Far eastern university - nicanor reyes medical foundation

NEUROLOGY – THE VASCULAR System

ANATOMY OF THE VASCULAR SYSTEM
ANTERIOR CIRCULATION
• Origin: Carotid System
(Internal Carotid Artery)
• Supplies: 80% of brain
• Give rise to the branches of:
o Middle Cerebral Artery
o Anterior Cerebral Artery
All arteries that supply the supratentorial (cerebral cortex) and
posterior fossa (infratentorial) arise from the aortic arch.
VERTEBRAL ARTERIES
POSTERIOR CIRCULATION
• Origin: Vertebral /
Vertebrobasilar System
(Recording: Vertebral
Artery, that originates from
the Subclavian artery)
• Supplies: 20% of the brain
o Cerebellum
o Brain Stem
o Occipital Lobe
• Enter the cranium through the Foramen Magnum
• The two vertebral arteries:
o Unite at the junction between medulla and pons
to form a single Basilar Artery
• The Basilar artery:
o Divides at the junction between pons and
midbrain into:
§ Right Posterior Cerebral Artery
§ Left Posterior Cerebral Artery
FOUR PARTS OF THE.VERTEBRAL ARTERY
Notes: Vertebral Artery originates from the: subclavian artery
V1 • Before it enters the transverse foramen
Preforaminal • Runs upward and backward between the
(Prevertebral Longus coli and Scalenus anterior
Part) • Behind it are the transverse process of the 7th
cervical vertebra, the sympathetic trunk and its
inferior cervical region
V2 • Where it inserts at the transverse foramen of
Foraminal the cervical arteries
(Cervical Part) • Runs upward through the foramina in the
transverse processes of the C6 to C2
vertebrae, and is surrounded by branches from
the inferior cervical sympathetic ganglion (and
by a plexus of veins which unite to form the
vertebral vein at the lower part of the neck).
V3 • Arises from C2 before it pierces the dura
Extradural / • Will go up from the C2 foramen transversarium
Extra Spinal on the medial side of rectus lateralis then it will
(Atlantic Part) pierce the dura to become the V4
V4 • The only intracranial segment.
Intracranial • Pierces the dura mater and inclines
(Intradural) medialward to the front of the medulla
oblongata
• It is placed between the hypoglossal nerve and
the anterior root of the 1st cervical nerve and
beneath the first digitation of the ligamentum
denticulatum.
• At the lower border of the pons
(pontomedullary junction), the two vertebral
artery will unite to form the basilar artery.

CIRCLE OF WILLIS

AORTIC ARCH BRANCHES (First to last) • Consists of an arterial network located at the base of the skull
Note: Heart à Aorta à Ascending aorta and aortic arch • Allows continuous blood flow or continuous exchange between the
Brachiocephalic Bifurcates to the: anterior and posterior circulation
(Innominate) • Right Common Carotid Artery • A heptagon composed of:
Artery o Right Internal Carotid Artery o 2 Anterior Cerebral Arteries
o Right External Carotid Artery o 1 Anterior Communicating Artery – connects the two anterior
• Right Subclavian Artery à Right vertebral Cerebral Artery
artery o 2 Posterior Cerebral Arteries
Left Common Divide into: o 2 Posterior Communicating Arteries
Carotid Artery • Internal Carotid Artery à goes to the brain
• External Carotid Artery à goes to the face Middle Cerebral Artery is not part of the Circle of Willis. Posterior
and neck cerebral artery connects to internal carotid artery by inferior
Left Subclavian Gives rise to: communicating artery (From PARBS).
Artery • Left Vertebral Artery, etc

Page 1 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
BLOOD SUPPLY TO THE CEREBRAL HEMISPHERES
BLOOD SUPPLY TO THE CEREBRAL HEMISPHERES
Anterior Cerebral • Supplies medial surface of the cerebrum
Artery (ACA) • Arise from internal carotid arteries
Middle Cerebral • Supplies the dorsolateral surface of the
Artery (MCA) cerebrum
• Arise from internal carotid arteries
Posterior • Supplies the entire occipital lobe and some
Cerebral Artery areas of the temporal lobe, specifically the
(PCA) inferior and medial portions
• Arise from top of basilar artery
Lenticulostriate • Supply the deeper structures of the cerebral
Arteries hemispheres.
• Arise from the penetrating branches of larger
arteries
MIDDLE CEREBRAL ARTERY
Four Parts of the Middle Cerebral Artery
M1 • Most proximal part of MCA
(Sphenoidal • Origin: Sphenoid bone
/ Horizontal • Sometimes called the horizontal segment because
segment) of its horizontal configuration in the brain.
• Perforates the brain with numerous anterolateral
central (lateral lenticulostriate) arteries, which
irrigate / supply the deep structures of the
cerebral hemisphere, such as the basal ganglia.
M2 • Extending anteriorly on the insula, this segment is
(Insular / known as the insular segment.
Sylvian • It is also known as the Sylvian segment when the
segment) opercular segments are included.
• The MCA branches may bifurcate into trunks
(superior and inferior division) in this segment
which then extend into branches that terminate
towards the cortex.
M3 • Extends laterally exteriorly from the insula towards
(Opercular the cortex.
segment) • This segment is sometimes grouped as part of M2.
M4 • Irrigate the cerebral cortex
(Terminal / • Begin at the external margins of the Sylvian fissure
cortical and extend distally away on the cortex of the brain
segments)
CLINICAL CORRELATIONS
MCA and the Motor Homunculus
• MCA – supplies the lateral (dorsolateral) surface of the cerebral
hemisphere, including the representations of the face and arm of
homunculus
• MCA Infarction / Stroke – manifest with dysarthria (unable to
control, larynx, vocal cords, and surrounding muscles) and the
upper extremity is weaker than lower extremity
ACA and the Motor Homunculus
• ACA – supplies the medial surface including the representation
of the leg of the homunculus.
• ACA Infarction / Stroke – lower extremities are most affected
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
ANTERIOR CEREBRAL ARTERY
(red line)
• Supplies the midline structures of the brain especially the frontal
and superior medial parietal lobes.
o These include the (1) motor cortex that controls the
movement of the contralateral lower limb, the (2) sensory
cortex that controls sensation in the contralateral lower limb,
(3) Broca's area, and the (4) prefrontal cortex.
Four Parts of the Anterior Cerebral Artery
A1 • Arises from the internal carotid artery and extends
(Proximal) to the anterior communicating artery, which
supplies caudate nucleus and anterior limb of
the internal capsule
• Posterior limb is in the corticospinal tract
(supplied by MCA)
• Anteromedial central (medial lenticulostriate)
arteries arise from this segment.
A2 • Second segment of ACA
• Extends from the anterior communicating artery
(ACOM) to the bifurcation, forming the:
o Pericallosal Artery
o Callosomarginal arteries / branches
• The Recurrent artery of Heubner (Distal medial
striate artery), which irrigates the internal
capsule, usually arises at the beginning of this
segment near the ACOM.
• PARBS: It is affected in Syphilitic vasculitis
A3 • Last segment
(Pericallosal • One of the main terminal branches of the ACA
artery) • Extends posteriorly in the pericallosal sulcus to
form the internal parietal arteries (superior,
inferior) and the precuneal artery.
Good to know: Corpus callosum is the major commissural pathway
connecting the cerebral hemispheres that receives its
blood supply from anterior communicating artery, pericallosal artery,
and posterior pericallosal artery.
Page 2 of 8
BLOOD SUPPLY TO THE POSTERIOR FOSSA (INFRATENTORIAL) BLOOD SUPPLY TO THE SPINAL CORD
BLOOD SUPPLY TO THE POSTERIOR FOSSA LONGITUDINAL HORIZONTAL
Branches of: • Supplies:
• Vertebral Arteries o Brainstem
• Basilar Arteries o Cerebellum

• At each level of the brainstem, the following arise and supply a zone
on either side of the pons:
o Short median perforating branches (from the Basilar artery)
o Paramedian perforating branches (from the Basilar artery) Anterior Spinal Arteries (ASA) Radicular Arteries
• 1 – Unpaired • 6-8
• The lateral areas of brainstem and cerebellum are supplied by • Arise from: vertebral artery • Ventrally / Anteriorly located
three pairs of long circumferential arteries: • Supplies: anterior 1/3 of the • Arise from: intercostal,
o PICA (Posterior inferior cerebellar artery) spinal cord lumbar and sacral arteries
§ Most inferior • Embedded in: anterior • Connect with: the ASA at
§ Origin: Vertebral artery median sulcus various levels
o AICA (Anterior inferior cerebellar artery)
Posterior Spinal Arteries • Largest: located in the low
§ Origin: Proximal Basilar artery
(PSA) thoracic / upper lumbar region
o SCA (Superior cerebellar artery)
• 2 – Paired (Artery of Adamkiewicz)
§ Most superior
• 25%: from vertebral artery • Because of this uneven blood
§ Origin: Distal basilar artery
supply, the spinal cord is
§ Bifurcates into the: Posterior cerebral artery • 75%: from posterior inferior
most vulnerable to ischemia
cerebellar artery
at the midthoracic and
ANASTOMOSES AND COLLATERAL CIRCULATION • Supplies: posterior 2/3 of
upper lumbar levels (black
CIRCLE OF WILLIS the spinal cord
areas on the shown photo)
• A circulatory anastomosis that supplies blood to the brain and
surrounding structures. VENOUS DRAINAGE OF THE NERVOUS SYSTEM
• Plays an important role especially in order to stabilize cerebral blood
flow (Eg. In hemodynamically compromised patient)

CORTICOMENINGEAL ANASTOMOSES
• Communication of the 3 major cerebral vessels on the surface of the
hemispheres at the junctional zones of the areas supplied by these

ANASTOMOSES BETWEEN EXTRACRANIAL AND INTRACRANIAL

ARTERIES
• The ophthalmic artery communicates with the superficial temporal
and facial branches of the external carotid artery

FUNCTIONAL ANATOMY OF THE CEREBRAL VASCULATURE

• Clinically, the distribution of a presumed arterial lesion can be
inferred by relating the observed signs and symptoms to the
anatomy of the cerebral vessels.
• It is essential to be able to determine whether a lesion lies in the
distribution of either the carotid (anterior circulation) or
vertebrobasilar (posterior circulation) arterial systems.
Carotid System Vertebrobasilar System
(Anterior Circulation) (Posterior Circulation)
Hemiparesis Crossed Hemiparesis and
(contralateral weakness) Crossed Hemisensory loss
- Due to the involvement of
corticospinal tract and
spinothalamic tract of
brainstem
Hemisensory loss (contralateral) Diplopia (double vision)
Homonymous hemianopsia Dysphagia
Monocular Vision Loss Dysarthria
• because Ophthalmic artery
originates from ICA
Aphasia Dysequilibrium / Incoordination
• Cerebral veins drain into dural venous sinuses then ultimately,
into the internal jugular vein.
• Important sinuses to remember:
o Superior sagittal sinus – becomes the right transverse sinus
or confluence of sinuses
o Inferior sagittal sinus – drains to straight sinus
o Transverse sinuses (2) – drain to sigmoid sinus
o Sigmoid sinuses (2) – drain to IJV
o Cavernous sinuses (2) – drain to superior and inferior
petrosal sinuses
• The venous drainage of the brain is divided into:
o Superficial system
o Deep System
• The cerebral cortex and outer half of the white matter drain in to
the superficial system of veins located over the convexity of the
brain in the subarachnoid space
o The superficial veins of the superior half of the brain drain
into the superior sagittal sinus,
o Those from the inferior half drain into the transverse
sinuses

The last 4 manifestations (4 D’s) – attributed to the different

cranial nerves in the brainstem, which is supplied by the
vertebrobasilar system.

Sidenote: Sa recording, Contralateral Hemiparesis & Contralateral

Hemisensory loss sinasabi ni doc for the Vertebrobasilar System.
Page 3 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
• The deep white matter and deep nuclei of the brain drain into the
deep venous system, which includes the:
o Great cerebral vein of Galen
o Inferior sagittal sinus, and
o Straight sinus.

• Must remember because in patients with stroke, we must

maintain a specific range of MAP to avoid further ischemia to
the brain

Mean Arterial Pressure (MAP)

• Average arterial pressure in one cardiac cycle
• Influenced by the cardiac output and systemic vascular resistance,
which are under the influence of several variables
• Indicator of perfusion pressure seen by organs of the body

SAMPLE PROBLEM:
• Compute for the MAP of an individual with BP of 70/40 mm Hg
o 40 + [ (70–40) / 3] = 53, or
• From these venous channels, blood empties into the transverse o [70 + 2 (40)] / 3= 50
sinuses, sigmoid sinuses, and ultimately the internal jugular • Compute for the MAP of an individual with BP of 210/120 mm Hg
vein. o 120 + [ (210–120) / 3] =150, or
o [210 + 2 (120)] / 3 = 150

Cerebral Blood Flow

• Several factors can modify cerebral blood flow by altering different
elements in this equation. These have been divided arbitrarily into
two groups:
o Extracerebral factors – outside the cranial cavity that
modifies or regulates cerebral blood flow
§ Systemic BP
§ Efficiency of Cardiac Function
§ Blood Viscosity
o Intracerebral factors – intrinsic factors
• Veins on the inferior surfaces of the cerebral hemisphere end
directly or indirectly in the Cavernous Sinus.
FACTORS Increased CBF Decreased CBF
o Located on either side of the pituitary fossa and contains
the EXTRINSIC
Systemic BP MAP <50 – 70 mmHg
• Internal carotid artery
• CN III, IV, and VI;
CV Function • Arrhythmias
• Branches of CN V • Orthostatic
o Significance: Thromboses / occlusions in this area manifest hypotension
with ocular movement problems, abnormal sensation of the • loss of carotid sinus
faces (specifically the first segment of the trigeminal nerve) and aortic arch
reflexes

Blood Viscosity Anemia Polycythemia

INTRINSIC
State of Cerebral Arteriovenous
Atherosclerosis
BV malformation
(blockage in CBV)
Intracranial Increased ICP
Pressure (ICP)
CEREBRAL AUTOREGULATORY MECHANISM
Myogenic factors ↓ intraluminal ↑ intraluminal pressure
pressure
Neurogenic factors Parasympathetic Sympathetic

PHYSIOLOGY OF THE VASCULAR SYSTEM Biochem- ↓ pH (Acidosis) ↑ pH (Alkalosis)

CEREBRAL BLOOD FLOW Metabolic Lactic Acid
Normal CBF 750 ml/min (50-55 ml/100 gm brain tissue/min)
Oxygen 50 ml/min (3.7 ml/100 gm brain tissue/min) REGULATION OF CEREBRAL BLOOD FLOW
consumption AUTOREGULATION
Weight of 1,500 gm or 2% of the body weight • The normal brain is able to regulate its own blood supply,
adult brain autoregulation, in response to changes in arterial blood pressure
Brain 15% of the cardiac output and metabolic demand.
receives • Autoregulation is defined as the ability of an organ (e.g., the brain)
Brain utilizes 20% of the O2 consumed in the basal state to maintain blood flow constant for all but the widest extremes in
(CMRO2) perfusion pressure.
• Autoregulation of CBF occurs when the mean arterial blood
CORTICAL GRAY MATTER pressure is between 60 and 150 mmHg.
• Increased metabolic demand
• 6x the blood flow compared to the white matter

CEREBRAL BLOOD FLOW

• Directly proportional to the perfusion pressures (mean arterial
pressure – central venous pressure)
• Inversely proportional to the cerebrovascular resistance
Page 4 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
• PHOTO ABOVE: In hypertensive patients, brain is able to adapt to
the blood pressure à shift of graph to the right (upper limit is higher)
• When it is less than 60 mm Hg, blood flow decreases à collapse
of BV / impaired dilatation
• When it is more than 150 mm Hg, blood flow increases à
Cerebral edema
• Autoregulation is achieved with:
o Myogenic
o Neurogenic
o Chemical-metabolic mechanisms
• Autoregulation occurs in both large and small arterioles.
• It is a major homeostatic and protective mechanism.
• Cerebral vessels, like other hollow organs that contain smooth
muscle, can change diameter in response to intraluminal pressure.
o This is called the Bayliss effect that results in:
§ Vasoconstriction with increased intraluminal pressure &
§ Vasodilatation with decreased intraluminal pressure
• Therefore, autoregulation is:
o Primarily a pressure-controlled myogenic mechanism that:
o Operates independently but synergistically with other
neurogenic and chemical-metabolic factors.
AEROBIC CONDITIONS
• Glucose is metabolized through the glycolytic pathway, citric acid
cycle (Krebs), and respiratory chain.
• Yields 38 moles of ATP / mole of glucose
ANAEROBIC CONDITIONS
• The Krebs’ cycle and respiratory chain cannot be activated;
• The pyruvate derived from glycolysis is metabolized to lactate
• Yields only 2 moles ATP / mole of glucose
GLUCOSE
• The basic substrate for brain metabolism
• The astrocytes store glycogen and are the source of lactate,
which can be used by neurons to produce glucose.
CREATINE PHOSPHATE
• Another source of high-energy phosphate bonds
• More abundant than ATP in the brain
• Used to regenerate ATP from ADP, thus important for maintaining
level of tissue ATP

CHEMICAL FACTORS PARBS:

• Carbon dioxide – most potent physiologic and pharmacologic If there is reversible alteration in the cerebral function, like lack of
agent that influences cerebral blood flow oxygen will result to ischemia and becomes irreversible causing
• Cerebral blood vessels react rapidly to any change in local carbon infarction (ischemia – not totally blockage of flow; infarction –
dioxide tension (PaCO2). necrotic tissue) so after the vessel occlusion and deprivation of blood
flow to the brain, a series of events and ischemic cascade can lead
• Any increase in PaCO2 produces:
to neuronal dysfunction and neuronal death.
o Vasodilatation, and
o Increase in cerebral blood flow
PATHOPHYSIOLOGY
NEUROGENIC CONTROL
• Reversible alteration in cell function from the lack of oxygen results
• Neurogenic factors do not seem to have as great a role in the
in ischemia.
regulation of cerebral blood flow as chemical and metabolic factors
(PARBS) • Irreversible alteration results in infarction.
• After vessel occlusion and deprivation of blood flow to the brain, a
series of events unfold, the ischemic cascade that lead ultimately to
Source Neurotransmitter Effect
neuronal dysfunction and death.
EXTRINSIC
• Decreased cerebral blood flow (CBF) produces a gradient of
Sympathetic Norepinephrine Constrict
severity of deprivation of oxygen and glucose in brain tissue.
(Superior Cervical Neuropeptide Y Constrict
Ganglion)
Ischemic Penumbra
Parasympathetic Acetylcholine Dilate
(Facial and VIP Dilate
superficial petrosal Nitric Oxide Dilate
nerves)
Trigeminal nerve Substance P Dilate
CGRP Dilate
INTRINSIC
Locus ceruleus Norepinephrine Dilate
(microcirculation)
Raphe nuclei Serotonin Constrict
LOCAL
Interneurons Neuropeptide Y Constrict
VIP Dilate
Nitric oxide Dilate

CEREBRAL METABOLISM
• High metabolic activity and high oxygen consumption
characterize cerebral metabolism.
• A constant supply of energy is necessary for the support of
neuronal and neurologic functions: • Decreased CBF produces a gradient of severity of deprivation of
o Establishment of membrane potentials oxygen and glucose in brain tissue. Between the area of infarction
o Maintenance of transmembrane ionic gradients and normal tissue is an area called Ischemic Penumbra.
o Membrane transport • Ischemic Penumbra – area of jeopardized brain tissue between the
o Synthesis of cellular constituents, such as: area of infarction and normal tissue
§ Proteins o Neurons in this region have potentially reversible
§ Nucleic acids electrophysiologic failure due to energy deprivation but have
§ Lipids, and not experienced the cascade leading to neuronal death.
§ Neurotransmitters o The ischemic penumbra is the target of neuroprotective
• The energy needed is supplied in the form of high energy treatment in ischemic stroke.
phosphate bonds from ATP, which is synthesized in the brain, as
in other organ systems, through: In the photo, normal tissue’s CBF is 50. In the infarcted tissue, there
o Glycolytic pathway is none. In the penumbra, CBF is 15-30.
o Krebs (Citric Acid) Cycle
o Respiratory (Electron Transport) Chain

Page 5 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
ISCHEMIC CASCADE INTRACRANIAL ARTERIAL ANEURYSM
• An abnormal, localized dilatation of the arterial
lumen
• Most commonly encountered type is a round or
oval-shaped, berry-like structure, arising at the
bifurcation of the cerebral vessels.
• Due to a defect in thee
o Media, and
o internal elastic lamina
• Anterior communicating artery
o Most common location of aneurysm
o At the bifurcation of ACA and ACOM

LEFT:
Conventional angiogram, AP view,
showing a 7-mm left MCA bifurcation
aneurysm (arrow) after a left ICA injection

RIGHT:
• Hypoxia-ischemic event will result to mitochondrial failure. The same aneurysm (arrow) seen after
• This will lead to ATP-dependent pumps failure. three-dimensional rotational angiography
• Once there’s failure of pumps, it will lead to calcium accumulation.
• Intraneuronal calcium accumulation will result to neuronal injury.
• Damage in Na-K pump will cause increase sodium inside the cell
that follows water which causes cell swelling causing cytotoxic
edema.
• Since there’s deprivation of glucose metabolism, it will undergo
anaerobic metabolism that will cause lactic accumulation Different locations
causing intracellular acidosis that will contribute to the neuronal of aneurysm
injury.

CALCIUM-TRIGGERED CASCADE
• Large accumulation of glutamate in the extracellular space is
exerted through activation of:
o N-methyl-D-aspartate (NMDA) ARTERIOVENOUS MALFORMATION
o α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA)
receptors
• Massive entry of Ca2+ into the postsynaptic neuron
• Additional calcium-induced release of excitatory neurotransmitters
• During the ischemic process heightens neuronal necrosis
• The increase in intracellular Ca2+:
o Activates phospholipases
o Activates proteases, • Developmental abnormalities often seen in young adults
o Activates endonucleases • Resulted from defective communication between arteries,
o Generates oxygen free radicals and nitric oxide. capillaries, and veins, with dilatation of one or more of the vascular
• This leads to membrane, mitochondrial DNA, and microtubular elements, forming a variable-sized meshwork of tortuous blood
damage and, eventually, cell destruction. vessels “bag of worms”
• The walls may be thin and predisposed to rupture, or may be
PATHOLOGY OF THE VASCULAR SYSTEM hypertrophic.
NORMAL ARTERIAL HISTOLOGY • Rapid shunting of blood may produce a chronic ischemic state in
the neighboring brain (steal)
• Increased CBF

ATHEROSCLEROSIS
• The most important pathologic lesion responsible for cerebral
infarction
• Basic pathologic lesion: atherosclerotic plaque
• The intima is the layer that is principally involved (injury to arterial
wall causes focal desquamation of the endothelial cells exposing the
subendothelial connective tissue to the circulating platelets)
• Affects large-caliber blood vessels

• Intima – layer of endothelial cells surrounding the vessel lumen with

a small amount of extracellular connective tissue, the internal elastic
lamina From left to right:
• Media – diagonally-oriented smooth muscle cells surrounded by • Monocyte Adhesion
collagen and mucopolysaccharides • Monocyte Migration
• Adventitia – the outer layer consisting of fibroblasts and smooth • Foam cell formation
muscle cells with collagen and MPS • Proliferation of Smooth Muscle Cells
• Platelet Adhesion, Activation and Aggregation
The following pathologies are
just the overview of all our midterm topics :)

Page 6 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
 PATHOPHYSIOLOGY: STROKE
• Adhesion of monocytes to the vascular bed occur at the beginning
of atherosclerotic plaque formation.
• Once monocytes are activated, there will be migration.
• Monocytes later differentiate into macrophages and this leads to
local proliferation and ingestion oxidized LDL, transforming them
into foam cells.
• The foam cells, due to their cytoplasmic vesicles and high lipid
content, will eventually die and induce inflammatory process
resulting to the proliferation of smooth muscle cells.
• The result of proliferation will cause platelet adhesion, formation
of fibrous cap and fatty streak.

• Sudden onset of focal neurologic deficit

STABLE PLAQUE UNSTABLE PLAQUE
Unstable Plaque – has thrombus in the lumen with a tendency to
dislodge, travel to brain then become an embolus that will produce
stroke (EMBOLIC STROKE)
• Severe atheromatosis of basal arteries.
• Confluent yellow atheromatous plaques occur in the arterial walls.
• The basilar artery is elongated and stiff, and the lumen is distended.
• Atheromatous plaque in the wall of the basilar artery shows focal
subintimal cholesterol clefts, disruption of the elastic lamina, and
marked intimal proliferation severely reducing the lumen.
• Can be divided into focal or diffuse
o Focal can be ischemic or hemorrhagic
§ Ischemic / Cerebral infarction
à Large-vessel disease – Secondary to atherosclerosis
à Small-vessel disease / Lacunar (Lenticulostriate
arteries) – Secondary to hypertension
à Cardiac emboli – Secondary to atrial fibrillation
§ Hemorrhagic
à Focal (Intracerebral hemorrhage) – secondary to
Hypertension, AV Malformation, Aneurysm
à Diffuse (Subarachnoid hemorrhage) – secondary to
aneurysm (most common) or trauma
LARGE VESSEL INFARCTS
• The area of infarction is localized to the distribution of a diseased
blood vessel
• With the passage of time, the necrotic tissue in an infarcted area is
removed by phagocytes and replaced by a cavity containing cystic
fluid surrounded by an area of glial tissue
• In patient presented with hemiparesis, hemianesthesia, and
hemianopia – the occlusion will be in the MCA

LACUNAR INFARCTS
• Involves deep penetrating
artery – lenticulostriate
(which irrigates the deeper
FIBRINOID NECROSIS / subcortical structures
• Also called: Lipohyalinosis / such as the basal ganglia)
arteriolar sclerosis • Fibrohyalinosis with mural
• A segmental, non- thickening
atherosclerotic arteriopathy • Luminal stenosis
• Affects primarily smaller
intraparenchymal blood HEMORRHAGIC STROKES
vessels (eg. Lenticulostriate Intracerebral Hemorrhage
arteries) • Most often secondary to uncontrolled hypertension
• Found almost exclusively in the • Pic 1: Hyperdense at occipital region because blood appears white
brains of hypertensive patients on CT scan
• Pathology: Fibrinoid material and • Pic 2: Blood extends to the ventricular system
lipid-laden macrophages in the
subintimal layer
• Some of these lesions show
progressive luminal obliteration
and eventually result in small
areas of infarction called
lacunae (Lacunar infarction)
• Others produce progressive
weakening of the vessel wall and
microaneurysm formation and eventually rupture, producing an
intracerebral hemorrhage.

Page 7 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy
Subarachnoid Hemorrhage
• Diffuse type

CLINICAL CASE
A 50-year-old man experienced sudden onset of vertigo. Neurologic
examination showed dysarthria, difficulty with swallowing, left
Horner syndrome, left palatal weakness, and loss of pain sensibility
over the left face and right limbs and trunk. He had coarse ataxia
and incoordination of his left arm.

QUESTIONS
1. Where is the location of the lesion?
Infratentorial area affecting the brainstem & cerebellum

2. What is the vascular supply of this region?

Posterior Inferior Cerebellar Artery

3. What is the most likely etiology? Diagnosis?

Ischemic Stroke

SAMPLEX
From One More Trans:
https://drive.google.com/drive/u/0/folders/1SXUvuyWT3DgbBvgpMGD
pu5NXOc3xksTd

Page 8 of 8
Source: Dr. Escabillas’ lecture and PARBS trans
Sleepy crammers | stubby buddy