STROKE BRIDGING THE GAP

1. STROKEBRIDGING THE GAP ACUTE CARE REHABILITATION COMMUNITY

2. STROKE IS A NEUROVASCULAR CONDITION AFFECTING BLOOD VESSELS IN THE BRAIN

3. TWO BASIC TYPES • ISCHEMIC STROKE – occlusion of a cerebral artery causing damage to that portion of the brain dependent on the blood supply from the affected vessel. • HEMORRHAGIC STROKE – blood leakage from a cerebral artery that damages adjacent brain tissue.

4. BASICS OF BLOOD SUPPLY • CAROTID ARTERIES – supply the anterior portion of the brain – including most of the cerebrum. • VERTEBRAL ARTERIES – housed in the cervical vertebral column – they merge to form the basilar artery – supply the posterior portion of the brain – the cerebellum and brain stem.

5. MID CEREBRAL ARTERY – the largest vessel branching off the internal carotid artery – the most common site of cerebral occlusion. The MCA feeds: • Frontal Lobes • Temporal Lobes • Parietal Lobes • Basal Ganglia • Internal Capsule

6. The MCA has a main stem and several branches. Occlusion of the main stem affects the entire area of the brain supplied by the MCA. This distribution of the MCA is so large that a stroke of the main stem puts the victim at risk of death or severe disability.

7. EFFECTS OF COMPLETE MCA STROKE • Hemiplegia (paralysis) of the contral lateral (opposite) side affecting the lower side of the face, the arm, the hand, less affecting the leg • Contra lateral sensory loss in the same area • Contra lateral homonymous hemaniopsia – visual field defects affecting the same half of the visual fields of both eyes

8. RIGHT SIDE vs. LEFT SIDELaterality of an MCA stroke determines additional signs and symptoms.

9. LEFT CVAMost people are left brain hemisphere dominent. The speech language center is on the brain’s left side. Interruption of the circulation on the left side may result in:

10. Aphasia – partial or total loss of the ability to communicate through language • Expression – difficulty converting thoughts into language • Reception – difficulty understanding verbal and written language • Both – global aphasia • Paralysis on the right side of the body • Dysphagia

11. Impaired thought process – information processing delays • Impaired voluntary motion – apraxia • Confusion between left and right – poor discrimination • Loss of right visual field – right hemaniopsia • Easily frustrated • Compulsiveness or slowness

12. Approaches Do not underestimate his ability to learn and communicate • Use other forms of communication if he cannot speak • Do not overestimate his understanding of speech and overload him with “static” • Do not shout – keep the message short and simple • Do not use special voices • Divide tasks into simple steps • Give much feedback and point out every indication of progress. It is better to give too much encouragement than too little.

13. RIGHT (NON-DOMINENT) BRAIN HEMISPHERE • Unilateral neglect Decreased awareness or failure to attend to the left side • Lack of awareness or concerns about deficits • Paralysis on the left side of the body (hemiplegia or hemiparesis) • Excessive talking • Short attention span • Memory problems • Poor judgment

14. Time disorientation • Loss of left field of vision (left hemaniopsia) • Unconscious of neglect – person and environment • Impaired abstract thinking – concrete thinking predominates – doesn’t get the joke • Emotional lability • Lack of interest and motivation – lethurgy • Acts without thinking - impulsivity

15. APPROACHES • Do not overestimate his abilities. Spatial deficits are difficult to spot. • Use verbal clues • Break tasks into small steps with much feedback • Watch to see what he can do safely, rather than taking his word for it • Minimize clutter around him • Anticipate falls

16. STROKE IN OTHER ARTERIES Anterior Cerebral Artery (ACA) branches off the Internal Carotid Artery and supplies the frontal and parietal lobes • Least commonly affected by strokes • Contral lateral leg weakness • Sensory loss

17. Posterior Cerebral Artery arises from the top of the Basilar Artery and supplies the medial occipital lobe and inferior and medial temporal lobes • Vision is the primary function of the occipital lobe • Visual defects – contra lateral hemaniopsia

18. Vertebal Artery – basilar stroke affect the cerebellum, brain stem or both • Cerebellar strokes impair balance and coordination – ataxia • Brain stem stroke – rare, with devastating symptoms • Hemiparesis or Tetraplegia • Sensory loss affecting either one or both sides of the body • Double vision – diplopia • Dysconjugate gaze • Slurred speech • Dysphagia • Decrease level of consciousness

19. HEMORRAHAGIC STROKE • HTN • Rupture Aneurysm • Arteriovenous Malformation • Cause same focal symptoms as ischemic stroke • Results in more pronounced neck pain • Headache- “The worst headache of my life” • Light intolerance • Nausea and vomiting • Impaired level of consciousness

20. CRITERIA FOR ADMISSION TO REHAB

21. Medical necessity to be in an acute setting • Would benefit from daily doctor’s visit • Requires 24 hour nursing care • Capable of doing 3 hours of therapy a day • Has a rehab diagnosis that prevents them from returning to community living • Has a reasonable chance of returning to community living • We can reasonably document a significant change in function • Change from max to min assist transfers • Incontinent to continent • De-cannulize trach

22. DAY REHAB PROGRAM • Daily Program That Includes: • 3 hours of therapy with OP therapist • RN supervision of program • Group therapy with peers and psychologist • 5-6 hours per day • Facilitates transition to community