellar artery occlusion results
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Ipsilateral ataxia
Contralateral loss of pain & temperature
Ipsilateral facial analgesia
dysphagia and dysathria caused by weakness
of the ipsilateral muscle of the palate
– Nystagmus
– Contralateral hemiparesis
AICA infarct
• Physical state
– U/E; functional use
• Sensation
– Hearing loss
– Severe Dizziness
• Cognitive and perception-good
• ADL
– Modified independent
Lateral medullory inf.
• Physical state
– U/E; fine motor coordination ↓/ataxia
• Sensation
– Intact
– DZ
• Cognitive-good
• ADL
– Complete independent
Pons & midbrain ICH
• Physical state
– U/E; good grade/Ataxia severe-nonfunction
– Facial N. palsy
• Sensation
– Neurogenic bladder
• Cognitive-good
• ADL
– Feeding-moderate assit
– Other-maximal assist(sitting balance↓)
basi
basi
vert
Spinal a.
• ASA
• PSA
Spinal artery
ASA infarct
• Physical state
– U/E; C4<G/G>/C5<F+/F+>/C6<F-/F->
• Sensation
– C7level
• Cognitive-good
• ADL
– Maximal assist