44

Stroke Rehabilitation
M I C H A E L R . YO CHELS O N, A ND REW CU LLE N D ENNISO N, SR. ,
A N D A M Y L . KO LAR OVA

Introduction majority are MCA strokes. Ischemic strokes from thrombosis or

stenosis may occur in any large-vessel vascular territories.41 Lacu-
An understanding of stroke—from the recognition and acute nar strokes are most often associated with hypertension. Strokes
treatment to postacute and chronic management—is vitally seen at the border zone of two vascular territories (“border zone”
important for the rehabilitationist, as stroke is one of the most or “watershed” infarct) are more frequently seen due to hypoten-
common diagnoses in acute and subacute inpatient rehabilita- sion. They are commonly associated with cardiac surgeries due
tion. Furthermore, secondary stroke is a common complication of to hypoperfusion that occurs during the procedure, or they may
stroke and must be recognized and managed in the rehabilitation occur from microemboli, as may be seen from a cardiac etiology.40
setting. The mortality from stroke is decreasing due to better edu- Intracerebral hemorrhage (ICH) accounts for nearly 50% of
cation of the lay population in recognizing the symptoms, more stroke-related morbidity and mortality.11 These hemorrhagic
aggressive management in the field, the availability of more effec- strokes occur from a variety of underlying causes, hypertension
tive treatments, and faster time to treatment. As a result, stroke has being one common cause. The most common areas for a hemor-
gone from the third leading cause of death in the United States as rhagic stroke due to hypertension are the basal ganglia, thalamus,
recently as 200848,58,97 to the fifth leading cause in 2016, although cerebellum, and pons.103 Lobar hemorrhages from amyloid angi-
it remains the third leading cause of death among women.45,48 opathy are more often seen in those aged 60 years and older. Some
The overall prevalence of stroke is 2.6% among Americans over estimate that cerebral amyloid angiopathy accounts for up to 15%
the age of 20 years. This number is more than double in those over of ICHs in this age group.11,89 Although not considered “strokes,”
age 60 years and increases to about 15% of those over the age of nontraumatic hemorrhages may also result from other causes.
80 years. With the increased survival come increased numbers of An AVM or aneurysm may rupture and cause an ICH. Subdural
people living with disability and increasing numbers of secondary hematomas (SDHs) arise from the rupture of bridging veins due
strokes. One in four strokes are recurrent and one in five people to their vulnerability to shear injury. Subarachnoid hemorrhages
who suffer a stroke will have a recurrence within 5 years.45 The (SAHs) are located between the arachnoid and pia mater, track-
decrease in mortality results in an overall increase in cost. This ing down the sulci and following the contours of the brain. The
is in part because of the expense of some newer, more effective most common cause of a SAH is rupture of a berry aneurysm; the
treatments as well as the longer term cost of survival. The cost most frequent locations for a ruptured aneurysm are the anterior
of caring for stroke patients in the United States is estimated to cerebral artery (ACA) (27% to 35%), internal carotid artery (ICA)
be $105 billion per year as of 2012 data. This includes acute and (15% to 20%), posterior communicating (PComm) artery (25%),
chronic treatment, caregiver cost, and lost wages for those unable MCA (8% to 20%) and vertebrobasilar system (5% to 15%).8,10,71
to return to the work force.79,80 This chapter focuses primarily
on ischemic stroke, as that accounts for more than 85% of all
strokes.45,48 However, it also discusses hemorrhagic strokes,
Basic Neuroanatomy: A Brief Overview
arteriovenous malformations (AVMs), and aneurysm rupture.␣ An understanding of basic neuroanatomy is important to help
localize a stroke, determine management, and sometimes to dif-
Types of Strokes ferentiate between a stroke and stroke mimics, such as migraine,
seizure, and conversion disorder.94 This section includes the ana-
Strokes can be categorized in different ways. Ischemic strokes are tomic location, blood supply (Figs. 44.1–44.3), and basic function
the most common, accounting for approximately 85% to 90% of of different areas of the brain and brainstem (Tables 44.1–44.4).
strokes.34,45 Risk factors include smoking, diabetes, and hyperten- It is important to note that due to various pathways and circuits
sion and other cardiovascular risk factors. Ischemic strokes are fur- throughout the central nervous system (CNS), there is substantial
ther divided by location or vascular territory. The most common overlap in function.
type of ischemic stroke in the United States is a large-vessel throm- • The frontal lobe is the anterior portion of the brain; it extends
botic stroke in the territory of the middle cerebral artery (MCA). to the central sulcus of Rolando posteriorly and is inferiorly
Large-vessel atherosclerotic stenosis and occlusion is less common and laterally separated from the temporal lobes by the Sylvian
in the United States than in other areas of the world; it accounts fissure. The gyrus immediately in front of the central sulcus is
for 10% to 15% of strokes in the United States.24 Of those, the the precentral gyrus (primary motor cortex). The olfactory bulbs

954
 CHAPTER 44 Stroke Rehabilitation 955

Premotor Motor
area cortex

Knee
Angular gyrus
Hip
Trunk
Shoulder
Elbow
Wrist
Hand
Fingers
Thumb Parietal
Neck
Brow
Eyelid
Face Caudate
Lips nucleus
Jaw
Tongue
Pharynx Internal capsule
Frontal
Thalamus
Occipital
Lentiform
nucleus
Temporal Broca
area

Wernicke area
Primary
A Broca area auditory cortex
Arcuate
fasciculus

Hip Wernicke
Trunk
Shoulder Knee area
Elbow Ankle
Wrist
Hand Caudate
Fingers
Neck nucleus Geniculocalcarine
Brow tracts
Eyelid Toe Thalamus
Face
Lips
Lentiform Visual
Jaw C cortex
Tongue
nucleus
Pharynx

B
• Fig. 44.1(A–C) Surface anatomy of the cerebral cortex. (From https://netterimages.com/cerebrum-lateral-
views-labeled-anatomy-atlas-5e-physiology-frank-h-netter-5274.html.)

and tract run along the inferior aspect of the frontal lobe bilat- inferior to the occipital lobe is the cerebellum. The primary
erally near the interhemispheric fissure. The most anterior por- visual cortex is located in the occipital lobe.
tion is the frontal pole. • The insular cortex is covered laterally by a lip of the frontal
• The parietal lobe is separated from the frontal lobe by the cen- cortex anterior and parietal cortex posteriorly.
tral sulcus anteriorly but has no clear demarcation from the • Subcortical refers to several areas including the caudate nucleus
temporal lobes inferolaterally. The demarcation for the occipi- and putamen (striatum), globus pallidus, subthalamic nucleus,
tal lobe is at the parieto-occipital sulcus. Directly posterior to and substantia nigra. The caudate and putamen are separated
the central sulcus lies the postcentral gyrus/sulcus (primary by the internal capsule. The putamen forms the lateral portion,
somatosensory cortex). fusing with the head of the caudate anteriorly and ventrally.
• The temporal lobe has no clear demarcation from the pari- Just medial to the putamen is the globus pallidus, which has
etal or occipital lobes; it lies inferior to the frontal lobe, internal and external segments. The thalamus sits nearby, sepa-
separated by the Sylvian fissure. The most anterior portion rated from the lentiform nucleus by the posterior limb of the
is the temporal pole. The primary auditory cortex is located internal capsule. The substantia nigra is just dorsal to the cere-
near the Sylvian fissure in the superior medial portion of the bral peduncles and is separated from the globus pallidus by the
temporal lobe. internal capsule.
• The occipital lobe has no clear demarcation from the temporal • The brainstem is divided into the midbrain, pons, and medulla.
lobe. The parieto-occipital sulcus separates it from the parietal The midbrain connects the pons and cerebellum to the thal-
lobe. The most posterior portion is the occipital pole. Directly amus and cerebral hemispheres. It contains the cerebral
956 SECTION 4 Issues in Specific Diagnoses

Anterior peduncles as well as the aqueduct between the third and fourth
communicating ventricles. The pons links information from the medulla to the
artery
higher cortical areas of the cortex and is also connected to the
Recurrent artery
of Heubner
cerebellum through the middle cerebellar peduncle; it includes
A2 segment
the pontine reticular formation as well as centers for respira-
Anterior cerebral
artery A1 segment tion. The medulla contains the crossing of tracts relaying infor-
mation between the cortex and spinal cord. It contains centers
Middle for respiration as well as vasomotor and cardiac function and
cerebral M1 segment the mechanisms for cough, gag, and swallowing.
artery
Internal • The cerebellum consists of a midline vermis and two cerebel-
Anterior carotid lar hemispheres. The largest fissure is called the primary fissure
choroidal artery
artery and separates the cerebellum into anterior and posterior lobes.
Posterior
P2 segment The posterolateral fissure separates the posterior lobe from the
communicating flocculonodular lobe. The tonsils are at midline, and laterally
artery there are three cerebellar peduncles: the superior (which is the
P1 segment
Posterior cerebral most medial), the middle (which is the most lateral) and the
artery Basilar inferior (which is the most inferior).14,40,107␣
artery

Vascular Anatomy
The circle of Willis (see Fig. 44.2) is supplied by the right and
• Fig. 44.2Territories of the cerebral arteries. (From https://netterimages. left ICAs anteriorly and the basilar artery posteriorly. Prior to
com/color-illustration-of-territories-of-the-cerebral-arteries-labeled-jones- the bifurcation of the MCA and ACA, the ICA gives off the
1e-neurology-neurosciences-frank-h-netter-6951.html.)

Anterior cerebral Posterior cerebral Corpus callosum

artery artery

Anterior
cerebral
artery

Posterior cerebral
A Middle cerebral artery B artery

M4

M3 M2 M1 Lateral
lenticulostriate Middle cerebral
C arteries artery
• Fig. 44.3 (A–C) Circle of Willis. (From https://www.netterimages.com/cerebral-arterial-circle-willis-labeled-
anatomy-atlas-5e-general-anatomy-frank-h-netter-4694.html.)
 CHAPTER 44 Stroke Rehabilitation 957

TABLE
44.1
Cerebellar Stroke Syndromes

Rostral cerebellar syndrome Subthalamic region, thalamus, occipitotemporal Coma ± tetraplegia, ipsilateral dysmetria, Horner
lobes, lateral tegmental area of upper pons syndrome, contralateral pain/temp deficit,
cranial nerve IV palsy, dysarthria, headache,
dizziness, emesis, delayed coma
Medial cerebellar syndrome Lateral area of the lower pons Ipsilateral cranial nerve V, VII, VIII, Horner syndrome,
dysmetria, contralateral pain/temp deficit
Caudal cerebellar syndrome Dorsolateral medullary area Vertigo, headache, emesis, ataxia, delayed coma

Modified from Zorowitz RD: Stroke syndromes: infratentorial. In Stein J, Harvey RL, Winstein CJ, et al, editors: Stroke recovery and rehabilitation, ed 2, New York, 2015, Demos Medical Publishing.

TABLE
44.2
Major Artery Clinical Syndromes

Artery Deficits
L MCA S R face/arm weakness, Broca/nonfluent aphasia, ± sensory loss
L MCA I Fluent/Wernicke aphasia, R visual field deficit. R face/arm ± sensory loss; motor findings absent; confused; mild R weakness
L MCA D R pure motor hemiparesis, larger infarcts may produce cortical deficits
L MCA stem Combination of all above with R hemiplegia/anesthesia, R homonymous hemianopia and global aphasia; L gaze preference
R MCA S L face/arm weakness, L hemineglect to a variable extent, ± sensory loss
R MCA I Profound L hemineglect; L visual field and somatosensory deficits but hard to test due to neglect; mild L weakness may be present; R gaze
R MCA D L pure motor hemiparesis, larger infarct can include cortical and neglect
R MCA stem Combination of above with L hemi, L homonymous hemi, and profound L neglect with R gaze preference
L ACA R leg weakness with sensory loss, grasp reflex, frontal lobe behaviors, transcortical aphasia ± larger may cause R hemi with lower
extremity > upper extremity relatively
R ACA L leg weakness with sensory loss, grasp reflex, frontal behaviors, L hemineglect; larger infarcts may cause full L hemi
L PCA R homonymous hemianopia; extension to the splenium of the corpus callosum can cause alexia w/o agraphia; larger infarcts with thala-
mus and IC may cause aphasia, R hemisensory loss, and R hemiparesis
R PCA L homonymous hemianopia; larger infarcts with thalamus and IC may cause L hemisensory loss and L hemiparesis

ACA, Anterior cerebral artery; D, deep; I, inferior; IC, internal capsule; L, left; MCA, middle cerebral artery; PCA, posterior cerebral artery; R, right; S, superior.
Modified from Blumenfeld H: Neuroanatomy through clinical cases, ed 2, Sunderland, 2010, Sinauer Associates.

TABLE
44.3
Common Lacunar Syndromes

Syndrome Features Locations Vessels

Pure motor hemiparesis or Contralateral face, arm, and leg weak- Posterior limb IC, Lenticulostriate, anterior choroidal
dysarthria hemiparesis ness with dysarthria Corona radiata, or perforating branches of
Cerebral peduncle PCA, small MCA and basilar
branches
Pure sensory stroke Sensory loss—contralateral face and Thalamus, corona radiata, posterior Thalamoperforator branches of
body limb IC the PCA
Sensorimotor stroke Combination of thalamic and pure motor Posterior limb IC and either VPL or Thalamoperforator branches of the
hemiparesis thalamic sensory PCA or lenticulostriate
Ataxic hemiparesis Same as pure motor but with ataxia on Posterior limb IC, corona radiata, Same as pure motor hemiparesis
same side cerebral peduncle, red nucleus,
lentiform nucleus
Basal ganglia stroke Usually asymptomatic, but may cause Caudate, putamen, globus pallidus, or Lenticulostriate, anterior choroidal,
hemiballismus subthalamic nucleus thalamoperforator, or Heubner
arteries

IC, Internal capsule; MCA, middle cerebral artery; PCA, posterior cerebral artery; VPL, ventral posterolateral nucleus.
Modified from Blumenfeld H: Neuroanatomy through clinical cases, ed 2, Sunderland, 2010, Sinauer Associates.
958 SECTION 4 Issues in Specific Diagnoses

TABLE
44.4
Common Brainstem Syndromes

Region Name Supply Structures Features

Medulla
Medial medulla Medial medullary Branch of vertebral and Pyramidal tract and medial Contralateral arm/leg weakness,
syndrome anterior spinal lemniscus decreased position and vibration

Lateral medulla Wallenberg syndrome Vertebral > PICA CN XII, vestibular, and trigeminal Ipsilateral ataxia, vertigo, nystagmus,
nuclei, cerebellar peduncle, nausea, face decreased pain and
spinothalamic tract, sympa- temperature, Horner syndrome and
thetic tract, nucleus ambiguus decreased taste. Contralateral body
and solitarius decreased pain/temp, hoarseness,
dysphagia

Pons
Medial pons 1. Dysarthric hemipa- Paramedian branches of 1. Corticospinal/corticobulbar tract 1. Contralateral face/arm/leg weak-
basis resis the basilar and vertebral 2. Above + pons nuclei and ponto- ness, dysarthria
2. Ataxic hemiparesis cerebellar tract 2. All the above plus contralateral
ataxia
Medial pons 1. Millard-Gubler Branches of basilar, 1. Corticospinal/corticobulbar tract 1. Contralateral face/arm/leg weakness
basis/teg- syndrome ventral, and dorsal 2. Corticospinal/corticobulbar tract 2. Contralateral face/arm/leg weakness
mentum 2. Foville syndrome territories plus facial colliculus plus dysarthria with ipsilateral face
weakness/gaze
Lateral caudal AICA syndrome AICA Middle cerebellar peduncle, Ipsilateral ataxia, facial decrease in pain/
pons vestibular, trigeminal nuclei, temp, Horner syndrome, contralateral
spinothalamic, and sympathetic body decrease in pain/temp, vertigo,
tracts nystagmus
Dorsolateral SCA syndrome SCA Superior cerebellar peduncle, Ipsilateral ataxia plus possible AICA inclu-
rostral pons lateral structures sions
Bilateral pons Locked-in syndrome Basilar artery Bilateral corticospinal/corticobulbar/ Tetraplegia, facial palsy with sparing
pontine, reticular formation of eye blinking, bilateral horizontal
gaze palsy
Midbrain
Midbrain basis Weber syndrome PCA, basilar CN III, cerebral peduncle Ipsilateral third nerve palsy and contra-
lateral hemiparesis
Midbrain teg- Claude syndrome PCA, basilar CN III, superior cerebral peduncle, Ipsilateral third nerve palsy, contralat-
mentum red nucleus eral ataxia, rubral tremor
Midbrain Benedikt syndrome PCA, basilar All of the above plus substantia Ipsilateral third nerve palsy, contralateral
basis and nigra ± ML and ST tract hemiparesis, ataxia, tremor and
tegmentum involuntary movements
Dorsal rostral Parinaud syndrome PCA, basilar Rostral interstitial MLF Multiple oculomotor abnormalities
midbrain include upgaze palsy, tonic down-
ward gaze (“setting sun”), vertical
nystagmus, bilateral ptosis

Rostral Top of the basilar PCA, basilar Rostral midbrain, thalami, pos- Parinaud + abulia, hypersomnolence,
midbrain syndrome terior temporal and occipital memory impairment
lobes

AICA, Anteroinferior cerebellar artery; ML, medial lemniscus; MLF, medial longitudinal fasciculus; PCA, posterior cerebral artery; PICA, posteroinferior cerebellar artery; SCA, superior cerebellar artery;
ST, spinothalamic tract.
Modified from Blumenfeld H: Neuroanatomy through clinical cases, ed 2, Sunderland, 2010, Sinauer Associates.
 CHAPTER 44 Stroke Rehabilitation 959

ophthalmic, anterior choroidal, and PComm arteries. From the (rtPA) alteplase.27,51 There is very clear decrement in benefit and
ACA arise the anterior communicating artery, recurrent artery of increased risk of complications as time from onset elapses. The
Heubner, and the pericallosal and medial lenticulostriate arter- benefit of rtPA clearly outweighs the risk in the first 3 hours. The
ies. The MCA provides the lateral lenticulostriate, branching into benefit-to-risk ratio worsens over the next 90 minutes, but the risk
the superior (S), inferior (I), and deep (D) branches bilaterally for severe complications, primarily intracranial hemorrhage (ICH),
(MCA S, MCA I, and MCA D). The basilar artery bifurcates into still remains relatively low. Between 4.5 and 6 hours, however, the
the posterior cerebral artery (PCA), with the circle being com- risk of ICH increases, and the benefit decreases to the point that
pleted by the anastomoses of the PComm arteries with the PCA rtPA is no longer recommended beyond the 4.5-hour window. Of
bilaterally. The major vascular anatomy of the brain is shown in note, there are multiple contraindications to the administration of
Fig. 44.3. The vertebral arteries provide the majority of the blood rtPA, one of which is prior stroke or serious head trauma within the
supply to the brainstem structures and merge into the basilar preceding 3 months. Therefore this would rarely be appropriate for
artery, which provides the pontine and medullary branches. The a patient who experiences a recurrent stroke during his or her inpa-
posteroinferior cerebellar artery (PICA) supplies the medulla as tient rehabilitation period.37 A cardiac evaluation should include
well as portions of the spinothalamic tract. The anteroinferior an electrocardiogram (ECG), troponin, and chest x-ray. However,
cerebellar artery (AICA) supplies the pons, the facial and spinal these should not delay administration of the rtPA. Unlike intrave-
trigeminal nucleus and tract, as well as the inferior and middle nous rtPA, intraarterial thrombolytics can be given up to 6 hours
cerebellar peduncles and spinothalamic tract. Blood supply for after stroke onset.
the cerebellum is provided by three branches of the vertebral and In the inpatient rehabilitation setting, a stroke patient with
basilar arteries. The PICA supplies the lateral medulla, inferior a new or worsening neurologic deficit should be evaluated with
half of the cerebellum, and inferior vermis. The AICA supplies the noncontrast CT to make sure that there has not been hemor-
inferolateral pons, middle cerebellar peduncle, and ventral ante- rhagic conversion. Given the increased risk of seizures poststroke
rior strip of cerebellum between the PICA and superior cerebellar (approximately 10% incidence),12,42 an electroencephalogram
artery (SCA) territories. The SCA supplies the upper lateral pons, (EEG) is indicated if the neuroimaging does not indicate a new
superior cerebellar peduncle, and most of the superior half of the stroke or bleed.
cerebellar hemisphere.14,107␣ Mechanical thrombolysis expands the treatment window
of acute stroke up to 24 hours.22,39,86,92 However, it is lim-
Initial Workup/Management ited to large-vessel thrombotic strokes typically affecting the
carotid or MCA territory. These techniques can also be used
This section refers primarily to those patients being evaluated for in patients who have already received intravenous rtPA.76 It
a first stroke (or a recurrence greater than 3 months following a is possible that these interventions could be used in some-
previous stroke). Many of the principles in this section apply even one who has more recently had a stroke; however, the stud-
during a recurrence in the first 30 days, which is the period dur- ies typically required a prestroke Rankin score of 0 to 1, so it
ing which the patient is at highest risk for recurrence. However, remains unclear whether it would be appropriate for patients
certain contraindications, particularly related to anticoagulation, who are still in inpatient rehabilitation, as they would have
in the setting of acute stroke are also discussed. a higher Rankin score. The DAWN and DEFUSE 3 studies
Just as the general population should be able to recognize the demonstrate benefit of mechanical thrombolysis up to 24 and
warning signs of stroke, so should the nurses and other clinicians 16 hours, respectively, after stroke onset, allowing these treat-
caring for patients who are in the time window for increased risk of ments to be used for “wakeup” strokes.5,76,77 Previously, treat-
recurrence. Symptoms include the acute onset of focal neurologic ment in this population was extremely limited, because if you
symptoms (e.g., weakness, dizziness, or slurred speech), mental sta- could not determine the exact onset of symptoms, the patient
tus changes, or sudden severe headaches. Initiation of an emergency would be ineligible for treatment with intravenous rtPA and
response process is paramount as time is of the essence. Standard usually also ineligible for intraarterial thrombolysis.
protocols—including assessment, obtaining intravenous access, Hypertension is more commonly seen than hypotension. “Per-
administration of oxygen and appropriate fluids, and management missive hypertension” is reasonable, but significant elevations,
of hypotension and hypoglycemia—should be followed. The emer- particularly if a fibrinolytic therapy is being used, should be cor-
gency department should be ready to receive a stroke patient and rected. Overcorrection must be avoided, as arterial hypotension
have the physician assessment, including the National Institutes of is associated with a worse outcome. If the patient received fibri-
Health Stroke Scale (NIHSS), completed within minutes of arrival, nolytic therapy, blood pressures should be maintained below 185
and also a noncontrast computed tomography (CT) image of the mm Hg systolic and 110 mm Hg diastolic. If no fibrinolytic ther-
head within 20 minutes of arrival. A noncontrast magnetic reso- apy was used, the blood pressure may be allowed to go to 220 mm
nance imaging (MRI) scan of the brain using diffusion-weighted Hg systolic and 120 mm Hg diastolic. If the blood pressure must
imaging (DWI) is more sensitive than CT to ischemia, particularly be managed, an appropriate goal is a decrease of 15% gradually
in the posterior fossa and brainstem, but is often not feasible because over 24 hours. For patients with hypertensive lacunar infarcts and
of access or time constraints.51 Evaluation should include a thor- those with diabetes, it is recommended that their systolic blood
ough history to exclude stroke mimics such as seizure, migraine, and pressure is maintained below 130 mm Hg.11,57 Although there
conversion disorder. These mimics must be considered in patients is no clearly defined goal for blood pressure control poststroke, a
who are being evaluated for recurrent strokes as well as for primary Cochrane review by Zonneveld et al. did find a trend for “inten-
stroke.94 Seizures in particular should be considered if the new neu- sive blood pressure lowering in reducing the risk for recurrent
rologic deficit correlates with the same territory as the initial stroke. stroke and major vascular events.”106 In addition to blood pressure
If it is determined that the patient has suffered an ischemic stroke control, the patient’s oxygen saturation should be maintained at
and completes the workup within 4.5 hours of onset, he or she is a 94% or higher. Hypovolemia should be rapidly treated and main-
candidate for intravenous recombinant tissue plasminogen activator tenance intravenous fluids should be run.
960 SECTION 4 Issues in Specific Diagnoses

Hyperglycemia should also be treated, as it has been associ- of their stroke should continue this—the reason being that, in a
ated with worse outcomes. Very tight control is inadvisable, as the small randomized trial, it was noted that those who discontin-
patient could become hypoglycemic, particularly in the postacute ued had greater odds of death or dependency at 3 months post-
period when he or she may have a lower caloric intake than usual stroke.13,51 Although this does not necessarily imply that starting
and is increasing physical activity during therapy. A goal of 140 to a patient on a statin poststroke will provide neuroprotection, it is
180 mg/dL in the acute period is reasonable.51 recommended to continue the statin in those patients who had
Anticoagulation is often necessary for the treatment of already been taking it.␣
venothrombosis, atrial fibrillation, or other cardiac issues. It is
important that it not be started within 24 hours of the use of Complications of Stroke
intravenous rtPA. There is no indication for emergent anticoagu-
lation in the face of acute stroke or neurologic worsening. The risk Guidelines for the management of adult stroke rehabilitation and
of ICH is increased, and an improved outcome has not been dem- recovery have been published by the American Heart Associa-
onstrated. It has not been shown to reduce the risk of stroke recur- tion (AHA) and the American Stroke Association (ASA) and have
rence even in the face of a cardioembolic stroke.51 Dabigatran has been endorsed by the American Academy of Physical Medicine
been approved for the prevention of stroke associated with atrial and Rehabilitation and the American Society of Neurorehabilita-
fibrillation, but the timing of its initiation poststroke has not been tion.105 These guidelines will be referenced in the discussion of
established. both the prevention and management of complications as well
Antiplatelet agents should be used to reduce the risk of stroke as the rehabilitation treatment of stroke in this chapter, exten-
and stroke recurrence.24 Aspirin may be initiated at 325 mg sively referring to levels of evidence as noted in Fig. 44.4. Note
within 24 to 48 hours of onset of symptoms. If clopidogrel is that unless otherwise noted, all references to levels of evidence
being used as the antiplatelet agent, initiating treatment with the using the Level A–C/Class I–III system are in reference to the
maintenance dose of 75 mg/day will delay platelet inhibition by 2016 AHA/ASA Guidelines for Adult Stroke Rehabilitation and
approximately 5 days. Therefore either a loading dose of clopido- Recovery.
grel should be used or it should be started in conjunction with 325 In order to provide excellent stroke rehabilitation, it is critical
mg of aspirin.51 The European Stroke Prevention Study 2 (ESPS- for the rehabilitationist to be able to prevent, identify, and cor-
2) demonstrated that the combination of dipyridamole 200 mg rectly treat the common complications that follow stroke. Overall,
and aspirin 25 mg twice a day also reduces the risk of recurrent complications are frequent and are seen in up to 85% of stroke
stroke. Thus options for antiplatelet treatment to reduce risk for patients during hospitalization (Table 44.5).59
stroke recurrence should include aspirin alone, aspirin with dipyr- An autopsy study101 looking at cause of death in a sample of
idamole, or clopidogrel. The aspirin/dipyridamole may be less well 409 stroke patients identified different likely diagnoses at different
tolerated due to side effects of gastrointestinal (GI) symptoms and times out from stroke. The study evaluated 82 of the 95 patients
headaches. For any patient with a stroke severe enough to warrant who died within the first 3 months. Direct effects of stroke were
inpatient rehabilitation, the combination of aspirin and clopido- the most common cause of death in the first week (90%), pulmo-
grel is not recommended, as it has shown no benefit over mono- nary embolism (PE) most common in the second to fourth weeks
therapy in two studies and may increase the risk of bleeding in (30%), and bronchopneumonia in the second to third months
patients with prior stroke.33,45,53 In the POINT study, Johnston (27%). Of the 61 of 128 patients who died after 3 months, cardiac
et al. suggest that patients with mild ischemic stroke (NIHSS ≤3) disease was the most common cause (37%). Overall, death was
or high-risk transient ischemic attack (TIA) (ABCD2 ≥4) may due to causes other than stroke in 59% of ischemic stroke patients
benefit from a combination of clopidogrel and aspirin. Those and 24% of hemorrhagic stroke patients. These data point to the
treated with the combination therapy from day 2 through 90 importance of effective and mindful treatment in the rehabilita-
poststroke had a lower rate of stroke recurrence, major myocardial tion environment in relation to venous thromboembolism (VTE),
infarction, and death; however, the combination group did have prevention of pulmonary complications, and appropriate medi-
an increased risk of major hemorrhage.53 Currently there are no cations and lifestyle adjustments to decrease the rate of cardiac
clear guidelines on the best antiplatelet regimen for a patient who disease after discharge.
has had a stroke while taking aspirin.45
There is a great deal of interest in neuroprotective agents, Neurologic Complications
several of which have shown efficacy in animal studies. To date
there is very limited evidence of effective neuroprotection in Hemorrhagic Conversion
human studies. This may be due to differences between the study Hemorrhagic conversion is relatively common after ischemic
animals and humans or, in some cases, may just be a timing stroke even when current acute stroke interventions such as fibri-
issue. In the case of animal studies, the timing of administra- nolysis or mechanical thrombectomy have not been received;
tion of a neuroprotective agent can be hyperacute, whereas in previous studies have noted an incidence of 40.6% after cerebral
human studies, a delay in administration may render a treat- embolism79 and 43% in cerebral infarction.50 Okada et al. noted
ment ineffective. Intravenous magnesium has been studied and that bleeding risk was much higher in moderate- to large-size
has not shown benefit when given within 12 hours with the infarcts (50%) compared with small infarcts (2.9%) and that
possible exception of a moderate effect in lacunar strokes.72,91 bleeding risk increased with age. However, only the more severe
Statins have been felt to have a neuroprotective benefit due to parenchymal hematoma type 2 (PH2) within the Fiorelli classi-
their direct influence on endothelial function, reduction of oxi- fication (Table 44.6)35 was shown to be a significant predictor of
dative stress, antiinflammatory properties, influence on plaque neurologic deterioration and 3-month mortality. The PH2 clas-
stability, and other properties. Although neuroprotection has sification includes hemorrhagic conversion with a homogeneous
not been clearly established, patients taking a statin at the time hyperdensity occupying more than 30% of the infarct zone,
 CHAPTER 44 Stroke Rehabilitation 961

SIZE OF TREATMENT EFFECT

CLASS I CLASS IIa CLASS IIb CLASS III No Benefit

or CLASS III Harm
Benefit >>> Risk Benefit >> Risk Benefit ≥ Risk Procedure/ Treatment
Test
Procedure/Treatment Additional studies with Additional studies with broad
SHOULD be performed/ focused objectives needed objectives needed; additional COR III: Not No Proven
No benefit Helpful Benefit
administered registry data would be helpful
IT IS REASONABLE to COR III: Excess Cost Harmful
perform procedure/administer Procedure/Treatment Harm w/o Benefit to Patients
treatment MAY BE CONSIDERED or Harmful
ESTIMATE OF CERTAINTY (PRECISION) OF TREATMENT EFFECT

LEVEL A • Recommendation that • Recommendation in favor • Recommendation’s • Recommendation that

Multiple populations procedure or treatment of treatment or procedure usefulness/efficacy less procedure or treatment is
evaluated* is useful/effective being useful/effective well established not useful/effective and may
• Sufficient evidence from • Some conflicting evidence • Greater conflicting be harmful
Data derived from multiple
randomized clinical trials multiple randomized trials from multiple randomized evidence from multiple • Sufficient evidence from
or meta-analyses or meta-analyses trials or meta-analyses randomized trials or multiple randomized trials or
meta-analyses meta-analyses

LEVEL B • Recommendation that • Recommendation in favor • Recommendation’s • Recommendation that

Limited populations procedure or treatment of treatment or procedure usefulness/efficacy less procedure or treatment is
evaluated* is useful/effective being useful/effective well established not useful/effective and may
• Evidence from single • Some conflicting • Greater conflicting be harmful
Data derived from a
single randomized trial randomized trial or evidence from single evidence from single • Evidence from single
or nonrandomized studies nonrandomized studies randomized trial or randomized trial or randomized trial or
nonrandomized studies nonrandomized studies nonrandomized studies

LEVEL C • Recommendation that • Recommendation in favor • Recommendation’s • Recommendation that

Very limited populations procedure or treatment of treatment or procedure usefulness/efficacy less procedure or treatment is
evaluated* is useful/effective being useful/effective well established not useful/effective and may
• Only expert opinion, case • Only diverging expert • Only diverging expert be harmful
Only consensus opinion
of experts, case studies, studies, or standard of care opinion, case studies, opinion, case studies, or • Only expert opinion, case
or standard of care or standard of care standard of care studies, or standard of care

Suggested phrases for Should is reasonable may/might be considered COR III: COR III:
writing recommendations is recommended can be useful/effective/ may/might be reasonable No Benefit Harm
is indicated beneficial usefulness/effectiveness is is not potentially
is useful/effective/ is probably recommended unknown/unclear/uncertain recommended harmful
beneficial or indicated or not well established
is not indicated causes harm
should not be associated with
Comparative treatment/strategy A is treatment/strategy A is probably excess morbidity/
performed/
effectiveness recommended/indicated in recommended/indicated in mortality
administered/
phrases† preference to treatment B preference to treatment B
other should not be
treatment A should be it is reasonable to choose performed/
is not useful/
chosen over treatment B treatment A over treatment B administered/
beneficial/
effective other

• Fig. 44.4 Classification of recommendations and level of evidence. (From Winstein CJ, Stein J, Arena R,
et al: Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals
From the American Heart Association/American Stroke Association, Stroke 47[6]:e100, 2016.)

significant mass effect, or any homogenous hyperdensity located period. The most important risk factor to target for secondary
beyond the borders of the infarct zone. The presence of either stroke prevention is hypertension.30,57 In most cases antihyper-
hemorrhagic infarction type 1 (HI1), hemorrhagic infarction tensives should be restarted 24 hours poststroke in any patient
type 2 (HI2), or parenchymal hematoma type 1 (PH1) was not who was taking them prior to the stroke.57 Erdur et al. in their
shown to be associated with early neurologic decline or 3-month study of 5106 patients reported on the risk of stroke recurrence
mortality. The incidence of hemorrhagic transformation follow- during the period of acute inpatient hospitalization. The overall
ing intervention for acute stroke is complicated and beyond the risk in their study was less than 1%, but the patients at highest
scope of this chapter.93␣ risk for recurrence were those with a history of TIA, high-grade
symptomatic carotid stenosis, or stroke secondary to another
Repeat Stroke determined etiology (e.g., giant cell arteritis, cervical arterial
Because of more aggressive medical treatment specifically to dissection). Pneumonia poststroke was also associated with an
reduce secondary strokes, the rate of recurrence of stroke after increased risk of recurrence, and aphasia was associated with a
ischemic stroke and/or TIAs has dropped to about 3% to 4% decreased risk. There was no difference in the medical manage-
per year.67 The rate of recurrence is highest in the first 30 ment of those with and without recurrence.32 When a recur-
days following the initial stroke/TIA. Approximately half of rence of stroke is suspected during an inpatient rehabilitation
all strokes that recur within 90 days occur within the first 2 stay, the patient should be evaluated by CT to rule out hemor-
weeks, thus highlighting the importance of aggressive measures rhagic transformation and make sure that no acute neurosurgi-
and close monitoring during the acute inpatient rehabilitation cal intervention or management of intracranial hypertension is
962 SECTION 4 Issues in Specific Diagnoses

TABLE TABLE Fiorelli Classification of Intracranial

44.5
Medical Complications After Stroke59 44.6 Hemorrhage35
Recurrent stroke 9% Hemorrhage Classification Radiographic Appearance
Epileptic seizure 3% Hemorrhage infarction type 1 Small hyperdense petechiae
(HI1)
UTI 23%
Hemorrhage infarction type 2 More confluent hyperdensity
Chest infection 22%
(HI2) throughout the infarct zone;
Other infection 19% without mass effect

Falls 26% Parenchymal hematoma type Homogeneous hyperdensity occu-

1 (PH1) pying <30% of the infarct zone;
Falls with injury 5% some mass effect
Pressure sores 21% Parenchymal hematoma type Homogeneous hyperdensity
DVT 2% 2 (PH2) occupying >30% of the infarct
zone; significant mass effect; or
PE 1% any homogenous hyperdensity
located beyond the borders of
Shoulder pain 9% the infarct zone
Other pain 34%
Depression 16%
Anxiety 14%
Emotionalism (pseudobulbar affect) 12% AHA/ASA guidelines for ICH note a risk of early seizures up to
16%, with the majority of these occurring at onset. Risk of seizure
Confusion 36% is increased with cortical involvement. Additionally, on continuous
DVT, Deep venous thrombosis; PE, pulmonary embolism; UTI, urinary tract infection.
EEG monitoring, up to 28% to 31% of a group of individuals with
ICH were found to have evidence of seizures despite the fact that
most were receiving prophylaxis. Ultimately, given a lack of differ-
ence in outcomes, the ICH guidelines note an absence of convinc-
required. Assuming that that is not the case, evaluation with ing evidence to recommend the prophylactic use of anticonvulsants;
MRI, including DWI, will help to confirm a new stroke. Treat- however, they do recommend treating identified clinical or electro-
ment for an acute stroke recurrence within the first 30 to 90 graphic seizures.47 The AHA/ASA guidelines for SAH management
days follows the same guidelines as treatment for any other note a likely 3% to 7% risk of late seizures, although there is no con-
acute stroke with the exception of certain contraindications for sensus on either the immediate or chronic use of anticonvulsants.
treatment with thrombolytics or interventional procedures, as The risk of late seizure may be increased among those with a thicker
noted previously. If no new stroke has occurred, stroke mim- clot or rebleeding, and it is left to the discretion of the provider
ics must be considered. Testing to evaluate for infection, most whether to administer prophylaxis, balancing the negative effects of
commonly urinary tract infection (UTI) or pneumonia, should anticonvulsants with the presumed risk of seizure.25,71␣
be completed, as infection can cause a worsening of neurologic
symptoms. Seizures must also be considered in the differential Hydrocephalus
diagnosis as a stroke mimic, keeping in mind that nonconvulsive Acute hydrocephalus is common after aneurysmal SAH, occurring
status epilepticus (NCSE) can present as mental status changes in up to 15% to 87% of patients, whereas chronic, shunt-depen-
and may be quite subtle. In one study of 889 stroke patients, dent hydrocephalus can be seen in 8.9% to 48% of patients.25
NCSE was found in 3.6%.9,68␣ Although these patients are often treated with an extraventricular
drain and may apparently resolve in the acute stage, it is important
Seizures for the rehabilitationist to recognize the risk of chronic hydro-
The incidence of seizure following a stroke varies widely in the cephalus and to identify patients with a gradual decline in mental
literature depending on the study. In the early (first week) post- and functional status by implementing appropriate imaging and
stroke period, it is estimated to be 2% to 23%; this increases to neurosurgical consultation for shunt placement as needed.␣
up to 3% to 67% chronically. Based on our clinical experience
and some of the cited literature,4,12 it is more likely that the actual Cerebral Vasospasm
incidence is on the lower end of the range. Of use to the reha- Though not frequently seen in the rehabilitation environment,
bilitationist, one survey of a tertiary stroke rehabilitation program large-artery narrowing after aneurysmal SAH is visible in up to
identified an incidence of only 1.5%, and Langhorne et al. noted 50% of cases, usually occurring 7 to 10 days after the aneurysm’s
a 3% incidence during hospitalization after stroke and an eventual rupture and resolving spontaneously after 21 days. Vasospasm
5% incidence with follow-up up to 30 months.59,65 Should a sei- may contribute to a secondary ischemic injury and lead to further
zure occur, a workup for contributing causes should be pursued morbidity and mortality. Guidelines suggest oral nimodipine (IA)
and the addition of antiepileptic medications should be consid- and euvolemia with normal circulating blood volume (IB) for all
ered (IC, e13). The guidelines suggest that “routine prophylaxis patients with aneurysmal SAH to decrease the risk of vasospasm.
for patients with ischemic or hemorrhagic stroke is not recom- Transcranial Doppler and perfusion imaging with CT may be
mended” (IIIC, e13).105 used for monitoring.24,25␣
 CHAPTER 44 Stroke Rehabilitation 963

Venous Thromboembolism Gastrointestinal Bleeds

In terms of VTE prevention, a process on admission should A review of 6853 patients with ischemic stroke found that 100
be implemented to ensure appropriate prophylaxis. Given the (1.5%) developed a GI bleed during hospitalization, with 36
still notable risk for deep venous thrombosis (DVT) and PE (0.5%) requiring transfusion.78 Studies are lacking in the par-
in immobile patients, even in those appropriately treated with ticular population of stroke survivors in terms of gastric ulcer
pharmacologic or mechanical prophylaxis, a low threshold prophylaxis, so that data from other populations must be utilized
for repeat assessment for DVT and PE should be maintained to make an informed decision on treatment. Although many
even in the situation of appropriate prophylaxis. Illustrating physicians prescribe histamine 2 (H2) blockers with the thought
this, Samama noted a relative risk reduction of 63% with low that they will avoid the negative effects of proton pump inhibi-
molecular weight heparin (LMWH) compared with placebo tors (PPIs), one review62 of critically ill patients elicits concern
in a population of acutely ill medical patients. This study related to this practice. When both enterally fed and non–enter-
demonstrated a DVT rate of 14.9% in individuals without ally fed patients were included, studies demonstrated a decrease
prophylaxis and a rate of 5.5% in those on LMWH.88 Guide- in GI bleeding rate but no demonstrable effect on hospital mor-
lines support the use of prophylactic-dose heparin products tality with the use of an H2 blocker. However, in the subgroup
during acute and rehabilitation hospitalizations up to the time of patients receiving enteral feeds, the patients treated with an
that a patient regains mobility (IA). It is common practice to H2 blocker demonstrated both increased mortality and a lack
use ambulation of 150 ft as the threshold to discontinue pro- of protective effect against GI bleeds. It is up to the judgment
phylactic anticoagulation. After ICH, prophylactic-dose hepa- of the physician to interpret this information for the individual
rin products are recommended to be begun in 2 to 4 days in patient. Of particular relevance to stroke treatment, the combi-
most cases (IIbC). In both ischemic stroke and ICH, LMWH nation of a PPI and clopidogrel has not been definitively shown
is generally preferred over UFH (IIaA and IIbC, respectively). to increase the risk for cardiovascular events. If the combination
If anticoagulation is contraindicated, intermittent pneumatic is used, we would recommend omeprazole based on data from
compression is preferable to no prophylaxis (IIbB and IIbC, the COGENT trial.98␣
respectively). In both ischemic stroke and ICH, elastic com-
pression stockings are not recommended (IIIB and IIIC, Pain
respectively).105␣
Central Pain
Classically seen in Déjèrine-Roussy syndrome related to thalamic
Pulmonary Complications stroke, neuropathic pain may occur after a stroke in a variety
Additional care should be taken in the identification of dyspha- of locations. Appropriate care includes a thorough assessment of
gia and aspiration, as the presence of these findings increases the etiology, and other causes of pain should be excluded (IC). Medi-
risk of pneumonia by a relative risk of 3.17 and 11.56, respec- cation management should be tailored to the individual, taking
tively.64 See the section titled “Rehabilitation: Treatment of Stroke side effects and comorbidities into consideration (IC). Amytrip-
Sequelae” for recommendations on advancement to an oral diet.␣ tyline and lamotrigine have support as first-line agents (IIaB).
Although there are less data in the literature on other tricyclic
antidepressants (TCAs), consideration may be given to the use
Cardiovascular Complications of nortriptyline or other TCAs that have fewer anticholinergic
The AHA guidelines should be implemented with initiation of side effects than amitriptyline. Pregabalin, gabapentin, carbam-
antiplatelet medications and statins when clinically indicated. A azepine, and phenytoin may be considered as second-line agents
medically appropriate diet should be provided during patients’ (IIbB). As is frequently the case in chronic pain, an interprofes-
inpatient hospitalization, and education about lifestyle and diet sional approach should be attempted (IIaB), with utilization of
modifications should occur as part of their care. The AHA/ACC behavioral interventions as well as medications and modalities
guidelines on nutrition and cardiovascular diseases recommend through various team members. Transcutaneous electrical nerve
implementing a DASH diet for hypertension and the manage- stimulation (TENS) and deep brain stimulation have not been
ment of low-density lipoprotein (IA), limiting calories from established as effective treatments (IIIB), but there is some evi-
saturated fats to equal to or less than 5% to 6% of total intake dence to support the possible use of motor cortex stimulation, if
(IA) and limiting sodium intake to less than 2400 mg in patients accessible (IIbB), in patients who are poorly responsive to other
with hypertension and even to 1500 or 1000 mg in unresponsive interventions.105␣
cases (IB).31␣
Shoulder Pain
Hemiplegic shoulder pain is very commonly encountered during
Urinary Tract Infection rehabilitation and may restrict participation in and toleration of
UTIs are common and should be suspected with a decline in the therapy. Due to the multifactorial nature of shoulder pain fol-
functional status of a stroke patient, particularly in the setting of lowing stroke, a thorough examination should be undertaken—
fever, leukocytosis, dysuria, or a change in continence. Initially, particularly including a musculoskeletal evaluation, assessment
indwelling catheters should be removed within 24 hours of admis- of spasticity, determination of subluxation, and peripheral neu-
sion to rehabilitation (IB) as able. Urinalysis with reflex cultures rologic assessment—to determine regional sensory and motor
may identify UTIs early and prevent urosepsis, but care must be impairment that may be outside of the effect of CNS injury
taken not to overtreat so as to avoid secondary consequences of (IIaC). Ultrasound can be helpful for the diagnosis of soft tissue
antibiotic treatment, such as Clostridioides difficile (C. difficile) injury (IIbB).105 Additionally, a thorough knowledge of myofas-
colitis.105 cial pain referral patterns and evaluation for complex regional pain
964 SECTION 4 Issues in Specific Diagnoses

syndrome (CRPS) with compression of the metacarpophalangeal be provided to patients and caregivers to target environmental
joints and evaluation for skin and autonomic changes may be modification (IIaB). Participation in exercise programs with
helpful in identifying etiology.96 In certain cases, electrodiagnostic a goal to reduce falls is recommended (IB), and Tai Chi is a
evaluation can be beneficial should peripheral nerve or nerve root potentially effective intervention to decrease the risk of falls
injury be suspected. In terms of prevention, patients and families (IIbB).105 One small study demonstrated an increased risk for
should be trained on positioning and appropriate range of motion hip fractures due to falls in chronic elderly stroke patients defi-
(IC). The strongest evidence recommends botulinum toxin for cient in vitamin D, suggesting a benefit to supplementation.90␣
hypertonic muscles contributing to shoulder pain (IIaA), neuro-
pathic pain medications in those with signs consistent with neuro- Depression/Psychiatric Issues
pathic pain (e.g. allodynia and dysesthesia) (IIaA), and the use of
supportive devices and slings to limit forces leading to subluxation Guidelines strongly promote standardized assessments of mood,
and thus also potentially decreasing pain (IIaC). Less convincing education with a focus on adjustment, and the careful use of anti-
evidence also exists to support neuromuscular electrical stimula- depressants in those with poststroke depression (IB). However,
tion (NMES) (IIbA), acupuncture (IIbB), suprascapular nerve there is no clear recommendation of a particular antidepressant
block (IIbB), and subacromial/glenohumeral joint steroid injec- class in this population despite the fact that selective serotonin
tion (IIbB).105 Although previous work on NMES for subluxation reuptake inhibitors (SSRIs) are generally well tolerated (IIIA). The
has shown improvement in subluxation but a lack of significant use of SSRIs or dextromethorphan/quinidine is recommended
improvement in pain and function,60 new implantable devices26 for the treatment of pseudobulbar affect after stroke (IIaA). In
may be more useful than peripheral surface stimulation in decreas- addition to behavioral health professional consultation (IIaC),
ing pain, and these are beginning to be used. Should CRPS exist, education, counseling, and support (IIbB), a consistent exercise
a course of oral steroids, bisphosphonates, visual imagery includ- program of at least 4 weeks may be helpful for poststroke depres-
ing mirror visual feedback, and stellate ganglion blocks may all be sion (IIbB).105␣
considered.18 Finally, there is an option of surgical tenotomy of
shoulder internal rotators in cases of severely restricted shoulder Rehabilitation: Treatment of Stroke Sequelae
range of motion (IIbC). Overhead pulley exercises are particu-
larly not recommended (IIIC).105 Finally, in the case of adhesive For the initial inpatient hospitalization, the guidelines recom-
capsulitis, hydraulic distension with or without steroid has been mend that early rehabilitation for hospitalized stroke patients
used with promising but mixed results.20 Both fluoroscopic and should be “provided in environments with organized, interprofes-
ultrasound-guided techniques have been used successfully.7␣ sional stroke care” (IA) but that “very early mobilization within
24 hours of stroke can reduce the odds of a favorable outcome at
Contractures 3 months and is not recommended” (IIIA). In terms of provision
of rehabilitation after the initial hospitalization, guidelines suggest
Contractures may frequently develop after stroke and can restrict that stroke patients who are “candidates for postacute rehabilita-
eventual function and cause potential pain and skin breakdown. tion receive organized, coordinated, and interprofessional care”
Resting the hand and wearing wrist orthoses as well as regular (IA) and that those who “qualify for and have access to an IRF
stretching or serial casting may be helpful for reducing elbow and [inpatient rehabilitation facility] should receive care at an IRF
wrist contractures (IIbC). Surgical release of elbow flexor muscles rather than a SNF [skilled nursing facility]” (IB).105
can be considered for elbow pain and contractures (IIbB). Ankle
splints may also be helpful for preventing ankle plantarflexion Functional Assessment
contractures (IIbC). Care must be taken with splinting to avoid
skin breakdown. Guidelines recommend positioning the hemiple- Although a strong recommendation exists to obtain a formal
gic shoulder in the maximum external rotation tolerated for 30 assessment of functional status in both the acute hospitalization
minutes a day (IIaB).105␣ and subsequent levels of care (IB), the exact nature of the assess-
ment is less certain. Standardized measures of motor impairment,
upper extremity function, balance, and mobility are all generally
Skin Ulcers thought to be possibly useful (IIbC). It is also likely that serial
Appropriate skin management requires regular assessments with assessment with standardized measures could help to determine
use of standardized measures such as the Braden scale (IC). progress (IIbC). The communication evaluation should include
Regular interventions—including nutritional assessment, skin a range of interview, observation, and both standardized and
hygiene maintenance, turning and weight-shift schedules, and the nonstandardized measures with a goal of identifying strengths
appropriate use of pressure-relieving mattresses and wheelchair and weaknesses and developing compensatory strategies (IB). All
cushions—are also recommended, along with ongoing family stroke patients should receive a cognitive screening (IB), and those
education (IC).105␣ with deficits should receive more detailed testing (IIaC). Assess-
ment should also include sensory impairments in touch, vision,
and hearing (IIaB).105␣
Falls
Falls are a critical issue after stroke and require both a for- Cognition/Aphasia/Speech
mal fall prevention program during inpatient rehabilitation
(IA) as well as continued screening in the outpatient environ- The strongest recommendation for nondrug interventions appears
ment using an established measure such as the Berg Balance to be the use of enriched environments (IA), including the use of
Scale61 or the Morse Fall Scale70 (IIaB). Information should technology (such as internet, virtual reality, and music) and other
 CHAPTER 44 Stroke Rehabilitation 965

resources to improve patient engagement in the therapy process. Sensory Impairment

Class IIaB recommendations exist for the provision of cognitive
rehabilitation, including aspects of practice, compensation, and Vision
adaptive techniques to improve attention, memory, neglect, and In terms of eye movement impairments, guidelines strongly sup-
executive function. There is IIbA evidence for the use of both port the use of exercises to treat convergence insufficiency (IA).
compensatory strategies and external aids for memory. Further, There is also some support to a lesser degree for compensatory scan-
IIbB evidence exists for the use of errorless learning and music ning techniques both for functional ADLs (IIbB) and for scanning
therapy for memory impairments. Finally, exercise may be helpful and reading (IIbC). For visual field deficits, yoked prisms (IIbB),
in improving cognition and memory (IIbC). compensatory training (IIbB) and computerized vision retraining
Guidelines strongly recommend therapy for speech/language (IIbC) may all be considered, although the evidence is not strong.
pathology (IA) as well as partner training (IB) for those with apha- Regarding visual/spatial and perceptual impairments, evidence for
sia. Although intensive therapy is recommended, there is no agree- multimodal audiovisual spatial exploration training appears to be
ment on the best parameters for treatment (including amount, the strongest (IB). Virtual reality may also be considered (IIbB),
timing, intensity, distribution, and duration) (IIaA). Care may but the guidelines otherwise do not support or refute any par-
also be supplemented with computerized treatment (IIbA). No ticular intervention (IIbB). Apart from the previously mentioned
clear guidance is given on the exact treatment approach, but group use of yoked prisms, exercises for convergence insufficiency, and
therapy may be helpful and pharmacotherapy may be considered computer-assisted training for visual field deficits, the guidelines
(IIbB). do not support the use of other behavioral optometry methods
Recommendations for motor speech disorders, including such as eye exercises and colored filters (IIIB).105␣
apraxia of speech and dysarthria, include techniques and strategies
that target both physiologic support for speech (respiration, pho- Hearing
nation, articulation, and resonance) and global aspects of speech The data are less compelling in the treatment of hearing impair-
(loudness, rate, and prosody) (IC). Augmentative and alternative ments, but guidelines support referral to an audiologist for testing,
communication devices (IC) and telerehabilitation (IIaC) may be use of amplification systems, use of communication strategies, and
implemented as necessary. Additionally, listener education and the minimization of background noise (IIaC).105␣
other environmental modifications can help to promote success-
ful communication (IIbC). Hemineglect/Hemi-inattention
Several medications are used to treat cognitive and language Multiple interventions are recommended for hemineglect and
impairments after stroke. Both donepezil21 and rivastigmine74 hemi-inattention, including “prism adaptation, visual scanning
have shown promise in this regard, but their use is still not well training, optokinetic stimulation, virtual reality, limb activa-
established (IIbB). Additionally, antidepressant medication was tion, mental imagery, and neck vibration combined with prisms”
shown in one study to potentially have a beneficial effect on the (IIaA).105 Lower-level evidence recommends right visual field test-
prevention of long-term deficits in executive function; however, ing and repetitive transcranial magnetic stimulation, although
an immediate effect was not noted (IIbB).75 Atomoxetine, meth- this would likely be very difficult to implement given problems
ylphenidate, and modafinil are used in the community, although of availability (IIbB). Additionally, somatosensory retraining to
published data are limited (IIbC).105␣ improve sensory discrimination may be considered for individuals
with sensory impairments (IIbB).105␣
Dysphagia/Nutrition
Motor Impairment
Early dysphagia screening is important to decrease the risk of
aspiration, malnutrition, and dehydration (IB). Beyond the Notably, the guidelines find that the superiority of any of the
bedside swallow assessment, an instrumental assessment is specific approaches to neurorehabilitation—such as neurodevel-
probably indicated (IIaB), but the exact type of assessment is opmental therapy, Bobath, Brunnstrom, or proprioceptive neuro-
not totally clear (IIbC). In one review,64 incidence of dyspha- muscular facilitation—has not been established (IIbB).105
gia after stroke differed as follows: cursory screening techniques Apraxia: Evidence for the treatment of apraxia is limited,
identified an incidence of 37% to 45%; skilled screening identi- though guidelines support strategy or gesture training (IIbB) as
fied a rate of 51% to 55%; and instrumental testing, often via well as task practice with or without mental rehearsal (IIbC).
videofluoroscopy, identified an incidence of 64% to 78%. The Ataxia/Balance Impairment: Guidelines recommend balance
presumption is that there is a higher sensitivity with a more screening for all individuals with stroke (IC) and strongly rec-
intensive evaluation. The incorporation of the principles of neu- ommend a formal balance training program for those with poor
roplasticity (IIaB) and behavioral interventions (IIbA) is recom- balance and fear of falls (IA) as well as an assessment for assistive
mended for dysphagia treatment, but the use of drugs, NMES, devices and orthoses in those with balance issues after a stroke
transcranial direct current stimulation (tDCS), and transcranial (IA). Additionally, “postural training and task-oriented training
magnetic stimulation is not recommended in the most recent may be considered for rehabilitation of ataxia” (IIbC).105
guidelines (IIIA).105 Hemiparesis: In terms of medications, SSRIs have the most sup-
In the hospitalized patient with poor oral intake, feeding via port based on an RCT,23 but the guideline authors do not feel
nasogastric tube should be started within 7 days (IA); this should that the evidence has reached the level of a solid recommendation
be advanced to a percutaneous G-tube in those unable to advance (IIbB). Despite a small RCT showing possible short-term effect,
from tube feeding within 2 to 3 weeks following stroke (IB). Sup- the guideline authors do not feel that the use of levodopa is ade-
plements may be necessary in some to prevent or treat malnutrition quately established (IIbB) and, based on a negative randomized
(IIaB). Assessment for calcium and vitamin D supplementation controlled trial (RCT), recommend against the use of methylphe-
should be encouraged in those in long-term care facilities (IA).105␣ nidate or dextroamphetamine for motor recovery (IIIB).38␣
966 SECTION 4 Issues in Specific Diagnoses

Spasticity after admission (IB). Prompted voiding, through a timed void-

ing schedule, may be helpful in the hospital or at home, and
Guidelines strongly recommend the use of botulinum toxin in pelvic floor muscle training may be helpful after discharge to
both the upper and lower extremities in appropriate cases (IA). home (IIaB).105
Oral medications (IIaA) such as baclofen, dantrolene, and tizan- There are few high-quality studies related to bowel inconti-
idine and physical modalities (IIbA) such as NMES and vibra- nence after stroke, but usual care involves following the frequency
tion are also recommended. In severe cases, intrathecal baclofen and consistency of bowel movements using the Bristol Stool Scale
(IIbA) may be helpful. Current guidelines to not support the use and adjusting stool softeners and laxative medications as necessary
of splints and taping for wrist and finger spasticity after stroke to maintain regular bowel movements.␣
(IIIB).105␣
Sexual Dysfunction
Activities of Daily Living
Guidelines recommend offering patients an opportunity to dis-
Guidelines recommend that patients should receive therapy that cuss sexual issues and concerns in the hospital and outpatient
is functional and appropriately challenging and that allows for setting (IIbB).105 Topics may include safety concerns, changes
repeated practice (IA). Additionally, both activities of daily liv- in libido, and physical and emotional consequences of stroke.
ing (ADLs) (IA) and instrumental ADL (IADL) (IB) training Pharmacologic treatment for erectile dysfunction with a phos-
should be tailored to the patient’s needs and discharge situation. phodiesterase-5 (PDE5) inhibitor may be considered more
Constraint-induced movement therapy (CIMT) is recommended than 6 months poststroke assuming there are no other contra-
for those with adequate activation (IIaA). Robotic therapy and indications or drug-drug interactions relative to the use of a
NMES are recommended for those with more moderate to severe PDE5 inhibitor.1,2␣
upper limb paresis and minimal volitional movement within the
first few months (IIaA). Mental practice (IIaA), strengthening
exercises (IIaB), and virtual reality augmentation should also be
Transition to Home and Community
considered as adjuncts to functional therapy. Bilateral training With regard to transitioning from a hospital environment to the
programs may also be useful (IIbA). Finally, acupuncture is not community, guidelines support an individually tailored discharge
recommended (IIIA) due to lack of evidence that it provides ben- plan with the potential to utilize multiple methods of communi-
efit to improve ADLs.105␣ cation and support (IIaB). Caregiver involvement is thought to
be important, addressing education, training, counseling, assess-
Mobility ment, the development of support structures, and financial assis-
tance and guidance (IIbA). Early involvement of caregivers is also
The guidelines strongly recommend intensive mobility task train- supported (IIbB). In terms of resources in the community, a treat-
ing and the usage of ankle-foot orthoses (AFOs) in those with ing facility should provide information based on an up-to-date
forms of foot drop (IA). Guidelines give strong recommendations database on community resources, consider patient and caregiver
for the assessment and provision of ambulatory assist devices (IB), preferences in making referrals, and follow up with patients to
AFOs (IB), and wheelchairs (IC). Additionally, there is a recom- ensure that they are receiving appropriate and necessary services
mendation for group therapy with circuit training, cardiovascular (IC).105
training, and NMES devices in certain patients with foot drop All patients should be considered for community or home-
in place of an AFO (IIaA). Less strong recommendations exist based rehabilitation (IA); when recommended, a formal plan
for treadmill training (with or without body weight support) should be developed with a case manager or other clinical staff as a
and robot-assisted mobility training in qualifying patients and point person to ensure appropriate implementation (IIbB). Addi-
mechanically assisted walking for those not yet able to otherwise tionally, caregivers should be trained in supporting and imple-
participate in ambulation (IIbA). Guidelines do not yet support menting the program (IIaB).105
the use of acupuncture, TENS, rhythmic auditory cueing, EMG Guidelines strongly recommend participation in a tailored
biofeedback, or water-based exercises (IIbB), but research is ongo- exercise program in the home or community after the comple-
ing. There is a consideration that virtual reality may be beneficial tion of formal therapy (IA) with evidence to supporting improved
for gait (IIbB).105␣ fitness (IA) and a reduced risk for secondary stroke (IB). Guide-
lines recommend promoting “engagement in leisure and recre-
Bladder/Bowel ational pursuits” through the development of self-management
skills beginning as early as the inpatient environment (IIaB). For
Bladder incontinence is one of the most important predictors those considering a return to work, vocational rehabilitation ser-
of poorer functional outcomes, institutionalization, and mor- vices may be useful (IIaC). For those that do return to work, an
tality.66 Although detrusor hyperreflexia is the most common assessment of physical and cognitive abilities may be considered
subtype of incontinence after cortical and internal capsule (IIbC).105
ischemic stroke, there is a relatively higher incidence of detru- Prior to return to driving, a formal on-the-road evaluation is
sor areflexia in patients with cerebellar infarction and hemor- recommended (IC). Additionally, in preparation for an on-the-
rhagic stroke.17 During acute hospitalization, all patients with road test, an assessment of cognitive, perceptual, and physical abil-
stroke should provide a urologic history and be assessed for any ities is reasonable (IIaB). For those who fail an on-the-road test,
concern regarding urinary retention through bladder scanning a driver rehabilitation program may be considered (IIaB). Finally,
or intermittent catheterizations after attempted voiding (IB). the plan for a return to safe driving may include the use of a driv-
If present, a Foley catheter should be removed within 24 hours ing simulator (IIbC).␣
 CHAPTER 44 Stroke Rehabilitation 967

Prognosis recommended that rehabilitation practitioners become familiar

with it to guide prognosis. Using the GOS and the BI, Adams
The determination and communication of prognosis after stroke et al. (Figs. 44.5 and 44.6) demonstrated a high probability of
can be a very challenging task. It is important for the rehabilita- death or severe disability in patients with a NIHSS score equal to
tion physician to correctly interpret the current data to be able to or greater than 16 and a likely good recovery for a score of equal
guide patients and their support systems in planning and expecta- to or less than 6. Excellent recovery was noted in 46% of patients
tions. This includes several components: (1) understanding com- with NIHSS scores of 7 to 10 and in 23% of patients with scores
mon measures looking at outcome, (2) giving the likelihood of 11 to 15. Fonarow et al. found a highly predictive correlation
different overall levels of mortality and functional recovery based between NIHSS and 30-day mortality in Medicare beneficiaries
on initial presentation, (3) giving realistic time frames for natural with ischemic stroke. Thirty-day mortality rates were 4.2% for 0
recovery to occur, and (4) guiding expectations of improvement to 7, 13.9% for 8 to 13, 31.6% for 14 to 21, and 53.5% for 22
with particular impairments and activity limitations. to 42.36 Even in patients with minor stroke, 10-year mortality was
seen to be 32%, a relative risk of 1.7 compared with age- and sex-
Outcome Measures matched populations.84

Common and historically well-established instruments to mea-

sure disability following stroke include the Barthel Index (BI), TABLE
the Modified Rankin Scale (MRS), and the Glasgow Outcome 44.8
Modified Rankin Scale99
Scale (GOS) (Tables 44.7–44.9). Familiarity with these scales can
Score Description
assist in interpreting studies of general stroke outcomes. When
measured on admission to rehabilitation, scores on the BI43 less 0 No symptoms
than 40 tend to predict lack of independence in motor skills and
1 No significant disability despite symptoms; able to carry out
difficulty with other basic skills, whereas scores over 60 tend to
all usual duties and activities
demonstrate a transition from dependence to assisted indepen-
dence. Scores of 95 or greater have been used as a measure of 2 Slight disability; unable to carry out all previous activities,
complete independence in stroke outcome research.28 The MRS but able to look after own affairs without assistance
is a simple 0 to 6 ordinal scale that divides subjects into general 3 Moderate disability; requiring some help but able to walk
functional categories.99 Although originally intended for brain without assistance
injury, the GOS52 is used in some studies of stroke recovery and
has more recently been expanded into the Glasgow Outcome 4 Moderately severe disability; unable to walk without assis-
tance and unable to attend to own bodily needs without
Scale–Extended (GOS–E).104␣
assistance
5 Severe disability; bedridden, incontinent, and requiring
Initial Presentation Prediction constant nursing care and attention
In terms of initial evaluation, the NIHSS is a widely studied and 6 Dead
utilized tool with utility in determination of prognosis, and it is

TABLE
44.7
Barthel Index43

Activity Score
Feeding: 0 = unable, 5 = needs help cutting, spreading butter, etc, or requires modified diet, 10 = independent
Bathing: 0 = dependent, 5 = independent (or in shower)
Grooming: 0 = needs to help with personal care, 5 = independent face/hair/teeth/shaving (implements provided)
Dressing: 0 = dependent, 5 = needs help but can do about half unaided, 10 = independent (including buttons, zips, laces, etc.)
Bowels: 0 = incontinent (or needs to be given enemas), 5 = occasional accident, 10 = continent
Bladder: 0 = incontinent or catheterized and unable to manage alone, 5 = occasional accident, 10 = continent
Toilet Use: 0 = dependent, 5 = needs some help but can do something alone, 10 = independent (on and off, dressing, wiping)
Transfers (bed to chair and back): 0 = unable, no sitting balance, 5 = major help (one or two people, physical), can sit, 10 = minor help (verbal or
physical), 15 = independent
Mobility (on level surfaces): 0 = immobile or <50 yards, 5 = wheelchair independent, including corners, >50 yards, 10 = walks with help of one
person (verbal or physical) >50 yards, 15 = independent (but may use any aid; for example, stick) >50 yards
Stairs: 0 = unable, 5 = needs help (verbal, physical, carrying aid), 10 = independent
Total: (0–100)
968 SECTION 4 Issues in Specific Diagnoses

TABLE
44.9
Glasgow Outcome Scale (GOS)52 and Glasgow Outcome Scale–Extended (GOS–E)104

GOS GOS–E
1. Death Patient has sustained severe injury or has died without recovery of con- 1. Dead
sciousness.
2. Persistent Patient has sustained severe damage with prolonged state of unresponsive- 2. Vegetative state
vegetative state ness and a lack of higher mental functions/condition of unawareness with
only reflex responses but with periods of spontaneous eye opening.
3. Severe disability Patient has sustained severe injury with permanent need for help with activi-
ties of daily living.
Patient is dependent for daily support due to mental or physical disability— 3. Low severe disability
usually a combination of both. Patient cannot be left alone for more than
8 h at home.
Patient is dependent for daily support due to mental or physical disability— 4. Upper severe disability
usually a combination of both. Patient cannot be left alone for more than
8 h at home.
4. Moderate Patient does not need assistance in everyday life; employment is possible
disability but may require special equipment.
Patient has some disability such as aphasia, hemiparesis, or epilepsy and/ 5. Low moderate disability
or deficits of memory or personality but is capable of self-care. Patient is
independent at home but dependent outside. Patient is not able to return
to work even with special arrangements.
Patient has some disability—such as aphasia, hemiparesis, or epilepsy— 6. Upper moderate disability
and/or deficits of memory or personality but is capable of self-care.
Patient is independent at home but dependent outside. Patient is able to
return to work with special arrangements.
5. Low disability Patient has sustained light damage with minor neurologic and psychological
deficits.
Patient is able to resume normal life with the capacity to work even if prein- 7. Low good recovery
jury status has not been achieved. Some patients have minor neurologic
or psychological deficits. These deficits are disabling.
Patient is able to resume normal life with the capacity to work even if prein- 8. Upper good recovery
jury status has not been achieved. Some patients have minor neurologic
or psychological deficits. These deficits are not disabling.

Many factors are correlated with poorer outcome after isch- in certain situations may be reasonably encouraged to continue
emic stroke, such as lesion volume and age, though neither is to engage in attempts to regain function under the appropriate
highly specific and both are dependent on other factors.102␣ circumstances.63 However, at the same time it is important to
note that there is a general trend of decreased quality of life and
Time Frames for Recovery less functional independence based on a Barthel score greater
than 95 during the 5 years after stroke that is independent of
For ischemic stroke, the Copenhagen Stroke Study provides age, stroke severity, and other predictors of decline.28,29␣
guidance on time frames for duration of recovery, with mildly
impaired patients requiring on average 2 months, moderately Recovery Thresholds/Individual Impairments
impaired patients requiring 3 months, severely impaired patients
requiring 4 months, and the most severely impaired patients Regardless of intensity of rehabilitation and therapeutic inter-
requiring 5 months.54,55 Later studies have shown potential ventions, impairments and limitations are common after an
recovery even further out with severely impaired patients with ischemic cerebrovascular accident (CVA). The Framingham
Hankey et al. showing the median time to recovery in the Study demonstrated a range of issues after first-time ischemic
18.5% of severe patients who achieved independence (an MRS CVA at evaluation 6 months out from initial hospitalization:
score of <3) in their study to be to be 18 months.46 This fur- 26.2% with a BI below 60, 30.8% unable to walk unassisted,
ther reinforces the need to take into account stroke severity in 22.2% with bladder incontinence, 35.3% with depression, and
determining times frames of recovery in stroke (Figs. 44.7 and 25.9% institutionalized. Of note, the likelihood of a BI below
44.8). Notably, discoveries in the reversal of learned non-use 60 was dependent on age, including 16.7% of those aged 65 to
and the potential of massed practice within the CIMT model 74, 25.5% of those aged 75 to 84, and 45% of those aged 85 to
have altered opinions on time frames of recovery, and patients 94 years.56
 CHAPTER 44 Stroke Rehabilitation 969

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
0-3 points 4-6 points 7-10 points 11-15 points 16-22 points 23+ points
n = 170 n = 409 n = 323 n = 205 n = 103 n = 059

excellent good poor dead

• Fig. 44.5 Effect of baseline National Institutes of Health Stroke Scale score on outcome at 7 days. (From
Adams HP Jr., Davis PH, Leira EC, et al: Baseline NIH Stroke Scale score strongly predicts outcome after
stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment [TOAST], Neurology 53[1]:127, 1999.)

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
0-3 points 4-6 points 7-10 points 11-15 points 16-22 points 23+ points
n = 170 n = 409 n = 323 n = 205 n = 103 n = 059

excellent good poor dead

• Fig. 44.6 Effect of baseline National Institutes of Health Stroke Scale score on outcome at 3 months.
(From Adams HP., Jr., Davis PH, Leira EC, et al: Baseline NIH Stroke Scale score strongly predicts out-
come after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment [TOAST], Neurology
53[1]:128, 1999.)

In terms of individual impairment and disability, despite the Dysphagia is common in stroke patients, with up to 20%
heterogeneity of stroke presentation and outcome, there are data of patients in one study being shown by modified barium swal-
to guide expectations on time frames for improvement. low to be proven aspirators.95 However, despite this incidence, a
Aphasia recovery, similarly to motor recovery, is dependent relatively smaller percentage requires the eventual placement of a
upon initial impairment, but one study suggests time to stationary percutaneous gastrojejunostomy feeding tube, with only 5.7% of
language function following stroke to be 2 weeks for mild aphasia, this same sample of stroke patients receiving a tube. Notably, risk
6 weeks for moderate aphasia, and 10 weeks for severe aphasia.81 of tube placement is much higher (19.3%) in brainstem stroke
970 SECTION 4 Issues in Specific Diagnoses

100
In terms of predicting ambulation, sitting balance combined
with ability to recruit the hemiparetic leg is a predictive marker
for independent ambulation at 6 months. Of those who are able
80 to maintain sitting balance and recruit activation in the hemi-
paretic leg within 72 hours from stroke, 98% were independent
60 in ambulation at 6 months, whereas patients unable to main-
%
tain sitting balance or activate the hemiparetic leg within 72
hours had a 27% chance of independent ambulation. Those still
40
unable to maintain sitting balance and recruit the hemiparetic
All leg by day 9 had only a 10% likelihood of independent ambula-
20 Mild
Moderate
tion at 6 months.100
Severe Regarding visuospatial neglect, one study demonstrated
Very severe
0 that 31.5% of a group of 27 patients with evidence of visuospa-
0 1/7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18>18
tial neglect had continued evidence of neglect at 3 months.19
Weeks From Stroke Onset
Hier et al. demonstrated a relatively more rapid recovery from
left neglect, prosopagnosia, anosognosia than for hemianopia,
• Fig. 44.7Time course of recovery (peak to best neurologic outcome). hemiparesis, motor impersistence and extinction.49 The recov-
(From Jorgensen HS, Nakayama H, Raaschou HO, et al: Outcome and ery from homonymous hemianopia (HH) appears to be depen-
time course of recovery in stroke. Part II: time course of recovery. The dent upon severity of impairment with a recovery of 17% and
Copenhagen Stroke Study, Arch Phys Med Rehabil 76[5]:408, 1995.) 72% of patients with full HH and partial HH at 1 month,
respectively.44␣

100 Hemorrhagic Stroke

Intracerebral Hemorrhage
80 A recent metaanalysis looking at mortality and disability after ICH
showed 1- and 5-year survival rates to be 46% and 29% respec-
60 tively. Increased likelihood of death was associated with increased
% age, lower Glasgow Coma Scale (GCS) score, increased bleed vol-
ume, presence of ICH, and deep or infratentorial ICH location.
40
Ongoing annual risk of bleed ranged from 1.3% to 7.4% and was
All relatively increased after lobar rather than nonlobar bleeds. Nota-
Mild
20 Moderate bly, an MRS score of 0 to 2 was achieved by 53.7% to 83.7% of
Severe
Very severe
survivors at 6 months and 53.8% to 57.1% of survivors at 1 year.
0 The volume of ICH is helpful in determining prognosis, with a
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20>20 volume of over 60 cm3 and a GCS score below 9 showing a 91%
Weeks From Stroke Onset 30-day mortality. Those with an ICH volume below 30 cm3 and a
GCS score of 9 or greater had a 30-day mortality of 19%.82 Only
• Fig. 44.8
Time course of recovery (peak to best activities of daily living). 1 of the 71 patients with an ICH volume of greater than 30 cm3
(From Jorgensen HS, Nakayama H, Raaschou HO, et al: Outcome and could function independently at 30 days.15 The FUNC score—an
time course of recovery in stroke. Part II: time course of recovery. The ordinal scale based on ICH volume and location, age, GCS score,
Copenhagen Stroke Study, Arch Phys Med Rehabil 76[5]:409, 1995.) and preexisting cognitive status—was shown to predict outcome.87
In a prospective study, no patients with a score below 5 regained
patients. In those who receive a tube, one-third are removed by functional independence, whereas greater than 80% of those with
discharge from rehabilitation and 75% are removed by 1 year. a maximal score of 11 regained functional independence. Notably,
For upper extremity recovery, 80% of patients achieve maxi- 26% of the overall sample regained functional independence.␣
mum recovery at 3 weeks and 95% achieve maximum recovery
at 9 weeks.73 Additionally, the presence of voluntary finger exten- Subarachnoid Hemorrhage
sion and shoulder abduction can help to guide prognosis; 98% of Mortality is high after spontaneous SAH, with one large popu-
those with these abilities within 72 hours after stroke achieving lation study demonstrating that 10% of patients died prior to
some manual dexterity, as demonstrated by an action research arm reaching the hospital, 25% died in the first 24 hours, and 45%
test (ARAT) score of ≥10.76 Among those still lacking voluntary died within the first 30 days. Of the 44 patients who survived 30
finger extension and shoulder abduction within 72 hours, only days, 52% were classified as “mild to no handicap,” 18% as “mod-
25% achieve manual dexterity. In those patients with a contin- erate handicap” (not totally independent), 16% as “moderately
ued lack of voluntary finger extension and shoulder abduction severe handicap” (can be left alone for a period of time), and 14%
at 9 days, eventual manual dexterity was achieved by only 14% as “totally dependent” (requiring constant supervision). Volume
of patients. Proprioceptive loss is also associated with decreased of bleeding is important in terms of mortality, as the same study
long-term recovery of upper extremity functioning and indepen- identified that only 3 of 29 patients with a SAH smaller than
dence in daily living, although the difference in recovery between 15 cm2 died within 30 days.16,71 The International Subarachnoid
patients with and without proprioceptive impairment on admis- Aneurysm Trial (ISAT) comparing coiling and clipping demon-
sion to rehabilitation could not be demonstrated earlier on at 6 strated a mortality of 11% at 5 years following an endovascu-
weeks out from stroke.85 lar treatment and 14% after surgical clipping. The proportion