Cerebrovascular Accident (CVA) 2024 PDF

INTRODUCTION TO CEREBROVASCULAR ACCIDENT (CVA) OBJECTIVES At the end of this session students will be able to: Explain what a cerebrovascular accident (CVA) is in patient-appropriate language Describe the risk factors for CVA Describe a basic clinical presentation of CVA Respond...

INTRODUCTION TO CEREBROVASCULAR ACCIDENT (CVA) OBJECTIVES At the end of this session students will be able to: Explain what a cerebrovascular accident (CVA) is in patient-appropriate language Describe the risk factors for CVA Describe a basic clinical presentation of CVA Respond to simple clinical questions regarding this clinical pattern DEFINITION: CEREBROVASCULAR ACCIDENT STROKE Acute loss of blood flow to the brain due to an infarct (ischaemic stroke) or haemorrhage (haemorrhagic stroke). Irreversible damage to brain tissue AKA: “stroke” https://www.healthline.com/health/stroke/ischemic-vs-hemorrhagic-stroke BURDEN OF DISEASE Worldwide, 15 million people suffer a stroke annually. 5 million die and another 5 million permanently disabled (WHO 2023). An Australian has a stroke every 19 minutes (Stroke Foundation 2023) Regional Australians are 17 percent more likely to suffer a stroke than those in metropolitan areas (Stroke Foundation 2023) Uncommon in people < 40 years; if it occurs, the main cause is high blood pressure. (WHO 2023) Occurs in about 8% of children with sickle cell disease. (WHO 2023) AETIOLOGY/RISK FACTORS Modifiable factors Medical factors Non-modifiable factors High blood pressure Atrial fibrillation Age High cholesterol Diabetes Gender Smoking Fibromuscular Family history Obesity or overweight dysplasia (FMD) Diet Lack of exercise Alcohol Stroke Foundation 2023 PATHOPHYSIOLOGY Blood supply to brain interrupted: brain cells die due to lack of oxygen and nutrients Haemorrhage: blood loss through ruptured vessels, may be associated with vessel disease Infarct: blockage by thrombus or embolus (plug of material such as air) CLINICAL PRESENTATION CLINICAL PRESENTATION Depends on location of stroke Hemiplegia – weakness / numbness affecting one side of the body Difficulty speaking or understanding (dysphasia / dysarthria) Dizziness, loss of balance or an unexplained fall Loss of vision, sudden blurring or decreased vision in one or both eyes CLINICAL PRESENTATION Depends on location of stroke Headache, usually severe and abrupt onset or unexplained change in the pattern of headaches Difficulty swallowing (dysphagia) Cognitive / perceptual disorders COURSE AND PROGNOSIS Variable – related to severity of stroke, type of stroke, age Usually most rapid recovery takes place in the initial days following stroke, as the swelling in the brain goes down. Recovery will continue for many months and sometimes years. Those who take part in early and comprehensive rehabilitation have better outcomes. DIAGNOSIS Diagnosis and immediate referral to a stroke team is important given advances in reperfusion therapies. Strong working relationships are required between emergency department staff and the stroke team to improve timely assessment and early management. Investigations - CT / MRI (Australian and New Zealand Living Clinical Guidelines for Stroke Management) MANAGEMENT: ACUTE Admitted to hospital and be treated in a stroke unit with an interdisciplinary team. Implement standardised protocols to manage fever, glucose and swallowing difficulties in stroke patients. (Middleton et al. 2011) Antithrombotic therapy / surgery Australian and New Zealand Living Clinical Guidelines for Stroke Management MANAGEMENT: REHABILITATION Commence mobilisation (out-of-bed activity) within 48 hours of stroke onset unless otherwise contraindicated (e.g. receiving end-of-life care). (Bernhardt et al. 2015; Lynch et al. 2014) Structured to provide as much scheduled therapy (occupational therapy and physiotherapy) as possible. (Lohse et al. 2014; Schneider et al. 2016; Veerbeek et al. 2014) Group circuit class therapy should be used to increase scheduled therapy time. (English et al. 2015) Australian and New Zealand Living Clinical Guidelines for Stroke Management THE MULTI-DISCIPLINARY TEAM Physiotherapy Orthotist Occupational Therapy Pharmacist Speech Pathology Neuropsychologist Social Worker Clinical Exercise Physiologist Rehabilitation Physician Dietician Nurse Counsellor PHYSIOTHERAPY MANAGEMENT Collaborative goal setting with the stroke survivor and their family/carer (unless they choose not to participate) and should be well-defined, specific and challenging. (Sugavanam et al. 2013; Taylor et al. 2012) Reduced strength - progressive resistance training (Dorsch et al. 2018 ) Include individually-tailored exercise interventions to improve cardiorespiratory fitness. Task specific repetitive practice (e.g. sit to stand, walking, standing) Australian and New Zealand Living Clinical Guidelines for Stroke Management REFERENCES Australian and New Zealand Living Clinical Guidelines for Stroke Management: https://informme.org.au/guidelines/living-clinical-guidelines-for-stroke-management accessed 22/8/23 Bernhardt, J., Langhorne, P., Lindley, R. I., Thrift, A. G., Ellery, F., Collier, J.,... & Donnan, G. (2015). Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. Lancet, 386(9988), 46-55. Dorsch, S., Ada, L., & Alloggia, D. (2018). Progressive resistance training increases strength after stroke but this may not carry over to activity: a systematic review. Journal of Physiotherapy, 64(2), 84-90. English, C., Bernhardt, J., Crotty, M., Esterman, A., Segal, L., & Hillier, S. (2015). Circuit class therapy or seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a randomized controlled trial. International Journal of Stroke, 10(4), 594-602. Lohse, K. R., Lang, C. E., & Boyd, L. A. (2014). Is more better? Using metadata to explore dose–response relationships in stroke rehabilitation. Stroke, 45(7), 2053-2058. Lynch, E., Hillier, S., & Cadilhac, D. (2014). When should physical rehabilitation commence after stroke: a systematic review. International Journal of Stroke, 9(4), 468-478. Schneider, E. J., Lannin, N. A., Ada, L., & Schmidt, J. (2016). Increasing the amount of usual rehabilitation improves activi ty after stroke: a systematic review. Journal of physiotherapy, 62(4), 182-187. Sugavanam, T., Mead, G., Bulley, C., Donaghy, M., & Van Wijck, F. (2013). The effects and experiences of goal setting in stroke rehabilitation–a systematic review. Disability and rehabilitation, 35(3), 177-190. Stroke Foundation. https://strokefoundation.org.au/about-stroke accessed 22/8/23 Taylor, W. J., Brown, M., William, L., McPherson, K. M., Reed, K., Dean, S. G., & Weatherall, M. (2012). A pilot cluster randomized controlled trial of structured goal-setting following stroke. Clinical Rehabilitation, 26(4), 327-338. Veerbeek, J. M., van Wegen, E., van Peppen, R., van der Wees, P. J., Hendriks, E., Rietberg, M., & Kwakkel, G. (2014). What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one, 9(2), e87987. WHO https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html , accessed 22/8/23 EXAMPLES OF Q&A WITH CLINICAL EDUCATOR What is your understanding of Stroke occurs when there is a sudden interruption to the blood flow in the brain. It Stroke? can be due to an infarct, called an ischaemic stroke, or a bleed called a haemorrhagic stroke. EXAMPLES OF Q&A WITH CLINICAL EDUCATOR Please list some common signs Signs and symptoms relate to area of brain affected. Common symptoms include: & symptoms of stroke ? hemiplegia – weakness affecting one side of the body Difficulty speaking or understanding (dysphasia / dysarthria) Dizziness, loss of balance or an unexplained fall Vision changes - blurring or decreased vision Headache, usually severe and abrupt onset Difficulty swallowing (dysphagia) Cognitive / perceptual disorders