Understanding Stroke Brain Anatomy and Cerebral Circulation

Cathy Corrigan-Lauzon HRSRH Enhanced District Stroke Program

Revised June 2007

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

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

Cerebral Blood Supply

Cerebral Blood Supply side view

Middle Cerebral Artery

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

Posterior Cerebral Circulation

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

Circle of Willis

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

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

The Brain

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Frontal Lobe

Blood supply - ACA and MCA Major functions:

personality, behaviour motor function judgement/problem solving micturation expressive speech - Brocas word formation, articulation and speech production concentration, reasoning
12 Neuroanatomy and Cerebral Circulation Review, West GTA Stroke Network, 2003

Parietal Lobe

Blood supply ACA, MCA and PCA Major functions:

sensory function body part awareness visual spatial information

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

Temporal Lobe

Blood supply - MCA and PCA Major Functions:

understanding speech -Wernickes visual, olfactory and auditory perception learning, memory, emotional affect

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

Occipital Lobe

Blood supply - MCA,PCA Major Functions:

primary visual area some visual reflexes involuntary smooth eye movements recognition & identification of objects

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

Cerebellum

Blood supply Vertebrobasilar Major Functions:

control of fine motor movement coordinates muscle groups maintains balance, equilibrium

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

Brain Stem

Blood supply - PCA & Vertebrobasilar Major divisions - midbrain, pons, medulla Houses CN III-XII Serves as a pathway Reticular Activating System

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

Motor & Sensory Function

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Common Effects by Hemisphere

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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
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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

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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
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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

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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

24 http://www.nlm.nih.gov/medlineplus/ency/imagepages/18009.htm

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
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Ischemic Stroke CT scan

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Types of Stroke

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

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White box - site of the hemorrhage

Hemorrhagic Stroke

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
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Hemorrhagic Stroke CT scan

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Comparison of Stroke Types

Ischemic

Hemorrhagic

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

Can be fatal at time of onset Client more likely to be semi-conscious or unconscious Client appears more ill and deteriorates rapidly

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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

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What about TIAs?

Transient occlusion or reduction in cerebral blood flow Classic definition of TIA - symptoms lasting up to 24 hours Most true TIAs 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
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Stroke Recognition and Treatment

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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 patients witnessed stroke symptoms is 3 hours or less

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Time is Brain!

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What is rt-PA?

Tissue Plasminogen Recombinant Activator

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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
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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

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Emergency Management Strategies

Neurological vital signs Blood pressure Glycemic control Control of body temperature Oxygenation Hydration

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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
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TIA Symptoms

Same as stroke - sudden onset with loss of function Immediate recognition essential dont 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
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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

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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
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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

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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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