CNS VASCULAR DISEASE

Jeffrey W. Oliver, M.D.

 Learning Objectives
• Define the terms “stroke” and “transient
ischemic attack.”
• List factors which affect the severity of
brain ischemia.
• Explain the concept of selective
vulnerability.
• Demonstrate morphologic features of global
cerebral ischemia.
 Learning Objectives
• Estimate the time elapsed since a cerebral
infarct occurred based on morphology.
• Differentiate primary thrombotic from
embolic cerebral infarcts based on
morphology.
• List the characteristic morphologic
manifestations of hypertensive cerebral
hemorrhage.
 Learning Objectives
• List causes of subarachnoid hemorrhage.
• Recognize clinical and morphologic
features of arteriovenous malformations of
brain.
 CLINICAL TERMS
• Stroke - acute onset of focal neurologic
symptoms due to any pathologic process of
intracerebral blood vessels
• Transient Ischemic Attack (TIA) -
reversible ischemic brain injury
 FACTORS AFFECTING
SEVERITY OF ISCHEMIC
DAMAGE
• Collateral circulation
• duration of ischemia
• magnitude of flow reduction
• rapidity of flow reduction
 GLOBAL CEREBRAL
ISCHEMIA
• Due to hypotension/hypoperfusion
• Selective vulnerability – laminar infarcts
• Watershed infarcts - infarcts at border zones
between fields of arterial irrigation
• Respirator brain - autolytic softening that
occurs following prolonged mechanical
ventilation in a “brain dead” individual
 FOCAL INFARCTS
• Thrombotic infarcts - atherosclerosis,
vasculitis; usually nonhemorrhagic
• Embolic infarcts - mural thrombi, carotid
atherosclerosis; MCA most common;
usually hemorrhagic
• Venous infarcts - thrombosis of superior
sagittal sinus; very hemorrhagic
 CEREBRAL INFARCT
MORPHOLOGY
• After first 12 hours - red neurons
• Up to 48 hours - neutrophils, replaced by
macrophages stuffed with myelin debris
• 1-2 weeks - gliosis
• May resolve into cystic cavity
 CEREBRAL HEMORRHAGE
• Epidural hematoma
• Subdural hematoma
• Subarachnoid hemorrhage
• Intracerebral (intraparenchymal)
hemorrhage
HYPERTENSIVE VASCULAR
DISEASE
• Accounts for >50% of intraparenchymal
hemorrhages, usually basal ganglia or thalamus
• Charcot-Brouchard microaneurysms
• Lacunar infarcts
• Hypertensive encephalopathy - headache, seizures,
confusion with malignant HTN
• Muti-infarct dementia
• Binswanger’s disease - dementia and white matter
loss
 SUBARACHNOID
HEMORRHAGE
• Bleeding between arachnoid and pia
• Usually due to ruptured Berry (saccular)
aneurysm at branch points of Circle of
Willis
• Other causes: trauma, bleeding disorder,
AVM, rupture of intraparenchymal
hemorrhage into ventricular system
 VASCULAR
MALFORMATIONS
• Arteriovenous malformation - irregular tangle of
vessels with AV shunt, usually cerebrum; may
present as seizures, subarachnoid, or
intraparenchymal hemorrhage
• Cavernous hemangioma - Collection of dilated
vessels without AV shunt; usually cerebellum or
pons
• Capillary telangiectasia - microscopic foci of
dilated vessels separated by normal brain tissue;
usually pons