Blood Vessels Flashcards
54/F, known hypertensive w/ rising BUN and creatinine. Impression - hypertensive nephrosclerosis.
Renal Biopsy: HOMOGENOUS, pink, hyaline material on the walls of ARTERIOLES w/ NARROWING of the lumen.
Vascular pathology seen
Hyaline Arteriolosclerosis
55/M, presented w/ SUDDEN ONSET OF OLIGURIA and BP 220/110 mmHg. Patient eventually died.
Autopsy: “ONION SKIN”, concentric, laminated thickening of the walls of arterioles w/ luminal narrowing and necrotizing arteriolitis
Hyperplastic Arteriolosclerosis
67/M known hypertensive and diabetic, presented w/ exertional retrosternal chest heaviness lasting for 5 mins, relieved by rest and sublingual nitroglycerin.
Angiography revealed 75% stenosis of the LAD.
Diagnosis and pathologic consequence of atherosclerosis
Chronic Stable Angina Pectoris
Atherosclerotic stenosis
67/M known hypertensive and diabetic, presented w/ retrosternal chest heaviness lasting for 30 mins at rest, NOT relieved by sublingual nitroglycerin.
ECG - ST segment elevation leads II, III, avF
Autopsy: LARGE INTRAPLAQUE HEMORRHAGE that OCCLUDED THE WHOLE VESSEL
Diagnosis and pathologic consequence of atherosclerosis
Inferior wall STEMI
Acute Plaque Change (Hemorrhage)
34/F known case of ADPKD presented w/ SEVERE HEADACHE and EVENTUAL COLLAPSE.
Antemortem plain CT scan: ENHANCEMENT of sulci
Autopsy: multiple saccular dilatations along the vessels of COW with ruptured one on the ACA-ACoA junction
Subarachnoid Hemorrhage (SAH) secondary to Ruptured Intracranial Berry Aneurysm
55/M, known HPN w/ previous CXR and plain abdominal films only showing ATHEROMATOUS AORTA presented w/ PULSATING ABDOMINAL MASS.
Autopsy: fusiform dilation of the abdominal aorta with a point of rupture
Ruptured Abdominal Aortic Aneurysm
34/M, 6’5 w/ LONG FINGERS presented w/ chronic nonproductive cough.
PE: 120/10.
Patient suddenly went hypotensive, w/ muffled heart sounds and neck vein distention.
Autopsy: 200 cc of blood in the pericardial cavity w/ fusiform dilation of the abdominal aorta w/ a point of rupture.
Ruptured Thoracic Aortic Aneurysm
Marfan syndrome
34/M, 6’5 w/ LONG FINGERS presented w/ chronic nonproductive cough.
Presented w/ sudden onset of exquisite chest pain, tearing in character, radiating to the back w/ sudden cardiovascular collapse and death.
Autopsy: Secondary lumen in the thoracic aorta w/ point of tear noted proximal to the formation of secondary lumen
Aortic Dissection
65/F, known case of polymyalgia rheumatica presented w/ severe headache and diplopia associated w/ fever and fatigue.
PE: tenderness over the course of superficial temporal artery
Biopsy: intimal thickening of the artery, granulomatous inflammation of the internal elastic lamina w/ infiltrate of T cells and macrophages
Diagnosis
Giant Cell Arteritis (Large Arteries)
38/F, with fatigue, weight loss and fever and REDUCED BLOOD PRESSURE, WEAK PULSES IN THE CAROTIDS and UPPER EXTREMITIES, OCULAR DISTURBANCES and NEUROLOGIC DEFECTS.
Biopsy: intimal thickening of the artery, granulomatous inflammation of the internal elastic lamina w/ infiltrate of T cells and macrophages
Diagnosis
Takayasu Arteritis (Large Arteries)
56/M, known case of CHRONIC HEPA B, presented w/ RAPIDLY ACCELERATING HPN, ABDOMINAL PAIN, BLOODY STOOL and MYALGIA and eventually expired.
Biopsy: segmental TRANSMURAL necrotizing inflammation w/ EXTENSIVE fibrinoid necrosis and temporal heterogeneity lesions
Polyarteritis Nodosa (PAN)
4/F, presented w/ FEVER and MACULOPAPULAR RASH on trunk and extremities associated w/ CONJUNCTIVAL ERYTHEMA and CERVICAL LYMPH NODE ENLARGEMENT.
Biopsy: segmental TRANSMURAL necrotizing inflammation w/ LESS fibrinoid necrosis
Kawasaki Disease
45/M, presented w/ HEMOPTYSIS and HEMATURIA
Serology: p-ANCA/MPO-ANCA (+)
Biopsy: vasculitis pattern similar to PAN but lesions are of the same stage and with FRAGMENTED PMNs in post-capillary venules (leukocytoclasia)
Microscopic Polyangiitis
34/F, known case of BRONCHIAL ASTHMA
CBC: 62% eosinophils, (-) blasts
Serology: p-ANCA/MPO-ANCA (+)
Biopsy: Granulomatous inflammation involving the respiratory tract and necrotizing vasculitis
Churg-Strauss Syndrome
54/M, (+) hemoptysis and hematuria w/ increasing BUN and creatinine
Serology: c-ANCA (PR3-ANCA) (+)
Biopsy: necrotizing granulomas of the respiratory tract, necrotizing vasculitis and CRESCENTIC GLOMERULONEPHRITIS
(-) findings on immunofluorescence
Granulomatosis w/ Polyangiitis (Wegener Granulomatosis)
30/M, smoker w/ INTERMITTENT CLAUDICATION with right leg
Biopsy: segmental thrombosing acute and chronic vasculitis w/ microabscesses
Thromboangiitis obliterans (Buerger disease)
45/M, CHRONIC ALCOHOLIC, known case of LIVER CIRRHOSIS
multiple, radial, pulsatile arrays of dilated submucosal arteries that blanch in pressure
Spider telangiectasia
4/M, with SEIZURES, MENTAL RETARDATION and HEMIPLEGIA
PE: port wine stain on the left
CT scan: extraaxial hyperdense lesion on the left parietal convexity
Biopsy: dilated venous vessels
Sturge Weber Syndrome
4/F with PINKISH, EXOPHYTIC lesion on the LIP since birth
Biopsy: small, endothelial-lined spaces filled w/ RBCs
Capillary Hemangiomas
4/F with PINKISH, EXOPHYTIC lesion on the LIP AFTER history of TRAUMA
Biopsy: small, endothelial-lined spaces filled w/ RBCs
granulating acute and chronic inflammation
Pyogenic Granuloma
43/F w/ LIVER MASS
Biopsy: Dilated vascular spaces filled w/ blood
Cavernous Hemangioma
15/F, SHORT STATURE and AMENORRHEA presented w/ a MASS on the NECK (10 cm in widest dimension)
Biopsy: dilated endothelial lined space WITHOUT RBCs
Cavernous Lymphangioma; Turner Syndrome
29/M, known case of HIV, developed PUPRLE PLAQUES on bilateral lower extremities
Biopsy: dermal accumulation of jagged vascular channels lined and surrounded by plump spindle cells
Kaposi Sarcoma
46/M, exposed to VINYL CHLORIDE presented w/ a LIVER MASS
Biopsy: sheets of spindle cells w/ occasional vessel formation
Immunohistochemistry: CD31, vWF (+)
Hepatic Angiosarcoma
Vascular resistance is determined at the level of the
ARTERIOLES
Homogenous, pink hyaline thickening with associated luminal narrowing
Hyaline Arteriolosclerosis
Essential HPN
DM
Concentric, laminated thickening
“onion skin” lesions
Hyperplastic Arteriolosclerosis
Malignant HPN
Fibrinoid deposition and vessel wall necrosis (NECROTIZING arteriolitis)
Malignant HPN
Early lesions containing LIPID-FILLED FOAMY MACROPHAGES
Fatty streak
small flat yellow macules –> elongated streaks
Fibrous cap + lipid core
(+) neovascularization at the periphery
Atheromatous plaque
yellow to tan
MC sites of atherosclerosis
LOWER abdominal aorta and ILIAC arteries
Most dangerous consequence of atherosclerosis
Acute Plaque Change
THIN fibrous cap
LARGE lipid core
INCREASED inflammation
VULNERABLE PLAQUE
Thickened and densely collagenous fibrous cap w/ minimal inflammation and atheromatous core
STABLE PLAQUE
4 PRINCIPAL COMPONENTS OF ATHEROSCLEROTIC PLAQUES
cells – SMCs, macrophages and T lymphocytes
ECM – collagen, elastic fibers and proteoglycans
intracellular and extracellular lipids
calcifications in later stage plaques
Clinical manifestations of ANEURYSMS
(+) mass and mass effect
erosion of bone
rupture - hemorrhage and cardiovascular collapse
Abdominal aortic aneurysm (AAA) usually arise at the
INFRARENAL AORTA
fewer elastic fibers and collagen
more fragile vasa vasorum
HPN
CT defects - Marfan, Loeys-Dietz syndrome
Inflammatory disorders (aortitis)
Thoracic Aortic Aneurysm
40-60, M
HPN
young w/ CT defects - Marfan
Aortic dissection
sudden excruciating anterior chest pain radiating to the back
MC site of aortic dissection
ASCENDING AORTA - w/n 10 cm of the aortic valve
MC site of aortic dissection
ASCENDING AORTA - w/n 10 cm of the aortic valve
MC form of vasculitis among OLDER population (>50)
TEMPORAL, OPHTHALMIC
headache, pain tenderness along SUPERFICIAL TEMPORAL a
diplopia or complete vision loss
associated with POLYMYALGIA RHEUMATICA
LARGE Vessel Vasculitis
GIANT CELL ARTERITIS (TEMPORAL CELL ARTERITIS)
<50 y/o
AORTIC ARCH
great vessels
pulmonary, coronary, renal
ocular disturbances
PULSELESS DISEASE - weakening of pulses in the UPPER limbs
LARGE Vessel Vasculitis
TAKAYASU ARTERITIS
Morphology of LARGE VESSEL vasculitis
intimal thickening
medial granulomatous inflammation w/ elastic lamina fragmentation
T cell infiltrate (CD4 > CD8), macrophages, multinucleated giant cells
Associated w/ HEPATITIS B
RENAL and VISCERAL VESSELS EXCEPT - pulmonary
abdominal pain
HPN
MIDDLE Vessel Vasculitis
Polyarteritis Nodosa (PAN)
Morphology of MEDIUM VESSEL vasculitis
segmental, transmural necrotizing inflammation
FIBRINOID NECROSIS AND LUMINAL THROMBOSIS
*PAN - PROMINEN fibrinoid necrosis
*KAWASAKI - LESS prominent fibrinoid necrosis
temporal heterogeneity of lesions
Important cause of MI in CHILDREN
CORONARY ARTERIES
fever >5 days
conjunctival injection
mucosal erythema
cervical lymphadenopathy
polymorphous exanthem
MIDDLE Vessel Vasculitis
Kawasaki Disease
Seen in vasculitis associated with HSP and CT disorders
KIDNEY and LUNGS
hemoptysis
hematuria and proteinuria
SMALL Vessel Vasculitis
MICROSCOPIC POLYANGIITIS
MPO-ANCA/p-ANCA
PAN but temporally homogenous
leukocytoclastic vasculitis
Allergic granulomatosis and angiitis
Associated w/ asthma, allergic rhinitis and eosinophilia
Cutaneous
GIT
Renal
palpable purpura
GI bleed
FSGS
cardiomyopathy
SMALL Vessel Vasculitis
CHURG STRAUSS SYNDROME (Eosinophilic Granulomatous with Polyangiitis)
MPO-ANCA/p-ANCA
PAN + extravascular necrotizing granulomas and eosinophils
PROMINENT PULMONARY INVOLVEMENT
necrotizing granuloma
necrotizing vasculitis
necrotizing glomerulonephritis
SMALL Vessel Vasculitis
GRANULOMATOSIS W/ ANGIITIS (WEGENER’s GRANULOMATOSIS)
PR3-ANCA (c-ANCA)
acute necrotizing granulomas of respiratory tract
necrotizing or granulomatous vasculitis
crescentic G
Highly associated with HEAVY TOBACCO SMOKING
small to medium - TIBIAL AND RADIAL
Raynaud phenomenon
intermittent claudication
superficial nodular phlebitis
THROMBOANGIITIS OBLITERANS (BUERGER DISEASE)
focal acute and chronic vasculitis
thrombosis w/ micro abscesses
Small to medium
NEUTROPHILIC VASCULITIS
precipitated by HSV and parvovirus
recurrent oral aphthous ulcers
genital ulcers
uveitis
PATHERGY TEST
BEHCET SYNDROME
HLA-B51
neutrophilic infiltration of vessels
Exaggerated vasoconstriction of arteries and arterioles in response to cold or emotion
Raynaud Phenomenon
RED - WHITE - BLUE
Primary Raynaud
NON-progressive
SYMMETRIC
Secondary Raynaud
PROGRESSIVE
ASYMMETRIC
ASSOCIATIONS:
SLE, scleroderma, Buerger disease, atherosclerosis
Cancers associated with production of PROTHROMBOGENIC substances that cause the body to be in hypercoagulable state
LUNGS and PANCREATIC cancer
MC vascular ectasia
Regress spontaneously
NEVUS FLAMMEUS (birthmark)
MC HIV related malignancy worldwide
patch – plaque – nodule
Kaposi sarcoma - HHV-8
Benign tumor
THIN WALLED capillaries with scan stroma
Hemangioma
Benign tumor
UNENCAPSULATED, infiltrative borders
Large, cavernous blood filled vascular spaces
DEEP structures
Cavernous
VHL - chromosome 3 – loss of function – increased HIF-1 – increased VEGF – EXCESSIVE VESSEL GROWTH
VON HIPPEL LINDAU DISEASE
*AD
COMPONENTS:
CNS hemangioblastomas
cavernous hemangiomas
pancreas, kidneys, liver cysts
Renal cell ca
pheochromocytomas
Benign tumor
thin, endothelial lined spaces w/o RBC
Lymphangioma
