5. PATH Cerebrovascular Disease and Infections Flashcards by Andrew Niemann

What artery when blocked causes deficits in upper motor neuron type weakness, cortical type sensory loss and contralateral hemiplegia intially, contralateral leg more than arm or face, and causes alien hand syndrome- movements of the contralateral arm not under voluntary control?

Anterior Cerebral Arteries ACA

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Posterior cerebral A blockage causes contralateral homonymous hemianopia. What artery is the MC artery for infarcts and ischemia, causing aphasia*, hemineglect, hemianopia, face-arm sensorimotor loss, *GAZE TOWARDS side of lesion, and lacunes which are small deep infarcts involving pentrating branchs and other vessels?

Middle Cererbral A. - MC

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Cerebrovascular dz is the 3rd leading cause of death and has 3 major categories; thrombosis, embolism, and hemorrhage, stroke designtation applies to all these conditions especially acute symptomology, what is the resultant lesions of the brain parenchyma?

Infarction

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The MC Cerebrovascular disorders include global ischemia (whole brain), embolism, ruptured aneurysm and MC- hypertensive intraparenchymal hemorrhage, when blood flow is reduced, survival depends on collateral circulation, duration of ischemia and magnitude?

and rapidity of flow reduction

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There are two types of reduction in blood flow 1) global ischemia-generalized reduction of perfusion such as carddiac arrest, shock and severe HTN, and 2) focal ischemia-localized area, usually due to embolic or thrombotical arterial occlusion, but MC due to?

Athersclerosis in hypertesion

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What infarcts occur in most distal regions of the brain or SC of the arterial blood supply to two adjacent cerebral arteries, causing the region between the 2 vessels to become very susceptible to ischemia and infarction- causing a sickle shaped band of necrosis over the cerebral convexit a few centimeters lateral to the interhemispheric fissure?

Watershed (border zone) infarcts

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Occlusion of internal carotid artery or hypotension in a patient with carotid stenosis causes ACA-MCA susceptibility to infarct causing proximal arm and leg weakness and transcortical aphasia - language issues, what watershed area if damaged would cause higher order visual processing issues- less common?

PCA MCA overlap area

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Watershed areas are at the border zone between major cerebral arteries and are due to hypoperfusion, cortical border zone infarcts are due to ACA-MCA-PCA issues and what border zone infarcts are of deep white matter of centrum semiovale and corona radiata at the border zone between lenticulostriate and deep penetrating cortical branches of MCA?

Internal border zone infarcts

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The most sensitive areas of the brain to ischemia will be the ‘watershed’ areas between anterior and middle cerebral arterial circulations. The neurons, and the large pyramidal neurons in particular, are the most sensitive to what kinda of stress?

hypoxic/hypoglycemic

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There is little demarcation between the grey and white matter cut surface
there is ongoing liquefactive necrosis
Early changes (12-24 hours after):
Red neurons: microvacuolization, eosinophilia of the neuronal cytoplasm, and later nuclear pyknosis and karyorrhexis
Similar changes will occur later in astrocytes and oligodendroglia – reactive gliosis?
After the acute injury the reaction to damage begins with infiltration of neutrophils
Subacute changes (24 hours to 2 weeks):
Tissue necrosis, influx of macrophages, vascular proliferation, and reactive gliosis
Repair (mainly after 2 weeks):
macrophages can persist for months
Removal of necrotic tissue, loss of normal CNS architecture, and gliosis
The pattern of neuronal loss and gliosis are uneven in the neocortex, with preservation of some layers and destruction of others that is called pseudolaminar necrosis
fibroblastic proliferation with collagen deposition is uncommon in the CNS, except around organizing abscesses

MEOW

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Atherosclerosis commonly leads to stenosis of the internal carotid artery just beyong the carotid bifurcation, a carotid bruit continues into diastole- thrombi formed here can embolize distally esp in MCA,ACA and opthalmic A, a angioplasty and stenting or endarterectomy are needed to fix, symptoms associated with a lesion here include contralateral face arm weakness, contralat sensory changes and visual defects and ?

Aphasia/ Neglect

***Most likely at MCA

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Thrombotic occlusions are mostly due to atherosclerosis sites of primary thrombosis include carotid bifurcation, origin of MCA and either end of the basilar artery, rupture ulcertion or erosion of plaque exposes blood to thrombogenic substance causing thrombosis/clot… what is an intimal lesion that has a lipid core covered by a fibrous cap?

Atheroma

Major causes of stroke = thrombus or embolus

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Sources of emboli include cardioembolic infarcts such as AFib: left atrial appendage, Myocardial infarction: hypokinetic or akinetic areas, valvular disease: thrombi formed on prosthetic valves, artery to artery emboli: emboli from stenosed interna l carotidA or vertebral stenosis, what structure can causes a thromboembolus formed in the venous system bypassing lungs via it and goes straight to the brain aka PARADOXICAL EMBOLUS?

Patent Foramen Ovale

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Other sources of emboli include air emboli due to deep sea divers or iatrogenically, septic emboli due to bacterial endocarditis, fat/cholesterol emboli d/t long bong trauma and what emboli which is proteinaceous emboli ffrom marantic (non-bacterial thombotic) endocarditis (NBTE) due to hypercoagulable states like amniotic fluid emboli during child birth?

Marantic Emboli

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What causes shower embolization, which affected individuals manifest generalized cerebral dysfunction with disturbances of higher cortical function and consciousness, you see widespread white matter hemorrhages which is characteristic after trauma?

Bone marrow/fat embolization

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Hypercoagulability also causes emboli including heritable conditions such as protein S/C deficiency and antithrombin II def, dehydration, adenocarcinoma/malignancies, surgery, trauma, childbirth, DIC, hematologic dz such as sickle cell, leukemia, and vasculitis such as temproal arteritis, SLE, infections and neoplasms which are inflam processes which lead to?

BV vasculitis and luminal narrowing

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What has symptoms either positive or negative, motor, somatosensory, visual, auditory, olfactory, kinesthetic, emotional or cognitive and commonly caused by migraines, seizures and non-neuro conditions like cardiac arrhythmia or hypoglycemia in elderly, described as neurological deficit of less than 24 hours caused by temporary brain ischemia**?

Transient Ischemic Attacks TIA

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Transient Ischemic Attacks TIA >1hr are usually small infarcts but complete functional recovery can occur in 1 day, they are WARNING SIGNS for larger ischemic injury to the brain (stroke) and is a neuro emergency**, 15% of TIA pts have a stroke causing persistent deficits in 3 months, half of those in first 48 hours*, main mech for TIA is emoblus temporarily occludes and then disolves, an in situ thrombus formation and or?

Vasospasm

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Stoke is a major cause of death in US- and major cause of permanent disability, there are two types, 1) hemorrhagic (RED) are more likely to occur when emboli partially occlude vessel/undergo dissolution- red d/t reperfusion of damaged vessels 2) is what? which is pale/bland/anemia-bloodless and is thrombus (over athero-plaque) associated?

Ischemic Infarction

tPA is contraindicated in hemorrhagic infarcts

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Ischemic stroke is d/t inadequate blood supply causing infarciton/death of brain tissue– with many mechanisms including embolic: material from one location travels to another, thrombotic- locally formed clot, large vessel: MCA, small vessel: deep structures-BG/thalamus, and what which are small vessel infarcts resemblind small lakes?

Lacunar Infarcts- most commonly occur in lenticular nucleus, thalamus, internal capsule, deep white matter, caudate nuc and pons

usually due to hypertension

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Ischemic infarcts are due to thrombus or emboli, or hypoxia, and hemorrhagic are due to rupture aneurysm or hypertension in which there is a SAH or intracerebral hemorrhage respectively, note with reperfusion after ischemia there is injury which can be seen as ?

Punctate Hemorrhages

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What infarcts are from deep penetrating arteries and arterioles developing arteriolar sclerosis in lenticulostriate arteries, see lake like single or multiple small cavitary infarcts, localized infarcts causing pure motor hemiparesis - posterior limb internal capsule**, thalamic lacune causing contra somatosensory deficits and BG lacune causing hemiballismus?

Lacunar Infarcts

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What hemorrhages happens during HTN that causes small caliber penetrating vessels and the development of small hemorrhage- which is reabsorbed and leave small slit like cavities that are surrounded by brownish discoloration, w focal tissue destruction, pigment laden mø and gliosis?

Slit Hemorrhages

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What type of encephalopathy is a clinicopathologic syndrome of malginant HTN manifested by eye and kidney pathology, HTN risk factor assoc with deep brain parenchymal hemorrhages, comes with HA, confusoin, vomiting convulsions and coma, brain is edmatous and can lead to herniation of tonsil, petichiae and fibrinoid necrosis of arterioles in grey/white matter seen?

Hypertensive Encephalopathy

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What dementia is a stepwis decline in cognitive function, affects patients w bilarteral grey and white matter infarcts over the years, presents as dementia, gail abnls, pseudobulbar signs and other neuro deficits, caused by cerebral athersclerosis, vessel thrombosis/embolus and cerebral arteriorlar sclerosis from chronic HTN?

Vascular Multi-Infarct Dementia

Binswanger dz is a vascular dementia assoc with large area of subcortical white matter with myelin and axon loss. What microaneurysms are associated with chronic hypertension and can cause minute aneurysms in the basal ganglia?

Charcot-Bouchard Microaneurysms NOTE: saccular berry aneurysms occur in large intracranial vessels in subarachnoid space

Intraparenchymal hemorrhage is rupture of a small vessel in the brain associated with sudden onset of neuro symptoms (stroke), can see ganglionic and lobar hemorrhage caused by HTN and cerebral amyloid respectively, what is the risk factor MC associated with deep brain parenchymal hemorrhages?

HYPERTENSION

What angiopathy is MC assoc with lobar hemorrhage due to the same AB amyloid depositied in the walls of vessels as in AD, producing microbleeds, pts that have E2/4 allele will increase risk for repeat bleeding (E4 high risk in AD), typically related to ONLY the leptomeningeal and cerebral cortical arterioles and capillaries?

Cerebral Amyloid Angiopathy CAA

What AD ateriopathy is associated with NOTCH3 mutation leading to misfolding and collection of the receptor protein which is expressed in vascular smooth muscle, it is characterized by *recurrent strokes* usually infarcts and dementia, white matter changes at 35, stroke at 45, see thickening of media/ adventitia, loss of SM cells and *basophilic PAS+ deposits*?

Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy CADASIL

Stroke risk factors include **HTN/DM**, hypercholesterol, cigarette smoking, +family hx, cardiac dz- valvular/Afib/PFO, prior hx, and hypercoagulability... Stroke in young patient: think arterial dissection, PFO or hypercoagulability; also?

Sickle Cell!

An aneurysm is a localized abnormal dilation of a blood vessel or the heart, the MCC of clinically significant subarachnoid hemorrhage is rupture of what aneurysm in the cerebral artery (ACA= MC)- usually in circle of willis so begins as basilar SAH (base of brain)?

Rupture of Saccular (Berry) Aneurysm | absence of SM or intimal elastic lamina at birth

Anerysms can also come from extension of hematoma, as well as trauma, mycotic, saccular and dissection which are all most often in anterior circulation, atherosclerotic fusiform (not saccular) is mc in basilar A., most are not present at birth but develop overtime due to underlying defect in the medial of the vessel, as seen in ADPKD, ehlers danlos type IV, NF1, and MC?

MARFANS RISK: smoking/HTN (DUH)

Mycotic aneursym is caused by an infected artery wall and is fairly rare, caused by bacteria/fungus in the blood- such as mucor, aspergillus and?

Candida

2% of population has saccular aneurysms, 90% saccular found near major branch points of anterior circulation, rupture usually occurs in 5th decade slightly more frequent in females, 1/3 of ruptures are assoc with acute increases in ICP such as straining stool or sexual orgasm, aneurysms larger than what in diameter have a 50% risk of bleeding per year?

>10mm

With saccular or berry aneurysms, blood rushes into subarachnoid space* and causes a thunderclap headache or the WORST HEADACHE IVE EVER HAD**, 20-50% die w rupture, repeat bleeding is common in survivors, in the first few days after SAH- there is an inc. risk of additional ischemic injury from what?

Vasospasm affecting vessels bathed in extravasated blood Tx with clipping or coiling

There are four main groups of vascular malformations including cavernous, capillary telangiectasias, venous angiomas and what, which most often occur in cerebral hemispheres of young adult, can involve both vessels of subarachnoid space and may extend into brain parenchyma?

Ateriorvenous malformations AVM

Ateriorvenous malformations AVM (*MC) are tangeled vessels that show prominent pulsatile ateriovenous shunting with high blood flow- bypass a capillary bed (arteries to veins), they can often be complete resected without complication, 2x mc in men, present as seizure disorder in 10-30s, intracerebral hemorrhage orSAH, with the most common vessel affected being?

Middle Cerebral Artery - esp posterior branches (AVM/cavernous malf asso w hem) (nonfunctional cortex under AVM, tx w embolization prior to surgery or radiation tx to reduce size and bleeding)

There are 4 routes of infection 1) direct implantation via trauma or congenital malformations such as myelomenigocele 2) local extension via sinuses/teeth, cranial or spinal osteomyelitis, 3) peripheral NS- viruses (rabies/herpes zoster) and 4) the MC ?

Hematogenous spread of infection- MC is arterial primarily but retrograde venous spread via anastomosis with facial veins is possible

Infections can organize with scarring of foramina to produce a noncommunicating hydrocephalus or it could scar the vertex and impair reabsorption of CSF at the arachnoid granulations which would produce?

Communicating HydroCephalus

The meninges include dura mater, arachnoid and pia, 15% diffusion across the meninges, CSF-85% produced by choroid plexus of lateral third and fourth ventricles, complete exchange of CSF every 3-4hours, what is inflam process of the leptomeninges (inner two meniges, arachnoid and pia mater) and CSF within the subarachnoid space caused by microbes?

Meningitis acute pyogenic= bacteria aseptic= acute or subacte viral chronic= Tb/spirochetal/cryptococcal

Acute pyogenic meningitis: neonates: ecoli and Group B strep, Adolescents: N. meningitidis, elderly: strep pneumo** (MC overall) and listeria, immune supressed = klebsiella/anaerobic, H. Influenza - vax so no longer a common cause in 3m-2yo, clinical presentation of meningitis is HA, photophboia, irritable, cloudy consciousness and neck stiffness, LP shows cloudy/purulent CSF under pressure and it has what protein/glucose?

HIGH protein, LOW glucose

What type of meningitis develps by seeding of the CSF from subepidural or submeningeal granulomas,- CSF has no lymphatics, however lymphatics are in the epidural space- infections of the retropharyngeal, posterior mediastinal or retroperitoneal spaces may produce spinal epidural abcesses?

Tuberculus Mengingtis

Rabies (rhabdovirsu) binds at acetylcholine receptors at the NMJ and ASCENDS to CNS viA *MOTOR NERVES*, what virus produce latent infection of sensory ganglia, replicate in *schwann cells*, and ASCEND to the CNS in sensory* nerves,?

Herpes Simpelx and Zoster

Capillaries do NOT have fenestrations or intracellular clefts in the CNS/brain, they are surrounded by foot processes of adjacent astrocytes, molecules move across mainly by active transport and lipid solubility, there is relative IMPERMEABILITY to immunoglobulins, complement and antibiotics*** which is an important factor in pathogenesis of CNS infections and in the selection of abx tx... why?

The chosen ABx MUST be able to cross the BBB

Widespread infection, involving all tissue elements, characteristic of bacterial meningitis and many viral encephalitides, functional specialization of different cell populations and of specific neuro-anatomical regions determines the characteristic neurological sxs when specific cell types or anatomic areas are involved by the?

Infectious agent

Meningoencephalitis is inflam of the meninges AND brain parenchyma, chemical meningitis is NONBACTERIAL irritant in subarachnoid space (chemo), pyogenic is bacterial, aseptic is viral, an chronic meningitis is MC due to Tb, spirochetes such as neurosyphilis/neuroborreliosis or?

Cryptococcus | tb/neurpsyphilis has predilection for base of brain

Cerebral edema is assoc w infection- and inflammation cause loss of capillary integrity and loss of BBB** with transudation of intravascular fluid into brain or spinal cord, development of edem is accelerated by products released by both living bacteria and antibiotic lysed bacteria, and it is slowed and reversed by what only?

CORTICOSTEROIDS

Symptoms of acute meningitis (suppurative) include HA, meningeal irritation signs such as kernig (extend leg keeping hip flexed) and brudzinski (flex neck= flexed hip/kness if+), high fever* confusion and coma, full syndrome develops in several days however it may develop over a few hours with fulminant course, what should NOT be done?

DONT send pt home!

Acute meningitis locations: pneumococcal meningitis often denset over convexities near sagittal sinus, H. influenza usually basal location, what material can be seen obscuring vessels in the sulci?

Purulent/Cloudy material grossly

Acute meningitis suppurative is associated with what type of immune cell which fills the subarachnoid space, and follow leptomeningeal vasculature which when fulminant- inflam may extend to ventricles producing ventriculitis, phlebitis may lead to venous thrombosis and hemorrhagic infarction of brain, and focal cerebritis is inflam cells infiltrating walls of the veins and extend into brain substance?

BACTERIAL = Polymorphonuclear cells = NEUTROPHILS

What syndrome may occur and is associated wtih meningitis associated with septicemia with hemorrhagic infarction of the adrenal glands and cutaneous petechiae- occurs MC with meningococcal and pneumococcal meningitis?

Waterhouse-Friderichsen Syndrome

Leptomeningeal fibrosis can happen after pyogenic meningitis and lead to hydrocephalus-- the capsular polysaccharide of the microbe (in pneumococcal meningitis for example) can make a gelatinous exudate that promotes arachnoid fibrosis forming what is known as chronic?

Adhesive arachnoiditis

Complications of bacterial pyogenic meningitis include seizures, encephalitis, hearing loss, blindness, paralysis, fulminant especially with meningococcemia**- rash and adrenal hemorrhage leading to death which is?

Waterhouse-Friderichsen Syndrome

``` Lumbar Puncture (between 3rd/4th lumbar vertebrae) is done to check for meningitis and to get a gram stain of CSF, culutre CSF/blood, antigen detection in CSF/ urine, and PCR is done with the CSF. Match the following gram stain with bacteria.... Gram neg diplococci Gram pos diplococci Gram neg pleomorphic Gram pos cocci Gram Neg bacilli ``` ``` H. Influenza S. Pneumoniae N. Meningitidis S. Aureus/S Epi/ Streptococci E. Coli ```

``` Gram neg diplococci = N. Meningitidis Gram pos diplococci = S. Pneumoniae Gram neg pleomorphic =H. Influenza Gram pos cocci = S. Aureus/S Epi/ Streptococci Gram Neg bacilli = E. Coli ```

Glucose is typically decreased and protein is increased with bacterial infection, and neutrophils are assoc with bacteria, gross appearance is cloudy/turbid(chunky) with HIGH pressure. For virus, gross appearance is clear, normal pressure on puncture, NO neutrophils, instead you see *lymphs* (lymphocytic pleocytosis), and what with protein and glucose?

Protein is moderately inc | Glucose is normal

There is an increased risk of meningitis in people aged <5 or >60, in diabetes, HIV, contiguous infection (sinusitis), IV drug abuse, bacterial endocarditis and ?

Sickle Cell Anemia

Acute focal suppurative infections- brain abscess has same route as meningitis- acute bacterial endocarditis predisposes to multiple abscesses, congenital heart disease = r to l shunt removes pulmonary filtration of organisms, chronic pulmonary sepsis, systemic dz w immunosuppression, non immunosupressed MC is due to? 2

Strep and Staph

Acute focal suppurative infections causes abscesses- patients present with progressive focal neuro deficits and signs/sxs of increased intracranial pressure, CSF has high WBC (neutrophils), High protein and NORMAL glucose (acute), complications include abscess rupture with ventriculitis or meningitis and venous sinus thrombosis.. tx with surgical drainages and?

antibiotics

ON MRI/CAT scan with Acute focal suppurative infections you can see brain abscesses with central liquifactive necrosis and edema/fibrosis surrounding, outer margin has exuberant granulation tissue with neovascularization which leads to vasogenic edema- **ringed by fibroblasts depositing collagen**, and will show as?

ring enhancement on CT d/t increase vascularity from capillary proliferation and disrupted BBB

What is caused when bacterial or fungal infections of the skull bones (mastoiditis) or sinuses spread to subdural space to produce this, the arachnoid and subarachnoid spaces are usually unaffected, large ones can produce mass effect or thrombophlebitis of bridging veins that can cross subdural space and result in venous occlusion and **infarction of the brain?

Subdural Empyema

Subdural Empyema as signs and sx of where the infection is, fever, HA, stiff neck, CSF is similar to brain abscesses (NL glucose, high WBC, High protein) if left untreated causes focal neuro signs and sx, lethargy and coma, tx involves surgery, and after tx, residuum is usually only residual evidence wwhich is also called?

Thickened Dura

What abscess is MC associated with **osteomyelitis- and comes from another source of infection from surgery or sinusitis, the absecess of the spine may cause cord compression and constitute a neurosurg emergency?

Extradural Abscess (like in epidural space)

What bacterial colonized the oropharynx and rhinpharynx of asymptomatic carriers, spread by direct contract via resp droplets, more common in crowded populations like dorms/ barracks, Gram NEG diplococci assoc w rapid septicemia, fever, hypotension, DIC and petechial/purpuric lesions, hemorrhage infarction of adrenals and purpura fulminans which is hem skin lesions which progress to gangrene?

Neisseria Meningitidis *Chocolate Agar (same w H influenza)

Chronic meningitis has sx of fever headache, lethargy, confusion, N/V and stiff neck, CSF shows elevated protein, low glucose, and lymphocytic pleocytosis (sometimes w neutrophils), diagnosis made if sx and csf abnormalities persist or progress for more thatn **4WEEKS**, mc due to **Tb**, neuroborreliosis (lyme) and?

Neurosyphilis

M. Tuberculosis is located in base of the brain (arachnoiditis) obliterates cisterns and encases cranial nerves, subarachnoid space contains gelatinous or fibrinous exudate causing arachnoid fibrosis leading to hydrocephalus (and CN symptoms), also associated with what which is inflam of vessel walls, causing intimal thickening, arterial occlusion and infarction of underlying brain?

Obliterative Endartitis May see tuberculomas= well circumscribed intraparenchymal mass w central caseous necrosis -- may cause calcification if inactive ** GET CULTURE IN ADDITION TO SMEAR OF CSF

M. Tuberculosis causes diffuse meningoencephalitis- see white areas on leptomeninges, remember to look for acid fast staining with Tb- turns pink, and once can see on histo- reactive astrocytes and lymphocytic infiltrate, the swollen reactive astrocytes are known as?

Gemistocytes

What bug causes chronic meningitis with neuro sxs that follow a characteristic rash about 4 weeks later, see cranial nerve palsies (bells) and peripheral neuropathy, CSF WITH antibodies*, via PCR see that antibodies cross react with infectious mono, rheumatoid arthritis, SLE and syphilis, caused by ixodes tick?

Lyme dz or Borrelia Burgdorferi or Neuroborreliosis

Neurosyphilis is the tiertary stage of treponema pallidum, only seen in 10% pts, presents with meningovascular neurosyphilis , paretic neurosyphilis and or tabes dorsalis, most will have a mixture of the three but most often a combination of paretic neurosyphilis and?

Tabes Dorsalis ***Syphilis much higher due to AIDs***

Which T. Pallidum neurosyphilis is assoc with chronic meningitis involving the base of the brain and sometimes cerebral convexities and spinal leptomeninges (pia/arachnoid mater), , causes communicating hydrocephalus, obliterative endarteritis aka Heubner arteritis assoc w perivascular inflam rich in plasma and lymphs, cerebral gummas (plasma cell rich mass lesions) may occyr in meninges and extend to parenchyma?

Meningovascular Neurosyphilis

Which T. Pallidum neurosyphilis is insidious but progressive mental deficits that results in mood disturbances (delusions of grandeur**) that terminate in severe dementia (general paresis of the insane), assoc w perivascular iron deposits, also granular ependymitis = proliferationof subependymal glia under damaged endymal lining (hydrocephalus)?

Paretic neurosyphilis (invasion of brain by spirochete)

Which T. Pallidum group of sx is damage to sensory nerves (loss of myelin/axons) in the dorsal roots, impaired joint position sense and resultant ataxia (locomotor ataxia= widened gait), loss of pain sensation*, joint damage=charcot joints, lightening pains* and absence of deep tendon reflexes**?

Tabes Dorsalis causes pallor and atrophy in the dorsal columns of the spinal cord (cuneate fasiculus, gracile fasciculus)

What type of meningitis is assoc with absence of recognizable organism in patient with meningeal irritation, fever, and alterations of consciousness, 80% causes by enteroviruses, clinical course less fulminant than pyogenic, CSF shows *Lymph pleocytosis (inc cell count), moderate inc in protein and glucose near normal, usually self limiting and tx symptomatically?

Aseptic Viral Meningitis (note: An aseptic meningitis-like picture may develop subsequent to rupture of epidermoid cyst into the subarachnoid space or the introduction of a chemical irritant (chemical meningitis). In these cases, CSF is sterile with pleocytosis of neutrophils & ↑ protein concentration with normal glucose.)

Viral Meningitis is a CNS infection that may occur following hematogenous dissemination of viruses, they may reach the CNS through nerves* (olfactory/trigeminal sensory or motor nerves), brain mounts inflam response w population of *lymphocytes*, what is an important facet for several viruses including herpes, progressive multifocal leukoencephalopathy, etc?

LATENCY

Characteristic findings of viral encephalitis are perivascular cuffs of lymphocytes and microglial nodules, NOT neutrophils. What causes epidemic encephalitis via misquito vectors such as west nile - involves SC producing polio like syndrome w paralysis, CSF is colorless, inc pressure/protein, NL glucose, intially CNS is neutrophils and then converts to lymphocytes- multiple foci of necrosis in white /gray matter?

Arthropod Borne viral Encephalitis

Arthropod Borne viral Encephalitis such as west nile presents with seizures, confusion delirium, ocular palsies, reflex asymmetry and stupor/coma, can see microglial cells forming small aggregates around the foci of necrosis called microglial nodules, and what - which are particularly single cell neuronal necrosis with phagocytosis of the debris?

Neuronophagia (FYI)

What viral encephalopathy is MC in children and young adults, presents as mood, memory and behavior disturbances, some progress with weakness, lethargy, ataxia and seizures that take 4-6 weeks to resolve, associated with defect in TLR3 signaling pathway, is *NECROTIZING AND HEMORRHAGIC*?

Herpes Simplex-HSV-1

Herpes Simplex-HSV-1 has a tropism for inferior and medial temporal lobes, orbital gyri of frontal lobes as well, hemorrhagic lesions of the temporal lobes are characteristic of herpes simplex virus encephalitis, there is perivascular inflam with viral inclusion bodies in neurons and glial cells known as?

Cowdry Type A intranuclear inclusion bodies | HSV-2= 50% neonates born by vag delivery to women w active primary HSV = severe encephalitis

Herpes Simplex-HSV-1 encephalitis of the temporal lobe*** -- can also see cingulate gyrus destruction, massive temporal lobe destruction, hemorrhagic** necrotizing loss is characteristic, can also see intranuclear inclusions with migration of chromatin, ground glass nuclei which are multinucleated and what type of nodules?

Microglial nodules

What virus is the chickenpox cutaneous infection, latent phase is in sensory neurons of dorsal root or *trigeminal* ganglia, reactivation occurs and is shingles- painful vesicular skin eruption limited to a single or limited dermatome, also assoc w persistent postherpetic neuralgia syndrome where there is persistent pain as well as painful sensation following nonpainful stimuli (brushing clothes)?

Herpes Zoster (varicella-zoster)

What virus occurs in fetuses (TORCHES) and immunocompromised patients, in utero causes periventricular necrosis/leukomalacia is characteristic*, leading to severe brain dysfunction causing microcephaly and periventricular calcification*, in IC - see subacute encephalitis, tends to localize in paraventricular subependymal regions causing severe hemorrhagic necrotizing ventriculoencephalitis and chroid plexitis?

Cytomegalovirus CMV

Cytomegalovirus CMV can cause radiculoneuritis in the lower spinal cord and roots, and is assoc with prominent enlarged cells with intranuclear and intracytoplasmic inclusions*** both- CMV infection is confirmed via?

immunohistochemistry

What acutely has mononuclear cell perivascular cuffs and neuronophagia of the *anterior horn motor neurons* causing flaccid paralysis, and may extend to post horns and produce cavitations, and has a post syndrome which develops 25-35 years later assoc with progressive weakness with decreased muscle mass and pain?

Poliomyelitis | enterovirus transmitted fecal oral

What virus is lyssavirus genus of the rhabdoviridae family has an incubation period of 1-3 months and causes degen and inflam of the brainstem, infections ascend* along peripheral nerves from the wound site, and symptoms include malaise, fever, HA with local ****Paresthesias around the wound (needles and pins)**** which is diagnostic?

Rabies **distinct bullet shape virus**

Rabies causes extraordinary CNS excitability leading to violent motor responses progressing to convulsions, there is flaccid paralysis and resp center failure, see foaming of the mouth due to contracture of pharyngel muscles that produce aversion to swallowing, what is a PATHOGNOMONIC finding of round to oval eosinophilic cytoplasmic inclusions that are found in the pyramidal neurons of the hippocampus and purkinje cells of cerebellum***?

Negri Bodies

What is an aseptic meningitis occuring within 1-2 weeks of seroconversion acute phases include mild lymphocytic meningitis, perivascular inflammation and some myelin loss, chronic shows *microglial nodules with *multinucleated giant cells*, vessels have abnormal prominent endothelial cells and perivascular fomay or pigment laden mø and the white matter shows diffuse areas of myelin palor axonal swelling and gliosis?

HIV Aseptic Meningitis

HIV Aseptic Meningitis associated w dementia via inflam activation of microglial cells- no specific pathologic lesion or its correlate, what syndrome is characterized by paradoxical deterioration after starting therapy from the exuberant reconsitituted immune system/ inflammatory response?

Immune Reconstruction Inflammatory Syndrome IRIS

HIV is also associated with an increase incidence of WHAT CANCER**?

Primary CNS Lymphoma

What leukoencephalitis is caused by JC polyomavirus and has tropism for oligodendrocytes and there fore demyelination is its principle pathologic effect*, primary infxn is a-sx but reactivation during immunosuppresion*** exclusively occurs in IC patients (such as HIV+), causing irregular ill defined destruction of white matter- subcortical area of demyelination with lipid laden mø in center w dec # of axons?

Progressive Multifocal Leukoencephalopathy PML

Progressive Multifocal Leukoencephalopathy PML on histo stained for myelin shows *irregular, poorly defined areas of demylination which may become confluent in places, with enlarged oligo nuclei (represents effect of viral infection), white matter demyelination leading to loss of coordination and weakness, see reactive astrocytes and oligo nucleus filled with?

Glassy amphophilic Viral inclusions

Subacute sclerosing panencephalitis SSPE is a rare progressive clinical syndrome that occurs in NON-immunized kids or young adults months or years after initial infection by *measles virus (rubeola)*, see cognitive decline, spasticity of limbs and seizures, what virus?

Paramyxovirus spread via resp droplets

Subacute sclerosing panencephalitis SSPE due to paramyxovirus/rubeola/measles shows widespread gliosis and myelin degeneration ** viral includsion of oligos and neurons, variable inflammation of white and gray matter, and what which is also see in alz?

neurofibrillary Tangles

FYI: Three to five days after symptoms begin, a rash breaks out. It usually begins as flat red spots that appear on the face at the hairline and spread downward to the neck, trunk, arms, legs, and feet. Small raised bumps may also appear on top of the flat red spots. The spots may become joined together as they spread from the head to the rest of the body. When the rash appears, a person’s fever may spike to more than 104° Fahrenheit. After a few days, the fever subsides and the rash fades. Measles vaccine is usually combined with mumps and rubella (MMR), or combined with mumps, rubella and varicella

MEOW

Fungal meningoencephalitis is only seen in immunocompromised pts, via hematogenous dissemination, MC- candid, mucor, aspergillus and crypto, Diabetes = MUCORMYCOSIS, vasculitis = Mucor/aspergillosis, thrombosis causes hemorrhagic infarction that may become septic, endemic pathogens after pulmonary/cutaneous infxn affect CNS and include histo/coccidiodes and?

Blastomyces

Brain parenchymal infection causing granulomas is MC due to candida and cryptococcus, crytpo meningitis is MC in AIDS patients and may be fulminant and fatal in 2 weeks or may take years, on histo of the brain there are numerous areas of tissue destruction seen as what, associated with spread of organims in perivascular space?

Soap Bubbles * - high mag see cryptococci

crytpo meningitis may obstruct outflow of CSF via foramina of luschka and magendie leading to hydrocephalus, cellular immune dysfunction predisposes to it, (chronic), CSF stained via *INDIA INK PREP*, also do culture of CSF, urine, sputum blood and stools- What antigen is crypto CSF assoc with?

Cryptococcal Polysaccharide Antigen via india ink

What opporutnistic infection is MC in HIV or IC pts ( early in pregnancy, spreads to fetus resulting in severe brain damage (multifocal necrotizing brain lesions that may calcify).*** ), is it as protozoa, causes brain abscess located near grey-white junction of cerebral cortex and deep grey** nuclei, histo show central foci of necrosis, petechial hemorrhages surround by acute/chronic inflam, mø infiltration and *vascular proliferation*?

Toxoplasmosis Gondii

Toxoplasmosis Gondii is assoc with free tachyzoites and encysted (pseudocyst with) bradyzoites at the periphery of necrotic zones- may be ring enhancing lesions, again shows ring enhancement on imaging with central necrosis- seen on H/E and giemsa but most commonly?

Immunohistochemical

What protozoal dz is caused by naegleria (quick death necrotizing encephalo) or acanthamoeba (chornic granulomatous meningoencephalitis), naegleria fowleri- brain eating ameba, infects people when contaminated water enters brain through nose- via warm freshwater such as lakes, rivers hot springs and soil?

Cerebral Amebiasis best seen PAS or methenamine silver

What protozoal dz is caused by plasmodium falciparum- resulting in long term cognitive defects in survivors/ see reduced cerebral blood flow, ataxia, seizures and coma in acute phase?

Cerebral Malaria

What is the MC prion disease (which is abnormal forms of cellular protein that cause rapidly progressive neurocognitive DOs that may be sporadic/familial or transmitted- all dz are assoc w PrP prion protein and PRNP gene, heterozygosity at codon 129 protects against disease, see spongiform change- intracellular vacuoles in neurons and glia?

Creutz-Jakob Disease CJD (mad cow- rapidly progressive dementia) along w many others

Creutz-Jakob Disease CJD is he MC prion disease and 90% of cases in appear in 70s, caused via iatrogenic transmission via corneal transplant, brain implantation of electrodes and contam human growth hormone, presents with subtle changes in memory/behavior followed by RAPID dementia and startle?

**Myoclonus - involuntary jerking muscle contractions (die in 7 months) - 100% fatal

What kind of CJD comes from exposure to bovine spongiform encephalopathy from contaminated food or blood transfusion, in young adults, see behavioral changes early, and assoc w kuru plaque which are extracellular deposits of aggregated abnl protein which is CONGO RED AND PAS+?

Variant CJD 1995 - UK young adults

What fatal prion disease is associated with sleep disturbances initially, less than 3 year survival- caused by aspartate substitution at codon 129, presents with ataxia, autonomic disturbances, stupor and then coma and deatH?

FFI - Fatal Familial Insomnia

CJD and prion disease are assoc with spongiform change in cerebral cortex with neurons with vacuoles, cerebellar cortex shows kuru plaques via PAS stain, which represents aggregated PrPSC prions and cortical plaques surrounded by spongiform change seen in vCJD, in advanced cases there is severe neuronal loss, reactive gliosis and sometimes status* spongiosus = cyst like spaces with NO WHAT?

NO INFLAMMATION