CEREBROVASCULAR ACCIDENT

CEREBROVASCULAR ACCIDENTAuthor: Jovelyn S. Guradillo-Batican, PTRP, DPE, MAED(C)

GENERAL MEDICAL BACKGROUND

DEFINITION

Cerebrovascular Accident (CVA), commonly known as a stroke, refers to a sudden occurrence of permanent damage to an area of the brain due to interruption of blood supply. This interruption can result from various causes, including blocked blood vessels (ischemic stroke) or bleeding in the brain (hemorrhagic stroke). Prompt medical intervention is crucial to minimize brain damage and improve outcomes.

EPIDEMIOLOGY

CVA is the 5th leading cause of death globally, emphasizing its seriousness as a public health issue. It is also the leading cause of long-term disability among adults, affecting daily functioning and quality of life. Research indicates a higher prevalence of strokes in males compared to females (M > F); however, women tend to be affected more significantly after the age of 85 or post-menopause, potentially due to hormonal changes.

PHILIPPINE EPIDEMIOLOGY

In the Philippines, CVA ranks as the 3rd leading cause of mortality, reflecting the country's urgent need for preventive strategies and better healthcare infrastructure. As of January to April 2024, there were reported cases totaling 15,492, comprising approximately 10.1% of total deaths during this period. This statistic highlights the importance of both public awareness and interventions to reduce the incidence of strokes.

RISK FACTORS AND PREVENTION

Non-Modifiable Risk Factors

  • Family History: A genetic predisposition can increase risk; family history of cardiovascular disease is significant.

  • Age: Risk increases with age, particularly over 55 years.

  • Gender: Males have a higher risk overall, but women tend to incur more strokes post-menopause.

  • Race: Certain populations, particularly African Americans and Hispanics, exhibit higher stroke incidences.

  • Previous history of CVA: Those who have had prior strokes are at elevated risk for future events.

Modifiable Risk Factors

  • Diet: High in saturated fats, trans fats, and sodium, increasing blood pressure and cholesterol levels.

  • Smoking: Tobacco use significantly increases the risk of stroke due to its effects on blood vessels.

  • Sedentary lifestyle: Lack of physical activity contributes to obesity, hypertension, and poor cardiovascular health.

  • Stress: Chronic stress can lead to unhealthy lifestyle choices and increased blood pressure.

  • Comorbidities: Conditions such as Hypertension (Htn), Diabetes Mellitus (DM), Cardiac Conditions, and Hyperlipidemia can vastly increase stroke risk and should be actively managed.

ETIOLOGY

Types of Stroke

  1. Ischemic Stroke

    • Caused by atherosclerosis and the formation of blood clots in cerebral arteries.

    • Cerebral Thrombosis: A clot that forms within the cerebral arteries obstructing blood flow.

    • Cerebral Embolus: A thrombus formed elsewhere that travels to obstruct cerebral arteries.

  2. Hemorrhagic Stroke

    • Occurs when there is a rupture of blood vessels leading to bleeding in or around the brain.

    • Intracerebral Hemorrhage: Rupture of small blood vessels, often caused by aneurysms developed due to atherosclerosis.

    • Subarachnoid Hemorrhage: Bleeding into the subarachnoid space, often due to saccular or berry aneurysms.

    • Arteriovenous Malformation: A congenital defect resulting in tangled arteries and veins, leading to an increased risk of hemorrhage.

    • Lacunar Lesions: Small circumscribed lesions resulting from occlusions in deep penetrating branches of large vessels; account for 20% of strokes and are associated with conditions such as microatheroma or lipohyalinosis.

EARLY WARNING SIGNS

Recognizing the early warning signs is critical for timely intervention.

  • F - Face drooping on one side.

  • A - Arm weakness, being unable to lift one arm.

  • S - Speech difficulty, slurred speech or inability to speak.

  • T - Time to call emergency services (911) immediately if any symptoms are observed.

PATHOPHYSIOLOGY

Understanding the biological processes involved in stroke is crucial for management and prevention strategies.

CLASSIFICATIONS

Strokes can be classified based on various criteria, including:

  • Etiologic Factors: Ischemic Stroke, Hemorrhagic Stroke, Lacunar Stroke.

  • Management Categories: Transient Ischemic Attack (TIA), major strokes, deteriorating strokes (Stroke in Evolution), and strokes occurring in the young (individuals < 45 years).

  • Vascular Territory: Includes Anterior Cerebral Artery Syndrome, Middle Cerebral Artery Syndrome, Internal Carotid Artery Syndrome, Posterior Cerebral Artery Syndrome, and Brainstem Stroke (Vertebrobasilar Artery Syndrome).

REVIEW OF ANATOMY OF THE BRAIN AND CIRCULATION

In-depth knowledge of the brain's anatomy and its vascular supply is essential for understanding the implications of strokes and planning rehabilitation.

ANTERIOR CEREBRAL ARTERY

  • Supplies: Medial Frontal Lobe, Medial Parietal Lobe, Corpus Callosum, and Basal Ganglia.

ANTERIOR CEREBRAL ARTERY SYNDROME (ACA)

Structures Affected:

  • Contralateral hemiparesis/hemiplegia

  • Contralateral hemisensory loss

  • Urinary incontinence due to superior frontal gyrus involvement

  • Apraxia related to corpus callosum involvement

Signs and Symptoms:

  • Akinetic mutism, and reflexes can include grasp or sucking reflex responses.

MIDDLE CEREBRAL ARTERY

  • Supplies: Lateral Frontal Lobe, Lateral Temporal Lobe, Lateral Parietal Lobe, Basal Ganglia, and Internal Capsule.

MIDDLE CEREBRAL ARTERY SYNDROME (MCA)

Structures Affected:

  • Contralateral hemiparesis/hemiplegia, more pronounced in upper extremities and face

  • Contralateral hemianesthesia and hemianopsia

Signs and Symptoms:

  • Loss of conjugate eye movement, global aphasia, apraxia, unilateral neglect, and visuospatial deficits correlated with parietal lobe damage.

INTERNAL CAROTID ARTERY SYNDROME (ICA)

  • Occlusion can lead to MCA deficits and may present with symptoms such as Amaurosis Fugax (temporary loss of vision).

POSTERIOR CEREBRAL ARTERY

  • Supplies: Occipital Lobe, Medial & Inferior Temporal Lobe, Upper Brainstem, Midbrain, Diencephalon, and Thalamus.

POSTERIOR CEREBRAL ARTERY SYNDROME (PCA)

Peripheral Territory Affected:

  • Structures include optic radiation leading to contralateral homonymous hemianopsia, visual agnosia, dyslexia without agraphia, and memory defects.

Central Territory Affected:

  • Involves the thalamus, resulting in conditions like thalamic pain syndrome, ataxia, and contralateral hemiparesis.

BRAINSTEM STROKES

  • Weber Syndrome: Superior alternating hemiplegia resulting from PCA involvement.

  • Benedikt Syndrome: Midbrain stroke causing cranial nerve palsies and contralateral ataxia.

  • Foville Syndrome: Affects the pons, leading to conditions such as lateral gaze palsy and hemiparesis.

  • Locked-In Syndrome: Complete basilar artery syndrome, resulting in bilateral hemiplegia alongside cranial nerve palsy.

  • Wallenberg Syndrome: Lateral medullary syndrome impacting sensory, vestibular, and autonomic functions.

CLINICAL MANIFESTATIONS

Motor Symptoms: Flaccidity to spasticity; motor recovery may manifest through flexor synergy, extensor synergy, hemiparesis or hemiparalysis.Coordination and Balance: Difficulties may arise in various etiologies, impacted by musculoskeletal, vestibular, and neurological factors.Sensory Symptoms: Altered sensations may include pain, proprioceptive deficits, and loss of sensory integration.Speech and Language: Various forms of aphasia may develop, including Broca’s aphasia, Wernicke’s aphasia, and global aphasia, affecting communication profoundly.Other Manifestations: Dysphagia (difficulty swallowing), apraxia (inability to perform learned movements), seizures, neglect syndrome, and altered consciousness levels may also occur.Affective Status: Patients may experience a spectrum of emotional states ranging from apathy, euphoria, and significant depressive symptoms.

COMPLICATIONS

Strokes can lead to further health issues, including secondary complications such as pneumonia, urinary tract infections, and deep vein thrombosis post-stroke due to immobilization.

HEMISPHERIC DIFFERENCES

There are distinct variations in symptoms and recovery potential based on whether the left or right hemisphere is affected. Left hemisphere strokes may impact language abilities, while right hemisphere strokes may affect spatial awareness and emotional regulation.

DIAGNOSIS

Accurate diagnosis utilizes imaging techniques such as CT Scans, MRIs, MRAs, and Doppler Ultrasound for assessment and differentiation of stroke types.

PROGNOSIS

Good Indicators: Factors such as early onset of rehabilitation, a smaller area affected by the stroke, and the absence of cognitive deficits significantly improve outcomes.Poor Indicators: Comorbidities, larger affected areas, and uncontrolled underlying health conditions can predict poorer recovery trajectories.

GENERAL HEALTHCARE MANAGEMENT

A comprehensive and combined approach is critical, involving medical, pharmacological, and surgical management to address the complexities of stroke care.

MEDICAL MANAGEMENT

Goals:

  • Improve cerebral perfusion

  • Manage blood pressure and heart rate

  • Restore fluid and electrolyte balance

  • Control seizures and infections that may arise during recovery.

Strategies: Oxygen delivery to affected areas, monitoring cerebrospinal fluid dynamics, catheterization for urinary management, and tailored dietary management to support recovery are essential steps.

PHARMACOLOGIC MANAGEMENT

Types of Medications:

  • Thrombolytics: Alteplase (tPA) is utilized to treat deep vein thrombosis (DVT) by dissolving clots.

  • Anticoagulants: Medications like Warfarin and Heparin are crucial for preventing further clot formation that could lead to additional strokes.

  • Antithrombotics: Aspirin and Clopidogrel reduce the risk of clot formation and improve long-term outcomes.

  • Antihypertensives: Multiple classes of medications stabilize hypertension and lower the risks associated with stroke.

  • Hypoglycemic Agents: Metformin is often prescribed for managing Diabetes Mellitus (DM).

  • Muscle Relaxants: Diazepam and other medications help manage spasticity after a stroke.

SURGICAL MANAGEMENT

Intervention may involve addressing complications through aneurysm repairs, thrombectomy procedures to remove clots directly, and carotid endarterectomy to prevent future strokes.

OTHER HEALTHCARE MANAGEMENT

Comprehensive care involves multiple specialists: physicians focusing on medical management, occupational therapists (OT) for daily living skills, physical therapists (PT) for mobility and function, speech and language therapists (SLT) for communication deficits, rehabilitation nurses, social workers aiding in patient support, and neuropsychologists evaluating cognitive impairment.

PHYSICAL THERAPY ASSESSMENT

Points of Emphasis:

  • A thorough review of subjective reports

  • Vital signs during evaluations

  • Level of consciousness to gauge awareness

  • Motor and sensory integrity evaluations

  • Comprehensive functional assessments to plan interventions.

OUTCOME MEASURES

To track recovery effectively, various tools like stroke impact scales, balance assessments, functional independence measures, and neuropsychological evaluations should be employed.

SYNERGY PATTERN

Understanding motor recovery progresses through specific stages is significant in informing rehabilitation approaches.

BRUNNSTROM STAGES OF MOTOR RECOVERY

Patients typically progress through defined phases during recovery, with each stage showing distinct patterns of motor recovery.

PHYSICAL THERAPY IMPRESSION

Identifying areas related to non-progressive CNS disorders allows for targeted rehabilitation strategies.

PROBLEM LIST

Comprehensive evaluation of patient issues is crucial and should include impaired communication, motor function challenges, coordination problems, emotional status shifts, and complications like pain and swallowing difficulties.

PLAN OF CARE

Acute Phase

Focus on preventive and restorative interventions to minimize complications and promote recovery.

Chronic Phase

Concentrate on compensatory interventions tailored to treating existing complications and maximizing patient independence.

THANK YOU

Acknowledgment for all engagement and participation in the discussion about cerebrovascular accidents and their implications on health and recovery.