Stroke

NEUROPT HJS2073
STROKEMOHD NUH DANIAL BIN ROSDI
HDD12031406
PN. FATMA HAIZUNI

CONTENTS
Introduction
Definition
Risk Factor
Aetiology
Types
Classification

Introduction
Results from ischemia to a part of the brain or
hemorrhage into the brain that results in death of
brain cells.
In 2005, 17,909 stroke victims were admitted into
government hospitals alone throughout the country.
Of these, 3,245 of them were fatal. By 2020, this
figure is expected to exceed 25,000 every year.

Approximately 750,000 in USA annually
Third most common cause of death
1 leading cause of disability
25% with initial stroke die within 1 year
50-75% will be functionally independent
25% will live with permanent disability
Physical, cognitive, emotional, & financial impact

Blood Supply of the brain
 Anterior: Carotid Arteries – middle & anterior
cerebral arteries
 frontal, parietal, temporal lobes; basal ganglion; part of the
diencephalon (thalamus & hypothalamus)
Posterior: Vertebral Arteries – basilar artery
 Mid and lower temporary & occipital lobes, cerebellum,
brainstem, & part of the diencephalon
Circle of Willis – connects the anterior & posterior cerebral
circulation

Definition
A stroke occurs when the blood supply to part of your brain is
interrupted or severely reduced, depriving brain tissue of oxygen and
food. Within minutes, brain cells begin to die.

Risk Factor
Lifestyle risk factors:
 Being overweight or obese
 Physical inactivity
 Heavy or binge drinking
 Use of illicit drugs such as cocaine and methamphetamines
 Potentially treatable risk factors
 High blood pressure — risk of stroke begins to increase at blood pressure
readings higher than 120/80 millimeters of mercury (mm Hg). Your doctor will
help you decide on a target blood pressure based on your age, whether you
have diabetes and other factors.

 Cigarette smoking or exposure to secondhand smoke.
 High cholesterol — a total cholesterol level above 20 milligrams per
deciliter (5.2 millimoles per liter).
 Diabetes.
 Obstructive sleep apnea — a sleep disorder in which the oxygen
level intermittently drops during the night.
 Cardiovascular disease, including heart failure, heart defects, heart
infection or abnormal heart rhythm.

Other risk factors
Personal or family history of stroke, heart attack or transient ischemic attack.
 Being age 55 or older.
Race — African-Americans have higher risk of stroke than do people of other races.
Gender — Men have a higher risk of stroke than women. Women are usually older
when they have strokes, and they are more likely to die of strokes than are men. Also,
they may have some risk from some birth control pills or hormone therapies that
include estrogen, as well as from pregnancy and childbirth.

Aetiology
A stroke occurs when the blood supply to your
brain is interrupted or reduced. This deprives
your brain of oxygen and nutrients, which can
cause your brain cells to die.
A stroke may be caused by a blocked artery
(ischemic stroke) or a leaking or burst blood
vessel (hemorrhagic stroke). Some people may
experience a temporary disruption of blood flow
through their brain (transient ischemic attack, or
TIA).

Hypertension
Smoking
Heart disease-atrial fibrillation
Tumor
Infection

Acute stroke
Prognosis
• Stroke is the second leading cause of death
worldwide.
• Mortality rates are declining, however. Over
75% of patients survive a first stroke during
the first year, and over half survive beyond 5
years.

Complication
• Paralysis or loss of muscle movement.
• Difficulty talking or swallowing.
• Memory loss or thinking difficulties.
• Emotional problems.
• Pain.
• Changes in behavior and self-care.

Classification
Transient Ischemic Attack
 Temporary focal loss of neurologic function
 Caused by ischemia of one of the vascular territories of the brain
 Microemboli with temporary blockage of blood flow
 Lasts less than 24 hrs – often less than 15 mins
 Most resolve within 3 hours
 Warning sign of progressive cerebrovascular disease

subarachnoid
haemorrhage, which
occurs in the space
around the brain
intracerebral
haemorrhage, the more
common type, which
involves bleeding within
the brain tissue itself.
*Results from uncontrolled HPT and aneurysm

Pathophysiology
Ischaemic stroke
• Ischaemic strokes are due to an interruption in the blood supply to a
certain area of the brain which leads to the ischaemia, Infarction and
eventual necrosis of tissue. Ischaemic strokes are further divided into
global and focal strokes.
• Global strokes affect either the whole brain, watershed regions (those
most vulnerable to reduced blood supply) or selectively vulnerable areas.
• Focal strokes are described as large (regional) or small (lacunar) and are
directed to a particular area of the brain tissue. Focal strokes are very
common in the region of the brain that is supplied by the Middle Cerebral
Artery.

• Image showing the supply regions of the cerebral vessels.
ACA: Anterior cerebral artery; MCA: Middle cerebral artery;
PCA: Posterior cerebral artery.

Total anterior
cerebral infarctions
(TACI)
Partial Anterior
Cerebral Infarctions
(PACI)
Posterior Cerebral
infarctions (POCI)
Lacunar Cerebral
Infarction (LACI)
 give hemiplegia
contralateral to
the brain lesion,
hemianopia
contralateral to
the brain lesion
and a new
disturbance of
higher function.
 They occur in
occlusion of the
middle cerebral
artery trunks.
 gives one or a
combination of
motor/sensory
deficits,
hemianopia and
new higher
cerebral
dysfunction.
 They result in
occlusion of the
Middle Cerebral
Artery trunk with
good Anterior and
Posterior Cerebral
Artery Collaterals
circulation.
 give unequivocal
brainstem features
– isolated
hemianopia or
cortical blindness,
ipsilateral cranial
nerve palsy with
contralateral
motor/sensory
deficits, bilateral
motor/sensory
deficits, disorders
of conjugate eye
movement and
cerebellar
dysfunction
without ipsilateral
long tract deficit.
 involve sensory
and/or motor
systems, they are
specifically caused
by occlusion of the
lenticulostriate
artery (small
branches of the
middle cerebral
artery).

Percentages of ischemic stroke accoding to the
vessels
TACI (17%) POCI (24%) PACI (34%) LACI

• Haemorrhagic strokes are due to the rupture of a blood
vessels leading to compression of brain tissue from an
expanding haematoma. In addition, the pressure may lead to
a loss of blood supply to affected tissue with resulting
infarction.

Intracerebral haemorrhage
Intracerebral haemorrhage is the accumulation of blood anywhere within
the brain, i.e. – intraparenchymal haemorrhage, intraventricular
haemorrhage.
This will form a gradually enlarging haematoma (blood
pool).
Intracerebral Haemorrhages can be
caused by local vessel abnormalities
(hypertension, vasculitis, vascular
malformation) or systemic factors
(drugs, trauma, tumours and sickle
cell anaemia/leukaemia).
Haemorrhaging directly
damages brain tissue and
raises intracranial pressure
giving headaches, vomiting
nausea and eventually coma
and death.

Subarachnoid haemorrhage
Subarachnoid haemorrhage is the gradual collection of
blood in the subarachnoid space of the Dura.
These can be traumatic or
spontaneous. Spontaneous
haemorrhages occur through saccular
(berry) aneurysms and through
extensions of intracranial
haemorrhaging or due to similar
causes.
Approximately one third of
those who suffer a
subarachnoid haemorrhage
die.

Stroke sh.
Prevention
• electrical stimulation
• Supportive devices
Slings
wheelchair attachments
External shoulder orthoses such as strapping

Treatment
• Shoulder strapping within 48 hours of stroke may delay the
onset of HSP –consider referral to a physiotherapist.
• Functional Electrical Stimulation (FES) may improve
humeral lateral rotation and reduce glenohumeral
subluxation –consider referral to physiotherapist.
• While exercising is recommended after stroke, it is
important not to persist with movements which exacerbate
shoulder pain.
• Normal anatomical alignment should be maintained as
much as possible

Dr.’s Management
Dr. Ax
• CT scan:
– This is also called a CAT scan. A special x-ray machine uses a computer to take
pictures of your brain. It may be used to look at bones, muscles, brain tissue,
and blood vessels.
– You may be given dye before the pictures are taken. The dye is usually given in
your IV. The dye may help your caregiver see the pictures better. People who
are allergic to iodine or shellfish (lobster, crab, or shrimp) may be allergic to
some dyes. Tell the caregiver if you are allergic to shellfish, or have other
allergies or medical conditions.
• Magnetic resonance imaging: Using magnetic waves, this test, also called
an MRI, takes pictures of your head. An MRI may show the cause of a CVA.
• Carotid ultrasonography
• Arteriography

ultrasonographic examinations were
performed before the arteriography.
A Carotid ultrasound shows the
amount of blood flow carotid arteries,
the major blood vessels to the brain
located on either side of the neck.
Site of cerebral arteriography;
Cerebral arteriography

Dr.’s Tx
• Ischemic stroke: An ischemic stroke includes strokes caused
by a blockage in a blood vessel.
– Anticoagulant medicine: Treatment for an ischemic stroke
includes anticoagulant medicines which are also called blood
thinners. This medicine group keeps clots from forming in the
blood.
– Antiplatelet aggregating medicine: These medicines interact
with platelets to prevent blood clots from forming. Platelets are
a type of blood cell that join to form clots.
– Thrombolytic medicine: This medicine group is used in a stroke
caused by a clot in a blood vessel. Thrombolytics break apart
clots and restore blood flow.
• Hemorrhagic (bleed) stroke: This type of stroke may
require surgery.

Exercises to
improve
strength,
flexibility and
cardio-vascular
fitness.
Retraining
movement to
achieve
improve
coordination,
balance and
control.
Spasticity
management.
Contracture
management.
Management
of shoulder
subluxation
and shoulder
pain.

Mobility retraining to
improve independence
and provide access to
social, leisure and
community-based
activities.
Education and
support for the
person, their family
and carers in
managing physical
impairments.
Assessment for aids
and appliances such
as splints, braces and
wheelchairs.
Ambulation.

PT Tx
Improving motor control
These therapeutic interventions use sensory
stimuli (e.g. quick stretch, brushing, reflex
stimulation andassociated reactions) ,which are
based on neurological theories, to facilitate
movement in patients following stroke.
Limb physiotherapy
Limb physiotherapy includes passive, assisted-
active and active range-of-motion exercise for the
hemiplegic limbs.
This can be an effective management
for prevention of limb contractures and spasticity

Chest physiotherapy cough and forced expiratory
technique (FET) for bronchial hygiene clearance in
stroke patient.
Balance retraining
Early mobilisation the act of getting a patient to
move in the bed, sit up, stand, and eventually
walk.
People with acute stroke should be mobilised as
soon as possible within the first 3 days after
stroke (when their clinical condition permits).

Tone management
stretching, prolonged stretching, passive manipulation
by therapists, weight bearing, ice, contraction of
muscles antagonistic to spastic muscles, splinting, and
casting.
Electrical Stimulation could be used for tone
management
 Oedema management
Use of intermittent pneumatic pump, elastic stocking
or bandages and massage can facilitate the venous
return of the oedematous limbs and to prevent
complications like pressure ulcer.

Gait re-education
Treadmill training combined with use
of suspension tube.
 Functional Mobility Training
These tasks include bridging, rolling to sit
to stand and vice versa, transfer skills, walking
, stairing and earlier ambulation.

Tips for Standing
Hands must push off from bed/chair . do not
allow patient to hold onto frame/stick.
Never pull or lift patient using the affected arm.
Consider use of sling if arm is completely flaccid.
Think about foot placement, hand and buttock
position and use of momentum/verbal cues.

Positioning
strategy to discourage the development
of abnormal tone, contractures, pain and
respiratory complications.
It is an important element in maximizing the
patient's functional gains and quality of life.

Positioning
Lying on affected side
•One or two pillows for
head.
•Affected shoulder
positioned comfortably.
• Place unaffected leg
forward on one or two
pillows.
•Place pillows in front or
behind to give support.

Lying on unaffected side
•One or two pillows for
head.
•Affected arm forward and
supported on pillow(s)
•Affected leg backwards
on one or two pillows.
•Place pillow behind.

Sitting in bed
• Sitting in bed is
desirable for short
periods only.
•Must be upright and well
supported with pillows.
• Consider extra support
using pillows under arms
or knees.

Lying on back (if desired)
• Place three pillows in a
‘triangle’, supporting
shoulders and head.
•Place affected arm on
pillow.
• Ensure feet in a neutral
position.

HEP / Advise
• Family members help the person regain lost
skills by encouraging them to use the affected
arm or leg, helping them with their speech or
teaching them how to do tasks which may
have been forgotten, such as combing their
hair or using a cup, knife and fork.

Prevention
• Take your high blood pressure medicine regularly.
• Do not smoke or drink too much alcohol. Alcohol is found in beer, wine,
liquor, like vodka or whiskey, and other adult drinks. Different people have
different ideas about what too much means. It is important to remember
that how often you drink is as important as how much you drink.
• If you have atrial fibrillation (an irregular or fast heart beat), you may need
to take antithrombotic medicine. Having a recent heart attack may also
require you to take antithrombotics.
• Keep your blood cholesterol level in a normal range. Eat foods low in fat to
decrease the risk of developing plaque (fatty deposits) in your blood
vessels. If you have hyperlipidemia (high blood cholesterol level), talk to
your caregiver about ways to lower it.
• Monitor and control your blood sugar level if you have diabetes.

References
• http://neuro4students.wordpress.com/pathop
hysiology/
• http://www.drugs.com/cg/cerebrovascular-
accident.html
• http://www.mayoclinic.org/diseases-
conditions/stroke/basics/prevention/con-
20042884

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