Cerebral vascular disease: Pathology review

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Questions

USMLE® Step 1 style questions USMLE

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A 78-year-old right-handed man is brought to the emergency department following sudden-onset weakness in his right arm and inability to speak for twenty four hours. The patient’s daughter states she initially became concerned when he dropped his cup of coffee while walking to the kitchen table last night. The daughter states he has had a similar episode in the past that resolved spontaneously. He has a history of hypertension, for which he takes lisinopril. His temperature is 37°C (98.6°F), pulse is 92/min, and blood pressure is 158/104 mmHg. The patient is alert and visibly frustrated by not being able to speak. Physical examination reveals 2/5 strength in the right upper extremity and 4/5 strength in the right lower extremity. He follows written and verbal commands but is unable to speak or write. MRI of the head demonstrates ischemic changes in the cerebral territory supplied by the left middle cerebral artery. Which of the following histopathological findings are most likely to be observed in this patient’s brain at the present time?

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At the emergency department, 30-year-old Lydia presents with severe headache and confusion. Clinical examination reveals low grade fever and nuchal rigidity. Past medical history reveals she has polycystic kidney disease. Non-contrast CT reveals blood between the arachnoid and the pia mater. Lydia is treated supportively and sent home. Three days later she suddenly develops a severe headache, vomiting, and confusion. Later that day, 70-year-old Amanda presents with left-sided weakness and numbness, with her foot and leg more affected than her arm. She can speak fluently and understands everything being said to her. Past medical history includes hypertension, hyperlipidemia, and a myocardial infarction last year.

Based on their presentation, the diagnosis is that both Lydia and Amanda had a cerebral vascular accident, most often referred to as a stroke. A stroke is when there’s a sudden focal neurological deficit due to a part of the brain losing its blood supply.

Now, to safeguard the brain from hypoxia, the brain has a dual circulation called the circle of Willis, divided into an anterior and posterior circulation. The anterior circulation starts in the neck, where the common carotid artery splits into the external and internal branches. The internal carotid passes through the carotid canal of the temporal bone of the skull and into the cranial cavity. Once inside, the internal carotid artery gives off branches. First are the middle cerebral arteries that supply the lateral portions of the frontal, parietal, and temporal lobes. It’s also important to remember that the middle cerebral arteries supply the two language areas, Broca’s and Wernicke’s. From the initial segment of the middle cerebral arteries, small perforating arteries called lenticulostriate arteries arise to supply a part of the basal ganglia called the striatum, which includes the caudate and putamen, as well as the internal capsule. And that’s something you absolutely must remember for the exams! The internal carotid artery also gives rise to the anterior cerebral artery, which supplies the medial portion of the frontal and parietal lobes. The two anterior arteries connect with one another via a short blood vessel called the anterior communicating artery, forming the anterior portion of the circle of Willis.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Clinical pathology of the shock syndromes" Journal of Emergencies, Trauma, and Shock (2011)
  4. "Untreated brain arteriovenous malformation: Patient-level meta-analysis of hemorrhage predictors" Neurology (2014)
  5. "Intracranial Aneurysm and Hemorrhagic Stroke in Glucocorticoid-remediable Aldosteronism" Hypertension (1998)
  6. "ACR Appropriateness Criteria ® Cerebrovascular Disease" Journal of the American College of Radiology (2017)
  7. "Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms" Stroke (2015)
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