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Basic Pathology, Anatomy, and
Pathophysiology of Stroke
Caplans Stroke A Clinical Approach 4th Edition
Chapter 2
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PAT!"!#$%
&ECA'(S&S !) CE*EB*!+ASC"A* -A&A#E T!
B*A(' T(SSE
There are two major categories of brain damage in stroke patients:
(1) ischemia
(2) hemorrhage
Ischemia can be further subdivided into 3 mechanisms:
Thrombosis,
mbo!ism,"ecreased #$stemic %erfusion&
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Throm.osis
Thrombosis refers to an
obstruction of b!ood 'ow due to
a !oca!ied occ!usive process
within one or more b!ood
vesse!s&
-ecreased Systemic
Perf/sion
In decreased s$stemicperfusion, diminished
f!ow to brain tissue is caused b$
!ow s$stemic
perfusion pressure&
Em.olism
ateria! formed e!sewhere
within the vascu!ar s$stem
!odges in an arter$ and b!ocksb!ood 'ow&
*!ockage can be transient or
ma$ persist for hours or da$s
before moving dista!!$&
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#+*,-,./01I"I0T-.-*-
%I"+-#+*"+-,2
different causes, posedifferent c!inica!
prob!ems, and havedifferent management&
11
/--/
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#ubarachnoid /emorrhage
rteriovenous ma!formations that cause
the s$ndrome of subarachnoid
hemorrhage are either !ocated in the
brain, abutting on pia! or ventricu!ar
surfaces, or situated within the ventricu!ar
s$stem or the subarachnoid space&
12
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Intracerebra! and parench$ma!
hemorrhage describe b!eeding direct!$ into
the brain substance& The cause is most often h$pertension,
with !eakage of b!ood from sma!!
intracerebra! arterio!es damaged b$ thee!evated b!ood pressure
13
Intracerebra! hemorrhage
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The most common brain !ocations for
h$pertensive intracerebra! hemorrhages
are as fo!!ows: !atera! gang!ionic andcapsu!ar (456), tha!amus (126), !obar
white matter (176 to 256), caudate
nuc!eus (86), pons (86), and cerebe!!um(86)29,1&
14
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These hemorrhages are a!most a!wa$s
caused b$ head trauma& #ubdura! hemorrhages arise from injured
veins that are !ocated between the dura
mater and the arachnoid membranes&
1;
#ubdura! < epidura!
hemorrhage
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pidura! hemorrhages are caused b$
tearing of meningea! arteries, most often
the midd!e meningea! arter$&
*!ood accumu!ates rapid!$ over minutes to
hours between the sku!! and the dura
mater
1
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The prob!ems in these =ve major subt$pes
of stroke are >uite distinct and re>uire
different treatment strategies&
18
#T-? ./0I# +I"
T-T0T
#ome therapies suitab!e for ischemia wou!d be
disastrous if the prob!em were hemorrhage
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major important >uestion in ever$ stroke
patient is@where is the brain and vascu!ar
prob!em !ocatedA
19
0TB: .0 0TI. #IT#
C D#.+- 0" *-I0 #I0#
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%/B#IB 0" %T/%/B#IB
C *-I0 I#./I
(schemia0orma! etabo!ism and *!ood C!ow
.erebra! b!ood 'ow (.*C) is norma!!$ approEimate!$ 75m for each 155 g of brain tissue per minute, and
cerebra! oE$gen consumption, usua!!$ measured as the
cerebra! metabo!ic rate for oE$gen (.-2), is norma!!$
approEimate!$ 3&7 mF155 g per minute
44
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oca! brain effects of ischemia t b!ood 'ow !eve!s of approEimate!$ 25
mF155 g per minute,
e!ectroencepha!ographic () activit$ is
affected&
.-2 a!so begins to fa!! when .*C is
diminished be!ow 25 mF155 g per minute&
47
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rteria! occ!usion and reaction
Dascu!ar occ!usion most often begins with
formation of atherosc!erotic p!a>ues within
eEtracrania! and !arge intracrania! arteries& These p!a>ues contain a miEture of !ipid,
smooth musc!e, =brous and co!!agen
tissues, macrophages, and in'ammator$ce!!s
4;
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therosc!erotic p!a>ues and vascu!ar
stenosis cause brain ischemia in a variet$of wa$s&
%rogressive intima! thickening !eads to
stenosis or occ!usion of the arter$,
resu!ting in reduced dista! b!ood 'ow&
4
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Trombus formation
Thrombi form in situ when the bod$Gs
coagu!ation s$stem has been activated
and the b!ood is h$percoagu!ab!e /$percoagu!abi!it$ can be a !ife!ong
hereditar$ prob!em& #$stemic diseases,
such as cancer, regiona! enteritis, andthromboc$tosis, can cause increased
c!otting&
48
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The surviva! of the brain regions at risk
depends on a number of factors
(1) the ade>uac$ of co!!atera! circu!ation
(2) the state of the s$stemic circu!ation
(3) sero!ogic factors
(4) changes within the obstructing
vascu!ar !esion
(7) resistance within the microcircu!ator$
bed&
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*rain edema and increased
intracrania! pressure There are two t$pes of brain edema:
(1) water accumu!ation inside ce!!s,
termed c$totoEic edema (2) 'uid within the eEtrace!!u!ar space,
often termed vasogenic edema
75
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Intracrania! pressure ma$ a!so be increased,
!eading to increased morbidit$ and decreased
.*C&
Hhen intracrania! pressure is increased, the
pressure in the venous sinuses and draining
veins must a!so increase if b!ood is to be drained
norma!!$ from the cranium& *rain edema and increased intracrania! pressure
a!so cause headache, decreased
consciousness, and vomiting&71
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