Stroke

Stroke (cerebrovascular accident [CVA]) is the sudden loss of neurological function caused by an interruption of the blood flow to the brain.

Impairments may resolve spontaneously as brain swelling subsides (reversible ischemic neurological deficit), generally within 3 weeks.
Residual neurological impairments are those that persist
longer than 3 weeks and may lead to lasting disability

1. STROKE Dr. Maheshwari harishchandre Neurosciences ( M.P.Th ) Asst. Professor DVVPF College of Physiotherapy, Ahmednagar

2. Contents Definition Epidemiology Pathophysiology Cerebral circulation Territary involvement Clinical features Stages Physiotherapy management 10/04/18 stroke 2

3. Objectives After end of this lecture students should be able to know– Brain circulation, types of stroke & physiotherapy management for the same. 10/04/18 stroke 3

4. Def’n S troke (cerebrovascular accident [CVA]) is the sudden loss of neurological function caused by an interruption of the blood flow to the brain . Impairments may resolve spontaneously as brain swelling subsides ( reversible ischemic neurological deficit), generally within 3 weeks . . 10/04/18 4

5. Residual neurological impairments are those that persist longer than 3 weeks and may lead to lasting disability 10/04/18 stroke 5

6. Types Ischemic stroke is the most common type, affecting about 80% of individuals with stroke, and results when a clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients. 10/04/18 stroke 6

7. Hemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in or around the brain. 10/04/18 stroke 7

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9. Risk factors Major risk factors for stroke are - H ypertension , heart disease ( HD) D iabetes mellitus (DM ). In patients with ABI , approximately 70% have hypertension, 30% HD, 15 % congestive heart failure (CHF), 30% peripheral arterial disease (PAD ) and 15% DM. 10/04/18 stroke 9

10. Warning signs – Sudden numbness or weakness of face, arm, leg specially one side of body. Sudden confusion, trouble in speaking or understanding Sudden trouble in seeing in one or both eyes. Sudden trouble in walking, dizziness, loss of balance or coordination. Sudden severe headache with unknown cause. 10/04/18 stroke 10

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13. Cerebral circulation 10/04/18 stroke 13

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16. ACA supplies – MCA supplies – PCA supplies - 10/04/18 stroke 16

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22. Anterior Cerebral Artery Syndrome 10/04/18 stroke 22

23. ACA Sign & symptoms Structur e involved Contralat hemiparesis involving mainly LL (UL is spared) Primary motor area, medial aspect of cortex, internal capsule Contralat hemisensory loss Primary sensory area, medial aspect of cortex Urinary incontinence Posteromed aspect of sup. Frontal gyrus Problems with imitation & bimanual tasks, apraxia Corpus callosum Abulia (lack of will power 0r inability to take decision) Uncertain localization 10/04/18 stroke 23

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25. Sign & Symptoms Structure involved Contralat hemiparesis involv e UL &face Primary motor cortex & int capsule Contralat hemisensory loss Primary sensory cortex & int capsule Motor speech impairment – Broca’s Aphasia Broca’s cortical area Wernicke’s aphasia Wernicke’s cortical area Global Aphasia Post portion of sup. Temporal gyrus Perceptual deficit – unilat neglect , agnosia (inability to process sensory information) Parietal sensory asso cortex Contralat homonymous hemianopsia Optic radiation in int capsule 10/04/18 stroke 25

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27. Sign & symptoms Structure involved Peripheral territory – Contralat homonymous hemianopsia Primary visual cortex or optic radiation B/L homonymous hemianopsia calcarine cortex Visual agnosia Left occipital lobe Prospagnosia (inability to recognize face ) Visual asso . Cortex Dyslexia (learning disorder) Post part of corpus callosum Memory defect Lesion of inferomed temporal lobe Central territory – Thalamic pain, sensory impairment Ventral posterolat nucleus of thalamus Invol movt Subthalamic nucleus Contralat hemiplegia Cerebral peduncle of midbrain Weber syndrome( Occulomotor N palsy) Third nerve & cerebral peduncle of midbrain 10/04/18 stroke 27

28. Lat medullary ( wallenburg’s ) Syndrome Sign & Symptoms Structure involved Decreased pain & temp sensation over face Nucleus of V C.N Cerebellar ataxia (gait & limb ataxia) Cerebellum or inf cerebellar peduncles Vertigo, nausea, vomitting Vestibularnuclei Nystagmus Vest nuclei Horner’s syndrome Decending sympathetic tract Dysphagia & dysphonia IX & X C.N nuclei Sensory involvement of ipsilat UE,trunk , LE Cuneate & gracile nuclei Contralat . Lesion – Impaired pain & thermal sensation Spinothalamic tract 10/04/18 stroke 28

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30. Lacunar Syndrome Caused by small vessel disease deep in the cerebral white matter. Pure motor lacunar stroke – involvement of – post limb of Int cap, pons & pyramids Pure sensory lacunar stroke - – involvement of – ventrolat thalamus. 10/04/18 stroke 30

31. Stages Acute stage/flaccid /cerebral shock – (max 2wks) Subacute stage/stage of spasticity – ( upto 2 years) Chronic stage/stage of relative recovery – (more then 2 years) 10/04/18 stroke 31

32. Medical management Improve (O2)/cerebral perfusion – Maintain adequate B.P – Maintain cardiac output – Maintain electrolyte balance- Maintain BSL- Control ICP – Maintain bladder function- Maintain skin integrity & joint by protective positioning Pharmacological management – Anticoagulant drugs ---, Antiplatelet ---, Antihypertensive 10/04/18 stroke 32

33. Stages Stage 1 (Acute):- contra. Hemiparesis / paralysis Hypotonicity Reflexes – Sup- diminished or may be absent Deep – absent Loss of vol movt Loss of bowel / bladder function 10/04/18 stroke 33

34. Stage 2 – Hypertonicity Reflexes – Sup – diminished Deep – Hyperreflexia Babinski sign + ve - Loss of vol control- UL & LL synergy pattern In both synergic pattern – Wrist & finger flexors & Ankle invertors are involved In both synergic pattern – Latissimus dorsi , wrist & finger extensors, ankle evertors & teres major are not involved. 10/04/18 stroke 34

35. Stage 3 No recovery Abnormal tone with multiple contracture & deformity 10/04/18 stroke 35

36. complications 10/04/18 stroke 36

37. Shoulder hand syndrome A/K/A – RSD Begins with pain & progress to stiffness Stages - stage 1 - pain, oedema & stiffness over the shoulder joint & wrist joint - loss of abduction, ext rotation in shoulder & wrist extension - pallor & hypersensitivity to touch 10/04/18 stroke 37

38. Stage – 2 subsiding of pain Dystrophy of skin & muscles Early osteoporosis Stage – 3 Atrophic phase Periarticular fibrosis Intrinsic deformity of hand i.e claw hand irreversible 10/04/18 stroke 38

39. Management of complications Shoulder subluxation Shoulder hand syndrome – prevention : mobilization, reduce odema , proper handling & transfer tech. T/t – TENS, compression & elevation, icing, sympathectomy 10/04/18 stroke 39

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64. -Definition -Epidemiology -Pathophysiology -Cerebral circulation - Territary involvement -Clinical features -Stages -Physiotherapy management SUMMARY 10/04/18 stroke 64