Case 5 Flashcards
what do the internal carotid arteries bifurcate into?
the anterior cerebral artery, middle cerebral artery and the posterior communicating artery on each side of the head
what does the anterior cerebral artery supply?
Medial portions of the frontal lobes (including medial sensorimotor cortex).
Superior medial parietal lobes.
Anterior four-fifths of the corpus callosum.
Anterior portions of the basal ganglia and internal capsule.
Olfactory bulb and tract.
the anterior cerebral passes forward to travel in what?
the interhemispheric fissure (median longitudinal fissure) as it sweeps back and over the corpus callosum
what are the two major branches of the anterior cerebral artery?
- Pericallosal artery – this forms an anastomosis with the posterior cerebral artery.
- Callosomarginal artery
the middle cerebral artery turns laterally to enter what? where it bifurcates into what?
what branches does it give off?
the depths of the Sylvian fissure
here, it usually bifurcates into the superior and inferior divisions
• The branches of the middle cerebral artery form loops as they pass over the insula (insular branches) and then around and over the operculum (opercular branches) to exit the Sylvian fissure onto the lateral convexity.
what does the superior division of the MCA supply?
the cortex above the Sylvian fissure, including the lateral frontal love and usually including the peri-Rolandic cortex
what does the inferior division of the MCA supply?
the cortex below the Sylvian fissure, including the lateral frontal lobe and a variable portion of the parietal lobe
what does the MCA thus supply?
most of the cortex on the dorsolateral convexity of the brain
describe the path of the posterior cerebral artery. what are its territories?
it curves back after arising from the top of the basilar and sends branches over the inferior and medial termporal lobes and over the medial occipital cortex
territories therefore include inferior and medial temporal and occipital cortex
what are the vascular territories of arteries supplying deep cerebral structures?
• Lenticulostriate arteries - arise from the initial portions of the middle cerebral artery before it enters the Sylvian fissure, and they supply large regions of the basal ganglia and internal capsule.
• Anterior choroidal artery - arises from the internal carotid artery. Its territory includes portions of the globus pallidus, putamen, thalamus, and the posterior limb of the internal capsule.
- Thus, lacunar infarction in either the lenticulostriate or anterior choroidal territories often causes contralateral hemiparesis.
• Recurrent artery of Heubner - arises from the initial portion of the anterior cerebral artery to supply portions of the head of the caudate, anterior putamen, globus pallidus, and internal capsule.
• Small, penetrating arteries that arise from the proximal posterior cerebral arteries near the top of the basilar artery include the thalamoperforator arteries which supply the thalamus and sometimes extend to a portion of the posterior limb of the internal capsule.
what are the different types of stroke?
- Ischaemic stroke – this occurs when the flow of blood is prevented by a thrombus or an embolus, either from the heart or a large vessel (such as the carotid artery). Thromboembolic infarction is the cause of 80% of strokes.
- Haemorrhagic stroke – this results from rupture of a cerebral artery wall.
what are risk factors for a stroke?
- Asian and black African populations
- Age (above 40 years of age)
- Male
- Hypertension
- Hypercholesterolemia
- Diabetes
- Cigarette smoking
- Positive family history
- Cardiac disease
Give definitions for:
- stroke
- completed stroke
- stroke-in-evolution
- minor stroke
- transient ischaemic attack (TIA)
• Stroke – Stroke is defined as a syndrome of rapid onset of cerebral deficit (usually focal) lasting > 24 hours or leading to death, with no cause apparent other than a vascular one.
• Completed Stroke – means the deficit has become maximal, usually within 6 hours.
• Stroke-In-Evolution – describes progression during the first 24 hours.
• Minor Stroke – Patients recover without significant deficit, usually within a week.
• Transient Ischaemic Attack (TIA) - means a sudden focal deficit lasting from seconds to 24 hours with complete recovery. This definition is unsatisfactory as after 1 hour ischaemic damage has already occurred. TIAs have a tendency to recur, and may herald thromboembolic stroke.
Focal Neurological Deficit – this is a problem with nerve, spinal cord, or brain function. It affects a specific location, such as the left side of the face, right arm, or even a small area such as the tongue.
when does ischaemic stroke occur?
when inadequate blood supply to a region of the brain lasts for enough time to cause infarction of brain tissue
what can ischaemic stroke be a result of? what is the difference?
- It can be caused as a result of a thrombus (thrombolic infarct) or an embolus (embolic infarct).
- Embolic infarcts are considered to occur suddenly, with maximal deficits at onset, while thrombotic infarcts may have a more stuttering course.
what are small-vessel infarcts? what’s another name for them? what structures are affected?
lacunar infarcts = involve the small, penetrrating vessels that supply the deep structures
• The deep structures of the cerebral hemispheres these include the basal ganglia, thalamus, and internal capsule, while in the brainstem these include the medial portions of the midbrain, pons, and medulla.
- Lacunar stroke (stroke is less than a cm in diameter on the scan – due to small penetrating arteries being affected)
what are lacunar infarcts usually associated with?
small-vessel disease (lipohyalinotic thickening) caused by chronic hypertension
in addition to focal neurological deficits, what else can ischaemic stroke be associated with?
headaches or, less commonly, seizures
• Headache occurs in 30% of ischemic strokes. When headache is unilateral, it is more commonly on the side of the infarct. Seizures occur in 10% of stroke patients.
is stroke a big cause of death worldwide?
second most common, after ischaemic heart disease
what is the death rate following stroke?
20-25%
what are the main causes of stroke?
Thromboembolic infarction (80%), cerebral and cerebellar haemorrhage (10%) and subarachnoid haemorrhage (SAH) (about 5%) are the main causes; arterial dissection and arteriovenous malformations also contribute.
describe the development of ischaemic damage
• Immediate area - Ischaemia leads to the death of cells in the immediate area that is supplied by the blood vessels.
The tissue in the immediate area die within minutes to hours and this tissue cannot be repaired.
• Penumbra - The area surrounding the immediate are of infarct is known as the penumbra.
Here, the blood supply is compromised but not cut off.
The cells are under ‘threat’ but not dead.
There is the potential for rescue and repair.
It is crucial that treatment is administered early to prevent further damage to the penumbra.
what are the three things that cause ischaemic damage?
- Neurotransmitters – glutamate
- Ions – calcium and sodium
- Free Radicals – abnormal oxygen molecules (e.g. superoxide)
what are the different mechanisms that cause ischaemic damage?
- Excitotoxicity
- Reperfusion injury
- Free Radical Formation (oxidative stress)
- Apoptosis
- Inflammation
- Peri-infarct depolarizations