Stroke means cerebro-vascular attack/accident. A stroke is a condition in which the brain cells suddenly die because of a lack of oxygen. This can be caused by an obstruction in the blood flow or rupture of an artery, that feeds the brain. The patient may suddenly lose the ability to speak, there may be memory problems or one side of the body can become paralyzed. (Wikipedia)
Another may be defined as: –
Stroke is defined as, a certain neurological deficy by focal vascular lesion in the brain. The vascular lesion can be either a haemorrhaigc or ischemic. Involving the blood vassel supplying various parts of the brain. The extended of neurological involvement may range from mild motor deficy to gross involvement of various part namely sensory motor, perceftual, emotional, behaviors, memory, intelligence, speech and language function.(CL) Types of stroke-
1) Hemorrhagic
2) Ischemic
Ischemic Stroke:
In everyday life, blood clotting is beneficial. Bleeding from wound, blood clots work to slow and eventually stop the bleeding, In case of stroke, however, blood clots are dangerous because they can block arteries and cut off flow, a process called is ischemia. An ischemic stroke can occur in two ways-(ASA)
i) Embolic
ii) Thrombotic
Embolic Stroke:
In an emboli stroke, a blood clot forms some where in the body (usually heart) and travels through the bloodstream to the brain. Once in the brain, the clot eventually travels to a blood vessel small enough to block it passage. The clot lodges there, blocking the blood vessel and causing a stroke. This type of blood clot is called embolus.
Thrombotic Stroke:
Blood flow is impaired because of a blockage to one or more of the arteries supplying Blood to the brain. The process leading to this blockage is known as thrombosis. stroke caused in this way are culled thrombotic strokes. that because the medical word for a clot that form on a blood vessel deposit it thrombus- Blood clot strokes can also happen as the result of unhealthy blood vessels clogged with a build up of fatty deposits and cholesterol.
Hemorrhagic Stroke:
Hemorrhagic stroke occurs when blood vessel can leak or rupture, in the brain. The medical word for this type of breakage is haemorrhages. Haemorrhage can be caused by number of disorder which effect the blood vessels, including long-standing high blood pressure and cerebral aneurysms. An aneurysm is a weak or thin spot on a blood vessel wall. These weak spots are usually present at birth. A less common cause of hemorrhage is rupture of artery-venous malformation.
It’s two types:-
i) Intra-cerebral
ii) Sub-arachnoids (Between brain & meninges)
Intra-cerebral hemorrhage:-
In an intracerebral hemorrhage a blood vessel in the brain burst into the surrounding barin tissue damaging brain cell. High blood pressure, trauma and vascular malformation may covers of it.
Sub-arachniod Hemorrhage:(CL)
An aneurysm bursts in a large artery on or near the thin, delicate membrane and surrounding the brain. Blood spills into area around the rain, which is filled with a protective fluid causing the brain to be surrounded by contaminated fluid. It may cause
i) by certain severe head aehe.
ii) A-Sub arachnoid haemorrhagic is commonly cause by the rupture of on aneurysm.
Transient ischemic attack (TIA):
Transient ischemic attack (ITA) is like a stroke, producing similar symptoms but usually lasting only a few minutes and causing no permanent damage often called a mini stroke, a transient ischemic attack may be a warning about 1 in 3 people who have transient isomeric attack eventually has a stroke with about half occurring within a year after the transient ischemic attack.
Risk factors of stroke:(NSF-Australia):
i) High blood pressure
ii) Diabetes mallitus
iii) High cholesterol
iv) Obesity and overweight
v) Smoking cigarettes
vi) Physical inactivity
vii) Cardiovascular disease-
– heart failure
– heart infection/abnormal heart rhythm
viii) obstructive sleep apmea/reversible damage.
ix) Use of some brirth control pill/hormone therapy taht include estrogen.
x) Heavy drinking.
xi) Use of drug such as-coccaine
xii) Heavy use of alchohol
xiii) Depression middle-aged women with clinical depression have a higner misk of stroke.
Other risk factor:
i) Personal/family history of stroke.
ii) Previous heart attack/TIA
iii) Over age/Being age of 55
iv) High Level of homocysteine (on domino acid in blood)
v) Atherosclerosis
vi) African, a Mexican have higher mask
vii) Head injury or aneveysms.
Major symtoms of stroke:
i) Motor problem.
ii) Face Problem
iii) Speech problem
iv) Gait problem
v) Loss balance and co-ordination.
vi) Trouble/problem in speaking and understanding.
vii) Paralysis or numbness of the face, arm and leg.
viii) Unexplained dizziness.
ix) Develop certain paralysis, numbness, face, leg arm specially one side of the body.
x) Severe headache which may accompanied by vomiting, dizziness or allured consciousness.
xi) Blurred or poor vision in one or both eyes.
xii) Loss of balance or an unexplained fall difficulty swallowing.
xiii) Drooping eyelid and weakness of ocular muscle.
Pathology of stroke according to location/area: (CL)
i) When stroke occur in right cerebrum hemisphere- the result may be paralysis on the left side of the body, difficulty reasoning or thinking out solution of even the simple problem.
– A stroke occur in left cerebrum hemisphere can result in paralysis of the right side of the body and may disrupt the ability speak.
ii) A stroke involving the cerebellum may result in a lack of co-ordination (ataxia), clumsiness and balance problem, shaking or other muscular difficulties.
iii) Brainstem strokes are the must devastating and life threatening because they can disrupt the involuntary faction essential to life. Automatic functions that are cortical to life. Such as breathing digestion and heart beat
iv) Damage of cerebellum-Problem of reflexes, balance and certain aspects of movement and co-ordination.
v) Damage of frontal lobe-Problem in
– Planning
– Organizing
– Problem solving
– Selective attention
– Behavior and emotional problems.
– Defect in movement
Vi) Damage of left and might femoral lobe:-
– Person viable to differ loss of memory.
Vii) Problem of left and right partial lobe- disrupt of-
i) Sensation (ouch 8 pressure)
ii) Visuo-spacial deficits
iii) Unable to find his/her way around new or even ambition places.
iv) Disrupt patients ability to understand spoken and written language.
Cerebral Shock:
Flaccidity- Spastisity (Hypertonic)
Areflexia- Hyper-reflex
Clones (exaggerated)
Motor response:
Immediately after the onset of the stroke there is stage of cerebral shock with flaccidity and reflexes. Gradually there is replace by plasticity and hyper-reflexes abnormal mass movement (synergic movement). The duration of flaccidity vary from days to week.
Stage of stroke (CL)
Brum strom theory-
Stage-I : Flaccid and no movement
Stage-II: Spasticity begins and basic limb synergist movement and associated reaction.
Stage-III: Limb synergist most are produce voluntarily.
Stage-IV: Some movement combination not belonging to syneryst may appear spasticity declined.
Stage-V: More difficult movement combination is learnt improvement.
Stage-VI: Spasticity disappeared, isomated movement possible and co-ordination become normal.
Bo-Bath Stage
Stage-1: Flaccid
Stage-2: Spastic
Stage-3: Stage of spontaneous recovery.
Spasticity:
Severe degree of spasticity with made movement impossible-
– Moderate spasticity with allow some slow movt but they will be performed with too much effort and abrormal co-ordination.
– Mild spasticity with allow for gross movement. Normal co-ordination but fine movement of the limb specialy involving of the distal portion will be difficulty or impossible.
Distribution of spasticity upper and lower extremity:-
– Upper Extremity:-
1. Shoulder: Depressor and re-fracture
2. Shoulder: Internal rotator and adductor
3. Elbow: Flexor
4. Wrist and finger-Flexor.
5. Fore-arm-Pronated.
Lower extremities:
1. Pelvic girdle-Retractor
2. Hip- exterior, advisor and internal rote for.
3. Ankle and toes-Planter flexor and supinator.
4. Knee extensor.
Specificity also inverted of muscle of neck and trunk of the opposite side coughing late ral bending of patients towards the spastic sign.
Initial reflex:
Lower motor lession-0,1-No reflex.
Upper motor lession-
2- Normal
3- Exagagerated
4- Clonus.
Asymmetrical tonic neek reflex (ATNR):
Rotation of the head to one side course extension and adduction on the same side and Flexion and abduction of the opposite side.
Investigation:
1) Physical assessment:
taste the- 1) BP 8 cholesterol
2) Blood sugar and amino Acid levels.
2) Ultrasound-
A wond waned are carotid arteries in the need can provide a picture that indicates any narrowing or clotting.
2) Arteriography-
A catheter is inserted into the arteries to inject that can be pick up by X-ray.
4.CT- Scan:
a scanning device that creates a 3-D enrage that can show aneurysms bleeding or abnormal vessel with the brain.
5. Echo-cardio graphy.
6. Eye movement analyzer may diagnose.
Treatment (Rx):
1. History-onset of action.
Duration of illness
Progression
Associated fracture
Previous treatment
Present status
2. On observation:
Posture- General posture
Upper limb and lower limb attitude.
Facial symmetry cheek.
3. On Examination:
a) Higher function testing b)Behavior and orientation
c)Inteligency speech
ii) Sensory examination
a) Superficial
b) Deep
5. Motor examination
i) Tone
ii) ROM
iii) Contracture or deformity
iv) Muscle power
v) Muscle grading
6. Functional assessment the faction activities should be check
i) Weight bearing test
ii) Shifting
iii) Turning
In lying sitting and standing position-
i) Pelvic rotate
ii) Bridging
iii) Turning
iv) Rolling
Sitting position-
i) Weight Shifting
ii) Turning
iii) Bending
iv) Lateral bending
6. Standing position:-
i) Static balance
ii) Weight shifting
iii) Turning
iv) Gait analysis
Management :- CT)
i) Acute stage
ii) Spastic stage
The goal of Rx of acute stage:
i) Prevent ignorance of unawareness hemiplegics side.
Arrangement of the patients room:-
1) The hemiplegics side which can be greatly influence by the patient head position hence all the forms of stimulus lying emetine to the room, the negative, TV should be present on the hemiplegics side. So that the patient is force to turn to tent’s side. Which with stimulus life awareness of the hemiplegics side.
2) Decrease the tendency to develop synergic inter in the chronic stage.
3) Prevention of any joint restiction.
4) Prevention or complication due to immobility like-
– Chest complication.
– De-conditioning of the bone & muscle (bone weak due to osteoporosis)
5) Early weight bearing
6) Psychological counseling.
The goals can be achieved by following Rx:-
i) Arrangement of the patient room.
ii) Positioning of the patient in an appropriate way is essential to control the development of spasticity on to help in faster improvement in lateral shags.
iii) On the affected side-
– The shoulder should be protructed and flex
– The elbow & wrist should be extended
– The forearm should be supinated
– The Pelvis should be protract
– The hip & knee should be slight flexion.
– ankle should be newer position.
On the sound side:
– The arm should be rested on the pillow, kept in front of the patient.
– The shoulder girdle kept in production & slight elevation.
– The fore-arm should be supine
– The pelvic should be protraction postiion.
– Hip slightly adducted & Flex
– The knee in slightly slew ankle is neutral position.
On the supine position:-
1) The head should be kept in mid line on a pillow.
2) Pillow should be kept under the shoulder girdle to kept protracted
3) The shoulder should kept in abducted, supinated position & external rotation fore-arm in supplication.
4) The Elbow is in extend.
5) The wrist & singer extended.
6) A pillow is support an pelvis.
7) Leg is neutral position
The ankle is neutral position. (90. dorsiflexion).Mobilization and striating:
During flaccid stage:-
i) Mobilization in the form of gentle passive exercise and streatching of the various by articular muscle should be given.
ii) As they are very prone to develop, tightness. The mussel like transverse abdominals, Hamstring, Quadriceps, adductor musle of tensor fascia lava. beeps and arm flexor
iii) Passive exercise should be given of on the movement. at all the joint for at least ten repetition 3 to 4 times in day.
iv) Weight bearing activities can done.
Management of Stroke Singapore Ministry of Health
Guideline Title:
Stroke and transient ischaemic attacks. Assessment, investigation, immediate management and secondary prevention.
Bibliographic Source(s)
Singapore Ministry of Health. Stroke and transient ischaemic attacks. Assessment, investigation, immediate management and secondary prevention. Singapore: Singapore Ministry of Health; 2009 Jul. 64 p. [159 references]
Guideline Status:
This is the current version of the guideline.
This guideline updates a previous version: Singapore Ministry of Health. Stroke and transient ischaemic attacks: assessment, investigation, immediate management and secondary prevention. Singapore: Singapore Ministry of Health; 2003 Mar. 44 p. [49 references
Disease/Condition(s):
• Acute stroke (excluding subarachnoid haemorrhage)
• Transient ischaemic attack (TIA)
Guideline Category
Counseling
Diagnosis
Evaluation
Management
Prevention
Rehabilitation
Risk Assessment
Screening
Treatment
Clinical Specialty
Critical Care
Emergency Medicine
Family Practice
Geriatrics
Internal Medicine
Neurological Surgery
Neurology
Nursing
Nutrition
Physical Medicine and Rehabilitation
Preventive Medicine
Speech-Language Pathology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Emergency Medical Technicians/Paramedics
Health Care Providers
Hospitals
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
• To assist individual clinicians, hospital departments and hospital administrators in producing local protocols for:
• Assessment, investigation and immediate management of individuals with a transient ischaemic attack or acute stroke (other than a subarachnoid haemorrhage)
• Secondary prevention and risk factor management following a transient ischaemic attack or acute stroke
• To suggest methods for implementation and for clinical audit
• These guidelines are in keeping with the goals of health care for stroke patients, which are to:
• Reduce the incidence of stroke through primary prevention
• Reduce case fatality following a stroke
• Implement secondary prevention strategies to prevent a future vascular event
• Reduce the level of disability due to stroke
Target Population :
Adults in Singapore with stroke or transient is chaemic attack or with risk of stroke
Note: This guideline does not include patients with subarachnoid haemorrhage or young people with stroke.
Interventions and Practices Considered
Evaluation/Diagnosis:
1. Medical assessment, including history and physical examination
2. Multidisciplinary assessment as needed
3. Swallowing assessment
4. Routine and specialised investigations
5. Neuroimaging, including computed tomography (CT) and magnetic resonance imaging (MRI) brain scans
6.
Management/Treatment:
Immediate Management
1. Intravenous recombinant tissue plasminogen activator (rtPA)
2. Intra-arterial prourokinase
3. Mechanical devices
4. Heparins (unfractionated, low molecular weight or heparinoids)
5. Aspirin
6. Antiplatelet therapy
7. Decompression surgery
8. Discontinuation of antiplatelet and anticoagulant therapy (intraparenchymal haemorrhage)
9. Neurosurgical intervention
10. Medical management of common complications of stroke including hyperglycemia, hypoglycemia, fever, and venous thromboembolism
Note: The following measures were considered for immediate management but not recommended:
1. The routine use of drugs to limit neural damage, including the use of corticosteroids, neuroprotectants, plasma volume expanders, barbiturates, and streptokinase
2. Lowering of mild and moderately elevated blood pressure in the acute phase of stroke
Secondary Prevention
1. Long-term antiplatelet therapy (aspirin, ticlopidine, clopidogrel, dipyridamole) in selected patients
2. Warfarin in selected patients
3. Carotid endarterectomy in selected patients
4. Carotid artery stenting
5. Intracranial angioplasty and stenting
6. Measures to lower blood pressure and lipids in selected patients after the acute phase of stroke
7. Measures to control risk factors (e.g., diabetes mellitus and lifestyle modification) after stabilization of initial event
