Cerebrovascular diseasesCerebrovascular diseases

3-rd most common cause of death in developed 3-rd most common cause of death in developed countries (after cardiovascular diseases and countries (after cardiovascular diseases and

malignant tumors)malignant tumors)

Hemodynamic disorders in the Hemodynamic disorders in the CNSCNS

IschemicIschemic

Hemorrhagic Hemorrhagic

Brain ischemia Brain ischemia

CompleteComplete

Global Global

Regional Regional

Acute Acute

Chronic Chronic

Complete ischemiaComplete ischemia

In somatic deathIn somatic death

Irreversible Irreversible

In the entire brainIn the entire brain

Connected with ongoing autolysisConnected with ongoing autolysis

Global ischemiaGlobal ischemiaIn the clinical deathIn the clinical deathIn severe heart arythmiaIn severe heart arythmiaIn hypotensionIn hypotensionIn shockIn shock

„„Low flow“ statesLow flow“ states

Sequelae: according to duration, condition of the blood vessels, temperature Sequelae: according to duration, condition of the blood vessels, temperature of the body, age, perfusion (reperfusion) pressure, saturation blood with of the body, age, perfusion (reperfusion) pressure, saturation blood with oxygen…oxygen…

Neuronal cell population – most vulnerable, may be different in various part Neuronal cell population – most vulnerable, may be different in various part of the brain – cortex , basal ganglia, brain stemof the brain – cortex , basal ganglia, brain stem

Manifestation of infarcts: amnesia, blindness, motoric disrorders, Manifestation of infarcts: amnesia, blindness, motoric disrorders,

Global edema – increase of intracranial blood pressure – block of blood Global edema – increase of intracranial blood pressure – block of blood perfusion - „coma vigile“, brain death, autolysis – „respirator brain“ perfusion - „coma vigile“, brain death, autolysis – „respirator brain“

Regional (local) ischemiaRegional (local) ischemia

Brain infarct – „encefalomalacie“ (white, red)Brain infarct – „encefalomalacie“ (white, red)Hemispheric – occlusion of internal carotid arteryHemispheric – occlusion of internal carotid arteryBrain stem – occlusion of vertebral or basilar arteryBrain stem – occlusion of vertebral or basilar arterySize of infarct, extension – acc. to site of occlusion, size Size of infarct, extension – acc. to site of occlusion, size of stagnating thrombosis, speed of occlusionof stagnating thrombosis, speed of occlusionMechanism of occlusion – atherosclerosis, embolism, Mechanism of occlusion – atherosclerosis, embolism, thrombosis (underlined by hypercoagulative conditions, thrombosis (underlined by hypercoagulative conditions, vasculitides, trauma), venous thrombosis – vasculitides, trauma), venous thrombosis – accompanying intracranial inflammationsaccompanying intracranial inflammationsFinal result – postnecrotic (postmalatic) pseudocystFinal result – postnecrotic (postmalatic) pseudocyst

Chronic ischemiaChronic ischemia

Multiple stenoses and occlusions of small Multiple stenoses and occlusions of small arterial branchesarterial branchesBrain atrophy: thinning of cortex and gyri, Brain atrophy: thinning of cortex and gyri, widened sulci, internal hydrocephalus e widened sulci, internal hydrocephalus e vacuo, cribose and lacunar status (basal vacuo, cribose and lacunar status (basal ganglia and centrum semiovale)ganglia and centrum semiovale)Status verminosus : multiple small foci of Status verminosus : multiple small foci of gliosis subsequent to focal necroses of gliosis subsequent to focal necroses of ganglionic cellsganglionic cells

Infarcts of spinal cordInfarcts of spinal cord

Much less common than in the brainMuch less common than in the brain

Local compression – vertebral collumn injuries, Local compression – vertebral collumn injuries, disc prolapses into vertebral canal, tumors disc prolapses into vertebral canal, tumors (primary, secondary)(primary, secondary)

Multiple arterial occlusions – in cases of aortal Multiple arterial occlusions – in cases of aortal dissection (thoracal part of spinal cord), multiple dissection (thoracal part of spinal cord), multiple embolic occlusion (air embolism…)embolic occlusion (air embolism…)

Morphology – maximum decomposition Morphology – maximum decomposition centromedullary (grey matter)centromedullary (grey matter)

Intracranial bleedingIntracranial bleeding

TraumaticTraumatic

Non traumatic Non traumatic

Epidural Epidural

SubduralSubdural

Subarachnoideal Subarachnoideal

Intracerebral Intracerebral

Epidural bleeding (hematoma)Epidural bleeding (hematoma)

TraumaticTraumaticArterial (a. meningea media)Arterial (a. meningea media)Usually with skull fracture (very rarely without)Usually with skull fracture (very rarely without)Epidural space (intracranially not preformed)Epidural space (intracranially not preformed)Period of latency – hoursPeriod of latency – hoursDevelopment from inicial symptoms to irreversible brain Development from inicial symptoms to irreversible brain damage - fast (asymmetric compression, herniation, damage - fast (asymmetric compression, herniation, edema, brain death) edema, brain death) Requires urgent neurosurgery !!! (anisocoric pupils, Requires urgent neurosurgery !!! (anisocoric pupils, mydriasis on the affected size – „surgical pupil“)mydriasis on the affected size – „surgical pupil“)Fastly killing !!!Fastly killing !!!

Subdural bleeding (hematoma)Subdural bleeding (hematoma)

Both traumatic and „non-traumatic“Both traumatic and „non-traumatic“Venous (emissarial veins)Venous (emissarial veins)Not always accompanied by skull fractureNot always accompanied by skull fracturePeriod of latency – long and very variable (even weeks Period of latency – long and very variable (even weeks or months)or months)Speed of development from initial symptoms to Speed of development from initial symptoms to irreversible brain damage – very variable, may be longirreversible brain damage – very variable, may be longChronic forms: encapsulation, then osmotic expansion Chronic forms: encapsulation, then osmotic expansion (subdural „hygroma“)(subdural „hygroma“)Needs neurosurgery in the case of clinical Needs neurosurgery in the case of clinical symptomatology (may sometimes remain asymptomatic, symptomatology (may sometimes remain asymptomatic, when stopped early and resolves)when stopped early and resolves)

Subarachnoideal bleedingSubarachnoideal bleeding

Both traumatic and non-traumaticBoth traumatic and non-traumaticTraumatic – accompanying brain contusion (combined sources)Traumatic – accompanying brain contusion (combined sources)Non-traumatic – arterial – rupture of berry aneurysm of artery of Non-traumatic – arterial – rupture of berry aneurysm of artery of Willis circle and base of brainWillis circle and base of brainBerry aneurysm – inborn predisposition, defects of elastic Berry aneurysm – inborn predisposition, defects of elastic membranes, can be multiple, then another development due to membranes, can be multiple, then another development due to arterial hypertension and atherosclerosisarterial hypertension and atherosclerosisSite of berry aneurysm: r. communicans ant. 40%, a.cerebri media Site of berry aneurysm: r. communicans ant. 40%, a.cerebri media and it´s branches 34%, a. carotis int. 20%and it´s branches 34%, a. carotis int. 20%Clinically manifested as acute brain attackClinically manifested as acute brain attackRequires neurosurgery (danger of recurrence !!!)Requires neurosurgery (danger of recurrence !!!)

Intracerebral bleeding (hematoma)Intracerebral bleeding (hematoma)

Usually non traumaticUsually non traumaticArterial – arterial hypertension (in the momental rise of Arterial – arterial hypertension (in the momental rise of intracranial pressure…), usually in the basal ganglia and intracranial pressure…), usually in the basal ganglia and capsula interna (a. lenticulostriata, „Charcott´s capsula interna (a. lenticulostriata, „Charcott´s hemorrhagic“ artery), eventually from arteriovenous hemorrhagic“ artery), eventually from arteriovenous malformation, arteriovenous hemangioma, cavernous malformation, arteriovenous hemangioma, cavernous hemangioma, brain metastasis of malignant tumors hemangioma, brain metastasis of malignant tumors Complications – brain edema, progression into brain Complications – brain edema, progression into brain chambers and subarachnoideal spacechambers and subarachnoideal spaceNeurosurgical intervention – considered acc. to Neurosurgical intervention – considered acc. to circumstances and prognosis…circumstances and prognosis…Rare causes: extreme hemorrhagic disorder, vasculitidesRare causes: extreme hemorrhagic disorder, vasculitides

Craniocerebral traumaCraniocerebral trauma

Combination of traumatic changes:Combination of traumatic changes:

Trauma of the skullTrauma of the skullVascular trauma with bleedingVascular trauma with bleedingTrauma of the brain parenchymTrauma of the brain parenchym

Opened x closedOpened x closed

Traffic injuries, professional injuries, falls from the steps Traffic injuries, professional injuries, falls from the steps (in drunkness…), falls of objects with hit to the head, (in drunkness…), falls of objects with hit to the head, shotsshots

Vascular injuries with bleedingVascular injuries with bleeding

See the previously listed typesSee the previously listed types

Often combination of typesOften combination of types

Parenchymal brain injuriesParenchymal brain injuries

ConcusionConcusion

ContusionContusion

LacerationLaceration

Diffuse axonal damageDiffuse axonal damage

ConcussionConcussion

No detectable morphological damage No detectable morphological damage

Uncousciousness (very individual Uncousciousness (very individual duration)duration)

Amnesia (always)Amnesia (always)

Desorientation and anxiosity (often)Desorientation and anxiosity (often)

ContusionContusion

More severe trauma, morphological damage (smashing) of brain More severe trauma, morphological damage (smashing) of brain parenchymparenchymUnconsciousnessUnconsciousnessEdema (subsequences…)Edema (subsequences…)Always with subarachnoideal and parenchymatous bleedingAlways with subarachnoideal and parenchymatous bleedingCoup and contracoup – signs of deceleration of head in movement, Coup and contracoup – signs of deceleration of head in movement, under the place of hit, opposite to the place of hitunder the place of hit, opposite to the place of hitCoup without contracoup (or smaller) – without head movementCoup without contracoup (or smaller) – without head movement

Life theratening, needs intensive care, neurosurgical consultationLife theratening, needs intensive care, neurosurgical consultation

LacerationLaceration

Usually in penetrating trauma – shot, Usually in penetrating trauma – shot, other severe opened trauma, fatalother severe opened trauma, fatal

Diffuse axonal damage (injury)Diffuse axonal damage (injury)

Angular acceleration of the head - very tangential hit or Angular acceleration of the head - very tangential hit or touch by big power (traffic –car, train…)touch by big power (traffic –car, train…)Multiple mechanical disruption of axons, swelling of their Multiple mechanical disruption of axons, swelling of their ends ends Without combination with other type of trauma in about Without combination with other type of trauma in about 50% of cases50% of casesUnconsciousness (usually long duration), desorientation, Unconsciousness (usually long duration), desorientation, focal neurological symptoms, focal neurological symptoms, Recovery – needs very long time, may be incomplete – Recovery – needs very long time, may be incomplete – posttraumatic dementia in the most severe casesposttraumatic dementia in the most severe casesAnother morphologic (microscopical) development: Another morphologic (microscopical) development: proliferation of microglia, degeneration of the involved proliferation of microglia, degeneration of the involved tracts (different severity from case to case)tracts (different severity from case to case)

Temporal arteritis as an unusual cause of brain Temporal arteritis as an unusual cause of brain infarcts and deathinfarcts and death

(poster congress presentation)(poster congress presentation)