BRAIN BLOOD SUPPLY &

COMMONEST DISORDERS
(NEUROANATOMY & CLINICAL NEUROLOGY)

PRESENTED BY: NOOR ALMOHISH

FROM KING FAISAL UNIVERSITY – FIFTH YEAR MEDICAL STUDENT

OBJECTIVES:

 Brain Anatomy (General View)

 Anatomical view of brain blood supply

 Commonest site of occlusion and it’s associated symptoms

 Ischemic Stroke (cerebral infarction)

 Hemorrhagic stroke (intracerebral hemorrhage & subarachnoid hemorrhage)

 Subdural hematoma & epidural hematoma

BRAIN ANATOMY:
BRAIN BLOOD
SUPPLY
CEREBRAL CIRCULATION
ORIGIN
Carotid System VertebroBasilar System

Aortic arch
Aortic arch

Subclavian Subclavian
Common carotid

Internal carotid
Vertebral Vertebral
M.C.A. A.C.A.
Basilar

P.C.A P.C.A
CIRCLE OF
WILLS:
STROKE:
Disruption of cerebral blood flow leads to death of brain cells, resulting
in acute onset of focal neurologic deficits. Can be ischemic (80%) or
hemorrhagic (20%).
STROKE ETIOLOGIES:
COMMON STROKE SYMPTOMS ACCORDING
TO THE AFFECTED VESSELS:
EASY TO BE
REMEMBERED:
 DIAGNOSIS
:
 Emergent head CT without contrast  to differentiate ischemic
from hemorrhagic stroke and identify potential candidates for
thrombolytic therapy. Ischemic strokes < 6 hours old are usually
not visible on CT scan.

 Labs to draw immediately, in case thrombolytic therapy or

intervention may be required, include CBC, PT/PTT, cardiac
enzymes and troponin, BUN/creatinine.

 MRI to identify early ischemic changes not detected on CT.

TO DETECT THE UNDERLYING
CAUSE OF STROKE:
 Cardioembolic: ECG; echocardiogram.

 Thrombotic: Carotid ultrasonography; MRA; CTA; transcranial Doppler;

conventional angiography

Other potential causes that should be worked up if there is a high index of
suspicion: hypercoagulable states; sickle cell disease; vasculitis.
TREATMENT:
1. Acute —> Supportive treatment (airway protection, oxygen, IV uids) is initiated.

- If patient presents within 3 hours of stroke onset, thrombolytics are

indicated. If after 3 hours, give aspirin only.

If patient cannot take aspirin, give  clopidogrel.

If patient cannot take either aspirin or clopidogrel (allergy, intolerance), next

option is  ticlopidine.
 TREATMENT:
-BP control In general, do not give antihypertensive agents unless one of the
following three conditions is present:
1)The patient’s BP is very high (systolic >220, diastolic >120, or mean
arterial pressure >130 mm Hg).
2) The patient has a significant medical indication for antihypertensive
therapy. Examples include: Acute MI, Aortic dissection, Severe heart failure,
Hypertensive encephalopathy
3) The patient is receiving t-PA aggressive blood pressure
control is necessary to reduce the likelihood of bleeding.
 HEMORRHAGIC STROKE

Intracerebral Subarachnoid
hemorrhage
hemorrhage
INTRACEREBRAL HEMORRHAGE:
 Causes

1) Hypertension:

 (particularly a sudden increase in BP) is the most common cause (50% to 60% of
cases)  it cause rupture of small vessels deep within the brain parenchyma.

 Chronic HTN causes degeneration of small arteries, leading to micro aneurysms,

which can rupture easily  seen in older patients; risk increases with age.

2) Ischemic stroke may convert to a hemorrhagic stroke.

3)Other causes include amyloid angiopathy (10%), anticoagulant/antithrombo-

lytic use (10%), brain tumors (5%), and AV malformations (5%).
 Locations a. Basal ganglia (66%) b. Pons (10%)
c. Cerebellum (10%) d. Other cortical areas
 Abrupt onset of a focal neurologic de cit that
worsens steadily over 30 to 90 minutes
Features  Altered level of consciousness, stupor, or
coma
 Headache, vomiting
 Signs of increased ICP
 CT scan of the head diagnoses 95% of ICH (may
miss very small bleeds)
Diagnosis  Coagulation panel and platelets—check these to
evaluate for bleeding diathesis.

 Increased ICP
 Seizures
 Rebleeding
Complications  Vasospasm
 Hydrocephalus
 SIADH
CT scan show ICH
 TREATMENT OF ICH:
 Admission to the ICU

 ABC’s (airway, breathing, and circulation)—airway management is important

due to altered mental status and decreased respiratory drive. Patients often require
intubation

 BP reduction  indicated if systolic BP is >160 to 180 or diastolic BP is >105

(must be gradual so as to not induce hypotension).
 Nitroprusside is often the agent of choice.

 Mannitol (osmotic agent) and diuretics can be given to reduce ICP. Use these
agents only if ICP is elevated; do not give them prophylactically.

 Rapid surgical evacuation of cerebellar hematomas can be lifesaving. However,

surgery is not helpful in most cases of ICH.
SUBARACHNOID HEMORRHAGE:
 Locations  Saccular (berry) aneurysms occur at bifurcations of arteries
of the circle of Willis.

 Causes:

 Ruptured saccular (berry) aneurysms are the most common cause has
higher morbidity and mortality than other causes.

 Trauma is also a common cause.

 AV malformation.
 SAH CLINICAL FEATURES:
 Sudden, severe (often excruciating) headache in the absence of focal neurologic
symptoms; classic description is “the worst headache of my life” but may also be
more subtle.

 Sudden, transient loss of consciousness—in approximately 50% of patients

 Vomiting (common).

Meningeal irritation, nuchal rigidity, and photophobia—can take several hours

to develop.

Death—25% to 50% of patients die with the first rupture. (Those who survive
will recover consciousness within minutes).

 Retinal hemorrhages—in up to 30% of patients.

 DIAGNOSIS OF
SAH:
- Non-contrast CT scan

- Perform lumbar puncture (LP) if the CT scan is unrevealing or negative

and clinical suspicion is high. LP is diagnostic.

•Blood in the CSF is a hallmark of SAH. (Be certain that it is not blood from a
traumatic spinal tap)

• Xanthochromia (yellow color of the CSF) is the gold standard for diagnosis
of SAH  Xanthochromia results from RBC lysis. implies that blood has been in
CSF for several hours and that it is not due to a traumatic tap.

 Once SAH is diagnosed, order a cerebral angiogram. It is the defenitive study

for detecting the site of bleeding (for surgical clipping).
TREATMENT OF SAH:
 Surgical  Berry aneurysms are usually treated surgically: clip the
aneurysm to prevent re-bleeding.

 Medical therapy reduces the risks of re-bleeding and cerebral

vasospasm.
 Bed rest in a quiet, dark room.
 Stool softeners to avoid straining (increases ICP and risk of
rerupture).
 Analgesia for headache (acetaminophen).
 IV fluids for hydration.
 Control of HTN  lower the BP gradually because the elevation in BP
may be a compensation for the decrease in cerebral perfusion
pressure (secondary to increased ICP or cerebral arterial narrowing).
 Calcium channel blocker (nifedipine) for vasospasm  lowers the
incidence of cerebral infarction by one-third.
EPIDURAL & SUBDURAL
HEMATOMA:
 SUMMARY
:
1) Nervous system consist of: CNS and PNS

2) Vascular supply of the brain consist of anterior and posterior circulation,

communicating with each other to form circle of wills

3) Ischemic stroke can be converted to hemorrhagic stroke

4) Subarachnoid hemorrhage characterized by (worse headache in the whole

life)

5) Commonest artery to be injured in head trauma and cause epidural hematoma

is  middle meningeal artery
QUESTIONS
TIME:
Right or False:

Q1) Commonest cause of subarachnoid hemorrhage is rupture of aneurysm

Q2) Gold standard to diagnose subarachnoid hemorrhage is

Xanthochromia Q3) Origin of anterior brain circulation is subcalivian artery

Q4) Frontal lobe responsible for planning and personality

Q5) 85% of stroke cases are due to ischemic cause

QUESTIONS
TIME:
Q6) If the contralateral lower extremity affected by stroke, the site of affected
area:
A) Anterior cerebral artery
B) Middle cerebral artery
C) Posterior cerebral artery

Q7) If you have a case of ischemic stroke and the patient reach the hospital after
5 hours, you will treat the patient with:
D) Aspirin Only
E) Thrombolytic therapy only
F) Combination of A+B
QUESTIONS
TIME:
Q8) CSF flows in:
A) Subarachnoid space
B) Pia matter
C) Epidural space

Q9) If you have a case with symptoms of stroke and neurological deficit last for
less than 24 H and there is NO MRI finding, the most likely diagnosis:
D) Hemorrhagic stroke
E) Ischemic stroke
F) TIA

Q10) Most common cause of intracerebral hemorrhage:

G) Sudden increase in BP
H) Obesity
I) Drinking alcohol
REFERENCES: