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Stroke is a neurological conditions

1. craniotomy PRESENTED BY : SAIYAM NARULA

2. Indication Brain injury following trauma is one of commonest indication for craniotomy . Craniotomy usually done for Surgical removal of a tumor or blood clot ( hematoma). Decrease intracranial Pressure. Types of Craniotomy It can be classified into several types depending on location Frontal Craniotomy Parietal Craniotomy Occipital Craniotomy Temporal Craniotomy

3. Good afternoon everyone . My name is saiyam Narula and I am presenting a case of Mr. Jatinder Goel, age 66, a male business man living in siddhi Vinayak, nigdi. Who had undergone craniotomy.

4. CHIEF COMPLAINT Left side lower limb weakness . Difficulty in walking . Getting up from sitting position. Cannot talk properly.

5. History of present illness Acc. to patient, in march 2022, he started feeling weakness in left side of the body and nodding movement of head and neck. Then he consulted with a doctor in nigdi hospital and he stated that the patient has cerebral ataxia .He started taking medicines. Then after 6 months, he suffered stroke at his residence. His left side got weak and he got slurred speech. Then in November 2022, he came to ABMH and consulted Dr. Rajan. He suggested him to undergo right parietal craniotomy with evacuation of SDH. He underwent craniotomy on 29 nov,2022. then on 1 dec,2022 he got discharge. He was all right at the time of discharge.

6. But again after almost 2 months , on 27 Jan 2023, his MRI findings were done. According to MRI impression. Right fronto – parietal subacute hemorrhage with mass effect as described. Mild subarachnoid hemorrhage in right fronto parietal sulci. As compared to previous MRI 28/11/22 there is mild decrease in the size of right subdural bleed and mass effect Then again he underwent right parietal craniotomy with evacuation of SDH. On 30 Jan 2023. He got discharge on 14 Feb., 2023. After that he started coming to ABMH OPD . He has been taking physiotherapeutic treatment since 1 year.

7. Past medical history He has diabetes mellitus since 8 years hypertension since 3 years. Family history : His father had titubation. No personal and surgical history. Economical status is good.

8. On observation Body built : Mesomorphic Posture: In sitting At the time pt. came to OPD scapula is slightly elevated ankle is in eversion scar : scar in parietal region Swelling : absent Gait : Could not be assessed properly assessed as he was walking with assistance. External aid : used are walker and wheel chair.

9. ON PALPATION MUSCLE TONE Tone is normal Examination vitals Blood pressure : 120/80 mm Hg Pulse rate : 78/min Respiratory rate :18bpm

10. HIGHER MENTAL FUNCTION Level of Consciousness: Alert. Orientation : oriented for person and place. Communication : difficulty in speaking.

11. Mini-Mental State Examination (MMSE) : for Cognition, I took MMSE Total Score is 30 /30 Maximum Score Patient’s Score Questions 5  5 “What is the year? Season? Date? Day? Month?” 5  5 “Where are we now? State? County? Town/city? Hospital? Floor?”   3  3 The examiner names three unrelated objects clearly and slowly, then the instructor asks the patient to name all three of them. The patient’s response is used for scoring. The examiner repeats them until patient learns all of them, if possible.   5  5 “I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …) Alternative: “Spell WORLD backwards.” (D-L-R-O- W) 3  3 “Earlier I told you the names of three things. Can you tell me what those were?” 2  2 Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them. 1  1 “Repeat the phrase: ‘No ifs, ands, or buts.’” 3  3 “Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper.) 1  1 “Please read this and do what it says.” (Written instruction is “Close your eyes.”) 1  1 “Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.)       1  1 “Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect.) 30  30 TOTAL

12. CRANIAL NERVE EXAMINATION: All cranial nerves are intact. I Olfactory II Optic III Oculo- motor VI Trochlear V Trigeminal VI Abducens               VII Facial VIII Vestibulo- cochlear IX Glosso pharyngeal   X Vagus XI Spinal accessory XII Hypo- glossal            

13. SENSORY EXAMINATION: All Superficial , Deep and combined cortical sensation are intact.     SENSATION UPPER EXTRIMITY LOWER EXTRIMITY   RIGHT LEFT RIGHT LEFT SUPERFICIAL 1  1  1  1 Fine Touch  1  1  1  1 Crude Touch  1  1  1  1 Pain  1  1  1  1 Pressure  1  1  1  1 Temperature  1  1  1  1

14.   DEEP  1  1  1  1 Kinesthesia  1  1  1  1 Proprioception  1  1  1  1 Vibration  1  1  1  1   COMBINED CORTICAL         Stereognosis  1  1  1  1 Barognosis  1  1  1  1 Graphesthesia  1  1  1  1 Tactile localization  1  1  1  1 Two-point discrimination  1  1  1  1 Double simultaneous stimulation  1  1  1  1 Recognition of texture  1  1  1  1

15. GRADE RESPONSE 1 Intact: normal accurate response 2 Decreased: delayed response 3 Exaggerated: increased sensitivity or Awareness of stimulus after removal 4 Inaccurate: inappropriate perception Of stimulus 5 Absent: no response 6 Inconsistent: response inadequate Response

16. MOTOR EXAMINATION   Range of Motion   All ranges of UL are normal. In LL hip flexors is 70 Hip extension is 5 Hip abduction is 45 Knee flexion is 120 Knee extension is 0 Ankle dorsiflexion is 0 Ankle plantarflexion is 45

17. Manual muscle testing UPPER LIMB Shoulder flexors is 3+ Shoulder extensors is 3- Shoulder abduction is 3+ Internal rotation is 3 External rotation is 3 Elbow flexors is 3+ Elbow extensors is 3+ Wrist flexors, extensors is 3+ LOWER LIMB Hip flexors is 3+ Hip extensors is 2 Hip abduction is 3 Knee flexors is 3+ Knee extensors is 3- Ankle dorsiflexion is 0 Ankle plantarflexion is 3

18. VOLUNTARY CONTROL EXAMINATION UPPER EXTREMITY LOWER EXTREMITY   RIGHT LEFT   RIGHT LEFT Shoulder     Hip    2 Elbow     Knee    2 Wrist     Ankle  1 BRUNSTROM GRADING STAGES MOTOR RECOVERY 1 Period of flaccidity. No movements of the limbs can be elicited 2 Minimal voluntary movement response may be present. Spasticity begins to develop   3 Patient gains voluntary control of movement synergies. Spasticity has further increased and become severe   4 Some movement combinations that do not follow the paths of either synergy are mastered. Spasticity begins to decline.   5 If progress continues, more difficult movement combinations are learned as thebasic limb synergies lose their dominanceover motor acts 6 With the disappearance of spasticity, individual joint movements become possible with coordination

19. REFLEXES DEEP TENDON REFLEXES REFLEXES RIGHT LEFT Biceps  2  2 Brachioradialis  2 2  Triceps  2  2 Knee jerk  2  2 Ankle jerk  2  2 GRADE MAGNITUDE OF RESPONSE No response 1+ Present but depressed, low normal 2+ Average, normal 3+ Increased, brisker than average; possibly but not necessarily abnormal 4+ Very brisk, hyperactive, with clonus; abnormal SUPERFICIAL Babinski sign: Babinski sign is positive All deep tendon reflexes are normal.

20. SPEECH EXAMINATION: Speech examination is slurred speech BOWEL – BLADDER EXAMINATION: Normal    

21. COORDINATION: coordination by coordination test which was 38 out of 69 NO TEST LEFT 1 Finger to nose 4 2 Finger to therapist finger 4 3 Finger to finger 4 4 Alternate nose to finger 4 5 Finger opposition 4 6 Mass grasp 4 7 Disdiadochokinesia 4 8 Rebound test 4 9 Hand tapping 4 10 Foot tapping 11 Pointing and past pointing 3 12 Heel to knee and heel to toe 13 Toe to examiner’s finger 14 Heel on shin 1 15 Drawing a circle 16 Positioning holding 1 0 – Activity Impossible 1 – Severe Impairment 2- Moderate Impairment 3- Mild Impairment 4 – Normal Performance

22. BALANCE EXAMINATION: Balance is checked by Berg Balance Scale. Total score was 32/50. which means it represent 21 to 40 acceptable balance. Item description       score 1. sitting to standing   2 2.standing unsupported   2 3.sitting unsupported   4 4. standing to sitting   2 5.transfe   2 6.standing with eyes closed   2 7. standing with feet together   2 8. Reaching forward with outstretched hand 4 9. retrieving object from floor   2 10.Turning 360 degree   2 11.Turning to look behind   2 12. Placing alternate foot on stool   2 13.Standing one foot in front   2 14. Standing on one foot     2     Total score   32 0 to 20 – Balance impairment 21 to 40 – Acceptable balance 41 to 56 – Good balance

23. FUNCTIONAL INDEPENDENCE MEASURE SCALE : I took functional assessment by Barthel index total score is 80/100. FEEDING 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent 10 BATHING 0 = dependent 5 = independent (or in shower) ______ 5 GROOMING 0 = needs to help with personal care 5 = independent face/hair/teeth/shaving (implements provided) _____5_ DRESSING 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) _____10_ BOWELS 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent 10

24. BLADDER 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent 10 TOILET USE 0 = dependent 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping) 10 TRANSFERS (BED TO CHAIR AND BACK) 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 10 15 = independent MOBILITY (ON LEVEL SURFACES) 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 15 = independent (but may use any aid; for example, stick) > 50 yards STAIRS 0 = unable 5 = needs help (verbal, physical, carrying aid) 5 10 = independent TOTAL (0–100): _80/100

25. Investigation Right parietal craniotomy with evacuation of sub dural hemorrhage Right fronto – parietal subacute hemorrhage with mass effect as described. Mild subarachnoid hemorrhage in right fronto parietal sulci. As compared to previous MRI 28/11/22 there is mild decrease in the size of right subdural bleed and mass effect

26. Physiotherapy treatment Shorts terms goals Balance and coordination Static balance Weight bearing / weight shifts Perturbation Reach outs Pnf upper trunk pattern { lifting or chopping} 2. Dynamic balance Sit to stand Two leg apart/together One leg standing

27. Marching in one place Side stepping Parallel bars Perturbation board Tandem walking Obstacle walking Textures different/ sand / grass Lunges / squads To improve coordination Frenkel's exercises – walking on foot prints Walking sideways Walking around circle and figure of 8 Equilibrium and non equilibrium test Reach outs

28. To improve muscle strength and mobile training IG stimulator Active ranges of motion exercises then gradually progress to progressive resisted exercises with weight cuffs or with manual resistance Static cycle for 10 minute Gait training Initially in parallel bar Progress to walking without parallel bar Walking forward and backward Side stepping Crossed stepping Step up / step down activities Stair climbing Walk in a ramp / uneven surfaces

29. Train normal gait pattern (heel to toe) By giving constant verbal commands regarding step length , rotation of foot, heel strike. By waking over foot prints To improve Titubation Include exercise to enhance head and neck control Isometric exercises Up and down neck Chin tuck Implement gaze stabilization exercises to reduce titubation. To improve ankle dorsiflexion Single leg standing on wobble board and ask him to do weight shifts.

30. Put a hanky on the floor, to lift hanky with his affected side toes. Toe tap Draw a circle . Heel raises Seated marching Resistance band dorsiflexion Ankle alphabet : write alphabet with toe in the air promoting ankle movement. To improve speech Vowel exercises Motor exercises Gargle exercises

31. To improve or overcome Fatigue Energy conservation techniques are used. There should be rest periods in between and any activity or movement is broken into the smaller compliment. Functional priority should be done on the priority based. Motorized devices are used to maximum range . For e.g. If they can use lift , go for lift instead of stairs. Activities can be modified into simpler form.

32. Long term goals MAT exercises : To Improve trunk control Knee walking Reach outs Weight bearing activities Prone on elbow Walking independence Gradually reduce assistance devices as the patient progress Improve balance Dual task training kicking balling in standing, throwing activities , carrying an object while walking Reaching activities Sit to stand on moveable surfaces to increases challenges. Divert attention

33. Aerobic Exercises for cardiovascular conditioning Exercises of moderate intensity Like walking, static cycling , whirlpool or hydrotherapy activities. Group therapy , stress management etc.