Cerebrovascular Accident

Cerebrovascular Accident
Cerebrovascular accident (CVA), also known as stroke is a sudden impairment of
cerebral circulation in one or more of the blood vessels supplying the brain. CVA interrupts or
diminishes oxygen supply and commonly causes serious damage or necrosis in brain tissues. The
sooner circulation returns to normal after CVA, the better chances are for complete recovery.
However, half of those who survive CVA remain permanently disabled and experience a
recurrence within weeks, months or years.
CVA is the third most common cause of death in the United States today and the most
common cause of neurologic disability. It strikes 500,000 persons each year; half of them die as
a result. Although it mostly affects older adults, it can strike people of any age and occurs most
commonly in men, especially blacks.

Patient’s Profile
Name: Jonathan Fat
Age: 48
Address: Padada, Davao del Sur
Status: Married
Occupation: None
Date of Admission: December 23, 2010 - 7:45 am
Chief Complaint: Left sided weakness
Attending Physician: Dr. Navarro
Impression Diagnosis: Acute right thalamic hemorrhage with intraventricular extension; old left
frontal lobe infarct, subarachnoid hemorrhage; right occipital lobe; lacunar infarct, right lenty
form nucleus; DM II
Anatomy and Physiology of the Brain
MENINGES Cerebro Spinal Fluid
The meninges are three connective tissue membranes

enclosing the brain and the spinal cord. Their functions are to protect the CNS and blood vessels,
enclose the venous sinuses, retain the cerebrospinal fluid, and form partitions within the skull.
The outermost meninx is the dura mater, which encloses the arachnoid mater and the innermost
pia mater.
Cerebrospinal fluid (CSF) is a watery liquid similar in composition to blood plasma. It is
formed in the choroid plexuses and circulates through the ventricles into the subarachnoid
space, where it is returned to the dural venous sinuses by the arachnoid villi. The prime
purpose of the CSF is to support and cushion the brain and help nourish it. Figure 2–4
illustrates the flow of CSF through the central nervous system.
Major Regions of the BRAIN
The cerebral hemispheres (Figure 2–6), located on the most superior part of the brain, are
separated by the longitudinal fissure. They make up approximately 83% of total brain mass,
and are collectively referred to as the cerebrum. The cerebral cortex constitutes a 2-4 mm
thick grey matter surface layer and, because of its many convolutions, accounts for about
40% of total brain mass. It is responsible for conscious behaviour and contains three
different functional areas: the motor areas, sensory areas and association areas. Located
internally are the white matter, responsible for communication between cerebral areas and
between the cerebral cortex and lower regions of the CNS, as well as the basal nuclei (or
basal ganglia), involved in controlling muscular movement.
The diencephalon is located centrally within the forebrain. It consists of the thalamus,
hypothalamus and epithalamus, which together enclose the third ventricle. The thalamus
acts as a grouping and relay station for sensory inputs ascending to the sensory cortex and
association areas. It also mediates motor activities, cortical arousal and memories. The
hypothalamus, by controlling the autonomic (involuntary) nervous system, is responsible
for maintaining the body’s homeostatic balance. Moreover it forms a part of the limbic
system, the ‘emotional’ brain. The epithalamus consists of the pineal gland and the
CSFproducing
choroid plexus.
The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded
by white matter fibre tracts. Its major regions are the midbrain, pons and medulla
oblongata. The midbrain, which surrounds the cerebral aqueduct, provides fibre pathways
between higher and lower brain centres, contains visual and auditory reflex and subcortical
motor centres. The pons is mainly a conduction region, but its nuclei also contribute to the
regulation of respiration and cranial nerves. The medulla oblongata takes an important role
as an autonomic reflex centre involved in maintaining body homeostasis. In particular,
nuclei in the medulla regulate respiratory rhythm, heart rate, blood pressure and several
cranial nerves. Moreover, it provides conduction pathways between the inferior spinal cord
and higher brain centres.
The cerebellum, which is located dorsal to the pons and medulla, accounts for about 11% of
total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white
matter, and small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum
processes impulses received from the cerebral motor cortex, various brain stem nuclei and
sensory receptors in order to appropriately control skeletal muscle contraction, thus giving
smooth, coordinated movements.
Major cerebral arteries and the circle of Willis.
Blood supply to the brain

The major arteries are the vertebral and internal carotid arteries. The two posterior and single
anterior communicating arteries form the circle of Willis, which equalises blood pressures in the
brain’s anterior and posterior regions, and protects the brain from damage should one of the
arteries become occluded. However, there is little communication between smaller arteries
on the brain’s surface. Hence occlusion of these arteries usually results in localised tissue
damage.
Autoregulation
[Panerai 1998] describes autoregulation of blood flow in the cerebral vascular bed as the
mechanism by which cerebral blood flow (CBF) tends to remain relatively constant despite
changes in cerebral perfusion pressure (CPP). With a constant metabolic demand, changes
in CPP or arterial blood pressure that would increase or reduce CBF, are compensated by
adjusting the vascular resistance. This maintains a constant O2 supply and constant CBF.
Therefore cerebral autoregulation allows the blood supply to the brain to match its
metabolic demand and also to protect cerebral vessels against excessive flow due to arterial
hypertension. Cerebral blood flow is autoregulated much better than in almost any other
organ. Even for arterial pressure variations between 50 and 150 mm Hg, CBF only changes
by a few percent. This can be accomplished because the arterial vessels are typically able to
change their diameter about 4-fold, corresponding to a 256-fold change in blood flow. Only
when the brain is very active is there an exception to the close matching of blood flow to
metabolism, which can rise by up to 30-50% in the affected areas. It is an aim of PET,
functional MRI, near infrared spectroscopy (NIRS), and, possibly, near infrared imaging, to
detect or image such localised changes in cortical activity and associated blood flow.
Pathophysiology of CVA
Cerebrovascular accident orstroke (also called brain attack) results from sudden interruption of

blood supply to the brain, which precipitatesneurologicdysfunction lasting longer than 24 hours.
Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vessel by
cerebral thrombosis or embolism or hemorrhage (leakage of blood from a vessel causes
compression of brain tissue and spasm of adjacent vessels). Hemorrhage may occur outside the
dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid),
or within the brain substance itself (intracerebral).
Risk factors for stroke include transient ischemic attacks (TIAs) – warning sign of impending
stroke – hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes mellitus,
obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarette
smoking. Complications of stroke include aspiration pneumonia, dysphagia, constractures, deep
vein thrombosis, pulmonary embolism, depression and brain stem herniation.

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Cerebrovascular Accident

Cerebrovascular accident (CVA), also known as stroke is a sudden impairment of

recurrence within weeks, months or years.

commonly in men, especially blacks.

Name: Jonathan Fat

Address: Padada, Davao del Sur

Date of Admission: December 23, 2010 - 7:45 am

Chief Complaint: Left sided weakness

Attending Physician: Dr. Navarro

MENINGES Cerebro Spinal Fluid

The meninges are three connective tissue membranes

Blood supply to the brain

Cerebrovascular accident orstroke (also called brain attack) results from sudden interruption of

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