Recovery Related Issues

Question 1

2 Types of Recovery

Answer 1

Natural/Spontaneous and Post-natural

Question 2

Natural/Spontaneous Recovery

Answer 2

maximal, rapid, dramatic; duration of 3-12 weeks; treatment can make the patient progress even faster

Question 3

Post Natural Recovery

Answer 3

patient continues learning, but is much slower and less dramatic 6 months is the limit

Question 4

Physiology of Acute Phase

Answer 4

Visible microscopic changes in 24-48 hours

Edema in large infarcts

Increased intracranial pressure and tissue compression by 3rd day

Brain response to ischemia by autoregulatory mechanisms (vasodilation, diaschisis, circle of willis)

Bilateral reduction of blood circulation (depression of the neural metabolism)

Auto-regulatory Mechanisms: robbing Paul to pay Peter, if the brain needs blood it tries to find it from other areas

Question 5

Acute Phase

Answer 5

No collateral circulation - quick loss of energy is needed to maintain the ionic balance, if this doesn’t happen it leads to cellular energy loss

Cellular Energy Loss

• Release of glutamate and aspartate
• Excitatory-toxicity to calcium channels
• Excessive calcium to many destructive enzymes
• Inflammatory changes followed by Chromatolysis and Necrosis

Question 6

Chromatolysis

Answer 6

10-18 days Disintegration of micro-molecules, nissl bodies, and nucleolus displacement

Everything becomes liquified

After the 18 days, if the cell is healthy it will come back, if not it will die.

Question 7

Second Week, post stroke

Answer 7

Diminished swelling

Capillaries and astrocyte invasion

Necrotic tissue liquefaction

Phagocytosis of tissue-macrophagic cells (eats up debris)

Phagocytosis - can take up to 3 months if its a large lesion.

Question 8

Astrocyte Scar

Answer 8

Small lesion, post stroke

Question 9

Cystic Cavity Formation

Answer 9

Occurs in 3-6 months Lg. Lesion Basis for pessimism

Question 10

Sequence of Necrotic Process

Answer 10

Question 11

Repair Process

Structure/Function/Reaction

Answer 11

Question 12

Early & Late Reactions and the Functional Results

Answer 12

Question 13

Core Cells

Answer 13

Core cells are dead and can’t be saved

Question 14

Penumbra Cells

Answer 14

Penumbra Cells are the cells that surround the core cells.

The ischemic penumbra has idle neurons (electrically silent but metabolically ready for membrane potentials

idle neurons may survive for 20 mins without collateral circulation and 6-8 hours with collateral circulation

Question 15

Means of Reperfusion

Answer 15

Stent

tPa (clot-dissolving medication)

Merci retrieval system (remove the clot)

Question 16

Factors Contributing to Natural Recovery

Answer 16

Reperfusion with Collateral circulation - Collateral circulation is very closely related to the circle of Willis

Recovery from diaschisis - In the beginning the whole brain is reacting negatively, but after 2-3 weeks the swelling lowers; this is long-distance recovery

Recovery from Structural Disconnections - the pathways have been disconnected/some are broken

Intra-hemispheric reorganization

edema attenuation - reduced pressure

cell recovery in penumbra

Question 17

Positive Recovery Profile

Wertz, 1987

Answer 17

Tx benefits patients with single LH thrombo-embolic infarct, mild-moderate loss

post-onset period of 3 or less months, if given 3 hrs/week for 5 months

intensive Tx beneficial if 8-10 hrs/week for 3 months, begin in less than 6 months post-onset

Question 18

Culton Spontaneous Recovery

Answer 18

Found Support for natural restitution

These patients didn’t have any treatment

Non-chronic patients:
Most dramatic difference in results between the first and second tests

Chronic patients:

Testing between all the different times are very similar

This tells us that something is happening within the brain even without treatment

Question 19

Vignolo, 1965

Answer 19

Developed the Token Test

Pts with mild-moderate loss will do better than those with profound loss

People who are young (under 50) improved the best

Question 20

VA Cooperative Study on Aphasia

Wertz 1981

Answer 20

Patients randomly assigned to individual or group therapy

both groups improved beyond 26 weeks post-onset

recovery continued beyond spontaneous recovery period

individual Tx was better overall, but both groups improved

Question 21

Kertesz & McCabe Recovery Patterns

Answer 21

Anomics had full recovery

Broca and Conduction with best recovery

Globals with poor recovery

Wernicke bimodal recovery (little recovery in patients with jargon, better without jargon)

evolution into different aphasia types

Question 22

Lomas & Kertesz

Patterns of Spontaneous Recovery

Answer 22

Patients divided into 4 groups: LFLC (globals), LFHC (Broca’s), HFLC (Wernicke’s), HFHC (anomics)

equal improvements noted for all language tasks for groups with high comprehension

selective improvement in comprehension and imitation for patients with low comprehension

Question 23

Anna Basso

Prognostic Factors in Aphasia

Answer 23

Review of literature on prognostic factors, including age, sex, handedness, etiology, site and extent of lesion, severity and type of aphasia, restitution

Age relationship to recovery - Good predictor of recovery

Gender relationship to recovery - No significant difference in the severity and recovery rate across genders

Personality relationship to recovery - Pleasant and cooperative help in recovery

Question 24

Basso

Initial Severity Relationship to Recovery (1-10 weeks)

Answer 24

good predictor of aphasia outcome

greater initial severity is a negative recovery sign

mild initial aphasia has good recovery (95% plateaued within 2 weeks)

moderate initial aphasia 95% plateaued within 6 weeks

severe initial aphasia 95% plateaued within 10 weeks

Sparing of critical cortical area - Greater prognostic significance

Question 25

Basso Extent of Recovery

Answer 25

Good for patients with anomia and conduction aphasia fair/good for patients with Broca and Wernicke poor for patients with global

Question 26

Basso Rate of Recovery

Answer 26

Fast for patients with conduction and Wernicke intermediate for patients with Broca slow for patients with anomia and global

Question 27

Basso Recovery Pattern

Answer 27

Anomic aphasia is a common end-stage for both recovering fluent and non-fluent aphasics

Question 28

Overview of Contributing Factors (General)

Answer 28

Site and Lesion Size - the larger the lesions, the poorer the prognosis Lesion Nature - Multiple lesions render a poor prognosis Bilateral lesions - aphsasic residuals Silent stroke - 11% of patients with silent lesions prior to first stroke Multiple strokes = bad prognosis

Question 29

Overview of Contributing Factors in a Natural & Trained Restitution

Answer 29

Age - younger = better personality - postive = better severity - profound loss of lang. at initial eval. = bad prognosis Motivation - education = bad candidate because you question everything. Motivation = doesn't really translate into better results handedness - better recovery in left handedness following LH stroke time post onset - less than 6 months = better gender - no effect social milieu - Pts. who are socially active do better general health - Someone who has only stroke has better prognosis than someone who is complicated health wise personality - positive = better lesion size - bigger = worse lesion nature - poor for multiple lesions

Question 30

Aphasia Recovery & Bilingualism

Answer 30

Synergetic patterns = Nearly 50% 1. Parallel (41%) : both languages impaired similarly in the beginning and recovered at the same rate ​ 2. Differential (9%) : Both languages impaired to different degrees, but improved at the same rate Selective Recovery = (27%) only one lang. improves Successive = (6%) One recovers after the other Antagonistic = (4%) one lang. progressed whiel the other regressed Alternate antagonistic = Different lang. prevails at different periods If you provide tx in mother language it doesn't generalize to L2, but if you provide tx in L2 it generalizes to L1.

Question 31

Aphasia Recovery & Bilingualism Robot's and Pitre's Rules

Answer 31

Robot's Rule = Primary Language Pitre's Rule = Most frequent language