NEUROANATOMY

BLOOD SUPPLY OF THE BRAIN

Definition
A stroke is the death of brain tissue that occurs when the brain does not get enough blood and oxygen.

Types of stroke
Ischemic stroke: About 80 percent of strokes are ischemic strokes. They occur when blood clots or other particles block arteries to the brain and cause severely reduced blood flow (ischemia). This deprives the brain cells of oxygen and nutrients, and cells may begin to die within minutes. The most common ischemic strokes are:

Thrombotic stroke. This type of stroke occurs when a blood

clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot usually forms in areas damaged by atherosclerosis a disease in which the arteries are clogged by an accumulation of cholesterol-containing fatty deposits (plaques). This process can occur within one of the two carotid arteries of the neck that carry blood to the brain, as well as in other arteries. An ischemic stroke may also be caused by plaques that completely clog or markedly narrow an artery. This narrowing is called stenosis. Embolic stroke. An embolic stroke occurs when a blood clot or other particle forms in a blood vessel away from the brain commonly in the heart and is swept through the bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus. It's often caused by irregular beating in the heart's two upper chambers (atrial fibrillation). This abnormal heart rhythm can lead to poor blood flow and the formation of
a blood clot.

Hemorrhagic stroke

"Hemorrhage" is the medical word for bleeding. Hemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures. Hemorrhages can result from a number of conditions that affect the blood vessels, including uncontrolled high blood pressure (hypertension) and weak spots in the blood vessel walls (aneurysms). A less common cause of hemorrhage is the rupture of an arteriovenous malformation (AVM) a malformed tangle of thin-walled blood vessels, present at birth. There are two types of hemorrhagic stroke:

Intracerebral hemorrhage. In this type of stroke, a blood vessel

in the brain bursts and spills into the surrounding brain tissue, damaging cells. Brain cells beyond the leak are deprived of blood and are also damaged. High blood pressure is the most common cause of this type of hemorrhagic stroke. High blood pressure can cause small arteries inside your brain to become brittle and susceptible to cracking and rupture. Subarachnoid hemorrhage. In this type of stroke, bleeding starts in a large artery on or near the membrane surrounding the brain and spills into the space between the surface of your brain and your skull. A subarachnoid hemorrhage is often signaled by a sudden, severe "thunderclap" headache. This type of stroke is commonly caused by the rupture of an aneurysm, which can develop with age or result from a genetic predisposition. After a subarachnoid hemorrhage, vessels may go into vasospasm, a condition in which arteries near the hemorrhage constrict erratically, causing brain cell damage by further restricting or blocking blood flow to portions of the brain.

Clinical Features
Transient ischemic attacks (TIAs): Sudden vascular-related focal

neurologic deficit that resolves completely and lasts < 24 hr, generally < 1 hr. Acute ischemic stroke: Anterior cerebral artery (ACA): contralateral leg weakness Middle cerebral artery (MCA): contralateral hemiparesis and hemisensory deficit (face + arm > leg); aphasia (dominant hemisphere) or neglect (nondominant hemisphere); contralateral visual-field defect; deviation of gaze; dysarthria; and other cortical symptoms Posterior cerebral artery (PCA): occipital infarction and contralateral visual-field loss; contralateral hemiparesis; behavioral changes Vertebral arteries or basilar artery: crossed facial sensory and body motor signs; diplopia; facial numbness and weakness; vertigo; nausea and vomiting; tinnitus; hearing loss; ataxia; gait abnormality; hemiparesis; dysphagia; and dysarthria. Penetrating vessels: pure motor hemiparesis, pure sensory stroke, clumsy handdysarthria syndrome, or ataxic hemiparesis. Hemorrhagic stroke Subarachnoid (5%): Severe headache Rapid onset Photophobia Stiff neck

 Decreased level of consciousness Focal neurologic signs Intracerebral (intraparenchymal) (15%) Severe headache Focal neurologic signs (resembles ischemic stroke)

Risk Factors
Risk factors for stroke are classified into 3 categories: nonmodifiable, well-documented modifiable, and less welldocumented or potentially modifiable. Non-modifiable factors Increasing age. A person's risk of stroke doubles each year after age 55. Race. Strokes occur approximately twice as often in blacks and Hispanics as they do in whites. Gender. Men have a 50% higher chance of stroke than women do. Family history of stroke or transient ischemic attack (TIA). A TIA is a short, reversible form of stroke that may serve as an early warning sign of stroke Modifiable risk factors High blood pressure Smoking Diabetes

 Sickle cell anemia, a blood disorder that forms abnormal red blood cells High cholesterol levels in the blood, including total cholesterol and LDL or "bad cholesterol." Low levels of HDL or "good cholesterol" are also cause for concern Atrial fibrillation, an abnormal heart rhythm Potentially modifiable risk factors Obesity Sedentary lifestyle Alcohol abuse High blood levels of homocysteine, a blood component sometimes associated with a higher risk of stroke Drug abuse Blood disorders, such as blood that clots easily or deficiencies of various blood components Hormone replacement therapy (HRT). The AHA currently states that the risk of stroke associated with HRT appears low but needs further study. Use of birth control pills, or oral contraceptives

Investigations
Non-contrast CT to distinguish ischemic stroke from

hemorrhagic stroke Brain MRI & MRA CT-angiography (CT-A) Carotid duplex ultrasound Transcranial Doppler ultrasound Electrocardiogram Transthoracic echocardiogram (TTE) or transoesophageal echocardiogram (TEE)

Iintracerebral hemorrhage-Ventricular hemorrhage

Investigations (cont.) Laboratory tests:

Fasting lipids within 48 hours of symptom onset Complete blood count PT & PTT Chemistry panel (KFT, LFT, FBS, 2hrsPP)

Management of acute ischemic stroke

Intravenous recombinant tissue plasminogen activator (rt-PA) as soon as possible after onset of symptoms Indications: Firm clinical diagnosis of potentially disabling stroke Onset of symptoms or last time seen normal < 3 hr ago Absolute contraindications Onset > 3 hr ago or patient not seen normal within previous 3 hr Intracranial mass lesion or hemorrhage on non-contrast head CT Previous stroke or serious head trauma within previous 3 mo Any history of intracranial hemorrhage Current use of anticoagulants with PT > 15 sec or use of heparin within the past 48 hr Platelets < 100,000/mm3 Presenting symptoms suggestive of subarachnoid hemorrhage (worst headache of patient's life)

 Blood pressure > 185/110 mm Hg unless minimal doses of a smooth-acting I.V. agent such as labetalol were sufficient to lower below this range Previously known cerebral aneurysm or arteriovenous malformation Relative contraindications: Glucose < 50 or > 400 mg/dl Seizure at stroke onset Major surgery within 14 days Arterial puncture at a non-compressible site or lumbar puncture within 1 wk Rapidly improving symptoms suggestive of TIA GI or GU hemorrhage within 21 days Dose: 0.9 mg/kg (maximum dose, 90 mg) infused over 1 hour, with 10% of the total dose infused over the first minute; if treatment with rt-PA is suspected of inducing intracranial hemorrhage, the infusion should be suspended Aspirin (160 to 325 mg daily) administered within 48 hr of stroke onset; aspirin should be withheld for at least 24 hr after administration of thrombolytics Reduction of risk factors Management of cardioembolism Control hypertension Tobacco use Hyperlipidemia Diabetes Encourage exercise

Stroke prevention
Aspirin (160325 mg/day) Clopidogrel (75 mg) Dipyridamole (extended-release) + aspirin

Management of Intracerebral Hemorrhage

Surgical evacuation of hematoma Ventricular drainage for hydrocephalus Osmotic diuretics before hematoma evacuation Mannitol load, 0.51.0 g/kg I.V.; maintenance dose, 0.251.0 g q. 6 hr; titrate to keep serum osmolality 300310 mOsm/kg H2O Further supportive care as for ischemic stroke

Management of Subarachnoid Hemorrhage

Emergency CT scan Anticonvulsants at first sign of seizure Blood pressure should be gently, not drastically, controlled Begin Nimodipine on the first day and continue for 21 days Patients should be well hydrated, and blood pressure should be slightly high Surgical clipping or endovascular coiling within 72 hr of onset After clipping, daily Transcranial Doppler examinations to monitor vasospasm