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Stroke Definition: -

A stroke, previously known medically as a cerebrovascular accident (CVA), is therapidly developing loss of brain functions due to disturbance in the blood supply to the brain. It is also a medical emergency and can cause permanent

neurological damage, complications, and death. In most cases, the symptomsaffect only one side of the body (unilateral). Depending on the part of the brainaffected, the defect in the brain is usually on the opposite side of the body.However, since these pathways also travel in the spinal cord and any lesionthere can also produce these symptoms, the presence of any one of thesesymptoms does not necessarily indicate a stroke.

Patho physiology:

- Progression from reversible ischemia to infarction depends upon the degreeand duration of the reduced blood flow.

Interruption in the blood supply

Depletion of oxygen and glucose in the affected area

Reduces neuronal function

Neurons die or seriously damaged, further impairing brain functions.

Causes:

1. ischemia (lack of blood flow) caused by blockage such as:

thrombosis

arterial embolism

2. haemorrhage (leakage of blood) caused by rupture of the blood vesselsuch as:

Intracranialhaemorrhage 

intracerebralhaemorrhage

Symptom:1.  inability to move one or more limbs on one side of the body

2. Sudden confusion or trouble speaking

3. Sudden trouble in walking, loss of balance

4. Trouble seeing

5. Numbness or weakness of face, arm or leg.(one side of body)

6. Sudden severe headache

Diagnosis:

I. CT scans (most often without contrast enhancements)

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II. MRI scans

III.  Doppler ultrasound

IV. arteriography.

Risk factors:

1. old age

2. hypertension (high blood pressure)

3. previous stroke or transient ischemic attack (TIA)

4.  diabetes

5. high cholesterol

6.  Cigarette smoking and atrial fibrillation.

Part of the Brain affected area and each symptom:

In addition to the above CNS pathways, the brainstem give rise to most of thetwelve cranial nerves. A stroke affecting the brain stem and brain therefore canproduce symptoms relating to deficits in these cranial nerves:

• altered smell, taste, hearing, or vision (total or partial)

• drooping of eyelid (ptosis) and weakness of ocular muscles

• decreased reflexes: gag, swallow, pupil reactivity to light

• decreased sensation and muscle weakness of the face

• balance problems and nystagmus

• altered breathing and heart rate

• weakness in sternocleidomastoid muscle with inability to turn head to oneside

• weakness in tongue (inability to protrude and/or move from side to side)

If the cerebral cortex is involved, the CNS pathways can again be affected, butalso can produce the following symptoms:

• aphasia (difficulty with verbal expression, auditory comprehension,reading and/or writing Broca's or Wernicke's area typically involved)

• dysarthria (motor speech disorder resulting from neurological injury)

• apraxia (altered voluntary movements)

• visual field defect

• memory deficits (involvement of temporal lobe)

• hemineglect (involvement of parietal lobe)

• disorganized thinking, confusion, hypersexual gestures (with involvementof frontal lobe)

If the cerebellum is involved, the patient may have the following:

• trouble walking

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• altered movement coordination

• vertigo and or disequilibrium

Classification:

➢ Strokes can be classified into two major categories:

1. Ischemic strokes are those that are caused by interruption of theblood supply,

2. Hemorrhagic strokes are the ones which result from rupture of ablood vessel or an abnormal vascular structure.

a. Ischemic

In an ischemic stroke, blood supply to part of the brain is decreased, leading todysfunction of the brain tissue in that area. There are four reasons why thismight happen:

1. Thrombosis (obstruction of a blood vessel by a blood clot forming locally)

2. Embolism (obstruction due to an embolus from elsewhere in the body),

3. Systemic hypoperfusion (general decrease in blood supply, e.g., in shock)

4. Venous thrombosis

Classified as being due to:

(1) Thrombosis or embolism due to atherosclerosis of a largeartery

(2) Embolism of cardiac origin

(3) Occlusion of a small blood vessel

Type of ischemic stroke:

I.  TIA:

 Temporary reduction in perfusion to a focal region of the braincausing a short-live disturbance of functions.

Patient experience: slurred speech, aphasia or weakness.

II. RIND (reversible ischemia neurological deficit)

Focal brain deficit improves over a maximum of 72 hours.

May not completely resolve in all cases

III. Cerebral infarction

Permanently neurological disorder

C.i forms:

a. Stable-deficit is permanent and will not improve

b. Improving-return of previously lost neurological functionover several days to weeks

c. Progression-continue to deteriorate following the initialonset of focal deficit.

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Blood supplies by artery:

Anterior cerebral artery – medial aspect of frontal and parietal lobe. Middle cerebral artery – frontal, parietal and temporal lobe. Posterior cerebral artery-occipital and temporal lobes.

Clinical presentation:

a. internal carotid artery occlusion

b. middle cerebral artery occlusion

c. anterior cerebral artery occlusion

d. vertebrobasilar system

Hemorrhagic

Hemorrhagic strokes result in tissue injury by causing compression of tissuefrom an expanding hematoma or hematomas. This can distort and injure tissue.In addition, the pressure may lead to a loss of blood supply to affected tissue

with resulting infarction, and the blood released by brain haemorrhage appearsto have direct toxic effects on brain tissue and vasculature.[25]

Range in age the 20-70 years old

Most frequently in those who are 50-60 years old

Causes permanent neurological disability in 20-50%

Type:

1.  Intracranial haemorrhage 2. intracerebral haemorrhage

Intracranial haemorrhage is the accumulation of blood anywhere within the skullvault. A distinction is made between:

 intra-axial haemorrhage (blood inside the brain)

 extra-axial haemorrhage (blood inside the skull but outside thebrain).

Intra-axial haemorrhage is due to:

 intraparenchymal haemorrhage 

intraventricular haemorrhage (blood in the

ventricular system).

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types of extra-axial hemorrhage are:

epidural hematoma (bleeding between the dura mater and the skull)

 subdural hematoma (in the subdural space)

subarachnoid hemorrhage (between the arachnoidmater and pia mater).

Signs and symptoms:

Severe headache

Loss of consciousness vomiting

Causes:

traumarupture intracranial aneurysm(congenital weakening of blood vessel,bacterial infection)tumors

Complication:

➢ rebreeding

➢ hydrocephalus➢ delayed cerebral ischemia➢ seizures

Treatment:

1. thrombolysis (also known as a "clot buster"),

2. Hemorrhagic strokes benefit from neurosurgery.

3. stroke rehabilitation such as:

i. speech and language therapy

ii. physical therapy

iii. Occupational therapy.

Medication:

usually occurs more often in hemorrhagicstroke than in thrombosis because of theincreased intracranial pressure from theleaking blood compressing the brain.

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1. antiplatelet drugs such as :

i. aspirin 

ii.dipyridamole

iii. Control and reduction of hypertension the

use of statins.

iv.carotid endarterectomy and the use of anticoagulants.

Surgery:

carotid endarterectomy or carotid angioplasty :• can be used to remove significant

atherosclerotic narrowing (stenosis) of the carotid artery, which suppliesblood to the brain.

Care and rehabilitation:

Stroke rehabilitation: treatment to help them return to normal life as much aspossible by regaining and relearning the skills of everyday living. It also aims tohelp the survivor understand and adapt to difficulties, prevent secondarycomplications and educate family members to play a supporting role.

A rehabilitation team:

I. nursing staff(nursing care is fundamental in maintaining skin care,feeding, hydration, positioning)

II. physiotherapy

III. occupational therapy

IV. speech and language therapy

hemi paresis:

weakness of muscle on one side of the body, contra lateral to the side of brain in which the CVA occurred.

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Case study neurological case

Name : madam n

Age : 70 years oldOccupational : house wifeGender : femaleRace : ChineseReligion : ChristianDate of admission : 01/01/2011Date of assessment : 17/10/2011Doctor diagnosis : hemi paresis (left)Doctor management : stroke rehabilitationChief complaints : patient complaint pain on the neck, upper and

lower limb.

History

Current history: type of stroke :haemorrhage motor deficit :left

past history: previous stroke :yes (7 times) previous TIA :no previous mobility :limited

Investigation : CT scan (haemorrhagic)Surgical history : tracheotomy (4.5cm)Medical history : hypertensionMedication history : medication of hypertensionPersonal history :

cigarette smoking: no alcohol: no drug: no

Socio-economic: housing :teres distance :2 miles toilet :-patient using pampers

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bed :couchIncontinence:

bladder – yes bowel – yes

Observation

Built :Mesomorphic(medium)

Walking aids : Wheelchair

Gait : Unable to assess(pt cannot walking)

Posture : Kyphotic

Attitude of limb : Asymmetrical (sitting: left higher thanright)muscle wasting

(lying: both knee slight flex)muscletightness

Dominant hand : Right side

Mental/cognitive impairment : No

Communication impairment : Receptive

Visual field deficit : No

Hearing deficit : No

Perceptual status : Impaired

Contracture or deformity : No

Any trick movement : Yes(pt unable to straighten the limb during

take object)

Skin condition : Dryness and dehydration

Pressure sore : No

Any swelling : No

On palpation

 Tenderness :Tenderness both UL and Lower limb

Warmth :No

Swelling or edema :No

 Tightness :Yes both side(hamstring tightness)

On examination

Higher mental function:

1) Mental status:alertness ( )

attention ( )cooperation ( X )

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orientation:I. forward digit span (pt repeated number) ( )

II. backward digit span(pt read from behind)( X )

III. time ( )IV. place ( )V. person ( )

1) Memory:immediately(ask then repeated) ( )short term(ask after 5-10 minute) ( )long term(childhood memorial) ( X )

2) Language(speech):• dysarthria: patient inability to articulate spoken

words(slurred speech).

3) Emotional:Anxiety: ( X )Depression: ( X )Slowness of movement: ( )

4) Cranial nerve:

Cranialnerve

functions normal abnormal

Olfactory Smell

Optic Vision

Oculomotor Mt eyelid,eyeball,constrict of 

pupils

 Trochlear Mt eyeball upward

 Trigeminal Mastication, sensation foreye and face

Abducens Mt of eyeball into abduction

Facial Facial expression, sensationand taste for anterior 2-3 of tongue.

Vestibulacochl Hearing and balance POOR

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ear

Glossopharyngeal

Swallow and salivation

Vagus Motor and sensation forvisceral organ.

Accessory Motor to soft palate,trapezius andsternocleidomastoid, larynxand pharynx.

hypoglossal Tongue control and muscleof neck.

5) Muscle tone:Shoulder: Right lefti. Flexion ( ) ( )ii.Extension ( ) ( )iii.Abduction ( N ) ( ↑tone )iv.Adduction ( ) ( )

Elbow:I. Flexion ( ) ( ↑tone )II. Extension ( N ) ( )

Wrist:

I. Flexion ( ) ( )II. Extension ( N ) ( ↑tone )

hip:I. Flexion ( ) ( )II. Extension ( ) ( )III. Adduction ( N ) ( )IV. Abduction ( ) ( ↑tone )V. Internal rotation ( ) ( )VI. External rotation ( ) ( )

knee: Right LeftI. Flexion ( ) ( )II. Extension ( N ) ( ↑tone )

ankle:i. Plantar flexion ( ) ( )ii.Dorsiflexion ( ) ( ↑tone )iii.Inversion ( N ) ( )iv.Eversion ( ) ( )

1) Range of motion:

Shoulder: Right lefti. Flexion ( ) ( )

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ii.Extension ( LRO ) ( )iii.Abduction ( ) ( PFROM )iv.Adduction ( ) ( )

Elbow:I. Flexion ( ) ( )

II. Extension ( N ) ( PFROM )Wrist:

I. Flexion ( ) ( PFROM )II. Extension ( N ) ( )

hip:I. Flexion ( ) ( )II. Extension ( ) ( )III. Adduction ( ) ( )IV. Abduction ( PNC ) ( PFROM )V. Internal rotation ( ) ( )VI. External rotation ( ) ( )

knee:I. Flexion ( ) ( )II. Extension ( LRO ) ( PFROM )

ankle:i. Plantar flexion ( ) ( )ii.Dorsiflexion ( PNC ) ( )iii.Inversion ( ) ( PFROM )iv.Eversion ( ) ( )

1) Coordination:

i.Equilibrium test: Walking in circle :poor Standing with eye occluded :poor

ii.Non equilibrium test: Finger to nose :good Finger to therapist finger :good Heel over opposire site :poor

2) Sensation:

i.Light touch:• Pin prick :present• Cotton :absent

ii.temperature:• cold :present• hot :absent

3) proprioception: right lefti. upper limb: ( normal ) ( fair )ii.lower limb: ( normal ) ( fair )

4) balance:static :sitting(fair)standing(poor)

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dynamic :sitting(fair)standing(poor)

5) reflexs:babinski reflex:pt not cooperate.deep tendon reflex: right

left biceps jerk: ( ) (

) triceps jerk: ( ) (

) brachioradialis: ( normal ) (

normal ) knee jerk: ( ) (

) Achilles tendons: ( ) ( )

1) limb length: right left differenti. true length: (81.5 ) (82 ) (0.5 )ii.apparent length: (82 ) (82 ) (0 )

2) limb girth: right left differenti. elbow girth: (23 ) (24 ) (1 )ii.wrist girth: (15 ) (15.5 ) (0.5 )iii.knee girth: (35.5 ) (37 ) (2.5 )iv.ankle girth: (29 ) (31 ) (2 )

3) muscle bulk:upper limb: left right

different• deltoid: (32 ) (32 ) (0 )• biceps: (30.5 ) (31 )

(0.5 )• triceps: (29 ) (28 ) (1 )• brachioradialis: (23.5 ) (23 ) (0.5 )

lower limb:• VMO: (35 ) (34 ) (1 )• quadriceps: (38.5 ) (36 ) (2.5 )• hamstring: (41 ) (38 ) (3 )• calf: (30 ) (28.5 ) (2.5 )•

4) complications:painful shoulder : yescomments : joint stiffness

5) functional analysis:i. transfer bed to chair: ( 0 )ii.transfer w/c to toilet: ( 0 )

iii.shifting ability: ( 0 )iv.supine to side lying: ( 0 )

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v.side lying to sitting: ( 0 )vi.sitting to standing: ( 0 )vii.sitting: ( 1 )viii.standing: ( 0 )ix.ambulation: ( 0 )

Scoring: 0-maximum dependent1-maximum assistance2-moderate assistance3-minimum assistance4-independent

Physiotherapy impression:

pain due to inflammation of soft tissuehyper tonemuscle wasting on lower limb(quadriceps, calf and

hamstring)muscle weakness on upper and lower limbmuscle tightness both hamstring musclepoor balance and coordination (equilibrium)limited range of motionnot cooperate joint stiffnesslimited functional activityfair proprioceptiondecrease sensation

Short term goal:to relieve painto normalize muscle toneto stimulate muscle wastingto strengthening muscle weaknessto stretching and lengthening muscle tightnessto improve balance and coordinationto increase balanceto reduce joint stiffnessto re-educate joint movement and sensation

Long term goal:

to optimize functional activity daily living.to prevent secondary complication and deformity.

Plan of treatment:

standing with support( tilt table ): Within 30 minute. For (LL) joint approximation to prevent

osteoporosis.Passive stretching:

Both upper and lower limb.

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20 time each movement  To prevent joint stiffness and to increase ROM

Hot pack: Both upper and lower limb 10 minute

 To relieve pain Tens:

10 minute Burst  To relieve pain and stimulate muscle

Cycling: 10 minute both upper and lower limb  To increase range of movement and hand functional.

Frenkle’s exercise: 5 minute Upper limb  To improve hand functional

Bridging exercise: 10 times  To strengthening muscle

 Trunk exercise: 5 minute  To improve neck and trunk control

Pulley exercise: 10 minute

 To stretching abduction and flexion muscle(shoulder)Dumbled:

5 minute(upper limb)  To strengthening muscle

HEP: Continue exercise(stretching and strengthening) Positioning(to prevent pressure sore)

S- Patient complaint pain over the shoulder and knee.

O- Patient comes to department using wheelchair

Posture-mild kyphotic (neck protrude outward)

Attitude of limb-asymmetrical shoulder level

Skin condition-dryness and dehydration

Cold skin temperature

No redness, no swelling

crepitus sound at both hand and legs

 Tightness hamstring muscle

Balance:

• Static : sitting(fair) standing(poor)

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• Dynamic :sitting(fair)standing(poor)

Muscle bulk:

upper limb: left rightdifferent

•

deltoid: (32 ) (32 ) (0 )• biceps: (30.5 ) (31 )

(0.5 )• triceps: (29 ) (28 ) (1 )• brachioradialis: (23.5 ) (23 ) (0.5 )

lower limb:• VMO: (35 ) (34 ) (1 )• quadriceps: (38.5 ) (36 ) (2.5 )• hamstring: (41 ) (38 ) (3 )• calf: (30 ) (28.5 ) (2.5 )

A-Pain over the shoulder and knee

 Tightness muscle(hamstring)

Poor balance

Weakness of muscle (unaffected side)

Abnormal posture

P- Standing with support (tilt table 30 minute)

Passive stretching

Postural correction (mirror feedback)

Cycling UL and LL (10 minute) Joint approximation (hand)

Hand functional exercise (reaching object)

Sitting balance (on the floor and tilt table within 10 minute)

Pulley (stretching abduction and flexion muscle)

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Symptoms:

a. Hemiplegiab. Hemisensory deficitc. Hemianopsia(blindness ½ of the visual field)d. Aphasia

Symptom:

a. Weakness of the opposite legb. Apraxiac. Possible cognitive imparment

Symptom:

a. Severevertigo,vomiting,dysphagia

b. Decreased pain andtemperature

c. diplopia

Symtoms:

a. monoparesis to hemiparesis without a defect in

visionb. impairment of speech

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