Definition:

Cerebrovascular accident
Stroke or brain attack
Acute onset of neurological dysfunction due to an abnormality in cerebral
circulation with resultant signs and symptoms that correspond to
involvement of focal areas of the brain.
A sudden neurological deficit characterized by:
o Loss of motor control
o Altered sensation
o Cognitive or Language Impairment
o Disequilibrium or coma
Anatomy:

Anatomy of affectation
Frontal lobe
o Behavior and emotion
o Intelligence
o Voluntary movement
Parietal lobe
o Tactile and proprioceptive sensation
o Taste
Temporal lobe
o Speech and language
o Hearing
Occipital lobe
o Vision
Cerebellum
o Timing of motor activities
o Rapid smooth progression of movement
o Controls intensity of muscle contraction
o Controls instantaneous interplay between agonist & antagonist
muscles
o Postural control
o balance

Brainstem
o Midbrain
Rostral part of brainstem
Functions
Vision
Hearing
Eye movement
Body movement
Anterior part has cerebral peduncle
Huge bundle of axons from cortex
Important for voluntary motor control
o Pons
Between midbrain & medulla
2.5 cm
contains nuclei that relay signals from forebrain to cerebellum,
along with nuclei that deal with
sleep
respiration
swallowing
bladder control
hearing
equilibrium
taste
eye movement
facial expressions
facial sensation
posture
o Medulla oblongata
Caudal-most part of brainstem
Functions
Breathing
Heart rate
Lenticulostriate arteries
o Arise from MCA
o 6-12 long, small diameter
o Supply deep structures in cerebrum
Internal capsule
Reticular formation
Basal ganglia
o End-arteries (no collateral blood supply
o May be silent
Etiology:

Atherosclerosis
o Major contributory factor
o Plaque formation and accumulation of lipids, fibrin, complex
carbohydrates, and Ca deposits on arterial walls progressive
narrowing of lumen
Ischemic stroke
o Result of thrombus, embolism, or conditions that produce low
systemic perfusion pressures
o Lack of CBF deprive brain of O2 & glucose injury/death of
tissues
Hemorrhagic stroke
o Result of rupture of cerebral vessel/trauma
Epidemiology
Age related (> elderly)
Primary cause
o Atherosclerosis (adults)
More common in men (19% higher)

Pathophysiology
I. a. Ischemic Stroke
1. Thrombotic stroke
2. Embolic stroke
3. Lacunar stroke
Found in subcortical regions of the:
Basal ganglia
Internal capsule
Pons
Cerebellum
Small, circumscribed lesions
Measure <1.5cm in diameter
Strongly associated with hypertension (HPN)
Pathologically associated with microvascular changes that
often develop in the presence of chronic HPN
Also associated with diabetes milletus (DM) as a result of
chronic microvascular changes

I. b. Hemorrhagic Stroke

Clinical Manifestations


Name Location of Infarct Presentation
Pure motor
stroke/hemiplegia
Posterior limb of
internal capsule
Basis pontis
Corona radiate
Hemiparesis
Hemiplegia face, arm,
leg
Dysarthria
Dysphagia
Ataxic hemiparesis Post limb internal
capsule
Basis pontis
Corona radiate
Red nucleus
Lentiform nucleus
SCA infarcts
ACA infarcts
Cerebellar & motor
symptoms
Weakness & clumsiness
on ipsilateral body
Leg > arm
Aka homolateral ataxia
& crural paresis
Dysarthria/clumsy
hand
Basis pontis
Anterior limb of
internal capsule
Corona radiate
BG
Thalamaus
Cerebral peduncle
Dysarthria
Clumsiness of hand
Most prominent in
writing
Pure sensory stroke Contralateral
thalamus
Internal capsule
Corona radiate
Midbrain
Persistent/transient
numbness
Tingling
Burning
Unpleasant sensation
Mixed sensorimotor Thalamus
Posterior internal
capsule
Lateral pons
Hemiparesis/plegia
Ipsilateral sensory
impairment

Diagnosis
Early warning signs
o Sudden numbness/weakness
o Sudden confusion, trouble speaking or understanding
o Sudden trouble seeing
o Sudden trouble walking
o Sudden severe headaches
CT scan best for acute stroke
PET scan
Transcranial and Carotid Doppler

Differential Diagnosis
Seizures
Systemic infection
Brain tumor
Toxic-metabolic
Positional vertigo
Cardiac
Syncope
Trauma
Subdural hematoma
Herpes encephalitis
Transient global amnesia
Dementia
Demyelinating disease
Cervical spine fracture
Myasthenia gravis
Parkinsonism
Hypertensive encelopathy
Conversion disorder

Complications
Physiologic deconditioning
Venous thromboembolism
Pneumonia
Cardiac disease
Obstructive sleep apnea
Falls
Osteoporosis
Hydrocephalus


Prognosis
Predicting Disability and Functional Status
o Prognosis for recovery
Lacunar lesion excellent
Large vessel infarctions (thrombosis or embolism)
Prognosis related to volume of lesion
>10% intracranial volume poorest
54-80% stroke survivors
walk indep 3 months poststroke
Barriers to Motor Recovery
o Prolonged flaccidity
o Lack of voluntary movement within 2 weeks
o Severe spasticity
o Lack of movement out of synergy patterns
o Sensory deficits
Brunnstroms Recovery Stages
o Stage 1
Flaccidity
No movements elicited
o Stage 2
Basic limb synergies
Minimal voluntary movement
Spasticity develops
o Stage 3
Voluntary control of synergies
Spasticity increase (severe)
o Stage 4
Movement not follow synergy
Spasticity decrease
o Stage 5
More difficult combinations
Synergies lose dominance
o Stage 6
No spasticity
Individual joint motions possible
Coordination approaches normal
o NOTE: recovery stage can plateau at any stage
Medical management
Regulation of BP
Reduce of intake of
o Fats
o Sodium
o Potassium
Platelet inhibiting therapy
o Aspirin
o Anti-coagulants

Rehabilitation management
Acute stroke management
o Begin as soon as the patient is medically stable typically 72 hrs
o Goals
Maintain ROM and prevent deformity
Promote active movement and use of hemiplegic side
Improve trunk control, symmetry and balance
Improve functional mobility
Initiate self care activities
Improve respiratory and promoter function
o Specific activities
Positioning
ROM exercises
Breathing exercises (diaphragmatic)
Facial mm exercises
Swallowing and chewing exercises
Tongue movement exercises
Post acute rehabilitation
o Goals
Prevent secondary complications
Promote selective motor control
Normalization of postural tone
Develop independent functional mobility skills
Develop independent ADL
Develop cardio-respiratory endurance
Encourage socialization and motivation
o Specific activities
Reflex- inhibiting patterns
Rhythmic initiation
Prolonged icing
PNF
Facilitation techniques
Sitting and standing balance and tolerance
Gait training

Techniques of tx
Flaccid stage
o PROM on the affected side
o AROM on the affected side
o Bed positioning (supine, side-lying)
o Turning activities
o Sitting activities
o Facilitatory techniques
Spastic stage
o Reflex-inhibiting movements
o Inhibitory techniques
o Progression of that given during the flaccid stage
o Sitting and standing balance and tolerance
o Gait training

1. Half-lying: hip and knee flexion and extension of each limb, foot
flat on mat
2. Half-lying: hip abduction and adduction of each limb with the
foot flat, knee flexed; then with knee extended
3. Half-lying: hip and knee flexion and extension of each limb, heel
lifted off mat
4. Half-lying: heel of one limb to opposite leg (toes, ankle. shin,
patella)
5. Half-lying: heel of one limb to opposite knee, sliding down crest
of tibia to ankle
6. Half-lying: hip and knee flexion and extension of both limbs, legs
together
7. Half-lying: reciprocal movements of both limbs- flexion of one
leg during extension of the other
8. Sitting: knee extension and flexion of each limb; progress to
marking time
9. Sitting: hip abduction and adduction
10. Sitting: alternate foot placing to a specified target (using floor
markings or a grid)
11. Standing up and sitting down: to a specified account
12. Standing: foot placing to a specified target (floor markings or
grid)
13. Standing: weight shifting
14. Walking: sideways or forward to a specified count. (parallel
lines, or floor markings may be used as targets to control foot
placement, stride length, and step width)
15. Walking: turning around to a specified count. (Floor markings
can be helpful in maintaining a stable base of support).