Stroke

NEUROPT HJS2073

STROKEMOHD NUH DANIAL BIN ROSDI

HDD12031406PN. FATMA HAIZUNI

CONTENTS

Introduction

Definition

Risk Factor

Aetiology

Types

Classification

Introduction

Results from ischemia to a part of the brain or

hemorrhage into the brain that results in death of

brain cells.

In 2005, 17,909 stroke victims were admitted into

government hospitals alone throughout the country.

Of these, 3,245 of them were fatal. By 2020, this

figure is expected to exceed 25,000 every year.

Approximately 750,000 in USA annually

Third most common cause of death

1 leading cause of disability

25% with initial stroke die within 1 year

50-75% will be functionally independent

25% will live with permanent disability

Physical, cognitive, emotional, & financial impact

Anatomy of the brain

Blood Supply of the brain

Anterior: Carotid Arteries – middle & anterior cerebral arteries

frontal, parietal, temporal lobes; basal ganglion; part of the diencephalon (thalamus & hypothalamus)

Posterior: Vertebral Arteries – basilar arteryMid and lower temporary & occipital lobes, cerebellum,

brainstem, & part of the diencephalon

Circle of Willis – connects the anterior & posterior cerebral circulation

Circles of Willis

Definition

A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and food. Within minutes, brain cells begin to die.

Risk FactorLifestyle risk factors:

Being overweight or obese

Physical inactivity

Heavy or binge drinking

Use of illicit drugs such as cocaine and methamphetamines

Potentially treatable risk factors

High blood pressure — risk of stroke begins to increase at blood pressure readings

higher than 120/80 millimeters of mercury (mm Hg). Your doctor will help you decide

on a target blood pressure based on your age, whether you have diabetes and other

factors.

Cigarette smoking or exposure to secondhand smoke.

High cholesterol — a total cholesterol level above 20 milligrams per

deciliter (5.2 millimoles per liter).

Diabetes.

Obstructive sleep apnea — a sleep disorder in which the oxygen level

intermittently drops during the night.

Cardiovascular disease, including heart failure, heart defects, heart

infection or abnormal heart rhythm.

Other risk factors

Personal or family history of stroke, heart attack or transient ischemic attack.

Being age 55 or older.

Race — African-Americans have higher risk of stroke than do people of other

races.

Gender — Men have a higher risk of stroke than women. Women are usually

older when they have strokes, and they are more likely to die of strokes than are

men. Also, they may have some risk from some birth control pills or hormone

therapies that include estrogen, as well as from pregnancy and childbirth.

Aetiology

A stroke occurs when the blood supply to your brain is interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause your brain cells to die.

A stroke may be caused by a blocked artery (ischemic stroke) or a leaking or burst blood vessel (hemorrhagic stroke). Some people may experience a temporary disruption of blood flow through their brain (transient ischemic attack, or TIA).

HypertensionSmokingHeart disease-atrial fibrillation TumorInfection

Types of stroke

Ischaemic stroke

•Most common type of stroke and is caused by a blockage of the blood vessels supplying the brain. •This may be due to ‘hardening’ and narrowing of the arteries (atherosclerosis) or by a blood clot blocking a blood vessel.

Haemorrhagic

stroke

•The most severe type of stroke is a haemorrhagic stroke.•It occurs when a blood vessel in the brain bursts, allowing blood to leak and cause damage to an area of the brain.

Acute stroke

Prognosis • Stroke is the second leading cause of death

worldwide. • Mortality rates are declining, however. Over

75% of patients survive a first stroke during the first year, and over half survive beyond 5 years.

Complication• Paralysis or loss of muscle movement.• Difficulty talking or swallowing.• Memory loss or thinking difficulties. • Emotional problems.• Pain.• Changes in behavior and self-care.

ClassificationTransient Ischemic Attack Temporary focal loss of neurologic function

Caused by ischemia of one of the vascular territories of the brain Microemboli with temporary blockage of blood flow

Lasts less than 24 hrs – often less than 15 mins

Most resolve within 3 hours

Warning sign of progressive cerebrovascular disease

Stroke @ CVA

EmbolicThromboticIschaemic stroke

subarachnoid haemorrhage

, which occurs in the space around

the brain

intracerebral haemorrhage,

the more common type, which involves bleeding within the brain tissue

itself.

Haemorrhagic stroke

*Results from uncontrolled HPT and aneurysm

PathophysiologyIschaemic stroke

• Ischaemic strokes are due to an interruption in the blood supply to a certain area of the brain which leads to the ischaemia, Infarction and eventual necrosis of tissue. Ischaemic strokes are further divided into global and focal strokes.

• Global strokes affect either the whole brain, watershed regions (those most vulnerable to reduced blood supply) or selectively vulnerable areas.

• Focal strokes are described as large (regional) or small (lacunar) and are directed to a particular area of the brain tissue. Focal strokes are very common in the region of the brain that is supplied by the Middle Cerebral Artery.

• Image showing the supply regions of the cerebral vessels. ACA: Anterior cerebral artery; MCA: Middle cerebral artery; PCA: Posterior cerebral artery.

Total anterior cerebral infarctions (TACI)

Partial Anterior Cerebral Infarctions (PACI)

Posterior Cerebral infarctions (POCI)

Lacunar Cerebral Infarction (LACI)

give hemiplegia contralateral to the brain lesion, hemianopia contralateral to the brain lesion and a new disturbance of higher function.

They occur in occlusion of the middle cerebral artery trunks.

gives one or a combination of motor/sensory deficits, hemianopia and new higher cerebral dysfunction.

They result in occlusion of the Middle Cerebral Artery trunk with good Anterior and Posterior Cerebral Artery Collaterals circulation.

give unequivocal brainstem features – isolated hemianopia or cortical blindness, ipsilateral cranial nerve palsy with contralateral motor/sensory deficits, bilateral motor/sensory deficits, disorders of conjugate eye movement and cerebellar dysfunction without ipsilateral long tract deficit.

involve sensory and/or motor systems, they are specifically caused by occlusion of the lenticulostriate artery (small branches of the middle cerebral artery).

Percentages of ischemic stroke accoding to the vessels

TACI (17%) POCI (24%) PACI (34%) LACI

• Haemorrhagic strokes are due to the rupture of a blood vessels leading to compression of brain tissue from an expanding haematoma. In addition, the pressure may lead to a loss of blood supply to affected tissue with resulting infarction.

Intracerebral haemorrhageIntracerebral haemorrhage is the accumulation of blood anywhere within the brain, i.e. –

intraparenchymal haemorrhage,

intraventricular haemorrhage.

This will form a gradually enlarging

haematoma (blood pool).

Intracerebra

l Haemorrhages can be

caused by

local

vessel

abnormalities (hypertension, vasculiti

s, vascular malformation) or

systemi

c factors

(drugs,

trauma, tumours and sickl

e cell anaemia/leukaemia).

Haemorrhaging

directly damages brain

tissue and

raises

intracranial

pressure

giving headaches, vomiting nausea

and

eventually coma and

death

.

Subarachnoid haemorrhageSubarachnoid haemorrhage is the gradual

collection of blood in the subarachnoid space of the Dura.

These can be traumatic or

spontaneous

. Spontaneous haemorrhages

occur through saccular (berry)

aneurysms and

through extensions of intracranial haemorrhaging or due to

similar causes.

Approxi

mately one third of those who suffer a subarachnoid haemorrhage die.

Sign

s &

Sym

ptom

s

Stroke sh.

Prevention • electrical stimulation• Supportive devicesSlingswheelchair attachments External shoulder orthoses such as strapping

Treatment

• Shoulder strapping within 48 hours of stroke may delay the onset of HSP –consider referral to a physiotherapist.

• Functional Electrical Stimulation (FES) may improve humeral lateral rotation and reduce glenohumeral subluxation –consider referral to physiotherapist.

• While exercising is recommended after stroke, it is important not to persist with movements which exacerbate shoulder pain.

• Normal anatomical alignment should be maintained as much as possible

Dr.’s ManagementDr. Ax• CT scan:– This is also called a CAT scan. A special x-ray machine uses a computer to take

pictures of your brain. It may be used to look at bones, muscles, brain tissue, and blood vessels.

– You may be given dye before the pictures are taken. The dye is usually given in your IV. The dye may help your caregiver see the pictures better. People who are allergic to iodine or shellfish (lobster, crab, or shrimp) may be allergic to some dyes. Tell the caregiver if you are allergic to shellfish, or have other allergies or medical conditions.

• Magnetic resonance imaging: Using magnetic waves, this test, also called an MRI, takes pictures of your head. An MRI may show the cause of a CVA.

• Carotid ultrasonography

• Arteriography

ultrasonographic examinations were performed before the arteriography.

A Carotid ultrasound shows the amount of blood flow carotid arteries, the major blood vessels to the brain located on either side of the neck.

Site of cerebral arteriography; Cerebral arteriography

Dr.’s Tx

• Ischemic stroke: An ischemic stroke includes strokes caused by a blockage in a blood vessel.– Anticoagulant medicine: Treatment for an ischemic stroke includes

anticoagulant medicines which are also called blood thinners. This medicine group keeps clots from forming in the blood.

– Antiplatelet aggregating medicine: These medicines interact with platelets to prevent blood clots from forming. Platelets are a type of blood cell that join to form clots.

– Thrombolytic medicine: This medicine group is used in a stroke caused by a clot in a blood vessel. Thrombolytics break apart clots and restore blood flow.

• Hemorrhagic (bleed) stroke: This type of stroke may require surgery.

PT’s Management

Exercises to improve strength,

flexibility and cardio-vascular

fitness.

Retraining movement to

achieve improve coordination, balance and

control.

Spasticity managem

ent.Contracture

management.

Management of shoulder

subluxation and shoulder pain.

Mobility retraining to improve

independence and provide access to social, leisure and community-based

activities.

Education and support for the

person, their family and carers

in managing physical

impairments.

Assessment for aids and

appliances such as splints, braces and wheelchairs.

Ambulation.

PT TxImproving motor control These therapeutic interventions use sensory stimuli

(e.g. quick stretch, brushing, reflex stimulation andassociated reactions) ,which are based on neurological theories, to facilitate movement in patients following stroke.

Limb physiotherapy Limb physiotherapy includes passive, assisted-active

and active range-of-motion exercise for the hemiplegic limbs.

This can be an effective management for prevention of limb contractures and spasticity

Chest physiotherapy cough and forced expiratory technique (FET) for bronchial hygiene clearance in stroke patient.

Balance retrainingEarly mobilisation the act of getting a patient to

move in the bed, sit up, stand, and eventually walk.People with acute stroke should be mobilised as

soon as possible within the first 3 days after stroke (when their clinical condition permits).

Tone management stretching, prolonged stretching, passive manipulation by

therapists, weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting.

Electrical Stimulation could be used for tone management

Oedema managementUse of intermittent pneumatic pump, elastic stocking or

bandages and massage can facilitate the venous return of the oedematous limbs and to prevent complications like pressure ulcer.

Gait re-education Treadmill training combined with use

of suspension tube. Functional Mobility Training These tasks include bridging, rolling to sit

to stand and vice versa, transfer skills, walking , stairing and earlier ambulation.

Tips for StandingHands must push off from bed/chair . do not

allow patient to hold onto frame/stick.Never pull or lift patient using the affected arm.Consider use of sling if arm is completely

flaccid.Think about foot placement, hand and buttock

position and use of momentum/verbal cues.

Positioningstrategy to discourage the development

of abnormal tone, contractures, pain and respiratory complications.

It is an important element in maximizing the patient's functional gains and quality of life.

Positioning

Lying on affected side

•One or two pillows forhead.•Affected shoulderpositioned comfortably.• Place unaffected legforward on one or twopillows.•Place pillows in front orbehind to give support.

Lying on unaffected side

•One or two pillows forhead.•Affected arm forward andsupported on pillow(s)•Affected leg backwardson one or two pillows.•Place pillow behind.

Sitting in bed

• Sitting in bed isdesirable for shortperiods only.•Must be upright and wellsupported with pillows.• Consider extra supportusing pillows under armsor knees.

Lying on back (if desired)

• Place three pillows in a‘triangle’, supportingshoulders and head.•Place affected arm onpillow.• Ensure feet in a neutralposition.

HEP / Advise

• Family members help the person regain lost skills by encouraging them to use the affected arm or leg, helping them with their speech or teaching them how to do tasks which may have been forgotten, such as combing their hair or using a cup, knife and fork.

Prevention• Take your high blood pressure medicine regularly.• Do not smoke or drink too much alcohol. Alcohol is found in beer, wine,

liquor, like vodka or whiskey, and other adult drinks. Different people have different ideas about what too much means. It is important to remember that how often you drink is as important as how much you drink.

• If you have atrial fibrillation (an irregular or fast heart beat), you may need to take antithrombotic medicine. Having a recent heart attack may also require you to take antithrombotics.

• Keep your blood cholesterol level in a normal range. Eat foods low in fat to decrease the risk of developing plaque (fatty deposits) in your blood vessels. If you have hyperlipidemia (high blood cholesterol level), talk to your caregiver about ways to lower it.

• Monitor and control your blood sugar level if you have diabetes.

References

• http://neuro4students.wordpress.com/pathophysiology/

• http://www.drugs.com/cg/cerebrovascular-accident.html

• http://www.mayoclinic.org/diseases-conditions/stroke/basics/prevention/con-20042884

Thank You!!!