IPHREHAB : INTRACEREBRAL HEMORRHAGE & TREATMENT

IPHREHAB


INTRACEREBRAL HEMORRHAGE & TREATMENT
The management of patients with large intracerebral hemorrhages and coma includes the maintenance of adequate ventilation, use of controlled hyperventilation to a Pco2 of 25 to 30 mmHg, monitoring of intracranial pressure (ICP) in some cases and its control by the use of tissue-dehydrating agents such as mannitol (osmolality kept at 295 to 305 mosmol/L and Na at 145 to 150 meq), and  limiting intravenous infusions to normal saline.


Rapid reduction in blood pressure, in the hope of reducing further bleeding , is not recommended, since it risks compromising cerebral perfusion in cases of raised intracranial pressure. On the other hand, sustained mean blood pressure  of greater than 110mmHg may exaggerate cerebral edema and risk extension of the clot. It is at approximately this level of acute hypertension that the use of beta-blocking drugs(esmolol, labetalol) or angiotensin-converting enzyme inhibitory drugs is recommended.


In contrast to cerebral hemorrhage, the surgical evacuation of cerebellar hematomas is a generally accepted treatment and is a more urgent matter because of the proximity of the mass to brainstem and the risk of abrupt progression to coma and respiratory failure.




Course and Prognosis
The immediate prognosis for large and medium-size cerebral clots is grave; some 30 to 35 percent of patients die in 1 to 30 days.
Either the hemorrhage extends into the ventricular system or intracranial pressure is elevated to levels that preclude normal perfusion of the brain.
Sometimes the hemorrhage itself seeps into vital centers such as the hypothalamus or midbrain.


A volume of 30 ml or less, calculated from the CT scan, predicted a generally favorable outcome.
In patients with clots of 60 ml or larger and an initial Glasgow Coma Scale score of 8 or less, the mortality was 90 percent. As remarked earlier, it is the location of the clinical effects.

IPHREHAB : Embolic infarction

IPHREHAB


Embolic infarction
This is one of the most common cause of stroke. In most cases of cerebral embolism, the embolic material consists of a fragment that has broken away from a thrombus within the heart. Embolism due to fat, tumor cells, fibrocartilage, amniotic fluid, or air is a rare occurrence and seldom enters into the differential diagnosis of stroke.

Clinical Picture

Of all strokes, those due to cerebral embolism develop most rapidly. The embolus strikes at any time of the day or night. Getting up to go to the bathroom is a time of danger. The neurologic picture will depend on the artery involved and the site of obstruction.

It  is important to repeat that an embolus may produce a severe neurologic deficit that is only temporary; symptoms disappear as the embolus fragments. In other words , embolism is a common cause of a single evanescent stroke that may reasonably be called a prolonged TIA. Also as already pointed out, several emboli can give rise to two or three transient  attacks of differing pattern or , rarely , of almost identical pattern.

Causes of cerebral embolism:

Cardiac origin

Noncardiac origin

Undetermined origin

Laboratory Findings

Not infrequently the first sign of myocardial infarction is the occurrence of embolism; therefore it is advisable that an ECG and echocardiogram be obtained in all patients with stroke of uncertain origin. Prolonged study of heart rhythm with Holter monitoring should be undertaken.

In some 30 percent of cases, cerebral embolism produces a hemorrhagic infarction. CT scanning or MRI may be helpful in showing the more intense hemorrhagic infarcts, particularly if the scan is repeated on the second or third day.

Course and prognosis

Most patients survive the initial insult, and in many the neurologic deficit may recede relatively rapidly, as  indicated above. The eventual prognosis is determined by the occurrence of further emboli and the gravity of the underlying illness- cardiac failure myocardial infarction, bacterial endocarditis  and so on.

Treatment and prevention

Three phases of therapy : General medical management in the acute phase, Measures directed to restoring the circulation Physical therapy and rehabilitation These are much the same as described above the prevention of atherothrombotic infarction.

IPHREHAB : DIFFERENTIAL DIAGNOSIS AND TREATMENT CEREBRAL THROMBOSIS AND TIAs

IPHREHAB

DIFFERENTIAL DIAGNOSIS CEREBRAL THROMBOSIS AND TIA


Differential Diagnosis
Vascular disorders are mistaken for ischaemic stroke include intracerebral hemorrhage, subdural or epidural hematoma , and subarachnoid hemorrhage from rupture of an aneurysm or vascular malformation. These condition can often be distinguished by a history of trauma or of excruciating headache at onset, a more marked depression of consciousness, or by the presence of neck stiffness on examination. They can be excluded  by CT scan or MRI.


Differential Diagnosis: Other structural brain lesion such as tumor or abscess can also produce focal cerebral symptoms of acute onset. Brain abscess is suggested by concurrent fever, and both abscess and tumor can usually be diagnosed by CT scan or MRI. Metabolic disturbances, particularly hypoglycemia and hyperosmolar nonketotic hyperglycemia, may present in stroke like fashion. The serum glucose level should therefore be determined in all patients with apparent stroke.

Treatment of Cerebral Thrombosis and Transient Ischemic Attacks

The current treatment of it may be divided into four parts:

Management in the acute phase

Measures to restore the circulation and arrest the pathologic process

    1. Thrombolytic agents ( t-PA only for completed stroke,w/in 3~6hrs ) 2.Anticoagulant drugs ( Heparin, LMWH & warfarin)

    3. Antiplatelet drugs ( Aspirin  or  Clopidogrel, Dipyridamole or   Ticlopidine )

    4.Difibrase

    5. Neuroprotective agents: barbiturates, opioid  antagonist naloxone,Manitol

Treatment

Treatment of cerebral edema and raised intracranial pressure

Acute surgical revascularization 

Surgery for symptomatic carotid stenosis, Carotid endarterectomy, intralumenal stents, extracranial-intracranial bypass

Physical therapy and rehabilitation.

Measures to prevent further strokes and progression of vascular disease.

• Since the primary objective in the treatment  of  atherothrombotic disease is prevention , efforts to control the risk factors must continue. 
• Aspirin
• Hypotensive agents
• Oversedation should be avoided
• Systemic hypotension, severe anemia should be treated promptly
• Particular care should be taken to maintain the systemic blood pressure, oxygenation  and intracranial  blood flow during surgical procedures, especially in elderly patient.

Course and Prognosis

When the patient is seen early in the cerebral thrombosis, it is difficult to give an accurate prognosis.

As for the eventual or long-term prognosis of the neurologic deficit , there are many possibilities.

It must be mentioned that having had one thrombotic stroke, the patient is at risk in the ensuing months and years of having a stroke at the same or another site, especially if there is hypertension or diabetes mellitus.

IPHREHAB : HYPOTONIA MANIFESTATION

IPHREHAB :

HYPOTONIA MANIFESTATION


Signs and objective manifestations
Hypotonic patients may display a variety of objective manifestations that indicate decreased muscle tone.
Motor skills delay is often observed, along with hypermobile or hyperflexible joints, drooling and speech difficulties, poor reflexes, decreased strength, decreased activity tolerance, rounded shoulder posture, with leaning onto supports, and poor attention and motivation.
The extent and occurrence of specific objective manifestations depends upon the age of the patient, the severity of the hypotonia, the specific muscles affected, and sometimes the underlying cause. For instance, some hypotonics may experience constipation, while others have no bowel problems.

§Since hypotonia is most often diagnosed during infancy, it is also known as "floppy infant syndrome" or "infantile hypotonia." Infants who suffer from hypotonia are often described as feeling and appearing as though they are "rag dolls" or a "sack of jello," easily slipping through one's hands.

§They are unable to maintain flexed ligaments, and are able to extend them beyond normal lengths. Often, the movement of the head is uncontrollable.

§Hypotonic infants often have difficulty feeding, as their mouth muscles cannot maintain a proper suck-swallow pattern, or a good breastfeeding latch.

Developmental delay

Most low-tone infants have delayed developmental milestones, but the length of delay can vary widely. Motor skills are particularly susceptible to the low-tone disability.

Gross motor skills, and fine motor skills, both are affected. 

Hypotonic infants are late in lifting their heads while lying on their stomachs, rolling over, lifting themselves into a sitting position, remaining seated without falling over, balancing, crawling, and walking. Fine motor skills delays occur in grasping a toy or finger, transferring a small object from hand to hand, pointing out objects, following movement with the eyes, and self feeding.  

§Speech difficulties can result from hypotonia. Low-tone children learn to speak later than their peers, even if they appear to understand a large vocabulary, or can obey simple commands.

§ Difficulties with muscles in the mouth and jaw can inhibit proper pronunciation, and discourage experimentation with word combination and sentence-forming.

Diagnosis

Diagnosing a patient includes obtaining family medical history and a physical examination, and may include such additional tests as computerized tomography (CT) scans, magnetic resonance imaging (MRI) scans, electroencephalogram (EEG), blood tests, genetic testing (such as chromosome karyotyping and tests for specific gene abnormalities), spinal taps, electromyography muscle tests, or muscle and nerve biopsy.

Mild or benign hypotonia is often diagnosed by physical and occupational therapists through a series of exercises designed to assess developmental progress, or observation of physical interactions.

§Since a hypotonic child has difficulty deciphering his spatial location, he may have some recognizable coping mechanisms, such as locking the knees while attempting to walk.

§ A common sign of low-tone infants is a tendency to observe the physical activity of those around them for a long time before attempting to imitate, due to frustration over early failures.

§ Developmental delay can indicate hypotonia

Prognosis and treatment

There is currently no known treatment or cure for most (or perhaps all) causes of hypotonia, and objective manifestations can be life long. 

In some cases, muscle tone improves over time, or the patient may learn or devise coping mechanisms that enable him to overcome the most disabling aspects of the disorder. However, hypotonia caused by cerebellar dysfunction or motor neuron diseases can be progressive and life-threatening. 

Along with normal pediatric care, specialists who may be involved in the care of a child with hypotonia include developmental pediatricians (specialize in child development), neurologists, neonatologists (specialize in the care of newborns), geneticists, occupational therapists, physical therapists, speech therapists, orthopedists, pathologists (conduct and interpret biochemical tests and tissue analysis), and specialized nursing care. 

If the underlying cause is known, treatment is tailored to the specific disease, followed by symptomatic and supportive therapy for the hypotonia. 

In very severe cases, treatment may be primarily supportive, such as mechanical assistance with basic life functions like breathing and feeding, physical therapy to prevent muscle atrophy and maintain joint mobility, and measures to try and prevent opportunistic infections such as pneumonia. 

Treatments to improve neurological status might involve such things as medication for a seizure disorder, medicines or supplements to stabilize a metabolic disorder, or surgery to help relieve the pressure from hydrocephalus (increased fluid in the brain). 

Breast Feeding

Low-tone infants often have difficulty feeding, especially coordinating the suck-swallow reflex required for proper breastfeeding.

Take longer to breastfeed because of the poor timing of sucking bursts and the need for long rests. 

They will also require greater feeding frequency

A baby with low muscle tone may suck better when the head and bottom are level, indicating pillow support in the lap.

If nursing is too frustrating and stressful for mother and child, breast milk can be expressed by use of a breast pump and fed through a bottle.