cerebrovascularsystem patient cases perfusion territories perfusion territories venous drainage...

CerebrovascularCerebrovascularSystemSystem

PatientPatientCasesCases

Perfusion TerritoriesPerfusion Territories

Venous DrainageVenous Drainage

VertebrobasilarVertebrobasilarSystemSystem

Cardiovascular DiseaseCardiovascular Disease

Map of EssentialMap of EssentialConceptsConcepts

CircleCircleOf WillisOf Willis

Blood SupplyBlood SupplyTo BrainTo Brain

Carotid SystemCarotid System

Blood Supply toBlood Supply toSpinal CordSpinal Cord

Oxygen DemandsOxygen DemandsAnd MetabolismAnd Metabolism

DM McKeough© 2008

The Cerebrovascular SystemThe Cerebrovascular SystemThe Cerebrovascular SystemThe Cerebrovascular System Oxygen demands and metabolism Cerebrovascular disease Blood supply to the brain Carotid system

Stroke effects Vertebrobasilar system

Stroke effects Circle of Willis Perfusion Territories Venous drainage Blood supply to the spinal cord Patient cases

Last ViewedLast Viewed Cerebrovascular SystemCerebrovascular System ExitExitConcept MapConcept Map

Oxygen Demands 1/2Oxygen Demands 1/2Oxygen Demands 1/2Oxygen Demands 1/2 The CNS (brain and spinal cord) is the best The CNS (brain and spinal cord) is the best

protected organ in the human body including protected organ in the human body including mechanisms to protect its blood supply.mechanisms to protect its blood supply.

At approximately 3 pounds, the brain accounts At approximately 3 pounds, the brain accounts for about 2% of body mass.for about 2% of body mass.

Consumes 17% of cardiac output. Consumes 17% of cardiac output.

Responsible for 20% of oxygen consumption Responsible for 20% of oxygen consumption at rest.at rest.

The CNS (brain and spinal cord) is the best The CNS (brain and spinal cord) is the best protected organ in the human body including protected organ in the human body including mechanisms to protect its blood supply.mechanisms to protect its blood supply.

At approximately 3 pounds, the brain accounts At approximately 3 pounds, the brain accounts for about 2% of body mass.for about 2% of body mass.

Consumes 17% of cardiac output. Consumes 17% of cardiac output.

Responsible for 20% of oxygen consumption Responsible for 20% of oxygen consumption at rest.at rest.


Metabolism 2/2Metabolism 2/2Metabolism 2/2Metabolism 2/2

Brain’s sole source of energy is aerobic or Brain’s sole source of energy is aerobic or oxidative metabolism.oxidative metabolism.

Therefore, the brain requires a constant supply Therefore, the brain requires a constant supply of Oof O22 and glucose, 24 hours a day. and glucose, 24 hours a day.

Brain’s sole source of energy is aerobic or Brain’s sole source of energy is aerobic or oxidative metabolism.oxidative metabolism.

Therefore, the brain requires a constant supply Therefore, the brain requires a constant supply of Oof O22 and glucose, 24 hours a day. and glucose, 24 hours a day.


Cerebrovascular DiseaseCerebrovascular DiseaseCerebrovascular DiseaseCerebrovascular Disease

While the blood supply to the brain is highly While the blood supply to the brain is highly protected, cerebrovascular disease is the third protected, cerebrovascular disease is the third leading cause of death in American adults and leading cause of death in American adults and the number one cause of chronic functional the number one cause of chronic functional disability requiring rehabilitative intervention.disability requiring rehabilitative intervention.

While the blood supply to the brain is highly While the blood supply to the brain is highly protected, cerebrovascular disease is the third protected, cerebrovascular disease is the third leading cause of death in American adults and leading cause of death in American adults and the number one cause of chronic functional the number one cause of chronic functional disability requiring rehabilitative intervention.disability requiring rehabilitative intervention.


Blood Supply to the Brain Blood Supply to the Brain 1/61/6


Approximately 1,000 ml/min Approximately 1,000 ml/min delivered via two systems.delivered via two systems.

Anterior (Anterior (CarotidCarotid) system:) system: 70% of supply (35% from 70% of supply (35% from

each internal carotid artery)each internal carotid artery) Supplies the superior 2/3 of Supplies the superior 2/3 of

the brainthe brain Posterior (Posterior (VertebrobasilarVertebrobasilar) )

system:system: 30% of supply30% of supply Supplies the inferior 1/3 of Supplies the inferior 1/3 of

the brain and brainstemthe brain and brainstemLast ViewedLast Viewed Cerebrovascular SystemCerebrovascular System ExitExitConcept MapConcept Map



CarotidPerfusionTerritory(Superior 2/3)

A.

Verterbo-BasilarPerfusionTerritory(Inferior 1/3)


Anterior (Anterior (CarotidCarotid) ) system:system:

70% of supply (35% 70% of supply (35% from each internal from each internal carotid artery)carotid artery)

Supplies the Supplies the superior 2/3 of the superior 2/3 of the brainbrain

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Carotid SystemCarotid System 3/6


VertebrobasilarVertebrobasilarSystemSystem

Click to animateClick to animateClick to animateClick to animate

Posterior Posterior ((VertebrobasilarVertebrobasilar) ) system:system:

30% of supply30% of supply Supplies the inferior Supplies the inferior

1/3 of the brain and 1/3 of the brain and brainstembrainstem

4/6


Blood SupplyBlood Supply to the Brain to the Brain

Blood SupplyBlood Supply to the Brain to the Brain

5/6


Blood Supply to the Brain 6/6Blood Supply to the Brain 6/6Blood Supply to the Brain 6/6Blood Supply to the Brain 6/6


Carotid System 1/12Carotid System 1/12Carotid System 1/12Carotid System 1/12

Click to AnimateClick to AnimateClick to AnimateClick to Animate

Anterior cerebral a.

Middle cerebral a.

Anterior communicating a.

Internal carotid a.

Anterior (Anterior (CarotidCarotid) ) system:system:

70% of supply (35% 70% of supply (35% from each internal from each internal carotid artery)carotid artery)

Supplies the superior Supplies the superior 2/3 of the brain2/3 of the brain



Bilateral system, each Bilateral system, each hemisphere has its own carotid hemisphere has its own carotid artery.artery.

Supplies the superior two thirds Supplies the superior two thirds of the brain.of the brain.

Derived from: aorta, common Derived from: aorta, common carotid, internal carotid, carotid carotid, internal carotid, carotid foramen (adjacent to optic foramen (adjacent to optic chiasm)chiasm)

Anterior cerebral arteryAnterior cerebral artery (ACA) (ACA) Middle cerebral arteryMiddle cerebral artery (MCA) (MCA)

Bilateral system, each Bilateral system, each hemisphere has its own carotid hemisphere has its own carotid artery.artery.

Supplies the superior two thirds Supplies the superior two thirds of the brain.of the brain.

Derived from: aorta, common Derived from: aorta, common carotid, internal carotid, carotid carotid, internal carotid, carotid foramen (adjacent to optic foramen (adjacent to optic chiasm)chiasm)

Anterior cerebral arteryAnterior cerebral artery (ACA) (ACA) Middle cerebral arteryMiddle cerebral artery (MCA) (MCA)


Anterior Cerebral Artery 6/12Anterior Cerebral Artery 6/12Anterior Cerebral Artery 6/12Anterior Cerebral Artery 6/12

ADAM


Middle Cerebral Artery 7/12Middle Cerebral Artery 7/12Middle Cerebral Artery 7/12Middle Cerebral Artery 7/12

ADAM


Middle Cerebral Artery 9/12Middle Cerebral Artery 9/12Middle Cerebral Artery 9/12Middle Cerebral Artery 9/12



Perfusion territory by artery


Stroke EffectsStroke EffectsStroke EffectsStroke EffectsS&S of ACA occlusionDistribution

Contralateral legPrecentral gyrus

Paresis/ paralysisPostcentral gyrus

Sensory impairment

S&S of MCA occlusionDistribution

Contralateral face & armPrecentral gyrus

Paresis/ paralysisPostcentral gyrus

Sensory impairment

11/12


Middle Cerebral Artery Occlusion 12/12Middle Cerebral Artery Occlusion 12/12Middle Cerebral Artery Occlusion 12/12Middle Cerebral Artery Occlusion 12/12

Most common strokeMost common stroke L MCAL MCA

Most common effectsMost common effects Right hemiplegia Face & UE > LERight hemiplegia Face & UE > LE

If MCA perfuses lateral aspect of If MCA perfuses lateral aspect of hemisphere, how is the LE hemisphere, how is the LE affected?affected?

Occlusion occurs in the internal Occlusion occurs in the internal capsulecapsule


Vertebrobasilar System 1/11Vertebrobasilar System 1/11Vertebrobasilar System 1/11Vertebrobasilar System 1/11 Supplies the inferior one third of Supplies the inferior one third of

the brain; inferior surface of the the brain; inferior surface of the temporal and occipital lobes and temporal and occipital lobes and brainstem.brainstem.

Derived from: subclavian, Derived from: subclavian, vertebral, foramen magnum, vertebral, foramen magnum, anterior spinal, posterior inferior anterior spinal, posterior inferior cerebellar, basilar, anterior cerebellar, basilar, anterior inferior cerebellar, internal inferior cerebellar, internal auditory, superior cerebellar, auditory, superior cerebellar, posterior cerebral arteryposterior cerebral artery

Supplies the inferior one third of Supplies the inferior one third of the brain; inferior surface of the the brain; inferior surface of the temporal and occipital lobes and temporal and occipital lobes and brainstem.brainstem.

Derived from: subclavian, Derived from: subclavian, vertebral, foramen magnum, vertebral, foramen magnum, anterior spinal, posterior inferior anterior spinal, posterior inferior cerebellar, basilar, anterior cerebellar, basilar, anterior inferior cerebellar, internal inferior cerebellar, internal auditory, superior cerebellar, auditory, superior cerebellar, posterior cerebral arteryposterior cerebral artery

Click to animateClick to animate


Vertebrobasilar System 2/11Vertebrobasilar System 2/11Vertebrobasilar System 2/11Vertebrobasilar System 2/11



ADAMLast ViewedLast Viewed Cerebrovascular SystemCerebrovascular System ExitExitConcept MapConcept Map


ADAM

Vertebral a.

Basilar a.


Posterior Cerebral ArteryPosterior Cerebral Artery 7/11 7/11Posterior Cerebral ArteryPosterior Cerebral Artery 7/11 7/11


Posterior Cerebral Artery 8/11Posterior Cerebral Artery 8/11Posterior Cerebral Artery 8/11Posterior Cerebral Artery 8/11


Posterior Cerebral Artery 9/11Posterior Cerebral Artery 9/11Posterior Cerebral Artery 9/11Posterior Cerebral Artery 9/11


3 Cerebellar Arteries 3 Cerebellar Arteries 10/1110/11

3 Cerebellar Arteries 3 Cerebellar Arteries 10/1110/11

Superior cerebellar a.

Anterior inferior cerebellar a.

Posterior inferior cerebellar a.

Pons

Medulla


Stroke Effects 11/11Stroke Effects 11/11Stroke Effects 11/11Stroke Effects 11/11

S&S of vertebrobasilar occlusion (brainstem stroke)S&S of vertebrobasilar occlusion (brainstem stroke) Impaired life support systems (HR, RR, BP, consciousness)Impaired life support systems (HR, RR, BP, consciousness)

S&S of basilar artery occlusionS&S of basilar artery occlusion Impaired CN functionsImpaired CN functions Impaired long tract functions (motor/ sensory)Impaired long tract functions (motor/ sensory)

S&S of PICA occlusionS&S of PICA occlusion Impaired pain sensation in ipsilateral face and contralateral Impaired pain sensation in ipsilateral face and contralateral

bodybody


Circle of Circle of WillisWillis

Circle of Circle of WillisWillis


Perfusion TerritoriesPerfusion TerritoriesPerfusion TerritoriesPerfusion TerritoriesWatershed Territory

Primary Artery Territory


Venous Drainage 1/2Venous Drainage 1/2Venous Drainage 1/2Venous Drainage 1/2


Venous Drainage 2/2Venous Drainage 2/2Venous Drainage 2/2Venous Drainage 2/2


BloodBloodSupplySupplyto theto the

Spinal Spinal CordCord

BloodBloodSupplySupplyto theto the

Spinal Spinal CordCord

1/2


Spinal Arteries 2/2Spinal Arteries 2/2Spinal Arteries 2/2Spinal Arteries 2/2Anterior Posterior


Patient CasesPatient CasesPatient CasesPatient Cases

Sudden inability to speakSudden inability to speak Left leg weaknessLeft leg weakness Worst headache of lifeWorst headache of life Decreased vision in one eyeDecreased vision in one eye Left neglectLeft neglect Anterior cord syndromeAnterior cord syndrome


MinicaseMinicaseSudden Inability to Speak 1/5Sudden Inability to Speak 1/5

MinicaseMinicaseSudden Inability to Speak 1/5Sudden Inability to Speak 1/5While standing in the check-out line at the store, 55 year-While standing in the check-out line at the store, 55 year-old retired nurse realized she was suddenly unable to old retired nurse realized she was suddenly unable to speak. Consciousness, attention, voluntary movement, speak. Consciousness, attention, voluntary movement, and the ability to understand speech were all unaffected. and the ability to understand speech were all unaffected. Incredulous, but believing she knew what is happening to Incredulous, but believing she knew what is happening to her. She left the store and drove herself directly to the her. She left the store and drove herself directly to the emergency room. In the ER she communicated to emergency room. In the ER she communicated to doctors what she thought was occurring. With difficulty doctors what she thought was occurring. With difficulty she uttered two words: “stroke” and “speech”.she uttered two words: “stroke” and “speech”.

While standing in the check-out line at the store, 55 year-While standing in the check-out line at the store, 55 year-old retired nurse realized she was suddenly unable to old retired nurse realized she was suddenly unable to speak. Consciousness, attention, voluntary movement, speak. Consciousness, attention, voluntary movement, and the ability to understand speech were all unaffected. and the ability to understand speech were all unaffected. Incredulous, but believing she knew what is happening to Incredulous, but believing she knew what is happening to her. She left the store and drove herself directly to the her. She left the store and drove herself directly to the emergency room. In the ER she communicated to emergency room. In the ER she communicated to doctors what she thought was occurring. With difficulty doctors what she thought was occurring. With difficulty she uttered two words: “stroke” and “speech”.she uttered two words: “stroke” and “speech”.

Last ViewedLast Viewed Patient CasesPatient Cases ExitExitConcept MapConcept Map

MinicaseMinicase Sudden Inability to Speak 2/5Sudden Inability to Speak 2/5

MinicaseMinicase Sudden Inability to Speak 2/5Sudden Inability to Speak 2/5 Her past medical history was notable for overweight, Her past medical history was notable for overweight,

hypertension and type II diabetes. hypertension and type II diabetes. Examination revealed loss of the nasal-labial fold on Examination revealed loss of the nasal-labial fold on

the left and weakness in the left cheek and jaw. the left and weakness in the left cheek and jaw. Her jaw-jerk reflex was hyperactive. Her jaw-jerk reflex was hyperactive. All other movement, sensation, and reflexes were All other movement, sensation, and reflexes were

within normal limits. within normal limits.

Where is the lesion causing these symptoms?Where is the lesion causing these symptoms?

Her past medical history was notable for overweight, Her past medical history was notable for overweight, hypertension and type II diabetes. hypertension and type II diabetes.

Examination revealed loss of the nasal-labial fold on Examination revealed loss of the nasal-labial fold on the left and weakness in the left cheek and jaw. the left and weakness in the left cheek and jaw.

Her jaw-jerk reflex was hyperactive. Her jaw-jerk reflex was hyperactive. All other movement, sensation, and reflexes were All other movement, sensation, and reflexes were

within normal limits. within normal limits.



Minicase Follow-UpMinicase Follow-Up Sudden Inability to Speak 3/5Sudden Inability to Speak 3/5

Minicase Follow-UpMinicase Follow-Up Sudden Inability to Speak 3/5Sudden Inability to Speak 3/5 As confirmed by CT image, this woman was having a As confirmed by CT image, this woman was having a

stroke. stroke.

The occlusion involved a deep penetrating branch of The occlusion involved a deep penetrating branch of the the middle cerebral arterymiddle cerebral artery supplying the inferior frontal supplying the inferior frontal gyrus on the gyrus on the leftleft causing weakness in the lower part of causing weakness in the lower part of the right face and tongue and Broca’s aphasia. the right face and tongue and Broca’s aphasia.

As confirmed by CT image, this woman was having a As confirmed by CT image, this woman was having a stroke. stroke.

The occlusion involved a deep penetrating branch of The occlusion involved a deep penetrating branch of the the middle cerebral arterymiddle cerebral artery supplying the inferior frontal supplying the inferior frontal gyrus on the gyrus on the leftleft causing weakness in the lower part of causing weakness in the lower part of the right face and tongue and Broca’s aphasia. the right face and tongue and Broca’s aphasia.


Productive (Broca’s) Aphasia 4/5Productive (Broca’s) Aphasia 4/5Productive (Broca’s) Aphasia 4/5Productive (Broca’s) Aphasia 4/5

Produced by a lesion of Produced by a lesion of the inferior frontal gyrus the inferior frontal gyrus of the dominant of the dominant hemisphere.hemisphere.

Play recordingPlay recording




The key signs and symptoms in this case are:The key signs and symptoms in this case are: Suddenly unable to speakSuddenly unable to speak Consciousness, attention, voluntary movement, and Consciousness, attention, voluntary movement, and

the ability to understand speech were all unaffectedthe ability to understand speech were all unaffected Loss of the nasal-labial fold on the left and weakness in Loss of the nasal-labial fold on the left and weakness in

the left cheek and jawthe left cheek and jaw Her jaw-jerk reflex was hyperactiveHer jaw-jerk reflex was hyperactive

The key signs and symptoms in this case are:The key signs and symptoms in this case are: Suddenly unable to speakSuddenly unable to speak Consciousness, attention, voluntary movement, and Consciousness, attention, voluntary movement, and

the ability to understand speech were all unaffectedthe ability to understand speech were all unaffected Loss of the nasal-labial fold on the left and weakness in Loss of the nasal-labial fold on the left and weakness in

the left cheek and jawthe left cheek and jaw Her jaw-jerk reflex was hyperactiveHer jaw-jerk reflex was hyperactive


MinicaseMinicaseLeft Leg Weakness 1/5Left Leg Weakness 1/5


On attempting to stand after finishing breakfast, a On attempting to stand after finishing breakfast, a 67-year-old woman fell to the ground, hitting the 67-year-old woman fell to the ground, hitting the table on the way down, because she was unable table on the way down, because she was unable to support her body weight on her left leg. She to support her body weight on her left leg. She called for help from her husband who was unable called for help from her husband who was unable to get her off the floor and called for emergency to get her off the floor and called for emergency assistance. assistance.

On attempting to stand after finishing breakfast, a On attempting to stand after finishing breakfast, a 67-year-old woman fell to the ground, hitting the 67-year-old woman fell to the ground, hitting the table on the way down, because she was unable table on the way down, because she was unable to support her body weight on her left leg. She to support her body weight on her left leg. She called for help from her husband who was unable called for help from her husband who was unable to get her off the floor and called for emergency to get her off the floor and called for emergency assistance. assistance.




Her past history was positive for obesity, hypertension, Her past history was positive for obesity, hypertension, peripheral vascular disease, and smoking one pack per day for peripheral vascular disease, and smoking one pack per day for 52 years. 52 years.

She had hyperactive deep tendon reflexes in her left knee and She had hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot. ankle, and a positive Babinski sign in her left foot.

The left leg was flaccid and she had no voluntary control of The left leg was flaccid and she had no voluntary control of movement. movement.

She had mild impairment of light touch, pain, and temperature She had mild impairment of light touch, pain, and temperature sensation in her left leg. sensation in her left leg.

Voluntary movement, reflexes, and sensation were intact in all Voluntary movement, reflexes, and sensation were intact in all other regions of the body. other regions of the body.


Her past history was positive for obesity, hypertension, Her past history was positive for obesity, hypertension, peripheral vascular disease, and smoking one pack per day for peripheral vascular disease, and smoking one pack per day for 52 years. 52 years.

She had hyperactive deep tendon reflexes in her left knee and She had hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot. ankle, and a positive Babinski sign in her left foot.

The left leg was flaccid and she had no voluntary control of The left leg was flaccid and she had no voluntary control of movement. movement.

She had mild impairment of light touch, pain, and temperature She had mild impairment of light touch, pain, and temperature sensation in her left leg. sensation in her left leg.

Voluntary movement, reflexes, and sensation were intact in all Voluntary movement, reflexes, and sensation were intact in all other regions of the body. other regions of the body.



Minicase Follow-UpMinicase Follow-Up Left Leg Weakness 3/5Left Leg Weakness 3/5

Minicase Follow-UpMinicase Follow-Up Left Leg Weakness 3/5Left Leg Weakness 3/5 A head CT scan was done and the results A head CT scan was done and the results

suggested a probable rightsuggested a probable right anterior cerebral anterior cerebral artery infarct. artery infarct.

Follow-up hear CT scan one month later Follow-up hear CT scan one month later confirmed the presence of a hypodense area on confirmed the presence of a hypodense area on the anterior medial aspect of the right the anterior medial aspect of the right hemisphere consistent with a hemisphere consistent with a right anterior right anterior cerebral arterycerebral artery infarct infarct

A head CT scan was done and the results A head CT scan was done and the results suggested a probable rightsuggested a probable right anterior cerebral anterior cerebral artery infarct. artery infarct.

Follow-up hear CT scan one month later Follow-up hear CT scan one month later confirmed the presence of a hypodense area on confirmed the presence of a hypodense area on the anterior medial aspect of the right the anterior medial aspect of the right hemisphere consistent with a hemisphere consistent with a right anterior right anterior cerebral arterycerebral artery infarct infarct



Minicase Follow-UpMinicase Follow-Up Left Leg Weakness 5/5Left Leg Weakness 5/5The key signs and symptoms in this case are:The key signs and symptoms in this case are: Unable to support her body weight on her left legUnable to support her body weight on her left leg Hyperactive deep tendon reflexes in her left knee and ankle, and Hyperactive deep tendon reflexes in her left knee and ankle, and

a positive Babinski sign in her left foota positive Babinski sign in her left foot The left leg was flaccid and she had no voluntary control of The left leg was flaccid and she had no voluntary control of

movementmovement She had mild impairment of light touch, pain, and temperature She had mild impairment of light touch, pain, and temperature

sensation in her left legsensation in her left leg Voluntary movement, reflexes, and sensation were intact in all Voluntary movement, reflexes, and sensation were intact in all

other regions of the bodyother regions of the body

The key signs and symptoms in this case are:The key signs and symptoms in this case are: Unable to support her body weight on her left legUnable to support her body weight on her left leg Hyperactive deep tendon reflexes in her left knee and ankle, and Hyperactive deep tendon reflexes in her left knee and ankle, and

a positive Babinski sign in her left foota positive Babinski sign in her left foot The left leg was flaccid and she had no voluntary control of The left leg was flaccid and she had no voluntary control of

movementmovement She had mild impairment of light touch, pain, and temperature She had mild impairment of light touch, pain, and temperature

sensation in her left legsensation in her left leg Voluntary movement, reflexes, and sensation were intact in all Voluntary movement, reflexes, and sensation were intact in all

other regions of the bodyother regions of the body


MinicaseMinicaseSudden-onset Worst Headache of Life 1/7Sudden-onset Worst Headache of Life 1/7


A 68-year-old man suddenly developed “the worst of A 68-year-old man suddenly developed “the worst of my life.” On the morning of admission he was sitting my life.” On the morning of admission he was sitting watching TV when at 9:00 am he suddenly developed watching TV when at 9:00 am he suddenly developed an explosive headache worse than anything he had an explosive headache worse than anything he had ever experienced. The headache began in the bifrontal ever experienced. The headache began in the bifrontal area and over the next few minutes all over the head area and over the next few minutes all over the head and down the neck. He denied loss of consciousness, and down the neck. He denied loss of consciousness, nausea, vomiting or vision changes. nausea, vomiting or vision changes.

A 68-year-old man suddenly developed “the worst of A 68-year-old man suddenly developed “the worst of my life.” On the morning of admission he was sitting my life.” On the morning of admission he was sitting watching TV when at 9:00 am he suddenly developed watching TV when at 9:00 am he suddenly developed an explosive headache worse than anything he had an explosive headache worse than anything he had ever experienced. The headache began in the bifrontal ever experienced. The headache began in the bifrontal area and over the next few minutes all over the head area and over the next few minutes all over the head and down the neck. He denied loss of consciousness, and down the neck. He denied loss of consciousness, nausea, vomiting or vision changes. nausea, vomiting or vision changes.




History was positive for severe diffuse History was positive for severe diffuse atherosclerosis, including coronary disease and atherosclerosis, including coronary disease and peripheral vascular disease requiring multiple peripheral vascular disease requiring multiple bypass surgeries. bypass surgeries.

He was obese and smoked two packs a day for He was obese and smoked two packs a day for 43 years. 43 years.

Examination was unremarkable except for mild Examination was unremarkable except for mild nuchal rigidity. nuchal rigidity.

History was positive for severe diffuse History was positive for severe diffuse atherosclerosis, including coronary disease and atherosclerosis, including coronary disease and peripheral vascular disease requiring multiple peripheral vascular disease requiring multiple bypass surgeries. bypass surgeries.

He was obese and smoked two packs a day for He was obese and smoked two packs a day for 43 years. 43 years.

Examination was unremarkable except for mild Examination was unremarkable except for mild nuchal rigidity. nuchal rigidity.


Minicase Follow-UpMinicase Follow-UpSudden-onset Worst Headache of Life 3/7Sudden-onset Worst Headache of Life 3/7


Nuchal rigidity is often a sign of meningeal Nuchal rigidity is often a sign of meningeal irritation caused by inflammation, infection, or irritation caused by inflammation, infection, or hemorrhage in the subarachnoid space.hemorrhage in the subarachnoid space.

Nuchal rigidity is often a sign of meningeal Nuchal rigidity is often a sign of meningeal irritation caused by inflammation, infection, or irritation caused by inflammation, infection, or hemorrhage in the subarachnoid space.hemorrhage in the subarachnoid space.




The man underwent emergency head CT which The man underwent emergency head CT which demonstrated regions of hyperdensity in the demonstrated regions of hyperdensity in the subarachnoid space consistent with subarachnoid subarachnoid space consistent with subarachnoid hemorrhage layering in the medial longitudinal hemorrhage layering in the medial longitudinal fissure, lateral fissure, and around the brainstem. fissure, lateral fissure, and around the brainstem.

Next he was taken for an angiogram which clearly Next he was taken for an angiogram which clearly revealed an revealed an aneurysmaneurysm arising from the region of the arising from the region of the anterior communicating arteryanterior communicating artery. .

The man underwent emergency head CT which The man underwent emergency head CT which demonstrated regions of hyperdensity in the demonstrated regions of hyperdensity in the subarachnoid space consistent with subarachnoid subarachnoid space consistent with subarachnoid hemorrhage layering in the medial longitudinal hemorrhage layering in the medial longitudinal fissure, lateral fissure, and around the brainstem. fissure, lateral fissure, and around the brainstem.

Next he was taken for an angiogram which clearly Next he was taken for an angiogram which clearly revealed an revealed an aneurysmaneurysm arising from the region of the arising from the region of the anterior communicating arteryanterior communicating artery. .


The circle of Willis has been dissected, and three berry aneurysms are seen. Multiple aneurysms are seen in about 20-30% of cases of berry aneurysm. Such aneurysms are "congenital" in the sense that the defect in the arterial wall is present from birth, but the actual aneurysm takes years to develop, so that rupture is most likely to occur in young to middle age adults.

Berry Aneurysm Berry Aneurysm 5/75/7


The white arrow on the black card marks the site of a ruptured berry aneurysm in the circle of Willis. This is a major cause for subarachnoid hemorrhage.

Berry Aneurysm Berry Aneurysm 6/76/7




The key signs and symptoms in this case are:The key signs and symptoms in this case are: Suddenly developed “the worst of my life”Suddenly developed “the worst of my life” Headache began in the bifrontal area and over the next Headache began in the bifrontal area and over the next

few minutes was all over the head and down the neckfew minutes was all over the head and down the neck Examination was unremarkable except for mild nuchal Examination was unremarkable except for mild nuchal

rigidityrigidity

The key signs and symptoms in this case are:The key signs and symptoms in this case are: Suddenly developed “the worst of my life”Suddenly developed “the worst of my life” Headache began in the bifrontal area and over the next Headache began in the bifrontal area and over the next

few minutes was all over the head and down the neckfew minutes was all over the head and down the neck Examination was unremarkable except for mild nuchal Examination was unremarkable except for mild nuchal

rigidityrigidity


MinicaseMinicase Decreased Vision in One Eye 1/8Decreased Vision in One Eye 1/8

MinicaseMinicase Decreased Vision in One Eye 1/8Decreased Vision in One Eye 1/8 A 63-year-old woman went to an A 63-year-old woman went to an

ophthalmologist complaining of episodes of ophthalmologist complaining of episodes of decreased vision in her “right eye” over the decreased vision in her “right eye” over the past several weeks. past several weeks.

A 63-year-old woman went to an A 63-year-old woman went to an ophthalmologist complaining of episodes of ophthalmologist complaining of episodes of decreased vision in her “right eye” over the decreased vision in her “right eye” over the past several weeks. past several weeks.



MinicaseMinicase Decreased Vision in One Eye 2/8Decreased Vision in One Eye 2/8 Her medical history was notable for type II diabetes, Her medical history was notable for type II diabetes,

hypercholesterolemia, and coronary artery disease.hypercholesterolemia, and coronary artery disease. About 5-6 weeks ago the patient began having About 5-6 weeks ago the patient began having

“episodes of sudden blurry wavy” appearance of her “episodes of sudden blurry wavy” appearance of her vision. vision.

She believed this was mostly in the right eye but never She believed this was mostly in the right eye but never tried looking with only one eye at a time. tried looking with only one eye at a time.

Her medical history was notable for type II diabetes, Her medical history was notable for type II diabetes, hypercholesterolemia, and coronary artery disease.hypercholesterolemia, and coronary artery disease.

About 5-6 weeks ago the patient began having About 5-6 weeks ago the patient began having “episodes of sudden blurry wavy” appearance of her “episodes of sudden blurry wavy” appearance of her vision. vision.

She believed this was mostly in the right eye but never She believed this was mostly in the right eye but never tried looking with only one eye at a time. tried looking with only one eye at a time.



MinicaseMinicase Decreased Vision in One Eye 3/8Decreased Vision in One Eye 3/8 Episodes would last for 15-20 minutes, resolved with Episodes would last for 15-20 minutes, resolved with

no visual impairment, repeated 3-4 times per week, and no visual impairment, repeated 3-4 times per week, and were never accompanied by pain. were never accompanied by pain.

Previously she was able to recognize faces during the Previously she was able to recognize faces during the episodes but was unable to read. episodes but was unable to read.

The current episode, that began two days ago, has The current episode, that began two days ago, has resulted in persistent decreased vision on the right.resulted in persistent decreased vision on the right.

Episodes would last for 15-20 minutes, resolved with Episodes would last for 15-20 minutes, resolved with no visual impairment, repeated 3-4 times per week, and no visual impairment, repeated 3-4 times per week, and were never accompanied by pain. were never accompanied by pain.

Previously she was able to recognize faces during the Previously she was able to recognize faces during the episodes but was unable to read. episodes but was unable to read.

The current episode, that began two days ago, has The current episode, that began two days ago, has resulted in persistent decreased vision on the right.resulted in persistent decreased vision on the right.




Neurologic examination revealed fluent speech. Neurologic examination revealed fluent speech. Pupils 3 mm, constricting to 2 mm bilaterally. Pupils 3 mm, constricting to 2 mm bilaterally. Normal fundi. Visual acuity 20/30 right and 20/25 left. Normal fundi. Visual acuity 20/30 right and 20/25 left. Visual field testing revealed a right homonymous hemianopia. Visual field testing revealed a right homonymous hemianopia. Extraocular movements intact. Extraocular movements intact. Facial sensation intact to light touch and pinprick. Facial sensation intact to light touch and pinprick. Face symmetrical. Normal palate elevation. Face symmetrical. Normal palate elevation. Normal shoulder shrug. Tongue midline. Normal shoulder shrug. Tongue midline.


Neurologic examination revealed fluent speech. Neurologic examination revealed fluent speech. Pupils 3 mm, constricting to 2 mm bilaterally. Pupils 3 mm, constricting to 2 mm bilaterally. Normal fundi. Visual acuity 20/30 right and 20/25 left. Normal fundi. Visual acuity 20/30 right and 20/25 left. Visual field testing revealed a right homonymous hemianopia. Visual field testing revealed a right homonymous hemianopia. Extraocular movements intact. Extraocular movements intact. Facial sensation intact to light touch and pinprick. Facial sensation intact to light touch and pinprick. Face symmetrical. Normal palate elevation. Face symmetrical. Normal palate elevation. Normal shoulder shrug. Tongue midline. Normal shoulder shrug. Tongue midline.



MinicaseMinicase Follow-UpFollow-UpDecreased Vision in One Eye 5/8Decreased Vision in One Eye 5/8

MinicaseMinicase Follow-UpFollow-UpDecreased Vision in One Eye 5/8Decreased Vision in One Eye 5/8 The transient episodes of 15-20 minutes of decreased The transient episodes of 15-20 minutes of decreased

right-sided vision occurring over several weeks, right-sided vision occurring over several weeks, followed by a sudden-onset persistent deficit is followed by a sudden-onset persistent deficit is suggestive of TIAs preceding a cerebral infarct. suggestive of TIAs preceding a cerebral infarct.

A right homonymous hemianopia can be caused by a A right homonymous hemianopia can be caused by a lesion in the left hemisphere visual pathway anywhere lesion in the left hemisphere visual pathway anywhere from the left optic tract to the primary visual cortex. from the left optic tract to the primary visual cortex.

The patient’s age and past medical history raise the The patient’s age and past medical history raise the suspicion of cerebrovascular disease of the cause. suspicion of cerebrovascular disease of the cause.

The transient episodes of 15-20 minutes of decreased The transient episodes of 15-20 minutes of decreased right-sided vision occurring over several weeks, right-sided vision occurring over several weeks, followed by a sudden-onset persistent deficit is followed by a sudden-onset persistent deficit is suggestive of TIAs preceding a cerebral infarct. suggestive of TIAs preceding a cerebral infarct.

A right homonymous hemianopia can be caused by a A right homonymous hemianopia can be caused by a lesion in the left hemisphere visual pathway anywhere lesion in the left hemisphere visual pathway anywhere from the left optic tract to the primary visual cortex. from the left optic tract to the primary visual cortex.

The patient’s age and past medical history raise the The patient’s age and past medical history raise the suspicion of cerebrovascular disease of the cause. suspicion of cerebrovascular disease of the cause.



MinicaseMinicase Follow-UpFollow-UpDecreased Vision in One Eye 6/8Decreased Vision in One Eye 6/8 The patient was sent to the hospital where an initial CT scan The patient was sent to the hospital where an initial CT scan

suggested a suggested a left posterior cerebral arteryleft posterior cerebral artery infarct, and a follow-up infarct, and a follow-up MRI confirmed the presence of a left PCS infarct involving the MRI confirmed the presence of a left PCS infarct involving the left primary visual cortex. left primary visual cortex.

An magnetic resonance angiogram (MRA) revealed several An magnetic resonance angiogram (MRA) revealed several stenoses of the cerebral vessels compatible with diffuse stenoses of the cerebral vessels compatible with diffuse intracranial atherosclerotic disease. intracranial atherosclerotic disease.

She was treated with long-term oral anticoagulation. She was treated with long-term oral anticoagulation. Her right hemianopia did not improve, but over time she learned Her right hemianopia did not improve, but over time she learned

to adapt to her visual deficit. to adapt to her visual deficit.

The patient was sent to the hospital where an initial CT scan The patient was sent to the hospital where an initial CT scan suggested a suggested a left posterior cerebral arteryleft posterior cerebral artery infarct, and a follow-up infarct, and a follow-up MRI confirmed the presence of a left PCS infarct involving the MRI confirmed the presence of a left PCS infarct involving the left primary visual cortex. left primary visual cortex.

An magnetic resonance angiogram (MRA) revealed several An magnetic resonance angiogram (MRA) revealed several stenoses of the cerebral vessels compatible with diffuse stenoses of the cerebral vessels compatible with diffuse intracranial atherosclerotic disease. intracranial atherosclerotic disease.

She was treated with long-term oral anticoagulation. She was treated with long-term oral anticoagulation. Her right hemianopia did not improve, but over time she learned Her right hemianopia did not improve, but over time she learned

to adapt to her visual deficit. to adapt to her visual deficit.




MRI axial T2 weighted image of left posterior cerebral artery (PCA) infarction




The key signs and symptoms in this case are:The key signs and symptoms in this case are: Episodes of sudden “blurry/ wavy” appearance of her Episodes of sudden “blurry/ wavy” appearance of her

vision in her “right eye” over the past several weeksvision in her “right eye” over the past several weeks Right homonymous hemianopiaRight homonymous hemianopia

The key signs and symptoms in this case are:The key signs and symptoms in this case are: Episodes of sudden “blurry/ wavy” appearance of her Episodes of sudden “blurry/ wavy” appearance of her

vision in her “right eye” over the past several weeksvision in her “right eye” over the past several weeks Right homonymous hemianopiaRight homonymous hemianopia


MinicaseMinicase Left Neglect 1/5Left Neglect 1/5


A 61-year-old right-handed man was witnessed A 61-year-old right-handed man was witnessed slumping to the floor in the grocery store. slumping to the floor in the grocery store.

A 61-year-old right-handed man was witnessed A 61-year-old right-handed man was witnessed slumping to the floor in the grocery store. slumping to the floor in the grocery store.




On examination in the hospital he denied anything was wrong On examination in the hospital he denied anything was wrong but said, “They called an ambulance because they said I had a but said, “They called an ambulance because they said I had a stroke.” stroke.”

He was unaware of having any impairment and wanted to go He was unaware of having any impairment and wanted to go home. home.

He had profound left visual field neglect , no blink to threat on He had profound left visual field neglect , no blink to threat on the left, and no voluntary gaze to the left past midline. the left, and no voluntary gaze to the left past midline.

When trying to right, he moved the pen in the air off to the right When trying to right, he moved the pen in the air off to the right of the page. of the page.

When shown his left hand and asked what it was, he replied When shown his left hand and asked what it was, he replied “Someone’s hand.”“Someone’s hand.”

On examination in the hospital he denied anything was wrong On examination in the hospital he denied anything was wrong but said, “They called an ambulance because they said I had a but said, “They called an ambulance because they said I had a stroke.” stroke.”

He was unaware of having any impairment and wanted to go He was unaware of having any impairment and wanted to go home. home.

He had profound left visual field neglect , no blink to threat on He had profound left visual field neglect , no blink to threat on the left, and no voluntary gaze to the left past midline. the left, and no voluntary gaze to the left past midline.

When trying to right, he moved the pen in the air off to the right When trying to right, he moved the pen in the air off to the right of the page. of the page.

When shown his left hand and asked what it was, he replied When shown his left hand and asked what it was, he replied “Someone’s hand.”“Someone’s hand.”




When asked who’s hand it was he replied, “The When asked who’s hand it was he replied, “The doctor’s.” doctor’s.”

He had a marked right gaze preference. He had a marked right gaze preference. He had marked weakness in the lower portion of the He had marked weakness in the lower portion of the

left face. left face. Strength was 0/5 in the left arm and leg, the left plantar Strength was 0/5 in the left arm and leg, the left plantar

response was upgoing, and there was no response to response was upgoing, and there was no response to pinprick on the left side.pinprick on the left side.

What lesion is causing this man’s symptoms? What lesion is causing this man’s symptoms?

When asked who’s hand it was he replied, “The When asked who’s hand it was he replied, “The doctor’s.” doctor’s.”

He had a marked right gaze preference. He had a marked right gaze preference. He had marked weakness in the lower portion of the He had marked weakness in the lower portion of the

left face. left face. Strength was 0/5 in the left arm and leg, the left plantar Strength was 0/5 in the left arm and leg, the left plantar

response was upgoing, and there was no response to response was upgoing, and there was no response to pinprick on the left side.pinprick on the left side.

What lesion is causing this man’s symptoms? What lesion is causing this man’s symptoms?


MinicaseMinicase Follow-UpFollow-UpLeft Neglect 4/5Left Neglect 4/5

MinicaseMinicase Follow-UpFollow-UpLeft Neglect 4/5Left Neglect 4/5 The patient exhibits several forms of neglect. The patient exhibits several forms of neglect. In addition to anosognosia, he has left sensory neglect, to In addition to anosognosia, he has left sensory neglect, to

visual and tactile stimuli, as well as left motor neglect. visual and tactile stimuli, as well as left motor neglect. These signs and symptoms are most commonly seen in These signs and symptoms are most commonly seen in

patients with nondominant (usually right) parietal lobe lesions. patients with nondominant (usually right) parietal lobe lesions.

Given the sudden onset of the deficits, involvement of the left Given the sudden onset of the deficits, involvement of the left arm and leg, the presence of sensory and motor deficits, and arm and leg, the presence of sensory and motor deficits, and the patient’s age, the most likely cause is ischemic infarction the patient’s age, the most likely cause is ischemic infarction of the of the right internal carotidright internal carotid arteryartery. .

The patient exhibits several forms of neglect. The patient exhibits several forms of neglect. In addition to anosognosia, he has left sensory neglect, to In addition to anosognosia, he has left sensory neglect, to

visual and tactile stimuli, as well as left motor neglect. visual and tactile stimuli, as well as left motor neglect. These signs and symptoms are most commonly seen in These signs and symptoms are most commonly seen in

patients with nondominant (usually right) parietal lobe lesions. patients with nondominant (usually right) parietal lobe lesions.

Given the sudden onset of the deficits, involvement of the left Given the sudden onset of the deficits, involvement of the left arm and leg, the presence of sensory and motor deficits, and arm and leg, the presence of sensory and motor deficits, and the patient’s age, the most likely cause is ischemic infarction the patient’s age, the most likely cause is ischemic infarction of the of the right internal carotidright internal carotid arteryartery. .




The key signs and symptoms in this case are:The key signs and symptoms in this case are: AnosognosiaAnosognosia Left face, arm and leg plegia with positive Babinski’s Left face, arm and leg plegia with positive Babinski’s

signsign No blink to threat on the leftNo blink to threat on the left No voluntary gaze to the left past midlineNo voluntary gaze to the left past midline No response to pinprick on the leftNo response to pinprick on the left

The key signs and symptoms in this case are:The key signs and symptoms in this case are: AnosognosiaAnosognosia Left face, arm and leg plegia with positive Babinski’s Left face, arm and leg plegia with positive Babinski’s

signsign No blink to threat on the leftNo blink to threat on the left No voluntary gaze to the left past midlineNo voluntary gaze to the left past midline No response to pinprick on the leftNo response to pinprick on the left


Occlusion of the anterior spinal artery (anterior cord Occlusion of the anterior spinal artery (anterior cord syndrome) in the cervical region would produce syndrome) in the cervical region would produce what impairments?what impairments?

Occlusion of the anterior spinal artery (anterior cord Occlusion of the anterior spinal artery (anterior cord syndrome) in the cervical region would produce syndrome) in the cervical region would produce what impairments?what impairments?

Click for answer

The anterior spinal artery perfuses the anterior 2/3 of the spinal cord including the ventral horns as well as all tracts in the lateral and anterior columns, bilaterally. Damage to the lateral corticospinal tracts cause upper motor neuron signs, bilaterally, below the lesion level. Damage to lower motor neurons in the ventral horns cause lower motor neuron signs, bilaterally, at the lesion level. Damage to the lateral spinothalamic tracts cause absence of pain and temperature sensation, bilaterally, below the lesion level. Sparing of the dorsal columns leaves light touch, vibration, and position sense intact throughout.

Click for explanation

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UMN

DRG

UMN

DRG

R L

Anterior cord lesion

Lateral corticospinal tract lesionIpsilateral upper motor neurons signs

Contralateral loss of pain and temperature sense

Lateral spinothalamic tract lesion

Anterior Cord Syndrome

Common causes include anterior spinal artery infarct, trauma, and MS.

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