CEREBRAL ARTERY

The carotid and vertebral arteries pass through the neck to

supply blood to the head and brain.

The two carotid arteries The vertebral arteries

are located in the front
of the neck on either
side of the throat. These
arteries supply blood to
the face and cerebrum.
are two smaller arteries
that pass through the
spine into the brain.
They primarily supply
blood to the brain
stem, occipital and
cerebellum.
Motoneural pathways
Corticospinal- conduct motor impulses to the
anterior horn from opposite side of brain.
- control voluntary muscle activity

Vestibulospinal- uncrossed; ANS function

Corticobulbar- cross; for voluntary head and facial
muscle movement
Rubrospinal and reticulospinal- involuntary muscle
movement.
Peripheral nervous system
Cranial nerves-
> 12 pairs
> 3 sensory, 5 motor, 4 mixed

Spinal nerves
> 8-cervical, 12 thoracic, 5 lumbar, 5 sacral, 1
coccygeal
Roots
Dorsal- sensory from specific areas of body
Ventral- motor; from spinal cord to body; either somatic
or visceral- ANS.
Basic concepts in normal
neurologic function
Oxygen supply- brain requires 20% of O2 in the body
Glucose supply- brain requires 67 to 70% of glucose
in the body
Blood supply- brain requires 1/3 of cardiac output
CSF- 100-150 ml
 The single most important assessment
Evaluation of level of consciousness (LOC) and mentation are the most important
parts of the neuro exam. A change in either is usually the first clue to a deteriorating
 Full consciousness. The patientcondition.
is alert, attentive, and follows commands. If
asleep, she responds promptly to external stimulation and, once awake,
remains attentive.

 Lethargy. The patient is drowsy but awakens—although not fully—to

stimulation. She will answer questions and follow commands, but will do so
slowly and inattentively.

 Obtundation. The patient is difficult to arouse and needs constant

stimulation in order to follow a simple command. She may respond verbally
with one or two words, but will drift back to sleep between stimulation.

 Stupor. The patient arouses to vigorous and continuous stimulation; typically,

a painful stimulus is required.1 She may moan briefly but does not follow
commands. Her only response may be an attempt to withdraw from or
remove the painful stimulus.

 Coma. The patient does not respond to continuous or painful stimulation.

She does not move—except, possibly, reflexively—and does not make any
verbal sounds.
Assessing Cerebral Function
Mental Status-appearance and behavior, speech,
orientation (Frontal, Parietal, temporal)
Intellectual Function- count, interpretation of
saying/proverb (Frontal, Temporal)
Thought content- insights, ideas, illusions (Frontal)
Emotional Status- affect/mood appropriate (Frontal)
Perception- interpretation ability (Temporal)
Motor ability- perform skilled activity (frontal)
Language ability (Frontal, Temporal)
TO ASSESS MOTOR FUNCTION
AND CEREBELLAR FUNCTION
1. Resistance (place muscle at disadvantage)
2. Point to point testing/ rapid alternating
movement (coordination)
upper- pronate-supinate, finger touch
lower- heel to tibia
ataxia- uncoordinated voluntary muscle
coordination= cerebellar disease
3. Romberg’s test + vestibular dysfunction
heel to toe walk, hop in place (balance)
ASSESSING SENSORY FUNCTION

Begin with the feet and move up the body to the face,
comparing one side with the other. Refer to figure 60-11
for dermatome distribution of sensory nerves.

1. Tactile- cotton wisp touch, compare proximal and distal

2. Pain and temperature
3. Vibration- use of tuning forks signal when vibration
ceases
4. Proprioception- toe up and down determine direction.
5. Integration of sensation- 2 point discrimination
Stereognosis-objects and describe
Other reflexes
Corneal- blink (CN V and VII)
Abdominal reflex
Gag-swallowing (CN X)
Plantar- toe flexion
Cremasteric reflex
Oculocephalic- (-) no eye movement
(CN III,IV,VI)
Oculovestibular- caloric ice reflex
assess intact brain stem
Causes of altered level of
consciousness
   Structural: brain lesions that destroy tissue or occupy space that is
normally occupied by the brain·          Epilepsy·          Tumors·         
Trauma·       
 Cardiovascular: temporary or permanent interruption to the blood
supply to the brain·          Vasovagal response·          CVA         TIA·         
Hypertensive encephalopathy·          Shock·          Dysrhythmias·      
   Metabolic: abnormally high or low levels of circulating
metabolites·          Hypoxia·          Hypoglycemia·          Hyperglycemia·         
Renal failure (uremia)·          Liver failure·          Infection (sepsis)·       
 Environmental: external factors that cause deterioration of central
nervous system function·          Overdose·          Toxins·      
   Behavioral: abnormal mental status that results from internal
factors·          Psychiatric disorders 
Mnemonic for Causes of Altered Level
of Consciousness
A - alcohol, acidosis, anoxia
E - epilepsy, environment
I - insulin (diabetes)
O - overdose
U - uremia (metabolic), underdose
 
T - trauma, toxins, tumors
I - infection (sepsis)
P - psychiatric disorders
S - stroke (CVA)
3 compensatory mechanisms- ICP
Autoregulation- depends on cerebral perfusion
CSF regulation- production and reabsorption
depends on intra-cerebral volume.
Metabolic regulation-
↓O2 ↑CO2 = vasodilation =perfusion = ↑ICP (if
other 2 compensatory mechanisms are not
functioning properly)
Need to know:
 ICP -measure of CSF pressure.
> normal value- 10-20 mmHg
> value greater than 20 mmHg –intracranial hypertension
> rate of CSF production (0.3-0.4 cc/min)
>rate of CSF reabsorption
>pressure exerted in the sagittal sinus
as CSF returns to heart.
 Normal ICP- 5-15 mmHg
mild elevation- 16-20 mmHg
moderate elevation- 21-30 mmHg
severe elevation- 31-40 mmHg
very severe elevation - ≥ 41 mmHg
Cerebral Pressure Perfusion=
mean arterial pressure (MAP) – ICP =CPP
normal = 70-100 mmHg

Mean Arterial Pressure=

Systolic BP + (2 x Diastolic BP) ÷ 3 =MAP

CPP is inversely proportional to ICP

(e.g. inc. ICP = ↓ CBV to brain = ↑CO2 and ↓O2 = hypoxia)
Types of cerebral Edema
Vasogenic Edema- ↑ osmotic pressure in extracellular compartment
-due to head trauma
tx: osmotherapy, positioning,
diuretics, steroids

Cytotoxic Edema- failure Na- K pump in intracellular compartment

- due to water intoxication, encephalitis, hypoxia
tx: osmotherapy, hyperventilation

Interstitial Edema- increase CSF, Na and water around ventricles

-due to obstructive hydrocephalus
tx: temporary drain
Meds…ICP
Osmotic diuretic (mannitol) –reduce edema, check
hourly urine
Anti seizure drugs (dilantin)it crystallize ; provide
good oral care and massage gums
Corticosteroids (decadron)- reduce edema
H2 antagonist- (tagamet)- reduce acid production
Stool softeners

Opiates and sedatives are contraindicated coz of

respiratory depression and acidosis
Nursing Care:ICP
Safety
Maintain head midline to facilitate blood flow
Maintain head of bed 30-45 degrees
Avoid activities that can increase ICP
Treat hyperthermia and avoid infection, dressing care
Decrease environment stimuli- dim lights, speak softly,
touch gently, space interventions
Maintain fluid balance via accurate I and O
Monitor electrolyte balance
Monitor hyperventilation
Skin and mouth care
Primary trauma- types of skull
fractures (pp.1481, table 57-6)
Concussion- transient disorder due to injury in which
there is a brief loss of conciousness due to paralysis of
neuronal function
Contusion- extravasation of blood cells
Laceration- tearing of brain tissue or blood vessel due to
sharp brain fragment
Fracture-
 Linear- epidural bleeding
 Basilar- (most serious) may result in brain abscess or
meningitis
 Ottorhea or rhinorrhea
 Battle’s sign
 Raccoon eyes
Pathophysiology- head injury
1. depressed neuronal activity in RAS depressed
consciousness
2. depressed neuronal functioning in lower brain stem
and SC  depression of reflex activtiy  decreased eye
movements, unequal pupils  decreased response to
light stimulation  widely dilated fixed pupil
3. depressed respiratory center altered respiratory
pattern  decreased rate  respiratory arrest

For signs and symptoms see table 57-7 page 1482

Asssessment…brain tumor
Frontal lobe
 Personality disturbances
 Imappropriate affect
 Indifference of bodily functions

Precentral gyrus
 Jacksonian seizures
Occipital lobe
Visual disturbances preceeding convulsion
Temporal lobe
 Olfactory, visual and hallucinations
 Psychomotor seizures

Parietal lobe
 Inability to replicate pictures
 Loss of right-left discrimination
Subcortical
 hemiplegia
Meningeal tumors
 Symptoms are assc with compression of the brain and depend on
tumor location
Metastatic tumors
 H/A, N/V, because of Inc. ICP
Thalamus and sellar tumors
 H/A, N/V, vision disturbances, papilledema and nystagmus occur
from inc ICP, DI
4th and cerebellar tumors
 H/A, N/V and papilledema from inc ICP; ataxic gait and changes in
coordination
Cerebellopontine tumors
 Tinnitus and vertigo, deafness
Brainstem tumors
 H/A on awakening, drowsiness, vomiting, ataxic gait, facial muscle
weakness, hearing loss, dysphagia, dysarthria, “crossed-eyes”
craniotomy
Excision of a part of the skull (burr hole to
several centimeters)
for exploratory purposes and biopsy
To remove neoplasms
Evacuate hematomas or excess fluid
Control hemorrhage
Repair skull fractures
Remove scar tissues
Repair or excise aneurysms
Drain abscesses