Different Strokes for Different Folks Barb Bancroft, RN, MSN, PNP CPP Associates, Inc. www.barbbancroft.com
The usual first slide with statistics • 3rd leading cause of death in U.S. • 1st leading cause of disability in U.S. • 795,000 new cases per year • Broadly divided into ischemic (87%) and hemorrhagic strokes (13%) • 46% of all ischemic strokes (320,000)are caused by sudden occlusion of a large cerebral vessel • One large vessel ischemic stroke occurs every 90’ • Worse prognosis vs. small-vessel ischemic stroke (Roger VL, et al. and Smith WS)
The second usual slide with more startling numbers… • In the first minute of a stroke, your brain loses an estimated 1.9 million cells, resulting in the loss of 14 billion synapses and 7.5 miles of pathways—what you would lose in three weeks of normal aging. (January 2006 Stroke) • But the loss continues every minute the stroke is left untreated. If a stroke runs its usual 10-hour course, it can kill 1.2 billion nerve cells—what a normal brain loses over the course of 36 years. (UCLA neurologist Jeffrey Saver) (Interview) 2007:34(2). • TIME IS BRAIN!!
Is neurogenesis possible? • Prior to 1998 the answer was NO—all you could do was KILL neurons—booze, trauma, strokes, stress • Dr. Spickerman • GerdKemperman and Fred Gage discovered neurogenesis • BUT only in 2 areas of the brain… • The hippocampus and the olfactory bulb • How can you stimulate neurogenesis?
Antidepressants Statin drugs Lithium Say YES to drugs…
Exercise • One of the best ways to stimulate the growth of new neurons is to EXERCISE!
Meditation…and the monks… • Find a nice quiet environment • Close your eyes • Deep breaths • Relax muscles • “oingy-boingy, oingy-boingy, oingy-boingy”
Does the brain have the capability of forming new synapses? • Yes… • It’s called “plasticity” • Use it! Range of motion, start PT and OT within 24 to 48 hours if possible • Exercise—recruitment of pathways • Mirror neurons—monkey see, monkey do; LOOK in the mirror, move the right arm and the paralyzed arm will also move
Brain boosters • Challenge your powers of navigation—turn off the GPS and use a map; vary your routine—walking, driving home from work • Math on the fly—add shopping purchases, calculate miles when driving • Mind games—memorize phone numbers, CC#s, spell cities and states forward and backward • Ballroom dancing—learning steps—spatial, planning movements, balance
Brain boosters • New recipes—following steps, directions, planning • Tai chi—planning, sequence of movements • Assemble furniture—fix things at home • Musical instrument—fine motor, auditory, processing, procedural thinking • Drawing, painting , sculpture class—visual memory, creative imagination • Read the news actively every day—activates attention centers; remembering scores of sports events
A review of neuroanatomy • The lobes • The brainstem • The blood supply—anterior supply, posterior supply • REMEMBER THE WORD SYMMETRY
Orientation to the 3D brain--Lateral view—boxing glove ANTERIOR • Lobes—frontal, parietal, temporal, occipital • Sulci • Gyri • Lateral fissure (Fissure of Sylvius) • Central sulcus—precentral and postcentral gyrus POSTERIOR • Cerebellum • Brainstem
Sagittal (medial) section—location of brainstem • Dura • Tentorium cerebelli • Infratentorial • Supratentorial
Meningeal layers • Epidural (between bone and dura)—arteries from the external carotid branch across the top of the dura (epidural hematoma) • Dura • Subdural space—bridging veins (subdural hematoma) • Arachnoid • Subarachnoid space—this is the space where all of the cerebral arteries are located…anterior and posterior blood supplies meet at the base of the brain in the Circle of Willis (subarachnoid hemorrhage • Pia • brain
NIH STROKE SCALE (NIHSS) • NIHSS score is a measure of stroke severity rated from 1 to 42 based on findings on physical exam when the patient is evaluated at baseline, 2 hours, 24 hours, 7-10 days and 3 months, and then time varies • The higher the number, the greater the impairment • 1-7 = mild impairment • 8-15 = moderate impairment • Over 15 = severe impairment • NIHSS score greater than or equal to 12 has a 91% predictive positive value of a central large-vessel stroke • EMERGENCY! Actions taken during first few hours have a significant impact on the extent of future disability
THE FRONTAL LOBES… • Prime real estate of the brain • Comprises one-third of the cerebral cortex • Pre-frontal lobe--this is your “Mother” • “No, negative, don’t, stop…” She is inhibitory… • Gamma-amino-butyric-acid (GABA) • Judgment, insight, forward planning, following steps, directions, procedural thinking, socialization (you need bilateral frontal lobe disease to lose socialization)
Abstraction… • Textbooks tell you to interpret proverbs…What does “a rolling stone gathers no moss” mean? • HUH? Abstract (conceptual thinking vs. concrete thinking) • How are a car, plane and boat alike? • Cow, horse, and pig?
Frontal lobes… • Voluntary speech center (left frontal operculum) • Dr. Pierre Paul Broca • Broca’s aphasia (aphasia--communication disorder)* • Non-fluent aphasia—telegraphic, staccato speech • *~20% of strokes present with some type of aphasia • Kids and strokes • Left-handed people and strokes
Frontal lobes… • Pre-central gyrus– the motor cortex—upper motor neurons) • Voluntary movement center of brain • Send message through the Corticospinal tract through the internal capsule of cortex through the midbrain to brainstem where it crosses at the medulla (pyramids) • Contralateral symptoms (opposite side, below where it crosses) • FAT leg
Upper Motor Neurons/CS tract • Contralateral hemiparesis • ~(70% of anterior strokes present with hemiparesis)
NIH STROKE SCALE--#5 and #6 testing motor function of arms and legs • Extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine) and the leg 30 degrees (always tested supine) • Drift is scored if the arm falls before 10 seconds or the leg before 5 seconds) • Each arm is tested, in turn, beginning with the non-paretic arm.
Scoring • 0=no drift; 1=drifts before 10 seconds but does not hit bed; 2=some effort against gravity, cannot get to or maintain 90 (or 45) degrees; some effort against gravity; 3=no effort against gravity, limb falls; 4=no movement at all • Do same with legs—hold the leg supine at 30 degrees, drift is scored if the leg falls before 5 seconds (scored as above)
Motor function • The initial shock of the stroke—the patient may not be able to even hold the arm up • Reflexes may be absent • But as the nervous system recovers and the shock of the stroke is over… • Motor function may begin to recover, but will recover without a normal “MOM” or inhibitory input
Upper Motor Neurons/CS tract • No MOM? • Hemiparalysis (spastic paralysis) • Hyperreflexia • Babinski reflex present or absent?* (don’t’ use terms positive or negative—confusing) • “And that’s why we always stand to the side when we check reflexes…”
Josef Francois Felix Babinski • The Babinski reflex • Babinski, Josef Francois Felix, (1857-1932), a Parisian of Polish origin, described the famous abnormality of the extensor plantar response seen in disorders involving the corticospinal tracts in a series of short articles beginning in 1896. • English physicians used their “Rolls Royce” key
Reflex Chart—normal vs. stroke • Achilles, patellar, biceps, triceps (S1,2; L3,4; C5,6; C7,8) • Normal--2+ to 3+ • REMEMBER SYMMETRY is the word of the day….
Reflex Chart—normal vs. stroke • Areflexia may be present on the opposite side due to the “shock” of the stroke)—0 • As the brain recovers, and there’s no “mother” (inhibition), the reflexes are uncontrolled • Hyperreflexia 4+ in the limbs involved (more later) • TOES up
TEMPORAL LOBES… • Wernicke’s area (superior temporal gyrus)—reception of speech • Do you hear me? (Cranial nerve VIII, the acoustic nerve; primary sensory modality) • Do you understand what I am telling you? Higher cortical function (hearing and coma) • Interpretation of speech and sounds (superior temporal gyrus) • Coins jingling in pocket • Auditory agnosia
Best language (#9 on stroke scale) • In the NIHSS there is a picture attached as part of the evaluation; the patient is asked to describe what is happening in the picture, to name the items on the attached naming sheet, and to read from the attached list of sentences. • Comprehension is judged from the responses as well as to all of the commands on stroke scale questions #1-#8.
Scoring #9 • 0 = no aphasia • 1 = mild to moderate aphasia—some obvious loss of fluency or facility of comprehension • 2 = severe aphasia—all communication is through fragmentary expression; listener carries the burden of communication • 3 = mute, global aphasia—no usable speech or auditory comprehension; coma patients
TEMPORAL LOBES… • Recent memory (hippocampus) • Remember 3 items… • Red ball, clock, tennis shoe • Repeat them after me…immediate recall • Red ball, clock, tennis shoe • Continue with exam for 10 minutes and ask them to repeat those 3 items • Only two areas of the brain are capable of neurogenesis—the olfactory bulb and the hippocampus (CN I connected to the uncus connected to the hippocampus—smell and memory)
PARIETAL LOBES… • Postcentralgyrus (somatosensory cortex) • Right parietal lobe interprets left side of your body and the left side of your world • Damage to the parietal lobes results in difficulty recognizing body parts and acknowledging the opposite side of your world • Contralateralhemisensory loss • Integration of tactile sensations—touch, pressure, vibration, and proprioception (do you know where your body parts are? Did you have to look for them?)
PARIETAL LOBES..testing • Double simultaneous stimuli—kids vs. adults • Touch two areas at the same time.. • The neglect syndrome in adults (non-dominant parietal lobe) • Kids will always neglect their body and will recognize touch on the face
Stroke scale #11 • Extinction and inattention (formerly Neglect) • See scale • 0 = no abnormality • 1 = visual, tactile, auditory, spatial or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities • 2 = profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space
PARIETAL LOBES..testing • Ability to localize stimuli • Sharp vs. dull • Tests for proprioception—what’s proprioception? • Graphesthesia/agraphesthesia • Stereognosis/astereognosis • Anosognosia (unawareness of illness, denial of hemiplegia)—nondominant hemisphere • Apraxia—example: a dressing apraxiaideomotorapraxia constructional apraxia
OCCIPITAL LOBES… • Do you see this object? • If they can see it, CN2 (the optic nerve) • What is it? The occipital cortex (interpretation—higher cortical function) • Visual integration—problems manifest as cortical blindness (visual agnosia) • Optic radiations via temporal and parietal lobes--homonymous hemianopia • Visual field testing (#3 on the NIH STROKE SCALE)
Loss of vision—optic tract and optic radiations • Right parietal lobe sees the Left LOWER visual field in both eyes • Right temporal lobe sees the left UPPER visual field in both eyes • Stroke in parietal and temporal optic radiations = homonymous (same) hemianopsia (half loss of vision)
Brainstem (bulb)—midbrain, pons, medulla, and cerebellum (sits on top of brainstem) • Cranial nerve assessment Midbrain—optic—II; oculomotor—III • Pons—Ascending Reticular Activating System; pupils (pontine pupils)—(coma) CN V, VI, VII, VIII • Medulla—CV/respiratory center CN IX, X, XI, XII • Cerebellum—coordination, synergy, equilibrium (dysmetria, dysarthria, dyssynergia)
The light reflex tests two cranial nerves—CNII and CNIII—sensory via II, and motor via III • PERRLA (pupils equal, round, reactive to light and accommodation) • Located just beneath the tentorium • As the uncus herniates over the tentorium it puts pressure on the CNIII (severe cerebral edema, or a large intracranial bleed) • Dilated pupil on the side of the herniation
The BRAINSTEM…(the “bulb”) • The optic disk (also known as the optic papilla) • Papilledema (swelling of the optic disk due to increased intracranial pressure)
The BRAINSTEM… • CN III, IV, VI—follow my finger (extraocular movements) • CNIII also elevates the eyelid (levator palpebre) • diplopia