1
Brain Attack

• Cerebrovascular Accident
• Or
• Stroke

2
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.

3
(No Transcript)
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10

• 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)

11

• 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

12
Ischemic Stroke

• Thrombotic
• 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
• Atherosclerosis Greek hard paste

• Embolic
• 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

13
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

14
RIND and PRINDs

• 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

15

• 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

16
Hypofusion

• 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!

17
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

18
Hemorrhages

• Extracerebral hemorrhagesbleeding outside of the
  brain
• Subarachnoid
• subdural
• extradural

• Intracerebral hemorrhages
• Within brain substance bleed

19
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

20
Aneurysm

• 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

21
Berry Aneurysm
22
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

23
AVF

• Greatest risk is the potential for rupture and
  subsequent hemorrhage

24
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?

25
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.

26
(No Transcript)
27
Intracranial tumors, cont.

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

28
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

29
More IC Tumors--Primary

• Meningioma arise from the ________??
• Most benign of all, very slow growing,
  well-defined margins, usually dont invade brain
  substance
• Can usually be completely removed
• Symptoms are usually site specific

30
Secondary Intracranial tumors

• Metastatic carcinoma---cells have
  migratedusually 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.

31
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

32
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

33
Toxemia

• 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

34
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

35
Aphasias

• Fluent
• Wernickes
• Conduction
• Transcortical Sensory

• NonFluent
• Brocas
• Transcortical Motor
• Global
• Other forms
• Anomic
• Alexia and Agraphia
• Primary Progressive

36
(No Transcript)
37
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

38
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

39

• 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

40
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

41
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---

42

• No history of anticoagulant meds
• Heparin and Coumadin (Warfarin)

43
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

44
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

45
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.

46
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

47
Primary Indicator of Recovery?

• 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
• Degree of communication impairment
• global aphasia or hemineglect tend to
  perform poorly in rehab

48
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.