Collateral History : wife,son, neighbours, paramedics.
What happened? Neighbour saw him at top of ladder veer to the left and fall 2.5 m landing on his head . She called out to his wife who attended the scene. Wife says that he did not seem to hear her and his left arm was shaking . The shaking lasted for about 2minutes . He did not seem to regain consciousness until he was administered oxygen by the paramedics about 10 minutes later. He then seemed to come around but appeared confused . He was unable to move his Left arm, R arm and Right leg . Wife says he was well prior to going out to pick mangoes.
Stroke location and incidence: Cause % Clinical presentation 30day mort(%) Pathogenesis Cerebral infarction 85 Slowly / sudden evolving signs and symptoms 15-45 Cerebral hypoperfusion Embolism Thrombosis Intracerebral hem. 10 Sudden onset of stroke with raised intracranial pressure 80 Rupture of micro-aneurysm or arteriole Subarachnoid haemorrhage 5 Sudden headache with meningism 45 Rupture of saccular aneurysm on circle of Willis
Axonal Injury: A, Hypoxic/ischemic injury in cerebral cortex - "red neurons." shrunken cell B, Axonal spheroids at points of axonal disruption C, Swollen cell body and peripheral dispersion of Nissl substance (chromatolysis) H&E Stain.
Diagnosis: Recent cerebral infarction in left MCA distribution. Left cerebral hemisphere shows swelling with compression of the lateral ventricle mainly in the frontal area, due to recent infarct in the Middle Cerebral Artery (MCA) distribution. The brain in the MCA area shows discoloration of the cortex and also blurring between the cortex and white matter.
Infarct involving the inferior aspect of the left temporal lobe (PCA distribution). old new
A 67y man with IHD is rushed to ED after collapse. Brain at autopsy. M ost likely Artery involved?
External Carotid A .
Internal Carotid A.
Middle Cerebral A.
Sagittal venous sinus.
Anterior Cerebral A.
The trifurcation of the middle cerebral artery is a favored site for lodgment of emboli and for thrombosis secondary to atherosclerotic damage. This deprives the parietal cortex of circulation and produces motor and sensory deficits. When the dominant hemisphere is involved, these lesions are commonly accompanied by aphasia.
A 78y male, hypertensive. Sudden headache collapsed while morning walk. Image shows the lesion. Most likely cause?
Ruptured Berry Aneurysm.
Ruptured AV malformation.
AS- embolic infarct.
lesion is a hemorrhagic infarct in the distribution of the RMCA. The basic mechanism is arterial occlusion, usually by an embolus, with reperfusion and leakage through a damaged capillary bed following lysis of the embolus.
Coronal section shows the cerebral hemispheres through the anterior portion of third ventricle, anterior commissure, and the tip of the temporal lobes. This section is not quite symmetrical because it shows more of the anterior portion on the left side. The brain shows a recent area of necrosis in the right anterior cerebral artery distribution near the midline, with fragmentation of the tissue and poorly demarcated cortex and white matter. Corpus callosum is very thin and there is also an old slit-like lesion in the distribution of the left anterior cerebral artery. Diagnosis: Recent infarction in right anterior cerebral artery distribution, and old infarct, left anterior cerebral artery.
#1. LEFT PCA Atherosclerosis. #2. Old PCA infarction
This is a view of the cerebral hemispheres after brainstem and cerebellum have been removed at the level of the midbrain. There is circular marked atherosclerosis of the left posterior cerebral artery. The left occipital lobe (right side of the photograph) shows a collapsed cystic and pigmented area in the distribution of the posterior cerebral artery. Diagnosis #1. Atherosclerosis of the left posterior cerebral artery. #2. Old infarction, posterior cerebral artery distribution.
Recent right infarction MCA territory with hemorrhagic transformation
This is an axial view. The superior section is shown on the left side of the photograph and the inferior portion on the right side. The inferior portion is through the upper portion of the caudate nuclei and the thalami. The brain shows fragmentation, necrosis, and discoloration, predominantly of the cortex, in the right middle cerebral artery distribution. There is mass effect with compression of the ventricular system. Discoloration of the cortex within the lesion represents early hemorhagic transformation of the ischemic lesion. Diagnosis: Recent right infarction MCA territory with hemorrhagic transformation.
Old cystic infarct in the distribution of the left MCA
Coronal sections of cerebral hemispheres . One is anterior and through the optic chiasm and the posterior section is through the thalami. The left hemisphere (on the left side of the photograph) is smaller than the right hemisphere. The small size of the left hemisphere is due to a large cystic lesion that includes the external portion of the putamen, internal capsule, inferior portion of the frontal lobe and parts of the temporal lobe. Diagnosis: Old cystic infarct in the distribution of the left MCA.
Hypertension: Ruptured anterior communicating or anterior cerebral artery aneurysm
Coronal sections of the cerebral hemispheres through the frontal lobes and at the level of the genu of the corpus callosum. A hematoma has destroyed the area around the corpus callosum and inferior frontal gyri. Hematoma has ruptured into both lateral ventricles. The location of the hematoma is characteristic of a ruptured anterior communicating or anterior cerebral artery aneurysm due to hypertension.
Spontaneous hypertensive thalamic hemorrhage with intraventricular extension
Coronal section of the cerebral hemispheres through the pulvinar and quadrigeminal plate. The section shows a hematoma that has destroyed part of the thalamus on the left side. The hematoma has ruptured into the lateral ventricle and has compressed the quadrigeminal plate on the left side. Diagnosis: Spontaneous hypertensive thalamic hemorrhage with intraventricular extension.
Spontaneous hypertensive hemorrhage of the left putamen
Axial section of the brain through the level of the putamen and the upper portion of the thalami. The left hemisphere shows a localized hematoma that involves the putamen and part of the anterior limb of the internal capsule. The hematoma has not ruptured into the ventricle and has spared the insular cortex. Diagnosis: Spontaneous hypertensive hemorrhage of the left putamen.
Spontaneous hypertensive right cerebellar hemisphere hemorrhage. #2 Acute hydrocephalus
This is an axial section of the brain, brainstem and cerebellum. The section goes through the caudate nuclei, part of the anterior commissure, the midbrain and the upper portion of the fourth ventricle and cerebellar hemispheres. The brain shows hydrocephalus with dilatation of both anterior portions of the lateral ventricles and the temporal horns. The right cerebellar hemisphere is enlarged by a hematoma that has originated near the dentate nucleus and has destroyed part of the white matter of the cerebellar hemisphere and the folia.The fourth ventricle is compressed to the left side anteriorly. Diagnosis: Spontaneous hypertensive right cerebellar hemisphere hemorrhage. #2 Acute hydrocephalus.
Old hypertensive spontaneous hemorrhage left putamen
An axial section of the cerebral hemispheres. Shows a pigmented slit- like lesion in the left putamen. This pigmentation is rusty brown and within the cavity there is some old blood. The sulci in the insula are prominent. Diagnosis: Old hypertensive spontaneous hemorrhage left putamen.
Central pontine hemorrhage Due to cerebral Herniation.
This is a transverse section of the pons and cerebellum. The pons is almost completely destroyed by a hematoma that has replaced the tegmentum and most of the basis pontis . The hematoma has ruptured into the fourth ventricle which is obscured by this lesion. The cerebellum is normal . Diagnosis: Central pontine hemorrhage secondary to cerebral herniation – following increased intracranial pressure.
’ 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