Tina Postrel, SPT

UCF DPT c/o 2015

Stroke Prognosis, in general

Classifications of strokes

Prognosis◦ Ischemic stroke

Early prognosis

Late prognosis

◦ Hemorrhagic stroke Early prognosis

Define Vasospasm

Late prognosis

EBP

Rehab principles

Summary

The greatest amount of recovery occurs in the first 7-14 days◦ Swelling subsides

◦ Impairments may resolve spontaneously

◦ “Reversible ischemic neurological deficit”

Residual neurological impairments, may lead to permanent disability…

14% of persons who survive an initial

stoke or TIA will experience another

one within 1 year

By specific vascular

territory or region:

•Artery: MCA,

ACA, PCA

•Lobe: Frontal,

temporal,

occipital, etc.

By management:

•Minor/major

stroke

•Young stroke

•Deteriorating

Stroke

By Etiology:

•Thrombosis

(Ischemic)

•Embolus

(Ischemic)

•Hemorrhage

Early Prognosis: Late Prognosis:

Hemorrhagic Stroke POOR GOOD

Ischemic Stroke FAIR FAIR

80% of strokes are Ischemic◦ only 8% of those pts

actually receive tPA

◦ tPA given to Ischemic only

Associated c heart disease◦ Afib, MI, CAD

◦ Modification of risk factor for improved prognosis

Factors affecting early prognosis:◦ tPA◦ Hemorrhagic Transformation ◦ GCS <9 at admission◦ Infarct size correlation c edema

ICP rise 2-5 days later may necessitate Bone Flap

Early Prognosis is FAIRin IS!◦ Zone of Penumbra

◦ Physiologically stunned

◦ Salvaged if cerebral perfusion obtained

◦ Early mortality rate (<30 days) is minimal: 8%

◦ initial impairments less severe than hemorrhagic strokes

Late Prognosis is FAIR in IS!◦ Lower rate of functional return

Slower, more gradual rate of functional return when compared to hemorrhagic strokes

Factors affecting late prognosis:◦ GCS <9 at admission

◦ Comorbidities: Afib, DM

◦ PLOF

20% of strokes are Hemorrhagic

Aneurysm formation◦ Atherosclerosis

◦ Chronic HTN

◦ Arteriovenous Malformation

Associated c HTN◦ Clinical application

◦ Modification of risk factor

for improved prognosis

Early Prognosis is POOR in HS!◦ Hemorrhagic has high mortality rate

50% within 1st month

◦ severe functional impairments

-Hematoma expansions

-Edema formation-Intraventricular

hemorrhage

Rapid increase

in intracranial

pressure

Vasospasm

Risk 10 days

Hemorrhage release blood into extravascular space◦ RBCs break down◦ Byproducts irritate walls of artery◦ Can cause artery to contract & spasm◦ Spasm reduce blood flow down stream, at risk for

another stroke◦ Highest risk 5-10 days after HS

Late Prognosis is GOOD in HS!

Hematoma

resolves

Brain

compression

reduces

Neurological

function

recovers

Partially or

wholly return

to function!

“Early and Late Mortality of Spontaneous Hemorrhagic Transformation of Ischemic Stroke” (2014)

Hemorrhagic Transformation: ◦ Petechial hemorrhage:

Small, no space occupying effect

◦ Parenchymal Hematoma: “mass effect”

independently predicts both early and late mortality

Results: Predictors of Mortality-◦ 30 days:

PH

Low GCS @ admission

◦ 90 days:

PH

Infarct size

“Functional Outcome of Ischemic and Hemorrhagic Stroke Patients After Inpatient Rehabilitation” (2003)

Intervention: ◦ Inpatient Rehab: 60 mins, 2xday, 5 days per week

Results: ICH had a better rehab prognosis at D/C than ischemic strokes◦ Higher Canadian Neurologic Scale

◦ Higher Rivermead Mobility Index scores

◦ Higher Barthel Index scores (2.5x greater than ischemic strokes)

“Hemorrhagic and Ischemic Strokes Compared

Stroke Severity, Mortality, and Risk Factors”

(2009)

Results: HS have higher early morbidity◦ Linear association between stroke severity and HS

◦ HS have overall higher mortality risk than IS

Increased risk time-dependent

HS: 4x higher initial mortality

HS: 2.5x higher, s/p 1 week

HS: 1.5x higher, s/p 3 weeks

HS: same, s/p 3 mo

Ischemic Stroke Hemorrhage Stroke

Guidelines: tPA protocol in acute care; cardiovascularconsult, EKG/carotid doppler, Echo

Clearance by NSG for mobilization and SBP guidelines

Risks: hemorrhagic transformation; increase ICP 2-5 days after, may necessitate bone flap

Vasospasm risk (10 days)-Daily Transcranial dopplers

Pt education: Cardiovascular etiology

HTN etiology

Prognosis: Fair- less functional recovery long term

High incidence of early mortality, better long term functional recovery

1) O'Sullivan S, Schmitz T. Physical Rehabilitation: Assessment And Treatment. 5Th Ed. Philadelphia;: F.A. Davis; 2001. Available from: SPORTDiscus, Ipswich, MA.

2) Persson M, Fhager A, Elam M, et al. Microwave-based stroke diagnosis making global pre-hospital thrombolytic treatment possible. IEEE Transactions On Bio-Medical Engineering. June 12, 2014;Available from: MEDLINE, Ipswich, MA.

3) D'Amelio M, Terruso V, Aridon P, et al. Early and Late Mortality of Spontaneous Hemorrhagic Transformation of Ischemic Stroke. Journal Of Stroke & Cerebrovascular Diseases. 2014;23(4):649-654.

4) Schepers V, Ketelaar M, Visser-Meily A, de Groot V, Twisk J, Lindeman E. Functional recovery differs between ischaemic and haemorrhagic stroke patients. Journal Of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation) [serial online]. June 2008;40(6):487-489.

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7) Paolucci S, Antonucci G, Pratesi L, et al. Functional outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: a matched comparison. Stroke (00392499). December 2003;34(12):2861-2865.

8) Mayfield Clinic & Spine Institute: Subarachnoid Hemorrhage & Vasospasm. http://www.mayfieldclinic.com/PDF/PE-SAH.pdf Published February 2013. Accessed July 19, 2014.

9) Andersen K, Olsen T, Dehlendorff C, Kammersgaard L. Hemorrhagic and Ischemic Strokes Compared Stroke Severity, Mortality, and Risk Factors. Stroke. 2009.;40(6):2068-2072.