UNIVERSIDAD DE STA.

ISABEL HEALTH SERVICES DEPARTMENT

PHYSICAL THERAPY AND REHABILITATION MEDICINE SECTION
Roxas Avenue, Naga City, Camarines Sur

CARDIOVASCULAR ACCIDENT (CVA)

STROKE

Abay, Sylver Anne M.

Barreda, Renzo A.
Geroy, Ian Christian R.
Manaog, April Grace S.
Tiongson, David Hans R.
Medical Background
I. Definition
Stroke or cerebrovascular accident (CVA) is the sudden loss of neurological
function caused by an interruption of the blood flow to the brain. lschemic stroke is the
most common type, affecting about 80% of individuals with stroke, and results when a
clot blocks or impairs blood flow, depriving the brain of essential oxygen and nutrients.
Hemorrhagic stroke occurs when blood vessels rupture, causing leakage of blood in or
around the brain. Clinically, a variety of focal deficits are possible, including changes in
the level of consciousness and impairments of sensory, motor, cognitive, perceptual, and
language functions

II. Related Anatomy

A. The Nervous System
responsible for perceptions, behaviors and regulates body activities.
Consist of 2 parts:
a. CNS (Central Nervous System)
contains the brain and spinal cord
source of emotions and memories
b. PNS (Peripheral Nervous System)
composed of nerves and sensory receptors
divided into sensory and motor
Motor PN also consists of
• somatic nervous system
• autonomic nervous system
divided into 2: sympathetic and
parasympathetic
Meninges- protects the brain and spinal cord
a. Dura mater- most superficial layer
b. Arachnoid mater- middle and thin avascular covering
c. Pia mater- innermost layer and it is composed of thickenings
called denticulate ligaments that protects SC against sudden
displacement

B. Cell Structure of the Brain

Composed of neurons and neuroglia
a. Neurons are divided into 3 parts: cell body, dendrites and axon
 b. Neuroglia (Glial cells)
are smaller but they protect and nourish the neurons
Central Nervous System:
a. Astrocytes Abundant- star-shaped cells Form barrier
between capillaries and neurons Control the chemical
environment of CNS
b. Microglia Spider- like phagocytes Dispose of debris
c. Ependymal cells- line cavities of the brain and spinal cord
Circulate CSF
d. Oligodendrocytes- produce myelin sheath around nerve
fibers in the CNS
Peripheral Nervous System:
a. Schwann cells- form myelin sheath in the PNS
b. Satellite cells- protect neuron cell bodies

C. Brain Components
• Brainstem
Consist of medulla oblongata, pons, and midbrain
a. Medulla oblongata- superior part of spinal cord; inferior
part of brainstem (CN 9-12)
b. Pons- superior to medulla and anterior to cerebellum and it
is also the bridge that connects parts of the brain (CN
5-C8)
c. Midbrain- mesencephalon extends from pons to
diencephalon (CN 5-4)
• Cerebellum
- AKA: "The Little Brain"
Posterior to the brainstem and it evaluates the movement initiated
by motor areas in cerebrum.
General functions: balance, coordination and muscle tone
• Cerebrum
Largest Parts of the brain
2 parts (Telencephalon and Diencephalon)
2 Hemispheres (Left and Right)
a. Left hemisphere (DOMINANT) is primarily concerned
with:
• Math
• Analytical
• Language
• ldeomotor/ldeational Apraxia
b. Right hemisphere is primarily concerned with:
• Hemineglect
• Arts
• Music
• Memory
• Apraxia: dressing and constructional Apraxia
 • Diencephalon
Superior to brainstem
a. Thalamus- Major relay station for most sensory impulses
b. Hypothalamus
Control of the ANS
Production of hormones
Regulation of emotional and behavioral patterns,
eating and drinking, body temperature, and
circadian rhythms
c. Subthalamus- Plays a role in motor control
d. Epithalamus
Consists of pineal gland which secretes a hormone
called melatonin
induces sleep
D. The Cranial Nerve
Cranial Nerve Function

1- Olfactory Nerve Olfaction ( Smell )

II- 0 ptic Nerve Vision

111- Oculomotor Nerve Elevates Eyelids

Turns eye up, down, in
Constricts pupil
Accommodates lens

IV- Trochlear Nerve Turns the adducted eye down and causes
inward rotation of eye

V-Trigeminal Nerve Chew, feels front of head

VI- Abducens Nerve Turns eye out

VII- Facial Nerve Taste from anterior tongue

Muscles of facial expression
Tearing ( Lacrimal gland )

VIII- Vestibulocochlear Nerve Hearing, regulates balance

IX- Glossopharyngeal Nerve Taste from posterior tongue

Sensation from posterior tongue
Sensation from oropharynx
Salivation ( Parotid Gland )

X- Vagus Nerve Thoracic and abdominal viscera

Muscles of larynx and pharynx
Decreases heart rate

XI- Accessory Nerve Head movements, lifts shoulders (SCM

 and Trapezius)

XII- Hypoglossal Nerve Tongue movements and shape

E. Brodmann's Area
a. Frontal lobe
• Area 4- primary motor area
• Area 6 - premotor area (part of extrapyramidal circuit)
• Area 8 -frontal eye movement and pupillary change area
• Area 44 - motor speech (Broca's area)
b. Parietal lobe
• Area 3, 1, 2 - Primary sensory areas
• Area 5, 7 - Sensory association areas
• Area 39- Angular Gyrus
• Areas 5, 7, 39, 40 - common integrative area also called the
Gnostic area
• Area 43 - Primary gustatory area
c. Occipital lobe
• Area 17 - primary visual cortex
• Areas 18-19 - visual association areas
d. Temporal lobe
• Area 41 - primary auditory cortex
• Area 42 - Auditory association areas
• Areas 22- Wernicke's areas

Ill. Pathophysiology
• lschemic Stroke (80%)
Non- traumatic
Most common type
Clot blocks or impair blood flows depriving the brain of essential oxygen
and nutrients
Manifested by which artery is occluded
Has 3 types:
a. Thrombotic
Large vessel Thrombosis
Formation or development of a blood clot within the cerebral
arteries or their branches
40% (MC)
Gradual onset of symptoms
Sites:
• MCA( MC)
• Common carotid artery
b. Embolic
 Blood Clot or plaque that is released into bloodstream, traveling to
the cerebral arteries where they lodge in a vessels, producing
occlusion and infarction
20% (2nd MC)
Abrupt onset symptoms
c. Lacunar
Small vessels thrombosis
Penetrating artery disease (Small vessels deep in the cerebral
white matter)
Consistent with specific anatomical sites:
• Pure motor. Post. Limb or internal capsule(MC)
• Pure sensory: Thalamus
• Sensori- Motor : Junction between thalamus and internal
capsule (2nd MC)
• Other lacunar syndrome:
Dysarthria/clumsy hands syndrome
- Ataxic hemiparesis

• Hemorrhagic Stroke (20%)

Ruptured artery from uncontrolled hypertension or aneurysm that leads to blood
leakage in the brain
A variety of focal deficits are possible, including changes in the level of
consciousness and impairments of sensory, motor, cognitive, perceptual and
language function.
a. lntracerebral Stroke
Hypertensive hemorrhage
Caused by trauma, tumor, vasculitis (Inflammation of blood
vessels
MC:HTN
Subarachnoid Stroke/Hemorrhage
• Saccular "Berry'' Aneurysm
Congenital
Sites: Ant. Communicating artery (MC)
• Arteriovenous Malformation (AWM)
Congenital
Characterized by a tortuous tangle of arteries and
veins with agenesis of an interposing capillary
system
TRIAD: Hemorrhage, Migraine and Seizure
• Risk Factors
Hypertension, Heart disease (HD), Disorders of heart rhythm and Diabetes
mellitus (OM)
Approximately 70% have hypertension, 30% heart disease, 15% diabetes
mellitus.
Sleep apnea is an independent risk factor for stroke, doubling the risk of stroke or
death.
A number of stroke risk factors are specific to women. Women with early
menopause (before 42 years of age) have twice the risk of ischemic stroke as
women with later menopause.
 • Modifiable Risk Factors
a. Cigarette smoking - Current smokers have 2 to 4 times increased stroke risk
compared to nonsmokers or those who have quit for more than 10 years
b. Physical inactivity - Physical activity (moderate to vigorous exercise) is
associated with an overall 35% reduction in stroke risk whereas light exercise
(walking) does not appear to have the same benefit
C. Obesity
d. Diet

• Non-modifiable Risk Factors

a. Family history
b. Age
c. Gender
d. Race

IV. Epidemiology
Stroke is the 4th leading cause of death and the leading cause of long-term
disability among adults in the US.
As estimated 7, 000, 000 Americans are older than the age of 20 yrs. of age
experienced stroke.
Annually, 795, 000 experience strokes, 610, 000 first attacks and 185, 000
recurrent strokes.
Women have a lower age-adjusted stroke incidence than men. However, it is
reversed if women over 85 yrs. of age have an elevated risk compared to men.
Compared to whites, African Americans have twice the risk of first-ever stroke;
rates are also higher in Mexican Americans, American Indians, and Alaska
Natives.
The incidence of stroke increases dramatically with age, doubling in the decade
after 65 yrs of age.
Between 5% and 14% of persons who survive an initial stroke will experience
another 1 yr, within 5 years stroke will recur in 24% of women and 42% of men.
The incidence of stroke deaths is greater than 143, 000 annually and strokes
account for 1 of every 18 deaths in the US
lschemic strokes have a mortality rate: 8% to 12% at 1 month
Hemorrhagic stroke accounts for the largest number of deaths, with mortality
rates of 37% at 1 month.
Survival rates are lessened by increased age, hypertension, heart disease and
diabetes.
Predictors of mortality: LOC at stroke onset, lesion size, persistent severe
hemiplegia, multiple neurological deficits and history of previous stroke.
Long term disability: lschemic stroke survivors 65 or older, incidences of
disabilities observed at 6 months such as hemiparesis (50%), unable to walk
without assistance (30%) , dependent in activities of daily living (AOL) (26%),
aphasia (19%) and depression (35%).
 The largest group of stroke patients admitted to rehabilitation hospitals and about
½ of patients receive outpatient rehabilitation services.
Another indicator is 26% of patients with stroke are institutionalized in a long term
care facility
V. Etiology
• Atherosclerosis
is a major contributory factor in cerebrovascular disease. It is
characterized by plaque formation with an accumulation of lipids, fibrin,
complex carbohydrates, and calcium deposits on arterial walls that leads
to progressive narrowing of blood vessels.
• lschemic strokes are the result of a thrombus, embolism, or conditions that
produce low systemic perfusion pressures. The resulting lack of cerebral blood
flow (CBF) deprives the brain of needed oxygen and glucose, disrupts cellular
metabolism, and leads to injury and death of tissues.
a. Cerebral Thrombosis
refers to the formation or development of a blood clot within the
cerebral arteries or their branches. It should be noted that lesions
of extracranial vessels (carotid or vertebral arteries) can also
produce symptoms of stroke
b. Cerebral Embolus (CE)
is composed of bits of matter (blood clot, plaque) formed
elsewhere and released into the bloodstream, traveling to the
cerebral arteries where they lodge in a vessel, producing occlusion
and infarction.
• Hemorrhagic strokes with abnormal bleeding into the extravascular areas of the
brain, are the result of rupture of a cerebral vessel or trauma. Hemorrhage results
in increased intracranial pressures with injury to brain tissues and restriction of
distal blood flow.
a. lntracerebral hemorrhage (IH)
is caused by rupture of a cerebral vessel with subsequent bleeding
into the brain.
b. Primary cerebral hemorrhage
(nontraumatic spontaneous hemorrhage) typically occurs in small
blood vessels weakened by atherosclerosis producing an
aneurysm.
c. Subarachnoid hemorrhage (SH)
occurs from bleeding into the subarachnoid space typically from a
saccular or berry aneurysm affecting primarily large blood vessels.
VI. Signs & Symptoms
• The significance of recognizing early warning signs rests with prompt initiation of
emergency care under the rule that "time is brain." Patients and families are
encouraged to call 911 immediately, even if these symptoms go away quickly or
are not painful.

Box 1s.1 Stroke Early Warning Signs

STROKE
WARNING SIGNS
SUDDEN NUMBNESS OR WEAKNESS OF THE
FACE, ARM OR LEG, ESPECIALLY ON ONE
SIDE OFTHE BODY

SUDDEN CONFUSION, TROUBLE SPEAKING

OR UNDERSTANDING

SUDDEN TROUBLE SEEING IN ONE OR

BOTH EYES

SUDDEN TROUBLE WALKING, DIZZINESS,

LOSS OF BALANCE OR COORDINATION

SUDDEN SEVERE HEADAjCHE WITH NO

KNOWN CAUSE

Immediately call 9-1-1 or tho orTMilf'gency modlcaJ Hf'Yicos (EMS) numbClr

so an ambulance (idealfy with advanced IHe support) can be s.enl for you.
Also. check the time ao you11 know when the first symptoms appeared.
It's wry Important to tab l.mmodlata action. H gfvon within 3 hours of tho
start of symptoms. a clot-busting drug calkK::Itissue ptaaminogon activato,
(tPA) may NKfuce long-term disability for the most common typo of
sll'Oka.
e 2011 American Heart Association www.strokeassociadon.org

Table 1s.1 Clinical Manifestations of Anterior Cerebral Artery Syndrome

Signs and Symptoms Structures Involved
Contralateral hemipares,sinvolving mainly the LE (UE ismore spared) Primary motor area, medial aspect of cortex.
internal capsule
Contralateral hemisensory loss involving mainly he LE (UE is Primary sensory area, medial aspect of cortex
more spared)
Urinary incon inence Pos eromedial aspect of superior frontal gyrus
Problems with Imitation and blmanual tasks, apraxla Corpus callosum
Abulla(akinetic mutlsm), slowness, delay,lack of Uncertain locallzaIon
spontaneity,motor Inaction
Contralateral grasp reflex, sucklng reflex Uncertain localization
Can be asymptomatic if circle of Willis is competent

LE= lower extremity; UE = upper eXtJemity.

Table 1s.3 Clinical Manifestations of Posterior Cerebral Artery
Syndrome Signs and Symptoms Structures Involved
Peripheral Territory
Contralateral homonymous hemianopsia Primaryvisual con:ex oroptic radiation
Bilateral homonymoushemianopsia with some degreeof Calcarinecortex (macular sparing lsdue o occipital pole
macular sparing receiving collateral blood supply from MCA)
Visual agnosia Left occipital lobe
Prosopagnosia(difficulty naming people on sight) Visual association cortex
Dyslexia (difficulty reading) without agraphia Dominant calcarinelesion and posterior part of corpus
(difficulty writing).color naming (anomla),and color callosum
dlscriminatlon problems
Memory defect Lesion of lnferomedial portions of temporal lobe
bilaterally or on the dominan sideonly
Topographic disorientation Nondominant primary visual area, usually bilaterally
Central Territory
Central post-stroke (thalamlc) pain Venual posterolareral nudeusof thalamus
Spontaneous painand dysesthesias;sensory impairments
(all modalities)
Involuntary movements; choreoathetosis, lnten ion tremor, Subthalamic nudeus or its pallidalconnections
hemiballismus
Contralateral hemiplegia Cerebral peduncle of midbrain
Weber's syndrome Third nerve and cerebral peduncle of midbrain
Oculomotor nerve palsy and contralateral hemiplegla
Paresis of vertical eye movements, slight miosisand ptosis, Supranuclear fibersto third cranial nerve
and slugglsh pupillary light response

LE= lower extremlty; VE= upper ext,emity.

allle 1sA' dinlca) Manifestations ofVertebrobasi!a.r Artery Synd,ome
J.ttl! 1 Clinical Manifestations of Vertebrobasilar Azte1y Syndrome-ront'd
nd Symptoms Structures Involved

alf th bod Spi tamic act

Medial midpon1ine rome of p;uaf"lil!iClian branch of the mid--basilai

·tateral uwolvemeral

lateral midpontine syndrome

Conioobul

mbsa gait, la ng tosdc of du es.. superior

les ucleu:;

Uncertain
VII. Differential Diagnosis
A Bell's Palsy- paralysis/weakness on 1 side of the face because of the damage to
the seventh cranial nerve, responsible for motor innervations for the muscles of
the face. Paralysis occur in some or all the muscles of the affected side, other
symptoms of the condition are caused by inability to close the eye on the affected
side of the face, hypersensitivity to sound in affected area , pain, drooling or
impairment of taste
B. Syncope- fainting/ temporary loss of consciousness due to inadequate blood flow
to the brain
C. Subdural Hematoma- bleeding due to trauma that occurs between the outer and
the middle membrane covering the brain. Subdural hemorrhage is bleeding
between the dura and the arachnoid

VIII. Treatment
A Diagnostic Procedure
• Physical exam
• Blood tests.
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI)
B. Surgical
• Thrombectomy
is a procedure to remove a blood clot from a blood vessel. It can
be used for some people who've had a stroke. Blood clots in the
brain can cause ischemic strokes.
• Surgery
may also be indicated for resection of a superficial unruptured AVM
when there is high risk of rupture and stroke
C. Pharmacological
IX. PT Management
• Bed mobility training (rolling to side, supine to sit, and sit to supine )
• Transfers training ( sit to stand, toilet transfers, car transfers )
• Gait training on//
• AFO - If there is a presence of foot drop
• Hot Moist Pack x 20 mins - helps increase joint mobility
• FES x 10 minutes - helps re-educate mm to regain functional independence
• Motor Points x 5 minutes
• Stretching on affected UE and LE x 10 reps with 7 sec hold
• PREs on unaffected UE and LE x 10 reps
• TENS x 10 minutes on painful UE/LE can help relieve pain
• Rhythmic stabilization improves balance
• Stair climbing x 5 reps
• Adduction and abduction - to strengthen adductors and abductors of both LE
• Overhead pulley x 10 reps - Increase UE ROM
• OT activities (key precision, cones and extend your reach exerciser) - facilitate
fine motor coordination

X. Reference
Physical Rehabilitation (6th ed) - O'Sullivan, Schmitz, Fulk
Stroke: assessment. (n.d.). Physiopedia.
https://www.physio-pedia.com/Stroke:_Assessment?utm_source=physiopedia&u
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