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Head and Neck Pathology > Cerebrovascular Disease > Flashcards

Cerebrovascular Disease Flashcards

1
Q

What is stroke?

A

brain disease due to vascular pathology
> thrombosis, embolism or hypotension causing ischaemia/hypoxia
> haemorrhage causing disruption

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2
Q

Strokes are commonly associated with which conditions?

A
  1. atheroma
  2. diabetes
  3. hypertension
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3
Q

What is an infarction?
Causes?

A

critical reduction in arterial oxygenation
1. thrombotic (overall 80%+ of all strokes)
2. Embolic (atheroma, fat, air, mural)
3. hypotensive

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4
Q

What is a haemorrhagic stroke?
Types?

A

a condition where ruptured blood vessels cause bleeding in the brain
1. intracerebral
2. subarachnoid

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5
Q

What may cause hypoxia in the brain?
Type of damage caused?

A
  1. major fall in BP or systemic hypoxia
    > causing diffuse damage
  2. vessel blockage
    > causing focal damage
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6
Q

Describe diffuse hypoxic damage?
Location?
Pathology?
Symptoms?

A

depends on severity and duration of hypoxia
1. Location
most susceptible neurons are in hippocampus, Purkinje cells, cerebral cortex
2. Pathology
affected brain is oedematous, raising ICP
3. Symptoms
- causes anything from mild confusion through PVS (persistent vegetative state) to immediate brain death
- acute hypotension, may also cause focal damage
> “watershed” (border zone) infarcts – most often between anterior cerebral and middle cerebral artery supplies

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7
Q

Describe focal hypoxic damage?
Location?
Cause?
Symptoms?

A
  1. Location
    results depend on presence of collaterals
    - some exist on surface, e.g. Circle of Willis but not within brain
  2. Cause
    caused by focal vascular abnormality from thrombosis or embolism
  3. Symptoms
    clinical effects depends on: site, extent and speed of onset of vascular block
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8
Q

What are the thrombotic causes of focal hypoxia?

A

atheroma - commoner in DM and HTN
> usually thrombosis at carotid bifurcation, origin of middle cerebral artery or in basilar artery

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9
Q

What are the embolic causes of focal hypoxia?
(Hint: clots)

A
  1. cardiac mural thrombi
    > MI, valvular disease, atrial fibrillation
  2. arterial thromboemboli
    > especially from carotid plaques (sometimes include plaque material)
  3. paradoxical emboli - children with cardiac anomalies
  4. emboli of other material (tumour, fat, marrow, air)
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10
Q

Which artery is most affected by cerebral emboli?

A

middle cerebral artery territory most often affected
> emboli lodge at branches or stenoses
Note: often, occlusion cannot be identified post mortem > thromboemboli already lysed

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11
Q

Describe the different types of cerebral emboli and how they come to be?

A
  1. “shower” embolism of fat > occur after fractures
    > capillary blockages – disturb higher cortical function and consciousness, often with no localizing signs
  2. bone marrow embolism > after trauma
    > widespread haemorrhagic lesions of white matter
  3. tumour emboli
    > may also cause of hypoxia
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12
Q

Describe cerebral infarcts?
Types?

A
  • sometimes classified as “red” or “pale”
    > depends on presence or absence of haemorrhage from infarcted vessels
  • any infarct may show surrounding zone of lesser hypoxic damage and hyperaemic reaction, which may be oedematous
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13
Q

Describe venous cerebral infarcts?
Causes?
Location?

A

– usually beside sinuses
– associated with:
1. infection
2. dehydration
3. drugs (especially oral contraceptives)

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14
Q

Describe the clinical presentation of a stroke caused by a cerebral infarction?

A

slowly evolving signs and symptoms
> 30 day mortality = 15-45%

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15
Q

Describe the pathogenesis of stroke caused by cerebral infarction?

A
  1. Cerebral hypoperfusion
  2. Embolism
  3. Thrombosis
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16
Q

State the predisposing factors of a stroke caused by cerebral infarction?

A
  1. Heart disease (e.g. infective endocarditis, endocardial thrombus)
  2. Hypertension
  3. Atheroma
  4. Diabetes mellitus
17
Q

Describe the clinical presentation of a stroke caused by intracerebral haemorrhage?

A

sudden onset of stroke with raised intracranial pressure
> 30 day mortality = 80%

18
Q

Describe the pathogenesis of a stroke caused by intracerebral haemorrhage?

A

rupture of micro-aneurysm or arteriole

19
Q

What are the predisposing factors for a stroke caused by intracerebral haemorrhage?

A
  1. Hypertension
  2. Vascular malformation
20
Q

Describe the clinical presentation of a stroke caused by subarachnoid haemorrhage?

A

sudden headache with meningism
> 30 day mortality = 45%

21
Q

Describe the pathogenesis of a stroke caused by subarachnoid haemorrhage?

A

Rupture of saccular aneurysm on circle of Willis

22
Q

Describe the predisposing factors for a stroke cause by a subarachnoid haemorrhage?

A
  1. Hypertension
  2. Polycystic renal disease
23
Q

Describe the microscopic changes in infarction?

A
  1. increased eosinophilia of neurons
  2. neuronal death and cell infiltrate
  3. gliosis
24
Q

State causes of subarachnoid haemorrhage?

A
  1. most often due to cerebral artery berry (saccular) aneurysms
  2. intracerebral haemorrhages
  3. due to bleeding diseases, trauma, tumour, vasculitis etc
25
Q

Describe berry aneurysms?

A

thin-walled out-pouching
usually < 1 cm diameter
wall consists usually only of intima
rupture at apex, usually into subarachnoid space, but sometimes into brain or both

26
Q

Where are berry aneurysms found?

A

occur near major branch points on Circle of Willis or just beyond
> more common on anterior part of Circle or its branches
Note: incidental finding in ~ 2% of post-mortem examinations, multiple in maybe a third of these

27
Q

Describe the causes of berry aneurysms?

A
  1. genetic factors may be important in some cases
  2. cigarette smoking and hypertension also predisposing factors
  3. may be precipitated by sudden rise in ICP or BP
28
Q

Describe the clinical presentation of berry aneurysms?

A
  1. typically, sudden severe headache and rapid loss of consciousness
  2. may show meningism
  3. rebleeding common and makes prognosis worse
    > 10-15% die but most recover consciousness in minutes
29
Q

Describe the early effects of subarachnoid haemorrhage?

A

increased risk of vasospasm of other vessels which can lead to additional ischaemic injury, espec. if spasm involves Circle of Willis presumably due to vascular mediators

30
Q

Describe the late sequelae of subarachnoid haemorrhage?

A
  1. meningeal fibrosis and scarring
  2. possible obstruction of CSF flow/reabsorption
31
Q

Describe CSF in subarachnoid haemorrhage?

A
  1. initially, bright red blood
  2. later, yellow colour (xanthochromia) when red cells degenerate
32
Q

Describe Intraparenchymal (intracerebral or cerebral) haemorrhage?
Causes?

A
  • 80 % death rate
  • sudden onset, causing rapid rise in ICP

Causes
-1. 50%+ associated with hypertension
> microaneurysms (of Charcot-Bouchard)
> arteriosclerotic branch points
2. remainder due to vascular malformations, bleeding disease, vasculitis etc

33
Q

Intracerebal haemorrhage usually affects?
Consequences?

A

basal ganglia, brainstem, cerebellum or cerebral cortex

  1. major tissue disruption and destruction
  2. may extend into ventricles and/or subarachnoid space
    Note: in survivors, haematoma surrounded (like in infarcts) by zone of reaction, then repair with gliosis
34
Q

Name other causes of haemorrhage?

A
  1. angiomas
  2. AV malformations etc
35
Q

Describe the importance of hypertension in CVD?
What does it cause?
Associated with?

A
  1. common cause of CVD
  2. frequently associated with atheroma and diabetes
  3. responsible for:
    a. intracerebral haemorrhage
    b. rupture of berry aneurysms, so subarachnoid haemorrhage
    c. lacunar infarcts
    d. hypertensive encephalopathy (acute or chronic)
36
Q

Describe hypertension and lacunar infarcts?

A
  • arteriosclerosis +/- occlusion of vessels supplying basal ganglia, hemispheres and brainstem
  • causes single/multiple small cavitated infarcts (“lacunes”)
    > tissue loss with scattered compound granular corpuscles surrounded by gliosis
  • clinical effects depend on location : may be “silent”
37
Q

Describe acute hypertensive encephalopathy?
Cause?
Pathology?

A
  1. Definition
    - syndrome of diffuse cerebral dysfunction
    > headaches, confusion, vomiting and convulsions, sometimes leading to coma
  2. Cause
    - usually part of accelerated (malignant) phase hypertension
    - rapid treatment needed to reduce raised ICP
  3. Pathology
    - oedematous brain +/- tentorial or tonsillar herniation
    - arteriolar fibrinoid necrosis and petechiae throughout brain
38
Q

Describe chronic hypertensive encephalopathy?
Causes?
Consequences?

A
  1. Consequences
    one cause of vascular (multi-infarct) dementia
    - dementia often with focal neurological defects
  2. Causes
    caused by multifocal vascular disease over long time
    i. cerebral atheroma
    ii. thrombosis or embolism from carotids or heart
    iii. cerebral hypertensive arteriolosclerosis
39
Q

Summarize intracranial vascular pathology?

A
  1. Extradural and subdural haemorrhage
    - almost always trauma
  2. Subarachnoid haemorrhage
    - most often berry aneurysms
  3. Intracerebral haemorrhage
    - especially in hypertension
  4. Cerebral infarction
    - usually atheroma/thrombosis/embolism

Head and Neck Pathology (4 decks)

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