eMedicine Specialties > Physical Medicine and Rehabilitation > Stroke

Motor Recovery In Stroke: Differential Diagnoses & Workup

Author: Auri Bruno-Petrina, MD, PhD, Clinical Trainee, Pemberton Marine Medical Clinic, N Vancouver
Contributor Information and Disclosures

Updated: Oct 6, 2009

Differential Diagnoses

Acute Stroke Management
Botulinum Toxin: Dystonia Treatment

Other Problems to Be Considered

TIA is an event in which neurologic symptoms develop and disappear over several minutes and, by definition, completely resolve within 24 hours.

Reversible ischemic neurologic deficit is a transient neurologic event that lasts longer than 24 hours, resulting in only temporary impairment.

The degree of recovery of independent functioning during rehabilitation has been found to be greater than that which might have been expected by a reduction in neural impairments alone, suggesting that rehabilitation interventions play an important role in the patient's recovery of function. The 2 types of improvement are related in subtle and complex ways. Alternative compensatory functional strategies, such as one-handed dressing techniques for the hemiplegic patient, assume a major role in the performance of functional tasks when neurologic improvement is minimal or absent.

The degree of natural recovery of neurologic function varies, but figures on the relative frequencies of neurologic deficits during the early and later poststroke stages offer some insight into the degree of recovery that might be seen. The number of these deficits generally declines by approximately 33-50%. For example, the following reductions in prevalence from initial presentation have been found at 1-year follow-up:

  • Hemiparesis - From 73% at presentation to 37%
  • Aphasia - From 36% at presentation to 20%
  • Dysarthria - From 48% at presentation to 16%
  • Dysphagia - From 13% at presentation to 4%
  • Incontinence - From 29% at presentation to 9%

The time required for recovery also varies. Although most improvements in physical functioning occur within the first 3-6 months, later recovery also is observed commonly. Although it is tempting to specify a definitive prognosis in a stroke patient, it is important to recognize that a multiplicity of variables determine ultimate outcome, which is why expectations for recovery often are inaccurate.

Sexual behavior changes

 Following stroke, no significant changes occur in sexual interest or desire, but marked decline has been noted in the sexual behavior in both sexes.

  • Thirty-six percent of patients remained sexually active poststroke.
  • Thirty-three percent of men resumed unaltered intercourse.
  • Forty-three percent of women resumed unaltered intercourse.
  • Decreased frequency of intercourse resulting from altered sensation and custodial attitudes taken by the patient's spouse was reported.
  • Thirty-eight percent of men reported slow normal erections following stroke.
  • Twenty-nine percent of women reported slow normal vaginal lubrication poststroke.
  • Eleven percent of men had no coital activity prestroke, and 64% had none poststroke.
  • Thirty-five percent of women with no coital activity prestroke, and 54% had none poststroke
  • Ejaculation was normal in 73% of men prestroke and in 22% of men poststroke.
  • Orgasm was normal in 43% prestroke and in 11% normal poststroke.
  • Enjoyment of sex
    • Men - 84% prestroke and 30% poststroke
    • Women - 65% prestroke and 31% poststroke
  • The most common fears were of increased BP and of having another stroke.
  • Sixty percent of men and 70% of women were found to have decreased sexual contact with their spouse.
  • Thirty percent of patients reported having less than 1 sexual contact per month.
  • Twenty percent of patients reported having no sexual contact.
  • Spouses reported an overall feeling of psychological changes in their partner and changes in their sexual life poststroke.

Workup

Laboratory Studies

  • The goal of the initial laboratory evaluation of a patient with acute stroke is to establish an accurate diagnosis of the stroke and to determine the presence of any other intercurrent illness.
  • Initial laboratory tests include the following:
    • Electrolytes, glucose, and cholesterol levels
    • Complete blood cell (CBC) count
    • Prothrombin time and activated partial thromboplastin time
    • Erythrocyte sedimentation rate
    • Urinalysis

Imaging Studies

  • Computed tomography (CT) scanning of the head reveals acute hemorrhage, but it often is negative for the first 1-2 days in patients with cerebral infarction.6
  • Magnetic resonance imaging (MRI) shows changes of cerebral infarction as early as a few hours postonset, but a CT scan usually is performed early because it is less expensive and reveals those structural lesions (eg, hemorrhage, tumor, abscess) that may require surgical management. Because of its greater resolution, MRI is more sensitive than CT scanning in detecting small lacunar strokes. MRI is also more sensitive than CT scanning in detecting lesions in the brainstem and cerebellum.
  • Magnetic resonance angiography (MRA) is a technique for displaying details of cerebrovascular anatomy and pathology without the risks of conventional angiography.
  • Nuclear medicine scanning techniques, such as positron emission tomography (PET) scanning and single-photon emission computed tomography (SPECT) scanning, detect the uptake of radiolabeled materials with signal intensity dependent on blood flow to the soft-tissue region. Changes can immediately be detected within the ischemic zone during acute cerebral infarct and hemorrhage.

Other Tests

  • Lumbar puncture to reveal red blood cells in subarachnoid hemorrhage
  • Electrocardiography to assess for valvular lesions and thrombi
  • Transthoracic echocardiography or transesophageal echocardiography after suggested cerebral embolism
  • Swallowing video fluoroscopy if there is any doubt about aspiration

Procedures

  • Carotid endarterectomy is recommended for patients with symptomatic extracranial carotid artery disease with at least 70% stenosis in the internal carotid artery.

More on Motor Recovery In Stroke

Overview: Motor Recovery In Stroke
Differential Diagnoses & Workup: Motor Recovery In Stroke
Treatment & Medication: Motor Recovery In Stroke
Follow-up: Motor Recovery In Stroke
Multimedia: Motor Recovery In Stroke
References
Further Reading
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Keywords

stroke, strokes, stroke rehabilitation, stroke patients, hemiplegia, hemiplegic, brain stroke, after stroke, after a stroke, stroke motor, stroke recovery, stroke therapy, Brunnstrom, stroke rehab, post stroke, stroke exercises, stroke exercise, rehabilitation for stroke, treatment for stroke, treatment of stroke, stroke occupational therapy, neuroplasticity, recovery after cerebrovascular accident, recovery of neurologic function, stroke impairments

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Contributor Information and Disclosures

Author

Auri Bruno-Petrina, MD, PhD, Clinical Trainee, Pemberton Marine Medical Clinic, N Vancouver
Auri Bruno-Petrina, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, College of Physicians and Surgeons of British Columbia, and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Medical Editor

Milton J Klein, DO, MBA, Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital, Allegheny General Hospital, and Ohio Valley General Hospital.
Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds Novaritis; Novaritis  Novaritis; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

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