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Brain Attack

Cerebrovascular Accident Or Stroke

Generic term for temporary or permanent disturbance of brain function due to vascular disruption (Brookshire)
Also called cerebrovascular accident (CVA)

3rd leading cause of death in the USA; about 500,000 per year----150,000 die from stroke 80% of pts. Survive for at least 1 mo. Post; about 1/3 of those are alive 10 years post.

The Five Most Common Stroke Symptoms Include:

Sudden numbness or weakness of face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination

Sudden severe headache with no known cause

Other Important but less Common Stroke Symptoms Include: Sudden nausea, fever and vomiting distinguished from a viral illness by the speed of onset (minutes or hours vs. several days) Brief loss of consciousness or period of decreased consciousness (fainting, confusion, convulsions or coma)

Uncontrollable Stroke Risk Factors Include: Age The chances of having a stroke go up with age. Two-thirds of all strokes happen to people over age 65. Stroke risk doubles with 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 other racial 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 be due to circulation problems that diabetes can cause. In addition, brain damage may be more severe and extensive if blood sugar is high when a stroke happens. Treating diabetes may delay the onset of complications that increase stroke risk. However, even if diabetics are on medication and have blood sugar under control, they may still have an increased stroke risk simply because they have diabetes.

Coronary Heart Disease and High Cholesterol High cholesterol can directly and indirectly increase stroke risk by clogging blood vessels and putting people at greater risk of coronary heart disease, another important stroke risk factor. A cholesterol level of more than 200 is considered "high." Cholesterol is a fatty substance in the blood that our bodies make on their own, but we also get it from fat in the foods we eat. Certain foods (such as egg yolks, liver or foods fried in animal fat or tropical oils) contain cholesterol. High levels of cholesterol in the blood stream can lead to the buildup of plaque on the inside of arteries, which can clog arteries and cause heart or brain attack. Sleep Disordered Breathing - Sleep Apnea Sleep apnea is a major cardiovascular and stroke risk factor increasing blood pressure rates which may cause stroke or heart attack. Studies also indicate that people with sleep apnea develop dangerously low levels of oxygen in the blood while carbon dioxide levels rise, possibly causing blood clots or even strokes to occur. Diagnosing sleep apnea early may be an important stroke prevention tool.

Personal history of stroke or TIA

People who have already had a stroke or TIA are at risk for having another. After suffering a stroke, men have a 42 percent chance of recurrent stroke within five years, and women have a 24 percent chance of having another stroke. TIAs are also strong predictors of stroke because 35 percent of those who experience TIAs have a stroke within five years.

Lifestyle Factors that Increase Stroke Risk Include: Smoking Smoking doubles stroke risk. Smoking damages blood vessel walls, speeds up the clogging of arteries by deposits, raises blood pressure and makes the heart work harder. Alcohol Excessive consumption of alcohol is associated with stroke in a small number of research studies. Its specific role in stroke has not yet been determined or proven. Recent studies have also suggested that modest alcohol consumption (one 4 oz. glass of wine or the alcohol equivalent) may protect against stroke by raising levels of a naturally occurring "clot-buster" in the blood. Weight Excess weight puts a strain on the entire circulatory system. It also makes people more likely to have other stroke risk factors such as high cholesterol, high blood pressure and diabetes.

The Impact of Stroke Risk Factors

Most strokes occur in the 7th decade 85% of survivors return to prestroke-living environment (with some residual impairment)
15 % require institutional care (Greenberg, Aminoff, and Simon, 1993)

Ischemicdeprived of blood
Sometimes called occlusive

Hemorrhagiccaused by bleeding Loss of blood flow for 3-5 minutes causes necrosis of the CNS Infarct---death of tissue caused by interruption of blood supply

Ischemic Stroke
Artery is gradually occluded by a plug of material the collects in a given site
Uncommon in smaller arteries Usually in areas of disturbance like twists and bends in an artery

Artery is suddenly occluded by material that moves thought he vascular system to occlude an artery Often a fragment from a thrombosis Atrial fibrillation is a common cause

Atherosclerosis: Greek hard paste

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


Reversible ischemic neurologic deficits (less than 24 hours) Partially reversible ischemic neurologic deficits (longer than 24 hours but leave minor deficits after a few days TIAs sometimes called small strokes

Greenberg et al. (1993) 1/3 of pts who have TIAs or RINDs will within 5 years have a stroke that leaves them with permanent neurologic deficits

Insufficient blood flow to the brain and the brain stem Diaschisis---disruption of brain function in regions AWAY from the site of injury (but connected by neural pathways (within system)
Edema, decreased blood flow, neurotransmitters and diaschisis help diffuse impairment of brain function!

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) by extreme fluctuation in BP

Extracerebral hemorrhages bleeding outside of the brain
Subarachnoid subdural extradural

Intracerebral hemorrhages
Within brain substance bleed

Intracerebral Hemorrhage
90% occur in pts with high BP Cause(s): hypertentionpressure on arterial walls or chronic hypertensionweakening of small penetrating arteries causing microaneurysms Can cause snowball effect as the hemorrhage affects adjacent vessels

Pouches formed in arterial walls
berry or saccular, term depends upon the shape Nearly 50% of extracerebral aneurysms occur in the arteries at the base of the brain (vertebrals, basilar, internal carotid and Circle of Willis

Most are due to injury to MCA and ACA

2-3% occur in the posterior cerebral artery

Berry Aneurysm

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

Greatest risk is the potential for rupture and subsequent hemorrhage

Intracranial Tumors
Primary site: point of origin
Secondary site: originated elsewhere and moved
Relocation of tumor = metastasis---mets

Primary tumors: usually cerebrum and cerebellum

Occur at any age, most commonly age 25-50
MAY run in familieshypothesis?

Herniation Syndromes
Masses the force movement of brain substance (or brain stem) Tumors: course is deterioration of function
Early stage = lower intracranial pressure = causes nonspecific alterations of cognition ( forgetfulness, drowsiness, blurred or double vision, vertigo, lightheadedness, etc.

Intracranial tumors, cont.

Inc. IC pressure = increased sig. Symptoms: e.g., lethargy, stupor, bifrontal and bioccipital headaches (unaffected by analgesic meds), vomiting, imbalance.

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, 5-6 year development Glioblastoma Mul.: a most malignant and rapidly growing intracranial mass
Develops in 3-12 mo.average postsurgical survival is only 6-9 months

More IC Tumors--Primary
Meningioma: arise from the ________??
Most benign of all, very slow growing, welldefined margins, usually dont invade brain substance Can usually be completely removed Symptoms are usually site specific

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:
Breastmost frequent occurrence Lung Pharynx/larynx---least frequent occurrence.

Other causes of brain impairment

Hydrocephalus enlargement of the cerebral ventricles
Obstructive hydrocephalus IVPintraventricular shunt---VP shunt

Infections: abscesses and meningitis

brain abscess introduction of bacteria, fungus or parasites into brain tissue from infection site somewhere in the body 40% of sources are nasal sinuses, ME and mastoid cells

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

Due to substances invading the NS that inflame or poison nerve tissue May result from: drug overdoses or interactions, bacterial toxins (tetanus, botulism, diphtheria) or heavy metal poisoning (lead and mercury)----WTC??? TX is to remove the substance

Metabolic and Nutritional Disorders

Metabolic: rarely cause specific communication disorders
Severe hypoglycemia can cause cerebral dysfunction

Nutritional: rare in the USA

Wernickes Encephalopathy: thiamine deficiency, usually associated with alcoholism
Paralysis of eye muscles, incoordination, poor gait, mental confusion

Wernickes Conduction Transcortical Sensory

Brocas Transcortical Motor Global

Other forms:
Anomic Alexia and Agraphia Primary Progressive

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

Acute Therapy
After ischemic stroke, the area of infarction is 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 (to increase blood into the area of infarct, and; Corticosteroids used to reduce swelling of the brain

These neuroprotective measures have not been protective; most medical (acute) treatments for ischemic stroke have been limited to preservation of life Until 1995: National Institute of Neurological Disorders and Stroke (NINCDS) study on t-PA

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 post onset Negative finding: after 36 hours there was in an increased incident of intracerebral hemorrhage (6.4%)
Mortality of t-PA group was lower after 3 months post

1996, t-PA approved

For acute ischemic stroke, if
Administered within 3 hours of stroke;
No sign of intracerebral hemorrhage as confirmed by 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---

No history of anticoagulant meds

Heparin and Coumadin (Warfarin)

IF criteria for t-PA were not met?

Tx requires identification of etiology or locating the blockage in the internal carotid or heart
If carotid: tx of etiology is to remove thrombus via Carotid Endarterectomy (CAE), or via antiplatlets, e.g., aspirin If heart (cardiogenic): Coumadin or Heparin are administered

Chronic Therapy: Rehabilitation

Begins when pt is medically stable; initial goal: ambulate, communicate and ADLs 2nd goal: stimulate sph production and language use via social interactions

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 to handle 3 hours of activity per day BBA of 1997? Fiduciary Cap.

American Heart Association

6 major areas of stroke rehab:
1: handle concurrent illnesses and complaints 2: maximize independence 3: maximize psychosocial coping of family 4: promote reintegration 5: improve quality of life 6: prevent recurrent vascular events

Primary Indicator of Recovery?

1) Severity of neurological impairment.
The more severe the damage and subsequent impairments, the longer the hospital stay, the more complicated the treatment plan, the longer the recovery process

2) Degree of communication impairment: global aphasia or hemineglect tend to perform poorly in rehab

Contraindicators of Rehabilitation
Psychiatric Disorders;
Dementias, Apathy Syndrome, Negative Symptom Complex Not a functional loss: these conditions have less ambition, less motivation, poor effort to succeed, etc.