13.1 Cerebrovascular Accidents: Syndromes, Assessment, and Acute Care

Cerebrovascular Accidents: Syndromes, Assessment, and Acute Care

Sudden weakness, facial asymmetry, speech or visual change, or new severe imbalance can indicate stroke. In a clinic, stop the session and activate the local emergency stroke pathway. Record symptom onset or the last time the person was known to be at their baseline and report it to the receiving team. Saudi MOH urgent-care standards require rapid identification, stabilization and coordinated emergency transfer for suspected stroke. Symptoms that resolve still need urgent evaluation.

The stroke team uses urgent brain imaging to distinguish ischemia from hemorrhage and to guide treatment. Follow the Saudi Stroke Pathway Standards for a swallowing screen by a trained clinician before oral intake. Follow the stroke team’s plan if the screen is failed. The Saudi standards call for early multidisciplinary rehabilitation and therapy within 48 hours of admission for medically stable patients. AHA/ASA guidance advises against high-dose, very early mobilization within 24 hours after acute ischemic stroke.

Vascular Territories and Clinical Stroke Syndromes

Internal carotid circulation             Vertebrobasilar circulation
  ACA → medial frontal/parietal cortex    PCA → occipital and inferomedial temporal regions
  MCA → lateral cerebral hemisphere       Other branches → brainstem and cerebellum
        and deep perforator territory

Use the territory pattern as a clinical hypothesis and communicate the individual findings. The pattern varies with the branch, collateral supply, lesion extent and prior deficits.

Aphasia can occur when the dominant hemisphere language network is affected. Classic Broca-type aphasia is usually nonfluent and Wernicke-type aphasia is often fluent with impaired comprehension. Test these functions directly because real lesions can involve several language components. Contralesional spatial neglect and reduced awareness of deficits can follow a right hemispheric stroke. Field loss and neglect can coexist. Assess visual fields and attention separately during functional tasks. Limb apraxia can occur with either hemisphere involved and is commonly associated with left hemispheric lesions.

Central post-stroke pain can arise after injury to central sensory pathways, including thalamic or brainstem lesions. Burning pain or touch-evoked pain in an area with altered sensation prompts further assessment and consideration of other causes, such as a painful shoulder or peripheral neuropathy.

Brunnstrom's Six Stages of Motor Recovery

Brunnstrom's historical examination describes observable changes in voluntary movement and the influence of limb synergies. A synergy is a recurring combination of joint movements. For example, an upper-limb flexion pattern may combine shoulder abduction and external rotation, elbow flexion and forearm supination. An extension pattern may combine shoulder adduction, elbow extension and forearm pronation. Lower-limb flexion and extension patterns can couple the hip, knee and ankle. Test movement directly and record function separately.

Use the stages to describe what the person can do. Recovery varies across individuals, limbs and tasks. A manual strength grade alone cannot establish a stage. Use standardized impairment measures, such as the Fugl-Meyer Assessment, and observe activity and participation separately. Treatment selection depends on the current impairment and functional goal.

Post-Stroke Lateropulsion

Lateropulsion, historically called contraversive pushing, can appear as active displacement toward the more affected side or resistance to weight transfer toward the less affected side. It can affect sitting, standing, transfers and gait.

Observed behavior:  less affected limbs push → toward the paretic side
Examination:        leaning, limb use and response to upright correction
Training:           safe support → active midline orientation → functional practice

Karnath and colleagues found that their participants with severe pushing judged themselves upright when tilted toward the lesion side, about 18 degrees on average. The observed push was toward the paretic side. Lateropulsion has been associated with both thalamic and cortical lesions, and vertical perception can vary across patients and test conditions.

The Scale for Contraversive Pushing (SCP) records spontaneous posture, use of the less affected limbs to push, and resistance to correction in sitting and standing. Its maximum score is 6. One validation study found better agreement with clinical diagnosis when each component scored above zero. Document the protocol and interpret the findings with the examination. The Burke Lateropulsion Scale grades resistance in several functional positions and tasks, including walking when assessable.

Guard against falls and arrange support before moving. Guide active orientation to midline and practice the relevant transfer or standing task. Use tactile, proprioceptive, verbal and, when useful, visual references such as a door frame. Some patients also have neglect or difficulty interpreting visual cues. Use graded hands-on assistance for safety and avoid forceful correction that increases resistance.

Worked case. A 68-year-old in a stroke unit develops new left arm weakness greater than leg weakness, a left homonymous field deficit and left inattention. Stop and notify the stroke team immediately. The pattern raises concern for a right hemispheric event, possibly in the MCA territory. Once medically stable, assess field loss and inattention separately and test movement quality before assigning a motor stage. If the patient pushes left with the right arm and resists a return toward midline, document lateropulsion and practice an actively guided, safely supported transfer.