Stroke

Introduction

According to the World Health Organization, stroke is defined as an accident of the brain, the clinical symptoms of which rapidly develop into focal or global disturbances of brain function, symptoms persist for 24 hours or more, or result in death, without other obvious symptoms other than vascular origin cause, and Including cerebral infarction cerebral hemorrhage and subarachnoid hemorrhage.

Acute stroke is also often referred to as a cerebrovascular accident, which is not the term preferred by most stroke neurologists. A stroke is not an accident. A better and more meaningful term is brain attack, which has a similar meaning to a heart attack. [1]

There are two main types of strokes[1].

• The civilian type is an ischemic stroke caused by interruption of blood flow to a specific area of the brain. Ischemic stroke accounts for 85% of all acute strokes. According to the TOAST classification, there are four main types of ischemic stroke. These are large vessel atherosclerosis small vessels Disease (lacunar infarction) cardiogenic stroke and cryptogenic stroke (see left hand picture).
• Fifteen percent of acute strokes are hemorrhagic strokes caused by a ruptured blood vessel, i.e. acute bleeding. There are two main types of hemorrhagic strokes: intracerebral hemorrhage (ICH) and subarachnoid hemorrhage, accounting for about 5% of all strokes (see right-hand picture)

Regardless of the type of stroke, it is important to know that nearly 2 million neurons die every minute in an untreated large vessel ischemic stroke. This is the most important time to understand acute stroke and its treatment is the brain concept.

Epidemiology/ Etiology

Stroke-deaths-by-age

According to the World Health Organization (WHO), 15 million people worldwide suffer from a stroke each year. Of these, 5 million died and another 5 million were permanently disabled. [2] According to the 2010 Global Burden of Disease Study, stroke is the second leading cause of death and the third leading cause of death globally Leading causes of premature death and disability as measured in disability-adjusted life years (DALYs). Cerebrovascular disease is the largest neurological disorder, accounting for 4.1% of all DALYs worldwide.

In the United States, there are 800,000 new strokes each year. There is a new trip every 40 seconds. Stroke is the 5th leading cause of death and the 1st leading cause of disability. [1] Over 49,000 people in the UK die from stroke each year, nearly one in 10. Stroke was the fourth leading cause of death in 2010 Heart disease and respiratory disease are the second leading causes of death in the UK after cancer. [3]

There are many causes of stroke. Some of the most common risk factors include [1]

• High blood pressure, diabetes, high cholesterol, lack of exercise, obesity, genetics and smoking.
• Cerebral embolisms often originate in the heart, especially in patients with cardiac arrhythmias (atrial fibrillation), structural defects in valvular disease (atrial septal defect and ventricular septal defect), and chronic rheumatic heart disease.
• An emboli may become lodged in a pre-existing stricture.
• There is a J-shaped relationship between alcohol intake and ischemic stroke. Light to moderate alcohol consumption slightly reduces the risk of ischemic stroke, but heavy alcohol consumption greatly increases the risk. Alcohol consumption increases the risk of hemorrhagic stroke in a near-linear relationship.
  Read more about epidemiological incidence and global burden of stroke

Clinically Relevant Anatomy

At the base of the brain, the carotid and vertebrobasilar arteries form a ring of communicating arteries called the circle of Willis (see image below). Other arteries from this circle – anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery (PCA) – generated and propagated to all parts of the brain.

The image below clearly shows the functional areas of the cerebral cortex that may be affected by insufficient blood supply.

Injury Mechanism/Pathological Process

[4]

A stroke occurs when the blood supply to a specific area of the brain is interrupted, eventually leading to cell damage and cell death. Stroke can be broken down in two ways:

Ischaemic

Ischemic strokes are the most common, accounting for 80 percent of strokes, and occur when a blockage in a blood vessel affects blood flow to the brain.

Ischaemic Strokes are divided into:

1. Thrombosis – Formation of blood clots in the aorta of the brain or in small blood vessels deep in the brain. Clots usually form around atherosclerotic plaques.
2. Embolism – Clot bubbles or fat balls form in blood vessels elsewhere in the body and are carried to the brain.
3. Whole body hypoperfusion – a general decrease in blood supply, eg. 1. Shock 2. The development of small blood vessels (lacunar infarcts) caused by chronic uncontrolled hypertension, leading to the pathological entity of fatty hyalinosis and arteriolar sclerosis. These strokes occur within the basal ganglia Capsular thalamus and pons [1]. 3 Watershed strokes see link.
4. Venous Thrombosis

According to the TOAST [5] classification, there are four main types of ischemic stroke.

1. Large vessel atherosclerosis,
2. Small vessel disease (lacunar infarcts)
3. Cardioembolic strokes
4. Cryptogenic strokes

Haemorrhagic

1. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and bleeds.
2. Hemorrhagic stroke – bleeding from a blood vessel in the brain. High blood pressure is the main cause of cerebral hemorrhagic stroke.
3. Subarachnoid hemorrhagic stroke – bleeding in a blood vessel between the surface of the brain and the arachnoid tissue that covers the brain.

Notice. Some experts do not classify subarachnoid hemorrhage as a stroke because subarachnoid hemorrhage presents differently from ischemic and intracerebral hemorrhagic strokes.

Clinical Presentation

Strokes can occur in a predetermined syndrome due to the effects of reduced blood flow to specific areas of the brain related to test results. This enables clinicians to predict areas of the brain blood vessels that are likely to be affected.

Cortical areas and their vascular supply:

Location of Infarct & Deficits Produced

Left MCA Superficial Division

Motor cortex non-fluent (Broca’s area) aphasia due to damage to Broca’s area, resulting in motor weakness of the right face and upper arm. Cortical-type sensory loss of the right face and arm may also occur if the infarction involves the sensory cortex. Other deficiencies include fluent (Wernicke’s) Damage to Wernicke’s area leads to aphasia. [Aphasia: Impairment of Language Comprehension and Expression]

Right MCA Superficial Division

Weakness of movement on the left face and arm due to damage to the motor cortex. Left hemilateral vision (variable) due to damage to nondominant association areas. If the infarct involves the sensory cortex, cortical sensory loss of the left face and arm may also occur.

Left MCA Lenticulostriate Branches

Right pure superior motor hemiparesis due to damage to the basal ganglia (globus pallidus and striatum) and left internal capsular genu. Larger infarcts extending into the cortex may produce cortical deficits such as aphasia.

Right MCA Lenticulostriate Branches

Pure superior motor hemiparesis on the left due to damage to the basal ganglia (globus pallidum and striatum) and right genu of the internal capsule. Larger infarcts extending into the cortex may produce cortical deficits such as aphasia.

Left PCA

Right homonymous hemianopia due to damage to the left occipital visual cortex. Extending to the corpus interferes with the communication between the two visually associated areas, so it causes dyslexia without agraphia. Larger infarction involving internal capsule and thalamus possible Loss of sensation in the right hemisphere and right hemiparesis due to interruption of ascending and descending information through these structures. [Hematological anemia: loss of vision in half the field of view]

Right PCA

Left homonymous hemianopia due to damage to the right occipital visual cortex. Larger infarcts involving the internal capsule and thalamus may result in left hemisensory loss and left hemiparesis because of disruption of ascending and descending information through these sites structure.

Left ACA

Upper motor neuron weakness in the right leg due to damage to the motor cortex and loss of cortical sensation in the right leg due to damage to the sensory cortex. If the prefrontal cortex and supplementary motor area are involves.

Right ACA

Upper motor neuron weakness in the left leg due to damage to the motor cortex and cortical-type sensory loss in the left leg due to damage to the sensory cortex. If prefrontal cortex and non-dominant associative cortex are also seen Abnormal grasp reflex frontal lobe behavior and left sidedness participate.

[6][7][8]

Outcome Measures

NIH Stroke Scale

Dynamic Gait Index The 4-item Dynamic Gait Index and the functional gait assessment showed sufficient validity responsiveness and reliability for assessing walking function in stroke patients undergoing rehabilitation, but the functional gait assessment was is recommended for measuring Attributes [9].

Chedoke-McMaster Stroke Assessment

Chedoke Arm and Hand Activity Inventory

The CRS-R Coma Recovery Scale Revised is used to evaluate patients with impaired consciousness who are usually comatose.

Check out our stroke outcome measurement overview for more information

Differential Diagnosis

The differential diagnosis is broad and can include stroke-like symptoms such as TIA metabolic derangement (in other words, hypoglycemia, hyponatremia), hemiplegic migraine, infection, brain tumor, syncope, and conversion disorder. [1]

Management / Interventions

Early Management of Acute Stroke

The goal of acute care for stroke patients is to stabilize the patient and complete initial assessment and evaluation, including imaging and laboratory studies, in a short time. Key decision-making focused on the need for and determination of intubated blood pressure control Risk/benefit of thrombolytic intervention. [10]

Patients with a Glasgow Coma Scale score of 8 or less or a rapidly declining Glasgow Coma Scale score require emergency airway control by intubation.

A recent study demonstrated that high-intensity interval training and moderate-intensity continuous training improved gait in outpatients with chronic stroke. Moderate-intensity continuous aerobic training (MCT) improves aerobic capacity and mobility after stroke, according to post-stroke guidelines stroke. High-intensity interval training (HIT) has been shown to be more effective than MCT in healthy adults and patients with heart disease.

Physiotherapy

Physiotherapists should be involved early and should assess for themselves how much they can help their patients. Early mobilization was associated with better outcomes – even after accounting for the potential confounding effect of disease severity. If recovery is to be in Care received on wards separate from acute care should be as seamless as possible. The type and intensity of treatment should be determined by the patient’s needs rather than location. [11] Review by Harutoshi Sakakima et al. Indicates exercise as prototype preprocessing Stimulants that provide brain protection are a safe and feasible therapeutic option for endogenous neuroprotection in acute and chronic stroke patients [12].

A study by Carina U Persson et al. found senile arm paralytic aphasia and facial paralysis in index strokes to be predictors of increased muscle tone 7 years after ischemic stroke [13]. A randomized study examining the effects of electromyography-triggered functional electrical balance training Stimulation (EMG-triggered FES) to improve static balance dynamic balance and ankle muscle activation showed positive outcomes in stroke patients [14].

A single-blind randomized controlled trial comparing voluntary sit-to-stand training with assistive equipment versus manual sit-stand training at a rehabilitation hospital in Hong Kong showed that the effect of voluntary sit-stand training was positively associated with standing acceleration training Regaining sit-stand independence in subacute stroke survivors [15]. A systematic review showed that only lifestyle interventions including specific strategies for physical activity had a positive effect on physical activity levels compared with general lifestyle Intervention [16].

Primary Goals of Rehabilitation

1. Prevent complications
2. Minimise impairments
3. Maximise function

Optimising Post Stroke Rehabilitation

1. Early assessment using standardized assessments and validated assessment tools
2. Early adoption of evidence-based interventions relevant to individual patient needs
3. Patients have access to an experienced multidisciplinary rehabilitation team
4. Ongoing medical management of risk factors and comorbidities

A randomized controlled trial showed that the CARE4STROKE program had a positive effect on anxiety and depression in patients [17].

Upper Limb

Upper Limb Impairments:

• Subluxation
• Changes in Sensation
• Contracture
• Swelling
• Coordination Problems
• Weakness
• Altered Muscle Power
• Changes in Muscle Tone
• Hand Dysfunction

Aims of Treatment:

• Preventing shoulder pain, if not possible, should effectively manage the pain.
• Be selective in choosing compensatory versus remedial interventions to treat clients with projected low motor recovery and poor use of arm and hand functions.
• Provides therapy-focused rehabilitation services to clients anticipating changes in arm and hand function.
• Evidence of effectiveness using measures of known reliability and predictions of treatment planning and outcomes.

For severely injured and/or poorly restored upper limbs (Chedoke McMaster Stroke Assessment (CMSA) < stage 4 for arms and hands), treatment should focus on maintaining comfortable and painless movement of the arm and hand [18][19] .

• Focus on proper positioning for support at rest and careful handling during functional activities
• Attend classes supervised by professional rehabilitation clinicians in institutional or community settings, teaching clients and caregivers to perform self-range motion exercises.
• Avoid overhead pulleys (risk of injury to shoulder tissue)
• Use some form of external support for the stage 1 or 2 upper body during transfer and movement
• Position arms and hands in various positions, including within the client’s field of view
• Use some means of external support to protect the upper body during wheelchair use

In the upper extremity with moderate impairment, showing high potential for motivation and functional motor gain (CMSA => stage 4) [18][19]

• Engage in repetitive and heavy use of novel tasks that challenge stroke survivors to acquire the motor skills necessary to use the upper extremities involved in functional tasks and activities
• Participate in motor learning exercises, including the use of imagery.

Treatment Techniques:

• Strength training – There is evidence that strength training improves upper extremity strength and function in stroke patients without increasing tone or pain [20][21]. A randomized study examining the effects of balance training by electromyography-triggered functional electrical stimulation (EMG-triggered FES) improved static balance dynamic balance and ankle muscle activation indicated positive outcomes in stroke patients. Using high- and low-intensity arms improves strength and motor function after subacute stroke, a randomized controlled trial shows Resistance training [22].
• Modified Constraint-Induced Exercise Therapy (mCIMT) and CIMT address acquired nonuse of the upper extremities and decreased motor function affected after stroke [23] Some studies have shown that performing aerobic exercise prior to m-CIMT improves outcomes [24].
• Orthotics – Treatment combined with a dynamic wrist orthosis may not be better than manual therapy [25]. Long-term use of static orthoses needs to be supplemented with appropriate treatment opportunities to prevent clenching problems related to daily life and hygienic maintenance. [26]
• Games – Goal-oriented computer games have been shown to significantly reduce upper extremity injuries in stroke survivors [27][28]
• Virtual Reality – Virtual reality training has been shown to be effective in restoring upper extremity motor injuries and motor-related functional abilities [29][30]
• Mirror therapy – mirror therapy has been shown to be beneficial for motor control and function compared to traditional therapies [31][32][33]
• Robot-assisted therapy – has been shown to have beneficial effects on motor recovery and function [34][35][36]

Clinical Guidelines

Holistic management: national stroke clinical guidelines Royal College of Physicians September 2012

• Best practice recommendations for stroke care in Canada. Heart and Stroke Foundation and Canadian Stroke Network Ottawa, Ontario, Canada 2013 (see also 2010 Best Practice Recommendations for Stroke Care in Canada).
• Stroke management. National Stroke Foundation of Australia 2010.
• American Heart Association/American Stroke Association Guidelines

Acute Care

• Stroke: Diagnosis and initial management of acute stroke and transient ischemic attack. Nice Guide 2008.

Rehabilitation

• Stroke Rehabilitation: Long-term recovery after a stroke. Nice Guide 2014.
• Stroke Management Clinical Guidelines Physical Therapy Quick Guide. National Stroke Foundation of Australia 2010.
• Clinical practice guidelines for physical therapy for stroke patients. Royal Netherlands Physiotherapy Society (KNGF) 2014.
• Canadian best practice recommendations for stroke care: stroke rehabilitation. Heart and Stroke Foundation and Canadian Stroke Network Ottawa, Ontario, Canada 2013.

Enhancing Healthcare Team Outcomes

• Stroke prevention and management is best implemented with an interprofessional team approach.
• Public education and emergency medical services (EMS) are critical to improving stroke outcomes.
• Early stroke stages and rehabilitation stroke care that changes over time involves an interprofessional team to manage the disease. Evidence shows that hospitals with stroke teams demonstrate greater stroke knowledge and reduced door-to-needle time, leading to lower mortality rates and improved result.
• Once a stroke is diagnosed and treated urgently, the patient may require extensive physical rehabilitation speech therapy and/or dietary counseling.
• Prognosis was good for those who regained function within 3 months, but results were cautious for those with residual neurological deficits.
• At this point, nurses and physical therapists play a vital role in providing family and patient education, as activities of daily living can often be a challenge.
• Secondary prevention after acute stroke depends on the underlying stroke mechanism.
• The management of stroke is one of the most difficult and challenging issues facing health professionals. The best results can only be achieved through an interdisciplinary approach. [1]

Resources

• Stroke scales and clinical assessment tools
• The Evidence-Based Review of Stroke Rehabilitation (EBRSR) is a comprehensive and up-to-date review that examines treatment-based (and pharmacological) interventions relevant to stroke rehabilitation.

Presentations

Stroke: PT Assessment and Management This presentation, created by Dr. L. Surbala (MPT Neuro), discusses recovery impairments and etiological risk factors for the recovery phase of stroke. Stroke: PT Assessment and Management / View Presentation

Best Practices in Stroke Rehabilitation: The US Experience This presentation, authored by R.D. Zorowitz, MD, discusses current practice in stroke rehabilitation. Best Practices in Stroke Rehabilitation: The US Experience / View Presentation

Recent Advances in Post-Stroke Management of the Upper Extremity This presentation, created by Eusivia Pasi MPT, discusses current practice in stroke rehabilitation. Update on Management After Upper Extremity Stroke Update on Management After Upper Extremity Stroke / View Presentation