Module 4 GQ's

• Stroke is the 5th cause of death in the US and number one cause of long-term disability
• Groups with higher incidence of stroke

  • Men
  • African Americans
  • Mexican Americans
  • American Indians
  • Alaskan natives
• Stroke recurrence increases with age, doubling in persons over 65 years old
• Atherosclerosis


  Plaque formation accumulates on the arterial walls leading to progressive narrowing of blood vessels, interrupting blood flow at bifurcations, constrictions, dilations or angulations of arteries
• Common vascular sites for strokes

  • Common carotid artery or at its transition into the middle cerebral artery
  • Main bifurcation of the middle cerebral artery
  • Junction of vertebral arteries with the basilar artery
• Transient ischemic attack


  When people have a complete resolution of the deficit within minutes after the onset of the event
• The more proximal the location of the occlusion in a major cerebral artery nourishing the cerebral cortex, the more widespread cortical ischemia and greater type and severity of clinical deficits
• Thrombus


  Blockage of an artery that develops from the build-up of plaques within the wall of the vessel that slows blood flow substantially or blocks it all together
• Embolus


  Clot that forms elsewhere and travels to the brain lodging into one of the cerebral vessels
• Low systemic perfusion pressures

  Causes hypoxia, depriving the brain of needed oxygen and glucose, disrupting cellular metabolism and leading to injury and death of tissues
• Embolic stroke abruptly deprives an area of blood, resulting in almost immediate onset of deficits, with residual brain damage being permanent and resulting in prolonged and incomplete functional recovery
• Thrombotic stroke leads to ischemia or occlusion of an artery with resulting cerebral infarction or tissue death, with onset of signs being abrupt or worsening over several days
• Lacunar infarct


  Obstruction of blood flow in small, deep arteries, occurring most often in the basal ganglia, internal capsule, thalamus and brainstem, with signs developing slowly and often being purely motor or purely sensory, but with good recovery being the norm
• Hemorrhagic stroke


  Rupture of arteries and blood flows from broken vessel directly into intracranial structures, brain tissue, the ventricles of the brain or the subarachnoid space
• Major risk factors for stroke

  • Hypertension
  • Diabetes mellitus
  • Atrial fibrillation
  • Hyperlipidemia
  • Tobacco use
  • Cardiovascular disease
• Early warning signs of stroke

  • Face drooping
  • Arm weakness
  • Speech difficulty
  • Time to call 911
• Anterior cerebral artery stroke affects the most anterior-medial portions on the cerebrum, causing personality changes, cognitive changes, motor and sensory deficits
• Middle cerebral artery stroke affects the middle-lateral portions of the cerebrum, causing somatosensory deficits, motor deficits, special senses and autonomic function deficits, emotion and behavior deficits, and cognition, language & memory deficits
• Posterior cerebral artery stroke affects the posterior portion of the cerebrum, causing somatosensory deficits, motor deficits, special senses and autonomic function deficits, and cognition, language, memory deficits
• Thalamic syndrome


  Severe pain, contralateral hemisensory loss, flaccid hemiparesis, with vascular compromise of the hippocampus interfering with declarative memory
• Most common signs of vertebrobasilar artery ischemia


  • Gait and limb ataxia
  • Limb weakness
  • Oculomotor palsies
  • Oropharyngeal dysfunction
  • Vision problems
  • Double vision
  • Numbness
  • Dizziness
  • Headache
  • Vomiting
• Most common signs of acute cerebellar infarct

  • Dizziness
  • Inability to sit upright without support
  • Gait impairment
  • Nausea and vomiting
  • Dysarthria
  • Headache
• Complete occlusion of the basilar artery causes death due to ischemia of brainstem nuclei and tracts that control vital function, while partial occlusion can cause tetraplegia, loss of sensation, coma and cranial nerve signs, and locked-in syndrome
• Anterior inferior cerebellar artery stroke (lateral inferior pontine syndrome) causes

  • ipsilateral horizontal and vertical nystagmus
  • vertigo
  • nausea or vomiting
  • facial paralysis
  • paralysis of conjugate gaze
  • deafness
  • tinnitusataxia, and contralateral loss of pain and temperature sense
• Posterior inferior cerebellar artery stroke (lateral medullary or Wallenberg's syndrome) causes

  • ipsilateral decreased pain and temperature sensation in face
  • cerebellar ataxia
  • vertigo
  • nausea or vomiting
  • nystagmus
  • Horner's syndrome
  • dysphagia
  • dysarthria
  • contralateral loss of pain and temperature body
• Superior cerebellar artery stroke (lateral superior pontine syndrome) causes

  • ipsilateral cerebellar
  • ataxia
  • horizontal nystagmus
  • loss of optokinetic nystagmus
  • Horner's syndrome
  • vertigo
  • dizziness
  • nausea or vomiting,
  • contralateral loss of pain, temperature, discriminative touch, vibration and position sense
• Left hemisphere strokes can cause hemiparesis/hemiplegia, hemisensory loss, language and communication deficits, dysarthria, cautious behavior, disorganization, and loss of linear processing
• Right hemisphere strokes can cause hemiparesis/hemiplegia, hemisensory loss, inability to comprehend and produce emotional content of speech, left neglect, visuospatial disorders, impulsiveness, poor insight, loss of holistic processing, and fluctuations in performance
• Deficits commonly seen in patients poststroke

  • Paresis/paralysis on the side contralateral to the lesion
  • Loss of selective muscle activation or fractionation of movement and abnormal synergies
  • Voluntary movements can be absent, partially active and partially isolated or present when gravity is eliminated in early stages of recovery
• Stroke Rehabilitation Assessment of Movement

  • Measures thirty voluntary motor tasks of the upper and lower extremities
  • Best used for patients in acute or subacute settings with some ability to follow commands and for patients poststroke for which changes in active motor control, standing, and/or locomotion ability are expected
• Patient's motor presentation in Brunnstorm stage 1

  • Flaccid; no movement
• Patient's motor presentation in Brunnstorm stage 2

  • Increasing spasticity; weak synergies
• Patient's motor presentation in Brunnstorm stage 3


  • Peak spasticity; basic synergies
• Patient's motor presentation in Brunnstorm stage 4

  • Spasticity decreasing; earliest isolated motor control
• Patient's motor presentation in Brunnstorm stage 5

  • Spasticity decreasing; more isolated motor control
• Patient's motor presentation in Brunnstorm stage 6

  • No spasticity, selective motor control
• Fugl-Meyer Assessment of Physical performance

  • Stroke-specific, performance based impairment index
  • Designed to assess motor functioning, balance, sensation and joint functioning in patients with post-stroke hemiplegia
• UE flexor synergy movements

  • Scapular retraction/elevation or hyperextension
  • Shoulder abduction, ER
  • Elbow flexion
  • Forearm supination
  • Wrist and finger flexion
• UE extensor synergy movements


  • Scapular protraction
  • Shoulder adduction, IR
  • Elbow extension
  • Forearm pronation
  • Wrist and finger flexion
• LE flexor synergy movements

  • Hip flexion, abduction, ER
  • Knee flexion
  • Ankle dorsiflexion, inversion
  • Toe dorsiflexion