S4 Mini1: Stroke, Ischemic and Hemorrhagic 05/10/2013

spinal artery occlusion at the level

  than the medulla!
d is different
CNS Blood Supply REVIEW!!!!
n I. Spinal Cord Vasculature 1. Anterior Spinal Artery (1)
h,
&
Vertebral Arteries Vertebral Arteries Occlusion of the this artery below medullaà
e)
Bilateral loss of pain/temp (spinothalamic)
Anterior Spinal Artery Anterior Spinal Artery
al
Bilateral paralysis (Lateral corticospinal tracks) No
change in Touch/vib. /pres./ propri
se Posterior Spinal Arteries Posterior Spinal Arter
2. iesPosterior Spinal Arteries (2)
amic
Occlusion of this artery below medulla à
Posterior Segmental Posterior Segmental Loss of Dorsal column (touch/vib. /pressure/
Medullary Arteries Medullary Arteries proprioception)
Posterior
Anterior Anterior 3. Posterior segmental
Posterior Medullary arteries
n Intercostal Intercostal 4. Intercostal Arteries
Arteries Arteries 5. Lumbar Arteries
6. Sacral Arteries
Lumbar Arteries Lumbar Arteries
Spinal cord Strokes
Anterior spinal A. Posterior spinal A.
Sacral Arteries Symptoms Bilateral loss of
Sacral Arteries Loss of dorsal column
due to pain (no touch, vib., Propri.)
occlusion Bilateral paralysis Gait; loss of balance in
II. Blood Supply of Brain the dark
1. Internal Carotid Arterial System (supply blood
to Brain ONLY)
A. Ophthalmic artery
B. Anterior choroidal artery
Branches of Internal Carotid A
C. Posterior Communicating artery
D. Middle cerebral artery
E. Anterior Cerebral artery

2. Vertebral/basilar Arterial System

A. Basilar System/Branches Anterior Cho
a. Posterior Cerebral A.
b. Superior Cerebellar A. Artery
c. Anterior Inferior cerebellar A.
(AICA)
d. Paramedian pontine A.
e. Long circumferential branches
f. Short circumferential branches

B. Vertebral Arteries Why is deficit

a. Anterior spinal Artery restricted to the

2-Anterior
b. PICA: (Posterior Inferior Cerebellar Artery) Choroidal Artery lower limb? Look at
course of the artery
anches of Internal Carotid Artery Spinal Artery
c. Posterior & think about the
homunculus!
Branches of Internal Carotid -supplies
Artery the optic tract,
Anterior Choroidal
Artery
some choroidAnterior
plexus, part Artery
Cerebral of
the cerebral peduncle, and
Callosomarginal
Artery

portions of the internal

Pericallosal
artery
ior Choroidal Artery
es the optic tract,
capsule, thalamus &
oroid plexus, part of
ebral peduncle, and
ons of the internal
hippocampus
sule, thalamus & MCA MCA
ACA
hippocampus
Stroke: sudden death of brain cells in a localized are due to inadequate
4-Middle Cerebral Artery (MCA)
blood flow
•  Supplies some of precentral (motor) (
andischemic)
rd postcentral (somatosensory) gyri
• Epidemiology: 3 leading cause of death in the USA,
-into lateral sulcus…supplies the insula & most of the The leading cause of disability in USA
•  Occlusion of an anterior cerebral artery causes
contralateral motor and somatosensory deficits
o Blacks: age-adjusted rsk of
lateral surface death
of the cerebral1.49X
hemisphere
restricted to the lower limb!
o Hispanic> whites and black:
-Lenticulostriate branchesLacunar stroke
come off of the MCA and or stroke at earlier ages
supply deep structures like the basal ganglia and
internal capsule.
• Risk factors of Stroke
Non-modifiable
• Age
• Sex
• Race, ethnicity,
• History of migraine
headaches, sickle cell
disease, fibromuscular
dysplasia
• Heredity
Modifiable
• HTN
• Obesity
• Smoking
• Diabetes
• Cardiac disease: A-fib, Acute MI, Rheumatic heart, Valvular disease,
cardiomyopathy, bleeding disorder etc
• Hypercholesterolemia
• Hyperhomocystenmia
• Oral contraceptive
• Caroid stenosis, Transient ischemic attacks (TIAs),
• Lifestyel issued: excessive alcohol, tobacco use, illicit drugs (cocaine)

• Clinical correlation
Stroke
Onset Sudden (arterial ), suttering, slow-progressive ( venous)
Manifestation Sudden development of
• Motor deficit: Weakness/paralysis
• Sensory Def.:  sensation, numbness, tingling
• Visual def.:changes
• Language difficulty
o Broca’s aphasia: cant get words out
o Wernicke’s aphasia: nonsense
• Behavioral
Pattern of Deficit: • Pyramidal weakness: Strong upper extremities sdduction and flexion and
based on the anatomy strong leg extension
•
Associated symptoms postural, headache, palpitation
Duration Time to resolve or reach the max. deficit
Pathology Problem in lumen, vessel wall, outside of the vessle
Mechanism Embolic (slower), Thrombotic (slower), Hemorrhage ( sudden, devastated)
Etiology Congenital
Acquired: Trauma, inflammation/infection, toxic/metabolic, degenerative,
Autoimmune
Diagnositic tool Chief complain, PH, FH, ROS
Physical: General, Cardiac, Neuro
Lab test: CBC, coag, EKC, echo, MRI,
*****TIA: fully evaluated
Treatment: to prevent Thrombolytic Therapy - TPA if not contraindicated
any further damage to Anticoagulation: Heparin / low molecular wt. hep. Coumadin, anti-platelet drugs
the penumbra e.g. aspirin, dipyradamole, ticlopidine, clopidogrel
Physiotherapy & Rehabilitation
Correct Risk factors, Support therapy & Psychotherapy, Institutional Care
Stroke Prevention and Lifestyle Changes alcohol intake, tobacco use, illicit drugs, obesity, physical
Management inactivity
Atherosclerosis and Diabetes:
• Statins – LDL lowering by 10% = 15% drop in risk of stroke
• Carotid endarterectomy for tight stenosis
• Tight glycemic control not help, may worsen stroke risk
Atrial Fibrillation: ASA, Warfarin
Hypertension: Anti-Angiotensin agents
Intracranial Hemorrhage: Anti-Smoking
Surgical & Interventional Radiology Rx: ICH / Aneurysm / stroke
 S4 Mini1: Stroke, Ischemic and Hemorrhagic 05/10/2013
 
Cortical Stroke:
Watershed Zone: region of brain that have dual blood supply from two major arterial branches.
Watershead zone Deficits and Its pattern Diagnostics
occlusion
ACA-MCA proximal arm & leg
weakness  weaknesss
of shoulder, Hips)
MCA-PCA Problem with visual Dx: mental status exam
processing
MCA– most common Face (F),Arm (A)>Leg (L)
ACA L> F,A
Internal capule: L=F=A

Genu: corticobulbar fiber

Posterior limb:
corticosipinal, medial
lemniscuses, anterolateral
system

Branches from Internal Carotid Arteries

Artery (Superior  Travel Blood supply to Symptom due to
Inf.) occlusion
1 Ophthalmic a. Along the optic nerve and exit Eye balls and other orbital
through optic canal structures
2 Anterior Choroid a. Travel along optic track and Optic tract, some choroid
pass the cerebral peduncle plexus, part of cerebral
and travel to paracoid gland peduncle and portion of
internal capsule, thalamus &
hippocampus
3 Posterior Joins posterior cerebral arties NONE
Communicating a.
4 Middle Cerebral a. Lateral fissures and give Most of the precentral Restricted contralateral
(MCA) lenticulostrated branches (motor) and postcentral motor and
(medial-shorter and Lateral- (somatosensory) gyri somatosensory deficit
longer) for deep structures (basal ganglia and internal to face and upper limbs
and surrounding insula capsule) If L. hemisphere is
involved  Language
deficit
5 Anterior Cerebral a. Along the longitudinal fissure & Medial aspect of forntal & Contralateral motor
(ACA) (paricallosal, around corpus callosum parietal lobes and somatosensory
callosomarignal) Some of precentral (motor) deficit restricted to
and postcentral lower limbs
(somatosensory ) gyri:
medial aspects
Artery (Superior  Travel Blood supply to Occlusion/effects
Inf.)
Basilar Branches
Posterior Cerebral A. Medial & inferior surface of Superior Alternating (Weber’s)
occipital & temporal lobes Syndrome
Braches to rostral midbrain & a. Ipsilateral oculomotor nerve
caudal diencephalon palsy
To posterior choroidal artery: b. Contralateral  hemiplegia
rd
choroid plexus of 3 and lateral
ventricels
Superior Cerebellar A. Superior surface of the cerebellum Occlusion at cerebellar peduncle &
& some midbrain cerebellum  ataxia
Anterior Inferior • Anterior Inferior portion of • Spinal V Nucleus & track Loss of
cerebellar A. (AICA) cerebellum and parts of pons pain/temp of Ipsilateral face
• Labyrinth artery: inner ear • Spinothalamic tract  Contralateral  
pain/temp loss of body
• Descending sympathetic fiber 
Ipsilateral Horner’s syndrome
• Inferior cerebella peduncle,
vestibular nuclei  ataxia, vertigo,
nausea
Paramedian pontine Medial prtion of lower & upper pons Corticospinal track, facial nucleus,
A. abducens nucleus & pontine gaze center
will be affected
Long circumferential Most of tegmentum of the rostra& Gaze centers, spinothalamic tract will be
branches caudal pons affected
Short circumferential An area in ventrolateral pons Descending sympathetic fibers,
branches pontocerebellar fibers, spinothalamic
tracks will be affected
Vertebral Branches
Anterior Spinal A. Along the Anterior and Medial aspect sof  Medial medullary syndrome
anterior medulla In spinal cord, Bilateral loss of
fissures of Or spinal cord pain/temp (spinothalamic)
spinal cord Bilateral paralysis (Lateral corticospinal
tracks)
No change in Touch/vib. /pres./ propri
Posterior Inferior From
Inferior surface f the cerebellar
•  Wallenberg’s syndrome aka Lateral
•  Medial Medullary Syndrome
Cerebellar A. (PICA) vertebral
hemisphere medullary syndrome
-occlusion of branches of the anterior spinal artery (at the
artery
• Laterallevelmedulla
of medulla!) on one side or medullary branches of
vertebral artery th
• Choroid plexus of 4 ventricle
-affects:
Posterior Spinal A. Posterior aspect of medulla/spinal
-Corticospinal Tract Occlusion of this artery below medulla
cord -Medial Lemniscus Loss of Dorsal column (touch/vib.
Lateral Medullary Syndrome (Wallenberg s Syndrome) -Hypoglossal Nucleus (CN XII)! /pressure/ proprioception)
1-AICA (Anterior Inferior
(occlusion Cerebellar Artery)
of PICA/Vertebral artery)!
Wallenberg s affects:
1-Inferior cerebellar peduncle, vestibular nuclei -> ataxia, vertigo,
nausea
2-Trigeminal nucleus & tract -> ipsilateral pain/temp loss from face
3-Spinothalamic tract -> contralateral pain/temp loss from body
4-Descending sympathetic fibers -> Ipsilateral Horner s syndrome
5-Nucleus Ambiguus -> hoarseness, dysphagia
6-Nucleus Solitarius -> ipsilateral decreased taste

Horner s Syndrome =
1-ptosis -drooping of the eyelid
2-miosis - impaired dilations…patient has an abnormally
decreased pupil size
3-anhydrosis - decreased sweating on the ipsi face
Occlusion affects:
THE Connector= circle of Willis : Anterior Communicating Artery,
-Spinal V nucleus & tract -> loss of pain and temp sensation from the ipsilateral
face
-Spinothalamic tract -> contralateral pain/temp loss from body Anterior cerebral arteries, Internal Carotid Arteries, Posterior
-Descending sympathetic fibers -> Ipsilateral Horner s syndrome
-Inferior cerebellar peduncle, vestibular nuclei -> ataxia, vertigo, nausea
communicating Arteries, Posterior cerebral arteries
 S4 Mini1: Stroke, Ischemic and Hemorrhagic
Brainstem Strokes: Alternating symptoms
Basilar branch associated
Superior Alternating syndrome
=Weber’s
Occluded Posterior cerebral arteries/
artery basilar arteries
Effected 1. Unilateral damage of the
area ventral region of the mid
brain
(substanitia nigra, cerebral
peduncle affected: area of
corticospinal and
corticobulbar tracks)
Clinical 2. Alternating hemiplegia
symptom a. Ipsilateral oculomotor
nerve palsy
b. Contralateral hemiplegia
c. (for Benedikt’s, Ataxia
present due to
tegmental region
affected : superior
cerebral peduncle)
Vertebral branches associated
Medial Medullary Syndrome
Anterior Spinal artery (at the
level of medulla) on one side
1. Corticospinal tract
2. Medial leminiscus
3. Hypoglossal Nuculeus (CN
XII)
1. Contralateral loss of vol.
motor functions
2. Contralateral loss of
touch/vib./propri.
3. Ipsilateral loss of vol. motor
tougue muscles deviates
to the lesion side
05/10/2013
Lateral Medullary syndrome =
Wallenberg’s syndrome
PICA/Vertibral a.
1. Inferior cerebellar peduncle,
bestibular numclei
2. Trigeminal track
3. Spinothalamic track
4. Descending Sympathetic
fibers
5. Nucleus Ambiguus
6. Nucleus solitarus
1. Ataxia, Vertigo
2. Ipsilateral pain/temp loss of
face
3. Contralateral loss of
pain/temp below the neck
4. Ipsilateral horner’s
syndrome
5. Hoarseness, dysphagia
6. Ipsilateral decreased taste
Nystagmus

Parallel Loops
• Association coretex  caudate  Globus pallidus  DM (thalamus)  Association cortex
• Senesorimotor cortex  putamen  Globus pallidus  VA/VL (thalamus)  sensory motor cortex
• Limbic cortex  nucleus accumbens  ventral pallidum  DM (Thalamus)  Limbic cortex