Anatomy and Physiology

CVA BLEED VS INFARCT

A stroke, or cerebrovascular accident (CVA), is

the rapid loss of brain functions due to
disturbance in the blood supply to the brain. This
can be due to ischemia (lack of blood flow )
caused by blockage ( thrombosis, arterial
embolism ) or a hemorrhage (leakage of blood).
As a result, the affected area of the brain cannot
function, which might result in an inability to
move one or more limbs on one side of the body, inability to understand or formulate speech, or
an inability to see one side of the visual field.

What is Hemorrhagic Stroke?

Bleeding into the brain by the rupture of a blood
vessel. The cerebral hemispheres are supplied by 3
paired major arteries: the anterior, middle, and
posterior cerebral arteries. The anterior and middle
cerebral arteries are responsible for the anterior
circulation and arise from the supraclinoid internal
carotid arteries. The posterior cerebral arteries arise
from the basilar artery and form the posterior
circulation, which also supplies the thalami,
brainstem, and cerebellum.

Hemorrhagic stroke may be further subdivided into intracerebral hemorrhage ICH (within the
brain) and subarachnoid hemorrhage SAH (between the inner and outer layers of the tissue
covering the brain).
  Intracerebral hemorrhage
Bleeding occurs directly into the brain
parenchyma. The usual mechanism is
thought to be leakage from small
intracerebral arteries damaged by
chronic hypertension. Other
mechanisms include bleeding diatheses,
iatrogenic anticoagulation, cerebral
amyloidosis, and cocaine abuse.
Intracerebral hemorrhage has a
predilection for certain sites in the
brain, including the thalamus, putamen, cerebellum, and brainstem. In addition to the area of the
brain injured by the hemorrhage, the surrounding brain can be damaged by pressure produced by
the mass effect of the hematoma. Blood vessels carry blood to and from the brain. Arteries or
veins can rupture, either from abnormal pressure or abnormal development or trauma. The blood
itself can damage the brain tissue. Furthermore, the extra blood in the brain may increase the
pressure within the skull (intracranial pressure (ICP)) to a point that further damages the brain .

 Subarachnoid hemorrhage
The pathologic effects of subarachnoid
hemorrhage (SAH) on the brain are multifocal.
SAH results in elevated intracranial pressure
and impairs cerebral autoregulation. These
effects can occur in combination with acute
vasoconstriction, microvascular platelet
aggregation, and loss of microvascular perfusion, resulting in profound reduction in
blood flow and cerebral ischemia.

What is Ischemic stroke?

An ischemic stroke is death of an area of brain tissue
(cerebral infarction) resulting from an inadequate
supply of blood and oxygen to the brain due to

blockage of an artery. An ischemic stroke

typically results from blockage of an artery that
supplies blood to the brain, most commonly a
branch of one of the internal carotid arteries. As
a result, brain cells are deprived of blood. Most
brain cells die if they are deprived of blood for
4.5 hours.

Blood is supplied to the brain through two pairs of large arteries:

 Internal carotid arteries, which carry blood from the heart along the front of the neck
 Vertebral arteries, which carry blood from the heart along the back of the neck
In the skull, the vertebral arteries unite to form the
basilar artery (at the back of the head). The internal
carotid arteries and the basilar artery divide into
several branches, including the cerebral arteries.
Some branches join to form a circle of arteries (circle
of Willis) that connect the vertebral and internal
carotid arteries. When the large arteries that supply
the brain are blocked, some people have no symptoms
or have only a small stroke. But others with the same
sort of blockage have a massive ischemic stroke. Why? Part of the explanation is collateral
arteries. Collateral arteries run between other arteries, providing extra connections. These arteries
include the circle of Willis and connections between the arteries that branch off from the circle.
Some people are born with large collateral arteries, which can protect them from strokes. Then
when one artery is blocked, blood flow continues through a collateral artery, sometimes
preventing a stroke. Small collateral arteries may be unable to pass enough blood to the affected
area, so a stroke results

Commonly, blockages are blood clots (thrombi) or pieces of fatty deposits (atheromas, or
plaques) due to atherosclerosis. Fatty deposits can cause two types of obstruction:

 Cerebral thrombosis is a thrombus (blood clot) that develops at the site of fatty plaque
within a blood vessel that supplies blood to the brain.
 Cerebral embolism is a blood clot that forms in the heart or large arteries of the upper
chest or neck, or at another location in the circulatory system. Part of the blood clot
breaks loose, enters the bloodstream and travels through the brain’s blood vessels until it
reaches vessels too small to let it pass. A main cause of embolism is an irregular
heartbeat called atrial fibrillation. It can cause clots to form in the heart, dislodge and
travel to the brain.

When an artery that carries blood to the brain becomes

clogged or blocked, an ischemic stroke can occur.
Arteries may be blocked by fatty deposits (atheromas,
or plaques) due to atherosclerosis. Arteries in the neck,
particularly the internal carotid arteries, are a common
site for atheromas.

Arteries may also be blocked by a blood clot

(thrombus). Blood clots may form on an atheroma in
an artery. Clots may also form in the heart of people
with a heart disorder. Part of a clot may break off and
travel through the bloodstream (becoming an embolus).
It may then block an artery that supplies blood to the
brain, such as one of the cerebral arteries.
 The physiological demands served by the blood
supply of the brain are particularly significant
because neurons are more sensitive to oxygen
deprivation than other kinds of cells with lower rates
of metabolism. In addition, the brain is at risk from
circulating toxins, and is specifically protected in this
respect by the blood-brain barrier. As a result of the
high metabolic rate of neurons, brain tissue deprived
of oxygen and glucose as a result of compromised
blood supply is likely to sustain transient or
permanent damage. Brief loss of blood supply
(referred to as ischemia) can cause cellular changes, which, if not quickly reversed, can lead to
cell death. Sustained loss of blood supply leads much more directly to death and degeneration of
the deprived cells.

Blood clots in a brain artery do not always cause a stroke. If the clot breaks up spontaneously
within less than 15 to 30 minutes, brain cells do not die and people's symptoms resolve. Such
events are called transient ischemic attacks (TIAs).

If an artery narrows very gradually, other arteries (called collateral arteries—see

figure Supplying the Brain With Blood) sometimes enlarge to supply blood to the parts of the
brain normally supplied by the clogged artery. Thus, if a clot occurs in an artery that has
developed collateral arteries, people may not have symptoms.