ISCHEMIC STROKE

Clinical Consequences of Stroke

• stroke is associated with a wide range of clinical signs and symptoms
• resulting disability depends on:
  • location and extent of the brain lesion
    → Signs and symptoms of cerebral lesions
    → Brainstem syndromes
  • degree of neurological recovery (influenced by factors such as recanalization therapy, early and comprehensive rehabilitation)
    • early treatment and stroke rehabilitation can significantly improve recovery, allowing many patients to regain a substantial level of functionality
      
  • patient’s premorbid status
• the stroke recovery process is long and can come with many challenges; many people never fully recover
  • the greatest neuroplasticity, or rewiring of neural pathways and connections in the brain, occurs in the first 6 months after stroke onset 
  • stroke recovery is not linear, and most patients experience ups and downs during recovery
  • potential causes of temporary worsening:
    • new medication
    • overworking
    • emotional changes
    • stopping rehabilitation and exercising
• with significant disability, the early integration of palliative care in stroke management can provide significant benefits to patients and their families

• paresis
  
  • hemispheric stroke usually causes contralateral deficit (hemiparesis); brainstem or spinal cord lesions lead to quadriparesis or paraparesis
  • use the Oxford strength scale to asses the muscle strength in more detail
    
• spasticity
• ataxia
  
• perception disorders
  • visual field defects (typically hemianopsia, quadrantanopia, scotoma, or monocular blindness)  
  • diplopia
  • hypesthesia (impaired tactile, thermal, or pain sensation)
  • pain (such as thalamic pain, pain due to spasticity, frozen shoulder, etc.)
  • complex perceptual disorders due to lesions of association areas
    • face or color agnosia, neglect syndrome, anosognosia, etc.
    • problems with recognizing shapes and objects or even one’s own body
• dysphagia
  • due to bulbar or pseudobulbar syndrome
• problems with speech
  • aphasia (difficulty finding the right words or understanding what others are saying)
    • global, Broca´s, Wernicke´s
  • dysarthria
    • paresis of oropharyngeal muscles (bulbar x pseudobulbar syndrome)
      
    • apraxia
  • reading and writing problems (multiple factors – aphasia, a writing hand paresis, altered vision, etc.)

• poststroke mood disorders
  • anxiety (20%)
    • survivor focuses on worries and concerns
  • poststroke depression (PSD)
    • affects 1/2-2/3 of survivors
    • feelings of overarching sadness, lack of pleasure in old activities, or changes in eating and sleeping patterns
  • personality and behavioral changes, emotional lability
    • pseudobulbar affect (PBA), also known as emotional incontinence, causes sudden and unpredictable episodes of inappropriate involuntary crying or laughing, often in socially inappropriate situations  (Ahmed, 2013)
      
      • caused by disconnection between the frontal lobe (which controls emotions) and the cerebellum and brain stem
    • irritability and aggressiveness (physical or verbal)
    • apathy with a lack of motivation
      
    • disinhibition (tendency to say or do socially unacceptable things)
• vascular cognitive impairment (VCI)
  • problems with memory, attention, problem-solving, and executive functioning
• poststroke fatigue or tiredness
  • caused by physical changes or medications, but also mood changes, depression, anxiety, or difficulty sleeping
  • includes a decrease in both mental and physical energy levels, affecting the ability of a survivor to participate in daily or rehab activities
• incontinence
  • incontinence or difficulty controlling bladder/bowel
    
  • often multifactorial; may be caused by medication, muscle weakness, changes in sensation, thinking, and memory
• stroke-related epilepsy (STRE)
  • stroke is the cause of about 10% of all epilepsy cases and 55% of newly diagnosed seizures among the elderly  (Feyissa, 2019)