stroke, cva, cerebrovascular accident talk

Stroke is a type of cardiovascular disease.

It affects the arteries leading to and within the brain. A stroke occurs when a blood vessel that

carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens,

part of the brain cannot get the blood and oxygen it needs, so it starts to die.

WHAT IS A STROKE?

Ischemic stroke is caused by a lack of blood reaching part of the brain and is the most common type, accounting for over 80 percent of all strokes:

• Symptoms develop over a few minutes or worsen over hours.

• Ischemic strokes are typically preceded by symptoms or warning signs that may include loss of strength or sensation on one side of the body, problems with speech and language or changes in vision or balance.

• Ischemic strokes usually occur at night or first thing in the morning.

• Often a TIA (transient ischemic attack) or “mini stroke” may give some warning of a major ischemic stroke.

TYPES OF STROKE

Fifteen to 20 percent of strokes happen when a blood vessel ruptures in or near the brain. This is called a hemorrhagic or bleeding stroke:

• In hemorrhagic strokes, the fatality rate is higher and overall prognosis is poorer.

• People who have hemorrhagic strokes are younger.

• This kind of stroke is often associated with a very severe headache, nausea and vomiting, and usually the symptoms appear suddenly.

• A transient ischemic attack (TIA) or any other stroke warning sign may not precede this type of stroke.

TYPES OF STROKE

What are the risk factors I can’t control?

Increasing age – stroke affects people of all ages, from young children to elderly individuals. But the older you are, the greater your stroke risk.

Gender – in most age groups, more men than women have stroke, but more women die from stroke.

Heredity and race – people whose close blood relations have had a stroke have a higher risk of stroke themselves. Certain races have a higher risk of death and disability from stroke than others, because they have high blood pressure more often.

Prior stroke – someone who has had a stroke is at a higher risk of having another one.

RISK FACTORS FOR STROKE

Knowing your risk factors is the key to prevention - some can be changed or treated, others can’t.

What risk factors can I change or treat?

High blood pressure – this is the single most important risk factor for stroke. Know your blood pressure and have it checked at least once every two years. If it’s 140/90 or about, it’s high. Talk to your doctor about how to control it and take your medicine as directed;

Diet - improve your eating habits by avoiding foods which are high in fat and cholesterol, cut down on saturated fat, sugar and salt. Eat more fruit, vegetables, cereals, dried peas and beans, pasta, fish, poultry and lean meats;

RISK FACTORS FOR STROKE

6

Tobacco use – don’t smoke cigarettes or use other forms of tobacco;

Diabetes – while diabetes is treatable, having it increases your risk of stroke. Work with your doctor to manage diabetes and reduce other risk factors;

RISK FACTORS FOR STROKE

Carotid or other artery disease – the carotid arteries in your neck supply bloodto your brain. A carotid artery damaged by a fatty build-up of plaque inside the artery wall may become blocked by a blood clot, causing a stroke;

TIAs – Transient ischemic attacks (TIAs) are “mini strokes” that produce stroke-like symptoms but no lasting effects. Recognizing and treating TIAs can reduce the risk of a major stroke. Know the warning signs of a TIA and seek emergency medical treatment immediately;

Atrial fibrillation or other heart disease – in atrial fibrillation the heart’s upper chambers quiver rather than beat effectively, causing the blood to pool and clot, increasing the risk of stroke. People with other types of heart disease have a higher risk of stroke too;

Certain blood disorders – a high red blood cell count makes clots more likely, raising the risk of stroke. Sickle cell anemia increases stroke risk because the “sickled” cells stick to blood vessel walls and may block arteries;

High blood cholesterol – high blood cholesterol increases the risk of clogged arteries. If an artery leading to the brain becomes blocked, a stroke results.

RISK FACTORS FOR STROKE

Physical inactivity and obesity - being inactive, obese or both can increase your risk of cardiovascular disease. Exercise regularly – check with your doctor before you start. Start slowly and build up to at least 30 minutes a session at least three to four times per week. Try to maintain a healthy weight;

Excessive alcohol intake – drinking an average of more than one drink per day for women or more than two drinks a day for men raises blood pressure. Binge drinking can lead to stroke, so limit your alcohol intake.

Stress – decrease your stress level as much as possible and seek emotional support when it’s needed.

RISK FACTORS FOR STROKE

HOW TO RECOGNIZE IF YOU ARE HAVING A STROKE...

Call the Emergency Services immediately if you are experiencing:• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body;

• Sudden confusion, trouble speaking or understanding;

• Sudden trouble seeing in one or both eyes;

• Sudden trouble walking, dizziness, loss of balance or co-ordination;

• Sudden severe headache with no known cause.

HOW TO RECOGNIZE IF SOMEONE ELSE IS HAVING A STROKE...

At a recent American Stroke Association conference, a report was presented that showed a bystander may be able to spot someone having a stroke by giving a quick, simple test, as follows:• Asking the individual to smile;

• Asking him or her to raise both arms and keep them up;

• Asking the person to speak a simple sentence coherently.

If the person has trouble with any of these tasks, contact the Emergency Services immediately and describe the symptoms to the Dispatcher. Time is crucial in treating a stroke.

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History of Cerebrovascular Disease

Where have we been? Where are we now? Where should we go in the future?

400 BC-1700 ADEmphasis on Prognosis and early

Exploration of Brain Anatomy and Function

Hippocrates- circa 400 BCGalen 130-200 ADAndre Vesalius 1514-1564Johann Wepfer 1620-1695Sir Thomas Willis 1621-1675

The Past

Johann Jakob Wepfer 1620-1695Observationes Anatomicae, ex Cadaveribus Eorum, quos Sustulit Apoplexia (1658)Performed necropsies and showed that bleeding into the brain was an important cause of apoplexyDescribed the anatomy and presence of hardening and occlusions within the intracranial Carotid and Middle Cerebral Arteries

The Past-Pathology

Sir Thomas Willis 1621-1675

Dissections described and illustrated by Sir Christopher Wrenn in Cerebri Anatomi (1664)Clarified anatomy of the Brain and Cranial NervesDissected cranial arteries and described connections at the base of the Brain (Circle of Willis)Respected clinician who described TIAs and Migraine

The Past- Anatomy and Clinical

Sir Thomas Willis

Sedleian Professor of Natural Philosophy at Oxford University

Diagram of an Anastamosis - Willis 1664

Rudolph Ludwig Carl Virchow (1821-1902)Clearly showed that vascular occlusion caused infarctionDescribed the phenomenology of arterial thrombosisRecognized the important interaction between the vascular wall and the bloodDescribed embolism

The Past-Pathology & pathophysiology

Rudolph Ludwig Carl Virchow

Vieusseux -1810Dec 29, 1807 Vieusseux developed an unusual and severe pain in the left gum and jaw. 5 days later the pain recurred along with severe pain in the left eye. He then developed severe vertigo. “A peculiar and inexpressible perturbation in all his sensations” a giddiness that affected his vision and “occasioned feelings similar to those produced by a ship violently agitated.” He then lost his voice, had difficulty swallowing, and felt that his left side was weak.

Vieusseux -1810

He then examined himself and found that “the whole of his right side was so insensible that he could be scratched or pinched without experiencing any pain and that this insensibility abruptly terminated at a line dividing the whole body in a vertical direction”The sensations of heat and cold were totally different from normal on his right side but he was puzzled to find that he had not lost the perception of touch on his right side.The left side of the head and face were also insensible to pricking or scratching over the left forehead, nose, lips, chin, and ear.

Vieusseux -1810

The whole of the left side of the body preserved its usual degree of sensibility.” He also noted that his left eye was partially shut and the left corner of the mouth was drawn downward.His left leg dragged when he walked.During the next weeks the dysarthria and dysphagia improved but he developed hiccups“His intellectual faculties remained quite unimpaired so that he could accurately observe the whole succession of symptoms.”

Charles Miller Fisher

Pathology and Clinical Features of ICH (1961-71)Clinical features (1951-4) and pathology (1986) of Carotid Artery DiseaseClinical features of Vertebral artery disease (1971) and Vascular lesions in Lateral Medullary Infarcts (1961)Clinical and pathological features of Lacunar infarction (1965-present)

Charles Miller Fisher

1961

1951

Technology is rapidly improving and still developing. CT and MRI allow delineation of the location and type of lesion and CTA and CT perfusion, MRA, and extracranial and transcranial ultrasound (TCD) allow definition of arterial lesions. Echocardiography, cardiac rhythm monitoring, and blood analysis detect cardiac, aortic, and hematological causes of stroke. Neurologists of today can quickly and safely define the cause and extent of cerebrovascular disease.

Cerebrovascular Accident(Stroke)

I.Definition of Terms:

Cerebrovascular Accident- Also know as stroke and brain attacks -is a sudden loss of neurological function caused by an interruption of the blood flow to the brain

I. Definition of terms

-It is a non-traumatic brain injury caused by occlusion or rupture of cerebral blood vessel that results in sudden neurological deficit characterized by loss of motor control.

I. Definition of Terms

Aneurysm-It is a localized dilatation or bulging of the blood vessels especially arteries- It promotes rupture of the vessel as it continues to bulge.

I. Definition of Terms

APOPLEXY – sudden strike of paralysis, dumbness or fainting, from which victim is frequently failed to recover

oAtherosclerosis-Formation of multiple plaques

within the blood vessels.

I. Definition of Terms

Embolus- an object that migrates from one part of the body to causes blockage or occlusion to another part of the body.

I. Definition of terms

Hematocrit-Also know as Packed Cell Volume (PCV) or Erythrocyte Volume Fraction (EVF) -is the proportion of the blood volume, which is occupied by red blood cell.

I. Definition of Terms

Hemorrhage-Is the loss of blood at the circulatory system

or excessive presence of blood outside the circulation

- Can be internally or externally.

I. Definition of Terms

HypertensionAlso referred to as high blood pressure

(HTN or HPN.) It is a medical condition in which the blood

pressure is chronically elevated

Infarction-A process of anoxic death of tissue due to loss of blood supply because of occlusion or blockage of the artery

I. Definition of Terms

Ischemic-Insufficient blood flow to an organ cause by the blockage of the artery.Transient Ischemic Attack-(Mini Stroke) Caused by changes in blood supply in the brain produces same manifestation as stroke within 24 hours.

I. Definition of Terms

Thrombus- Is the final product of the blood coagulation step in hemostasis It is achieved via the aggregation of platelets that form a platelet plug. It is physiologic in injury but pathologic in case of thrombosis

II. Epidemiology

Stroke is the third leading cause of death.The most common cause of disability among adults at the United StatesIt is approximately 700,000 individuals was affected each year.

II. Epidemiology

About 500,000 are new strokes and 200,000 are recurrent strokes (Usually people older than 65 y/o).In United States, in 1960’s 200 per 100,000 are affected by stroke and it was decreased as it reached to late 1960’s –1970’s.

II. Epidemiology

In 1980’s the stroke is flattened because of the improvement of cranial computed tomography (CT) and Magnetic Resonance imaging (MRI). According to age, 28% higher possibilities in people older than 65 y/o than younger ones

II. Epidemiology

According to sex, having an incidence of stroke, Men are 19% higher rather than women. According to race, Black Americans are more prone rather that White Americans. Asian Countries are more prone having stroke compared to United States. (Cause by intracranial hemorrhage)

Causes Percentage

Large vessel occlusion/infarction

32

Embolism 32

Small vessel occlusion/ lacunar

18

Intracerebral hemorrhage 11

Subarachnoid hemorrhage 7

II. Epidemiology

Table 77-2 Causes of stroke (Delisa)

II. Epidemiology

Most of the patients who die from acute stroke succumb in the first 30 days.Survival in the first 30 days of new stroke reported to be 70- 85% dependent on the stroke type.

II. Epidemiology

In Intracerebral Hemorrhage is only 20-50% , cause death usually occur in first 3 days. In Cerebral infraction is 85%. After 30 days of survival, the death rate declines.

III. Epidemiology

Stroke is most commonly cause of chronic disability.

II. Etiology

A. Atherosclerosis-Major contributory factor of Cerebrovascular Accident. -accumulation of lipids, fibrins, complex carbohydrates and calcium deposit on the arterial walls that leads to progressive narrowing of blood vessels.

Found in the bifurcations of vessels.

II. Etiology

B. Ischemic Strokes-Results from a thrombus, embolism or conditions that produce low systemic perfusions pressures.

II. Etiology

C. Cerebral ThrombosisRefers to the formation of development of

a blood clot within the arteries and their branches.

Moving thrombus is called embolus.

II. Etiology

Thrombosis Ischemia Infarction IntraCerebral Hemorrhage Is cause by the ruptured of cerebral vessel

with subsequent bleeding to brainTypes of IntraCerebral Hemorrhage

II. Etiology

-Primary CEREBRAL Hemorrhage -occurs in small blood vessels

weakened by atherosclerosis produces aneurysm.-SUBARACHNOID hemorrhage

-hemorrhage occurs at the sub arachnid space typically from a saccular or berry aneurysm affecting primary vessels.

II. Etiology

E. Artriovenous malformation Is a congenital defect that can cause

stroke.-The arteries and veins are tortuous tangled with interposing capillaries system.

III. Risk Factors of Stroke

Hypertension- Is the most important risk factors It is define as a blood pressure higher

than 160/95 mmHg. Among the survivors of stroke, 67% of

them have chronic hypertension It gives risk in cerebral infarction,

thrombotic, lacunars and hemorrhagic stroke.

III. Risk Factors of Stroke

2. Heart disease Is an important risk factor for strokeAtrial fibrillation and valvular heart disease

increase the risk of cerebral infarction because of presence of cerebral emboli.

III. Risk Factors of Stroke

3.Diabetes Mellitus Independent risk factor that doubles the

risk of stroke. It increases the risk of ischemic stroke

to three to six times. The prevalence of diabetes among

stroke survivors is 20%.

III. Risk Factors of Stroke

4. Hyperlipidemia Poses only small additional risk for strokes

mainly for individuals younger at age of 55. Increase in blood viscosity, hematocrit and

serum fibrinogen have been implied the risk factor of stroke.

Risk Factors of stroke

Smoking It is an important factor for cardiovascular

disease but influence for stroke is not cleared.

The risk for heavy smokers (>40 cigarettes) is twice than light smokers (<10 cigarettes).

III. Risk Factors Of Stroke

- Some studies that smoking to an increased risk of hemorrhagic stroke in addition to ischemic cerebral infarction.

III. Risk factor of stroke

6. Transient Ischemic Attack-Is another important risk factor.- An About 10 % of individuals with TIA will go on to have a major stroke within 90 days and 5 % will have a major stroke within 2 days.

III. Risk Factors of stroke

7. ObesityHypertension and diabetes mellitus are in

common in obese and strong influences risk of stroke.

Some studies says that weight loss has positive influences on blood pressure and diabetic control and also helps in reduction of risk of strokes.

IV. Stroke Prevention

Active promotions of lifestyle changes by physicians have the best potential to decrease the annual rate of new stroke occurrence.

IV. Stroke Prevention

To the individuals who have a stroke in the past history additional intervention and medication was given like: -Antiplatelet therapy- Anticoagulation-Carotid Endarterectomy.

IV. Stroke Prevention

Antiplatelet Therapy-Aspirin is the most frequently prescribe antiplatelet agent.-Aspirin achieves a significant anti platelet effect at fairly low serum concentrations.

IV. Stroke Prevention

Anticoagulation -The use of Warfarin anticoagulation for primary stroke prevention in non-valvular atrial fibrillation.-Warfarin reduces relative stroke risk by 58%to 86%over that in control subjects.

IV. Stroke Prevention

Carotid Endarterectomy Is a surgical procedure that use to correct

the carotid stenosis It is the removal of material inside the

artery.

PATHOPHYSIOLOGY

CEREBRAL BLOOD FLOW (CBF)

Controlled by auto-regulatory mechanism that modulates a constant rate of blood flow through the brain.These mechanisms provide homeostatic balance.

ISCHEMIC CASCADE

Within seconds to minutes of the loss of perfusion to a portion of the brain, an ischemic cascade is unleashed.

CLASSIFICATIONS OF STROKE

• IschemicThrombusEmbolismLacunar

• HemorrhagicSubarachnoid Intracerebral

ISCHEMIC STROKE

ThrombusDue to Atherosclerotic Plaque FormationOccurs frequently at major vascular branching

sites including COMMON CAROTID and VERTEBROBASILAR ARTERIES.

Occurs often in the presence of chronic hypertension.

ISCHEMIC STROKE

EmbolismMajor Source of cerebral emboli is the

heart.Atrial fibrillationMost emboli lodge in the middle

cerebral artery distribution because 80% of the blood carried by the large neck arteries flow through the middle cerebral arteries.

ISCHEMIC STROKE

Most Frequent Target:Superficial branches of cerebral and

cerebellar arteries.

ISCHEMIC STROKE

ISCHEMIC STROKE

ISCHEMIC STROKE

Lacunars InfarctLacunar infarcts occur as a result of an

occlusion of small, deep penetrating arteries known as Lenticulostriate Arteries branch from the MCA.

Occlusions of these vessels or penetrating branches of the circle of Willis, including vertebral or basilar arteries, are referred to as lacunar strokes.

ISCHEMIC STROKE

Small arteriole becomes torturous and develops subintimal dissection and micro-aneuryms rendering the arteriole susceptible to occlusion from micro-thrombi.

Fibrin Deposition

HEMORRHAGIC STROKE

Subarachnoid HemorrhageBleeding that occurs between the Dura

and Pia Mater.Commonly caused by:1.ARTERIOVENOUS MALFORMATION

(AVM)1. ANEURYSMS

HEMORRHAGIC STROKE

1. AVM• Tangled, dilated blood vessels in which arteries flow

directly into veins.• Occur most often at the junction of cerebral arteries,

usually within the parenchyma of the frontal-parietal region, frontal lobe, lateral cerebellum, or overlying occipital lobe.

• Results to seizures.

HEMORRHAGIC STROKE

2. Aneurysms• Focal dilations in the artery• Found in the anterior region of the Circle of Willis,

particularly near branches of the Anterior Communicating Artery, ICA, MCA and junctions of almost any branch site.

• Contributing factors include atherosclerosis and hypertension.

HEMORRHAGIC STROKE

Intracerebral HemorrhageOriginates from deep penetrating vessels and

causes injury to the brain tissue by disrupting connecting pathways and causing localized pressure injury.

Bleeding in the surrounding brain tissue.Also caused by AVM and aneurysms.

OCCLUSIONS IN THE ARTERIES

• ANTERIOR CEREBRAL ARTERY (ACA)First of the two terminal branches of the internal

carotid artery (ICA). It supplies the medial aspect of the cerebral hemispheres (frontal and parietal) and subcortical structures, including basal ganglia.

Proximal occlusion results to minimal defects since the Anterior Communicating artery allows perfusion of the proximal ant. cerebral artery.

ACA occlusions are uncommon.ACA

OCCLUSIONS IN THE ARTERIES

OCCLUSIONS IN THE ARTERIES

• VERTEBROBASILAR ARTERYArise from the subclavian arteries and travel

into the brain along the medulla where they merge at the inferior border of the pons to form the basilar artery. The basilar artery eventually gives rise to two Posterior Communicating Artery.

SIGN AND SYMPTOMS

SIGN AND SYMPTOMS…

Symptoms of stroke depend on the type and which area of the brain is affected. Signs of ischemic stroke usually occur suddenly, and signs of hemorrhagic stroke usually develop gradually. Symptoms include the following:

SIGN AND SYMPTOMS…

Difficulty speaking or understanding speech (aphasia)Difficulty walkingDizziness or lightheadedness (vertigo)Numbness, paralysis, or weakness, usually on one side of the body Seizure (relatively rare)Severe headache with no known causeSudden confusion

SIGN AND SYMPTOMS…

Sudden decrease in the level of consciousnessSudden loss of balance or coordinationSudden vision problems (e.g., blurry vision, blindness in one eye)Vomiting

COMPLICATION

COMPLICATION…

Complications may result from ischemic cascade or develop as a result of the patient becoming immobile or bedridden.

COMPLICATION…

Complications that may occur within 72 hours of stroke include the following:Cerebral swelling (edema)Increased intracranial pressure (ICP)Intracerebral hemorrhageSeizures

MUSCULOSKELETAL

loss of voluntary movement and immobility result in loss of range of movement and contractures. UE: limitations in shoulder motions of flexion, abduction, and external rotationContructureDisuse atrophy and muscle weaknessImpairments in gait, balance, fallsOsteoporosis

NEUROLOGICAL

SEIZURES- common right after stroke during the acute phase and late-onset seizures can also occur several month after strokeCommon in occlusive carotid disease (17%) HYDROCEPHALUS- may experience headache, nausea, vomiting, ↑ lethargy, and ataxia.

CARDIOVASCULAR/PULMONARY

THROMBOPHLEBITIS/DVT -complication for all immobilized

patientsDVT signs: - rapid onset of unilateral leg

swelling with dependent edema - tenderness, dull ache, or tight

feeling in calf; not severe pain

CARDIOVASCULAR/PULMONARY

CARDIAC FUNCTION - impaired cardiac output - cardiac decompensation - serious rhythm disorders - directly alter cerebral perfusion and produce

additional focal signs - exhibit low work capacities result acute illness,

bedrest, and limited activities level. - ↓ activity levels may also related to depression

CARDIOVASCULAR/PULMONARY

PULMONARY FUNCTION - ↓lung volume - ↓pulmonary perfusion - ↓vital signs - altered chest wall excursion - ↑fatigue - ↓endurance

CARDIOVASCULARPULMONARY

ASPIRATION- more common during any phase of recovery and can occur during any phase of swallowingDYSPHAGIA- lead to dehydration and compromised nutrition

INTEGUMENTARY

Ischemic damage and subsequent necrosis of the skin results in skin breakdown and decubitus ulcerSkin breakdown typically over bony prominence from pressure, friction, shearing and/or maceration

Differential Diagnosis

Differential Diagnosis

LethargyDizziness/VertigoSlurred speechLoss of coordinationUncontrollable eye movementsBehavioral changes

Differential DiagnosisDisease

Hypoglycemia

Mass Lesions

History

Blood sugar is too low

Cerebral AbscessSubdural HematomaMetastatic Tumor

Distinguishing FeaturesHunger, Nervousness, Cold sweat, Convulsion

Progressive syndrome, Rigorous headache, Stiff/aching at the neck, shoulders and back

Differential DiagnosisDisease

Multiple Sclerosis

Epilepsy

Encephalitis

History

Autoimmune disease that affects the CNS

Abnormal electrical activity in the brain

Inflammation in the brain

Distinguishing FeaturesDecrease attention span, urinary frequency, hearing loss

Electric shock feeling, drooling, twitching movements

Fever, , delirium, deafness, dementia

LABORATORY TEST AND DIAGNOSTIC TOOLS

TEST AND MEASURES

1. Urinalysis-Detects infection, diabetes, renal

failure, dehydration-can reveal diseases that have gone unnoticed because they do not produce striking signs or symptoms.

TEST AND MEASURES

2. Blood analysis-Provides complete blood count, platelet count, prothrombin time, partial thromboplastin time, and erythrocyte sedimentation rate.

TEST AND MEASURES

3. Fasting blood glucose level-Is used to screen for and diagnose diabetes and pre-diabetes.-Collected after an 8 to 10 hr fast

4. Blood chemistry profile-Test measures the value of a different substance in the blood. These values provide information on the function of different organ systems (kidney, liver, etc.) or the risk for

TEST AND MEASURES

5. Blood cholesterol and lipid profile-Is a group of simple blood tests

that reveal important information about the types, amount and distribution of the various types of fats (lipids) in the bloodstream.

6. Thyroid function tests-A collective term for blood tests

used to check the function of the thyroid

TEST AND MEASURES7. Full cardiac evaluation

-Includes electrocardiograph to detect arrhythmias as source of emboli or coincidental heart disease.

8. Echocardiography -Also known as a cardiac ultrasound -It uses standard ultrasound techniques to image two-dimensional slices of the heart. The latest ultrasound systems now employ 3D real-time imaging.

TEST AND MEASURES9. Lumbar puncture

-diagnostic and at times therapeutic procedure that is performed in

order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or occasionally

as a treatment ("therapeutic lumbar puncture") to relieve increased

intracranial pressure.

IMAGING

1. Computerized Tomography -Commonly used imaging technique -Allows identification of large arteries and vein, and venous sinuses -Used to rule out other brain lesions

Hemorrhagic stroke Ischemic stroke

2. Magnetic Resonance Imaging-Measures nuclear particles

as they interact with powerful magnetic field

IMAGING

IMAGING

3. Positron Emission Tomography-Allows imaging of regional blood flow and localized cerebral metabolism

4. Transcranial and Carotid Doppler-Used for noninvasive imaging of the neck and chest level.

Transcranial Doppler

IMAGING

5. Cerebral Angiography-Invasive and involves the

injection of radiopaque dye into blood vessels with subsequent radiography

Cerebral Angiogram showing a transverse projection of vertebrobasilar and posterior cerebral circulation

PT Management

INTRODUCTION Recovery begins as people get better from the immediate effects of a stroke. Over months and even years, other areas of the brain might learn to take over from the dead areas.

Rehabilitation is the process of overcoming or learning to cope with the damage the stroke has caused.

Stroke can cause weakness or paralysis in one side of the body and problem with balance or coordination.

PT role Helps regain as much mobility and muscle control as possible.

Assess the stroke survivor’s strength, endurance, ROM, gait abnormalities and sensory deficits to design individualized rehabilitation program.

PT role Work at patient bedside assuring adequate ROM and teaching bed mobilities, rolling and sitting.

Helps survivors regain the use of stroke impaired limbs, teach compensatory strategies to reduce the effect of remaining deficits and establish ongoing program to help people retain their newly learned skills.

ConsiderationsPositioning

The room should be arranged to maximize patient awareness of the hemiplegic side. Affected side should be towards the main part of the room.

Since patient spends significant time on bed, we have to prevent undesirable posture which can lead to contractures or pressure sores.

REMEMBER

BE PATIENT. REHABILITATION IS A SLOW AND OFTEN FRUSTRATING PROCESS. DON’T WORRY IF THERE ARE DAYS WHEN LITTLE PROGRESS SEEMS TO BE MADE.

REMEMBER

BE POSITIVE. CONSTANT ENCOURAGEMENT AND PRAISE ARE NEEDED TO KEEP UP EVRYONE’S SPIRITS.  

REMEMBER

NO PROGRAM CAN SUCCEED WITHOUT A STRONG DESIRE BY THE PATIENT TO BE INDEPENDENT.NEVERTHELESS; FAMILY INVOLVEMENT IS ALSO A KEY INGREDIENT IN A SUCCESSFUL REHABILITATION PROGRAM. 

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Neuro-ophthalmology:

• Visual field abnormalities…primarily those related to neuro-ophthalmic problems

• Case

• Field defect in relation to anatomical location

• Importance of the history and examination

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case

A 43y woman complains of a mild headache (left forehead). The headache has been present 2 months, and is not getting better.

As you listen she tells you the sight is dim in left eye.

Examination confirms red colours in the left eye are not as bright as when seen with the right eye.

Further examination shows a pale optic disk and afferent pupillary defect, and visual field defect, but even without these findings a CT scan is needed. CT scan details:

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case

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Recall…visual pathway

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Recall…disease of the eye itself causes various visual symptoms

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Recall…disease of the eye itself causes various visual symptoms

cataract

glaucoma

Retinitis pigmentosa or advanced glaucoma

Macular degeneration

Retinal vascular occlusion

Refractive error

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Optic nerve

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Optic nerveNo symptoms

Loss of colour vision

Central scotoma(or greater)

Pain behind eye with eye movements + visual symptoms

Headache and visual symptoms

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Pituitary (chiasmal) area

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Pituitary (chiasmal) area

right left

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Retrochisamal

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Retrochisamal

Large lesion anywhere

Smaller lesions…specificfeatures…this is temporal lobe

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Visual symptoms mini-quiz

Central vision reduced ARMD

Superior retinal vein occlusion

Tunnel vision…young patient…RP

This field both eyes…CVA/SOL

Loss of colour vision…optic nerveunilateral

This field both eyes…CVA/SOL

Temporal lobe

Central vision reducedoptic nerveYoung patient

old patient

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Questions

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Summary

• The history can give you a BIG clue• CT/MRI helpful …

but experts will locate lesion without• Horizontal border to defects….eye• Vertical…..retro-chiasm• Early disease…few if any symptoms• Small pituitary tumours…no field defect

(microadenomas)• Key symptoms can be very localising..eg

loss of colour vision in one eye, gradual increase in headache over 2 months,

Cardioembolic Stroke:Diagnosis and Management

Treatment of Acute

Cardioembolic Stroke

Recent trial results Risk factors for early stroke recurrence Risk of hemorrhagic complications Risk factors for sympotomatic ICH Recommendations for therapy

Treatment of AcuteCardioembolic Stroke

Risk of Early Stroke Recurrence

Multiple recent emboli Mechanical heart valve Atrial fibrillation + high risk features Established intra-cardiac thrombus

Treatment of AcuteCardioembolic Stroke

Acute Medical Stroke Therapy

Acute Medical Treatment of Stroke

Restore Blood FlowThrombolyticsMechanical devices

Stroke progression or recurrent thromboembolism AnticoagulantsAntiplatelet agents

Stroke Code

Who is eligible for tPA?What needs to be checked before starting the tPA infusion?Common errors to avoid

Stroke Code

Who is eligible for tPA?What needs to be checked before starting the tPA infusion?Common errors to avoid

Guidelines for Anticoagulant Therapy

Urgent administration of anticoagulants

has not yet been associated with lessening the risk of early recurrent stroke or improving outcomes. Because it can increase the risk of brain hemorrhage, routine use cannot be recommended.

American Heart Association, 2003

Guidelines for Anticoagulant Therapy

Anticoagulants are not recommended for

any subgroup of patients with acute stroke based on any presumed mechanism or location (e.g., cardioembolic, large vessel atherosclerotic, vertebrobasilar, or “progressing” stroke) because data are insufficient.

American Academy of Neurology / AHA, 2003

International Stroke TrialRecurrent Stroke Within 14 Days(N = 19,435)

Treatment of Acute

Cardioembolic Stroke

Guidelines for Aspirin Therapy

Early aspirin therapy (160-325 mg/day) is recommended

Delay aspirin for at least 24 hours after tPA

Aspirin can be used safely in combination with low doses of subcutaneous heparin

Acute Ischemic Stroke

Guidelines for Acute Stroke Therapy

tPA is recommended for eligible patients within 3 hours of stroke onset Aspirin is recommended for non-tPA eligible patients

Use of full-dose anticoagulation with intravenous, subcutaneous, or low molecular weight heparins should be avoided

ACCP, 2004

Risk of Hemorrhagic Complications

Anticoagulation increases the risk of extracranial hemorrhage by about 2%

Spontaneous hemorrhagic transformation is common and usually asymptomatic

Anticoagulation increases the risk of symptomatic ICH by about 2%

Treatment of AcuteCardioembolic Stroke

Risk Factors for Symptomatic ICH

Infarct size Timing of reperfusion (12 - 48 hours) Excesssive anticoagulation / tPA Heparin bolus? Severe hypertension?

Treatment of AcuteCardioembolic Stroke

Recommendations for Therapy

Aspirin for acute therapy (t-PA if eligible)

If low risk for early recurrence: begin warfarin (days to weeks)

If high risk of early recurrence: consider early anticoagulation if low risk for symptomatic hemorrhage

Treatment of AcuteCardioembolic Stroke

Diagnostic criteria for cardioembolism Clinical and neuroimaging features Aortic atheroma Patent foramen ovale Treatment of cardioembolic stroke

Cardioembolic Stroke:Diagnosis and Management