Bleeding in the Skull Region · Am J Case Rep. 2015; 16: 50–52. The child had a normal...

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


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 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


trichrom

Fe


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

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)


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.




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




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





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.





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

?

Pancreatitis chronica fibroproductiva

Pseudocystis pancreatis postnecrotica

Emphysema pulmonum atrophicum

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

Bleeding in the Skull Region · Am J Case Rep. 2015; 16: 50–52. The child had a normal...

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