Chapter Two: Literature Review

Chapter Two

Literature Review

Part (I)

2.1. Historical Overview about stroke:

Episodes of stroke and familial stroke occurrence have been reported as
early as 2700 years ago in ancient Mesopotamia and Persia (Ashrafian, 2010).

Hippocrates, the “father of medicine,” first recognized stroke, he called the

condition apoplexy, which is a Greek term that stands for “struck down by
violence.” While the name described the sudden changes that can occur with a
stroke. From the late 14th to the late 19th century the word apoplexy was also
used to describe any sudden death that began with a sudden loss of consciousness,
especially one in which the victim died within a matter of seconds after losing
consciousness. The word apoplexy may have been used to describe the symptom
of sudden loss of consciousness immediately preceding death and not an actually
verified disease process. Physicians had little knowledge of the anatomy and
function of the brain, the cause of stroke or how to treat it and the only established
therapy was to feed and care for the patient until the attack ran its course. Even
myocardial infarction may have been described as apoplexy in the past (J. E.
Thompson, 1996).

As technology advanced, physicians and scholars began to evaluate

pathophysiological changes. Thomas Willis (1621-1675), the leading
neuroanatomist of the 17th century, did much experimental work performed
injection experiments on cadavers and noted that if he injected the carotid artery
on one side, the dye solution would come from the carotid on the opposite side.
In 1664, Willis published his monumental work Cerebri Anatome, the most
complete and accurate account of the nervous system that had hitherto appeared,

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and a description of the hexagonal net- work of arteries at the base of the brain
that we know as the circle of Willis. Although others had described the circle
before Willis, he was the first to grasp its physiological and pathological
significance. He recorded the clinical histories of two patients in whom he
suggests that the anatomical configuration of the arteries at the base of the brain
could prevent apoplexy. Willis was the first to recognize that lesions in the region
of the internal capsule will produce hemiplegia (J. E. Thompson, 1996).

In 1658, in his Apoplexia, Johann Jacob Wepfer (1620–1695) discovered

that something disrupted the blood supply in the brains of people who died from
apoplexy. He also discovered the cause of hemorrhagic stroke when he suggested
that people who had died of apoplexy had bleeding in their brains. Wepfer also
identified the main arteries supplying the brain, the vertebral and carotid arteries,
and identified the cause of ischemic stroke, or cerebral infarction, when he
suggested that apoplexy might be caused by a blockage to those vessels. Thus
stroke became known as cerebrovascular disease (National Institute of
Neurological Disorders and stroke (NINDS), 2020).

In the decades that followed, medical science continued to study the cause,
symptoms, and treatment of apoplexy. In the 1900s, the focus of physicians’
attention began to change from characteristics of individuals to those common
characteristics shared by all patients who experience strokes. Their attention
shifted to physiological changes instead of focusing solely on outward clinical
signs and, finally, in 1928, apoplexy was divided into categories based on the
cause of the blood vessel problem. After this, apoplexy became known by such
terms as stroke and cerebrovascular accident (CVA)." Stroke is now often
referred to as a "brain attack" to denote the fact that it is caused by a lack of blood
supply to the brain, very much like a heart attack is caused by a lack of blood
supply to the heart (Demarin et al., 2011).

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Today, there is a wealth of information available on the types, cause,
prevention, risk, and treatment of stroke. Although there is no cure, most stroke
victims now have a good chance for survival and recovery. Immediate treatment,
supportive care, and rehabilitation can all improve the quality of life for stroke
victims (Demarin et al., 2011).

2.2. Anatomy and Physiology of Human Brain:

Brain and spinal cord, constituting central nervous system, have high
metabolic demand as these are made up of very sensitive and delicate nervous
tissue. This demand is fulfilled by aerobic combustion of glucose. For this, there
is very much necessity of adequate and continuous supply of glucose and oxygen
Which are transported through bloodstream. It is interesting to note that, though
central nervous system (brain and spinal cord) constitutes only 2% of body
weight, it receives 17% of cardiac output and utilizes 20% of total oxygen utilized
by body. Central nervous system tissue is very much sensitive and highly
vulnerable to injury due to lack of blood supply, so lack of oxygen (hypoxia).
Experimental studies as well as clinical observation established that, in case of
arrest of blood supply to the brain for 10 seconds, there occurs loss of
consciousness and if it continues for 10 minutes for even a tiny area of the tissue,
it leads to irreversible damage (Samar Deb, 2014).

The brain lies in the cranial cavity and weighs between 1450 and 1600 g. It
receives 15% of the cardiac output and has a system of autoregulation ensuring
the blood supply is constant despite positional changes. The arrangement of the
arteries serving the brain is unique, and they are connected to each other by a
structure called the circle of Willis (see Figure 2.1). This arrangement ensures
that blood pressure remains equal in both halves of the brain. Should one of the
arteries serving the brain become narrowed by arterial disease or thrombus then

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there will be an alternative route available, maintaining the essential supply of
oxygen and glucose required by the brain (Peate & Muralttharan nair, 2017).

Figure 2.1 Circle of Willis. Source (Tortora & Derrickson, 2009).

Nearly 100 billion neurons compose the adult brain, which can be divided
into the cerebrum (with two cerebral hemispheres), diencephalon, brain stem
(which includes the midbrain, pons, and medulla oblongata), and cerebellum
(Jahangir Moini, 2020) (see FIGURE 2-2).

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FIGURE 2-2 The structures of the brain (Tortora & Derrickson, 2017).

The brain’s major parts can be classified or categorized in several ways. In

all of these systems, the dominant part is the cerebrum, the large pinky-gray
wrinkled structure that forms more than three-quarters of the brain’s total volume.
The cerebrum is divided into left and right hemispheres, which are linked by a
“bridge” of nerve fibers, the corpus callosum. The cerebrum, which includes the
hippocampus and amygdala, is also known as the telencephalon. Together with
the parts it wraps around the thalamus, hypothalamus, and associated parts,
collectively known as the diencephalon it comprises the major brain “division”
known as the forebrain (prosencephalon). Below the forebrain is the midbrain
(mesencephalon), a small division that includes groups of nerve-cell bodies
known as nuclei, such as the basal ganglia. Below the midbrain is the hindbrain
(rhombencephalon), with the pons as its uppermost part, and beneath it the

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cerebellum and the medulla, which tapers to merge with the spinal cord (Carter
et al., 2019).

Brain is richly supplied by arteries. Brain is encased inside cranial cavity

and covered by meninges (see FIGURE 2.3). Source of the arteries are from
outside the cranium so these arteries will have to enter the cranium. Entering the
cranium, the arteries and their main branches pierce dura mater and then
arachnoid mater and are initially placed in subarachnoid space. Final sets of
branches penetrate brain tissue in the form of two groups which are.

1. Superficial (cortical): Which have two characteristics.

a) They supply superficial cortical part of brain.
b) They form anastomosis on the surface of the brain which will help in
collateral circulation.
2. Deep (central, ganglionic or nuclear): Which have two characteristics.
a) They supply deeper part of brain, e.g., white matter (fiber bundles) and
deep-seated mass of gray matter like basal nuclei.
b) These branches are end arteries which do not have any anastomosis before
capillary level.
 Sources of arteries: Sources of arteries to the brain are from two bilateral
arterial systems which are.
1. Vertebrobasilar arterial system.
2. Carotid arterial system (Samar Deb, 2014).

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FIGURE 2.3 Cranial meninges associated with the brain (Carter et al., 2019).

The brain, is the largest and most complex part of the nervous system,
contains nerve centers associated with sensory perceptions and integration. It
issues motor commands to skeletal muscles and carries on higher mental
activities. The brain coordinates muscular movements and regulates the functions
of internal organs. The cranial meninges surround the brain and are continuous
with the spinal cord meninges. The cerebral cortex, comprised of gray matter with
billions of interneurons, represents areas for conscious awareness and decision-
making processes. Sensory areas receive information from various receptors,
association areas interpret sensory input, and motor areas involve planning and
controlling muscle movements. All of these functional regions are influenced and
integrated together in making complex decisions. Each hemisphere primarily
interprets sensory and regulates motor functions on the opposite (contralateral)
side of the body. Twelve pairs of cranial nerves arise from the base of the brain
and are designated by number and name (see FIGURE 2.4). The cranial nerves

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are part of the PNS; most arise from the brainstem region of the brain. Although
most of these nerves conduct both sensory and motor impulses, some contain only
sensory fibers associated with special sense organs. Others are primarily
composed of motor fibers and are involved with the activities of muscles and
glands (Carter et al., 2019).

FIGURE 2.4 The cranial nerves attached to the base of the human brain (Tortora &
Derrickson, 2017).