CEREBRO-VASCULAR
DISEASE & STROKE
Faizan Zaffar Kashoo
CEREBRO-VASCULAR DISEASE
& STROKE



Stroke is the commonest cause of death in
developed countries.
Hypertension is the most treatable risk factor.
Thromboembolic infarction (80%), cerebral and
cerebellar haemorrhage (10%) and subarachnoid
haemorrhage (about 5%) are the major
cerebrovascular problems.
DEFINITIONS





Stroke is defined as the clinical syndrome of rapid onset of cerebral
deficit (usually focal) lasting more than 24 hours or leading to
death, with no apparent cause other than a vascular one.
Completed stroke means the deficit has become maximal, usually
within 6 hours.
Stroke-in-evolution describes progression during the first 24
hours.
Minor stroke. Patients recover without significant deficit, usually
within a week.
Transient ischemic attack (TIA). This means a focal deficit, such
as a weak limb, aphasia or loss of vision lasting from a few seconds
to 24 hours. There is complete recovery. The attack is usually sudden.
PATHOPHYSIOLOGY
COMPLETE STROKE
One of three mechanisms is usual:



arterial embolism from a distant site
arterial thrombosis
haemorrhage into the brain (intracerebral or subarachnoid).
Less commonly:





venous infarction
polycythaemia (hyperviscosity syndromes)
fat and air embolism
multiple sclerosis
mass lesions (e.g. brain tumour, abscess, subdural haematoma)
Modifiable risks





Cardiovascular Disease
 Hypertension
 CAD
Diabetes
Dyslipidemia
 High total Cholesterol
 and/or Low HDL
Atrial Fibrillation
Asymptomatic Carotid
Artery Stenosis






Cigarette smoking
Sickle Cell Disease
Dietary Factors
Obesity
Physical Activity
Hormone Replacement
Therapy
Types of stroke


Ischemic stroke syndrome
Hemorrhagic stroke syndrome
Ischemic Stroke Syndrome

Lacunar Infarction
Infarction of small penetrating arteries in pons and
basal ganglia
 Associated with chronic HTN present in 80-90%
 Pure motor or sensory deficits

Ischemic Stroke Syndromes

Basilar Artery Occlusion
Severe quadriplegia
 Coma
 Locked-in syndrome-complete muscle paralysis except
for upward gaze

Ischemic Stroke Syndromes

Vertebrobasilar Syndrome

Posterior circulation supplies brainstem, cerebellum,
and visual cortex
Dizziness, vertigo, diplopia, dysphagia, ataxia, cranial
nerve palsies, and limb weakness, singly or in combination
 HALLMARK: Crossed neurological deficits: ipsilateral
CN deficits with contralateral motor weakness

Ischemic Stroke Syndromes

Middle cerebral artery occlusion

Dominant Hemisphere (usually the left)
Contralateral weakness/numbness in arm and face
greater than leg
 Contralateral hemianopsia
 Gaze preference toward side of infarct
 Aphasia (Wernicke’s -receptive, Broca’s -expressive or
may have both)
 Dysarthria

Ischemic Stroke Syndromes

Middle cerebral artery occlusion

Nondominant hemisphere
Contralateral weakness/numbness in arm and face greater
than in the leg
 Constructional Apraxia
 Dysarthria
 Inattention, neglect,

Ischemic Stroke Syndromes

Anterior Cerebral Artery Infarction




Contralateral weakness/numbness greater in leg than arm
Dyspraxia
Speech perseveration
Slow responses
Acute stroke: immediate care,
and thrombolysis
Paramedics and members of the public are encouraged
to make the diagnosis of stroke on a simple history and
examination
 – FAST:
■ Face – sudden weakness of the face
■ Arm – sudden weakness of one or both arms
■ Speech – difficulty speaking, slurred speech
■ Time – the sooner treatment can be started, the
better.
 Dedicated units with multidisciplinary, organized teams
deliver higher standards of care than a general hospital
ward

Investigations
The purpose of investigations in both stroke and
TIA is:
 to confirm clinical diagnosis
 to distinguish between haemorrhage and
thromboembolic infarction
 to look for underlying causes of disease and to
direct therapy, either medical or surgical
Imaging TIA & stroke patients

Imaging TIA and stroke patients CT and MRI. CT
imaging will demonstrate haemorrhage immediately
while a patient with an infarct may have a normal scan.
Infarctions are usually detectable at 1 weeK although
50% are never detected on CT. CT or MRI should be
carried out urgently in the majority of cases. Diffusionweighted imaging (DWI) MR can identify infarcted
areas within a few minutes of onset. Conventional T2
weighting is no better than CT. Imaging will also show
the unexpected, e.g. subdural haematoma, tumour or
abscess.
Further investigations





Routine bloods (for polycythaemia, infection,
vasculitis, thrombophilia, syphilitic serology,
clotting studies, autoantibodies, lipids)
Chest X-ray
ECG
Carotid Dopplers
Angiography
Management of cerebral infarction




The possible sources of embolus should be sought (e.g.
carotid bruit, atrial fibrillation, valve lesion, evidence of
endocarditis, previous emboli or TIA)
Assess hypertension and postural hypotension
The brachial blood pressure should be measured in
each arm; a difference of more than 20 mmHg is
suggestive of subclavian artery stenosis.
The neurological deficit should be carefully
documented.
Immediate management






Admit to multidisciplinary hospital stroke unit if possible.
General medical measures
Care of the unconscious patient, Oxygen by mask, Assessment
of swallowing, Check BP and look for source of emboli.
Immediate brain imaging is essential.
Cerebral infarction : If CT shows infarction, give aspirin (300
mg/day initially) antiplatelet therapy if no contraindications, give
alteplase thrombolysis, which must be started within 3 hours
(aim for 90 min) of stroke; informed consent is essential.
Cerebral haemorrhage: If CT shows haemorrhage, do not give
any therapy that may interfere with clotting. Neurosurgery may
be required.
Surgical treatment


Internal carotid endarterectomy: Surgery is
recommended in TIA or stroke patients shown
to have internal carotid artery stenosis greater
than 70%. Successful surgery reduces the risk of
further TIA/stroke by approximately 75%.
Endarterectomy has a mortality around 3%, and
a similar risk of stroke.
Percutaneous transluminal angioplasty (stenting)
is an alternative procedure.
Prognosis


Twenty-five per cent of patients die within 2
years of a stroke. Around 30% of this group die
in the first month
Gradual improvement usually follows stroke,
although the late residual deficit may be severe.
Of those who survive, about one-third return to
independent mobility and one-third have serious
disability requiring permanent institutional care.
Medical management and
pharmacological consideration
1.



Thrombosis and TIA
80% to 100% die in few minutes
Improve circulation
tissue plasminogen activator (t-PA)
heparin (anticoagulant drugs)
warfarin
Clot prevention
aspirin, dipyridamole and sulfinptrazone
Surgical treatment (remove clot from artery)
Thromboendarterectomy
Medical management and
pharmacological consideration
Embolic infarction
2.
•
Emphasis on prevention
Similar to thrombotic infarction
Anticoagulant therapy
Medical management and
pharmacological consideration
3.
Hypertensive hemorrhage

Control hypertension
Medical management of associated
problems
SPASTICITY
PHARMACOLOGICAL
1. Centrally acting drug
diazepam
2.
Peripherally acting drug
Procaine
Phenol
Botalulinum toxin A
Baclofen
SURGICAL TREATMENT
1.
2.
Tenotomy
Neurotomy
Medical management of associated
problems
SEIZURES
Thrombotic and embolic stroke – early onset
Hemorrhagic stroke – late onset
Drugs
Phenytoin
Carbamazepine
Medical management of associated
problems




Respiratory involvement
Fatigue – respiratory inefficiency
50% more O2 than normal
Decrease lung volume
Medical management of associated
problems
TRAUMA
Falls – improper balance
 Hip wrist and humerus fracture are common
 Osteoporosis .

Medical management of associated
problems
THROMBOPHLEBITIS
Clot formation
 Common in weaker leg

Medical management of associated
problems
REFLEX SYMPATHETIC DYSTROPHY
Sympathetic blockers
 Oral or intramuscular corticosteroids

STAGES OF RECOVERY

Cerebral shock



Immediately after cerebral ischemia
Last between few hrs to days
Recovery phase

Flaccid stage


Recovery stage



Severe sensory loss and muscle is flaccid
Tone improves
Distal parts recover first
Spasticity of stage



Proximal spasticity appears
Limbs in synergetic pattern (atypical pattern)
UL in flexion and LL in extension pattern
Factors that influence the recovery




Quality of the rehabilitation treatment.
The motivation of the patient and his family.
Age of the patient.
Persistence of the flaccid stage and delay in
treatment.
Evaluation
It the process of Collecting information to
establish a baseline level of performance to plan
intervention and progress.

Components of evaluation
Level of consciousness
Mental status examination
Cranial nerve examination
Sensory examination
Motor and reflex examination
Gait examination
Functional tests
Prognosis
Short and long term goals
intervention










Evaluation of primary impairments
Active movements
70 – 80 % of stroke patient have weakness. 
Weakness and control is assessed. 
Timing of muscle firing. 
Sequence of movement. 
Speed of movement. 
Do not assist the client. 

Evaluation of primary impairments
Assisted movements
Correct alignment to gather additional information 
Assist weak muscles 
Stabilize joint and document the pattern of 
movement

Evaluation of primary impairments
Tone

Modified ashworth scale 
Equilibrium and protective reactions
Equilibrium reactions are assessed while slowly 
moving the part away from base of support
Protective reactions by hopping or stepping and 
positive support

Evaluation of secondary
impairments
Loss of joint range and muscle shortening
Poor alignment 
Muscle activation problem 
Functional consequence of two joint muscle. 
Eg: gartrocsoleus 

Evaluation of secondary impairments
Pain
Visual analog pain rating scale 
McGill pain questionnaire 
Shoulder pain 

Functional evaluation
Activity of daily living

Barthel index 
Motor assessment scale 
Function independence measure 
Motor function and balance
Fugl Meyer scale 
Berg balance scale 
Functional reach 

Recognizing needs
What movement and function is possible? 
What movement and function are not possible? 
How do primary and secondary impairment 
relate to functional performance?
Goal setting
Functional goal

Stand independently and perform grooming activity 
Short term goal

Client will length hamstring and plant foot flat on 
the ground while standing
Long term goal
Able to perform most of the functional activities 

Choosing intervention
Two school of though
Use normal side 
Use affected side 
Using both will benefit the patient 
Impairment based intervention 

Common impairment and suggested
interventions
WEAKNESS AND LOSS OF CONTROL
Trunk control

First Level- basic trunk movements in 3 planes. 
Second level- trunk movement with extremity 
movement.
Extremity control
Weight bearing and assisted movements. 
Distal re-education. 

Common impairment and suggested
interventions
MUSCLE ACTIVATION DEFICIT
Improper initiation

Uses proximal more than distal 
Inappropriate muscle selection

Uses stronger than weaker 
Inappropriate sequencing
Co-contraction and out of sequence


Excessive force production
Inappropriate effort during movement 

Common impairment and suggested
interventions
HYPOTONICITY
Quick icing. 
Quick stretch in mid range. 
Weight bearing. 
Proper alignment. 
Mild stretching at the end of range. 
Common impairment and suggested
interventions
HYPERTONICITY
Proximal instability

Improve stability of upper trunk – decrease arm 
hypertonicity
Poor joint alignment

Stretching of gastronemius and soleus – active. 
During activity
Proper sequence of activity 
Inhibition of spastic pattern is wrong. 

Common impairment and suggested
interventions
Toe posturing
Toe clawing

Poor alignment 
Toe curling
Instability of trunk and leg 

Common impairment and suggested
interventions
LOSS OF ALIGNMENT
TRUNK
Atypical starting position for functional activity. 
Shortening towards affected side. 
Forwards flexion of trunk. 
Rotation towards affected side. 
Functional activity
Supine
Bridging
Rolling – Task oriented
Kneeling – Task oriented
Transition activity
Feeding
Reach and grasp
Half kneeling
Standing
Walking
Side walking











Therapies to hand
Activation of abductor digiti minimi
First dorsal interrosei
Postural asymmetry
Changing the orientation from
horizontal to vertical support
Trunk extension facilitation
Sit to stand
Orientation to Mid line