1
Q
What are the social impacts of having a stroke?
A
- 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
2
Q
What are key features of a clinical assessment in someone presenting with stroke?
A
- 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 severe stroke
3
Q
What is on the NIH stroke Scale
A
- 0 No stroke symptoms
- 1–4 Minor stroke
- 5–15 Moderate stroke
- 16–20 Moderate to severe stroke
- 11 items on the list
4
Q
What is the vascular territories of the brain?
A
5
Q
How does a Total Anterior Circulation (TAC) stroke present?
what areas of the brain are affected and what is the prognosis?
A
presents with all of the following being affected
- motor or sensory
- cortical
- hemianopia
Suggests a global involvement of the anterior and middle cerebral artery and sometimes the posterior cerebral artery
60% dead at 1 year
35% dependant at 1 year
6
Q
How does a Partial Anterior Circulation (TAC) stroke present?
what is the prognosis?
A
presents with 2 of the following being affected
- motor or sensory
- cortical
- hemianopia
20% dead at 1 year
30% dependant at 1 year
7
Q
How does a Lacunar stroke present?
what is the prognosis?
A
presents with motor or sensory signs only
10% dead at 1 year
25% dependant at 1 year
8
Q
DASHING
What are cerebellar signs?
A
DASHING
- Dysdiadokinesia & Dysmetria: inability to perform rapidly changing hand movements
- Ataxia: gross incoordination of muscle movements
- Slurred speech: imprecise, slow, distorted
- Hypotonia: on the side of the lesion
- Intentional tremor: wide tremor during intentional movements e.g holding out hand
- Nystagmus: repetitive, involuntary oscillation of the eyes, and potential blurred vision
- Gait issues: broad-base/ rolling gait (side to side more than usual)
9
Q
How does a Posterior Circulation present?
what is the prognosis?
A
Hemianopia, brain stem signs, cerebellar signs
20% dead at 1 year
20% dependant at 1 year
10
Q
How does an Anterior circulation stroke present?
A
- Unilateral weakness
- Unilateral sensory loss or inattention
- Isolated dysarthria
- Dysphasia
- Vision: h. hemianopia, m. blindness, v. inattention
11
Q
What is an ACA infarct and how does it present?
A
- 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.
12
Q
What is a Left MCA infarct?
A
- Left Middle Cerebral Artery Infarct (most common)
- it supplies most of the frontal, parietal and temporal lobes
- Presents with Dysphasia, right-sided weakness/ numbness
13
Q
What is a Right MCA infarct?
A
- Right Middle Cerebral Artery Infarct
- Presents with neglect, left-sided weakness/ numbness
14
Q
How does a Posterior circulation stroke present?
A
- Isolated h. hemianopia
- Diplopia and disconjugate eyes
- Nausea and vomiting
- Incoordination and unsteadiness
- Unilateral or bilateral weakness and/or sensory loss
- Non specific signs
15
Q
What is a Brainstem/ infarct?
A
- Presents with diplopia, visual field defects, facial weakness, contralateral limb weakness/numbness, incoordination
16
Q
What are the causes of Stroke?
(2 main)
A
- Haemorrhagic
- circle of Willis
- arterio-venous dysplasia
- intracerebral haemorrhage
- Ischaemic
- thromboembolic brain infarct
- brain vessel thrombosis
- embolus from extracranial thrombosis
17
Q
What imaging is done to distinguish the cause of stroke? (2)
- how would each type of stroke present
A
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 the evaluation of acute ischemic stroke and is sensitive in the detection of small and early infarcts
18
Q
What is a Watershed Infarct?
A
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.
19
Q
What is Critical Ischaemia?
- what imaging can be done?
A
- 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
20
Q
What is the treatment/ management of ischaemic clots?
A
All patients are considered high risk
Sinus rhythm patients
- 300mg Aspirin (high dose) - Anti-platelet medication to prevent clotting
- referral to specialist assessment (not with tPA or else it causes bleeding)
- Clopidogrel 75 mg long termafter 2 weeks
→ Patients with AF: Warfarin or DOAC (rivaroxaban, apixaban, dabigatran) : along with heart monitoring
- Alteplase: tPA (tissue Plasminogen Activator)- clot dissolved:
- up to 6 hours from onset of stroke increases the chance of a near-complete recovery
- Stent retrieval: CT angiogram with dye
21
Q
What are vascular risk factors for Stroke?
A
- 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
22
Q
What screening/ investigations can be done to screen for risk factors?
A
- ECG - the regular rhythm of the heart, clots may interrupt this
- Bloods- diabetes and hyperlipidaemia
- FBC, ESR, clotting, electrolytes and creatine, fasting glucose and lipids, urinalysis
- Thrombophilia screen
- Vasculitic screen
- CXR
- Ultrasound (Carotid doppler)- to pick up a clot in the carotid bifurcation (dissected carotid)
- Echo- to see if there is a hole in the heart (patent foreman ovale)
23
Q
How is Carotid stenosis treated (clot in the carotid bifurcation)
A
- the plaque is removed and the artery is closed up
24
Q
What are the 3 factors that makeup Virchow’s triad?
A
- Hypercoaguable state
- Circulatory stasis
- Vascular wall injury
25
What are the 5 TOAST subtypes of ischaemic stroke?
* Large artery atherosclerosis
* Cardioembolism
* Small vessel occlusion
* Stroke of other determined aetiology
* Stroke of undetermined aetiology
26
What are Initial/Acute Speech and language Therapy concerns after a stroke?
* 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
27
What are the four main communications diagnoses to consider in speech and language therapy?
* **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
28
What is a videofluoroscopy used for in SLT?
investigation for dysphagia used to show the movement of food
checking if the person has a safe swallow
29
What are Post-Stroke problems that impact on therapy?
(give 5)
* 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
30
What are the 4 key types of Assessments carried out by Physiotherapy?
* 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
31
What are further Assessments that a specialist OT could carry out based on the patients' needs?
* Cognition
* Attention
* Memory
* Driving Advice
* Functional Tasks
* ADLs
* Perception
* Apraxia
* Sexual Advice
32
What is the importance of neuroplasticity in physical therapy?
(give 6 out of 10)
**_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)_
33
What is hypertonia?
- two causal branches
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
34
Explain the development of hypertonia following a UNM lesion
* 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
35
Define Spasticity
Disordered sensorimotor control resulting from an upper motor neurone lesion, presenting an intermittent or sustained involuntary activation of muscles (EU-Spasm 2005)
36
What is the difference between Spasticity and Rigidity?
_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)
37
What other conditions can mimic stroke?
| (give 4 of 8)
* Seizures
* Tumour
* Migraine
* Bells palsy
* Hypoglycaemia
* Infection (and cerebral hypoperfusion)
* Subdural haemorrhage
* Functional disorder
38
What is Bells Palsy
- Key features/ presentation
- difference from stroke
- management
* 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
39
What are the Non-Modifiable risk factors of Stroke?
* Age
* Male sex
* Family history
* Previous stroke
* Ethnic origin: African, Caribbean, South-asians
40
What are the Modifiable risk factors for Stroke?
* Hypertension
* Diabetes Mellitus
* Atrial fibrillation
* High cholesterol
* Carotid stenosis
* Thrombotic tendency
* Transient ischaemic attacks (TIA)
* Smoking
41
What is the definition of a Stroke?
A clinical syndrome characterized by rapidly developing symptoms and/or signs of focal and at times global, loss of cerebral function with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.
42
What is the pathophysiology of Stroke?
* Ischaemia from atherothrombotic occlusion or embolism (85%)
* Left atrium in patients with atrial fibrillation
* Left ventricle in patients with myocardial infarction or heart failure
* Primary haemorrhage causing direct neuronal injury, and pressure effects (15%)
43
What are common symptoms of a stroke?
* **Hemiparesis/ monoparesis**
* *Hemisensory loss**
* **Hemianopia**
* **Hemineglect**
* **Dysphasia**
* **Squint / double vision**
* **Vertigo**
* **Balance and coordination problems**
44
What are atypical/ non-specific symptoms of a stroke?
* Altered consciousness
* Dizziness
* ‘Confusion’
* ‘Off legs’
* Headache
* Vomiting
45
What signs are examined in a clinical setting when a patient presents with a stroke?
* Conscious level
* Neurological signs
* Blood pressure
* Heart rate and rhythm
* Peripheral pulses
46
What are therapeutic approaches to the treatment of an acute ischaemic stroke?
* Canulise the occluded artery
* improve regional blood flow in the penumbra
* Reduce cerebral oedema
* Reduce energy requirements of the ischaemic brain
* Protect ischaemic neuronal cells by inhibiting overexcitation and blocking calcium channels
* Prevent the immune response
47
What is the full medical management of a stroke?
* Aspirin 300mg daily for two weeks
* Iv fluids-2L N/S per 24hrs
* Oxygen 2L via nasal cannulae if oxygen saturation is \<94%
* Antihypertensives should not be used to treat moderately high BP acutely unless BP is \>220/120 mm HgMetropol
* Metropolol/Labetalol
* Current anti-hypertensives should be continued
* Heparin increases the incidence of bleeding into an infarct (2 weeks) and has no benefit in terms of mortality or function
48
When would Neursosrugery be used?
* Large cerebellar infarct or bleed
* Acute hydrocephalus
* Iv Mannitol
* Craniectomy
49
What would be used to reverse anticoagulants and when?
Used in a Primary intracerebral haemorrhage
* Fresh frozen plasma
* Vitamin k
* Tranexamic acid
50
What are early complications of Stroke?
* Hyperglycemia (BM\>12)
* Hypertension
* Fever
* Infarct extension or rebleeding
* Cerebral oedema, herniation
51
What are the late complications of stroke?
* Aspiration pneumonia
* Urinary tract infection (from catheterization)
* Deep vein thrombosis (\intermittent Pneumatic Compression stockings)
* Pulmonary embolism
* Incontinence
* Pressure sores
* Depression/anxiety
* Seizures
* Pain
306: Elderly
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