Cerebrovascular

Towards the top of the head

Towards the feet

Same side

Opposite side

Everything a person can see when the eyes are fixed. AKA Field of Vision

Noteworthy event or series of events

Sudden temporary blindness

Episodic Monocular Blindness: A shade being pulled down over one eye or FOV

Plaque embolus or thromboembolus from the ipsilateral ICA

Bright plaque within the vessels of the retina

Cholesterol crystals are contained within the atheromatous

Double vision

bilateral blindness in half of each eye

Temporary blindess in one eye; Amaurosis Fugax

Right side of each eye

Poor articulation, slurred speech

Impairment of speech. The patient knows what he/she wants to say, but can't speak easily

Loss of expression of speech and comprehension of language

Difficulty swallowing

Partial or incomplete paralysis (weakness)

Partial or incomplete paralysis affecting only one side of the body

Complete paralysis or stroke

Paralysis of one half of the body

Numbness, tingling or lack of feeling

Partial paralysis in one limb

Failure of muscular coordination

Confusion and headaches

Feeling a tendency to fall

Sensation of moving around in space

An unpleasant sensation usually preceding vomiting

Pass out

Failure of a part to maintain its normal position

Hemorrhagic and Ischemic

The rupture of an aneurysmal artery

• AV Malformation
• Trauma
• Atherosclerosis
• Inflammation

• Blood flows into or out of the brain
• 30-50% of patients die

• Epidural: between dura mater and skull
• Subdural: between dura and arachnoid mater
• Subarachnoid (SAH): between arachnoid and pia mater
• Intraparenchymal: Within the brain

10%

10%

80%

To prevent further bleeding, the ruptured vessel needs to be occluded by surgical clip/repair, embolic therapy, or thrombus formation

• Pressure from bleed and resultant hematoma
• Vasospasm
• Hydrocephalus

When an aneurysm ruptures, blood extravasates under arterial pressure into the subarachnoid space and quickly spreads through the cerebrospinal fluid around the brain and spinal cord. Blood released under high pressure may directly cause damage to local tissue.

True

The pathophysiology of vasospasm is unclear

3rd day

Depends on amount of blood around the brain and resultant hematoma

Usually very ill patients already in the hospital

Many times the patients have involuntary movements

Usually agressively treated with drugs

Neurologic status intact

Mild headache

Slight nuchal rigidity (involuntary sustained muscle contraction)

Neurologic deficit evidenced by cranial nerve involvement

moderate to severe headache with pronounce meningeal signs

(Photophobia, nuchal rigidity)

Drowsiness and confusion with or without focal neurologic deficits

Pronounced meningeal signs

• Stuporous with pronounced neurologic deficits
• (Hemiparesis, dysphagia)

Nuchal rigidity

Deep coma state with decerebrate posturing and other brain stem dysfunction

Sudden throbbing, or explosive headache

Nausea or vomiting

Visual disturbances

Motor deficits

Loss of consciousness

Atheroembolus: A fragment of plaque travels to the brain and occludes a small artery that feeds brain cells

Thromboembolus: A fragment of thrombus travels to the brain and occludes a small artery that feeds brain cells

Cerebrovascular disease is the 3rd leading cause of death in the US

Heart disease is the leading cause

Cancer (trachea, bronchus, and lung) are second

75% of the brain's substance is fed by blood

Most common cause of arterial stenosis is atherosclerosis

Intracranial disease is less common than extracranial in the US

Opposite for Asian and African origins

700,000 Americans will have had a stroke in 2006, 157,000 of them will die

Strokes cost about $43 million per year

Stroke brain cell infarction has occurred

A focal neurological impairment of the functional capacity of that part of the brain

The deficit effect becomes the SYMPTOM of stroke or TIA

A true stroke results in a permanent neurologic deficit

Sudden onset of symptoms

Symptoms come and go, unstable

No progress or resolution of symptoms, stable

Average TIA lasts from seconds to 30 minutes

Symptoms always resolve in under 24 hours

Usually embolic from heart or carotid

Caused by temporary loss of blood supply

Permanent cell damage may occur if TIA lasts for hours

Neurologic deficit that lasts longer than 24 hours with symptoms resolving in time, in a way similar to that of a TIA

Less than a week, less than three days

Invariably produces brain cell infarction

Age - increasing age

Sex - men over women, women are more likely to die from stroke

Heredity and Race - more likely if a family member has had a stoke. Africans have a higher risk of death, and Asians have a greater risk of intracranial generated stroke

Prior stroke or heart disease

High Blood Pressure - atherosclerosis

Diabetes 

Smoking

A fib - prevent clots with anticoagulants

Blood cholesterol

Obesity and inactivity 

Excessive alcohol

Atherosclerosis

Heart embolus

Hypertension

Dissection

Prethrombotic

Vasospasm

Intimal damage and collagen exposure

Severe stenosis damages the intima to rupture

Blood hemorrhages into the plaque (ulceration)

Collagen fibers exposed and a thrombus forms

True

Left atrium

A fib can dislodge thromboembolus

damage to endothelium stimulates thrombus formation

Effects the mitral valve where a thrombus may form

Elevated blood pressure can contribute to heart disease

Worsens atherosclerosis of large arteries

Injures small vessels of kidney and brain - hyaline (glassy) arteriolar sclerosis

Advances to occlusion of arteriole and can cause infarction

Occurs between vessel layers

Effects patients between 20 and 50

Caused by hypertension, trauma, and FMD

Occurs commonly distal to the bifurcation, below base of skull

Leads to hemorrhage and thrombus between endothelium and media - two distinct lumens

Abnormalities in blood coagulation

Usually in veins

Also in arteries

Internal carotid artery

70-80% of CCA flow will pass through the ICA

8 - outside the cranium 

• Anterior
• Posterior
• Medial 
• Terminal

Extracranial ICA

Carotid canal/foramen, enters the cranium

Carotid siphon

Terminal ICA at bifurcation

Opthalamic Artery

• -Lacrimal A branch
• -Supraorbital A branch
• -Frontal A branch

Anastomoses with branches of the middle meningeal artery (of the internal maxillary A)

Arises from the mid part of the opthalmic artery and passes through the supraorbital notch where it anastomoses with the frontal branch of the superficial temporal artery and the facial atery

Passes to the forehead where it anastomoses with branches of the superficial temporal artery and the facial artery

Anterior cerebral and Middle cerebral arteries

Passes above the optic nerve to the fissure between the two hemispheres, then around the Corpus Collosum where it gives blood to the frontal lobes

Originate from the subclavian arteries

Pass into the sixth cervical vertebra

Goes into the foramen magnum where they join to form the basilar artery

Right is usually smaller than left vertebral

Gives off the posterior inferior cerebellar artery (PICA)

Anterior cerebral arteries

Middle cerebral arteries

Posterior cerebral arteries

Communicating arteries

Posterior cerebral artery by the posterior communicating artery

Four main vessels feed the brain:

• -Right and left ICAs
• -Right and left vertebral arteries

True

True

• Acom might not be present
• Pcoms might not be present

Most common is one or both Pcoms missing