Cerebrovascular diseases
• Cerebrovascular diseases are brain disorders
caused by pathologic processes involving blood
vessels.
• the three main pathogenic mechanisms are:
(1) thrombotic occlusion
(2) embolic occlusion
(3) vascular rupture.
Cont. ….
• Stroke is the clinical designation
applied to all of these conditions
when symptoms begin acutely.
Hypoxia, Ischemia, and Infarction
• cerebral blood flow normally remains stable over a wide
range of blood pressure and intracranial pressure
because of autoregulation of vascular resistance.
Cont. ….
• the brain may be deprived of oxygen by two general
mechanisms:
1. functional hypoxia, caused by a low partial pressure
of oxygen (e.g., high altitude), impaired oxygen-
carrying capacity e.g., severe anemia.
2. ischemia, either transient or permanent, due to
tissue hypoperfusion.
Global Cerebral Ischemia
• widespread ischemic-hypoxic injury can occur in the
setting of severe systemic hypotension, usually
when systolic pressures fall below 50 mm Hg, as in
cardiac arrest and shock.
• the clinical outcome varies with the severity and duration of
the insult.
• when the insult is mild, there may be only a transient
postischemic confusional state, with eventual complete
recovery.
Cont. ….
• in severe global cerebral ischemia, widespread neuronal
death occurs irrespective of regional vulnerability,
patients who survive often remain severely impaired
neurologically and in a persistent vegetative state.
Morphology
• in the setting of global ischemia, the brain is swollen,
with wide gyri and narrowed sulci.
• Early changes, occurring 12 to 24 hours after the insult,
include acute neuronal cell change (red neurons).
• Subacute changes, occurring at 24 hours to 2 weeks,
include necrosis of tissue, influx of macrophages,
vascular proliferation, and reactive gliosis
Cont. ….
• Repair, seen after 2 weeks, is characterized by removal of
necrotic tissue and gliosis
A B
A. Acute hypoxic-ischemic injury in the cerebral cortex. The cell bodies are
shrunken and eosinophilic (“red neurons”), and the nuclei are pyknotic.
B. Collection of microglial cells forming a poorly defined nodule, a common
finding in viral infections.
Focal Cerebral Ischemia
• cerebral arterial occlusion leads first to focal ischemia and
then to infarction in the distribution of the
compromised vessel.
• the size, location, and shape of the infarct and the
extent of tissue damage that results may be modified
by collateral blood flow.
Cont…..
Embolic infarctions
• more common than infarctions due to thrombosis,
cardiac mural thrombi are a frequent source of emboli;
myocardial dysfunction, valvular disease, and atrial
fibrillation are important predisposing factors.
Cont…..
Thrombotic occlusions
• causing cerebral infarctions usually are
superimposed on atherosclerotic plaques.
• common sites are the carotid bifurcation, the origin of
the middle cerebral artery, and either end of the
basilar artery, it can cause small infarcts of only a few
millimeters in diameter, so-called “lacunar infarcts”
Cont…..
• Infarcts can be divided into two broad groups:
nonhemorrhagic infarcts result from acute vascular
occlusions and may evolve into hemorrhagic infarcts
when there is reperfusion of ischemic tissue, either
through collaterals or after dissolution of emboli.
Morphology
• hemorrhagic infarcts usually manifest as multiple,
sometimes confluent, petechial hemorrhages
Cont…..
• the macroscopic appearance of a nonhemorrhagic
infarct evolves over time.
in the first 6 hours, the tissue is unchanged in
appearance
by 48 hours, the tissue becomes pale, soft, and swollen.
Cont. …
from days 2 to 10, the injured brain turns gelatinous
and friable, and the boundary between normal and
abnormal tissue becomes more distinct as edema
resolves in the adjacent viable tissue.
from day 10 to week 3, the tissue liquefies, eventually
leaving a fluid-filled cavity, which gradually expands as
dead tissue is resorbed
Cont…..
• Microscopically
• the tissue reaction follows a characteristic sequence,
after the first 12 hours, ischemic neuronal change (red
neurons) and cytotoxic and vasogenic edema appear.
Intracranial Hemorrhage
• hemorrhages within the brain are caused by:
(1) hypertension and other diseases leading to vascular
wall injury
(2) structural lesions such as arteriovenous and cavernous
malformations
(3) tumors.
• Subarachnoid hemorrhages most commonly
are the result of ruptured aneurysms
Primary Brain Parenchymal Hemorrhage
• spontaneous (nontraumatic) intraparenchymal
hemorrhages are most common in mid to late adult
life, with a peak incidence at about 60 years of age.
• most are due to the rupture of a small
intraparenchymal vessel.
• Hypertension is the leading underlying cause, and
brain hemorrhage accounts for roughly 15% of deaths
among individuals with chronic hypertension.
Cont…..
• hypertensive intraparenchymal hemorrhages
typically occur in the basal ganglia, thalamus, pons,
and cerebellum, with the location and the size of the
bleed determining its clinical manifestations.
• if the individual survives the acute event, gradual
resolution of the hematoma ensues, sometimes with
considerable clinical improvement.
Morphology
• on microscopic examination, early lesions consist of
clotted blood surrounded by edematous brain
tissue.
Subarachnoid Hemorrhage and Saccular
Aneurysms
• the most frequent cause of clinically significant
nontraumatic subarachnoid hemorrhage is rupture of
a saccular (berry) aneurysm.
• hemorrhage into the subarachnoid space also may
result from vascular malformation, trauma, rupture of
an intracerebral hemorrhage into the ventricular
system, coagulopathies, and tumors.
Cont…..
• about 90% of saccular aneurysms occur in the anterior
circulation near major arterial branch points multiple
aneurysms exist in 20% to 30% of cases.
• healing and the attendant meningeal fibrosis and
scarring sometimes obstruct CSF flow or disrupt CSF
resorption, leading to hydrocephalus.
Vascular Malformations
• Vascular malformations of the brain are classified
into four principal types based on the nature of the
abnormal vessels: arteriovenous malformations (AVMs),
cavernous malformations, capillary telangiectasias, and
venous angiomas.
Cont…..
• AVMs, the most common of these, affect males :
females (2:1)and most commonly manifest between 10
and 30 years of age with seizures, an intracerebral
hemorrhage, or a subarachnoid hemorrhage.
• The risk for bleeding makes AVM the most
dangerous type of vascular malformation.
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