10/11 - CVA Pathology and Medical Management Flashcards Preview

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Flashcards in 10/11 - CVA Pathology and Medical Management Deck (55)
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1
Q

More common side for CVA

A

Left (possibly due to fluid dynamics of L vs R branch from aortic arch); MCA most common

2
Q

Transient Ischemic Attack (TIA)

A

Transient episode of neurological dysfunction

Temporary disturbance in blood supply to the brain spinal cord or retina without permanent death of tissue.

Symptoms usually last ? 1 hour.

3-17% 90-day risk of a completed stroke.
Up to 50% occur within 48 hours of the TIA

3
Q

Stroke

A

Disruption of the vascular supply to the brain brainstem or spinal cord that leads to infarction (death) of CNS tissue.

Symptomatic or silent.
Symptomatic strokes manifest by cerebral or spinal dysfunction caused by CNS infarction.
Silent strokes are documented CNS infarction that was asymptomatic

4
Q

Stroke epidemiology

A

?795 000 strokes per year in the United States
?610 000 are first strokes
> 5 000 000 stroke survivors in the US
#1 cause of disability in the US
4th leading cause of death in the US (#2 worldwide)

4-8% recurrence in 1st 3 months

Overall 7-10% recurrence/year
Highest in first year

Survival*
~50% at 3 years
~33% at 10 years
*comorbidities common

5
Q

Ischemic stroke

A

61-87%; Thrombotic Vs Embolic; Large Vs Small vessel; Arterial Vs Venous

6
Q

Hemorrhagic

A

Intraparenchymal Vs Subarachnoid
Primary Vs Secondary (conversion)
Higher proportion of hemorrhage in children

7
Q

Large vessel thrombotic stroke

A

Slow stuttering onset due to gradual occlusion +/- collateral circulation
Possibly preceded by TIA

8
Q

Small vessel thrombotic ?lacunar? stroke

A

Associated with longstanding hypertension and diabetes

Basal ganglia internal capsule and brainstem

9
Q

Cardioembolic Etiologies in Ischemic Stroke

A
Valvular atrial fibrillation 
Nonvalvular atrial fibrillation 
Acute myocardial infarction 
Bacterial endocarditis
DVT with a patent foramen ovale
Mitral valve prolapse
Prosthetic mechanical heart valves
Possible injury in multiple vascular distributions
10
Q

Cerebral venous thrombosis

A

Relatively rare

Higher risk in peripartum period OCPs + smoking coagulopathies

11
Q

Hemorrhagic Stroke facts

A
Intraparenchymal (75%) vs. subarachnoid (25%)
Fast  large volumes of blood
Increased mortality
If survived  decreased morbidity
BP and ICP control
MAP = 1/3 (SBP-DBP) + DBP
MAP-ICP=CPP
Vomiting  systolic BP >220 mm HG  severe headache  coma  decreased level of consciousness and progression over minutes-hours suggest hemorrhage.

Rapid deterioration in neurological status is common

12
Q

Intraparenchymal Hemorrhagic Stroke

A

75% of hemorrhagic strokes

Hypertensive hemorrhages
Rupture of micro-aneurysms
Putamen»thalamus pons cerebellum and cerebral hemispheres.

Non-hypertensive hemorrhages
Sympathomimetic agents
Cavernous angiomas amyloid angiopathy intracranial tumors bleeding disorders trauma vasculitis hemorrhagic conversion infection

13
Q

Subarachnoid Hemorrhagic Stroke

A
25% of hemorrhagic strokes
Progressive deficits over minutes to hours 
Headache and decreasing consciousness
Etiologies:
Saccular aneurysms
Most common cause of SAH
45 % risk of death in the 1st 30 days
Most within a few days
Arteriovenous malformations (AVMs)
14
Q

EMS Management of stroke

A
Airway  breathing and circulation (ABC)
Cardiac monitoring 
Intravenous access 
Oxygen  if needed
Rapid identification of stroke/time of onset
Rule out (and treat) stroke mimics
Keep NPO (no food or drink)
Alert receiving ED 
Rapid transport to closest appropriate facility
15
Q

ED Evaluation

A
General medical examination
Identify contributing factors:
Drug exposures  trauma  cardiac conditions
NIH Stroke Scale
Glasgow Coma Scale
Dysphagia screen
Airway  breathing and circulation (ABC)
Adequate hydration
Treat elevated temperatures
Glucose control
Cardiac monitoring for 1st 24 hours
Cautious initial approach to HTN
16
Q

Non-enhanced brain CT scan (NECT) (Medical Diagnosis)

A

The acute study of choice
Quick and affordable
Blood and bone visible
Radiation exposure
Does not show brain tissue changes such as hypoxia/anoxia
Helps identify nonvascular etiologies
E.g. brain tumor
Certain findings may predict hemorrhage with TPA
Early infarct signs including edema and mass effect
Poor visualization of small cortical and subcortical acute infarcts
Not as useful for imaging the ?posterior fossa? because of bone artifacts

17
Q

Vascular Evaluation

A
Conventional angiogram
Still appears to be gold standard
Magnetic Resonance Angiogram (MRA)
CT angiogram
Carotid ultrasound 
Transcranial doppler ultrasound
18
Q

Magnetic Resonance Imaging

A
Better than CT
Identifies:
Acute small cortical strokes
Posterior fossa lesions
Acute vs. chronic lesions 
Subclinical satellite lesions
May be preferable when TPA is not considered
No radiation exposure
Considerations:
More time consuming and less available
Patient contraindications
Claustrophobia
Internal devices
Metal implants
19
Q

AHA/ASA Guidelines for Ischemic Stroke - Medical Treatment

A
Airway  breathing and circulation (ABC)
Airway protection in dysphagia or decreased LOC/NPO
Adequate hydration
Treat elevated temperatures
Glucose control
Cardiac monitoring for 1st 24 hours
Cautious initial approach to HTN
Oxygen only if hypoxic
Identify etiology of hypovolemia or hypotension
20
Q

AHA/ASA Guidelines for Ischemic Stroke - Medical Treatment

A

Intravenous (IV) TPA given in ? 3 hours of stroke onset in appropriate patients
Possible expansion of window to 4.5 hours in selected patients
SBP <120
PT implications?

21
Q

AHA/ASA Guidelines for Hemorrhagic Stroke ? Medical Treatment

A
ABCs 
Rapid transport
Immediate imaging
Careful blood pressure management 
Normalize fluid balance and electrolytes
Control seizures
Normalize body temperature
Correct any bleeding disorders (specific to the problem)
DVT prophylaxis
Clot evacuation and ventricular drainage as required
22
Q

Pressure Monitors

A

Control intracranial pressure (ICP)
Elevate head osmotherapy (mannitol) hyperventilation barbiturate coma sedatives ventricular monitors lasix
Risk of decreasing cerebral perfusion pressure
Cerebral perfusion pressure = mean arterial pressure ? intracerebral pressure (CPP=MAP-ICP)

23
Q

Pressure Management

A
20-30% develop acute hydrocephalus
Most require shunting
Clip ligation or coiling for aneurysm
Prevent and treat vasospasm (peak day 5-7)
Seizure prophylaxis may be indicated
24
Q

ASA Clinical Practice Guideline for Stroke

A
Algorithm A  B  C
Key points of ?prevention of complications  minimize impairments  and maximize function.?
Secondary prevention of another stroke
Early assessment and intervention
Standardized evaluation and tools
EBP ? based interventions
Multidisciplinary team
Pt and family ed and team
Community resources
25
Q

Physical Therapy Examination - Review

A

History and systems review
Identify problem areas
individual
therapist
Make hypotheses
Test your hypotheses with your examination
task analysis
tests and measures
Clinical Impression
Link participation difficulties with activities and impairments
Combined with the history what is the prognosis for change?
How do you prioritize your interventions?
Set goals that address impairments in body structure and function AND activities

26
Q

Stroke Examination

A
History
Age and living situation
Participation and Activity level
Type and location of stroke
How long since stroke
Medications
Blood pressure parameters
Co-morbid  pre-morbid conditions
Systems Review
Neuromuscular
Musculoskeletal
Cardiopulmonary/Vascular
Cognition/Communication
Integumentary
Genitourinary
Gastrointestinal
Endocrine
27
Q

Neuromuscular Impairments of Body Structure/function

A
Lack of adequate force production
Lack of adequate timing
Abnormal synergistic movement patterns
Muscle imbalance
Lack of adequate motor planning
Decreased postural control
Sensory-Perceptual  visual deficits
28
Q

Risk of falls: <30 days post CVA

A
<30 Berg Balance Score
Apraxia
Cognitive deficits
Low Functional Independence Measure (FIM) scores
Predictive of increased fall rates
29
Q

Risk of falls: >6 months post CVA community dwelling

A

Self-reported persistent balance problems while dressing is predictive of falls

30
Q

Fall predictors in older adults

A

Incontinence
Medications
History of falls
These factors are not predictive of falls post CVA

31
Q

Apraxia

A

Loss of ability to execute skilled or learned movement patterns on command in the absence of weakness sensory loss comprehension difficulty abnormality of tone or posture or intellectual deterioration.

32
Q

Ideational apraxia

A

Planning of a movement fails

Patient is unable to conceptualize how a movement pattern must be organized.

33
Q

Ideomotor Apraxia

A

Plan for the movement is intact but the execution fails.
Damage within pathways connecting the areas in which the plan is conceived to those responsible for innervating the motor plan

34
Q

Aphasia

A

Impairment of language associated with damage to the language dominant hemisphere.
Nearly always involves damage to the left fronto-temporal and/or temporo-parietal regions.

May affect verbal expressive output fluency comprehension naming reading writing and repeating.

35
Q

Global aphasia

A

commonly associated with a large lesion in the frontal temporal and parietal lobes of the brain causing an almost total reduction of all aspects of spoken and written language

36
Q

Broca’s (expressive motor) aphasia

A

loss of the ability to produce language (spoken or written)

37
Q

Receptive aphasia also known as Wernicke?s aphasia fluent aphasia or sensory aphasia

A

loss of ability to understand language (spoken or written)

38
Q

Hemi-Neglect

A

Failure to attend to respond to and/or report stimulation that is introduced contralateral to the lesion.
Most often seen with non-dominant parietal association area lesions.
Affects contralesional side.
Persistent neglect is a negative functional outcome predictor.

39
Q

Intrapersonal Hemi-Neglect

A

Contralateral hemineglect of patient?s own body associated with anosagnosia (denial of deficit)

40
Q

Peripersonal hemi neglect

A

Hemispatial neglect of contralateral stimuli within reaching distance.

41
Q

Extrapersonal hemi neglect

A

Hemispatial neglect of contalateral stimuli beyond reaching distance.

42
Q

Dysarthria

A

Difficulty producing speech

43
Q

Dysphagia

A

Difficulty swallowing
Difficulty eating
Dealing with secretions

44
Q

Stroke Tests and Measures

A
6MWT
10 m walk
Modified Ashworth Scale
Berg Balance Test
Functional Reach Test
Dynamic Gait Index
Fugl-Meyer  (Motor )
Orpington Prognostic Scale
Postural Assessment Scale for Stroke
Stroke Impact Scale
Tardieu Spasticity Scale
Action Research Arm Test (ARAT)
Chedoke-McMasters
45
Q

Fugl-Meyer Motor scale

A

100 point motor domain is reliable valid and responsive to clinical change

46
Q

Chedoke-McMaster Stroke Assessment

A

Measure of impairments and disability level
Impairments in 6 dimensions: shoulder pain postural control arm hand leg foot
measured on a 7 point scale following Brunnstrom stages
Disability measured by gross motor function and walking
measured on same 7 point scale as FIM

47
Q

Postural Assessment Scale for Stroke Patients (PASS)

A
Maintaining a Posture (0-3)
Sitting without support with feet on floor
Standing with support
Standing without support
Standing on non-paretic leg
Standing on paretic leg
Changing Posture (0-3)
Supine to affected side lateral
Supine to non-affected side lateral
Supine to sitting EOT
Sitting on edge of table to supine
Sitting to standing
Standing to sitting
Standing  picking up pencil from floor
48
Q

Stroke Impact Scale (SIS)

A

Questionnaire
5 point scale - Not Difficult at all to Extremely Difficult
Physical problems
Memory and thinking
Mood and emotions
Communication
Activities in a typical day
Mobility in home and community
Hand function
Ability to participate in usual meaningful activities
On a scale of 0=100 how much have you recovered?

49
Q

Action Research Arm Test (ARAT)

A

Total score 0-57
Scored 0-3 on each item
Minimal clinical important difference (MCID) 5.7 points

50
Q

Additional Tests and Measures

A
Glasgow Coma Scale (GCS)
NIH Stroke Scale  (NIHSS)
Montreal Cognitive Assessment (MOCA) 
Modified Tardieu Scale
Functional Independence Measure(FIM)
51
Q

Glasgow Coma Scale (GCS)

A

EYE OPENING
None = 1 Even to supra-orbital pressure
To pain = 2 Pain from sternum/limb/supra-orbital pressure
To speech = 3 Non-specific response not necessarily to command
Spontaneous = 4 Eyes open not necessarily aware
MOTOR RESPONSE
None = 1 To any pain; limbs remain flaccid
Extension = 2 Shoulder adducted and shoulder and forearm internally rotated
Flexor response = 3 Withdrawal response or assumption of hemiplegic posture
Withdrawal = 4 Arm withdraws to pain shoulder abducts
Localizes pain = 5 Arm attempts to remove supra-orbital/chest pressure
Obeys commands = 6 Follows simple commands
VERBAL RESPONSE
None = 1 No verbalization of any type
Incomprehensible = 2 Moans/groans no speech
Inappropriate = 3 Intelligible no sustained sentences
Confused = 4 Converses but confused disoriented
Oriented = 5 Converses and oriented
TOTAL (3?15): _______

52
Q

NIH Stroke Scale (NIHSS)

A
Time Intervals: Baseline  2 hours post treatment  24 hours post onset  7-10 days  3 months  other
Scored 0 1 2 scale with 0 = normal
Level of Consciousness
Best Gaze
Visual
Facial Palsy
Motor Arm
Motor Leg
Limb ataxia
Sensory
Best Language
Dysarthria
Extinction and Inattention (neglect)
53
Q

Montreal Cognitive Assessment (MOCA)

A

MOCA
Scale 0-30
Consider language difficulties

54
Q

Modified Tardieu Scale

A

Velocity One = V1
Slow movement
Goniometric measurement at this joint angle
Velocity Two = V2
Fast movement
Goniometric measurement at this joint angle
May provide more precision in documenting amount of spasticity and amount of contracture

55
Q

Functional Independence Measure (FIM)

A
20 functional items  measured on 7 point scale:
7 = Independence 
6= Modified Independence 
5= Supervision (subject does 100%)
4= Minimal Assist (subject does 75%)
3= Moderate Assist (subject does 50%)
2= Maximal Assist (subject does 25%)
1= Total Assistance (subject does < 25%)