Cerebrovascular disease (Stroke)

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

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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.

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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.

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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)

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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.

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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.

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Risk factors

• Modifiable
• Hypertension
• Diabetes
• Smoking
• Hyperlipidemia
• Excess Alcohol
• Heart disease (AF) Oral contraceptives
• Hypercoagulability.

• Non modifiable
• Age
• Male sex
• Race
• Heredity

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Clinical Categories

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

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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.

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Causes of hypotension

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

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Watershed/Boundary zone infarcts
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Focal Ischemia

• Thrombosis
• Progressive, recurrent,
• Pale or ischemic infarct.
• Eg. Lacunar infarct
• Embolism / Hemorrhage
• Sudden.
• Red or hemorrhagic infarct.
• Atherosclerosis rupture/embolism

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Embolism formation
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Local infarction
Cell death 6min central infarct area or umbra,
surrounded by a penumbra of ischemic tissue that
may recover
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Haemorrhagic - Arterial embolus
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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.

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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.

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Cerebral edema
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Edema, loss of demarcation
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Acute Infarction Oedema
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Cerebral Infarct Red Neurons
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Cerebral Infarct - 1 Week
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Cerebral Infarct - 2 Weeks
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Cerebral Infarction Macrophages
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Cerebral Infarct - Cyst formation
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Infarct with Punctate hemorrhage
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Cerebral Infarction - Late
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C. Infarct - Cyst formation
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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
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Intracranial Hemorrhage

• TRAUMA
• Epidural
• Subdural
• VASCULAR TRAUMA
• Intracerebral
• Subarachnoid
• Mixed cerebral-subarachnoid
• Intracerebral - Hypertension
• Subarachnoid - Berry aneurysm Hptn.
• Mixed cerebral Vascular malformations.

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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.

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Subarachnoid Hemorrhage
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Ruptured Berry Aneurism
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Intraventricular Hemorrhage
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Cerebral Infarction? hemorrhage
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Cerebral Infarction? hemorrhage
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Lacunar Infarct in pons
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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.

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Ischemic penumbra
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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.
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Anatomy Stroke.
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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

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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

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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).

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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 

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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 ?

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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
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Hypertensive Intracerebral Hem Sites
1. Putamen-Claustrum 2. Cerebral white
matter 3. Thalamus 4. Pons 5. Cerebellum
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Stroke types and incidence
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Anatomy Stroke.