Stroke Rehabilitation- PMR Refresher Course Jaipur

1. STROKE EPIDEMIOLOGY AND STROKE
SYNDROMES
Dr. Trilochan Srivastava
MD, DM (Neurology)
Fellowship in Cerebrovascular Intervention
Professor
Department of Neurology
SMS Medical College, Jaipur

2. STROKES ACCOUNT FOR 10% OF ALL-CAUSE MORTALITY
Other causes
27%
Cancer
12%
Stroke
10%
Accidents
9%
Respiratory infections 7%
HIV/AIDS 5%
chronic obstructive pulmonary
disease 5%
Perinatal causes
Diarrhoea
Tuberculosis
3%3%
4%
2%
Malaria
Coronary heart
disease
13%
Stroke is the 3rd leading cause of death and the 1st cause of severe morbidity
worldwide
(~ 3 ‰ of population/year, 600 hemiplegic/100.000 people)

3.  10% of strokes are fatal
 ~35% will die within the 1st year (~20% within the 1st month)
 ~30% will experience a new & often more serious stroke within the
next 5 years (~10% within the 1st year)
 ~30% of survivors becomes handicapped and/or develops
vascular Dementia
«cross» cardiovascular risk!
 After a stroke: x2 or x3 risk for myocardial infarction
 In ~10% of patients with myocardial infarction, stroke will
occur within the next 5 years
Epidemiological data with clinical significance
* Framingham Heart Study; American Heart Association, Heart and Stroke Facts statistical update,
Lees KR, et al. BMJ 2000;320:991–994; Hankey GJ, Warlow CP. Lancet 1999;354:1457–1463

4. Incidence – Mortality of
ischemic & hemorrhagic Stroke
The majority of strokes is ischemic
Ischemic
strokes
Hemorragic
strokes
Mortality1stmonth
%

5. MEAN AGE OF STROKE INCIDENCE,
PREVALENCE AND MORTALITY

6. STROKE EPIDEMIOLOGY IN INDIA
 The estimated adjusted
prevalence rate of
stroke range, 84-
262/100,000 in rural and
334-424/ 100,000 in
urban areas.
 The incidence rate is
119-145/100,000 based
on the recent population
based studies.

7. STROKE STATISTICS IN INDIA
 Most important cause of Disability
 Stroke is the No. 3 cause of death (#1 – Heart Disease, #2 –
Cancer)
 Prevalence 55.6 per 100,000 all ages (Dalal 2007)
 1.44-1.64 million cases of new acute strokes every year
(WHO 2005, Murthy 2007)
 0.63 million deaths (WHO 2005)
 28-30 day case fatality ranges from 18-41% (Dalal et al
2008, Das et al 2007)
 By 2015, India report 1.6 million cases of stroke annually, at
least one-third of whom disabled

8. STROKE PREVALENCE

9. ANNUAL INCIDENCE

10. STROKE STATISTICS
 Every 3.1 minutes someone dies of a stroke
 Stroke risk increases with age
 12% of strokes occur in the population aged <40
years (Shah + Mathur 2006)
 For each decade after age 55, the risk of stroke
doubles.
 72% of all strokes occur in people over the age
of 65

11. 1,1
3,1
6,6
11,5
0,4
1,2
12,0
0,3
0,8
2,1
3,0
6,3
0
2
4
6
8
10
12
14
20-34 35-44 45-54 55-64 65-74 75+
Age
%ofpopulation
Frequency of Stroke in relation with age &
gender
NHANES: 1999-2002 CDC/NCHS and NHLBI
 Men
 Women

12. RISK OF RECURRENCE IN PATIENTS WITH PREVIOUS
TRANSIENT ISCHEMIC ATTACK (TIA) OR STROKE
After TIA After Stroke
30 days* 4 - 8% 3 - 10%
1 year 12 - 13% 10 - 14%
5 years 24 - 29% 25 - 40%
* Early recurrence: cardioembolism & stroke from extracranial atherosclerosis

13. RISK FACTORS
Non-modifiable:
 Age : Doubling of strokes’ frequency for every 10 years after 55
yrs of age
 Gender: Men x 1,4 increased risk ; >75 yrs same risk in both
gender
 Family history of stroke (inheritance)
 History of stroke or myocardial infraction

14. MAJOR MODIFIABLE RISK FACTORS
 Hypertension: the most potent risk factor (60% of stroke, in mild x2 increase
of risk & in severe x7)
 Diabetes: elevated risk x4 , even more when hypertension coexists
 Dyslipidaemia: Hypercholesterolaemia > 240 mg/dl
correlation with stroke mortality
 Smoking: possibility of stroke x2
cessation reduces the risk (50%) during the 1st year
 Risk for embolic events:
- Atrial fibrillation, myocardial infarction-arterial wall clot
- Εndocarditis, artificial valves, cardiac surgery
- carotid stenotic disease

15. OTHER MODIFIABLE RISK FACTORS
 Obesity, high fat and sodium diet
 Insulin resistance
 Decreased physical activity (walking for 30 min per day)
 Increased alcohol consumption (>2 drinks per day)
 Heart disease : CD,CHF
 Patent foramen ovale (paradoxical embolism)
 Arteriopathy : Inflammatory vessel damage caused by infectious diseases
(syphilis, chlamydia, Η.p), collagen disease angiitis (SLE, polyarteritis
nodosa), antiphospholypidemic syndrome
 Migraine
 Hypotheroidism
 Sleep apnoea syndrome
 Drug use

16. STROKE SYNDROMES

17. CEREBROVASCULAR DISEASE
 Ischemic stroke
 Hemorrhagic stroke
 Cerebrovascular anomalies such as intracranial
aneurysms and arteriovenous malformations
(AVMs)

18. STROKE
Definition:
 abrupt onset of a neurologic deficit that is
attributable to a focal vascular cause last > 24
hrs
 Transient ischemic attack (TIA) - all neurologic
signs and symptoms resolve within 24 h regardless
of whether there is imaging evidence of new
permanent brain injury

19. DEFINITION OF TERMS
 Thrombosis: inappropriate clotting
 Embolism: migration of clots
 Ischemia: loss of blood supply in a tissue due to
impeded arterial flow or reduced venous drainage
 Infarction: cell death

20. HEMORRHAGIC STROKE
 HT
 Hemorrhage are
classified by location
 Bleeding into subdural
and epidural spaces
is principally produced
by trauma
 SAHs are produced by
trauma and rupture of
intracranial aneurysms

21. ISCHEMIC STROKE

22. APPROACH TO THE PATIENT
Rapid evaluation is essential for use of
time sensitive treatments such as
thrombolysis
Important clues pointing to stroke:
 Hemiparesis
 Changes in vision
 Changes in gait
 Disturbance in the ability to speak or
understand
 Sudden severe headache

23. ISCHEMIC STROKE
 Acute occlusion of an intracranial vessel causing
reduction in blood flow to the brain region
 The magnitude of flow reduction is a function of
collateral blood flow

24. CAUSES OF ISCHEMIC STROKE
 Carotid /Intracranial
Atherosclerosis
 Embolism: CAD, AF
 30% of strokes remain
unexplained despite
extensive evaluation

25. CARDIOEMBOLIC STROKE
 Responsible for 20% of all
ischemic strokes
 Embolism of thrombotic
material forming on the
atrial or ventricular wall or
the left heart valves
 Thrombi then detach and
embolize into the arterial
circulation
 Embolic strokes tend to be
sudden in onset, with
maximum neurologic
deficit at once

26. CARDIOEMBOLIC STROKE CAUSES:
 Rheumatic heart
disease
 Non-rheumatic AF
 MI
 Prosthetic valves
 Ischemic
cardiomyopathy

27. CAROTID ATHEROSCLEROSIS
 10% of all ischemic
strokes
 frequently within the
common carotid
bifurcation and proximal
internal carotid artery
 RISK FACTORS:
 Male gender, older age,
smoking, hypertension,
diabetes, and
hypercholesterolemia

28. OTHER CAUSES OF STROKE
 Intracranial Atherosclerosis
 Dissection of Internal Carotid Artery
 Hypercoagulability
 Venous sinus thrombosis
 Fibromuscular dysplasia
 Vasculitis
 Drugs (amphetamines, cocaine,
phenylpropanolamine)

29. TRANSIENT ISCHEMIC ATTACK (TIA)
 Episodes of stroke symptoms that last briefly
 Duration < 24 hrs
 May arise from emboli to the brain or from in situ
thrombosis
 Amaurosis fugax – transient monocular blindness
occurs from emboli to the central retinal artery of
the eye

30. TRANSIENT ISCHEMIC ATTACK (TIA)
 Risk of stroke after a TIA is ~10-15% in the first 3
months with most events occurring in the first 2
days
 Acute antiplatelet therapy is effective and
recommended

31. STROKE SYNDROMES

32. STROKE SYNDROMES

33. STROKE WITHIN THE ANTERIOR CIRCULATION
 Middle Cerebral Artery
 Anterior Cerebral Artery
 Anterior Choroidal Arteries
 Internal Carotid Artery
 Common Carotid Artery

34. MIDDLE CEREBRAL ARTERY
 Occlusion of the
proximal MCA or one of
its major branches is
most often due to an
embolus rather than
intracranial
atherothrombosis

35. MIDDLE CEREBRAL ARTERY
 The proximal MCA (M1 segment) supplies the following:
Basal Ganglion
 Putamen
 Outer globus pallidus
 Posterior limb of the internal capsule
 Corona radiata
 Most of the caudate nucleus

36. MCA
 In the sylvian fissure,
the MCA divides into
the superior and
inferior divisions (M2
branches)
 Superior division
supplies
 Frontal and superior
parietal cortex
 Inferior division
supplies
 Inferior parietal and
temporal cortex

37. MIDDLE CEREBRAL ARTERY
 Entire MCA is occluded at its origin :
 contralateral hemiplegia, hemianesthesia
 homonymous hemianopia, gaze preference to
the ipsilateral side
 Dysarthria is common because of facial
weakness
 Global aphasia

38. MIDDLE CEREBRAL ARTERY: PARTIAL
SYNDROMES
 Brachial syndrome : embolic occlusion of a single
branch include hand, or arm and hand, weakness
alone
 Frontal Opercular Syndrome: facial weakness with
nonfluent (Broca) aphasia, with or without arm
weakness
 Lacunar stroke within internal capsule - pure motor
stroke or sensory-motor stroke contralateral to the
lesion

39. STROKE WITHIN THE ANTERIOR CIRCULATION
 Anterior Cerebral Artery

40. ANTERIOR CEREBRAL ARTERY
 Paralysis of opposite foot and leg: Motor
leg area
 A lesser degree of paresis of opposite arm
 Urinary incontinence: Sensorimotor area in
paracentral lobule

42. STROKE WITHIN THE POSTERIOR
CIRCULATION
 Posterior Cerebral Artery
 Vertebral Artery
 Posterior Inferior Cerebellar
Artery
 Basilar Artery

43. STROKE WITHIN THE POSTERIOR
CIRCULATION
 Result from atheroma
formation or emboli that
lodge at the top of the
basilar artery
 May also be caused by
dissection of the
vertebral artery

44. POSTERIOR CEREBRAL ARTERY
 (1) P1 syndrome: midbrain,
subthalamic, and thalamic
signs, which are due to
disease of the proximal P1
segment of the PCA or its
penetrating branches
 (2) P2 syndrome: cortical
temporal and occipital
lobe signs, due to
occlusion of the P2 segment
distal to the junction of the
PCA with the posterior
communicating artery.

45. POSTERIOR CEREBRAL ARTERY
 P1 Syndromes
 third nerve palsy with
contralateral ataxia
(Claude's syndrome) or
with contralateral
hemiplegia (Weber's
syndrome)
 contralateral
hemiballismus (if
subthalamic nucleus is
involved)
 thalamic Déjerine-
Roussy syndrome -
contralateral
hemisensory loss
followed later by an
agonizing, searing or
burning pain in the
affected areas

46. POSTERIOR CEREBRAL ARTERY
 P2 Syndromes
 Occulsion of the PCA causes
infarction of the medial
temporal and occipital lobes
 Contralateral homonymous
hemianopia with macula
sparing is the usual
manifestation
 acute disturbance in memory
(hippocampus)
 peduncular hallucinosis -
visual hallucinations of
brightly colored scenes and
objects
 infarction in the distal PCAs
produces cortical blindness
(blindness with preserved
PLR)
 Anton's syndrome – unaware
of blindness and in denial

47. BASILAR ARTERY
 Atheromatous lesions are
most frequent in the
proximal basilar and the
distal vertebral segments
 Complete basilar occlusion
“locked-in" state of
preserved consciousness
with quadriplegia and
cranial nerve signs
suggests complete pontine
and lower midbrain
infarction

48. BASILAR ARTERY
 Occlusion of the superior
cerebellar artery results in
 Ipsilateral cerebellar ataxia,
nausea and vomiting,
dysarthria, contralateral loss of
pain and temp sensation
 Occusion of the anterior
inferior cerebellar artery
results in
 Ipsilateral deafness, facial
weakness, vertigo, nausea and
vomiting, nystagmus, tinnitus
and contralateral loss of pain
and temperature sensation

49. LATERAL MEDULLARY SYNDROME
(OCCLUSION OF VERTEBRAL, POSTERIOR INFERIOR CEREBELLAR ARTERIES)
On side of lesion
 Pain, numbness, impaired sensation over
one-half the face: Descending tract and nucleus
fifth nerve
 Ataxia of limbs, falling to side of lesion:
Uncertain—restiform body, cerebellar
hemisphere, cerebellar fibers, spinocerebellar
tract (?)
 Nystagmus, diplopia, oscillopsia, vertigo, nausea,
vomiting: Vestibular nucleus
 Horner's syndrome (miosis, ptosis, decreased
sweating): Descending sympathetic tract
 Dysphagia, hoarseness, paralysis of palate,
paralysis of vocal cord, diminished gag reflex:
Issuing fibers ninth and tenth nerves
 Loss of taste: Nucleus and tractus solitarius
 Numbness of ipsilateral arm, trunk, or leg:
Cuneate and gracile nuclei
 Weakness of lower face: Genuflected upper
motor neuron fibers to ipsilateral facial nucleus
On side opposite lesion
 Impaired pain and thermal sense over half the
body, sometimes face: Spinothalamic tract

50. MEDIAL MEDULLARY SYNDROME
(OCCLUSION OF VERTEBRAL ARTERY OR OF BRANCH OF VERTEBRAL OR
LOWER BASILAR ARTERY)
On side of lesion
 Paralysis with atrophy of
one-half half the tongue:
Ipsilateral twelfth nerve
On side opposite lesion
 Paralysis of arm and leg,
sparing face; impaired
tactile and proprioceptive
sense over one-half the
body: Contralateral
pyramidal tract and medial
lemniscus

51. CONCLUSION
STROKE SYNDROME
Anterior circulation
 MCA
 ACA
Posterior circulation
 Vertebral artery-PICA
 Basilar artery- AICA,
SCA
 PCA

52. 52
THANK
YOU