Stroke and Brain Injury
By Devon Benike
Stroke

A stroke or sometimes called a “brain
attack” occurs when blood flow to a
region of the brain is obstructed, the brain
cells, deprived of the oxygen and glucose
needed to survive, die.
Modifiable Risk Factors
Hypertension (most important)
 Cigarette smoking
 Diabetes
 Cardiac or arterial disease
 Atrial fibrillation
 Metabolic syndrome,
 Poor diet
 Physical inactivity
 Alcoholism

Epidemiology
Stroke is the third leading cause of death
in America and the number one cause of
adult disability.
 700,000 people in the United States suffer
a stroke, or ≈1 person every 45 seconds,
and nearly one third of these strokes are
recurrent.
 More than half of men and women under
the age of 65 years who have a stroke die
within 8 years.

Epidemiology
23% of stroke victims have a previous
stroke history
 The 30 day survival rate is 88% for
ischemic and 62% for hemorrhagic
strokes
 Approximately 25% of stroke victims die
as a result of the event itself or
complications
 Only 26% of stroke victims recover most
or all of their pre-stroke health an function

How does a stroke occur?
Ischemic stroke is similar to a heart attack, except it
occurs in the blood vessels of the brain. Clots can
form either in the brain's blood vessels, in blood
vessels leading to the brain or even blood vessels
elsewhere in the body which then travel to the brain.
87% of all strokes are of this nature.
 Hemorrhagic strokes occur when a blood vessel in
the brain breaks or ruptures. The result is blood
seeping into the brain tissue, causing damage to brain
cells. The most common causes of hemorrhagic stroke
are high blood pressure and brain aneurysms. An
aneurysm is a weakness or thinness in the blood
vessel wall.

Symptoms
Weakness or numbness of the face, arm or
leg on one side of the body
 Loss of vision
 Loss of speech, difficulty talking or
understanding what others are saying
 Sudden or severe headache with no
known cause
 Loss of balance, unstable walking, usually
combined with another symptom

Signs of a stroke: FAST
What is FAST?
 Facial weakness - can the person smile?
Has their mouth or eye drooped?
 Arm weakness - can the person raise both
arms?
 Speech problems - can the person speak
clearly and understand what you say?
 Time to call 911

TIAs
About 30% of patients who subsequently have an ischemic
stroke have a small warning episode termed a transient
ischemic attack.
 A TIA is like an ischemic stroke in that it is results in the
sudden loss of function of a particular part of the body
because of a sudden lack of blood flow to a part of the brain.
 The difference between a TIA and an ischemic stroke is that
in a TIA the symptoms disappear completely within 24 hours.
In 75% of cases the symptoms clear within one hour, often
within only a few minutes, because the blockage in the artery
clears itself very quickly before the affected brain tissue has
died. 30% of people have damage evident on sensitive brain
imaging techniques such as MRI after a TIA.
 http://brainfoundation.org.au/a-z-of-disorders/107-stroke

Laboratory Diagnosis

Your doctor will check your pulse and
blood pressure, and examine the rest of
your body (heart, lungs, etc). The doctor
will check your strength, sensation,
coordination and reflexes. In addition, you
will be asked questions to check your
memory, speech and thinking.
Tests and Evaluations

CT scan
A CT scan uses X-rays to produce a 3-dimensional image of
your head. A CT scan can be used to diagnose ischemic
stroke, hemorrhagic stroke, and other problems of the brain
and brain stem.
 MRI scan

An MRI uses magnetic fields to produce a 3-dimensional
image of your head. The MR scan shows the brain and spinal
cord in more detail than CT. MR can be used to diagnose
ischemic stroke, hemorrhagic stroke, and other problems
involving the brain, brain stem, and spinal cord.
 http://www.strokecenter.org/patients/stroke-diagnosis/how-astroke-is-diagnosed/
Tests that View the Blood
Vessels that Supply the Brain
Cartoid Doppler
Painless ultrasound waves are used to take a picture of the carotid arteries
in your neck, and to show the blood flowing to your brain. This test can
show if your carotid artery is narrowed by arteriosclerosis (cholesterol
deposition).
 Transcranial doppler
(TCD)
Ultrasound waves are used to measure blood flow in some of the arteries in
your brain.
 MRA
This is a special type of MRI scan which can be used to see the blood
vessels in your neck or brain.
 Cerebral Arteriogram
A catheter is inserted in an artery in your arm or leg, and a special dye is
injected into the blood vessels leading to your brain. X-ray images show
any abnormalities of the blood vessels, including narrowing, blockage, or
malformations (such as aneurysms or arterio-venous malformations).
Cerebral arteriogram is a more difficult test than carotid doppler or MRA,
but the results are the most accurate.

Complications
A stroke can sometimes cause temporary or permanent
disabilities, depending on how long the brain suffers a lack of
blood flow and which part was affected.
 Paralysis or loss of muscle movement. Sometimes a lack of
blood flow to the brain can cause a person to become
paralyzed on one side of the body, or lose control of certain
muscles, such as those on one side of the face. With physical
therapy, you may see improvement in muscle movement or
paralysis.
 Difficulty talking or swallowing. A stroke may cause a
person to have less control over the way the muscles in the
mouth and throat move, making it difficult to talk, swallow or
eat. A person may also have a hard time speaking because a
stroke has caused aphasia, a condition in which a person has
difficulty expressing thoughts through language.

Complications
Memory loss or trouble with understanding. It's common that
people who've had a stroke experience some memory loss.
 Pain. If a stroke causes you to lose feeling in your left arm, you
may develop an uncomfortable tingling sensation in that arm.
You may also be sensitive to temperature changes, especially
extreme cold. This is called central stroke pain or central pain
syndrome (CPS). This complication generally develops several
weeks after a stroke, and it may improve as more time passes.
But because the pain is caused by a problem in the brain instead
of a physical injury, there are few medications to treat CPS.
 Changes in behavior and self-care. People who have a stroke
may become more withdrawn and less social or more impulsive.

Medical Treatment
Medical treatment for stroke:
 Specific treatment for stroke will be
determined by your physician based on:
 your age, overall health, and medical history
 severity of the stroke
 location of the stroke
 cause of the stroke
 your tolerance for specific medications,
procedures, or therapies
 type of stroke

Medications
Medications used to the dissolve blood clot(s) that
cause an ischemic stroke Medications that dissolve
clots are called thrombolytics or fibrinolytics and are
commonly known as "clot busters.”
 Medications and therapy to reduce or control
brain swelling Corticosteroids and special types of
intravenous (IV) fluids are often used to help reduce
or control brain swelling, especially after a
hemorrhagic stroke.
 Medications that help protect the brain from
damage and ischemia Medications of this type are
called neuroprotective agents, with some still under
investigation in clinical trials.

Types of surgery to treat or prevent
a stroke:

Carotid endarterectomy Carotid endarterectomy is a procedure used to remove
plaque and clots from the carotid arteries, located in the neck. These arteries supply
the brain with blood from the heart. Endarterectomy may help prevent a stroke from
occurring.

Carotid stenting A large metal coil (stent) is placed in the carotid artery much like
a stent is placed in a coronary artery. The femoral artery is used as the site for
passage of a special hollow tube to the area of blockage in the carotid artery. This
procedure is often done in radiology labs, but may be performed in the cath lab.

Craniotomy A craniotomy is a type of surgery in the brain itself to remove blood
clots or repair bleeding in the brain.

surgery to repair aneurysms and arteriovenous malformations (AVMs) An
aneurysm is a weakened, ballooned area on an artery wall that has a risk for
rupturing and bleeding into the brain. An AVM is a congenital (present at birth) or
acquired disorder that consists of a disorderly, tangled web of arteries and veins. An
AVM also has a risk for rupturing and bleeding into the brain. Surgery may be
helpful, in this case, to help prevent a stroke from occurring.
Effects of disease on ability to
exercise
Following a stroke, submaximal oxygen
uptake is increased and peak oxygen
uptake is decreased.
 V02 peak is half that of age-matched
healthy counterparts, resulting in a lower
maximal workloads.
 Only 20-34% of individuals with a stroke
are able to achieve 85% of age predicted
maximal heart rate.

Effects of disease on ability to
exercise
The functional implications for stroke
survivors are that they tend to breath
harder with exertion, fatigue
approximately 2.5 times more rapidly, and
are less efficient in mobility skills and
activities of daily living.
 This leads individuals to adopt a sedentary
lifestyle

Effects of medications on exercise
Vasodilators may increase the cool-down
period required after exercise to prevent
post exercise hypotension.
 Medications that limit cardiac output by
reducing heart rate may cause lower peak
heart rates.
 Diuretics reduce fluid volume and may
alter electrolyte balance, causing
dysrhythmias.

Effects (acute) of a session of
exercise

Stroke patients have been shown to
achieve significantly lower maximal
workloads and heart rate and blood
pressure responses than control subjects
during progressive exercise testing to
volitional fatigue.
Effects (chronic) of Training



Recurrent stroke and coronary artery disease
(CAD) are leading cause of death following
stroke; exercise alone can reduce mortality
rate by 20% or more
Leg cycling results in 60% greater VO2peak
Treadmill
◦
◦
◦
◦
-workload response
-blood pressure
-Resting heart rate
-Cholesterol levels
Effects (chronic) of exercise training

Exercise can improve aerobic capacity,
cardiovascular fitness, motor performance
and mood after stroke.
Exercise Testing

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
Supervised by a physician with a 12-lead
electrocardiogram (ECG)
Leg cycle (5-10 W/min using ramp protocol)
Treadmill (0.5-2 METS/stage)
6-12 minute walk
Combined Arm and Leg Ergometer (60% peak
power)
Steppers (25 steps/minute with increases at 7
steps)
Muscle Strength Tests
Flexibility Tests
Neuromuscular Tests
Exercise Testing






Aerobic: Cycle and Treadmill tests
Measures: HR, BP, RPE, Vo2peak
Endpoints: Serious dysrthythiams, >2STsegment depression or evaluation, ischemic
threshhold, SBP>250 mmhg or DBP>115
mmhg, Volitional fatigue
Strength: Manual Muscle Test
Measures: Force generated on dynamometer
Endpoints: Pounds, Kilograms, # of reps,
Max torque
Exercise prescription

Three-tier exercise training aproach
- First stage – Return to function
- Second stage – reduce risk of another stroke
by influencing glucose regulation, decreasing
weight & blood pressure, & regulating blood
lipid levels
- Third Stage – Improve aerobic fitness by
exercising 20-60 , three – seven days/week
Exercise prescription
Aerobic- 40-70% V02peak, 3-5
days/week, 20-60 min session
 Strength – 3 sets of 8-12 reps, 2
days/week
 Flexibility – 2 days/week (before and/or
after aerobic & strength activities)
 Neuromuscular- 2 days/week (consider
performing on same day as strength
activities)

Summary and conclusion
A stroke or sometimes called a “brain
attack” occurs when blood flow to a
region of the brain is obstructed
 Stroke is the third leading cause of death
in America and the number one cause of
adult disability.
 Ischemic stroke (blood clot) 87%
Hemorrhagic (busted artery) 13%
 What is FAST?

References
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Durstine, L. J., Moore, G. E., Painter, P. L., & Roberts, S. O. (2003). ACSM'S Exercise
Management for Persons With Chronic Diseases and Disabilities (3rd Edition ed.). American
College of Sports Medicine.
Wilkins, L. W. (2010). ACSM's Guidelines for Exercise Testing and Prescription (8th Edition ed.).
American College of Sports Medicine.
R.F. Macko, MD; C.A. DeSouza, PhD; L.D. Tretter, BS; K.H. Silver, MD; G.V. Smith, PhD; P.A.
Anderson, PhD; Naomi Tomoyasu, PhD; P. Gorman, MD; D.R. Dengel, PhD. 1997 American
Heart Association, Inc. 28:326-330
Glasberg, Glenn D. Graham, Richard C. Katz, Kerri Lamberty and Dean RekerPamela W.
Duncan, Richard Zorowitz, Barbara Bates, John Y. Choi, Jonathan J.Management of Adult
Stroke Rehabilitation Care:2005 American Heart Association. 1524-4628.
Cifu DX, Stewart DG. Factors affecting functional outcome after stroke:a critical review of
rehabilitation interventions. Arch Phys Med Rehabil. 1999;80(5 suppl 1):S35–S39.
Royal College of Physicians. National Clinical Guidelines for Stroke.2nd ed. Prepared by the
Intercollegiate Stroke Working Party. London:RCP; 2004. Available at:
http://www.rcplondostroke/index.htm. Accessed April, 2012.
http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=complications
http://my.clevelandclinic.org/heart/disorders/vascular/stroke.aspx
http://www.ninds.nih.gov/disorders/stroke/preventing_stroke.htm
http://www.strokecenter.org/patients/stroke-diagnosis/how-a-stroke-is-diagnosed/
http://www.stroke.org/site/PageServer?pagename=SYMP