PREDISPOSING FACTORS: PRECIPITATING FACTORS:

 62 yrs of age  Alcohol Abuse

 sex: male  Hypertension
 Cigarette smoking
 Undesirable levels of
cholesterol
 Diet: high fat and high
Na
 Sedentary Lifestyle

Atherosclerosis

Formation of plaque
deposits

Thrombosis

Hypertension Occlusion by
major vessel

Vascular wall becomes weakened and fragile

Leaking of blood from the fragile vessel wall

  Headache
Cerebral  Unconsciousness,
Hemorrhage N/V,
 Visual disturbances

Mass of blood forms and grows Visual disturbances

Formation of small and large Vasospasm of

clots tissues and
arteries

 Dizziness
 Confusion Cerebral Hypoperfusion
 headache

Impaired distribution of
O2 and glucose

Tissue hypoxia and cellular

starvation

Cerebral Ischemia

Initiation of
ischemic cascade

Anaerobic
Production of O2 free
metabolism by
radicals and other reactive
mitochondria
O2 species
Generates large amount Failure production of
of lactic acid adenosine triphosphate

Metabolic acidosis Failure of energy

dependent process (ion Damage to the blood
pumping) vessels endothelium

Release of excitatory neurotransmitter

glutamate

Influx of Ca

Activates enzymes that Failure of

digest cell proteins, mitochondria
lipids and nuclear
material

Further energy depletion

Transient ischemic attack

Brain sustain an irreversible

cerebral damage

Breakdown of the protective blood

brain barrier

Compression of tissue

Increased intracranial
 Impaired perfusion and
function

Middle Anterior Posterior Internal Vertebrovascelar Anteroinferior Posteroinferior

cerbral cerebral cerebral Carotid System Cerebellar Cerebellar
artery artery artery artery
Lateral Frontal lobe Occcipital Branches Cerebellum and Cerebellum Cerebellum
hemisphere, lobe, info brain stem
frontal, anterior ophthalmic,
parietal and and medial PCA,
temporal position of anterior
lobes, basal temporal choroidal,
ganglia lobe ACA, MCA

 Contralateral  Contralateral  Contralateral  Contralateral  Alternating  Ipsilateral  Ataxia

hemiparesis Hemiparesis Hemiparesis Hemiparesis motor ataxia  paralysis of
or hemiplegia  foot and leg  intention with facial weaknesses  facial the larynx
 unilateral deficits tremor asymmetry  dysmetria paralysis and soft
neglect greater than  diffuse  contralateral  contralateral  Ipsilateral palate
altered the arm sensory loss sensory  hemisensory loss of  Ipsilateral
consciousnes  contralateral  pupilary alterations impairments sensation loss of
s hemisensory dysfunction  homonymous  attaxic gait in face sensation in
 homonyms  alterations  loss of  hemianopsia  homonymous  sensation face
 hemianopsia deviation of conjugate gaze  ipsilateral  hemianopsia changes on  nystagmus
 inability to eyes forward  nystagmus, periods of  nystagmus, trunk and  dysartria
turn eyes affected side loss of depth blindness  conjugate gaze limbs  contralateral
forward  expressive perception  aphasia if  dysarthria  nystagmus on body
affected side  Aphasia  cortical dominant  disorrientation  hiccups and
 vision  confusion blindness hemisphere is  vertigo coughing
changes  amnesia  homonymous involved  Vertigo
 dyslexia  apathy,  hemianopsia  N/V
dysgraphia  shortened  perseveration
 aphasia attention  dyslexia,
 agnosia span  memory
 memory  loss of deficits
deficit mental acuity  visual
 vomitting  Apaxia  hallucinations
 incotinence
Anatomy and Physiology

BRAIN

The main function of the nervous system:

 Sensory input- sensory receptors monitor numerous external and internal stimuli that
may be interpreted as touch, temperature, taste, smell, sound, blood pressure and
body position. Action potentials from the sensory receptors travel along nerves to the
spinal cord and brain, where they are interpreted.
 Integration- the brain and spinal cord are the major organs for processing sensory
input and initiating responses. The input may produce an immediate response, may
be stored as memory or may be ignored.
 Homeostasis- the nervous system plays an important role in the maintenance of
homeostasis. This function depends on the ability of the nervous system to detect,
interpret and respond to changes in internal and external conditions. In response,
the nervous system can stimulate or inhibit the activities of other system to help
maintain a constant internal environment.
 Mental activity- the brain is the center of mental activity including consciousness,
memory and thinking.
 Control of muscles and glands- skeletal muscles normally contract only when
stimulated by the nervous system. Thus, through the control of skeletal muscle, the
nervous system controls the major movements of the body. The nervous system
also participates in controlling cardiac muscle, smooth muscle and many glands.
 It is the portion of the central nervous system contained within the skull. The
brain is the control center for movement, sleep, hunger, thirst, and virtually every other
vital activity necessary to survival. All human emotions—including love, hate, fear,
anger, elation, and sadness—are controlled by the brain. It also receives and interprets
the countless signals that are sent to it from other parts of the body and from the
external environment. The brain makes us conscious, emotional, and intelligent.

Occupying the skull cavity (cranium), the adult human brain normally weighs from 2 1/4
to 3 1/4 lb (1-1.5 kg). Differences in weight and size do not correlate with differences in
mental ability; an elephant's brain weighs more than four times that of a human. In
invertebrates a group of ganglia or even a single ganglion may serve as a rudimentary
brain.

By means of electrochemical impulses the brain directly controls conscious or voluntary

behavior, such as walking and thinking. It also monitors, through feedback circuitry,
most involuntary behavior—connections with the autonomic nervous system enable the
brain to adjust heartbeat, blood pressure, fluid balance, posture, and other functions—
and influences automatic activities of the internal organs. There are no pain receptors in
brain tissue. A headache is felt because of sensory impulses coming chiefly from the
meninges or scalp.

Anatomically the brain has three major parts, the hindbrain (including the
cerebellum and the brain stem ), the midbrain, and the forebrain (including the
diencephalon and the cerebrum). Every brain area has an associated function, although
many functions may involve a number of different areas.

1.1 Brain stem

The brain stem is the lowest part of the brain. It serves as the path for
messages travelling between the upper brain and spinal cord, and is also the seat of
basic and vital functions such as breathing, blood pressure, and heart rate, as well as
reflexes like eye movement and vomiting. The brain stem has three main parts: the
medulla, pons, and midbrain. A canal runs longitudinally through these structures
carrying cerebrospinal fluid. Also distributed along its length is a network of cells,
referred to as the reticular formation, that governs the state of alertness.

The medulla, which is part of the brainstem, controls basic functions such as
breathing rate, heartbeat and the activity of the intestines. The midbrain, also part of the
brainstem, controls movements and contains nerve centres involved in hearing and
vision.

1.2 Cerebellum

The cerebellum coordinates body movements. Located at the lower back

of the brain beneath the occipital lobes, the cerebellum is divided into two lateral
(side-by-side) lobes connected by a fingerlike bundle of white fibers called the
vermis. The outer layer, or cortex, of the cerebellum consists of fine folds called
folia. As in the cerebrum, the outer layer of cortical gray matter surrounds a
deeper layer of white matter and nuclei (groups of nerve cells). Three fiber
bundles called cerebellar peduncles connect the cerebellum to the three parts of
the brain stem—the midbrain, the pons, and the medulla oblongata.
 The cerebellum coordinates voluntary movements by fine-tuning commands from
the motor cortex in the cerebrum. The cerebellum also maintains posture and
balance by controlling muscle tone and sensing the position of the limbs. All
motor activity, from hitting a baseball to fingering a violin, depends on the
cerebellum.

1.3 Cerebrum

The cerebrum consists of two hemispheres that are incompletely separated

by the great longitudinal fissure. This sulcus separates the cerebrum into the right and
left hemispheres. The two hemispheres are joined at the lower portion of the fissure by
the corpus callosum. The outside surface of the hemispheres has a wrinkled
appearance that is the result of many folded layers or convolutions called gyri, which
increase the surface area of the brain, accounting for the high level of activity carried
out by such a small-appearing organ. The external or outer portion of the cerebrum (the
cerebral cortex) is made up of gray matter approximately 2 to 5 mm in depth; it contains
billions of neurons/cell bodies, giving it a gray appearance. White matter makes up the
innermost layer and is composed of nerve fibers and neuroglia (support tissue) that
form tracts or pathways connecting various parts of the brain with one another
(transverse and association pathways) and the cortex to lower portions of the brain and
spinal cord (projection fibers). The cerebral hemispheres are divided into pairs of frontal,
parietal, temporal, and occipital lobes.

The four lobes are as follows:

 Frontal – the largest lobe. The major functions of this lobe are concentration,
abstract thought, information storage or memory, and motor function. It also
contains Broca’s area, critical for motor control of speech. The frontal lobe is
also responsible in large part for an individual’s affect, judgment, personality,
and inhibitions.
 Parietal – a predominantly sensory lobe. The primary sensory cortex, which
analyzes sensory information and relays the interpretation of this information
 to the thalamus and other cortical areas, is located in the parietal lobe. It is
also essential to an individual’s awareness of the body in space, as well as
orientation in space and spatial relations.
 Temporal – contains the auditory areas. Contains a vital area called the
interpretive area that provides integration of somatization, visual, and auditory
areas and plays the most dominant role of any area of the cortex in
cerebration.
 Occipital – the posterior lobe of the cerebral hemisphere is responsible for
visual interpretation.

Corpus Callosum

Is a thick collection of nerve fibers that connects the two hemispheres of the
brain and is responsible for the transmission of information from one side of the brain to
the other.

Basal Ganglia

Are masses of nuclei located deep in the cerebral hemispheres that are
responsible for control of fine motor movements, including those of the hands and lower
extremities.

Thalamus

Lies on either side of the third ventricle and acts primarily as a relay station for
all sensation except smell. All memory, sensation, and pain impulses also pass through
this section of the brain.

Hypothalamus

Located anterior and inferior to the thalamus. The hypothalamus lies

immediately beneath and lateral to the lower portion of the wall of the third ventricle. It
includes the optic chiasm (the point at which the two optic tracts cross) and the
mamillary bodies (involved in olfactory reflexes and emotional response to odors). The
infundibulum of the hypothalamus connects it to the posterior pituitary gland. The
hypothalamus plays an important role in the endocrine system because it regulates the
pituitary secretion of hormones that influence metabolism, reproduction, stress
response, and urine production. It works with the pituitary to maintain fluid balance and
maintains temperature regulation by promoting vasoconstriction or vasodilation.

The site of the hunger center and is involved in appetite control. It contains the
centers that regulate the sleep-wake cycle, blood pressure, aggressive and sexual
behavior, and emotional responses. The hypothalamus also controls and regulates
the autonomic nervous system.

Pituitary Gland

Located in the sella turcica at the base of the brain and is connected to the
hypothalamus. The pituitary is a common site of brain tumors in adults; frequently they
are detected by physical signs and symptoms that can be traced to the pituitary, such
as hormonal imbalance or visual disturbances secondary to pressure on the optic
chiasm.

1.4 Diencephalon

The thalamus , which forms the major part of the diencephalon, receives
incoming sensory impulses and routes them to the appropriate higher centers. The
hypothalamus , occupying the rest of the diencephalon, regulates heartbeat, body
temperature, and fluid balance.