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Neuro Pathology > Pathology of Cerebro-Vascular Disease > Flashcards

Pathology of Cerebro-Vascular Disease Flashcards

1
Q

What are the major blood vessels of the brain?

A

Right and left internal carotid arteries
Right and left vertebral arteries
Basilar artery
Right and left anterior cerebral arteries
Right and left middle cerebral arteries
Right and Left posterior cerebral arteries
Anterior communicating artery
Right and left posterior communicating arteries

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2
Q

What does the right middle cerebral artery supply?

A

Left body strength

Left body sensation

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3
Q

What does the left middle cerebral artery supply?

A

Right body strength
Right body sensation
Language

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4
Q

What does the right posterior cerebral artery supply?

A

Perception of the left visual field

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5
Q

What does the left posterior cerebral artery supply?

A

Perception of the right visual field

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6
Q

What is the cerebellum supplied by (Arteries)?

A

Posterior inferior, anterior inferior and superior cerebellar arteries

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7
Q

Presentation of brain aneurysm

A

Severe headache
Vomiting
Extremely sudden presentation
Possible coma

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8
Q

Investigation of brain aneurysm

A

Unenhanced CT

LP

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9
Q

What does LP stand for?

A

Lumbar puncture

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10
Q

Where do most intracranial aneurysms arise from?

A

Branch points of the circle of willis

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11
Q

Treatment of ruptured intracranial aneurysm

A

Endovascular coil embolisation

Surgical clipping

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12
Q

Prevalence of aneurysms

A

2%

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13
Q

Complications of intracranial aneurysm

A

Hydrocephalus
Vasospastic infarcts
Disability

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14
Q

Lobes of the brain

A

Frontal
Parietal
Temporal
Occipital

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15
Q

Do the veins of the brain accompany the arteries?

A

No

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16
Q

Definition of stroke

A

Focal neurological deficit (loss of function affecting a specific region of the CNS) due to disruption of blood supply

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17
Q

Pathological mechanism of stroke

A

Interruption of supply of O2 and nutrients, causing damage to brain tissue

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18
Q

Causes of interruption to supply of oxygen to brain causing stroke

A 
Vessel wall abnormality
- atheroma
- vasculitis 
- outside pressure 
Blood flow 
- decreased
- increased BP 
Blood constitutents
- thrombosis of arteries and rarely veins 
- bleeding due to anticoagulation, reduced platelets and clotting factors
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19
Q

3 main causes of localized interrupted blood supply

A
  1. ATHEROMA AND THROMBOSIS of the artery causing ischaemia
  2. THROMBOEMBOLISM causing ischaemia
  3. RUPTURED ANEURYSM of a cerebral vessel causing haemorrhage
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20
Q

Internal carotid artery thrombosis typically causes ischaemia where?

A

Middle cerebral artery territory

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21
Q

Definition of ischaemia

A

A relative or absolute lack of blood supply in a tissue or an organ

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22
Q

What does TIA stand for?

A

Transient ischaemic attack

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23
Q

What is the viability of the tissues in a TIA?

A

Still viable tissues

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24
Q

What is the viability of the tissues in a stroke?

A

Infarcted tissue

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25
Q

Pathogenesis of ischaeimc stroke

A

Brain very sensitive to oxygen ischaemia
A few minutes hypoxia or anoxia will cause brain ischaemia
Can lead to infarction

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26
Q

What is a localized area of brain death called?

A

Regional cerebral infarct

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27
Q

Histology of infarcted brain tissue

A

Loss of neurones
Foamy macrophages
Repair process leading to gliosis

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28
Q

What is gliosis the CNS equivalent of?

A

Fibrosis

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29
Q

What two factors can cause an aneurysm to form?

A

Weakening of wall

HTN

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30
Q

2 common sites of ruptured vessels causing haemorrhagic stroke

A

Basal ganglia
- microaneurysms form in HTN patients
Circle of willis
- berry aneurysms form in HTN patients

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31
Q

Causes of generalised problem with blood supply or hypoxia affecting the brain

A
  1. Low O2 in blood
    - CO poisoning
    - near drowning
    - resp arrest e.g. pneumonia
  2. Inadequate supply of blood (blood flow not occurring)
    - cardiac arrest with immediate resolution
    - Hypotension
    - brain swelling e.g. trauma due to compressed vessels
  3. Inability to use O2 (RARE)
    - e.g. cyanide poisoning
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32
Q

What are watershed zones?

A

Areas of the brain that are poorly perfused

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33
Q

What % of strokes occur in patients over 65 y/o?

A

75%

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34
Q

Two types of stroke

A

Ischaemic

Haemorrhagic

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35
Q

Causes of ischaemic stroke

A 
Large artery atherosclerosis (35%)
Cardioembolic e.g. AF (25%)
Small artery occlusion e.g. lacune (25%)
Undetermined/cryptogenic (10-15%)
Rare causes (<5%)
- arterial dissection 
- venous sinus thrombosis
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36
Q

What % of strokes are ischaemic?

A

85%

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37
Q

What % of strokes are haemorrhagic?

A

15%

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38
Q

Types of haemorrhagic stroke

A

Primary intracerebral haemorrhage 70%
Secondary haemorrhage 30%
- SAH
- AV malformation

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39
Q

Stoke risk increases with what?

A

Age

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40
Q

What is the public awareness campaign for stroke?

A

FAST

  • Facial weakness
  • Arm weakness
  • Speech problems
  • Time to call 999
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41
Q

Risk factors for stroke

A 
HTN
Smoking
DM
Cholesterol 
Diet
Activity 
High BMI / Sedentary lifestyle
Alcohol 
Previous stroke
Older
Male
Family history
Impaired cardiac function 
- recent heart attack 
- AF
Oral contraceptives (with oestrogen)
HRT 
Hypercoagulable states
- malignancy 
- genetic
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42
Q

What is the most important modifiable risk factor for stroke?

A

HTN

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43
Q

Where does HTN tend to cause the damage in stroke?

A

Small end arteries in the basal ganglia and brain stem

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44
Q

Why does increased serum lipid levels lead to increased risk of stroke?

A

Blood vessel wall atheroma

Increased plasma level of low density lipoprotein (LDL) results in excessive amounts of LDL within the arterial wall

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45
Q

What contributes to LDL-C deposition in arterial walls?

A

HTN
Smoking
DM

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46
Q

What colour is brain tissue on CT?

A

Black

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47
Q

What colour is CSF on CT?

A

Black

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48
Q

What colour on bone on CT?

A

White

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49
Q

Which of MRI and CT is easier to pick up smaller strokes?

A

MRI

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50
Q

What arteries make up the anterior circulation to the brain?

A

2 internal carotid arteries

  • 2X ACA
  • 2 MCA
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51
Q

What arteries make up the posterior circulation to the brain?

A

2 vertebral arteries - 1 basilar

  • 3 pairs of cerebellar arteries
  • 2 posterior cerebral arteries
52
Q

Symptoms of ACA occlusion

A

Contralateral
Paralysis of foot and leg
Sensory loss over foot and leg
Impairment of gait and stance

53
Q

Symptoms of MCA occlusion

A

Contralateral
- paralysis of face/arm/leg
- sensory loss of face/arm/leg
Homonymous hemianopia
Gaze paralysis to opposite side
Loose visual fields on same side as the paralysis
Aphasia if stroke on dominant (left) side
Unilateral neglect and agnosia for half of external space if non dominant stroke (usually right side)

54
Q

Symptoms of damage to the left hemisphere

A

Hemiplegia
Homonymous hemianopia
Dysphagia

55
Q

Symptoms of damage to the right hemisphere

A

Left hemiplegia
Homonymous heminaopia
Neglect syndromes (agnosia)

56
Q

Types of neglect syndromes (agnosia)

A

Visual
Sensory
Anosagnosia
Prosphanosia

57
Q

What is anosagnosia?

A

Denial of hemiplegia - unawareness that have had stroke

58
Q

What is prosophanosia?

A

Failure to recognise faces

59
Q

What is a feature of main lacunar stroke syndromes?

A

Devoid of ‘cortical signs

Affects deep pathways in the brain so dont cause cortical syndromes e.g. no dysphagia, neglect, hemianopia

60
Q

What does a lacunar stroke syndrome usually present as?

A

Weakness
Clumsiness
Numbness
Ataxic hemiparesis

61
Q

Symptoms of posterior circulation damage to the brain

A

Depends on where affected

  • brain stem
  • cerebellum
  • thalamus
  • occipital and medical temporal lobes
62
Q

Symptoms of brainstem dysfunction

A 
Coma 
Vertigo 
Nausea and vomiting 
CN palsies
Ataxia 
Hemiparesis
Hemisensory loss 
Crossed sensorimotor deficits
Visual deficits
63
Q

Types of stroke

A

Total anterior circulation stroke (TACS)
Partial anterior circulation stroke (PACS)
Lacunar stroke (LACS)
Posterior circulation stroke (POCS)

64
Q

Which of the types of stroke has the worst prognosis?

A

TACS

65
Q

Which of the types of stroke has the best prognosis?

A

LACS / POCS

66
Q

What % of patients with a TIA have stroke recurrence within the 1st 2 weeks?

A

10%

67
Q

Treatment of TIA

A

Antiplatelets
Anti HTNs
Statins
Endarterectomy

68
Q

Causes of TIA

A 
Athersclerotic narrowing
Embolic-cardiac source (AF, recent MI)
Hypercoagulable state
Arterial dissection 
Venous sinus thrombosis
69
Q

What should acute ischaemic stroke therapies do?

A

Restore blood supply
Prevent extension of ischaemic damage
Protect vulnerable brain tissue

70
Q

What does TPA stand for?

A

Tissue plasminogen activator

71
Q

What does TPA do?

A

It is involved in the breakdown of blood clots

72
Q

What is the strict criteria for TPA use?

A

< 4.5 hours from symptom onset
Disabling neurological deficit
Symptoms present > 60 mins
Consent obtained

73
Q

Exclusion criteria for IV TPA

A 
Anything that increases the possibility of haemorrhage 
- blood on CT scan 
- recent surgery 
- recent episodes of bleeding
- coagulation problems 
BP > 125 systolic or > 110 diastolic 
Glucose < 2.8 or > 22 mmol/L
74
Q

What does the benefit of TPA decline with?

A

Time

75
Q

What is the effective treatment in symptomatic internal carotid artery stenosis?

A

Carotid endarterectomy

76
Q

What can be used in secondary prevention of stroke?

A 
Anti HTNs
Anti platelets
Lipid lowering agents
Warfarin for AF
Carotid endarectomy
77
Q

After the acute phase has settled, what is the management of acute stroke?

A

Prevention of stroke recurrence
Prevention of complications related to stroke
Rehabilitation
Re-integration into the community

78
Q

What are the objectives of stroke care?

A

Reduce mortality
Reduce residual disability amongst survivors
Improve psychological status of patients and care givers
Improve patient/care giver knowledge
Maximize quality of life

79
Q

Investigations for stroke

A 
Routine blood tests 
- FBC
- glucose
- lipids
- ESR
CT or MRI 
ECG 
Carotid doppler USS 
Cerebral angiogram/venogram 
Hypercoagulable blood screen
80
Q

Definition of stroke

A

Is the sudden onset of focal or global neurological symptoms caused by ischemia or haemorrhage and lasting more than 24 hours

81
Q

What % of strokes are ischaemic?

A

85%

82
Q

Definition of TIA

A

Sudden onset of focal or global neurological symptoms if the symptoms resolve within 24 hours

83
Q

How quickly do most TIAs resolve?

A

1 - 60 mins

84
Q

Definition of ischaemia

A

Failure of the cerebral blood flow to a part of the brain, caused by an interruption of the blood supply to the brain

85
Q

How much of the metabolic rate does the brain use at rest?

A

20%

86
Q

Pathology of stroke

A

Varying degrees of hypoxia (decreased O2)
Hypoxia stresses the brains metabolism - this is especially important in ischaemic pneumbra
If prolonged the hypoxia leads to anoxia
Anoxia leads to infarction (complete cell death leading to necrosis)

87
Q

Definition of anoxia

A

No oxygen

88
Q

What further damage can occur after necrosis in stroke?

A

Oedema

Secondary haemorrhage

89
Q

What arteries do lacunar infarcts involve?

A

Perforating arteries around the internal capsule, thalamus and basal ganglia

90
Q

A stroke of the anterior cerebral artery will cause what?

A

Contralateral hemiparesis and sensory loss

LL > UL

91
Q

A stroke of the middle cerebral artery will cause what?

A

Contralateral hemiparesis and sensory loss, UL > LL
Contralateral homonymous hemianopia
Aphasia

92
Q

A stroke of the posterior cerebral artery will cause what?

A

Contralateral homonymous hemianopia with macular sparing

Visual agnosia

93
Q

A stroke of the basillar artery causes what?

A

Locked in syndrome

94
Q

What is webers syndrome and what does it result in?

A

Stroke of the branches of the posterior cerebral artery that supply the midbrain
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

95
Q

What does a stroke of the posterior inferior cerebellar artery?

A

Ipsilateral facial pain and temp loss
Contralateral limb/torso pain and temp loss
Ataxia
Nystagmus

96
Q

What does a stroke of the anterior inferior cerebellar artery cause?

A

Symptoms similar to posterior inferior cerebellar artery stroke but also
ipsilateral facial paralysis and deafness

97
Q

What does a stroke of the retinal / ophthalmic artery result in?

A

Amaurosis fugax

98
Q

What does a lacunar stroke present with?

A

Isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia

99
Q

What do lacunar strokes have a strong association with?

A

HTN

100
Q

What is conduction aphasia?

A

Speech is fluent but repetition is poor
Aware of the errors they are making
Comprehension is normal

101
Q

What causes conduction aphasia?

A

Stroke affecting the arcuate fasiculus (the connection between wernickes and brocas)

102
Q

What % of patients with intracranial venous thrombosis have sagittal sinus thrombosis?

A

50%

103
Q

Features of intracranial venous thrombosis

A

Headache (may be sudden onset)

Nausea and vomiting

104
Q

Presentation of sagittal sinus thrombosis

A

Seizures
Hemiplegia
Headache
N and V

105
Q

Causes of cavernous sinus syndrome

A

Cavernous sinus thrombosis
Local infection (e.g. sinusitis)
Neoplasia
Trauma

106
Q

Presentation of cavernous sinus thrombosis

A

Headache
N and V
Periorbital oedema
Ophthalmoplegia (6th nerve damage occurs before 3rd and 4th)
If trigeminal nerve involvement - hyperaesthesia of upper face and eye pain
Central retinal vein thrombosis

107
Q

What does lateral sinus thrombosis typically cause?

A

6th and 7th CN palsies

108
Q

Treatment of ischaemic stroke due to occlusion of anterior circulation presenting < 4.5 hours ago

A

Thrombolysis AND thrombolectomy

109
Q

What is the tool to assess patients with stroke symptoms in an acute setting and what does this stand for?

A

ROSIER

Recognition of stroke in the emergency room

110
Q

Patients following an ischaemic stroke should receive what?

A

Aspirin 300mg once daily for 14 days before considering anticoagulant treatment

111
Q

If have had TIA or a stroke, how long can you not drive for?

A

4 weeks

112
Q

Secondary prevention of stroke

A

1st line - clopidogrel

2nd line - aspirin in combination with modified release dipyridamole

113
Q

Criteria for thrombectomy

A
  1. 6 - 24 hours. If potential to salvage brain tissue - as shown by CT perfusion or diffusion weighted MRI sequences showing limited infarct core volume AND confirmed occlusion of proximal anterior circulation
  2. ASAP and within 6 hours. If confirmed proximal anterior circulation stroke demonstrated by CTA or MRA
114
Q

What does an anterior cerebral artery stroke cause and NOT cause?

A

Would CAUSE - leg weakness

Would NOT CAUSE - Face weakness or speech impairment

115
Q

Criteria for carotid endarectomy

A

Suffered stroke or TIA in the carotid territory and are not severely disabled
Who have carotid stenosis > 70% (ECST criteria) or > 50% (NASCET criteria)

116
Q

What is the first line radiological investigation for suspected stroke and what does it rule out?

A

Non contrast CT head

Rules out haemorrhagic event

117
Q

What tests must be done if < 55 y/o with no obvious cause of the stroke?

A

Autoimmune and thrombophilia screening

118
Q

What is the scale tool used to measure disability or dependence in activities of daily living in stroke patients?

A

Barthel index

119
Q

What is characteristic of brain stem infarcts?

A

‘Crossed findings’ - with cranial findings IPSILATERAL to the lesion and motor or sensory findings on the CONTRALATERAL side of the body

120
Q

What is webers syndrome?

A

Midbrain stroke syndrome
- involves fascicles of the oculomotor nerve resulting in an ipsilateral CN III palsy and contralateral hemiplegia or hemiparesis

121
Q

What is the most commonly survived stroke which affects the brainstem? What is this syndrome called?

A

Stroke affecting the posterior inferior cerebellar artery (PICA) - called lateral medullary syndrome

122
Q

Presentation of lateral medullary syndrome

A

Facial and contralateral body loss of sensation along with nystagmus and ataxia

123
Q

What is a feature of lacunar infarct?

A

Isolated hemisensory loss

124
Q

What does pontine haemorrhage commonly occur secondary to?

A

Chronic HTN

125
Q

Presentation of pontine haemorrhage

A 
Life threatning
Reduced GCS
Quadraplegia
Miosis
Absent horizontal eye movements
126
Q

A stroke of where can cause aphasia?

A

Dominant hemisphere middle cerebral artery strokes

127
Q

What does a cerebellar stroke present similarly to?

A

Vestibular neuritis

Neuro Pathology (21 decks)

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