Based on the information provided: - The patient likely experienced an ischemic stroke in the territory of the right middle cerebral artery. - This would involve structures supplied by the right MCA, including the: 1. Parietal lobe (interpretation of language, sensory perception) 2. Parts of the frontal lobe 3. Parts of the temporal lobe The left sided weakness, greater weakness proximally in the upper limb, and receptive dysphasia are consistent with an ischemic stroke in the right MCA territory. The large parietal lesion seen on CT further localizes the stroke to this region.

1. Neurological disorders
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T/MS
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T neurological rehabilitation

2. Neurological disorders
STROKE

3. STROKE
 A stroke or cerebrovascular accident
(CVA) is typically defined as an
accident with ‘rapidly developing
clinical signs of focal or global
disturbance of cerebral function, with
symptoms lasting 24 hours or longer
or leading to death, with no apparent
cause other than of vascular origin’

5.  The cerebrum is divided into four
lobes
 Frontal
 parietal
 occipital
 temporal

6. Frontal lobe
 Personality, behavior, emotions
 Judgment, planning, problem
solving
 Speech: speaking and writing
(Broca’s area)
 Body movement (motor strip)
 Intelligence, concentration, self
awareness

7. Paraital lobe
 Interprets language, words
 Sense of touch, pain, temperature
(sensory strip)
 Interprets signals from vision,
hearing, motor, sensory and
memory
 Spatial and visual perception

8. Occipital lobe
 Interprets vision (color, light,
movement)

9. Temporal lobe
 Understanding language
(Wernicke’s area)
 Memory
 Hearing
 Sequencing and organization

10. Blood supply of the Cerebrum
 The anterior, middle and posterior cer
ebral arteries each supply a
specific territory of the brain:
 The anterior cerebral arteries supply
the anteromedial area of the cerebrum.
 The middle cerebral arteries supply the
majority of the lateral cerebrum.
 The posterior cerebral arteries supply
a mixture of
the medial and lateral areas of
the posteriorcerebrum.

12. CLASSIFICATION AND
AETIOLOGY
OF STROKE

13. Ischemic stroke
 There are several mechanisms which can result in
an ischaemic stroke including:
 Embolism: An embolus from somewhere else in
the body (e.g. the heart) causes obstruction of a
cerebral vessel, resulting in hypoperfusion to the
area of brain the vessel supplies.
 Thrombosis: A blood clot forms locally within a
cerebral vessel (e.g. due to atherosclerotic plaque
rupture).
 Systemic hypoperfusion: Reduced blood supply
to the entire brain secondary to systemic
hypotension (e.g. cardiac arrest).
 Cerebral venous sinus thrombosis: Blood clots
form in the veins that drain the brain, resulting in
venous congestion and hypoxia which damages
brain tissue.

14. Haemorrhagic stroke
 There are two sub-types of haemorrhagic
stroke:
 Intracerebral haemorrhage: Bleeding
within the brain itself secondary to a
ruptured blood vessel.
◦ Intraparenchymal (bleeding within the brain
tissue)
◦ Intraventricular (bleeding within the ventricles)
 Subarachnoid haemorrhage: Bleeding
that occurs outside of the brain tissue,
between the pia mater and arachnoid
mater.

15. Bamford classification of ischaemic
stroke
 The most commonly used classification
system for ischaemic strokes is the
Bamford classification (or Oxford
classification) system. This categorises
stroke based on the initial presenting
symptoms and clinical signs. This system
does not require imaging to classify the
stroke, instead, it is a purely clinical
diagnosis.

16. Total anterior circulation
stroke (TACS)
 All three of the following need to be
present for a diagnosis of TACS:
 Unilateral weakness (and/or sensory
deficit) of the face, arm and leg
 Homonymous hemianopia
 Higher cerebral dysfunction
(dysphasia, visuospatial disorder)

17. Partial anterior circulation
stroke (PACS)
 Two of the following need to be
present for a diagnosis of PACS:
 Unilateral weakness (and/or sensory
deficit) of the face, arm and leg
 Homonymous hemianopia
 Higher cerebral dysfunction
(dysphasia, visuospatial disorder)

18. Posterior circulation
syndrome (POCS)
 One of the following need to be
present for a diagnosis of POCS:
 Cranial nerve palsy and a contralateral
motor/sensory deficit
 Bilateral motor/sensory deficit
 Conjugate eye movement disorder (e.g.
horizontal gaze palsy)
 Cerebellar dysfunction (e.g. vertigo,
nystagmus, ataxia)
 Isolated homonymous hemianopia

19.  Lacunar syndrome (LACS)
 One of the following needs to be
present for a diagnosis of LACS:
 Pure sensory stroke
 Pure motor stroke
 Senori-motor stroke
 Ataxic hemiparesis

20. Clinical manifestation of
stroke
 RIGHT MCA:
 left hemiplegic,
 hemianopsia,
 Anonia, agrapia,
 constructional apraxia and topographic dyspraxia.
 LEFT MCA:
 right hemiplegic ,
 global aphasia, expressive aphasia.
 ACA:
 personality problem ,
 abolia ,akinetic mutism, apatic.

21.  PCA:
short term memory loss occur
vision problem
Dizziness
vertigo and nausea

22. Symptoms after a stroke in the right
hemisphere
 impaired vision on the left side of both eyes.
As if both glasses on the left side have
been taped off (hemianopia)
 not realizing that the left side of the body or
space exists (neglect)
 visuospatial problems
 often someone has little insight into his own
behavior, problems and limitations
(anosognosia)
 less understanding of (he or she does
not 'understand') social situations
 language is often taken literally and jokes and
underlying messages are not easily
understood

23.  difficulty understanding humor
 difficult to estimate what the other
emotion in the voice explains as
anger, relief, sadness, joy (prosody)
 recognizing faces can be bad
(prosopagnosia)
 difficulty in seeing the whole
 do not know how one should dress in
what order (apraxia)
 fast, impulsive behavior, and sometimes
inappropriate behavior

24. Symptoms after a stroke in the left
hemisphere
 vision on the right side of both eyes may
have decreased(hemianopia)
 speech and language problems (aphasia)
 problems with object recognition (agnosia)
 problems with
daily activities, routines which formerly we
nt well (apraxia)
 memory for verbal (spoken) things
 decreased analytical skills
 left and right confusion

25.  difficulty in dealing with
numbers, understanding numbers and
money
 shows some insecure, anxious
and withdrawn behavior
 Chance of changing moods, easily
overwhelmed by emotions

26. Stroke assessment

27.  Review History and Patient Report
 Choose Evaluation Tools
 Performance of Evaluation
 Determine clinical Problem
 Prioritize Goals
Evaluation
Assessment
Set Goals
Choose method to
measure Progress
Choose method treatment
Measurement of Outcome
Assessment
Set Goals

28. Chart and Social Details
 Name, DOB, Occupation, Interests i.e.
hobbies
 Diagnosis ie MCA vs ACA vs PCA
 Date of Admission
 History of Presenting Illness
 Relevant Past History
 Surgical
 Tests i.e. Xrays, Biochemistry, CT Scan,
MRI
 Medications
 Social Background

29. Observation
 Conscious Level
 Appearance
 Posture or Deformities
 Patient Colour
 Skin Condition
 Oedema

30. Observation
 Quality of movement- spontaneous
and involuntary- Facial symmetry and
expression
 Apparent neglect
 Aids and Appliances
 Gait and/or use of wheelchair

31. Subjective Assessment
 Patient perception of his level of
function
 Ability to participate in daily activities
 Perception of major problem i.e.
treatment goal
 History of presenting illness
 Any existing medical symptom that
may affect treatment i.e. dizziness,
chest pain, dyspnoea, arthritis,
numbness etc

32. Subjective Assessment
 Odaema
 Vision
 Sensation
 Pain (where, How much, what gives relief)
 Dominance
 Past or present physiotherapy treatment
 Social history- family/ accommodation/ hobbies/
occupation
 Comment on patient communication problem, motivation
and cognitive status

33. Objective Assessment
 Functional Movements Tested
◦ Level of Independence
 6 - independent
 5 - requires supervision
 4 - requires verbal cueing
 3 - requires minimal physical assistance of 1
 2 - requires moderate physical assistance of 1
 1 - requires physical assistance of 2
 0 - unable to perform with maximal assistance

34.  Power
 Sensation
 Reflexes
 Plantars
 Coordination
 Vision
 Speech

35. Objective Assessment
 Supine to Side lying
 Rotation and flexion of neck
 Hip and Knee flexion
 Flexion and Protraction of shoulder
 Rotation of Trunk
◦ Problems?

36. Objective Assessment
 Side lying to sitting over edge of bed
 Lateral Flexion of neck
 Lateral Flexion of trunk
 Push up through abducted arm
 Lower legs over side of bed
◦ Problems?

37. Objective Assessment
 Sitting Posture
◦ Weight distribution, ant pelvic tilt, trunk and neck
extension, head balanced on level shoulder
◦ Problems- if patient leans or falls
◦ Why? To which direction?
◦ Is he aware of falling? Sensory loss? spatial
neglect? Verticality ? Is patient afraid ?eye sight
dependent? Dizziness reason ?

38. Objective Assessment
 Sitting Balance
◦ Static and Dynamic sitting balance
 hold position (time)
 head movements
 Turn body/ Touch quadrants/ Touch toes/ Lift
leg/ Touch floor at side
 External displacement -
 Sitting on Balanced board
 External push applied in ant/post and lateral directions
◦ Observe righting, equilibrium and
protective reactions during movement. Are
they slow?

39. Objective Assessment
 Standing up
 Foot placement, forward inclination of trunk with ant
pelvic tilting, ant translation of knee with DF of ankle,
extension of hip and knee
◦ Problems- lack of appropriate force generation,
lack of DF (short TA, odema), pusher (loss of
verticality), lack of forward inclination of trunk
(does he lean backward- extensor tone ?
Positive supporting reaction?
 Sitting down
◦ Forward trunk inclination and ant pelvic tilting,
even weight distribution, controlled lowering,
BOS

40. Case study
 A 47 years old man came to
physiotherapy clinic with complain of
sudden onset of left sided weakness
and aphasia on examination therapist
found the upper limb weakness is more
pronounced then lower limb weakness
with receptive dysphasia ,CT finding
shows a large hypo dense lesion in
parietal area .list the possible
structure/area involve ?