Lecture 22: Vasculatur Neuroogy, Anatomy,, clinical syndromes and cerebral hemorrhage

Question 1

What are the two blood vessels responsible for entire arterial supply to the brain?

Answer 1

i. Internal carotid artery (straight shot up)
- goes into circle willis as the middle cerebral artery
ii. Vertebral Arteries: comes off subclavian artery, goes straight to the brain
- two vertebral arteries join and form basilar artery

Question 2

Where does internal carotid artery enter skull? What are its branches? How does it terminate?

Answer 2

Enters at foramen lacerum
Has the following branches
i. ophthalmic artery (occlusion could lead to ipsilateral blindness)
ii. anterior choroidal artery (AChA)…no clinical significance
iii. Posterior communicating artery (joings anterior and posterior circulation)
ICA terminates as the
i. anterior cerebral artery (ACA)
ii. middle cerebral artery (MCA)

Question 3

Where does vertebral artery originate? Where does it enter? What are its branches? Where do they terminate?

Answer 3

Originates from Subclavian Arteries
Enters at foramen magnum
Branches include
-anterior and posterior spinal arteries
-Posterior inferior cerebellar artery (PICA)
Terminates as BASILAR ARTERY (two vertebral arteries fuse to form basilar)

Question 4

How are vertebral and ICA blood supply linked?

Answer 4

Via Posterior communicating artery (PComm)

Question 5

What clinical feature would you get if you occlude Anterior Cerebral Artery (from ICA)? And on what side?

Answer 5

LEG weakness

Contralateral

Question 6

What are major clinical features of Middle Cerebral Artery occlusion (from ICA)? Which side?

Answer 6

-Face and arm weakness (mebbe leg),
-sensory loss
-field cut (half of visual field gone)
-aphasia
-neglect
CONTRALATERAL for all symptoms

Question 7

What are major clinical features of Posterior Cerebral Artery occlusion (from ICA)? Which side?

Answer 7

Field cut (visual)
Contralateral

Question 8

What is a hallmark of a brainstem vascular problem?

Answer 8

Crossed symptoms
-facial and arm weakness contralateral to one another
Crossed symptoms
-facial and arm weakness contralateral to one another

Question 9

What is Weber Syndrome? What are the symptoms?

Answer 9

Medial midbrain syndrome
CN III ipsilatearl palsy and left hemiparesis (crossed signs)
MOA: occlusion of distal basilar artery and occlude the short circumferental branches of PCA and Basilar

Question 10

What is Pontine/Locked in Syndrome?

Answer 10

Anterior pons wiped out
MOA: occlusion of basilar artery…loss of midbasilar artery = no blood supply to anterior pons
Known as “locked in” syndrome because they are awake but just can’t move
Symptoms: Contralateral hemiparesis or Quadruparesis/locked in syndrome, gaze palsy, facial palsy

Question 11

What is Wallenberg/Lateral medullary syndrome?

Answer 11

Occlusion of Posterior inferior cerebellar artery (PICA) or contributing vertebral artery (VA)
Symptoms: right face and left body crossed sensory loss, right Horner’s, ataxia, vertigo, hiccups
Dysmetria
-cerebellum, vestibular nuclei, spinal trigeminal nuclei, nucleus ambiguous, spinothalamic and hypothalamic tract

Question 12

Where do lacunar arteries (perforators) come from? What are major clinical features of lacunar occlusion (perforators)? Which side

Answer 12

Branches of middle cerebral artery

• contralateral motor or sensory deficit without cortical signs (so mentally sound)
• no aphasia, no confusion, no neglect, no apraxia…that’s what it means by no cortical signs

Question 13

What symptoms do you get from cerebellar infarctin?

Answer 13

Ataxia, right dysmetria, vertigo, nausea/vomiting from the ataxia
Occlusion of PiCA, AiCA or SCA

Question 14

What symptoms do you get from BA occlusion?

Answer 14

Locked in, ataxia, oculomotor deficits, crossed sensory/motor deficits

Question 15

What symptoms do you get from VA occlusion?

Answer 15

• lower cranial nerve deficits (nucleus ambiguous)
• ataxia
• crossed sensory deficits
• Lateral Medullary Syndrome

Question 16

What causes dysarthria?

Answer 16

Problem with articulation of speech
Facial weakness
Tongue weakness
So it can be caused by MCA, ACA, PCA, VA and BA occlusions
Not localizing

Question 17

Where is the occlusion if you have sensory/motor deficits only?

Answer 17

Contralateral perforators

Question 18

What are the two types of strokes?

Answer 18

i. ischemic strokes (80%)

ii. Hemorrhagic storke (20%)

Question 19

What types of hemorrhagic stroke are there?

Answer 19

i. Intracerebral hemorrhage

ii. SubArachnoid hemorrhage

Question 20

What are symptoms of subarachnoid hemorrhage:

Answer 20

worst headache of life
-with or without focal signs
-CT scan detects 95%
-lumbar puncture is required for 5% other
CSF is bloody or yellow (degradation of blood products

Question 21

How do you figure out where the aneurysm is?

Answer 21

From an angiogram

Question 22

Where are aneurysm typically located?

Answer 22

At branch points
AComm
PComm
Middle Cerebral Artery (MCA) bifurcation

Question 23

What are treatment options for aneurysms?

Answer 23

• clipping or coiling of aneurysm
• nimodipine (calcium channel block) to reduce secondary neurological injury from vasopasm
• neurocritcal care

Question 24

What is another cause of subarachnoid hemorrhages aside from aneurysms?

Answer 24

AVMs (arterial venous malformations)

-high pressure blood flow of artery will rupture the vein vasculature (which is not used to handling the high pressure

Question 25

What is most common MOA of intracerebral hemorrhage? And where is the most common hemorrhage location?

Answer 25

Hypertension, hypertension, hypertension

-happens at small deep blood vessels (perforators) and at branch points

Question 26

Charcot-Bouchard aneurysms

Answer 26

microscopic outpouching that occur at 90 degree arteriolar or small penetrating artery branch points

Question 27

Cerebral amyloid angiopathy

Answer 27

A type of intracerebral hemorrhage that is NOT caused by high blood pressure

Question 28

Where is R face/arm/leg weakness and headache localized?

Answer 28

A. Subarachnoid hemorrhage from L MCA aneurysm
B. ICH from L deep perforating arteries
C. left MCA ischemic stroke
D. Any of the above (answer)

Question 29

How can you distinguish venous occlusion from arterial occlusion?

Answer 29

The former is slow progressing and the latter is acute presentation