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15. Central Nervous System Pathology > 3. Cerebrovascular diseases > Flashcards

3. Cerebrovascular diseases Flashcards

1
Q

Types of cerebrovascular disease

A
  1. Cerebral Ischemia
  2. Cerebrovascular accidents (cerebral infarction)
  3. Intracranial haemorrhages
  4. Vascular malformations
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2
Q

Definition of cerebral ischemia

A

The brain receives 15% of resting cardiac output & accounts of 20% of total body oxygen consumption, a highly aerobic, oxygen-limiting tissue which can be deprived of oxygen by various mechanisms

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3
Q

Causes of cerebral ischemia

A
  1. Global Cerebral Ischemia
    - Due to generalized reduction of cerebral perfusion (cardiac arrest, shock, severe hypotension)
  2. Focal Cerebral Ischemia
    - Due to reduction of blood flow to a localized area of
    the brain (thrombosis, embolism, vasculitis)
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4
Q

Pathological effects & complications of cerebral ischemia

A
  1. Cortical laminar necrosis
    - Preservation of some layers of the cortex & involvement of others
  2. Border zone/watershed infarct
    - Occurs at area of supply by anterior & middle cerebral arteries
    - Produces a sickle-shaped band of necrosis over the cerebral convexity a few centimeters lateral to the interhemispheric fissures
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5
Q

Definition of cerebrovascular accidents (cerebral infarction)

A

Commonly known as ‘strokes’; sudden focal brain necrosis (cerebral infarction) due to complete & prolonged cerebral ischemia; clinically categorized as ischemic or hemorrhagic infarction

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6
Q

Etiologies and associations with cerebrovascular accidents (cerebral infarctions)

A
  1. Hypertension
  2. Diabetes mellitus
  3. Atherosclerosis
  4. Transient ischemic attack (TIA)
    - Brief episodes of non-traumatic neurological defect due to focal brain or retinal ischemia (usually <1h)
  5. Cardiac arrhythmias (e.g. atrial fibrillation)
  6. Vascular malformations
    - Berry aneurysms
    - Arteriovenous malformations
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7
Q

2 types of CVA/Cerebral infarction

A
  1. Ischemic infarction

2. Hemorrhagic infarction

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8
Q

Types of ischemic infarction

A
  1. Thromotic infarcts (mostly due to atherosclerosis,
    commonly found in the carotid bifurcation, origin of middle cerebral artery & either end of the basilar artery)
  2. Embolic infarcts (thromboembolism from cardiac arrhythmias, vegetations from valvular diseases like infective endocarditis, fat emboli from long bone fractures; most commonly lodges in middle cerebral arterial branches)
  3. Lacunar infarcts (due to arteriolar sclerosis secondary to hypertension, multiple small cavitary infarcts which occur in the basal ganglia, internal capsule, thalamus & pons)
  4. Paradoxical embolic infarcts (venous thromboemboli passing directly back into systemic circulation via cardiac abnormalities, particularly in children)
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9
Q

Hemorrhagic infarction

A

Essentially results from anything that causes an intracerebral hemorrhage

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10
Q

Morphology of ischemic infarct

A
  1. Bland area of infarct
  2. Punctate hemorrhages reflecting ischemia - reperfusion injury
  3. Possible causes: thrombosis, embolism
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11
Q

Morphology of hemorrhagic infarct

A
  1. Hemorrhagic area of infarct

2. Possible causes: hypertension, Charcot-Bouchard aneurysms, arteriovenous malformations

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12
Q

Morphology of lacunar infarct

A
  1. Small cavitary infarcts
  2. Usually found in basal ganglia, internal capsule, thalamus & pons
  3. Possible causes: hypertension
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13
Q

Morphology of shower embolisation

A
  1. Widespread white matter petechial hemorrhages
  2. Characteristic of fat emboli (bone marrow embolization)
  3. Differentials: malaria, vasculitis, acute hypertensive encephalopathy
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14
Q

Pathological effects and complications of cerebrovascular accidents (cerebral infarction)

A
  1. Sudden focal deficit
  2. Signs of raised intracranial pressure (vomiting, nausea, headache)
  3. Multi-infarct dementia
    - Clinical syndrome characterized by progressive dementia, gait abnormalities, pseudobulbar signs & superimposed focal deficits over the course of many months or years
    - Pathological basis: multiple bilateral gray matter (cortex, basal ganglia, thalamus) & white matter (centrum semiovale) infarcts
    - Contributors to infarcts include cerebral atherosclerosis, thromoembolic events & cerebral arteriolar sclerosis from chronic hypertension
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15
Q

Investigative modalities for cerebral infarction

A
  1. Non-enhanced CT scan: to determine type of infarct
    (ischemic appears hypodense, hemorrhagic appears
    hyperdense)
  2. CT/MRI angiogram: to determine location of infarct
  3. Perfusion imaging: to determine penumbra
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16
Q

Radiological interventions for cerebral infarction

A
  1. Thromoembolic clot: arterial thrombolysis or balloon guide catheter-assisted clot removal
  2. Cerebral aneurysm: balloon-assisted Guglielmi detachable coil placement
  3. Arteriovenous malformations: embolization with Onyx liquid
17
Q

Definition of intracranial haemorrhage

A

Can be classified as being intra-axial (intracerebral/intraparenchymal) & extra-axial (subarachnoid, subdural, epidural)

18
Q

Types of intracranial haemorrhage

A
  1. Intracerebral (Intraparenchymal) Hemorrhage
  2. Subarachnoid Hemorrhage
  3. Subdural Hemorrhage
  4. Epidural (extradural) Haemorrhage
19
Q

Definition of intracerebral (intraparenchymal) haemorrhage

A

Hemorrhage within the brain parenchyma

  • Involves small intraparenchymal vessels
  • Non-enhanced CT scan: localized hyperdense lesion within brain parenchyma
20
Q

Causes of intracerebral haemorrhage

A
  1. Hypertension (most common cause, results in weakening of arteriolar walls)
  2. Cerebral amyloid angiopathy (deposition of amyloid in vascular walls which weakens them)
  3. Ruptured arteriovenous malformation
  4. Ruptured Charcot-Bouchard aneurysm (due to chronic hypertension, occurs in the basal ganglia, internal capsule, thalamus & pons)
  5. Trauma
  6. Venous sinus thrombosis
  7. Coagulopathy
21
Q

Pathological effects and complications of intracerebral haemorrhages

A

Hemorrhagic stroke

22
Q

Definition of subarachnoid haemorrhage

A

Hemorrhage into the subarachnoid space (space containing CSF, between pia & arachnoid mater)

  • Involves cerebral arteries found within the subarachnoid space
  • Non-enhanced CT scan: hyperdense lesion tracking into the sulci of the brain
23
Q

Causes of subarachnoid haemorrhage

A
  1. Ruptured berry aneurysms (aka saccular aneurysms,
    mostly found within the anterior circulation of the circle of Wilis; associated with polycystic kidney disease & aortic coarcation)
  2. Ruptured arteriovenous malformation
  3. Extension from other intracranial hemorrhages
    (traumatic hematoma, intracerebral hemorrhage into
    ventricular system)
24
Q

Pathological effects & complications of subarachnoid haemorrhage

A
  1. Thunderclap headache
  2. Additional ischemic damage (due to vasospasm of
    vessels bathed in extravasated blood)
  3. Meningeal fibrosis & scarring (can lead to
    obstructive hydrocephalus if it involves the foramina of Luschka & Magendie or non-obstructive hydrocephalus if it involves the arachnoid granulations)
25
Q

Definition of subdural haemorrhage

A

Hemorrhage between the arachnoid & dura mater
- Involves bridging veins from the convexities of the cerebral hemispheres through the subarachnoid space & subdural space to empty into the dural venous sinuses
- Non-enhanced CT scan: hyperdense lesion at
periphery without a smooth inner contour

26
Q

Causes of subdural haemorrhage

A

Trauma (especially in infants due to thin-walled bridging veins & elderly due to brain atrophy & hence greater brain mobility)

27
Q

Pathological effects & complications of subdural haemorrhage

A
  1. [Acute subdural hematoma] acute increase in intracranial pressure require immediate surgical decompression
  2. [Chronic subdural hematoma] may re-bleed, undergoes organization, good prognosis
28
Q

Epidural (extradural) haemorrhage

A

Hemorrhage between dura & skull

  1. Involves middle meningeal artery
  2. Non-enhanced CT scan: hyperdense lesion at periphery with a lenticular (convex) appearance on its inner surface
29
Q

Causes of epidural (extradural) haemorrhage

A

Skull fracture (especially temporal bone as fracture lines can cross course of middle meningeal artery)

30
Q

Pathological effects & complications of epidural (extradural) haemorrhage

A

Loss of consciousness → lucid interval → sudden deterioration due to excessively raised intracranial pressure (vomiting, restlessness, loss of consciousness)

31
Q

Definition of vascular malformations

A

Vascular malformations are principally classified into 4 main groups

32
Q

Types of vascular malformations

A
  1. Arteriovenous Malformation
  2. Cavernous Malformation
  3. Capillary Telangiectasias
  4. Venous Angiomas
33
Q

Arteriovenous malformations

A
  1. Tangled network of dilated vessels with prominent pulsatile arteriovenous shunting with high blood flow
  2. Involves vessels in the subarachnoid space &/or intraparenchymal vessels
34
Q

Complications of arteriovenous malformations

A
  1. Intracerebral hemorrhage & hemorrhagic stroke

2. Subarachnoid hemorrhage

35
Q

Cavernous malformation

A
  1. Greatly distended, loosely organized vascular channels
    with thin, collagenized walls devoid of intervening brain
    tissue with a low flow & no arteriovenous shunting
  2. Occur most often in the cerebellum, pons & subcortical
    regions
36
Q

Capillary Telangiectasias

A
  1. Microscopic foci of dilated, thin walled vascular channels separated by brain tissue
  2. Occur most often in the pons
37
Q

Venous angiomas

A

Aggregates of ectatic venous channels

15. Central Nervous System Pathology (8 decks)

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