Brain Attack Day One

8/3/2019 Brain Attack Day One

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Brain Attack

Cerebrovascular Accident

OrStroke


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Stroke

Generic term for temporary or permanentdisturbance of brain function due to vasculardisruption (Brookshire) Also called cerebrovascular accident (CVA)

3rd leading cause of death in the USA; about500,000 per year----150,000 die from stroke

80% of pts. Survive for at least 1 mo. Post; about1/3 of those are alive 10 years post.


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The Five Most Common Stroke Symptoms Include:

Sudden numbness or weaknessof face, arm or leg, especially on one side of thebody

Sudden confusion, trouble speaking orunderstanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss ofbalance or coordination

Sudden severe headache with no known cause


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Other Important but less Common StrokeSymptoms Include:

Sudden nausea, fever and vomitingdistinguished from a viral illness by thespeed of onset (minutes or hours vs. several

days)

Brief loss of consciousness or period ofdecreased consciousness (fainting,confusion, convulsions or coma)


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Uncontrollable Stroke Risk Factors Include: Age The chances of having a stroke go up with age. Two-thirds ofall strokes happen to people over age 65. Stroke risk doubleswith 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 otherracial 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 bedue to circulation problems that diabetes can cause. Inaddition, brain damage may be more severe and extensive ifblood sugar is high when a stroke happens. Treating diabetesmay delay the onset of complications that increase stroke risk.However, even if diabetics are on medication and have bloodsugar under control, they may still have an increased stroke

risk simply because they have diabetes.


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Coronary Heart Disease and High Cholesterol

High cholesterol can directly and indirectly increase stroke riskby clogging blood vessels and putting people at greater risk ofcoronary heart disease, another important stroke risk factor. Acholesterol level of more than 200 is considered "high."Cholesterol is a fatty substance in the blood that our bodiesmake on their own, but we also get it from fat in the foods weeat. Certain foods (such as egg yolks, liver or foods fried inanimal fat or tropical oils) contain cholesterol. High levels ofcholesterol in the blood stream can lead to the buildup ofplaque on the inside of arteries, which can clog arteries andcause heart or brain attack.

Sleep Disordered Breathing - Sleep Apnea Sleep apnea is a major cardiovascular and stroke risk factorincreasing blood pressure rates which may cause stroke orheart attack. Studies also indicate that people with sleep apneadevelop dangerously low levels of oxygen in the blood whilecarbon dioxide levels rise, possibly causing blood clots or evenstrokes to occur. Diagnosing sleep apnea early may be animportant stroke prevention tool.

Personal history of stroke or TIA

People who have already had a stroke or TIA are at risk forhaving another. After suffering a stroke, men have a 42 percentchance of recurrent stroke within five years, and women have a24 percent chance of having another stroke. TIAs are also

strong predictors of stroke because 35 percent of those whoexperience TIAs have a stroke within five years.


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Lifestyle Factors that Increase Stroke Risk Include:

Smoking

Smoking doubles stroke risk. Smoking damages bloodvessel walls, speeds up the clogging of arteries bydeposits, raises blood pressure and makes the heartwork harder.

Alcohol

Excessive consumption of alcohol is associated withstroke in a small number of research studies. Its specificrole in stroke has not yet been determined or proven.Recent studies have also suggested that modest alcoholconsumption (one 4 oz. glass of wine or the alcoholequivalent) may protect against stroke by raising levels ofa naturally occurring "clot-buster" in the blood.

Weight

Excess weight puts a strain on the entire circulatorysystem. It also makes people more likely to have otherstroke risk factors such as high cholesterol, high bloodpressure and diabetes.


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The Impact of Stroke Risk Factors


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Most strokes occur in the 7 th decade

85% of survivors return to prestroke-livingenvironment (with some residualimpairment)

15 % require institutional care(Greenberg, Aminoff, and Simon, 1993)


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Ischemic deprived of blood Sometimes called occlusive

Hemorrhagic caused by bleeding

Loss of blood flow for 3-5 minutes causesnecrosis of the CNS Infarct---death of tissue caused by

interruption of blood supply


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Ischemic Stroke

Thrombotic Artery is gradually

occluded by a plug of material the collects ina given site

Uncommon in smallerarteries

Usually in areas of disturbance like twistsand bends in an artery

Atherosclerosis: Greek hard paste

Embolic Artery is suddenly

occluded by materialthat moves thought hevascular system toocclude an artery

Often a fragment froma thrombosis

Atrial fibrillation is acommon cause


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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


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RIND and PRINDs

Reversible ischemic neurologic deficits(less than 24 hours)

Partially reversible ischemic neurologicdeficits (longer than 24 hours but leaveminor deficits after a few days

TIAs sometimes called small strokes


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Greenberg et al. (1993) 1/3 of pts who have TIAs or RINDs will

within 5 years have a stroke that leavesthem with permanent neurologic deficits


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Hypofusion

Insufficient blood flow to the brain and thebrain stem

Diaschisis---disruption of brain function inregions AWAY from the site of injury (butconnected by neural pathways (withinsystem) Edema, decreased blood flow,

neurotransmitters and diaschisis help diffuseimpairment of brain function!


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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) byextreme fluctuation in BP


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Hemorrhages

Extracerebralhemorrhages

bleeding outside of thebrain Subarachnoid subdural

extradural

Intracerebralhemorrhages

Within brain substancebleed


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Intracerebral Hemorrhage

90% occur in pts with high BP Cause(s): hypertention pressure on arterial

walls or chronic hypertension weakeningof small penetrating arteries causingmicroaneurysms

Can cause snowball effect as thehemorrhage affects adjacent vessels


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Aneurysm

Pouches formed in arterial walls berry or saccular, term depends upon the shape

Nearly 50% of extracerebral aneurysms occurin the arteries at the base of the brain(vertebrals, basilar, internal carotid and Circleof Willis

Most are due to injury to MCA and ACA 2-3% occur in the posterior cerebral artery


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Berry Aneurysm


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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


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AVF

Greatest risk is thepotential for

rupture andsubsequenthemorrhage


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Intracranial Tumors Primary site: point of origin

Secondary site: originated elsewhere andmoved

Relocation of tumor = metastasis--- mets

Primary tumors: usually cerebrum andcerebellum Occur at any age, most commonly age 25-50

MAY run in families hypothesis?


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Herniation Syndromes

Masses the force movement of brainsubstance (or brain stem)

Tumors: course is deterioration of function Early stage = lower intracranial pressure =

causes nonspecific alterations of cognition (

forgetfulness, drowsiness, blurred or doublevision, vertigo, lightheadedness, etc.


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Intracranial tumors, cont.

Inc. IC pressure = increased sig. Symptoms:e.g., lethargy, stupor, bifrontal and

bioccipital headaches (unaffected byanalgesic meds), vomiting, imbalance.


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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, 5-6year development

Glioblastoma Mul.: a most malignant and

rapidly growing intracranial mass Develops in 3-12 mo. average postsurgical

survival is only 6-9 months


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More IC Tumors--Primary

Meningioma: arise from the ________?? Most benign of all, very slow growing, well-

defined margins, usually dont invade brainsubstance

Can usually be completely removed

Symptoms are usually site specific


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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:

Breast most frequent occurrence Lung Pharynx/larynx---least frequent occurrence.


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Other causes of brain impairment

Hydrocephalus enlargement of the cerebralventricles

Obstructive hydrocephalus IVP intraventricular shunt---VP shunt

Infections: abscesses and meningitis brain abscess introduction of bacteria, fungus or

parasites into brain tissue from infection sitesomewhere in the body

40% of sources are nasal sinuses, ME and mastoid cells


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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


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Toxemia

Due to substances invading the NS thatinflame or poison nerve tissue

May result from: drug overdoses orinteractions, bacterial toxins (tetanus,botulism, diphtheria) or heavy metal

poisoning (lead and mercury)----WTC??? TX is to remove the substance


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Metabolic and Nutritional

Disorders Metabolic: rarely cause specific

communication disorders

Severe hypoglycemia can cause cerebraldysfunction

Nutritional: rare in the USA Wernickes Encephalopathy: thiamine

deficiency, usually associated with alcoholism Paralysis of eye muscles, incoordination, poor gait,

mental confusion


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Aphasias

Fluent Wernickes

Conduction Transcortical Sensory

NonFluent Brocas

Transcortical Motor Global

Other forms: Anomic Alexia and Agraphia Primary Progressive


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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


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Acute Therapy

After ischemic stroke, the area of infarctionis 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 (toincrease blood into the area of infarct, and;

Corticosteroids used to reduce swelling of thebrain


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These neuroprotective measures have notbeen protective; most medical (acute)

treatments for ischemic stroke have beenlimited to preservation of life

Until 1995: National Institute of

Neurological Disorders and Stroke(NINCDS) study on t-PA


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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 postonset

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


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1996, t-PA approved

For acute ischemic stroke, if Administered within 3 hours of stroke;

No sign of intracerebral hemorrhage as confirmedby 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---


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No history of anticoagulant meds Heparin and Coumadin (Warfarin)


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IF criteria for t-PA were not met?

Tx requires identification of etiology orlocating the blockage in the internal carotid

or heart If carotid: tx of etiology is to remove thrombus

via Carotid Endarterectomy (CAE), or viaantiplatlets, e.g., aspirin

If heart (cardiogenic): Coumadin or Heparinare administered


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Chronic Therapy:

Rehabilitation Begins when pt is medically stable; initial

goal: ambulate, communicate and ADLs

2nd goal: stimulate sph production andlanguage use via social interactions


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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 tohandle 3 hours of activity per day

BBA of 1997? Fiduciary Cap.


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American Heart Association

6 major areas of stroke rehab:1: handle concurrent illnesses and complaints

2: maximize independence3: maximize psychosocial coping of family4: promote reintegration

5: improve quality of life6: prevent recurrent vascular events


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Primary Indicator of Recovery?

1) Severity of neurological impairment. The more severe the damage and subsequent

impairments, the longer the hospital stay, themore complicated the treatment plan, thelonger the recovery process

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


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Contraindicators of

Rehabilitation Psychiatric Disorders;

Dementias, Apathy Syndrome, Negative

Symptom Complex Not a functional loss: these conditions have

less ambition, less motivation, poor effort tosucceed, etc.

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Brain Attack Day One