This document discusses pathology of the nervous system. It covers various disease mechanisms including increased intracranial pressure, vascular and circulatory disorders, trauma, infections, tumors, demyelinating diseases, and developmental abnormalities. It describes the main cell types in the central nervous system and their functions. Key pathologies covered include strokes, herniations, hydrocephalus, and effects of trauma. Specific vascular disorders like ischemia, infarction, hemorrhage, and their causes are explained.
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Foramen magnum meningiomas are challenging tumors, requiring special considerations because of the vicinity of the medulla oblongata, the lower cranial nerves, and the vertebral artery. It accounts for 1-3% of all intracranial Meningioma.
Foramen magnum meningiomas are challenging tumors, requiring special considerations because of the vicinity of the medulla oblongata, the lower cranial nerves, and the vertebral artery. It accounts for 1-3% of all intracranial Meningioma.
This ppt presentation discusses about the various models of mental illness. I found it useful to download as it gives a fair idea about various models which are generally not found in books.
Definition of stroke and cerebrovascular disorders and pathophysiology of cerebral infarct and CT imaging overview of acute-subacute and chronic infarcts and penumbra.
causes of cerebral edema , Radiological signs of acute infarct and hemorrhagic infarct and comparison of MRI and CT in the diagnosis of acute infarct
Role of diffusion weighted imaging (DWI) and diffusion perfusion mismatch
CEREBROVASCULAR ACCIDENT/STROKE • Also called “brain attack”, cerebral infarction, cerebral hemorrhage, ischemic stroke or stroke • A stroke is caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue.
intracranial hemorrhage- by KEMISA HASSEN ZAINABU IIHS_jinjaUGANDA (2).pptxHASSENZAINABUKEMISA
By the end of this we shall be able to know the following
definition.of intracranial hemorriage
Classification of intracranial hemorriage
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Cns
1. Pathology of thePathology of the
Nervous SystemNervous System
Karen SantaCruz MDKaren SantaCruz MD
Brent Clark MD, PhDBrent Clark MD, PhD
2. Pathology of the Nervous SystemPathology of the Nervous System
IntroductionIntroduction
IncreasedIncreased
intracranialintracranial
pressurepressure
Vascular andVascular and
circulatorycirculatory
disordersdisorders
TraumaTrauma
InfectionsInfections
TumorsTumors
DemyelinatingDemyelinating
diseasesdiseases
DegenerativeDegenerative
diseasesdiseases
DevelopmentalDevelopmental
AbnormalitiesAbnormalities
3. Hematoxylin and Eosin Luxol fast-blue-PASLuxol fast-blue-PAS
BielschowskyBielschowsky
4. Cell typesCell types
1.1. Neuron:Neuron: functions in neural transmission, mostfunctions in neural transmission, most
vulnerable cell, limited regenerationvulnerable cell, limited regeneration
2.2. AstrocyteAstrocyte: major reactive cell of CNS forms ‘scar’: major reactive cell of CNS forms ‘scar’
3.3. OligodendrocyteOligodendrocyte: highly vulnerable, limited: highly vulnerable, limited
proliferation, forms myelin sheathproliferation, forms myelin sheath
4.4. Ependymal cellEpendymal cell: vulnerable, limited regeneration,: vulnerable, limited regeneration,
lines ventricles (ependymal granulations)lines ventricles (ependymal granulations)
5.5. Microglial cellMicroglial cell: monocyte/macrophage (bone: monocyte/macrophage (bone
marrow) derived phagocytic cell, antigenmarrow) derived phagocytic cell, antigen
presentation, producer of cytokines,presentation, producer of cytokines,
inflammatory cellinflammatory cell
5. IntroductionIntroduction
Cellular reactions of the central nervous systemCellular reactions of the central nervous system
Neurons: permanentNeurons: permanent
Axonal retraction (axonal spheroids)Axonal retraction (axonal spheroids)
Ischemic cell changesIschemic cell changes
Atrophy and degenerationAtrophy and degeneration
Intraneuronal deposits and inclusionsIntraneuronal deposits and inclusions
(neurodegenerative diseases)(neurodegenerative diseases)
Glia: proliferate, form glial ‘scar’Glia: proliferate, form glial ‘scar’
10. Mechanisms of dysfunction causingMechanisms of dysfunction causing
diseasedisease
Pathophysiological (toxic/metabolic)Pathophysiological (toxic/metabolic)
StructuralStructural
Focal lesions correlate with localizing symptomsFocal lesions correlate with localizing symptoms
System degenerations correlate with functionallySystem degenerations correlate with functionally
localizing symptoms (ie motor neuron disease)localizing symptoms (ie motor neuron disease)
Increased intracranial pressure (generalized orIncreased intracranial pressure (generalized or
focal), can cause global symptoms or brainfocal), can cause global symptoms or brain
herniation since the volume of the brain is fixed byherniation since the volume of the brain is fixed by
the skullthe skull
13. TYPES OF HERNIATIONTYPES OF HERNIATION
1.1. SubfalcineSubfalcine
(cingulate)(cingulate)
2.2. TranstentorialTranstentorial
(uncal)(uncal)
3.3. TonsillarTonsillar
(foramen(foramen
magnum)magnum)
4.4. ExtracranialExtracranial
14. TRANSTENTORIAL (UNCAL)TRANSTENTORIAL (UNCAL)
HERNIATIONHERNIATION
SHIFT OF THE BRAIN FROM THE MIDDLE TOSHIFT OF THE BRAIN FROM THE MIDDLE TO
THE POSTERIOR FOSSA THROUGH THETHE POSTERIOR FOSSA THROUGH THE
TENTORIAL INCISURATENTORIAL INCISURA
MAY BE UNILATERAL OR “CENTRAL”MAY BE UNILATERAL OR “CENTRAL”
SECONDARY EFFECTS INCLUDE:SECONDARY EFFECTS INCLUDE:
Compression of the third cranial nerve(s)Compression of the third cranial nerve(s)
Duret hemorrhages in midline rostral brainstemDuret hemorrhages in midline rostral brainstem
Compression of the contralateral cerebral peduncleCompression of the contralateral cerebral peduncle
(Kernohan’s notch)(Kernohan’s notch)
Compression of the posterior cerebral artery withCompression of the posterior cerebral artery with
infarction of the medial occipital lobeinfarction of the medial occipital lobe
16. DURET HEMORRHAGESDURET HEMORRHAGES
Midline Duret hemorrhages plus Kernohan’sMidline Duret hemorrhages plus Kernohan’s
notch in the right cerebral pedunclenotch in the right cerebral peduncle
17. HYDROCEPHALUSHYDROCEPHALUS
DILATATION OF THE VENTRICULARDILATATION OF THE VENTRICULAR
SYSTEMSYSTEM
NONCOMMUNICATING: Due toNONCOMMUNICATING: Due to
obstruction within the ventricular system,obstruction within the ventricular system,
e.g., tumor, aqueductal stenosise.g., tumor, aqueductal stenosis
COMMUNICATING: Due to obstruction ofCOMMUNICATING: Due to obstruction of
CSF flow in the subarachnoid space withCSF flow in the subarachnoid space with
decreased reabsorptiondecreased reabsorption
19. COMMUNICATINGCOMMUNICATING
HYDROCEPHALUSHYDROCEPHALUS
Dilatation of the entire ventricular system including theDilatation of the entire ventricular system including the
aqueduct and fourth ventricular foramina. There isaqueduct and fourth ventricular foramina. There is
thickening and scarring of the meninges, secondary tothickening and scarring of the meninges, secondary to
previous subarachnoid hemorrhageprevious subarachnoid hemorrhage
20. Summary: Microscopic and grossSummary: Microscopic and gross
brain abnormalitiesbrain abnormalities
Cell types: Function and proliferative capacityCell types: Function and proliferative capacity
Mechanisms of CNS dysfunction:Mechanisms of CNS dysfunction:
Pathophysiological “invisible” lesions: metabolic, toxicPathophysiological “invisible” lesions: metabolic, toxic
Structural “visible” abnormalities: mass, edema,Structural “visible” abnormalities: mass, edema,
hydrocephalus, cytologic abnormalities.hydrocephalus, cytologic abnormalities.
Increased intracranial pressureIncreased intracranial pressure
Causes of cerebral edema: focal and generalizedCauses of cerebral edema: focal and generalized
Types of herniation: cingulate, uncal, tonsillarTypes of herniation: cingulate, uncal, tonsillar
Hydrocephalus: non-communicating and communicatingHydrocephalus: non-communicating and communicating
26. RISK FACTORS:RISK FACTORS:
hypertension (lacunar infarcts)hypertension (lacunar infarcts)
Lacunar infarct of theLacunar infarct of the
globus pallidusglobus pallidus
Lacunar infarct of theLacunar infarct of the
ponspons
27. Other causes of ischemiaOther causes of ischemia
Systemic Hypotension: Results in watershedSystemic Hypotension: Results in watershed
infarctsinfarcts
Hypoxia or Anoxia: Lack of oxygen or poorHypoxia or Anoxia: Lack of oxygen or poor
perfusion after MI results in watershed infarctsperfusion after MI results in watershed infarcts
and/or damage in vulnerable regions, ieand/or damage in vulnerable regions, ie
hippocampus and cerebellumhippocampus and cerebellum
Venous thrombosis: Rare, causes hemorrhagicVenous thrombosis: Rare, causes hemorrhagic
infarcts, consider coagulopathyinfarcts, consider coagulopathy
31. VENOUS INFARCTIONVENOUS INFARCTION
Venous infarction usuallyVenous infarction usually
results from venous sinusresults from venous sinus
thrombosisthrombosis
Risk factors include aRisk factors include a
number of states thatnumber of states that
result in hyperviscosityresult in hyperviscosity
or increased coagulabilityor increased coagulability
Grossly they are veryGrossly they are very
hemorrhagichemorrhagic
32. Transient Ischemic AttacksTransient Ischemic Attacks
Lasts less than 24 hours by definitionLasts less than 24 hours by definition
Attributed to transient embolizationAttributed to transient embolization
Occurs in patients with atheroscleroticOccurs in patients with atherosclerotic
stenosisstenosis
Harbinger of cerebral infarctionHarbinger of cerebral infarction
33. Summary: Strokes due toSummary: Strokes due to
ischemia/infarctionischemia/infarction
Large vessel atherosclerotic disease (non-Large vessel atherosclerotic disease (non-
hemorrhagic)hemorrhagic)
Embolic (hemorrhagic)Embolic (hemorrhagic)
Hypertensive (hemorrhages and lacunes)Hypertensive (hemorrhages and lacunes)
Vasospasm (2° to subarachnoid hemorrhage)Vasospasm (2° to subarachnoid hemorrhage)
Watershed infarcts: hypotension and hypoxiaWatershed infarcts: hypotension and hypoxia
Venous thrombosis (rare, hemorrhagic)Venous thrombosis (rare, hemorrhagic)
TIA: clears in 24 hours -by definition, oftenTIA: clears in 24 hours -by definition, often
associated with large vessel diseaseassociated with large vessel disease
34. Strokes Due toStrokes Due to
HemorrhageHemorrhage
HypertensionHypertension
AneurysmsAneurysms
Vascular MalformationsVascular Malformations
Bleeding DiathesisBleeding Diathesis
TraumaTrauma
41. Summary: Strokes due toSummary: Strokes due to
hemorrhagehemorrhage
Hypertension: Most common cause of brainHypertension: Most common cause of brain
hemorrhage, sites include basal ganglia, pons,hemorrhage, sites include basal ganglia, pons,
cerebellum and cerebral white mattercerebellum and cerebral white matter
Aneurysms:Aneurysms:
Berry aneurysm: Most common type, causesBerry aneurysm: Most common type, causes SAHSAH
Mycotic aneurysm: Rare, parenchymal bleed, bacterialMycotic aneurysm: Rare, parenchymal bleed, bacterial
Atherosclerotic: Rarely bleed, may cause mass effect,Atherosclerotic: Rarely bleed, may cause mass effect,
fusiformfusiform
Vascular malformations and clottingVascular malformations and clotting
abnormalitiesabnormalities
42. Closed Head InjuryClosed Head Injury
ConcussionConcussion
Immediate and temporary disturbance of brainImmediate and temporary disturbance of brain
function.function.
Grading (1.Grading (1. mildmild: no LOC/smpt <15 min, 2.: no LOC/smpt <15 min, 2.
modmod: no LOC/smpt >15min, 3.: no LOC/smpt >15min, 3. severesevere: any LOC): any LOC)
CauseCause
Shearing of axonsShearing of axons
Signs: Amnesia, confusion, headache, visualSigns: Amnesia, confusion, headache, visual
disturbances, nausea, vomiting, dizzinessdisturbances, nausea, vomiting, dizziness
43. Closed Head InjuryClosed Head Injury
Epidural hematomaEpidural hematoma: Middle meningeal artery: Middle meningeal artery
tear (temporal bone fracture), accumulatestear (temporal bone fracture), accumulates
rapidly (arterial)rapidly (arterial)
Subdural hematomaSubdural hematoma: Shearing of bridging: Shearing of bridging
veins, accumulate in hours to days (rarelyveins, accumulate in hours to days (rarely
weeks+)weeks+)
Subarachnoid hemorrhageSubarachnoid hemorrhage: Occurs with: Occurs with
contusions or intraparenchymal hemorrhagecontusions or intraparenchymal hemorrhage
(also with berry aneurysms)(also with berry aneurysms)
44. TRAUMA AS A CAUSE OFTRAUMA AS A CAUSE OF
HEMORRHAGEHEMORRHAGE
subdural hematomasubdural hematoma
45. Closed Head InjuryClosed Head Injury
ContusionsContusions: Brain against bone, coup (at site: Brain against bone, coup (at site
of impact)/contrecoup (side opposite impact)of impact)/contrecoup (side opposite impact)
Intracerebral hemorrhageIntracerebral hemorrhage: Shearing of brain: Shearing of brain
vessels, high impactvessels, high impact
Diffuse Axonal InjuryDiffuse Axonal Injury: Shearing of axons: Shearing of axons
results in post-traumatic neurologic deficitsresults in post-traumatic neurologic deficits
Cerebral EdemaCerebral Edema: Occurs with and without an: Occurs with and without an
obvious structural lesionobvious structural lesion
Note: Can occur without evidence of hemorrhageNote: Can occur without evidence of hemorrhage
46. TRAUMA AS A CAUSE OFTRAUMA AS A CAUSE OF
HEMORRHAGE: contusionsHEMORRHAGE: contusions
47. Other traumatic injuriesOther traumatic injuries
Penetrating injuries: Bullets, bone fragments,Penetrating injuries: Bullets, bone fragments,
result in laceration with the potential forresult in laceration with the potential for
infectioninfection
Spinal cord injury: Fractures, vertebralSpinal cord injury: Fractures, vertebral
dislocation, penetrating injury, the spinal corddislocation, penetrating injury, the spinal cord
may be crushed or the site of hemorrhagemay be crushed or the site of hemorrhage
48. Summary: TraumaSummary: Trauma
Closed head injuries:Closed head injuries:
Sites (epidural, subdural, subarachnoid,Sites (epidural, subdural, subarachnoid,
parenchymal) and typical etiologyparenchymal) and typical etiology
Contusion, hemorrhage, diffuse axonal injury,Contusion, hemorrhage, diffuse axonal injury,
edemaedema
Penetrating injuries:Penetrating injuries:
Causes and risks (infection)Causes and risks (infection)
Spinal cord injuriesSpinal cord injuries
50. Infections: Route of entryInfections: Route of entry
Hematogenous (most common)Hematogenous (most common)
Localized source: abscess, heart valve, lung infectionLocalized source: abscess, heart valve, lung infection
Other: mosquitos, needlesOther: mosquitos, needles
Direct implantation (trauma)Direct implantation (trauma)
Local extension (ear infectionLocal extension (ear infection abscess)abscess)
Axonal transport (rabies, HSV)Axonal transport (rabies, HSV)
51. MeningitisMeningitis
Inflammation of the meningesInflammation of the meninges
FeverFever
HeadacheHeadache
Stiff neckStiff neck
Decreased level of consciousnessDecreased level of consciousness
Bacterial (purulent)Bacterial (purulent)
Tuberculous (granulomatous)Tuberculous (granulomatous)
Fungal (granulomatous)Fungal (granulomatous)
52. Bacterial MeningitisBacterial Meningitis
Neonates: E. Coli, group B streptococciNeonates: E. Coli, group B streptococci
Infants and children: Hemophilus influenzaInfants and children: Hemophilus influenza
(before immunization)(before immunization)
Young adults: Neisseria meningitidisYoung adults: Neisseria meningitidis
Adults: Streptococcus pneumoniae and ListeriaAdults: Streptococcus pneumoniae and Listeria
monocytogenesmonocytogenes
53. Meningitis: CSF findingsMeningitis: CSF findings
Increased white blood cellsIncreased white blood cells
Neutrophils withNeutrophils with bacterialbacterial meningitismeningitis
Mononuclear cells (lymphocytes andMononuclear cells (lymphocytes and
macrophages) withmacrophages) with TB and fungalTB and fungal infectionsinfections
Lymphocytes withLymphocytes with viralviral infectioninfection
Increased protein (mild with viral)Increased protein (mild with viral)
Reduced glucose withReduced glucose with bacterialbacterial meningitismeningitis
60. Cerebral AbscessCerebral Abscess
Localized (contained) infectionLocalized (contained) infection
Hematogenous spread (heart valves), penetratingHematogenous spread (heart valves), penetrating
wound, paranasal sinuses, middle earwound, paranasal sinuses, middle ear
Oral flora may be the source of an abscess afterOral flora may be the source of an abscess after
dental manipulationdental manipulation
Organisms are mixed and frequently anaerobicOrganisms are mixed and frequently anaerobic
Surrounding cerebral edema is commonSurrounding cerebral edema is common
CSF is frequently sterileCSF is frequently sterile
62. Cerebritis in Immune-compromisedCerebritis in Immune-compromised
PatientsPatients
Fungal InfectionsFungal Infections
AspergillusAspergillus
CandidaCandida
MucorMucor
ProtozoalProtozoal
ToxoplasmaToxoplasma
Ameba infections can be seen inAmeba infections can be seen in
immunocompromised patients and rarelyimmunocompromised patients and rarely
non-immunocompromised individualsnon-immunocompromised individuals
63. Viral infectionViral infection
Route of entryRoute of entry
May be blood borne, respiratory or fecal/oralMay be blood borne, respiratory or fecal/oral
Rabies-peripheral nerveRabies-peripheral nerve
Acute viral encephalitisAcute viral encephalitis
Herpes-activation of latent infectionHerpes-activation of latent infection
Arbovirus-mosquito borne (West Nile virus)Arbovirus-mosquito borne (West Nile virus)
Polio-enteric virus with neuronal tropismPolio-enteric virus with neuronal tropism
Immunocompromised hostsImmunocompromised hosts
CMVCMV
HSV/VZVHSV/VZV
PMLPML
HIV encephalitis (HIVE)HIV encephalitis (HIVE)
64. ACUTE (VIRAL) ENCEPHALITISACUTE (VIRAL) ENCEPHALITIS
microscopic featuresmicroscopic features
Lymphocytic infiltratesLymphocytic infiltrates Microglial proliferationMicroglial proliferation
with microglial noduleswith microglial nodules
74. Primary Tumors of the CentralPrimary Tumors of the Central
Nervous SystemNervous System
GliomaGlioma
AstrocytomaAstrocytoma
OligodendrogliomaOligodendroglioma
EpendymomaEpendymoma
Neuronal lineageNeuronal lineage
MeningiomaMeningioma
Nerve Sheath TumorsNerve Sheath Tumors
75. Primary brain tumors: Cell typesPrimary brain tumors: Cell types
1.1. Neuron:Neuron: Gangliocytoma, gangliogliomaGangliocytoma, ganglioglioma
medulloblastomamedulloblastoma
2.2. AstrocyteAstrocyte:: Astrocytoma, glioblastomaAstrocytoma, glioblastoma
3.3. OligodendrocyteOligodendrocyte:: OligodendrogliomaOligodendroglioma
4.4. Ependymal cellEpendymal cell:: EpendymomaEpendymoma
5.5. Microglial cellMicroglial cell:: Tumors derived from microglialTumors derived from microglial
cells have not been described.cells have not been described.
6.6. Meningeal cellMeningeal cell:: Meningiomas are derived fromMeningiomas are derived from
arachnoidal cells and are usually dural-based.arachnoidal cells and are usually dural-based.
77. GliomasGliomas
Diffusely infiltrating (not easily resected)Diffusely infiltrating (not easily resected)
Histologic appearance (grade) correlates withHistologic appearance (grade) correlates with
overall survivaloverall survival
May become more malignant (higher grade) overMay become more malignant (higher grade) over
time (especially astrocytomas which becometime (especially astrocytomas which become
glioblastomas)glioblastomas)
May spread via CSFMay spread via CSF
Rarely (never) metastasizeRarely (never) metastasize
102. DISEASES OF MYELINDISEASES OF MYELIN
DEMYELINATING DISEASES:DEMYELINATING DISEASES:
Acquired disorders of myelin, such as multipleAcquired disorders of myelin, such as multiple
sclerosis.sclerosis.
DYSMYELINATING DISEASES:DYSMYELINATING DISEASES:
Genetic disorders of myelin and its turnover,Genetic disorders of myelin and its turnover,
such as leukodystrophiessuch as leukodystrophies
103. MULTIPLE SCLEROSISMULTIPLE SCLEROSIS
Multiple sclerosis is the most common diseaseMultiple sclerosis is the most common disease
of CNS myelin; prevalence of 1:1000.of CNS myelin; prevalence of 1:1000.
Central nervous system myelin is selectivelyCentral nervous system myelin is selectively
destroyed (axons are relatively preserved)destroyed (axons are relatively preserved)
Onset is frequently in 30 and 40 year old ageOnset is frequently in 30 and 40 year old age
groups.groups.
The disease is typically progressive with relapsingThe disease is typically progressive with relapsing
and remitting accumulations of focal neurologicand remitting accumulations of focal neurologic
deficits.deficits.
The etiology is thought to be autoimmune inThe etiology is thought to be autoimmune in
naturenature
108. PONTINE MS PLAQUEPONTINE MS PLAQUE
adjacent sections for myelin andadjacent sections for myelin and
axonsaxons
Luxol fast-blue-PASLuxol fast-blue-PAS BielschowskyBielschowsky
113. Myasthenia GravisMyasthenia Gravis
An autoimmune neuromuscular disease that resultsAn autoimmune neuromuscular disease that results
from autoantibodies at the neuromuscular junction.from autoantibodies at the neuromuscular junction.
Characterized by variable weakness of voluntary muscles (eyeCharacterized by variable weakness of voluntary muscles (eye
muscles may be weak)muscles may be weak)
Worsens with activity (and late in the day)Worsens with activity (and late in the day)
May be associated with other autoimmune disordersMay be associated with other autoimmune disorders
such as thyroid disease, rheumatoid arthritis and SLEsuch as thyroid disease, rheumatoid arthritis and SLE
Often associated with a thymoma, removal of theOften associated with a thymoma, removal of the
thymoma may be curative.thymoma may be curative.
114. LEUKODYSTROPHIESLEUKODYSTROPHIES
CLINICAL: A variety of inherited diseases withCLINICAL: A variety of inherited diseases with
variable age of onset (usually in childhood) andvariable age of onset (usually in childhood) and
rate of progression, which typically result inrate of progression, which typically result in
diffuse severe dysfunction.diffuse severe dysfunction.
PATHOGENESIS:PATHOGENESIS: Recessive mutations inRecessive mutations in
proteins related to myelin structure orproteins related to myelin structure or
metabolismmetabolism
The peripheral nervous system also may beThe peripheral nervous system also may be
involved in a number of formsinvolved in a number of forms
115. PATHOLOGY OFPATHOLOGY OF
LEUKODYSTROPHIESLEUKODYSTROPHIES
Demyelination in large confluent foci within the cerebralDemyelination in large confluent foci within the cerebral
hemispheres and other siteshemispheres and other sites
GENERAL:GENERAL:
1.1. Loss of myelin and oligodendrogliaLoss of myelin and oligodendroglia
2.2. Relative preservation of axonsRelative preservation of axons
DISEASE SPECIFIC:DISEASE SPECIFIC:
1.1. Globoid cells (Krabbe’s disease)Globoid cells (Krabbe’s disease)
2.2. Metachromatic material in macrophages and neuronsMetachromatic material in macrophages and neurons
(metachromatic leukodystrophy, aryl sulfatase deficient)(metachromatic leukodystrophy, aryl sulfatase deficient)
3.3. Adrenal atrophy and cytosomal inclusions (ALD,Adrenal atrophy and cytosomal inclusions (ALD,
peroxisomal abnormality)peroxisomal abnormality)
122. DISEASES OF PERIPHERALDISEASES OF PERIPHERAL
NERVENERVE
CLASSIFICATION BY PATHOLOGYCLASSIFICATION BY PATHOLOGY
Demyelinating neuropathiesDemyelinating neuropathies
Guillain-Barre-Landry syndromeGuillain-Barre-Landry syndrome
Chronic inflammatory demyelinating polyneuropathyChronic inflammatory demyelinating polyneuropathy
(CIDP)(CIDP)
Axonal neuropathies: most neuropathies areAxonal neuropathies: most neuropathies are
axonal but pathology often is nonspecificaxonal but pathology often is nonspecific
Examples include hypertrophic neuropathies,Examples include hypertrophic neuropathies,
herpes zoster, HIV, alcoholic and diabeticherpes zoster, HIV, alcoholic and diabetic
neuropathiesneuropathies
126. Summary:Summary:
Demyelinating/DysmyelinatingDemyelinating/Dysmyelinating
diseasesdiseases
Demyelinating disease: most common is MS,Demyelinating disease: most common is MS,
acute disseminated encephalomyelitis (rare,acute disseminated encephalomyelitis (rare,
follows viral infection, vaccination)follows viral infection, vaccination)
Leukodystrophies: Genetic diseases (manyLeukodystrophies: Genetic diseases (many
enzyme abnormalities are defined) resulting inenzyme abnormalities are defined) resulting in
myelin loss, occur early in life.myelin loss, occur early in life.
Peripheral nerve demyelination: Guillain-BarrePeripheral nerve demyelination: Guillain-Barre
Syndrome, autoimmune, potential forSyndrome, autoimmune, potential for
remyelination with complete recoveryremyelination with complete recovery
127. NeurodegenerativeNeurodegenerative
diseasesdiseases
Dementia:Dementia:
Alzheimer’s disease, Pick’s diseaseAlzheimer’s disease, Pick’s disease
Movement Disorders:Movement Disorders:
Parkinson’s disease, Huntington’sParkinson’s disease, Huntington’s
disease, Multiple Systems Atrophydisease, Multiple Systems Atrophy
Motor Disease:Motor Disease:
ALS, Werdnig-Hoffman, PoliomyelitisALS, Werdnig-Hoffman, Poliomyelitis
Prion diseasePrion disease
128. Alzheimer’s disease: ClinicalAlzheimer’s disease: Clinical
featuresfeatures
Clinical features of dementiaClinical features of dementia
Impairment of recent memoryImpairment of recent memory
Aphasia (naming), apraxia (motor), agnosiaAphasia (naming), apraxia (motor), agnosia
(object), executive functioning(object), executive functioning
Impaired level of functionImpaired level of function
Progressive over timeProgressive over time
47% of people over 85 years of age are47% of people over 85 years of age are
affectedaffected
129. Alzheimer’s disease: PathogenesisAlzheimer’s disease: Pathogenesis
The amyloid hypothesis:The amyloid hypothesis:
Abnormal APP processingAbnormal APP processing
leads to deposits ofleads to deposits of
insoluble B-pleatedinsoluble B-pleated
amyloid proteinamyloid protein
136. Other DementiasOther Dementias
Dementia with Lewy bodiesDementia with Lewy bodies
Second most common neurodegenerative cause ofSecond most common neurodegenerative cause of
dementiadementia
Lewy bodies and neurodegeneration affect brainstemLewy bodies and neurodegeneration affect brainstem
and cortexand cortex
Pick’s disease and other frontal temporalPick’s disease and other frontal temporal
dementiasdementias
Classification depends on histologic examination andClassification depends on histologic examination and
is complicatedis complicated
137. Parkinson’s disease: ClinicalParkinson’s disease: Clinical
findingsfindings
Idiopathic Parkinson’s disease (vs.Idiopathic Parkinson’s disease (vs.
parkinsonism or parkinsonian syndrome),parkinsonism or parkinsonian syndrome),
est 1% of population over 50 years of ageest 1% of population over 50 years of age
TremorTremor (rest)(rest)
RigidityRigidity (cogwheel rigidity)(cogwheel rigidity)
BradykinesiaBradykinesia (mask-like facies, loss of arm-(mask-like facies, loss of arm-
swing)swing)
Festinating gait (loss of righting reflexes)Festinating gait (loss of righting reflexes)
138. Parkinson’s disease: Gross andParkinson’s disease: Gross and
microscopic findingsmicroscopic findings
Gross--Gross--loss of pigmentloss of pigment in thein the substantiasubstantia
nigranigra
Microscopic--Lewy bodies with pigmentedMicroscopic--Lewy bodies with pigmented
neuronal cell loss and gliosisneuronal cell loss and gliosis
cortical Lewy bodies present in 80% or morecortical Lewy bodies present in 80% or more
of PD casesof PD cases
142. Other Extrapyramidal MovementOther Extrapyramidal Movement
DisordersDisorders
Parkinson’s disease: HypokineticParkinson’s disease: Hypokinetic
Huntington’s disease: HyperkineticHuntington’s disease: Hyperkinetic
Choreiform movementsChoreiform movements
Intellectual declineIntellectual decline
Multiple Systems AtrophyMultiple Systems Atrophy
Parkinsonian featuresParkinsonian features
Symptoms suggestive of olivopontocerebellarSymptoms suggestive of olivopontocerebellar
degenerationdegeneration
Shy-Drager syndrome (parasympathetic dysfunction)Shy-Drager syndrome (parasympathetic dysfunction)
143. Motor neuron diseaseMotor neuron disease
Amyotrophic lateral sclerosis (Lou Gehrig’sAmyotrophic lateral sclerosis (Lou Gehrig’s
disease)disease)
Results in progressive weakness, eventually resultingResults in progressive weakness, eventually resulting
in paralysis of respiratory muscles and death oftenin paralysis of respiratory muscles and death often
within 2-5 years of diagnosiswithin 2-5 years of diagnosis
Degeneration of upper (motor cortex) and lowerDegeneration of upper (motor cortex) and lower
(spinal cord) motor neurons(spinal cord) motor neurons
144. Motor Neuron DiseaseMotor Neuron Disease
ALS: Adult form of motor neuron diseaseALS: Adult form of motor neuron disease
associated with both upper (brain) and lowerassociated with both upper (brain) and lower
(spinal cord) motor involvement(spinal cord) motor involvement
Werdnig-Hoffman disease: The baby is weakWerdnig-Hoffman disease: The baby is weak
(floppy) at birth. Lower (spinal cord) motor(floppy) at birth. Lower (spinal cord) motor
neurons are involved.neurons are involved.
Poliomyelitis: Lower motor neurons arePoliomyelitis: Lower motor neurons are
destroyed.destroyed.
145. Prion disease (SpongiformPrion disease (Spongiform
encephalopathy): Clinical findingsencephalopathy): Clinical findings
50-70 years old,50-70 years old, rapidly evolving dementiarapidly evolving dementia,,
often withoften with myoclonusmyoclonus and a characteristic EEGand a characteristic EEG
pattern (of repetitive sharp waves)pattern (of repetitive sharp waves)
Early symptoms include personality changes,Early symptoms include personality changes,
impaired judgement, gait abnormalities, vertigo,impaired judgement, gait abnormalities, vertigo,
In some patients cerebellar and visualIn some patients cerebellar and visual
abnormalities predominateabnormalities predominate
MajorityMajority die w/in 6 monthsdie w/in 6 months, frequently w/in 3, frequently w/in 3
mo.mo.
146. Prion disease: PathogenesisPrion disease: Pathogenesis
Transmissible but not “infectious”Transmissible but not “infectious”
Prion proteinPrion protein, Prusiner--1997 Nobel Prize, (not a, Prusiner--1997 Nobel Prize, (not a
“slow virus”)“slow virus”)
PrPPrPCC
-- produced normally in most cells --amino acid-- produced normally in most cells --amino acid
sequence is identical to the PrPsequence is identical to the PrPSCSC
--abnormal protein, the--abnormal protein, the
difference is in the secondary conformation (B-pleateddifference is in the secondary conformation (B-pleated
vs alpha helical) PrPvs alpha helical) PrPSCSC
causes post-translationalcauses post-translational
modification of PrPmodification of PrPCC
Transmitted by direct inoculation (corneal transplants,Transmitted by direct inoculation (corneal transplants,
dural grafts, pituitary products)dural grafts, pituitary products)
147. Prion disease: Gross andPrion disease: Gross and
microscopic findingsmicroscopic findings
Gross appearance--may be normal due toGross appearance--may be normal due to
short duration of diseaseshort duration of disease
Microscopic appearance--vacuolation ofMicroscopic appearance--vacuolation of
neuropil, vacuoles are within nerve cellneuropil, vacuoles are within nerve cell
bodies and neuronal processesbodies and neuronal processes
cell loss and gliosis may be prominentcell loss and gliosis may be prominent
151. Developmental Abnormalities:Developmental Abnormalities:
PathologyPathology
Organ inductionOrgan induction (2.5-6 weeks): neural tube defects:(2.5-6 weeks): neural tube defects:
anencephaly, spinal dysraphism, encephalocele,anencephaly, spinal dysraphism, encephalocele,
holoprosencephalyholoprosencephaly
Neuronal (glial) migrationNeuronal (glial) migration (3-6 months):(3-6 months):
lissencephaly, microcephaly, polymicrogyria, agenesis oflissencephaly, microcephaly, polymicrogyria, agenesis of
the corpus callosumthe corpus callosum
MyelinationMyelination (2 months-juvenile)(2 months-juvenile)
SynaptogenesisSynaptogenesis (20 week gestation-adulthood):(20 week gestation-adulthood):
trisomy 21, fragile X, cretinismtrisomy 21, fragile X, cretinism
In general,In general, earlier insults cause more severe structuralearlier insults cause more severe structural
damagedamage
152. Organ Induction:Organ Induction:
Dysraphic DisordersDysraphic Disorders
Failure of neural tube folds to close duringFailure of neural tube folds to close during
developmentdevelopment
Prenatal testing may reveal an elevated maternal serumPrenatal testing may reveal an elevated maternal serum
AFPAFP
Folate deficiency: Folic acid supplementation prior toFolate deficiency: Folic acid supplementation prior to
conception may reduce the incidence of neural tubeconception may reduce the incidence of neural tube
defects up to 70%defects up to 70%
Neural tube defects range from small bony defects in theNeural tube defects range from small bony defects in the
lumbosacral region (spina bifida occulta) tolumbosacral region (spina bifida occulta) to
craniorachischisis.craniorachischisis.
Myelomeningoceles occur most commonly in theMyelomeningoceles occur most commonly in the
lumbosacral regionlumbosacral region
153.
154.
155.
156. Neuronal migration disordersNeuronal migration disorders
Lissencephaly (smooth brain)/pachygyria (fewLissencephaly (smooth brain)/pachygyria (few
enlarged gyrienlarged gyri
Polymicrogyria (many small gyri)Polymicrogyria (many small gyri)
Heterotopias (circumscribed collections) andHeterotopias (circumscribed collections) and
dysplasias (disorganized lamination)dysplasias (disorganized lamination)
Occur with other developmental abnormalities forOccur with other developmental abnormalities for
example in patients with chromosomal abnormalitiesexample in patients with chromosomal abnormalities
May be the focus of seizure activityMay be the focus of seizure activity
157. SeizuresSeizures
Result from abnormal electrical activity of a group ofResult from abnormal electrical activity of a group of
brain cells and cause an altered mental state or tonicbrain cells and cause an altered mental state or tonic
clonic movements. May be partial (focal) orclonic movements. May be partial (focal) or
generalized.generalized.
In children seizures may result from neuronal migrationIn children seizures may result from neuronal migration
abnormalities or from abnormalities acquiredabnormalities or from abnormalities acquired
subsequent to brain damage (such as inflammation)subsequent to brain damage (such as inflammation)
A first time seizure in an adult would warrant anA first time seizure in an adult would warrant an
imaging study to rule out tumor or other structuralimaging study to rule out tumor or other structural
abnormalityabnormality
158.
159.
160. Neuronal Storage DiseaseNeuronal Storage Disease
Result from inborn errors of metabolism (deficientResult from inborn errors of metabolism (deficient
enzyme or abnormal lysosomal function)enzyme or abnormal lysosomal function)
Progressive, poor treatment options (bone marrowProgressive, poor treatment options (bone marrow
transplant)transplant)
Accumulation of metabolic products in the neuronAccumulation of metabolic products in the neuron
Tay Sachs diseaseTay Sachs disease
Neuronal ceroid lipofuscinosisNeuronal ceroid lipofuscinosis
Glycogen storage diseaseGlycogen storage disease
168. Shaken Baby SyndromeShaken Baby Syndrome
General: Violent shaking causes accelerationGeneral: Violent shaking causes acceleration
((shearingshearing) injury of axons:) injury of axons: diffuse axonal injurydiffuse axonal injury
Neurologic: Blindness/mental retardation in infantsNeurologic: Blindness/mental retardation in infants
less than 1 year of age. Present with apnea, seizures,less than 1 year of age. Present with apnea, seizures,
lethargy, bradycardia, respiratory difficulty, coma.lethargy, bradycardia, respiratory difficulty, coma.
Pathology:Pathology: Oculo-cerebral damage can occurOculo-cerebral damage can occur
without external evidence of head injury.without external evidence of head injury. RetinalRetinal
and optic nerve sheath hemorrhage—and optic nerve sheath hemorrhage—
ophthalmoscopic exam importantophthalmoscopic exam important
Microscopic: Axonal spheroidsMicroscopic: Axonal spheroids
170. Pathology of the Nervous SystemPathology of the Nervous System
IntroductionIntroduction
IncreasedIncreased
intracranialintracranial
pressurepressure
Vascular andVascular and
circulatorycirculatory
disordersdisorders
TraumaTrauma
InfectionsInfections
TumorsTumors
DemyelinatingDemyelinating
diseasesdiseases
DegenerativeDegenerative
diseasesdiseases
DevelopmentalDevelopmental
AbnormalitiesAbnormalities
171.
172. The more people IThe more people I
meet…meet…
The more I likeThe more I like
my dogmy dog
Editor's Notes
Alpha-fetoprotein (AFP), a substance naturally produced by the fetus&apos;s liver. The level of AFP in the mother&apos;s blood increases steadily during pregnancy.
An abnormally high AFP level can be a sign of a neural tube defect.
An abnormally low AFP level can be a sign of Down syndrome.
Human chorionic gonadotropin (hCG), a hormone produced by the placenta when a woman becomes pregnant. The level of hCG steadily increases during the first 14 to 16 weeks of pregnancy, typically peaks around the 14th week, and then gradually decreases. Abnormally high hCG can be a sign of Down syndrome.
Estriol, a form of estrogen that increases during pregnancy. It is produced in large amounts by the placenta. Estriol can be detected in the blood as early as the 9th week of pregnancy and continues to increase until delivery. Abnormally low estriol can be a sign of Down syndrome.
Inhibin-A, a protein produced by the fetus and placenta. Abnormally high inhibin-A can be a sign of Down syndrome.