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

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.

Stroke statistics Incidence: ~ 2000/10 6 per year First event / Recurrent events = 5/1 –~ 30 % die within the first 3 weeks Stroke – 3 rd 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

Stroke statistics (cont.) Prevalence: ~ 6000/10 6 (60% disabled) Recurrence rate following 1 st 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 ~ % of stroke survivors regain functional independence, but % are permanently disabled ; ~ 20 % require institutional care at 3 months after onset.

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?

Neuroimaging in the study of structural impairment

CT lesion imaging in ACA, MCA and PCA infarctions

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

Application of the Lesion Effect Paradigm (LEP) in the study of structural impairment Use of normalized lesion data in the study of aphasia

Application of the LEP in the study of structural impairment (cont.) Use of normalized lesion data in the study of neglect

Cerebral blood supply

Cerebral vascular territories

Cerebral vascular supply coronal section

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

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

Rehabilitation oriented assessment of structural impairment in sensory-motor cortex following stroke MCA and ACA supply of the cortical sensory-motor cortex

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.

Rehabilitation oriented assessment of structural impairment in damage to the left peri-Sylvian regions General: Aphasic syndromes; acquired dyslexia; ideomotor & ideational apraxia. Posterior-inferior frontal areas: Speech production; phonology; syntax. Posterior-superior temporal areas: Speech comprehension; semantics. Inferior parietal regions: Reading; calculation; praxis; repetition; auditory-verbal short-term memory. Superior temporal regions: Auditory perception & gnosis.

Rehabilitation oriented assessment of structural impairment in damage to the right peri-Sylvian regions General: Neglect phenomena; construction and dressing apraxia; impaired pragmatic control of language. Posterior-inferior frontal areas: Expressive prosody; contribution to pragmatics. Posterior-superior temporal areas: Receptive prosody; contribution to pragmatics. Inferior parietal regions: Spatial cognition; spatial motor behavior; spatial attention. Superior temporal regions: Auditory perception; music ?

Rehabilitation oriented assessment of structural impairment in damage to occipito-temporal & occipito-parietal regions General: Impaired visual perception, and visually- guided behavior. Occipito-temporal regions: Impaired functioning of the “system of What” (ventral stream); visual agnosia; prosopagnosia. Occipito-parietal regions: Impaired functioning of the “system of Where” (dorsal stream); optic ataxia; neglect phenomena

Rehabilitation oriented assessment of structural impairment in damage to structures of the limbic system General: Emotion; memory; motivation. Amygdala: Impaired emotional behavior. Hippocampus: Amnesia. Cingulum: Impaired motivational behavior; impaired attentional selection.