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65 Cards in this Set

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Cerebrovascular Disease is what rank in the cause of death in the US?
#3
What are the 2 major types of Cerebrovascular Accidents ("stroke")? Which type is more common in the US?
1. Deprivation of blood &/or oxygen = infarct
-Thrombosis
-Embolism

2. Hemorrhage

**Infarcts more common in US
After how long of a total loss of oxygen are there irreversible cell changes in the brain?
5-6 minutes

**there is selective vulnerability of neurons
What are the 2 patterns of Hypoxic-Ischemic injury?
1. Global ischemia

2. Focal ischemia
Give 5 examples of things that can cause Global Ischemia
1. Cardiac arrest
2. Hypotension
3. Suffocation
4. Atmospheric
5. Poisoning
What is the severe manifestation of Global Ischemia?
Persistent Vegetative State
What is the pathology seen in the Brain after Global Ischemia?
1. Diffuse softening

2. Slow autolysis
What parts of the adult brain are comparatively vulnerable to hypoxic/ischemic injuries?
1. Cerebral Cortex
2. Hippocampus
3. Purkinje cell layer in the Cerebellum
Define Watershed areas
Territories of the brain where 2 blood supplies meet & the blood supply from the 2 vessels does not overlap
Define Watershed areas
Territories of the brain where 2 blood supplies meet & the blood supply from the 2 vessels does not overlap
-
-
What is this picture showing?
Watershed area between the Anterior Cerebral Artery (ACA) & the Middle Cerebral Artery (MCA)
What are the causes of Focal Ischemia?
Occlusions of vessel
1. In situ Thrombosis
2. Vasculitis
3. Hypercoagulable state
4. Arterial dissection
5. CADASIL = Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts & Leukoencephalopathy

Embolism
What is the most common cause of In situ Thrombosis?
Atherosclerosis
What are the most common sites of Atherosclerosis
1. Thrombosis of Carotid Bifurcation
2. Middle Cerebral Artery
3. Top & bottom of Basilar Artery
Where would an infarct occur producing Focal Ischemia in a Hypercoagulable state?
Venous infarction
What are the sources of Emboli in Focal Ischemia?
1. Heart
-Mural thrombus post-MI
-Heart valves
-Atrial Fibrillation

2. Carotid arteries or Aorta

3. Paradoxical via Patent Foramen Ovale

4. Fat, tumor, air
What is the #1 general site for emboli to lodge?
Middle Cerebral Artery

**generally lodge in branchpoints or stenotic foci
What are the gross appearances of Infarcts:
1. 0-6 hours
2. 48 hours
3. 2-10 days
4. 10-21 days
0-6 hrs = no gross changes
48 hrs = pale, soft, swollen, indistinct gray-white border
2-10 days = friable, demarcation of injury
10-21 days = liquefaction
What are the Acute (12-24 hrs) Microscopic changes seen in Ischemic Injury?
1. Red neurons

2. Microvacuolization

3. Nuclear Pyknosis = condensation and reduction in the size of a cell or cell nucleus
Acute Ischemic injury of Purkinje cells in Cerebellum
1. red neurons
2. have lost nucleoli
3. cells are shrinking
What is this picture showing?
What are the Subacute (24 hrs - 2 wks) Microscopic changes seen in Ischemic injury?
1. Necrosis
2. Macrophages
3. Vascular proliferation
4. Gliosis
After how long does the Repair phase occur in Ischemic Injury?
> 2 wks
End-result of a Focal Infarct
What is this picture showing?
What is a Pale infarct?
Usually due to a platelet thrombus that develops over a disrupted plaque

Infarct in which little or no bleeding into tissue spaces occurs when the blood supply is obstructed

Treat with Anticoagulation
What are Hemorrhagic Infarcts? What are they usually the consequence of?
An infarct that is red because of the infiltration of blood from collateral vessels into the necrotic area

Embolism
Which type of infarct do you want to avoid Anticoagulatives as a treatment - Pale or Hemorrhagic?
Hemorrhagic
Hemorrhagic infarct
-arrow denotes an occluded vessel in the MCA distribution
-Petechial hemorrhages
What is seen here?
Lacunar Infarct
-most commonly due to HTN or Diabetes
-cystic areas of microinfarction <15 mm in diameter
-caused by Hyaline Arteriosclerosis
What is seen here?
What are Lacunar Infarcts? What are they due to?
Cystic areas of microinfarction less than 15 mm in diameter

Hyaline Arteriosclerosis due to:
-HTN (most common)
-Diabetes

**pic is Lacunar Infarct of Pons
What are 4 consequences of Infarcts?
1. Destruction of vital areas
2. Massive edema & death
3. Permanent neurological deficits
4. Multiple small infarcts may lead to dementia
What are the 4 locations of Hemorrhage?
1. Intraparenchymal
2. Subarachnoid
3. Subdural
4. Epidural
What is the #1 cause of Intraparenchymal Hemorrhage? What is the pathogenesis?
Hypertension

Acclerated atherosclerosis -> increased fragility -> Charcot-Bouchard aneurysms -> necrosis
Hypertensive Hemorrhages
What is shown here?
What are the most common sites of Intraparenchymal Hemorrhage?
1. Putamen
2. Thalamus
3. Pons
4. Cerebellum
5. others
What is a Subarachnoid Hemorrhage? What is the most frequent cause?
Bleeding between the pia mater and the arachnoid of the brain

Berry Aneurysm rupture

*can also be due to:
-extension into ventricular system
-vascular malformation
-coagulopathy
-tumors
Subarachnoid Hemorrhage
-there is no Dura on the brain
-blood is directly on the surface of the brain
What is seen here?
What disorders have increased #'s of Berry Aneurysms?
1. AD Polycystic Kidney Disease
2. NF1
3. Marfan Syndrome
4. Ehlers-Danlos, IV
5. Fibromuscular Dysplasia of Extracranial Arteries
What are the risk factors for Berry Aneurysm?
Smoking & HTN
What is the pathology of Berry Aneurysms?
Thin walled outpouching at arterial branchpoints

Neck portion is devoid of muscle or elastica
What is the most common location for Berry Aneurysms to occur?
Anterior circulation is most common
Berry Aneurysm
What is seen here?
What factors increase the likelihood of rupture of Berry Aneurysms?
1. size > 10 mm
2. 5th decade of life
3. Women gender
4. increased intracranial pressure
What is the clinical manifestation of Berry Aneurysm rupture?
1. Sudden onset of severe Occipital headache
2. decribed as "worst headache of my life"
What % of people die after their 1st bleed from Berry Aneurysm rupture?
25-50%
What are the early complications of Berry Aneurysm rupture? Late?
Early = Vasospasm

Late = Meningeal scarring -> hydrocephalus
What is an Epidural Hemorrhage?
Hemorrhaging from the Middle Meningeal Artery leading to a hematoma in the virtual space b/w the inner aspect of the Cranial bones & the Dura Mater
Temporoparietal skull fracture + tear of the Middle Meningeal Artery
Epidural Hemorrhage
Which hemorrhage is a neurological emergency, Epidural or Subdural? Why?
Epidural b/c the Middle Meningeal Artery has been torn & is under arterial pressure so the hematoma progresses quickly
Left = Epidural Hematoma

Right = Subdural Hematoma
What is seen on the Left? Right?
Epidural Hematoma
Fracture of Temporalparietal skull
Middle Meningeal Artery
What is seen here?
What is the cause?
What has ruptured?
What is the cause of a Subdural Hematoma?
Tearing of "bridging veins" that connect Superficial Cerebral Veins & the Dural Venous Sinuses
What are the manifestations of Subdural Hematomas?
Focal, nonfocal, headache, confusion, usually slower in progression than Epidural

Surgical drainage, if needed

Usually due to blunt head injuries
-car accident
-baseball bat
What are predisposing factors for Subdural Hematomas?
1. Brain atrophy
2. Shaking
3. Whiplash
In what people are Subdural Hematomas commonly seen in?
1. Blunt trauma
2. Elderly people, especially those who are hospitalized or stay in nursing homes & often fall out of bed
3. Boxers
4. Shaken baby
Subdural Hematoma
What is seen here?
What are some "other" causes of Hemorrhage?
1. Blood dyscrasias
2. Fat emboli
3. Amyloid angiopathy
4. Vascular malformations
Amyloid Angiopathy

Hemorrhage b/c vessels get brittle
What is seen here? What could it lead to?
What is Arteriovenous Malformation?
Defective malformation of capillaries in a normal part of the brain
-arterial blood enters directly into the veins, usually by way of arteriovenous anastomoses that form at the defective site
What gender is more susceptible to Arteriovenous Malformations? What are the complications? Where do they most commonly occur?
1. Men

2. Seizures & hemorrhage

3. MCA territory
What do Arteriovenous Malformations look like?
Tangle of torturous vessels with blood vessels separated by Gliotic brain
Arteriovenous Malformation
-tortuous arteries & veins which form cortical-subcortical networks of "worm-like" ateriovenous shunts embedded in hemosiderin laden glial tissue
What is seen here?
Vascular Malformation characterized by back-to-back hyalinized vessels with foci of hemosiderin
Cavernous Angioma
Vascular Malformation characterized by dilated thin-walled vessels separated by normal brain. Most commonly occur in the Pons
Capillary Telangiectasia
Where do Capillary Telangiectasia's most commonly occur?
Pons