NPTE Neuro: Stroke & TBI

Anterior Cerebral Artery (ACA) Syndrome: supplies which side of brain

Causes contralateral hemiparesis/hemisensory loss primarily affecting the lower extremity, plus urinary incontinence.

supplied medial side of brain

s/s of ACA syndrome

Contralateral hemiparesis (LE)

Contralateral hemisensory loss (LE)

Urinary incontinence

Problems with imitation, bimanual tasks, apraxia

Slowness, delay, motor inaction

Contralateral grasp reflex, sucking reflex

ACA=ABCD=baby/kid so think kid needs to use TWO hands, they IMITATE you, they are slower, grasp and sucking is what babies do too! ALSO BABIES CRAWL SO LE AFFECTED

Middle Cerebral Artery (MCA) Syndrome: supplies which side of brain

Causes contralateral hemiparesis/hemisensory loss primarily affecting the upper extremity and face.

supplied lateral side of brain

S/S of MCA

Contralateral hemiparesis (UE and face)

Contralateral hemisensory loss (UE and face)

Language speech impairments - Broca, Wernicke, Global aphasia

Perceptual disorders - e.g., Unilateral neglect

Contralateral homonymous hemianopsia

miles per hour think of:

M-mouth

P-perceptual

H-hemonymous hemianopsia

Posterior cerebral artery: supplies which side of brain

supplies posterior side of brain

what are the two types of stroke?

Ischemic Stroke: Occurs when a clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients. more common.

Hemorrhagic Stroke: Occurs when blood vessels rupture, causing leakage of blood in or around the brain

Broca's Aphasia

Expressive/non-fluent aphasia located in the frontal lobe; patient has slow, hesitant speech.

Wernicke's Aphasia

Receptive/fluent aphasia located in the temporal lobe; patient lacks comprehension and produces word salad.

lesion to superior MCA would see? what about inferior MCA? what about stem of MCA

brocas aphasia

inferior MCA: wernickes

stem: brocas and wenickes so GLOBAL APHASIA

all seen with left MCA

Unilateral Neglect

Lack of awareness of the weak side, typically seen in Right MCA strokes.

how to recognize Homonymous Hemianopsia - Right or Left MCA

R MCA-LHH so cover right side of eyeball and that means it would be right nasal vision loss and left temporal vision loss. this goes the opposite for L MCA

Posterior Cerebral Artery (PCA) Peripheral Territory

Causes contralateral homonymous hemianopsia, prosopagnosia, dyslexia without agraphia, and memory deficits.

Posterior Cerebral Artery (PCA) Central Territory

Involves the thalamus, causing Central Post-Stroke Thalamic Pain Syndrome.

PCA Peripheral territory for S/S

Contralateral homonymous hemianopsia

• Visual agnosia - PROSOPagnosia (diff recognize people)

• Dyslexia (difficulty reading) WITHOUT

Agraphia (difficulty writing)

• Color discrimination

• Memory deficits

• Topographical disorientation (diff with directions)

Right Hemisphere Stroke Behavior

Left hemiparesis/hemisensory

loss

Impairments Visual- perceptual impairments:

- Neglect

- Difficulty with VISUAL cues

Behavior Quick, impulsive, safety risk

Intellectual Rigidity of thought

Emotional Difficulty with negative

emotions

THINK CHILD

Left Hemisphere Stroke Behavior

Right hemiparesis/hemisensory

loss

Language impairments:

- Aphasias

- Difficulty with VERBAL cues

Slow, cautious

Highly distractible

Difficulty with positive emotions

THINK OLD

spasticity vs synergy

inc in muscle tone-PROM

synergy-combo movement-AROM

think in spasticity has P so PROM

synergy is like energy so think you need to move actively

Upper Extremity spasticity pattern

Scapula • Retraction, downward rotation

Shoulder • Adduction, IR, depression

Elbow • Flexion

Forearm • Pronation

Wrist • Flexion, adduction

Hand • Finger flexion, clenched fist

thumb, adducted in palm

THINK CHICKEN DANCE

LE spasticity pattern

Pelvis Retraction (hip hiking)

Hip • Adduction (scissoring)

• IR

• Extension

Knee Extension

Foot

and

Ankle

• Plantarflexion

• Inversion

• Equinovarus

• Toes claw (tarsometatarsal extension,

metatarsophalangeal flexion)

• Toes curl (tarso- and metatarsophalangeal flexion)

THINK BALLERINA

Upper Extremity flexion Synergy

Scapula retraction/elevation

or hyperextension

• Shoulder abduction, external

rotation

• Elbow flexion

• Wrist and finger flexion

THINK SHOW OF YOUR BICEP

Upper Extremity Extension Synergy

Scapular protraction, shoulder adduction/IR, elbow extension, forearm pronation, wrist/finger flexion.

THINK TriCep SHOWING

Lower Extremity Flexion Synergy

Hip flexion/abduction/ER, knee flexion, ankle dorsiflexion and inversion.toe df

THINK SOMEONE SITTING WITH LEG CROSSED LIKE A DUDE DOES

Lower Extremity Extension Synergy

Hip extension/adduction/IR, knee extension, ankle plantarflexion and inversion. toe pf

THINK BALLERINA

Brunnstrom stages of stroke recovery

Stage 1: Flaccidity

• No active limb movement

• Stage 2: Beginning of minimal voluntary movement

• In synergy, with associated reactions

• Increase tone

• Stage 3: Voluntary control of movement synergy (Spasticity at peak)

• Further increase tone to peak level

• Stage 4: Movement outside of synergy

• Decrease tone

• Stage 5: Increase complex movement, greater independence from limb

synergies

• Stage 6: Individual joint movement, coordinated movement

• Stage 7: Normal function

what are rancho lvls of 1,2,3?

RESPONSE:

I No Response Coma

II Generalized response Non-purposeful

whole body, vocal Inconsistent

III Local response Purposeful

Local and specific Inconsistent

Follows simple commands -

close eyes, squeeze hands

RLA Level 1,2,3 Management Strategy

Positioning: Head neutral, prevent ulcer, sit (if stable)

• Gentle PROM: Joint integrity, skin integrity

• Respiratory care: Postural drainage, percussion, vibration

• Educate family: What to expect, how to be more involved

RLA 4 level

Behavior: CONFUSED AND AGITATED: (just came out from coma or long sleep so you wake up and be like ugh what time is it)

• Heightened activity, just coming out of coma

• Aggressive: Doesn't cooperate, verbalization is incoherent,

confabulations (story make up)

Attention:

• No selective attention

Memory:

• No long- and short-term memory

RLA level 4 management

CONFUSED:

• Consistent: Same therapist, same staff, family introduce yourself

daily. ESTABLISH A ROUTINE

• Orient the patient: Calendar, clock

MEMORY:

• NO CARRYOVER: Chart and graph to measure progress

AGITATED: Calm behavior. DO NOT confront!

• Environment - Closed - prevent harm to others

• Be creative - Give options!! DONT GIVE YES/NO QUESTIONS

RLA Level V vs Level VI

Level V is Confused-Inappropriate

Behavior:

• Responds consistently to simple commands

• Responds inconsistently to complex

commands

• With structure, able to socialize for short

period

Memory: Memory impaired. Inappropriate use

of objects. Can't learn new task.

level VI is Confused-Appropriate

Behavior:

• Follows simple instruction consistently

• Goal oriented behavior with external input

Memory: Carryover of previous skills present

(self-care)

RLA- stage 7,8

Level VII - Automatic Appropriate

• Oriented in home and hospital

• Daily routine - automatic but robot-like

• Judgement impaired

• Able to initiate social or recreational

activity with structure

Level VIII - Purposeful Appropriate

Carryover of new skills present

• Impaired judgement in an emergency

situation, abstract reasoning and

reduced tolerance for stress

how to manage level 7 and 8

Focus on re-entry to work and community

• Emphasize skills related to problem solving, social interaction

• Trial period of independent living

• Adaptation at work or school to return to normal life