Stroke Basics: Types, Neuropsychological Presentations, and Outcomes
Stroke Basics: Types, Neuropsychological Presentations, and Outcomes
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Content
0.96 -> hi everyone my name is sarah sims and
we're really happy that you could all
5.04 -> join us today for the lecture in volume 5 of
our 12 week no neuropsychology didactic series
11.44 -> and that brings you lectures from experts
in the field covering different topics
14.8 -> each week this series was created by trainees
and early career neuropsychologists to provide
20.32 -> free high quality didactic opportunities we would
really like to thank everyone in the committee
30.08 -> and our sponsors for their financial support of
the series you can also find us on youtube so
36.56 -> please like and subscribe to see all
the videos that are posted each week
42.32 -> before we start we want to make um
everyone aware of our youtube channel
47.04 -> and also here are disclaimers for the series
so this training is not meant to replace
51.36 -> formal education and neuropsychology and the
views of the speakers are their own questions
58.56 -> can be submitted via the q a box on the lower
left of your screen and a recording of today's
63.6 -> lecture will be provided on our website and
youtube later this week all right so now it's my
69.6 -> pleasure to introduce dr elaine mahoney today for
our talk on stroke basics so dr mahoney received
76.4 -> her phd in clinical psychology from university
of wisconsin milwaukee in 2018 she also has an
83.2 -> ms in clinical psychology from the university
of wisconsin-milwaukee and a ba in psychology
89.52 -> and cognitive sciences from rice university she
completed a pre-doctoral internship in clinical
95.44 -> psychology and a post-doctoral fellowship in
neuropsychology at the james a haley veterans
101.44 -> hospital in tampa florida dr mahoney's clinical
practice includes the assessment of in treatment
106.8 -> of adults with traumatic brain injury stroke and
brain tumors and her research has focused on the
111.84 -> ongoing rehabilitation needs of individuals living
with chronic sequelae of traumatic brain injury
118 -> so thank you for joining us dr mahoney go ahead
and take it away okay let me go ahead and share my
127.28 -> okay you screen see that all good i'm
gonna say we're good um so as sarah said
133.44 -> i'm elaine i am a neuropsychologist at uab spain
rehab i work as an inpatient neuropsychologist
141.76 -> with patients who are days weeks months out from
a stroke a traumatic brain injury a brain tumor
148.32 -> and you know pretty much anything else that
can happen with the brain that needs rehab
152.56 -> so stroke is a favorite population of mine
because you get to see all the things you
158 -> learn in your neuroanatomy classes all the things
you learn in your neuropsych classes in a really
164.4 -> strong and impressive way and you really
get to help these patients kind of get
169.68 -> back to their life after going through
something that's been really stressful
173.36 -> so today we're going to take it back to basics
and talk about different types of strokes the
179.2 -> kinds of neuropsyc presentations you would see
with different strokes and then we'll spend a
183.92 -> little bit of time talking about what recovery
looks like and what outcomes are after stroke
193.92 -> okay so my objectives today just what i talked
about we're going to talk about types of strokes
198.32 -> neuropsych presentations and outcomes okay so
i said we're talking about basics we're going
203.28 -> to start really basic so what is a stroke i
think this is a term that gets thrown around
208.88 -> colloquially and our patients often have
heard of people who have had strokes but
213.28 -> but getting down to what classifies as a stroke
and this was the definition i came across that
218.32 -> i think kind of captures the the idea the best
and so it's a sudden onset of impairment in some
224.56 -> sort of neurologic functioning that's due to
a severe decrease of blood supply to the brain
230.96 -> and the different types of strokes are
different ways that that blood supply gets
235.2 -> decreased but this is kind of the overarching
idea of what a stroke is for some reason
241.2 -> the flow of blood to the brain has been decreased
and that causes all kinds of different impairments
248.48 -> you may see different terms when
you're learning about stroke so
252.08 -> cerebrovascular accident or cva is
probably the second most common after
257.36 -> stroke you may also hear cerebral infarct or
infarction and then you don't see this too
263.44 -> much in kind of the scientific literature but
sometimes on patient handouts they'll call it a
268.4 -> brain attack so that's something to be aware of is
another term that people use for stroke sometimes
275.76 -> okay so there are two main types of stroke
an ischemic stroke that you can see on the
282.08 -> left of this diagram and a hemorrhagic
stroke that you can see on the right
286.4 -> we're also going to talk briefly about
something called a transient ischemic attack
290.4 -> or a tia but let's start with ischemic
stroke so ischemic stroke is the most
297.2 -> common type of stroke in adults so about 87
of all adult strokes are ischemic in nature
304.16 -> and an ischemic stroke occurs when there's a
blockage of a blood vessel that prevents blood
310.24 -> from continuing to flow through that vessel so
you can see in this picture here at the top let me
316.72 -> get a laser pointer for you there's some sort of
blockage in this artery and there therefore you um
338.8 -> at the site of the occlusion so most commonly what
this is is you get some fatty plaque buildup on
345.92 -> the inside of your artery um and then either
it kind of bleeds and there's a blood clot
350.88 -> formed right there or it pinches off that artery
completely and again therefore blood can no longer
357.12 -> flow through that artery you can also have an
embolus which is a fatty plaque or a blood clot
366.16 -> or some sort of you know little clot that travels
through your circulatory system from somewhere
371.92 -> else in your body and ends up in your brain and
blocking an artery in the brain so a lot of times
378.32 -> you can have what's called like a cardioembolic
stroke which means that a clot from your heart
383.84 -> travels through your circulatory system up to your
brain causing a stroke but it can really come from
389.68 -> anywhere in the body when we're talking about an
embolus it doesn't really make a difference if
394.96 -> you have a thrombus or an embolus for what it's
going to do to your brain again that blockage is
399.84 -> really the key component of an ischemic stroke and
again it's blocking that blood from continuing to
405.84 -> flow through the artery and perfusing the parts of
the brain that require those nutrients that oxygen
412.48 -> and everything that it takes to keep the neurons
functioning so the reasons that you might have an
418.56 -> ischemic stroke so we already kind of talked
about that fatty buildup of plaque in your
423.04 -> arteries that's known as atherosclerosis and so
this comes from poor diet from genetic causes
430.8 -> and it kind of narrows those arteries so
that either you can have a thrombus form
437.12 -> or you just have a narrower artery which means
an embolus is more likely to get stuck right
444.64 -> we all know that cardiovascular cerebrovascular
health is really important for preventing stroke
450.56 -> so this includes conditions like hypertension
high cholesterol diabetes obstructive sleep apnea
458.4 -> any of these conditions put you at higher risk of
having an asthenic stroke and then another thing
464.4 -> that's kind of interesting that people don't
often think about with stroke is anytime you
468.88 -> have a surgery or you suffer a trauma you're at
higher risk of stroke so a lot of the patients
475.44 -> that we see that have strokes when they're younger
it comes from this surgical or traumatic cause so
482.8 -> when you have say a heart surgery your heart
can throw some clots that can end up in your
488.08 -> brain leading to an ischemic stroke when you
break some of your long bones like your femur
493.6 -> it's common for a fatty kind of plaque a fatty
embolus to break off and that can also end up
500.08 -> in an ischemic stroke so that's kind of a lesser
thought of in a less common way of ending up with
505.68 -> an ischemic stroke but it definitely still does
happen and especially in that younger population
513.12 -> ischemic strokes can be kind of hard to see
on cts right at the beginning because again
518.16 -> all we're seeing is you know this brain tissue
that's no longer getting blood and it takes some
522.64 -> time for that to have an impact not very much
time without blood brain tissue starts to die
528.48 -> within about five minutes but again that doesn't
show up on ct often when patients are admitted
534.8 -> to the er it's not uncommon to have a ct scan
that looks fairly normal however in the you know
542.8 -> following days the the evidence of that ischemic
stroke will become very clear on ct so you can see
549.2 -> within 24 hours here in this right hemisphere
you're starting to lose gray white matter
555.92 -> differentiation and by two days after you can see
this damaged tissue in the right hemisphere so
564.8 -> what what does the what does having a
clot an ischemic stroke do to your brain
569.28 -> so the primary injury is that like i said when
brain tissue isn't getting blood oxygen energy
577.76 -> the tissue dies and that's kind of the primary
injury that happens in an ischemic stroke so you
582.8 -> can see in this bottom picture here the
direct tissue that that artery perfuses
588.32 -> dies off those neurons die off there's also an
area around that dead tissue known as the penumbra
596.4 -> which is kind of at risk tissue so this tissue
if you know there isn't blood flow coming from
602.08 -> other arteries if we don't re-establish the
patient's blood flow there's a possibility
607.28 -> that this tissue will also die and kind of
that's the focus of the initial intervention
612.8 -> is making sure we preserve as much of that
penumbra to keep functioning as high as possible
620.96 -> after you know you've had the stroke and that
tissue has died because of the lack of oxygen
627.44 -> and blood there's also risk for secondary injury
so vasospasm is something that can happen after
635.36 -> kind of a clot has passed and this is basically a
constriction of your blood of your blood vessels
641.6 -> which unfortunately can lead to either another
stroke or continued reduced blood flow and
646.8 -> further damage to the brain it's also possible
for you to have a hemorrhagic transformation so
653.6 -> you can imagine when one blood vessel gets blocked
off the pressure in the other blood vessels can
660.24 -> increase because the heart is still pumping the
same amount of blood um but it can't go one way so
666.08 -> more blood is going to be pushed another way which
can lead to a rupture of another blood vessel
671.44 -> and a bleed in the brain which we'll talk about
in a little bit whenever something happens to the
676.88 -> brain there's a risk for swelling or edema and
this is commonly seen when people have a stroke
683.52 -> and whenever you have swelling there's only so
much room inside the skull for the brain and so
688.8 -> we're at risk of the brain herniating or kind of
pushing through the small openings in the skull
696 -> so all of these things kind of contribute to
what the patient's deficits will look like
701.84 -> once they make it to rehab once they
you know go home after having a stroke
708.16 -> a hemorrhagic stroke is a rarer phenomenon but
it still accounts for about 12 percent of adult
714 -> strokes and this occurs when there's a rupture
in a blood vessel and that results in bleeding
720.08 -> in the brain tissue or in the meninges
so this can result in an intracerebral
726 -> hemorrhage so if a blood vessel bursts in
the brain tissue you're going to get blood
731.52 -> kind of pouring out onto that brain tissue it can
also result in a subarachnoid hemorrhage so our
739.28 -> cerebral arteries go through the subarachnoid
space over this over the surface of the brain
745.84 -> and therefore if the blood vessel ruptures there
you're not going to get brained or blood directly
751.28 -> on brain tissue but you're going to get pooling
of blood in between the arachnoid matter and the
756.88 -> pia mater outside of the brain and both of these
are are bad for your brain and cause deficits and
763.2 -> we'll talk about how in a second the main cause of
a hemorrhagic stroke is hypertension so that makes
769.92 -> sense right if there's a lot of pressure on those
arteries they're more likely to rupture and result
775.84 -> in a bleed however another cause for a hemorrhagic
stroke is an aneurysm which you can see down here
781.68 -> so an aneurysm is just a little out pouching
of an artery unfortunately these uh the walls
787.92 -> of an aneurysm are not as strong as the walls of
your artery and so they're more likely to rupture
795.28 -> and avm is another malformation of your
arteries that is more likely to bleed
800.96 -> than than your regular arteries so both of those
are factors that can cause a hemorrhagic stroke
807.2 -> um cerebral amyloid angiopathy is a condition
where your arteries are kind of a little bit
814.8 -> leaky and you get a lot of little bleeds a lot of
little hemorrhagic strokes that can cause you know
821.44 -> progressive deficits as you have more and more of
these these incidents so unlike an ischemic stroke
830.08 -> a hemorrhagic stroke is really easily detected um
early on on ct and that's because blood new blood
837.92 -> shows up bright white on a ct so here on the left
we have an example of an intracerebral hemorrhage
845.68 -> you can see here in the right hemisphere this
is a pretty large one and on the right here we
850.08 -> have an example of a subarachnoid hemorrhage so
there's blood in this subarachnoid space which
855.44 -> kind of fills in all those little crevices around
the brain so the primary injury for a hemorrhagic
861.68 -> stroke the brain tissue doesn't like blood being
right on it it's neurotoxic so blood touching
868.48 -> your brain tissue like in an intracerebral
hemorrhage causes neuronal death there's also
875.44 -> reduced blood flow right because imagine you have
a hose and you stick a hole in the side of it
880.8 -> and water starts pouring out there there's going
to be less water going through the end of the hose
886.08 -> where you want it to go and so unfortunately in
addition to having all of this blood on the brain
892.4 -> more distal parts that are perfused by that
artery are also getting reduced blood flow
899.36 -> there's also risk for secondary injuries here so
as blood fills some of the space inside the skull
906.96 -> there's less room for the brain right so we're
going to have increased intracranial pressure and
912.24 -> potentially herniation so in this bottom diagram
you can see that when we have a hemorrhage here
918.64 -> in this hemisphere it's pushing brain
tissue down and we're starting to experience
924.72 -> herniation through the small opening down here and
so this is really dangerous because this pressure
932.4 -> is putting pressure on the brain stem which of
course is very critical for us staying alive so
939.52 -> when we see this kind of herniation this often
calls for surgical intervention to relieve some
945.52 -> of the pressure in the brain and so we may take
off a portion of the skull and that gives room
953.52 -> for this swelling and this pressure to be relieved
in that direction instead of putting pressure on
958.48 -> the brain stem they may also have to go in and do
something like clipping or coiling an aneurysm um
965.6 -> so that to stop that flow of blood into the
brain and unfortunately whenever you do surgery
971.92 -> on the head you increase risk for seizures you
increase risk for infection for further bleeds
979.68 -> um and so these are all secondary injuries that
can kind of increase the deficits that came from
985.28 -> having this hemorrhagic stroke and cause more
complications for the patients down the road
992.48 -> okay so i said we'd also talk about this transient
ischemic attack so this technically isn't a stroke
998.96 -> sometimes it's called a mini stroke and what it
is it's a period of stroke-like symptoms so you
1004.56 -> may have weakness on one side of your body you
may have sensory loss or speech difficulties
1010.08 -> but it goes away within 24 hours and it doesn't
really leave a mark on your brain so oftentimes
1017.04 -> this is just diagnosed because people have the
symptoms and they resolve but there's no real
1023.12 -> way for us to test if somebody's had one of these
uh so the most likely cause of a tia is a thrombus
1031.2 -> that breaks up relatively quickly so you can
imagine you're having that kind of atherosclerosis
1036.72 -> that builds up inside your artery it causes a
blockage of your blood vessel but the pressure
1042.64 -> of the blood breaks it up pretty quickly normal
blood flow is restored and your symptoms go away
1049.92 -> so you might think great it doesn't really it
doesn't really matter you know it didn't cause
1053.92 -> any long-lasting difficulties however it's a
warning sign it's a warning sign that you've
1060.8 -> got some cerebrovascular difficulties that put
you at high risk for having a stroke and about a
1068.56 -> third of people who experience a tia will go on to
have a full stroke and about half of those people
1074.96 -> will have a stroke within a year so we really
emphasize to our patients that these tias while
1082.24 -> you know you're not having memory problems and
you're not having weakness and you can still walk
1087.28 -> it really is a warning sign that there
needs to be serious action taken towards
1093.04 -> taking care of some of these risk factors
like high blood pressure like high cholesterol
1098.4 -> through things like appropriate
medication use diet and exercise
1104.64 -> okay so moving on to the neuropsychological
presentations but before we do that we have
1110.56 -> to talk a little bit about the vasculature
of the brain and i think this is an area that
1114.88 -> can be a little bit intimidating to trainees it's
there's so many arteries they're hard to remember
1121.68 -> and i think working with a stroke population
really helps you to kind of learn this vasculature
1127.84 -> and learn how the blood how the brain receives
blood um from the circulatory system so we're
1133.76 -> going to do a brief little review of it before we
talk about different kinds of stroke presentations
1140.08 -> so our brain receives blood um from the heart in
two ways um so blood gets pushed up the front of
1148.24 -> your neck and the internal carotid arteries and
up through your spine in the vertebral arteries
1155.52 -> so you have kind of two two entry points into
the brain through the neck so those come up and
1164.56 -> form this circle of willis that's on the inferior
surface of your brain so you've got your vertebral
1171.68 -> arteries coming up here they come together and
form the basilar artery and off of that comes
1179.28 -> the the feeding arteries to the brain stem to the
cerebellum we'll talk about that in a little bit
1186.72 -> you have your and then in your circle of
willis you have your posterior your middle
1192.4 -> and your anterior cerebral arteries and these
kind of take the whole surface of the brain
1199.12 -> and perfuse blood giving it oxygen
1202.72 -> giving it glucose giving it all the things
that the neurons need to function optimally
1208.88 -> so when we think about different areas that
are fed by those three main arteries your
1215.76 -> middle cerebral artery actually perfuses most of
the lateral surface of your brain um so all of
1223.04 -> this in red is perfused by the middle cerebral
artery the anterior cerebral artery perfuses
1230.24 -> the anterior portion of the medial surface of
your brain and the posterior cerebral artery
1237.12 -> like its name perfuses the posterior portion of
your brain but also your medial temporal lobe
1243.04 -> so that's something that's really important
to keep in mind when we're thinking about
1247.12 -> what makes sense in terms of cognitive deficits
if you have a posterior cerebral artery stroke
1253.44 -> okay i'm going to keep these pictures on each
one because i know this is again a hard thing
1258.4 -> to learn and so the more you kind of think through
it the clearer it becomes so we're going to start
1264.56 -> with a middle cerebral artery stroke and we're
starting here because this is the most common type
1269.92 -> of stroke that you'll see and that's because it
perfuses the largest area of the brain most of the
1277.12 -> highest percentage of blood flows through the
mca and so you're just most likely to have a
1282 -> stroke in some portion of your mca so again we're
gonna we're talking about the lateral surface
1289.04 -> of your frontal parietal and temporal lobes
and if you can see on this side one again
1295.12 -> it's the lateral surface but there's also
some deep fibers into your basal ganglia
1302 -> so with a middle cerebral artery stroke and mca
stroke um these are kind of the things you're
1307.04 -> going to be looking for thinking about if you see
a patient you know has had this type of stroke um
1313.52 -> and to get all of these things you would probably
have to have a stroke right at the very beginning
1319.6 -> of the mca so that doesn't happen very commonly
um and so when you think about a specific patient
1327.52 -> they may have one portion of their mca blocked
off and you may see a subset of these symptoms but
1333.92 -> again this is kind of the overall picture of what
you should be thinking about for an mca stroke
1338.4 -> so the first is you're going to have contralateral
motor weakness so if you have a left mca stroke
1344.32 -> you're going to have motor weakness on the right
side right and so it's going to be more pro more
1352.4 -> apparent in the upper extremity compared to the
lower extremity so you're going to expect more
1358.96 -> arm weakness than you are leg weakness and so
let's think about that we know that our motor
1364.88 -> strip has a homunculus right and the legs of the
homunculus kind of tuck into that medial surface
1373.28 -> of the brain and then the body kind of flips
over a down around the lateral surface so it
1378.96 -> makes sense that if we have an mca stroke which
affects the lateral surface of the brain we're
1385.04 -> going to see more motor weakness in the arm than
the leg right so that's that's kind of how you can
1392.96 -> reason your way through using your knowledge of
neuroanatomy what you would expect to see from
1397.92 -> the patient in front of you similarly we're going
to expect to see contralateral hemi sensory loss
1404.64 -> again more in the arm than the leg so they might
have numbness they might have tingling they might
1410.24 -> have no sensation at all in their arm on the
opposite side from where the stroke happens
1416.8 -> you're also going to see contralateral facial
droop so this is a motor a deficit a motor and
1422.32 -> sensory deficit of the face and again this
makes sense because the face is represented
1428.08 -> on the lateral surface of that motor and sensory
strip you might see a contralateral homonymous
1435.92 -> hemianopsia or in easier words to say a field
cut so and this is because you're damaging some
1443.84 -> of the fibers that kind of go from the eyes back
to the posterior portion of the brain so there's
1450.32 -> there's impairment there where you're going to
get a deficit of vision to the contralateral side
1457.6 -> and in addition to that you get an
ipsilateral gaze preference so for
1462.24 -> example if i have a left mca stroke i may
not be able to see the right side of space
1468.4 -> and therefore my gaze preference might be to the
left side of space so hopefully that makes sense
1476.48 -> we're going to split the mca strokes up
into the left and the right hemisphere
1480.64 -> because they give you very different
cognitive presentations so if you have a
1485.36 -> left mca stroke we're hitting the language centers
of the brain and so here this shows you um the
1493.6 -> superior branch of the metal cerebral artery
perfuses the left frontal lobe and broca's area
1502.24 -> right whereas the inferior branch of the mca in
the left hemisphere perfuses the left parietal
1509.76 -> and temporal lobes hitting bernicke's area and so
when you get a stroke to your left mca it's very
1517.68 -> likely that you're going to have some difficulties
with either expressive language receptive language
1524.48 -> or both depending on where in the mca the stroke
was and so i'm sure a lot of you have seen this
1531.44 -> cookie theft picture before this is one way that
we can assess um if someone has an aphasia right
1538.4 -> and so if you hit that superior branch of the mca
and get a broca's aphasia it may look something
1545.6 -> like this you have a lot of non-fluency of speech
it's very difficult to express ideas you have a
1553.76 -> lot of nouns and verbs but not a lot of helping
words if you on the other hand hit the inferior
1562.16 -> part of your mca you're going to end up with more
of a wernicke's aphasia where you can produce a
1568.88 -> whole lot of speech but the comprehension piece
is missing and therefore it's not making a whole
1574.32 -> lot of sense so these are just two examples and i
strongly strongly encourage you on youtube to go
1580.8 -> watch videos of patients who have either a
broca's or wernicke's aphasia because it's really
1587.68 -> it becomes a lot more clear what that speech
pattern will sound like when you kind of see
1592.08 -> it in front of you so when we hear left
mca stroke aphasia is the number one thing
1598.96 -> that we're thinking of from a cognitive
perspective but we also might see something
1603.6 -> like apraxia so the ability to do meaningful
purposeful movements with your with your limbs so
1610.96 -> this is where we test like show me how you
would make a peanut butter and jelly sandwich
1615.92 -> show me how you would salute show me how
you would strike a match and blow it out
1620.96 -> things like that um and then a syndrome you can
get with a left mca stroke is gerstman syndrome
1627.44 -> so this happens when you hit your left angular
gyrus and it's just kind of a conglomeration of
1633.52 -> a few different notable impairments so that's
right left confusion so not being able to tell
1639.92 -> you're right from your left finger agnosia um
agraphia and a calculia and it's just kind of
1647.52 -> this weird conglomeration of symptoms you get
if you hit that that spot in your brain and
1652.16 -> again it's common to hit that especially when
you have an inferior division left mca stroke
1659.84 -> when we hit the right hemisphere the right mca we
get a very different cognitive profile so the most
1667.44 -> notable thing you see with a right mca stroke
especially if you hit the right parietal lobe
1673.2 -> is a left sensory neglect so this is
commonly presented as a visual neglect
1680.48 -> so for example when i ask a patient to
copy any of these pictures you can see
1685.6 -> that they're neglecting details on the left
side so their right side looks pretty good
1691.68 -> but the the left side isn't isn't complete
sometimes they can get parts of it drawing
1697.76 -> over from the right side but they're definitely
lacking in detail you might think okay well
1702.88 -> they just can't see it but no when you tell
them to draw from their memory they continue
1709.2 -> to neglect the left side of space this isn't
a visual problem at all it's an attentional
1715.76 -> problem so for them when there is something
competing on the right side of space they will
1721.84 -> not and cannot pay attention to the left side of
space and so this is a visual issue in that you
1728.4 -> ask them to cross out every line on the page and
they do not attend to anything on the left side
1735.92 -> you put a plate of food in front of them they get
upset because it seems like it's a really small
1740.32 -> amount because they're only seeing um what's
on their right side they're only attending to
1745.44 -> what's on their right side um but this really
affects all your senses so they might often
1751.68 -> neglect the left side of their body oftentimes
when you go in and you see a patient with pretty
1756.64 -> significant left neglect you'll find their left
arm hanging from their wheelchair in a really
1761.52 -> uncomfortable lifting position and it's because
they don't have attention to that left side
1767.6 -> hearing if there's sounds on both
sides they'll neglect the sound
1771.52 -> on the left tactile they'll neglect the tactile
sensation on the left it's a fully attentional
1777.44 -> it kind of crosses sensory modalities so while
we often look at it as a visual issue just keep
1784.56 -> in mind that this is really a visual attention
attentional and an attentional issue overall
1792 -> one other thing that we commonly get with a
right mca stroke is anasagnosia so this is an
1797.12 -> unawareness of their deficits so this is the
patient you go in the room and you ask them
1801.92 -> okay so like what are you noticing since your
stroke and they say actually i'm pretty fine i
1806.88 -> think i'm i think i'm back at baseline and they
can't move half of their body um they have this
1813.36 -> profound neglect to one side they may have some
memory issues they may have attention they their
1818.72 -> brain is telling them everything's okay and that
checking monitoring piece of their brain has
1823.6 -> been damaged so now they just kind of lack this
overall awareness which can be really difficult
1829.52 -> um when we're trying to help them get better and
they don't understand what problems they're having
1835.2 -> you may also see communication changes when
you have a right mca stroke so we often think
1840.8 -> of the left hemisphere as being language but
the right hemisphere is really important for
1846 -> porosity for tone for understanding the
meaning behind language sometimes and
1851.76 -> you may also see a lot of dysarthria so that's
kind of what a right mca stroke would look like
1858.48 -> all right moving forward so the anterior
cerebral artery remember here we're perfusing
1863.36 -> most of the lateral or the medial surface of the
brain so here we're going to have contralateral
1869.04 -> motor and sensory impairments but now we're going
to have greater impact on the lower extremity
1874.8 -> because remember the legs are hanging in that
medial surface you're also going to see some
1879.92 -> reemergence of some frontal reflexes so these are
things that you would see like in infants but then
1885.36 -> they go away as you develop but if you damage part
of the frontal lobe you may see re-emergence of
1891.04 -> like a grasp reflex or um like a rooting reflex
or something like that because we are hitting a
1899.28 -> lot of the prefrontal cortex here um you're likely
to see cognitively a lot of inattentive impulsive
1908.16 -> perseverative tangential circumstantial all of
that behavior starting to come out these patients
1913.92 -> might be inappropriate they may lack inhibition
they may have really bad safety awareness
1921.52 -> or they might go the other way and have really
bad initiation and kind of just sit and not eat
1927.2 -> their lunch when it's brought unless somebody
prompts them and just require a lot of prompting
1933.04 -> when you get hit the left anterior cerebral
artery you might get some aphasia like a
1938.16 -> transcortical aphasia which looks like um like a
broca's or a vernicus but you preserve repetition
1945.52 -> um and if you hit the right hemisphere aca you
may still get some of that left neglect like we
1950.56 -> just talked about so these are just some examples
of some aca strokes you can see there's a lot of
1957.12 -> damage to the medial portion of the brain all
right when we hit the posterior cerebral artery
1965.68 -> um not surprisingly a lot of the deficits relate
to vision and visual perceptual abilities um so
1973.6 -> here again you might get a field cut you might
get full cortical blindness if you hit both sides
1980.72 -> but then the thing we need to keep in mind
as neuropsychologists is that the pca does
1985.44 -> perfuse the medial temporal lobe so when we're
thinking about the cognitive profile here
1990.88 -> we need to be thinking about memory impairment
right because we may hit the hippocampus here but
1996.56 -> in addition to that we may also experience some
behavioral emotional symptoms and that's because
2002.96 -> you're hitting that limbic system in the medial
temporal lobe um so these patients might have like
2008 -> an exaggerated fear response they may have a lot
of paranoia that really get in the way with them
2014.8 -> um recovering and interacting with their loved
ones so while we think of posterior as mostly
2020.32 -> being like a visual problem we want to remember
that the pca profuses the medial temporal lobes
2025.84 -> and so we may expect to see some cognitive and
behavioral deficits that come from that impact as
2030.96 -> well one just little note here if you hit the left
pca and you also hit the splitting of the corpus
2038.96 -> closum you might get a kind of rare syndrome
of alexia without a graphia which means that
2045.28 -> your patient can't read but they can write and
so it can be really interesting you can have
2050.4 -> them write a sentence for you and they can't
read it back they can write it perfectly fine
2056.08 -> you take it away you give it back to them ask
them to read what it says and they can't read what
2059.84 -> they've written and it's just kind of a disconnect
disconnection syndrome and it's just kind of a
2065.12 -> rare thing you get when you hit your left pca
and you're splitting of your corpus callosum
2072.48 -> all right we can have strokes to our brain stem
obviously this is very problematic um because uh
2078.4 -> your brain stem is required for you to stay alive
and functioning correctly um so one interesting
2084.72 -> thing we would see as neuropsychologists with a
brain stem stroke is you get kind of crossed motor
2089.28 -> and sensory findings so you get contralateral
weakness and sensory loss of your body but you get
2095.84 -> ipsilateral of your face and this is because the
brain stem is where a lot of your cranial nerves
2101.92 -> come from and so where they decastate where
they cross over is different from where your
2108.32 -> the nerves from your body cross over and so you
can get this interesting pattern where you have
2113.04 -> maybe left facial weakness um but right sided
body weakness and that's really indicative of an
2120.56 -> of a stroke kind of at the brain stem region um
you might also see eye movement abnormalities
2126.88 -> dysarthria so kind of slurred speech dysphagia
difficulty swallowing and at its worst you may
2133.2 -> have what's called a locked in syndrome so this
is kind of preservation of your cortex so you can
2139.04 -> think you can remember but you've got complete
loss of kind of motor you can't really engage with
2147.2 -> your environment um but you can still perceive and
think and all of that so again at its worst that's
2154.16 -> what a brain stem stroke can result in and then
finally we have a cerebellar stroke so we didn't
2160.96 -> talk about the arteries perfusing the cerebellum
but they come off of the basilar artery um here in
2167.68 -> front of your brain stem and they perfuse um in a
few different arteries around your cerebellum when
2174.32 -> you have a cerebellar stroke the main thing you're
going to see is a lot of lack of coordination so
2180.48 -> you might get ataxia dysmetria dysdiadoconesia
which is a loss of rapid alternating movements
2189.12 -> and basically these people are just going to have
difficulty kind of coordinating on their motor
2194 -> functioning they're also going to have things like
dizziness nausea vomiting headaches double vision
2201.28 -> nystagmus it's very it's perfused by a lot of the
same areas as the brainstem so you're going to
2208.72 -> get the dysarthria the dysphagia similarly
to when you get a brainstem stroke stroke
2214 -> and while we think of the cerebellum as being
really important for this motor coordination it's
2218.8 -> important to keep in mind that the cerebellum does
play a cognitive function as well and so sometimes
2223.6 -> when you get a cerebellar stroke you can get
something called cerebellar cognitive affective
2228.4 -> syndrome and this is basically just a grouping of
symptoms both cognitive and emotional that result
2236.56 -> from cerebellar damage the cognitive symptoms
are usually disexecutive attentional deficits
2244.16 -> sometimes a little bit of memory deficits and the
emotional symptoms are usually depressive symptoms
2251.28 -> so you can kind of while we think of it as being
primarily a motor problem keep in mind that with
2257.44 -> a cerebellar stroke it would not be unexpected
for you to see cognitive deficits as well
2265.2 -> and then the last kind of neuropsyc symptom i
wanted to talk about is post stroke depression
2270.4 -> so depression is very common after stroke
and you may think of course they just had
2275.12 -> a stroke so they're going to be adjusting
to that and having some depressive symptoms
2279.6 -> but it seems more than more than just that so
meta-analyses have reported about a third of
2286 -> stroke patients will develop post-stroke
depressions in the five years following
2289.84 -> stroke um however this paper here showed
that the rates are actually likely higher
2294.88 -> um when you consider kind of mild
depressive symptoms so that one-third
2299.36 -> really comes from meeting criteria for a major
major depressive disorder um the presence of
2304.96 -> post-drug depression is related to poor functional
outcome and greater mortality so it's something
2310.24 -> we really need to be on top of and aware that
this is a fairly common occurrence after stroke
2316.8 -> um the etiology is like i said yeah they just
had a stroke but there also seems to be very
2323.2 -> specific changes in brain chemistry that lead to
depression more commonly after stroke than other
2328.64 -> types of head injuries and it's been shown that
while therapy and medication both help medication
2335.44 -> actually seems to have the biggest impact on
alleviating symptoms of post-stroke depression
2343.6 -> all right recovery from stroke so i want to talk
about outcomes but it's very difficult because
2351.52 -> it's so varied from patient to patient
from stroke to stroke from the brain they
2357.36 -> brought in before the stroke from all the other
things going on in their body and in their lives
2363.12 -> after their stroke but in generalities we can
say that most patients with stroke will show
2370.88 -> a rapid recovery in the first three months
post-stroke with continued improvement seen across
2376.96 -> kind of six to 12 months at which point it kind
of plateaus um that doesn't mean that functionally
2383.68 -> patients can't see improvements after a year it's
just that the neural recovery portion is over
2389.6 -> um and now we're really working on figuring out
the optimal compensatory strategies to improve
2395.52 -> their functioning in a day-to-day fashion um the
final extent how far they're going to get back how
2402.16 -> if they're going to get back to their baseline if
they're going to get 80 back is really affected by
2406.8 -> a lot of different factors that we'll talk about
um so these are kind of the positive prognostic
2412.64 -> factors these are the things i'm thinking about
when i'm trying to counsel my patients of am i
2417.84 -> going to get better how much better am i going to
get am i going to have to live like this forever
2422.8 -> um so these are the things that are kind of good
signs for me so lower stroke severity the nihs
2430.32 -> is a stroke scale that physicians will give
like in the ed in the early stages of stroke
2437.84 -> that kind of goes through and ranks different
areas of functioning and this gives us kind
2442.64 -> of a severity score so obviously a less severe
stroke is a is a good sign in terms of prognosis
2449.44 -> similarly if you have a smaller sized infarct
under imaging if your stroke happens at the
2456.08 -> very end of a branch of the mca versus
you know affecting more of the brain
2462.16 -> that's going to be a good sign ischemic strokes
tend to recover better than hemorrhagic strokes
2468.8 -> likely due to all the complications that can come
with increased intracranial pressure and the need
2474.64 -> for surgery and things like that with hemorrhagic
strokes having fewer comorbid conditions is a good
2480.24 -> thing so the patient that only has you know one
cerebrovascular condition versus all the cerebral
2486.08 -> supervascular conditions is likely to do better
um as they recover younger age having a younger
2493.04 -> brain to heal is a better thing higher ses
educational attainment greater social support
2498.64 -> are all positive prognostic factors um and then
being in a non-minoritized racial group and
2505.04 -> this is a huge issue in most of health care but
especially in stroke um that minority individuals
2512.64 -> are more likely to have a stroke and they're more
likely to have a poor outcome with stroke and the
2517.6 -> reasons behind that um are still something that's
being researched but i can say that they've shown
2524.64 -> that it's something beyond just ses education and
social support so this is something that needs to
2531.44 -> be a critical focus and i think it's somewhere
that neuropsychologists can play a great role in
2536 -> figuring out why we have such a disparity
between different ethnic and racial groups
2544.08 -> there's certain interventions we can do that put
people at a better starting point for for getting
2550.72 -> better after stroke the biggest thing is if we can
identify that someone's having a stroke quickly
2557.12 -> there are things that can be done to break up the
clot to re-establish blood flow and help them to
2564.64 -> have a less devastating stroke um so tpa is an
enzyme that helps go in and kind of break up the
2571.92 -> stroke um and again that means that blood can
continue to flow to the brain we're more likely
2577.68 -> to preserve a larger portion of that penumbra and
therefore we're going to have less deficits from
2583.28 -> both a cognitive and a physical standpoint the
downside of this is you have to use it within
2589.12 -> four hours where it doesn't really work and so
it's really critical that we teach the community
2595.84 -> how to identify when someone's having a stroke
so that they can get this intervention early
2600.48 -> and that's why we've come up with all of these
great acronyms here so it started with the fast
2605.6 -> telling people to look for facial drooping arm
weakness speech difficulty and then there's been
2612 -> research that shows this doesn't really encompass
all the symptoms that a patient might have from
2616.16 -> a stroke so there's been two additional be fast
and faster which incorporate kind of the balance
2624.4 -> headache dizziness and then also of visual changes
so you can see taking into account more of those
2630.16 -> posterior strokes and cerebellar strokes whereas
fast really is is optimal for an mca stroke
2638.8 -> they can also go in and you know
break up that clot mechanically
2642.72 -> obviously that's a more invasive procedure
than just giving you some medication
2647.52 -> but it really makes a difference so this
figure shows kind of the improvement uh
2652.56 -> scene from giving tpa within the first three
hours after stroke and so all of these patients
2658.16 -> this is the percentage of patients that do
better than those who haven't received tpa
2663.2 -> obviously we're going to need to do that
surgical intervention for hemorrhagic stroke
2666.72 -> stroke rehab what i do and then afterwards kind
of those behavioral health interventions helping
2672.88 -> people get to wear their cpap helping them figure
out exercise routines that work for them and diet
2677.68 -> plans that are good for their health and for their
brain in preventing another stroke that's what's
2683.04 -> going to really lead to you know the best possible
outcome this is probably the slide i spent the
2690.24 -> longest time which is funny because this is all
it says um there are so many articles that say you
2695.52 -> know 50 of people with stroke can't walk without a
device or in this sample 47 had cognitive deficits
2704.08 -> at five years and i just i struggle with that
because again like i said every single person
2711.12 -> brings a different brain into having a stroke you
can have a stroke at literally any portion of any
2717.04 -> artery in your brain that will cause different
severity and different types of deficits and so
2722.8 -> it's really hard to take a group of 200 stroke
patients and make any sort of generalities
2728.32 -> about about how they will recover and so i'm going
to leave it with stroke is a leading cause of
2735.04 -> long-term disability in the united states and in
the world um and so it's really important that we
2741.2 -> as neuropsychologists work with you know community
partners work with physicians to help people
2748.16 -> learn the steps they can take to prevent stroke
so keeping yourself healthy from a cardiovascular
2754.56 -> perspective help to have early identification
when a stroke is happening so that you can
2760.32 -> get some of these reperfusion therapies um and
then work with people who have had strokes to
2767.2 -> make sure that they stay healthy afterwards
and that they learn all the strategies they
2772.24 -> can learn to live functional lives despite the
deficits that may persist from their stroke
2778.8 -> all right so there's my references
now i'm gonna open it up for questions
2785.36 -> thank you so much dr mahoney that was a great talk
and great covering of all the basics of stroke is
2790.64 -> really helpful um we have a couple of questions
[Music] so we have the first one what are the
2798.08 -> differences if any for strokes in pediatric
patients so i am an adult neuropsychologist and
2805.84 -> therefore don't have a great broad understanding
of pediatric stroke but i do know that
2814.72 -> that strokes are not uncommon in kind of the
perinatal period um and that that children
2823.04 -> also do have strokes at time although obviously
to a lesser rate than the elderly population
2827.76 -> honestly i'm not the best person to answer this
question um but i will tell you that the stucky
2832.72 -> board review book has a great um they do a great
coverage of both adult and pediatric stroke in
2838.96 -> their stroke chapter so that's where i
would i'd refer you as a starting point
2843.2 -> yeah thanks it's really helpful to have good
resources yeah so another question is what kind
2848.24 -> of post-stroke interventions are helpful i know
you already talked about prevention of stroke as
2853.52 -> a good way to make sure you make things worse but
what sort of maybe specific interventions are good
2859.92 -> for maybe increasing functionality yeah so in
the acute period obviously we're trying to get
2865.84 -> um people as much physical occupational and speech
rehabilitation as we can um and the role we play
2873.84 -> as neuropsychologists in that is trying to figure
out first of all in our assessment piece what do
2879.28 -> those patients need where are the deficits where
are the gaps um and then secondly coming up with
2887.2 -> ways to ensure that participation is optimal
that strategy use is optimal and so as
2893.6 -> an inpatient neuropsychologist that's
a large part of my role is figuring out
2898.48 -> how to guide the team to best work with individual
patients once we get out of acute rehab patients
2906.48 -> will likely go on to continue to have physical
therapy speech therapy um but they may also need
2912.56 -> a lot of mental health and neuropsychological
support here so that's where we're really kind
2918.96 -> of trying to tackle that post-stroke depression
that adjustment to disability and making sure that
2925.04 -> they are continuing to function and do things
they enjoy and do things that are meaningful
2931.84 -> because that only leads them to have a better
long-term recovery if we can figure out how to
2937.12 -> get the the patient that love to go fishing
but now feels like how am i going to do that
2941.44 -> when i need to use a walker if we can help them
problem solve and navigate that from you know just
2947.6 -> a problem solving therapy that can often have
the biggest impact even if you know their need
2953.6 -> to use the walker doesn't change and so i think a
lot of times early on in the intervention portion
2960.96 -> that we leave that to the people who know how
to do that really well and we just help guide
2965.12 -> them i think later on we have a very large role
in helping figure out the quality of life piece
2974 -> yeah thank you so another question is how do
you usually communicate to patients and their
2979.28 -> families issues surrounding recovery and then
patients experiencing chronic effects of stroke so
2985.92 -> maybe they've had it several years ago um
and passed the bulk of their recovery yeah so
2992.48 -> uh like i said i work in an acute rehab and so i
think i get it a little bit easy and that i can
2997.68 -> kind of pass the buck and say at this early stage
it's really hard for us to know what you're going
3002.88 -> to get back and what you're going to get back to
but we really just need to focus on the present
3007.28 -> moment but i will tell you i work with lots of
people who've had who are in the chronic phase
3011.68 -> um and my goal is kind of something i said here is
that sure we are outside the window of your brain
3020.8 -> naturally recovering um you know if you can't
move your leg in this direction at this point
3028.48 -> maybe we're not going to be able to do that but
there's a lot of ways we can improve functioning
3035.12 -> even with these deficits so say someone
has chronic memory deficits we can teach
3040.48 -> them the strategies right we can teach them
to use the lists to have the memory station
3046.88 -> to you know keep a notebook a memory journal
a pill box all the things right so we figure
3053.2 -> out where are the areas that they're having
difficulty functioning and we help provide
3058 -> those strategies that they may not have thought
of to improve their day-to-day independence and so
3063.6 -> i i come at it from this positive perspective of
okay we're three years out we know that things
3069.44 -> aren't just with time naturally gonna get better
so we're gonna have to take some action right
3073.44 -> we're gonna have to figure out some solutions for
this um and then kind of help guide them through
3078 -> that process and use our knowledge of those
strategies to help find what works best for them
3084.88 -> another question is are there differences in post
outcomes for the different stroke syndromes so
3091.36 -> like maybe it was a mca versus a pca stroke um
is there differences in how their outcomes look
3098.4 -> um i don't know that that's been because again
there's so many um so it's very simplistic of
3105.36 -> me to say a left mca stroke right so when you
go into the medical record you're going to see
3110.32 -> um a left m1 segment you know it's so even
within an mca stroke that's such a diverse
3117.28 -> grouping i will say that i know so you're most
likely to get say aphasia with an mca potentially
3123.76 -> an aca stroke and that does impact functioning
to a severe level right if you can't communicate
3129.44 -> that really impacts your quality of life and your
ability to function at work with your family and
3134.32 -> all that and so from observational uh you know
experience i would say that those patients who
3143.2 -> have kind of those large mca strokes are are worse
off than say a pca stroke but again that's a large
3151.04 -> mca stroke you can also get a pretty a pretty tiny
mca stroke that only affects you motorically so
3157.2 -> it's hard to speak in those and this is why i
struggled so much with the outcomes is it's hard
3161.44 -> to speak in generalities about stroke it really is
a kind of patient by patient stroke by stroke um
3168.24 -> thing yeah and like you said it really helps you
learn the vascular and neurons every patient is
3175.76 -> different so you have to learn something new
each time exactly we also had a question you
3179.6 -> mentioned um depression and stroke patients and
satisfactoring and is there any shared mechanisms
3185.92 -> between the vascular system and the depression
that can occur with stroke or is it more so just
3192.16 -> the out functional decline related to depression
yeah so my understanding of the research is that
3200.56 -> it's a little bit of both but it seems to be
a specific brain chemistry kind of metabolic
3207.44 -> neurotransmitter kind of thing that comes
from having a stroke and and so it's not
3212.96 -> necessarily from the vasculature itself but i
think from the uh the loss of neuronal tissue
3219.84 -> um the swelling and all of that causes changes in
brain chemistry that lead to the syndrome known
3226.4 -> as post-stroke depression and so you know that
might look a little bit different than um just
3231.84 -> the adjustment to disability proportion and i
think that that's why they believe that kind of
3237.36 -> antidepressant medication sometimes helps a little
bit more than just therapy um for these patients
3244 -> great but it's a it's a brain chemistry issue
from my understanding awesome thank you um and
3249.52 -> then another question was um you mentioned that
hemorrhagic strokes were typically poorer outcomes
3255.28 -> um and so we're just wondering like what is the
effects of the blood directly on brain tissue
3261.76 -> is that getting really into like the
neurochemistry yeah um so my understanding
3267.36 -> of it is that um just blood is neurotoxic to
neurons um and so you're gonna have cell death
3275.6 -> um when that brain that blood is directly on the
brain tissue and so that's going to happen in
3280.56 -> your intracerebral hemorrhages right you're going
to have that blood directly on the brain tissue
3284.96 -> and kind of the the death of those neurons um
but you know a lot of hemorrhagic strokes are
3290.72 -> subarachnoid hemorrhages because that's again
where the arteries travel through before they
3294.88 -> kind of go into the brain tissue to perfuse um and
so you get the same you get you get neuronal death
3303.04 -> from that as well from pressure from swelling
from compression of the brain against the skull
3309.12 -> and so it's kind of both of those factors both
kind of the increased intracranial pressure
3316.4 -> along with the kind of direct chemical
effects of blood touching brain tissue
3324 -> great i think that's all of our questions for
school so thank you these are great questions
3328 -> and obviously there's a lot of research that
you can you can do on your own into stroke
3333.04 -> um and and it's a super interesting topic and
hopefully this gives you a jumping off point
3338.96 -> yes thank you so much that was a great talk and
a great um covering of all the strokes basics so
3344.72 -> thank you so much for that um and everyone
please join us again next week um at 7 p.m
3350.24 -> eastern we're going to be talking about culturally
competent neuropsychological interviewing skills
3354.8 -> building your toolkit so we'll
see you all then thank you so much
Source: https://www.youtube.com/watch?v=BwIAricGgAg