Pathology - S2B4 - Neuro 2

Front 1

Cerebrovascular Disease is what rank in the cause of death in the US?

Back 1

#3

Front 2

What are the 2 major types of Cerebrovascular Accidents ("stroke")? Which type is more common in the US?

Back 2

1. Deprivation of blood &/or oxygen = infarct
-Thrombosis
-Embolism

2. Hemorrhage

**Infarcts more common in US

Front 3

After how long of a total loss of oxygen are there irreversible cell changes in the brain?

Back 3

5-6 minutes

**there is selective vulnerability of neurons

Front 4

What are the 2 patterns of Hypoxic-Ischemic injury?

Back 4

1. Global ischemia

2. Focal ischemia

Front 5

Give 5 examples of things that can cause Global Ischemia

Back 5

1. Cardiac arrest
2. Hypotension
3. Suffocation
4. Atmospheric
5. Poisoning

Front 6

What is the severe manifestation of Global Ischemia?

Back 6

Persistent Vegetative State

Front 7

What is the pathology seen in the Brain after Global Ischemia?

Back 7

1. Diffuse softening

2. Slow autolysis

Front 8

What parts of the adult brain are comparatively vulnerable to hypoxic/ischemic injuries?

Back 8

1. Cerebral Cortex
2. Hippocampus
3. Purkinje cell layer in the Cerebellum

Front 9

Define Watershed areas

Back 9

Territories of the brain where 2 blood supplies meet & the blood supply from the 2 vessels does not overlap

Front 10

Define Watershed areas

Back 10

Territories of the brain where 2 blood supplies meet & the blood supply from the 2 vessels does not overlap

Front 11

-

Back 11

-

Front 12

What is this picture showing?

Back 12

Watershed area between the Anterior Cerebral Artery (ACA) & the Middle Cerebral Artery (MCA)

Front 13

What are the causes of Focal Ischemia?

Back 13

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

Front 14

What is the most common cause of In situ Thrombosis?

Back 14

Atherosclerosis

Front 15

What are the most common sites of Atherosclerosis

Back 15

1. Thrombosis of Carotid Bifurcation
2. Middle Cerebral Artery
3. Top & bottom of Basilar Artery

Front 16

Where would an infarct occur producing Focal Ischemia in a Hypercoagulable state?

Back 16

Venous infarction

Front 17

What are the sources of Emboli in Focal Ischemia?

Back 17

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

Front 18

What is the #1 general site for emboli to lodge?

Back 18

Middle Cerebral Artery

**generally lodge in branchpoints or stenotic foci

Front 19

What are the gross appearances of Infarcts:
1. 0-6 hours
2. 48 hours
3. 2-10 days
4. 10-21 days

Back 19

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

Front 20

What are the Acute (12-24 hrs) Microscopic changes seen in Ischemic Injury?

Back 20

1. Red neurons

2. Microvacuolization

3. Nuclear Pyknosis = condensation and reduction in the size of a cell or cell nucleus

Front 21

Acute Ischemic injury of Purkinje cells in Cerebellum
1. red neurons
2. have lost nucleoli
3. cells are shrinking

Back 21

What is this picture showing?

Front 22

What are the Subacute (24 hrs - 2 wks) Microscopic changes seen in Ischemic injury?

Back 22

1. Necrosis
2. Macrophages
3. Vascular proliferation
4. Gliosis

Front 23

After how long does the Repair phase occur in Ischemic Injury?

Back 23

> 2 wks

Front 24

End-result of a Focal Infarct

Back 24

What is this picture showing?

Front 25

What is a Pale infarct?

Back 25

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

Front 26

What are Hemorrhagic Infarcts? What are they usually the consequence of?

Back 26

An infarct that is red because of the infiltration of blood from collateral vessels into the necrotic area

Embolism

Front 27

Which type of infarct do you want to avoid Anticoagulatives as a treatment - Pale or Hemorrhagic?

Back 27

Hemorrhagic

Front 28

Hemorrhagic infarct
-arrow denotes an occluded vessel in the MCA distribution
-Petechial hemorrhages

Back 28

What is seen here?

Front 29

Lacunar Infarct
-most commonly due to HTN or Diabetes
-cystic areas of microinfarction <15 mm in diameter
-caused by Hyaline Arteriosclerosis

Back 29

What is seen here?

Front 30

What are Lacunar Infarcts? What are they due to?

Back 30

Cystic areas of microinfarction less than 15 mm in diameter

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

**pic is Lacunar Infarct of Pons

Front 31

What are 4 consequences of Infarcts?

Back 31

1. Destruction of vital areas
2. Massive edema & death
3. Permanent neurological deficits
4. Multiple small infarcts may lead to dementia

Front 32

What are the 4 locations of Hemorrhage?

Back 32

1. Intraparenchymal
2. Subarachnoid
3. Subdural
4. Epidural

Front 33

What is the #1 cause of Intraparenchymal Hemorrhage? What is the pathogenesis?

Back 33

Hypertension

Acclerated atherosclerosis -> increased fragility -> Charcot-Bouchard aneurysms -> necrosis

Front 34

Hypertensive Hemorrhages

Back 34

What is shown here?

Front 35

What are the most common sites of Intraparenchymal Hemorrhage?

Back 35

1. Putamen
2. Thalamus
3. Pons
4. Cerebellum
5. others

Front 36

What is a Subarachnoid Hemorrhage? What is the most frequent cause?

Back 36

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

Front 37

Subarachnoid Hemorrhage
-there is no Dura on the brain
-blood is directly on the surface of the brain

Back 37

What is seen here?

Front 38

What disorders have increased #'s of Berry Aneurysms?

Back 38

1. AD Polycystic Kidney Disease
2. NF1
3. Marfan Syndrome
4. Ehlers-Danlos, IV
5. Fibromuscular Dysplasia of Extracranial Arteries

Front 39

What are the risk factors for Berry Aneurysm?

Back 39

Smoking & HTN

Front 40

What is the pathology of Berry Aneurysms?

Back 40

Thin walled outpouching at arterial branchpoints

Neck portion is devoid of muscle or elastica

Front 41

What is the most common location for Berry Aneurysms to occur?

Back 41

Anterior circulation is most common

Front 42

Berry Aneurysm

Back 42

What is seen here?

Front 43

What factors increase the likelihood of rupture of Berry Aneurysms?

Back 43

1. size > 10 mm
2. 5th decade of life
3. Women gender
4. increased intracranial pressure

Front 44

What is the clinical manifestation of Berry Aneurysm rupture?

Back 44

1. Sudden onset of severe Occipital headache
2. decribed as "worst headache of my life"

Front 45

What % of people die after their 1st bleed from Berry Aneurysm rupture?

Back 45

25-50%

Front 46

What are the early complications of Berry Aneurysm rupture? Late?

Back 46

Early = Vasospasm

Late = Meningeal scarring -> hydrocephalus

Front 47

What is an Epidural Hemorrhage?

Back 47

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

Front 48

Temporoparietal skull fracture + tear of the Middle Meningeal Artery

Back 48

Epidural Hemorrhage

Front 49

Which hemorrhage is a neurological emergency, Epidural or Subdural? Why?

Back 49

Epidural b/c the Middle Meningeal Artery has been torn & is under arterial pressure so the hematoma progresses quickly

Front 50

Left = Epidural Hematoma

Right = Subdural Hematoma

Back 50

What is seen on the Left? Right?

Front 51

Epidural Hematoma
Fracture of Temporalparietal skull
Middle Meningeal Artery

Back 51

What is seen here?
What is the cause?
What has ruptured?

Front 52

What is the cause of a Subdural Hematoma?

Back 52

Tearing of "bridging veins" that connect Superficial Cerebral Veins & the Dural Venous Sinuses

Front 53

What are the manifestations of Subdural Hematomas?

Back 53

Focal, nonfocal, headache, confusion, usually slower in progression than Epidural

Surgical drainage, if needed

Usually due to blunt head injuries
-car accident
-baseball bat

Front 54

What are predisposing factors for Subdural Hematomas?

Back 54

1. Brain atrophy
2. Shaking
3. Whiplash

Front 55

In what people are Subdural Hematomas commonly seen in?

Back 55

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

Front 56

Subdural Hematoma

Back 56

What is seen here?

Front 57

What are some "other" causes of Hemorrhage?

Back 57

1. Blood dyscrasias
2. Fat emboli
3. Amyloid angiopathy
4. Vascular malformations

Front 58

Amyloid Angiopathy

Hemorrhage b/c vessels get brittle

Back 58

What is seen here? What could it lead to?

Front 59

What is Arteriovenous Malformation?

Back 59

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

Front 60

What gender is more susceptible to Arteriovenous Malformations? What are the complications? Where do they most commonly occur?

Back 60

1. Men

2. Seizures & hemorrhage

3. MCA territory

Front 61

What do Arteriovenous Malformations look like?

Back 61

Tangle of torturous vessels with blood vessels separated by Gliotic brain

Front 62

Arteriovenous Malformation
-tortuous arteries & veins which form cortical-subcortical networks of "worm-like" ateriovenous shunts embedded in hemosiderin laden glial tissue

Back 62

What is seen here?

Front 63

Vascular Malformation characterized by back-to-back hyalinized vessels with foci of hemosiderin

Back 63

Cavernous Angioma

Front 64

Vascular Malformation characterized by dilated thin-walled vessels separated by normal brain. Most commonly occur in the Pons

Back 64

Capillary Telangiectasia

Front 65

Where do Capillary Telangiectasia's most commonly occur?

Back 65

Pons