Cerebrovascular Disease Pathology Study Guide

Cerebrovascular Disease Pathology Video

Cerebrovascular Disease

Cerebrovascular disease is a significant source of morbidity and mortality due to cerebrovascular impairment and neurologic dysfunction.

Cerebrovascular disease is typically the result of:

Ischemia (85% of cases)
Hemorrhage (15% of cases)

Since serum glucose serves as their primary energy source, neurons are especially vulnerable to ischemia, and may undergo necrosis within 3-5 minutes.

Cerebrovascular Disease. Brain infarct INFARCT.jpg: Lucien Monfils derivative work: Suraj - Not altered. CC BY-SA 3.0
Cerebrovascular Disease. MRI demonstrating white matter changes in the brain of patients with CADASIL Bohlega S, Al Shubili A, Edris A, Alreshaid A, Alkhairallah T, AlSous MW, Farah S, Abu-Amero KK. - Not altered.CC BY 2.0
Cerebrovascular Disease. Types of brain herniation RupertMillard - Brain herniation types.svg by Delldot. Not altered.CC BY-SA 3.0
Cerebrovascular Disease. Cerebral angiogram showing a small indirect Barrow type D right carotid cavernous fistula Doctors Sumeer Thinda, Mark R Melson and Rachel W Kuchtey from Nashville, USA - Not altered. CC BY 2.0.
Examples of normal white matter versus severe white matter lesions with and without small vessel disease. Normal white matter and severe white matter lesions of the parietal deep white matter with and without small vessel disease. A-Ai, normal appearing white matter and a normal white matter artery (Aii). B, white matter lesion indicated by widespread pallor of the central white matter with typical sparing of the subcortical U-fibres (arrow); Bi, higher magnification of white matter lesion exhibiting severe rarefaction, i.e., myelin and axonal loss; Bii, white matter arterioles from white matter lesion area exhibting arteriolosclerosis with hyalinisation (arrows) of vessel walls. C, white matter lesion with severe white matter pallor; Ci, magnifies image of severe white matter rarefaction; Cii, white matter arteriole with enlarged perivascular space but no small vessel disease-related fibrosis or hyalinisation. Of note, this case exhibited severe tau pathology in the overlying cortex, suggesting Wallerian-like degeneration to be the cause for white matter damage. Images captured from serial sections. Histological stain Luxol fast blue was used for images A, Ai, B, Bi, C and Ci; H&E stain was used for Aii, Bii and Cii. Scale bars represent 1mm in A, B and C and 20μm in Ai, Aii, Bi, Bii, Ci and Cii. Is the time ripe for new diagnostic criteria of cognitive impairment due to cerebrovascular disease? Consensus report of the International Congress on Vascular Dementia working group BMC Medicine. Not Altered. CC.

Global Cerebral Ischemia

Global cerebral ischemia is ischemia that effects the entire cerebral tissue.

Important causes of global cerebral ischemia include:

Minimal perfusion (e.g. atherosclerosis)
Abrupt reduction in blood flow (e.g. cardiogenic shock)
Persistent hypoxia (e.g. anemia)
Hypoglycemia episodes (e.g. insulinoma)

Clinical findings of global cerebral ischemia depend on the length and severity of the trauma.

Mild global ischemia causes momentary confusion that quickly goes away
Severe global ischemia causes diffuse necrosis and may result in a vegetative state condition
Infarcts in watershed regions which may effect memory, sensory, and motor functions

Global Cerebral Ischemia. CT-scan of the brain with a RIGHT MCA infarct. Lucien Monfils - Not altered. CC BY-SA 3.0

Ischemic Stroke

An ischemic stroke can cause regional ischemia that causes focal neurologic impairments that continue longer than 24 hours.

Transient ischemic attack (TIA) is the name given to an incident if the symptoms last less than 24 hours.

Subtypes of ischemic strokes include:

Thrombotic (e.g. atherosclerotic plaque rupture)
Embolic (e.g. from thromboemboli from the heart in atrial fibrillation)
Lacunar (e.g. from hyaline arteriolosclerosis, an adverse effect of hypertension)

Symptoms of ischemic stroke depend on the region of brain involvement.

A pure motor stroke results from the interior capsule being involved
Thalamus causes a pure sensory stroke

Histologic findings (if obtained) for strokes show:

An early microscopic observation is an eosinophilic alteration in the cytoplasm of neurons (red neurons) (12 hours after infarction)
Coagulative necrosis (24 hours)
Neutrophil infiltration (days 1-3)
Microglial cell infiltration (days 4-7)
Granulation tissue (weeks 2-3)

Liquefactive necrosis is the outcome of ischemic stroke.

Liquefactive necrosis results in the development of a cystic area filled with fluid that is encircled by gliosis.

Ischemic Stroke. Dense artery sign in a patient with middle cerebral artery infarction shown on the left. Right image after 7 hours. Hellerhoff - Not altered. CC BY-SA 3.0.
Ischemic Stroke. A CT showing early signs of a middle cerebral artery stroke with loss of definition of the gyri and grey white boundary CFCF - Not altered. CC BY-SA 3.0
Ischemic Stroke. Histopathology at high magnification of a normal neuron, and an ischemic stroke at approximately 24 hours on H&E stain: The neurons become hypereosinophilic and there is an infiltrate of neutrophils. There is slight edema and loss of normal architecture in the surrounding neuropil. Mikael Häggström, M.D. - Not altered. CC0
Ischemic Stroke. CT scan of an intraparenchymal bleed (bottom arrow) with surrounding edema (top arrow) James Heilman, MD - Not altered. CC BY-SA 3.0
Ischemic Stroke. A slice of brain from the autopsy of a person who had an acute middle cerebral artery (MCA) stroke Marvin 101 - Not altered. CC BY-SA 3.0
Ischemic Stroke. A slice of brain from the autopsy of a person who had an acute middle cerebral artery (MCA) stroke Marvin 101 - Not altered. CC BY-SA 3.0

Intracerebral Hemorrhage

An intracerebral hemorrhage is due to brain parenchyma bleeding.

Symptoms of intracerebral hemorrhage include:

Headache
Nausea
Vomiting
Altered mental status (AMS)
Coma

Intracerebral hemorrhage may result from:

Lenticulostriate vessel rupture
Aneurysm rupture

The most typical location of the brain involved by intracerebral hemorrhage is the basal ganglia.

Intracerebral hemorrhage hemorrhages may be caused by hypertension.

Hypertension treatment decreases the risk of intracerebral hemorrhage by half.

Intracerebral Hemorrhage. Spontaneous ICH with hydrocephalus on CT scan[8] Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A - Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A . Not altered. CC BY 2.0
Intracerebral Hemorrhage. Axial CT scan showing hemorrhage in the posterior fossa[8] Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A - Yadav YR, Mukerji G, Shenoy R, Basoor A, Jain G, Nelson A. Not altered. CC BY 2.0
Intracerebral Hemorrhage. This image shows an Intracerebral and Intraventricular haemorrhage of a young woman. The woman was one week post partum, with no known trauma involved. Glitzy queen00 at English Wikipedia -Not altered. Public Domain.

Subarachnoid Hemorrhage

Subarachnoid hemorrhage is hemorrhage that involves the subarachnoid area of the brain.

Subarachnoid hemorrhage symptoms include:

Sudden “thunder clap” headache
Worst headache of life
Suddenly neck stiffness

A spinal tap in a patient with subarachnoid hemorrhage reveals xanthochromia (yellow hue due to bilirubin breakdown).

In subarachnoid hemorrhage, a spinal tap reveals xanthochromia (yellow hue due to bilirubin breakdown).

Causes of subarachnoid hemorrhage include:

Berry aneurysm rupture (85% of cases)
Arteriovenous (AV) abnormalities
Anticoagulation complication

Subarachnoid Hemorrhage. Autopsy of a case with subarachnoid hemorrhage. The arachnoid mater is left in place on the exterior surface, containing extensive hemorrhage that also fills the sulci, as detailed in magnified image. Mikael Häggström, M.D. Not altered. CC0
Subarachnoid Hemorrhage. Arteriogram showing a partially coiled aneurysm (indicated by yellow arrows) of the posterior cerebral artery with a residual aneurysmal sac. The person was a 34-year-old woman initially treated for a subarachnoid hemorrhage. Promod Pillai, Aftab Karim and Anil Nanda - Not altered. CC BY 2.0.
Subarachnoid Hemorrhage. A subarachnoid hemorrhage. James Heilman, MD - Not altered. CC BY-SA 3.0