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Stroke Frank Elterman MS3 Definition • Stroke – Abrupt interruption of cerebral blood flow which can be hemorrhagic or ischemic depriving the brain of oxygen and nutrients http://strokesymptomsformen.org/stroke-symptoms-on-men/ Statistics/Risk Factors • 3rd leading cause of death in the United States [2] • 1 in every 15 deaths is related to a stroke [2] • Annual cost of stroke care is around $30 billion and this increases as life expectancy goes up [2] Modifiable Non-Modifiable Atrial Fibrillation Atherosclerosis Carotid Stenosis Diabetes Excess Alcohol Intake Hyperlipidemia Hypertension Illicit Drug Use Obesity Sedentary Lifestyle Smoking Age Family History Sex Race [1],[2] Ischemic Strokes • 80-90% of strokes are ischemic in nature [1] • This is caused by narrowed or blocked arteries inhibiting blood flow • Can be reversed if blood flow is restored within 15 minutes • Thrombotic – caused by a blood clot usually formed around areas with atherosclerosis that supply the brain [1] • Embolic – blood clot or debris that is formed by vessels away from the brain and travel in the bloodstream until it gets lodged in a narrow artery in the brain [1] • Commonly come from the heart caused by irregular heart beats (atrial fibrillation) [1] Homunculus http://www.billbuxton.com/homonulus.jpg Sensory distribution of the body mapped out on the brain Anterior Cerebral Artery • Weakness of contralateral leg/foot • Sensory loss of contralateral leg/foot • Gait apraxia (unable to perform learned motor tasks) • Urinary incontinence • Possible Akinetic Mutism (inability to make a decision) Adapted form the Gray’s Anatomy Textbook Middle Cerebral Artery • Contralateral hemiplegia and • • • • • hemianesthesia (paralysis and loss of sensation) Effects face and arms more than the legs Gaze preference away from side of hemiplegia Homonymous hemianopsia (decreased vision or blindness in half the visual field) Dominant hemisphere – global aphasia (*explained later on) Non-dominant hemisphere – anosognosia (denial/indifference) Adapted form the Gray’s Anatomy Textbook Posterior Cerebral Artery • • • • • Contralateral hemiparesis Hemisensory loss Amnesia Hemianopsia Macular vision spared Adapted form the Gray’s Anatomy Textbook Basilar Artery • • • • • • • Often fatal Dysarthria (difficulty articulating) Dysphagia (difficulty swallowing) Diplopia (double vision) Somnolence (drowsiness) Amnesia Locked-in-syndrome (quadriplegic with only vertical eye movement) Adapted form the Gray’s Anatomy Textbook Vertebral Artery • Ipsilateral facial sensory loss • Hemiataxia (loss of muscle cordination on one side) • Nystagmus (involuntary eye movements) • Horner’s Syndrome (ptosis – eyelid droop miosis – pupil constriction anhydrosis – no sweating) • Contralateral pain and temperature sensation loss Adapted form the Gray’s Anatomy Textbook Aphasias • Broca’s – Cannot express oneself with retaining full comprehension • Damage to Brodmann's 44 and 45 • “If it’s Broca, you can’t talka” • Wernicke’s – (Receptive) Fluid speech with meaningless content • Damage to Brodmann’s 22 • Conduction – Cannot repeat sentence • Global – All aspects of language are effected http://www.nidcd.nih.gov/health/voice/pages/aphasia.aspx Hemorrhagic Stroke • Occurs when a blood vessel in the brain ruptures or leaks [1] • Hemorrhages are a consequence of varied conditions including hypertension and aneurisms. [1] • Intracerebral hemorrhage – occurs when a blood vessel bursts and spills into surrounding brain tissue [1] • Associated with hypertension [1] • Subarachnoid hemorrhage – bleeds into a space, not directly onto the brain tissue and the patient may have a sudden and severe “thunderclap” headache [1] • Associated with ruptured aneurisms [1] Testing/Diagnosis • Before any type of treatment it is vital to figure out what kind • • • • • • • of stroke the patient has experienced Begin with a thorough history and physical examination Blood work – CBC, PT, PTT, INR, Glucose, Lipids, etc… [1] CT scan – Without dye to visualize hemorrhagic strokes [1] MRI – Can be used to detect damage of brain tissue due to an ischemic stroke [1] Carotid ultrasound – Used to check for narrowing and or blockage of the carotid arteries [1] Arteriography – For better visualization of arteries [1] Echocardiography – Used to visualize the heart and to check for emboli that may have traveled to the brain [1] Treatment • Ischemic Stroke – • Emergency treatment with medications must be started within 4 ½ hours, but the sooner the better [1] • Aspirin, Tissue Plasminogen Activator (TPA) Warfarin, Heparin, Clopidogrel [1] • A catheter may be used to remove the clot mechanically [1] • Carotid endarterectomy – surgeon removes plaque from carotid arteries [1] • Angioplasty and stenting are other useful methods [1] http://cdrlibraryblog.blogspot.com/2010_07_01_archive.html Treatment • Hemorrhagic Stroke – • If the patient is taking medications like Warfarin or Clopidogrel, blood products and reversing drugs may be given to try to stop the bleeding [1] • Lowering blood pressure may also be necessary to reduce the risk of a seizure [1] • Surgical repair may be used for prevention and treatment [1] • Aneurism clipping, aneurism embolization and removing arteriovenous malformations [1] http://www.strokecenter.org/patients/about-stroke/subarachnoidhemorrhage/ Post-Acute Medical Complications • Major causes of death 1 month s/p stroke: stroke itself, pneumonia, cardiac disease, PE [4] • Other common complications: UTI, msk pain, pulmonary aspiration, depression, falls, seizure, pressure ulcer, venous thromboembolism [4] • Urinary incontinence = 50-70% after 1 month, down to 15% at 6 months • Dysphagia – often recovers quickly; sometimes g-tube feeding is required • Glenohumeral subluxation - (30-50% of pts) causes poststroke shoulder pain. If spasticity becomes severe then Botulinum toxin injections can help. Rehabilitation • The goal of rehabilitation is to help re-establish the patient’s • • • • pre-stroke state of independence helping make activities of daily living less difficult [3] Though a stroke may damage certain areas of the brain, rehabilitation helps recruit other areas of the brain to take over function [3] It begins while the patient is still in the hospital and continues based on need Many times it is a lifelong process Rehab is not just important for the current disabilities attributed to the stroke, but for future prevention as well [3] • For example, a rehab team will work with the patient to encourage lifestyle changes including diet and exercise management http://www.how-to-draw-funny-cartoons.com/cartoon- Motor Recovery • Motor control returns proximally before distally • LE motor control returns more fully and quickly than UE • Poor Prognostic Indicators [4]: • Severe proximal spasticity • Absence of voluntary hand movement at 4-6 weeks • Prolonged flaccid period • Absence of proprioceptive facilitation response at 9 days Brunnstrom’s Stages of Motor Recovery [5] • 1 – Flaccid limb • 2 – Some spasticity with weak flexor and extensor synergies • 3 – Prominent spasticity, voluntary motion occurs w/in synergy patterns • 4 – Some selective activation of muscles outside of synergy patterns. Spasticity reduced. • 5 – Most limb movement independent from limb synergy; spasticity even more reduced, but still present with rapid movements • 6 – Near normal coordination with isolated movements • 7 – Restoration to normal Neurofacilitary Therapies [4,5] • Proprioceptive neuromuscular facilitation (PNF) • Functional movements require coordinated activity of multiple muscle groups • Practice complex movements to facilitate performance of functional activities • Brunnstrom technique • Only therapy specifically for patients with stroke • First voluntary movements after stroke are synergy • Facilitate strength and control of synergy patterns • Techniques enhance abnormal synergy patterns therefore out of favor • Neurodevelopmental technique (NDT) (Bobath approach) • For children with CP • Later broadly applied • Patients using developmental patterns of movement • Rolling • Sitting • Crawling • Stepping • Normalize muscle tone • Rood Method [4] • Uses cutaneous stimuli to activate motor function and to inhibit spastic antagonists • Constraint-induced Movement Therapy (CIMT) [4] • Constraining the non-hemiplegic limb in order to force/encourage use of the affected limb • Associated with less short-term arm impairment than traditional therapy Neuromuscular Electrical Stimulation (NMES), [5] • Apply electric current to cause muscle contraction • Used for trapezius and suprascapularis to prevent shoulder subluxation • Wrist and finger extensors to enhance voluntary opening • EMG feedback to trigger NMES current • Patient initiates movement, if reaches threshold NMES fires to complete movement • Forced use, patient must initiate movement to complete task • Enhance motor relearning • Pain limits therapy Functional Outcomes [4] • 10% of patients are functional at time of stroke • 50% are functional at 6 months post-stroke • The most improvement in ADLs post-stroke are seen in the first 6 months • 5% of patients will continue to show improvement up to 12 months • Disability Frequency at 6 months: • • • • 15% - unable to walk 20% -Needs assist to transfer 50% - Needs assist to bathe 30% - Needs assist to dress Prevention • Control hypertension • Lower Cholesterol • Do not smoke cigarettes or use illicit drugs • Keep diabetes under control • Eat a healthy diet with fruits and vegetables and keep weight under control • Exercise • Limit alcohol usage • Anti-platelet medications / Anticoagulants http://www.favoredfaces.com/healthhygieneetiquette.htm Works Cited • • • • • [1] Mayo Clinic Staff. Stroke. http://www.mayoclinic.com/health/stroke/DS00150. Published July 1, 2010. Accessed December 4, 2011. [2] Romero J. Prevention of ischemic stroke: overview of traditional risk factors. Current Drug Targets [serial online]. July 2007;8(7):794-801. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed December 4, 2011. [3] WebMD Staff. Stroke Rehabilitation Overview. http://www.webmd.com/stroke/tc/stroke-rehabilitation-overview. Published October 22, 2009. Accessed December 9, 2011. [4] Choi, H., Sugar, R., David, E.F., Shatzer, M., Krabak, B.(2003). Stroke. In R. Hurley, E. Wolfberg, C. Sahl(Eds.), Physical Medicine and Rehabilitation Poketpedia (pp. 92-96). Philadelphia; Lippincott Williams & Wilkins. [5] Furman, M.B., Sthalekar, N.D., Berkwits, L., Falco, F.J.E.(2008). Stroke: Diagnosis and Rehabilitation. In J. Merritt, & S. Ward(Eds.), Physical Medicine and Rehabilitation Secrets (pp. 247-258). Philadelphia; Mosby Elsevier.