This document defines stroke as the sudden loss of neurological function caused by an interruption of blood flow to the brain. It classifies strokes as either ischemic, caused by a clot blocking blood flow, or hemorrhagic, caused by a ruptured blood vessel. Risk factors include hypertension, atrial fibrillation, and smoking. Symptoms vary depending on the affected brain region but may include weakness, sensory changes, speech problems, and visual issues. Complications can include muscle contractures, seizures, and cardiac or pulmonary issues.

1. STROKE
OR
CEREBROVASCULAR ACCIDENT
(CVA)

2. DEFINATION
Stroke or brain attack is the sudden loss of neurological
function caused by an interruption of the blood flow to
the brain.
Classification:
 Ischemic stroke : is the most common type results
when a clot blocks or impairs blood
flow, depriving the brain of essential
oxygen and nutrients.
 Hemorrhagic stroke: occurs when blood vessels rupture,
causing leakage of blood in or
around the brain.

7. EPIDEMIOLOGY
• Third leading cause of death
• Most common cause of disability among
adults in U.S
• The incidence is about 1.25 times greater for
males then females M>F
• Compared to whites, African-Americans have
twice the risk of first ever stroke

8. ETIOLOGY
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Atherosclerosis
Ischemic strokes
Cerebral thrombosis
Cerebral embolus
Intracerebral hemorrhage
Cerebral hemorrhage
Subarachnoid hemrrohage
Arteriovenous malformation (AVM)

9. RISK FACTORS
Modifiable:
• History of TIAs
• HTN
• Atrial fibrillation
• High RBC count
• Undesirable levels of blood cholestrol
• Heart disease
• Cigarette smoking
• Alcohol consumption
• Obesity
• DM

10. Non-modifiable:
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Prior stroke
Age
Race
Gender
Family history of stroke

11. PATHOPHYSIOLOGY
Interruption of blod flow
Complete cerebral circulatory arrest
Irreversible cellular damage with core area of
Ischemic
Ischemic
focal infarction
cascade
penumbra
Release of excess neurotransmitters
(glutamate and aspartate)
Damage brain cells

12. TRANSIENT ISCHEMIC ATTACK (TIA)
• Temporary interruption of blood supply to the brain.
• Symptoms last for only a few minutes or for several
hours
• Not last longer then 24 hours
• No evidence of residual brain damage or permanent
neurological dysfunction
• Etiological factors: occlusive episodes, emboli,
reduced cerebral perfusion(arrhythmias, decreased
cardiac output, hypotension, overmedication with
antihypertensive medication or cerebrovascular spasm

13. WARNING SIGNS OF STROKE:
• Sudden numbness or weakness of the face, arm
or leg esp on one side of the body
• Sudden confusion, trouble speaking or
understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance
or coordination
• Sudden, severe headaches with no known cause

14. ACA syndrome
ACA is the smaller terminal branch of the internal
carotid artery.
• Supplies:
• Medial aspect of cerebral hemisphere(frontal &
parietal lobes)
• Sub cortical structures BG ( anterior internal
capsule, inferior caudate nucleus, anterior 4/5th
of corpuscallosum)

18. Signs and symptoms :
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•
•
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Contra lateral hemi paresis (LE > UE)
Contra lateral hemi sensory loss (LE > UE )
Urinary incontinence
Problems with imitation and bimanual tasks,
apraxia
Structures involved :
• Primary motor area, medial aspect of cortex,
internal capsule
• primary sensory area
• Posteriomedial aspect of superior frontal gyrus
• corpus callosum

19. MCA syndrome
MCA is the second of the two main branches of the
internal carotid artery.
Supplies:
• Lateral aspect of cerebral hemisphere( frontal,
temporal, and parietal lobes )
• Subcortical structures (IC, corona radiata , globus
pallidus, putamen )

22. Signs and symptoms:
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Contralateral hemiparesis (UL and face > LL)
Contralateral sensory loss (UL and face > LL)
Motor speech impairment
Receptive speech impairement
Global aphasia
Perceptual deficits (unilateral neglect, anosognosia,
apraxia and spatial disorganization)
• Contralateral homonymous hemianopsia
• Sensory ataxia
Structures involved :
Primary motor area, primary sensory area, broca’s area,
Wernicke’s area, optic radiation in internal capsule

23. PCA syndrome
PCA is the terminal branches of the basilar artery.
Supplies:
• Occipital lobe
• Medial & inferior temporal lobe
• Upper brainstem
• Most of thalamus

25. Signs and symptoms:
 Peripheral territory:
• Contralateral homonymous hemianopsia
• Visual object agnosia
• Prosopagnosia
• Dyslexia
• Memory defect
 Central territory:
• Post stroke (thalamic ) pain
• Sensory impairments
• Involuntary movements, intention tremor, hemiballismus
• Contralateral hemiplegia
• weber’s syndrome ( 3RD N. PALSY + CONTRALATERAL
HEMIPLEGIA)

26. Vertebrobasilar artery syndrome
1. Medial medullary syndrome( Dejerine
syndrome)
Signs and symptoms
• Ipsilateral: paralysis with atrophy of half tongue with
deviation to the paralyzed side when tongue is
protruded
• Contralateral:
 Paralysis of UE and LE
 Impaired tactile & proprioceptive sense(medial
lemniscus)
Structures involved
CN XII, corticospinal tract or medial lemniscus

28. 2. Lateral medullary Syndrome (Wallenberg’s
syndrome):
Signs and symptoms
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Ipsilateral:
Decreased pain & temp sensation over face(V n.)
Ataxia of limbs and gait
Vertigo, nausea, vomitting, nystagmus
Horner’s syndrome: miosis, ptosis, decreased
sweating(sympathetic tract)
 Dysphagia, hoarsness of voice, paralysis of vocal cord(IX, X n.)
 Sensory impairment of ipsilateral UE, trunk, or LE
• Contralateral :
Impaired pain and thermal sense over 50% of body
Structures involved
CN V, Cerebellum, vestibular nuclei, descending sympathetic tract,
CN IX

29. 3. Complete basilar artery syndrome ( locked-in
syndrome )
Signs and symptoms
• Tetraplegia
• Bilateral cranial nerve palsy
• Coma
• Cognition is spared
Structures involved
• Corticospinal tracts bilaterally
• Long tracts to cranial nerve nuclei bilaterally
• Reticular activating system

30. 4.Medial inferior pontine syndrome:
Signs and symptoms
• Ipsilateral:
 Nystagmus
 Ataxia of limb & gait
 Diplopia on lateral gaze(6th n.)
 Paralysis of conjugate gaze to side of lesion
• Contralateral:
 Paresis of face, UE and LE
 Impaired tactile & proprioceptive sense over 50 % of the body
Structures involved
 Vestibular connections, middle cerebellar peduncle, CN VI,
corticobulbar and corticospinal tract

32. 5.Lateral inferior pontine syndrome:
Signs and symptoms
• Ipsilateral:
 Nystagmus,vertigo,nausea,vomitting (vest. N.)
 Facial paralysis(7th n.)
 Ataxia(cerebellar peduncle)
 Impaired sensation over face(5th n.)
• Contralateral:
 Impaired pain & thermal sense over half the
body(spinothalamic tract)

33. 6. Medial midpontine syndrome
Signs and symptoms
• Ipsilateral:
 Ataxia of limb & gait (middle cerebellar peduncle)
• Contralateral:
 Paralysis of face,arm,leg(CST, corticobulbar tract)
 Deviation of eyes
7. Lateral midpontine syndrome
Signs and symptoms
• Ipsilateral:
 Ataxia of limbs( middle cerebellar peduncle)
 Paralysis of muscles of mastication( CN V)
 Impaired sensation over face(CN V )

35. 8. Lateral superior pontine syndrome
Signs and symptoms
• Ipsilateral:
 Ataxia of limb & gait(middle cerebellar peduncle)
 Dizziness, nausea, vomiting, nystagmus( vest nuc)
 Horner’s syndrome( desc symp tract)
• Contralateral:
 Impaired pain, thermal sense (spinothalamic tract)
 Impaired touch, vibration & position sense(medial
lemniscus)
9.Medial superior pontine syndrome
Signs and symptoms
 Cerebellar ataxia( Sup and midd cerebellar peduncle )
 Paralysis of face, UE and LE( CST & CBT)

37. PRIMARY IMPAIRMENTS
1.
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SENSATION
Rarely absent
Impaired
Most common distribution pattern: face-UL-LL
Proprioceptive losses common
Loss of superficial touch and pain and temp
sensation common
• Abnormal sensations such as numbness,
dysesthesias, or hyperesthesia
• Profound hemisensory loss

38. 2. PAIN
• Ischemic stroke or hemorrhagic stroke result
severe headache and face pain.
• Post stroke thalamic pain characterised by :
• Constant, severe burning pain with intermittent
sharp pains.
• Paroxysmal spasms of pain may be triggered by
simply stroking , pin prick, heat or cold
3.
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VISUAL CHANGES
Homonymous hemianopsia
Visual neglect
Forced gaze deviation

39. 4. MOTOR FUNCTION
Stages of motor recovery

40. 5. ALTERATIONS IN TONE
FLACCIDITY
SPASTICITY
• Spasticity stronger in:
Upper limb
• Scapular retractors
• Shoulder adductors,depressors,internal rotators
• Elbow flexors, forearm pronators
• Wrist & finger flexors
Lower limb
• Pelvic retractors
• Hip adductors, Internal rotators
• Knee extensors
• Ankle plantar flexors
• Toe flexors

41. 6. ABNORMAL SYNERGY PATTERNS

42. 7. ABNORMAL REFLEXES
• Hyporeflexia with flaccidity & hyperreflexia with
spasticity
• Primitive reflexes
• Associated reactions
8. ALTERED COORDINATION
9. ALTERED MOTOR PROGRAMMING
10. POSTURAL CONTROL AND BALANCE
• Ipsilateral pushing ( pusher syndrome )
Is an unusal motor behaviour characterised by
active pushing with the stronger extremities
toward the hemiparetic side, leading to a lateral
postural imbalance

43. 11. Cognitive & perceptual disorders:
• Body scheme & body image disorders
• Spatial relation disorders
figure-ground dis
• Agnosias
form dis
• Apraxias
• anosognosia
• Hemineglect
• Memory, attention disorders
• Confabulations
• Dementia
• Delirium

44. 12.Speech, language and swallowing
• Aphasia
• Fluent and non fluent aphasia
• Global aphasia
• Dysarthria
• Dysphagia
13. Emotional status
• Pseudobulbar affect
• Apathy
• Euphoria
• Depression
14. Bladder and bowel dysfunction
• Urinary incontinence

46. COMPLICATIONS AND INDIRECT
IMPAIRMENTS
 Musculoskeletal
• Contractures
• Disuse atrophy
• Muscle weakness
• Osteoporosis
 Neurological
• Seizures
• Hydrocephalus
 Cardiovascular / Pulmonary
• Thrombophlebitis / Deep vein thrombosis
• Cardiac function : impaired CO and serious rhythm
disorders
• Pulmonary function : decreased lung volume,
decreased pulmonary perfusion and vital capacity

47. THANK YOU