Cerebrovascular Accident PDF

Cerebrovascular Accident I.​ MOTOR NEURON / CORTICOSPINAL TRACT / PYRAMIDAL TRACT (4) (Loc: anteromedial side of brain stem) -​ Upper motor neuron (excites and inhibits LMN) -​ From motor cortex (BA 4, 6, 321) to SC -​ Corona radiata - group of motor axons; ac...

Cerebrovascular Accident I.​ MOTOR NEURON / CORTICOSPINAL TRACT / PYRAMIDAL TRACT (4) (Loc: anteromedial side of brain stem) -​ Upper motor neuron (excites and inhibits LMN) -​ From motor cortex (BA 4, 6, 321) to SC -​ Corona radiata - group of motor axons; action of neuromotor descending to lower part of CNS -​ When have a lesion expect weakness and paralysis -​ White matter - Internal capsule (post limb) -​ Lesion: weakness and paralysis -​ Midbrain -​ Tecum (CTS will NOT pass) -​ Cerebral peduncle (where CST descending-medial side) -​ Tegmentum -​ Crus cerebri AKA: Basis Pedunculi (base of the MB) -​ Base = front -​ DSE -​ Weber -​ CN 3 -​ Medial base of MB -​ (+) HEMIPLEGIA -​ Benedikt -​ CN 3 -​ Tegmentum of MB -​ (-) HEMIPLEGIA -​ Base of Pons -​ Anterior -​ Pyramids of medulla -​ Anterior -​ Decussate (tumawid) 90% Lat. CTS -​ not crossed 10% -​ Lateral CTS 90% -​ For limbs/appendicular muscle -​ Ant CTS 10% -​ For axial *Motor neuron stays in anterior/front/base front Aira C. Gonzales, PTRP  ​ Occipital lobe - vision ​ Parietal lobe - sensory ​ Frontal lobe - motor neuron -​ Level of decussation of Ant CTS is in spinal cord -​ The Upper motor neuron journey will end in anterior gray matter or horn cell -​ BELL MAGENDIE LAW ○​ “SPAM” ​ Sensory-posterior ​ Anterios-motor ○​ “VEM-DAS” ○​ Ventral-efferent motor ○​ Dorsal-Afferent sensory Lower motor neuron -​ Anterior horn cell -​ Start of the journey of Lower motor neuron -​ Where the UMN and LMN meets -​ LMN (loc.: Alpha, Beta, & Gamma) -​ Alpha - extrafusal muscle fiber -​ Gamma - intrafusal muscle fiber Upper motor neuron lesion Lower motor neuron lesion -​ Hypertonia -​ Hypotonia -​ *Recurrent inhibitory* -​ Flaccid -​ Spasticity (velocity dependent -​ Decrease DTR resistance) *muscle spindle -​ Increased DTR Disuse atrophy Denervated atrophy -​ Antigravity muscle -​ Severe muscle wasting 🌟Pathologic reflexes (Gold standard in diagnosing the UMNL) Spontaneous muscle activity -​ Fasciculation (can be seen in a -​ Babinski sign naked eye) and fibrillation (seen in electromyography) -​ Severe cases manifest as muscle cramping -​ D/t upregulation phenomenon* (sensitivity to acetylcholine) Pseudobulbar palsy Bulbar palsy Aira C. Gonzales, PTRP  -​ Lesion of corticobulbar tract -​ Lesion of cranial nerves (CBS) -​ Tongue fasciculation -​ Pseudobulbar affect / emotional incontinence (uncontrollable emotion) *LMN is cranial nerves and spinal nerves ○​ LMN: cranial nerve (UMN: corticobulbar tract or CBS) ○​ LMN: spinal nerve (UMN: CTS) II.​ BLOOD SUPPLY *ICA manage the circulation in anterior *Vertebral A. Manage the circulation in posterior ​ Internal Carotid A. ○​ Ophthalmic A / OA ○​ ACA ​ ACOM A. - artery that connect the 2 ACA 🌟 ​ Terminal ​ Only artery that can be “asymptomatic” ​ Medial striate / recurrent A. Of heubner *Striate = watershed areas (no water) - because they are in dulo that’s why their have a little amount of blood ○​ MCA ​ Most terminal branch ​ “Largest” ​ MC affected in stroke ​ Small branches that go to innermost of the brain called Lateral striate A. / Lenticulostriate (some books says that this is the Aira C. Gonzales, PTRP  terminal branch of MCA) ​ PCA ○​ Have 2 branch ​ Central - diencephalon & midbrain ​ Peripheral - supply temporal & occipital lobe ​ Basilar A. ○​ AICA - first branch of BA *Blood supply of cerebellum(3) = PICA, AICA, & SUCA (superior cerebellar A.) *PICA - dumaan sa lat. Medulla *Wallenberg syndrome *AICA - lat. Inf. Pons *SUCA - lat sup. Pons *Anterior spinal A. - supply medial medulla *Determine syndrome *PCA nag exit sa midbrain CIRCLE OF WILLIS 1.​Ant communicating A. 2.​ACA 3.​ICA 4.​Post communicating A. 5.​PCA 6.​Vestibular A. III. DEFINITION OF TERMS ​ Stroke / Brain Attack / CVA / Apoplexia ○​ Sudden onset of neurologic dysfxn secondary to the loss of blood supply to brain ○​ >24hrs 🌟 ○​ Non-traumatic ​ Transient Ischemic Attack ○​ “MINI STROKE” ○​ Temporary 24 hrs - weeks Aira C. Gonzales, PTRP  ○​ Not used anymore* ​ Deteriorating Stroke ○​ “STROKE IN EVOLUTION” ○​ Progression of symptoms after admission to hospital ○​ EARLY = onset - 3 days ○​ LATE = 3 - 7 days ○​ F) i.​ If >85 y/o F>M ​Family history ​Previous stroke B.​MODIFIABLE RISK FACTORS :) ​Hypertension (treatable) i.​ Normal 90 >120 i.​ 2 - 6 times increase to have stroke ​Smoking i.​ 2 - 4 increase to have stroke 1.​ Light smokers - 40 cid / day ​Diabetes i.​ 3-6 time increase to have stroke ​Diet & obesity i.​ *Physical activity decreased risk 35% ​Hypercholesterolemia i.​ Low density lipoprotein (LHL) 1.​ Bad cholesterol 2.​ Normal value = 60 3.​ Male: 10mm) (microaneurysm, pseudoaneurysm) surgical slipping, surgical px’s w/ long standing HTN coiling ○​🌟 ​ Sites: deep penetrating arteries Putamen - MC ​ SAH secondary to saccular ○​ “worst headache in my life” ○​ Subcortical white matter ○​ Thalamus ○​ Pons ○​🌟 ​ Sites: anterior circulation ○​ ICA Ant. Communicating A. - MC ○​ Cerebellum - least common ○​ MCA ​ Onset: rapidly progressing w/ severe ​ Other cause: arteriovenous headache malformation (AVM) ​ High acute mortality ○​ Tangled web of arteries & veins ​ Those who will survive will have rapid by passing capillaries neurologic recovery within 2 - 3 ​ Site: Ant. Circulation months. ​ Onset: 2nd - 3rd decade ○​🌟 ​ Triad: Hemorrhage (first will show) ○​ Migraine ○​ Seizure Subarachnoid hemorrhage (SAH) grading -​ Used to know the severity of SAH Aira C. Gonzales, PTRP *Hunt and Hess Grading HUNT AND HESS SCALE 1 Awake, mild headache, slight nuchal rigidity 2 Awake, headache, nuchal rigidity, CN involvement 3 Confused & drowsy, mild focal neurologic deficit 4 Stupor, moderate to severe hemiparesis 5 Coma, herniation, posturing VI. STROKE SYNDROMES ​🌟 Major blood supply ○​ ACA 🌟 Generalization of the BLOOD SUPPLY of the Brain ​ Supply: medial frontal & medial parietal ○​ MCA ​ Supply: LAHAT ng lateral except occipital ○​ PCA ​ Supply: Medial & inferior, temporal & occipital, SHET & medial midbrain ○​ VBA ​ Brain stem & cerebellum Stroke syndromes ​ ICA Aira C. Gonzales, PTRP  ○​ ○​ ○​ 🌟 First branch ophthalmic artery (OA) 🌟 OA - amaurosis fugax MCA - aphasia ○​ UE > LE ​ ACA ○​ Asymptomatic (rare) ○​ LE > UE & face ○​ (+) Perseverance ○​ Hemiplegia & hemiparesthesia ○​ Gait Apraxia (new name) - astasia (x - stand) & abasia (x - walk) (old name) ​ AKA: Disconnection apraxia ○​ Akinetic mutism - “tahimik/ lack the ability to move or speak” (severe) ○​ Abulian - partial response ○​ (+) Grasp reflex, groping reflex (dakma) ○​ (+) Palmomental reflex ○​ (+) Sucking reflex ○​ Urinary incontinence ​ Neurogenic bladder ○​ Paratonia - force dependent mov’t ​ Px is unaware that his hand moving ​ “alien hand syndrome ​ Types: gegenhalten (resist) & mitgehen (assist) ​ PCA Peripheral Central ○​ 🌟 ​ Photo (visual problem) Hemianopsia w/ macular sparing ​ Central post stroke syndrome ○​ “thalamic pain syndrome” / determine - roussy after 3-6 ○​ Visual agnosia months ​ Dyschromatopsia ​ C/L hemiballismus ​ Prosopagnosia ○​ Subthalamus (inability to recognize ​ C/L hemiplegia face) ​ CN 3 palsy ​ Alexia w/o agaraphia ○​ Weber syndrome (c/l hemi & (“pure word CN 3 plasy) blindness”) ​ Simultanagnosia (inability to perceive more than one object at a time) ​ Past (memory) ○​ Immediate recall ○​ Short term memory loss ○​ Long term memory loss Aira C. Gonzales, PTRP  ○​ Topographic amnesia ​ MCA ○​ UE & face > LE ○​ Dysphagia ○​ Hemianopsia Left AKA: Analytical / categorical 🌟 Right AKA: representational hemisphere 🌟 ​ 🌟 ​ Aware Aphasias “MGBUWL” ○​ Broca - upper stem of MCA ​ ​ ​ Unaware Neglect syndrome Denial of impairment ○​ Wernicke - Lower ​ Dressing apraxia (pseudo) ○​ Global - Main ​ Constructional apraxia (pseudo) ​ Slow & cautious ○​ D/t Visuospatial deficit ​ Apraxias ○​ Ideational apraxia ○​ Ideomotor apraxia ​ ​ 🌟 Body Image / body scheme deficit Affective agnosia (inability to perceive emotions) ​ Sad / depressed (d/t difficulty in ​ Quick & impulsive expression of positive emotion) ​ Happy (d/t difficulty in expression ​ (+) Perseverance negative emotion) ​ ​ 🌟 ​ Disorganized 🌟 Memory loss (language related) (+) Gerstmann syndrome(BA area ​ ​ ​ Rigidity of thought Poor judgment & poor insights Memory loss (Visuospatial related) 39) ​ Inability to self correct ​ Irritable ​ VBA ○​ Brainstem stroke syndromes Brain stem stroke Location Affection Manifestation syndrome Weber ​ Motor Medial basal midbrain 🌟CNCST3 C/L hemiplegia I/L CN 3 palsy Benedikt ​ Sensory Tegmentum of the midbrain tract -​ CN 3 🌟 -​ Spinothalamic (STT) C/L hemisensory I/L CN 3 palsy C/L Ataxias -​ Superior C/L Loss of PVT Cerebellar C/L chorea peduncles -​ Medial lemniscus Aira C. Gonzales, PTRP Locked in Bilateral basal/base -​ All in the pons -​ Severe cases: syndrome ​ Motor of pons & medulla 🌟 oblongata (CN 5 - 12) upward gaze 🌟 -​ CST & CBT -​ Okay and CN 1-4 Millard-gubler ​ Motor Lateral pons 🌟 CST CN 6-7 C/L hemiplegia I/L CN 6-7 palsy Wallenberg Lateral medulla -​ STT ​ C/L *Crossed oblongata - PICA -​ CN 5 hemisensory hemianesthesia* -​ Inferior (body) ​ Sensory cerebellar ​ I/L peduncle hemisensory -​ Sympathetic (face) -​🌟tract Vestibular Nucleus - CN ​ I/L Ataxias ​ I/L horner syndrome 8 ​ I/L nystagmus -​ ambiguus ​ I/L CN 9,10,11 -​ 9,10,11 🌟 nucleus - CN palsy Determine Medial medulla CST C/L hemiplegia syndrome oblongata - Anterior CN 12 I/L CN 12 palsy ​ Motor spinal A. Medial lemniscus C/L PTV loss *Cerebellar peduncles -​ Loc: Lateral of brain stem -​ Connection of the brain stem to cerebellum -​ 1 pair each area (2) -​ Spinocerebellar tract -​ Inferior cerebellar peduncles -​ Middle cerebellar peduncles -​ Superior cerebellar peduncles -​ The only C/L ataxia in cerebellar *Medial lemniscus -​ Fasciculus gracilis & fasciculus cutaneous (dorsal Aira C. Gonzales, PTRP  column) -​ Proprioception -​ Two-point discrimination -​ Vibration -​ Dorsal column, medial lemniscus system “DCML sys” -​ Level of Decussation of dorsal column = medulla oblongata SUCA AICA (Inferior Pons) PICA (lateral MO) (superior Pons) Lateral superior Lateral inferior pontine syndrome Wallenberg syndrome pontine syndrome Middle Middle cerebellar peduncles Inferior cerebellar peduncles cerebellar peduncles I/L Ataxias I/L Ataxias I/L Ataxias STT - C/L STT - C/L hemisensory STT - C/L hemisensory hemisensory Sympathetic tract: I/L horner's syndrome Sympathetic tract: I/L Sympathetic horner's syndrome tract: I/L horner's syndrome Medial lemniscus - C/L PVT loss CN 8 🌟 CN 5,7,8 🌟 CN 5,8,9,10,11 🌟 VII. Others A.​Aphasias Name Naming Comprehe Fluency Repetition Reading Writing Lesion nsion comprehe site nsion Aira C. Gonzales, PTRP Anomia (MC Poor Good Good Good G G Angular residue) gyrus Conduction Poor Good Good Poor G P Supramarg inal gyrus, arcuate fasciculus (parietal operculum ) Transcortical Poor Good Poor Good G P Medial motor frontal border zone Broca Poor Good Poor Poor G P 3rd frontal (shh)(motor) convolutio n Transcortical Poor Poor Good Good G P Medial sensory parietal border zone Wernicke's Poor Poor Good Poor P P Post sup. (sensory) Temporal gyrus Isolation of Poor Poor Poor Good N/A N/A N/A language (Parang parrot) Global Poor Poor Poor P P P Broca & Wernicke/s area Pure word G P G P G G Heschl’s deafness gyrus Pure word P G P P G G AKA: mutism aphemia Pure word G G G G P G PCA: blindness Alexia w/o agraphia B.​Synergy Patterns ​ Spared (hindi kasali sa pagbalik) “FLATS EDEMA” ○​ Finger Edema ○​ Lats Dorsi ○​ Ankle Evertors ○​ Teres Major Aira C. Gonzales, PTRP  ○​ Serratus Anterior FLEXION SYNERGY EXTENSION SYNERGY UE Scapular Retraction/Elevation or Scapular Protraction Hyperextension Shoulder Abduction and ER Shoulder Adduction,* IR Elbow Flexion* Elbow Extension Forearm Supination Forearm Pronation* Wrist and Finger Flexion Wrist and Finger Flexion LE Hip Flexion,* Abduction, ER Hip Extension, Adduction.* IR Knee Flexion Knee Extension* Ankle Dorsiflexion, Inversion Ankle plantarflexion,* Inversion Toe Dorsiflexion Toe Plantar Flexion C.​Brunnstrom’s stages of Recovery Stage Tone Movement 1 Flaccidity No movement Aira C. Gonzales, PTRP  2 Spasticity begins to appear Minimal voluntary movement 3 Peak of spasticity, severe Mastered mov’t of synergy 4 Spasticity begins to decline Some movement outside the synergy are mastered (Pron-supi, elbow flexion) (Forward arm raise) (Put hand behind) 5 Spasticity continue to decline More difficult mov’t combination are mastered (Pron-supi, elbow extension) (Horizontal arm raise) (Overhead activity) 6 Disappear Individual jt. mov't are possible 7 Normal Normal D.​Functional Walking Categories I.​ Physiologic walker -​ Px stands only during exercise or within the parallel bars II.​ Household walker A.​Limited household walker 1.​ Px's can do household chores with assistance B.​Unlimited HHW 1.​ Px's can do household chores w/o assistance 2.​ Px can not go out of the house III.​ Community walker A.​Most limited CW 1.​ Up & down curbs 2.​ Manage stairs to some degrees B.​Least limited CW 1.​ Up & down stairs completely 2.​ Can go to uncrowded places C.​Unlimited CW 1.​ Can go to crowded places a)​ Such as shopping center Aira C. Gonzales, PTRP