Hemorrhagic Strokes By Taylor Gore - PowerPoint Presentation

Slide1

Hemorrhagic Strokes

By Taylor GoreSlide2

Hemorrhagic stroke vs. ischemic stroke

Intracerebral hemorrhage

Occurs from rupture of cerebral vessels

Can be a result of high blood pressure

Ischemic Stroke

Caused by the development of a thrombus and/or embolusLeads to blockages that causes a lack of oxygen to vital tissuesSlide3

Types of intracerebral hemorrhage

Primary ICH

78%-88% of all hemorrhages

Spontaneous rupture of small vessels damaged by:

Chronic hypertensionAmyloid angiopathy

Secondary ICHCerebrovascular abnormalities

TumorsImpaired coagulation Slide4

Symptoms of intracerebral hemorrhage

Hypertensive Hemorrhage:

Severe headache

VomitingBP >170/90Abrupt onsetRuptured Aneurysm:

Headache with loss of consciousnessDecerebrate rigidity

ComaSlide5

Medical Management of intracerebral hemorrhage

Hypertensive Hemorrhage

Blood Pressure Management

Surgical removal of clot

Ruptured Aneurysm Surgical removal of clot

Lower arterial pressures Bed rest 4 to 6 weeks Anti-seizure meds

Comatose Stroke Treat shock Maintain flow of oxygen in airway Seizure management Tube feedingSlide6

Functional Outcomes of Hemorrhagic StrokeSlide7

Rehabilitation Outcomes: Ischemic versus hemorrhagic strokes

Robert

Perna

and Jessica TempleSlide8

Methods

Retrospective study

284 outpatients at Southwestern treatment facility

172 ischemic, 112 hemorrhagic

Nearly all participants within six months after strokeSlide9

METHOds

Measured disability using The Mayo Portland Adaptive Inventory-4

Measures impairments in physical, cognitive, emotional, behavioral, and social functioning

Three subscales:

Ability Index (0-47): evaluates mobility and memory Adjustment Index (0-46): assesses emotional and behavioral symptoms (depression, fatigue, etc.)

Participation Index (0-30): measures aspects of independenceOverall Score 0-111: lower scores indicate greater function

Good predictive validity for posttreatment outcome, level of functioning, return to employment, and independent living status

All subjects involved in postacute outpatient program with twice weekly treatment for three months

Occupational therapy, speech therapy, physical therapy, social work, and neuropsychology

Care based on intake evaluations for stroke symptomsSlide10

Results

No significant differences in scores on MPAI-4 between ischemic and hemorrhagic stroke at discharge

No significant differences in changes in scores on MPAI-4 from admission to discharge between ischemic and hemorrhagic strokeSlide11

Functional Outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: A matched comparison

Stefano

Paolucci

, MD; Gabriella Antonucci, PhD; Maria

Grazia Grasso, MD, PhD; Maura Bragoni, MD, PhD; Paola Coiro, MD; Domenico De Angelis, MD; Francesca Romana Fusco, MD; Daniela Morelli, MD; Vincenzo Venturiero, MD, PhD; Elio Troisi, MD; Luca Pratesi, MDSlide12

Methods

Included stroke survivors admitted to 50 bed rehabilitation unit following their first stroke

Rehab staff: physicians (physiatrists, neurologists, cardiologists, urologists, and otolaryngologists), neuropsychologists, nurses, physiotherapists, occupational and speech therapists, social services care manager, dietitians, and support staff

All patients submitted to clinical, neurological, neuropsychological, functional, and neuroradiological examinations

CT scans performed on all patients

MRIs performed on some patients

Exclusions due to: Absence of brain lesion on CT scan or MRI Patients with secondary hemorrhages Subarachnoid hemorrhage

Previous strokes

Chronic disabling pathologies (severe Parkinson’s disease, polyneuropathy, severe cardiac/liver/renal failure, cancer, etc.)Slide13

METHODS

Patients were divided into ischemic and hemorrhagic stroke groups

Patients were matched by basal stroke severity (same Canadian Neurological Scale score), basal disability (same Barthel Index score), age (within 1 year), sex, and onset-admission interval (within 3 days)

eliminated the influence of these prognostic factors

All patients assessed using Rivermead Mobility Index (RMI), Canadian Neurological Scale (CNS), and Barthel Index (BI) at admission and dischargeSlide14

MEthods

Therapy focused on practical ADL skills

Individual physiotherapy performed 60 minutes twice a day for 6 days a week

Each pair of patients received therapy from the same therapist Had access to daily training for unilateral spatial neglect, speech therapy, and training for swallowing, bowel, and bladder dysfunctionSlide15

Results

Efficiency: amount of improvement in the rating score of each scale divided by duration of rehabilitation stay

Effectiveness: the proportion of potential improvement achieved during rehabilitation (discharge score – initial score)/(maximum score – initial score) x 100

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Is early rehabilitation effective in treating Intracerebral hemorrhage?

Slide17

A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of Patients with hemorrhagic stroke

364 patients who suffered from hemiplegia following ICH admitted to 21 emergency hospitals in China

Inclusion criteria: after admission were stabilized within one week of symptoms, Glasgow Coma Scale >8, limb disability, age 40-80 years

Exclusion criteria: history of cerebrovascular disease with residual symptoms, onset of ICH more than 3 weeks prior, tetraplegia, history of dementia, not local residents

Early rehabilitation group vs. control group: all patients underwent same routine internal medical intervention Early rehabilitation: Three stages including physical and occupational therapy emphasizing ADL training immediately after enrollment

Primary rehabilitation: aimed at practicing basic ADLs, conducted at Emergency Department or Neurology Department during first month after stroke, 45 minutes per day/5x week, access to daily training for unilateral spatial neglect, speech deficit, and swallowing, bowel, and bladder dysfunction Secondary rehabilitation: focused on balance and walking, conducted at Physical Department during seconds and third month after stroke

Third rehabilitation: enhanced ADL and motor functions, conducted by family members/nurses trained to rehabilitate patients at home with therapists directing training and visiting the home every two weeksSlide18

A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of Patients with hemorrhagic stroke

All patients assessed using the

Fugl-Myere

assessment scale (FMA) and Modified Barthel Index (MBI) at admission and 1,3, and 6 months following the stroke

Statistically significant differences in FMA scores at 1 month, 3 months, and 6 months after stroke between rehab and control group Statistically significant differences in MBI scores at 1 month, 3 months, and 6 months after stroke between rehab and control groupSlide19

What are effective therapeutic interventions for stroke?Slide20

Ottowa

Panel evidence-based clinical practice guidelines for post-stroke rehabilitation

Target Population

Adult patients presenting with hemiplegia or hemiparesis after a single ischemic or hemorrhagic stroke

Patients had to be medically stable Had to be able to follow simple instructions and to interpret and respond to feedback signals

Excluded patients with multiple CVAs, other neurological problems, subarachnoid hemorrhages, subdural hemotomas, bilateral neurological signs, cancer, cardiac conditions, dermatologic conditions, serious cognitive deficits or severe communication problems, major medical problems that would inhibit participation in therapy, and psychiatric

Hyper-acute: first 12 hours Acute: first week following the stroke Subacute: from the first to 6th week Post-acute: 6 weeks to 6 months

Chronic: after 6 monthsSlide21

Recommendations

Therapeutic Exercise

Task-oriented Training

Biofeedback

Gait Training Balance Training Constraint-induced Movement Therapy

Treatment of Shoulder Subluxation Electrical Stimulation

Transcutaneous Electrical Nerve Stimulation Therapeutic Ultrasound Acupuncture Intensity and Organization of RehabilitationSlide22

References

Bai, Y., Hu, Y., Wu, Y.,

YuLian

, Z., He, Q., Jiang, C., . . . Fan, W. (2012). A prospective, randomized, single-blinded trial on the effect of early rehabilitation on daily activities and motor function of patients with hemorrhagic stroke.

Journal of Clinical Neuroscience, 1376-1379.Panel, T. O. (2006). Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation. Topics in Stroke Rehabilitation, 1-269.Paolucci, S., Antonucci, G., Grasso, M. G., Bragoni, M.,

Coiro, P., De Angelis, D., . . . Pratesi, L. (2003). Functional outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: a matched comparison. Stroke, 2861- 2865.Perna, R., & Temple, J. (2015). Rehabilitation Outcomes: Ischemic Versus Hemorrhagic Strokes.

Behavioural Neurology, 1-6.