The normal adult skull is a rigid bony structure of fixed volume, containing brain, cerebrospinal

fluid (CSF) and blood.

The brain tissue is the largest component in the skull. It has a mass of about 1400 g and
consists of supporting (glial) and neural elements, and intracellular and extracellular water.

Cerebrospinal Fluid (CSF)

There is about 150 ml of CSF in the craniospinal axis, of which about 75 ml is within the skull. It
is produced constantly, at a rate of 0.3 ml/min (500 ml/day), in a process of active secretion by
Na+/K+-ATPase and carbonic anhydrase.

The CSF has a variety of functions. It helps to ensure a constant supply of glucose and
maintains a chemically stable environment, necessary for neurotransmission. It also effectively
reduces the mass of the brain to about 50 g, which reduces the inertia of the brain and allows
rapid head movement without damage to the delicate neural structures

Cerebral Blood Flow (CBF)

CBF is typically 750 millitres per minute or 15% of the cardiac output. This equates to 50 to 54
millilitres of blood per 100 grams of brain tissue per minute.
The arteries deliver oxygenated blood, glucose and other nutrients to the brain and
the veins carry deoxygenated blood back to the heart, removing carbon dioxide, lactic acid,
and other metabolic products. Since the brain is very vulnerable to compromises in its blood
supply, the cerebral circulatory system has many safeguards. Failure of these safeguards
results in cerebrovascular accidents, commonly known as strokes. The amount of blood that
the cerebral circulation carries is known as cerebral blood flow. The presence of gravitational
fields or accelerations also determine variations in the movement and distribution of blood in
the brain, such as when suspended upside-down.
 The cerebral arteries are derived from the internal carotid and vertebral, which at the base of
the brain form a remarkable anastomosis known as the arterial circle of Willis. It is formed in
front by the anterior cerebral arteries, branches of the internal carotid, which are connected
together by the anterior communicating; behind by the two posterior cerebral arteries,
branches of the basilar, which are connected on either side with the internal carotid by the
posterior communicating.
The basilar artery and middle cerebral arteries, though they supply the brain, are not
considered part of the circle.
Role of intracranial pressure

In adults,the brain,spinal cord,and spinal fluid are encased,along with the cerebral vessels,in a
rigid bony enclosure. Because brain tissue and spinal fluid are essentially incompressible,the
volume of blood,spinal fluid, and brain in the cranium at any time must be relatively constant.
More importantly, the cerebral vessels are compressed whenever the intracranial pressure
rises. Any change in venous pressure promptly causes a similar change in intracranial pressure.
Thus, a rise in venous pressure decreases cerebral blood flow both by decreasing the effective
perfusion pressure and by compressing the cerebral vessels. This relationship helps to
compensate for changes in arterial blood pressure at the level of the head.

Autoregulation

The brain is intolerant of hypo- or hyperperfusion, and therefore requires a constant flow of
blood over a range of pressures, this is achieved by autoregulation. This is thought to be a
myogenic mechanism whereby pressure changes are sensed and induce either a reflex
constriction (increased pressure) or relaxation (low pressure) of the vascular smooth muscle,
predominantly in the arterioles. In patients with chronic untreated hypertension, the
autoregulatory curve is shifted to the right to protect against the development of
encephalopathy. Autoregulation is easily impaired by head injury, tumours or vasodilatory
drugs (e.g. volatile anaesthetics). Cerebral autoregulation may also become impaired after
stroke.

Stroke

A cerebral vascular accident known as CVA or STROKE occurs when cerebral artery becomes
blocked or ruptures. As a part of the brain loses its normal supply of blood- temporary,
permanent or even fatal neurological deficits may follow. Risk factors for stroke include: age,
smoking, high blood pressure, high cholesterol, diabetes and heart arrhythmias . Ischemic
strokes are caused by a blockage. There are 2 types of ischemic strokes. The first type, called
thrombotic stroke occurs when atherosclerotic plaque develops in the brain artery gradually
restricting blood flow. Eventually a blood clot called thrombus can form completely
obstructing the blood flow in the artery. The other type of ischemic stroke called an embolic
stroke is caused by a travelling clot. The travelling clot is often a piece of plaque that is broken
off from the cerebral artery or from an artery from elsewhere in the body. The clot travels
through the circulatory system eventually lodging in and completely blocking the blood flow of
the cerebral artery. When an artery is blocked that part of the brain loses its normal supply of
oxygen, rich blood and nutrients .This leads to various neurological deficits depending on
which area of the brain is affected. Strokes in the brain’s right hemisphere may cause paralysis
on the left side of the body called hemoplagia. These strokes may also cause left side neglect a
condition in which visual impairment causes the patient to neglect objects on their left side.
Right hemisphere strokes may also cause short term memory loss, spatial and perceptual
problems, impulsive behavior and loss of artistic abilities. Strokes in the brain’s left
hemisphere may cause paralysis of the right side of the body. These strokes may also cause
aphasia which is an impairment or loss of speech and language comprehension. Left
hemisphere strokes may also cause mood swings, difficulty with math and memory loss.
Strokes in the brain’s cerebellum may cause coordination problems, dizziness, nausea ,
vomiting and abnormal reflexes. Strokes in the brain stem may cause visual problems,
swallowing difficulty and breathing difficulty requiring long term ventilatory support. Brain
stem strokes ultimately can be fatal. Another last type of stroke called hemorrhagic stroke is
caused by blood leaking into the brain. There are 2 types of hemorrhagic strokes. Cerebral
hemorrhage occurs when an artery in the brain breaks open allowing blood to leak into and
damage brain cells in that region. Subarachnoid hemorrhage occurs when an artery in the
brain leaks blood into a space on the brain surface damaging brain cells in that region.
Recognising the symptoms of stroke and getting the patient to the hospital are key to surviving
stroke.