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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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Columbia University PHYT M8620 - Intro to Stroke

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