PT 634 W1: intro and medical management

What are some non-modifiable risks of stroke?

Age

Race (Blacks, Hispanics, and Asians increased risk)

Sex (at < 60yrs old, men have increased incidence of stroke, > 60yrs equal incidence)

Genetic disorders, family history

Previous stroke or Transient Ischemic Attack (TIA)

Pregnancy

What are some modifiable and medical risk factors of stroke?

HTN Smoking DM High Cholesterol Obesity Physical inactivity Alcohol Smoking Cocaine Stress Cardiac *Afib Circulation disorders Malignancy Hep C/HIV

Why is important to prevent stroke?

Integral part of rehabilitation

How do we identify patients that are at high risk?

The group at highest risk for stroke is patients with stroke!

What are some life stytle modifications that can reduce SBP?

weight reduction

DASH diet

sodium restriction

physical activity

limit alcohol intact

What is normal BP

systolic less than 120 and less than 80 diastolic

What is elevated BP?

120-129 systolic

and

less than 80 diastolic

What is high BP stage 1

Systolic 130-139 or 80-89 diastolic

What is high BP stage 2?

140 or higher Systolic

or 90 or higher diastolic

What is hypertensive crisis

higher than 180 systolic and/or higher than 120 diastolic

What is the signs of stroke FAST?

face

arm

speech

time

What does F stand for in fast

face ask the person to smile. is one side face drooping

What does A stand for in fast

arms. ask person to raise arm. is one arm weak?

What does S stand for in fast

speech. ask the person to speak. is their speech slurred?

What does T stand for in fast

time call 911 right awway at first sign of stroke

What is BEFAST

balance - does patient have sudden loss of balance

eyes - has person lost vision in one or both eyes

face

arms

speech

time

What factor is most important when someone suddenly has stroke

TIME! GET HELP NOW

What are some lifestyle modification for stroke?

Self-directed and self management approaches

Multidisciplinary education

Modifiable risk factors

Mediterranean

Diet

Exercise: 5 days, >150mins moderate

Smoking, alcohol, and drug cessation

Medication compliance: BP (<130/80), cholesterol, HL, afib, etc

Physical activity recommendations after stroke

What are types of stroke (CVA)?

ischemic (infarcts, infarction) 87%

hemorrhagic (13%)

What are the types of ischemic strokes?

◦ Transient Ischemic Attack (TIA)

◦ Embolic or Thrombotic

◦ Lacunar Stroke

What are the types of hemorrhagic strokes?

◦ Subarachnoid Hemorrhage (SAH) ◦ Intracerebral Hemorrhage (ICH) ◦ Intraventricular Hemorrhage (IVH)

What is the initial presentation of a hemorrhagic stroke?

often present with more severe symptoms initially, such as sudden and intense headaches, nausea, vomiting, and rapid neurological deterioration due to the bleeding in the brain. This can lead to a higher mortality rate initially

What is the recovery of a hemorrhagic stroke?

While the initial prognosis can be worse, some individuals with hemorrhagic stroke may show improvement over time, especially if the bleeding is controlled and brain damage is limited. The recovery can be more variable, but there can be significant recovery in certain cases, especially with timely medical intervention and rehabilitation

What is the initial presentation of a ischemic stroke?

Ischemic strokes may not seem as severe initially since they are caused by a blockage (rather than bleeding) and the brain tissue is not immediately exposed to blood. Symptoms might be less dramatic in the early stages

What is the recovery of a ischemic stroke?

However, ischemic strokes tend to lead to greater long-term impairments because the ischemia (lack of blood flow) can cause permanent brain damage if not rapidly treated. In the long term, individuals with ischemic strokes may face more significant functional impairments, as the brain tissue that was deprived of oxygen may not recover fully.

Ischemic stroke causes

embolism or thrombosis

What is an embolic stroke?

occurs when a blood clot or other debris forms elsewhere in the body and travels through the bloodstream to the brain, blocking a blood vessel

is a sudden onset

Sources:

• Patent Foramen Ovale • Ischemic heart Disease • Arrhythmia (A- FIB) • Endocarditis • Valvular Disease • Atherothrombotic, cholesterol

What is a thrombotic stroke?

occurs when a blood clot (thrombus) forms in one of the arteries supplying blood to the brain, leading to a blockage and reduced blood flow

Gradual onset of symptoms, often developing over hours or days

Sources:

• Atherosclerosis • HTN and DM increase risk for plaque formation • Non-atheromatous diseases of the vessel wall ◦ Collagen disease ◦ Vasculitis ◦ Fibromuscular dysplasia ◦ Trauma

What is a transient ischemic attack?

• Sudden onset of focal neurological symptoms due to inadequate blood supply.

• Resolve within 24hrs or less with no residual deficits.

• Most often caused by emboli

• 5-10% of patients will have a stroke within 1yr

• TIAs are often a warning sign for future strokes. Timely medical intervention is crucial to prevent permanent damage

TIAs are often a _______ for future strokes. Timely medical intervention is crucial to prevent permanent damage

warning sign

What is a lacunar stroke?

type of ischemic stroke caused by occlusions of small penetrating arteries in the deep subcortical regions of the brain, leading to the formation of small cavities or "lacunae.“

Onset of focal deficit may be sudden or progress over several hours, some are asymptomatic.

• Associated with hypertension

Best prognosis

• CT – might show deep, small infarct, some too small to visualize

• MRI – shows even small infarcts, preferred

Common location for lacunar strokes?

• Basal ganglia (motor control issues)

• Internal Capsule (motor and sensory deficits)

• Pons (vital functions: breathing & eye movements)

• Thalamus (sensory deficits)

Acute signs and symptoms of ischemic stroke?

Dysarthria

Dysphagia

Hemiplegia/hemiparesis

Acute mental status changes

Ataxia

Facial droop

Sensory loss

Hemianopia or other visual changes

what are Medical Differential Diagnosis-ischemic stroke?

• Hyper/hypoglycemia • Migraine • Seizures • Space occupying lesions (tumor, abscess) • Drug Toxicity • Psychogenic • Hypertensive/Wernicke’s encephalopathy

What are some medical management of ischemic stroke clinical evaluation?

• Sudden onset of symptoms: weakness, numbness, speech, vision, coordination •

Neurologic assessment, NIH stroke scale

• Code stroke

What are some medical management of ischemic stroke imaging?

• CT/A – can show early hemorrhagic changes (bleeding)

• MRI/A – earlier detection of ischemic changes, infarcts

What are some medical management of ischemic stroke additional tests?

• CT/MRI Angiogram- evaluate blood vessel barrowing or blockages

• Carotid ultrasound- plaque or stenosis

• Echocardiogram- find source of embolism

What are some medical management of ischemic stroke lab studies?

• To rule out other conditions (e.g., infections, blood clotting disorders) and assess risk factors (e.g., cholesterol, glucose) • CBC, glucose, electrolyte, PT/PTT/INR, cardiac enzymes, hypercoagulable work up

What are some medical management of pharmacology of ischemic stroke?

Fibrinolytics: tPA

Overview of Fibrinolytics: tPA

◦ Alteplase (Activase) for acute ischemic strokes

◦ Dissolves clot and restores blood flow

◦ Needs to be administered within 4.5 hrs of stroke

◦ Optimal 3 hours

◦ Risk of hemorrhagic conversion

◦ Dramatically improves prognosis

tPA outcomes for ischemic stroke from study

◦ Patients treated with tPA are 30% more likely to experience minimal or no disability at 3 months.

◦ Average LOS shorter

◦ Discharge home vs rehab or nursing home

What are some surgical management of ischemic stroke?

•Carotid Angioplasty and stenting •Mechanical thrombectomy •Carotid Endarterectomy

What is a subarachnoid hemorrhage (SAH)?

•Subarachnoid hemorrhage (SAH) is bleeding into the space between the brain and the membranes covering the brain (subarachnoid space)

common causes:

• Ruptured aneurysm (most common cause). • Arteriovenous malformations (AVMs). • Trauma or head injury. • Cerebral vasculitis or other vascular conditions

What are some subarachnoid SAH signs/symptoms?

Severe, sudden headache “worst headache of my life”: WHOL

Neck stiffness – Brudzinski sign

Knee extension-Kernig’s sign

Photophobia

Nausea, vomiting

Focal neurological deficits

10-25% of pts also have a seizure in first few minutes

What is kernigs and bruzkinski test?

What are some medical management of subarachnoid hemorrhage?

Imaging

• CT /A– most sensitive • MRI/A – inferior to CT for SAH • Cerebral angiography – looks at vascular anatomy, site of bleed, aneurysms

Lab studies

– CBC, electrolytes, serum chemistry panel, PT/PTT/INR, blood typing/screening

Other

• Protect airway • Manage BP (patient specific) • Manage hydrocephalus/intracranial pressure • Monitor for vasospasm

differential diagnosis of subarachnoid hermorrhage?

• Hyper/hypoglycemia • Migraine • Seizures • Tumor • Abscess • Meningitis

Vasospasm complication for SAH

• Narrowing of IC vessels due to smooth muscle cell contractions

• Delayed cerebral ischemia

• Onset 4-20 days

• Most deadly complication

• Diagnosed by angiogram •

Monitored by Transcranial Dopplers (TCDs) and neuro exams

• HA, lethargy

Vasospasm treatment

• Triple H therapy (hypertension, hypervolemia, hemodilution)

• Meds to increase BP, large amounts of fluids • PT precautions

• Intraarterial vasodilators

• Balloon dilatation

SAH increased ICP complication

• Increased ICP >15mmHg

• Brain herniation: displacement of brain parenchyma

• Midline Shift: lateral displacement of falx cerebri

• Hydrocephalus

symptoms of increased ICP?

papilloedema, AMS, LOC, HA, BP, sz, posturing

ICP medical management external ventricular drain

• Catheter inserted into ventricles to drain excess CSF

• Indications: hydrocephalus, increased ICP, post SAH, post-op

• Short term, Emergency management

ICP medical management external ventricular drain pt considerations monitoring ICP

• SS increased ICP= HA, nausea, AMS, vitals • Avoid sudden head movements

• Keep EVD transducer aligned with external auditory meatus

ICP medical management external ventricular drain pt considerations positioning

• HOB elevated to 3-45 degrees for optimal drainage

• Avoid kinks or tension on tubing

ICP medical management external ventricular drain pt considerations activity tolerance

• Mobilization is safe!

• EVD MUST BE Clamped for mobilization- communicate with RN

What is ventriculoperitoneal shunt (VPS)?

•The VPS helps to drain excess CSF from the brain to the abdominal cavity, where the fluid is absorbed by the body, relieving pressure on the brain (internal)

Components

• Ventricular Catheter: inserted into ventricle to drain excess CSF

• Shunt abdomen, regulates flow of the CSF to abdominal cavity

• Peritoneal Catheter: Tube that directs drained CSF to the peritoneal cavity in abdomen so fluid is absorbed by body

• Long-term solution (i.e NPH, congenital conditions)

• Increased mobility & functionality, less monitoring

VPS PT considerations

Monitor for SS indicating increased ICP (can’t see value

What is an intracerebral hemorrhage (ICH)?

• Intracerebral hemorrhage (ICH) is a type of stroke where a blood vessel in the brain ruptures, leading to bleeding within the brain tissue

• 8-13% of all strokes

• Causes: HTN, Aneurysm, AVMs, Trauma, drug abuse, coagulation disorders or anticoagulant use

Intracerebral hemorrhage keypoint?

• Key Point: ICH is a medical emergency with high mortality and acute neurological disability, making rapid diagnosis and intervention critical.

• Rapidly expanding bleed can lead to unconsciousness or death, will cause damage to brain cells surrounding hemorrhage.

• More likely to result in death or disability than an ischemic stroke or a SAH

ICH signs and symptoms

Sudden onset of headache followed by decreased consciousness Hemiparesis Sensory changes Hemianopia Dysarthria Ataxia, LOB Vomiting

most common location of ich?

◦ Basal ganglia (40-50%) ◦ Lobar regions (20-50%) ◦ Thalamus (10-15%) ◦ Pons (5-12%) ◦ Cerebellum (5-10%) ◦ Other brainstem sites (1-5%

ICH differential diagnosis?

Ischemic Stroke SAH AVM HTN Encephalopathy Hyper/hypoglycemia Migraine Seizures Space occupying lesions (tumor, abscess

ICH medical management initial stabilization

• Airway management • BP control <140 mmHg • IV antihypertensives • Labetalol, nicardipine, esmolol • Reduce ICP

ICH medical management imaging

CT

ICH medical management hematoma expansion prevention

• Reverse anticoagulation • Vit K, prothrombin complex concentrates • Platelet transfusion

Medical Management of ICH surgical intervention

• Surgical Evacuation of blood • Craniotomy • Craniectomy

What precautions are present with craniectomy?

helmet precautions

Medical Management of ICH seizure prophylaxis

Anticonvulsants

What is a cerebral aneurysm?

• An abnormal ballooning or dilation of a blood vessel in the brain due to a weakness in the vessel wall.

•Can lead to SAH or ICH

What is a saccular (berry) aneurysm?

• Most common type (80%), often located at branch points in arteries, especially the circle of Willis

What is a fusiform aneurysm?

• Diffuse widening of a vessel, commonly affecting large arteries • Less common than saccula

What is a Mycotic Aneurysms

Caused by infection, usually bacterial, leading to weakened vessel wall

What are some cerebral aneurysm risk factors?

• HTN • Smoking • Family History • Genetic Conditions (Ehlers-Danlos) •Previous SAH •Age (30-60 year) •Gender

What are some cerebral aneurysm signs and symptoms?

Unruptured aneurysm: Often asymptomatic or nonspecific

Ruptured aneurysm

• Sudden severe HA (“Worst HA of my life” • Nausea/vomiting • Neck Stiffness • Photophobia • Loss of consciousness • Neurologic deficits

Cerebral aneurysm diagnosis?

• CT scan: first-line for suspected ruptured aneurysm, reveals blood

• MRI/MRA: Can detect unruptured aneurysm and provide detailed vascular imaging

• Cerebral Angiography: The gold standard for detailed visualization of aneurysms, especially for surgical plannin

Cerebral aneurysms treatment?

• Conservative Management (for small, unruptured aneurysms) • Blood pressure control and lifestyle modification (e.g., smoking cessation)

• Surgical Clipping: Clip aneurysm at base to prevent rupture

• Endovascular Coiling: minimally invasive procedure placing coils inside aneurysm to promote clotting and seal it off

• Flow Diversion: New technique that uses stent to reroute blood flow, reducing pressure on aneurysm

What is arteriovenous malformation AVM?

• AVM is a rare, abnormal tangle of arteries and veins that disrupts normal blood flow, bypassing the capillary system. This creates a high-flow, low-resistance pathway between arteries and veins

Etiology

• Most AVMs are congenital, arising during fetal development • Acquired AVMs can occur due to trauma, surgery or radiation therapy • Often diagnosed in young adults • Tend to present with hemorrhages at a younger age compared to aneurysms (20-40 years old)

imaging for AVM?

• CT scan: Initial imaging for hemorrhage or mass effect- may mask AVM if large bleed

• MRI/MRA: Provides detailed information about the location, size, and structure of the AVM

• Cerebral Angiography: Gold standard for definitive diagnosis, used to visualize the blood vessels feeding the AVM and draining veins.

AVM complications?

• Asymptomatic until they cause significant neurological deficits or bleeding.

• Early detection, through imaging, and appropriate treatment are essential to minimize complications.

• SAH or ICH

• Neurologic Damage 2/2 to bleed or ischemia

• Recurrence after treatment

AVM treatments?

• Surgical Resection via craniotomy

• Endovascular Embolization (glue or coils) to decrease AVM blood supply

• Sterotatic Radiosurgery (Gamma knife) to shrink or obliterate the AVM

• Useful in deep or hard to reach AVMs

What are medical complications post stroke?

Neurologic

Musculoskeletal

Cardiopulmonary

Integumentary

Gastrointestinal

Urinary

Depression

Fatigue

Central pain

Insomnia

Examples of antiplatelet medications?

Aspirin, Aggrenox, Clopidogrel

Examples of anticoagulants medication?

Warfarin, Heparin

What are examples of statin medication?

: simvastatin, atrovastatin

to lower cholesterol

What are some blood pressure medications?

ARBs (valsartan), ACE inhibitors (lisinopril) , Beta-blockers (metropolol), Calcium channel blockers (nicardipine), Diuretics (lasix)

What are some examples of antieleptics medications?

carbamazepine, valproic acid, phenytoin

Settings for Patients with Stroke: acute inpatient care consist of?

Acute IP care

◦ Primary Stroke Center, Comprehensive Stroke Center, Acute Stroke-Ready Hospital ◦ ICU/step-down ◦ Triage- Discharge planning

Settings for patients with stroke: acute inpatient care discharge planning locations

◦ Acute Rehabilitation

◦ Subacute Rehabilitation

◦ LTACH

Home with

◦ Outpatient

◦ Day Rehab

Stroke early mobility: immobility and ICU

• Impact on strength/function, LOS, cost, delirium, QOL, infection, pulmonary system

Stroke early mobility: AVERT study and expansion with 24H

• RCT comparing usual care and VEM

• Unfavorable outcome of disability at 3 months

• QOL and disability the same at 12 months

Stroke early mobility: recommendations

after 24 hours

short and frequent mobility

interdisciplinary communication

Safety checklist for stroke patients

EVD closed

ICP controlled for 24H with no mannitol or hypertonic saline

No active titration of vasopressors or antihypertensives

CAM-ICU negative for delirium

Stable neurologic exam

SAH-aneurysm treated

24H after onset of symptoms

What is a inpatient acute rehab setting?

• Free standing or hospital based

•CARF accredited, stroke certified

•Must have a medical necessity

• Must tolerate 180 minutes of therapy daily for at

least 5 days week

• Split between PT, SLP, OT

• Goal: Bridge between Acute care and next level of

care

◦ Possible Discharge locations

◦ Home PT

◦ Outpatient PT

◦ Skilled Nursing with or without subacute rehabilitation

◦ Back to acute care

Goal is Home

◦ Assess current function + prognosis

◦ Assess home environment

◦ Caregiver support

◦ Equipment needs

What is the subacute rehab setting?

◦ Located in a SNF(skilled

nursing facility) or hospital

based

◦ Not CARF accredited

◦ Less intense

◦ Needs 24hour care

What is the long-term acute care hospital setting (LTACH)

Under Medicare, the patient must need

more than 25 days of hospitalization.

◦ Average LOS =30 days

Typically, patients require:

• Prolonged ventilator use or weaning

• Ongoing dialysis for chronic renal failure

• Intensive respiratory care

• Multiple IV medications or transfusions

• Complex wound care/care for burns

•May Discharge to

• AIR

• Subacute rehabilitation

• Home

What is the home/outpatient setting for patients post stroke?

Outpatient

◦ 1 discipline

Day Rehab

◦ 2-3 disciplines

◦ 3 hours a time

Home Therapy