CENTRAL NERVOUS SYSTEM

Learning objectives:
On completion of this session, you will be able to:
 
1. Recognise the different types of intracranial haemorrhage and describe its
pathogenesis.
2. Discuss the causes and complications of intracranial haemorrhage.
3. Detail how to differentially diagnose different types of intracranial haemorrhage
based on macroscopic appearances.
4. Describe the different types of space occupying lesions seen in the cranium and
the complications associated with each type of lesion.
6. Understand the effects of raised intracranial pressure.

CNS Case 1
Room no Pots/gross Photomicrographs Radiology
1 K19, K27, CNS_Image1- CNS_photomicrograph CNS_Radiology1-3
3 1
2 K20, K29, CNS_Image1- CNS_photomicrograph CNS_Radiology1-3
3 1
3 K22, K28, CNS_Image1- CNS_photomicrograph CNS_Radiology1-3
3 1

An 83 year-old female was found collapsed on the floor of her bedroom by her daughter.
There was blood oozing from a laceration on the left scalp sustained from the fall. She
regained consciousness when her daughter lifted her from the floor. She had been a
regular attendee at the cardiology clinic. She was on warfarin for atrial fibrillation; her
most recent INR measurement was within the therapeutic range. She also had a history
of hypertension. She was on anti-hypertensive medications for this but it had proved
difficult to control. She was admitted to the hospital for closure of her scalp wound and
neurological observation. Her blood pressure on admission was 200/120mmHg. A CT
scan of the brain was performed. Two representative coronal plane views of the brain
scan are shown in CNS_Radiology1 and 2. Her condition rapidly deteriorated over 12
hours and she died the following day. An autopsy was performed at the request of the
coroner.

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CNS_Radiology1 CNS_Radiology2

1. Describe what you see in CNS_Radiology1 and 2. What is your clinical

impression?
Charcot Bouchard aneurysm – micro aneurysm

The autopsy was performed. Removal of the skull and dura revealed the findings shown
in image CNS_Image1. Coronal sectioning of brain revealed the findings shown in image
CNS_Image2.

CNS_Image1 CNS_Image2

2. Describe the features seen in CNS_Image1 and CNS_Image2? What are these
post mortem findings?

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3. What do you think is the sequence of events leading to her death? What other
autopsy findings would lead you to this conclusion?

Discussion: Is it possible that the patient had an accidental fall and sustained a
subdural haematoma and intracerebral haematoma as a result of the fall?

4. What are the risk factors for haemorrhagic stroke in this lady?

A histologic section was taken from the basal ganglia of the deceased’s brain.

CNS_photomicrograph_1

5. Describe the histological features seen in CNS_photomicrograph_1.

6. Specimens K19, K20, K22 are from patients who were found collapsed at home
without a history of trauma. What is the diagnosis in these cases and what is the
most likely cause of the pathology?

7. List the non-traumatic aetiologies of intracerebral haemorrhage.

8. What it meant by the term stroke? What are the different types of stoke and
what imaging methods are best for differentiating these different types? Discuss
the importance of accurate diagnosis on stroke management. The above image
shows the cerebral arterial circulation (circle of Willis). What parts of this
circulation are affected by stroke? What is meant by the term transient
ischaemic attack?

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 CNS_Radiology3 CNS_Image3

9. The above images show another type of intracranial haemorrhage which may
also be associated with trauma. Describe the findings in CNS_Radiology3 and
CNS_Image3. What is your diagnosis? K27, K28, K29 are similar examples of
the same condition.

10. What other types of intracranial haemorrhage may be seen associated with
trauma? How do you classify intracranial haemorrhage? What is the aetiology
of each type of haemorrhage? Do you know of any other potentially lethal non-
haemorrhagic traumatic injuries to the brain, which may only be visible on
microscopic examination?

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5
Case 2
Room no Pots/gross Radiology
1 K23, CNS_Image4-5 CNS_Radiology4
2 K31, CNS_ Image4-5 CNS_Radiology4
3 K24, CNS_ Image4-5 CNS_Radiology4

A 29 year old man presents to the Emergency Dept. complaining of “the worst headache
of his life” with nausea. He describes a very sudden onset to the headache. While he is
being seen, he becomes unconscious and has a seizure. A CT scan, (CNS_Radiology4) is
performed immediately and emergency surgery planned, but he dies shortly thereafter. A
post mortem is performed at the request of the coroner. Review of hospital notes during
the autopsy reveals that the man went to the Emergency Dept. two weeks prior to his
death with a headache that was less severe.

CNS_Radiology4

1. Describe the findings in CNS_Radiology4. What is your clinical diagnosis?

2. What are the complications of this condition?

3. How do you interpret the history of a recent headache?

4. What caused this man’s seizure?

5. How do you manage a patient with a ruptured berry aneurysm?

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CNS_Image4 CNS_Image5

6. Describe the findings of autopsy shown in CNS_Image4 and 5. Where do you

think is the source of the bleed?

7. K23, K24, K31 are examples of SAH. Please describe what you see in these
specimens.

8. What are the causes of SAH? What non-CNS conditions may be associated with
SAH?

9. What is the cause of death in this case?

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Case 3
Room Pots/gross Photomicrographs Radiology
no
1 K35, K34 CNS_Photomicrograph2-7 CNS_Radiology5-6
2 K37 CNS_Photomicrograph2-7 CNS_Radiology5-6
3 K38, K39 CNS_Photomicrograph2-7 CNS_Radiology5-6

A 35 year-old man visited his general practitioner complaining of persistent headache for
4 months. He was self-medicating during that time, taking different forms of pain killers
which gradually lost effectiveness at relieving his headache. In recent days, he started
experiencing nausea in the morning. He became concerned after feeling drowsy and
decided to seek medical advice. He had no medical history. He thought his headache was
due to migraines, as his mother had previously experienced migraine headaches.

1. You are his GP. What may be causing his symptoms?

2. What are the possible explanations of the condition suffered by the patient?

A brain CT scan was performed following admission to the hospital. The representative
radiology images are as follow.

CNS_Radiology5
CNS_Radiology6

3. Describe the findings in CNS_Radiology5 and CNS_radiology6. What is your

differential diagnosis? How could a definitive diagnosis be made?

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 Room Pots/gross
no
1 K35, K34
2 K37
3 K38, K39

4. What are the abnormalities seen in the gross specimens listed in the above table?

CNS_photomicrographs2
BLOOD CNS_photomicrographs3
VESSELS
EPITHELIOID ROUND TO
POLYGONAL CELLS WITH
INDISTINCT
INTERCELLULAR BORDERS

PALISADING OF
MALIGNANT
NUCLEI

NECROSIS

CNS_photomicrographs4 CNS_photomicrographs5

CLASSIC
WHORLED 9
PATTERN OF
MENINGOTHELIAL
CELLS
 MALIGNANT
EPITHELIAL
CELLS

CNS_photomicrographs6
CNS_photomicrographs7

5. What types of primary brain tumours do you know of? (Referring to

CNS_photomicrographs2-7)

6. How else may this patient have presented?

7. What determines the clinical outcome of a brain tumour?

8. Give one example where a specific genetic abnormality in a brain tumour will
influence the prognosis and treatment of the tumour.

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