Macroscopic Neuropathology MT3 M Koenig ANSWER Version.pptx

Neuropathology Tutorial BSMS Module 202 Module Tutorial 3 Academic Year 2021/22 Case 1 history An 80-year old lady was travelling on a bus when the driver had to break suddenly. She hit the front of her head on the pole she was holding on to. She felt fine for several hours but then became nauseou...

Neuropathology Tutorial BSMS Module 202 Module Tutorial 3 Academic Year 2021/22 Case 1 history An 80-year old lady was travelling on a bus when the driver had to break suddenly. She hit the front of her head on the pole she was holding on to. She felt fine for several hours but then became nauseous and was sick. She also complained of increasing headache and visual disturbance. She was taken to hospital where , after several hours, cardiorespiratory arrest occurred. Resuscitation was unsuccessful and she died. This specimen shows the autopsy findings. Case 1 questions, images on next 2 slides Describe the macroscopic findings in terms of: • What is the specimen? • What is the lesion (abnormality)? • What is its size, shape, colour, consistency? How would you explain the clinical features of nausea, vomiting, headache and visual disturbance? What is the cause of death and why? Case 1 External Externalsurface surfaceof ofdura dura mater mater Coronal Coronalsection sectionof of brain brain Case 1 Coronal Coronalsection sectionof of brain brain Internal Internalsurface surfaceof ofdura dura mater mater Case 1 answers • What is the specimen and what is the lesion? Coronal section of brain with flattening of the (right) hemisphere over an area measuring xyz mm. Second specimen is a piece of dura mater with adherent subdural firm haematoma of dark red colour without features of organization/remodelling measuring xyz mm. Possible subfalcine herniation. • How would you explain the clinical features of nausea, vomiting, headache and visual disturbance? Raised intracranial pressure. Transtentorial herniation causes oculomotor nerve compression and/or visual disturbances. • What is the cause of death and why? Raised intracranial pressure +/- tonsillar herniation and compression of the medulla oblongata. Case 2 history An 55-year old gentleman suddenly collapses whilst gardening. He experiences a short period of unconsciousness and severe crushing headache. He taken to hospital by ambulance. On examination he shows neck stiffness. Cardiorespiratory arrest occurs two hours after his collapse. Resuscitation is unsuccessful. This specimen shows the autopsy findings. Case 2 Right Rightinternal internal carotid carotidartery artery What Whatis isthe the anatomical anatomical structure? structure? Please Pleaseidentify identifyits its constituent constituent vessels. vessels. IfIfthis thislesion lesionhad had been beenfound foundwhilst whilst asymptomatic, asymptomatic, what whatintervention intervention would wouldyou you propose? propose? Describe Describethe the lesion. lesion. What Whatis isthe thecause cause of ofdeath? death? Left Leftvertebral vertebral artery artery Case 2 answers • Circle of Willis • Berry aneurysm measuring xyz mm located at the branching point between anterior cerebral artery and anterior communicating artery. • COD: Raised intracranial pressure. • Berry aneurysms develop in life, are usually sporadic but associated with adult polycystic kidney disease, Ehler’s Danlos syndrome, Neurofibromatosis type I and Marfan’s syndrome. Smoking and hypertension predispose to rupture. • 40% anterior, 55% middle, 5% posterior. • Interventional radiology to coil the aneurysm (vascular approach) or clip it (craniotomy). • Control hypertension. Case 3 history An 55-year old lady was walking in the lake district and suddenly collapsed. She experienced numbness and weakness of one side of her body (face, arm, leg). 24 hours after hospital admission, cardio-respiratory arrest occurred, and she died. This specimen shows a transverse section of the brain. In addition, the heart weighed 590 g (female normal 150 - 300g). Case 2 What Whatis isthe thelesion? lesion? What Whathas has happened? happened? Why Whyis isthe theheart heart weight weightimportant? important? What Whatis isthe thecause cause of ofdeath? death? Which Whichconditions conditions predispose predisposeaa person personto tothis? this? Case 3 answers • Specimen/lesion: Transverse section of brain with intracerebral haemorrhage extending into the lateral ventricles. • Intraparenchymal haemorrhage occurs owing to rupture of intraparenchymal blood vessels and is often caused by hypertension. • 590g of heart weight equates to cardiac hypertrophy indicating increased outflow load most often due to hypertension. • COD: Raised intracranial pressure. • Predisposing risk factors: Hypertension, old age, coagulopathies, vasculitis. Tonsillar herniation Image Imagesource: source:@BrainsSlicer @BrainsSlicer88Oct Oct20 20 Case 4 history An 55-year old gentleman was admitted to hospital with a history of a fall at home, leg weakness in both legs and new onset urinary incontinence. Further history shows several weeks of back pain before the fall. Over the next days, the patient develops septicaemia and dies owing to multi-organ failure. This specimen shows the lower spine at autopsy. Case 4 What Whatis isthe thelesion? lesion? What Whathas has happened? happened? Can Canyou youthink thinkof of any anycauses causesfor for this? this? Which Whichconditions conditions predispose predisposeaa person personto tothis? this? Case 4 answers Specimen/lesion: Sagittal (or longitudinal) section of spinal column with dislocation and a cavity measuring xyz mm. The spinal cord is compressed and there is associated haemorrhage in the CSF space (intradural). No other focal lesions are seen (e.g. metastasis) and the remaining vertebrae appear normal (e.g. osteoporosis). DD: Trauma, abscess, metastasis, osteoporotic fracture, TB (Pott’s disease), myeloma, sarcoma, disc prolapse. This is a spinal abscess (staphylococcus aureus) which has caused destruction of a vertebral disk with subsequent dislocation of the spine. Transient bacteraemia is common and bacteria may traverse the blood brain barrier, especially in immunocompromised persons e.g. skin or tooth abscesses, minor injuries, lumbar puncture, surgery. Case 5 history An 19-year old student in their first year of university experienced fever and acute onset headache with confusion, nausea and being sick. He/she became intolerant to bright light and developed a rash that did not blanche under pressure/tension. He/she was admitted to hospital and treated but did not survive. The images show classical autopsy findings. Morgan Blakeley @JMGardnerMD 3:02PM 22 Morgan BlakeleySep @JMGardnerMD 3:02PM 22 2019 Sep 2019 Case 5 What Whatclinical clinical features featuresmight mightthis this patient patientshow? show? What Whatinvestigation investigation can canconfirm confirmthis this diagnosis? diagnosis? What Whatare are contraindications contraindications against againstsuch suchand and investigation investigationand and why? why? Case 5 answers Clinical features: Non-blanching skin rash, photophobia, neck or nuchal stiffness, fever, headaches, drowsiness. Investigations: Lumbar puncture to obtain CSF for bacterial culture. Contraindications: Raised intracranial pressure with risk of tonsillar herniation! If in doubt, exclude such before lumbar puncture! Start antibiotic therapy immediately. Newborns: Group B streptococci, E. coli. Children: Meningococcus/Neisseria meningitides, Streptococcus pneumoniae, Haemophilus influenzae Adults: Meningococcus/Neisseria meningitides, Streptococcus pneumoniae Old age: Meningococcus/Neisseria meningitides, Streptococcus pneumoniae, Listeria monocytogenes Immunocompromised: All above + viruses + fungal infections Non-infectious meningitis: Metastasis to the meninges, drug reactions, sarcoidosis, vasculitis. OPTIONAL Revision coup - contrecoup (a moving head, usually!!!) Coup Coup//blow blow Impact Impactresults resultsin inaa contusion/bruise contusion/bruise in inthe thecontact contactarea area Impact onto a stationary head Impact onto a stationary head does not necessarily produce a does not necessarily produce a contrecoup injury because the contrecoup injury because the brain brainhas hasno noinertia inertiaat atthe thetime time of impact. of impact. Impact onto a stationary head Impact onto a stationary head may mayproduce produceaacontrecoup contrecoup injury if the impact force is injury if the impact force is strong enough. strong enough. Contrecoup Contrecoup// counterblow counterblow Brain Braininertia inertia rebounds rebounds (‘sloshes’) (‘sloshes’)the the brain braininto intothe the opposite oppositedirection direction where whereitithits hitsthe the other otherside sideof ofthe the cranium craniumresulting resulting in inaasecond second contusion/bruise contusion/bruise