STROKE

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STROKE

Need for focus


According to the World Health
Organization (WHO) Global Burden of
Disease report, stroke was the second
leading cause of mortality worldwide in
1990 and the third leading cause of
mortality in developed countries
 Stroke is a disease that affects the arteries leading
to and within the brain. It is the No. 5 cause of
death and a leading cause of disability in the
United States.
 A stroke occurs when a blood vessel that carries
oxygen and nutrients to the brain is either blocked
by a clot or bursts (or ruptures).
 There are two main types of stroke: ischemic, due to
lack of blood flow, and hemorrhagic, due to bleeding.
 Both cause parts of the brain to stop functioning
properly.
 Signs and symptoms of a stroke may include
an inability to move or feel on one side of the
body, problem understanding or speaking, dizziness,
or loss of vision to on side
Classification of stroke

Depending on etiology
 Ischemic
 Hemorrhagic
Depending on management
TIA, minor stroke, established stroke,
deteriorating, young stoke
Depending on territories of vessels-
MCA, ACA, PCA, ICA, etc.
Classification of stroke
 Hemorrhagic type -
 Intracerebral haemorrhage (IH)
 Subarachnoid hemorrhage (SAH)
 Subdural Hemorrhage(SDH)
Ischemic stroke –
 Atherosclerosis
 Thrombus
 Emboli
 Ischemic penumbrae
Classification of stroke
Ischemic stroke

 This is the most common type of stroke. It happens


when the brain's blood vessels become narrowed
or blocked, causing severely reduced blood flow
(ischemia).
 Blocked or narrowed blood vessels are caused by
fatty deposits that build up in blood vessels or by
blood clots or other debris that travel through the
bloodstream, most often from the heart, and lodge
in the blood vessels in the brain.
Hemorrhagic stroke

 Hemorrhagic stroke occurs when a blood vessel in


the brain leaks or ruptures.
 Brain hemorrhages can result from many
conditions that affect the blood vessels. Factors
related to hemorrhagic stroke include:
• Uncontrolled high blood pressure
• Bulges at weak spots in your blood vessel walls
(aneurysms)
• Trauma (such as a car accident)
• Protein deposits in blood vessel walls that lead to
weakness in the vessel wall (cerebral amyloid
angiopathy)
• Ischemic stroke leading to hemorrhage
Transient Ischemic Attack (TIA),

 A transient ischemic attack (TIA), commonly


known as a mini-stroke, is a minor stroke whose
noticeable symptoms usually end in less than an
hour.
 TIA causes the same symptoms associated with
stroke, such as weakness or numbness on one
side of the body, sudden dimming or loss of vision,
difficulty speaking or understanding
language, slurred speech, or confusion.
Risk factors

Non
Modifiable modifiable
 Smoking  Age ( 55 risk is
 Obesity 1 in 6)
 Lack of  Gender
exercise  Race (African &
 Diet American)
 Excess alcohol  Family history
Indicators

 Sudden numbness or weakness


 Sudden confusion, trouble speaking or
understanding
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of
balance or coordination
 Sudden, severe headaches with no known
cause

National Stroke
Other important but less
common

 Sudden nausea, fever, and


vomiting

 Brief loss of consciousness or a


period of decreased
consciousness
How this sounds

 Heart attack
 Accident
 Head injury

 Stroke

 Brain attack
Anterior Cerebral Artery
Syndrome
 Hemiparesis mainly lower limb
 Contralateral hemi sensory loss mainly lower
limb
 Urinary incontinence
 Imitation and bimanual tasks (Corpus
callosum)
 slowness, delay, lack of spontaneity, motor
inaction
 Contralateral grasp reflex, sucking reflex
Middle Cerebral Artery
Syndrome
 Hemiparesis mainly upper limb
 Contralateral hemi sensory loss mainly
upper limb
 Broca’s or non fluent aphasia
 Wernicke’s or fluent aphasia
 Perceptual deficits(non dominant
hemisphere)
 Contralateral homonymous hemianopsia
 Loss of conjugate gaze to the opposite
side
Primary impairments
Sensation

 Frequently impaired( 53% ) but


rarely absent
 Face-UE-LE pattern
 pain
 Thalamic pain
Primary impairments
Motor Recovery Stages

STAGE 1
period of flaccidity immediately
following the acute episode.
Primary impairments
Motor Recovery Stages

STAGE 2
limb synergies or some of their
components may appear as
associated reactions, At this time,
spasticity begins to develop.
Primary impairments
Motor Recovery Stages

STAGE 3
Established movement synergy,
Spasticity has further increased
and may become severe.
Primary impairments
Motor Recovery Stages
STAGE 4
Some movement combinations
that do not follow the paths of
either synergy are mastered,
spasticity begins to decline.
Primary impairments
Motor Recovery Stages
STAGE 5
More difficult movement
combinations are learned as the basic
limb synergies lose their dominance
over motor acts.
Primary impairments
Motor Recovery Stages
STAGE 6
 disappearance of spasticity,
coordination approaches normal.
normal motor function is restored

Brunnstrom, S: Movement Therapy in Hemiplegia. Harper &


Row, New York, 1970, with permission.
Primary impairments
Weakness
 Distal more involved than proximal.
 Mild weakness also occurs on the Ipsilateral.
 Selective loss of type II fast twitch fibers with
an increase in the percentage of type I fibers.
 Functioning motor units and discharge firing
rates decrease.
 Degeneration of alpha motor neurons.
 Increased movement time and reaction time.
 Increased co activation of agonists and
antagonists
Primary impairments
Alterations in Tone

 Flaccidity (hypotonicity)

 Spasticity (hypertonicity)
Abnormal Synergy
Patterns
Upper extremity
Flexion Synergy Components
Scapular retraction/elevation abduction,
external rotation, Elbow flexion Forearm
supination Wrist and finger Flexion
extensor Synergy Components
Scapular protraction, Shoulder adduction, internal
rotation, Elbow extension, Forearm pronation, Wrist
and finger flexion
Abnormal Synergy
Patterns
Lower limb synergy
 Flexor synergy
Hip flexion, abduction, external
rotation, Knee flexion Ankle
dorsiflexion, inversion, toe dorsiflexion.
 Extensor synergy
Hip extension, adduction, internal
rotation, Knee extension, Ankle plantar
flexion, inversion, Toe plantar flexion
Primary impairments

 Abnormal Reflexes
 Altered Coordination - problems with timing
and sequencing of muscles
 Altered Motor Programming - The patient
demonstrates difficulty planning and executing
purposeful movements
Ideational apraxia-inability to produce movement
either on command or automatically.
ideomotor apraxia the patient is unable to
produce a movement on command but is able to
move automatically.
Some common associated reactions
Primary impairments

 Postural Control and Balance –


 Reactive postural control - ankle,
hip and stepping strategies
 Anticipatory postural control.
 Asymmetry weight bearing in sitting
and standing
 pusher syndrome or Ipsilateral
pushing – Misperception in vertical
orientation
Primary impairments
Speech, Language, and Swallowing

Aphasia -
Fluent aphasia
(Wernicke’s/sensory/receptive),
Non fluent aphasia
(Broca’s/expressive aphasia)
Global aphasia
Primary impairments
Speech, Language, and Swallowing

Dysarthria –
 Respiration, articulation, phonation
and sensory feedback may be
affected
 Lesion located in the primary motor
cortex in the frontal lobe, the primary
sensory cortex in the parietal lobe.
Primary impairments
Speech, Language, and Swallowing

 Dysphagia –
Delayed triggering of the swallowing
reflex
 reduced pharyngeal peristalsis (58 %)
Reduced lingual control (50%)
Lesions of medullary brainstem (CN IX
and X), large vessel pontine lesions,
Acute hemispheric lesions (MCA and
Primary impairments
Perception

Body scheme/body
image
Postural model of the body
including the relationship
of the body parts to each
other and the relationship
of the body to
the environment.
Primary impairments
Perception

Agnosias
Agnosia is the inability to recognize
incoming information despite intact
sensory capacities
 Visual object Agnosia,
 Auditory Agnosia
 Tactile Agnosia (Astereognosis)
Primary impairments
Cognitive deficits

 Alertness
 Attention
 Orientation
 Memory
 Executive functions
Primary impairments
Cognitive deficits

 Perseveration –
 Continued repetition of words

 Confabulation –
 Inappropriate words or fabricated
stories
Primary impairments
Emotional Status

Pseudobulbar affect (PBA)


emotional outbursts

Euphoria–
Exaggerated
Feelings Of Well-being
Complications and Indirect
Impairments

Musculoskeletal
Cardiovascular/Pulmonary
Seizures
Bed rest complication
Risk factors

 Lifestyle risk factors


• Being overweight or obese
• Physical inactivity
• Heavy or binge drinking
• Use of illegal drugs
Medical risk factors

•High blood pressure


•Cigarette smoking or secondhand smoke exposure
•High cholesterol
•Diabetes
•Obstructive sleep apnea
•Cardiovascular disease, including heart failure, heart
defects, heart infection or irregular heart rhythm,

•Personal or family history of stroke, heart attack or


transient ischemic attack.

•COVID-19 infection
End of the
complaints
What am I going to
do
TESTS

 A physical exam
 Blood tests.
 Computerized
tomography (CT)
scan.
 Magnetic resonance
imaging (MRI)
 Carotid ultrasound.
 Echocardiogram.
Treatment
 Ischemic stroke
 EMERGENCY IV MEDICATION:
Therapy with drugs that can break up a clot has to be
given within 4.5 hours from when symptoms first started
if given intravenously.
The sooner these drugs are given, the better. Quick
treatment not only improves your chances of survival
but also may reduce complications.
 An IV injection of tissue plasminogen activator
(TPA) — also called alteplase (Activase) or
tenecteplase (TNKase) — is the gold standard
treatment for ischemic stroke.
 An injection of TPA is usually given through a vein
in the arm within the first three hours. Sometimes
TPA can be given up to 4.5 hours after stroke
symptoms started.
 Emergency endovascular procedures

 Medications delivered directly to the


brain. Inserting a long, thin tube (catheter) through
an artery in the groin and thread it to the brain to
deliver TPA directly where the stroke is happening.
 Removing the clot with a
stent retriever.
 A device attached to a
catheter to directly remove
the clot from the blocked
blood vessel in the brain.

 This procedure is particularly


beneficial for people with
large clots that can't be
completely dissolved with
TPA.
OTHER PROCEDURES

• Carotid
endarterectomy. Carotid
arteries are the blood
vessels that run along
each side of the neck,
supplying the brain
(carotid arteries) with
blood.
• This surgery removes the
plaque blocking a carotid
artery and may reduce the
risk of ischemic stroke.
 Angioplasty and
stents. In an angioplasty,
a surgeon threads a
catheter to the carotid
arteries through an artery
in the groin.
 A balloon is then inflated
to expand the narrowed
artery. Then a stent can
be inserted to support the
opened artery.
Hemorrhagic stroke

 Emergency measures:blood-thinning
medications to prevent blood clots, you may
be given drugs or transfusions of blood
products to counteract the blood thinners'
effects. You may also be given drugs to lower
the pressure in the brain (intracranial
pressure), lower blood pressure, prevent
spasms of the blood vessels and prevent
seizures.
 Surgery.
 Surgical clipping. A
surgeon places a tiny
clamp at the base of
the aneurysm to stop
blood flow to it. This
clamp can keep the
aneurysm from
bursting, or it can keep
an aneurysm that has
recently hemorrhaged
from bleeding again.
 Surgical AVM
removal:Surgeons may
remove a smaller TVM if it's
located in an accessible area
of the brain. This eliminates
the risk of rupture and lowers
the risk of hemorrhagic
stroke. However, it's not
always possible to remove
an AVM if it's located deep
within the brain, it's large, or
its removal would cause too
much of an impact on brain
function.
 Coiling (endovascular
embolization).
 Using a catheter inserted
into an artery in the groin
and guided to the brain,
the surgeon will place tiny
detachable coils into the
aneurysm to fill it. This
blocks blood flow into the
aneurysm and causes
blood to clot.
 Stereotactic
radiosurgery.: Using
multiple beams of
highly focused
radiation. stereotactic
radiosurgery is an
advanced minimally
invasive treatment
used to repair blood
vessel malformations.

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