Peripheral Vestibular and Cerebellum Disorders. Transcript General Cerebral Vasculature Review and Vascular Syndromes of the Vestibular System

Peripheral Vestibular and Cerebellum Disorders with Applications (MODULE FOUR) Transcript General Cerebral Vasculature Review and Vascular Syndromes of the Vestibular System Presentation by Dr. Datis Kharrazian Okay, we re going to get into general cerebral vasculature blood flow, and we re going to transition to the vestibular system. So, one of the things I just want you guys to know is, you ve been learning through the process. I think at this point, everyone s learned the basic regions of the brain, their functions of deficit, their functions of spontaneous activity. You guys know seizures, you guys know the exam findings, you guys have forms to explain all the symptoms. So for the most part, you have all the major forms, but there is a major deficit in what we ve shared with you that we don t want to let it continue any longer. We need to make sure you guys know the vasculature. So we re going to review just general cerebral vasculature, and then what I m going to do is, I m going to end that with how cerebral vasculature involvement takes place with dizziness and vertigo, the syndromes that can cause dizziness and vertigo, whether it s vestibular migraine, whether it s stroke, whether it s vertebral basilar insufficiency. Whatever those key things are as it relates to these concepts. And then what s going to happen is, Dr. Brock will then start teaching everyone diff-di, and for the most part, the first day, we re really going to go over the basic physiology concepts, differential diagnosis, applications, and then tomorrow, we start with treatments. So we re going to go into nutritional, neurochemical applications for all the vestibular diseases, and then we re going to go into actual repositioning and therapeutic strategies for the vestibular system. Okay? But you have to know what you re treating, and you have to know what things you treat and what things you refer out, what things are emergencies, and so forth. So, this is the overview for this module. We re going to cover each of these major topics as we go through. So, right now we re going to go into general cerebral vasculature and vascular syndromes of the vestibular system. Now, once we get with this through this, we ll go into how all these pathways integrate, and then Dr. Brock will go into integration, and that will really, I think lead Hopefully you guys will leave here with a very good understanding of vestibular basic physiology and integration and so forth. These are the different types of vestibular conditions. So when you look at someone who s got a peripheral vestibular disease, is it inflammatory? Is it vascular? Is it structural? Is it endolymphatic hydrop? Is it MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 1

vestibular receptor site damage? Or is it essential lesion or integration disorder, which we ll focus mostly next module on. So, the goal of this module is for you guys to have someone come in that has, let s say, dizziness or vertigo, and then you re going to go through each of these diff-dis. Is it that the vestibular system s inflamed? Is there lack of blood supply going there? Is there a rupture, you know, an open window or round window? Do they have otosclerosis? Is there a compressive tumor? Is it a dislodged crystal? These are the key things that all have characteristic patterns. Do they have Ménière s disease? Do they have this hydrop? Do they have some kind of drugs? Medications cause ototoxicity. So if you know this flow chart, you should be able to like I said someone comes in with dizziness, just smile, because you can easily go through it. Okay? Now, what I m going to focus in will be the vascular parts of this at the end, but I want to review the vascular syndromes first. Now, for the most part, one of the key things with vascular insults, when you look at patients that come in with dizziness, the key thing that strongly suggests to you that there s a vascular component to their dizziness, is there s a rapid onset or acute symptoms. That s a very characteristic pattern of infection to the vestibular system, or some time of vascular compromise. Okay? So immediate onset of dizziness, just came out of nowhere, it s severe, it s sudden, you immediately start to think: Is it inflammatory? Or is it vascular? Okay? To be honest, most people that have an acute immediate onset of symptoms are generally just going to go to the ER, and get help. They re not going to, like, walk into, let s say, an alternative health care provider, or a rehabilitation center. They re going to go, There s something seriously wrong, they re scared, and they re going to go in. However, you may be with a patient, or the patient trusts you and nobody else, and they come in and they have an acute onset of symptoms, so but for the most part, when people if you had immediate dizziness and vertigo, and all of these sudden onset symptoms, you would probably end up, you know, calling for help and things like that. But the key feature of these pathways is that they re acute onset. So what I want to really go over I have about four parts to this presentation that will take us into lunch. I want to review the cerebrovascular circulation, I want to show you some tools we made for you, so it can really help you learn this very efficiently, and then I want you guys to understand how using cerebrovascular collateral shunting can support brain therapy. So if you have an area of the brain that s injured, you may not activate that area of the brain directly with stimulus, but you may activate another region that shares the same vascular supply, to shunt blood there, because they re too unstable. Okay? Or, there s reasons sometimes when you do some kind of stimulus to the patient that doesn t involve that part of the brain, but it changes that function, because you re actually activating similar blood supply. Okay? It s not Activation is not all about activating a specific region, but it s also shunting blood there, okay? And then you want to understand cerebrovascular pathology, so we ll talk about these: Whether it s TIA, or stroke, or vestibular migraine, or vertebrobasilar insufficiency. They all have characteristic patterns. I want to make sure you guys are familiar with those. And then we ll focus at the very end on, as we transition more specifically into this vestibular module, the vascular insults that cause vertigo and dizziness. Okay? Because whether we re focused on peripheral or central, you ve got to know what the red flags are. You ve got to make sure you know when someone is coming in and they have a stroke, versus some type of vestibular peripheral disorder, right? You just have to know that. So we have to cover this as a key part of MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 2

your diagnostic skill, so you don t miss something that could really impact someone s life in a negative way, and you have any medical legal issues, and things of that nature. Getting the patient where they need to go. So, one of the key things, to start with, with cerebrovasculature is just this circle of Willis. I m sure you guys all remember studying this, right? Just take a second right now. Grab a piece of paper, and let s just go through this really quickly, okay? There s some things you re just going to have to memorize, or you ll never be good at this. Okay? This is one of them. This diagram right here is something that you should be able to just do from memory. It s going to save you a lot of time as you learn all the To try to learn vasculature without knowing this would make this very, very difficult, okay? So, when you look at the vasculature, they refer to brain vasculature, cerebral vasculature There s the anterior circulation and posterior circulation. So here you see the internal You see the internal carotid artery that comes in, becomes the middle cerebral artery that s part of the anterior circulation. And then you have the vertebral arteries that then combine and form the basilar artery, which is your posterior circulation. So, let s start here. You have two vertebral arteries that come together. So, if you guys can take a piece of paper and then draw one side, and then draw the other side coming in, and you have the two vertebral arteries forming the basilar artery. So they re coming in through the front of the spinal cord, and they go through right? the cervical spine, and the foramen cervical foramen they go all the way through, they get up to the medullary areas. Right around the pons they form together, become the basilar artery. Right? So they re right in front of the brain stem. And the key thing that I want you to really make sure you understand is, we re not so concerned about the anterior spinal artery, but we re in this module but we see this first branch before it becomes the basilar artery? This is the posterior inferior cerebellar artery. This is a common area for stroke, and this is a common area for dizziness and vertigo. So you just want to understand where this is. This is the artery that supplies the cerebellum. When you have vertebrobasilar insufficiency, and you have compromise in the vertebral arteries, or you have plaquing in these arteries, there s less blood flow into the split, the division, the posterior inferior cerebellar artery. PICA. Right? It s called PICA syndrome, or Wallenberg syndrome, or lateral medullary syndrome. This is all involved with that. So again, know that the vertebral artery is from the basilar, but the branch before they form the basilar is the posterior inferior cerebellar artery. Now, the basilar artery gets formed, and then you have a branch off it, and this is the anterior inferior cerebellar artery. This is important to us because any compromise of the anterior cerebral artery can also cause dizziness and vertigo. This would be a lateral pontine syndrome. Okay? Then you have the basilar you have these pontine divisions of the basilar artery, and then these are going to then the basilar artery s going to then form again into two separate divisions called the posterior cerebral artery, but before it becomes the posterior cerebral artery, you have the superior cerebellar artery. [9.31] So basically, you have three major blood supplies to the cerebellum and to pathways from the cerebellum to the brainstem: the posterior inferior cerebellar artery, the anterior inferior cerebellar artery, and the superior cerebellar artery. Which means that if someone has a vascular compromise that causes dizziness, MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 3

and other brainstem symptoms, you re thinking of one of these three arteries, most common one being the posterior inferior cerebellar artery. Okay? So, here s another way to look at it. If someone has a vascular compromise, and they have dizziness as one part of their component, and nausea and vertigo and nystagmus, if it s a vascular component, you re looking at blood supply to the cerebellum, which is posterior inferior cerebellar, anterior inferior cerebellar, and superior cerebellar artery. Those are the three main arteries. Okay? Now, when you look at the blood supply so we re going to focus on those again at the end, and I m going to show you those syndromes and how they all bridge I just want to give you the big picture first, as a review. So the posterior cerebral arteries So the basilar artery then divides to left and right posterior cerebral artery, and for the basic concept, the posterior cerebral arteries, they give vascularization of blood supply to the posterior areas of the brain, the midbrain, the top part of the brainstem, and the thalamus. Right? Just know the generalizations: Posterior cerebral artery is going to give vascularization and blood supply to the posterior regions of the brain, the top part of the brainstem, the midbrain, and the thalamus. Okay? Because, you guys, if you try to just If you get overwhelmed trying to memorize every single little branch and their name, you re wasting time. Just know the basic concepts, okay? Now, the posterior cerebral arteries then basically attach to the internal carotid artery where you have the middle cerebral artery. So here you see the internal carotid artery. Obviously it s coming in, in the front, and then that turns into the middle cerebral artery, and then the middle cerebral artery gives blood supply to the frontal parietal cortical areas. Right? There s an inferior and [superior] division, some of it temporal, and the outer part of the front of the brain is mostly middle cerebral artery. And then you have the middle cerebral artery that then branch Then you have branches off the middle cerebral artery, the anterior cerebral artery, and the communicating branches of them. And then the anterior cerebral artery s going to give blood supply to a Mohawk distribution midline, parasagittal. Okay? So, really, really, simple. Posterior cerebral artery, posterior division okay? of the brain, top of the brainstem, the midbrain, and the thalamus. The middle cerebral artery is going to be your frontal, parietal, even some parts of your temporal areas, but the anterior division of the brain and bits of the cortical area of the brain, and the middle cerebral artery has deep branches which vascularize the internal capsule. The internal capsule is a very common area for stroke. So a lot of pure motor strip hemipareses, pure sensory type patterns, are in the internal capsule, which is supplied by deep branches of the middle cerebral artery. Okay? And then you have the anterior cerebral artery, which is the Mohawk distribution in the front. So, look at some pictures. You can see how they work. So, here they are when you look at them on a brain specimen. Two vertebral arteries coming together; there s the basilar artery. There s your posterior inferior cerebellar artery. You can see that it s giving vascular supply to the cerebellum. And then you can see the brainstem here. This comes off, and then you have divisions to the cerebellum, the anterior and inferior cerebellar. And then before the basilar artery divides again, you have the superior cerebellar arteries. So those are the three vascular supplies to the cerebellum. And then you can see the posterior division here, coming in. But as you see the posterior communicating artery combined with the internal carotid artery, and becoming the middle cerebral artery, the middle cerebral artery comes into deep areas inside the brain, fires gets blood flow to the internal capsule there s the basal ganglia and then the anterior portion of the brain. And then the anterior cerebral arteries come in, and they go midline, in the middle of the brain. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 4

So if you ever take a brain specimen, and it s like and you pull it open like that, the blood supply you see there, that s all anterior cerebral artery. Okay? So, here s another illustration. But I want you to see something. You see the temporal lobe here? I want you to see, if you look at the middle cerebral artery, you see the temporal lobe? When they cut it off, you can see that the middle cerebral artery branches out to the cortex, but then these inner branches here, these lenticular striatal arteries, go into the internal capsule, the common area for stroke, especially lacunar strokes. Okay? So, here s a picture of the middle cerebral artery. You can see that you have superior divisions, inferior divisions, and all the areas of the frontal lobe, the parietal lobe, some areas of the temporal lobe are all supplied by the middle cerebral artery. And you know, you can go down and memorize all these different names, but I just want you to understand the concepts. Now, we have an entire module just on vascular syndromes and the vasculature, but we have to make sure, as we re getting you guys to where we want to take you, you guys at this point know the vasculature and the basic concepts. It s going to help you as you divine rehab protocols and all the other various things that we re going to get into clinically. Now, here s the posterior cerebral artery. So, here s what s been cut out. The basilar artery and the brainstem have been cut out. The pons This is the midbrain, so this is the basilar artery, then forming two divisions, and then you can see the posterior cerebral artery gives blood supply to the midbrain. You guys all see that, right in there? And then it gives all the blood supply to the posterior divisions of the brain, occipital lobe, the caudal areas of the temporal lobe. And then here s the anterior cerebral artery. This is all midline. So your Mohawk vasculature. Okay? Here s another picture. You guys can see, again, how it looks in the brain. So I just want you to see these images so you can get these oriented with yourself, okay? So and here you guys see a really good illustration of cerebellar vasculature. You see the vertebral artery coming up to form the basilar. Here we see the posterior inferior cerebellar artery coming off here. Here we see the anterior inferior cerebellar artery. And then here you guys, up here, can see the superior cerebellar artery. Okay? These are vascular syndromes. And here s another illustration of the cerebellum pattern. So let s recap one more time. Vertebral arteries. They come in. Before they form at the basilar artery, there s a branch: posterior inferior cerebellar. Then they become the basilar artery, right? Basilar artery has a first division: anterior inferior cerebellar artery. Goes all the way up, you have pontine branches. Before it divides, there s another branch called the superior cerebellar artery. Then the posterior cerebral artery right? develops, and you have communication to the internal capsule, and the middle cerebral artery branches off I m sorry, to the internal carotid artery. Then the middle cerebral artery branches off to the internal carotid artery, then there s a branch anterior, the anterior communicating artery, to the anterior cerebral arteries, and then you have that vasculature. Okay? Posterior cerebral artery: midbrain, thalamus, posterior brain circulation. Middle cerebral artery: anterior brain circulation, and the internal capsule, right? Middle cerebral artery. Anterior cerebral artery is going to be the Mohawk distribution throughout. Easy. Okay? Which one causes Which branches cause dizziness MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 5

and vertigo and nystagmus? Posterior inferior cerebellar, anterior inferior cerebellar, or superior cerebellar? Okay? Which one would cause a stroke pattern only in the feet? Anterior Cerebral Artery, because the Mohawk. Remember the somatosensory cortex? What would spare the feet but cause loss in face and arm? Middle cerebral artery. Because remember that homunculus distribution? So the minute you, you know, you see someone s impairments, if you know your vasculature, you can go, Oh, that s the blood supply, right? So, what we did intentionally is, we gave you the brain compilation charts very first, and then made sure you guys knew all the regions and all the sections and knew all the functions, and now we re going to overlap the circulation and the vasculature over it, so now these strokes and terms are really easy to learn, because you already know the functions. You ve just got to know the general concepts of these blood supplies are to that they go to. Okay. Here s some other, just, illustrations so you can see the picture and really get this in your visual memory. Middle cerebral artery you see in red, and then you can see the anterior cerebral artery and Mohawk distribution, and then posterior cerebral artery, the posterior regions of the brain. Okay? If you look at the specimen here, this thing, this vasculature on the outer area, this whole area here is the middle cerebral artery, and then parasagittal anterior cerebral artery. Okay. So as you guys know, up to this point, we gave you this brain region localization form, and we gave you this brain compilation form. Okay? So, what we ve added to your intake forms, this module, just a basic vasculature atlas, Okay? This are just some really beautiful diagrams that summarize the vasculature and blood flow to the brain. Make sure you guys know them, right? Whenever we give you a form or compilation form, that means you need to memorize it, if you re trying to go where we want you to go. [19.59] So, you know, Dr. Brock and I have a vision of really taking people to a very competent and clinical level. So when there s something that we feel you just have to memorize, we ll put together forms, and give it to a chart, and say, You just need to memorize and know this, okay? So you need to know your atlas that we gave you, and so you know all these things. Now, you don t have to actually know every single name and branch, but to be quite honest, it s not hard. You can spend a few minutes and memorize and then draw them out. It will help you. So here you are. You can see that parasagittal, the intracerebral artery view, and then you can see the posterior division there. Now, this is a great part of this illustration chart, because it shows you, when you cut the brain not looking at it from the outer, but the deep structures here s the anterior cerebral artery, here s the middle cerebral artery, and the posterior communicating artery comes in, supplies the posterior regions of the brain the thalamus and the midbrain and then you have the anterior choroidal artery, which is a branch of the IC, and impacts some of the internal capsule findings. But for the most part, most of the projections to the internal capsule that you guys see here are from the lenticulostriatal arteries, these little branches here, from the middle cerebral artery. These little tiny blood vessels are very prone to have little lacunar infarcts boom! and then people have pure motor hemipareses, or pure sensory, or a combination of both, depending on what part of the internal capsule that a person has compromised. Okay? So those are the divisions there. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 6

Now, if you have those visually in your head, that s how people read cerebral angiographs. So you can have someone get a study, and you can cure it. Like, you can see the vertebral arteries from in the basilar, you can see the posterior communicating artery, right? See some of the anterior cerebral circulation. It s just exactly like the images. So know your vasculature, know how they work, and that s part of the learning step that we need you to do as we move you along into the goal that we have to teach you. Now, this is one of the charts we gave you from the very first module, which was the clinical decision-making tree. And one of the things that we know, and we ve gone over is, we say, know your patient s history, and from the patient s history, you should be able to come up with regions of the brain that are involved. And we made the brain region localization form to help you immediately identify the chief complaints, so you can localize the history. Then we went into initial survey, and we went over: hey, what s their posture like, what s their facial tone like, what s their gait like before you really get into a really deep examination how s their speech, how s their language. That also helps you localize the region, right? Then once you localize the region, we talked about clinical applications. But here s the thing that I want to focus in on now. One of the things on this flowchart is, identify regions with common vasculature to activate collateral regions using the same arterial branches. So you guys, you may have someone who s so compromised that you can t activate that region specifically, but you get blood flow there. Okay? You can, by doing similar pathway projections. So, here s what I mean like this. So let s say someone had injury to this region of their brain. Okay? What blood supply is this? This is middle cerebral artery. So if you re looking at this region of the brain, and you re looking at this somatosensory strip, could you do motor activity? Could you do motor If they had sensory paresthesias in their right arm, could you just give them a motor activity and coordination to activate that without totally stimulating that area of the brain? Right? You may even get away with doing some, like, frontal lobe executive functions, and then have shunting of blood to the middle cerebral artery, and then see some change in their exam findings. So, I think sometimes people get confused. They re like, Hey, why did I have a person, like, think about something, and it changed their sensory perception? Why did I have someone, like, focus on counting backwards or timelining, and all of a sudden their spasticity changed? Because as you activate regions of the brain, you get shunting there. So when you look at some of these vascular PET scan studies, and they see blood flow go to certain regions, as soon as you use an activity Like, if I did this, like I m doing this right now, if there was an imaging study looking at my vasculature shunting, my entire middle cerebral artery would be activated. So I m getting vasculature to my entire left side of my brain. So I might see other collateral local areas change because of that. So that s important to know as you re working up patients, testing things that change their function. But if you don t know your vasculature, everything becomes a mystery. It s strange why that happened! It s not strange. You just didn t know your vasculature. So knowing your vasculature helps you figure out other areas. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 7

So for example let s go back here. So if we wanted to have some activation here to the somatosensory cortex, you could use branches of the middle cerebral artery and try different various types of functions to see if it would make any difference there. Here s another one. So this is the speech area; left side of the brain. So if you had impairment there First of all, what artery supplies this? Middle cerebral artery, left middle cerebral artery. Okay? So, if you have a person where you Listen, they try to do language and speech; the minute they do it, they get fatigued, they get tired, they re frustrated. What happens if you What if you go a little bit higher up and start to activate the frontal eye fields? So the language centers aren t working so well, so you have them do right saccades. Right saccades activate the left frontal eye field, and now you do what? You shunt blood flow there. So now their speech changes. So this is something you should understand. Sometimes when you do exam findings, and other things change, even though it s not supposed to be for that function, since you re getting shunting of blood flow to that nearby tissue, you can change their activity. So if someone damaged, let s say, their speech areas of their brain, and you went in there and started to do frontal eye field activity with saccades, you re going to nourish that area of the brain with blood flow and circulation, and impact outcomes. Okay? So, once you know your vascularization really well, exam findings changing from various types of activities all of a sudden become very clear. Okay? What if you guys had injury to this area? So, what vascular supply area is this? Anterior cerebral artery. Okay? So, what else could you do here? You could do sensory motor to feet, you can do any type of things that activate the somatosensory distribution to feet, to make some kind of shunting or blood flow to that region, right? So, we know, like, for example, a lot of kids that this is also where the micturition center area of the brain is; some people get a stroke here, they usually end up, you know, urinating so kids that have bed-wetting, enuresis all the time, they have lack of frontal activity in their midline. And what are they also? They re toe-walkers. So what if you do motor-coordinating activities with their feet? What are you getting blood flow to? You re getting blood flow to the anterior cerebral artery, and the same distribution and shunting of the micturition center. Okay? So, vasculature is important to learn and figure out other types of therapies. Okay. So I hope this makes you understand why we have this area of the flow chart. Because once we find the region we localize the region our clinical workup is, we identify exercises to activate the involved region right? usually specific to the area that s involved, or we may do things presynaptic, or we may impact vasculature and blood flow to that area. So if I have something going on with spasticity on my left on my right arm right? I know my right motor strip is involved. I can maybe activate that region by doing movements and seeing if that changes my arm spasticity, right? I can activate presynaptic areas. I might activate my right cerebellum to activate this area presynaptically, or I might do other types of things like visualizing my hand in movement to fire my parietal somatosensory areas to shunt flow to my MCA to see if that changes my spasticity. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 8

So, once you identify a region, you can either activate that area, you can either do presynaptic projections to it, or you can do vascularization. How would you know which one you would do? You would try some things and see if your exam findings change or not change. And the things that change in a positive ways will be the therapies that you do. Okay? So any time you re trying to do brain rehab, you try to either activate the region, activate projections that are presynaptic to it, or activate areas that have collateral shunting of blood flow. Okay? So, let s move on here. So, you have now the brain region localization form, you have your brain compilation forms, you have your cerebral vasculature atlas, and we made together for you a stroke complication chart. And I m going to update this as we go through. All these charts and things we re going to keep adding to, making you more efficient as time goes on, but we don t want to give it all to you at once and have you get depressed, okay? But we just want to give you each of these and the key concepts and pieces to really help you. So, you guys, here they are. Just remember, you ve got to memorize this. This is a chart, if it were made, were given to you, which means you ve got to memorize it. You memorize it, this all becomes easy. Okay. And a lot of times people go, Hey, I don t know where to start. I m trying to learn functional neurology; I don t know where to start. Start with all the charts, the inflow charts, and forms we give you. Memorize that. Don t waste your time with other stuff yet. Memorize that and that gives you a strong foundation to understand all of the other material. Okay? [30.03] So, here we have if you guys look at the way these MCA distributions and the middle cerebral artery strokes take place, you have superior divisions and you have inferior divisions, and then you have the deep areas, which are in the lenticulostriatal areas, which impact the internal capsule, and then same with these stem. Stem is right where it branches off the internal carotid artery. So if it branches right off the internal carotid artery, you have more findings than if it was just the end part of the artery, right? So as you get closer to the source of the internal cerebral to the internal carotid artery, you have more damage and so forth. So, if you have a left middle cerebral artery damage, what area of and you obviously you re going to impact motor areas of the face and arm, but you wouldn t have any leg pattern leg manifestation. So if someone had spastic upper motor neuron patterns, and it included their face and their arm but not their leg, you would think it s MCA. Okay? What if it just involved the leg? ACA. What if all three of them face, arm, leg then it s not MCA or ACA, it s probably in the internal capsule. Because all these different branches of the arteries of all these projections of these pathways from the somatosensory strips eventually come together into a little area of the brain called the internal capsule. So when you see So, think of it this way. If you just see leg spasticity, upper motor neuron signs and it s stroke, you think it s what? Anterior cerebral artery. If it s just face and arm, middle cerebral artery. If it s face, arm, and leg, you re probably looking at internal capsule. Makes it very easy, right? So you have here areas that are This is a left, left, left, left. This whole page is left. So what part of the area is involved with left? Hemineglect, or language? Language. So as people get more of the inferior divisions involved of it, specifically, they start to get the receptive aphasias, and they get more of the somatosensory parietal symptoms, and paresthesias involved with the parietal somatosensory strip. Okay? But does it include the leg? No. Doesn t include the leg. Just includes the face and arm, but not the left. Then as you go deep, you get the lenticulostriatal areas. So these right pure motor hemiparesis means face, arm, leg. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 9

It s all three. Okay? And then you get to the stem branches, which can then cause gaze preferences, and the frontal eye field changes, and the whole cascade of things. But just understand the concept. If you have If you re impacting the left side, for the most part you re going to have language issues. If you have middle cerebral artery involvement on the right side, you have more of a hemineglect type of pattern. As you have injury to the blood vessels closest to the stem of it, you have more symptoms. As you branch out, the artery branches out, you have less symptoms, because of less tissues that are involved. Okay? And now you see the right MCA, and same thing. You have superior divisions, inferior divisions. Would you expect to see language issues with the right MCA? No. But you would expect to see hemineglect patterns. Okay? And you would expect to see weakness on the opposite side. So with the MCA, once again, face and arm weakness are the key issues here. And then you see more of the hemineglect patterns as it hits the parietal lobe, and then as you get into the deep areas, you have your pure motor stroke patterns, and then you get into the ACA, left, and that right ACA. These involve the leg without the face and arm. And then you get the posterior cerebral artery, which then causes your visual losses, your hemianopias. Right? And things of that nature. So, you can learn those really quickly just by memorizing this chart. Okay? Now, the next page of this chart, the third page of this chart, or fourth page of this chart, starts to go into the brainstem syndromes. And you guys, the brain cortical areas are really easy to remember. When you get to the brainstem, it gets a little bit more complicated. Okay? But to make it easy, here s what I m suggesting that you do. Before you start memorizing the brainstem sections, read this paper. Okay? By Dr. Gates. The rule of four of brainstem. If you read this, it all becomes easier. Everything for the brainstem and vascular syndromes become easier, because it talks about how the brainstem is oriented. So here s how this works: You have midline, or lateral. So the blood supply to the brainstem either impacts the midline division or the lateral divisions. Okay? Now, in midline structures, you have what do you put in here? MN, motor neurons. Those are for the cranial nerves, right? And then you re looking at cranial nerves 3, 4, 6, and 12. And then there s the medial longitudinal fasciculus. The medial longitudinal fasciculus is the pathway that makes your eyes have conjugated activities, so when you move one to the left, the one to the right follows at the same speed, and you have conjugate movement between them. People that have lesions, like MS, which is a common area that impacts medial longitudinal fasciculus, their eyes don t have conjugate movement. Okay? The medial lemniscus, which is your dorsal column projections right? so, posterior column vibration sense, proprioception coming in from dorsal columns, and then you have your motor pathways, like your corticospinal. So if you see someone that has a midline vascular syndrome, you d expect to see the cranial nerve involved, specific to the regions, so with 3 and 4, in the midbrain right? 6 in the pons, and 12 in the medulla. Very easy, right? Here s the other thing. The midline structures of the brainstem are all divisible by twelve: 3, 4, 6, and 12. It s the rule of four. Okay? Four cranial nerves 3, 4, 6, 12 all divisible by twelve, all midline. So cranial nerves midline, with medial longitudinal fasciculus, with medial column, dorsal column, and then the motor pathways, corticospinal. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 10

So with medial brainstem stroke syndromes, you can have contralateral facial weakness that involves the pons and midbrain; contralateral hemiparesis, arms and leg; contralateral loss of vibration sense; and depending on if it s in the midbrain, pons, or medulla, you d have those cranial nerve symptoms on the same side. And that s one of the features of brainstem syndromes. You get ipsi- and contra-. Any time you see ipsi- and contra- exam findings for a stroke, you know it s got to be in the brainstem. Okay? If it s in the cortex, or in the internal capsule, it s going to be on one side. But if you see brainstem cranial nerve involvement, and contralateral symptoms whether it s spinothalamic loss, or it s motor loss, you know you have a brainstem syndrome pattern. Okay? Now, with the lateral ones, here you have SC, SV, and the SC stands for spinocerebellar. This is important for us for this module, because where do you think posterior inferior cerebellar artery strokes take place? They take place in the lateral medullary area. Okay? Anterior inferior cerebellar arteries, superior cerebellar arteries, they all impact areas of projection to the cerebellum or the lateral pontine areas. So the lateral medullar area is the posterior inferior cerebellar artery; the lateral pontine areas, the anterior cerebral artery, and the superior cerebellar artery really impact projections from the cerebellum to other areas, and you get exact symptoms of either one. Okay? But the key thing is, with lateral brainstem syndromes, you have spinocerebellar; you have cranial nerve 5 trigeminal sensory nuclei, so you get sensory loss in the face; you get sympathetic fibers that are involved so you get your Horner s syndromes; and then you get your spinothalamic projections here. So when you look at lateral brainstem syndromes, you get ipsilateral Horner s, ipsilateral sensory alteration of pain, contralateral loss of temperature, and then cranial nerves 9, 10, or 11 vagal loss of pharyngeal spinal accessory, or facial, or trigeminal involved, depending if it s in the pons or medulla. So, save yourself a lot of headaches, save yourself a lot of frustration. Try to go through an read the paper we have by Dr. Gates, understand the rule of four, and then once you understand the rule of four, you can go right in there and then go back and then look at your midbrain, vascular syndromes. And guess what? They all get really easy. But if you try to memorize them first, it s a nightmare. Okay? And again, if you understand the concepts and the general rules, it s very easy to understand everything else. If you just try to purely memorize, it becomes very difficult. So my suggestion to you is: Read that paper and then learn the brainstem. And now, over the summer, or between now and the next session, these are the four things you just need to memorize. And if you haven t memorized these other ones yet, honestly, you re wasting your time. You re becoming inefficient as a learner. You should have all these just memorized without question. Someone could pull out anything from these charts, and you should know it. Okay? So, let s get into mechanisms of cerebrovascular insults. [39.40] Before I go there, let me just recap one thing. At this point, you guys know You re going to You know the concept of shunting, right? You guys know your vasculature; some of you, you ll have to recall and think about how much you need to go back and memorize, and then you get it down. And then once you get it down, it becomes Everything else becomes easier; things make more sense. Because as you memorize this When people learn functional neurology, when they first start, it s like this huge mass of everything, MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 11

and you go, Oh my God, when am I going to know it all? But as you learn key concepts and principles, it just gets smaller and smaller and smaller. Right? So hopefully if you guys memorize your brain compilation form, everything whoossht got smaller and easier to learn. As you learn your vasculature whoossht everything gets smaller to learn. And then you go, Wow, neurology s really easy. Okay? And then everything else applies. When people don t know their basics and fundamentals, they don t know how to interpret an exam finding, they don t know what to do next, they get confused, they see an exam finding and they freak out. So just make sure you have a good foundation. Now, let s talk about things that actually can happen to the vascular system. So you guys remember You guys know your pathways, you guys know the distribution. But let s talk about what can happen. So, you can have different types of stroke. You can have the hemorrhagic stroke. with the hemorrhagic stroke, the artery just ruptures. Most people don t survive a hemorrhagic stroke. Okay? You can an ischemic stroke, where either an emboli or a thrombus blocks vascular circulation. So an emboli would mean, like, a piece of plaquing breaks off, and then causes stroke into a smaller blood vessel. A thrombus is something like bone debris, or an air bubble, or some kind of cholesterol plaque breaks off and then goes into the vascular system, and then ends up in the smaller blood vessel. The smaller blood vessels are either in the heart or in the brain. So when people get thrombolytic events, they usually end up with small particles ending up in the small blood vessels of the heart, causing stroke, or small blood vessels of the brain causing heart attack or in the brain causing stroke. Okay? Then you have lacunar insult, which is a small-diameter infarct, usually by an occlusion penetrating a branch of a larger artery. Then you can have transient ischemic attacks, which is an episode of neurological the deficit in ischemia, but it s under twenty-four hours, and there isn t significant damage but there is potentially some damage. And then you have microvascular disease, where the entire blood vessels of the brain are ruptured. And then you have migraine. Okay? So, once you ve memorized the vasculature and you feel really comfortable with it, you want to understand the concepts of each one of these diseases, so it helps you understand clinical applications and diagnoses. So, here s a plaque, here s a clot; it breaks off. There s your emboli, or thrombus, and you get compromise. Two types of stroke: a hemorrhagic stroke, the blood vessel ruptures; embolic stroke, you get an emboli that blocks function. I m going to show you guys a video that really does a really good illustration, animation, of different types of strokes, okay? Just a couple minutes, so Ben, if you re ready for some audio There are two types of stroke: hemorrhagic and ischemic. A hemorrhagic stroke occurs when a blood vessel in the brain bursts, due to high blood pressure, atherosclerosis, or a congenital malformation. A burst vessel causes bleeding into the brain and decreased blood flow in the damaged vessel. Blood buildup increases pressure in the brain, damaging nerve cells, and collapsing smaller vessels. The second type of stroke is ischemic stroke, which occurs when blood flow through a vessel is blocked. There are three categories of ischemic stroke: thrombotic, thromboembolic, and embolic. A thrombotic stroke occurs MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 12

when flow in a blood vessel in the brain is obstructed by arteriosclerosis. A thromboembolic stroke occurs when a clot breaks off from an arteriosclerotic plaque, and lodges in the downstream vessel, blocking blood flow. An embolic stroke occurs when a clot travels to the brain from elsewhere in the body. Patients with atrial fibrillation, or who have suffered a heart attack, are at high risk of embolic stroke. This is because slow, irregular, or interrupted blood flow has a tendency to clot. Sometimes an individual will experience a transient ischemic attack TIA which is temporary, and improves before cells die. A TIA is a precursor to a thrombotic stroke, or short-term embolus. Okay. So, here s a scenario with the person having a TIA. So what makes it How do you know if it s a TIA? Well, you don t know initially, because they have symptoms of a stroke, but then either So the theory is, they do There s a spasm of the artery, or there was an occlusion and the occlusion dissolved and broke away. Okay? So that s the theory. When this starts to happen, they re going to have a stroke. When people start to have TIAs, there s a very high probability they re going to have a stroke, okay? Now, I would also suggest, for your learning the vascular system, I wrote up pretty detailed key concepts for all the major mechanisms in vasculature and strokes in your material. So read over the key concepts, read over the Gates paper, memorize your charts, and then you ll really start to This vascular part of the brain becomes very easy to learn. Okay? So, let s see this example here. Now, first of all, do you see her face? Do you see a difference? See a facial paresis on the left side? Right? So, the question is, which arteries could be involved that can cause a facial paresis? Could the anterior cerebral artery be involved? No, because the anterior cerebral artery doesn t distribute to that area. It s going to be a leg. So right away you know it s going to be what? Middle cerebral artery, or it s going to be the middle cerebral artery and the impact could be either in the MCA branches, or involving the what? Motor areas. Or it could be in the internal capsule where you would have arm or leg. But you don t see arm or leg in this one. So here you go. [ unintelligible ] Volume?... and sensation s happening again. Smile, is that smile? It s all tingly on the left side. On the left side. The doctor said breathe in, breathe out, if I m having distress, and I m trying. I don t know why this is happening to me. It happened this morning again. And when I left the hospital Monday night about twelve thirty in the morning. So now I m taking a picture for an example of what happens. It s six forty-three. My hand is hard to lift up So arm s involved and to touch something, touch my nose. Okay. So, her face and arm are involved. She didn t say anything about leg. What branch? MCA branch, right? Left or right side? Right side. Okay. Now, she videotaped this because when she went and told her doctors she was having symptoms of weakness and pins and tingling on her face and these sensory symptoms, they just said it s stress. So she had to videotape it, and she s showing she has a TIA. So, this MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 13

has happened before, so she s having these episodes of TIAs. What s going to happen next? She s going to have a stroke. So when you start to see TIA issues, you really want to get in there and figure out clinically what you can do to reduce this risk. We re going to talk about treatment applications and all those as well. Let me show you another case. Ben, we have videos for a few of these. Okay. So this is a person who gets hemiballistic after diabetic lacunar stroke. My sugar was way, way high. First it s a long period of time with this. On Monday afternoon I just started gradually kind of losing control of my right side of my body. And Tuesday, of course, it was worse. And Tuesday, Wednesday, and today are all about the same. So again, this is a thalamic stroke, branch of what artery? Smaller branch of what supplies the thalamus? Posterior circulation, right? Posterior cerebral. But just Again, you should be able to look at a finding, and if you know your anatomy we just went over, it becomes very easy to determine what things are there, okay? So, this is a paper that you guys have in your notes. But just the key thing is, there s lacunar strokes are very, very common, and they impact the basal ganglia, they impact the thalamus, the corona radiate, and here you can see an illustration here where it impacts the basal ganglia. So all your major fibers go through the internal capsule. And here s an illustration; you have just a little small occlusion that impacts that pattern. Okay. So, let me show you a case of basilar migraine. You guys may have seen this before. [unintelligible] Well, a very, very heavy ah, heavy vertation tonight. We had a very, very barrison, but let s go ahead, terris tasing but a havvin pet. Right? She s lost the ability to produce words. She basically had a basilar migraine. So what does What s the blood flow for the basilar artery? Basilar artery supplies the entire pons. Right? So when that starts to get into spasm, and starts to constrict, you lose all blood supply to pathways that project for autonomics, for speech, motor pathways, and it looks like it s a stroke, but there s no hemiparesis, no loss; it s just this type of deficit. [50.10] Now, the other thing that you want to know, especially when you get into diagnosing vestibular disorders: People sometimes have migraines, and migraines can be anywhere, but for vestibular migraines, the majority of them have auras or prodrome patterns before. Okay? So, let me show you an illustration of visual aura. So if someone had a visual aura, and then they got really dizzy, you d probably think they had a vestibular migraine. They may or may not have a headache. Most vestibular migraines don t have headaches. They especially don t have headaches along with their dizziness. They ll have a prodrome and an aura in many cases, and then they ll have dizziness. Okay? So, this is an illustration of what a person going through a visual aura will have. You guys can start to see some deficit in the visual system. So, what they would be experiencing. Now you see it gets bigger and bigger. See the color changes. MODULE FOUR TRANSCRIPT: Cerebral Vasculature Review Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 14