Hi, this is Dr. Ira Rashbaum from Rusk Rehabilitation, part of NYU Langone Health. I'm a clinical professor of physical medicine and rehabilitation at New York University School of Medicine. This is going to be a focused review on stroke rehabilitation. Definition of stroke. A sudden diminution or loss of consciousness, sensation, and or voluntary motion caused by rupture or obstruction as by a clot of a blood vessel or vessels of the brain. Learning objective number one, understand stroke risk factors, both modifiable and non-modifiable. Stroke epidemiology and statistics. As per the most recent update from the CDC in 2015, stroke is the fifth leading cause of death in the United States after heart disease, cancer, chronic lower respiratory diseases and accidents. The American Heart Association estimates 795,000 strokes occur annually, of which 610,000 are new cases and 185,000 are recurrent cases. This again is also the most recent update from the American Heart Association. From 1990 to 2010, the stroke death rate fell 37% in high income countries, but only 14% in low and middle income countries. And the age standardized stroke death rate decreased 21% between 2006 and 2016. In adults aged 55 to 75 years, the risk of stroke is one in five in women and one in six in men. The direct and indirect cost of stroke in 2015 was estimated at $45.5 billion per year as the most recent 2019 update. Stroke risk factors that are modifiable include medical conditions and behaviors. Medical conditions include hypertension, cardiac disease such as coronary artery disease and congestive heart failure, atrial fibrillation, patent foramen ovale, dyslipidemia, diabetes mellitus, carotid artery stenosis, prior stroke or transient ischemic attack, hypercoagulable state, sleep apnea, chronic kidney disease with a creatinine greater than 1.5, and pregnancy and the first six weeks post-delivery. Modifiable behaviors include cigarette smoking, alcohol abuse, physical inactivity, obesity, illicit drug use, and oral contraceptives. Regarding the non-modifiable risk factors, these include age, which is the most important. The older you are, the greater the risk of having a stroke with every year. Regarding gender, males tend to have greater risk than females overall. Regarding race, African Americans have a greater risk than Caucasians, greater than Asians. African Americans have a higher risk of death in the acute period after the onset of stroke and also a family history of stroke is a non-modifiable risk factor. Regarding stroke types, overall approximately 13% of strokes are hemorrhagic and 87% are ischemic as per the most recent CDC update in 2017. Hemorrhagic strokes are about 30%, thrombotic or major vessel occlusions are about 35%, lacunar strokes are about 20%, and cryptogenic and vasospasm about 1%. Learning objective number two, identify the clinical characteristics of the most commonly encountered strokes, including those involving cerebral arteries as well as cerebellar strokes and brainstem stroke syndromes. Major vessels involved in stroke include the middle cerebral artery or MCA, anterior cerebral artery or ACA, posterior cerebral artery or PCA, the vertebral basilar system, and the internal carotid artery. Regarding internal carotid artery ischemic stroke, one can have an ocular infarction, which would involve the central retinal artery or retinal arterial branch, which would be involved with blindness. A particular type of transient blindness of one eye is called amaurosis fugex, which is often described as a black curtain being pulled over your eye. In left middle cerebral arterial strokes involving an occlusion with full territorial infarction, strokes can include global aphasia, oral apraxia, right hemiplegia with left idiomotor apraxia, right hemorisensory deficit, and right hemianopsia. All of these will be covered further in this focused review. When the left middle cerebral artery stroke involves the superior division territory, you can have Broca's aphasia, oral apraxia, right hemiplegia with left idiomotor apraxia, proximal before distal recovery of motor function or strength, decreased tone or hypotonia followed by increased tone or hypertonia, and a right hemisensory deficit. When this involves the left middle cerebral artery distribution in the inferior division, you can have Wernicke's aphasia, a type of fluent aphasia, as well as right hemianopsia. And when the superior angular gyrus is involved, you can have agnosia involving fingers or left right, acalculia, agraphia, and apraxia. This is an MRI of an individual with an infarction or stroke involving the middle cerebral artery. The viewer can see an image that best depicts an area on the MRI which depicts the abnormality of stroke in the distribution of the middle cerebral artery. Now let's talk about important stroke-related definitions. Aphasia is defined as an inability to use or understand language secondary to a brain lesion, not only stroke, but other factors involving the brain. Apraxia is an inability to execute a voluntary motor function despite being able to demonstrate normal motor function previously. Hemianopsia or hemianopia is blindness in one half of the visual field of one or both eyes. This is a video courtesy of Dr. Jonathan Howard M.D. from NYU School of Medicine in his neurology video textbook. This video clip is that of a patient who has Broca's aphasia due to a left middle cerebral artery stroke. Broca's aphasia is a common form of non-fluent aphasia in which the patient can comprehend what you are saying to him, however his ability to express what he is saying is severely impaired as you will see. So sir, are you able to speak at all? Can you just try to speak? Just try to tell me your name please. Try one more time, I know it's frustrating. Okay, let's just test your understanding. Close your eyes. Open your mouth. Stick out your tongue. Good. Okay, just be normal. Smile. Big smile. Big smile. Okay. Lift up your left hand. Good. Lift up your right hand. Are you able to lift your right hand at all? which is the inability to recognize, interpret, or identify objects or persons despite having prior knowledge of their character. Apresodia is defined as an impaired ability to comprehend the emotional content or the emotion conveyed. Anosognosia is a decreased awareness of one's disability or disablement, and ebulia is an impaired ability to make decisions or act independently. This is a video of a stroke patient with Wernicke's aphasia or fluent aphasia. Speech production is not a problem for this individual. However, as you will hear, the content of the speech is not very clear because his ability to comprehend and to conceptualize are both quite impaired due to his stroke. Patrick, we're not all able to go to this place here. Let's go to your place here, which is this place here. When I first came here, at first I didn't know exactly what was going on with me. I was speaking to my wife, I mean, my daughter, and also this guy just spoke to my mother. They never told me nothing of what's going on with me. Why am I here? Why am I not here? What's going on? I have no idea. Now let's talk about when the stroke affects the right middle cerebral artery or the MCA. Characteristics of this type of stroke include left hemiplegia, with the upper limb being more impaired or weak than the lower limb, adenosagnosia, apresodia of sensory, motor, and or speech, left hemi-inattention, left hemi-sensory loss, left hemi-anopsia, and apraxia. Another factor that can occur when someone sustains a stroke is hemi-inattention or hemi-neglect, the preferred term is generally hemi-inattention, where the patient has decreased attention to generally the impaired or involved part of their body. When this does occur, particularly at inpatient rehab, it is probably a good idea to position the bed in the room so that family, friends, and staff approach the patient from the affected side to increase the stimulation. Sometimes ophthalmologists or optometrists will prescribe prism lenses for the glasses to make sure that they can have a greater field of view appreciation. Eye patching sometimes occurs, as well as visual stimulation and visual spatial or visual scanning therapy. There seems to be a possible role of transcranial magnetic stimulation in the management of hemi-inattention, but what is not generally effective is verbal stimulation and electric stimulation. In posterior cerebral artery stroke syndromes, these are characterized by contralateral homonymous hemi-anopsia or a quadrantinopia, where only one of the quadrants in both fields of views is impaired. They can also have something called propos-agnosia, which is an inability to recognize faces. This can often be very traumatic, particularly to family members of the stroke patient. Alexia without agraphia, cholera-agnosia, visual object-agnosia, left spatial neglect with a right-sided lesion, contralateral hemicentery loss, cortical blindness can occur, not due to any kind of ophthalmic issues, but a brain impairment when bilateral occipital lobes in the brain are affected, and also sometimes patients can have Anton syndrome, which is denial of cortical blindness. This is a magnetic resonance imaging study of a patient with a posterior cerebral arterial stroke. In anterior cerebral artery stroke syndromes, they can have apathy, ebulia, again redefined as an impaired ability to make decisions or act independently, and this can often be misconstrued as depression. Yes, sometimes patients with stroke are depressed, but ebulia is managed through a speech-language therapy approach rather than through a psychotherapy approach or through psychological medications. Anterior cerebral artery stroke syndrome patients can be impulsive with decreased safety awareness, and they can have lower extremity weakness on the other side of the body from where the stroke occurred in the brain, and they can also have weak shoulder strength and grasp. This is a brain computer tomography scan of a patient with an anterior cerebral arterial stroke.

stroke rehabilitation

modifiable risk factors

non-modifiable risk factors

ischemic stroke

hemorrhagic stroke