“The true measure of a man is how he treats someone who does him absolutely no good.”

– Ann Landers

Pathology of Cerebro-vascular Disease

(Stroke)

Dr. Venkatesh M. ShashidharDr. Venkatesh M. ShashidharAssociate Professor of PathologyFiji School of Medicine

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Introduction: Stroke is the third most common

cause of death and the second most common cause of neurologic disability after Alzheimer's disease.

Its incidence has decreased in recent decades, but the decrease appears now to have leveled off, and it remains the leading cause of institutionalization for loss of independence.

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Introduction: “Stroke” Cerebro Vascular accident (CVA) Acute neurological deficit ↓ blood supply. Third leading cause of death. (2/1000/y) Varying severity, location & types Global / Focal Transient Ischemia evolving & completed. Low O2 (hypoxia) / Low blood supply.

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Brain Blood Supply Features:

High oxygen requirement. Brain 2% of body weight - 15% of cardiac

output 20% of total body oxygen.

Continuous oxygen requirement Few minutes of ischemia - irreversible injury.

Neurons - Predominantly aerobic. Sensitive areas:

Adults -Hippocampus, 3,5th & 6th layer of cortex, Purkinje cells. Border zone (watershed areas)

Brain stem nuclei in infants.

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Stroke Types:

Clinical Transient Ischemic Attack –TIA <24h Evolving stroke Completed stroke Recurrent / multiple stroke.

Pathological Focal / Global Ischemic (white/pale) & hemorrhagic

(red) Lacunar infarcts (pale chronic cystic)

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Common Types and Incidence: Infarction: Incidence 80% - mortality 40%

50% - Thrombotic – atherosclerosis Large-vessel 30% (carotid, middle cerebral) Small vessel 20% (lacunar stroke)

30% Embolic (heart dis / atherosclerosis) Young, rapid, extensive.

Hemorrhage: Incidence 20% - mortality 80% Intracerebral or subarachnoid. aneurysm, hypertension/congenital.

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Etiology: Complication of several disorders Atherosclerosis – most common. Hypertension, smoking, diabetes. Heart disease – Atrial fibrillation. Other:

Trauma – fat embolism Tumor, Infection Caissons disease – Bends *Pacific.

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Risk factors: Non modifiable Age Male sex Race Heredity

Modifiable Hypertension Diabetes Smoking Hyperlipidemia Excess Alcohol* Heart disease (AF)

Oral contraceptives Hypercoagulability.

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Clinical Categories: Global Ischemia.

Hypoxemic encephalopathy Hypotension, hypoxemia, anemia.

Focal Ischemia. Obstruction to blood supply to focal

area. Thrombosis, embolism or hemorrhage.

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Global Ischemia: Etiology:

Impaired blood supply - Lung & Heart disorders. Impaired O2 carrying – Anemia/Blood dis.

Morphology: Laminar necrosis, Hippocampus, Purkinje cells. Border zone infarcts – “Watershed” Sickle shaped band of necrosis on cortex.

Clinical Features: Mild transient confusion state to Severe irreversible brain death. Flat EEG,

Vegetative state. Coma.

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Causes of hypotension

Myocardial infarction Septic shock Internal hemorrhage

Massive GI bleed ruptured varices bleeding ulcer, carcinoma

Ruptured aortic aneurysm. Shock, Others

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Watershed/Boundary zone infarcts:

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Focal Ischemia: Thrombosis:

Progressive, recurrent, Pale or ischemic infarct. Eg. Lacunar infarct

Embolism / Hemorrhage: Sudden. Red or hemorrhagic infarct. Atherosclerosis – rupture/embolism

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Embolism formation:

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Local infarction:

Cell death ~ 6mincentral infarct area or umbra, surrounded by a penumbra of ischemic tissue that may recover

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Haemorrhagic - Arterial embolus

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Infarct Pathogenesis: Reduced blood supply – hypoxia/anoxia. Altered metabolism Na/K pump block. Glutamate receptor act. calcium

influx. 1-6 min – ischemic injury – vacuolation. >6 min – cell death.

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Infarct Stages: Immediate – 6 hours

No Change both gross & micro Acute stage – 2 days

Oedema, loss of grey/white matter border. Inflammation, Red neurons, neutrophils

Intermediate stage – 2 weeks. Demarcation, soft friable tissue, cysts Macrophages, liquifactive necrosis

Late stage – After 4 weeks. Fluid filled cysts with dark grey margin (gliosis) Removal of tissue by macrophages Gliosis – proliferation of glia, loss of

architecture.

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Cerebral edema

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Edema, loss of demarcation:

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Acute Infarction: Oedema

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Cerebral Infarct : Red Neurons

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Cerebral Infarct - 1 Week

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Cerebral Infarct - 2 Weeks

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Cerebral Infarction: Macrophages

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Cerebral Infarct - Cyst formation

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Infarct with Punctate hemorrhage

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Cerebral Infarction - Late

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C. Infarct - Cyst formation

’’Smile’ at each other, smile Smile’ at each other, smile at your friends, smile at at your friends, smile at your partner, smile at your partner, smile at strangers - it doesn't strangers - it doesn't matter who it is – This will matter who it is – This will help you to grow up in help you to grow up in greater love for each other.greater love for each other.

Mother Teresa1910-1997, Roman Catholic Missionary

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Intracranial Hemorrhage:

TRAUMA: Epidural Subdural

VASCULAR & TRAUMA Intracerebral Subarachnoid

Mixed cerebral-subarachnoid

• Intracerebral - Hypertension• Subarachnoid - Berry aneurysm + Hptn.• Mixed cerebral – Vascular malformations.

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Hypertensive CVD Massive Intracerebral Hemorrhage

Ganglionic & Lobar hemorrhages Putamen(60%), thalamus, ventricles.

Slit hemorrhages. Microhemorrhages heal as slit spaces.

Lacunar infarcts Brain stem pale infarcts – arteriolar sclerosis

Hypertensive encephalopathy Headache, confusion, vomiting – raised ICP.

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Subarachnoid Hemorrhage:

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Ruptured Berry Aneurism

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Intraventricular Hemorrhage:

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Cerebral Infarction hemorrhage

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Cerebral Infarction hemorrhage

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Lacunar Infarct in pons

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Summary: Stroke: Acute neurological deficit - Clinical Cerebrovascular Accident – pathology. Ischemic/Hemorrhagic Thrombosis, Embolism/Hemorrhage Atherosclerosis, Hypertension, Heart Disease. Global – Systemic Hypoxia – Watershed infarct Focal – Thrombosis, Embolism or Hemorrhage Liquifaction necrosis Cyst formation, gliosis. Hypertension – Pale, Lacunar infarcts, slit hem.

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Ischemic penumbra:

““The ultimate measure The ultimate measure of a man is not where of a man is not where he stands in moments he stands in moments of comfort, but where of comfort, but where he stands in time of he stands in time of challenge and challenge and controversy” controversy”

– Martin Luther King Jr.

Anatomy – Stroke.

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Left (Dominant) Hemisphere Stroke: Common Pattern

Aphasia Right hemiparesis Right-sided sensory loss Right visual field defect Poor right conjugate gaze Dysarthria Difficulty reading, writing, or

calculating

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Right (Non-dominant) Hemisphere Stroke: Common Pattern

Defect of left visual field Extinction of left-sided stimuli Left hemiparesis Left-sided sensory loss Left visual field defect Poor left conjugate gaze Dysarthria Spatial disorientation

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Brain Stem Stroke: Common Pattern

Pure Motor - Weakness of face and limbs on one side of the body without abnormalities of higher brain function, sensation, or vision (MCA/ACA)

Pure Sensory - Decreased sensation of face and limbs on one side of the body without abnormalities of higher brain function, motor function, or vision   (PCA).

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Brain Stem / Cerebellum / Post Hemisp. Patterns.

Motor or sensory loss in all four limbs Crossed signs Limb or gait ataxia Dysarthria Dysconjugate gaze Nystagmus Amnesia Bilateral visual field defects 

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Investigations:

CT of the brain without contrast – location/ext.

Electrocardiogram - heart Chest x-ray - heart complete blood count, platelet count – hemat. PT, aPTT – coagulation. Serum electrolytes – complications. Blood glucose - DM Renal and hepatic chemical analyses – status. National Institutes of Health Scale (NIHSS)

score – clinical/prognosis ?

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“We must all suffer from one of two pains: the pain of discipline or the

pain of regret” The difference is Discipline weighs ounces.. while regret

weighs ton’s..! Jim Rohn

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Hypertensive Intracerebral Hem: Sites

1. Putamen-Claustrum

2. Cerebral white matter

3. Thalamus

4. Pons

5. Cerebellum

55%

15

10

10

10

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Stroke types and incidence:

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Anatomy – Stroke.