What is Cerebral Ischemia? - Oren Zarif - Cerebral Ischemia

During a stroke, cerebral ischemia occurs when blood vessels in the brain become blocked. The brain then cannot receive sufficient oxygen or nutrients. Treatment involves restoring breathing, heart rate, and blood pressure. Next, efforts are made to reduce pressure within the brain. tPA, an anticoagulant, cannot be used to treat ischemia, but patients who take anticoagulants are not a good candidate for this procedure. Surgical removal of clots may be necessary and may take place up to 24 hours after the stroke symptoms have started. Anticoagulants and aspirin are long-term treatments.

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Depending on the type of ischemia, the brain can suffer from focal or global ischemia. In a focal ischemia, a blood clot blocks blood flow to a specific region of the brain. If a blood clot is causing the ischemia, it is called focal ischemia. Another type of cerebral ischemia is called embolism. A small piece of clot can also cause focal ischemia.

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When the brain is affected by ischemia, histological changes occur within 12 to 24 hours. Neurons shrink and become "red," which is a result of cytoplasmic eosinophilia and nuclear pyknosis. These neuronal cells eventually die. The brain also undergoes liquefactive necrosis. As a result, the brain tissue appears as viscous material that contains neutrophils and cell debris.

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One of the most common causes of cerebral ischemia is a heart attack. When untreated, a heart attack may result in a blood clot and slow the flow of blood to the brain. This clot can even prevent blood flow to major organs. Besides heart attacks, other medical conditions can cause cerebral ischemia, such as sickle-cell anemia. If the patient has a congenital heart defect, he or she may be more susceptible to developing blood clots.

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When CBF fails, a global cerebral ischemia results. Neuronal necrosis results in selective degeneration of neurons. Early in the ischemic period, cytotoxic edema results from the breakdown of the blood-brain barrier. Moreover, glutamate release triggers massive intracellular calcium concentration and excitotoxicity, which causes neuronal death. Another factor contributing to brain injury is tissue acidosis, which is particularly important in hyperglycemic states.

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While cerebrovascular disease is the most common cause of ischemic stroke, there are other underlying causes as well. Blood clots block the flow of oxygen-rich blood to the brain. In addition to clots, atherosclerosis, and tumors can impede blood flow in the arteries. If this happens, cerebral ischemia can cause serious problems. Therefore, it's important to recognize the causes and treatment of cerebral ischemia as soon as possible.

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In the last decade, new insights have been made regarding the pathogenesis of delayed cerebral ischemia (DCI). The sole causal mechanism of DCI has been challenged by several hypotheses. Microcirculation dysfunction, impaired autoregulation, and spreading depolarization are now among the alternative explanations. Preventing DCI largely relies on optimizing cardiac performance and blood volume. Neurological monitoring is essential for early detection and treatment.

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Cerebrovascular ischemia can be either focal or global. The former occurs when a blood clot blocks an artery, and affects a small area of the brain. The latter occurs when the brain receives little blood flow and an entire region of the brain is affected. Surgical treatment depends on the severity of the symptoms, and the region affected. Surgery is usually performed only for severe cases. While surgical treatment may be necessary, it's not recommended for the majority of cases.

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An ischemic stroke can have many symptoms, including the following: a coma, decreased awareness, and difficulty breathing. Transient ischemic attack is characterized by temporary blockages of blood flow to the brain. It usually resolves on its own, although symptoms like facial drooping and difficulty raising the arm may occur as a warning sign of a full-blown ischemic stroke. Once diagnosed, treatment is needed to restore normal functions to the brain.

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The brain heals itself over a period of four to six weeks. There are two major pathways of neuronal death. Early neuronal death occurs due to necrosis, while delayed neuronal death is due to apoptosis. Inflammation increases the chances of cellular death. There are several ways to reverse the damage. One way is through poststroke therapy. In the meantime, poststroke therapies can reduce brain ischemia and slow the progression of the stroke.

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The initial workup of suspected cerebral ischemia includes basic lab tests such as a complete blood count, coagulation factors, EKG, and cardiac enzymes. A stat non-contrast head CT is also necessary to rule out hemorrhage or mass lesion. Vascular imaging is useful in identifying the cause of acute ischemic stroke, particularly in cases of large vessels. The patient may experience cytotoxic edema.