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Rehabilitation Following CVA

Lecture overview. Epidemiological considerations in stroke rehabilitation.Brief survey of the brain vascular supply and of stroke syndromes.Principles of medical care and rehabilitation in stroke. Rehabilitation oriented assessment of structural impairment in different cortical regions follow

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Rehabilitation Following CVA

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    1. Rehabilitation Following CVA Nachum Soroker, M.D. Loewenstein Rehabilitation Hospital Raanana, and Sackler Faculty of Medicine, Tel-Aviv University, Israel

    2. Lecture overview Epidemiological considerations in stroke rehabilitation. Brief survey of the brain vascular supply and of stroke syndromes. Principles of medical care and rehabilitation in stroke. Rehabilitation oriented assessment of structural impairment in different cortical regions following stroke.

    3. Stroke statistics Incidence: ~ 2000/106 per year First event / Recurrent events = 5/1 ~ 30 % die within the first 3 weeks Stroke – 3rd leading cause of death behind heart diseases and cancer 7.6 % of ischemic strokes and 37 % of hemorrhagic strokes result in death within 30 days Stroke death rate fell ~ 15% from 1988 to 1998 ~ 30 % recover completely ~ 40 % left with disability : ~ 90 % initially unable to walk ~ 75 % initially have upper limb plegia / paresis ~ 50 % have some language / speech problems

    4. Stroke statistics (cont.) Prevalence: ~ 6000/106 (60% - 3600 - disabled) Recurrence rate following 1st stroke or TIA: 14 % within 1y % survival in 1 and 4 years following ischemic stroke, in different age groups: <65y : 81, 70 | 65-74y : 81, 59 | 75-84y : 67, 42 Stroke survivors - 24 % of all severely disabled people living in the community ~ 28 % of strokes occur in people under the age of 65 ~ 50-70 % of stroke survivors regain functional independence, but 15-30 % are permanently disabled ; ~ 20 % require institutional care at 3 months after onset.

    5. Admission of the stroke patient to rehabilitation Pre admission (things to do in the general hospital): Establish diagnosis – Neuroimaging Reduce secondary brain damage (Neuroprotection?, TPA, Normoglycemia, Hypothermia?) Identify and treat risk factors HTN, DM, IHD post MI, AF, Dyslipidemia, Hypercoagulability & Thrombophilia, Smoking, Morbid obesity, Alcoholism, Vasculitis, Carcinomatosis Specific importance: Carotid stenosis, LV mural thrombus In hemorrhagic conditions (SAH, ICH): Consider angiography / MRA / CTA Prevent complications (Aspiration pneumonia, UTI, Pressure sores, DVT - PE, Upper GIT bleeding, Convulsions) Select preventive strategy to reduce risk of recurrence Decide: Rehabilitation needed or not; if yes - where?

    6. Neuroimaging in the study of structural impairment

    7. CT lesion imaging in ACA, MCA and PCA infarctions

    8. CT lesion imaging in capsular-putaminal (A) and thalamic (B) hemorrhages

    10. Application of the LEP in the study of structural impairment (cont.)

    11. Cerebral blood supply

    13. Cerebral vascular supply coronal section

    14. Verify diagnosis Special care: ICH - r/o underlying malignancy or focal vascular pathology Complete identification and treatment of risk factors Adjust secondary prevention antithrombotics/anticoagulants, statines, ace-inhibitors, folate & Vit B Treat coexisting disease conditions Special care: IHD, peptic disease Medical care and physician role in stroke rehabilitation

    15. Medical care and physician role in stroke rehabilitation (cont.) Prevent and treat complications Aspiration pneumonia, UTI, Pressure sores, DVT & PE, Upper GIT bleeding Post-stroke depression, anxiety, hypoarousal, motivational problems Post-stroke epilepsy Post hemorrhage hydrocephalus Organize a coherent list of tasks and objectives to guide follow-up of the patient throughout the rehabilitation period Disease processes, control of risk factors, secondary prevention Impairment - Disability - Handicap Lead interdisciplinary team work

    16. Rehabilitation oriented assessment of structural impairment in sensory-motor cortex following stroke

    17. Rehabilitation oriented assessment of structural impairment in damage to the frontal lobes General: Impaired working memory; increased environmental dependency & reflexive behavior (stimulus boundness); impaired goal setting, behavioral planning and control. Dorsolateral prefrontal: Executive behavior deficits: Impaired data retrieval, set shifting, response inhibition, abstraction, creativity. Orbitofrontal: Social behavior deficits: Disinhibited, tactless, impulsive behavior; imitation & utilization behavior. Medial frontal: Motivational behavior deficits: Apathy, reduced interest & initiative.

    18. Rehabilitation oriented assessment of structural impairment in damage to the left peri-Sylvian regions

    19. Rehabilitation oriented assessment of structural impairment in damage to the right peri-Sylvian regions

    20. Rehabilitation oriented assessment of structural impairment in damage to occipito-temporal & occipito-parietal regions

    21. Rehabilitation oriented assessment of structural impairment in damage to structures of the limbic system

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