Transcript aocpmr.org

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
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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
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Contralateral hemiparesis
Hemisensory loss
Amnesia
Hemianopsia
Macular vision spared
Adapted form the Gray’s Anatomy
Textbook
Basilar Artery
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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
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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
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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
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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
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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:
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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
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[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.