STROKE CLINICAL MANIFESTATION

STROKE CLINICAL PICTURE

1. STROKE CLINICAL MANIFESTATION - NITHIN NAIR

2. CLINICAL MANIFESTATION The focal neurological deficit resulting from a stroke, whether embolic, thrombotic, or hemorrhagic, is a reflection of size and location of the lesion and the amount of collateral blood flow. Clinical syndromes resulting from occlusion or haemorrhage in the cerebral circulation vary from partial to complete. Ischemic stroke account for (80%), hemorrhagic stroke account for (20%) of strokes.

3. Clinical picture.... THROMBOSIS TIA EMBOLISM Uneven progression Onset develops within minutes or hours or days (thrombus in evolution) 60% occur during sleep- patient unaware of problem, rises and falls to floor No headache or in mild form Comorbid factors – hypertension, diabetes, or vascular diseases. Linked to atherosclerotic thrombosis. Preceded or accompanied by stroke Last 2-30 minutes (less than 24 hours) Normal neurological findings between attacks If transient symptoms persist on awakening, may indicate future stroke. Occurs rapidly There are no warnings MCA infarct (common) Headache Often a manifestation of heart diseases, including atrial fibrillation and MI As embolus passes through artery, client may have neurological defecits that resolve as embolus breaks and passes into small artery

4. Clinical picture.... HYPERTENSIVE HEMORRHAGE RUPTURED SACCULAR ANEURYSM Severe headache Vomiting at onset Blood pressure > 170/90 (normally essential hypertension) Abrupt onset Gradually evolves over hours or days according to speed of bleeding No recurrence of bleeding Rapid improvement (not usual as hemorrhaged blood absorbs slowly.) Asymptomatic before rupture. With rupture, blood spills under high pressure into sub arachnoid space. Excruciating headache with/without loss of consciousness Decerebrate rigidity with coma If severe – persistent deep coma, respiratory arrest, circulatory collapse leading to death (within 5 min) If mild – consciousness regained within hours then confusion, amnesia, headache, stiff neck, drowsiness.

5. GENERAL SIGNS AND SYMPTOMS Sensory : Tingling, numbness or decreased sensation (cortical sensations) on the affected side of the body. Crossed anesthesia ( Ipsilateral facial impairments with contralateral trunk and limb involvement.)

6. General signs and symptoms..... Weakness : Paresis (80-90%) Unable to generate force to initiate and control movement. UE > LE (affection) Distal muscles > Proximal muscles ( strength deficits) Selective loss of type II fast-twitch fibres and increase in percentage of type I fibres.

7. General signs and symptoms..... Motor : Immediately after the onset of stroke, there is a stage of cerebral shock with flaccidity and areflexia . Gradually replaced by development of spasticity, hyperreflexia and synergy pattern. Upper extremities Lower extremities Shoulder Girdle : depressor and retractor Pelvic girdle : Retractors Shoulder : internal rotators and adductors Hip : Extensors, adductor and internal Rotators Elbow : Flexors Knee : Extensors Wrist and Finger : Flexors Ankle and Toes : Plantor flexors and supinators Forearm : Pronators

8. General signs and symptoms..... Flexion Synergy Extension Synergy Scapular retraction/elevation or hyperextension. Shoulder abduction, external rotation Elbow flexion Forearm supination Wrist and finger flexion Scapular protraction Shoulder adduction , internal rotation Elbow extension Forearm pronation Wrist and finger flexion Hip flexion , abduction, external rotation Knee flexion Ankle dorsiflexion , inversion Toe dorsiflexion Hip extension, adduction , internal rotation Knee extension Ankle plantarflexion , inversion Toe plantarflexion

9. General signs and symptoms..... An inspection of the synergy components reveals that following muscles do no take part in either of the synergies. Latissimus dorsi Teres major Serratus anterior Wrist and finger extensors Ankle evertors

10. General signs and symptoms..... Reflexes : Flaccidity all reflexes are suppressed or absent. Spasticity Deep tendon reflexes become hyperactive, presence of clonus , plantar reflexes show babinski sign positive Release of primitive reflexes : ATNR (most common) Associated reactions : Tonic postural reactions in muscle. For eg : Vigorous contraction of elbow flexors (stronger UE) Flexion of hemiparetic elbow

11. General signs and symptoms..... Altered Co-ordination : Proprioceptive losses sensory ataxia. Strokes affecting cerebellum cerebellar ataxia. Basal ganglia involvement bradykinesia or involuntary movements.

12. General signs and symptoms..... Potural control and Balance : Reactive postural control and anticipatory postural control affected. Unable to maintain balance in sitting or standing or to move in a weightbearing posture without loss of balance. Disruptions in central sensorimotor processing. Sitting /standing : asymmetry (weight shifted towards affected side) Postural sway in standing. Delays in onset of motor activity, abnormal timing and sequencing of muscle activity and abnormal co-contraction disorganization of postural synergies.

13. General signs and symptoms..... Visual Changes : Homonymous hemianopia (loss of vision in the nasal half of one eye and temporal half of the eye corresponding to the hemiplegic side) Visual negelect (visual inattention) Lack of conjugate gaze

14. General signs and symptoms..... Speech and language changes : This occurs due to lesion involving dominant parietal lobe . Broca’s /motor/expressive/non-fluent aphasia Wernicke’s /sensory/receptive/fluent aphasia Global/conductive /total aphasia Ability to understand – intact Ability to respond – affected Difficulty in articulating speech Ability to understand – affected Abiity to respond – intact Speech is totally irrelevant Loss of understanding and production of speech Indication of extensive brain damage.

15. General signs and symptoms..... Apraxia : (Inability to carry out learned purposeful movements ) Ideomotor Ideational Constructional Understands purpose of movement Unable to do it on command Does it automatically Extreme absent- mindedness Fails to perform purposeful movement both spontaneously and on command Difficulty in spatial organisation of movement or objects. Inability to imitate.

16. General signs and symptoms..... Agnosia : (Failure to recognise objects despite having an intact visual, auditory and tactile sensations) Visual Auditory Tactile Inability to recognise common objects which is seen clearly by patient. Lesion in the dominant parieto -occipital region. Inability to recognise familiar sounds or music. Lesion in the dominant temporal lobe. Inability to recognise object by using hand although there is no sensory defect. Lesion in dominant parietal lobe.

17. General signs and symptoms..... Perceptual Dysfunction : (Occurs due to lesion of non dominant parietal lobe) Body Scheme/ Body Image dysfunction : (Unilateral neglect, Anosognosia , Somatoagnosia , Right-left discrimination, Finger agnosia ) Spatial relation disorder ( figure ground discrimination, form discrimination, topographic disorientation, vertical disorientation, depth and distance disorientation)

18. General signs and symptoms..... Cognition and behavioral changes : (Occurs due to lesion of either of cerebral hemisphere) Left hemisphere lesion – depressed, low profile, anxious and have a negative attitude towards life, cautios and insecure Right hemisphere lesion – euphoric, over-confident, impulsive, over estimate their capacity, denial of being disabled. Difficulty in orientation, attention, conceptual abilities, memory and learning (short-term memory usually affected)

19. General signs and symptoms..... Dysphagia : (occurs in patients with bilateral cerebral hemisphere or brain stem lesion Leading to – aspiration Contibutors – altered sensation, incomplete laryngeal elevation and closure, palatal paralysis, defective lip closure and postural imbalance.

20. General signs and symptoms..... Bowel and bladder dysfunction : (Common in acute phase. In flaccid state – overflow incontinence. Disturbance in bowel functions – incontinence and diarrhoea or constipation and impaction.) Sexual dysfunction : Affects individual desire, libido, erectile or lubrication, orgasm or ejaculation. It could be due to depressed state or sensorimotor dysfunction.

21. Secondary manifestations Psychological dysfunction : Depression, social withdrawal, anxiety, insomnia, emotional liability, aggressiveness, verbal abusing, over dependancy ) Deep Vein Thrombosis : ( occurs in hemiplegia due to immobilization) Cardiac and Respiratory deconditioning : occurs due to decreased physical activity. Endurance level is drastically reduced.

22. Secondary manifestations Pain : Common in stroke affecting thalamus ( thalamic syndrome). Intense burning pain on the opposite side of body. Musculoskeletal complications : Pain and joint stiffness (common), Subluxation of GH joint on affected side ( due to decreased tone in flaccid stage), loss of ROM and contractures, disuse atrophy, osteoporosis.

23. REFERENCE.... PHYSICAL REHABILITATION – SUSAN O’B SULLIVAN NEUROLOGICAL REHABILITATION – DARCY UMPHRED PHYSIOTHERAPY IN NEURO CONDITIONS – GLADY SAMUEL RAJ