Pathology+of+stroke

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Pathology+of+stroke

  1. 1. “ The true measure of a man is how he treats someone who does him absolutely no good.” – Ann Landers
  2. 2. Pathology of Cerebro-vascular Disease (Stroke) Dr. Venkatesh M. Shashidhar Associate Professor of Pathology Fiji School of Medicine
  3. 3. Introduction: <ul><li>Stroke is the third most common cause of death and the second most common cause of neurologic disability after Alzheimer's disease. </li></ul><ul><li>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. </li></ul>
  4. 4. Introduction: <ul><li>“ Stroke” Cerebro Vascular accident (CVA) </li></ul><ul><li>Acute neurological deficit ↓ blood supply. </li></ul><ul><li>Third leading cause of death. (2/1000/y) </li></ul><ul><li>Varying severity, location & types </li></ul><ul><li>Global / Focal </li></ul><ul><li>Transient Ischemia evolving & completed. </li></ul><ul><li>Low O2 (hypoxia) / Low blood supply. </li></ul>
  5. 5. Brain Blood Supply Features: <ul><li>High oxygen requirement. </li></ul><ul><ul><li>Brain 2% of body weight - 15% of cardiac output </li></ul></ul><ul><ul><li>20% of total body oxygen. </li></ul></ul><ul><li>Continuous oxygen requirement </li></ul><ul><ul><li>Few minutes of ischemia - irreversible injury. </li></ul></ul><ul><li>Neurons - Predominantly aerobic. </li></ul><ul><li>Sensitive areas: </li></ul><ul><ul><li>Adults -Hippocampus, 3,5 th & 6 th layer of cortex, Purkinje cells. Border zone (watershed areas) </li></ul></ul><ul><ul><li>Brain stem nuclei in infants. </li></ul></ul>
  6. 6. Stroke Types: <ul><li>Clinical </li></ul><ul><ul><li>Transient Ischemic Attack –TIA <24h </li></ul></ul><ul><ul><li>Evolving stroke </li></ul></ul><ul><ul><li>Completed stroke </li></ul></ul><ul><ul><li>Recurrent / multiple stroke. </li></ul></ul><ul><li>Pathological </li></ul><ul><ul><li>Focal / Global </li></ul></ul><ul><ul><li>Ischemic (white/pale) & hemorrhagic (red) </li></ul></ul><ul><ul><li>Lacunar infarcts (pale chronic cystic) </li></ul></ul>
  7. 7. Common Types and Incidence: <ul><li>Infarction: Incidence 80% - mortality 40% </li></ul><ul><ul><li>50% - Thrombotic – atherosclerosis </li></ul></ul><ul><ul><ul><li>Large-vessel 30% (carotid, middle cerebral) </li></ul></ul></ul><ul><ul><ul><li>Small vessel 20% (lacunar stroke) </li></ul></ul></ul><ul><ul><li>30% Embolic (heart dis / atherosclerosis) </li></ul></ul><ul><ul><ul><li>Young, rapid, extensive. </li></ul></ul></ul><ul><li>Hemorrhage: Incidence 20% - mortality 80% </li></ul><ul><ul><li>Intracerebral or subarachnoid. </li></ul></ul><ul><ul><li>aneurysm, hypertension/congenital. </li></ul></ul>
  8. 8. Etiology: <ul><li>Complication of several disorders </li></ul><ul><li>Atherosclerosis – most common. </li></ul><ul><li>Hypertension, smoking, diabetes. </li></ul><ul><li>Heart disease – Atrial fibrillation. </li></ul><ul><li>Other: </li></ul><ul><ul><li>Trauma – fat embolism </li></ul></ul><ul><ul><li>Tumor, Infection </li></ul></ul><ul><ul><li>Caissons disease – Bends *Pacific. </li></ul></ul>
  9. 9. Risk factors: <ul><li>Non modifiable </li></ul><ul><li>Age </li></ul><ul><li>Male sex </li></ul><ul><li>Race </li></ul><ul><li>Heredity </li></ul><ul><li>Modifiable </li></ul><ul><li>Hypertension </li></ul><ul><li>Diabetes </li></ul><ul><li>Smoking </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Excess Alcohol* </li></ul><ul><li>Heart disease (AF) Oral contraceptives </li></ul><ul><li>Hypercoagulability. </li></ul>
  10. 10. Clinical Categories: <ul><li>Global Ischemia . </li></ul><ul><ul><li>Hypoxemic encephalopathy </li></ul></ul><ul><ul><li>Hypotension, hypoxemia, anemia. </li></ul></ul><ul><li>Focal Ischemia . </li></ul><ul><ul><li>Obstruction to blood supply to focal area. </li></ul></ul><ul><ul><li>Thrombosis, embolism or hemorrhage. </li></ul></ul>
  11. 11. Global Ischemia: <ul><li>Etiology: </li></ul><ul><ul><li>Impaired blood supply - Lung & Heart disorders. </li></ul></ul><ul><ul><li>Impaired O2 carrying – Anemia/Blood dis. </li></ul></ul><ul><li>Morphology : </li></ul><ul><ul><li>Laminar necrosis, Hippocampus, Purkinje cells. </li></ul></ul><ul><ul><li>Border zone infarcts – “ Watershed ” </li></ul></ul><ul><ul><li>Sickle shaped band of necrosis on cortex. </li></ul></ul><ul><li>Clinical Features : </li></ul><ul><ul><li>Mild transient confusion state to </li></ul></ul><ul><ul><li>Severe irreversible brain death. Flat EEG, Vegetative state. Coma. </li></ul></ul>
  12. 12. Causes of hypotension <ul><li>Myocardial infarction </li></ul><ul><li>Septic shock </li></ul><ul><li>Internal hemorrhage </li></ul><ul><ul><li>Massive GI bleed ruptured varices </li></ul></ul><ul><ul><li>bleeding ulcer, carcinoma </li></ul></ul><ul><li>Ruptured aortic aneurysm. </li></ul><ul><li>Shock, Others </li></ul>
  13. 13. Watershed/Boundary zone infarcts:
  14. 15. Focal Ischemia: <ul><li>Thrombosis: </li></ul><ul><ul><li>Progressive, recurrent, </li></ul></ul><ul><ul><li>Pale or ischemic infarct. </li></ul></ul><ul><ul><li>Eg. Lacunar infarct </li></ul></ul><ul><li>Embolism / Hemorrhage: </li></ul><ul><ul><li>Sudden. </li></ul></ul><ul><ul><li>Red or hemorrhagic infarct. </li></ul></ul><ul><ul><li>Atherosclerosis – rupture/embolism </li></ul></ul>
  15. 16. Embolism formation:
  16. 17. Local infarction: Cell death ~ 6min central infarct area or umbra , surrounded by a penumbra of ischemic tissue that may recover
  17. 18. Haemorrhagic - Arterial embolus
  18. 19. Infarct Pathogenesis: <ul><li>Reduced blood supply – hypoxia/anoxia. </li></ul><ul><li>Altered metabolism  Na/K pump block. </li></ul><ul><li>Glutamate receptor act.  calcium influx. </li></ul><ul><li>1-6 min – ischemic injury – vacuolation. </li></ul><ul><li>>6 min – cell death. </li></ul>
  19. 20. Infarct Stages: <ul><li>Immediate – 6 hours </li></ul><ul><ul><li>No Change both gross & micro </li></ul></ul><ul><li>Acute stage – 2 days </li></ul><ul><ul><li>Oedema, loss of grey/white matter border. </li></ul></ul><ul><ul><li>Inflammation, Red neurons, neutrophils </li></ul></ul><ul><li>Intermediate stage – 2 weeks. </li></ul><ul><ul><li>Demarcation, soft friable tissue, cysts </li></ul></ul><ul><ul><li>Macrophages, liquifactive necrosis </li></ul></ul><ul><li>Late stage – After 4 weeks. </li></ul><ul><ul><li>Fluid filled cysts with dark grey margin (gliosis) </li></ul></ul><ul><ul><li>Removal of tissue by macrophages </li></ul></ul><ul><ul><li>Gliosis – proliferation of glia, loss of architecture. </li></ul></ul>
  20. 21. Cerebral edema
  21. 22. Edema, loss of demarcation:
  22. 23. Acute Infarction: Oedema
  23. 24. Cerebral Infarct : Red Neurons
  24. 25. Cerebral Infarct - 1 Week
  25. 26. Cerebral Infarct - 2 Weeks
  26. 27. Cerebral Infarction: Macrophages
  27. 28. Cerebral Infarct - Cyst formation
  28. 29. Infarct with Punctate hemorrhage
  29. 30. Cerebral Infarction - Late
  30. 31. C. Infarct - Cyst formation
  31. 32. ’ 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 Teresa 1910-1997, Roman Catholic Missionary
  32. 33. Intracranial Hemorrhage: <ul><li>TRAUMA: </li></ul><ul><ul><li>Epidural </li></ul></ul><ul><ul><li>Subdural </li></ul></ul><ul><li>VASCULAR & TRAUMA </li></ul><ul><ul><li>Intracerebral </li></ul></ul><ul><ul><li>Subarachnoid </li></ul></ul><ul><li>Mixed cerebral-subarachnoid </li></ul><ul><li>Intracerebral - Hypertension </li></ul><ul><li>Subarachnoid - Berry aneurysm + Hptn. </li></ul><ul><li>Mixed cerebral – Vascular malformations. </li></ul>
  33. 36. Hypertensive CVD <ul><li>Massive Intracerebral Hemorrhage </li></ul><ul><ul><li>Ganglionic & Lobar hemorrhages </li></ul></ul><ul><ul><li>Putamen(60%), thalamus, ventricles. </li></ul></ul><ul><li>Slit hemorrhages. </li></ul><ul><ul><li>Microhemorrhages heal as slit spaces. </li></ul></ul><ul><li>Lacunar infarcts </li></ul><ul><ul><li>Brain stem pale infarcts – arteriolar sclerosis </li></ul></ul><ul><li>Hypertensive encephalopathy </li></ul><ul><ul><li>Headache, confusion, vomiting – raised ICP. </li></ul></ul>
  34. 37. Subarachnoid Hemorrhage:
  35. 38. Ruptured Berry Aneurism
  36. 40. Intraventricular Hemorrhage:
  37. 41. Cerebral Infarction  hemorrhage
  38. 42. Cerebral Infarction  hemorrhage
  39. 43. Lacunar Infarct in pons
  40. 44. Summary: <ul><li>Stroke: Acute neurological deficit - Clinical </li></ul><ul><li>Cerebrovascular Accident – pathology. </li></ul><ul><li>Ischemic/Hemorrhagic </li></ul><ul><li>Thrombosis, Embolism/Hemorrhage </li></ul><ul><li>Atherosclerosis, Hypertension, Heart Disease. </li></ul><ul><li>Global – Systemic Hypoxia – Watershed infarct </li></ul><ul><li>Focal – Thrombosis, Embolism or Hemorrhage </li></ul><ul><li>Liquifaction necrosis  Cyst formation, gliosis. </li></ul><ul><li>Hypertension – Pale, Lacunar infarcts, slit hem. </li></ul>
  41. 45. Ischemic penumbra:
  42. 46. “ 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.
  43. 47. Anatomy – Stroke.
  44. 48. Left (Dominant) Hemisphere Stroke: Common Pattern <ul><li>Aphasia </li></ul><ul><li>Right hemiparesis </li></ul><ul><li>Right-sided sensory loss </li></ul><ul><li>Right visual field defect </li></ul><ul><li>Poor right conjugate gaze </li></ul><ul><li>Dysarthria </li></ul><ul><li>Difficulty reading, writing, or calculating </li></ul>
  45. 49. Right (Non-dominant) Hemisphere Stroke: Common Pattern <ul><li>Defect of left visual field </li></ul><ul><li>Extinction of left-sided stimuli </li></ul><ul><li>Left hemiparesis </li></ul><ul><li>Left-sided sensory loss </li></ul><ul><li>Left visual field defect </li></ul><ul><li>Poor left conjugate gaze </li></ul><ul><li>Dysarthria </li></ul><ul><li>Spatial disorientation </li></ul>
  46. 50. Brain Stem Stroke: Common Pattern <ul><li>Pure Motor - Weakness of face and limbs on one side of the body without abnormalities of higher brain function, sensation, or vision (MCA/ACA) </li></ul><ul><li>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). </li></ul>
  47. 51. Brain Stem / Cerebellum / Post Hemisp. Patterns. <ul><li>Motor or sensory loss in all four limbs </li></ul><ul><li>Crossed signs </li></ul><ul><li>Limb or gait ataxia </li></ul><ul><li>Dysarthria </li></ul><ul><li>Dysconjugate gaze </li></ul><ul><li>Nystagmus </li></ul><ul><li>Amnesia </li></ul><ul><li>Bilateral visual field defects  </li></ul>
  48. 52. Investigations: <ul><li>CT of the brain without contrast – location/ext. </li></ul><ul><li>Electrocardiogram - heart </li></ul><ul><li>Chest x-ray - heart </li></ul><ul><li>complete blood count, platelet count – hemat . </li></ul><ul><li>PT, aPTT – coagulation . </li></ul><ul><li>Serum electrolytes – complications . </li></ul><ul><li>Blood glucose - DM </li></ul><ul><li>Renal and hepatic chemical analyses – status . </li></ul><ul><li>National Institutes of Health Scale (NIHSS) score – clinical/prognosis ? </li></ul>
  49. 53. “ 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 ton’s..! Jim Rohn
  50. 54. Hypertensive Intracerebral Hem: Sites 1. Putamen-Claustrum 2. Cerebral white matter 3. Thalamus 4. Pons 5. Cerebellum 55% 15 10 10 10
  51. 55. Stroke types and incidence:
  52. 56. Anatomy – Stroke.

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