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ABSTRACT This case report describes a patient with a large right hemispheric acute ischemic stroke resulting in significant

neglect. The patient was a 69-year-old man, who stated that he twisted his right ankle and fell onto a tabletop. Patient remained on the tabletop for approximately 20-25 minutes until he was able to call out to his family. The family found the patient unable to move or walk. Additionally, he had slurred speech and obvious facial weakness. The patient reportedly had no loss of consciousness, headache, nausea, vomiting, shortness of breath or other constitutional complaints at the time of onset. His son sends him to hospital. Upon arrival, he was found to have flaccid hemiplegia on the left, with a significant facial droop. The patient also developed complete hemianopsia, left gaze deviation, significant neglect of his left side as well as a profound left sided sensory loss. However, the patient denied when he was informed that he might be having stroke and wanted to be treated only for his ankle. Usually, the problems that can be developed in acute stroke patient are muscle weakness with difficulty to ambulate and perform daily activities, cognitive impairment, swallowing and speech impairment, bladder and bowel problems, spasticity and other social problems. An appropriate assessment tools should be done to confirm and analyze the problems in stroked patient such as NIH stroke scale (NIHSS), motor assessment scale (MAS) and functional independence measure (FIM) as an assessment tool. However, assessment should be relevance and related to the patient problems. Aim of treatment also should be starts as soon as possible to minimize the potential of possible complications.

THE CURRENT ROLE OF PHYSIOTHERAPY IN NEUROLOGICAL PRACTICE ; STROKE

WHAT IS STROKE ?

AUSTRALIAN BRAIN FOUNDATIAON DEFINATION : Stroke is the most common cause of death after heart disease and cancer in Western countries, yet most people do not understand the nature of stroke, the need all support and understanding they can get from those closest to them. Ignorance of stroke creates fear and misunderstanding which can build barriers stroke persons and their support. A stroke is cause by either blockage or rupture of a blood vessel surrounding the brain. These events may than produce

motor, sensory or intellectual dysfunction.

W.H.O CLASSIFICATIONS A STROKE 2003

Definition: Rapidly developing clinical signs of focal (global) disturbance of cerebral

functions with symptoms leading 24 hours or longer or leading death, with no apparent cause other than vascular origin.

THE CURRENT ROLE OF PHYSIOTHERAPY IN NEUROLOGICAL PRACTICE ; STROKE

THE STRUCTURES OF THE BRAIN: The brain is divided into the three main components. Cerebrum which is responsible for higher intellectual function, integration of sensory stimuli of all type, initiation of the final common pathway for movement and fine control movement. The cerebellum, which is responsible for further control of movement and co-ordination The brain stem, which is responsible for a variety of important function

including co-ordination of eye movements and maintenance of balance, respiration and blood pressure.

THE BLOOD SUPPLY TO THE BRAIN : Blood circulation to the brain is via two major systems as shown . The largest amount of blood is conducted by two carotid arteries , the pulsations of which may be readily felt in your own neck. The two smaller vertebral arteries comprise the vertebrobasilar

circulation system and serve the hind brain , reaching the brain by traveling in close association with the vertebral column at the of neck . back

WHAT CAUSES A STROKE ? Blockage of a blood vessel within the brain. Rupture of a blood vessel within the brain.

THE CURRENT ROLE OF PHYSIOTHERAPY IN NEUROLOGICAL PRACTICE ; STROKE

Rupture of a blood vessel into the space surrounding the brain, the subarachnoid space. It does not usually cause distortion of brain structure, but may cause spasm of the blood vessels nearby, thus impairing the blood supply to this area. this form of subarachnoid haemorrhage. haemorrhage is called

WHAT CAUSES BLOOD VESSELS TO BLOCK OR RUPTURE ? Blood vessels in the brain most commonly block because a blood clot has broken off and traveled along an artery up into the brain until the vessel size allows no further passage. The source of the clot is usually as follows. The internal carotid artery where deposits of fatty material ( atheroma ) cause narrowing of the artery ( stenosis ). The site of this narrowing is most often at the point where the common carotid artery devides into its internal and external branches. The heart: For this to occur, the heart usually has a major functional or structural abnormality, such as an abnormal rhythm ( atrial fibrillation ), recent heart attack ( myocardial infarct ) or a generalised weakness of heart muscles ( cardiomyopathy )

THE CURRENT ROLE OF PHYSIOTHERAPY IN NEUROLOGICAL PRACTICE ; STROKE

Rupture of the blood vessels is less common and is usually due to a defect in the vessel wall. This may occur in three major ways. The effects of high blood pressure ( hypertension ) over a prolonged period of time cause damage to the brain Rupture of a defect in the wall of vessels surrounding the brain . The defect is in the form of an outpouching of the artery and is called aneurysm , or Berry aneurysm . Rupture of the malformed blood vessels within the brain . These malformations occur at the junction of the arterial and venous small blood vessels deep within

system and are hence termed arteriovenous malformations, or A-V malformations.

WHAT FACTORS PREDISPOSE ONE TO DEVELOP A STROKE ? increase in age hypertension smoking diabetes others - high cholesterol , obesity , lack of exercises and stress

THE CURRENT ROLE OF PHYSIOTHERAPY IN NEUROLOGICAL PRACTICE ; STROKE

SYMTOMS OF SMALL WARNING STROKES Approximately 50% of patients who subsequently have a stroke due to blockage of a blood Vessel ( cerebral infarction ) have a small warning episode termed a TIA attack. This may often be of the same clinical pattern as the eventual stroke but of briefer duration . Many of these warnings last for minutes only, although occasionally they may last for several hours , or even up to 24 hours. TIAs may be located in either the carotid or vertebrobasilar circulation systems. The symptoms which may be experienced are follows: In the region of the carotid arteries Fleeting blindness of vision in one eye. Speech disturbance Weakness or paralysis of face , arm or leg. In the region of the vertebral arteries Vertigo Double vision Facial numbness or weakness Slurring speech Swallowing difficulty Arm or leg weakness or paralysis Loss of balance

THE CURRENT ROLE OF PHYSIOTHERAPY IN NEUROLOGICAL PRACTICE ; STROKE