BRAIN INJURY

Dr Mazlina Mazlan
Rehabilitation Physician
`The Adaptive System: Plasticity and Recovery’
January 2010
 THE BRAIN
How does the brain looks like after injury?
 ACQUIRED BRAIN INJURY
• Definition
– Injury to the brain
– Occurs after birth
– May have been caused by an external
physical force or by a metabolic disorder(s)
– Includes traumatic and non-traumatic brain
injury

TRAUMATIC + NON-TRAUMATIC
BRAIN INJURY

Examples?
 ACQUIRED BRAIN INJURY
What are the mechanisms of brain lesion?

Disruption of
Bleeding into
blood supply to the
brain tissue or
brain/ part of brain: Axonal injury around brain
Direct tissue tissue
damage

thrombus, emboli,
haemorrhagic disruption,
vasculitis, reduced cerebral perfusion (cardiac arrest, GI bleed),
infection
 ACQUIRED BRAIN INJURY
What are the mechanisms of brain lesion?

Disruption of
Bleeding into
blood supply to the
brain tissue or
brain/ part of brain: Axonal injury around brain
Direct tissue tissue
damage

SAH, SDH, EDH

compression from tumour, trauma

 BRAIN INJURY
• Can we expect to identify the neurological
problems the patient has when we know which
part of the brain is injured?

YES, Most of the time

• Why?

Because different parts of the brain control different activities

NEUROLOGICAL SEQUELAE
α lobes involved
α blood supply involved
 BRAIN INJURY
• Features / Neurological sequelae :
– Upper motor neuron
– Motor impairment
– Sensory impairment : touch, pressure, heat, vision,
hearing, etc
– Balance and co-ordination impairment
– Cognitive function impairment : awareness, memory,
judgment, understanding, intelligent, reasoning
– Speech impairment
– * movement disorders 2o extrapyramidal system
BLOOD SUPPLY
 THE BRAIN
Blood Supply

• brain receives blood from two sources: internal

carotid arteries and vertebral arteries blood
supply to the brain is very important
• brain cells must have a continuous supply of O2
and other nutrients from the blood to function
• therefore, blood is pumped continuously from
the heart to the brain via several artery groups
 THE BRAIN
Circle Of Willis

• The internal carotid arteries branch to form two

major cerebral arteries: the anterior cerebral
artery (ACA) and middle cerebral artery
(MCA)
• The right and left vertebral arteries come
together at the level of the pons to form the
midline basilar artery.
• The basilar artery joins the blood supply from
the internal carotids in an arterial ring at the
base of the brain
THE BRAIN
Blood supply
THE BRAIN
Blood supply
 MCA
• largest cerebral artery
• branch of internal carotid
• most commonly affected
by cerebrovascular
accident (CVA).
• Supplies: most of the
outer convex brain
surface & deep surfaces :
basal ganglia, internal
capsules.
• Key functional areas:

1. Primary motor cortex for face

and arm
2. Broca’s area for language
expression MCA

3. Wernickes’a area for language

comprehension
4. Primary sensory cortex for face
and arm
5. Parietal lobe for 3D visuospatial
perception of body &
environment, interpret &
express emotion
6. Optic radiation
NEUROLOGICAL SEQUELAE

α blood supply involved

Classic picture:

• Contralateral hemiplegia: Greater in the

upper extremities and than in the lower
extremities.
• hemianesthesia/hyperesthesia
• Other sensory deficit: impaired position
sense, 2-point discrimination
• homonymous hemianopsia
• deviation of the head and eyes toward the
side of the lesion
• Classic picture:

• + if dominant lobe: receptive aphasia

and/or expressive aphasia
• + if non-dominant lobe: amorphosynthesis
(defective perception of sensation from
one side of the body), hemineglect and
visuospatial deficits.
• insight and judgment may be affected.
• a large infarction can compress brain stem
and LOC
 ACA
• branch of internal carotid
• runs above optic nerve
• joined by anterior
communicating artery
• Supplies: the medial
surface of frontal, parietal
and orbital & deep
surfaces : internal
capsules.
 ACA
• Key functional areas:
ACA
1. Primary motor cortex for the
leg and foot areas, urinary
bladder PCA

2. additional motor planning

areas in the medial frontal
lobe

3. primary somatosensory
cortex for the leg and foot
NEUROLOGICAL SEQUELAE

α blood supply involved

• Contralateral sensorimotor deficit : Greater
in the foot and leg than in the arm.
• face and tongue largely are spared
• frontal lobe personality changes
• apraxia
• primitive reflexes
• bowel and bladder incontinence
 PCA
• terminal branch of basilar
artery
• cortical branches run
through undersurface of
temporal lobe and
occipital lobe
• Small penetrating
branches supplies:
thalamus, hypothalamus,
midbrain
 PCA
• Key functional areas:
ACA
1. primary visual cortex
PCA
* transfer of visual
information to the
language-dominant
hemisphere
NEUROLOGICAL SEQUELAE

α blood supply involved

• Contralateral visual field defects of
hemianopsia
• may report a grayness, difficulty focusing
or blurred vision.
• + if dominant hemisphere: problems with
language or memory, dyslexia, color
anomia (cannot name colors) and alexia
(cannot read words)
• + if non-dominant lesion: prosopagnosia
(cannot recognize familiar faces).
NEUROLOGICAL SEQUELAE

α lobes involved
BRAIN INJURY
Examples

• Monoplegia/hemiplegia
• Broca’s dysphasia
• Change of behavior
– anti-social /loss of
inhibitions / poor
judgement / emotional
lability etc, etc
• Primitive reflexes
BRAIN INJURY
Examples
• Difficulty hearing spoken
words (dominant)
• Difficulty appreciate music
(non-dominant)
• Auditory hallucinations
• Wernicke’s dysphasia
• Seizures
• Memory disturbance
 BRAIN INJURY
Examples
• Sensory disturbances
– eg x appreciate size, shape,
texture (astereognosis)
• Not aware of weak limbs –
anosognosia (dominant)
• Problem of geographic
memory– geographical
agnosia (dominant)
• Apraxia
 BRAIN INJURY
• Examples
• Visual problems
• Visual hallucination
• Distortion of shape
• Disappearance of colour
from vision
 BRAIN INJURY
• Examples
• Problem in balance
– Ataxia
– Dysmetria
– Dysdiadochokinesis

• Dysarthria
• Nystagmus
 The End

Dr Mazlina Mazlan
Department of Rehabilitation Medicine
UMMC
January 2010