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Stroke
Generic term for temporary or permanent disturbance of brain function due to vascular disruption (Brookshire)
Also called cerebrovascular accident (CVA)
3rd leading cause of death in the USA; about 500,000 per year----150,000 die from stroke 80% of pts. Survive for at least 1 mo. Post; about 1/3 of those are alive 10 years post.
Other Important but less Common Stroke Symptoms Include: Sudden nausea, fever and vomiting distinguished from a viral illness by the speed of onset (minutes or hours vs. several days) Brief loss of consciousness or period of decreased consciousness (fainting, confusion, convulsions or coma)
Uncontrollable Stroke Risk Factors Include: Age The chances of having a stroke go up with age. Two-thirds of all strokes happen to people over age 65. Stroke risk doubles with each decade past age 55. Uncontrollable Stroke Risk Factors Gender Males have a slightly higher stroke risk than females. But, because women in the United States live longer than men, more stroke survivors over age 65 are women. Race African-Americans have a higher stroke risk than most other racial groups. Family history of stroke or TIA Risk is higher for people with a family history of stroke or TIA. Personal history of diabetes People with diabetes have a higher stroke risk. This may be due to circulation problems that diabetes can cause. In addition, brain damage may be more severe and extensive if blood sugar is high when a stroke happens. Treating diabetes may delay the onset of complications that increase stroke risk. However, even if diabetics are on medication and have blood sugar under control, they may still have an increased stroke risk simply because they have diabetes.
Coronary Heart Disease and High Cholesterol High cholesterol can directly and indirectly increase stroke risk by clogging blood vessels and putting people at greater risk of coronary heart disease, another important stroke risk factor. A cholesterol level of more than 200 is considered "high." Cholesterol is a fatty substance in the blood that our bodies make on their own, but we also get it from fat in the foods we eat. Certain foods (such as egg yolks, liver or foods fried in animal fat or tropical oils) contain cholesterol. High levels of cholesterol in the blood stream can lead to the buildup of plaque on the inside of arteries, which can clog arteries and cause heart or brain attack. Sleep Disordered Breathing - Sleep Apnea Sleep apnea is a major cardiovascular and stroke risk factor increasing blood pressure rates which may cause stroke or heart attack. Studies also indicate that people with sleep apnea develop dangerously low levels of oxygen in the blood while carbon dioxide levels rise, possibly causing blood clots or even strokes to occur. Diagnosing sleep apnea early may be an important stroke prevention tool.
Lifestyle Factors that Increase Stroke Risk Include: Smoking Smoking doubles stroke risk. Smoking damages blood vessel walls, speeds up the clogging of arteries by deposits, raises blood pressure and makes the heart work harder. Alcohol Excessive consumption of alcohol is associated with stroke in a small number of research studies. Its specific role in stroke has not yet been determined or proven. Recent studies have also suggested that modest alcohol consumption (one 4 oz. glass of wine or the alcohol equivalent) may protect against stroke by raising levels of a naturally occurring "clot-buster" in the blood. Weight Excess weight puts a strain on the entire circulatory system. It also makes people more likely to have other stroke risk factors such as high cholesterol, high blood pressure and diabetes.
Most strokes occur in the 7th decade 85% of survivors return to prestroke-living environment (with some residual impairment)
15 % require institutional care (Greenberg, Aminoff, and Simon, 1993)
Ischemicdeprived of blood
Sometimes called occlusive
Hemorrhagiccaused by bleeding Loss of blood flow for 3-5 minutes causes necrosis of the CNS Infarct---death of tissue caused by interruption of blood supply
Ischemic Stroke
Thrombotic
Artery is gradually occluded by a plug of material the collects in a given site
Uncommon in smaller arteries Usually in areas of disturbance like twists and bends in an artery
Embolic
Artery is suddenly occluded by material that moves thought he vascular system to occlude an artery Often a fragment from a thrombosis Atrial fibrillation is a common cause
Greenberg et al. (1993) 1/3 of pts who have TIAs or RINDs will within 5 years have a stroke that leaves them with permanent neurologic deficits
Hypofusion
Insufficient blood flow to the brain and the brain stem Diaschisis---disruption of brain function in regions AWAY from the site of injury (but connected by neural pathways (within system)
Edema, decreased blood flow, neurotransmitters and diaschisis help diffuse impairment of brain function!
Hemorrhages
Extracerebral hemorrhages bleeding outside of the brain
Subarachnoid subdural extradural
Intracerebral hemorrhages
Within brain substance bleed
Intracerebral Hemorrhage
90% occur in pts with high BP Cause(s): hypertentionpressure on arterial walls or chronic hypertensionweakening of small penetrating arteries causing microaneurysms Can cause snowball effect as the hemorrhage affects adjacent vessels
Aneurysm
Pouches formed in arterial walls
berry or saccular, term depends upon the shape Nearly 50% of extracerebral aneurysms occur in the arteries at the base of the brain (vertebrals, basilar, internal carotid and Circle of Willis
Berry Aneurysm
Arteriovenous Malformation
Arteriovenous malformation Collections of dilated, thin-walled vein connected to a tangled mass of equally thin-walled arteries.
Usually present at birth; most will not live to 60s-70s without a hemorrhage. Symptoms include headaches and CNS symptoms Can be removed surgically or vessel is tied off
AVF
Greatest risk is the potential for rupture and subsequent hemorrhage
Intracranial Tumors
Primary site: point of origin
Secondary site: originated elsewhere and moved
Relocation of tumor = metastasis---mets
Herniation Syndromes
Masses the force movement of brain substance (or brain stem) Tumors: course is deterioration of function
Early stage = lower intracranial pressure = causes nonspecific alterations of cognition ( forgetfulness, drowsiness, blurred or double vision, vertigo, lightheadedness, etc.
More IC Tumors--Primary
Meningioma: arise from the ________??
Most benign of all, very slow growing, welldefined margins, usually dont invade brain substance Can usually be completely removed Symptoms are usually site specific
Viral infections
2 common sources:
General infections (mumps/measles) and viruses transmitted by bites (animal or insect)
Equine encephalitis and rabies
Tx is palliative: tx. Vital signs, nutrition, fluid balance to help system rid virus
Toxemia
Due to substances invading the NS that inflame or poison nerve tissue May result from: drug overdoses or interactions, bacterial toxins (tetanus, botulism, diphtheria) or heavy metal poisoning (lead and mercury)----WTC??? TX is to remove the substance
Aphasias
Fluent
Wernickes Conduction Transcortical Sensory
NonFluent
Brocas Transcortical Motor Global
Other forms:
Anomic Alexia and Agraphia Primary Progressive
Chronic Therapy
Rehabilitation with goal to reestablish the most normal lifestyle as possible
Acute Therapy
After ischemic stroke, the area of infarction is surrounded by tissue that will either recover or die: the ischemic penubra
Routine tx have been vasodilators: inc. cerebral blood flow and to inc. arterial pressure (to increase blood into the area of infarct, and; Corticosteroids used to reduce swelling of the brain
These neuroprotective measures have not been protective; most medical (acute) treatments for ischemic stroke have been limited to preservation of life Until 1995: National Institute of Neurological Disorders and Stroke (NINCDS) study on t-PA
Rehabilitation team
Physiatry,nursing, social services, psychology and, PT, OT, SLP and vocational tx Settings: rehabilitation unit (inpatient), SNF, outpatient clinic, or at home. Rehab unit qualifier: pt must be able to handle 3 hours of activity per day BBA of 1997? Fiduciary Cap.
2) Degree of communication impairment: global aphasia or hemineglect tend to perform poorly in rehab
Contraindicators of Rehabilitation
Psychiatric Disorders;
Dementias, Apathy Syndrome, Negative Symptom Complex Not a functional loss: these conditions have less ambition, less motivation, poor effort to succeed, etc.