Stroke

Question 1

WHO definition of stroke

Answer 1

a clinical syndrome characterised by rapidly developing clinical signs of focal, and at times global disturbance of cerebral function

Symptoms last > twenty four hours or cause death

No apparent cause other than that of vascular origin

Question 2

What is a transient ischaemic attack (TIA)

Answer 2

neurological deficit of presumed vascular origin lasting less than 24 hours

• typically last less than 10 minutes
• suggestions to change definition definition to <1 hour

Relatively benign in terms of immediate consequences as symptoms resolve

Warning Stroke more appropriate than mini stroke as it is a direct sign that a stroke may potentially occur

important to have investigated

Question 3

Stroke types (2)

Answer 3

ischaemic (85%)

hemorrhagic (15%)

Question 4

Types of ischaemic stroke

Answer 4

thrombotic
embolic
hypo-perfusion

Question 5

Types of hemorrhagic stroke

Answer 5

subarachnoid

intracerebral

Question 6

Pathogenesis of ischaemic stroke

Answer 6

large artery thromboembolism 50%

small artery disease - 20-25%

embolism associated with cardiac dysfunction 20%

non atheromatous arterial disease 5%

blood disease <5%

Question 7

Ischaemic cascade

Answer 7

process of stroke injury at the cellular level

irreversible damage begins immediately at the core

the penumbra may be viable for up to 6 hours

Question 8

ischaemic cascade continued

Answer 8

rapidly initiated within seconds to minutes after the loss of blood flow to a region of the brain
comprises a series of subsequent biochemical events that lead to disintegration of cell membranes and neuronal death at the core of the infarction

severe focal hypoperfusion leads to excitotoxicity and oxidative damage which in turn cause microvascular injury, BBB dysfunction and initiate inflammation
exacerbates initial injury and can lead to permanent cerebral damage

Amount of permanent damage is dependant on : degree and duration of ischemia and brain’s capability to recover

Question 9

Pathogenesis of haemorrhagic stroke

Answer 9

hypertension 
- acute hypertension 
- alcohol
-amphetamines 
arterial disease
- vascular malformations

Diasthesis (bleeding disorders)

• Anticoagulants
• Antiplatelets
• Thrombolytic therapy

Trauma

Question 10

Look up the pathogenesis of hemorrhagic and ischaemic stroke

Answer 10

Kahn’s academy?

Question 11

Pathogenesis of haemorrhagic stroke cont

Answer 11

intracerebral haemorrhage activates a nuclear factor which then perpetuates inflammation

inflammation along with oxidative stress leads to secondary brain damage

induction of antioxidative defence components and inhibition of the nuclear factor protect affected area of the brain

phagocytosis mediated haematoma clean up also stimulated facilitating removal of the haematoma (source of toxicity and inflammation)

Question 12

Dominant (usually left) hemisphere functions

Answer 12

language
skilled motor formulation (Praxis)

Arithmetic sequential and analytical calculating skills

musical ability : sequential and analytical skills in trained musicians

Sense of direction : following a set of written directions in sequence

Question 13

Non dominant (usually right) hemisphere functions

Answer 13

Prosody (emotion conveyed by tone of voice

visual spatial analysis and spatial attention

arithmetic ability to estimate quantity to correctly line up columns of numbers on the page

musical ability : in untrained musicians, and for complex musical pieces in trained musicians

sense of direction : finding one’s way by overall sense of spatial orientation

Question 14

Anterior circulation includes

internal carotid artery system

Answer 14

anterior cerebral artery

middle cerebral artery

Question 15

Posterior circulation includes

vertebrobasilar artery system

Answer 15

vertebral artery 
posterior inferior cerebellar artery 
basilar artery 
anterior inferior cerebellar artery 
posterior cerebral artery

Question 16

Symptomology of Middle Cerebral Artery - Right

Answer 16

L Hemiplegia ; upper limb affected more than lower limb 
L Hemianaesthesia 
L hemianopia / quadrantopia 
Gaze palsy 
Dysarthria
Unilateral neglect / inattention 
agnosognosia 
autopagnosia
motor impersistence 
disinterest/poor motivation/apathy 
impulsiveness 
dyspraxia - constructional /dressing 
impaired ability to judge distance
astereognosis 
verticality problems 
coma- depending on extent of lesion

Question 17

Symptomology middle cerebral artery -Left

Answer 17

R hemiplegia ; upper limb affected more than lower limb 
R hemianaesthesis 
R hemianopia /quadrantopia 
Dysphasia - receptive and/or expressive 
anomia 
dyspraxia - ideomotor/ideational 
Gerstmann's syndrome : R/L confusion, finger agnosia, acalculia, dysgraphia 
Coma - depending on extent of lesion

Question 18

anterior cerebral artery

Answer 18

contralateral hemiplegia - lower limb affected more than upper limb 
cortical sensory loss to leg and foot 
urinary incontinence 
dyspraxia of left limbs 
Abulia 
Slow to respond to commands; decreased mental quickness
flat affect, lack of spontaneity, apthy 
distractible 
perservation of movement 
notable reduction in speech output 
facial/tongue weakness
grasp/sucking reflex may be present

Question 19

Posterior cerebral artery

Answer 19

homonymous hemianopia (cortical blindness if bilateral lesions)
colour blindness
hemianaesthesia (mild to severe)
verbal dyslexia
memory deficits
poor orientation in space
gerstmann’s syndrome : R/L confusion, finger angosia, acalculia, dysgraphia

Question 20

Posterior inferior cerebella artery

Answer 20

vertigo/nausea/vomiting/nystagmus at rest or with eye movement
ipsilateral loss of pain and temperature to face
contralateral loss of pain and temperature to body
diplopia
hoarseness
dysarthria
dysphagia
transient contralateral hemiparesis
Cerebellar ataxia - falling to side of lesion
Ipsilateral paralysis of muscles of the soft palate, pharynx and larynx causing dysphagia and dysarthria
Horner’s syndrome : ipsilateral small pupil, ptosis, enophthalmos (sunken eye ball), lack of sweating on one side of face

Question 21

Vertebral artery or branch of vertebral / lower basilar artery

Answer 21

ipsilateral paralysis with atrophy of half the tongue (CN XII)
Contralteral hemiparesis of arm and leg (sparing face)
Contralateral impaired tactile and proprioceptive sense

Question 22

Stroke classification

Answer 22

Stoke syndromes are usually divided into
Large vessel stroke within the anterior circulation

large vessel stroke within the posterior circulation

Small vessel disease of either vascular bed

Question 23

Bamford oxfordshire stroke classifications

Answer 23

TACS: total anterior circulation syndrome (15%)
PACS: Partial anterior circulation syndrome (35%)
LACS: Lacunar syndrome (25%)
POCS: posterior circulation syndrome (25%)

Once the type of stroke is known (infarct vs hemorrhage) the letter S is replaced with I and H respectively

Question 24

TACS

Answer 24

large cortical and subcortical stroke in MCA/ACA
high mortality, poor functional outcome (long term dependancy)

symptoms include all three of the following 
Higher cerebral dysfunction 
- neglect (right hemisphere) 
-Aphasia (L hemisphere) 
-Apraxia 

Homonymous hemianopia
motor sensory deficit
>2/3 face + arm + leg

Question 25

PACS

Answer 25

``` cortical stroke in MCA branch fair prognosis, high chance of functional recovery symptoms at maximum deficit include two of the following -higher cerebral dysfunction -homonymous hemianopia -motor sensory deficit or -higher cerebral dysfunction or -limited motor/sensory deficit ```

Question 26

Lacunar syndrome (LACS)

Answer 26

``` subcortical stroke in deep perforating artery good prognosis Symptoms include on of the following - sensori-motor stroke - pure sensory stroke -pure motor stroke -ataxic hemiparesis no evidence of higher cerebral or visuospatial or hemianopia or vertebrobasilar dysfunction ```

Question 27

Posterior circulation syndrome (POCS)

Answer 27

lesion in posterior cerebral hemisphere, brainstem or cerebellum often good recovery, high reoccurrence symptoms at maximum deficit include one of the following - cerebellar or brainstem syndromes cranial nerve palsy with contralateral motor/sensory deficit loss of consciousness isolated homonymous hemianopia

Question 28

What percentage of strokes can be prevented

Answer 28

80%

Question 29

Non modifiable risk factors for stroke

Answer 29

Age Gender (male>female) FH

Question 30

Medical risk factors for stroke

Answer 30

TIA AF Diabetes Fibromuscular dysplasia

Question 31

Modifiable (lifestyle) risk factors for stroke

Answer 31

hypertension - hypecholesterolemia - smoking (tobacco) - obese / overweight - inadequate nutrition - inactivity - excessive alcohol consumption

Question 32

Prognosis : overall

Answer 32

``` General prognosis following stroke - 25% well recovered 25% moderately impaired 25% dependant 25% deceased ``` mortality rate 10% infarction 50% hemorrhagic

Question 33

1 year prognosis for TACS

Answer 33

high mortality, poor functional outcome 60% mortality (40% at 30 days) 35% dependant <5% independant

Question 34

1 year prognosis PACS

Answer 34

fair prognosis, high chance of functional recovery 15% mortality (5% at 30 days) 30 % dependant 55% independant

Question 35

1 year Prognosis LACS

Answer 35

good prognosis 10% dead (5% at 30 days) 30% dependant 60% independant

Question 36

POCS: 1 year prognosis

Answer 36

often good recovery, high reoccurrence 20% dead (<10 at 30 days 20% dependant 60 independant

Question 37

summary

Answer 37

A stroke is a clinical syndrome characterised by rapidly developing clinical signs of focal, and at times global disturbance of cerebral function • Immediate damage occurs due to ischaemia/ haemorrhage with secondary damage resulting from cellular processes including inflammation, excitotoxicity and oxidative stress • Clinical signs and symptoms are dependent of location and extent of lesion • Stroke is one of Australia’s biggest killers and a leading cause of disability • More than 80% of strokes can be prevented • Prognosis is dependent on type, location and extent of lesion

Question 38

Recovery after stroke is affected by what? (4)

Answer 38

- Individual patient characteristics - Type, location and severity of the lesion - Severity of deficits - Environment the patient is exposed to during the recovery periods

Question 39

Poor functional outcomes are linked to

Answer 39

``` prior stroke admission stroke prolonged unconsciousness urinary incontinence >1/52 Cognitive deficits Sensory inattention presence of unilateral spatial neglect ```

Question 40

Degree of motor loss following a stroke

Answer 40

important factor influencing outcome after stroke 10 times more likely to recover function if motor deficit is mild initial lack of sitting balance correlated with dependant gait at 6/52

Question 41

list 5 other influences on recovery post stroke

Answer 41

``` age pre-morbid function co-morbidities isolated or difficult social situation patient motivation and attitude ```

Question 42

factors influencing loss of function following stroke

Answer 42

``` motor impairment (70-99%) sensory impairment (66%) Visual inattention (58%) Neglect (43%) Apraxia (39%) Aphasia (33%) Dysphagia (38%) Dysarthria (35%) Visual disturbances (35%) Cognitive dysfunction(21%) ```

Question 43

Motor impairments - Weakness

Answer 43

most common impairment most significant contributor to reduced function Normally decreased distally >proximally Large variation in nature and distribution of weakness

Question 44

Motor impairments - Spasticity

Answer 44

No relationship found between function and spasticity | No improvement in function has been found following reduction in spasticity

Question 45

Motor impairments - Adaptive features

Answer 45

Arise as a result of the primary impairments develop in response to loss of innervation, immobility and disuse (eg. muscle stiffness, muscle shortening, joint stiffness, shoulder subluxation, pain) Increase the overall degree of motor impairment and often interfere with recovery

Question 46

Neuroplasticity definition

Answer 46

the brain's ability to change, remodel and reorganise for purpose of better ability to adapt to a new situation

Question 47

neuroplasticity

Answer 47

the brain's ability to reorganise itself by forming new neural connections throughout life allows neurones to compensate for injury and disease and to adjust their activity in response to new situations or changes in environment how we adapt to changing conditions, learn new facts and develop new skills describe changes in neural system at many levels - molecular, morphological, synaptic, cortical, functional

Question 48

Neuroplasticity theory

Answer 48

presynaptic cells that provide input to the postsynaptic cell will have their synaptic connections strengthened connections that are not active will gradually have their influence weakened change in neural function in response to input is the basis of cellular neuroplasticity

Question 49

Influences on neuroplasticity

Answer 49

enriched or impoverished environments patterns of use or non-use sensory inputs motor skill practice

Question 50

Principle 1 of neuroplasticity and rehab

Answer 50

body parts can compete for representation in the brain and use of body part can enhance its representation representation areas increase or decrease depending on use In the case of a stroke that damages a body part's representation in the primary motor cortex, plasticity permits some reorganisations that will restore a representation the process must be competitive with all other body parts

Question 51

Principle 2

Answer 51

the premotor cortex can substitute for the motor cortex to control movement -while the primary motor cortex has the largest and most powerful contribution to the function of the corticospinal tract, the premotor cortex also contributes

Question 52

principle 3

Answer 52

the intact hemisphere can take over some motor control -there are ipsilateral corticospinal neural pathways (weak in humans) -these pathways innervate many more proximal than distal muscles the transcollosal connections provide another possible role of the intact hemisphere MRI studies demonstrate that the damaged hemisphere has increased blood flow when bilateral movements are made

Question 53

Principle 4

Answer 53

neuroplastic mechanisms can be facilitated - physiotherapists can influence cortical reorganisation after stroke with - rehab techniques sensory stimulation environmental enrichment

Question 54

Motor learning continuum

Answer 54

learner gains a basic idea of movement pattern the movement pattern is adapted to real word tasks performance becomes more consistent, efficient and automatic

Question 55

The rehabilitation environment

Answer 55

very important in optimising functional recovery | patients in stroke units more likely to be alive, independent and living at home one year after stroke

Question 56

Aims of physiotherapist following stroke (6)

Answer 56

``` prevent secondary complications optimise cardiorespiratory function optimise motor performance increase physical fitness and strength inspire interest and motivation promote mental and physical vigour ```

Question 57

Commencement of intervention

Answer 57

immediate start providing the patient is medically stable patients who receive early intervention are more likely to walk independently, are discharged earlier and are more likely to return home care needs to be taken not to place extreme demands on the affected limbs in the early stages

Question 58

Dosage and delivery

Answer 58

evidence that more is better type of practice is equally important to amount - task specific/task related functional practice context specific must practice in different task and environmental contexts Practice +++++ Learning is directly related to the amount of practice undertaken Repetition +++++ in both strength training and skill development, repetition is an important aspect of practice let fatigue and quality of movement guide you as to the intensity of the exercise and the number of repetitions to be completed

Question 59

Maximise practice time

Answer 59

only a small percentage of a patient's daily time is spent with a physio exercise classes and circuit training independant practice outside of therapy time (alone, with family or physio assistant maximise participation in ADLs and mobility with nursing and care staff mental practice can produce positive effects in performance

Question 60

Knowledge of expected outcomes

Answer 60

prognosis is dependant on type, location and extent of lesion

Question 61

knowledge of dyscontrol following stroke

Answer 61

70-99% of patients with a motor impairment following stroke will have reduced function weakness is the most common motor impairment

Question 62

Knowledge of recovery mechanisms

Answer 62

neuroplasticity is the brain's ability to change, remodel and reorganise for purpose of better ability to adapt to a new situation body parts can compete for representation in the brain and use of body part can enhance its representation the premotor can substitute for the motor cortex to control movement the intact hemisphere can take over some motor control neurplastic mechanisms can be facilitated

Question 63

knowledge of motor skill acquisition

Answer 63

patient must be actively involved in rehab practice practice practice practice must be task orientated goals must be meaningful to the patient so that they have the motivation to persevere

Question 64

optimisation of the rehab environment

Answer 64

commence as soon as patient is medically stable more physio is better type of practice is as important as amount practice ++++ Repetition ++++