Pathology of Stroke-CVA

1. Pathology of Stroke-CVA “ The true measure of a man is how he treats someone who does him absolutely no good...” – Ann Landers True beauty lies in the Heart….

2. CPC 4.3.5 – Robert <ul><li>Robert is a 62 year old recently retired from QLD railways . </li></ul><ul><li>He lives in Cairns with his wife Rose and their son Aiden who is 40 yrs old with Downs syndrome. </li></ul><ul><li>He has fallen from a ladder whilst picking mangoes. </li></ul><ul><li>His wife found him unconscious in the back yard. </li></ul><ul><li>On arrival at the A&E department he is conscious but appears confused . He is complaining of a pain in his L arm . </li></ul> CPC 4.3.5 – Robert <ul><li>Robert is a 62 year old recently retired from QLD railways . </li></ul><ul><li>He lives in Cairns with his wife Rose and their son Aiden who is 40 yrs old with Downs syndrome. </li></ul><ul><li>He has fallen from a ladder whilst picking mangoes. </li></ul><ul><li>His wife found him unconscious in the back yard. </li></ul><ul><li>On arrival at the A&E department he is conscious but appears confused . He is complaining of a pain in his L arm . </li></ul>

3. CPC 4.3.5 – Robert <ul><li>What happened:Patient is unable to talk </li></ul><ul><li>Collateral History : wife,son, neighbours, paramedics. </li></ul><ul><li>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. </li></ul> CPC 4.3.5 – Robert <ul><li>What happened:Patient is unable to talk </li></ul><ul><li>Collateral History : wife,son, neighbours, paramedics. </li></ul><ul><li>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. </li></ul>

4. CPC 4.3.5 – Robert <ul><li>PMH: Hypertension diagnosed in 2000. a bit forgetful taking medication. </li></ul><ul><li>PSH: 1968 appendicectomy. </li></ul><ul><li>SH married for 40 years to Rose, they had 2 children . Their oldest Aiden was born with downs syndrome and has lived with them all his life ; alcohol 2 beers x2/week, non smoker. </li></ul><ul><li>FH mother: breast ca age 72 years ; well age 85yr </li></ul><ul><li>Father died CVA aged 71 </li></ul><ul><li>Brother has hypertension and type 2 DM </li></ul><ul><li>Allergies : aspirin </li></ul><ul><li>Immunisation Fluvax 4.06, Pneumovax 2004 </li></ul><ul><li>Medication Ramipril 2.5mg OD [when remembers it] </li></ul> CPC 4.3.5 – Robert <ul><li>PMH: Hypertension diagnosed in 2000. a bit forgetful taking medication. </li></ul><ul><li>PSH: 1968 appendicectomy. </li></ul><ul><li>SH married for 40 years to Rose, they had 2 children . Their oldest Aiden was born with downs syndrome and has lived with them all his life ; alcohol 2 beers x2/week, non smoker. </li></ul><ul><li>FH mother: breast ca age 72 years ; well age 85yr </li></ul><ul><li>Father died CVA aged 71 </li></ul><ul><li>Brother has hypertension and type 2 DM </li></ul><ul><li>Allergies : aspirin </li></ul><ul><li>Immunisation Fluvax 4.06, Pneumovax 2004 </li></ul><ul><li>Medication Ramipril 2.5mg OD [when remembers it] </li></ul>

5. CPC 4.3.5 – Robert <ul><li>T 36.4 C rr 16/min BP 168/98 mmHg pulse 110 bpm irregular , O2 sats RA 92% (on mask O2 4l/min) BMI 31 BGL 16m/mol </li></ul><ul><li>General appearance : confused to place and time ; no memory of fall or period preceding fall; drooping R side face and R side of body </li></ul><ul><li>EMST cervical collar ABCDE </li></ul><ul><li>Peripheries : no clubbing . CRT<2 secs </li></ul><ul><li>CVS Irregular HR no murmurs , no carotid Bruits </li></ul><ul><li>CNS GCS 13 Pupils R>L sluggish response[AVPU]; </li></ul> CPC 4.3.5 – Robert <ul><li>T 36.4 C rr 16/min BP 168/98 mmHg pulse 110 bpm irregular , O2 sats RA 92% (on mask O2 4l/min) BMI 31 BGL 16m/mol </li></ul><ul><li>General appearance : confused to place and time ; no memory of fall or period preceding fall; drooping R side face and R side of body </li></ul><ul><li>EMST cervical collar ABCDE </li></ul><ul><li>Peripheries : no clubbing . CRT<2 secs </li></ul><ul><li>CVS Irregular HR no murmurs , no carotid Bruits </li></ul><ul><li>CNS GCS 13 Pupils R>L sluggish response[AVPU]; </li></ul>

6. CPC 4.3.5 – Robert <ul><li>Boggy Haematoma L temporo parietal area. </li></ul><ul><li>Gross dysphasia , drooping R side of face , </li></ul><ul><li>Flaccidity R side of body , brisk reflexes with equivocal plantar reflex </li></ul><ul><li>Painful swelling with bruising lower L arm just distal to elbow , unable to test L power, tone or reflexes due to pain when moving L arm </li></ul><ul><li>Power/reflexes/tone normal L leg </li></ul><ul><li>Sensation : responds to pain </li></ul><ul><li>Resp., GI, Renal: all normal </li></ul> CPC 4.3.5 – Robert <ul><li>Boggy Haematoma L temporo parietal area. </li></ul><ul><li>Gross dysphasia , drooping R side of face , </li></ul><ul><li>Flaccidity R side of body , brisk reflexes with equivocal plantar reflex </li></ul><ul><li>Painful swelling with bruising lower L arm just distal to elbow , unable to test L power, tone or reflexes due to pain when moving L arm </li></ul><ul><li>Power/reflexes/tone normal L leg </li></ul><ul><li>Sensation : responds to pain </li></ul><ul><li>Resp., GI, Renal: all normal </li></ul>

7. CPC 4.3.5 – Robert <ul><li>Head injury </li></ul><ul><ul><li>Contusion, Concussion </li></ul></ul><ul><ul><li>Epidural hematoma </li></ul></ul><ul><ul><li>Subdural hematoma </li></ul></ul><ul><li>Cerebrovascular accident ( stroke ) </li></ul><ul><ul><li>CVA: embolic </li></ul></ul><ul><ul><li>CVA: haemorrhagic </li></ul></ul><ul><ul><li>Metabolic cause </li></ul></ul><ul><ul><li>Seizure ? cause </li></ul></ul><ul><li>Trauma to L arm ?# radius / ulna </li></ul> CPC 4.3.5 – Robert <ul><li>Head injury </li></ul><ul><ul><li>Contusion, Concussion </li></ul></ul><ul><ul><li>Epidural hematoma </li></ul></ul><ul><ul><li>Subdural hematoma </li></ul></ul><ul><li>Cerebrovascular accident ( stroke ) </li></ul><ul><ul><li>CVA: embolic </li></ul></ul><ul><ul><li>CVA: haemorrhagic </li></ul></ul><ul><ul><li>Metabolic cause </li></ul></ul><ul><ul><li>Seizure ? cause </li></ul></ul><ul><li>Trauma to L arm ?# radius / ulna </li></ul>

8. Education must award self-confidence, the courage to depend on one’s own strength. - Baba Education must award self-confidence, the courage to depend on one’s own strength. - Baba

9. Pathology of Cerebro-vascular Disease (Stroke) Dr. Shashidhar Venkatesh Murthy Associate Professor & Head of Pathology Pathology of Cerebro-vascular Disease (Stroke) Dr. Shashidhar Venkatesh Murthy Associate Professor & Head of Pathology

10. . Introduction: <ul><li>“ Stroke” Acute neurological deficit – clinical. </li></ul><ul><li>Cerebro Vascular accident ( CVA ) – Pathology. </li></ul><ul><li>Low O2 (hypoxia) / Low blood supply. </li></ul><ul><li>Varying severity, location & types </li></ul><ul><li>Transient, evolving & completed. </li></ul><ul><li>Global / Focal, arterial / venous </li></ul><ul><li>Ischemic / hemorrhagic. </li></ul>

11. . 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>

12. . 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>

13. . Anatomy – Stroke.

14. . Stroke Types: <ul><li>Clinical </li></ul><ul><ul><li>Transient Ischemic Attack –TIA resolve <24h </li></ul></ul><ul><ul><li>Evolving stroke – increasing >24h. – Thromb. </li></ul></ul><ul><ul><ul><li>Recurrent / multiple stroke – sec. factors. </li></ul></ul></ul><ul><ul><li>Completed stroke – no change… embolic. </li></ul></ul><ul><li>Pathological </li></ul><ul><ul><li>Focal / Global </li></ul></ul><ul><ul><li>Ischemic & hemorrhagic. </li></ul></ul><ul><ul><li>Venous infarcts. (young, infections) </li></ul></ul>

15. . 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><ul><li>Venous thromboembolism (rare) </li></ul></ul><ul><li>Hemorrhage: Incidence 20% - mortality 80% </li></ul><ul><ul><li>Berry aneurysm, Microaneurysm, Atheroma. </li></ul></ul><ul><ul><li>Intracerebral or subarachnoid. </li></ul></ul>

16. . 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

17. . Hypertensive Intracerebral Hem: Sites 1. Putamen-Claustrum 2. Cerebral white matter 3. Thalamus 4. Pons 5. Cerebellum 55% 15 10 10 10

18. . 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>

19. . 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>

20. . 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>

21. . 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><ul><li>Impaired O2 utilization – Cyanide poisoning. </li></ul></ul><ul><li>Morphology : </li></ul><ul><ul><li>3rd, 5th and 6th layers of the cortex, CA1 sector of the hippocampus and in the Purkinje cells in the cerebellum </li></ul></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>

22. . Morphology in Global Ischemia

23. . Watershed/Boundary zone infarcts:

24. . Lamellar necrosis in global ischemia. Carotid thrombosis

25. . Local infarction: Cell death ~ 6min central infarct area or umbra , surrounded by a penumbra of ischemic tissue that may recover

26. . 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 – Red neuron, vacuolation. </li></ul><ul><li>>6 min – cell death, karyorrhexis. </li></ul>

27. . Infarct Stages: <ul><li>Immediate – <24 hours </li></ul><ul><ul><li>No Change gross, micro  Na/K loss, Ca+ influx. </li></ul></ul><ul><li>Acute stage – < 1week </li></ul><ul><ul><li>Oedema , loss of grey/white matter border. </li></ul></ul><ul><ul><li>Inflammation , Red neurons, necrosis, neutrophils </li></ul></ul><ul><li>Intermediate stage – 1- 4 weeks. </li></ul><ul><ul><li>Clear demarcation, soft friable tissue, cysts </li></ul></ul><ul><ul><li>Macrophages, liquifactive necrosis </li></ul></ul><ul><li>Late stage – > 4 weeks. </li></ul><ul><ul><li>Removal of tissue by macrophages </li></ul></ul><ul><ul><li>Fluid filled cysts with dark grey margin ( gliosis ) </li></ul></ul><ul><ul><li>Gliosis – proliferation of glia at periphery. </li></ul></ul>

28. . Cerebral edema

29. . Cerebral Edema: narrow sulci, flat gyri.

30. . Axonal Injury: A, Hypoxic/ischemic injury in cerebral cortex - &quot;red neurons.&quot; shrunken cell B, Axonal spheroids at points of axonal disruption C, Swollen cell body and peripheral dispersion of Nissl substance (chromatolysis) H&E Stain.

31. . Cerebral Edema: Normal Edema

32. . Edema, loss of demarcation:

33. . Cerebral Infarct : Red Neurons

34. . Acute Infarction: Oedema

35. . Cerebral Infarct - 2 Weeks

36. . Cerebral Infarct – 1-4 Week

37. . Cerebral Infarction: Macrophages

38. . Cerebral Infarct - Cyst formation

39. . C. Infarct - Cyst formation

40. . Cerebral Infarction - Late Cystic space

41. . Specific focal Infarcts Coronary artery involvement MCA ACA PCA

42. . MCA stroke.

43. . MCA stroke. Wikipedia: GNU Free Documentation license

44. . MCA stroke. Wikipedia: GNU Free Documentation license

45. . Haemorrhagic - Arterial embolus

46. . Infarct with Punctate hemorrhage

47. . Cerebral Infarction - Late

48. . Cerebral Infarction - Late

49. . Hypertensive CVD <ul><li>Intraerebral/Subarachnoid Hemorrhage </li></ul><ul><ul><li>Microaneurysm hemorrhages – Basal ganglia. Putamen(60%), thalamus, ventricles. </li></ul></ul><ul><ul><li>Berry aneurysm hemorrhages – subarachnoid. </li></ul></ul><ul><li>Chronic Hypertension: (dementia) </li></ul><ul><ul><li>Slit hemorrhages. Microhemorrhages heal as slit with pigment. </li></ul></ul><ul><ul><li>Lacunar infarcts: Brain stem - pale infarcts. A.sclerosis </li></ul></ul><ul><li>Hypertensive encephalopathy-Malignant. </li></ul><ul><ul><li>Headache, confusion, vomiting – Raised ICP. </li></ul></ul>

50. 51. Central Pontine Hemorrhage - Herniation