Ataxia in the Stroke Patient Kelli Kulpa BSN, RN Alverno College MSN Student Neurosciences Department Froedtert Hospital

Ataxiain the Stroke Patient

Kelli Kulpa BSN, RNAlverno College MSN StudentNeurosciences Department

Froedtert Hospital

Objectives

• Describe pathophysiology of cerebellum as it relates to smooth muscle movements

• Describe how ischemia to cerebellum causes ataxia in stroke patient

• Identify presence of ataxia in stroke patient

• Identify appropriate nursing interventions and outcomes

TOPICS TO REVIEW

STROKE

CEREBELLUM

ATAXIA

NIH STROKE SCALE

CARE OF THE PATIENT WITH ATAXIA

Stroke• “Syndrome of acute focal

neurologic deficit from a vascular disorder that injures brain tissue” Porth (2005, p. 1245)

• US leading cause of mortality & morbidity

• About 700,000 Americans afflicted with stroke

• Many survivors left with some degree of deficit

Image from Microsoft Clipart

(Porth, 2005)

Risk Factors for Stroke

• Controllable• Hypertension (HTN)• Atrial Fibrillation• High Cholesterol• Diabetes• Tobacco Use & Smoking• Alcohol Use• Physical Inactivity• Obesity

• Uncontrollable• Age• Race• Gender• Family History• Previous Stroke or TIA• Fibromuscular Dysplasia• Patent Foramen Ovale

(National Stoke Association, 2009)


Uncontrollable Risk Factor• AGE:

• Risk of stroke increases with age

• After age 55, risk doubles for every decade that passes

• Increased prevalence of controllable risk factors as age increases

• Hypertension• High Cholesterol• Diabetes

• RACE: AFRICAN-AMERICAN• Most impacted race in US• Twice as likely to die from

stroke than Caucasians• Occur earlier in life

• Reasons not fully understood, but have a higher rate of risk factors

• ex: 41% have HTN



Uncontrollable Risk Factor

• GENDER: WOMEN• 55,000 more women than men experience stroke each

year

• Unique risk factors:• Oral Contraceptives• Pregnancy• Hormone replacement therapy• Post-menopausal with thick waist and high triglyceride

levels• Suffer more migraines, increase risk 3-6 times



Uncontrollable Risk Factor• FAMILY HISTORY

• Evidence suggests genes influence vulnerability to HTN & stroke

• A region on:• Chromosome 13 in Caucasians• Chromosome 19 in African-Americans

• Carotid intimalmedial wall thickness (IMT)• Surrogate measure of subclinical atherosclerosis• Strong predictor of future ischemic strokes• Homozygous for 6A genotype

• Genetically predisposed to produce less stromelysin 1• High carotid artery wall thickness & greater risk of stroke


(Morrison, Brown, Kardia, Turner, & Boerwinkle, 2003)

(Humphries & Morgan, 2004)

Controllable Risk Factor & Inflammation

• Inflammation can influence the development of atherosclerosis• Causes endothelial dysfunction

• One of the earliest manifestations of atherosclerosis

• Inflammatory markers associated: • Coronary disease development• Disease severity• Occurrence of coronary events

• Progression of atherosclerosis may be associated with high concentrations of inflammatory markers

(Humphries & Morgan, 2004)

GREAT!

SORRY!Cannot control if you

have a history of stroke

OPPS!Cannot control age

GOOD JOB!

TEST YOUR KNOWLEDGE• Select the controllable risk factors for stroke

(Multiple answers)

Hypertension

Age

Previous Stroke

Hyperlipidemia

Yes!Women are at higher risk of stroke & also have

increased mortality.

Sorry!Women are at higher risk of stroke & also have

increased mortality.

TEST YOUR KNOWLEDGE

• Men are at higher risk of stroke

TRUE

FALSE

Types of Stroke

• ISCHEMIC• Interruption of blood flow in

a cerebral vessel• Most common type• Account for 70-80% of strokes

• HEMORRHAGIC• Bleeding into the brain tissue,

from blood vessel rupture

• Caused by: • HTN• Aneurysms• AVM• Head injury

• Much higher fatality rate• 37-38% of occurrence results in death

(American Heart Association, 2010)

(Porth, 2005)Image from Microsoft Clipart

Cell Ischemia

• Reduced or absent blood flow deprives cell of needed nutrients

• Effects occur quickly• No stored glucose in brain• Incapable of anaerobic metabolism

(Porth, 2005)

Neuronal Injury: Excitotoxicity

• Ischemia depletes neuronal energy stores causing energy dependent membrane ion pumps to fail

• Results in increased extracellular glutamate concentration

• Release of excitotoxic glutamate & aspartate open up calcium channels• Influx of calcium, sodium and chloride

• Intracellular calcium responsible for activation of a series of destructive enzymes

• Out flux of potassium • Resulting in irreversible neuronal damage

• Results in release of cytokines and other mediators(Porth, 2005)

Inflammation Following Ischemia• Rapid production of inflammatory mediators

• White blood cell (WBC) recruitment to ischemic area as early as 30 minutes

• Capillary endothelium produces adhesive proteins causing WBCs to adhere to capillary lining

• WBCs move into injured tissue

• Phagocytize injured cells

• Extent of inflammation can be determined by C-reactive protein levels

Image used with permission from http://images.wellcome.ac.uk/

(Porth, 2005)

Try againThere are increased levels

of glutamate.

GOOD JOB!No energy is getting to the

cell.

Try againPhosphorus is not directly

related to this process

Try againIf the cell is not getting

adequate blood flow, there is not enough energy

available.

TEST YOUR KNOWLEDGE• Neural cell ischemia is caused from:

Too much energy available to the cell

Lack of phosphorus available

Energy dependent membrane ion

pumps fail

Decreased levelsof glutamate

Cerebellum• Stores learned sequences of

movements

• Fine tuning & coordination of movement produced elsewhere in brain

• Integrates all information to produce fluid movements

(Dubuc, 2002)

Image used with permission from http://thebrain.mcgill.ca/flash/i/i_06/i_06_cr/i_06_cr_mou/i_06_cr_mou.html#3

Movement• Motor cortex:

• Sends signals to cerebellum• Communicates movement to

make

• Cerebellum:• Makes continuous

adjustments

• Final result:• Smooth movement, key with

delicate maneuvers(Porth, 2005)

Image used with permission from http://thebrain.mcgill.ca/flash/i/i_06/i_06_cr/i_06_cr_mou/i_06_cr_mou.html

CerebellumHover over the highlighted words for definition

Cerebellum Involvement

• Receives proprioceptor input from vestibular system

• Feedback from muscles, tendons, & joints

• Indirect signals from somesthetic, visual, & auditory systems to provide background info for ongoing movement

(Porth, 2005)

• Can continuously assess status of each body part• Position• Rate of movement• Forces, such as gravity,

opposing it

(McGill University, 2002)

Dampening Muscle Movement• All body movements are pendular

• Intact cerebellum analyzes proprioceptive information to predict:• Future position of moving parts• Speed of movement• Projected time course of movement

• As movement approaches target, Cerebellum will:• Inhibit agonist muscles• Excite antagonist muscles

(Porth, 2005)


(Porth, 2005)

“Require a burst of energy from an agonist muscle group; the movement is programmed from the start, so the movement proceeds from start to finish without modification”

Type of Movement

Simple Movement

Self-terminating Movement: require smooth muscle sequence of coordinated agonist & antagonist movements programmed by higher brain centers to start, then are modified as the movement proceeds

Complex MovementClick for Explanation Click for Explanation

Porth (2005, p. 1194)


Try again;This is part of the

somesthetic system.

GOOD JOB!

OPPS!Vestibular apparatus, try

again.

Try again;This is part of the

somesthetic system.

TEST YOUR KNOWLEDGE• Proprioreceptor input is:

Meaningfulness of integrated sensory

information from various sensory systems

The inner ear structures that are associated with balance

and position sense

Any sensory nerve ending responding to stimuli from

within body related to movement & spatial position

Concerning perceptions of ‘where’ the stimulus is in space and in relation to

body parts

Opps!Think this through again. Movement is pendulous.

Yes!Movement is pendulous, so muscles have

to be stopped.

TEST YOUR KNOWLEDGE

• As movement approaches a target, the cerebellum will:

Inhibit agonist muscles & Excite antagonist muscles

Excite agonist muscles & Inhibit antagonist muscles

Ataxia• People with ataxia experience

• Failure of muscle control in arms and legs• Results in:

• Lack of balance & coordination• Disturbance in gait


(National Institute Of Neurological Disorders And Stroke, 2010)

Acquired (non-genetic) Ataxia

• Conditions that can cause acquired ataxia• Stroke• Multiple Sclerosis• Tumors• Alcoholism• Peripheral neuropathy• Metabolic disorders• Vitamin deficiencies



Ataxia after Stroke

• Right side of cerebellum controls coordination on right side of body, left side controls left

• When nerve cells are lost or damaged:• Provide less control to muscles• Resulting in: loss of coordination

• During a stroke:• Blood supply is interrupted or severely reduced• Deprivation of oxygen and nutrients to brain tissue• Brain cells begin to die

(Mayo Clinic Staff, 2009)


Recent Findings

• 15% of all cerebral strokes involve the cerebellum

(Timmann et al., 2009)

• Anterior lobe of cerebellum is involved in motor control• Concluded from a study containing 34

patients with cerebellar infarcts(Schmahmann, Macmore, & Vangel, 2009)


Cerebellar Ataxia

How does alcohol relate?Select the beer for the answer!

• Decomposition of movement

• Each component of the movement occurs separately instead of being blended into a smooth action

(Porth, 2005)

“Ethanol specifically affects cerebellar function, persons who are inebriated often walk with a staggering and unsteady gait” Porth (2005, p. 1213)


(Porth, 2005)

Ataxia

• Rapid alternating movements are performed slowly and jerky• Such as pronation-supination-

pronation of hands

• Touching a target:• Movements broken down

into small steps• Each movement goes too far,

then overcompensated• DYSMETRIA

SELECT THE TARGET TO SEE AN ANIMATION OF DYSMETRIA


(Porth, 2005)

Clinical Pearl

• Read the CT or MRI reports to identify where the infarct is located in the brain. If the cerebellum is involved, chances are ATAXIA will be exhibited in the patient


Try again

GOOD JOB!

OPPS!

Try again

TEST YOUR KNOWLEDGE• Ataxia is:

Weakness

Impaired speech

Lack of coordination

No need to pay taxes

Almost there…look closer at the options.

Think again,motor cortex is involved in movement, but not directly

related to ataxia.

Try again;not related to movement

AWESOME!

TEST YOUR KNOWLEDGE• What part of the brain was infarcted if the

patient has ataxia?

Cerebellum

Parietal Lobe

Motor Cortex

Cerebrum

Opps!Ataxia after a stroke is not a genetic cause of ataxia.

Genetic ataxia is caused from mutations in genes.

Yes!Acquired ataxia is non-genetic.

TEST YOUR KNOWLEDGE

• Ataxia in stroke is acquired ataxia.

True

False

National Institute of Health Stroke Scale (NIHSS)

• Stroke scale functions:• Document and communicate

• Baseline deficits• Changes over time

• First used in 1989• Administered in mean time of 6.6 minutes• Interrater and intrarater agreement is good


(Jensen & Lyden, 2006)


• Strongly predicts the likelihood of recovery after stroke

• Total score • > 16 high probability of death or severe disability• <6 predicts a good recovery


(Duncan et al., 2005)


• 15 Item Clinical Deficit Scale• Assess:

• Level of Consciousness• Gaze• Vision• Facial Palsy• Arm & Leg Strength• Limb Ataxia• Neglect• Dysarthria• Aphasia

REMEMBER:MUST BE ASSESSED

IN ORDER LISTED


(Jensen & Lyden, 2006)

NIHSSLimb Ataxia

“A few items consistently show poor agreement, notably ataxia,

dysarthria, and facial weakness” Jensen & Lyden (2006, p. 2)

YOU’RE NOT THE ONLY ONE WHO MAY MAKE AN ERROR

SCORING ATAXIA!!!

NIHSSLimb Ataxia

• Assesses evidence of a unilateral cerebellar lesion

• Assesses incoordination from weakness

• Test with eyes open, in intact visual field

• Test on bilateral extremities

(NIH Stroke Scale International, 2001)(National Institute Of Neurological Disorders And Stroke, 2001)

Evaluating Limb Ataxia

• Scored if present out of proportion to weakness

• Two instances when ataxia would not be assessed• Absent in patients who do not understand or are

paralyzed• Untestable (UN) if amputation or joint fusion

present

(NIH Stroke Scale International, 2001)(National Institute Of Neurological Disorders And Stroke, 2001)

Click on picture of face to view

example of finger-nose-finger test

with ataxia present

Finger-Nose-Finger Test• Ask patient to touch your

index finger with his index finger and then back to his nose

• Repeat enough times to fully assess for ataxia, moving your index finger each time to make a new target

• Then repeat using other extremity

(NIH Stroke Scale International, 2001)


Heel-Shin Test

• Ask patient to move right heel up and down the left shin

• Repeat enough times fully assess for ataxia

• Then repeat using other extremity

(NIH Stroke Scale International, 2001)


Click on picture to view example of

heel-shin test with ataxia present

Limb Ataxia• SCALE DEFINITION

• 0 Absent (Not present or paralyzed)• 1 Present in 1 limb (an arm or a leg)• 2 Present in 2 limbs (both arms, both legs,

or arm and leg on same side of body)

• UN Amputation or joint fusion (explain)

• The link below will take you to the National Institute of Health Stroke Scale Training Video• Assessment #7 Limb Ataxia http://www.youtube.com/watch?

v=8AXtl3QPH7Y&feature=related

(NIH Stroke Scale International, 2001)Video used with permission from NIHSS English Training Campus

Great job!Ataxia is incoordination, not weakness!

False:Ataxia is incoordination, not weakness!

TEST YOUR KNOWLEDGE

• Ataxia occurs because of muscle weakness after a stroke.

True

False

Great job!Ataxia is assessed after weakness!

Think about the order of the exam.Ataxia is assessed after weakness!

TEST YOUR KNOWLEDGE• Ataxia needs to be assessed prior to weakness in the NIH Stroke

Scale.

True

False

Great job!Ataxia is not present because the patient is

unable to perform the test.The score would be absent due to paralysis.

No, ataxia is not present because the patient isunable to perform the test.

The score would be absent or 0 due to paralysis.

TEST YOUR KNOWLEDGE• If the patient has weakness in the right arm and is unable to lift the

arm off the bed, would ataxia be present?

Yes

No

Try again!Only score UN if amputation

or joint fusion present.

GREAT JOB!

Try again!Ataxia is only present in the

R arm.

Try again!Ataxia is present in R arm.

TEST YOUR KNOWLEDGE• The patient exhibits some weakness in the right arm and is able to perform the finger-nose-

finger test. The patient misses the assessors finger. The patient completes test on left arm without difficulty. What score would be given for the upper extremity test?

0

2

1

UN

Treatment

• There is no current cure of ataxia following a cerebellar stroke

• Physical & Occupational Therapy• Strengthen muscles• Assistive devices

• Assist in walking and other activities of daily living (ADLs)



Nurse Sensitive Outcomes

• Impaired Mobility• Mobilize early to prevent complications

• Active & Passive range of motion (ROM)• Participate in self-care & activities frequently

• Teach safe use of assistive devices• Educate & Facilitate adaptation of home/work

environment for maximal independence• Teach safety precautions• Expected outcomes:

• Optimal independence with ADLs & mobility• Maintain safety precautions

(Bader & Littlejohns, 2004)


Self-Care Deficit• Evaluate ability to perform ADLs• Consult occupational therapy (OT)• Assess for risk of falls• Expected outcomes:

• Functional abilities recognized & advanced

(Bader & Littlejohns, 2004)


Safety• Identify Fall Risk

• Implement fall prevention strategies• Universal Fall Risk Interventions• Fall Precautions due to activity impairment

• Expected outcome:• Effective in decreasing vulnerability to falls and

related injury(Summers et al., 2009)


Anticipatory grieving related to loss of functional abilities• Facilitate discussions to allow patient/family to

voice concerns• Neuropsychiatry consult to evaluate cognitive vs.

depressive issues• Rehabilitation consult to evaluate needs• Support Groups• Expected outcomes:

• Supported & given resources to assist with coping(Bader & Littlejohns, 2004)

Coping• Challenges:

• Loss of independence• May feel alone• Lead to depression & anxiety

• Therapy or counseling may lessen sense of isolation and help cope

• Can lead to increased stress on the patient• Habitual Stress

• The physiologic & behavioral changes induced by generalized stress response can threaten homeostasis

(Porth, 2005)(Mayo Clinic Staff, 2009)

Generalized Stress Response

• Stroke is a life changing event people do not have time to prepare for

• Stress can impact controllable risk factors for stroke• Hypertension• High cholesterol• Tobacco use• Alcohol use• Physical Inactivity• Obesity

Generalized Stress Response (GSR)

(Porth, 2005)

Renin-Angiotensin-Aldosterone Pathway

(Porth, 2005)

Hormone Involvement in GSR• Corticotropin-releasing Factor (CRF)

• Released by the hypothalamus• Stimulates ACTH release

• Adrenocorticotropic hormone (ACTH)• Released from the anterior pituitary gland• Stimulates synthesis and release of cortisol

• Cortisol• Released from adrenal cortex• Affects many systems and processing in the body

(Porth, 2005)

Effects of Cortisol• Cardiovascular

• arterioles more responsive to sns• increased contractility

• Liver • stored glucose released into blood

• Pancreas• decreased insulin release

• Adipose tissue • lipids released from periphery,

redeposited in trunk

• Skeletal • decreased bone deposition

• Renal• calcium lost in urine• Na+/K+ pump reabsorbs Na+ and

H2O into blood, secretes K+ into urine

• Muscular• actin and myosin break down

• Immune • production of prostaglandins

blocked• thymus atrophies• neutrophils can't leave blood• monocytes and macrophages less

active

(Porth, 2005)

Try again!Ataxia affects movement,

not tissue perfusion.

Try again;Ataxia does not affect breathing in the stroke

patient.

Great job!Very important to also

consider fall risk!

Try again;Ataxia does not affect breathing in the stroke

patient.

TEST YOUR KNOWLEDGE• Identify the most appropriate nursing diagnosis in terms of special

needs when ataxia is present.

Impaired gas exchange

Impaired physical mobility

Ineffective breathing pattern

Impaired tissue perfusion

GREAT!Currently no treatment

available. PT & OT to help with function.

Try again;Not used for treating ataxia.

Try again;Movements are impaired

because of communication error in the brain.

Try again;Used for stroke treatment, but not for treating ataxia.

TEST YOUR KNOWLEDGE• Treatment for ataxia in the stroke patient is:

TPA

Muscle Relaxers

Heparin

No Treatment Available

Case Study

• A 67 year old male with a history of afib and prior stroke (with no deficits) was admitted from home with acute onset of nausea, generalized weakness, ataxia, and left sided weakness. Initial MRI noted a large acute ischemic infarct within the left cerebellum and smaller infarcted areas within the cerebellar vermis and right cerebellum with occlusion of the right internal carotid artery.

Try again;Be more specific

Try again;Be more specific.

GREAT!!!

Case Study• What is the anticipated medical diagnosis of the

patient?

Cerebellar Stroke

Weakness

Stroke

Try again;Ataxia is present in both

upper extremities.

GREAT!Score 2 if present in bilateral upper or lower extremities,

or an arm and leg on the same side of the body.

Opps!Ataxia is present, therefore,

0 cannot be the score.

Case Study• When tested for ataxia, it was present on the bilateral upper

extremities. What score would be given according to the NIHSS?

0

2

1

Great!Think safety with patients

experiencing ataxia!This patient has left sided

weakness, plus BUE ataxia. This could make using mobility

devices harder.

Try again,This could be present in the

patient, but does not relate to ataxia.

Sorry,This would be appropriate, but not specific to the symptom of

ataxia.

Case Study• What appropriate nursing diagnosis would be given

to this patient related to the presences of ataxia?

Impair tissue perfusion

Impaired memory

Risk for injury: falls

The End

• With the completion of the tutorial, you are now able to:• Describe pathophysiology of cerebellum as it

relates to smooth muscle movements• Describe how ischemia to cerebellum causes

ataxia in stroke patient• Identify presence of ataxia in stroke patient• Identify appropriate nursing interventions and

outcomes

ReferencesAmerican Association Of Neuroscience Nurses. (2008). Guide to the care of the hospitalized patient with ischemic stroke. 2nd ed. Retrieved February 10, 2010, from http://www.guideline.gov/American Heart Association. (2010). Heart disease and stroke statistics - 2010 update. Retrieved from http://www.americanheart.orgBader, M., & Littlejohns, L. R. (2004). AANN core curriculum for neuroscience nursing (4th ed.). St. Louis, MO: Saunders. Duncan, P. W., Zorowitz, R., Bates, B., Choi, J. Y., Glasberg, J. J., Graham, G. D.,...Reker, D. (2005). Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke, 36, e100-e143. doi:10.1161/01.STR.0000180861.54180.FFHumphries, S., & Morgan, L. (2004). Genetic risk factors for stroke and carotid atherosclerosis: insights into pathophysiology from candidate gene approaches. The Lancet Neurology, April (3) 227-236.Jensen, M. B., & Lyden, P. (2006). Stroke scales: an update. Stroke Clinical Updates, XVI(1), 1-7. Retrieved from http://www.stroke.org/site/DocServer/SCU_-_Jan-Feb_2006.pdf?docID=5166Mayo Clinic Staff. (2009). Ataxia. Retrieved from http://www.mayocliMayo Clinic Staff (2009) nic.com/health/ataxia/DS00910/DSECTION%3DcausesMcGill University. (2002). The brain from top to bottom. Retrieved March 12, 2010, from http://thebrain.mcgill.ca/flash/index_d.htmlMorrison, A. C., Brown, A., Kardia, S. L., Turner, S. T., & Boerwinkle, E. (2003). Evaluating the context-dependent effect of family history of stroke in a genome scan for hypertension. Stroke, 34, 1170-1175. doi:10.1161/01.STR.0000068780.47411.16Mosby (2002). Mosby's pocket dictionary of medicine, nursing, & allied health (4th ed.). St. Louis, MO: Mosby, Inc.National Institute Of Neurological Disorders And Stroke. (2010). NINDS ataxias and cerebellar or spinocerebellar degeneration information

page. Retrieved from http://www.ninds.nih.gov/disorders/ataxia/ataxia.htmNational Institute Of Neurological Disorders And Stroke. (2001). NIH stroke scale. Retrieved from http://stroke.nih.govNational Stoke Association. (2009). Stroke risk factors am I at risk for a stroke? Retrieved from http://www.stroke.org/site/PageServer?pagename=RISKNIH Stroke Scale International. (2001). NIH stroke scale (NIHSS) in English. Retrieved from http://www.nihstrokescale.org/NIHSS English Training Campus. (21). 2 9 7 limb ataxia. Retrieved April 1, 2010, from http://www.youtube.com/watch?v=8AXtl3QPH7Y&feature=relatedPorth, C. M. (2005). Pathophysiology: concepts of altered health states (7th ed.) Lippincott. Schmahmann, J. D., Macmore, J., & Vangel, M. (2009). Cerebellar stroke without motor deficit: clinical evidence for motor and non- motor domains within the human cerebellum. Neuroscience, 162, 852-861. Shah, S. (n.d.). Pathophysiology of stroke. Retrieved March 12, 2010, from http://www.ferne.org/Summers, D., Leonard, A., Wentworth, D., Saver, J. L., Simpson, J., Spilker, J. A.,...Mitchell, P. H. (2009). Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the American Heart Association. Stroke, 40. doi:10.1161/STROKEAHA.109.192362Timmann, D., Konczak, J., Ilg, W., Donchin, O., Hermsdorfer, J., Gizewski, E. R., Schoch, B. (2009). Review: current advances in lesion-symptom mapping of the human cerebellum. Neuroscience, 162, 836-851. Wellcome Images. (n.d.). Wellcome Images. Retrieved February 12, 2010, from http://images.wellcome.ac.uk/

Documents

Ataxia in the Stroke Patient Kelli Kulpa BSN, RN Alverno College MSN Student Neurosciences Department Froedtert Hospital