C 61 Cerebral Blood Flow

By Prof. Dr. Abdul Majid MBBS, M.Phil, FCPS

Cerebral Blood Flow

Blood flow to the brain is supplied by four large arteries-two carotid & two vertebral arteries-which merge to form a circle of Willis at the base of the brain. The arteries arising from the circle of Willis travel along the brain surface & give rise to pial arteries, which branch out into

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smaller vessels called penetrating arteries & arterioles. The penetrating vessels are separated slightly from the brain tissue by an extension of the subarachnoid space called the Virchow-Robin space. Finally arterioles give rise to capillaries.

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Normal rate of cerebral blood flow: Normal blood flow through the brain of the adult person averages 50 to 65ml/100g/min or 750 to 900ml/min or 15% of the resting cardiac output.

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Regulation of cerebral blood flow: As in other tissues of the body it is highly related to metabolism of the tissue. Several metabolic factors are believed to contribute to cerebral blood flow regulation; 1. Carbon dioxide concentration. 2. Hydrogen ion concentration .

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3. Oxygen concentration. 4. Substances released from astrocytes. Role of CO2: Increase in CO2 in the arterial blood increases cerebral blood flow by combining first with water in the body fluids to form carbonic acid,

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with subsequent dissociation of this acid to form hydrogen ions. The hydrogen ions then cause vasodilatation of the cerebral vessels. Other substances that increase the acidity of the brain tissue include lactic acid, pyruvic & any acidic material formed during the course of tissue metabolism.

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Increased hydrogen ion concentration greatly depresses neuronal activity. Therefore, it is fortunate, that increased hydrogen ion concentration increases cerebral blood flow also.

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Role of oxygen deficiency: Whenever, there is decreased blood flow to the brain, decreased oxygen supply immediately causes vasodilatation. Role of substances released from astrocytes: Astrocytes surround the blood vessels of the CNS.

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Astrocytes are star shaped nonneuronal cells that support & protect as well as provide nutrition. The substances released from astrocytes may be nitric oxide, metabolites of arachidonic acid, potassium ions & adenosine.

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Role of auto regulation: During normal daily activities, arterial pressure can fluctuate widely, rising to high levels during states of excitement or strenuous activity & falling to low levels during sleep. However, cerebral blood flow is auto regulated b/w arterial pressure limits

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of 60 & 140mmHg. (mean ABP) in normal persons. In hypertensive cases upper limit is 160 to 180mmHg. But, if ABP decreases below 60mmHg, cerebral blood flow becomes severely decreased.

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Role of sympathetic nervous system: It prevents vascular hemorrhages into the brain by constriction of large & intermediate sized brain arteries.

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Cerebral stroke occurs when cerebral blood vesicles are block or ruptured: Almost all elderly people have blockage of some small arteries in the brain. Most strokes are caused by arteriosclerotic plaques that occur in one are more of the feeder arteries to the brain.

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The plaques can activate the clotting mechanism of the blood, causing the blood clot to occur & block blood flow in the artery, there by leading to acute loss of brain function in a localized area.

Cerebrospinal Fluid System

The cerebrospinal fluid volume is 150ml & it is formed at the rate of 500 to 550ml/day. This fluid is present in the ventricles of the brain, in the cisterns around the out side of the brain, & in the subarachnoid space around both the brain & the spinal cord.

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All these chambers are connected with one another & the pressure of the fluid is maintained at a constant level. Average pressure is 130mm of water, ranging from 70 to 180mm of water. Functions: A major function of the CSF is to cushion the brain with in its solid vault.

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The brain & CSF have about the same specific gravity so the brain floats in the fluid. Therefore, if a blow to the head is not to intense, moves the brain simultaneously with the skull, causing no one portion of the brain to the contorted by the blow.

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Countercoup: When a blow to the head is extremely severe, it may not damage the brain on the side of the head where blow is struck but on the opposite side. This phenomenon is called countercoup. If contusion occurs on the same side as the impact injury, it is called coup injury.

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Formation, flow & absorption of CSF: About 2/3rd or more of this fluid originates as secretion from the choroid plexuses in the four ventricles, mainly in the two lateral ventricles.

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Additional small amounts of fluid are secreted by ependymal surfaces of all the ventricles & by the arachnoidal membranes. A small amount comes from the brain itself through the prevescular spaces that surround the blood vessels passing through the brain.

Concentration of Various Substances in Human CSF & Plasma

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Flow: The fluid secreted in the lateral ventricles passes first into the 3rd ventricle. It flows down along the aqueduct sylvius into the 4th ventricle. Finally it passes out of the 4th ventricle through three small openings, two lateral foramina of Luschka & a midline foramen of Magendie,

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entering the cisterna magna, a fluid space behind the medulla & beneath the cerebellum. The cisterna magna is continuous with the subarachnoid space that surrounds the entire brain & spinal cord.

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Than the fluid moves upwards from the cisterna magna through the subarachnoid spaces surrounding the cerebellum. From here it is absorbed by arachnidal villi which project into large sagital sinus & other venous sinuses of the cerebellum. These villi act as valves.

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In the brain parevescular spaces act as lymphatics. Causes of high CSF pressure: 1. Brain tumor. 2. Hemorrhage or infection that occurs in the cranial vault. 3. Decrease number of arachnoid villi or abnormal absorptive properties of arachnoid villi.

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Measurement of CSF pressure: The person lies exactly horizontally on his or her side so that the fluid pressure in the spinal canal is equal to the pressure in the cranial vault. A spinal needle is than inserted into the lumber spinal canal blow the lower end of the

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cord & the needle is connected to a vertical glass tube that is open to the air at its stop. The spinal fluid is allowed to rise in the tube as high as it will. If it rises to a level 136mm above the level of the needle, the pressure is set to be 136mm of water pressure

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or dividing this by 13.6, which is the specific gravity of mercury, about 10mmHg pressure. Raised CSF pressure causes edema of optic disc called papilledema. Hydrocephalus: Hydrocephalus mean excess water in the cranial vault.

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Types: 1. Communicated type (External Hydrocephalus). 2. Non-communicated type (Internal Hydrocephalus). Communicated type: The communicated type of hydrocephalus is usually caused

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by blockage of fluid flow in the subarachnoid spaces around the basal regions of the brain or by blockage of the arachnoid villi. Non-communicated type: The non-communicated type is usually caused by block in the aqueduct of sylvius or by the blockage of foramina of Magendie & Luschka .

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Blood CSF & blood brain barriers: The concentration of several important constituents of the CSF are not the same as in ECF elsewhere in the body. Many large molecular substances hardly pass at all from the blood into the CSF are into interstitial fluids of the brain, even though these same substances pass readily into

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the usual interstitial fluids of the body. Therefore, it is said that barriers, called blood CSF barrier & blood brain barrier exist b/w the blood & the CSF & brain fluid respectively. In generally the blood CSF & blood brain barriers are highly permeable to water, carbon dioxide, oxygen,

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& most lipid soluble substances such as sodium, chloride, and potassium; and almost totally impermeable to plasma proteins and most non-lipidsoluble large organic molecules. Brain edema: one of the most serious complications of abnormal cerebral

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fluid dynamics is the development of brain edema. Because the brain is encased in a solid cranial vault, accumulation of extra edema fluid compresses blood vessels, often causing seriously decreased blood flow & destruction of brain tissue.

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Causes: The usual cause of brain edema is either greatly increase capillary pressure or damage to capillary wall that makes a wall leaky to fluid, a common cause is serious blow to the head leading to brain concussion, in which the brain

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tissues & capillaries are traumatized & capillary fluid leaks into the traumatized tissues. Positive feedback mechanism sets in leading to further decreased blood flow, dilatation of arterioles & damage to sodium potassium pumps & edema of cells.