Intro to stroke - Recovery vs compensation o Recovery: nerve impingement, hydrocephalus, Bell’s palsy, mild stroke Axon growth 1-3mm/day Neuroplasticity can lead to full recovery o Compensation: complete lesion of nerve, ALS o Depends on: Diagnosis, patient goals, literature (will pt be candidate for full recovery or require compensation? Direct your intervention according to what literature says) - Physical therapy o Optimize motor performance in functional activities (activity based interventions more effective for stroke pts) Task & context specific exercise and training of everyday actions Acquisition of skill (proficiency; ability to perform in different settings) Increase strength Improve endurance & fitness (stroke pts lack strength, endurance, fitness) - Arterial system o Anterior circulation = anterior cerebral + middle cerebral o Posterior circulation = posterior cerebral o Basilar a. under pons o Vertebral a. under medulla o Internal carotid a. goes into brain. External carotid a. goes outside of brain o Basilar a. if affected, less blood flow to posterior brain (only one basilar a., nothing to back it up) o Stroke of posterior inferior cerebellar a. (PICA) = cerebellar sign affecting cerebellum - CN1-4 = above brainstem. CN 5-12 at brainstem - CN 9-12 = oral motor - Crossing of motor nerves at medulla - Locked in syndrome = conscious, but unable to produce speech, limb, facial movements. Can move eyes - Dura mater arachnoid mater pia mater o Subdural hematoma is venous (low pressure). Symptoms occur slowly o Subarachnoid hemorrhage is arterial (high pressure). Symptoms occur immediately (don’t need to know exactly where the stroke is according to signs & symptoms. MD’s job) Brainstem = medulla + pons- CSF drains into subarachnoid space to venous system o Deep cerebral veins to great vein of galen o All veins to dural sinuses o Sigmoid sinus to jugular vein - If blockage b/w lateral and 3rd ventricle, lateral ventricles will enlarge - CSF – shock absorption, nutrition, filter waste o Production – choroid plexus o Lateral ventricles interventricular foramina 3rd ventricle cerebral aqueduct 4th ventricle foramens of magendie and luschka subarachnoid space dural sinuses - Stroke (“brain attack”) o 3rd leading cause of death in US o Leading cause of long term disability in US 40% moderate activity limitations, 15-30% severely disabled o Stroke belt – area w/ high incidence of stroke or other CV disease o Black vs Hispanic > Caucasian o Survival time post 1st stroke decreases as you get older o Risk of recurrent stroke increases as time goes on o Women’s health issue b/c women are more impaired and survive longer - Stroke – rapid clinical signs of cerebral function due to interruption of blood flow leading to cell death w/ no cause other than that of vascular origin o Ischemic 87% TIA – no evidence of infarction and clinical signs < 24hrs. No cell death on imaging o Hemorrhagic 13% ICH intracerebral hemorrhage – blood leaks into brain tissues SAH subarachnoid hemorrhage – blood leaks into membranes surrounding brain - Warning signs = FAST o Face (fallen on one side, can they smile) o Arms (raise both arms and hold there) o Speech (slurred) o Time – call 911 - Risk factors o Ischemic – HTN, DM, smoking, cardiac arrhythmias, atherosclerosis, post menopause on estrogen & progestin, family hx o Hemorrhagic – HTN, anticoagulation problems, vascular abnormalities, drug abuse, tumors, pregnancy, family hx - MD evaluation o NIHSS o Blood test o CT scan (high sensitivity for ICH) o MRI Diffusion weighted imaging (DWI) – highly sensitive to infarct w/in minutes, represents cytotoxic edema Fluid-attenuation-inversion-recovery (FLAIR): vasogenic edema (blood brain barrier disrupted) w/in 6 hrs o MRA (magnetic resonance angiography) – image blood vessels Venous systemo CTA/CTP imaging o Doppler – evaluate velocity and direction of flow to carotid and vertebral a. - Penumbra – hypoxic cell death to tissue area surrounding ischemic event (ischemic, thrombotic, or embolic stroke) - Ischemic strokes o Medication tPA – only FDA approved tx for acute ischemic stroke - 1-3% of pts receive it - Given 0-4.5 hrs after symptom onset Intraarterial thrombolytic agent (PROACT) – tx for intraarterial occlusion - 3-6hrs o Prevent stroke recurrence Manage HTN w/ meds and antiplatelet meds o Surgical management INR – removal of clots CEA c symptomotology – clear benefit CEA s symptomogotology – do medicine Stents (treat narrow or weak arteries) and angioplasty (widen obstructed arteries) Cardiac surgery – PFO (patent foramen ovale – atrial septum did not close properly), myxomas (tumors in upper left or right side of heart, can lead to embolism) - Hemorrhagic strokes – cause swelling. Bleeding time is small. They will continue to worsen even after bleeding stops due to swelling o ICH – bleeding from deep inside the brain, directly into brain parenchyma Hematoma/clot o SAH – bleeding introduced into ventricles Usually from AVM (arteriovenous formation), aneurysm, large ICH Graded w/ Hunt & Hess scale - 1 – asymptomatic or slight HA or neck pain - 2 – worst HA of life, nuchal rigidity, no focal neural signs (impairments of nerve, spinal cord, or brain function that affects a specific region of the body e.g. weakness in left arm, right leg, paresis, or plegia - 3 – drowsiness, confusion, mild focal deficit - 4 – persistent stupor or semicoma, early signs of decerebrate posturing (everything on body in extension), vegetative disturbances (difficulty w/ respiration or cardiac) - 5 – deep coma & decerebrate posturing o Medical management Prevent and treat vasospasm (arterial vessels in cerebrum stiffen and narrow) Prevent delayed cerebral ischemia (area where blood pooled is not responding and pushing on both side of brain at that area) Prevent by: controlling BP, ICP (intracerebral pressure, normal <15 mmHg), hydration, seizure prophylaxis (antiseizure meds) o Surgical management Aneurysm clipping – prevent blood flow into aneurysm Hematoma evacuation AVM removal o Blood is an irritant in brain and causes seizures Attempt to reabsorb hematoma before surgical
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