Cerebrovascular Disorders

Stroke is the leading cause of death after myocardial infarction and cancer
Vascular disorders can either lead to:
o Ischemia (vessel blockage)

Global cerebral ischemia occurs when there is generalized reduction of

cerebral perfusion (cardiac arrest, shock, severe hypotension)

Focal cerebral ischemia follows a reduction or cessation of blood flow to a

localized area of the brain due to arterial occlusion or hypoperfusion
o Hemorrhage (rupture of vascular structures)

Common etiologies include hypertension and vascular anomalies (aneurysms

and malformations)

Cerebral Ischemia and Hypertensive Changes

Ischemic Cerebrovascular Disease
Definition
o Atherosclerosis of large vessels or embolic occlusion of distal vessels, resulting in
absence of blood flow
o Majority of infarcts result from the disruption and embolization of platelet thrombi or
atherosclerotic plaque material leading to obstruction of intracranial arteries

Epidemiology
o Increased risk of disease with diabetes, hypertension, smoking, family history, and
hyperlipidemia
o Accounts for 70-80% of all strokes
o More common in men
o Increased incidence with age

1/1000 for ages 45-55

1/33 if >85

Pathology (Gross)
o 6-8 hours of infarction

No detectable findings
o 24-48 hours postinfarction

brain swelling, hyperemia, and dusky discoloration in a well defined vascular

territory
o First noticeable change is subtle blurring of gray white junction
o Large infarcts lead to mass effect with possible herniations
o Embolic infarcts with reperfusion lead to hemorrhagic areas of necrosis

Histology
o < 12 hours

No microscopic changes
o 12-48 hours

Circumscribed areas of pallor with red-dead neurons (cytoplasmic

hypereosinophilia on H&E stain and shrunken pyknotic nuclei)
o 3-30 days (subacute phase)

Consists of macrophage infiltrate with cavitation of cortical layers 2-6 and loss
of axons within lesion
o Months to years

Remote infarction typically consists of circumscribed organized area of

cavitation with scattered macrophages and residual glial tissue

Imaging Characteristics
o After 1 to 2 days, wedge-shaped lesion of hypodensity on CT and T1 weighted MRI in
classic cerebrovascular distributions of blood supply
o Diffusion weighted MRI can detect changes within minutes of ischemia

Hypertensive Cerebrovascular Disease:

Ischemic Changes

The most important effects of hypertension on the brain include lacunar infarcts, slit
hemorrhages, and hypertensive encephalopathy, as well as massive hypertensive
intracerebral hemorrhage

Lacunar
Infarcts
Slit
Hemorrhages

Hypertensive
Encepalopathy

A consequence of CNS
arterial lesions
Lacunes - small cavitary
infarcts
Slitlike cavity surrounded
by brownish discoloration
On microscopic examination,
may show focal tissue
destruction, pigment-laden
macrophages and gliosis
Characterized by diffuse
cerebral dysfunction
including headaches,
confusion, vomiting,
convulsions, sometimes coma

Definition
o Most lesions are lacunar infarcts- usually smaller than 1cm caused by occlusion of
deep perforating arteries
o Most commonly occur in the basal ganglia, thalamus, and deep cerebral white matter

Lacunar infarcts in the caudate and putamen

Epidemiology
o Strongly associated with hypertension
o Incidence varies with ethnicity
o No gender predilection
o Risk increases with age
Presentation
o Typically presents with one of five syndromes: sensory deficits, motor deficits caused
by involvement of the internal capsule posterior limb, combination of previous two, ataxic
hemiparesis, and dysarthria / clumsy hand syndrome
o Accumulation of lacunar infarcts can lead to stepwise decrease in mental function (multiinfarct dementia)
Imaging Charateristics
o MRIs (T2 and FLAIR) typically reveal variable bright areas in the white matter and deep
cerebral nuclei
Pathology (Gross)
o Area of infarction <1 cm typically located in deep cerebral nuclei or deep cerebral white
matter
Histology
o Vascular changes consistent with hypertensive disease include: atherosclerosis,
lipohyalinosis, involving deep cerebral arteries
o Widening of perivascular spaces around affected blood vessels
o Liquefaction necrosis leaving a fluid filled slitlike cavity
o If hemorrhage was initially present, hemosiderin laden macrophages can be identified

Hypertensive Cerebrovascular Disease:

Spontaneous Intracerebral Hemorrhage

Intracerebral hemorrhage in the basal ganglia

Definition
o Intracerebral hemorrhage (ICH) typically originating within the deep brain parenchyma in
the setting of chronic hypertensive disease
Clinical Features
o Onset is abrupt (a patient may clutch his head complaining of severe headache and lapse
into a coma)
o Death may occur when hematoma reaches 30 mL
o Enlarging hematoma may cause death by transtentorial herniation or may lead to
intraventricular hemorrhage
Epidemiology
o Thought to account for 15-20% of all incidents of stroke
o Peak incidence at age 60
o Incidence of intracerebral hemorrhage is approximately 28:100 000 in whites and twice
that in blacks
o About 80% of patients with intracerebral hemorrhage have hypertension
Prognosis and Treatment
o Outcome dependent on size of the hemorrhage
o Small hematomas (<10mL) generally have high survival rates
o Large hematomas (>60mL) carry a poor prognosis and high mortality rate
o Blood pressure control is only definitive treatment