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 effective for stroke pts o Optimize motor performance in functional activities activity based interventions more 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 Brainstem medulla pons 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 Venous system 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 o Hemorrhagic 13 TIA no evidence of infarction and clinical signs 24hrs No cell death on imaging 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 estrogen progestin family hx pregnancy family hx MD evaluation o NIHSS o Blood test o CT scan high sensitivity for ICH o MRI o Ischemic HTN DM smoking cardiac arrhythmias atherosclerosis post menopause on o Hemorrhagic HTN anticoagulation problems vascular abnormalities drug abuse tumors Diffusion weighted imaging DWI highly sensitive to infarct w in minutes Fluid attenuation inversion recovery FLAIR vasogenic edema blood brain represents cytotoxic edema barrier disrupted w in 6 hrs o MRA magnetic resonance angiography image blood vessels o 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 o Surgical management Manage HTN w meds and antiplatelet meds 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 removal Swelling in head causes brain to herniate b c skull can t expand Blood will push on both sides of affected area Hemicraniectomy remove part of skull to enable swelling to occur relieving pressure will settle down and skull is reattached or use prosthetic o Skull placed in peritoneum or frozen Neurovascular clinical syndromes control of legs o Anterior cerebral a affected frontal lobe judgment off inappropriate behavior lose o Middle cerebral a affected frontal temporal parietal speech left side broca s aphasia motor wernicke s aphasia sensory lose sensory control of arm face visual homonymous hemianopsia ex right homonymous hemianopsia only