CEREBROVASCULAR

ACCIDENT

By:

Kennedy Hernandez, PTRP, RPT

 Study Outline:
a. Different lobes of the Cerebrum
• Anatomy of the Cerebrum
• Anatomy of Cerebral and brainstem arteries
• Different manifestation of Cerebral and
brainstem stroke
• Different types of strokes based on
pathophysiology
 I. Lobes of the Cerebrum

1. Frontal (FroMOTal ) – motor lobe

2. Parietal (pARAYtal ) – pain, proprioception,
body sensation
3. Occipital (OcSEEPital) – for sight and PCA
4. Temporal (TEMPOral)- for auditory or
sound
 II. Blood supply of the Cerebrum
a. Middle Cerebral Artery (MCA)

- Supplies all the lateral part, basal ganglia,

internal capsule
- “ LAHAT ng LATERAL MCA YAN”
- Most occluded artery in CVA
2. Anterior Cerebral Artery (ACA)

- Supplies Medial frontal and parietal

3. Posterior Cerebral Artery (PCA)

- Supplies the medial temporal and occipital,

thalamus
 Blood supply of the brainstem:

 Midbrain - SCA

 Pons – AICA

> Medulla oblongata- PICA

 CRANIAL NERVES LOCATION

 Midbrain – 3,4

 Pons – 5,6,7,8

 Medulla Oblongata – 8,9,10,11,12

 FRONTAL LOBE
1. Area 4 – Primary motor area

- If damaged, there will be weakness

- It will start with flaccidity then it becomes spastic
- Homonculus – inverted or upside down person

- “ LAHAT PAG CVA CONTRALATERAL”

- MCA – MCDO – UE>LE
- ACA – LE>UE
 MCA ACA PCA

Contralateral Contralateral none

Hemiplegia, Hemiplegia,
UE >LE LE>UE
2. Area 6 – Initiation and coordination of
motor performance

- If damage, no weakness but will lead to

incoordination
- Incoordination is CONTRALATERAL
- In the cerebellum, incoordination will be

IPSILATERAL
- CODE: inCoordiSIXTION
3. Area 8 – Frontal eye field

- For conjugate eye movement, for scanning of

the eyes
- Function is CONTRALATERAL
- Supplied by MCA, ACA
- Moving eye movement - CN 3,4,6 at the
brainstem
- If damaged, FRONTAL GAZE PALSY – Pt looks
towards the lesion (lobe)

- “ TIGNAN ANG FRONTAL LOBE, SEE THE

FRONTAL”

- PONTINE GAZE PLASY – look away from the

lesion

- PANTENE GAZE PALSY – look at the hemiparetc

side
 MCA ACA PCA

(+) Frontal (+) Frontal (+) Pontine

gaze palsy gaze palsy gaze palsy
(+) Forced (+) Forced
gaze deviation gaze deviation
 QUESTION:
A patient recovering from a middle cerebral artery
stroke presents with gaze deviation of the eyes. In
this type of stroke the involved eye may deviate
toward:

1. Hemiplegic side
2. Up and in
3. Sound side
4. Down and out
A patient recovering from a middle cerebral artery
stroke presents with gaze deviation of the eyes. In
this type of stroke the involved eye may deviate
toward:

1. Hemiplegic side
2. Up and in
3. Sound side
4. Down and out
4. Area 9,10,11,12- Pre frontal area

- Important for judgement, insight, behavior

- Seat of intelligence, ambition
- If ACA stroke prone to behavioral
problems
5. Area 44 – Broca’s Area

- Primary speech motor area

- Located at Frontal lobe – Forty Four

- BROCA’S APHASIA - Abnormal Expression

but normal comprehension
- “ API SIYA SA KABOBOCA”
- AKA:

1. Motor

2. Expressive

3. Anterior

4. Non Fluent

5. Executive
 QUESTION:
A patient is 2 days post left CVA and has just been moved from the
intensive care unit to a stroke unit. When beginning the
examination, the therapist finds the patient’s speech slow and
hesitant. The patient is limited to one and two word productions
and expression are awkward and ardous. However, the patient
demonstrates good comprehension. These difficulties are
consistent with:

1. Global aphasia
2. Dysarthria
3. Broca’s aphasia
4. Wernicke’s aphasia
A patient is 2 days post left CVA and has just been moved from the
intensive care unit to a stroke unit. When beginning the
examination, the therapist finds the patient’s speech slow and
hesitant. The patient is limited to one and two word productions
and expression are awkward and ardous. However, the patient
demonstrates good comprehension. These difficulties are
consistent with:

1. Global aphasia
2. Dysarthria
3. Broca’s aphasia
4. Wernicke’s aphasia
6. Area 22 – Wernicke’s Area

- Primary comprehension area

- Located at Temporal lobe – Twenty two

- WERNICKE’S APHASIA - Abnormal

comprehension but normal expression
- “ API SIYA SA COMPREHENSION”
- AKA:

1. Sensory

2. Receptive

3. Posterior

4. Fluent

“ STORY OF BROCA AND VICKY”

 QUESTION:
A patient has a recent history ( 2 strokes in the past 4 months). He
demonstrates good return of his right lower extremity and is
walking with a straight cane. The therapist is concentrating
on improving his balance and independence in gait.
Unfortunately, his speech recovery is lagging behind his
motor recovery. He demonstrates a severe fluent aphasia.
The BEST strategy to use during physical therapy is:

1. Demonstrate and gesture to get the idea of the task across

2. Utilize verbal cues, emphasizing consistency and repetitions
3. Consult with the speech pathologist to establish a
communication board
4. Have the family present to help interpret during PT sessions.
A patient has a recent history ( 2 strokes in the past 4 months).
He demonstrates good return of his right lower extremity
and is walking with a straight cane. The therapist is
concentrating on improving his balance and independence in
gait. Unfortunately, his speech recovery is lagging behind
his motor recovery. He demonstrates a severe fluent aphasia.
The BEST strategy to use during physical therapy is:

1. Demonstrate and gesture to get the idea of the task

across
2. Utilize verbal cues, emphasizing consistency and repetitions
3. Consult with the speech pathologist to establish a
communication board
4. Have the family present to help interpret during PT sessions.
 Arcuate fasciculus – connects Broca’s and
Wernicke’s aphasia

> ArCUate – CU – CONNECT/CONDUCT

 If damaged – lead to conduction aphasia, Normal

comprehension and expression but problem with

REPETITION

 Global aphasia – cannot comprehend and verbalize

> Connects two hemisphere – corpus callosum

> Corpus CLOsum - CLOSURE/CONNECTION
 TRANSCORTICAL APHASIA - KATABI –
NEAR Broca’s and Wernicke’s

 SynTacTic APHASIA – SYNTAX –

grammar, TELEGRAPHIC

 SEMANTIC APHASIA – choice of words;

word substitution
a. Dominant ( Left Lobe)

- Aphasia- dominant hemisphere

- “ API SIYA DOMI NANT”

b. Non dominant ( Right lobe)
- Prosody – problem with melody/ rhythm
- Affected area 44

 Aprosody – no melody
 Dysprosody – Abnormal melody
 Affective agnosia – affected emotions, area 22
affected
 GNOSIA – to recognize/know
 MCA ACA PCA
Aphasia none
Global Aphasia
Aprosody with
affective agnosia
 PARIETAL LOBE
1. AREA 312 – Primary sensory area, located at
the parietal lobe

- Post cental gyrus

- Primary somesthetic area
- Supplied by MCA and ACA
- If damaged, will lead to Contralateral
Hemianesthesia
- MCA – UE
- ACA – LE
 MCA ACA PCA
Contralateral Contralateral none
Hemianesthesia Hemianesthesia
more of the more of LE than
hands and face UE
3. Area 39,40 – Primary Gnostic area

- Located at the parietal lobe

- Divided into:
a. Non dominant Parietal “ PAG
NEGLECTED KA, KINOCONTRA
KA KASI NON DOMINANT KA NA”
b. Dominant parietal
– Apraxia –
- Apraxia divided into:

1. Dominant Parietal – supplied by MCA

2. Corpus callosum – supplied by ACA,

disconnection Apraxia
 Apraxia

- Inability to execute skilled movement in the

absence of paralysis and sensory problem,
supplied by MCA
 Types of apraxia:

1. Ideomotor – Pt cant do skilled movement

upon command, L dominant parietal lobe

2. Ideational – Pt has (-) motor plan (-)

command; L dominant parietal lobe
3. Dressing apraxia- Right parietal

4. Constructional apraxia- Right parietal

 TYPES OF APRAXIA
NONDOMINANT (R DOMINANT ( L Parietal)
Parietal) 1. Ideomotor
1. Dressing 2. Ideational
2. Constructional 3. Gertsman Syndrome
3. Hemineglect/Unilatera - Agraphia
l neglect - Alcalculia
4. Anosognosia - Finger agnosia
- R & L discrimination
 MCA ACA PCA

Apraxia Disconnection none

Neglect apraxia
Incontinence-
spastic bowel
and bladder
 QUESTION:
Which intervention would be LEAST likely used to improve left
sided neglect in a patient with left hemiplegia?

1. Hooklying, lower trunk rotation, and lightly resisted “knee

rocks”
2. Rolling, supine to side lying on right using PNF lift pattern
3. Bridging with both arms positioned in extension at the sides
4. Sitting with hands forward resting on large ball, weight
shifting moving ball to the left
Which intervention would be LEAST likely used to improve
left sided neglect in a patient with left hemiplegia?

1. Hooklying, lower trunk rotation, and lightly resisted “knee

rocks”
2. Rolling, supine to side lying on right using PNF lift pattern
3. Bridging with both arms positioned in extension at the
sides
4. Sitting with hands forward resting on large ball, weight
shifting moving ball to the left
Following a CVA involving the dominant right
hemisphere, a patient exhibiting unilateral neglect
would generally not:

1. Eat food only from the right siude of the plate

2. Bump a one arm driven wheelchair into things on
the left side
3. Ignore or deny the existence of the left sided limbs
4. Shave or put make up only on the left side of the face
Following a CVA involving the dominant right
hemisphere, a patient exhibiting unilateral neglect
would generally not:

1. Eat food only from the right side of the plate

2. Bump a one arm driven wheelchair into things on
the left side
3. Ignore or deny the existence of the left sided limbs
4. Shave or put make up only on the left
 APRAXIA JINGLE
- APRAXIA
- PARIETAL SIYA- parietal lobe
- PARA SAKIN SIYA- Dominant
hemisphere, Ipsilat
- APARALYSIS SIYA- without paralysis
 QUESTION:
A patient is recovering from a right CVA. She tells the physical
therapist that she is thirsty and asks for a can of soda. When
the therapist gives the can and instructs her to open it, she is
unable to complete the task. Later after the treatment
session, when she is alone, the therapist observes her
drinking from the can. The therapist suspects she may have
a primary deficit in:

1. Anosognosia
2. Ideational apraxia
3. unilateral neglect
4. Ideomotor apraxia
A patient is recovering from a right CVA. She tells the physical
therapist that she is thirsty and asks for a can of soda. When
the therapist gives the can and instructs her to open it, she is
unable to complete the task. Later after the treatment
session, when she is alone, the therapist observes her
drinking from the can. The therapist suspects she may have
a primary deficit in:

1. Anosognosia
2. Ideational apraxia
3. unilateral neglect
4. Ideomotor apraxia
A PT attempts to have a patient with right hemiplegia
brush his teeth while working on standing
tolerance. The therapist notices that the patient
attempts to put the toothpaste directly in his mouth
and hair. The PT would document this finding as:

1. Ideomotor apraxia
2. Ideational apraxia
3. Constructional apraxia
4. Conduction aphasia
A PT attempts to have a patient with right
hemiplegia brush his teeth while working on
standing tolerance. The therapist notices that
the patient attempts to put the toothpaste
directly in his mouth and hair. The PT would
document this finding as:

1. Ideomotor apraxia
2. Ideational apraxia
3. Constructional apraxia
4. Conduction aphasia
 TEMPORAL LOBE
1. Area 41,42 – Primary auditory area

- Bilateral represented
- If Both Area 41 is damaged, lead to CORTICAL
DEAFNESS
- “ BILAT LANG MAY DEAFNESS”
- Unilateral Left lesion – (-) deafness
2. Area 22 – Auditory association area

- If Left Area 22 is damaged, lead to

Wernicke’s aphasia
 OCCIPITAL LOBE
Area 17 - Primary visual area

- If damaged, lead to CONTRALATERAL

HOMONYMOUS HEMIANOPSIA
 Homonymous hemianopsia

- symptom CONTRALATERAL
- Affected MCA and PCA
 Visual pathway:

1. MoNERVEvular blindness – optic nerve

affected
2. Bitemporal CHIASM – optic chiasm afected
3. Homonymous hemianopsia – the rest and
contralateral manifestation
 QUESTION:
The PT suspects a patient recovering from a middle cerebral
artery stroke is exhibiting a pure hemianopsia. This can be
examined using a:

1. Distance acuity chart placed on a well lighted wall at

patient’s eye level 20 feet away-Snellen chart
2. Penlight held approximately 12 inches (ocular pursuit) from
the eyes and moved to the extremes of gaze right and left
3. Penlight held 6 inches (convergence) from the eyes and
moved toward the face
4. Visual confrontation test with a moving finger
The PT suspects a patient recovering from a middle cerebral
artery stroke is exhibiting a pure hemianopsia. This can be
examined using a:

1. Distance acuity chart placed on a well lighted wall at patient’s

eye level 20 feet away- Snellen chart
2. Penlight held approximately 12 inches from the eyes and
moved to the extremes of gaze right and left- Ocular pursuit
3. Penlight held 6 inches from the eyes and moved toward the
face- Convergence
4. Visual confrontation test with a moving finger
A PT examines a patient with a right CVA and determines the
patient has a profound deficit of homonymous hemianopsia.
The BEST initial strategy to assist the patient in
compensating for the deficit is to:

1. Teach the patient to turn the head to the affected left side
2. Provide constant reminders, printed notes on the left side,
telling the patient to look to the left.
3. Place items eating utensils on the left side
4. Rearrange the room so while in bed the left side is facing the
doorway
A PT examines a patient with a right CVA and determines the
patient has a profound deficit of homonymous hemianopsia.
The BEST initial strategy to assist the patient in
compensating for the deficit is to:

1. Teach the patient to turn the head to the affected left

side
2. Provide constant reminders, printed notes on the left side,
telling the patient to look to the left.
3. Place items eating utensils on the left side
4. Rearrange the room so while in bed the left side is facing the
doorway
2. Area 18,19 – Association area for vision

- Area 18 – responsible for color perception, if

damaged lead to DYSCHROMATOPSIA
- If area 18,19 is damaged, lead to VISUAL
AGNOSIA
 QUESTION:
A 63 year old patient with left hemiplegia is able to recognize his
wife after she is with him for a while and talks to him but he
is unable to recognize the faces of his children when they
come to visit. The children are naturally very upset by their
father’s behavior. The BEST explanation for the problem is:

1. Ideational apraxia
2. Anosognosia
3. Somatognosia
4. Visual agnosia
A 63 year old patient with left hemiplegia is able to recognize
his wife after she is with him for a while and talks to him but
he is unable to recognize the faces of his children when they
come to visit. The children are naturally very upset by their
father’s behavior. The BEST explanation for the problem is:

1. Ideational apraxia
2. Anosognosia
3. Somatognosia
4. Visual agnosia
MANIFESTATION OF
CEREBRAL ARTERIES
 1. Middle Cerebral Artery (MCA)

- Contralateral Hemiplegia, More of UE than

LE
- Contralateral Hemianesthesia, more of
hands, face
- Frontal gaze palsy
- Forced gaze deviation
- Aphasia
- Global aphasia (Dominant)
- Aprosody with affective agnosia (Non

dominant)
- Neglect (Non dominant)

- Apraxia

- Gerstmann Syndrome
 QUESTION:
A patient is referred for rehabilitation following a middle
cerebral artery stroke. Based on this diagnosis a PT can
expect the patient will present with:

1. Contralateral hemiplegia with thalamic sensory syndrome

and involuntary movements
2. Contralateral hemiparesis and sensory deficits, arms more
involved than the leg
3. Decreased pain and temperature to the face and ipsilateral
ataxia with contralateral pain and thermal loss of the body
4. Contralateral hemiparesis and sensory deficits, leg more
involved than the arm.
A patient is referred for rehabilitation following a middle
cerebral artery stroke. Based on this diagnosis a PT can
expect the patient will present with:

1. Contralateral hemiplegia with thalamic sensory syndrome

and involuntary movements
2. Contralateral hemiparesis and sensory deficits, arms
more involved than the leg
3. Decreased pain and temperature to the face and ipsilateral
ataxia with contralateral pain and thermal loss of the body
4. Contralateral hemiparesis and sensory deficits, leg more
involved than the arm.
 2. Anterior Cerebral Artery (ACA)
- Contralateral Hemiplegia, more of LE than UE
- Contralateral Hemianesthesia, more of LE than

UE
- Frontal gaze palsy

- Forced gaze deviation

- Disconnection Apraxia

- Incontinence – spastic bowel and bladder

- (+) grasp reflex
- (+) groping reflex
- (+) gegenhalten
- Perseveration
- Akinetic mutism – coma vigil
- Abulia
 QUESTION:
A patient recovering from a CVA presents with predominant
involvement of the contralateral lower extremity and lesser
involvement of the contralateral upper extremity. The
patient also demonstrates mild apraxia. These clinical
manifestations are characteristics of:

1. MCA
2. PCA
3. ACA
4. Basilar artery syndrome
A patient recovering from a CVA presents with predominant
involvement of the contralateral lower extremity and lesser
involvement of the contralateral upper extremity. The
patient also demonstrates mild apraxia. These clinical
manifestations are characteristics of:

1. MCA
2. PCA
3. ACA
4. Basilar artery syndrome
You see a patient who had a CVA two weeks ago. The
patient has motor and sensory impairments primarily
in the opposite lower extremity. There is some
confusion and perseveration. Based on these findings,
the vascualr problem can be characterized as:

1. TIA
2. Internal carotid syndrome
3. ACA
4. MCA
You see a patient who had a CVA two weeks ago. The
patient has motor and sensory impairments
primarily in the opposite lower extremity. There is
some confusion and perseveration. Based on these
findings, the vascular problem can be characterized
as:

1. TIA
2. Internal carotid syndrome
3. ACA
4. MCA
 3. Posterior Cerebral Artery
- Visual deficits
- Dyschromatopsia – cant recognize color
- Proposagnosia – cant recognize face
- Alexia with agraphia – inability to read
- Visual agnosia
- Thalamic pain syndrome – Intolerable
pain, cant be treated
- “PAIN PCA”
- Hippocampus- located at the temporal
lobe of the limbic system
- Supplied by PCA
- Function: short term memory
- “ MAY HIPPO SA CAMPUS PAG
NAKASHORT”
- Long term memory – frontal lobe
- Common problem in CVA, TBI –
short term memory
 4. Vertebro basilar artery
Cranial nerve affected:
 Diplopia – (CN 4,6) – double vision
- Vertical – CN 4
- Horizontal – CN 6
- Mx: Patch one eye

- Types of strabismus:
1. Esotropia – internal squinting, affected CN 6
2. Exotropia – external squiting, affetced CN 3
 Dizzines – CN 8

 Dysphagia – CN 9,10,11

 Dysarthria – CN 9,10,11

- Cerebellar manifestation – RAS

 5. Types of brainstem stroke

1. Weber – Midbrain (medial basal)

2. Benedikt- Midbarin (tegmentum)
3. Locked in – Pons (bilateral basal)
4. Millard Gubler- Pons (lateral)
5. Wallenberg – Medulla (lateral)
 TWO GENERAL MANIFESTATIONS
EXPECTED OF A BRAINSTEM
STROKE:
1. CONTRALATERAL HEMIPLEGIA
2. IPSILATERAL CRANIAL NERVE PALSY

ALSO KNOWN AS ALTERNATING

/CROSSED HEMIPLEGIA
 WEBER’S SYNDROME
 Medial basal midbrain
 Contralateral Hemiplegia
 Ipsilateral CN 3 Palsy ( ipsilateral Ptosis)
 BENEDIKT’S SYNDROME
CONTRA:
 pain and temperature loss

 joint position loss

 ataxia

 chorea

 Ipsilateral CN3 palsy

 TEGMENTUM OF MIDBRAIN
 LOCKED IN SYNDROME
 Bilateral pons
 bilateral hemiplegia
 Bilateral CN palsy

 Left only is (+) Vertical gaze

 QUESTION:
A patient with a CVA demonstrates a locked in state
characterized by spastic quadriplegia and bulbar palsy. To
facilitate communication with this patient the PT should
instruct the family to:

1. Encourage use of eye movements to signal letters

2. Give the patient a chance to mouth responses even though
vocalization is poor
3. Look closely at facial expression to detect signs of
communication
4. Use a communication board with minimal hand movements
A patient with a CVA demonstrates a locked in state
characterized by spastic quadriplegia and bulbar
palsy. To facilitate communication with this patient
the PT should instruct the family to:

1. Encourage use of eye movements to signal letters

2. Give the patient a chance to mouth responses even
though vocalization is poor
3. Look closely at facial expression to detect signs of
communication
4. Use a communication board with minimal hand
 MILLARD GUBLER SYNDROME
 Lateral pons
 Contralateral Hemiplegia
 Ipsilateral 6th and 7th nerve Palsy
 WALLENBERG’S OR LATERAL
MEDULLARY SYNDROME
 Lateral medulla
 Ipsilateral:
 loss of FACIAL sensation
 Hemi ataxia
 horner’s syndrome
 nystagmus
 dysphagia
 Contralateral : loss of pain and temperature
 QUESTION:
A 76 year old patient suffered a cerebral thrombosis four days
ago. She presents with the following symptoms: decreased
pain and temperature sensation on the ipsilateral face,
nystagmus, vertigo, nausea, dysphagia, ipsilateral Horner’s
syndrome, contralateral loss of pain and temperature
sensation of the body. The MOST LIKELY site of the
thrombosis is the:

1. PICA
2. PCA
3. Mid basilar artery
4. ICA
A 76 year old patient suffered a cerebral thrombosis four days
ago. She presents with the following symptoms: decreases
pain and temperature sensation of the ipsilateral face,
nystagmus, vertigo, nausea, dysphagia, ipsilateral Horner’s
syndrome, contralateral loss of pain and temperature
sensation of the body. The MOST LIKELY site of the
thrombosis is the:

1. PICA
2. PCA
3. Mid basilar artery
4. ICA
 RIGHT VS. LEFT CVA
 RIGHT BRAIN FCNS  LEFT BRAIN
 Perception FCNS
 Imagination  Language /
 Memory Communications
 The Arts and music  Higher skill
 Logic
 QUESTION:
A patient suffers a CVA resulting in a right hemisphere
damage. This patient will MOST LIKELY exhibit:

1. negative, self deprecating comments and frequent

depression
2. Poor judgement with increased safety issues
3. Slow, cautious behaviours
4. Hesitancy, requiring more frequent and support
A patient suffers a CVA resulting in a right hemisphere
damage. This patient will MOST LIKELY exhibit:

1. negative, self deprecating comments and frequent

depression
2. Poor judgement with increased safety issues
3. Slow, cautious behaviours
4. Hesitancy, requiring more frequent and support
 Right vs Left CVA
 Right CVA a.k.a  LEFT CVA a.k.a.
 Right Hemispheric  Left hemispheric lesion
lesion  Dominant hemispheric
 Non-Dominant lesion or CVA
Hemispheric lesion or  Right hemiplegic
CVA
 Left Hemiplegic
 Analyze if it belongs to Right or Left
CVA??
 Visuomotor perception and
memory intact
 Visuomotor or perceptual
deficits
 Loss of visual memory
 Left sided neglect
 Impulsive/ quick
/unorganized/ overestimates
capabilities and
underestimates their
problems
 Eliminates the use of words
 Poor judgement
 Cautious, slow, hesitant,
insecure
 Distorted body image
 Learns from mistakes
 Gives feedbacks
 Aphasia
 Unable to communicate
effectively
 Vocabulary and auditory
retention span decreased
 Verbal fluency retained
 Ideomotor and ideational apraxia
 Dressing apraxia
 Constructional apraxia
 Learning is impaired
 Cannot be trusted
 Frequent falls
 Realistic in the appraisal of their
existing problems
 Safety problems
 Difficulty with abstract reasoning
 Unaware of their impairment
 Agnosia
 Difficulty of expression of
positive emotions
 Difficulty of expression of
negative emotions
 Disorganized problem solving
 TYPES OF STROKE ACCDG TO
THE PATHOPHYSIOLOGY
I. ISCHEMIC STROKE ( 80-90%)

A. THROMBOTIC STROKE (40%)

- associated with atherosclerosis

-atherosclerosis is the major risk factor
associated with HTN
- large vessels
- Gradual in onset

- Commonly occurs at night and during periods

of inactivity
- 50% with hx of TIAs

- With severe impairments

B. EMBOLIC STROKE:

- 30% of all strokes

- Abrupt in onset
- Rare TIAs
- Usually cardiac in origin
- Atrial fibrillation most common cardiac cause
- Involve smaller vessels
- MCA most commonly affected
- Produces less severe damage compared to
Thrombotic
C. Lacunar:

-20% of all stroke cases

- also caused by atherosclerosis due to HTN
-gradual onset
- mild manifestation
-Pure motor or pure sensory stroke
- 85% good neurologic recovery
II. Hemorrhagic ( 10-20%)

- rarest but most catastrophic

- elevated ICP
- with Headache
- with Hydrocephalus
- the stroke in the young
 Two types:
 Intracerebral vs. Subarachnoid Hemorrhage
 OTHER RELATED TOPICS ON
CVA
1. Genu recurvatum
- due to weakness of quadriceps or extensor spasticity
- PT Mx: Eccentric contraction of quadriceps or closed
chain exercises

2. Foot drop – weakness of TA or EHL or spasticity of

gatrocnemius

3. Elevated and retracted pelvis – PT Mx: light

resistance to forward pelvic rotation during swing
4. Positioning of stroke pt:
- Side lying on sound side with shoulder protracted,

arm extended resting on a pillow.

- Supine, pillow under the scapula arm extended, small

towel under the knee

5. Difficulty clearing the foot during swing

– due to weakness of hip flexors or dosiflexors
- PT Mx: forward steps –up in standing using graduated
height steps
6. Hip hiking on the affected leg in swing
- PT mx: INITIAL – marching while sitting on a

theraball
- To strengthen hip hikers – do downward manual

pressure on the pelvis

7. Difficulty stair climbing, can position foot on the step

but cant transfer weight up to the next stair
- PT Mx: standing, partial wall squats, closed chain
exercises
8. Wheelchair for stroke – seat height lower at 17.5,
nornal is 20

9. Posterior Leaf spring – Pt with medio lateral control

on the ankle

10. Solid AFO – Pt with (+) footdrop and spasticity

11. Metal upright AFO – Pt. with edema

12. Why supine for a long time is discourage on stroke pt
– it encourages ATNR, STNR, labyrinthiune reflex

13. How to facilitate extension of elbow on the hemiplegic

side – turn the head towards the affected side

14. Homolateral synkinesis

15. Raimiste’s phenomena - opposite

16. Pt performs sidestepping towards the
hemiplegic side, compensation for weak
abductors is:
– lateral trunk flexion towards the unaffected
side
THE END