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Learning Issues

  • Causes and consequences of stroke
  • Risk factors of CeVD
  • Ethical/legal issues
  • Multidisciplinary approaches
  • Anatomy of the brain
  • Complications of stroke
  • Management of stroke
  • Diagnosis and severity of stroke

Mind map

  • Two types of stroke: haemorrhagic (aneurysm, hypertension, anticoagulants) or ischaemic (atherosclerosis: embolus (e.g. AF) or thrombus (e.g. carotid artery))
    • Just like coronary artery disease
    • Type of necrosis = liquefactive (can also occur in tuberculosis)
  • Blood supply to the brain
    • Sources: subclavian --> vertebral --> basilar; internal carotid
    • Forms: Circle of Willis (collateral)
  • Bleeding in the brain; affects CT appearance
    • Extradural
    • Subdural
    • Subarachnoid
    • Intracerebral (haemorrhagic stroke)
  • CT: haemorrhagic stroke = white; Ischaemic = dark
  • Disability
    • People are 2x as afraid of stroke than death --> vegetable state
    • Dysphasia (expressive vs receptive)
    • Dysphagia
    • Neglect
    • Weakness (motor cortex); upper vs lower limb
    • Changes in reflexes (motor cortex)
    • Contractions (motor cortex)
    • Also sensory cortex can be effected
  • Nerves cross over from one side to the other, so that a stroke on one side will effect movement on the other side (note ipsilateral/contralateral)
    • Need to know motor and sensory pathways to know where they cross
  • Management
    • Rehabilitation
    • Physiotherapy
      • Mobility
      • Gross motor movements
  • Speech therapist
    • Learn to express yourself, regain speech if possible
  • Occupational therapy
    • Get the person to do the things they could do normally with minimal support
  • Multidisciplinary teams, with specific roles
    • Nurse
    • Dietitian
    • Registrar, intern, specialist
      • Intern required to do leg work, history taking and some coordination
    • All have specific roles
    • Hierarchical stuff

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.

Early recognition

  • Various systems have been proposed to increase recognition of stroke. Different findings are able to predict the presence or absence of stroke to different degrees. Sudden-onset face weakness, arm drift (i.e., if a person, when asked to raise both arms, involuntarily lets one arm drift downward) and abnormal speech are the findings most likely to lead to the correct identification of a case of stroke increasing the likelihood by 5.5 when at least one of these is present). Similarly, when all three of these are absent, the likelihood of stroke is significantly decreased (– likelihood ratio of 0.39). While these findings are not perfect for diagnosing stroke, the fact that they can be evaluated relatively rapidly and easily make them very valuable in the acute setting.
  • Proposed systems include FAST (stroke) (face, arm, speech, and time),[12] as advocated by the Department of Health (United Kingdom) and The Stroke Association, the American Stroke Association (www.strokeassociation.org), National Stroke Association (US www.stroke.org), the Los Angeles Prehospital Stroke Screen (LAPSS) and the Cincinnati Prehospital Stroke Scale (CPSS).[14] Use of these scales is recommended by professional guidelines.
  • For people referred to the emergency room, early recognition of stroke is deemed important as this can expedite diagnostic tests and treatments. *A scoring system called ROSIER (recognition of stroke in the emergency room) is recommended for this purpose; it is based on features from the medical history and physical examination.[15][16]

Subtypes

  • If the area of the brain affected contains one of the three prominent central nervous system pathways—the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:
    • hemiplegia and muscle weakness of the face numbness
    • reduction in sensory or vibratory sensation
    • initial flaccidity (hypotonicity), replaced by spasticity (hypertonicity), hyperreflexia, and obligatory synergies.[17]
  • In most cases, the symptoms affect only one side of the body (unilateral). Depending on the part of the brain affected, the defect in the brain is usually on the opposite side of the body. However, since these pathways also travel in the spinal cord and any lesion there can also produce these symptoms, the presence of any one of these symptoms does not necessarily indicate a stroke.
  • In addition to the above CNS pathways, the brainstem gives rise to most of the twelve cranial nerves. A stroke affecting the brain stem and brain therefore can produce symptoms relating to deficits in these cranial nerves (if the stroke affects the cranial nerve nuclei):
    • altered smell, taste, hearing, or vision (total or partial)
    • drooping of eyelid (ptosis) and weakness of ocular muscles
    • decreased reflexes: gag, swallow, pupil reactivity to light
    • decreased sensation and muscle weakness of the face
    • balance problems and nystagmus
    • altered breathing and heart rate
    • weakness in sternocleidomastoid muscle with inability to turn head to one side
    • weakness in tongue (inability to protrude and/or move from side to side)
  • If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms:
    • aphasia (difficulty with verbal expression, auditory comprehension, reading and/or writing Broca's or Wernicke's area typically involved)
    • dysarthria (motor speech disorder resulting from neurological injury)
    • apraxia (altered voluntary movements)
    • visual field defect
    • memory deficits (involvement of temporal lobe)
    • hemineglect (involvement of parietal lobe)
    • disorganized thinking, confusion, hypersexual gestures (with involvement of frontal lobe)
    • lack of insight of his or her, usually stroke-related, disability
  • If the cerebellum is involved, the patient may have the following:
    • altered walking gait
    • altered movement coordination
    • vertigo and or disequilibrium

Associated symptoms

  • Loss of consciousness, headache, and vomiting usually occurs more often in hemorrhagic stroke than in thrombosis because of the increased intracranial pressure from the leaking blood compressing the brain.
  • If symptoms are maximal at onset, the cause is more likely to be a subarachnoid hemorrhage or an embolic stroke.

Risk factors for stroke

  • Haemorrhagic
    • Vessel wall abnormalities
    • Defects in homeostasis
  • Ischaemic stroke
    • Smoking
    • Lipid disorders
    • Diabetes
  • Both
    • Hypertension

High blood pressure is the number one risk factor for strokes. The other major risk factors are:

  • Atrial fibrillation
  • Diabetes
  • Family history of stroke
  • High cholesterol
  • Increasing age, especially after age 55
  • Race (black people are more likely to die of a stroke)
  • People who have heart disease or poor blood flow in their legs caused by narrowed arteries are also more likely to have a stroke.

The chance of stroke is higher in people who live an unhealthy lifestyle by:

  • Being overweight or obese
  • Drinking heavily
  • Eating too much fat or salt
  • Smoking
  • Taking cocaine and other illegal drugs
  • Birth control pills can increase the chances of having blood clots. The risk is highest in woman who smoke and are older than 35.

See also http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004662/

Video

  • Slowness (physical only)
  • Worst part - can't walk from place to place as easily
  • Has to reorientate himself
  • Didn't know what a stroke was until he had one himself
    • Felt no pain, just that when he tried to walk, he couldn't do it
  • Didn't go immediately to hospital (in denial) - thought he was overtired
  • His risk factors
    • High blood pressure
    • Diabetes
    • Cholesterol
  • Tasks that require physical movement are greatly lost
    • Washing, walking
    • Lost his ability to play piano, but now teaches
  • Can't put on socks, get into shower as well
  • It has affected him and his wife, not his children so much
  • His mental capacities are OK
    • Planning thinking power helped him from being depressed - more determined because he can think well
  • Rehabilitation
    • Started on first day in intensive care
    • Went to gym daily for an hour
    • 2 days per week to OT for hand, shoulders and arm; with puzzles and
    • First thing was to learn to stand from a sitting position and then sit again, and repeat
    • Then learned to walk long distances
    • Father in law (physio) taught him to walk up and down slopes and rough surfaces: it has to be continuous and ongoing (when it stops, you regress and things go wrong)
  • Thinks he should fear a further stroke, but he doesn't
  • You get great attention for disability - go out of their way to help
    • Children sometimes ask, and then he explains it to them
  • Wife
    • He was sleeping, giggling a lot
    • Could hardly walk, one leg was dragging
    • He's become quieter, slower and not as independent
    • This has put a strain on the relationship - doing a lot more than she used to do
    • She does feel frustrated with his disability sometimes. She gets angry
      • He used to do shopping etc, which was helpful
    • He still tries - taking out garbage and making tea; he doesn't have emotional help, or respite care
    • He'd like help cleaning, showering
  • His life would have been terrible without his wife - he wouldn't have let anyone else touch him
  • Loves him, so helps, but she does sometimes get angry
  • Physiotherapy is a big deal - really helps; without it, regression occurs
  • No pain - less likely to seek help than with MI
  • They probably should have provided services e.g. respite care - help the carer. It's good for everyone, too (see other people)
  • Worst thing to happen = lose cognitive function, speech
    • Temporal lobe stroke = psychotic symptoms
    • Not being able to do the things you like any more

Other notes

Aims

  • Think about and explore the issues raised by the scenario
  • Consider the medical science issues surrounding cerebrovascular disease
  • To consider the impact of stroke on the lives of the patient and the carer.

Key concepts

  • The definition and causes of a “stroke”
  • Risk factors associated with cerebrovascular disease *
  • The complications and outcomes of strokes
  • Impact of stroke
  • Explore the scenario plenary and video and identify key issues

Learning goals

  • Causes and consequences of stroke
  • Risk factors of CeVD
  • Ethical/legal issues
  • Multidisciplinary approaches
  • Anatomy of the brain
  • Complications of stroke
  • Management of stroke
  • Diagnosis and severity of stroke
  • Preview learning activities related to this scenario

Introduction to stroke

  • “Stroke” is a sudden neurological deficit caused by cerebrovascular disease
  • Strokes are common in older people, but can occasionally occur in young people with predisposing factors
  • Strokes account for around 9-10% of all deaths in our society (3rd most common cause of death behind malignancies and ischaemic heart disease).
  • Common causes of stroke include thrombosis in arteries supplying the brain, thromboembolism (usually from the left-sided cardiac chambers) and haemorrhage, which can be intracerebral, subarachnoid, subdural or epidural.
  • Major risk factors for stroke include hypertension, smoking, hyperlipidaemia and diabetes mellitus (i.e., the major risk factors for atherosclerosis)
  • View video of Leon and his wife and discuss issues around living with stroke
  • What was his reaction to the stroke?
  • Why do you think that he initially denied his stroke?
  • How has it affected his work and home life? Construct a list of things he couldn’t do on his own.
  • How has it affected his wife - her ability to carry out normal daily activities, her relationships with family and others, and her physical well-being?
  • Suggest ways in which the quality of life could be improved for both Leon and his wife?


Appendix: Short glossary of stroke-related terms

  • Aneurysm: A permanent abnormal balloon-like bulging of an arterial wall. The bursting of an aneurysm in a brain artery causes a haemorrhagic stroke.
  • Aphasia: A problem with communication because of damage to an area of the brain. A person with aphasia may find it hard to talk, read, write or understand others when they speak. (Also see dysphasia)
  • Apraxia: Being unable to do a body movement because the brain has difficulty planning that movement. (Also see also dyspraxia)
  • Aspiration: When material such as food, fluid or saliva goes into the windpipe.
  • Atherosclerosis: This means hardening or narrowing of the arteries. It is a disease of the blood vessels. It is caused by the build-up of fatty deposits that reduces blood flow through the artery.
  • Atrial fibrillation: Also called AF. A heart disorder where the heart beats irregularly. Sometimes the heart may also beat too quickly.
  • Arteriovenuous Malformation: Also called an AVM. This is a tangled mass of blood vessels. This malformation can occur anywhere in the body including the brain.
  • Carotid duplex: An ultrasound test that looks at the arteries in the neck that supply the brain. This is to see how well the blood flows through these arteries.
  • Carotid endarterectomy: An operation to unblock narrowed carotid arteries in your neck.
  • Cerebral infarct: An area of dead cells in the brain caused by a loss of blood supply to that area (an ischaemic stroke).
  • Cognition: A word used to explain our thinking ability. Cognition includes things such as remembering things, paying attention, solving problems and making decisions.
  • Dysarthria: A type of speech problem where speech becomes slurred or a person is unable to say things clearly.
  • Dysarthria is caused by weakness in the muscles used for speaking and may occur after a stroke.
  • Dysphagia: This means difficulty swallowing. Dysphagia can occur after a stroke because of weakness in the muscles needed for swallowing.
  • Dysphasia: This means difficulty with language and communication. This can be difficulty with speaking, understanding what is said and writing. (Also see Aphasia)
  • Dyspraxia: Difficulty doing a body movement because the brain has difficulty planning that movement. (Also see also apraxia)
  • Embolic stroke: A stroke caused by a blood clot that has come from somewhere else in the body (an embolus).
  • Emotional lability: Uncontrollable outbursts of emotion (such as laughing to crying) without real cause. It may only last a few weeks or continue for a long period.
  • Enduring power of attorney: Also called EPOA. A legal agreement which enables someone to appoint a trusted person or people to make financial and property decisions on their behalf.
  • Haemorrhagic stroke: This is a type of stroke where a blood vessel in the brain bursts and causes bleeding into the brain.
  • Hemianopia: This means loss of vision to one part of the visual field. This can lead to trouble seeing on one side of your body.
  • Hemiparesis: This means weakness on one side of the body. Hemiparesis can affect the arm, the leg or both.
  • Hemiplegia: This means paralysis (no movement) on one side of the body. Hemiplegia can affect the arm, the leg or both.
  • Hypertonia: High muscle tone – where affected muscles are stiff or tight. (Also see spasticity.)
  • Hypotonia: Low muscle tone – where affected muscles are ‘floppy’.
  • International normalised ratio: Also called INR. A laboratory test which measures the time it takes for blood to clot and compares it to an average.
  • Intracerebral haemorrhage: A type of haemorrhagic stroke caused by bleeding into the brain.
  • Ischaemic stroke: A type of stroke where a blood clot blocks a blood vessel in the brain.
  • Neglect: A problem caused by stroke where a person is unaware of, or ignores, things on one side of the body.
  • Perception: The way our brain interprets what our eyes see.
  • Perseveration: Getting stuck on one idea, action or response.
  • rt-PA: Recombinant tissue plasminogen activator. Also referred to as t-PA. The drug administered intravenously to break up a blood clot. See ‘thrombolysis’.
  • Respite care/services: The provision of short-term and temporary care for stroke survivors to allow carers time away from their caring responsibilities. This can be provided in your own home or in a dedicated facility.
  • Subarachnoid haemorrhage:Also called a SAH. This is bleeding on the surface of the brain.
  • Spasticity: High muscle tone – where affected muscles are stiff or tight.
  • Standard alcoholic drink: An alcoholic drink that contains 10 grams of alcohol. This is the amount of alcohol a healthy liver can break down in an hour. Approximately equal to one pot (10 oz or 285 ml glass) of full strength beer, one glass (100 ml) of table wine or one nip (30 ml) of spirits.
  • Subarachnoid haemorrhage: A type of haemorrhagic stroke where there is bleeding over the surface of the brain.
  • TIA: (transient ischaemic attack) A ‘mini-stroke’ where symptoms last for less than 24 hours.
  • Thromobolysis: process of administering the drug rt-PA intravenously to break up a blood clot.
  • Thrombotic stroke: A stroke caused by a blood clot that has formed in the brain (a thrombus).
  • Verbal dyspraxia: A type of speech problem where people have difficulty planning the movements of the mouth and tongue needed for speaking.

Plenary: Leon and his wife Rene

  • Impressions
    • Impact
      • Slower, everything is slower overall
      • Physically slow, mentally fine
  • Walks slowly
    • Worst part
      • Not being able to walk like before
    • Stroke itself
      • No pain, couldn’t walk/get up
      • Was in denial, didn’t go straight to hospital
  • Thought he was just overtired
  • Knowledge about risk? No. didn’t understand risk factors
    • Diabetes mellitus, hypercholesterolaemia, hypertension, family history. Not a smoker (which is a big risk factor)
    • Changes in lifestyle
      • Physical tasks are limited, PIANO
      • Effect on family – hard on wife, otherwise treated the same
    • Frustration?
      • Yes initially, but was ok because his brain was unaffected
      • Suicidal? No. felt more invigorated and determined
    • Rehabilitation
      • ICU gym
      • Occupational therapy: 2 days/week
      • Had to learn to stand and sit and walk again
      • Had to retrain hands/legs in different walking conditions
      • Was initially helped by his father in law, when this stopped, his progress regressed
      • 5 months – 2x/week physiotherapy walking
      • 2 months 1x/week
  • Rene
    • The stroke itself:
      • Became sleepy, slow, tired, didn’t want to move & giggling
      • One leg was dragging, went to the doctor
      • Fantastic attitude
    • Changes
      • Quieter, slower, not as independent
      • Frustration, now does so much more
      • Sometimes gets angry
    • Support
      • Helps where he can
      • He doesn’t understand frustration
      • Help eg: used to do the shopping, showering, cleaning, general housework
      • Has done a lot for him



Difficulties for self

  • Loss of independence
  • Reassessment of goals
  • Lack of mobility
  • Loss of skills
  • Positive outlook
  • Dignity
  • Determination/another stroke/death
  • Rehabilitation
  • Social interactions
  • Financial problems

Difficulties for carer

  • Taking person to the toilet at night
  • Having someone home to talk to – social isolation?
  • Emotional burden
  • Personal sacrifice
  • Maintaining good relationship with person
  • Rearrange life