Stroke: Pembimbing: Dr. Handojo Pudjowidyanto, Sps

STROKE
Harri Haryana
Pembimbing : dr. Handojo Pudjowidyanto, SpS

STROKE :THIS IS NOT JUST A
STROKE :DISEASE,
THIS
THIS IS
ISA
ADISASTER
DISASTER !!
Harri Haryana, SpKFR 2
AS A KILLER :
1.CARDIOVASCULAR
DISEASE
2.CANCER
3.STROKE

AS A DISABLING DISEASE :
STROKE IS THE
CHAMPION!!!
…it is the single most expensive disease, costing
some $ 1.2 billion a year, even before the costs of
physicians services and nursing home and other
nonhospitalized care are figure in..
( Stroke Foundation, Inc. N.Y. )
FACTS ABOUT STROKE :
1. A stroke does not have to be

fatal
2. Strokes can be prevented
3. Most strokes have good
prognosis functionally

What is definition
of stroke ?

DEFINITION
The WHO defines stroke as
“ rapidly developing clinical signs of focal (at times

global) disturbance of cerebral function, lasting
more than 24 hours or leading to death with no
apparent cause other than that of vascular origin ”

Brain anatomy

Could you describe
the risk factor?

RISK FACTORS
 Nonmodifiable
- Age ( increase after age 55 yr)
- Sex (male > female)
- Race (African American 2 x > White > Asian)
- Family history of stroke

RISK FACTORS
• Hypertension
• History of TIA / prior stroke
• Heart disease : CHF, CAD,Valvular heart disease, AF
• Diabetes
• Cigarette smoking
• Carotid stenosis
Modifiable • Cocain use
(treatable) • High dose estrogen
• Systemic disease associated with hypercoagualable
state
• Hyperlipidemia
• Migrain headaches
• Sleep apnea
• Patent foramen ovale

Hypertension
 The most important risk factor.

 The degree of risk increases with elevation and
becomes particularly strong with levels higher than
160/95 mm Hg.
 In the Framingham study, a sevenfold increased risk of
cerebral infarction.
 Increases the risk of thrombotic, lacunar, and
hemorrhagic stroke and increases the likelihood of SAH.
Harri Haryana, SpKFR Source

12 : Braddom
Cigarette smoking
 The relative risk of stroke for heavy smokers (>40

cigarettes/day) is twice that of light smokers (<10
cigarettes/day)
 Cessation of smoking reverses risk to that of
nonsmokers within 5 years after quitting
Source : Braddom
Cardioembolism
Blood clots may form in the heart

from a variety of causes. When
these clots are emitted from the
heart and travel to the brain, we
consider these strokes
“cardioembolic”.
Atrial fibrillation is the most

common and treatable cause of
cardioembolic strokes, with a
stroke risk ~5% per year.

CLASSIFICATION OF STROKE
Types of stroke ?

 Pathophysiology
 Ischemic strokes are
caused by decreased
blood flow to a region of
the brain resulting in
death of brain tissue.
 Hemorrhagic strokes
are caused by a rupture
of vessels in the brain
and secondary bleeding
into brain tissue.

Ischemic Hemorrhagic
Subarachnoid
Type Thrombotic Embolic Lacunar Intracerebral (ruptured
(hypertensive) aneurysm)
Incidence 60% 20% 5% 10% 5%
Factors Occurs when the
associated with Occurs Occurs while patient is calm Occurs during
onset during sleep awake and unstressed activity
Perfusion Small lesion
Major causes / failure distal seen From ruptured
etiology to site of mainly: Hypertension aneurysms and
severe Due mainly to putamen, vascular
stenosis or cardiac pons, malformation
occlusion of source thalamus,
major caudate,
vessels internal
capsule
Gradual onset or
Presentation Slowly Sudden, Abrupt or sudden onset of
progressive immediate gradual local neurologic Sudden onset
deficit deficit onset deficit
Source : Sara Cuccurullo

Another
classification ?

 Time of stroke
- TIA
- RIND
- Stroke in evolution
- Complete stroke

Transient Ischemic Attack
(TIA)
 TIA occurs when the occlusion of
a cerebral artery is transient, so
patients develop transient
neurologic symptoms that
resolve within ~ 1 day
 Patients with TIA are at risk for

future strokes and heart attacks.
 Amaurosis Fugax is a transient

loss of vision due to embolus to
the retinal artery. This is a
classic “TIA” that warns the
physician there is disease in the
carotid artery.

RIND
A cerebral infarct that lasts longer
than 24 hours but fewer than 72
hours is called a reversible ischemic
neurologic deficit or RIND

Please explain about
Bamford clinical classification ???
Harri Haryana, SpKFR

Stroke 22
 The Oxford Community Stroke
Project classification (OCSP, also
known as the Bamford or Oxford
classification) relies primarily on
the initial symptoms
 To understand bamford’s clinical
classification, you should know
about Circle of Willis

Bamford Clinical Classification
Total Anterior Circulation Syndrome (TACS)
Partial Anterior Circulation Syndrome (PACS)
Posterior Circulation Syndrome (POCS)
Lacunar Syndromes (LACS)

Neuroanatomic location of ischemic stroke
ARTERY MAIN PROBLEMS
• Sensory & motor deficit face/arm > leg

Superior • Head & eyes deviated toward side of infarct
divison • Left side lesion  global aphasia initially, then turns
(rolandic and
into Broca’s aphasia
prerolandic
area) • Right side lesion  deficit spatial perception,
MIDDLE apraxia, hemineglect
CEREBRAL
ARTERY
(MCA)
Inferior division • Homonymous hemianopsia

(lateral
• Left side lesion  Wernicke’s aphasia
temporal and
inferior parietal • Right side lesion  left visual neglect
Harri Haryana, SpKFR lobes) 27
Sources : Sara Cuccurullo

ACA
MCA

Neuroanatomic location of ischemic
stroke
ANTERIOR • Hemiparesis LE > UE

CEREBRAL
ARTERY
• Personality disfunction
(ACA) • Head and eyes may be
deviated toward side lesion
acutely
• Urinary incontinence with
contralateral grasp reflex
• Disturbances in gait and
stance = gait apraxia

POSTERIOR • Hemisensory deficit

CEREBRAL • Visual impairment
ARTERY (PCA) • Visual agnosia
• Prosopagnosia (can’t read faces)
• Alexia (can’t read)

SYNDROMES LOCATION
WEBER’S Medial basal • Ipsilateral third nerve palsy

midbrain • Contralateral hemiplegia
VERTEBRO
BASILAR • Ipsilateral third nerve palsy
SYSTEM BENEDICT’S Tegmentum of • Contralateral loss of pain &
midbrain temperature sensation
• Contralateral loss of joint
position
• Contralateral ataxia
• Contralateral chorea
LOCKED-IN Bilateral basal • Bilateral hemiplegia
pons • Bilateral cranial nerve palsy
Harri Haryana, SpKFR Source : Braddom 33

SYNDROMES LOCATION `
ARTERY
MILLARD-GUBLER Lateral pons • Ipsilateral sixth nerve palsy

• Ipsilateral facial weakness
VERTEBRO
BASILAR • Contralateral hemiplegia
SYSTEM
• Ipsilateral hemiataxia
• Ipsilateral loss of facial pain &
WALLENBERG’S Lateral temperature sensation
medulla • Contralateral loss of body pain &
temperature sensation
• Nystagmus
• Ipsilateral Horner’s syndrome
• Dysphagia & dysphonia
Harri Haryana, SpKFR Source : Braddom 34

Lacunar Strokes
constitute approximately 20% of all
strokes, resulting from occlusions
in the deep penetrating branches
of the large vessels that perfuse
the subcortical structures,
including internal capsule, basal
ganglia, thalamus, and brainstem.
Common risk factors for lacunar
strokes include hypertension,
diabetes, and hyperlipidemia.

Is it the same if
stroke occurs in
the Left or
Right
Hemisphere ?

Characteristics of Right and Left Hemiplegic Patients
Right Hemiplegic (Left-Brain Left Hemiplegic (Right-Brain

Injured) Injured)
 Communication impairment  Visual/motor perceptual
problems
 Learns by demonstration
 Loss of visual memory
 Will learn from mistakes
 Left side neglect
 May require supervision due to
communication problems  Impulsive
 Lack insight/judgement, requires
supervision

OK, I knew about stroke. But
I’ve got one. When should
rehabilitation begin after
all????

MANAGEMENT OF STROKE :
1. NON-SURGICAL ( Neurology )
SURGICAL ( Neurosurgery )
2. REHABILITATION
• Never a simple task / always complicated
• should be a “tailor-made program”
Stroke Rehabilitation???
Ask the Physiatrist

Physiatrists and Stroke
 Medical management during acute inpatient

rehabilitation and as an outpatient
 Blood pressure (SpS, SpPD, SpJP)
 Bowel and bladder dysfunction
 Skin
 Language impairments
 Swalowing Dissorder
 Cognitive and attentional impairments
 Spasticity
 Activity Daily Living

Timing of therapy
 Specific therapy schedules should be individual
for each patient
 The literature doesn’t provide specific
guidelines on the amount of therapy needed for
specific problems
 Endurance, medical stability, mood, motivation,
and other considerations affect the degree and
duration of physical patient can tolerate
Source : Braddom
 much of the benefits in mortality appear to relate to
prevention and/or earlier recognition of medical
complications of stroke and earlier mobilization
 The timing and progression depend on the patient’s

condition. These activities should begin as soon as
possible (generally within 24 to 48 hours of
admission) unless the stroke survivor is unresponsive or
medically/neurologically unstable

How to manage PMR
program to a stroke
patient ?

The first step of Rehabilitation
Medicine Program :
TO ESTABLISH THE
DIAGNOSIS OF STROKE
Haemorrhagic / Non-Haemorrhagic ?
Which cerebral artery is involved ?

WHY THIS IS IMPORTANT ?
1. To anticipate the possible
problems which will be developing
2. To decide the appropriate
rehabilitation medicine strategy

PMR Management in a stroke
patient
 Acute phase
 Sub acute phase
 Chronic phase
Source : Module
ACUTE PHASE
Stroke
Goals :
• Prevent complications of stroke
• Prevent complications of immobilization
ACUTE PHASE
What can I do ????

Intervention PMR in acute phase
- Maintain skin integrity

- Prevent arise sinergic pattern and spastic
- Prevent joint stiffness and shortening of the muscles
- Prevent cardiorespiratory complication
- Contend swallowing function disorder and prevent aspiration
- Management of communication disorder
- Bowel and bladder management
- Multisensory stimulation
Source : module
Upper Extremity Spasticity

Lower Extremity Spasticity

Rehabilitation during the acute post stroke phase
 Evaluate & manage medical problem
 Monitor and adjust medication
 Maintain hydration & nutrition
 Facilitate rest and sleep
 Venous thromboembolism prophylaxis
 Proper bed and chair positioning
 Frequent turns & position changes
 Range of motion exercises
 Deep breathing and cough exc
 Frequent skin inspections
Swallowing
Harri Haryana, SpKFR
evaluation 53
 Removal of indwelling catheter, if possible, with planned, tim bed
toileting program
 Bowel evacuation regimen
 Sitting in chair
 Supervised bedside exc
 Self-performance of ADL
 Mobilization exc
 Standing & gait training as able
 Educational program on stroke, recovery, and personal care
 Communication evaluation and training
Psychological
Harri Haryana, SpKFR support to the patient Source
54 : Braddom
 Family education and support
PHYSICAL THERAPY

SUBACUTE PHASE
 Goals :
- Optimally neurologic recovery and
reorganization process
- Minimize and prevent complications

Intervention PMR in subacute phase
- Continue the acute phase intervention
- Swallowing function therapy
- Therapeutic exercise :
1. Muscle reeducation approach
2. Neuro-facilitation approach
3. Conductive educational approach
4. Motor learning approach
5. Strength training and physical conditioning
6.Constraint-induced movement therapy
7. Body-weight support treadmill training
8. Cognitive perceptual therapy
9. Visual imagery approach
- Electrotherapy
1. Electrical stimulation
2. Biofeedback
- Cardiorespiration fitness therapy
- Orthotic
- Assisted walking aids / ADL aids

- Emotion counselling
- Sexual counselling
- Educate to prevent complications
- Group therapy

WALKERS
CHRONIC PHASE
Goals :
- Optimally functional ability
- Maintain functional ability that had been
achieved
- Prevent complications
- Optimally quality of life
Intervention PMR in chronic phase
 Adaptation training
 Revocational training
 Counselling and education for resocialization
 Home program to maintain :
- prevent joint stiffness and shortening of the muscles

- fitness training
- activity daily living according to independence level
 Education and training to family/care giver to prevent
complications
OCCUPATIONAL
THERAPY

GAIT ANALYSIS
SAGITTAL
PLANE
FRONTAL
PLANE

Hemiplegic Gait
Anterior rotation of the
pelvis
Circumduction
Equinovarus foot
Short strides
ENERGY EXPENDITURE

AMBULATION TRAINING
&
GAIT EXERCISES
Harri Haryana, SpKFR

START LOW, GO SLOW 66
Mother
tongue
SPEECH THERAPY
GOOD
PROGNOSIS
GOOD,
COMPREHENSIVE,
MOTIVATION
WELL-PLANNED
Harri Haryana, SpKFR PROGRAM
70
Complications
 Bronchopneumonia
 Ulcer pressure
 Shoulder subluxation
 Shouder hand syndrome
 Osteoarthrosis
 Osteoporosis
 Neuropatic pain
 Dementia
SHOULDER
SUBLUXATION
BE CAREFUL
for
SHOULDER-HAND
SYNDROME
Prognosis
Depend on :
 Large and location of the lession
 Comorbiditas
 Complications
 Motivation of the patient
 Familly support
 Facility dan professional terapist
How we can predict
patient outcome?

National Institute of Health Stroke Scale (NIHSS)
 NIHSS is a systematic assessment tool that provides a quantitative

measure of stroke-related neurologic deficit.
 The scale is simple, valid, and should take no more than 5-8 minutes
to perform by a trained health care provider.
 Maximum score of NIHSS is 42. Patients with scores > 10 are consider
to have moderate-to-severe strokes. Patients with scores under 4 are
considered to have mild strokes.
 Though the NIHSS is simple and standardized, training is necessary to

ensure all providers score patients in a standardized way.

NIHSS training:
Http://www.ninds.nih.Gov
/doctors/stroke_scale_trai
ning.htm

Modified Rankins Scale
• A simple, validated outcome measure that focuses on a

person’s level of function.
• Commonly used in patients with neurologic disorders,

particularly stroke.
• Discrete measures, ranges 0-6. No halves or thirds!
• Can be done in person or over the telephone
• Other more detailed outcome measures include the Barthel

Index, the Glascow Outcome Score, Katz, FIM, etc.
Modified Rankins Scale

What is
Neuroplasticity?

 Neuroplasticity refers to the ability of the central
nervous system to reorganize and remodel, particularly
after central nervous system injury.
 Possible mechanisms of neural plasticity
contributing to functional recovery might include:
 dendritic sprouting over time,
 new synapse formation, and
 the processes of long-term potentiation and depression

Source : Braddom
CLINICAL APPLICATION
NEUROPLASTICITY IN REHABILITATION
 Task-specific, repetitive training

 Constrained induced Movement Therapy
(CIMT)
 Robotic trainers
 Motor imagery

CIMT
 Warrant the most attention because it is safe,
does not require added technology, and has been
among the most extensively studied.
 Based on a theory proposed by Edward Taub that
patients with motor impairment in an upper limb
after stroke learn to depend more on the
unaffected limb for performing functional tasks
because attempts to use the affected arm often
result in failure and frustration.

Robotic

trainers
A very common gait training system that is now available in many
physical therapy clinics is body weight–supported treadmill
training (BWSTT).
 BWSTT uses a standard treadmill and an overhead
counterweighted cable system with a rock climbing–style harness

Motor imagery
 Motor imagery can be defined as the covert

cognitive process of imagining a movement
of your own body part without actually
moving that bodypart
 Initially developed to improve the

performance of athletes and has been
adopted in rehabilitation programs for
persons with stroke to support motor
recovery
Motor Imagery

Thank You

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STROKE

Pembimbing : dr. Handojo Pudjowidyanto, SpS

Harri Haryana, SpKFR 3

1. A stroke does not have to be

Harri Haryana, SpKFR 5

Harri Haryana, SpKFR 6

The WHO defines stroke as

“ rapidly developing clinical signs of focal (at times

Harri Haryana, SpKFR 7

Harri Haryana, SpKFR 8

Harri Haryana, SpKFR 9

Harri Haryana, SpKFR 10

Harri Haryana, SpKFR 11

 The most important risk factor.

Harri Haryana, SpKFR Source

 The relative risk of stroke for heavy smokers (>40

Blood clots may form in the heart

Atrial fibrillation is the most

Harri Haryana, SpKFR 14

Harri Haryana, SpKFR 15

Harri Haryana, SpKFR 16

Harri Haryana, SpKFR 17

Source : Sara Cuccurullo

Harri Haryana, SpKFR 18

Harri Haryana, SpKFR 19

 Patients with TIA are at risk for

 Amaurosis Fugax is a transient

Harri Haryana, SpKFR 20

Harri Haryana, SpKFR 21

Harri Haryana, SpKFR

Harri Haryana, SpKFR 26

• Sensory & motor deficit face/arm > leg

Inferior division • Homonymous hemianopsia

Sources : Sara Cuccurullo

Harri Haryana, SpKFR 29

ANTERIOR • Hemiparesis LE > UE

Harri Haryana, SpKFR 31

ARTERY MAIN PROBLEMS

POSTERIOR • Hemisensory deficit

Harri Haryana, SpKFR 32

WEBER’S Medial basal • Ipsilateral third nerve palsy

Harri Haryana, SpKFR Source : Braddom 33

MILLARD-GUBLER Lateral pons • Ipsilateral sixth nerve palsy

Harri Haryana, SpKFR Source : Braddom 34

Harri Haryana, SpKFR 35

Harri Haryana, SpKFR 36

Right Hemiplegic (Left-Brain Left Hemiplegic (Right-Brain

Harri Haryana, SpKFR 37

Harri Haryana, SpKFR 38

Harri Haryana, SpKFR 40

 Medical management during acute inpatient

Harri Haryana, SpKFR 41

 The timing and progression depend on the patient’s

Harri Haryana, SpKFR 43

Harri Haryana, SpKFR 44

Harri Haryana, SpKFR 45

Harri Haryana, SpKFR 46

Harri Haryana, SpKFR 49

- Maintain skin integrity

Harri Haryana, SpKFR 51

Harri Haryana, SpKFR 52

 Evaluate & manage medical problem

 Monitor and adjust medication