bleeding in the skull region · am j case rep. 2015; 16: 50–52. the child had a normal...
TRANSCRIPT
CNS Pathology - I
Bleeding in theSkullRegion
Jaroslava Dušková
Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague
Bleeding in the Skull Region- contents
extracranial
intracranialextracerebral
intracerebral
traumatic brain lesions
disturbances of brain perfusionencephalomalacia
white, red, mixed
Bleeding in the Skull Region
extracranial
intracranialextracerebral
epiduralsubdural
subarachnoidal
intracerebral
arterial (circumscribed or destructive)
venouscapillary
v.cerebri
magna Galeni
ED
SD
SA IP
Intracranial expansion – pressure cones
Cone Anatomy Pathology Clinical manifestation
OccipitalHerniation of cerebellar tonsils
into foramen occipitale
magnum
Compression of vital
centres in medulla
oblongata
Apnoe. Cave! Lumbar puncture
contraindicated!
TemporalTranstentorial herniation of
uncus gyri parahippocampalis
Compression of
contralateral capsula
interna, head nerves, aa.
cerebri post., Duret´s
hemorhages in the
brainstem.
Mydriasis. Ophtalmophlegia,
Kernohan´s false localisation
feature. Visual field fallouts.
Interhemispherical Subfalcine herniationCompression of a. cerebri
anteriorFrontal lobes dysfunction.
Haematoma epidurale
!!!Lucid interval
Haematoma
epidurale
Haematoma epidurale
15.03.2009 died 18.03.
2009
Head injury - 15.03.2009
death - 18.03.2009 Actress Miss Richardson, 45, was flown from intensive care in Montreal
to the Lenox Hill Hospital in New York after suffering a head injury
during a private ski lesson at the exclusive Mont Tremblant resort on
Monday afternoon
Miss Richardson fell during a lesson but initially showed no visible
signs of injury
An hour later, she complained of a headache and was admitted to the
Hospitalier Laurentien in nearby Ste-Agathe.
She was later transferred to intensive care at the Sacre-Coeur Hospital
75 miles away in Montreal before being flown New York via private jet
One doctor said she had most likely suffered from a blood clot on the
brain, while another said her condition could be “talk and die
syndrome”, where a person at first seems unharmed by an impact but
later suffers a rapid collection of blood between the skull and the brain
Haematoma
subdurale
whiplash
injuries in
car
accidents
Haematoma subdurale
Haematoma
subdurale
Haematoma
subdurale
Haematoma
subdurale
Haematoma subdurale vetustior fossae cerebri mediae lat. sin.
Liquor cerebrospinalis
oil red
Fe
Hygroma subdurale
Circulus
arteriosus Willisi
Aneurysma art.
vertebralis dx.
Aneurysma art.
vertebralis dx.
Haematoma
subarachnoideale
hypoxicum
Haematoma subarachnoideale hypoxicum convexitatis cerebri
Hydrocefalus - zvýšené množství
mozkomíšního moku
obstrukční – nekomunikující
komunikující
– hypersekreční
– hyporesorpční (jizvení v obl.
Pacchionských granulací) – komb. s
obstrukčním
e vacuo
normotenzní (?
Angioma racemosum cerebri et
meningum
Malformatio arteriovenosa
vG-el
Malformatio arteriovenosa
trichrom
Fe
Malformatio arteriovenosa
Types of CNS vascular malformations
arteriovenous
capillary teleangiectasia
cavernous hemangioma (cavernoma)
venous angioma
Haemorrhagia
subcorticalis
cerebri et cerebelli
circumscripta
Haemorrhagiae cerebri circumscriptae
Haemorrhagia
comminutiva
cerebri et
haemocephalus
Haemorrhagia
comminutiva
cerebelli
Haemorrhagia
vetustior
cerebri
Male – 33 yrs.
Clin. Dg.
Ethylismus chronicus
Epilepsia
Moribundus adlatus
Haemorrhagia intracranialis lat. dx.
Aneurysma arteriae baseos cerebri ruptum??
Haemorrhagia
extensa
ggl.basalium ad
ventriculos
cerebri
progressaAtherosclerosis aortae et peripherica gr. II
Haemocephalus
Circulus Willisi
Purpura cerebri
Pseudocystes posthaemorrhagicae
cerebri
CSF Fe
Fe
Fe
HE
FeHE
Secondary Brain Haemorrhage
Systemic disease or
therapy
– leukemia
– coagulopathy
– anticoagulant agents
Drug abuse
– cocain
– amphetamin
– apetite suppressants
Non vascular brain
pathology
– glioma
– metastasis
melanoma
choriocarcinoma
carcinomas (manif.!)
– disseminated
angioinvasive fungal
infections
– sickle cell anemia
Fetal & Neonatal Bleeding
Bleeding in the Skull Region
extracranial
(Caput succedaneum, cephalhaematoma externum: subperiostal, subaponeurotic)
intracranialextracerebral
intracerebral
Kefal
haema-
toma
ext.
Haematoma
subapo-
neuroticum
Haematoma subarachnoidale hypoxicum
Haemorrhagiae subependymales
Germinal Zone (GZ) Bleeding
25% preterm neonates
(decreased recently)
GZ: periventricular, large calibre capillaries, highly vascularized esp. in the 3rd. trimestre
Haemorrhagia
strati
germinalis
Patogenesis of GZ Bleeding
Perinatal ev. intranatal hypoxia– disorder of cerebral perfusion autoregulation
– ischemic endothelial capillary lesions in the GZ
– myocardial energy reserves exhausted
– perinatal circulation failure
– cerebral hypoxia venous haemorrhage
Blood pressure increase– muscle activity of neonate
– resuscitation
– arteficial ventilation
„Baby Flying“ vs. Shaken Baby Syndrome
RISKS
1. intermeningeal &
cerebral bleeding
2. retinal bleeding
3. joint & long bone growth
zones damage
4. cervical vertebrae &
ligaments damage
5. tripping and severe
injury
Pediatricians & Neurologists & Pathologists AGAINST !!!
= Child Abuse and
Neglect syndrome
Josephsen JB et al.:
Life-Threatening Neonatal Epidural Hematoma
Caused by Precipitous Vaginal Delivery. 1/3Am J Case Rep. 2015; 16: 50–52.
2977 g male infant was born at 40 5/7 weeks gestation to a 26
year-old gravida 5, para 5 woman
the patient refused external monitoring and did not remain
consistently in bed due to discomfort.
rupture of membranes occurred while the patient was standing
at the bedside
precipitous, vertex delivery. The neonate fell approximately 80
cm to the linoleum floor below, striking his head.
Josephsen JB et al.:
Life-Threatening Neonatal Epidural Hematoma
Caused by Precipitous Vaginal Delivery. 2/3Am J Case Rep. 2015; 16: 50–52.
The child had a normal neurological exam with no signs of local
trauma to the skull on initial evaluation; Apgar scores were 8
and 9 at 1 and 5 minutes, respectively
At 5 hours of life, an apneic episode associated with cyanosis
and bradycardia
The neurological exam results continued to be normal
an area of left parietal scalp edema was newly appreciated
Josephsen JB et al.:
Life-Threatening Neonatal Epidural Hematoma
Caused by Precipitous Vaginal Delivery. 3/3Am J Case Rep. 2015; 16: 50–52.
CT scan of the head revealed a mildly displaced left parietal bone fracture with an underlying acute epidural
hematoma measuring 1.3 cm at its maximal thickness, and adjacent traumatic subarachnoid hemorrhage.
an emergent craniotomy with evacuation of the epidural hematoma.
At 3 months of age, a CT scan showed well-healed bone around the craniotomy site without any residual
intracranial hemorrhage.
Pre-operative axial non-contrast brain CT that shows a
lenticularly-shaped hyperdensity, consistent with an epidural
hematoma, exerting a mass effect on the adjacent left parietal
lobe.
Immediate post-operative axial non-contrast brain CT shows
resolution of the mass effect after evacuation of epidural
hematoma. There is minimal post-operative
pneumocephalus.
Chronic Traumatic Encephalopathy Punch-Drunk Syndrome in boxers – dementia pugilistica
clinically obvious years after the last fight
three stages:– affective disorder mild incoordination
– dysphasia, apraxia, agnosia, apathy, blunting of affection
– global cognitive decline & parkinsonism
present in 20% of profess. boxers over 50
more likely to develop in boxers with long careers
SN degeneration, neuronal loss, Alzheimer intracellular changes – tau inclusions
Acta Neuropathologica, 2018, 135:303–305
Keene CD et al.: First confirmed case
of chronic traumatic encephalopathy
in a professional bull rider
First-diagnosed concussion at age 16 with confirmed loss of
consciousness (LOC)
additional exposures approximately biennially until age 21 when he
sustained five head injuries over the course of a 12-month period.
At age 23, stepped on by a rearing bull crushing his helmet with LOC
for 1 h, meeting criteria for moderate brain injury.
Initial Glasgow Coma Scale was 10, and remained 10 for 24 h before
returning to 14 out of 15 by day 2.
CT evaluation : negative for pathoanatomical brain injury lesions.
MRI Evaluation 3 months later: multiple regions of hemorrhagic foci
bilaterally in the frontal lobes, right temporal lobe, left hippocampus,
and left brainstem, consistent with microhemorrhage following shear
injury meeting radiographic criteria for diffuse axonal injury
Acta Neuropathologica, 2018, 135:303–305
Keene CD et al.: First confirmed case
of chronic traumatic encephalopathy
in a professional bull rider
Post-traumatic headache, memory loss, concentration problems,
attentional dysfunction.
Mood lability, disinhibition, irritability, explosivity, depression, anxiety.
Diplopia, photophobia, phonophobia, vestibular dysfunction, insomnia.
Dysarthria with mild aphasia, difficulty with mental flexibility and
planning, motor slowing.
Exaggerated somatic concern, hostility, and conceptual disorganization.
Family members described a very bright, jovial, and affable young man
who was conscientious and loving but in the last 6–9 months of life
rapidly deteriorated, becoming reclusive and hypervigilant with
paralyzing panic attacks, and displaying significant behavioral changes
characterized by erratic and impulsive decisions until he commited a
suicide at 25.
Acta Neuropathologica, 2018, 135:303–305
Keene CD et al.: First confirmed case
of chronic traumatic encephalopathy
in a professional bull rider
The fresh whole brain 1360 g
external examination normal
for age
no evidence of mass lesions,
destructive lesions,
hemorrhage, herniations, or
cortical atrophy.
Multifocal traumatic white
matter lesions, axonal loss
hemosiderin, foamy
macrophages
Positive phospho-tau
immunostaining of
neurofibrillary tangles, neurites,
and glial inclusions in bilateral
orbitofrontal cortex
Microscopy
Closed Cerebral Trauma–traumatology classification
Type of injury
Diffuse – commotion
– diffuse axonal injury
Focal– contusion
Compression– hematomas (epidural,
subdural, intracranial)
– hygroma
Therapy
Conserv.
Conserv.sometimesevacuation
SURGICAL
Brain Perfusion Failure
Encephalomalaciawhite
red
mixed
Causesischemia
venostasisPostencephalomalatic pseudocyst (event.)
Arteriosclerosis
Cerebral Arteries Atherosclerosis
Morphological features – encephalomalacia
– encephalopathia angiosclerotica: atrophia cerebri diffusa
status cribrosus
status lacunaris
hydrocephalus ext. et int. e vacuo
Encephalomalacia
partim rubra
cerebri
Encephalomalaciae partim rubrae N59/05
sin.
sin.
N 510/05
Pseudocystis cerebri
trichrom - el
Embolia thrombotica a. cerebri mediae
Status cribrosus
Cleaning
reaction
Macrophages
Astrocytes
Pseudocystis postencephalomalacica
Cerebral Arteries Atherosclerosis
Clinical features
– cerebral infarction (event. death)
– pyramidal and extrapyramidal signs
– atherosclerotic (multiinfarct)
dementia
(-100ml!)
N ****/2002
woman 92 yrs
History
found at home unconscious
CT atypical expansive frontal lesion most
probably a metastasis
sonography – pancreatic lesion / neoplasia?
died one month later after a prolonged coma
Dura mater without metastatic spread – normal finding
?
Multifocal haemorrhagic brain lesions
Encephalomalaciae rubrae vetustiores cerebri
Encephalomalaciae rubrae vetustiores cerebri
?
Pancreatitis chronica fibroproductiva
Pseudocystis pancreatis postnecrotica
Emphysema pulmonum atrophicum
Bronchopneumonia fibrinosoproductiva
Bronchopneumonia fibrinosoproductiva
Diagnosis
Morbus principalis
Aetas provecta (92 anni).
Atherosclerosis universalis gravis
praecipue aa. basalium cerebri.
Diagnosis
Complicationes
Encephalomalaciae partim rubrae corticis et subst.
albae loborum frontalium cerebri.
Pancreatitis chronica fibroproductiva. Pseudocystis
postnecrotica capitis pancreatis. Emphysema
pulmonum vesiculare atrophicum. Bronchopneumonia
fibrinosoproductiva focalis
Causa mortis
Oedema cerebri.
Malignancy
Not Confirmed by Autopsy
increased clinical expectations due to
increasing incidence of many neoplasms
esp. with increasing life span
insufficient differential diagnostic thinking
THE „GOLD STANDARD“
FOR MALIGNANCY CONFIRMATION IS
BIOPSY