2.  Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant signs and symptoms that correspond to involvement of focal areas of the brain.  To be classified as stroke focal neurological deficits must persist for at least 24 hrs.  Motor deficits are characterized by paralysis (HEMIPLEGIA) or weakness (HEMIPARESIS).  Typically on the side of the body opposite the site of the lesion.

4.  Reverse ischemic neurological deficit- impairments may resolve with neurological recovery generally within 3 weeks.  Residual neurological impairments are those that persist longer than 3 weeks and may lead permanent disability and dependence  Thromboembolic infarction (80%), cerebral and cerebellar hemorrhage (10%) and subarachnoid hemorrhage (about 5%) are the major cerebrovascular problems.  Transient ischemic attack refers to the temporary interruption of blood supply to the brain.  Symptoms of focal neurological deficit may last for only a few minutes or for several hrs not more than 24hrs.

6. One of three mechanisms is usual:  a. arterial embolism from a distant site  b. arterial thrombosis  c. hemorrhage into the brain ( intracerebral or subarachnoid).  d. Less commonly:  e. venous infarction  f. Polycythemia ( hyper viscosity syndromes)  g. fat and air embolism  h. multiple sclerosis  i. mass lesions (e.g. brain tumour, abscess, subdural hematoma)

7. 1.Cardiovascular Disease a. Hypertension b. CAD (Coronary Artery Disease ) 2. Diabetes 3. Dyslipidemia. a. High total Cholesterol b. and/or Low HDL 4. Atrial Fibrillation 5. Asymptomatic Carotid Artery Stenosis 6. Cigarette smoking 7. Sickle Cell Disease 8. Dietary Factors 9. Obesity 10. Physical Activity 11. Hormone Replacement Therapy

8.  Sudden, severe headaches with no known cause  Sudden weakness or numbness of the face, arm, or leg on one side of the body.  Loss of speech or trouble talking or understanding speech.  Sudden dimness or loss of vision particularly in only one eye.  Unexplained dizziness,unsteadness or sudden falls especially along with any of the previous symptoms.

9.  1. Ischemic stroke syndrome  2. Hemorrhagic stroke syndrome  3. Vascular syndromes. 1) Ischemic Stroke Syndrome Lacunar Infarction  i. Infarction of small penetrating arteries in pons and basal ganglia  ii. Associated with chronic HTN present in 80- 90%  iii. Pure motor or sensory deficits.

10. Basilar Artery Occlusion  Occipital headache  Diplopia  Progressive quadriplegia  Bulbar paralysis, coma death.  Locked -in syndrome –results from ventral pontine lesions defined as quadriplegia anarthria with preserved consciousness and sensation.

11.  Anterior cerebral artery syndrome  Middle cerebral artery syndrome  Internal carotid artery syndrome  Posterior cerebral artery syndrome Anterior cerebral artery syndrome: It supplies medial aspect of cerebral hemisphere frontal and parietal lobes Contralateral hemiparesis Sensory loss with greater involvement of the lower extremity.

12.  Supplies entire lateral aspect of the cerebral hemisphere frontal, temporal and parietal lobes.  Contralateral spastic hemiplegia  Sensory loss of face,upper extremity(UE) and lower extremity (LE) with face and upper extremity more involved than LE. Unilateral neglect Anosognosia ( without knowledge of disease), Apraxia (disorder of voluntary movement characterized by the inability to accomplish a skilled or purposeful movement) spatial disorientation Homonymous hemianopsia visual field defect.

13.  Complete occlusion of ICA produces massive infarction in both MCA and ACA.  COMA  DEATH. Posterior cerebral artery syndrome  Supplies occipital lobe and medial inferior temporal lobe  Contralateral sensory loss or thalamic sensory syndrome (thalamic pain)  Homonymous hemianopsia  Visual agnosia, impairment in recognition of visually presented objects  prosopagnosia, cortical blindness  Contralateral hemiplegia

14.  Twenty-five per cent of patients die within 2 years of a stroke. Around 30% of this group die in the first month  Gradual improvement usually follows stroke, although the late residual deficit may be severe.  Of those who survive, about one-third return to independent mobility and one -third have serious disability requiring permanent institutional care.

15.  Computerized tomography (CT)  Magnetic Resonance Imaging ( MRI)  Positron Emission Tomography (PET)  Ultrasound Transcranial doppler  Cerebral angiography

16. 1)Thrombosis and TIA  a. 80% to 100% die in few minutes  b. Improve circulation  i. tissue plasminogen activator (t -PA)  ii. heparin (anticoagulant drugs)  iii. Warfarin 2) Clot prevention  Aspirin, dipyridamole and sulfinptrazone 3) Surgical treatment (remove clot from artery )  Thromboendarterectomy

17.  Cerebral shock a. Immediately after cerebral ischemia b. Last between few hrs to days  Recovery phase a. Flaccid stage i. Severe sensory loss and muscle is flaccid b. Spasticity Stage i.Tone improves ii. Distal parts recover first c. Recovery stage i. Proximal spasticity appears ii. Limbs in synergetic pattern (atypical pattern) iii. UL in flexion and LL in extension pattern

18.  Level of consciousness  Mental status examination  Cranial nerve examination  Sensory examination  Motor and reflex examination  Gait examination  Functional tests  Prognosis  Short and long term goals  Intervention

19. GOALS:  Prevention of Medical Complications  Prevention of Deconditioning and Contractures  Training of New Skills  Maximize Functional Independence  Optimize Psychosocial Adaptation of Patients and Families  Enhance Quality of Life

20. Flaccid stage  Passive Range of Motion  Weight bearing and facilitation.  Electrical stimulation can be used to muscle contractions and prevent muscle atrophy.  Sensory re-education techniques can include touching different textured objects, massage, vibration, pressure, determining joint position, identifying different temperatures.  Increasing Tone and Spasticity  quick icing.

21.  Spasticity Management: ◦ Positioning and Orthotics ◦ Stretching and Other Exercises ◦ Prolong icing for prolong time. ◦ Medications ◦ Postural Inhibiting positions

22.  Increasing Tone and Spasticity  Emergence of Synergy Patterns  Functional Skills Training ◦ Personal Care Skills ◦ Mobility Activities ◦ Instrumental Activities of Daily Living ◦ Gait training typical hemiplegic gait. ◦ gait involving flexion of the hip because of footdrop and circumduction of the leg.