Stroke Symposium

Question 1

What are the social impacts of having a stroke?

Answer 1

• Lack of confidence
• live in fear of another stroke
• find it difficult to talk about their stroke and their effect on their lives
• feel friends and family treat them differently
• unable to care for their family in the same way as before
• breakdown of relationships

Question 2

What are key features of a clinical assessment in someone presenting with stroke?

• assessment?

Answer 2

• Sudden onset of focal neurological or monocular symptoms
• Symptoms and signs should fit within a vascular territory
• Negative symptoms rather than positive symptoms
  
  • numbness
• a higher examination score means a more sever stroke

Question 3

What is on the NIH stroke Scale

Answer 3

• 0 No stroke symptoms
• 1–4 Minor stroke
• 5–15 Moderate stroke
• 16–20 Moderate to severe stroke
• 11 items on the list

Question 4

What is the vascular territories of the brain?

Answer 4

Question 5

What is an ACA infarct?

Answer 5

• Anterior Cerebral Infarct
• Presents as contralateral hemiparesis with loss of sensibility in the foot and lower extremity,
  
  • sometimes with urinary incontinence.
• This is due to the involvement of the medial paracentral gyrus.

Question 6

What is a Left MCA infarct?

Answer 6

• Left Middle Cerebral Artery Infarct (most common)
  
  • it supplies most of the frontal, parietal and temporal lobes
• Presents with Dysphasia, right-sided weakness/ numbness

Question 7

What is a Right MCA infarct?

Answer 7

• Right Middle Cerebral Artery Infarct
• Presents with neglect, left-sided weakness/ numbness

Question 8

What is a Brainstem infarct?

Answer 8

• Presents with diplopia, visual field defects, facial weakness, contralateral limb weakness/numbness, incoordination

Question 9

What are the causes of Stroke?

(2 main)

Answer 9

• Haemorrhagic
  
  • circle of Willis
  • arterio-venous dysplasia
  • intracerebral haemorrhage
• Ischaemic
  
  • thromboembolic brain infarct
  • brain vessel thrombosis
  • embolus from extracranial thrombosis

Question 10

What imaging is done to distinguish the cause of stroke? (2)

• how would each type of stroke present

Answer 10

CT

• dark/low areas
• haemorrhage or clots would present as bright white on the scan

MRI

• Diffusion-weighted imaging (DWI) is a commonly performed MRI sequence for evaluation of acute ischemic stroke and is sensitive in the detection of small and early infarcts

Question 11

What is a Watershed Infarct?

Answer 11

Watershed cerebral infarctions (WI) , also known as border zone infarcts occur at the border between cerebral vascular territories where the tissue is furthest from arterial supply and thus most vulnerable to reductions in perfusion.

Question 12

What is Critical Ischaemia?

• what imaging can be done?

Answer 12

• when there is high metabolic demand of the brain - no glucose score
• may be due to a clot that reduces perfusion of the brain
• <20ml/100g/min
  
  • the electrical function stops - neurons are still alive, potentially salvageable
  • reversible ischaemia - only for a limited time
• <10ml/100g/min
  
  • neuronal death within minutes -
  • irreversible ischaemia - cerebral infarction
• CT perfusion imaging - greener the better

Question 13

What is the treatment/ management of ischaemic clot?

Answer 13

• tPA (tissue Plasminogen Activator)
  
  • clot dissolver
• Stent retrieval
  
  • CT angiogram with die
• Anti-platelet medication to prevents clotting
  
  • Aspirin after 24hrs (not with tPA or else it causes bleeding)
  • Clopidogrel after 2 weeks

Question 14

What are vascular risk factors for Stroke?

Answer 14

• Diabetes: promotes prothrombotic state, facilitates platelet adhesion
• Smoking: prothrombotic state, platelet activation and adhesion, endothelial injury
• Hypertension: shearing force on blood vessels, endothelial injury, prothrombotic state
• Hyperlipidaemia: lipid accumulation in foamy macrophages forms atherosclerotic plaques that can be dislodged and become a clot
• LDL: oxidised to free radicals –> promotes inflammation

stress

Question 15

What screening/ investigations can be done to screen for risk factors?

Answer 15

• ECG - regular rhythm of heart, clots may interrupt this
• Bloods- diabetes and hyperlipidaemia
• Ultrasound- to pick up a clot in the carotid bifurcation (dissected carotid)
• Echo- to see if there is a hole in the heart

Question 16

How is Carotid stenosis treated (clot in the carotid bifurcation)

Answer 16

• the plaque is removed and the artery is closed up

Question 17

What are the 3 factors that makeup Virchow’s triad?

Answer 17

• Hypercoaguable state
• Circulatory stasis
• Vascular wall injury

Question 18

What are the 5 TOAST subtypes of ischaemic stroke?

Answer 18

• Large artery atherosclerosis
• Cardioembolism
• Small vessel occlusion
• Stroke of other determined aetiology
• Stroke of undetermined aetiology

Question 19

What are Initial/Acute Speech and language THerapy concerns after a stroke?

Answer 19

• Ability to swallow
  
  • carried out by a trained nurse, with various types of foods starting with half teaspoons of water
  • looking for distress, pocketing food, and wet speech
• If they fail, they are NBM with
  
  • ​1/2 tsp of water, NG tube (team decision) and mouthcare
• try and identify which CN is causing the impairment
  
  • ​CN V, VII, XII
• Assess communication abilities​

Question 20

What are the four main communications diagnoses to consider in speech and language therapy?

Answer 20

• Expressive and receptive dysphasia:
  
  • difficulty in putting words together to make meaning
  • Aphasia: a cognition communication disorder, damage to the areas of the brain responsible for language comprehension and expression,
• Verbal dyspraxia
  
  • difficulty with voluntary control and voluntarily controlling the movements of the tongue and lips to make speech sounds and to speak clearly
• Dysarthria
  
  • muscles weakness, the person knows what they want to say but the muscle is weak so speech sounds slurred

Question 21

What is a videofluoroscopy used for in SLT?

Answer 21

investigation for dysphagia used to show the movement of food

checking if the person has a safe swallow

Question 22

What are Post-Stroke problems that impact on therapy?

(give 5)

Answer 22

• Contractures
• Tissue Breakdown/Pressure Sores
• Stiffnesss within joints, especially when artritic
• Muscle Tone changes
• Respiratory Complications
• Urinary Problems
• Pain
• Circulatory Problems
• Depression and Anxiety
• Personality changes
• Osteoporosis
• CV Deconditioning
• Hygiene difficulties
• Oedema
• Constipation
• Special senses effected
• Dysphasia
• Motor weakness

Question 23

What are the 4 key types of Assessments carried out by Physiotherapy?

Answer 23

• Subjective Assessment
  
  • HPC, PMH, SH, DH, Input to date
• Objective Assessment
  
  • Vision, ROM, MRC, Tone, JPS, Sensation
• Functional Assessments
  
  • Bed Mobility, Lie to sit, Sitting balance, Sit to stand, Standing Balance, Transfers, Mobility
• Occupational Assessment
  
  • Role, Mood, Continence etc

Goal Setting

Question 24

What are further Assessments that a specialist OT could carry out based on the patients’ needs?

Answer 24

• Cognition
• Attention
• Memory
• Driving Advice
• Functional Tasks
• ADLs
• Perception
• Apraxia
• Sexual Advice

Question 25

What is the importance of neuroplasticity in physical therapy? (give 6 out of 10)

Answer 25

**_1. Use It or Lose It_** **_2. Use It and Improve It_** 3. **Specificity** - The nature of the training experience dictates the nature of the plasticity." From a treatment standpoint, specificity highlights the importance of tailoring an activity or exercise to produce a result in specific circuitry. _4. **Repetition Matters** – need hundreds of thousands of reps. 400 per day. Physio cannot do it alone in a 45 minute session. Hence the need for a 24 hour MDT approach._ 5. **Intensity Matters** – follows the same principle above that you need sufficient intensity, how many sessions, how long etc. Again showing more intensive therapy is more productive and has more lasting results. 6. **Time Matters -** Different forms of plasticity occur at different times during recovery. Early training shows more lasting results. However increasing evidence is showing even if therapy starts late it makes improvements. _7. **Salience Matters** - the more important to the patient it is the better the neuroplasticity._ 8. Age Matters – Younger brains are more plastic. 9_. **Transference or Generalization** – skills learnt in therapy need to be transferable to “real life” environments._ 10. _**Interference** - often have to balance new skills with unlearning learnt behaviour (compensatory movements)_

Question 26

What is hypertonia? - two causal branches

Answer 26

It is _an abnormally high level of muscle tone or tension_ causal branches include * **CNS Damage (neural component)** * A direct result of blood alteration, ischaemia/haemorrhage, causing neuronal change and disordered information to be sent via corticospinal pathways. * **Biomechanical component** * Muscle shortening and lengthening for cross bridges in muscle fibres depending on the direction of pull

Question 27

Explain the development of hypertonia following a UNM lesion

Answer 27

* UNM lesion * Disordered information to the corticospinal pathways * Disordered Tone * Changes in the muscle reflexes * Loss of reciprocal innervation within the agonists and antagonists * this causes an abnormal pull on the muscle * Muscle contraction/crossing of actin and myosin bridges depending on the pull * Leading to reduce Thixotropy * Thixotropy = Muscle tissue has a curious mechanical property of becoming more pliable and flexible with repeated movement. This physical property is known as Thixotropy. Muscle, like paint, exhibits thixotropic properties: both become stiff and semisolid with disuse and are temporarily made more mobile by agitation * Leading to loss of elastin within the muscle * Contracture * A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff

Question 28

Define Spasticity

Answer 28

Disordered sensorimotor control resulting from an upper motor neurone lesion, presenting an intermittent or sustained involuntary activation of muscles (EU-Spasm 2005)

Question 29

What is the difference between Spasticity and Rigidity?

Answer 29

_Spasticity_ * Resistance in 1 direction * Characteristic posture changes * Sensitive to sensory input _Rigidity – Extra Pyramidal_ * Resistance in all directions * No static postural changes * Not Sensitive to sensory input * Cogwheel = rigidity plus tremor (in parkinsons)

Question 30

What other conditions can mimic stroke? | (give 4 of 8)

Answer 30

* Seizures * Tumour * Migraine * Bells palsy * Hypoglycaemia * Infection (and cerebral hypoperfusion) * Subdural haemorrhage * Functional disorder

Question 31

What is Bells Palsy - Key features/ presentation - difference from stroke - management

Answer 31

* Key feature is **LOWER MOTOR VII** palsy _(i.e. involvement of forehead/incomplete eye closure)_ * a stroke is forehead sparing * Gradual onset * Ask about recent viral illness, taste disturbance, headache, incoordination * May occur post-surgery for acoustic neuroma * Look for vesicles in the ear and mouth (Ramsey Hunt syndrome) * Management usually steroids for 1 week (with PPI cover), +/- aciclovir if signs VZV