Introduction

• A sudden occurrence of a permanent damage to

an area of the brain caused by a blocked blood
Rehabilitation of Stroke vessel or bleeding within the brain
Chapter 23 de Lisa
Chapter 44 Braddom

Raul Michael Cembrano, MD

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Epidemiology Risk factors

From Navarro, Baroque, Lokin real stroke burden in the
Philippines. 2014

• 2nd leading cause of death in the • Non modifiable

Philippines Ischemic strokes =70%
• Sex
• Hemorrhagic =30%
• Ethnicity
• Major co morbidities:
• Hypertension
• Age

• Diabetes • Family history

• Dyslipidemia
• Smoking

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Risk Factors Categories

• Modifiable • Vascular occlusion

• Hypertension
• Heart disease • Cerebral thrombosis
• Ischemic/hypertensive
• Valvular
• Cerebral embolism
• Arrhythmia • lacunar
• Smoking
• Diabetes • Hemorrhagic
• Elevated fibrinogen
• Intracerebral hemorrhage
• Erythrocytosis
• Hyperlipidemia • Subarachnoid hemorrhage

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 Stroke syndromes Stroke syndromes
Internal Carotid Syndrome Middle Cerebral Artery Syndrome

• From no observable deficits • Middle cerebral artery syndrome

• Due to good collateral • Usually embolic in larger
circulation segments
• Catastrophic • Usually thrombotic in smaller
segments
• Embolic
• Stenosis

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Stroke syndromes Stroke syndromes

Middle Cerebral Artery Syndrome Middle Cerebral artery Syndrome

• Superior Division • Inferior division

• Supplies the rolandic and prerolandic areas • Supplies the temporal and parietal lobes
• Left side lesions: language comprehension
• Sensory deficit
• Optic radiation: contralateral homonymous
• Contralateral weakness/paralysis of face, hemianopsia
arm and leg
• Right side lesions: unilateral neglect
• Arm more affected than leg
• Attention deficit
• Recovery: • Constructional apraxia
• Gait: spastic hemiparetic • Dressing apraxia
• Little recovery of the arm • Perceptual deficit

• Left hemisphere: aphasia • aprosodia

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Stroke Slyndromes Stroke Syndromes

Middle Cerebral Artery syndrome Anterior Cerebral Artery syndrome

• Lacunar stroke • Median and paramedian regions of the

frontal cortex
• Lenticulostriate
• Contralateral hemiparesis/plegia with
• Affect internal capsule less effect on face and upper limbs
• Pure motor weakness • Sensory deficit of the contralateral side
• Anterior horn of the internal capsule
• Left hemisphere: transcortical motor
• Dysarthria aphasia

• Hand clumsiness • Paratonic rigidity (gegenhalten)

• Thalamus • Sucking reflex/grasp reflex may occur
• Pure sensory deficit • Urinary incontinence

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 Stroke Syndromes Stroke Syndromes
Anterior Cerebral Artery Syndrome Vertebrobasilar syndromes

• Vertebral and basilar arteries

• Large lesions
• Supply the brainstems and cerebellum
• Behavioral changes • May affect both sides of the brainstem
• Motor impairment is bilateral with asymmetric
• Lack of spontaneity corticospinal signs
• Cranial nerve lesions are ipsilateral
• Tendency to perseverate • Sensory deficits with dorsal column preservation
• Dysarthria
• Diminished reasoning ability • Dysphagia
• Disequilibrium
• Bilateral hemisphere • Vertigo
• Horner’s syndrome
• Abulia

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Stroke Syndrome Stroke Syndrome

Vertebrobasilar syndrome Vertebrobasilar syndrome

• Lateral medullary Syndrome (Wallenberg’s Syndrome)

• Lacunar
• Lateral wedge of the medulla
• Common • Occlusion of the vertebral artery and posterior
cerebellar artery
• Contralateral pain and temperature deficit
• Often asymptomatic
• Ipsilateral Horner’s syndrome
• Pontine lacunar infarcts • Dysarthria
• Dysphagia
• Pure motor deficit • Dysphonia
• Nystagmus
• Nausea and vomitting
• Ipsilateral limb ataxia

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Other
syndromes Stroke Syndrome
Vertebrobasilar Syndrome

• Basilar artery occlusion

• Motor and sensory loss
• Comatose
• Do not recover
• Locked In Syndrome
• Motor loss
• Sensory preserved
• Upward gaze and blinking may occur
• Can see, hear but unable to speak

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 Other
syndromes Stroke Syndrome
Vertebrobasilar Syndrome

• Weber’s Syndrome
• Involves the third cranial nerve
nucleus
• Seen in focal midbrain
infarctions
• Ipsilateral cranial nerve III
palsy with contralateral motor
and sensory deficit

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Other
Syndromes Stroke Syndrome
Posterior Cerebral artery syndrome

• Supplies the temporal and

occipital lobe and thalamus
• Partial or complete hemianopia
• Difficulty in reading and naming
objects
• Contralateral sensory loss and
rarely central pain (thalamus)

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Evaluation Evaluation
Special populations

• History • In children
• Physical examination and vital signs
• Check fo coagulation
• Diagnostics abnormalities
• CT scan
• Carotid and cardiac anomalies
• MRI (rare)
• Blood chemistry
• Young adults, check for:
• ECG
• Carotid ultrasound • Carotid dissection
• Cerebral angiography • Vasculitides

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 Acute Management Secondary prevention

• Goals: • Focusing on risk factor reduction

• Limit or reverse neurologic • Cessation of smoking
damage
• Behavioral changes
• IV thrombolysis with rTPA
• Mechanical thrombectomy • Exercise

• Prevent secondary complications • Control of hypertension and

diabetes
• Monitor fever, blood pressure
and hyperglycemia

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Secondary Prevention Rehabilitation

Acute Phase

• Antiplatelet Medications • Goal: prevention of complications of immobility

• DVT
• Aspirin • Pressure sore
• Clopidrogel • Contracture
• Goal: Prevention of aspiration and complications of
• Dipyridamole dysphagia
• Bedside swallowing test should be done
• Warfarin
• NGT insertion for unconscious or lethargic patients
• Statins • Management of urinary incontinence
• Carotid endarterectomy • Catheterization
• Identify communication dilemma/status
• Carotid stenting

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Rehabilitation Examination for Aphasia

Recovery

• Compensatory
• Use of orthotics
• Use of Assistive devices
• Maximize Neural reorganization and return of function
• No hand function by 4 weeks post stroke-poor
recovery
• Recovery from Aphasia
• Dependent on type and severity
• Visuospatial deficit recovery
• Unilateral neglect
• Anosognosia

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 Classification of Aphasia Rehabilitation
Cognition and communication treatment strategies

• Evaluation
• mental status assessment should be done
• Mini mental status assessment tool
• NIH stroke scale tool
• Formal Neuropsychological assessment
• Hemispatial neglect assessment and
management
• Use of cues to remind of the other side
• Fresnel prisms

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Rehabilitation Rehabilitation
Cognition and Communication management strategies
Visual Deficits
• Evaluation and management of
other cognition problems such as:
• Evaluation of visual deficits done
• Apraxia at bedside
• Dementia • Compensatory strategies for
patients with visual deficits
• Attention deficits without hemispatial defects
• Depression
• Patching -extra ocular muscle
• Use of anti depressants and incoordination and diplopia
serotonin reuptake inhibitors
(SSRI’s)

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Rehabilitation Rehabilitation
Dysphagia Dysphagia

• 40% affected • Treatment strategies

• Increases the risk of pneumonitis and • Chin tuck maneuver
aspiration pneumonia

• Affect both oral preparatory and pharyngeal • Change in food consistencies

phases
• Change in food amount
• Standard evaluation:
• Bedside swallowing test
• If unable to swallow:
• Videoflouroscopic swallowing study • NGT
(VFSS)
• Jejunostomy tube
• Fiberoptic endoscopic evaluation for
swallowing (FEES) • Gastrostomy tube

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 Rehabilitation Rehabilitation
Motor function Brunstromm’s stages of recovery

• Evaluation via usual motor

grading
• Constant monitoring to see the
recovery rates
• Spasticity may hamper or assist
limb function
• Recovery rates can also be
assessed using Brunstromm’s
stages of recovery

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Rehabilitation Rehabilitation
Motor Recovery Motor Recovery

• Paralysis • Motor recovery may occur a few hours to

days
• Range of motion • Traditional approach
• Bobath
• Electrotherapy
• Roods
• Positioning • CIMT
• Splinting • Robot aided recovery
• Virtual reality
• Biofeedback
• Mirror therapy

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Rehabilitation Rehabilitation
Mobility Pain and sensation

• As motor improvement progresses • Manage central pain

mobility exercises and therapy should
be done • Tricyclic antidepressants
• Improve balance and tolerance on
both sitting and standing • Sensation recovery
• Gait retraining • Impairment resolution
strategies are few
• Body weight partiallysupported
treadmill
• Use of assistive devices
• Wheelchair transfer

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 Outcomes Medical management during
Rehabilitation
Cardiac Disease

• Lacunar injury-excellent • 75% of stroke patients may have

coexisting cardiac disease
• Walking: -54% to 80% may walk
after 3 months • Negative impact to outcomes
• ADLs-initially dependent but • Can cause decrease in
over time may recover some or participation in rehabilitation
all of the ADLs
• Should be promptly treated
• Improve exercise tolerance and
close monitoring

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Medical Management during Medical Management during

Rehabilitation Rehabilitation
Urinary tract Pain

• Stroke m ay cause: • Shoulder and arm pain (hemiplegic shoulder pain)

• U rinary incontinence
• Early Treatment of Subluxation of the shoulder-
• U rinary infection lesser pain
• U rge incontinence • Spasticity- may increase pain
• C heck for prem orbid urinary dysfunction due to other causes
such as prostate enlargem ent • Treatment:
• Evaluate bladder filling via: • Centrally acting pain relievers
• U ltrasound
• Tricyclic antidepressants
• C ystom etry
• Gabanoids
• U rodynam ics

• C atheterization program s
• NSAiDs as rescue meds
• C lean interm ittent catheterization • Antispasticity meds
• In dw elling foley catheterization • Desensitization techniques and stretching

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Medical Management during Management of other conditions

Rehabilitation during Rehabilitation
Deep vein thrombosis Depression

• Often due to immobility and paralysis • Commonly seen

• Diagnostics • Brain catecholamine depletion at frontal

lobe
• Venous duplex ultrasound • Signs:
• Use of Heparin or other • Persistently depressed mood
anticoagulants as prevention
• Loss of interest in socialization
• Alternative methods: early application
of pneumatic compression pumps • Limited participation in Rehabilitation

• Positioning and range of motion • Treatment

exercises as prevention • Serotonin reuptake Inhibitors

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 Sexuality in Stroke Long term care

• Sexual performance and libido is affected by: • Recovery rates may depend on the
• Co morbidities like hypertension and diabetes severity of stroke
• Fear of a repeat of stroke during the act of sex • Mortality rates increase for every
• Medications such as SSRIs recurrence of stroke
• Treatment • Strategies include:
• Sildenafil or tadalafil for erectile dysfunction
(use with caution, not allowed if patient is
• Prevention of recurrence of stroke
taking nitroglycerin etc)
• Maintenance of Independence and
• Flibanserin to improve libido in women (under community relations
study)

• Sexual counseling • Continuous check ups should be

done

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Thank you!

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