Cerebrovascular Accident
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1. 3 mechanisms of injury that occur in ischemic CVA: 1. local
hypoxia
2. local hypoglycemia
3. build-up of toxic metabolic waste
2. abulia: abnormal lack of ability to act or make decisions. The
sever form is termed akinetic mutism
3. ACA supplies: the medial cerebral hemisphere (frontal and
parietal lobes) and subcortical structures (BG, anterior fornix
and anterior 4/5ths of corpus callosum)
4. acute signs and symptoms of stroke include:: -numbness
and/or weakness of the face, arm, or leg on ONE side
-confusion and slurring of speech
-visual disturbances in one or both eyes
-dizziness, gait disturbances, and/or balance/coordination
dysfunction
-Severe headache (thunder) with no known cause
5. Aerobic capacity after stroke: Reduced to 50-70%
Twice the O2 consumption seen in walking
6. Agnosia: The inability to recognize familiar objects using one or
more of the sensory modalities, while often retaining the ability
to recognize the same object using other sensory modalities
7. Amaurosis Fugax is a frequent accompanying symptoms of:
internal carotid artery syndrome
8. Aneuryms acount for 90% of _______: SAH
9. Aneurysm: Abnormal distension of blood vessels at
bifurcations caused by disease or weakening of the vessel
walls
10. Aneurysm Tx.: Surgical clipping
Endovascular coiling
11. Anosognosia: Severe condition including denial, neglect and
lack of awareness of the presence or severity of one' s
paralysis.
Lesion: non-dominant parietal lobe
12. Anterior watershed zone: ACA meets MCA (leads to bilateral
UE weakness)
13. Apraxia: Inability to perform particular purposive actions, as a
result of brain damage.
14. Apraxia is most often seen in __________ hemisphere lesions.
While ataxia-like syndromes are more often seen in _________
hemisphere lesions.: Left, right
15. Are CVA's preventable?: Yes! 80% of CVA's are preventable
16. ___________________ are more common than _________________ in
bowel and bladder dysfunctions: Constipation/impaction,
incontinence
17. Ateriovenous malformation (AVM): Masses of abnormal blood
vessels which appear as a tangle of arteries and veins
High pressure arteries connected to low pressure veins
(instead of through capillaries)
18. Atherosclerosis: the most common form of vascular disease;
associated with accumulation of lipids, fibrous tissue and
calcium deposits on arterial walls forming plaques that narrow
the lumen, platelets aggregate around the platelets and
produce clots.
19. AVM bleeds are often less devastating, why?: The bleeds are
primarily into the malformation and only incidentally into the
adjacent brain
20. basilar artery syndrome can be catestrophic because of::
bilateral pontine damage leading to Coma, locked-in
syndrome, akinetic mutisms, or tetraplegia
21. Brunnstrom's Stages of Recovery Stage 1: Flaccidity, no
movement
22. Brunnstrom's Stages of Recovery Stage 2: Min voluntary
movement, spasticity begins to develop
23. Brunnstrom's Stages of Recovery Stage 3: Voluntary control
of movement synergies, spasticity peaks
24. Brunnstrom's Stages of Recovery Stage 4: Mastery of some
movement combo outside of the synergies, spasticty begins to
decline
25. Brunnstrom's Stages of Recovery Stage 5: Difficult
movemebt combo are learned, synergies lose their dominance
26. Brunnstrom's Stages of Recovery Stage 6: Disappearance of
spasticity. coordinated joint movements
27. Brunnstrom's Stages of Recovery Stage 7: Normal movement
28. Central PCA syndromes include:: Thalamic pain syndrome
Hemiballism
Contralateral hemiplegia from cerebral peduncle involvement
29. Cerebellar hemorrhage: Results in ataxia and vestibulopathy
30. Cerebrovascular disease: any disorder in which areas of the
brain transiently or permanently affected by ischemia or
hemorrhage; a disorder in which one or more blood vessels of
the brain is/are impaired by a pathologic process
31. Cognitive/behavior deficits in (L) CVA: Difficulty with
processing info in sequential/linear manner
Described as: slower, negative, cautious, uncertain, depressed,
anxious
32. Cognitive/behavior deficits in (R) CVA: Difficulty grasping the
whole idea or the overall organization of a pattern or activity
Described as: indifferent, quick, impulsive, euphoric, pt.
overestimates their ability while minimizing their problems.
Major Issue: SAFETY!!
33. complete blockage of the internal carotid without adequate
collateral circulation will result in deficits in both _______ and
________: MCA and ACA
34. Constructional Apraxia: Difficulty in recognizing parts to a
whole secondary to faulty spatial analysis & conceptualization
of the task.
35. CVA is defined as: a sudden loss of neurological function
resulting from interruption of blood flow to the brain; also
know as stroke/brain attack
36. damage or dying neurons release excessive amounts of 50. __________ given within 12 hours of ischemic CVA has been
_______: glutamate shown to decrease the mortality and morbidity in people
>65 years old: nimodepine (neuroprotective agent)
cells that normally take up this neuro-transmitter are 51. _____________ have a 30% higher incidence of CVA's and up to
compromising causing disturbance of energy 80% greater risk of developing a subsequent stroke: Men (in
metabolism(inability to produce ATP), facilitates entry of Ca2+ comparison to women)
into cells, activated catabolic enzymes that further degrade
the neural structures. this leads to an area of apoptosis and additionally, black men have 50% greater incidence than white
tissue death beyond infarction, usually within 3-4 hours men
(ischemic cascade)
52. Hemorragic CVA: Intracerebral (d/t HTN or cerebral amykiud
37. Depth and Distance Perception: Inaccurate judgment of angiopathy)
direction, distance and depth. SAH (d/t ruptured aneurysm or AVM)
Lesion: non-dominant occipital lobe
53. Hemorrhagic CVA have ________ survivability, but __________
38. Dressing Apraxia: Inability to dress oneself properly owing to functional recovery than ichemic strokes: poorer, better
a disorder in body scheme or spatial relations.
39. Dysarthria: Impairment of speech production due to secondary (Ischemic CVAs have better survivability but poorer functional
damage to CNS or PNS recovery)
Affects respirtation, phonation, articulation and resonance 54. How does recovery form a CVA occur?: Reduction of
40. Dysphagia: Deficits in swallowing due to lesions of CN IX and swelling or edema
X Existence of collateral blood flow
Causes delayed triggering of swallow reflex, decreases Neuroplasticity
pharyngeal peristalsis, decreased lingual control 55. how is the prognosis of thrombic CVA's compared to embolic
41. embolism: obstruction of blood flow secondary to a blood CVA's?: thrombic CVAs have a poorer prognosis
clot that is not inherent to the cerebral vascular system 56. Hyperreflexia, clonus, spasms, weakness, incoordination
42. Emotional liability: Unstable or changeable emotional state, fatigue, pain, are all indicative of ___________________: spacticity
characterized by a pathological rapid change from laughing to 57. Hypoperfusion: Results from systemic hypotension, leading to
weeping with only slight provocation decreased blood flow to the brain
43. Extension synergy LE: Hip extension, adduction*, IR 58. Hypoperfusion can lead to __________________: watershed lesions
Knee extension* where certain areas of the brain do not get sufficent blood
Ankle PF*/IV supply
Toe PF
59. Ideomotor vs Ideational apraxia: Ideomotor: Breakdown
44. Extension syngery UE: Scapular protraction between concept & performance; movement is not possible
Shoulder adduction*/IR upon command but occurs automatically.
Elbow extension
Forearm pronation* Ideational: Failure in the conceptualization of the task;
Wrist/finger flexion purposeful movement is not possible, either automatically or
45. Figure-Ground Discrimination: Inability to visually distinguish on command.
a figure from the background in which it is embedded. 60. if the dominant language hemisphere is affected in ACA
Lesion: non-dominant parietal lobe syndrome, what will you see?: the patient will have abuila
46. Finger Agnosia: Inability to identify the fingers of one's own and a reduction in the rate or complexity of language and
hand; correlates highly with poor dexterity speech
Lesion: parietal lobe of either hemisphere
47. Flexion synergy LE: Hip Flexion*/abd/ER non-dominant side = unilateral neglect
Knee flexion 61. In ACA syndrome, _______________________________ is affected by
Ankle DF/IV paresis and sensory loss: contralateral LE>UE
Toe DF 62. In an MCA occlusion, if the L hemisphere is involved (and it
48. Flexion synergy of UE: Scapular retraction/elevation is language dominant ) is will result in __________________. if the
Shoulder abduction/ER non-dominant (typically the R hemisphere) is involved,
Elbow flexion* especially the parietal lobe, it will result in _________________.:
Forearm supination global aphasia; perceptual deficits (anosognosia, unilateral
Wrist/finger flexion neglect, spatial disorganization)
49. Form Consistency: Inability to perceive or to attend to subtle
differences in form and shape.
Lesion: non-dominant parieto-temporo-occipital region
63. Incidence of Hemorragic CVA: Dramatically increases after 65
y/o and exponentially with increased age
Men > women
Black > white
64. Intracerebral Hemorrhage (ICH): Typified by gradual and
steady evolution that occurs over minutes, hours, and days
(usually sudden onset)
Usually occurs during physical activity in the daytime
Severe headache, vomitting and seizures at onset
65. _________ is most commonly involved in embolic CVAs: MCA
66. _________ is the primary arterial supply to the medulla and
posterior-inferior cerebellum: vertebral artery
67. Lacunar CVA: Has characteristics of both ischemic and
hemorrhagic CVA
68. light alcohol consumption can decrease risk of CVA by
decreasing platelet aggregation: this is just a fun fact that i
feel is important for you to be reading right now.......go get a
drink......do it for your health.
69. loss of blood flow to the brain leads to:: decreased o2 and
metabolites (glucose), resulting in neuronal dysfunction and
cell death; stores of o2 and glucose are used within minutes
triggering the onset of neurologic deficits
without blood flow, there is also a toxic build-up of metabolic
waste, resulting in additional damage.
70. MCA occlusion is generally _____ more often than thrombic:
embolic
71. MCA occlusion results in: contralateral spastic paresis
contralateral hemianesthesia
homonymous hemianopsia with impairment of conjugate gaze
in the direction opposite the lesion
72. MCA supplies:: the entire lateral surface of the brain (fronto-
temporo-parietal) as well as subcortical structures (BG and
posterior internal capsules), corona radiata, globus pallidus,
caudate and putamen
73. Medical Intervention of SAH/AVM: Surgery is Tx of choice
Lowering BP
Treat cerebral edema
Anticonvulsants
74. Memory and representational deficits after stroke: Difficulty
describing details of imagined representations from long term
memory
75. most common form of cerebral emboli: cardiogenic;
fragments from a thrombus within the heart can dislodge and
enters the cerebral circulation/75% of cardiac emboli lodge in
the brain
76. Motor Neglect after stroke: Failure to move in contralesional
space despite awareness of stimulus there
Hemispace deficit =reference between right <-> left
77. NIHS scale: An 11-item standardized assessment of neurologic
outcome and degree of recovery from stroke that is designed
to be completed in 5-8 minutes
78. Oral Apraxia: Subtype of ideomotor apraxia in which
buccofacial muscles cannot produce purposeful movement.
79. Pathogenesis of a hemorragic CVA: Hyalinization of blood
vessels (smooth muscle cells replaced by collagen. Changes
the permeability of the vessel wall which leads to hardening
and calcification and therefore loss of elasticity)
Accumulation of fats and proteinaceous materal leading to
vessel walls that are prone to leak and rupture
80. PCA supplies:: occipital lobe, medial/inferior temporal lobe,
upper brainstem, midbrain, posterior diencephalon and
thalamus
81. Peripheral PCA syndromes include:: Transient global amnesia
Dyslexia without agraphia
Visual symptoms including visual agnosia, cortical blindness,
contralateral homoymous hemianopsia, prosopagnosia,
topographic disorientation
82. Pontine hemorrhage: Tetraplegia and coma
Very poor prognosis
83. Position in space: Inability to perceive & to interpret spatial
concepts such as up, down, under, over, in, out, etc.
Lesion: non-dominant parietal lobe
84. Posterior watershed zone: PCA meets MCA (leads to cortical
blindness and aphasia)
85. Primary ICH: A spontaneous bleed due to microvascular
disease associated with HTN and/or aging
Rupture of microaneurysms that burst as a result of HTN
Small penetrating arteries are most involved
86. Prognosis of ICH: Good because lesions are characterized by
compression as opposed to tissue destruction. (although in
general this type of stroke is very fatal becuase of the
displacement of brain tissue and significant increase in HTN
which can compress vital centers)
87. Prosopagnosia: Inability to recognize familiar faces
88. Psychological problems are more severe with ______ CVA:
Left
89. Putaminal hemorrhage: Similar to MCA stroke but with greater
alteration of consciousness
90. Reflex sympathetic dystrophy (RSD): Also known as complex
regional pain syndrome
Causes swelling and tenderness in the fingers, hands and
shoulder
91. Right CVAs result in __________ weakness and sensory loss.
Left CVAs result in _________ weakness and sensory loss: left-
sided, right-sided
92. Right-left discrimination: iInability to identify the R or L side of
one's own body or the examiner.
Lesion: parietal lobe of either hemisphere
93. Secondary complications of a SAH often prove _______: fatal
2˚ complications include Vasospasm and inflammatory and
fibrotic responses in the meninges
94. Secondary ICH occurs due to ______________________: trauma,
impaire coagulation, toxic exposure
95. Sensory Neglect after stroke: Lack of awareness in
contralesional hemispace
80% of Right CVA demonstrate visual neglect.
96. Severe aphasia of both production and comprehension
resulting in poor reading and auditory comprehension,
repetition, naming and writing. Speech is non-fluent. This is
known as:: global aphasia
97. sever ischemia leads to necrosis of neurons and supporting
cellular elements (glial cells). The ______________________ may
remain viable for several hours from collateral arteries
anastomosing with branches of the occluded vascular tree:
penumbra
98. Simultanagnosia: Inability to percieve the hwole or the "big
picture", only sees 1 element of an object at a time (decreased
visual span, tubular vision)
99. Somatognosia: Lack of awareness of the body strucutre and
the relationship of body parts in oneself or in others
Difficulty performing transfers, following directions
100. Somatognosia is due to lesions in ______________________.
Unilateral neglect is due to lesions in _____________________:
Dominant parietal lobe/posterior temporal lobe, non-
dominant parietal-occipital area
101. Spacticity peaks in the Brunnstorm's stages of recovery
during stage ______________. It disappears at stage ___________: 3,
6 environment
102. Spatial Memory Deficit: Impaired memory of location of
objects/places (ie. Furniture in home)
Lesion: non-dominant parietal lobe
103. Spatial Relations Deficit: Inability to perceive the relationship
of one object in space to another object, or to oneself.
Difficulty crossing midline. i.e. drawing a clock, setting a table
Lesion: non-dominant parietal lobe
104. Subarachnoid Hemorrhage (SAH): Causes extreme elevations
in ICP due to obstruction of CSF coupled with cerebral edema
Common sites: Anterior communicating artery, posterior
communicating arter and middle cerebral artery
105. surgical management of ischemic CVA: -carotid
endarterectomy (treatment of choice for TIA)
-posterior fossa decompression (secondary to cerebellar
edema)
106. Syndromes of lacunar CVA can be either of three things:
Pure motor (internal capsule-posterior limb)
Facial weakness (internal capsule-anterior limb)
Pure sensory (posterolateral thalamus)
107. systemic cause of ischemia CVA: -low systemic perfusion
secondary to cardiac failure or significant blood loss
-widespread hypo-perfusion and ischemia lead to anoxic brain
injury
-neurological deficits are global and bilateral in nature
108. Thalamic hemorrhage: Results in contralateral hemiplegia with
disproportionately greater sensory loss
109. Thrombic ischemia: the development of existence of a blood
clot within the cerebral vascular system. This makes up 40% of
CVS's and typically occurs in a vessel that is already partially
occluded by atherosclerosis
110. Thrombic occlusion have the tendency to develop at sites
of turbulent flow. They are most common in:: internal carotid
artery & vertebral artery
Basilar artery & middle cerebral artery
111. thrombolytic agents are given within _____ hours ofo nset to
break up the thrombus to restore normal circulation.: 6; this
helps increases chance of recovery and minimize disability
112. Topographical Disorientation: Difficulty in understanding &
remembering the relationship of one location to another,
unable to trace path/route
Lesion: non-dominant occipito-parietal lobe
113. True or false? Left-sided CVAs are more associated with
aphasias and apraxia: True!
114. true or false: MRI's are typically used for patients with a
pacemaker: false; MRI's CANNOT be performed if patient has
a pacemaker or any other implantable device
115. True or false? There is a significant chance of re-bleeding
with mild/mod SAH: False! Mod/severe
116. Unilateral neglect: Inability to register and to integrate stimuli
and perceptions form one side of the body and the
117. upper division MCA involvement of the dominant
hemisphere results in _____________ aphasia. lower division
MCA occlusion of the dominant hemisphere result in
____________ aphasia: broca's, wernickes
118. Vertical Disorientation: Distorted perception of what is
vertical; causes imbalance & distorted midline orientation
Lesion: non-dominant parietal lobe
119. Wallenberg's Syndrome: a vertebral artery syndromes
characterized by ipsilateral vertigo. nausea, nystagmus,
ipsilateral hoarseness and dysphagia, Horners syndrome,
ipsilateral ataxia, ipsilateral loss of facial sensation to pain and
temperature, ipsilateral loss of sensation on arm, trunk and leg,
contralateral loss of pain and temperature
120. What are contractures?: Shortening of muscles, tendons,
ligaments, joint capsule which leads to restricted ROM
121. what are the most common origins of emboli: A-fib and MI
122. What is spasticity?: Lack of inhibition from higher levels
causes an increase in stretch reflexes, exaggerated flexor
muscle response,
123. what is the danger of using anticoagulation therapy with
patients experiencing an ischemic CVA?: there is a risk of
conversion into a hemorrhagic CVA
124. what is the most common type of CVA?: ischemia (80%)
125. What is the most modifiable risk factor of a hemorragic
CVA?: Hypertension
126. What is the motor recovery progression after stroke: 139. Why do stroke patients have incoordination?: Cerebellar or
Initially flaccid BG involvement
Development of spasticity, hyperreflexia and synergies Proprioceptive losses
Spasticty and synergies decline and advanced movment motor weakness
patterns are possible Ataxia
127. What is the typical hemi arm posture?: Combination of Impaired stretch reflex response
flexion and extension patterns 140. Why is the cerebellum and brainstem a concern with
- Shoulder ADD (Extension) stroke?: Cerebellar edema may develop, resulting in death
- Elbow flexion (Flexion) from brainstem compression or herniation
- Forearm pronation (Extension)
- Wrist flexion (Flexion)
128. What is the typical hemi leg posture?: Combination of flexion
and extension patterns
- Hip flexion and adduction
- Knee extension
- Ankle plantarflexion
129. What type of stroke is caused by bleeding from an arterial
source into the brain parenchyma and is the most fatal?:
Intracerebral Hemorrhage
130. When does recovery from ICH occur?: When/if blood is
reabsorved before signficant tissue destruction occurs
131. Where do lacunar CVAs occur?: In the deep white matter of
the brain where tiny arterioles branch off of larger vessels &
are vulnerable to hypertensive hemorrhage or the vessel may
thicken or thrombose
132. which areas are most prone to anoxic brain injury?:
hippocampus (memory deficits)
purkinje fibers of the cerebellum (ataxia)
basal ganglia (incr. muscle tone)
133. which imaging intervention is most commonly used with
CVA patients?: CT scan
134. which of the following is the single most significant
controllable modifiable risk factor for CVA

A. Hypertension
B. adult onset diabetes (type2)
C. Cigarette smoking
D. Drug use: A. hypertension
135. while ischemia CVA is rarely fatal, _________________ is a
potential fatal sequela: cerebral edema (peaks in 3 to 4 days)
136. Why are AVMs a concern?: Due to the lack of capillary
communication, there is no O2 or glucose exchange in that
area
137. Why do contractures occur?: Lack of muscle opposition
Hypertonicity
Lack of normal positioning
138. Why do stroke pateints have paresis?: A decrease in the
number of functioning agnosti motor units
Recruitment order may be altered
Firing rates decrease
Denervation changes in corticospinal tract
Atrophy of muscle fibers