Neuropathology: Stroke With Kartik Rangaraj MD

Neuropathology
Stroke
With Kartik Rangaraj MD
Mohamed abdikani Jama, dr.abdikani7868@gmail.com

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Stroke
3rd leading cause of death
Stroke vs. Transient Ischemic Attack (TIA)
• Stroke: infarction of brain tissue due to lack of blood supply
• TIA: temporary neurologic deficit due to relative ischemia that improves when blood supply
is restored (symptoms usually lasting less than 1 hour)
Pathophysiology
• Ischemic (85 %)
• Hemorrhagic (15 %)

Ischemic Stroke
Focal cerebral ischemia Global cerebral ischemia
Embolic Hypotension
• Cardioembolic, artery to artery,

paradoxical embolus
Thrombotic
• Atherosclerotic disease, lipohyalinosis,

vasculitis
Cryptogenic

Ischemic Stroke: Characteristics
• Cerebrovascular localization
• Maximal at onset
• May have stepwise progression depending on etiology

Ischemic Stroke: Characteristics
Hypertension, diabetes, tobacco, h/o stroke/TIA, heart disease

(atrial fib, valvular disease, cardiomyopathy),
hypercholesterolemia, and age
Genetic conditions
CADASIL (cerebral autosomal dominant arteriopathy with
subcortical infarcts and leukoencephalopathy Notch3 gene),
sickle cell disease, hypercoagulable states (cancer, pregnancy,
oral contraceptives, antiphospholipid syndrome, protein C
Risk factors deficiency)

Pathophysiology of Focal Cerebral Ischemia
Embolism
• Atrial fibrillation
• Valvular disease with thrombus
• Wall motion abnormalities from previous myocardial infarction
• Dilated cardiomyopathy
• Septal aneurysms with PFO
• Carotid artery
• Atherosclerotic disease
• Dissection

Thrombosis
• Majority due to atherosclerosis
• Risk factors: age, male, HTN, smoking, diabetes, hypercholesterolemia
• Other etiologies:
• Hypercoagulable state, drug abuse (amphetamines, heroin, and cocaine), sickle cell
disease
• Common sites:
• Carotid bifurcation, origin of middle cerebral artery, and basilar artery

Arteritis
• May be primary or secondary
• Etiologies:
• Primary CNS angiitis, syphilis, tuberculosis, toxoplasmosis, aspergillosis, CMV/VZV

encephalitis
• Other:
• Temporal arteritis, polyarteritis nodosa, connective tissue diseases

Definitions
• Aphasia: inability to use or understand language due to a lesion in the brain
• Alexia: inability to perceive written words
• Agraphia: inability to write words, not related to weakness or sensory deficit
• Dysarthria: slurred or stuttering speech due to motor weakness or incoordination, while

language is intact
• Apraxia: inability to carry out a learned motor task, not due to motor or sensory deficits or
inability to understand
• Ataxia: impairment in the performance and coordination of movements, not due to

weakness
• Dysphagia: difficulty swallowing due to motor weakness or incoordination

Ischemic Stroke Syndromes
Pure motor hemiplegia

• Contralateral pons or internal capsule lacune
Pure sensory stroke

• Contralateral thalamus lacune
MCA syndrome
• Hemiparesis (more common in face and arm than leg), aphasia, sensory loss, hemianopsia,
eye deviation

Ischemic Stroke Syndromes
ACA syndrome
• Lower extremity weakness and sensory loss, incontinence, limb apraxia
PCA syndrome
• Homonymous hemianopsia
• Sensory loss
Wallenberg Syndrome (PICA occlusion)
•
sensation

Acute Stroke Evaluation and Workup
• ABCs
• NIH Stroke Scale
• Glucose, CBC, PT/PTT, electrolytes, toxicology screen, pregnancy test, troponin
• EKG

Acute Stroke Evaluation and Workup
Head CT
• Look for hemorrhage (CT without contrast is better for bleeds than MRI)
• Signs of ischemia
• Edema
• MCA dot sign and hyperdense MCA sign
MRI/MRA
• Diffusion-weighted imaging

NIH Stroke Scale
Category Score/Description Score
1a. Level of Consciousness 0 = Alert
(Alert, drowsy, etc.) 1 = Drowsy
2 = Stuporous
3 = Coma
1b. LOC Questions 0 = Answers both correctly
(Month, age) 1 = Answers one correctly
2 = Incorrect
1c. LOC Commands 0 = Obeys both correctly
(Open/close eyes, make fist/let go) 1 = Obeys one correctly
2 = Incorrect
2. Best Gaze 0 = Normal
(Eyes open patient follows examiner`s finger or face) 1 = Partial gaze palsy
2 = Forced deviation
3. Visual Fields 0 = No visual loss
(Introduce visual stimulus/threat to pt`s visual field quadrants) 1 = Partial Hemianopia
2 = Complete Hemianopia
3 = Bilateral Hemiaopia (Blind)
...
Link: http://img.medscape.com/fullsize/migrated/550/818/jnn550818.fig1.gif

Hyperdense MCA Sign
Yan B et al.: https://openi.nlm.nih.gov/detailedresult.php?img=PMC4013049_pone.0096123.g001&query=Hyperdense+MCA+Sign&it=xg&req=4&npos=16,

PubMed, CC BY 4.0
Hyperdense MCA Sign
1 hour after
symptoms:
Yan B et al.: https://openi.nlm.nih.gov/detailedresult.php?img=PMC4013049_pone.0096123.g001&query=Hyperdense+MCA+Sign&it=xg&req=4&npos=16,

PubMed, CC BY 4.0
Post-Acute Stroke Workup
• MRI/MRA
• Cholesterol levels, TSH, RPR, B12, Homocysteine, ESR
• Echocardiogram
• Carotid ultrasound
• Specialized testing if young patient or no risk factors
• CADASIL skin biopsy
• Hypercoagulable workup

Treatment of Ischemic Stroke
ABCs Anticoagulation
• Heparin helps and hurts, only used in Afib
Blood pressure control and dissection
• SBP < 220

Thrombolytics
• DBP < 120
• tPA
Antiplatelets
• Aspirin Rehabilitation

tPA
Criteria
• Clinical diagnosis of ischemic stroke
• Age > 18
• Time to tPA administration less than 3 hours from onset of symptoms
• Head CT without evidence of hemorrhage or large stroke

tPA
Contraindications
• Stroke or serious head trauma in last 3 mo
• History of intracranial hemorrhage or AVM
• MI in past 6 wks
• Major surgery or trauma in last 2 wks
• GI or urinary tract hemorrhage in last 3 wks
• LP or arterial puncture at non-compressible site in last wk
• Aggressive BP therapy needed

tPA
Contraindications
• Elevated PT/PTT
• Platelet count < 100,000
• Glucose < 40 or > 400
• Pregnancy
• NIHSS < 4 or > 22
• Improving symptoms
• Seizure at onset

Secondary Prevention
• Antiplatelet agent
• Aspirin vs. clopidogrel (Plavix) vs. dipyridamole (Aggrenox)
• Anticoagulation for atrial fibrillation or clot
• Carotid endarterectomy in appropriate patients (>70 % stenosis)
• Smoking cessation
• Diabetes control
• Hypertension control
• Cholesterol control

Summary: Ischemic Stroke
Risk factors
• Age, gender, previous TIA/stroke, hypertension, diabetes, heart disease, smoking,
hypercholesterolemia, CADASIL
Preventive medicine
• Primary: treat underlying risk factors; aspirin for high risk cohort; endarterectomy for specific
patients
• Secondary: treat underlying conditions, anti-platelet agents, anti-coagulation
Signs & symptoms

• Focal weakness, sensory change, ataxia, vertigo, language difficulties, visual changes

Summary: Ischemic Stroke
Differential diagnosis
• migraine
Acute and post acute diagnostic workup

• Head CT, metabolic screen, MRI, ECHO, carotid U/S
Treatments
• Aspirin, oxygen, tPA (hemorrhage risk), clopidogrel, anticoagulation

Hemorrhagic Stroke
Intracerebral hemorrhage Subarachnoid hemorrhage

• Hypertensive • Aneurysms
• Mass lesions • Traumatic

• Metastatic lesions choriocarcinoma,
melanoma, thyroid carcinoma, lung
carcinoma, renal carcinoma
• Vascular malformations
• Amyloid angiopathy
• Cocaine/amphetamine use

Hypertensive Hemorrhage
• Basal ganglia (50 60 %)
• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

• Thalamus
• Pons
• Cerebellum
• Lobar
• Associated with
atherosclerosis and
DBP > 110 mmHg

Hemorrhagic Stroke
Reverse coagulopathy
• FFP for elevated PT/PTT
• Platelets for thrombocytopenia
Control blood pressure

• Labetalol is drug of choice
Treatment

Hemorrhagic Stroke
Identify underlying structural abnormalities
• Tumors
• MRI with contrast
• AVMs
• Cerebral angiography
Treatment

Hemorrhagic Stroke: Summary
Risk factors
• Hypertension, AVMs, cocaine use, amyloid angiopathy, metastatic tumors
Preventive medicine
• Blood pressure control
Signs & symptoms

• Headache, focal neurologic symptoms, decreased level of consciousness
Differential diagnosis
•

Hemorrhagic Stroke: Summary
Acute and post acute diagnostic workup

• MRI to evaluate for underlying lesions, sometimes with repeat in 6 weeks when blood
products resolve
Treatments
• Blood pressure control
• Reversal of coagulopathy
• Treatment of underlying lesions

This document is a property of: Mohamed abdikani Jama
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.


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Neuropathology

With Kartik Rangaraj MD

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

3rd leading cause of death

Stroke vs. Transient Ischemic Attack (TIA)

• Stroke: infarction of brain tissue due to lack of blood supply

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

Focal cerebral ischemia Global cerebral ischemia

• Cardioembolic, artery to artery,

• Atherosclerotic disease, lipohyalinosis,

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• May have stepwise progression depending on etiology

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

Hypertension, diabetes, tobacco, h/o stroke/TIA, heart disease

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• Valvular disease with thrombus

• Wall motion abnormalities from previous myocardial infarction

• Septal aneurysms with PFO

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• Majority due to atherosclerosis

• Risk factors: age, male, HTN, smoking, diabetes, hypercholesterolemia

• Carotid bifurcation, origin of middle cerebral artery, and basilar artery

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• May be primary or secondary

• Primary CNS angiitis, syphilis, tuberculosis, toxoplasmosis, aspergillosis, CMV/VZV

• Temporal arteritis, polyarteritis nodosa, connective tissue diseases

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• Aphasia: inability to use or understand language due to a lesion in the brain

• Alexia: inability to perceive written words

• Agraphia: inability to write words, not related to weakness or sensory deficit

• Dysarthria: slurred or stuttering speech due to motor weakness or incoordination, while

• Ataxia: impairment in the performance and coordination of movements, not due to

• Dysphagia: difficulty swallowing due to motor weakness or incoordination

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

Pure motor hemiplegia

Pure sensory stroke

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

Wallenberg Syndrome (PICA occlusion)

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• NIH Stroke Scale

• Glucose, CBC, PT/PTT, electrolytes, toxicology screen, pregnancy test, troponin

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• MCA dot sign and hyperdense MCA sign

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

Yan B et al.: https://openi.nlm.nih.gov/detailedresult.php?img=PMC4013049_pone.0096123.g001&query=Hyperdense+MCA+Sign&it=xg&req=4&npos=16,

Yan B et al.: https://openi.nlm.nih.gov/detailedresult.php?img=PMC4013049_pone.0096123.g001&query=Hyperdense+MCA+Sign&it=xg&req=4&npos=16,

• Cholesterol levels, TSH, RPR, B12, Homocysteine, ESR

• Specialized testing if young patient or no risk factors

• CADASIL skin biopsy

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• SBP < 220

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• Time to tPA administration less than 3 hours from onset of symptoms

• Head CT without evidence of hemorrhage or large stroke

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• History of intracranial hemorrhage or AVM

• Major surgery or trauma in last 2 wks

• GI or urinary tract hemorrhage in last 3 wks

• LP or arterial puncture at non-compressible site in last wk

• Aggressive BP therapy needed

Mohamed abdikani Jama, dr.abdikani7868@gmail.com

• Platelet count < 100,000