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Cerebrovascular disease (Stroke)

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Hemorrhage: Incidence 20% - mortality 80% Intracerebral or subarachnoid. aneurysm, hypertension/congenital. ... Berry aneurysm + Hptn. Mixed cerebral ... – PowerPoint PPT presentation

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Title: Cerebrovascular disease (Stroke)


1
The true measure of a man is how he treats
someone who does him absolutely no good.
Ann Landers
2
Pathology of Cerebro-vascular Disease (Stroke)
Dr. Venkatesh M. Shashidhar Associate Professor
of Pathology Fiji School of Medicine
3
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.

4
Introduction
  • Stroke Cerebro Vascular accident (CVA)
  • Acute neurological deficit ? blood supply.
  • Third leading cause of death. (2/1000/y)
  • Varying severity, location types
  • Global / Focal
  • Transient Ischemia evolving completed.
  • Low O2 (hypoxia) / Low blood supply.

5
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.

6
Stroke Types
  • Clinical
  • Transient Ischemic Attack TIA lt24h
  • Evolving stroke
  • Completed stroke
  • Recurrent / multiple stroke.
  • Pathological
  • Focal / Global
  • Ischemic (white/pale) hemorrhagic (red)
  • Lacunar infarcts (pale chronic cystic)

7
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.
  • Hemorrhage Incidence 20 - mortality 80
  • Intracerebral or subarachnoid.
  • aneurysm, hypertension/congenital.

8
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.

9
Risk factors
  • Modifiable
  • Hypertension
  • Diabetes
  • Smoking
  • Hyperlipidemia
  • Excess Alcohol
  • Heart disease (AF) Oral contraceptives
  • Hypercoagulability.
  • Non modifiable
  • Age
  • Male sex
  • Race
  • Heredity

10
Clinical Categories
  • Global Ischemia.
  • Hypoxemic encephalopathy
  • Hypotension, hypoxemia, anemia.
  • Focal Ischemia.
  • Obstruction to blood supply to focal area.
  • Thrombosis, embolism or hemorrhage.

11
Global Ischemia
  • Etiology
  • Impaired blood supply - Lung Heart disorders.
  • Impaired O2 carrying Anemia/Blood dis.
  • Morphology
  • 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.

12
Causes of hypotension
  • Myocardial infarction
  • Septic shock
  • Internal hemorrhage
  • Massive GI bleed ruptured varices
  • bleeding ulcer, carcinoma
  • Ruptured aortic aneurysm.
  • Shock, Others

13
Watershed/Boundary zone infarcts
14
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15
Focal Ischemia
  • Thrombosis
  • Progressive, recurrent,
  • Pale or ischemic infarct.
  • Eg. Lacunar infarct
  • Embolism / Hemorrhage
  • Sudden.
  • Red or hemorrhagic infarct.
  • Atherosclerosis rupture/embolism

16
Embolism formation
17
Local infarction
Cell death 6min central infarct area or umbra,
surrounded by a penumbra of ischemic tissue that
may recover
18
Haemorrhagic - Arterial embolus
19
Infarct Pathogenesis
  • Reduced blood supply hypoxia/anoxia.
  • Altered metabolism ? Na/K pump block.
  • Glutamate receptor act. ? calcium influx.
  • 1-6 min ischemic injury vacuolation.
  • gt6 min cell death.

20
Infarct Stages
  • Immediate 6 hours
  • No Change both gross micro
  • Acute stage 2 days
  • Oedema, loss of grey/white matter border.
  • Inflammation, Red neurons, neutrophils
  • Intermediate stage 2 weeks.
  • Demarcation, soft friable tissue, cysts
  • Macrophages, liquifactive necrosis
  • Late stage After 4 weeks.
  • Fluid filled cysts with dark grey margin
    (gliosis)
  • Removal of tissue by macrophages
  • Gliosis proliferation of glia, loss of
    architecture.

21
Cerebral edema
22
Edema, loss of demarcation
23
Acute Infarction Oedema
24
Cerebral Infarct Red Neurons
25
Cerebral Infarct - 1 Week
26
Cerebral Infarct - 2 Weeks
27
Cerebral Infarction Macrophages
28
Cerebral Infarct - Cyst formation
29
Infarct with Punctate hemorrhage
30
Cerebral Infarction - Late
31
C. Infarct - Cyst formation
32
Smile at each other, smile at your friends,
smile at your partner, smile at strangers - it
doesn't matter who it is This will help you to
grow up in greater love for each other.Mother
Teresa1910-1997, Roman Catholic Missionary
33
Intracranial Hemorrhage
  • TRAUMA
  • Epidural
  • Subdural
  • VASCULAR TRAUMA
  • Intracerebral
  • Subarachnoid
  • Mixed cerebral-subarachnoid
  • Intracerebral - Hypertension
  • Subarachnoid - Berry aneurysm Hptn.
  • Mixed cerebral Vascular malformations.

34
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35
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36
Hypertensive CVD
  • Massive Intracerebral Hemorrhage
  • Ganglionic Lobar hemorrhages
  • Putamen(60), thalamus, ventricles.
  • Slit hemorrhages.
  • Microhemorrhages heal as slit spaces.
  • Lacunar infarcts
  • Brain stem pale infarcts arteriolar sclerosis
  • Hypertensive encephalopathy
  • Headache, confusion, vomiting raised ICP.

37
Subarachnoid Hemorrhage
38
Ruptured Berry Aneurism
39
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40
Intraventricular Hemorrhage
41
Cerebral Infarction? hemorrhage
42
Cerebral Infarction? hemorrhage
43
Lacunar Infarct in pons
44
Summary
  • Stroke Acute neurological deficit - Clinical
  • Cerebrovascular Accident pathology.
  • Ischemic/Hemorrhagic
  • Thrombosis, Embolism/Hemorrhage
  • Atherosclerosis, Hypertension, Heart Disease.
  • Global Systemic Hypoxia Watershed infarct
  • Focal Thrombosis, Embolism or Hemorrhage
  • Liquifaction necrosis ? Cyst formation, gliosis.
  • Hypertension Pale, Lacunar infarcts, slit hem.

45
Ischemic penumbra
46
The ultimate measure of a man is not where he
stands in moments of comfort, but where he stands
in time of challenge and controversy Martin
Luther King Jr.
47
Anatomy Stroke.
48
Left (Dominant) Hemisphere Stroke Common Pattern
  • Aphasia
  • Right hemiparesis
  • Right-sided sensory loss
  • Right visual field defect
  • Poor right conjugate gaze
  • Dysarthria
  • Difficulty reading, writing, or calculating

49
Right (Non-dominant) Hemisphere Stroke Common
Pattern
  • 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

50
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).

51
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 

52
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 ?

53
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 tons..! Jim Rohn
54
Hypertensive Intracerebral Hem Sites
1. Putamen-Claustrum 2. Cerebral white
matter 3. Thalamus 4. Pons 5. Cerebellum
55 15 10 10 10
55
Stroke types and incidence
56
Anatomy Stroke.
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