“The true measure of a man is how he treats someone who does him absolutely no good...” – Ann Landers

True beauty lies in the Heart….

CPC 4.3.5 – Robert • Robert is a 62 year old recently retired from QLD

railways.• He lives in Cairns with his wife Rose and their

son Aiden who is 40 yrs old with Downs syndrome.

• He has fallen from a ladder whilst picking mangoes.

• His wife found him unconscious in the back yard. • On arrival at the A&E department he is

conscious but appears confused. He is complaining of a pain in his L arm.

CPC 4.3.5 – Robert • What happened:Patient is unable to talk• Collateral History: wife,son, neighbours,

paramedics.• What happened? Neighbour saw him at top of

ladder veer to the left and fall 2.5 m landing on his head. She called out to his wife who attended the scene. Wife says that he did not seem to hear her and his left arm was shaking. The shaking lasted for about 2minutes. He did not seem to regain consciousness until he was administered oxygen by the paramedics about 10 minutes later. He then seemed to come around but appeared confused . He was unable to move his Left arm, R arm and Right leg. Wife says he was well prior to going out to pick mangoes.

CPC 4.3.5 – Robert • PMH: Hypertension diagnosed in 2000. a bit

forgetful taking medication.• PSH: 1968 appendicectomy.• SH married for 40 years to Rose, they had 2

children. Their oldest Aiden was born with downs syndrome and has lived with them all his life; alcohol 2 beers x2/week, non smoker.

• FH mother: breast ca age 72 years; well age 85yr• Father died CVA aged 71• Brother has hypertension and type 2 DM• Allergies: aspirin• Immunisation Fluvax 4.06, Pneumovax 2004• Medication Ramipril 2.5mg OD [when remembers

it]

CPC 4.3.5 – Robert • T 36.4 C rr 16/min BP 168/98 mmHg pulse

110 bpm irregular, O2 sats RA 92% (on mask O2 4l/min) BMI 31 BGL 16m/mol

• General appearance : confused to place and time; no memory of fall or period preceding fall; drooping R side face and R side of body

• EMST cervical collar ABCDE• Peripheries : no clubbing. CRT<2 secs• CVS Irregular HR no murmurs, no carotid

Bruits• CNS GCS 13 Pupils R>L sluggish

response[AVPU];

CPC 4.3.5 – Robert • Boggy Haematoma L temporo parietal area. • Gross dysphasia, drooping R side of face, • Flaccidity R side of body, brisk reflexes with

equivocal plantar reflex • Painful swelling with bruising lower L arm just

distal to elbow, unable to test L power, tone or reflexes due to pain when moving L arm

• Power/reflexes/tone normal L leg• Sensation : responds to pain • Resp., GI, Renal: all normal

CPC 4.3.5 – Robert • Head injury

– Contusion, Concussion– Epidural hematoma– Subdural hematoma

• Cerebrovascular accident (stroke)– CVA: embolic– CVA: haemorrhagic– Metabolic cause– Seizure ? cause

• Trauma to L arm ?# radius / ulna

Education must award self-Education must award self-confidence, the courage to depend confidence, the courage to depend

on one’s own strength.on one’s own strength.

- Baba- Baba

Pathology of Cerebro-vascular Disease

(Stroke)

Dr. Shashidhar Venkatesh Dr. Shashidhar Venkatesh MurthyMurthy

Associate Professor & Head of Pathology

Introduction:• “Stroke” Acute neurological deficit – clinical.• Cerebro Vascular accident (CVA) – Pathology.• Low O2 (hypoxia) / Low blood supply.• Varying severity, location & types• Transient, evolving & completed. • Global / Focal, arterial / venous• Ischemic / hemorrhagic.

Introduction:• Stroke is the third most common cause of

death and the second most common cause of neurologic disability after Alzheimer's disease.

• Its incidence has decreased in recent decades, but the decrease appears now to have leveled off, and it remains the leading cause of institutionalization for loss of independence.

Brain Blood Supply Features:• High oxygen requirement.

– Brain 2% of body weight - 15% of cardiac output

– 20% of total body oxygen.

• Continuous oxygen requirement– Few minutes of ischemia - irreversible injury.

• Neurons - Predominantly aerobic.• Sensitive areas:

– Adults -Hippocampus, 3,5th & 6th layer of cortex, Purkinje cells. Border zone (watershed areas)

– Brain stem nuclei in infants.

Anatomy – Stroke.

Stroke Types:

• Clinical– Transient Ischemic Attack –TIA resolve <24h– Evolving stroke – increasing >24h. – Thromb.

• Recurrent / multiple stroke – sec. factors.

– Completed stroke – no change… embolic.

• Pathological– Focal / Global– Ischemic & hemorrhagic.– Venous infarcts. (young, infections)

Common Types and Incidence:

• Infarction: Incidence 80% - mortality 40% – 50% - Thrombotic – atherosclerosis

• Large-vessel 30% (carotid, middle cerebral)• Small vessel 20% (lacunar stroke)

– 30% Embolic (heart dis / atherosclerosis)

• Young, rapid, extensive.

– Venous thromboembolism (rare)

• Hemorrhage: Incidence 20% - mortality 80% – Berry aneurysm, Microaneurysm, Atheroma.– Intracerebral or subarachnoid.

Stroke location and incidence:

Cause %Clinical presentation

30day mort(%) Pathogenesis

Cerebral infarction

85 Slowly / sudden evolving signs and symptoms

15-45 Cerebral hypoperfusion Embolism Thrombosis

Intracerebral hem.

10 Sudden onset of stroke with raised intracranial pressure

80 Rupture of micro-aneurysm or arteriole

Subarachnoid haemorrhage

5 Sudden headache with meningism

45 Rupture of saccular aneurysm on circle of Willis

Hypertensive Intracerebral Hem: Sites

1. Putamen-Claustrum

2. Cerebral white matter

3. Thalamus

4. Pons

5. Cerebellum

55%

15

10

10

10

Etiology:• Complication of several disorders

• Atherosclerosis – most common.

• Hypertension, smoking, diabetes.

• Heart disease – Atrial fibrillation.

• Other: – Trauma – fat embolism– Tumor, Infection– Caissons disease – Bends *Pacific.

Risk factors:• Non modifiable• Age• Male sex• Race• Heredity

• Modifiable• Hypertension• Diabetes• Smoking• Hyperlipidemia• Excess Alcohol*• Heart disease (AF)

Oral contraceptives• Hypercoagulability.

Clinical Categories:

• Global Ischemia.– Hypoxemic encephalopathy– Hypotension, hypoxemia, anemia.

• Focal Ischemia.– Obstruction to blood supply to focal area.– Thrombosis, embolism or hemorrhage.

Global Ischemia:• Etiology:

– Impaired blood supply - Lung & Heart disorders.– Impaired O2 carrying – Anemia/Blood dis.– Impaired O2 utilization – Cyanide poisoning.

• Morphology:– 3rd, 5th and 6th layers of the cortex, CA1 sector of the

hippocampus and in the Purkinje cells in the cerebellum – Laminar necrosis, Hippocampus, Purkinje cells.– Border zone infarcts – “Watershed”– Sickle shaped band of necrosis on cortex.

• Clinical Features:– Mild transient confusion state to– Severe irreversible brain death. Flat EEG, Vegetative state.

Coma.

Morphology in Global Ischemia

Watershed/Boundary zone infarcts:

Lamellar necrosis in global ischemia.

Carotid thrombosis

Local infarction:

Cell death ~ 6mincentral infarct area or umbra, surrounded by a penumbra of ischemic tissue that may recover

Infarct Pathogenesis:

• Reduced blood supply – hypoxia/anoxia.• Altered metabolism Na/K pump block. • Glutamate receptor act. calcium influx.• 1-6 min – ischemic injury – Red neuron,

vacuolation.• >6 min – cell death, karyorrhexis.

Infarct Stages:• Immediate – <24 hours

– No Change gross, micro Na/K loss, Ca+ influx.

• Acute stage – < 1week – Oedema, loss of grey/white matter border.– Inflammation, Red neurons, necrosis, neutrophils

• Intermediate stage – 1- 4 weeks.– Clear demarcation, soft friable tissue, cysts– Macrophages, liquifactive necrosis

• Late stage – > 4 weeks.– Removal of tissue by macrophages– Fluid filled cysts with dark grey margin (gliosis)– Gliosis – proliferation of glia at periphery.

Cerebral edema

Cerebral Edema: narrow sulci, flat gyri.

Axonal Injury:

A, Hypoxic/ischemic injury in cerebral cortex - "red neurons." shrunken cellB, Axonal spheroids at points of axonal disruption C, Swollen cell body and peripheral dispersion of Nissl substance (chromatolysis)

H&E Stain.

Cerebral Edema:

Normal Edema

Edema, loss of demarcation:

Cerebral Infarct : Red Neurons

Acute Infarction: Oedema

Cerebral Infarct - 2 Weeks

Cerebral Infarct – 1-4 Week

Cerebral Infarction: Macrophages

Cerebral Infarct - Cyst formation

C. Infarct - Cyst formation

Cerebral Infarction - Late

Cystic space

Specific focal Infarcts

Coronary artery involvementMCAACAPCA

MCA stroke.

MCA stroke.

Wikipedia: GNU Free Documentation license

MCA stroke.

Wikipedia: GNU Free Documentation license

Haemorrhagic - Arterial embolus

Infarct with Punctate hemorrhage

Cerebral Infarction - Late

Cerebral Infarction - Late

Hypertensive CVD• Intraerebral/Subarachnoid Hemorrhage

– Microaneurysm hemorrhages – Basal ganglia. Putamen(60%), thalamus, ventricles.

– Berry aneurysm hemorrhages – subarachnoid.

• Chronic Hypertension: (dementia) – Slit hemorrhages. Microhemorrhages heal as slit with

pigment.– Lacunar infarcts: Brain stem - pale infarcts. A.sclerosis

• Hypertensive encephalopathy-Malignant.– Headache, confusion, vomiting – Raised ICP.

Central Pontine Hemorrhage - Herniation

Subarachnoid Hemorrhage:

Ruptured Berry Aneurism

Fusiform atherosclerotic

aneurysm

Saccular(berry) Aneurysm:

Intracerebral Hemorrhage:

Intracerebral Hemorrhage:

Lacunar Infarct in pons

Left (Dominant) Hemisphere Stroke: Clinical

• Aphasia • Right hemiparesis • Right-sided sensory loss • Right visual field defect • Poor right conjugate gaze • Dysarthria • Difficulty reading, writing, or

calculating

Diagnosis: Recent cerebral infarction in left MCA distribution.Left cerebral hemisphere shows swelling with compression of the lateral ventricle mainly in the frontal area, due to recent infarct in the Middle Cerebral Artery (MCA) distribution. The brain in the MCA area shows discoloration of the cortex and also blurring between the cortex and white matter.

Right (Non-dominant) - Hemisphere Stroke:

• Defect of left visual field • Extinction of left-sided

stimuli • Left hemiparesis • Left-sided sensory loss • Left visual field defect • Poor left conjugate gaze • Dysarthria • Spatial disorientation

CNS AV Malformations:

• Many types:– AV Malformation *– Cavernous angioma– Telangiectasia– Venous angioma

• Cause of Seizure disorders & hemorrhage.

• Most common congenital vascular malformation.

• Typically located in the outer cerebral cortex underlying white matter.

Summary:• Stroke: Ischemic / Thrombotic / Hemorrhagic

– Acute neurological deficit - Clinical– Cerebro Vascular Accident – Pathology.

• Etiology: Thrombosis, Embolism, Hemorrhage.• Risk factors: AS, Hypertension, Smoking.• Global – Systemic Hypoxia – Watershed & lamellar infarct• Focal – Basal ganglia, Putamen, Int. capsule (MCA) • Pathogenesis: Infarction Liquifaction necrosis Cyst

formation with peripheral gliosis. (loss of neural function)• Hypertension & CVA:

– Atherosclerosis - Thrombosis– Haemorrhage (Intra/subarachnoid), – chronic benign: Lacunar infarcts & slit hemorrhages. – Hypertensive Encephalopathy,

Cerebral Infarction: Microscopy

Loss of MyelinLoss of Myelin

Red NeuronsRed Neurons Neutrophil Infil.Neutrophil Infil.Macrophages & Macrophages & early Gliosisearly Gliosis

GliosisGliosis

““The ultimate measure of a The ultimate measure of a man is not where he stands man is not where he stands in moments of comfort, but in moments of comfort, but where he stands in time of where he stands in time of

challenge and controversy” challenge and controversy”

– Martin Luther King Jr.

This photograph shows a slice through the cerebral hemispheres. The most likely pathogenesis is:

1 2 3 4 5

0%

95%

0%0%5%

1.Cerebral trauma due to head injury.

2.Hypertensive hemorrhage.

3.MCA Embolism from a mural thrombosis on a myocardial infarct.

4.Atheroma and thrombosis at the carotid bifurcation.

5.Bleeding due to Severe thrombocytopenia.

Section of Brain specimen. The lesion is most likely caused by?

1 2 3 4 5

2%6%

19%

73%

0%

1. Gunshot

2. Coup injury-Contusion

3. Contra coup injury.

4. Ruptured ACA aneurysm.

5. Hypertensive narrowing.

Stroke. Most likely clinical feature?

1 2 3 4 5

2%

81%

2%

12%

3%

1. Visual deficit.

2. Hemiparesis – leg

3. Memory deficit.

4. Aphasia

5. Emotional disturbance.

ACA infarct involving the medial and parasagittal aspect of the motor cortex, causing contralateral paralysis of the leg.

This photograph shows a slice through the cerebral hemispheres. The most likely cause is,

1 2 3 4 5

20%

70%

2%0%

8%

1. Head injury.

2. Hypertensive hemorrhage.

3. Embolic infarct.

4. Atherosclrerotic narrowing.

5. Severe thrombocytopenia.

Stroke Patient. Most likely Artery involved?

1 2 3 4 5

19%

9%5%5%

62% Infarct involving the inferior aspect of the left temporal lobe (PCA distribution).

1. ACA.

2. PCA

3. MCA

4. Vertebral

5. Basilar

old

new

A 67y man with IHD is rushed to ED after collapse. Brain at autopsy. Most likely Artery involved?

1 2 3 4 5

5% 3%10%

2%

81%

1. External Carotid A.

2. Internal Carotid A.

3. Middle Cerebral A.

4. Sagittal venous sinus.

5. Anterior Cerebral A.

The trifurcation of the middle cerebral artery is a favored site for lodgment of emboli and for thrombosis secondary to atherosclerotic damage. This deprives the parietal cortex of circulation and produces motor and sensory deficits. When the dominant hemisphere is involved, these lesions are commonly accompanied by aphasia.

A 78y male, hypertensive. Sudden headache collapsed while morning walk. Image shows the lesion. Most likely cause?

1 2 3 4 5

26%

13%10%

0%

51%

1. Ruptured Berry Aneurysm.

2. Ruptured AV malformation.

3. Hemorrhagic infarct.

4. Lacunar infarct.

5. AS- embolic infarct.

lesion is a hemorrhagic infarct in the distribution of the RMCA. The basic mechanism is arterial occlusion, usually by an embolus, with reperfusion and leakage through a damaged capillary bed following lysis of the embolus.

Stroke Patient. Most likely Artery involved?

1 2 3 4 5

7%

86%

0%0%7%

Infarct involving the ACA distribution.

1. PCA

2. ACA.

3. MCA

4. Vertebral

5. Basilar

28y M, Fever 7d, presents acute hemiparesis & ipsilateral pupillary dilatation. Image cerebellum & pons. ? Diagnosis

1 2 3 4 5

22% 22%

56%

0%0%

1. Stroke posterior Cer. Art.

2. Bacterial Meningitis.

3. Cerebellar Astrocytoma

4. Glioblastoma multiforme

5. Transtentorial herniation

70y M, senile dementia, recent MI, dies of multiorgan failure. Brain at autopsy. ? Most common complication

1 2 3 4 5

30%28%

4%

38%

0%

1. Dissection.

2. Haemorrhage.

3. Infection.

4. Thrombosis.

5. Recanalization.

78y M, Hypertensive presents with progressive dementia. Image shows section of brain. ? Diagnosis

1 2 3 4 5

17%

3% 2%3%

75%

1. Old embolic infarct.

2. Hemorrhagic infarct.

3. Lacunar infarct

4. Recent embolic infarct.

5. Atherosclerotic block.

A 72y woman, 1 year history of declining memory developed sudden headache and decreased consciousness and collapsed while washing dishes. Image shows the lesion. Most likely cause?

1 2 3 4 5

10% 8% 8%2%

73%

1. Ruptured Berry Aneurysm.

2. Ruptured AV malformation.

3. Hemorrhagic infarct.

4. Lacunar infarct.

5. AS- embolic infarct.

Brain Stem Stroke: Common Pattern

• Pure Motor - Weakness of face and limbs on one side of the body without abnormalities of higher brain function, sensation, or vision (MCA/ACA)

• Pure Sensory - Decreased sensation of face and limbs on one side of the body without abnormalities of higher brain function, motor function, or vision   (PCA).

Recent right ACA

infarction

Coronal section shows the cerebral hemispheres through the anterior portion of third ventricle, anterior commissure, and the tip of the temporal lobes. This section is not quite symmetrical because it shows more of the anterior portion on the left side. The brain shows a recent area of necrosis in the right anterior cerebral artery distribution near the midline, with fragmentation of the tissue and poorly demarcated cortex and white matter. Corpus callosum is very thin and there is also an old slit-like lesion in the distribution of the left anterior cerebral artery. Diagnosis: Recent infarction in right anterior cerebral artery distribution, and old infarct, left anterior cerebral artery.

#1. LEFT PCA

Atherosclerosis. #2. Old

PCA

infarction

This is a view of the cerebral hemispheres after brainstem and cerebellum have been removed at the level of the midbrain. There is circular marked atherosclerosis of the left posterior cerebral artery. The left occipital lobe (right side of the photograph) shows a collapsed cystic and pigmented area in the distribution of the posterior cerebral artery. Diagnosis #1. Atherosclerosis of the left posterior cerebral artery. #2. Old infarction, posterior cerebral artery distribution.

Recent right infarction MCA territory with hemorrhagic

transformation

This is an axial view. The superior section is shown on the left side of the photograph and the inferior portion on the right side. The inferior portion is through the upper portion of the caudate nuclei and the thalami. The brain shows fragmentation, necrosis, and discoloration, predominantly of the cortex, in the right middle cerebral artery distribution. There is mass effect with compression of the ventricular system. Discoloration of the cortex within the lesion represents early hemorhagic transformation of the ischemic lesion. Diagnosis: Recent right infarction MCA territory with hemorrhagic transformation.

Old cystic infarct in the distribution of

the left MCA

Coronal sections of cerebral hemispheres . One is anterior and through the optic chiasm and the posterior section is through the thalami. The left hemisphere (on the left side of the photograph) is smaller than the right hemisphere. The small size of the left hemisphere is due to a large cystic lesion that includes the external portion of the putamen, internal capsule, inferior portion of the frontal lobe and parts of the temporal lobe. Diagnosis: Old cystic infarct in the distribution of the left MCA.

Hypertension:Ruptured anterior communicating or anterior cerebral

artery aneurysm

Coronal sections of the cerebral hemispheres through the frontal lobes and at the level of the genu of the corpus callosum. A hematoma has destroyed the area around the corpus callosum and inferior frontal gyri. Hematoma has ruptured into both lateral ventricles. The location of the hematoma is characteristic of a ruptured anterior communicating or anterior cerebral artery aneurysm due to hypertension.

Spontaneous hypertensive

thalamic hemorrhage

with intraventricular

extension

Coronal section of the cerebral hemispheres through the pulvinar and quadrigeminal plate. The section shows a hematoma that has destroyed part of the thalamus on the left side. The hematoma has ruptured into the lateral ventricle and has compressed the quadrigeminal plate on the left side. Diagnosis: Spontaneous hypertensive thalamic hemorrhage with intraventricular extension.

Spontaneous hypertensive

hemorrhage of the

left putamen

Axial section of the brain through the level of the putamen and the upper portion of the thalami. The left hemisphere shows a localized hematoma that involves the putamen and part of the anterior limb of the internal capsule. The hematoma has not ruptured into the ventricle and has spared the insular cortex. Diagnosis: Spontaneous hypertensive hemorrhage of the left putamen.

Spontaneous hypertensive right

cerebellar hemisphere hemorrhage. #2 Acute

hydrocephalus

This is an axial section of the brain, brainstem and cerebellum. The section goes through the caudate nuclei, part of the anterior commissure, the midbrain and the upper portion of the fourth ventricle and cerebellar hemispheres. The brain shows hydrocephalus with dilatation of both anterior portions of the lateral ventricles and the temporal horns. The right cerebellar hemisphere is enlarged by a hematoma that has originated near the dentate nucleus and has destroyed part of the white matter of the cerebellar hemisphere and the folia.The fourth ventricle is compressed to the left side anteriorly. Diagnosis: Spontaneous hypertensive right cerebellar hemisphere hemorrhage. #2 Acute hydrocephalus.

Old hypertensive spontaneous

hemorrhage left

putamen

An axial section of the cerebral hemispheres. Shows a pigmented slit- like lesion in the left putamen. This pigmentation is rusty brown and within the cavity there is some old blood. The sulci in the insula are prominent. Diagnosis: Old hypertensive spontaneous hemorrhage left putamen.

Central pontine

hemorrhage Due to

cerebral Herniation.

This is a transverse section of the pons and cerebellum. The pons is almost completely destroyed by a hematoma that has replaced the tegmentum and most of the basis pontis . The hematoma has ruptured into the fourth ventricle which is obscured by this lesion. The cerebellum is normal . Diagnosis: Central pontine hemorrhage secondary to cerebral herniation – following increased intracranial pressure.

Cerebral Infarction

hemorrhage

Cerebral Infarction

hemorrhage

Brain Stem / Cerebellum / Post Hemisp. Patterns.

• Motor or sensory loss in all four limbs • Crossed signs • Limb or gait ataxia • Dysarthria • Dysconjugate gaze • Nystagmus • Amnesia • Bilateral visual field defects 

Investigations:

• CT of the brain without contrast – location/ext.• Electrocardiogram - heart• Chest x-ray - heart• complete blood count, platelet count – hemat.• PT, aPTT – coagulation.• Serum electrolytes – complications.• Blood glucose - DM• Renal and hepatic chemical analyses – status.• National Institutes of Health Scale (NIHSS)

score – clinical/prognosis ?

“We must all suffer from one of two pains: the pain of discipline or the

pain of regret” The difference is Discipline weighs ounces.. while regret

weighs ton’s..! Jim Rohn

Anatomy – Stroke.

’’Smile’ at each other, smile Smile’ at each other, smile at your friends, smile at at your friends, smile at your partner, smile at your partner, smile at strangers - it doesn't strangers - it doesn't matter who it is – This will matter who it is – This will help you to grow up in help you to grow up in greater love for each other.greater love for each other.

Mother Teresa1910-1997, Roman Catholic Missionary