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Brain Attack
Cerebrovascular Accident
OrStroke
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Stroke
Generic term for temporary or permanentdisturbance of brain function due to vasculardisruption (Brookshire) Also called cerebrovascular accident (CVA)
3rd leading cause of death in the USA; about500,000 per year----150,000 die from stroke
80% of pts. Survive for at least 1 mo. Post; about1/3 of those are alive 10 years post.
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The Five Most Common Stroke Symptoms Include:
Sudden numbness or weaknessof face, arm or leg, especially on one side of thebody
Sudden confusion, trouble speaking orunderstanding
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss ofbalance or coordination
Sudden severe headache with no known cause
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Other Important but less Common StrokeSymptoms Include:
Sudden nausea, fever and vomitingdistinguished from a viral illness by thespeed of onset (minutes or hours vs. several
days)
Brief loss of consciousness or period ofdecreased consciousness (fainting,confusion, convulsions or coma)
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Uncontrollable Stroke Risk Factors Include: Age The chances of having a stroke go up with age. Two-thirds ofall strokes happen to people over age 65. Stroke risk doubleswith each decade past age 55.
Uncontrollable Stroke Risk Factors Gender Males have a slightly higher stroke risk than females. But,because women in the United States live longer than men,more stroke survivors over age 65 are women.
Race
African-Americans have a higher stroke risk than most otherracial groups.
Family history of stroke or TIA Risk is higher for people with a family history of stroke or TIA.
Personal history of diabetes
People with diabetes have a higher stroke risk. This may bedue to circulation problems that diabetes can cause. Inaddition, brain damage may be more severe and extensive ifblood sugar is high when a stroke happens. Treating diabetesmay delay the onset of complications that increase stroke risk.However, even if diabetics are on medication and have bloodsugar under control, they may still have an increased stroke
risk simply because they have diabetes.
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Coronary Heart Disease and High Cholesterol
High cholesterol can directly and indirectly increase stroke riskby clogging blood vessels and putting people at greater risk ofcoronary heart disease, another important stroke risk factor. Acholesterol level of more than 200 is considered "high."Cholesterol is a fatty substance in the blood that our bodiesmake on their own, but we also get it from fat in the foods weeat. Certain foods (such as egg yolks, liver or foods fried inanimal fat or tropical oils) contain cholesterol. High levels ofcholesterol in the blood stream can lead to the buildup ofplaque on the inside of arteries, which can clog arteries andcause heart or brain attack.
Sleep Disordered Breathing - Sleep Apnea Sleep apnea is a major cardiovascular and stroke risk factorincreasing blood pressure rates which may cause stroke orheart attack. Studies also indicate that people with sleep apneadevelop dangerously low levels of oxygen in the blood whilecarbon dioxide levels rise, possibly causing blood clots or evenstrokes to occur. Diagnosing sleep apnea early may be animportant stroke prevention tool.
Personal history of stroke or TIA
People who have already had a stroke or TIA are at risk forhaving another. After suffering a stroke, men have a 42 percentchance of recurrent stroke within five years, and women have a24 percent chance of having another stroke. TIAs are also
strong predictors of stroke because 35 percent of those whoexperience TIAs have a stroke within five years.
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Lifestyle Factors that Increase Stroke Risk Include:
Smoking
Smoking doubles stroke risk. Smoking damages bloodvessel walls, speeds up the clogging of arteries bydeposits, raises blood pressure and makes the heartwork harder.
Alcohol
Excessive consumption of alcohol is associated withstroke in a small number of research studies. Its specificrole in stroke has not yet been determined or proven.Recent studies have also suggested that modest alcoholconsumption (one 4 oz. glass of wine or the alcoholequivalent) may protect against stroke by raising levels ofa naturally occurring "clot-buster" in the blood.
Weight
Excess weight puts a strain on the entire circulatorysystem. It also makes people more likely to have otherstroke risk factors such as high cholesterol, high bloodpressure and diabetes.
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The Impact of Stroke Risk Factors
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Most strokes occur in the 7 th decade
85% of survivors return to prestroke-livingenvironment (with some residualimpairment)
15 % require institutional care(Greenberg, Aminoff, and Simon, 1993)
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Ischemic deprived of blood Sometimes called occlusive
Hemorrhagic caused by bleeding
Loss of blood flow for 3-5 minutes causesnecrosis of the CNS Infarct---death of tissue caused by
interruption of blood supply
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Ischemic Stroke
Thrombotic Artery is gradually
occluded by a plug of material the collects ina given site
Uncommon in smallerarteries
Usually in areas of disturbance like twistsand bends in an artery
Atherosclerosis: Greek hard paste
Embolic Artery is suddenly
occluded by materialthat moves thought hevascular system toocclude an artery
Often a fragment froma thrombosis
Atrial fibrillation is acommon cause
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Transient Alchemic Attack (TIA)
Temporary disruptions of circulation, e.g,less than 24 hours in length
Quickly developing: Sensory disturbances, limb weakness, slurred
sph., visual complaints, dizziness, confusion, or
mild aphasia
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RIND and PRINDs
Reversible ischemic neurologic deficits(less than 24 hours)
Partially reversible ischemic neurologicdeficits (longer than 24 hours but leaveminor deficits after a few days
TIAs sometimes called small strokes
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Greenberg et al. (1993) 1/3 of pts who have TIAs or RINDs will
within 5 years have a stroke that leavesthem with permanent neurologic deficits
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Hypofusion
Insufficient blood flow to the brain and thebrain stem
Diaschisis---disruption of brain function inregions AWAY from the site of injury (butconnected by neural pathways (withinsystem) Edema, decreased blood flow,
neurotransmitters and diaschisis help diffuseimpairment of brain function!
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Hemorrhagic stroke
(cerebral hemorrhage) Caused by disruption of a cerebral blood
vessel Due to weakness of the vessel wall, by
traumatic injury to the vessel or (rarely) byextreme fluctuation in BP
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Hemorrhages
Extracerebralhemorrhages
bleeding outside of thebrain Subarachnoid subdural
extradural
Intracerebralhemorrhages
Within brain substancebleed
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Intracerebral Hemorrhage
90% occur in pts with high BP Cause(s): hypertention pressure on arterial
walls or chronic hypertension weakeningof small penetrating arteries causingmicroaneurysms
Can cause snowball effect as thehemorrhage affects adjacent vessels
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Aneurysm
Pouches formed in arterial walls berry or saccular, term depends upon the shape
Nearly 50% of extracerebral aneurysms occurin the arteries at the base of the brain(vertebrals, basilar, internal carotid and Circleof Willis
Most are due to injury to MCA and ACA 2-3% occur in the posterior cerebral artery
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Berry Aneurysm
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Arteriovenous Malformation
Arteriovenous malformation Collections of dilated, thin-walled vein connected
to a tangled mass of equally thin-walled arteries. Usually present at birth; most will not live to 60s-70s
without a hemorrhage. Symptoms include headaches and CNS symptoms
Can be removed surgically or vessel is tied off
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AVF
Greatest risk is thepotential for
rupture andsubsequenthemorrhage
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Intracranial Tumors Primary site: point of origin
Secondary site: originated elsewhere andmoved
Relocation of tumor = metastasis--- mets
Primary tumors: usually cerebrum andcerebellum Occur at any age, most commonly age 25-50
MAY run in families hypothesis?
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Herniation Syndromes
Masses the force movement of brainsubstance (or brain stem)
Tumors: course is deterioration of function Early stage = lower intracranial pressure =
causes nonspecific alterations of cognition (
forgetfulness, drowsiness, blurred or doublevision, vertigo, lightheadedness, etc.
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Intracranial tumors, cont.
Inc. IC pressure = increased sig. Symptoms:e.g., lethargy, stupor, bifrontal and
bioccipital headaches (unaffected byanalgesic meds), vomiting, imbalance.
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Symptoms Determined by Cell
Type and Growth Rate Gliomas: most common form---2 particular
types are astrocytoma and glioblastoma
multiforme Astrocytoma: usually benign, slow growth, 5-6year development
Glioblastoma Mul.: a most malignant and
rapidly growing intracranial mass Develops in 3-12 mo. average postsurgical
survival is only 6-9 months
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More IC Tumors--Primary
Meningioma: arise from the ________?? Most benign of all, very slow growing, well-
defined margins, usually dont invade brainsubstance
Can usually be completely removed
Symptoms are usually site specific
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Secondary Intracranial tumors
Metastatic carcinoma---cells have migrated usually passed by bloodstream
Prognsosis is poor: mean survival rate: 2-6 mo. Primary sources of Met. CA are:
Breast most frequent occurrence Lung Pharynx/larynx---least frequent occurrence.
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Other causes of brain impairment
Hydrocephalus enlargement of the cerebralventricles
Obstructive hydrocephalus IVP intraventricular shunt---VP shunt
Infections: abscesses and meningitis brain abscess introduction of bacteria, fungus or
parasites into brain tissue from infection sitesomewhere in the body
40% of sources are nasal sinuses, ME and mastoid cells
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Viral infections
2 common sources: General infections (mumps/measles) and viruses
transmitted by bites (animal or insect) Equine encephalitis and rabies
Progression depends on the virus Slow: Jakob-Creutzfeld v. (Bovine Spongiform
Encephalitis)
Rapid: AIDs Tx is palliative: tx. Vital signs, nutrition, fluid
balance to help system rid virus
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Toxemia
Due to substances invading the NS thatinflame or poison nerve tissue
May result from: drug overdoses orinteractions, bacterial toxins (tetanus,botulism, diphtheria) or heavy metal
poisoning (lead and mercury)----WTC??? TX is to remove the substance
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Metabolic and Nutritional
Disorders Metabolic: rarely cause specific
communication disorders
Severe hypoglycemia can cause cerebraldysfunction
Nutritional: rare in the USA Wernickes Encephalopathy: thiamine
deficiency, usually associated with alcoholism Paralysis of eye muscles, incoordination, poor gait,
mental confusion
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Aphasias
Fluent Wernickes
Conduction Transcortical Sensory
NonFluent Brocas
Transcortical Motor Global
Other forms: Anomic Alexia and Agraphia Primary Progressive
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Post Stroke Considerations
Acute therapy Focuses on preservation of life and preventing
further expansion of injury due to the stroke Chronic Therapy
Rehabilitation with goal to reestablish the most
normal lifestyle as possible
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Acute Therapy
After ischemic stroke, the area of infarctionis surrounded by tissue that will either
recover or die: the ischemic penubra Routine tx have been vasodilators: inc. cerebral
blood flow and to inc. arterial pressure (toincrease blood into the area of infarct, and;
Corticosteroids used to reduce swelling of thebrain
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These neuroprotective measures have notbeen protective; most medical (acute)
treatments for ischemic stroke have beenlimited to preservation of life
Until 1995: National Institute of
Neurological Disorders and Stroke(NINCDS) study on t-PA
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Tissue Plasminogen Activator
t-PA A clot-buster: delivered intravenously; breaks up
the clot allowing blood flow to return to the
deprived area of the brain NINCDS found pts who recd t -PA within 3 hours of symptom onset have better recovery at 3 months postonset
Negative finding: after 36 hours there was in anincreased incident of intracerebral hemorrhage (6.4%) Mortality of t-PA group was lower after 3 months post
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1996, t-PA approved
For acute ischemic stroke, if Administered within 3 hours of stroke;
No sign of intracerebral hemorrhage as confirmedby CT; No previous stroke or head trauma in 3 mo prior to
dose; No major surgery in past 14 days before stroke; No hx of subarachnoid or intracranial hemorrhage; No hx of hypertension No hx of GI or urinary tract hemorrhage, and---
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No history of anticoagulant meds Heparin and Coumadin (Warfarin)
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IF criteria for t-PA were not met?
Tx requires identification of etiology orlocating the blockage in the internal carotid
or heart If carotid: tx of etiology is to remove thrombus
via Carotid Endarterectomy (CAE), or viaantiplatlets, e.g., aspirin
If heart (cardiogenic): Coumadin or Heparinare administered
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Chronic Therapy:
Rehabilitation Begins when pt is medically stable; initial
goal: ambulate, communicate and ADLs
2nd goal: stimulate sph production andlanguage use via social interactions
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Rehabilitation team
Physiatry,nursing, social services,psychology and, PT, OT, SLP and
vocational tx Settings: rehabilitation unit (inpatient),SNF, outpatient clinic, or at home.
Rehab unit qualifier: pt must be able tohandle 3 hours of activity per day
BBA of 1997? Fiduciary Cap.
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American Heart Association
6 major areas of stroke rehab:1: handle concurrent illnesses and complaints
2: maximize independence3: maximize psychosocial coping of family4: promote reintegration
5: improve quality of life6: prevent recurrent vascular events
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Primary Indicator of Recovery?
1) Severity of neurological impairment. The more severe the damage and subsequent
impairments, the longer the hospital stay, themore complicated the treatment plan, thelonger the recovery process
2) Degree of communication impairment:global aphasia or hemineglect tend toperform poorly in rehab
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Contraindicators of
Rehabilitation Psychiatric Disorders;
Dementias, Apathy Syndrome, Negative
Symptom Complex Not a functional loss: these conditions have
less ambition, less motivation, poor effort tosucceed, etc.