CEREBROVASCULAR DISEASES - pathkids.compathkids.com/trainingdays/CVD.pdfOverview Development of CNS...
Transcript of CEREBROVASCULAR DISEASES - pathkids.compathkids.com/trainingdays/CVD.pdfOverview Development of CNS...
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CEREBROVASCULAR
DISEASES
Dr. Aditya Shivane Consultant Neuropathologist
Derriford Hospital, Plymouth
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Overview
Development of CNS Vasculature
Anatomy & Structure of Brain Blood Vessels
Cerebrovascular Diseases (CVD)
Cases
A CVD Autopsy
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Development of CNS Vasculature
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PNVP
SVZ
Phase I
Phase II Phase III
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Anatomy & Structure of Brain
Blood Vessels
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WATER-SHED ZONES
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Structural Differences
• Endothelial cells are joined by tight
junctions; No fenestrations
• Muscle coat is thinner than in the extracranial
arteries of corresponding size
• External elastic lamina is lacking
• Adventitia is very thin
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Cerebrovascular Diseases
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Atherosclerosis & Small Vessel Disease
Hypertensive Angiopathy
Vasculitis
Aneurysms & Vascular Malformations
Cerebral Amyloid Angiopathy
CADASIL, Moyamoya Syndrome, FMD
Haematological disorders (Thrombosis, APLA syndrome, Anticoagulation)
Focal & Global Brain Ischaemia
Brain Haemorrhages
Vascular Dementia
Hypoglycaemic Brain Damage, Gas & Fat Embolism
Spinal Cord Vascular Disorders
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ISCHAEMIA HAEMORRHAGE ISCHAEMIA HAEMORRHAGE
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CASE 1
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A 62-year-old man noted a mild bi-parietal
headache and slight weakness in his right arm
and hand when he went to bed one evening. The
following morning, his wife found him unable to
speak or to move his right arm or leg.
Neurological examination revealed expressive
dysphasia but normal comprehension, right
hemiparesis (more marked in the arm than the
leg), a mild loss of position and vibratory senses
on the right and astereognosis in the right hand.
Angiography revealed stenosis of the left carotid
artery at the bifurcation and occlusion of the left
MCA..
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Cerebral Infarction
• DWI
• PM- Unfixed (24hrs); Fixed (12hrs)
• Fixed brain - Blurred GW junction; Palpation
• Histology - Eosinophilia (4-12h)
- PMN (15-24h)
- Foam cells (2 days)
- PMN disappear (5 days)
- Astrocyte proliferation (1 wk)
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CEREBRAL
ATHEROSCLEROSIS WITH
A LARGE MCA TERRITORY
INFARCT
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SEVERITY OF ATHEROSCLEROTIC LESIONS IN THE
ARTERIAL CERVICOCEREBRAL TREE
EVOLUTION OF LESIONS CAUSED BY ATHEROMATOUS
CAROTID STENOSIS
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CASE 2
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A 49-year-old hypertensive man had a severe
bi-frontal headache as he was returning home
from work one evening. His wife noted that he
was confused and went straight to bed. One
hour later, she was unable to rouse him.
Neurologic examination revealed a comatose
patient breathing deeply, with dilated, fixed
pupils. There was little spontaneous
movements of the left extremities; the right
extremities failed to move, even when
supraorbital pressure was applied. A CT scan
confirmed the diagnosis.
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HYPERTENSIVE ANGIOPATHY
WITH INTRACEREBRAL
HAEMORRHAGE
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Hypertension Intraluminal pr. Vasocon.
Forced vasodilatation
(breakthrough of autoregulation)
BBB breakdown
abrupt BP
Pathogenesis of Cerebral changes in Hypertension
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BBB breakdown
Localized Focal oedema
Widespread Diffuse oedema
Macrophages,Astrocytes,
SMCs & Necrosis HTN
Encephalopathy
Remote focal necrosis (lacunae)
Multiple SURVIVAL DEATH
Cognitive impairment
dementia
+
STAGE 1
STAGE 2
STAGE 3
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CEREBRAL / MENINGEAL HAEMORRHAGE
Traumatic Non-traumatic
Arteriolar change Rupture of vascular Blood dyscrasias others
malformation
Hypertensive Aneurysms Leukaemia Tumour
Amyloid angiopathy AVM Platelet disorders Herniation
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CASE 3
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A 65-year-old man complains of intense focal
headache usually in the temporal or occipital
region. He notices scalp tenderness especially
on resting his head on the pillow. He also has
difficulty in chewing, early morning body aches
and weight loss.
The neurologic examination revealed a
palpable, tender, swollen and non-pulsatile
artery just in front of the ear, coursing distally
into the hairline. A biopsy of the artery was
performed.
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TEMPORAL / GIANT-CELL
ARTERITIS
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VASCULITIS
Non-infectious Infectious
Primary Secondary Drug-induced
TA SLE, PAN Bacterial
GCA WG, CSA, SS Viral
PACNS Behcet, Malig. Fungal
Kawasaki others
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CASE 4
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A 36-year-old house wife developed a sudden
acute generalised headache, nausea and
vomiting. By the time she reached the
emergency department, she was in a semi-
conscious state.
The neurologic examination revealed dilated
pupils, nuchal rigidity, a positive Kernig sign
and a flaccid paralysis of all four extremities.
A CT scan confirmed the diagnosis of sub-
arachnoid haemorrhage. Cerebral
angiography revealed an aneurysm of the left
MCA that had ruptured.
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INTRACEREBRAL &
SUBARACHNOID HAEMORRHAGE
SECONDARY TO RUPTURED MCA
ANEURYSM
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ICA
30%
ACA
30%
MCA
30%
VBA
10%
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CASE 5
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A 35-year-old previously healthy man is being
referred to a neurologist with symptoms of
recent-onset complex partial seizures and
headaches. He also has difficulties carrying
out tasks that require planning and occasional
episodes of dizziness and hallucinations.
The neurologic examination revealed only a
mild weakness involving the right arm and leg.
The CT/ MRI scans and the angiography
confirmed a well-circumscribed highly vascular
malformative lesion.
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ARTERIO-VENOUS
MALFORMATION (AVM)
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CASE 6
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A 70-year-old man presented acutely with
severe bi-frontal headache, vomiting and
seizures. He lapsed into coma an hour later.
Previously he had experienced one similar
episode of acute headache and vomiting for
which he was hospitalised and discharged a
week later. No other clinical details are
available.
The CT/ MRI scans revealed a large
hematoma in the right posterior frontal region
with significant oedema and mass effect. A old
cystic lesion was also noted in the left
temporal lobe.
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CEREBRAL AMYLOID
ANGIOPATHY (CAA)
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CAA
• ‘The pathological process during which one of the
amyloid proteins that are known to be associated with
CNS disease in the humans, progressively deposits
in the walls of cerebral blood vessels and is followed
by degenerative vascular changes’.
• Syn: congophilic angiopathy, dyshoric angiopathy
• Now recognised as a major cause of non-
hypertensive lobar cerebral haemorrhage in the
elderly.
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CAA
• overlaps with AD biologically; 80% of AD pts.
have CAA.
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CASE 7
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A 62-year-old man presented with a 3-year history of
progressive mental decline, including deterioration in
memory and speech. He also experienced frequent
attacks of migranous headaches . He had a family
history significant for several relatives who had similar
problems, some of whom died secondary to this condition.
The patient had no significant past medical history and
had been otherwise healthy. A neurologic examination
was significant for decreased short-term memory, slurred
speech and visual field defects .
MRI showed diffuse, multicentric cerebral white matter
enhancement, most prominently noted in both temporal
lobes. He underwent an excision of a portion of the
anterior temporal lobe and inferior temporal gyrus.
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CEREBRAL AUTOSOMAL
DOMINANT ARTERIOPATHY WITH
SUB-CORTICAL INFARCTS AND
LEUKOENCEPHALOPATHY
(CADASIL)
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CASE 8
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A 28-year-old woman presented to her GP with
persistent headaches. They were worse first thing in the
morning when she also felt nauseous. Past medical
history was unremarkable and she was not on any
medication except for the oral contraceptive.
Her mother died at the age of 46, after developing a
DVT following a hysterectomy.
She was mildly obese. Heart rate 72 beats/minute,
regular. BP 130/80 mmHg. Neurological examination
was unremarkable, although the optic discs looked
swollen. A CT scan of the head was arranged, which
was reported as normal. However, her condition
deteriorated rapidly 5 days later with increasing
headaches, vomiting and drowsiness. She was
admitted to hospital, but died within a few hours.
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CEREBRAL VENOUS SINUS
THROMBOSIS
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CASE 9
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A 26-year-old woman, with history of peptic ulcer and
family history of cerebrovascular disease was referred
to medicine clinic with asthenia and generalized
discomfort. She reported a cerebrovascular accident
manifesting as a right arm and leg weakness ten
months ago, almost completely receded at observation
time; she also complained of recurrent episodes of
proximal deep venous thrombosis (DVT) of lower limbs
in the last seven months.
The laboratory investigations showed increased blood
levels of anti-cardiolipin (ACA) and lupus
anticoagulant (LA) antibodies.
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ANTI-PHOSPHOLIPID
ANTIBODY SYNDROME
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CASE 10
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VASCULAR DEMENTIA
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A Cerebrovascular Disease
Autopsy
• Whole brain, spinal cord (if clinically involved).
• Circle of Willis- aneurysms; dissection under water.
• Vertebral A- check patency/ dissect out. C1/ f.magnum.
• Carotid A- check patency/ dissect out. Bifurcation.
• Dural sinuses- thrombosis; microbiology.
• Aorta, Myocardium, cardiac valves, visceral organs.
• Blood, urine samples.
• Fresh brain, skeletal muscle.
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Review
Autopsy approach to stroke Seth Love
Histopathology 2011; 58 (3): 333-351.