DEPARTEMEN PATOLOGI ANATOMI

FAKULTAS KEDOKTERAN
UNIVERSITAS SUMATERA UTARA MEDAN
2013
PNS
Kumpulan neuron = ganglia
CNS
Kumpulan dari neuron = nuclei
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BRAIN
Consist in large part of 2 cell types
NEURONS GLIAL
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Have :
Cell body
Dendrites
intergrating signals
Axon
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NEURONS
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90% of all CNS cells
Stuctural & functional support for neuronal elements
Functions include:
Glia-neuronal signaling
Extracellular buffering electrolytes & metabolites
Turnover neurotransmitters
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GLIAL
Glial divided into :
Macroglial
Astrocyte
Oligodendrocyte
Ependymal
Microglial
-
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CELLULAR REACTIONS
Neurons
Acute (RED neuron, karyolysis)
Subacute, chronic, cell loss, gliosis
Axonal
Inclusions (lipid, prot., carb., viruses)
Glia, gliosis
Swelling
Fibers
Inclusions
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ACUTE NEURONAL INJURY
RED NEURONS
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Hallmark Chronic CNS injury
Neuronal loss
&
Gliosis
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Normal motor units :
Two adjacent motor units
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Abnormal motor units
Segmental demyelination:
Axon & myocytes remain intact
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Random internodes of myelin are injured
Remyelinated by multiple Schwann cells
Abnormal motor units
Axonal degeneration:
Resulting :
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Axon & myelin sheath undergo
anterograde degeneration (green)
Denervation atrophy
of the myocytes within its
motor unit
Abnormal motor units
Reinnervation of muscle:
Sprouting of adjacent (red)
uninjured motor axons leads to
fiber type grouping of myocytes

Injured axon attempts axonal
sprouting
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Abnormal motor units
Myopathy :
Scattered myocytes of adjacent
motor units are small
(degenerated / regenerated)

Neurons & nerve fibers are
normal
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PERIPHERAL NERVE
Same categories of
disease as other tissues

The pattern of disease,
reflects the unique structure & function of nerves
Inflammatory
Traumatic
Metabolic
Toxic
Genetic
Neoplastic
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INFLAMMATORY NEUROPATHIES
Characterized by inflammatory cell infiltrates in :
Peripheral nerves
Roots
Sensory
Autonomic ganglia
Immune mechanisms
presumed to be the primary cause of the inflammation
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Immune-Mediated Neuropathies
Guillain-Barr Syndrome
(Acute Inflammatory Demyelinating
Polyradiculoneuropathy)
Chronic Inflammatory Demyelinating
Polyradiculoneuropathy
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Guillain-Barr Syndrome
(Acute Inflammatory Demyelinating Polyradiculoneuropathy)
Is a life-threatening disease PNS
Incidence (U.S.)
1 -3 / 100.000
persons
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Guillain-Barr Syndrome
Characterized clinically :
Weakness
beginning in the distal
limbs
Rapidly advancing to affect
proximal muscle function
("ascending paralysis")
Microscopic :
Inflammation & demyelination
of spinal nerve roots & peripheral nerves
(radiculoneuropathy)
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Chronic Inflammatory Demyelinating
Polyradiculoneuropathy
In some patients :
Acute Guillain-Barr
syndrome
Subacute / chronic
course
Usually :
Relapses & remissions
over the period of
several years
Often symmetric
Mixed sensorimotor
polyneuropathy
Some patients
predominantly
sensory / motor
impairment
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INFECTIOUS POLYNEUROPATHIES
Many infectious processes affect peripheral nerve
Cause unique and specific pathologic changes in
nerves
Leprosy Diphtheria Varicella zoster
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Evidence of recurrent demyelination
With well-developed onion bulb structures
Remyelination
Steroid treatment
Plasmapheresis
Biopsies of sural nerves show :
Clinical remissions
occur with :
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Leprosy
Lepromatous &
tuberculoid leprosy
Peripheral nerve
involvement in
Mycobacterium
leprae
Invade Schwann
cells
Proliferates &
infects other cells
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Diphtheria
Peripheral nerve
involvement
Effects of diphtheria exotoxin
Begins with
paresthesias
and weakness
Early loss of
proprioception
Vibratory
sensation
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Earliest changes seen in :
Sensory ganglia

Incomplete blood-nerve barrier allows
entry of the toxin

Selective demyelination of axons extends
into adjacent anterior & posterior roots
(mixed sensorimotor nerves)
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Varicella zoster
The most common viral infections of PNS
Reactivation
Painful,
Vesicular skin
eruption
Distribution of sensory
dermatomes (shingles), most
frequently thoracic or
trigeminal
Chickenpox
Latent infection neurons in
sensory ganglia of spinal cord & brain stem
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Varicella zoster
Virus
Transported along
the sensory nerves
To the skin
(where it establishes
an active infection
of epidermal cells)
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Varicella zoster
Ganglia :
Neuronal destruction & loss
Abundant mononuclear
inflammatory infiltrates
Regional necrosis with hemorrhage
may also be found
Peripheral nerve :
Axonal degeneration after the
sensory neurons death
Focal destruction of large motor
neurons of the anterior horns
/cranial nerve motor nuclei
Intranuclear inclusions in PNS (-)
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Classical Disease Patterns
Degenerative
Inflammatory
Neoplastic
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Classical CNS Disease Patterns
Degenerative
Inflammatory
Neoplastic
Traumatic
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CNS MALFORMATIONS
Neural Tube
Anencephaly, Encephalocele, Spina Bifida
Forebrain
Polymicrogyria, Holoprosencephaly, Agenesis of Corpus
Callosum
Posterior Fossa (Infratentorial)
Arnold Chiari (infratentorial herniation), Dandy-Walker
(cerebellar cyst)
Syringomyelia/Hydromyelia
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Fetal -protein in :
Amniotic fluid &
Maternal circulation
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SPINA
BIFIDA
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POLYMICROGYRIA
Small gyri
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HOLOPROSENCEPHALY
Failure prosencephalon to develop, and separate, often leads to cyclops.
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CEREBRAL EDEMA
(Normal weight 1200-1300 grams)
Vasogenic
(disrupted BBB)
Intravascular
INTER-cellular
[ECS/EXTRA
Cellular Space]
Cytotoxic
INTRA-
cellular space
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Gyrus mendatar
Sulcus menyempit
Rongga ventrikel tertekan
CEREBRAL EDEMA
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CEREBRAL EDEMA
Subfalcine (SUPRA-tentorial)
Cingulate (TENTORIAL)
Cerebellar tonsilar (SUB-tentorial, or
INFRA-tentorial)
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CEREBRAL EDEMA
D.D.:
EVERYTHING
SYMPTOMS
HEADACHE
HALLUCINATIONS
COMA
DEATH
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HYDROCEPHALUS
Impaired RESORPTION
Increased PRODUCTION
OBSTRUCTION
COMMUNICATING (entire)
NON-COMMUNICATING (part)
HIGH Pressure
NORMAL Pressure
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PERINATAL Brain Injuries
Cerebral Palsy
refers to non-progressive diffuse cerebral
pathology apparent at childbirth
Three most
common types
of perinatal
brain injuries
Intraparenchymal Hemorrhage
Intraventricular hemorrhage
(premies)
Periventricular leukomalacia
(i.e., infarcts)
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Various patterns of CNS injury in newborns
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CNS TRAUMA
Skull Fractures
Parenchymal Injuries
Traumatic Vascular Injury
Sequelae
Spinal Cord Trauma
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BRAIN TRAUMA
Contusion (bruise)
Laceration (tear)
Coup/Contre-Coup
Concussion
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HAIRLINE
DEPRESSED,
aka
DISPLACED
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Skull fracture types
HEMATOMAS/HEMORRHAGE
EPIDURAL (fx)
SUBDURAL (trauma No fx)
SUBARACHNOID (arterial, no trauma)
INTRAPARENCHYMAL (any)
INTRAVENTRICULAR (no trauma, rare in
adults, common in premies)
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EPIDURAL HEMATOMA
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The lucid interval is a classic feature of the epidural
hematoma
SUBDURAL HEMATOMA
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No lucid interval, but instead a sudden &
progressive worsening of symptoms
SUBARACHNOID
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INTRAPARENCHYMAL
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SPINAL CORD TRAUMA
Parallels BRAIN patterns of injury on
a cellular basis
Usually secondary to spinal column
displacement
Level of injury mirrors motor loss:
Death Quadriplegia Paraplegia
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Cerebrovascular Diseases
(CVA, Stroke)
Ischemic ( blood and 02)
Global
Focal (regional):
ACUTE: edema neuronal microvacuolization pyknosis
karyorrhexis neutrophils
CHRONIC: macrophages gliosis

Hemorrhagic (rupture of artery/aneurysm)
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HYPERTENSIVE CVA
Intracerebral
Basal Ganglia Region
(lenticulostriate arteries of internal capsule,
putamen)
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SUBARACHNOID
HEMORRHAGE
Rupture of large intracerebral arteries
which are the primary branches of the
anatomical circle (of Willis)
Congenital (berry aneurysms)
Atherosclerotic (atherosclerotic
aneurysms, or direct wall rupture)
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CNS DEGENERATIVE DISEASES
CORTEX
Dementias
BASAL GANGLIA
and BRAIN STEM
Parkinsonism
SPINOCEREBELLAR
Ataxias
MOTOR NEURONS
Muscle
atrophy
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THANK YOU
SELAMAT BELAJAR
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