W23 - Cerebrovascular disease and trauma

Question 1

What are the 2 types of cerebral oedema? Define each

Answer 1

1. Vasogenic = disruption of BBB
2. Cytotoxic = 2ndary to cellular damage i.e. hypoxia, ischaemia

Question 2

Cerebral oedema leads to ______ _______

Answer 2

Cerebral oedema leads to raised ICP

Question 3

There is a rarer form of oedema called hydrocephalic oedema. What is it?

Answer 3

Hydrocephalic oedema = movement of water across the ventricle ependyma cells into the astrocytes

Question 4

What do you see?

Answer 4

Loss of 1) sulci, 2) gyri, 3) ventricles = cerebral oedema

Question 6

CSF is produced by the _____ _____ in the ________ ________

Answer 6

CSF is produced by the choroid plexus in the lateral ventricles

Question 7

There are 2 types of hydrocephalus - name and define them.

Answer 7

Non-communicating = involves obstruction of CSF flow

Communicating = involves no obstruction but problems with reabsorption of CSF into venous sinuses (i.e. in meningitis) - problem is usually in the subarachnoid space

Question 8

Normal ICP is _____ for a supine adult at rest

Answer 8

Normal ICP is 7-15 mmHg for a supine adult at rest

Question 9

Name 3 herniation types in brain

Answer 9

1. Subfalcine herniation
2. Transtentorial herniation
3. Tonsillar herniation

Question 10

What is the consequence of raised ICP?

Answer 10

herniation of brain where space is available

Question 12

Subfalcine herniation - what is it?

Answer 12

generally caused by unilateral frontal, parietal or temporal lobe disease that creates a mass effect with medial direction of the ipsilateral cingulate gyrus beneath the free edge of the falx cerebri due to raised intracranial pressure.

relatively rare and not too acute

Question 13

Transtentorial herniation - what is it?

Answer 13

aka uncal herniation, is when the medial temporal lobe is squeezed by a unilateral mass across and under the tentlike tentorium that supports the temporal lobe

Question 14

Tonsillar herniation - what is it?

Answer 14

the cause is an expanding infratentorial mass (eg, cerebellar hemorrhage), forcing the cerebellar tonsils, through the foramen magnum.

Question 15

When the integrity of the BBB is disrupted, the resultant oedema is described as ______

Answer 15

vasogenic

Question 16

Which of the following types of herniation does not involve cerebral cortex?

A) Subfalcine

B) Transtentorial

C) Tonsillar

D) Uncal

Answer 16

C) Tonsillar

Question 17

TIA - usually lasts ______ and there is usually no permanent brain injury

_____ of those with TIA get significant infarct within 5 years

Answer 17

TIA - usually lasts 5 minutes and there is usually no permanent brain injury

1/3 of those with TIA get significant infarct within 5 years

Question 18

What do you see?

Answer 18

Axial CT

Large mass in left occipital lobe

You can see it has holes in it = AVM mass with tissue in the middle of it

Question 19

This is a brain resection. What do you see?

Answer 19

AVM resection

Question 20

Non-traumatic intra-parenchymal haemorrhage:

• most common location?
• most common cause?

Answer 20

Non-traumatic intra-parenchymal haemorrhage:

• most common location = basal ganglia
• most common cause = hypertension (>50% of bleeds)

Question 21

AVM:

• location in the brain?
• Age at presentation?
• Sequelae of AVM bleed?
• Treatment of AVM bleed?

Answer 21

AVM:

• location in the brain = anywhere in the CNS
• Age at presentation = 20s-50s
• Sequelae of AVM bleed = high presssure bleed so it’s MASSIVE (high mortality/morbidity)
• Treatment of AVM bleed = surgery, embolization, IR surgery

Question 22

Brain resection - what is it?

Answer 22

Cavernous angioma - it’s all blood vessels, no brain parenchyma

Question 25

Define cavernous angioma

Answer 25

Well-defined malformative lesion composed of closely packed vessels with no parenchyma interposed between vascular spaces

*AVM has parenchyma inbetween, cavernous angioma does not**

Question 26

What do these 2 images show?

Answer 26

Left = rupture of berry aneurysm with lots of blood leaked out

Right = 3 berry aneurysms (typically at bifurcations)

Question 27

Cavernous angioma:

• where does it occur?
• at what age does it present?
• Sequlae of bleed?
• Treatment?

Answer 27

Cavernous angioma:

• where does it occur = anywhere in the CNS
• at what age does it present = after 50s
• Sequlae of bleed = low pressure, recurrent bleeds
• Treatment = surgery

Question 29

What signs are these called?

What are they a sign of?

Name additional presentations

Answer 29

1. Left (battle sign) - mastoid process haemorrhaging, right (raccoon eyes)
2. Indicate skull base fracture
3. • Ottorhoea, rhinorrhoea

Question 30

What is a brain contusion?

Answer 30

Brain in collision with skull, aka “surface bruising”

NB: if pia mater torn = laceration

Question 31

What is coup and contrecoup in terms of brain contusion?

Answer 31

A coup injury refers to the brain damage that occurs directly under the point of impact. In contrast, a contrecoup injury occurs on the opposite side of the brain from where the head is struck

Question 32

Subarachnoid haemorrhage - what is it?

Answer 32

Subarachnoid haemorrhage is rupture of a berry aneurysm, which are present in 1% of general population

Question 33

Subarachnoid haemorrhage:

• what % have berry aneurysms?
• where do these ruptures usually occur?
• What causes greatest risk of rupture?

Answer 33

Subarachnoid haemorrhage:

• what % have berry aneurysms = 1% of general population
• where do these ruptures usually occur = 80% at internal carotid artery bifurcation, 20% at vertebro-basilar circulation
• What causes greatest risk of rupture = 6-10 mm diameter

Question 34

What does this specimen show?

Answer 34

Grade 2 Diffuse Axonal Injury = focal lesion in corpus callosum, in addition to diffuse axonal damage

Question 35

Subarachnoid haemorrhage is your ______________ presentation

Answer 35

Subarachnoid haemorrhage is your thunderclap headache presentation

Question 37

What % of patients who experience a TIA will get a significant infarct within 5 years?

Answer 37

33%

Question 38

What is the most common cause of non-traumatic intraparenchymal haemorrhages?

Answer 38

Hypertension

Question 42

What is diffuse axonal injury in TBI?

Answer 42

Diffuse axonal injury:

• occurs at MOMENT of injury
• shear + tensile forces affecting axons
• midline structures commonly affected (i.e. corpus callosum)

Question 43

Commonest cause of coma when there is no bleed is….

Answer 43

Diffuse axonal injury

Question 45

Some American football players develop psychiatric conditions, suicide idealation, domestic violence - what is the distinct pathology linked to this?

Answer 45

Chronic Traumatic Encephalopathy (CTE)

=> due to repetitive head injury