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Cerebral Blood

Flow & Stroke


Lecture 27
Cerebral Circulation
Blood flow to CNS
delivers O , glucose, nutrients
2

removes C O2, lactic acid, metabolites


Cerebral vasculature
unique anatomy & physiology

safety mechanisms

Brain highly vulnerable to disrupted blood


flow ~
Stroke
CVA: cerebrovascular accident
Failure of safety mechanisms

#3 cause of death for U.S. adults


#1 cause of chronic functional incapacity
about 2 million adults ~
CVAs
neurological symptoms and signs
usually focal

localized
acute
sudden onset
result from diseases involving
blood vessels. ~
Causes of CVAs
cardiac disease
trauma
infection
neoplasm (tumor)
exogenous toxins
arterio-venous malformations
(AVMs) ~
Types of CVAs
Occlusive CVA:
due to the closure of a blood vessel -

usually due to atherosclerosis &

thrombosis.
Hemorrhagic CVA:
due to bleeding from a blood vessel

usually due to either hypertension or an

aneurysm. ~
Stroke: Ischemia
Insufficiency of blood supply
Glucose & O
2 deprivation, build-up of
wastes
NOT synonymous Anoxia:

O2 deprivation only
Few seconds: little or no damage
6-8 minutes ---> Infarction
neurons & other cells die ~
Blood Supply of Brain
Arises from aortic arch
2 common carotid arteries
(extracranial)
give rise to external & internal carotid

2 vertebral arteries ~
anterior cerebral
middle cerebral
Posterior cerebral

basilar
internal carotid

vertebral

external carotid

aortic arch
Blood Supply: Arterial Territories
Internal carotid arteries
supply each cerebral hemisphere

branches:

anterior cerebral artery


middle cerebral artery
anterior choroidal artery ~
Anterior Cerebral Arteries
Surface branches
supply cortex and white matter of :
inferior frontal lobe

medial surface of the frontal and

parietal lobes
anterior corpus callosum ~
Anterior Cerebral Arteries
Penetrating branches supply:
deeper cerebrum

diencephalon

limbic structures

head of caudate

anterior limb of internal capsule ~


Middle Cerebral Arteries
Surface branches supply
cortex & white matter of

hemispheric convexity
(all four lobes and insula).
Penetrating branches
deep white matter

some diencephalic structures ~


Anterior Choroidal Arteries
Supply
anterior hippocampus &

posterior limb of the internal

capsule ~
Vertebral Arteries
Rise from subclavian artery
Branches
anterior spinal arteries &

posterior inferior cerebellar arteries.

2 vertebral arteries join at the junction of the pons


and medulla
form basilar artery

basilar divides into 2 posterior cerebral arteries.

~
Posterior Cerebral Arteries
Surface branches supply
cortex and white matter of medial

occipital lobes
inferior temporal lobes

posterior corpus callosum

Penetrating branches supply:


parts of the thalamus

parts of the midbrain ~


Cerebral Artery Areas
1. anterior cerebral
1 2. Middle cerebral

2 3. Penetrating branches
3 of middle cerebral

54 4. anterior choroidal

5 5. Posterior cerebral
Anastomoses
Interconnections between blood vessels
overlapping blood supply

safety mechanism

retrograde filling

e.g., circle of Willis


Others between...
opthalmic artery & external carotid

surface branches of anterior, middle, posterior ~


Functions of Cortical Areas
Frontal lobe
Prefrontal lobes
anterior to motor cortex

weigh consequences of future action and

plan accordingly (an executive function);


performance of delayed responses

Inferior frontal lobes


emotional responding ~
Frontal lobe
Precentral gyri
control contalateral movement

Broca's area (L. Hemi.)

language production
R. Hemi.: may be more involved in

music production. ~
Parietal lobe
Postcentral gyrus
Anterior parietal lobe

primary somatosensory cortex (S1)

Posterior parietal cortex (PPC)


higher-order sensory areas

convergence from other sensory systems

left parietal lobe: reading and writing


right parietal lobe: spatial information. ~
Temporal lobe
Language & object recognition
memory
L. Hemi.: verbal information

R. Hemi.: nonverbal information

Inferior temporal lobes


higher-order visual perception ~
Temporal lobe
Superior temporal gyrus
primary auditory cortex (A1)

Superior temporal lobe


L. Hemi.: language comprehension

R. Hemi.: music comprehension

except trained musicians ~


Occipital Lobe
Analysis of visual information.
Primary visual cortex (V1)
Visual association cortex

color
movement
shape ~
Infarction in the territories of
the cerebral arteries
Middle cerebral artery
Most common stroke syndrome.
contralateral weakness
face, arm, and hand more than legs

contralateral sensory loss


face, arm, and hand more than legs

visual field cut

damage to optic radiations


Middle Cerebral Artery
Aphasia: language disturbances
more likely with L. Hemi. damage

especially men
Broca's: production
Wernicke's: comprehension ~
Middle Cerebral Artery
Impaired spatial perception
more likely after R. Hemi. damage

spatial neglect

dressing apraxia
constructional apraxia
topographagnosia ~
Anterior cerebral artery
Motor distrubance contralateral distal leg
urinary incontinence
speech disturbance (may be more of a
motor problem)
apraxia of left arm (sympathetic apraxia)
if anterior corpus callosum is affected
If bilateral may cause apathy, motor
inertia, and muteness ~
Posterior Cerebral Artery
Visual disturbances
contralateral homonymous hemianopsia

(central vision is often spared)


L. Hemi: lesions alexia
(with or without agraphia)
Bilateral lesions: cortical blindness
patients unaware they cannot see
(Anton's syndrome)
Memory impairment if temporal lobe is affected ~
Posterior Cerebral Artery
Proximal occlusion
contralateral hemisensory loss,

spontaneous pain and dysesthesia if

thalamus affected
(thalamic pain syndrome)
contralateral severe proximal chorea
(hemiballism) ~
Treatment
Pharmacologic
anticoagulants

vasodilators

antihypertensives

steroids

antagonism of excitatory amino

acid neurotoxicity ~
Treatment
Surgery
remove aneurysms

remove pressure following hemorrhage

Radiation to treat AVMs


Embolization therapy to
plug vessels of an AVM

or to treat an aneurysm

(direct surgery usually preferable)


Stroke Rescue?
Cell transplant - experimental
Inject immature nerve cells
grown from human cancer cells
Cells mature ---> bridge damaged areas
Rats: function restored
Human: June 23, 1998
no ill effects

no recovery yet ~