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Facial palsy
Arm weakness
Speech impairment
Time (call immediately)
What does FAST stand for?
IV alteplase ((tPA), tenecteplase
What medication is used in someone with acute ischemic CVA?
1. >80 y.o
2. previous CPA
3. diabetic
4. NIHSS score >25 (very severe)
5. taking anti-coagulates
What are the 5 exceptions to tPA
brainstem lesions, large infarcts, edema resulting in herniation
Top causes for death in first few days (stroke)
pneumonia (25%), PE, cardiac disease
Top causes for death in first week (stroke)
1. urinary continence
2. young age
3. mild CVA
4. rapid improvement
5. good perceptual abilities
6. no cognitive disorders
What are some characteristics that show a probable outcome returning to independence post-stoke?
1. urinary continence
2. poor comorbid functioning
3. delayed rehab
What are some characteristics that show a negative outcome returning to independence post-stoke?
younger patients, men
Which population is at an increased risk of having a post-CVA seizure
want to encourage profusion t o area
Why do clinicians allow for a more elevated blood pressure in those that had a ischemic CVA?
88.9%
FAST has identified ____% of cases of CVA or TIA
4.5 hours (ideally, 3)
How quickly must tPA or tenecteplase be administered from onset of symptoms
180-200 mmHg
What is a common SBP cap for ischemic CVA?
140 mmHg
What is a common SBP cap for hemorrhagic CVA?
want to prevent further bleed
Why does hemorrhagic stroke have more strict parameters for blood pressure?
first 3-5 days
When does cerebral edema peak post-CVA?
BP management, medications, intraventricular drains, surgery (burr holes/ craniectomy)
what are the medical management of cerebral edema post-stoke?
large hemispheric stroke, basilar thrombosis, brainstem infarct, cerebellar stroke
What are risk factors for requiring mechanical ventilation post-stroke
true (food, water, dusk, etc.)
T/F patients on mechanical ventilation are at higher risk for aspiation?
Passy Muir Valve (can breath in)
Trach Cap (in and out)
Decannulation
What are the steps towards removing trach?
1. brainstem CVA
2. weak voice/ cough
3. poor oral hygine
4. difficulty swallowing oral secretions
What are 4 risk factors for aspiration?
Dysarthria
difficulty forming words
causes increased HR, decreased endurance
Why is dehydration dangerous for those post-CVA
body needs calories to heal
Why is malnutrition dangerous for those post-CVA
1. poorer functional mobility
2. increased medical complication
3. lower self care scores
Malnourishment predicts lower functional status following CVA. What is affected as a result?
1/3
(associated with poor functional outcomes, higher mortality)
Approximately _____ of all stroke survivors suffer from depression.
early mobilization, medications, neuropsychology
How can we prevent depression in post-CVA patients?
14%; 24%
____% of patients who had a CVA will exerience a fall in acute care
____% of patients who had a CVA will experience a fall inpatient rehab
50-75%; 9-15%
Without anticoagulation _______% of patients who had a CVA will have a DVT
______% will have a PE
2-7 days
When is peak onset for DVT/ PE post-CVA?
early mobilization
What can be done to help prevent DVT/ PE in patients post-CVA
pneumonia
(UTI very common in patients who are incontinent)
What is most common infection post-CVA?
bladder schedule (every 2-4 hours), foley (short term)
What can be done to help with urinary innocence?
1. spastic muscle imbalance (contracted shoulder)
2. muscle weakness
3. neglect
4. trauma (pulling on patient arm)
5. structural changes (loss of ER, flexion)
What are 5 factors that hemiplegic shoulder pain may be associated with?
early mobilization, proper positioning, turning schedule
How to reduce pressure injuries?
sacrum, ischial tuberosity, heels
Common areas for pressure injury?
all patients should be assessed by rehab professionals ASAP (within first 48 hours)
What did the canadian "best practice recommendations for stroke care" find?
serious stoke (hemorrhagic) had reduced less favorable outcomes with early mobilization; ischemic had favorable outcomes
What did the AVERT trial (2015) find?
1. functional ability
2. cognition
3. safety
4. support
5. prior roles
What are 5 factors to consider when making discharge recommendations?
timing matters
Principle that suggests the earlier stroke rehab was initiated, the better the outcomes, regardless of severity of stroke
gait training in first 3 hours of therapy
What is the most important predictor of gait outcomes
aggressiveness matters
Principle that suggests the earlier paticipation in hgiher-level, more advanced activities is associated with better outcomes
(even in "low level" patients)
true
T/F Participation in higher level actibities results in improvement of lower level activities without direct practice of these activities
Inpatient rehab
Facility with intense multidiscipilinary care; licensed as a hospital; 3 hours of therapy at least 5 days/ week; 24 hour nursing care; daily physician supervision
Skilled Nursing Facility (SNF)
Facility with minimal guidelines regarding care; no therapy requirement, MD supervision not daily, nursing care ~8 hours
older, female, hospitalized 6 months prior to CVA, higher CVA severity, longer stay
What kind of patients are usually admitted to a SNF?
false (IPR was lower)
T/F risk of mortality and readmissions was lower for those who went to SNF over IPR after acute hospitalization for CVA
gait activities, UE motor control, home management, problem solving (SLP)
What activities were found to increase FIM scorre? (minutes of therapy being spent on)
bed mobility, sitting activities, auditory comprehension (SLP), orientation (SLP)
What activities were found to have lower FIM score (minutes of therapy being spent on)
1. lower mortality
2. less likely to be institutionalized
3. improved independence
4. no longer of a hospital stay
What are benefits of organized CVA programs?
1. decreasing edema
2. improved circulation
3. spontaneous neural reorganization (influenced by rehab/ functional movements)
4. functional recovery (improving independence)
How may patients recover quickly following CVA?
1. genetics
2. co-morbidities
3. age
4. initial severity
5. mechanism of CVA
6. location/ size
What are 6 factors that impact recovery from stroke?
3 months
(can continue up to 6 months, but slower.... functional recovery can continue long past that)
When does neurological recovery peak?
inital stroke severity and age
(also pre-morbid health, physical abilities, presence of depression, level of social support, urinary continence, biomarkers)
What are the strongest predictors of rehab outcomes following CVA?
compensatory approach
Focus on skill based training augments by environmental adaptations (utilized more as time passes)
restorative approaches
focus on skill-based training augmented by strategy training and physical exercise program (utilized more early on)
C. He had his stroke less than three hours before getting to the emergency department
Patient X, a 71-year-old male, was at home when his wife noticed that he was slurring his words and having difficulty moving his left arm. She immediately called 911 and he was taken to the emergency room. He received tPA.
What do we know if he received tPA?
A. He has had a hemorrhagic stroke
B. He had his stroke more than three hours before getting to the emergency department
C. He had his stroke less than three hours before getting to the emergency department
D. We do not have enough information to determine anything at this time
B. The patient has a history of a stroke
Which of the following risk factors would indicate the higher risk for another stroke?
A. The patient has been a pack a day smoker for the last seven years
B. The patient has a history of a stroke
C. The patient has a history of uncontrolled hypertension
D. The patient has a history of controlled diabetes
E. All the above
A patient had a brainstem CVA. Which of the following complications as a clinician would we be worried about him developing?
A. Pneumonia
B. DVT
C. Seizures
D. Pressure injuries
E. All the above
B. Home with outpatient PT
CVA patinet's initial evaluation demonstrated that he has weakness in his right hemibody in both his Upper and Lower extremities, he has some cognitive concerns, and requires maxA for sitting balance and bed mobility.
Which of the following discharge recommendations would NOT be appropriate?
A. Inpatient Rehabilitation
B. Home with outpatient PT
C. Sub acute skilled rehab
D. Long term care facility
Rood
Which clinician used developmental sequence to obtain motor responses
flexion, adduction, ER, supination, wrist/finger flexion
What is the UE D1 flexion pattern?
extension, abduction, IR, pronation, wrist/finger flexion
What is the UE D1 extension pattern?
flexion, abduction, ER, supination, wrist/finger flexion
What is the UE D2 flexion pattern?
extension, adduction, IR, pronation, wrist/finger flexion
What is the UE D2 extension pattern?
hip flexion, adduction, ER, DF, Inversion, toe extension
What is the LE D1 flexion pattern?
hip extension, abduction, IR, PF, eversion, toe flexion
What is the LE D1 extension pattern?
hip extension, abduction, ER, PF, inversion, toe flexion
What is the LE D2 extension pattern?
hip flexion, abduction, IR, DF, enversion, toe extension
What is the LE D2 flexion pattern?
Knott and Voss (PNF)
Who came up with D1/D2 patterns?
medial aspect of cerebral hemispheres
(frontal and parietal)
What part of brain does anterior cerebral artery (ACA) supply blood to?
basal ganglia, anterior 4/5ths corpus callosum
What subcortical structures does the anterior cerebral artery (ACA) supply blood to?
yes
(executive functioning, memory, basic/ complex mental features, pattern recognition, matching)
Would you expect any COGNITIVE impairments with Anterior Cerebral Artery Syndrome ?
left hemisphere (frontal lobe)
What side of the brain might present with aphasia?
right hemisphere (frontal lobe)
What side of the brain might present with poor safety awareness/ impulsivity?
Wenicke's area (expressive)
lesion in auditory association cortex of left lateral temporal lobe;
Someone who has no issue producing language, although this language is nonsensical.
Broca's (receptive) aphasia
Lesion in premotor area of left frontal lobe
Someone who understands language, but has trouble producing language output and can only express 1-2 words
cognitive, balance, motor (LE), function
(no sensory or cranial nerves impairment)
What kind of impairments would you expect from Anterior Cerebral Artery Syndrome?
lateral aspect of hemispheres (frontal and parietal)
What part of brain does middle cerebral artery (MCA) supply blood to?
posterior internal capsule, globus pallidus, caudate nucleus, putamen
What subcortical structures does the middle cerebral artery (MCA) supply blood to?
MCA (50%)
What is the most common CV?
cognitive, sensory, motor (UE), balance, function
(not cranial nerve, coordination,
What deficits would be expected to be seen with MCA stoke?
Pusher's syndrome
Impaired perception of body posture in relation to gravity (mismatch of 18º towards side of lesion); usually damage to right thalamus from MCA stroke
Type II (loss of muscle cross-sectional area; greater on involved side)
Which nerve fibers progressively decline after stroke?
Apraxia
The inability to perform movements in the absence of motor and sensory types
constructional apraxia
Type of apraxia; inability to organize or arrange component parts into a final product; impairs setting table, making bed, dressing
ideomotor apraxia
Type of apraxia; Inability to carry out purposeful movement on command
ideational apraxia
Type of apraxia; Incorrect use of an object: using toothbrush to comb hair
posterior aspect of hemispheres
(occipital and medial/inferior temporal)
What part of brain does posterior cerebral artery (PCA) supply blood to?
upper brainstem, midbrain, posterior diencephalon (thalamus)
What subcortical structures does the posterior cerebral artery (PCA) supply blood to?
visual, balance, functional
(not cognitive, cranial nerves, sensory, motor, coordination)
What deficits would be expected to be seen with PCA stoke?
homonymous hemianopsia
Loss of the entire visual field on one hemisphere
cerebellum and brainstem
What part of brain does posterior inferior cerebral artery (PICA) supply blood to?
cranial nerves, sensory, coordination, balance, function,
(not cognitive, motor)
What deficits would be expected to be seen with PICA stoke?
trigeminal (V), vestibulocochlear(VIII), glossopharyngeal(IX), vagus (X), spinal accessory (XI)
Which cranial nerves may be affected in PICA stroke?
- dysarthria and dysphagia
- ipsilateral loss of pain/ temp (face)
- contralateral loss of pain/temp (trunk/ extremities)
- ataxia
- vertigo
- Horner's syndrome (miosis, ptosis, loss of sweating)
Symptoms of Wallenberg syndrome (PICA stroke)
cerebellum, medulla, pons, inner ear, cerebellum
What part of brain does vertebrobasilar artery supply blood to?
cranial nerves, sensory, motor, coordination, balance, function
(not cognitive)
What deficits would be expected to be seen with vertebrobasilar artery stoke?
CN 5-7; 9-12
Which cranial nerves would be affected with vertebrobasilar artery stroke?
DCML, spinalthalamic tract
(pain/ temp, light touch, proprioception)
Which pathways would be affected in vertebrobasilar artery stroke?
Locked-in syndrome
Large vertebrobasilar strokes;
the patient is cognitively intact, but the only movement the patient has is ocular movement, specifically vertical gaze. Cranial nerve 8 is spared, so patients do have preservation of hearing.