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Understanding Stroke Brain Anatomy and Cerebral Circulation Cathy Corrigan-Lauzon HRSRH Enhanced District Stroke Program Revised June

Understanding Stroke

Brain Anatomy and Cerebral

Circulation

Understanding Stroke Brain Anatomy and Cerebral Circulation Cathy Corrigan-Lauzon HRSRH Enhanced District Stroke Program Revised June

Cathy Corrigan-Lauzon HRSRH Enhanced District Stroke Program

Revised June 2007

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What is a Stroke?

  • “Stroke” is a term used to describe neurological changes lasting more than 24 hours caused by an interruption in the blood supply to a part of the brain. If the blood flow ceases for an extended period of time, the cerebral tissues involved die causing permanent neurological deficits.

Cerebral Circulation Review

  • Brain derives its arterial supply from carotid and vertebral arteries

  • Carotid and vertebral arteries begin extracranially

  • Internal carotid arteries and branches supply anterior 2/3 of cerebral hemispheres

  • Vertebral and basilar arteries supply posterior and medial regions of hemispheres, brainstem, cerebellum and cervical spinal cord

Cerebral Blood Supply 4

Cerebral Blood Supply

Cerebral Blood Supply 4
Cerebral Blood Supply – side view 5

Cerebral Blood Supply side view

Cerebral Blood Supply – side view 5
Middle Cerebral Artery 6 http://www.strokecenter.org/education/ais_vessels/ais049b.html

Middle Cerebral Artery

Middle Cerebral Artery 6 http://www.strokecenter.org/education/ais_vessels/ais049b.html

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http://www.strokecenter.org/education/ais_vessels/ais049b.html

Posterior Cerebral Circulation

Posterior Cerebral Circulation 7 http://www.strokecenter.org/education/ais_vessels/ais049c.html

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http://www.strokecenter.org/education/ais_vessels/ais049c.html

Circle of Willis

Circle of Willis  Sits at the base of the brain  Joins the anterior and
  • Sits at the base of the brain

  • Joins the anterior and posterior circulation

  • Important route of

secondary or collateral circulation

  • Most common site for congenital aneurysm

http://www.strokecenter.org/education/ais_vessels/ais048.html

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Location

Location 9 http://www.nlm.nih.gov/medlineplus/ency/imagepages/18009.htm
10 http://www.meddean.luc.edu/lumen/meded/Neuro/neurovasc/navigation/cow.htm
10 http://www.meddean.luc.edu/lumen/meded/Neuro/neurovasc/navigation/cow.htm

The Brain

The Brain 11
Frontal Lobe  Blood supply - ACA and MCA  Major functions:  personality, behaviour 

Frontal Lobe

  • Blood supply - ACA and MCA

  • Major functions:

    • personality, behaviour

    • motor function

    • judgement/problem solving

    • micturation

    • expressive speech - Broca’s word formation, articulation and speech production

Frontal Lobe  Blood supply - ACA and MCA  Major functions:  personality, behaviour 
  • concentration, reasoning

Parietal Lobe  Blood supply – ACA, MCA and PCA  Major functions:  sensory function

Parietal Lobe

  • Blood supply ACA, MCA and PCA

  • Major functions:

    • sensory function

    • body part awareness

    • visual spatial information

Parietal Lobe  Blood supply – ACA, MCA and PCA  Major functions:  sensory function

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Neuroanatomy and Cerebral Circulation Review, West GTA Stroke Network, 2003

Temporal Lobe  Blood supply - MCA and PCA  Major Functions:  understanding speech -Wernickes

Temporal Lobe

  • Blood supply - MCA and PCA

  • Major Functions:

    • understanding speech -Wernickes

    • visual, olfactory and auditory perception

    • learning, memory, emotional affect

Occipital Lobe  Blood supply - MCA,PCA  Major Functions:  primary visual area  some

Occipital Lobe

  • Blood supply - MCA,PCA

Occipital Lobe  Blood supply - MCA,PCA  Major Functions:  primary visual area  some
  • Major Functions:

    • primary visual area

    • some visual reflexes

    • involuntary smooth eye movements

    • recognition & identification of objects

Cerebellum

  • Blood supply - Vertebrobasilar

  • Major Functions:

    • control of fine motor movement

    • coordinates muscle groups

    • maintains balance, equilibrium

Cerebellum  Blood supply - Vertebrobasilar  Major Functions:  control of fine motor movement 
Brain Stem  Blood supply - PCA & Vertebrobasilar
Brain Stem
Blood supply - PCA &
Vertebrobasilar
  • Major divisions - midbrain, pons, medulla

  • Houses CN III-XII

  • Serves as a pathway

  • Reticular Activating System

Brain Stem  Blood supply - PCA & Vertebrobasilar  Major divisions - midbrain, pons, medulla
Motor & Sensory Function 18

Motor & Sensory Function

Motor & Sensory Function 18
Common Effects by Hemisphere 19

Common Effects by Hemisphere

Common Effects by Hemisphere 19
COMMON EFFECTS OF A RIGHT HEMISPERIC STROKE Left visual field loss (homonymous hemianopsia) Dysphagia Usually retain
COMMON EFFECTS OF A RIGHT
HEMISPERIC STROKE
Left visual field loss (homonymous hemianopsia)
Dysphagia
Usually retain language ability but may have difficulty
producing speech (dysarthria)
Left-sided weakness (hemiparesis) or paralysis (hemiplegia)
Sensory impairment
Denial of paralysis, “forget” or “ignore” objects or people on
their left side (neglect)
Impaired ability to judge spatial relationships (misjudge
distances and depth leading to falls, unable to guide hands to
button a shirt, problems with directions such as up / down, no
concept of time)
Impaired ability to locate and identify body parts
Short-term memory impairments (difficulty remembering new
information) and apraxia (inability to carry out learned
movement in the absence of weakness or paralysis)
Behavioral changes such as impaired judgement or insight into
limitations, overestimate physical ability, impulsivity,
inappropriateness and difficulty comprehending and expressing
emotions
COMMON EFFECTS OF A LEFT HEMISPERIC STROKE Right visual field loss (homonymous hemianopsia) Dysphagia May develop
COMMON EFFECTS OF A LEFT
HEMISPERIC STROKE
Right visual field loss (homonymous hemianopsia)
Dysphagia
May develop aphasia (loss of language including spoken,
written, reading and comprehension) but may also have
dysarthria
Right-sided weakness (hemiparesis) or paralysis
(hemiplegia)
Sensory impairment
Usually have normal perception
Usually judgement is intact with good insight into
limitations
Short-term memory impairments (difficulty remembering
new information) and apraxia (inability to carry out
learned movement in the absence of weakness or paralysis)
Often develop a slow and cautious behavioral style. They
need frequent instructions and feedback to complete tasks
Better able to comprehend and express emotions
Types of Stroke  Ischemic 80 - 84%  Caused by blockage of the artery resulting

Types of Stroke

  • Ischemic 80 - 84%

  • Caused by blockage of the artery resulting in reduction of blood flow and cell death

  • Include thrombotic, lacunar, embolic cryptogenic

  • CT scan negative until a few days post stroke then hypodense area - indicates infarction

Types of Stroke  Ischemic 80 - 84%  Caused by blockage of the artery resulting

Thrombotic Stroke

  • Atherosclerosis in cerebral arteries

  • Similar to CAD leading to MI

  • Atherogenesis decades long process

  • In thrombotic stroke lumen of artery narrows

to point of obstruction

Lacunar stroke  Thrombosis of small, deep penetrating arteries causing a small lake or cavity 
Lacunar stroke
Thrombosis of small,
deep penetrating
arteries causing a
small lake or cavity
Seen with chronic
hypertension
Only minor deficits
seen
Necrotic brain cells
reabsorbed with time,
leaving a very small
cavity or lacune

Embolic Stroke

  • A clot travels from source outside of brain

  • Encounters vessel with lumen narrow enough

to block its passage

  • Clot lodges there, blocking blood flow

  • Most common source - heart

  • Common conditions - atrial fibrillation,

valvular disease, ventricular thrombi,

atherosclerosis of the proximal aorta

Ischemic Stroke CT scan

Ischemic Stroke – CT scan 26
Types of Stroke  Hemorrhagic 10 - 20%  May be classified as subarachnoid due to

Types of Stroke

Types of Stroke  Hemorrhagic 10 - 20%  May be classified as subarachnoid due to
  • Hemorrhagic 10 - 20%

  • May be classified as

subarachnoid due to ruptured aneurysm or trauma or intracerebral due to hypertension

  • CT will show hyperdense area indicating bleeding into the damaged tissue

Types of Stroke  Hemorrhagic 10 - 20%  May be classified as subarachnoid due to
Hemorrhagic Stroke  White box - site of the hemorrhage  Orange region - brain areas

Hemorrhagic Stroke

  • White box - site of the hemorrhage

Hemorrhagic Stroke  White box - site of the hemorrhage  Orange region - brain areas
  • Orange region - brain areas damaged by the stroke

  • Cells normally nourished by the hemorrhaging blood vessel, deprived of oxygen and other nutrients, perish very quickly leading to disability

Hemorrhagic Stroke CT scan 29

Hemorrhagic Stroke CT scan

Hemorrhagic Stroke CT scan 29
Comparison of Stroke Types Ischemic  Rarely leads to death in the first hour  Client

Comparison of Stroke Types

Ischemic

  • Rarely leads to death in

the first hour

  • Client may be drowsy but unlikely unconscious unless the infarct is large

  • Client may deteriorate in the first 24-48 hours

Hemorrhagic

  • Can be fatal at time of onset

  • Client more likely to be semi-conscious or unconscious

  • Client appears more ill and deteriorates rapidly

Determinant Factors

  • Location of damage

  • Severity of damage

  • How well the body responds to the cerebral assault and repairs the blood

supply to the brain

  • How quickly other areas of brain tissue take over the work of the damaged cells

What about TIA’s?

  • Transient occlusion or reduction in cerebral blood flow

  • Classic definition of TIA - symptoms lasting up to 24 hours

  • Most “true” TIA’s last 2 to 20 minutes with complete symptom resolution - symptoms lasting more than 1 hour is most likely as a result of permanent damage from stroke

  • Serious warning sign of an increased risk for stroke - 5% occur within 48 hours of a TIA

What about TIA’s?  Transient occlusion or reduction in cerebral blood flow  Classic definition of
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Stroke Recognition and Treatment 34

Stroke Recognition and Treatment

Stroke Recognition and Treatment 34
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Initiating Acute Stroke Care - 3 Golden Hours  In the community  Call 9-1-1 immediately

Initiating Acute Stroke Care - 3

Golden Hours

  • In the community

    • Call 9-1-1 immediately

    • Stroke Code initiated by Paramedics en route - goal to identify a possible stroke and get the patient to the ED as quickly as possible

  • In-Patient

    • Time of onset of the patient’s witnessed stroke symptoms is 3 hours or less

  • Time is Brain! 37

    Time is Brain!

    Time is Brain! 37
    Time is Brain! 37

    What is rt-PA?

    • Tissue Plasminogen Recombinant Activator

    What is rt-PA?  Tissue Plasminogen Recombinant Activator 38
    Ischemic Penumbra  Area around infarct  Infarcted brain tissue dies quickly - brain cells within

    Ischemic Penumbra

    • Area around infarct

    • Infarcted brain tissue dies

    quickly - brain cells within

    the penumbra remain viable for several hours after stroke

    • Penumbra cells supplied

    with blood by collateral arteries

    • Reperfusion important as circulation becomes inadequate with time

    Ischemic Penumbra  Area around infarct  Infarcted brain tissue dies quickly - brain cells within
    Cerebral Reperfusion in Acute Ischemic Stroke Goal - To limit irreversible ischemic damage during an acute

    Cerebral Reperfusion in Acute

    Ischemic Stroke

    • Goal - To limit irreversible ischemic damage during an acute ischemic stroke caused by an arterial occlusion. Thrombolysis will

    promote reperfusion

    of viable tissue

    Cerebral Reperfusion in Acute Ischemic Stroke Goal - To limit irreversible ischemic damage during an acute

    Emergency Management Strategies

    • Neurological vital signs

    • Blood pressure

    • Glycemic control

    • Control of body temperature

    • Oxygenation

    • Hydration

    Emergency Management Strategies  Neurological vital signs  Blood pressure  Glycemic control  Control of
    Emergency Management Strategies  Neurological vital signs  Blood pressure  Glycemic control  Control of
    Hemorrhagic Stroke  Treatment based on the underlying cause of the bleed and the extent of

    Hemorrhagic Stroke

    • Treatment based on the underlying cause of the bleed and the extent of brain damage

    • Treatment includes medication and surgical intervention

    • Management of ICP with antihypertensives or surgical evacuation of hematoma

    • In patients with ruptured aneurysm - clip or embolization

    TIA Symptoms  Same as stroke - sudden onset with loss of function  Immediate recognition

    TIA Symptoms

    • Same as stroke - sudden onset with loss of function

    • Immediate recognition essential -

    don’t self diagnose or wait for

    symptom resolution

    • Treat as a medical emergency - urgent medical assessment to rule out stroke and initiate interventions to prevent stroke

    Transient Ischemic Attack (TIA)  Strategies to prevent a stroke  Maintain a healthy weight -

    Transient Ischemic Attack (TIA)

    • Strategies to prevent a stroke

      • Maintain a healthy weight - eat a reduced-fat diet

      • Reduce alcohol intake to 1-2 drinks / day

      • Exercise - 30 minutes 3-4 times / week

      • Become smoke free and drug free

      • Management of hypertension (ACE inhibitors)

      • Management of heart disease (anticoagulants), diabetes and hyperlipidemia (statins)

      • Carotid endarterectomy may be indicated with stenosis

      • Antiplatelets for plaque / clot formation

    Stroke Recovery  The most rapid recovery occurs during the first 3 to 4 months -

    Stroke Recovery

    • The most rapid recovery occurs during the first 3 to 4 months - may continue over

    many months or years

    • Mild (6 wks); Moderate (13 wks); Severe (17 wks)

    • Recovery process is affected by the:

    Survivor's age and general health

    Survivor's personality

    Survivor's coping abilities and emotional state

    Support of family and loved ones

    Stroke Risk

    • A person who has had a stroke has a

    higher risk of having another one

    • Risk highest in the first year - 15 times the risk among the general population

    • Risk remains high for the first five years

    • 30% of people with previous stroke will have another one

    References Black J, Hakanson Hawks J, Keene A. Medical-Surgical Nursing Clinical Management for Positive Outcomes. 2001

    References

    Black J, Hakanson Hawks J, Keene A. Medical-Surgical Nursing Clinical Management for Positive Outcomes. 2001

    Habel M, Management of the Patient with Stroke HRSRH Neurosciences Critical Care 10-Module Program, Module 8: Seizures / Stroke (CVA) Neuroanatomy and Cerebral Circulation Review, West GTA Stroke Network, 2003 Heart and Stroke Foundation of Ontario, Tips and Tools for Everyday Living: A Guide for Stroke Caregivers, 2002 Heart and Stroke Foundation Get Stroke Smart, 1999 Martin Memorial Health Systems, Health Library A-Z, 2004

    (www.mhs.com) Medical Imaging of Cerebrovascular Disease, Unit 2: Anatomy of the Cerebrovascular System, klmccor, 1999

    Google Image Search

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