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Stroke is an acute onset of neurological dysfunction due
to an abnormality in cerebral circulation with resultant
signs and symptoms that correspond to involvement of
focal areas of the brain.
To be classified as stroke focal neurological deficits must
persist for at least 24 hrs.
Motor deficits are characterized by paralysis
(HEMIPLEGIA) or weakness (HEMIPARESIS).
Typically on the side of the body opposite the site of the
lesion.
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Reverse ischemic neurological deficit- impairments may
resolve with neurological recovery generally within 3 weeks.
Residual neurological impairments are those that persist
longer than 3 weeks and may lead permanent disability and
dependence
Thromboembolic infarction (80%), cerebral and cerebellar
hemorrhage (10%) and subarachnoid hemorrhage (about 5%)
are the major cerebrovascular problems.
Transient ischemic attack refers to the temporary
interruption of blood supply to the brain.
Symptoms of focal neurological deficit may last for only a few
minutes or for several hrs not more than 24hrs.
One of three mechanisms is usual:
 a . arterial embolism from a distant site
 b. arterial thrombosis
 c . hemorrhage into the brain ( intracerebral or
subarachnoid).
 d. Less commonly:
 e . venous infarction
 f. Polycythemia ( hyper viscosity syndromes)
 g. fat and air embolism
 h. multiple sclerosis
 i . mass lesions (e.g. brain tumour, abscess, subdural
hematoma)
1.Cardiovascular Disease
a . Hypertension
b. CAD (Coronary Artery Disease )
2. Diabetes
3. Dyslipidemia .
a. High total Cholesterol
b. and/or Low HDL
4. Atrial Fibrillation
5. Asymptomatic Carotid Artery Stenosis
6. Cigarette smoking
7. Sickle Cell Disease
8. Dietary Factors
9. Obesity
10. Physical Activity
11. Hormone Replacement Therapy
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Sudden, severe headaches with no known cause
Sudden weakness or numbness of the face, arm, or leg
on one side of the body.
Loss of speech or trouble talking or understanding
speech.
Sudden dimness or loss of vision particularly in only one
eye.
Unexplained dizziness,unsteadness or sudden falls
especially along with any of the previous symptoms.
1. Ischemic stroke syndrome
 2. Hemorrhagic stroke syndrome
 3. Vascular syndromes.
1) Ischemic Stroke Syndrome
Lacunar Infarction
 i . Infarction of small penetrating arteries in pons and
basal ganglia
 ii . Associated with chronic HTN present in 80- 90%
 iii . Pure motor or sensory deficits.
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Basilar Artery Occlusion
 Occipital headache
 Diplopia
 Progressive quadriplegia
 Bulbar paralysis, coma death.
 Locked -in syndrome –results from ventral pontine
lesions defined as quadriplegia anarthria with preserved
consciousness and sensation.
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Anterior cerebral artery syndrome
Middle cerebral artery syndrome
Internal carotid artery syndrome
Posterior cerebral artery syndrome
Anterior cerebral artery syndrome:
It supplies medial aspect of cerebral hemisphere frontal
and parietal lobes
Contralateral hemiparesis
Sensory loss with greater involvement of the lower
extremity.
Supplies entire lateral aspect of the cerebral hemisphere
frontal, temporal and parietal lobes.
 Contralateral spastic hemiplegia
 Sensory loss of face,upper extremity(UE) and lower
extremity (LE)
with face and upper extremity more involved than LE.
Unilateral neglect
Anosognosia (without knowledge of disease),
Apraxia (disorder of voluntary movement characterized by
the inability to accomplish a skilled or purposeful
movement)
spatial disorientation
Homonymous hemianopsia visual field defect.
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Complete occlusion of ICA produces massive infarction in
both MCA and ACA.
COMA
DEATH.
Posterior cerebral artery syndrome
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Supplies occipital lobe and medial inferior temporal lobe
Contralateral sensory loss or thalamic sensory syndrome
(thalamic pain)
Homonymous hemianopsia
Visual agnosia, impairment in recognition of visually
presented objects
prosopagnosia, cortical blindness
Contralateral hemiplegia
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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.
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Computerized tomography (CT)
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Magnetic Resonance Imaging ( MRI)
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Positron Emission Tomography (PET)
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Ultrasound Transcranial doppler
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Cerebral angiography
1)Thrombosis and TIA
 a . 80% to 100% die in few minutes
 b. Improve circulation
 i . tissue plasminogen activator (t -PA)
 ii . heparin (anticoagulant drugs)
 iii . Warfarin
2) Clot prevention
 Aspirin , dipyridamole and sulfinptrazone
3) Surgical treatment (remove clot from artery )
 Thromboendarterectomy
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Cerebral shock
a . Immediately after cerebral ischemia
b. Last between few hrs to days
Recovery phase
a . Flaccid stage
i . Severe sensory loss and muscle is flaccid
b. Spasticity Stage
i .Tone improves
ii . Distal parts recover first
c . Recovery stage
i . Proximal spasticity appears
ii . Limbs in synergetic pattern (atypical pattern)
iii . UL in flexion and LL in extension pattern
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
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GOALS:
 Prevention of Medical Complications
 Prevention of Deconditioning and Contractures
 Training of New Skills
 Maximize Functional Independence
 Optimize Psychosocial Adaptation of Patients and
Families
 Enhance Quality of Life
Flaccid stage
 Passive Range of Motion
 Weight bearing and facilitation.
 Electrical stimulation can be used to muscle contractions
and prevent muscle atrophy.
 Sensory re-education techniques can include touching
different textured objects, massage, vibration, pressure,
determining joint position, identifying different
temperatures.
Increasing Tone and Spasticity
 quick icing.
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Spasticity Management:
◦ Positioning and Orthotics
◦ Stretching and Other Exercises
◦ Prolong icing for prolong time.
◦ Medications
◦ Postural Inhibiting positions
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Increasing Tone and Spasticity
Emergence of Synergy Patterns
Functional Skills Training
◦ Personal Care Skills
◦ Mobility Activities
◦ Instrumental Activities of Daily Living
◦ Gait training typical hemiplegic gait.
◦ gait involving flexion of the hip because of footdrop
and circumduction of the leg.