Stroke Basics
These are the two main types of strokes
What are ischemic and hemorrhagic?
First imaging you get when concerned for stroke
What is CT head/brain noncon?
Also would expect to get MRI/MRA w/ con to see burden remeber blood is dark on T2, infarction is white
Also get TTE/TEE, Carotid US or CTA, can get LP if SAH suspected
Unilateral ACA stroke will most commonly affect this
What are the legs?
Motor and sensory
can also affect bowel/bladder (paracentral gyrus) and executive fxn if b/l or hypoplastic vessels/weird anatomy
Biggest clue on exam that stroke is located in the brainstem
This therapy technique is the "use what you got" technique, uses flexor/extensor synergies
What is Brunnstrom technique?
Rationale- originally developed gross movements as an infant so no need to discourage synergies
The percent of strokes that are ischemic
What is about 87%? (48% thrombotic, Embolic 26%, Lacunar 13%)
13% are hemorrhagic
SBP goals for ischemic and hemorrhagic strokes respectively
What is SBP <220, SBP<180
Permissive HTN but don't want to hemorrhage out
Return to normotension over days to weeks
Hemineglect is most commonly seen with a stroke affecting what part of the brain?
Nondom parietal lobe
Can be seen with dominant as well
Name the midline structures in Rule of 4's
What is Motor (Corticospinal), Medial Lemniscus, Motor Nuclei 3,4,6,12, MLF
Also known as the neurodevelopmental technique, aim to eliminate primitive reflexes, do not allow patients to use flexor/extensor synergies
What is Bobath technique?
Rationale- patient's may never advance past synergy patterns if not forced to do controlled/fine motor
This is the most common type of ischemic stroke
What is Thrombotic stroke?
Time frame to give tPA
What is 3-4.5 hours?
The type of visual deficit would you expect with a unilateral PCA stroke- be specific
Contralateral Hemianopsia w/ Macular sparing
Macula spared due to collateral flow from MCA
Name the "side" structures in Rule of 4's
What are the STT, Spinocerebellar tract, Sensory nucleus of 5, Sympathetics
Therapy intervention shown to be useful for Broca Aphasia
What is Melodic Intonation Therapy
Use non-dom side of head- musicality
The usual onset of embolic, thrombotic, lacunar stroke respectively
What is sudden, gradual, variable?
Embolic: Sudden, can also present with seizures
Thrombotic: gradual, 50% present with previous TIA in the same distribution.
lacunar: abrupt or gradual
ICP and CPP goals in stroke management
What is ICP<20, CPP>60?
CPP = MAP - ICP
Bilateral PCA stroke syndrome, "blind and denying"
What is Anton Syndrome?
This stroke syndrome can present with hoarse voice, dypshagia, ipsilateral ataxia/nystagmus, ipsilateral horner syndrome
What is Wallenberg Syndrome
"Dr. Wallenberg at the VA says don't PICA horse that can't eat"
Can be both VA and PICA
Therapy technique where cutaneous stimuli is used to enhance motor control, reduce spasticity
What is Rood technique?
Rood = Rude stop touching me
The three most commonly affected areas of the brain with lacunar strokes
What is putamen, thalamus, internal capsule?
tPA INclusions (given ischemic with negative CT and within time frame) there are a total of 5 others- (hint- age group, VS, labs, imaging findings)
What is- Adult, SBP<185, INR<1.7, Plt >100K, stroke territory <1/3 MCA territory
BP can be managed acutely and SBP >185 not absolute C/I
Lab values can vary by hospital protocol but these are the recommendations
Alexia without agraphia can occur with a lesion here- Be specific (dom/nondom)
What is PCA territory dominant side?
Infarct of splenium of corpus callosum so language centers are intact but unable to receive information from contralateral visual cortex and visual word form area may be disrupted
Intractable hiccups (singultus) can be a symptom of this brainstem stroke syndrome
What is Wallenberg?
MOA- Imbalance and involuntary inspiration by destruction of the expiratory area in the medulla and is related in the nucleus ambiguus and dorsal motor nucleus of the vagus nucleus
Brunnstrom Stage of recovery corresponding to when spasticity first decreases
What is Stage 4
1. Flacid, 2. Spastic w/ UE flexor and LE extensor synergy, 3. Spasticity Peaks, 4. SPasticity decreases, 5. Complex voluntary movements, 6. Spasticity gone, 7. Normal