CEREBRO-VASCULAR DISEASE & STROKE

Faizan Zaffar Kashoo

CEREBRO-VASCULAR DISEASE & STROKE

Stroke is the commonest cause of death in developed countries. Hypertension is the most treatable risk factor. Thromboembolic infarction (80%), cerebral and cerebellar haemorrhage (10%) and subarachnoid haemorrhage (about 5%) are the major cerebrovascular problems.

DEFINITIONS

Stroke is defined as the clinical syndrome of rapid onset of cerebral deficit (usually focal) lasting more than 24 hours or leading to death, with no apparent cause other than a vascular one. Completed stroke means the deficit has become maximal, usually within 6 hours. Stroke-in-evolution describes progression during the first 24 hours. Minor stroke. Patients recover without significant deficit, usually within a week. Transient ischemic attack (TIA). This means a focal deficit, such as a weak limb, aphasia or loss of vision lasting from a few seconds to 24 hours. There is complete recovery. The attack is usually sudden.

PATHOPHYSIOLOGY COMPLETE STROKE

One of three mechanisms is usual:

arterial embolism from a distant site arterial thrombosis haemorrhage into the brain (intracerebral or subarachnoid).

Less commonly:

venous infarction polycythaemia (hyperviscosity syndromes) fat and air embolism multiple sclerosis mass lesions (e.g. brain tumour, abscess, subdural haematoma)

Modifiable risks

Cardiovascular Disease Hypertension CAD Diabetes Dyslipidemia High total Cholesterol and/or Low HDL Atrial Fibrillation Asymptomatic Carotid Artery Stenosis

Cigarette smoking Sickle Cell Disease Dietary Factors Obesity Physical Activity Hormone Replacement Therapy

Types of stroke

Ischemic stroke syndrome Hemorrhagic stroke syndrome

Ischemic Stroke Syndrome

Lacunar Infarction
Infarction of small penetrating arteries in pons and basal ganglia Associated with chronic HTN present in 80-90% Pure motor or sensory deficits

Ischemic Stroke Syndromes

Basilar Artery Occlusion

Severe quadriplegia Coma Locked-in syndrome-complete muscle paralysis except for upward gaze

Ischemic Stroke Syndromes

Vertebrobasilar Syndrome

Posterior circulation supplies brainstem, cerebellum, and visual cortex

Dizziness, vertigo, diplopia, dysphagia, ataxia, cranial nerve palsies, and limb weakness, singly or in combination HALLMARK: Crossed neurological deficits: ipsilateral CN deficits with contralateral motor weakness

Ischemic Stroke Syndromes

Middle cerebral artery occlusion

Dominant Hemisphere (usually the left)

Contralateral weakness/numbness in arm and face greater than leg Contralateral hemianopsia Gaze preference toward side of infarct Aphasia (Wernickes -receptive, Brocas -expressive or may have both) Dysarthria

Ischemic Stroke Syndromes

Middle cerebral artery occlusion

Nondominant hemisphere
Contralateral weakness/numbness in arm and face greater than in the leg Constructional Apraxia Dysarthria Inattention, neglect,

Ischemic Stroke Syndromes

Anterior Cerebral Artery Infarction

Contralateral weakness/numbness greater in leg than arm Dyspraxia Speech perseveration Slow responses

Acute stroke: immediate care, and thrombolysis

Paramedics and members of the public are encouraged to make the diagnosis of stroke on a simple history and examination FAST: Face sudden weakness of the face Arm sudden weakness of one or both arms Speech difficulty speaking, slurred speech Time the sooner treatment can be started, the better. Dedicated units with multidisciplinary, organized teams deliver higher standards of care than a general hospital ward

Investigations
The purpose of investigations in both stroke and TIA is: to confirm clinical diagnosis to distinguish between haemorrhage and thromboembolic infarction to look for underlying causes of disease and to direct therapy, either medical or surgical

Imaging TIA & stroke patients

Imaging TIA and stroke patients CT and MRI. CT imaging will demonstrate haemorrhage immediately while a patient with an infarct may have a normal scan. Infarctions are usually detectable at 1 weeK although 50% are never detected on CT. CT or MRI should be carried out urgently in the majority of cases. Diffusionweighted imaging (DWI) MR can identify infarcted areas within a few minutes of onset. Conventional T2 weighting is no better than CT. Imaging will also show the unexpected, e.g. subdural haematoma, tumour or abscess.

Further investigations

Routine bloods (for polycythaemia, infection, vasculitis, thrombophilia, syphilitic serology, clotting studies, autoantibodies, lipids) Chest X-ray ECG Carotid Dopplers Angiography

Management of cerebral infarction

The possible sources of embolus should be sought (e.g. carotid bruit, atrial fibrillation, valve lesion, evidence of endocarditis, previous emboli or TIA) Assess hypertension and postural hypotension The brachial blood pressure should be measured in each arm; a difference of more than 20 mmHg is suggestive of subclavian artery stenosis. The neurological deficit should be carefully documented.

Immediate management

Admit to multidisciplinary hospital stroke unit if possible. General medical measures Care of the unconscious patient, Oxygen by mask, Assessment of swallowing, Check BP and look for source of emboli. Immediate brain imaging is essential. Cerebral infarction : If CT shows infarction, give aspirin (300 mg/day initially) antiplatelet therapy if no contraindications, give alteplase thrombolysis, which must be started within 3 hours (aim for 90 min) of stroke; informed consent is essential. Cerebral haemorrhage: If CT shows haemorrhage, do not give any therapy that may interfere with clotting. Neurosurgery may be required.

Surgical treatment

Internal carotid endarterectomy: Surgery is recommended in TIA or stroke patients shown to have internal carotid artery stenosis greater than 70%. Successful surgery reduces the risk of further TIA/stroke by approximately 75%. Endarterectomy has a mortality around 3%, and a similar risk of stroke. Percutaneous transluminal angioplasty (stenting) is an alternative procedure.

Prognosis

Twenty-five per cent of patients die within 2 years of a stroke. Around 30% of this group die in the first month Gradual improvement usually follows stroke, although the late residual deficit may be severe. Of those who survive, about one-third return to independent mobility and one-third have serious disability requiring permanent institutional care.

Medical management and pharmacological consideration

1.

Thrombosis and TIA 80% to 100% die in few minutes Improve circulation tissue plasminogen activator (t-PA) heparin (anticoagulant drugs) warfarin Clot prevention aspirin, dipyridamole and sulfinptrazone Surgical treatment (remove clot from artery) Thromboendarterectomy

Medical management and pharmacological consideration

2.

Embolic infarction
Emphasis on prevention
Similar to thrombotic infarction Anticoagulant therapy

Medical management and pharmacological consideration

3.

Hypertensive hemorrhage

Control hypertension

Medical management of associated problems

SPASTICITY

PHARMACOLOGICAL 1. Centrally acting drug

diazepam
2.

Peripherally acting drug

Procaine Phenol Botalulinum toxin A Baclofen

SURGICAL TREATMENT
1. 2.

Tenotomy Neurotomy

Medical management of associated problems

SEIZURES
Thrombotic and embolic stroke early onset Hemorrhagic stroke late onset

Drugs
Phenytoin Carbamazepine

Medical management of associated problems

Respiratory involvement Fatigue respiratory inefficiency 50% more O2 than normal Decrease lung volume

Medical management of associated problems

TRAUMA
Falls improper balance Hip wrist and humerus fracture are common Osteoporosis .

Medical management of associated problems

THROMBOPHLEBITIS
Clot formation Common in weaker leg

Medical management of associated problems

REFLEX SYMPATHETIC DYSTROPHY
Sympathetic blockers Oral or intramuscular corticosteroids

STAGES OF RECOVERY

Cerebral shock

Immediately after cerebral ischemia Last between few hrs to days

Flaccid stage

Recovery phase

Severe sensory loss and muscle is flaccid

Tone improves Distal parts recover first Proximal spasticity appears Limbs in synergetic pattern (atypical pattern) UL in flexion and LL in extension pattern

Recovery stage

Spasticity of stage

Factors that influence the recovery

Quality of the rehabilitation treatment. The motivation of the patient and his family. Age of the patient. Persistence of the flaccid stage and delay in treatment.

Evaluation
It the process of Collecting information to establish a baseline level of performance to plan intervention and progress.

Components of evaluation
Level of consciousness Mental status examination Cranial nerve examination Sensory examination Motor and reflex examination Gait examination Functional tests Prognosis Short and long term goals intervention

Evaluation of primary impairments

Active movements
70 80 % of stroke patient have weakness. Weakness and control is assessed. Timing of muscle firing. Sequence of movement. Speed of movement. Do not assist the client.

Evaluation of primary impairments

Assisted movements
Correct alignment to gather additional information Assist weak muscles Stabilize joint and document the pattern of movement

Evaluation of primary impairments

Tone
Modified ashworth scale

Equilibrium and protective reactions

Equilibrium reactions are assessed while slowly moving the part away from base of support Protective reactions by hopping or stepping and positive support

Evaluation of secondary impairments

Loss of joint range and muscle shortening
Poor alignment Muscle activation problem Functional consequence of two joint muscle. Eg: gartrocsoleus

Evaluation of secondary impairments

Pain
Visual analog pain rating scale McGill pain questionnaire Shoulder pain

Functional evaluation
Activity of daily living
Barthel index Motor assessment scale Function independence measure

Motor function and balance

Fugl Meyer scale Berg balance scale Functional reach

Recognizing needs
What movement and function is possible? What movement and function are not possible? How do primary and secondary impairment relate to functional performance?

Goal setting
Functional goal
Stand independently and perform grooming activity

Short term goal

Client will length hamstring and plant foot flat on the ground while standing

Long term goal

Able to perform most of the functional activities

Choosing intervention
Two school of though
Use normal side Use affected side Using both will benefit the patient Impairment based intervention

Common impairment and suggested interventions

WEAKNESS AND LOSS OF CONTROL Trunk control
First Level- basic trunk movements in 3 planes. Second level- trunk movement with extremity movement.

Extremity control
Weight bearing and assisted movements. Distal re-education.

Common impairment and suggested interventions

MUSCLE ACTIVATION DEFICIT Improper initiation
Uses proximal more than distal

Inappropriate muscle selection

Uses stronger than weaker

Inappropriate sequencing
Co-contraction and out of sequence

Excessive force production

Inappropriate effort during movement

Common impairment and suggested interventions

HYPOTONICITY
Quick icing. Quick stretch in mid range. Weight bearing. Proper alignment. Mild stretching at the end of range.

Common impairment and suggested interventions

HYPERTONICITY Proximal instability
Improve stability of upper trunk decrease arm hypertonicity

Poor joint alignment

Stretching of gastronemius and soleus active.

During activity
Proper sequence of activity Inhibition of spastic pattern is wrong.

Common impairment and suggested interventions

Toe posturing

Toe clawing
Poor alignment

Toe curling
Instability of trunk and leg

Common impairment and suggested interventions

LOSS OF ALIGNMENT

TRUNK
Atypical starting position for functional activity. Shortening towards affected side. Forwards flexion of trunk. Rotation towards affected side.

Functional activity
Supine Bridging Rolling Task oriented Kneeling Task oriented Transition activity Feeding Reach and grasp Half kneeling Standing Walking Side walking

Therapies to hand

Activation of abductor digiti minimi

First dorsal interrosei

Postural asymmetry

Changing the orientation from horizontal to vertical support

Trunk extension facilitation

Sit to stand

Orientation to Mid line