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A patient with a history of alcohol abuse suffers a stroke. The effects of…
A patient with a history of alcohol abuse suffers a stroke. The effects of the stroke have left him with the inability to speak, use his right arm, or walk without assistance.
Background Information
Anatomy of the Brain & Functions
Cerebrum & Structures
Cerebrum: divided into two halves called the left & right hemispheres
Sulci: shallow depressions between the folds of the brain
Gyri: folds in the brain tissue
Longitudinal Fissure: deep indentation that divides the cerebrum into 2 halves
Precentral Gyrus: location of primary motor area; regulates body's motor function
Postcentral Gyrus: location of the primary sensory area; involved in body's sensory functions
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Central Sulcus: separates the frontal and parietal lobes of the cerebrum
Cerebellum
Cerebellum: primary function is to regulate motor movements and assist w/ equilibrium
Arbor Vitae: help provide valuable sensory info. to the brain
Diencephalon Structures
Diencephalon (located in the middle of the brain, deep to cerebrum)
Corpus Callosum: band of white matter that is a communication pathway for the 2 cerebral hemispheres
Pineal Gland: secretes melatonin & regulates circadian rhythm
Intermediate mass of the Thalamus: connects the right & left side of the thalamus; communicates btwn left & right thalamus
Thalamus: relay center to & from the cerebrum; filters out sights & sounds
Hypothalamus: controls the release of hormones from the pituitary gland; controls homeostasis of the body
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Brain Stem Structures
Brain Stem: inferior to the diencephalon & cerebrum
Midbrain: regulates eye movement; location of the corpora quadrigemina
Pons: region acts as a bridge & relays information between medulla oblongata & higher brain regions
Corpora Quadrigemina: four bumps (colliculi) involved in visual & auditory reflexes
Brain Meninges: protective membranes
Dura Mater: most superficial, thickest layer; attached to the bones of the skull
Arachnoid Mater: middle layer; stringy proteins make it look like a spiderweb
Pia Mater: deepest, thinnest layer; attached to the outer surface of the brain
Subarachnoid Space: underneath the arachnoid mater filled with cerebrospinal fluid (CSF)
Dural Venous Sinus: space between the layers of dura mater where blood is found
Arachnoid Granulations: small openings in arachnoid mater that allow CSF to drain into the dural venous sinus
Brain Ventricles
Cerebrospinal Fluid (CSF): fluid that fills the brain ventricles
Ependymal Cells: specific cells that generate CSF
Choroid Plexus: leaky blood vessels in the brain that provide the fluid for CSF
Lateral Ventricles: 2 ventricles found in the cerebral hemispheres
3rd Ventricle: ventricle found in the diencephalon, specifically the thalamus
4th Ventricle: ventricle found in the brainstem, anterior to cerebellum
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Cranial Nerves
Olfactory (I): the sense of smell
Optic (II): sense of vision
Oculomotor (III): movement of eyeball & regulation of pupil & lens shape
Trochlea (IV): movement of eyeball
Trigeminal (V): collect sensory information of the face, scalp, & teeth; contraction of chewing muscles
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Stroke Pathophysiology
Effects of Alcohol on the Brain
Cerebellum
Alcohol Intoxication leads to impaired cerebellar function specifically:
Disturbance of Gait: rarely can walk in a straight line, people often sway & stagger, falling & bumping into objects likely (due to temporary cerebellar disturbance)
Loss of Balance & Posture: cannot stand on one foot when intoxicated, rather they tip & fall over
Inability to Detect Proprioceptive Info: when asked to close eyes & touch nose, frequently will be unable to complete task; due to reduced ability to sense proprioceptive info, plus incoordination of skeletal muscles
Alcohol is an indirect GABA (Gamma-Aminobutyric Receptor)
GABA is a major inhibitory neurotransmitter in the brain
Alcohol believed to mimic GABA's effect in the brain, binding to GABA receptors & inhibiting neurons from sending signals
GABA & Glutamate receptors in the reward centers of the basal forebrain create a system of positive reinforcement
Alcohol inhibits the major excitatory neurotransmitter NMDA (N-Methyl-D-Aspartate)
When alcohol is consumed, it causes NMDA to release other inhibitors like dopamine in the nucleus accumbens (the brain's reward center)
Neurochemical effects cause mild buzz, slow reaction times, and alcohol tolerance/dependence (leading to addiction)
Effect of acute tolerance is unpredictable; someone may have overactive receptors & a lot of overactive neurons that can cause the inhibitory or depressant effect of alcohol to become dangerous
Can lead to alcohol poisoning & death
Stroke: occurs when there's a loss of blood flow to parts of the brain
Without oxygen & nutrients from the blood, brain cells begin to die; leads to brain damage, disability, & death
Types of Stroke
Ischemic Stroke: caused by a blood clot that blocks/clogs a blood vessel in the brain
80% of strokes
Hemorrhagic Stroke: caused by a blood vessel that breaks & bleeds into the brain
Transient Ischemic Attack (Mini-Stroke): when blood supply is blocked from the brain for a short period of time
Can lead to higher risk of full stroke
Stroke Risk Factors: High blood pressure (primary risk), diabetes, heart diseases (AFIB), smoking, age, race and ethnicity, high cholesterol, unhealthy diet, obesity, alcohol & illegal substance abuse, lack of physical activity
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Subarachnoid Hemorrhage: bleeding occurs in the space between the surface of brain or skull; ruptured cerebral aneurysm
Intracerebral Hemorrhage: bleeding that occurs within the brain tissue due to changes in arteries from long-term hypertension
Thrombotic (cerebral Thrombosis): blood clot forms from inside a diseased or damaged artery in the brain, from cholesterol containing deposits (plaques)
Embolic (cerebra embolism): when a clot or small piece of plaque from one arteries leading to brain or heart & lodges narrowed brain arteries
Stroke: Why symptoms & outcomes vary from patient to patient
Different location of stroke inside the brain
Any blood vessel inside the brain can be blocked & with this, can cause a variety of different symptoms depending on the location of the stroke in the cerebrum. With this as well, the outcome of the person who undergoes the stroke will vary -- think patient that had a stroke in their primary motor cortex vs further in the frontal lobe.
Different severity of the stroke
Depending on the location and blood vessels that may be locked, it determines the patient's ability to rebound from the stroke.
Type of stroke
Based on the type of stroke, it determines the extent of damage that is actually caused to the cerebrum & corresponding brain structures. A patient with a miniature stroke will recover faster than one who has an ischemic stroke to a major functional part of the brain.
Age of patient
A 30 year old's brain will be able to adapt better than an 80 year olds brain that is affected by dementia. Age determines the severity the stroke will affect the patient & their likeliness to overcome its ailments through post-stroke aftercare
Alcohol abuse could lead to stroke due to alcohol's ability to trigger atrial fibrillation
With an irregular heartbeat, it can cause blood clots to form in the heart; clots move from the heart to the brain, causing a stroke
Liver damage from alcoholism can stop the liver from making substances that help your blood clot
Without clotting agents, increase risk for having a stroke by brain hemorrhaging
Drinking too much alcohol raises the blood pressure (BP) which gives the risk of stroke
Blood vessels damaged by high BP can narrow, rupture, leak, or cause blood clots to form in arteries leading to brain, causing stroke
This patient has these specific symptoms because a blood clot has travelled to the brain, blocking the blood vessels to the left frontal lobe of his brain
This could have affected Broca's area, the part of the brain linked to speech, and his primary motor cortex or precentral gyrus
The direct cause of a stroke includes either a blocked artery, leaking, or bursting of a blood vessel; this, then, disrupts the blood flow to the brain
Stroke
Brain's depletion of blood
Damage to brain, specifically primary motor cortex
Damage to Broca's area
Aphasia (loss of ability to understand or express speech)
Frustration, depression, & other mood changes
Impair ability to read or write
Involuntary muscle tightening or spasicity
Chronic pain
Muscle fatigue
Impaired ability to use muscles or performs specific movements
Depression or other mood changes
Memory lapses
Difficulty sleeping
Lack of energy
Struggle to resume enjoyable activities
Feelings of sadness, worthlessness
Brain edema
Neurologic damage/ impaired motor function
Loss of basic functions like swallowing, walking, fine motor skills
Loss of consciousness
Coma
Seizure
Impaired movement/ neuropathy/ loss of range of motion
Not being able to move due to stroke
Pneumonia
Breathing problems
Pleurisy
Respiratory failure
Death
Bacteria from lungs spread into the blood
Bacteremia & Septic shock
Death
Even further impaired ability to swallow
Bedsores or Pressure Ulcers
Possible infection
Deep Vein Thrombosis
Pulmonary Embolism
Death
Chronic venous insufficiency
Blood pools in veins
Pain & leg swelling
Post-thrombotic syndrome
Pain
Swelling
Ulcers & sores
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Limb Contractures
Change in muscle form/ shortened
Weakness or paralysis
Alcoholism
Long-Term Effects
Liver Disease
Inflammation of the liver
Liver Scarring (Fibrosis)
Cirrhosis (late-stage scarring of liver)
Accumulation of fluid in peritoneal cavity
Spontaneous bacterial peritonitis of ascitic fluid
Sepsis
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Hepatorenal syndrome (kidney failure)
Death
Weight loss & protein malnutrition
Denaturing of proteins
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Inability to remove toxins from blood
Hepatic Encephalophy (decline in brain function from severe liver disease)
Brain damage
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Fluid build up in legs & ascites
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Confusion & personality changes
Portal hypertension (increase in blood pressure within portal venous system of veins)
Liver failure
GI bleeding from varices, astrites, & hepatic encephalopathy
Anemia
Low RBC, WBC, & platelets
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Liver failure
Death
Fatty Liver/Hepatic Steatosis
Fat building up in the liver
Leads to cirrhosis & all its effects (variceal bleeding, ascites, encephalopathy, & liver failure)
Decreased clotting ability
Stroke
Damage to lining of the stomach
Increase production of stomach acid
Lead to ulcers
Inability to process certain nutrients
Thiamine Deficiency
Wet Beriberi (neuropathy w/ high-output congestive heart failure)
GI Beriberi (vomiting, lactic acidosis)
Coma
Dry Beriberi (neuropathy)
Korsakoff syndrome
High Blood Pressure
Hardening & thickening of arteries
Stroke
Heart attack
Weakened blood vessels bulge
Aneurysm
Blood pumping against higher pressure in blood vessels; works harder & heart walls thicken
Heart failure
Cerebellar atrophy
If patient stops drinking and avidly attends physical & occupational therapy, he may be able to coordinate his hands to play piano, but not to the same ability as before
Most likely, he will regain some ability to speak, but will only come back with intensive PT & OT