Brain Circulation

Haytham Eloqayli

Neurophysiology
Haytham Eloqayli
Consultant neurosurgery and spine surgery. PhD in neuroscience and epilepsy European specialty I in neurosurgery Jordanian specialty in neurosurgery Norwegian specialty in neurosurgery Ex-Associated prof.-NTNU (Norway)

Brain Circulation
- Total cessation of blood flow to the brain causes
unconsciousness within 5 to 10 seconds.

CBF (adult)

Normal Ischemia (reversible)

50-65 ml/100 g/minute 8-23 ml/100 g/minute

Infarction (irreversible)

< 8 ml/100 g/minute

Brain Circulation
CBF (adult) depends on

Cerebral perfusion pressure (CPP) Autoregulation (MAP, brain metabolism) sympathetic: the large- and intermediate-sized brain arteries

Brain Circulation

CPP= MAP-ICP
MAP= DBP + 1/3 (pulse pressure) e.g BP 119/80 MAP= 80 +1/3(119-80) = 93. ICP= 10 mm Hg (130 millimeters of water)

ICP & CPP

Normal intracranial pressure
CPP 70 = = MAP 80 ICP 10 mm Hg

Autoregulation

small arterioles and the blood capillaries. blood capillaries:

-the number of blood capillaries is high where the metabolic

needs are high. - less "leaky" than the blood capillaries in other tissue (tight junctions and glial cells projections). This makes the principle of BBB.

Autoregulation

CBF is autoregulated with MAP between 60-140 mm Hg

Autoregulation
-

vasodilitation - decrease MAP

- increase in carbon dioxide concentration

- increases hydrogen ion concentration (PH) - decrease in cerebral tissue Po2

vasoconstriction
-Increase MAP, arterial Pco2, PH

Rosner view of cerebral blood flow

Defective autoregulation

Monro-Kellie Doctrine

Blood 10%

Brain 80%

CSF 10%

Vintracranial vault = Vbrain + Vblood + Vcsf

Cerebrospinal Fluid System

ventricles of the brain, cisterns around the outside of the brain, the subarachnoid space around both the brain and the spinal cord Total amount at any time 150 milliliters formation rate about 500 milliliters each day

Cerebrospinal Fluid System

Formation of CSF

2/3 as secretion from the choroid plexuses in the four ventricles but mainly in the two lateral ventricles 1/3 as secretion by the ependymal surfaces of the

ventricles and by the arachnoidal membranes

Cerebrospinal Fluid System

Monro-Kellie Doctrine

Blood 10%

Brain 80%

CSF 10%

Vintracranial vault = Vbrain + Vblood + Vcsf

Direct neuronal disruption

Blood-brain barrier injury

Vasogenic edema

Cytotoxic edema

Ischaemia

Hyperemia

Intracranial hypertension

Haematoma

Increased cerebral blood volume CSF volume

Intracranial compensation

The brain is essentially non-compressible Any increase in intracranial volume decreases CSF or CBV CSF - primarily displaced into the spinal subarachnoid space Blood - venoconstriction of CNS capacitance vessels displaces blood in jugular venous system

ICP-Volume Curve
ICP mm Hg

100
80 60 40 Small volume marked ICP

ICP controlled due to compensation

20
0 Volume

Exhaustion of compensation

Once these limited homeostatic mechanisms are exhausted additional small increases in intracranial volume produce marked elevations in ICP

Raised ICP may 1.decrease CBF resulting in vicious cycle. 2. can cause brain herniation.

Herniation

ICP rises are not equally distributed throughout the skull & pressure gradients develop

This may result in herniation

laterally (cingulate herniation) downwards (transtentorial herniation)