2. CerebrovascularSystem Patient Cases Perfusion Territories Perfusion Territories Venous Drainage Venous Drainage Vertebrobasilar System Cardiovascular Disease Cardiovascular Disease Map of Essential Concepts Circle Of Willis Of Willis Blood Supply Blood Supply To Brain To Brain Carotid System Carotid System Blood Supply to Blood Supply to Spinal Cord Spinal Cord Oxygen Demands Oxygen Demands And Metabolism And Metabolism DM McKeough © 2008

3. The 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 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 Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

4. Oxygen Demands 1/2 The CNS (brain and spinal cord) is the best protected organ in the human body including mechanisms to protect its blood supply. The CNS (brain and spinal cord) is the best protected organ in the human body including mechanisms to protect its blood supply. At approximately 3 pounds, the brain accounts for about 2% of body mass. At approximately 3 pounds, the brain accounts for about 2% of body mass. Consumes 17% of cardiac output. Consumes 17% of cardiac output. Responsible for 20% of oxygen consumption at rest. Responsible for 20% of oxygen consumption at rest. The CNS (brain and spinal cord) is the best protected organ in the human body including mechanisms to protect its blood supply. The CNS (brain and spinal cord) is the best protected organ in the human body including mechanisms to protect its blood supply. At approximately 3 pounds, the brain accounts for about 2% of body mass. At approximately 3 pounds, the brain accounts for about 2% of body mass. Consumes 17% of cardiac output. Consumes 17% of cardiac output. Responsible for 20% of oxygen consumption at rest. Responsible for 20% of oxygen consumption at rest. Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

5. Metabolism 2/2 Brain’s sole source of energy is aerobic or oxidative metabolism. Brain’s sole source of energy is aerobic or oxidative metabolism. Therefore, the brain requires a constant supply of O 2 and glucose, 24 hours a day. Therefore, the brain requires a constant supply of O 2 and glucose, 24 hours a day. Brain’s sole source of energy is aerobic or oxidative metabolism. Brain’s sole source of energy is aerobic or oxidative metabolism. Therefore, the brain requires a constant supply of O 2 and glucose, 24 hours a day. Therefore, the brain requires a constant supply of O 2 and glucose, 24 hours a day. Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

6. Cerebrovascular Disease While the blood supply to the brain is highly protected, cerebrovascular disease is the third leading cause of death in American adults and the number one cause of chronic functional disability requiring rehabilitative intervention. While the blood supply to the brain is highly protected, cerebrovascular disease is the third leading cause of death in American adults and the number one cause of chronic functional disability requiring rehabilitative intervention. Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

7. Blood Supply to the Brain 1/6 Approximately 1,000 ml/min delivered via two systems. Approximately 1,000 ml/min delivered via two systems. Anterior ( Carotid ) system: Anterior ( Carotid ) system: 70% of supply (35% from each internal carotid artery) 70% of supply (35% from each internal carotid artery) Supplies the superior 2/3 of the brain Supplies the superior 2/3 of the brain Posterior ( Vertebrobasilar ) system: Posterior ( Vertebrobasilar ) system: 30% of supply 30% of supply Supplies the inferior 1/3 of the brain and brainstem Supplies the inferior 1/3 of the brain and brainstem Approximately 1,000 ml/min delivered via two systems. Approximately 1,000 ml/min delivered via two systems. Anterior ( Carotid ) system: Anterior ( Carotid ) system: 70% of supply (35% from each internal carotid artery) 70% of supply (35% from each internal carotid artery) Supplies the superior 2/3 of the brain Supplies the superior 2/3 of the brain Posterior ( Vertebrobasilar ) system: Posterior ( Vertebrobasilar ) system: 30% of supply 30% of supply Supplies the inferior 1/3 of the brain and brainstem Supplies the inferior 1/3 of the brain and brainstem Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

8. Blood Supply to the Brain 2/6 Carotid Perfusion Territory (Superior 2/3) A.A. Verterbo- Basilar Perfusion Territory (Inferior 1/3) Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

9. Anterior ( Carotid ) system: Anterior ( Carotid ) system: 70% of supply (35% from each internal carotid artery) 70% of supply (35% from each internal carotid artery) Supplies the superior 2/3 of the brain Supplies the superior 2/3 of the brain Anterior ( Carotid ) system: Anterior ( Carotid ) system: 70% of supply (35% from each internal carotid artery) 70% of supply (35% from each internal carotid artery) Supplies the superior 2/3 of the brain Supplies the superior 2/3 of the brain Click to animate Carotid System 3/6 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

10. VertebrobasilarSystem Click to animate Posterior ( Vertebrobasilar ) system: Posterior ( Vertebrobasilar ) system: 30% of supply 30% of supply Supplies the inferior 1/3 of the brain and brainstem Supplies the inferior 1/3 of the brain and brainstem Posterior ( Vertebrobasilar ) system: Posterior ( Vertebrobasilar ) system: 30% of supply 30% of supply Supplies the inferior 1/3 of the brain and brainstem Supplies the inferior 1/3 of the brain and brainstem 4/6 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

11. Blood Supply to the Brain 5/6 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

12. Blood Supply to the Brain 6/6 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

13. Carotid System 1/12 Click to Animate Anterior cerebral a. Middle cerebral a. Anterior communicating a. Internal carotid a. Anterior ( Carotid ) system: Anterior ( Carotid ) system: 70% of supply (35% from each internal carotid artery) 70% of supply (35% from each internal carotid artery) Supplies the superior 2/3 of the brain Supplies the superior 2/3 of the brain Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

14. Carotid System 2/12 Bilateral system, each hemisphere has its own carotid artery. Bilateral system, each hemisphere has its own carotid artery. Supplies the superior two thirds of the brain. Supplies the superior two thirds of the brain. Derived from: aorta, common carotid, internal carotid, carotid foramen (adjacent to optic chiasm) Derived from: aorta, common carotid, internal carotid, carotid foramen (adjacent to optic chiasm) Anterior cerebral artery (ACA) Anterior cerebral artery (ACA) Middle cerebral artery (MCA) Middle cerebral artery (MCA) Bilateral system, each hemisphere has its own carotid artery. Bilateral system, each hemisphere has its own carotid artery. Supplies the superior two thirds of the brain. Supplies the superior two thirds of the brain. Derived from: aorta, common carotid, internal carotid, carotid foramen (adjacent to optic chiasm) Derived from: aorta, common carotid, internal carotid, carotid foramen (adjacent to optic chiasm) Anterior cerebral artery (ACA) Anterior cerebral artery (ACA) Middle cerebral artery (MCA) Middle cerebral artery (MCA) Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

15. Carotid System 3/12 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

16. Carotid System 4/12 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

17. Carotid System 5/12 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

18. Anterior Cerebral Artery 6/12 ADAM Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

19. Middle Cerebral Artery 7/12 ADAM Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

20. Carotid System 8/12 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

21. Middle Cerebral Artery 9/12 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

22. Carotid System 10/12 Perfusion territory by artery Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

23. Stroke Effects S&S of ACA occlusion Distribution Contralateral leg Precentral gyrus Paresis/ paralysis Postcentral gyrus Sensory impairment S&S of MCA occlusion Distribution Contralateral face & arm Precentral gyrus Paresis/ paralysis Postcentral gyrus Sensory impairment 11/12 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

24. Middle Cerebral Artery Occlusion 12/12 Most common stroke Most common stroke L MCA L MCA Most common effects Most common effects Right hemiplegia Face & UE > LE Right hemiplegia Face & UE > LE If MCA perfuses lateral aspect of hemisphere, how is the LE affected? If MCA perfuses lateral aspect of hemisphere, how is the LE affected? Occlusion occurs in the internal capsule Occlusion occurs in the internal capsule Most common stroke Most common stroke L MCA L MCA Most common effects Most common effects Right hemiplegia Face & UE > LE Right hemiplegia Face & UE > LE If MCA perfuses lateral aspect of hemisphere, how is the LE affected? If MCA perfuses lateral aspect of hemisphere, how is the LE affected? Occlusion occurs in the internal capsule Occlusion occurs in the internal capsule Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

25. Vertebrobasilar System 1/11 Supplies the inferior one third of the brain; inferior surface of the temporal and occipital lobes and brainstem. Supplies the inferior one third of the brain; inferior surface of the temporal and occipital lobes and brainstem. Derived from: subclavian, vertebral, foramen magnum, anterior spinal, posterior inferior cerebellar, basilar, anterior inferior cerebellar, internal auditory, superior cerebellar, posterior cerebral artery Derived from: subclavian, vertebral, foramen magnum, anterior spinal, posterior inferior cerebellar, basilar, anterior inferior cerebellar, internal auditory, superior cerebellar, posterior cerebral artery Supplies the inferior one third of the brain; inferior surface of the temporal and occipital lobes and brainstem. Supplies the inferior one third of the brain; inferior surface of the temporal and occipital lobes and brainstem. Derived from: subclavian, vertebral, foramen magnum, anterior spinal, posterior inferior cerebellar, basilar, anterior inferior cerebellar, internal auditory, superior cerebellar, posterior cerebral artery Derived from: subclavian, vertebral, foramen magnum, anterior spinal, posterior inferior cerebellar, basilar, anterior inferior cerebellar, internal auditory, superior cerebellar, posterior cerebral artery Click to animate Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

26. Vertebrobasilar System 2/11 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

27. Vertebrobasilar System 3/11 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

28. Vertebrobasilar System 4/11 ADAM Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

29. Vertebrobasilar System 5/11 ADAM Vertebral a. Basilar a. Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

30. Vertebrobasilar System 6/11 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

31. Posterior Cerebral Artery 7/11 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

32. Posterior Cerebral Artery 8/11 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

33. Posterior Cerebral Artery 9/11 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

34. 3 Cerebellar Arteries 10/11 Superior cerebellar a. Anterior inferior cerebellar a. Posterior inferior cerebellar a. Pons Medulla Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

35. Stroke 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 occlusion S&S of basilar artery occlusion Impaired CN functions Impaired CN functions Impaired long tract functions (motor/ sensory) Impaired long tract functions (motor/ sensory) S&S of PICA occlusion S&S of PICA occlusion Impaired pain sensation in ipsilateral face and contralateral body Impaired pain sensation in ipsilateral face and contralateral body 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 occlusion S&S of basilar artery occlusion Impaired CN functions Impaired CN functions Impaired long tract functions (motor/ sensory) Impaired long tract functions (motor/ sensory) S&S of PICA occlusion S&S of PICA occlusion Impaired pain sensation in ipsilateral face and contralateral body Impaired pain sensation in ipsilateral face and contralateral body Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

36. Circle of Willis Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

37. Perfusion Territories Watershed Territory Primary Artery Territory Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

38. Venous Drainage 1/2 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

39. Venous Drainage 2/2 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

40. Blood Supply to the Spinal Cord 1/2 Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

41. Spinal Arteries 2/2 Anterior Posterior Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

42. Patient Cases Sudden inability to speak Sudden inability to speak Sudden inability to speak Sudden inability to speak Left leg weakness Left leg weakness Left leg weakness Left leg weakness Worst headache of life Worst headache of life Worst headache of life Worst headache of life Decreased vision in one eye Decreased vision in one eye Decreased vision in one eye Decreased vision in one eye Left neglect Left neglect Left neglect Left neglect Anterior cord syndrome Anterior cord syndrome Anterior cord syndrome Anterior cord syndrome Sudden inability to speak Sudden inability to speak Sudden inability to speak Sudden inability to speak Left leg weakness Left leg weakness Left leg weakness Left leg weakness Worst headache of life Worst headache of life Worst headache of life Worst headache of life Decreased vision in one eye Decreased vision in one eye Decreased vision in one eye Decreased vision in one eye Left neglect Left neglect Left neglect Left neglect Anterior cord syndrome Anterior cord syndrome Anterior cord syndrome Anterior cord syndrome Last Viewed Last Viewed Cerebrovascular System Cerebrovascular System Exit Concept Map Concept Map

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

44. Minicase Sudden Inability to Speak 2/5 Her past medical history was notable for overweight, hypertension and type II diabetes. Her past medical history was notable for overweight, hypertension and type II diabetes. Examination revealed loss of the nasal-labial fold on the left and weakness in the left cheek and jaw. Examination revealed loss of the nasal-labial fold on 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 within normal limits. All other movement, sensation, and reflexes were 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, hypertension and type II diabetes. Her past medical history was notable for overweight, hypertension and type II diabetes. Examination revealed loss of the nasal-labial fold on the left and weakness in the left cheek and jaw. Examination revealed loss of the nasal-labial fold on 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 within normal limits. All other movement, sensation, and reflexes were within normal limits. Where is the lesion causing these symptoms? Where is the lesion causing these symptoms? Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

45. Minicase Follow-Up Sudden Inability to Speak 3/5 As confirmed by CT image, this woman was having a stroke. As confirmed by CT image, this woman was having a stroke. The occlusion involved a deep penetrating branch of the middle cerebral artery supplying the inferior frontal gyrus on the left causing weakness in the lower part of the right face and tongue and Broca’s aphasia. The occlusion involved a deep penetrating branch of the middle cerebral artery supplying the inferior frontal gyrus on the left causing weakness in the lower part of the right face and tongue and Broca’s aphasia. As confirmed by CT image, this woman was having a stroke. As confirmed by CT image, this woman was having a stroke. The occlusion involved a deep penetrating branch of the middle cerebral artery supplying the inferior frontal gyrus on the left causing weakness in the lower part of the right face and tongue and Broca’s aphasia. The occlusion involved a deep penetrating branch of the middle cerebral artery supplying the inferior frontal gyrus on the left causing weakness in the lower part of the right face and tongue and Broca’s aphasia. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

46. Productive (Broca’s) Aphasia 4/5 Produced by a lesion of the inferior frontal gyrus of the dominant hemisphere. Produced by a lesion of the inferior frontal gyrus of the dominant hemisphere. Play recording Play recording Play recording Play recording Produced by a lesion of the inferior frontal gyrus of the dominant hemisphere. Produced by a lesion of the inferior frontal gyrus of the dominant hemisphere. Play recording Play recording Play recording Play recording Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

47. Minicase Follow-Up Sudden Inability to Speak 5/5 The key signs and symptoms in this case are: Suddenly unable to speak Suddenly unable to speak Consciousness, attention, voluntary movement, and the ability to understand speech were all unaffected Consciousness, attention, voluntary movement, and the ability to understand speech were all unaffected Loss of the nasal-labial fold on the left and weakness in the left cheek and jaw Loss of the nasal-labial fold on the left and weakness in the left cheek and jaw Her jaw-jerk reflex was hyperactive Her jaw-jerk reflex was hyperactive The key signs and symptoms in this case are: Suddenly unable to speak Suddenly unable to speak Consciousness, attention, voluntary movement, and the ability to understand speech were all unaffected Consciousness, attention, voluntary movement, and the ability to understand speech were all unaffected Loss of the nasal-labial fold on the left and weakness in the left cheek and jaw Loss of the nasal-labial fold on the left and weakness in the left cheek and jaw Her jaw-jerk reflex was hyperactive Her jaw-jerk reflex was hyperactive Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

48. Minicase Left Leg Weakness 1/5 On attempting to stand after finishing breakfast, a 67-year-old woman fell to the ground, hitting the table on the way down, because she was unable to support her body weight on her left leg. She called for help from her husband who was unable to get her off the floor and called for emergency assistance. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

49. Minicase Left Leg Weakness 2/5 Her past history was positive for obesity, hypertension, peripheral vascular disease, and smoking one pack per day for 52 years. Her past history was positive for obesity, hypertension, peripheral vascular disease, and smoking one pack per day for 52 years. She had hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot. She had hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot. The left leg was flaccid and she had no voluntary control of movement. The left leg was flaccid and she had no voluntary control of movement. She had mild impairment of light touch, pain, and temperature sensation in her left leg. She had mild impairment of light touch, pain, and temperature sensation in her left leg. Voluntary movement, reflexes, and sensation were intact in all other regions of the body. Voluntary movement, reflexes, and sensation were intact in all other regions of the body. Where is the lesion causing these symptoms? Where is the lesion causing these symptoms? Her past history was positive for obesity, hypertension, peripheral vascular disease, and smoking one pack per day for 52 years. Her past history was positive for obesity, hypertension, peripheral vascular disease, and smoking one pack per day for 52 years. She had hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot. She had hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot. The left leg was flaccid and she had no voluntary control of movement. The left leg was flaccid and she had no voluntary control of movement. She had mild impairment of light touch, pain, and temperature sensation in her left leg. She had mild impairment of light touch, pain, and temperature sensation in her left leg. Voluntary movement, reflexes, and sensation were intact in all other regions of the body. Voluntary movement, reflexes, and sensation were intact in all other regions of the body. Where is the lesion causing these symptoms? Where is the lesion causing these symptoms? Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

50. Minicase Follow-Up Left Leg Weakness 3/5 A head CT scan was done and the results suggested a probable right anterior cerebral artery infarct. A head CT scan was done and the results suggested a probable right anterior cerebral artery infarct. Follow-up hear CT scan one month later confirmed the presence of a hypodense area on the anterior medial aspect of the right hemisphere consistent with a right anterior cerebral artery infarct Follow-up hear CT scan one month later confirmed the presence of a hypodense area on the anterior medial aspect of the right hemisphere consistent with a right anterior cerebral artery infarct A head CT scan was done and the results suggested a probable right anterior cerebral artery infarct. A head CT scan was done and the results suggested a probable right anterior cerebral artery infarct. Follow-up hear CT scan one month later confirmed the presence of a hypodense area on the anterior medial aspect of the right hemisphere consistent with a right anterior cerebral artery infarct Follow-up hear CT scan one month later confirmed the presence of a hypodense area on the anterior medial aspect of the right hemisphere consistent with a right anterior cerebral artery infarct Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

51. Minicase Follow-Up Left Leg Weakness 4/5 Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

52. Minicase Follow-Up Left Leg Weakness 5/5 The key signs and symptoms in this case are: Unable to support her body weight on her left leg Unable to support her body weight on her left leg Hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot Hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot The left leg was flaccid and she had no voluntary control of movement The left leg was flaccid and she had no voluntary control of movement She had mild impairment of light touch, pain, and temperature sensation in her left leg She had mild impairment of light touch, pain, and temperature sensation in her left leg Voluntary movement, reflexes, and sensation were intact in all other regions of the body Voluntary movement, reflexes, and sensation were intact in all other regions of the body The key signs and symptoms in this case are: Unable to support her body weight on her left leg Unable to support her body weight on her left leg Hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot Hyperactive deep tendon reflexes in her left knee and ankle, and a positive Babinski sign in her left foot The left leg was flaccid and she had no voluntary control of movement The left leg was flaccid and she had no voluntary control of movement She had mild impairment of light touch, pain, and temperature sensation in her left leg She had mild impairment of light touch, pain, and temperature sensation in her left leg Voluntary movement, reflexes, and sensation were intact in all other regions of the body Voluntary movement, reflexes, and sensation were intact in all other regions of the body Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

53. Minicase Sudden-onset Worst Headache of Life 1/7 A 68-year-old man suddenly developed “the worst of my life.” On the morning of admission he was sitting watching TV when at 9:00 am he suddenly developed an explosive headache worse than anything he had ever experienced. The headache began in the bifrontal area and over the next few minutes all over the head and down the neck. He denied loss of consciousness, nausea, vomiting or vision changes. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

54. Minicase Sudden-onset Worst Headache of Life 2/7 History was positive for severe diffuse atherosclerosis, including coronary disease and peripheral vascular disease requiring multiple bypass surgeries. History was positive for severe diffuse atherosclerosis, including coronary disease and peripheral vascular disease requiring multiple bypass surgeries. He was obese and smoked two packs a day for 43 years. He was obese and smoked two packs a day for 43 years. Examination was unremarkable except for mild nuchal rigidity. Examination was unremarkable except for mild nuchal rigidity. History was positive for severe diffuse atherosclerosis, including coronary disease and peripheral vascular disease requiring multiple bypass surgeries. History was positive for severe diffuse atherosclerosis, including coronary disease and peripheral vascular disease requiring multiple bypass surgeries. He was obese and smoked two packs a day for 43 years. He was obese and smoked two packs a day for 43 years. Examination was unremarkable except for mild nuchal rigidity. Examination was unremarkable except for mild nuchal rigidity. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

55. Minicase Follow-Up Sudden-onset Worst Headache of Life 3/7 Nuchal rigidity is often a sign of meningeal irritation caused by inflammation, infection, or hemorrhage in the subarachnoid space. Nuchal rigidity is often a sign of meningeal irritation caused by inflammation, infection, or hemorrhage in the subarachnoid space. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

56. Minicase Follow-Up Sudden-onset Worst Headache of Life 4/7 The man underwent emergency head CT which demonstrated regions of hyperdensity in the subarachnoid space consistent with subarachnoid hemorrhage layering in the medial longitudinal fissure, lateral fissure, and around the brainstem. The man underwent emergency head CT which demonstrated regions of hyperdensity in the subarachnoid space consistent with subarachnoid hemorrhage layering in the medial longitudinal fissure, lateral fissure, and around the brainstem. Next he was taken for an angiogram which clearly revealed an aneurysm arising from the region of the anterior communicating artery. Next he was taken for an angiogram which clearly revealed an aneurysm arising from the region of the anterior communicating artery. The man underwent emergency head CT which demonstrated regions of hyperdensity in the subarachnoid space consistent with subarachnoid hemorrhage layering in the medial longitudinal fissure, lateral fissure, and around the brainstem. The man underwent emergency head CT which demonstrated regions of hyperdensity in the subarachnoid space consistent with subarachnoid hemorrhage layering in the medial longitudinal fissure, lateral fissure, and around the brainstem. Next he was taken for an angiogram which clearly revealed an aneurysm arising from the region of the anterior communicating artery. Next he was taken for an angiogram which clearly revealed an aneurysm arising from the region of the anterior communicating artery. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

57. 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 5/7 Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

58. 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 6/7 Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

59. Minicase Follow-Up Sudden-onset Worst Headache of Life 7/7 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 few minutes was all over the head and down the neck Headache began in the bifrontal area and over the next few minutes was all over the head and down the neck Examination was unremarkable except for mild nuchal rigidity Examination was unremarkable except for mild nuchal rigidity 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 few minutes was all over the head and down the neck Headache began in the bifrontal area and over the next few minutes was all over the head and down the neck Examination was unremarkable except for mild nuchal rigidity Examination was unremarkable except for mild nuchal rigidity Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

60. Minicase Decreased Vision in One Eye 1/8 A 63-year-old woman went to an ophthalmologist complaining of episodes of decreased vision in her “right eye” over the past several weeks. A 63-year-old woman went to an ophthalmologist complaining of episodes of decreased vision in her “right eye” over the past several weeks. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

61. Minicase Decreased Vision in One Eye 2/8 Her medical history was notable for type II diabetes, hypercholesterolemia, and coronary artery disease. Her medical history was notable for type II diabetes, hypercholesterolemia, and coronary artery disease. About 5-6 weeks ago the patient began having “episodes of sudden blurry wavy” appearance of her vision. About 5-6 weeks ago the patient began having “episodes of sudden blurry wavy” appearance of her vision. She believed this was mostly in the right eye but never tried looking with only one eye at a time. She believed this was mostly in the right eye but never tried looking with only one eye at a time. Her medical history was notable for type II diabetes, hypercholesterolemia, and coronary artery disease. Her medical history was notable for type II diabetes, hypercholesterolemia, and coronary artery disease. About 5-6 weeks ago the patient began having “episodes of sudden blurry wavy” appearance of her vision. About 5-6 weeks ago the patient began having “episodes of sudden blurry wavy” appearance of her vision. She believed this was mostly in the right eye but never tried looking with only one eye at a time. She believed this was mostly in the right eye but never tried looking with only one eye at a time. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

62. Minicase Decreased Vision in One Eye 3/8 Episodes would last for 15-20 minutes, resolved with no visual impairment, repeated 3-4 times per week, and were never accompanied by pain. Episodes would last for 15-20 minutes, resolved with no visual impairment, repeated 3-4 times per week, and were never accompanied by pain. Previously she was able to recognize faces during the episodes but was unable to read. Previously she was able to recognize faces during the episodes but was unable to read. The current episode, that began two days ago, has resulted in persistent decreased vision on the right. The current episode, that began two days ago, has resulted in persistent decreased vision on the right. Episodes would last for 15-20 minutes, resolved with no visual impairment, repeated 3-4 times per week, and were never accompanied by pain. Episodes would last for 15-20 minutes, resolved with no visual impairment, repeated 3-4 times per week, and were never accompanied by pain. Previously she was able to recognize faces during the episodes but was unable to read. Previously she was able to recognize faces during the episodes but was unable to read. The current episode, that began two days ago, has resulted in persistent decreased vision on the right. The current episode, that began two days ago, has resulted in persistent decreased vision on the right. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

63. Minicase Decreased Vision in One Eye 4/8 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. Where is the lesion causing these symptoms? Where is the lesion causing these symptoms? 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. Where is the lesion causing these symptoms? Where is the lesion causing these symptoms? Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

64. Minicase Follow-Up Decreased Vision in One Eye 5/8 The transient episodes of 15-20 minutes of decreased right-sided vision occurring over several weeks, followed by a sudden-onset persistent deficit is suggestive of TIAs preceding a cerebral infarct. The transient episodes of 15-20 minutes of decreased right-sided vision occurring over several weeks, followed by a sudden-onset persistent deficit is suggestive of TIAs preceding a cerebral infarct. A right homonymous hemianopia can be caused by a lesion in the left hemisphere visual pathway anywhere from the left optic tract to the primary visual cortex. A right homonymous hemianopia can be caused by a lesion in the left hemisphere visual pathway anywhere from the left optic tract to the primary visual cortex. The patient’s age and past medical history raise the suspicion of cerebrovascular disease of the cause. The patient’s age and past medical history raise the suspicion of cerebrovascular disease of the cause. The transient episodes of 15-20 minutes of decreased right-sided vision occurring over several weeks, followed by a sudden-onset persistent deficit is suggestive of TIAs preceding a cerebral infarct. The transient episodes of 15-20 minutes of decreased right-sided vision occurring over several weeks, followed by a sudden-onset persistent deficit is suggestive of TIAs preceding a cerebral infarct. A right homonymous hemianopia can be caused by a lesion in the left hemisphere visual pathway anywhere from the left optic tract to the primary visual cortex. A right homonymous hemianopia can be caused by a lesion in the left hemisphere visual pathway anywhere from the left optic tract to the primary visual cortex. The patient’s age and past medical history raise the suspicion of cerebrovascular disease of the cause. The patient’s age and past medical history raise the suspicion of cerebrovascular disease of the cause. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

65. Minicase Follow-Up Decreased Vision in One Eye 6/8 The patient was sent to the hospital where an initial CT scan suggested a left posterior cerebral artery infarct, and a follow-up MRI confirmed the presence of a left PCS infarct involving the left primary visual cortex. The patient was sent to the hospital where an initial CT scan suggested a left posterior cerebral artery infarct, and a follow-up MRI confirmed the presence of a left PCS infarct involving the left primary visual cortex. An magnetic resonance angiogram (MRA) revealed several stenoses of the cerebral vessels compatible with diffuse intracranial atherosclerotic disease. An magnetic resonance angiogram (MRA) revealed several stenoses of the cerebral vessels compatible with diffuse 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 to adapt to her visual deficit. Her right hemianopia did not improve, but over time she learned to adapt to her visual deficit. The patient was sent to the hospital where an initial CT scan suggested a left posterior cerebral artery infarct, and a follow-up MRI confirmed the presence of a left PCS infarct involving the left primary visual cortex. The patient was sent to the hospital where an initial CT scan suggested a left posterior cerebral artery infarct, and a follow-up MRI confirmed the presence of a left PCS infarct involving the left primary visual cortex. An magnetic resonance angiogram (MRA) revealed several stenoses of the cerebral vessels compatible with diffuse intracranial atherosclerotic disease. An magnetic resonance angiogram (MRA) revealed several stenoses of the cerebral vessels compatible with diffuse 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 to adapt to her visual deficit. Her right hemianopia did not improve, but over time she learned to adapt to her visual deficit. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

66. Minicase Follow-Up Decreased Vision in One Eye 7/8 MRI axial T2 weighted image of left posterior cerebral artery (PCA) infarction Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

67. Minicase Follow-Up Decreased Vision in One Eye 8/8 The key signs and symptoms in this case are: Episodes of sudden “blurry/ wavy” appearance of her vision in her “right eye” over the past several weeks Episodes of sudden “blurry/ wavy” appearance of her vision in her “right eye” over the past several weeks Right homonymous hemianopia Right homonymous hemianopia The key signs and symptoms in this case are: Episodes of sudden “blurry/ wavy” appearance of her vision in her “right eye” over the past several weeks Episodes of sudden “blurry/ wavy” appearance of her vision in her “right eye” over the past several weeks Right homonymous hemianopia Right homonymous hemianopia Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

68. Minicase Left Neglect 1/5 A 61-year-old right-handed man was witnessed slumping to the floor in the grocery store. A 61-year-old right-handed man was witnessed slumping to the floor in the grocery store. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

69. Minicase Left Neglect 2/5 On examination in the hospital he denied anything was wrong but said, “They called an ambulance because they said I had a stroke.” On examination in the hospital he denied anything was wrong but said, “They called an ambulance because they said I had a stroke.” He was unaware of having any impairment and wanted to go home. He was unaware of having any impairment and wanted to go home. He had profound left visual field neglect, no blink to threat on the left, and no voluntary gaze to the left past midline. He had profound left visual field neglect, no blink to threat on 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 of the page. When trying to right, he moved the pen in the air off to the right of the page. When shown his left hand and asked what it was, he replied “Someone’s hand.” When shown his left hand and asked what it was, he replied “Someone’s hand.” On examination in the hospital he denied anything was wrong but said, “They called an ambulance because they said I had a stroke.” On examination in the hospital he denied anything was wrong but said, “They called an ambulance because they said I had a stroke.” He was unaware of having any impairment and wanted to go home. He was unaware of having any impairment and wanted to go home. He had profound left visual field neglect, no blink to threat on the left, and no voluntary gaze to the left past midline. He had profound left visual field neglect, no blink to threat on 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 of the page. When trying to right, he moved the pen in the air off to the right of the page. When shown his left hand and asked what it was, he replied “Someone’s hand.” When shown his left hand and asked what it was, he replied “Someone’s hand.” Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

70. Minicase Left Neglect 3/5 When asked who’s hand it was he replied, “The doctor’s.” When asked who’s hand it was he replied, “The 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 left face. He had marked weakness in the lower portion of the left face. Strength was 0/5 in the left arm and leg, the left plantar response was upgoing, and there was no response to pinprick on the left side. Strength was 0/5 in the left arm and leg, the left plantar response was upgoing, and there was no response to 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 doctor’s.” When asked who’s hand it was he replied, “The 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 left face. He had marked weakness in the lower portion of the left face. Strength was 0/5 in the left arm and leg, the left plantar response was upgoing, and there was no response to pinprick on the left side. Strength was 0/5 in the left arm and leg, the left plantar response was upgoing, and there was no response to pinprick on the left side. What lesion is causing this man’s symptoms? What lesion is causing this man’s symptoms? Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

71. Minicase Follow-Up Left 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 visual and tactile stimuli, as well as left motor neglect. In addition to anosognosia, he has left sensory neglect, to visual and tactile stimuli, as well as left motor neglect. These signs and symptoms are most commonly seen in patients with nondominant (usually right) parietal lobe lesions. These signs and symptoms are most commonly seen in patients with nondominant (usually right) parietal lobe lesions. Given the sudden onset of the deficits, involvement of the left arm and leg, the presence of sensory and motor deficits, and the patient’s age, the most likely cause is ischemic infarction of the right internal carotid artery. Given the sudden onset of the deficits, involvement of the left arm and leg, the presence of sensory and motor deficits, and the patient’s age, the most likely cause is ischemic infarction of the right internal carotid artery. The patient exhibits several forms of neglect. The patient exhibits several forms of neglect. In addition to anosognosia, he has left sensory neglect, to visual and tactile stimuli, as well as left motor neglect. In addition to anosognosia, he has left sensory neglect, to visual and tactile stimuli, as well as left motor neglect. These signs and symptoms are most commonly seen in patients with nondominant (usually right) parietal lobe lesions. These signs and symptoms are most commonly seen in patients with nondominant (usually right) parietal lobe lesions. Given the sudden onset of the deficits, involvement of the left arm and leg, the presence of sensory and motor deficits, and the patient’s age, the most likely cause is ischemic infarction of the right internal carotid artery. Given the sudden onset of the deficits, involvement of the left arm and leg, the presence of sensory and motor deficits, and the patient’s age, the most likely cause is ischemic infarction of the right internal carotid artery. Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

72. Minicase Follow-Up Left Neglect 5/5 The key signs and symptoms in this case are: Anosognosia Anosognosia Left face, arm and leg plegia with positive Babinski’s sign Left face, arm and leg plegia with positive Babinski’s sign No blink to threat on the left No blink to threat on the left No voluntary gaze to the left past midline No voluntary gaze to the left past midline No response to pinprick on the left No response to pinprick on the left The key signs and symptoms in this case are: Anosognosia Anosognosia Left face, arm and leg plegia with positive Babinski’s sign Left face, arm and leg plegia with positive Babinski’s sign No blink to threat on the left No blink to threat on the left No voluntary gaze to the left past midline No voluntary gaze to the left past midline No response to pinprick on the left No response to pinprick on the left Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

73. Occlusion of the anterior spinal artery (anterior cord syndrome) in the cervical region would produce 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 1/2 Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

74. UMN DRG UMN DRG R L Anterior cord lesion Lateral corticospinal tract lesion Ipsilateral 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. Click to animate 2/2 Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map

75. The End © DM McKeough 2008 Last Viewed Last Viewed Patient Cases Patient Cases Exit Concept Map Concept Map