Cerevrovascular disease

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Cerevrovascular disease

• Dr. Basu MD

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Topic

• Cerebral (intracranial) hemorrhage
• Types
• Etiology
• Morphology
• Clinical features

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Intracranial hemorrhage types

• Non traumatic Spontaneous hemorrhage
• Intracerebral (Primary Brain Parenchymal
  Hemorrhage)
• Sub-arachnoid Hemorrhage
• Mixed Hemorrhage
• Traumatic

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Spontaneous hemorrhageEtiology

• A . Intracerebral (intraparenchymal) -
  predominantly, hypertensive.
• B. Subarachnoid - predominantly, aneurysmal.
• C. Mixed intracerebral and subarachnoid - usually
  associated with rupture of arteriovenous
  malformations.

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Spontaneous Intracerebral / intraparenchymal
hemorrhage

• AGE MIDDLE TO LATE ADULT LIFE
• PICK AGE 60 YEARS
• Cause
• 1.Acute and chronic raise of blood pressure.
• 2. Rupture of Charcot Bouchard microaneurysm
• 50 of all hemorrhage

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Spontaneous Intracerebral / intraparenchymal
hemorrhage

• Risk factors
• It can develop in an ischemic Infract
  particularly if reperfusion occur.
• If the patient is on anticoagulant therapy
• In case of Amyloid angiopathy.
• Location
• Putamen 60
• Thalamus
• Pons

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Hemorrhages involving the basal ganglia area
Hypertensive hemorrhage
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Rupture of Charcot Bouchard microaneurysm

• IT IS A FEATURE OF CHRONIC HYPERTANSION
• Involve a vessels less than 300micrometer in
  Diameter.
• SITE BASAL GANGLIA

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Complication of Intracranial hemorrhage

• Mass effect can cause Herniation
• Secondary Brain stem or Duret hemorrhage

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Clinical Features Hypertensive hemorrhage

• Sudden loss of consciousness
• Vomiting, Headache increased intracranial
  pressure

• EFFECT OF BRAIN STEM COMPRESSION
• IRREGULAR RESPIRATION
• PERIOD OF APNEA CHEYNE STROKE BREATHING
• DILATED NONRESPONSIVE PUPIL
• SPASTICITY

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SUBARACHONOID HAEMORRHAGE

• Etiology
• RUPTURE OF SACCULAR Aneurysm ( Berry aneurysm )
• Size 6-10 mm.

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Berry aneurysm

• Berry aneurysms arise in a weak (ness) point in
  the arterial wall (media).
• Disease associated Marfan syndrome, Ehlar
  Danlos, Adult polycystic kidney disease.

Angiogram
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Circle of Willis And the sites of berry
aneurysm.
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Morphology

• If less than 3 mm in diameter asymptomatic.
• 30 Cases multiple.
• CSF will show blood.

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Subarachnoid Hemorrhage
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Clinical features Subarachnoid Hemorrhage

• Women are effected more than male.
• Giant aneurysm gt 25 mm in diameter.
• It gradually enlarges from child hood, become
  large enough to produce symptoms in adulthood by
  sudden increased blood pressure.

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Clinical Signs In subarachnoid Hemorrhage.

• Headache, come , vomiting is present, herniation,
  acute Hydrocephalous.
• Additional features
• EVIDENCE OF MENINGIAL IRITATION IS PRESENT
• 1. NECK RIGIDITY
• 2. BLOODY CSF

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Mixed intracerebral and subarachnoid hemorrhage

• Cause Vascular malformations.
• This are 4 TYPES
• ARTERIOVANOUS MALFORMATION
• CAPILLARY TELANGECTASIS
• VENOUS ANGIOMA
• CAVERNOUS ANGIOMA

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ARTERIOVANOUS MALFORMATION

• Common in the cerebral hemispheres. Males are
  affected twice as often as females.
• AGE 10 30

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HAPHAZARDLY ARRANGED BLOOD VESSELS, CONTAINING
ARTERIES AND VEINS AND TRANSITIONAL FORMS OF THE
VESSELS.
Microscopy
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TRAUMATIC BRAIN HAEMORRHAGE
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• TRAUMATIC HAEMORRHAGE IN THE BRAIN

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Classification according to the anatomical
Location of the Hemorrhage.

• THREE TYPES
• 1. Epidural Hematoma
• 2. Sub-dural Hematoma.
• 3. Traumatic parenchymal Injuries.

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Epidural Hematoma

• Cause
• Rupture of Meningeal Artery on the occasion of a
  skull fracture.
• X- ray show evidence of lateral skull area
  fracture.

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CT Scan Fusiform Hyperdense lesion produce
mass effect.
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Clinical Effect Mass Effect

• If not immediately drained
• It will cause the following effects -
• 1. Uncal and Tonsillar Herniation
• 2. Brain Stem compression and DEATH

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Sub-Dural Hematoma

• Cause Rupture of the Bridging Veins

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CT Showing the Hematoma

• CAUSE
• Key Small brain big skull.
• More brain mobility.
• RAPID CANGE IN THE HEAD Velocity.
• Types
• Acute Subdural Hematoma (child)
• Chronic subdural hematoma ( adult)

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Acute Subdural Hematoma

• Seen in infants
• Cause
• More spacer in cranium, less brain matter
• Excess brain mobility
• Hemorrhage due to minor trauma.

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CHRONIC SUBDURAL HEMATOMA

• Relative slow progress, contain venous blood.
• Associated with brain atrophy, which gives
  brain more mobility.
• This make the vein more vulnerable to trauma.

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CHRONIC SUBDURAL HEMATOMA CLINICAL PICTURE
HEAD Injury, or, Minor trauma
2 weeks/2 months
Onset of Headache, dizziness, consciousness
disturbance.
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Traumatic Parenchymal Injuries

1. Concussion
2. Contusion and Laceration
3. Intracerebral hemorrhage
4. Generalized brain edema.

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Concussion

• Definition
• Concussion may result when the head strikes
  against an object or is struck by an object.
• Concussions may produce unconsciousness or
  bleeding in or around the brain.

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This can cause concussion !!
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Concussion

• It is associated with minimum morphological
  change.
• Unconsciousness is due to the injury to the
  Reticular activating System.

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Contusion and Laceration

• Contusion Injury to the Superficial Brain
  parenchyma due to the Blunt trauma.
• Laceration CONTUSION TEAR OF THE
  SUPERFICIAL LAYERS OF THE BRAIN.

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Coup Contusion
Hit on Immobile Head
Injury Directly beneath the area of blunt force
no skull fracture
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Contrecoup contusion
INJURY
In fall if the occipital area strikes the floor
Injury in the Frontal and temporal poles area in
a mobile head.
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Laceration

• CONTUSION TEAR OF THE SUPERFICIAL LAYERS OF
  THE BRAIN.

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Traumatic Intracerebral hemorrhage

• Multiple often associate with contusion and edema
  of the Brain.

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Diffuse axonal injury

• Injury to white matter
• Damage to axon at node of Ranvier.
• Common sites
• Corpus callosum, periventricular area,
  hippocampus.
• Clinical coma after trauma without evicence of
  parenchymal injury.
• Histology axonal swelling.

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Spinal cord injury location
Lesion to thoracic segment Paraplegia
Lesion to cervical segment Tetraplagia
Above C4 Respiratory arrest due to paralysis of diaphram
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Thank You !!!