NEURO: PART 1

Ms. Kaye Angat | MedSurg 2 Lec Ashanti

ANATOMY AND PHYSIOLOGY o group of neuron cell bodies that are next
to each other in the central nervous
system, the whole thing is called a
Nucleus.
o group of neuron cell bodies that are
located outside of the central nervous
system is called a Ganglion.

• Have nerve fibers that extend out from the

- Involved in nearly everything we do. From how neuron cell body.
we see, to how we walk and talk. o Dendrites - that receive signals from
CENTRAL NERVOUS SYSTEM other neurons.
• Brain o Axons - that send signals along to other
• Spinal cord neurons.
PERIPHERAL NERVOUS SYSTEM • Where two neurons come together is called a
• Somatic SYNAPSE.
• Autonomic o That’s where one end of an axon
releases Neurotransmitters, further
Can be split into an Afferent and an Efferent division. relaying the signal to the dendrites or
• AFFERENT DIVISION directly to the cell body of the next
o Brings sensory information from the neuron in the series.
outside into the central nervous system. o To trigger the release of
o Includes visual receptors, auditory neurotransmitters, neurons use an
receptors, chemoreceptors, and electrical signal that races down the
somatosensory or touch receptors. axon, known as the Action potential.
• EFFERENT DIVISION
o Brings motor information from the GLIAL CELLS
central nervous system to the periphery,
ultimately resulting in contraction of
skeletal muscles to trigger
▪ movement through the somatic
nervous system.
o Contraction of the smooth muscles to
trigger
▪ activity of the internal organs
○ To help speed up that electrical signal. The
through the autonomic nervous
axons are intermittently wrapped by a fatty
system.
protective sheath called Myelin
■ which comes from glial cells like
Made up of two main types of cells:
Oligodendrocytes in the central
1. Neurons
nervous system
2. Glial Cells
■ Schwann cells in the peripheral
nervous system.
NEURONS ○ ASTROCYTES
■ only present in the central nervous
system.
■ give structural and metabolic
support to neurons, as well as
■ act as resident immune cells
o help seal and nourish the
blood-brain barrier.
• Main cells of the nervous system.
• Composed of a Cell Body:
o which contains all the cell’s Organelles.

A.M.S | 1
 BLOOD-BRAIN BARRIER GREY MATTER (CEREBRAL CORTEX)
Divided into:
• FRONTAL LOBE
o Controls movement, and executive
function, which is our ability to make
decisions.

• PARIETAL LOBE
Consists of: o Processes sensory information, which
• Tight junctions lets us locate exactly where we are
o that connect Endothelial cells that line physically and guides movements in a
the capillaries in the brain. three-dimensional space.
o Seal off the space between the • TEMPORAL LOBE
endothelial cells, and they’re o Plays a role in hearing, smell, and
surrounded by Basement membranes memory, as well as visual recognition of
as well as astrocytes which further faces and languages.
strengthen the barrier. o Surrounds and communicates with the
Hippocampus and helps send
Think of the blood-brain barrier as the brain’s information from short-term to long-
bouncer, a highly selective membrane that turns term memory.
bacteria and other large, shady-looking molecules • OCCIPITAL LOBE
that are floating around in the blood away at the o Primarily responsible for vision.
door, while letting in nutrients like water, oxygen,
glucose, and smaller, fat-soluble molecules.

CEREBRUM

WHITE MATTER
There are deeper structures that are subcortical or below
the cortex, like the INTERNAL CAPSULE.
• Highway that allows information to flow through
neurons that are going to and from the cerebral
cortex.
• The most obvious few regions in the brain.
• Divided into two CEREBRAL HEMISPHERES:
o RIGHT CEREBRAL HEMISPHERE
▪ Receives afferent fibers and
sends efferent fibers to the left
side of the body.
BASAL GANGLIA
o LEFT CEREBRAL HEMISPHERE
▪ Receives afferent fibers and Two deep structures:
sends efferent fibers to the right • PALLIDUM
side of the body. • STRIATUM
• OUTERMOST AREA o Divided into Caudate nucleus and
o GREY MATTER (CEREBRAL CORTEX) Putamen
▪ Made up of billions of neuron o Receives input from the cerebral cortex
cell bodies. about a desired movement —> and it
• INNERMOST AREA sends output to the other basal ganglia
o WHITE MATTER structures —> to control smooth
▪ Made up of the axons that come movement by —> inhibiting undesired
off of all of those neurons. movements.

As an example, when you walk, you have to move

one leg at a time. When one leg steps forward, the
other leg gets inhibited by the basal ganglia. That it’s
stationary, and that prevents you from falling.

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 • receives motor input from the brain and
integrates them together to help fine-tune
motor activity and store it as muscle memory.
● Ex. Riding a bicycle, something you
typically can do pretty easily, even if you
haven’t used a bike in a while.

DIENCEPHALON
BARINSTEM
Composed of an upper part called the Thalamus and a
lower part called the Hypothalamus.

THALAMUS
• Collection of Nuclei.
o Millions of nerve cell bodies that process
the sensory information coming in from
the body to the cerebral cortex.
o Motor information going from the • Located right in front of the cerebellum.
cerebral cortex to the body. • Made up of three parts and it connects to the
HYPOTHALAMUS spinal cord:
• Regulate the body temperature. o MIDBRAIN - Uppermost part
• Sleep and wake cycle. ▪ participates in vision,
• Eating and drinking. ▪ hearing,
• To help do all of this, the hypothalamus regulates ▪ motor control,
the release of the major endocrine hormones. ▪ sleep-wake cycle,
• Sends signals to the PITUITARY GLAND. ▪ consciousness.
o Pea-sized gland, that hangs by a stalk o PONS - Middle part contains
from the base of the brain and has two ▪ nuclei that control facial
parts: expressions and sensation,
▪ Anterior ▪ body equilibrium and posture.
▪ Posterior o MEDULLA - Lower part
o Produces and secretes hormones when ▪ Regulate blood pressure
it signals the hypothalamus. ▪ breathing
Together, they form the Hypothalamic-pituitary axis. ▪ swallowing
▪ coughing
▪ vomiting
▪ digestion.

SPINAL CORD

CEREBELLUM
• Long rod of nervous tissue that extends down
from the brainstem to the lumbar region of the
vertebral column.
• Information travels up the spinal cord through
afferent (sensory fibers)
• and down the spinal cord through efferent (
motor fibers)
• Cross-section of the spinal cord:
• Sits down at the base of the skull. o WHITE MATTER
• Helps with coordinating movement, precision, ▪ On the outside and that contains
and balance. the afferent and efferent fibers
o GREY MATTER
• Receives sensory input about body position from
▪ On the inside it contains the
the spinal cord and
nerve cell bodies arranged in
three grey columns or horns
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 that look a bit like a butterfly, MENINGES
when put both sides together.
• Three pairs of GREY HORNS are divided into:
o Anterior (Ventral) Horns
o Posterior (Dorsal) Horns
o Lateral Horns

ANTERIOR (VENTRAL) HORNS

• Receive information from the motor cortex of - Brain and spinal cord are covered by the
the brain and then send it to the skeletal muscles meninges, which are three protective layers of
to trigger voluntary movement. the brain.
● PIA MATER
○ Inner layer
● ARACHNOID MATER
○ Middle layer
● DURA MATER
○ Outer layer
POSTERIOR (DORSAL) HORNS
• Take sensory information from the outside world PIA & ARACHNOID MATERS
and send it to the sensory cortex of the brain. • Form the SUBARACHNOID SPACE.
o Sensory information includes o Houses the CEREBROSPINAL FLUID (CSF)
▪ pressure ▪ Clear, watery liquid which is
▪ vibration pumped around the spinal cord
▪ fine touch and brain, cushioning them from
▪ proprioception or the impact and bathing them in
awareness of one’s bodily nutrients.
position in space.
PERIPHERAL NERVOUS SYSTEM

LATERAL HORNS
• Mainly involved with the sympathetic division of
the autonomic motor system.
• Consists of nerves which are enclosed Bundles of
• These helps regulate processes like
Axons
o urination
o connect the central nervous system to
o digestion
every other part of the body.
o heart rate.

There are 12 CRANIAL NERVES pairs that exit from the

skull and innervate the head and neck.

SPINAL CORD (Cont.)

• Responsible for coordinating REFELEXES,
o which are fast involuntary responses to
a stimulus.
• Emerge from the cerebrum: CN I and CN II
o E.g. Like getting banged on the knee with
• The rest: emerge from different parts of the
a hammer.
brainstem.
o The reason that’s possible is that some
1. CN I - Olfactory nerves
sensory neurons synapse in the spinal
2. CN II - Optic nerves
cord, instead of going up to the brain,
3. CN III - Oculomotor nerve
and shorter distances mean faster
4. CN IV - Trochlear nerves emerge from
signals.
the midbrain.
5. CN V - Trigeminal nerve
6. CN VI - Abducens nerve
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 7. CN VII - Facial nerve AUTONOMIC NERVOUS SYSTEM
8. CN VIII - Vestibulocochlear nerves
emerge from the pons.
9. CN IX - Glossopharyngeal nerve
10. CN X - Vagus nerve
11. CN XI - Accessory nerve
12. CN XII - Hypoglossal nerves all emerge
from the medulla.
• The cranial nerves are numbered based on their
• Both sympathetic and parasympathetic.
front to back position when viewing the brain.
• Made up of a relay that includes two neurons:
o Except for cranial nerves eleven and
○ PREGANGLIONIC NEURONS
twelve, which are inverted.
■ Have their cell bodies in nuclei
throughout the spinal cord in the
• There are also 31 PAIRS OF SPINAL NERVES
lateral horns.
which exit various regions of the spinal cord and
■ Axons of preganglionic neurons exit
innervate the rest of the body.
the spinal cord to reach the ganglia
and synapse with postganglionic
neurons.
○ POSTGANGLIONIC NEURONS
■ Have their cell bodies in ganglia out
of the spinal cord.
■ Axons of postganglionic neurons
exit the ganglia to reach the organs
and synapse with the target organ
cells.
o 8 PAIRS OF CERVICAL NERVES
o 12 PAIRS OF THORACIC NERVES
• Signals for the autonomic nervous system start
o 5 PAIRS OF LUMBAR NERVES
in some hypothalamic centers.
o 5 PAIRS OF SACRAL NERVES
○ HYPOTHALAMIC NEURONS
o 1 PAIRS OF COCCYGEAL NERVES
■ Have really long axons (up to 1.4
meters or 4.5 feet)
PNS Divided into the somatic and autonomic nervous
■ they carry signals all the way down
systems.
to the spinal cord nuclei where they
synapse with preganglionic neuron
SOMATIC NERVOUS SYSTEM
cell bodies.

• Made up of afferent or sensory nerves,

o which have axons that carry sensory SYMPATHETIC & PARASYMPATHETIC NERVOUS
information from the peripheral tissues SYSTEMS
like the skin, back to the cell bodies in • Have opposite effects on the body.
the posterior horns of the spinal cord.
• Efferent or motor nerves
o that contain the axons that carry motor
information from the cell bodies in the
anterior horns of the spinal cord to the
neuromuscular junction, which is where
these axons come into contact with the
skeletal muscle cells

• SYMPATHETIC NERVOUS SYSTEM

o Controls functions like:
▪ ↑ the heart rate
▪ ↑ blood pressure
▪ ↓ digestion.
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 o All of this maximizes blood flow to the ASSESSMENT OF THE NEUROLOGICAL SYSTEM
muscles and brain and can help either WHEN?
run away from a threat or fight it, • Comprehensive client assessment,
o which is why it’s also called the fight or • Focused exam
flight response.
• PARASYMPATHETIC NERVOUS SYSTEM WHAT?
o Slows the heart rate • Client is experiencing issues that might be
o stimulates digestion. related to neurological function
o The effects can be summarized as rest o Facial droop or confusion.
and digest.
HOW?
RECAP • Process of completing a neurological
NERVOUS SYSTEM assessment
• SUPPLIES:
o Cotto ball
o Turning fork
o An object that can be easily recognized
by touch like a paper clip, key, or coin
o Reflex hammer
o Tongue blade
o Drapes
o Gloves.
- CENTRAL NERVOUS SYSTEM
• Prepare for the Exam
● BRAIN
o Ensuring your client is in a comfortable
● SPINAL CORD
position
○ Pathway through which afferent
o Your hands are warm,
and efferent fibers travel to
o Temperature in the room is
connect the brain and
comfortable.
peripheral nervous system.
o Provide privacy by closing the door and
- PERIPHERAL NERVOUS SYSTEM
curtains
● Nerves that connect the central nervous
o Properly draping your client
system to the muscles and organs.
▪ Exposing areas of their body as
○ SOMATIC NERVOUS SYSTEM
needed to perform your
■ Controls skeletal
examination.
muscles
• Before the procedure
○ AUTONOMIC NERVOUS
o Explain the procedure to your client
SYSTEM
o Answer any questions they might have
■ SYMPATHETIC &
before obtaining verbal consent.
PARASYMPATHETIC
o Perform hand hygiene
SYSTEMS
o Collect your supplies.
● Control smooth
• Neurological system assessment involves much
muscles and
observation
glands.

ANATOMICAL LANDMARKS
• Assess spinal cord intactness
o Locate the deep tendon reflexes
o Commonly tested deep tendon reflexes
▪ Triceps
▪ Biceps
▪ Brachioradialis
▪ Patellar reflexes
▪ Achilles reflexes

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 METHODS OF ASSESSMENT FOR THE o Pat their thighs with both hands and
NEUROLOGICAL SYSTEM then flip their hands, alternating the
• Inspection palmar and anterior aspects of the
• Palpation hands.
NORMAL:
EVALUATE THE CLIENT’S CEREBELLAR FUNCTION ▪ Smooth contact with the surface
• Balance and coordination of their thighs with increasing
• Sensory function speed without pausing or
o Ability to feel and differentiate between faltering.
light touch and pain ABNORMAL:
• Motor function ▪ Slow, uncoordinated, or jerky
o Deep tendon reflexes. movements is called
Dysdiadochokinesis, and is an
ASSESSMENT OF CEREBELLAR FUNCTION unexpected finding.
OBSERVING GAIT (how they walk)
• Do this as they enter the examination room or ASSESSMENT OF SENSORY FUNCTION
• If seated or in a bed, ask them to stand and walk SUPERFICIAL TOUCH
across the room. • Ask client to close their eyes
o Take note of: • Use a cotton wisp to gently touch the surface of
▪ Posture the skin, on their face, arms, or legs.
▪ Coordination o Expect them to tell you when and where
▪ Movement of their legs and feet. they feel the cotton touch their skin.
o Their gait should appear smooth and PAIN PERCEPTION
steady without hesitation, shuffling, or
swaying.

BALANCE & EQUILIBRIUM

• Romberg test
o Ask your client to stand with their feet
together with their eyes open
o arms at their sides. • Using the sharp and dull edges of a broken
▪ They should remain balanced, tongue depressor
and their body shouldn’t sway. • Ask client to close their eyes
o Next, ask them to close their eyes for • Gently touch the pointed edge and dull edge to
about 30 seconds the skin (face, arms, legs) alternating between
▪ Observe their ability to stay the two sides.
upright. o Expect them to correctly identify the
o Be sure to stay close to your client to location and type sensation.
support them in the event they lose their
balance. VIBRATORY SENSATION
o NORMAL: • Instruct client to close their eyes
▪ Should be able to maintain their • Place the stem of a vibrating tuning fork on a
balance with only mild swaying bony prominence, like the great toe joint.
o ABNORMAL: o Expect them to tell
▪ Loss of balance you when they feel
▪ Excessive swaying the vibration and
▪ Moving their feet when it stops.
▪ Begin to fall
STEREOGNOSIS
COORDINATION • Is the ability to perceive the form of an object by
• Rapid Alternating Movements touch.
o Tap the tip of their thumbs to the tip of • Ask your client to close their eyes
each finger on their hands as quickly as • Then place a familiar object like a key or
possible.
paperclip in your client’s hand.
NORMAL:
• Test both hands with different objects.
▪ Swift movement while making
o Expect them to correctly identify the
contact between the thumb and
objects bilaterally.
each finger.

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GRAPHESTHESIA • Achilles reflex
• Ability to identify characters written on the skin. o With the client’s knee flexed at a 90-
• Ask your client to close their eyes and open one degree angle, support the client’s foot
of their hands exposing their palm. and slightly dorsiflex it.
• Use your finger or the dull edge of the tongue o Strike the achilles tendon
depressor to write a number on their palm; and ▪ Observing for plantar flexion.
repeat with a different number on the other
hand. Grade each reflex on a 0 to 4 scale
o Expect them to correctly identify the
number you wrote on each palm.
o Inability to correctly identify:
▪ damage to peripheral nerves or
the spinal nerve that supplies
that region of the body being
tested.
• 0 --- no response
ASSESSMENT OF MOTOR FUNCTION • 1+ --- Reflex is sluggish or diminished
TENDON REFLEXES (Upper Extremities) • 2+ --- Reflex is normal and as expected
• Triceps reflex • 3+ --- Reflex is more brisk than expected
o Flex client’s arm at the elbow to a 90- • 4+ --- Reflex is hyperactive or Clonus
degree angle, supporting the arm. o Clonus
o Use the reflex hammer to strike the ▪ An involuntary contraction and
triceps tendon 1 to 2 inches just above relaxation of the skeletal
the olecranon process. muscles
▪ Observe contraction of the Hypo- or Hyperactive reflexes
triceps muscle and extension of • Can be due to problems like:
the elbow. o severe electrolyte imbalances
• Biceps reflex o spinal cord injuries
o Flex arm to a 45-degree angle. o peripheral nerve damage
o Place your thumb over the biceps o upper or lower motor neuron damage.
tendon at the antecubital fossa
o Strike your thumb with the reflex NURSING IMPLICATIONS
hammer. • Correctly assess, interpret, report, and
▪ Observe contraction of the
document your assessment findings.
biceps muscle with flexion of
• Report to the health care provider
the elbow.
o If assessment reveals something
• Brachioradialis reflex
potentially abnormal or emergent
o Flex arm to a 45-degree angle and
▪ Depressed reflexes
support their arm so it is slightly
▪ Diminished sensation
pronated.
• Monitoring client progress and changes from
o Strike the brachioradialis tendon, which
baseline.
is located about 2 to 3 inches above the
SUMMARY
wrist
Assessment of the neurological system helps identify
▪ Observe for flexion of the elbow,
problems with cerebellar, motor, and sensory function.
along with slight supination of
• Supplies
the forearm.
o Cotton ball
o Tuning fork
o Object that can be easily recognized by
TENDON REFLEXES (Lower Extremities)
touch like a paper clip, key, or coin
• Patellar reflex
o Reflex hammer
o Located by positioning your client’s knee
o Tongue blade
at a 90-degree angle.
o Drapes and Gloves.
o Allow the leg to hang dependently
• Methods of assessment
o Strike the patellar tendon just below the
o Inspection
patella.
o Palpation.
▪ Observe for extension of the
lower leg, contraction of the • Nursing Care
quadriceps, and extension of o Correctly assess, interpret, report, and
the knee. document findings.

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 ISCHEMIC STROKE ▪ visual recognition of faces and
TWO MAIN TYPES OF STROKE: languages
1. Ischemic OCCIPITAL LOBE
2. Hemorrhagic • primarily responsible for vision
CEREBELLUM
HEMORRHAGIC STROKE • helps with muscle coordination and balance.
• when an artery in the brain breaks, creating a BRAINSTEM
pool of blood that damages the brain. • plays a vital role in functions like
▪ heart rate
ISCHEMIC STROKE ▪ blood pressure,
• when there’s a blocked artery that reduces ▪ breathing,
blood flow to the brain ▪ gastrointestinal function,
• are much more common ▪ consciousness.
• the amount of damage they cause is related to
the parts of the brain that are affected and how BRAIN
long the brain suffers from reduced blood flow Receives blood from the:
▪ TRANSIENT ISCHEMIC ATTACK ▪ left and right internal carotid
o if symptoms self-resolve within arteries
24 hours, and there are usually ▪ left and right vertebral arteries,
minimal long-term problems. o which come together to form the
basilar artery.
BASIC ANATOMY
Few regions of brain INTERNAL CAROTID ARTERIES
• turn into the left and right middle cerebral
arteries which serve the lateral portions of the
frontal, parietal, and temporal lobes of the brain.

CEREBRUM
• most obvious
• divided into two cerebral hemispheres
• each of which has a cortex (an outer region)
▪ divided into four lobes:
o frontal lobe, parietal lobe, • Each of the internal carotid arteries also give off
temporal lobe, occipital lobe branches called the ANTERIOR CEREBRAL
CEREBELLUM ARTERIES
• down below, as well as the brainstem which ▪ which serve the medial portion
connects to the spinal cord. of the frontal and parietal lobes
RIGHT CEREBRUM and connect with one another
• controls muscles on the left side of your body with a short little connecting
LEFT CEREBRUM blood vessel called the
• controls muscles on the right side of your body ANTERIOR COMMUNICATING
FRONTAL LOBE ARTERY.
• controls movement
• controls executive function (ability to make VERTEBRAL ARTERIES & BASILAR ARTERY
decisions) • gives off branches to supply the cerebellum and
PARIETAL LOBE the brainstem.
• processes sensory information • BASILAR ARTERY
• lets us locate exactly where we are physically o divides to become the right and left
• guides movements in a three dimensional space. posterior cerebral artery
TEMPORAL LOBE ▪ which mainly serve the
• plays a role in: occipital lobe and some of
▪ hearing the temporal lobe as well as
▪ smell the thalamus.
▪ memory

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INTERNAL CAROTID ARTERIES TWO PARTS OF PLAQUE:
• each give off a branch called the posterior 1. soft cheesy-textured interior
communicating artery which attaches to the 2. hard outer shell – fibrous cap
posterior arteries on each side.

CIRCLE OF WILLIS
• together, the main arteries and the
communicating arteries complete what is called
the Circle of Willis
• a ring where blood can circulate from one side to BRANCH POINTS:
the other in case of a blockage. - Most common sites of Atherosclerosis
• offers alternative ways for blood to get around • Internal carotid arteries
an obstructed vessel. • Middle cerebral arteries
In general, the brain can get by or adapt on diminished
blood flow Usually, though, it takes years for plaque to build
• especially when it happens gradually because up, and this slow blockage only partially blocks
that allows enough time for collateral the arteries, and so even though less blood
circulation to develop, makes it to brain tissue, there’s still some blood.
• which is where a nearby vessel starts sending out
branches of blood vessels to serve an area that’s
in need. Strokes happen when there’s a:
• sudden & complete blockage, or
• near-complete blockage of an artery

PLAQUES
• sit in the lumen of the blood vessel
• they’re constantly being stressed by
mechanical forces from blood flow
• it’s often the smaller
plaques that are more
dangerous.
But once the supply of blood flow is reduced to below
• The fibrous caps of smaller plaques are:
the needs of the tissue
▪ softer than the larger ones
• it causes tissue damage, which we call an
▪ prone to getting ripped off
ischemic stroke.
• Once that happens, the inner cheesy filling is
exposed to the blood and is thrombogenic
ISCHEMIC STROKE HAPPEN IN TWO MAIN WAYS
(tends to form clots very quickly)

1. ENDOTHELIAL CELL DYSFUNCTION PLATELETS

• when something • adhere to the
irritates or inflames exposed cheesy
the slippery inner lining material,
of the artery—the • they release chemicals that enhance the
Tunica Intima. clotting process.
• One classic irritant is the toxins found in Tabacco • Within a minute that artery can be fully
which float around in the blood damaging the blocked
endothelium.
• That damage becomes a site for 2. EMBOLISM (Embolic Stroke)
ATHEROSCLEROSIS (plaque forms)
• typically happens
o when a buildup of fat, cholesterol, proteins,
when a blood clot
calcium, and immune cells forms and starts
breaks off from one
to obstruct arterial blood flow.
location, travels through the blood, and gets
lodged in an artery downstream
o typically, an artery, arteriole, or capillary
with a smaller diameter.
• These blood clots typically emerge from
atherosclerosis, but they can also form in the
heart.

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For example: Lacunar stroke classically develop as a result of:
• stagnant blood can form a clot and blood can • HYALINE ARTERIOLOSCLEROSIS
stagnate due to: o occurs when the arteriole wall gets filled
o an atrial fibrillation or with protein.
o after a heart attack o This can happen as a result of:
▪ hypertension
IF A CLOT FORMS IN THE: ▪ diabetes
• LEFT ATRIUM o can make the artery wall quite thick,
o it moves into the reducing the size of the lumen.
left ventricle and
from there it has a
direct route to the
brain
• RIGHT ATRIUM
o A.k.a low-pressure vein
o Then it goes into the right ventricle and gets
lodged in the pulmonary capillaries with no SHOCK
way of getting to the brain • Problem specific to an artery
• can lead to a reduction in blood flow throughout
the entire body
• In these cases, the tissues that are the furthest
downstream are affected the most.
o This is because healthy tissue
continues to extract what it needs
o UNLESS if a person has a heart defect like: from the blood flowing by, leaving
ATRIAL SEPTAL DEFECT little or no oxygen and nutrients for
▪ that allows blood and the tissue furthest away.
potentially a blood clot to • The “furthest downstream” tissues in the brain
wander from the right side of are at the border of two different blood supplies.
the heart over to the left side of
the heart. WATERSHED INFARCT
o In that situation, a venous or right atrial • Is when the blood flow throughout the body is
blood clot will have bypassed the diminished for any reason, they get damaged.
pulmonary circulation and established a
route to the brain.

LACUNAR STROKE
• One specific type of
ischemic stroke
• they typically involve the
deep branches of the
Middle cerebral artery
o that feed the basal
ganglia.
MECHANISM OF ISCHEMIC STROKE
LACUNAR
• refers to “lake”
• called that since after a lacunar stroke the
damaged brain tissue develops fluid filled
pockets called cysts that look like little lakes
under a microscope.

ISCHEMIC CORE
• the brain tissue that will likely die from ischemia
ISCHEMIC PENUMBRA
• tissue around the core
• preserved for a period of time by collateral
circulation and has a chance to survive if blood
flow is restored quickly enough
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Regardless of the type of an Ischemic Stroke, without a STROKE SYMPTOMS
steady supply of glucose and oxygen: • depend on the exact part of the brain that is
• cells run out of energy within minutes and you affected
get a high buildup of sodium and calcium levels.
• Cytotoxic edema If a stroke affects the:
o High sodium levels draws water into the • ANTERIOR or MIDDLE CEREBRAL ARTERY
cell making it swell STROKE can cause:
• HIGH CALCIUM o numbness
o leads to the buildup of reactive oxygen o sudden muscle weakness
radicals that react with lipids in the • BROCA’S AREA
membranes of mitochondria and o usually in the left frontal lobe
lysosomes. o can cause: slurred speech
▪ Damage to these organelles • WERNICKE’S AREA
allows apoptosis-inducing o usually in the left temporal lobe
factors and degradative o can cause: difficulty understanding
enzymes to seep out of the cell. speech
• POSTERIOR CEREBRAL ARTERY STROKE
o can affect vision

Common stroke symptoms is FAST

F - Facial drooping
A - Arm weakness
S - Speech difficulties
T – Time
o obviously not a symptom but just a
OVER A PERIOD OF 4-6 HOURS:
reminder to get help as quickly as
• immune cells begin to haul away damaged cells
possible to minimize cell injury and
• the resulting inflammation damages the blood
maximize the chance of a full
brain barrier
recovery.
o allowing fluid and proteins to get into
the brain tissue causing swelling or
DIAGNOSTICS
Vasogenic Edema.
• Because the skull creates a fixed volume the CT or MRI
swelling leads to a mass effect where: • To diagnose and confirm the location and
o CINGULATE or UNCALHERNIATION size of an ischemic stroke, medical imaging
▪ the swollen brain tissue pushes
into the unaffected side of the ANGIOGRAPHY
brain • which uses contrast injected into the blood,
o CEREBELLAR TONSIL HERNIATION can help to visualize the exact location
▪ slips down and out of the base of where blood flow is blocked within an artery.
the skull
▪ which is particularly dangerous
because it can push onto the
brainstem and affect breathing
and consciousness.

FLAIR SEQUENCE MRIs

• it’s possible to distinguish a new stroke
injury from an old one.

TREATMENT
Ultimate treatment:
• to reestablish blood flow as quickly as possible
to prevent further cell death, particularly in the
penumbra - every minute counts.

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THROMBOLYTIC ENZYMES HEMORRHAGIC STROKE
• TISSUE PLASMINOGEN ACTIVATOR or TPA Two main types of stroke:
o are used to activate the body’s
• Hemorrhagic stroke - occurs when an artery
natural clot busting mechanisms,
ruptures and bleeds within the brain.
o but TPA does have a time limit of
when it can be used. • Ischemic stroke - occurs when an artery gets
ASPIRIN blocked.
• also used to prevent platelets from forming
HEMORRHAGIC STROKES: Two types:
additional clots.
• Intracerebral hemorrhage
SURGERY o when bleeding occurs within the
• If TPA is unsuccessful, surgical procedure can cerebrum
be used that push a wire through the artery o more common
and physically remove the clot • Subarachnoid hemorrhage
• MECHANICAL EMBOLUS REMOVAL IN o when bleeding occurs between the pia
CEREBRAL ISCHEMIA, called MERCI mater and arachnoid mater of the
o the wire grabs on to the clot and Meninges
draws it out of the Artery ▪ the inner and middle layers
• SUCTION REMOVAL that wrap around the brain.
o the wire is used to physically break
down the clot and clot fragments are
removed with suction.

After a stroke has occurred, there is an elevated

risk of having additional strokes. It is important to
minimize risk factors

MINIMIZE RISK FACTORS:

• quit smoking
• having:
o healthy blood pressure
o normal LDL cholesterol levels INTRACEREBRAL HEMORRHAGE
o controlling other diseases like diabetes
• Intraparenchymal hemorrhage
• surgery
o An intracerebral hemorrhage that
o to help clean arteries obstructed by
involves just the brain tissue.
severe atherosclerosis
• Intraventricular hemorrhage
o CAROTID ENDARTERECTOMY
o if the blood extends into the ventricles
▪ the internal carotid artery is
of the brain which store cerebrospinal
opened up and atherosclerotic
fluid.
plaque is removed.
ANATOMY
o STENT
▪ may be placed to keep the CEREBRUM
artery opened up

RECAP
ISCHEMIC STROKE
• occurs when there’s an acute decrease in the
arterial blood supply.
• Has two cerebral hemispheres:
• It can be due to:
• each of which has a cortex an outer region
o atherosclerosis,
o thrombus, o Cortex have four lobes:
o embolus, ▪ the frontal lobe
o reduction in blood flow. ▪ parietal lobe
The goal is to: ▪ temporal lobe
• identify symptoms and reestablish blood flow ▪ occipital lobe.
o to prevent long-term damage Additional structures:
Remember this a common acronym is FAST: ▪ Cerebellum - which is down
below
• Facial drooping, Arm weakness, Speech
▪ Brainstem - which connects to
difficulties and Time
the spinal cord.
13
 • Right Cerebrum Internal Carotid Arteries
o Controls muscles on the left side of your • Each give off a branch called the posterior
body and vice versa. communicating artery
• Frontal lobe o which attaches to the posterior arteries
o Controls movement, and executive on each side.
function, which is our ability to make
decisions. CIRCLE OF WILLIS
• Parietal lobe • So together, the main arteries and the
o processes sensory information, which communicating arteries complete what’s called
lets us locate exactly where we are the Circle of Willis.
physically and guides movements in a • A ring where blood can circulate from one side to
three-dimensional space. the other in case of a blockage.
• Temporal lobe
o plays a role in hearing, smell, and
memory, as well as visual recognition of
faces and languages.
• Occipital lobe
o which is primarily responsible for vision.
• Internal Capsule
o Within the cortex, which is like a highway
that allows information to flow through
neurons that are going to and from the
cerebral cortex. FEW WAYS INTRACEREBRAL HEMORRHAGE
• Basal ganglia MIGHT HAPPEN:
o Helps controls smooth movement and • Hypertension or high blood pressure.
cognitive function, along with the • Arteriovenous malformations
cerebellum. • Vasculitis
• Cerebellum • Can also be secondary, arising after an ischemic
o helps with muscle coordination and stroke
balance.
• Brainstem HYPERTENSION
o plays a vital role in functions like heart • Can lead to various vessel wall abnormalities.
rate, blood pressure, breathing, • Hypertension can lead to:
intestinal motility, and consciousness. Hyaline Arteriolosclerosis
o which results from hydrostatic pressure
BRAIN RECEIVES BLOOD FROM: pushing proteins out of the blood vessel
• Left and right internal carotid arteries. lumen and into the interstitial space
• Left and right vertebral arteries. within the blood vessel walls.
• Basilar artery. o Over time as more of these proteins
Internal Carotid Arteries deposit in the walls, the blood vessels
• Turn into the left and right middle cerebral become more stiff and brittle, and
arteries — which serve the lateral portions of the therefore more vulnerable to rupture.
frontal, parietal, and temporal lobes of the brain. • Hypertension can also cause tiny bulges in the
• Each of the internal carotid arteries also give off wall of small arteries, called
branches called the Anterior Cerebral Arteries Microaneurysms
o which serve the medial portion of the o These microaneurysms are called
frontal and parietal lobes and Charcot-Bouchard aneurysms, and
o connect with one another with a short they’re most likely to be found on small
little connecting blood vessel called the arteries like lenticulostriate vessels
anterior communicating artery. ▪ which arise from the anterior
Vertebral Arteries and Basilar Artery part of the circle of Willis and
• give off branches to supply the cerebellum and supply the basal ganglia.
the brainstem.
• Basilar artery
o divides to become the right and left
posterior cerebral artery which mainly
serve the occipital lobe and some of the
temporal lobe as well as the thalamus.

14
 ARTERIOVENOUS MALFORMATIONS o If this happens, there’s bleeding into
dead tissue, and it’s called a
Hemorrhagic Conversion.

Once there’s an Intracerebral Hemorrhage:

• blood starts spewing out from a damaged blood
vessel creating a pool of blood which increases
pressure in the:
• Tangle of blood vessels that directly connect an o skull
artery to a vein o nearby tissue cells
o a bit like a capillary bed, but with much, o blood vessels.
much larger blood vessels. • It also means that less blood is flowing
• Over time these abnormal vessels can rupture downstream to the cells that need it, which
causing a hemorrhagic stroke. leaves the downstream tissue deprived of
oxygen-rich blood.
VASCULITIS • Healthy tissue can die from both the direct
• Damage the arteries in the cerebrum themselves pressure and the lack of oxygen within a few
• An inflammation of the blood vessel walls, hours.
Vascular Tumors, like a
o Hemangioma: Increased pressure within the skull
▪ which is a benign vascular tumor • Can lead to brain Herniation
of the endothelial cells of blood o which is when the brain moves across
vessels. structures in the skull.
• Cerebral Amyloid Angiopathy o These structures include:
o which is a degenerative disease where ▪ falx cerebri - divides the two
abnormal protein deposits in the walls of halves of the brain
arterioles making them less compliant. ▪ tentorium cerebelli - divides the
occipital lobes from the
cerebellum
▪ foramen magnum - is the hole in
the base of the skull, where the
spinal cord connects with the
brain.

ISCHEMIC STROKE
Intracerebral hemorrhage can also be secondary, arising
after an ischemic stroke.

SYMPTOMS
• Stroke symptoms depend on the exact part of
the brain that is affected.
Anterior or middle cerebral artery stroke
ISCHEMIC STROKE
• can cause numbness and sudden muscle
• Caused by a blockage of blood flow to a part of
weakness.
the brain, and within hours it usually leads to
Broca’s area
brain tissue death.
o which is usually in the left frontal lobe
• Arteries within the ischemic tissue are
• can cause slurred speech or difficulty
themselves made up of endothelial cells that die
understanding speech, respectively.
off
Wernicke’s area
• and that means that if there’s Reperfusion
o which is usually in the left temporal lobe
o return to blood flow, there’s an
• can cause slurred speech or difficulty
increased chance that the damaged
understanding speech, respectively.
blood vessel might rupture causing a
Posterior cerebral artery stroke
hemorrhage.
• Then it can affect vision.
15
 SUMMARY
Intracerebral hemorrhage
• is a type of hemorrhagic stroke, where an artery
breaks within the cerebrum.
• The result is that a pool of blood forms which
increases intracranial pressure, and downstream
tissue gets deprived of oxygen-rich blood.
Treatment
• Medications aimed at controlling the high
intracranial pressure.
FAST • Surgical interventions like a craniotomy and
• Facial drooping stereotactic aspiration which can help remove
• Arm weakness the pool of blood.
• Speech difficulties Goal
• Time. • Identify symptoms and reestablish blood flow to
o Time is obviously not a symptom but prevent long-term damage.
just a reminder to get help as quickly • To help remember this a common acronym is
as possible to minimize cell injury FAST: Facial drooping, Arm weakness, Speech
and maximize the chance of a full difficulties, and Time.
recovery.

DIAGNOSIS
• CT Scan
• MRI
• Angiography
o uses contrast injected into the blood, can
help to visualize the exact location
where blood accumulates in the brain
tissue.

MEDICAL TREATMENT
• Drugs that help control hypertension and relieve
intracranial pressure.
• Surgery
o Craniotomy
▪ relieving intracranial pressure
when there’s a bleed near the
surface of the skull.
▪ Part of the skull bone is removed
to drain any accumulated blood
and relieve pressure.
o Stereotactic Aspiration
▪ If there’s a bleed that’s located
deep in the brain tissue, this an
be done to aspirate off blood
and relieve intracranial
pressure.
▪ Stereotactic aspiration is done
under a CT scanner to help guide
a needle to the exact spot where
blood needs to be drained.
16