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STROKE (CVA)

Introduction

A cerebrovascular accident (CVA), typically referred to as a stroke, is a common medical condition caused by a sudden interruption of blood supply to a part of the brain. It results in various cognitive, emotional, and physical deficits throughout the body, and disability of the upper extremity is extremely common. Many stroke patients consequently encounter severe functional impairments of the arm and/or hand, which often lead to difficulty performing bimanual activities in daily life. The chief component of stroke rehabilitation is physical and/or occupational therapy, which could include a variety of traditional and emerging interventions, while medications like thrombolytics, warfarin, or anti-hypertensive drugs may also be used to manage symptoms and prevent future complications. Surgery may be indicated for certain patients who have relatively intact motor control and sensation, and tendon lengthening and tendon transfer procedures are two options commonly used to relieve pain and restore function.1,2
 

Pathophysiology

  • A stroke is caused by either the blockage of a blood vessel supplying the brain, as in ischemic stroke, or bleeding into or around the brain, as in hemorrhagic stroke, which results in the death of brain cells.3
  • Upper motor neuron syndrome which can be seen in patients who sustained a stroke can be characterized by muscle weakness, decreased motor control, easy fatigability, altered muscle tone, and exaggerated deep tendon reflexes that can lead to an imbalance of muscle forces across a joint, ultimately leading to static or dynamic joint deformities.
  • More than 50% of stroke survivors experience some level of lasting hemiparesis or hemiplegia resulting from damage to neural tissues, and these patients are typically unable to perform basic activities of daily living (ADLs)
    • The relationship between hand function and the ability to perform ADLs is stronger than it is for any other limb region, making the recovery of hand functionality extremely important3
    • Some common risk factors for stroke include older age, hypertension, diabetes, heart disease, smoking history, illegal drug use, atrial fibrillation, and family history4

Related Anatomy

  • Common carotid arteries
  • Vertebral arteries
  • Circle of Willis
  • Anterior cerebral artery
  • Middle cerebral artery
  • Posterior cerebral artery
  • Posterior inferior cerebellar arteries
  • Lenticulostriate arteries
  • Intrinsic muscles of the hand, wrist, forearm, elbow, arm and shoulder
  • Extrinsic muscles of the hand, wrist, forearm, elbow, arm and shoulder

Incidence 

  • With an annual incidence of ~795,000, stroke is the fourth leading cause of death and the leading cause of long-term disability in the United States5
  • About 87% of all strokes are ischemic strokes6
  • Up to 80% of stroke survivors report residual upper limb functional deficits7

 Related Conditions

  • Hemorrhagic stroke
  • Ischemic stroke
  • Transient ischemic attack (TIA)
  • Cerebral thrombosis
  • Cerebral embolism
  • Atherosclerosis
  • Intracerebral hemorrhage
  • Subarachnoid hemorrhage
  • Arteriovenous malformation
  • Aneurysm
  • Hemiplegia
  • Hemiparesis

Differential Diagnosis

  • Seizure
  • Systemic infection
  • Brain tumor
  • Toxic-metabolic disorders
  • Positional vertigo
  • Conversion disorder
  • Epidural or subdural bleeds
  • Brain abscess
  • Endocarditis
  • Multiple sclerosis
  • Neurosyphilis
  • Encephalitis
ICD-10 Codes

  • STROKE (CVA)

    Diagnostic Guide Name

    STROKE (CVA)

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    STROKE  (CVA)I63.9   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
CVA Upper Extremity Deformity
  • Severe neglected right upper extremity deformity after a CVA.
    Severe neglected right upper extremity deformity after a CVA.
Symptoms
Impaired hand and arm function with or without pain
Impaired bimanual dexterity with muscle weakness
Synergistic movements
Reduced sense of touch, temperature, pain, and proprioception
Spasticity of hand and upper extremity
Typical History

The typical patient is a 77-year-old female smoker with a history of hypertension who called 911 after noticing several abnormal signs that suggested a stroke, including weakness and numbness in her left arm, blurred vision, confusion, and difficulty speaking. An ambulance brought the patient to the local ED where an ischemic stroke was diagnosed.  The patient was given IV tPA.  Ultimately she also had an endovascular procedure to retrieve clots.  The patient had experienced an ischemic stroke of the right hemisphere, which resulted in a variety of symptoms in her left arm and hand, such as pain, synergistic movements, and a reduced sense of touch, temperature, and proprioception. These symptoms severely impaired her hand and arm function, and made it particularly difficult for her to perform any activities that required bimanual dexterity, which eventually led her to seek out treatment for her residual deformities.14

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals

The goals of treatment should be individualized to the patient:

  •  
    • Reducing pain - the most important reason for surgery
    • Improving hygiene
    • Enhancing functionality
    • Correcting disfiguring and/or nonfunctional contractures
  • Most neurological recovery occurs within the first 2 to 6 months from injury and can continue up to 12 months. Therefore, definitive surgery should be delayed until at least 6 months in patient with upper motor neuron syndrome from CVA to ensure that an adequate period of time has passed for meaningful neurological recovery.
  • Surgical planning  should also keep in mind that an ischemic stroke disrupts the cerebral blood flow autoregulation.  Therefore, stroke patients have an increased risk of recurrent stroke for nine months after their initial event.16
  • A preoperative evaluation of the stroke patient includes analyses of sensibility, motor control, and spasticity present in the upper limb, along with psychological factors, which determine the patient's ability to participate in a training program.
  • A preoperative evaluation of the stroke patient includes analyses of sensibility, motor control, and spasticity present in the upper limb, along with psychological factors, which determine the patient's ability to participate in a training program.
    • Determine if spasticity, rigidity or contractures are present.
    • Passive range of motion assessment should be performed while moving the joint in its full arc motion with quick or slow movements to detect and quantify the degree of muscle spasticity or rigidity, respectively.
    • Cognition and the ability to communicate must be assessed to ensure that the patient is an appropriate candidate for surgery
      • If the patient is unable to understand and follow commands, he or she will not be able to adhere to postoperative restrictions or complete rehabilitative programs which may result in poor outcomes after surgery
      • In addition to psychological effects from the brain injury ie. depression, hostility, resentments, patients may manifest the inability to understand (receptive aphasia), the inability to communicate (expressive aphasia), or inability to perform a previously learned action (apraxia).
  • Additional studies such as a EMG or selective nerve blocks or botulinum toxin injections can also be helpful in determining the next best step in treatment:
    • Dynamic EMG analysis is most useful in determining if effort related muscle activation (volitional control) is present in hemiparetic patients and if limitation in full joint motion is due to muscle weakness or dyssynergy
    • Selective neuromotor blockade with local anesthesia can be pivotal in differentiating muscle spasticity from muscle contractures
      • Since muscle spasticity is neurally mediated, temporary neuromuscular blockade will improve passive joint motion whereas in contractures, it will not. 
Conservative
  • Rehabilitation therapies are the principal interventions in both the acute and chronic phases of stroke recovery, and their primary focus is regaining upper limb functionality8
  • Occupational and/or physical therapy
    • The primary healthcare intervention utilized for stroke survivors with functional impairments
    • Therapy should begin at the acute stage and be individualized due to the wide variety, size, and location of stroke lesions and the influence of stroke severity on recovery8; treatments may include the following:
      • Hand-strengthening exercises
      • Modified constraint-induced movement therapy (mCIMT)8
      • Cathodal transcranial direct current stimulation (c-tDCS)4
      • Biofeedback
      • Functional electrical stimulation
      • Mirror therapy
      • Thermal stimulation
      • Intermittent pneumatic compression
      • Patient education
      • Active sensory training
      • Robot-assisted therapy
        • New form of physical therapy, through which patients practice their paretic limb by resorting to or resisting the force offered by the robots3
        • End-effector systems and devices
        • Exoskeleton systems and devices
        • Commercial and non-commercial hand and wrist devices
      • Virtual reality and interactive video games
        • New therapy method in which patients practice certain activities repeatedly9
      • Bran machine interface (BMI)
        • Novel technology that uses physiological signals originating in the brain to activate or deactivate external devices or computers10
    • Preoperative rehabilitation with occupation and/or physical therapy may also be recommended before tendon transfer to re-establish supple passive range of motion of the targeted joints11
  • Thrombolytics indicated for occlusive disease
  • Warfarin/aspirin therapy indicated for embolic disease and hypercoagulable states
  • Anti-hypertensive medications
Operative
  • Upper extremity surgery is most commonly performed to relieve pain or correct flexion deformities caused by spasticity in stroke patients, especially those who have relatively intact motor control and sensation, and in whom extension at the wrist, fingers, or thumb is restricted by mild flexor spasticity12
    • Surgical procedures are typically performed on the nonfunctional upper extremity to correct spastic flexion contractures that cause pain or prevent adequate hygiene
    • If the deformity is primarily due to spasticity rather than fixed myostatic contracture, anesthetic block of the median and/or ulnar nerve preoperatively enables the surgeon to determine that extension will be improved after the appropriate flexor tendons are lengthened12
  • Spastic contracture of the shoulder – adductor and internal rotation deformity17
    • Fractional lengthening of the pectoralis major, latissimus dorsi, and teres major
    • Tenotomy of pectoralis major, lattisumus dorsi, and teres major
    • Resection of the subscapularis tendon
      • The anterior capsule of the shoulder must be carefully preserved because damaging it can result in shoulder instability.
  • Elbow flexion contracture
    • Release of brachioradialis, brachilias and/or biceps motor units
      • Long standing spasticity and deformity can be associated with the formation of heterotopic ossification to occur, thus limiting the magnitude of elbow extension correction with muscle releases alone. If this is the case, an anterior osteocapsular release may be necessary in addition to resection of any heterotopic ossification.
    • If contracture is severe, lengthening of the biceps, myotomy of the brachialis, release of the brachioradialis, and flexorpronator muscle release from the medial epicondyle can be helpful.
  • Forearm, wrist and finger contractures (forearm pronator deformity, intrinsic spasticity, clenched fist deformity, thumb-in-palm deformity) can sometimes be helped by:
    • Z-plasty lengthening flexor tendons or fractional lengthening of flexor muscles. Flexor tendon lengthening is appropriate for those stroke patients who have some intact sensation intact and volitional control of their flexor tendons.15,17,18
    • Before a decision is made to lengthen the wrist flexor tendons, the surgeon must determine if the patient can extend the fingers if the wrist flexor tendons are lengthened12
    • Superficialis to profundus (STP) tendon transfer is a useful tool for correcting these contractures, especially the severe clenched fist deformity which is interfering with hand hygiene. Patients who are candidates for STP tendon transfer typically have no volitional control over their flexors and have a painful clenched fist.15.  During an STP tendon transfer, the flexor profundus tendons are cut proximally and the flexor superficialis tendons are cut distally. The FDP are then sutured as a group to the FDS tendon.  This results in lengthened flexors.  Proper balancing of the added length is important in order to avoid postoperative swan neck deformities. This is accomplished by setting the tension with the wrsit in neutral and MP's and PIP's at 45 degrees of flexion.15,17,18
    • Flexor-pronator origin release or slide can be used after stroke but is more commonly used for spastic contracures associated with cerebral palsy.
    • Tenotomy as an isolated procedure is rarely indicated for the care of the spastic contracture caused by a stroke.
    • Tendon transfer
      • Regarded as a temporary or permanent substitute when function is lost from peripheral nerve injuries or injuries to the musculotendinous unit itself, or when function is imbalanced due to spasticity12
      • Transfer of the ECU to the radial wrist extensors is sometimes useful after stroke to rebalance a spastic wrist flexion contracture.
    • Joint arthrodesis
    • Decompression of the median and/or ulnar nerves
  • Neurectomy
    • Chemical neurectomy ie. Injection of 5% Phenol into the motor branch of certain nerves has found a place in the augmentation of rehabilitative services and upper limb surgeries in in stroke patients
      • Musculocutaneous nerve block reduce spasticity in the elbow flexor muscles.
      • Median nerve block reduces spasticity in the finger/wrist flexors. This procedure may be used to buy time prior to planning release procedures to the finger flexors such as the STP procedure.
      • Ulnar nerve block reduces spasticity of the intrinsic muscles. It may also be used during STP release to temporarily denervate the intrinsic muscles.
        • Phenol nerve blocks usually wear off in 6 months.
    • Operative neurectomy or excision of a peripheral nerve is a definitive measure and may be indicated in some severe irreparable cases where functional recovery is unlikely.
  • Botox acts by blocking neuromuscular transmission via inhibiting acetylcholine release.
    • Focal spasticity, particularly resulting from cerebral disorders, is currently being treated successfully with BTX via injection in the spastic muscles, and BTX is now considered a temporary pharmacological treatment of choice in focal spasticity.
Treatment Photos and Diagrams
Surgical Procedures
  • The first step of a Superficialis to Profundus Transfer is to suture all four FDS tendons together and all four FDP tendons together before cutting the FDS tendons distally and the FDP tendons proximally. The FPL ( not shown) requires z-lengthening.
    The first step of a Superficialis to Profundus Transfer is to suture all four FDS tendons together and all four FDP tendons together before cutting the FDS tendons distally and the FDP tendons proximally. The FPL ( not shown) requires z-lengthening.
  • In the second step of the STP Transfer the FDS tendons are sutured to the FDP tendons. Swan neck deformities are avoided by suturing the tendons together while the wrist is in neutral and the MP’s and PIP’s are flexed 45 degrees.
    In the second step of the STP Transfer the FDS tendons are sutured to the FDP tendons. Swan neck deformities are avoided by suturing the tendons together while the wrist is in neutral and the MP’s and PIP’s are flexed 45 degrees.
Complications
  • Brain edema
  • Pneumonia
  • Seizure
  • Deep venous thrombosis
  • Limb contractures
Outcomes
  • The superficialis-to-profundus tendon transfer procedure combined with lengthening of the flexor pollicis longus, flexor carpi ulnaris, and flexor carpi radialis and carpal tunnel release has been reported as an adequate and relatively simple treatment for clenched fist from spastic hemiplegia that leads to good results lasting into the long term13
  • One study reported that ten 30-minute sessions of c-tDCS paired with occupational therapy elicited some improvements in severely affected arm-hand function for acute stroke patients4
  • Another study found that routine use of mCIMT was effective for patients with active finger extension8
  • Sufficient evidence supports the use of biofeedback and electrical stimulation as additional therapies to supplement usual care for stroke patients8
  • There is an increasing body of evidence that robot-aided rehabilitation can be highly beneficial to stroke patients, and from the trends seen in current research, it appears that a combination of robotic and traditional treatment may produce the best results10
Key Educational Points
  • Although the one-year mortality rate for individuals experiencing a stroke is declining, the prevalence of stroke has remained stable; this means that most of the more than 7 million stroke survivors in the U.S. face chronic physical, psychological, and social impairments9
  • The most important reason to operate on a patient after having a stroke is to relieve pain.
  • The following rules have been proposed to help surgeons select hemiplegic patients who will likely benefit from surgery designed to improve function:
    • The patient is ≥9 months post-stroke and has good cognition and motivation
    • Some selective extension is present at the fingers or thumb
    • The patient spontaneously uses the hand for some functional activities
    • Proprioception is intact and two-point discrimination is <10 mm and preferably 5 mm at the palm or fingers
    • The patient has no fixed joint contractures12
  • All pain syndromes in the upper limb must be differentiated from central pain syndromes.
    • Careful examination of the area of maximal symptoms will usually localize the pain. However, if the patient does not respond to stress or palpation, it’s possible that the patient is afflicted with a central problem that will not respond to local decompression.  A local nerve block can help differentiate; if pain is effectively relieved, the source of the problem is likely not a central problem.
  • When both wrist and finger flexion deformities are present, the sublimis-to-profundus transfer is considered a reliable method of achieving the amount of flexor tendon lengthening necessary12
  • When excessive finger flexion is present without wrist flexion, a sufficient flexor tendon lengthening can be obtained by fractional tendon lengthening12
  • Hand rehabilitation often begins after the acute stage of stroke recovery, which is when treatment has the greatest potential for improvements; due to this missed window of opportunity, only minor additional measurable improvement occurs 6 months after stroke, often leading to less-than-satisfactory results10
  • Although hand rehabilitation robotics have developed markedly in recent years, the progression of clinical use of these interventions has not caught up with the pace of designing prototypes3
  • Patients with antiphospholipid syndrome are hypercoagulable and have an increased risk for stroke
References

Cited

  1. Kim J, Yim J. Effects of an Exercise Protocol for Improving Handgrip Strength and Walking Speed on Cognitive Function in Patients with Chronic Stroke. Med Sci Monit 2017;23:5402-5409. PMID: 29131814
  2. Ekstrand E, Rylander L, Lexell J, Brogårdh C. Perceived ability to perform daily hand activities after stroke and associated factors: a cross-sectional study. BMC Neurol 2016;16(1):208. PMID: 27806698
  3. Yue Z, Zhang X, Wang J. Hand Rehabilitation Robotics on Poststroke Motor Recovery. Behav Neurol 2017;2017:3908135. PMID: 29230081
  4. Rabadi MH, Aston CE. Effect of Transcranial Direct Current Stimulation on Severely Affected Arm-Hand Motor Function in Patients After an Acute Ischemic Stroke: A Pilot Randomized Control Trial. Am J Phys Med Rehabil 2017;96(10 Suppl 1):S178-S184. PMID: 28837443
  5. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation 2014;129(3):e28-e292. PMID: 24352519
  6. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017;135(10):e146-e603. PMID: 28122885
  7. Faria-Fortini I, Michaelsen SM, Cassiano JG, et al. Upper extremity function in stroke subjects: relationships between the international classification of functioning, disability, and health domains. J Hand Ther 2011;24(3):257-64. PMID: 21420279
  8. Wattchow KA, McDonnell MN, Hillier SL. Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence. Arch Phys Med Rehabil 2017;S0003-9993(17)30470-7. PMID: 28734936
  9. Tsoupikova D, Stoykov NS, Corrigan M, et al. Virtual immersion for post-stroke hand rehabilitation therapy. Ann Biomed Eng 2015;43(2):467-77. PMID: 25558845
  10. McConnell AC, Moioli RC, Brasil FL, et al. Robotic devices and brain-machine interfaces for hand rehabilitation post-stroke. J Rehabil Med 2017;49(6):449-460. PMID: 28597018
  11. Wilbur D, Hammert WC. Principles of Tendon Transfer. Hand Clin 2016;32(3):283-9. PMID: 27387072
  12. Waters RL. Upper extremity surgery in stroke patients. Clin Orthop Relat Res 1978;(131):30-7. PMID: 657640
  13. Heijnen IC, Franken RJ, Bevaart BJ, Meijer JW. Long-term outcome of superficialis-to-profundus tendon transfer in patients with clenched fist due to spastic hemiplegia. Disabil Rehabil 2008;30(9):675-8. PMID: 17852274
  14. Goldstein LB. Modern medical management of acute ischemic stroke. Methodist Debakey Cardiovasc J 2014; 10(2): 99-104.
  15. Pomerance JF, Keenan MA. Correction of severe spastic flexion contractures in the nonfunctional hand. J Hand Surg. 1996; 21A: 828-833. 
  16. Jørgensen ME, Torp-Pedersen C, Gislason GH, Jensen PF, Berger SM, Christiansen CB, Overgaard C, Schmiegelow MD, Andersson C. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA. 2014;312(3):269-277. 
  17. Laing RE, Hurst LCH: Painful post stroke shoulder with dislocation and grotesque contracture. Orthopaedic Review Vol. XI(5), May 1982.
  18. Braun R, Rise G, Roper B: Preliminary experience with supervicialis to profundus tendon transfer in the hemiplegic upper extremity.  J Bone Joint Surg 56-A:466-472, April 1974.

New Articles

  1. Carlsson H, Gard G, Brogårdh C. Upper-limb sensory impairments after stroke: Self-reported experiences of daily life and rehabilitation. J Rehabil Med 2017. PMID: 29068038
  2. Ekstrand E, Lexell J, Brogårdh C. Grip strength is a representative measure of muscle weakness in the upper extremity after stroke. Top Stroke Rehabil 2016;23(6):400-405. PMID: 27145212

Reviews

  1. Grant VM, Gibson A, Shields N. Somatosensory stimulation to improve hand and upper limb function after stroke-a systematic review with meta-analyses. Top Stroke Rehabil 2017:1-11. PMID: 29050540
  2. Wattchow KA, McDonnell MN, Hillier SL. Rehabilitation Interventions for Upper Limb Function in the First Four Weeks Following Stroke: A Systematic Review and Meta-Analysis of the Evidence. Arch Phys Med Rehabil 2017;S0003-9993(17)30470-7. PMID: 28734936

Classics

  1. Baker RN. Medical and surgical management of the ischemic stroke. J Rehabil 1963;29:22-5. PMID: 14080931
  2. Millikan CH. The etiology and mechanism of stroke. J Rehabil 1963;29:16-8. PMID: 14080929
  3. Braun R, Rise G, Roper B: Preliminary experience with supervicialis to profundus tendon transfer in the hemiplegic upper extremity.  J Bone Joint Surg 56-A:466-472, April 1974.
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