Download Cerebrovascular Accident (Stroke)

Cerebrovascular Accident
(Stroke)
Dayna Ryan, PT, DPT
Winter 2012
CVA/Stroke Epidemiology
Population Statistics for 2006
• Age
–
–
–
–
18-44……………………..0.5%
45-64……………………..2.4%
65-74……………………..7.6%
75 +………………………11.2%
• Sex
– Male ......................2.9%
– Female...................2.3%
• Race
– White...............................2.4%
– Black/African American….4.6%
– American Indian/
Alaska Native....................2.6%
– Asian............................... 1.8%
• Average length of stay in acute
care hospital in 2006 = 4.9 days
CVA Risk Factors that Cannot Be Changed
• Age
– Risk approximately doubles for each decade of life after age 55
• Heredity (family history) and race
– Your stroke risk is greater if a parent, grandparent, sister or
brother has had a stroke.
– African Americans have a much higher risk of death from a stroke
than Caucasians do. This is partly because blacks have higher
risks of high blood pressure, diabetes and obesity.
• Sex (gender)
– Stroke is more common in men than in women.
– At all ages, more women than men die of stroke. Use of birth
control pills and pregnancy pose special stroke risks for women.
• Prior stroke, TIA or heart attack
– A person who's had one or more TIAs (mini-stroke) is almost 10
times more likely to have a stroke than someone of the same age
and sex who hasn't.
– If you've had a heart attack, you're at higher risk of having a
stroke, too.
CVA Risk Factors that Can Be Changed,
Treated, or Controlled
• High blood pressure
• Cigarette smoking
– nicotine and carbon monoxide in cigarette smoke damage the
cardiovascular system in many ways
– use of oral contraceptives combined with cigarette smoking
greatly increases stroke risk.
• Diabetes mellitus
– While diabetes is treatable, the presence of the disease still
increases your risk of stroke.
• Carotid or other artery disease
– The carotid arteries in your neck supply blood to your brain. A
carotid artery narrowed by fatty deposits from
atherosclerosis (plaque buildups in artery walls) may become
blocked by a blood clot. Peripheral artery disease is the
narrowing of blood vessels carrying blood to leg and arm muscles.
It's caused by fatty buildups of plaque in artery walls. People
with peripheral artery disease have a higher risk of carotid artery
disease, which raises their risk of stroke.
CVA Risk Factors that Can Be Changed,
Treated, or Controlled
• Atrial fibrillation
▫ The heart's upper chambers quiver instead of
beating effectively, which can let the blood pool
and clot. If a clot breaks off, enters the
bloodstream and lodges in an artery leading to the
brain, a stroke results.
• Other heart disease
▫ Dilated cardiomyopathy (an enlarged heart),
heart valve disease and some types of congenital
heart defects also raise the risk of stroke.
CVA Risk Factors that Can Be Changed,
Treated, or Controlled
• Sickle cell disease (also called sickle cell
anemia) —
– This is a genetic disorder that mainly affects
African-American and Hispanic children.
– Sickled cells (poor O2 absorption) tend to
stick to blood vessel walls, which can block
arteries to the brain and cause a stroke.
• High blood cholesterol
– Also, it appears that low HDL (“good”)
cholesterol is a risk factor for stroke in men,
but more data are needed to verify its effect in
women.
CVA Risk Factors that Can Be Changed,
Treated, or Controlled
• Poor diet
▫ Diets high in saturated fat, trans fat and cholesterol can raise
blood cholesterol levels.
▫ Diets high in sodium (salt) can contribute to increased blood
pressure. (salt attracts water into blood, so increase blood
volume)
▫ Diets with excess calories can contribute to obesity.
▫ Diet containing five or more servings of fruits and vegetables per
day may reduce the risk of stroke.
• Physical inactivity and obesity —
▫ Being inactive, obese or both can increase your risk of high blood
pressure, high blood cholesterol, diabetes, heart disease and
stroke.
▫ Try to get a total of at least 30 minutes of activity on most or all
days.
“Give Me 5” Campaign
• Sponsored by American Academy of Neurology,
the American College of Emergency Physicians
and the American Heart Association/American
Stroke Association
• If any of these are positive, call 9-1-1
Type of CVA: Ischemic
• 83% of all strokes
• From atherosclerosis
• Two types
▫ Cerebral thrombus (blood
vessel clogs)
▫ Cerebral embolism (clot
from heart, upper body, or
neck dislodges and move to
brain to clog artery)
Type of CVA: Ischemic
• Most often caused by
atherosclerosis, or gradual
cholesterol deposition
• Another cause is blood
clots in the heart, which
can occur as a result of
irregular heartbeat (for
example, atrial
fibrillation), heart attack,
or abnormalities of the
heart valves.
• If the artery remains
blocked for more than a
few minutes, the brain cells
may die – why immediate
medical treatment is
absolutely critical.
Type of CVA: Hemorrhagic
• 17% of all strokes
• Results from a weakened
vessel that ruptures and
bleeds into the surrounding
brain
▫ Blood accumulates and
compresses the surrounding
brain tissue
• Two types:
▫ Intracerebral hemorrhage
▫ Subarachnoid hemorrhage
• Weakened blood vessels
from:
▫ Aneurysms
▫ Arteriovenous malformations
(AVMs).
• Aneurysm
▫ Ballooning of a weakened
region of a blood vessel.
• Arteriovenous
malformation (AVM)
▫ a cluster of abnormally formed
blood vessels. Any one of these
vessels can rupture, also
causing bleeding into the brain.
Type of CVA:
Intracerebral Hemorrhage
• Most common cause of
intracerebral hemorrhage
is high blood pressure
(hypertension)
• If the amount of blood
increases rapidly, the
sudden buildup in
pressure can lead to
unconsciousness or
death
• Usually occurs in
•Intracerebral hemorrhage
selected parts of the
occurs when a diseased blood
brain, including the basal
vessel within the brain bursts,
ganglia, cerebellum,
allowing blood to leak inside the
brainstem, or cortex
brain
Type of CVA:
Subarachnoid Hemorrhage
• Area of the skull surrounding
the brain (the subarachnoid
space) rapidly fills with blood.
• Patient with subarachnoid
hemorrhage may have a
sudden, intense headache, neck
pain, and nausea or vomiting.
• Sudden buildup of pressure
outside the brain may also
cause rapid loss of
consciousness
Occurs when a blood
vessel just outside the
brain ruptures.
• Most often caused by
abnormalities of the arteries at
the base of the brain, called
cerebral aneurysms.
Watershed Stroke
• These areas receive their
blood supply from the
farthest-end branches of
two adjacent vascular
territories and require
adequate blood pressure
to ensure that enough
blood is pumped into
them at all times.
• Caused by lack of blood
profusion to these areas
of the brain due to:
▫ Congestive heart failure
▫ Atherosclerosis
▫ Hypotension (shock)
• A watershed stroke in the
region of overlapped
distribution between the
anterior cerebral artery
and the middle cerebral
artery classically
presents with weakness
of proximal arm and leg
muscles and preservation
of distal strength
▫ colloquially, the "man in a
barrel" presentation
Carotid Angiogram
This is an angiogram of
the right carotid artery
showing a severe
narrowing (stenosis) of
the internal carotid
artery just past the
carotid fork. There is
enlargement of the
artery or ulceration in
the area after the
stenosis in this close-up
film. Note the
narrowed segment
toward the bottom of
the picture.
Middle Cerebral Artery
Middle Cerebral Artery
• Supplies internal capsule
and basal ganglia
• The blood clot may block
the passage of blood
through a brain artery,
depriving nearby tissue of
oxygen and nutrients 
results in a stroke.
Middle Cerebral Artery
• Lesions can affect the optic radiation
Middle Cerebral Artery CVA
• Contralateral
hemiparesis, arm > leg
• Contralateral sensory
impairment
• Expressive (can’t speak it
though they know what
they want to say) or
receptive aphasia
(rabbling, can’t
understand)
• Apraxia
• Homonymous
hemianopsia
(contralateral)
• Perceptual deficits if right
lesion, e.g. unilateral
neglect
Expressive Aphasia
Homonymous
Hemianopsia
Anterior Cerebral Artery (medial view)
http://www.strokecenter.org/pat/ais.htm
Anterior Cerebral Artery CVA
• Contralateral
hemiparesis affecting leg
> arm
• Contralateral sensory
impairment affecting leg
> arm
• Loss of bowel/bladder
control
• Apraxia
• Mental impairment with
perseveration, confusion,
amnesia
• Decreased motivation
• Motor inaction
Posterior Cerebral Artery
(Inferior and Medial Views)
Posterior Cerebral Artery CVA
• Contraleral homonymous
hemianopia
• Dyslexia
• Memory deficit
• Topographical
disorientation
• Cranial nerve III palsy
(oculomotor)
• Contralateral
hemiparesis
• Thalamic syndrome
=Sensory impairment in all
modalities
▫ Pain
▫ Paresthesias
• Pain and temperature
sensory loss (spinalthalamic)
• Ataxia, athetosis, or
choreiform movement
• Visual agnosia=inability to
different objects visual.
Basilar Artery and Vertebral Artery
Vertebral Artery CVA
•
•
•
•
•
•
Ataxia
Vertigo
Nausea
Vomiting
Nystagmus
Impaired pain and
temperature sensation in
ipsilateral face
• Horner’s Syndrome
(sympathetic dysfunction
causing ptosis (eye
dropping))
• Dysphagia
• Sensory impairment in
contralateral arm, trunk,
and leg
Basilar Artery CVA
• Coma
• Quadriplegia
• “Locked in” syndrome
▫ Intact consciousness
▫ No motor ability other
than eye blinks to
respond
• Bilateral cerebellar
ataxia
• Thalamic pain
syndrome
• Diplopia or other
visual field deficits
including blindness
Lacunar Strokes
• Caused by occlusion of a
small branch of the larger
arteries
• Tend to be located deeper
in the brain because there
are more smaller arterial
branches there
• Symptoms depend on
location
Typical Impairments with Lacunar
Infarcts
•
•
•
•
Contralateral weakness
Sensory loss (specifics depend on location)
Ataxia
Dysarthria
• Site of lesions: internal capsule, thalamus, basal
ganglia, and pons
Characteristics of CVA
RIGHT
• Weakness/paralysis on the left
side
• Decreased attention span
• Left hemianopsia
• Decreased
awareness/judgment
• Memory deficits
• Impulsive behaviors
• Decreased spatial orientation
and abstract reasoning
• Emotional lability
LEFT
• Weakness/paralysis on the
right side
• Increased frustration
• Decreased
processing/sequencing
• Aphasia (expressive, receptive,
global)
• Dysphagia
• Ideomotor or ideational
apraxia
• Decreased discrimination
between right and left
• Right hemianopsia
Characteristics of CVA
BRAINSTEM
• Unstable vital signs
• Decreased consciousness
• Decreased ability to swallow
• Weakness on both sides of the
body
• Paralysis on both sides of the
body
CEREBELLUM
• Decreased balance
• Ataxia
• Decreased coordination
• Nausea
• Decreased ability for postural
adjustment
• Nystagmus
CVA Signs/Symptoms
• Sensory: contralateral deficits
• Motor
▫ Hypotonia with cerebral shock followed by
hypertonia (spasticity and clonus)
▫ + Babinski if motor tracts affected
▫ Contralateral paresis
▫ Apraxia
▫ Decreased muscle endurance (because decreased
motor units)
▫ Increased reaction time
▫ Decreased ability to fractionate movement
Preventive Care
• Brain attack campaign
• Placing stent in carotid artery if plaque build-up
is present
• Carotid endarterectomy
Carotid Endarterectomy
• Endarterectomy is a
surgical procedure
removing plaque material
from the lining of an
artery.
• Risk of stroke if blood
clot dislodged.
• Surgeons have varying
success rates – check
their record.
Emergency Care
• Recombinant tissue plasminogen activator (RTPA) to dissolve blood clot
▫ Must be administered within 3 hours of blockage
▫ Treatment is 30% effective in helping people
recover from stroke
Preventive and Emergency Care
Medical Care of CVA
Ischemic
• Calcium channel
antagonist
• Anticoagulation therapy
• BP regulation
• Cholesterol medications
Hemorrhagic
• Surgical evacuation of
blood
• Medication to decrease
intracranial pressure
• Surgical repair of
aneurysm or
arteriovenous
malformation (if not
repairing themselves)
Movement Symptoms Associated
with CVA
•
•
•
•
•
•
•
•
•
Decreased force production
Sensory impairment
Abnormal synergies
Altered temporal sequencing of muscle
contractions
Impaired regulation of muscle force
Delayed response time
Abnormal muscle tone
Loss of range of motion
Altered biomechanical alignment, e.g. scapula
Treatment of Symptoms
• Spasticity
▫ Baclofen
▫ Botox
• Catheter
• Anti-depressants