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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.
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
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
Vertebrobasilar Syndrome
Nondominant hemisphere
Contralateral weakness/numbness in arm and face greater than in the leg Constructional Apraxia Dysarthria Inattention, neglect,
Contralateral weakness/numbness greater in leg than arm Dyspraxia Speech perseveration Slow responses
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 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
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.
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
Embolic infarction
Emphasis on prevention
Similar to thrombotic infarction Anticoagulant therapy
Hypertensive hemorrhage
Control hypertension
SURGICAL TREATMENT
1. 2.
Tenotomy Neurotomy
Drugs
Phenytoin Carbamazepine
Respiratory involvement Fatigue respiratory inefficiency 50% more O2 than normal Decrease lung volume
STAGES OF RECOVERY
Cerebral shock
Recovery phase
Recovery stage
Spasticity of stage
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
Functional evaluation
Activity of daily living
Barthel index Motor assessment scale Function independence measure
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
Choosing intervention
Two school of though
Use normal side Use affected side Using both will benefit the patient Impairment based intervention
Extremity control
Weight bearing and assisted movements. Distal re-education.
Inappropriate sequencing
Co-contraction and out of sequence
During activity
Proper sequence of activity Inhibition of spastic pattern is wrong.
Toe clawing
Poor alignment
Toe curling
Instability of trunk and leg
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
Postural asymmetry
Sit to stand