What is the neurological aspect (etiology) for strokes?
An ischemic stroke is when there is a blood clot that occludes a vessel in the brain (most commonly middle cerebral artery), resulting in hypoxia and neuronal cell death. The stroke can be thrombotic (blood clot occludes a cerebral artery) or embolic (blood clot breaks off from somewhere in the body and blocks a smaller artery in the brain) in origin. A hemorrhagic stroke is when there is a rupture of a blood vessel, again resulting in hypoxia and neuronal cell death. Affected areas: Any area supplied by that blood vessel can be affected as well as the surrounding areas due to secondary cell death and/or swelling during a hemorrhagic stroke. With a Right MCA CVA the most commonly affected areas of the brain are those involved in motor function of the left body (primary motor cortex), language (Broca’s area), swallowing (motor cortex), executive functioning (frontal lobe), memory (temporal lobe) and attention (parietal lobe).
What are the epidemiological apects for strokes?
Strokes have a higher prevalence in males, people of African or South Asian heritage, and in middle-to-low-income countries. Increased risk with age (>64 y/o).
Modifiable risk factors: excessive drug/alcohol use, smoking, physical inactivity, diet, hypertension, hyperlipidemia, cardiac diseases, use of contraceptive/postmenopausal hormone, obesity.
Nonmodifiable risk factors: older age, race/ethnicity, heredity, sex.
What does FAST stands for?
Face (drooping), Arms (whether arms can be raised without assistance, potential weakness in right arm), Speech slurring, and Time (reminds bystanders to seek immediate medical help).
What are the clinical aspects (signs and symptoms) for strokes?
FAST signs indicate onset: Face (drooping), Arms (whether arms can be raised without assistance, potential weakness in right arm), Speech slurring, and Time (reminds bystanders to seek immediate medical help).
Impairments depend on the location of the stroke. Common symptoms: hemiparesis/hemiplegia, speech difficulties (dysarthria, aphasia), dysphagia, ataxia, impaired spatial awareness (neglect), numbness, problems with balance/coordination, cognitive and visual deficits.
Differential diagnosis: Noncontrast CT scan: blood clot and areas of insufficient blood flow can be detected. MRI can give more detail if needed. Neurologic exam: See neuro exam lecture for more details of neuro exam.
Expected progression: A stroke has an acute onset. Neurological recovery is most seen within the first 24 hours to the first 3 months. However, improvements can be seen at a slower recovery until the first year until the chronic phase begins.
What are the functional implications of a stroke?
Difficulty with ADLs/IADLs: eating, dressing, toileting, bathing, functional ambulation, stairs, cooking, housekeeping, driving, groceries… Ability to communicate: social interactions with friends/family/colleagues, productivity (work) and leisure activities. May avoid social gatherings due to distress and anxiety because they are not able to communicate well and move with ease and have an increased risk of future stroke incidence. Person becomes more dependent on others.
What is the rehabilitation treatment for a stroke?
1) PT: Work on muscle strengthening, ROM, coordination and gait to improve strength/atrophy. Use neuroplasticity to regain impaired movements through specific and repetitive exercises.
2) OT: Work on ADLs/IADLs and eventually productivity and leisure. Progressive return to daily activities helps improve mental health. Both through treatment activities and adaptation of environment. OTs can also assist with dysphagia depending on the site.
3) SLP: Help with aphasia/dysphagia to improve communication skills, Dieticians help improve diet and Social worker for family support.
What is the medical treatment for a stroke?
Medical: Ischemic CVA given Thrombolytic drugs (tPA) if within 4 hours (dissolves clot). Hemorrhagic CVA: evacuation of a hematoma/removal of bone flab (if needed). Potential neurosurgery (if possible and needed)
Other medications include anticoagulant, antiplatelet, blood pressure control and statins (reduce blood cholesterol levels).
