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CEREBROVASCULAR
ACCIDENT
(STROKE)
PRESETED BY:
JENNIFER ARGEL
BS OT-4

• Stroke ranks as the third leading cause of
death behind heart disease and cancer
...

• Of people who suffer a stroke, 28% are
younger than 65 years
...
25
times higher in men than in women

CVA / Stroke
• WHO: “acute neurologic dysfunction of
vascular origin with symptoms and signs
corresponding to the involvement of focal
areas of the brain”
• neurologic deficits must persist longer
than 24 hours to be labeled a CVA

Causes of Stroke
•
•
•
•

ISCHEMIA
HEMORRHAGE
RELATED SYNDROMES
TRANSIENT ISCHEMIC ATTACKS

ISCHEMIA
ISCHEMIC STROKE
- the most common type, affecting about
80 percent of individuals with stroke, and
results when a clot blocks or impairs blood
flow, depriving the brain of essential
oxygen and nutrients

Signs and Symptoms:
- Numbness or weakness of
the face, arm, or leg,
especially on one side of the
body
- Confusion or change in
mental status
- Trouble speaking or
understanding speech
- Visual disturbances
- Difficulty walking, dizziness,
or loss of balance or
coordination
- Sudden severe headache

Risk Factors
NONMODIFIABLE
RISK FACTORS
1
...
Gender
3
...
Ethnicity
5
...
Hypertension
2
...
Management of diabetes and glucose
metabolism
4
...
excessive use of alcohol
6
...
Lifestyle factors

• Cardiac Sources:
– atrial fibrillation (pooling of blood in the
dysfunctional atrium leads to the production of
emboli)
– sinoatrial disorders
– acute myocardial infarction
– Endocarditis
– cardiac tumors
– valvular (both native and artificial) disorders

HEMORRHAGE
HEMORRHAGIC STROKE
- occurs when blood vessels rupture,
causing leakage of blood in or around the
brain

CAUSES:
- deep hypertensive
intracerebral hemorrhages
- ruptured saccular aneurysms
- bleeding from arteriovenous
malformations
- spontaneous lobar
hemorrhages

RELATED SYNDROMES
• Cerebral anoxia and aneurysm can also
result in hemiplegia
• Other causes of hemiplegia:
– head injuries
– Neoplasms
– infectious diseases of the brain

TRANSIENT ISCHEMIC
ATTACKS (TIA)
• characterized by mild, isolated, or
repetitive neurologic symptoms that
develop suddenly, last from a few minutes
to several hours but not longer than 24
hours, and clear completely
• seen as a sign of an impending stroke
• Most TIAs occur in people with
atherosclerotic disease

Circle
Of
Willis

Circle of Willis
• is a confluence (actually a hexagon) of
vessels that gives rise to all of the major
cerebral arteries
...


MIDDLE CEREBRAL ARTERY
• most common cause of stroke
• results of ischemia in MCA:
– contralateral hemiplegia with greater
involvement of the arm, face, and tongue;
– sensory deficits
– contralateral homonymous hemianopia
– aphasia - lesion is in the dominant
hemisphere

MIDDLE CEREBRAL ARTERY
• Perceptual deficits in in the nondominant
hemisphere lesion:
– Anosognosia
– unilateral neglect
– impaired vertical perception
– visual spatial deficits
– perseveration

ANTERIOR CEREBRAL ARTERY

ANTERIOR CEREBRAL ARTERY
• It supplies the medial aspect of the
cerebral hemisphere (frontal and parietal
lobes) and subcortical structures, including
the basal ganglia (anterior internal
capsule, inferior caudate nucleus), anterior
fornix, and anterior four fifths of the corpus
callosum

ANTERIOR CEREBRAL ARTERY
• Occlusion
– contralateral lower extremity weakness that is
more severe than that of the arm
– Apraxia
– mental changes
– primitive reflexes
– bowel and bladder incontinence may be
present

ANTERIOR CEREBRAL ARTERY
• Total Occlusion
– contralateral
hemiplegia with severe
weakness of the face,
tongue, and proximal
arm muscles
– marked spastic
paralysis of the distal
end of the lower
extremity

• Intellectual changes:
–
–
–
–
–
–
–
–
–

Confusion
Disorientation
Abulia
Whispering
slowness
distractibility
limited verbal output
perseveration
amnesia

ANTERIOR CEREBRAL ARTERY

POSTERIOR CEREBRAL ARTERY

POSTERIOR CEREBRAL ARTERY
• two posterior cerebral
arteries (PCAs) arise
as terminal branches
of the basilar artery
and each supplies the
corresponding
occipital lobe and
medial and inferior
temporal lobe

• also supplies the:
–
–
–
–

upper brainstem
Midbrain
posterior diencephalon
including most of the
thalamus

POSTERIOR CEREBRAL ARTERY
• symptoms is
• possible outcomes:
potentially broad and – Sensory and motor deficits
– involuntary movement disorders
varied because this
– memory loss
artery supplies the
– alexia
– astereognosis
upper brainstem
region, as well as the – dysesthesia
– akinesthesia
temporal and occipital – contralateral homonymous
hemianopia or quadrantanopia
lobes
– anomia
– topographic disorientation
– visual agnosia

POSTERIOR CEREBRAL ARTERY

CEREBELLAR ARTERY SYSTEM
• OCLUSION:
– ipsilateral ataxia
– contralateral loss of pain and temperature
sensitivity
– ipsilateral facial analgesia
– dysphagia and dysarthria caused by
weakness of the ipsilateral muscles of the
palate, nystagmus, and contralateral
hemiparesis

VERTEBROBASILAR ARTERY SYSTEM
• The vertebral arteries arise from the
subclavian arteries and travel into the
brain along the medulla where they merge
at the inferior border of the pons to form
the basilar artery
...


VERTEBROBASILAR ARTERY SYSTEM
• The vertebral arteries supply the cerebellum
– (via posterior inferior cerebellar arteries)

• and the medulla
– (via the medullary arteries)
...
Other
important but less common stroke symptoms include:
• Sudden nausea, fever, and vomiting distinguished from a viral
illness by the speed of onset (minutes or hours vs several days)
• Brief loss of consciousness or a period of decreased
consciousness (fainting, confusion, convulsions, or coma)

Early Warning Signs of Stroke
• To help recognize the onset of stroke
remember the:
F – face
A – arm
S – speech
T – time to call help

Medical Management

• Specific treatment of stroke depends on:
– type and location of the vascular lesion
– severity of the clinical deficit
– concomitant medical and neurologic problems
– availability of technology and personnel to
administer special types of treatment
– cooperation and reliability of the client

DEEP VEIN THROMBOSIS (DVT)
• DVT is the formation of a blood clot
(thrombus) in a deep vein, usually in the
lower extremity
• incidence of DVT in individuals with stroke
ranges from 22% to 73%
• Pulmonary embolism - most common
cause of death in the first 30 days after a
stroke

DEEP VEIN THROMBOSIS (DVT)
• evaluation:
– daily evaluation of leg
temperature
– Color
– Circumference
– Tenderness
– appearance

• preventive treatments
– medication
– use of elastic
stockings
– use of reciprocal
compression devices
– early mobilization of
the client

Respiratory problems and
Pneumonia
• Ventilatory insufficiency
– major factor contributing to the high frequency
of pneumonia

• hemiparesis associated with stroke

Respiratory problems and Pneumonia
• Symptoms:
– low-grade fever
– increased lethargy

• Medical management:
– administration of fluids and antibiotics
– aggressive pulmonary hygiene
– mobilization of the client

Cardiac Disease
• stroke itself may cause the cardiac
abnormality, or the client may have had a
pre-existing cardiac condition
• Evaluation:
– Monitoring of the heart rate
– blood pressure
– electrocardiogram (ECG)

Bowel and Bladder Dysfunction
• Common
• timed or scheduled
toilet program
– essential in treating
urinary incontinence

• Catheterization

• Physician’s
responsibilities:
– ordering a specific bowel
program that includes:
•
•
•
•
•
•

time schedule
adequate fluid intake
stool softeners
Suppositories
oral laxatives
medications or procedures
to treat fecal impaction

Evaluation and Intervention Procedures
for Clients Who Sustained a Stroke
• location of the stroke is determined by:
– CT or MRI

• acute stage
– exhibit little to no contralateral motor function
(hemiparesis or hemiplegia) because of:
• severe weakness
• no response to contralateral sensory stimuli
• severe attention deficit

• first 3 to 6 months after a stroke is the most
crucial time and that the greatest improvement

Client-Centered Assessments
• Client-centered practice
– approach to providing occupational therapy
which embraces a philosophy of respect for,
and partnership with, people receiving
services

Client-Centered Assessments
• Canadian Occupational Performance
Measure (COPM)
– standardized tool that uses a client-centered
approach to allow the recipient of treatment
to:
• identify areas of difficulty
• rate the importance of each area
• rate his or her satisfaction with current
performance

• Top-Down Approach to Assessment

Standardized Tools
• Arnadottir Occupational Therapy
Neurobehavioral Evaluation (A-ONE)
– objectively documents the way that
dysfunction of client factors (e
...
, left-sided
neglect, apraxia, and spatial dysfunction)
affects self-care and mobility tasks
...

2
...

4
...
Symptoms of dysphagia secondary to proximal
malalignment
6
...

2
...

4
...

6
...

8
...


Pain
Contracture and deformity
Loss of selective motor control
Weakness
Superimposed orthopedic limitations
Loss of postural control to support UE control
Learned nonuse
Loss of biomechanical alignment
Inefficient and ineffective movement patterns

• Integration into Function
– Standardized evaluations
– self-reported measures of UE function
– Upper Extremity Complications after
Stroke Subluxation
– Abnormal Skeletal Muscle Activity
– Maintaining Soft Tissue Length
– Positioning Programs
– Splinting

– Standardized evaluations
• Test d’Evaluation des Membres Supérieurs de
Personnes Agées (TEMPA)
• Arm Motor Ability Test (AMAT)
• Jebsen Test of Hand Function
• AMPS

– self-reported measures of UE function
• Motor Activity Log
– actual use of the involved UE outside structured therapy
time; reported by the patient or family; six-point scale

• 36-item Manual Ability Measure (MAM-36)
– 36 gender-neutral, commonly performed everyday hand
tasks

– Upper Extremity Complications after Stroke
Subluxation
• Types:
– inferior (head of the humerus below the glenoid fossa)
– anterior (head of the humerus anterior to the fossa)
– superior (head of the humerus lodged under the
acromion-coracoid)

• Treatment
– support the flail shoulder in bed
– wheelchair
– upright position

– Abnormal Skeletal Muscle Activity
• low-tone stage (acute stage)
– Little or no muscle activity
– Problems:
» edema
» Overstretching of the joint
capsule of the glenohumeral
joint
» Eventual shortening of muscles
» Overstretching of the
antagonists
» Risk of joint and soft tissue
injury during ADLs and mobility
tasks

• Progression
– Clonus
– stereotypic posturing
of the trunk and limbs
– hyperactive stretch
reflexes
– increased resistance
to passive limb
movements that are
dependent on velocity

– Maintaining Soft Tissue Length
• 24-hour regimen
• resting postures during waking hours
• teaching the client and significant others
appropriate ROM procedures
• daytime and nighttime positioning programs
• staff and family education
• Prolonged static positioning

– Positioning Programs
• promoting normal resting alignment of the trunk
and limbs in an effort to maintain tissue length on
both sides of the joints
• providing stretch to muscle groups that have been
identified as being prone to contracture or already
shortened
• placing particular focus on maintaining passive
external rotation of the shoulder

– Splinting
• protecting the tissues from shortening or
overstretching
• preventing injury to the extremity
• serving as an adjunctive treatment to control
edema
• provide palmar arch support
• maintain neutral wrist deviation
• neutral position of the wrist between flexion and
extension
• effective for clients in whom spasticity is
developing

Inability to Perform Chosen Tasks
Secondary to Visual Impairment
• site of the lesion
– determines the visual dysfunction and the
effect on performance of tasks

• remediation:
–
–
–
–

eye calisthenics
Fixations
Scanning
visual motor
techniques
– bilateral integration

• adaptive techniques
–
–
–
–
–
–

working distance
use of prisms
adaptations for driving
Reading
changes in lighting
enlarged print

Psychosocial Adjustment
• psychologic
manifestations
–
–
–
–
–
–
–
–
–

Anxiety
Agoraphobia
substance abuse
sleep disorders
Mania
Aprosody
behavioral problems
lability
personality changes

• pharmacologic
interventions
– antidepressants
– benzodiazepines
– Neuroleptic
medications



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