Cerebrovascular Accident

General Information
Case no.	5.A Cerebrovascular Accident
Authors	Ethan Hood, PT, DPT, MBA, Board Certified Clinical Specialist in Geriatrics Physical Therapy, Board Certified Clinical Specialist in Neurologic Physical Therapy Jessica Schwartz, MSPAS, PA-C
Diagnosis	Acute left middle cerebral artery (MCA), cerebrovascular accident (CVA)
Setting	Emergency Department, with transfer to Neurology Ward
Learner expectations	☑ Initial evaluation □ Re-evaluation □ Treatment session
Learner objectives	Recognize the symptoms of stroke and determine most likely location based on presenting symptoms and physical exam. Develop an appropriate rehabilitation plan of care, including the roles of the team members involved. Determine a safe and appropriate discharge plan for a patient who has been diagnosed with a CVA, including any durable medical equipment that may eventually be required. Identify how to work collaboratively with other medical teams when caring for a patient with a CVA (e.g., medicine, neurology, physical therapy, occupational therapy (OT), speech therapy (ST), case management, and nursing).

Medical
Chief complaint	“Right side weakness and unable to speak properly” for 2 hours
History of present illness	The patient is a 67-year-old right-handed male who presented to the emergency department due to severe right side weakness and speech deficits. He was last seen in his normal state of health the night prior when going to bed. The symptoms started in the morning around 06:00 when the patient woke up. The patient’s wife noted weakness on the patient’s right side, specifically that he was not using his right upper extremity. She also noted that the patient’s right-side face looked “funny.” He was having difficulty with his speech, which the wife described as “trouble finding words, can’t seem to get the words out.” The patient confirmed with shaking his head “no” that he cannot feel his right arm. He denied headache or vision changes. The patient’s wife noted that although he had walked this morning, he was still required some assistance. He is typically independent with all mobility. His symptoms have been persistent without change since he woke up 1 hour ago this morning. He has not had any fevers or chills, recent illness, recent travel, or heart palpitations. He has never had symptoms like this in the past.
Past medical history	Hypertension, coronary artery disease, myocardial infarction with drug-eluding stent placement 10 years ago, hypercholesterolemia, diabetes mellitus type 2, smoked for 25 years (1 pack/day)—quit 10 years ago, and obesity—body mass index = 30.1
Past surgical history	Drug-eluding stent placed 10 years ago
Allergies	No known drug allergies
Medications	Lisinopril, Metoprolol tartrate, Aspirin, Atorvastatin, Metformin
Precautions/Orders	Stroke team consult: NPO until cleared by ST Bedrest for 24 hours then activity as tolerated Physical therapy and OT

Social history
Home setup	Resides in a split-level house with his wife. Three steps are there to enter the home with a left railing. Eight steps to the second floor are with a right railing ascending. Bedroom and bathroom are on the second floor. Woodworking shop and den are on the lower level, with eight steps and right rail to descend.
Occupation	Retired 2 years ago from teaching high school English for 35 years.
Prior level of function	Independent with functional mobility, activities of daily living (ADLs), and instrumental ADLs. Walks 1 mile/day with his wife and dog (+) Drives
Recreational activities	Fly fish and hunting (bow and arrow) Woodworking and makes his own furniture Visits two sons who live locally

Vital signs	Hospital day 0: emergency department
Blood pressure (mmHg)	168/90
Heart rate (beats/minute)	88
Respiratory rate (breaths/minute)	18
Pulse oximetry on room air (SpO₂)	97%
Temperature (°F)	96.9

Imaging/Diagnostic test	Hospital day 0: emergency department
Electrocardiogram (ECG)	1. Atrial Fibrillation, no acute ST-T wave changes
Chest X-ray	1. No acute Cardiovascular and pulmonary pathology noted
Computed tomography (CT)—head without contrast	1. No acute masses, hemorrhages, or infarcts noted
Magnetic resonance imaging (MRI)—brain Magnetic resonance angiography (MRA)—head and neck with and without contrast	Acute infarction in the left frontal and parietal lobes in the MCA territory (Fig. 5.1) No hemorrhage or mass noted Moderate occlusion noted at middle one-third of left M1 segment of the left MCA with some collateral flow
Transthoracic two-dimensional echocardiography	Left ventricle ejection fraction 65% No wall motion abnormalities Left and right ventricles without any hypertrophy or increased wall thickness Left and right atrial sizes normal, no dilation. No evidence of any valvular stenosis or regurgitation No evidence of clots or vegetation noted based on the limitations of transthoracic approach

Fig. 5.1 (a,b) Acute infarction in the left frontal and parietal lobes in the MCA territory. (Source: Arterial Ischemia. In: Valdueza Barrios J, Schreiber S, Röhl J, et al, ed. Neurosonology and Neuroimaging of Stroke: A Comprehensive Reference. 2nd ed. Thieme; 2017.)

Medical management	Hospital day 0: emergency department
Medications	Continue aspirin Metformin Hold lisinopril and metoprolol tartrate for first 2–3 days to allow permissive hypertension
Diet	Nothing by mouth (NPO) until seen by speech therapy Diet safety to be determined with swallow evaluation
Vitals	Every 4 hours with neuro checks Monitor telemetry for arrhythmias

Lab		Reference range	Hospital day 0: emergency department
Complete blood cell count	White blood cells	5.0–10.0 × 10⁹/L	7.6
	Hemoglobin	14–17.4 g/dL	14.1
	Hematocrit	42–52%	44
	Platelets	140–400 k/μL	190
Basic metabolic profile	Glucose	60–100 mg/dL	200
	Blood urea nitrogen (BUN)	6–25 mg/dL	21
	Creatinine	0.7–1.3 mg/dL	1.07
	Sodium	135–145 mEq/L	139
	Potassium	3.5–5.0 mEq/L	4.0
	Chloride	98–106 mEq/L	105
	Bicarbonate	21–28 mEq/L	25
	Calcium	8.6–10.3 mg/dL	8.8
Other	Fingerstick glucose	60–100 mg/dL	210
	International normalized ratio (INR)	1.0	0.8–1.2
	Troponin	< 0.02 ng/mL	< 0.02
	Hemoglobin A1C	4.0–5.6%	8.5%
	Cholesterol	< 200 mg/dL	240
	Low-density lipoprotein	65–180 mg/dL	170
	High-density lipoprotein	> 35 mg/dL	55
	Triglycerides	< 150 mg/dL	105

Pause points
Based on the above information: Is there any significance with the diagnostic tests and measures? Who are the members of the stroke team and what are their roles? Based on the above findings, describe what should be prioritized for the physical therapy examination.

Pause points

Based on the above information:

Is there any significance with the diagnostic tests and measures?
Who are the members of the stroke team and what are their roles?
Based on the above findings, describe what should be prioritized for the physical therapy examination.

Hospital Day 1: Physical Therapy Examination
Subjective
“I have difficulty finding the right word.” “My right side is weak.”
Objective
Vital signs	Pre-treatment			Post-treatment
Vital signs	Supine	Sitting	Standing	Post-treatment
Blood pressure (mmHg)	136/78	140/80	142/84	144/86
Heart rate (beats/min)	77	76	84	88
Respiratory rate (breaths/min)	12	12	16	16
Pulse oximetry on room air (SpO₂)	97%	96%	97%	96%
Modified rate of perceived exertion (RPE) scale (0–10)	1/10	2/10	3/10	4/10
Pain	0/10	0/10	1/10 at right shoulder	1/10 at right shoulder
General	A 67-year-old male, well developed and well nourished Supine in bed, awake, and in no acute distress Lines notable for peripheral intravenous line, urinary catheter, and telemetry
Cardiovascular and pulmonary	Auscultation: Clear lung sounds, irregularly irregular cardiac rhythm Pulses: 3 + bilateral dorsalis pedis and posterior tibialis
Gastrointestinal	Slight abdominal distension, no tenderness to palpation
Genitourinary	(+) urinary catheter
Cognition	Awake and alert Oriented once—able to state his name but not his birthdate, location, time, or situation Speech appears very slow and labored; has difficulty finding correct words to answer questions Follows one-step commands 100% of the time
Musculoskeletal	Range of motion	Passive range of motion of right upper extremity (RUE) and right lower extremity (RLE): within functional limit (WFL). Active range of motion of left upper extremity (LUE) and left lower extremity (LLE): WFL.
	Strength	L shoulder flexion: 5/5 R shoulder flexion: 1/5 L elbow flexion: 5/5 R elbow flexion: 1/5 L wrist extension: 5/5 R wrist extension: 0/5 L hip flexion: 5/5 R hip flexion: 3 + /5 L knee extension: 5/5 R knee extension: 3 + /5 L ankle dorsiflexion: 5/5 R ankle dorsiflexion: 3 + /5
	Aerobic	Not tested
Neurological	Balance	Static unsupported sitting: fair + , requires tactile cues for midline posture. Static unsupported standing: poor + , requires minimal assist with tactile cues for midline posture. Berg Balance Scale = 30/56
	Coordination	L cerebellar function intact with no dysdiadochokinesia LUE finger to nose intact. Unable to be performed on RUE Pronator drift unable to be performed due to weakness in RUE LLE heel to shin intact. RLE ataxic with heel to shin
	Cranial nerves	II–XII grossly intact except for noted right side facial droop, sparing the forehead Vision intact, fully tracking with eyes, with no visual field deficits. Denies diplopia.
	Reflexes	Brachioradialis: 1 + L, 2 + R Biceps brachii: 1 + L, 2 + R Triceps brachii: 1 + L, 2 + R Patellar: 1 + L, 2 + R
	Sensation	RUE: loss of sensation to crude touch and pinprick LUE, RLE, LLE: intact to crude touch and pinprick
	Tone	RUE flaccid, RLE hypotonic
Functional status
Bed mobility	Rolling to left: supervision with bedrails Supine to sit: minimal assistance once with head of bed elevated ~30 degrees
Transfers	Sit to/from stand: minimal assistance once with wide base quad cane
Ambulation	Ambulated 15 feet with minimal assistance and wide base quad cane Gait deviations notable for right hemiparetic gait, lack of right arm swing and movement requiring physical therapist to support, and poor right weight shift requiring physical therapy verbal and tactile cues to facilitate. Gait speed 0.20 m/second Fig. 5.2
Stairs	N/A
Other	Barthel Index: 30/100 Functional independence measure: 51 total score (35 motor, 16 cognitive)

Fig. 5.2 An example of a physical therapist guarding the patient during an ambulation trial.

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“To walk normal again”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☑ Physical therapist’s	Patient is to be seen twice a day for 4–5 days for therapeutic exercise, gait training, transfer training, endurance training, neuromuscular reeducation, patient and family education, positioning to minimize shoulder pathology and pain, and to facilitate discharge to appropriate care level.

Bloom’s Taxonomy Level	Case 5.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. Based on the patient’s presentation, what would be the best discharge environment? Why? 5. Based on this patient’s current presentation and history, what would be appropriate physical therapy prognosis? 6. How should the physical therapist rate the patient’s right hemibody tone?
Analyze	7. What is the significance of the patient’s Berg Balance Scale? 8. In terms of function, what is the importance of the patient’s gait speed? 9. What outcome measures may assist with functional prognosis? 10. What is the most likely etiology of this patient’s infraction based on his clinical presentation and workup thus far?
Apply	11. What cranial nerves are involved with eye function?
Understand	12. Why did medical management withhold blood pressure medications despite the patient’s current readings? What is the rationale? 13. What would be the most therapeutic position for this patient while he is in bed? Why?
Remember	14. What is the typical presentation of an MCA infarction? 15. What are some differences in presentation between a right MCA and a left MCA infarct? 16. What affected area of the brain causes expressive aphasia?

Bloom’s Taxonomy Level	Case 5.A Answers
Create	1. Patient presents with right hemibody weakness with reduced tone, impaired transfers, gait, and high fall risk on standardized balance testing due to the effects of L MCA distribution stroke impairing ADLs and function. Recommend skilled physical therapist to address the following goals. Recommend assisting once with all mobility while in hospital. Anticipate patient being a good acute inpatient rehabilitation candidate. 2. Short-term goals: Patient will demonstrate sit to/from stand transfer with contact guard assistance within 3 days to facilitate improved transfer ability. Patient will ambulate 30 feet on level surfaces with minimal assistance and wide base quad cane, demonstrating step to pattern, within 3 days to improve gait and endurance. 3. Long-term goals: Patient will ambulate 50 feet on level surfaces with contact guard assistance with wide base quad cane within 7 days to facilitate improve function in home. Patient will ascend/descend three steps with minimal assistance and left handrail when ascending within 7 days to facilitate getting into and out of his home.
Evaluate	4. Based on the patient’s age, prior level of function, past medical history, level of cognition, current functional status, and tolerance to activity, a discharge location of acute inpatient rehab would be most appropriate. 5. Based on the patient’s presentation, past medical history, and prior level of function, it is anticipated that the patient will be able to return to independence with functional mobility and community ambulation. He may, however, need adaptive equipment to assist with ADLs depending on his right upper extremity’s return. 6. The patient’s hemibody tone would be rated as follows: RUE, 0/4; RLE, 1/4.
Analyze	7. The Berg Balance Scale indicated that the patient is a high fall risk. 8. The patient’s current speed of 0.20 m/second is extremely slow and not conducive to the patient being a safe community ambulatory at this time. 9. The outcome measures that may assist with functional prognosis are the Functional Independence Measure and the Stroke Rehabilitation Assessment of Movement. 10. This patient most likely has a cardioembolic stroke due to atrial fibrillation. His electrocardiogram suggests evidence of atrial fibrillation, and his cardiac exam reveals an irregularly irregular rhythm. This is an example of a cerebrovascular accident as the initial presentation of new onset atrial fibrillation.
Apply	11. Cranial nerves II, III, IV, VI, and VIII are involved with eye function.
Understand	12. Medical management withheld for antihypertensives to allow the patient to have permissive hypertension in the first 24 hours after his acute ischemic stroke. This allows for adequate perfusion to areas of salvageable brain tissue (penumbra). 13. The most therapeutic position for this patient while he is in bed is right side lying. This is to maintain glenohumeral joint integrity (Fig. 5.3).
Remember	14. The typical presentation of an MCA infarction is upper extremity, followed by face and lower extremity, respectively. 15. While the following is not inclusive, a right MCA would have findings on the left side of the body with behavioral changes of impulsivity and minimal insight into deficits. An infarct of the left MCA would have deficits on the right side of the body, with insight into their deficits and tendencies to be extremely cautious. 16. Broca area (located in the dominant frontal lobe) causes expressive aphasia.