Hypoxia generally refers to a lack of oxygen in any part of the body. In a neurological context, it refers to a reduction of oxygen to the brain despite adequate amounts of blood.
A decrease in oxygen supply to the brain can occur due to choking, strangling, suffocation, head trauma, carbon monoxide poisoning, cardiac arrest, and as a complication of general anesthesia. A failure to deliver oxygen and glucose to the brain causes a cascade of abnormal events. The extent of damage is directly proportional to the severity of the injury. The severity of cerebral ischemia, a low-oxygen state caused by arterial obstruction or lack of blood supply, and the duration of blood-flow loss in the brain determine the extent of brain damage. The neurons can suffer temporary dysfunction, or there may be irreversible damage to nerve cells that are sensitive to minute changes in oxygen levels. Severe damage involving extensive areas can occur (cerebral infarction). Cerebral hypoxia/ischemia can be caused by a broad spectrum of diseases that affect the cardiovascular pumping system or the respiratory system. There are four types of disorders to consider: focal cerebral ischemia, global cerebral ischemia, diffuse cerebral hypoxia, and cerebral infarction.
Focal cerebral ischemia
Focal cerebral ischemia (FCI) is often results from a blood clot in the brain. The blood flow in the affected area is reduced. The reduction could be severe or mild but usually FCI causes irreversible injury to sensitive neurons. The clinical signs and symptoms last approximately 15–30 minutes.
Global cerebral ischemia
Global cerebral ischemia (GCI) is a serious condition caused by ventricular fibrillation or cardiac asystole, which stops all blood flow to the brain. If the GCI lasts more than five to ten minutes, then it is likely the person will have suffered a loss of consciousness that makes recovery doubtful.
Diffuse cerebral hypoxia
Diffuse cerebral hypoxia (DCH) is limited to conditions that cause mild to moderate hypoxemia, or low arterial-oxygen content due to deficient blood oxygenation. Pure cerebral hypoxia causes cerebral dysfunction but not irreversible brain damage. Pure cerebral hypoxia can occur due to pulmonary disease, altitude sickness, or severe anemia.
Cerebral infarction (CI) is a severe condition caused by a focal vascular occlusion in an area of the brain. This causes an area of destruction resulting from a lack of oxygen delivery.
Pathology of cerebral ischemia
Lack of oxygen causes neurons in the brain to die in several ways. Autolysis can occur, which results from the digestion of nerve tissues by enzymes. Cerebral infarction causes the death of neurons; transient cessation of the cerebral circulation for a few minutes causes selective areas of ischemic necrosis. This type of necrosis is especially evident in highly vulnerable neurons that are sensitive to abrupt oxygen deprivation. More prolonged periods of moderate-to-severe hypoxemia or carbon monoxide poisoning can cause a loss of the outer sheath of neurons.
Molecular mechanisms of cerebral hypoxia
In cases of severe ischemia to brain tissue, the tissue loses structural integrity within a few seconds or a few minutes. Soon after there is an abnormal exchange of ions in neurons through a process called depolarization; this is characterized by an influx of sodium and calcium ions inside the neuron, and a simultaneous efflux of potassium ions outside the neuron.
Cerebral edema refers to abnormal increases in water content in the brain and occurs with all types of cerebral ischemia and hemorrhagic stroke. Increased water retention in the brain causes an increase in intracranial pressure. This pressure causes the brain to be pushed against the skull, resulting in neurologic deterioration and death due to herniation. Cerebral edema and herniation of the brain is the cause of death for approximately 75% of all fatal stroke victims and 33% of fatalities for all ischemic events to the brain.
Symptoms vary depending on the severity of damage. Symptoms of mild cerebral hypoxia can include poor judgment, memory loss, inattentiveness, and a decrease in motor coordination. In more severe cases, there can be permanent neurologic deficits, coma, seizures, or death.
Treatment depends on the cause and availability of equipment. Treatment is urgent and includes basic and advanced life-support measures. It is important to maintain breathing, dispense intravenous fluids and medications, and maintain stability with blood products and medications that control blood pressure and seizures. The outlook depends on the extent of cerebral ischemia.
Goldman, Lee, et al. Cecil's Textbook of Medicine, 21st ed. Philadelphia: W. B. Saunders Company, 2000.
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Laith Farid Gulli, MD
Robert Ramirez, DO