nervous system, jan 2011
TRANSCRIPT
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THE NERVOUS SYSTEM
Dr. Grace Widjajahakim, Sp. PA(Anatomical Pathology)
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Normal BrainFrontal lobe , parietal lobe, occipital lobe.Midbrain (†)Pons (◊)MO (x)Cerebellum (*)
Globus pallidus (+)Putamen (◊)Caudate nucleus ()Lateral ventricles(□)Hippocampus (x)
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I.CEREBRAL EDEMA
• Adalah penumpukan air yang berlebih dalam parenkhim otak.
• Cerebral edema:
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Normal Brain
HE Stain
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• Hydrocephalus = accumulation of excessive CSF within the ventricular system.
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II.CEREBROVASCULAR DISEASE
• 3 proses dasar: 1. thrombotic occlusion of vessels 2. embolic ,, 3. vascular rupture1-2: Loss of oxygen & metabolic
substrates→ischemic injury/ infarct3: Hemorrhage→direct tissue damage
→secondary ischemic injury
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Histopatologi
Neural injury dibagi 3: 1.Early changes ( 12-24 jam ): * red neuron
(microvacuolization →cytoplasmic eosinophilia, nuclear pyknosis & karyorrhexis)
* infiltrasi neutrofil sekeliling lesi2. Subacute changes ( 24 jam- 2 mgg ): *nekrosis
jaringan. Khas: >> makrofag, proliferasi pembuluh darah dan reaktif glosis
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3. Repair ( > 2mgg ): Khas: seluruh jaringan nekrotik menghilang, struktur CNS hilang dan gliosis
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Hemorrhage
Perdarahan Akut: bekuan darah dikelilingi jaringan otak yang edema. Edema hilang, muncul hemosiderofag, ditepi lesi terdapat proliferasi astrosit
(Centre & Right): Necrotic & oedematous
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*Vascular malformations: 1. AVM ( Arteriovenous malformations) 2. Cavernous angiomas
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3. Capillary telangiectasias
4. Venous angiomas ( varices )
* Hypertensive Cerebrovascular Disease* Vasculitis
Abnormally dilated capillary of widely varying calibre, separated by neural tissue
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III.CENTRAL NERVOUS SYSTEM TRAUMA
• Traumatic Parenchymal Injuries• Traumatic Vascular Injury: epidural hematoma,
subdural hematoma, subarachnoid hemorrhage.
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IV.Infections of the Nervous System
Ada 4 cara: 1. Hematogenous spread2. Direct implantation3. Local extension4. Peripheral nerves
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Epidural & Subdural Infections
• Meningitis:– Acute »Bacterial meningitis
»Viral meningitis– Chronic meningitis » Tubercoluous meningitis
» Neurosyphilis
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Acute: Ad 1. Bacterial Meningitis
• Neutrophils fill the entire subarachnoid space
• Abscesses• Phlebitis may also lead to
venous occlusion & hemorrhagic infarction
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Acute: Ad 2. Viral Meningitis
• Microscopic examination:• Mild to moderate infiltration of the
leptomeninges with lymphocytes
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Chronic: Ad 1. Tuberculous Meningitis• Mononuclear
cells/mixture of PMN & Mono cells
• Arachnoid fibrosis may produce hydrocephalus
• Intraparenchymal mass (brain: tuberculoma)
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Chronic: Ad 2. Neurosyphilis
• Perivascular inflammatory plasma cells & lymphocytes
• Cerebral gummas (mass lesions rich in plasma cells).
A chronic meningitis usually involving the base of the brain & sometimes the cerebral convexities & the spinal leptomeninges.
• Necrotic centre of the gumma surrounded by macrophages & plasma cells.
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Parenchymal Infections
• Brain Abscesses• Viral Encephalitis• Arboviruses• Herpes Simplex Virus Type 1 • ,, 2• Herpes Zoster• Cytomegalovirus• Poliovirus
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• Rabies• HIV• Fungal Encephalitis• Cerebral Toxoplasmosis• Prion Diseases
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Ad 1. Brain Abscesses
• Neovascularization around the necrosis
• Edema• Granulation
tissue
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Ad 2. Viral Encephalitis
• Perivascular & parenchymal mononuclear cell infiltrates.
• Inclusion bodies
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Ad 3. Arboviruses
Characteristically:• Lymphocytic meningoencephalitis (sometimes
with neutrophils) perivascular distribution.• Severe cases: Necrotizing vasculitis + focal
hemorrhages.
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Ad 4. Herpes Simplex Virus Type 1
• Perivascular inflammatory.• Cowdry type A intranuclear viral inclusion bodies
in neurons & glia.
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Ad 5. Herpes Simplex Virus Type 2
• Manifests in adults as meningitis.• Disseminated severe encephalitis occurs in
many neonates born by vaginal delivery to women with active primary HSV genital infections.
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Ad 6. Varicella-Zoster Virus(Herpes Zoster)
Chickenpox, a common childhood infection, is caused by the varicella-zoster virus.
Hemorrhagic lesions of ganglia
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Ad 7. Cytomegalovirus
• Localize in the paraventricular subependymal regions of the brain severe hemorrhagic necrotizing ventriculoencephalitis & choroid plexitis.
• A common opportunistic viral pathogen in individuals with AIDS.
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Ad 8. Poliovirus
PoliomyelitisA small group of inflammatory cells surrounding the remnants of
an anterior horn cell.
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Ad 9. Rabies
Negri body within Purkinje cell cytoplasm ( Negri bodies pyramidal cells of the hippocampus).
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Ad 10. HIV Encephalitis
A focal lesion (microglial nodule perivascular multinucleated cells.
Few lymphocytes (CD4 )
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Ad 11. Fungal Encephalitis
1. Aspergillosis
Aspergillus infection invasion with thrombosis & subsequent infraction.
•Filamen.•PMN around the vessels (venule & capillary).
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2. Cryptococcosis
‘Soap-bubble’ cysts.
Cysts large number of the organism.Fibroplasia & giant-cell formation.
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Ad 12. Cerebral Toxoplasmosis
IHC
Toxoplasma gondii infection pseudocyst within an infected cell (cell membrane forming the cyst wall).
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Ad 13. Prion Disease
“Mad cow disease” bovine spongiform encephalopathy.
Spongiform change in the cerebral cortex( abundant cortical amyloid plaques, surrounded by spongiform change).
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V. DEMYELINATING DISEASES
• Multiple Sclerosis• Guillain-Barrẻ Syndrome
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Ad 1. Multiple Sclerosis• Irregular plaques of
demyelination
• Gross cross section of brain showing plaques
Periventricular white matter is a large “plaque” of demyelination.
Luxol fast blue stain for myelin
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Ad 2. Guillain-Barrẻ Syndrome
An acute to subacute demyelinating neuropathy that affects both the central and peripheral nervous system and most often develops as an idiosyncratic reaction to vaccination.
Myelin sheaths damaged.
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VI. DEGENERATIVE DISEASES
• Alzheimer’s Disease• Parkinson’s Disease• Huntington’s Disease• Diabetic Neuropathy
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Ad 1. Alzheimer’s DiseaseAtrophy frontal and parietal regions, also temporal. Characterized: narrowed gyri&widened sulci.
Celebral cortex: neurofibrillary “tangle” (long pink filamen within the neuronal cytoplasm).
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Congo red stain: Cerebral artery: amyloid deposition
Silver-stain: Two amyloid plaques appears as a brownish-red dot surrounded by poliferating neurites creating “bull’s-eye” pattern.
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Ad 2. Parkinson’s Disease• Loss of dark
pigmentation on substantia nigra.
• Lewy bodies in a neocortex (homogenous pink bodies with a surrounding halo).
Normal midbrain
HE stain IHC
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Ad 3. Huntington’s DiseaseGenetic disease caused by an abnormally large number of triplet repeats in the Huntington gene.
Severe loss of small neurons in caudate&putamen with reactive astrocytosis. The head of caudate has become shrunken with ex vacuo dilation of lateral ventricles
Globus pallidus (+)Putamen (◊)Caudate nucleus ()Lateral ventricles(□)Hippocampus (x)
Normal Brain
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Ad 4. Diabetic Neuropathy
Diabetic neuropathy is a peripheral neuropathy in which sensory and motor nerves are damaged or destroyed as a result of ischemic microvascular disease and nonenzymatic glycosylation of neuronal component.
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VII. TUMORS
A. CENTRAL NERVOUS SYSTEM:# GLIOMAS: - Astrocytoma - Oligodendroglioma - Ependymoma# Poorly Differentiated Neoplasms:
Medulloblastoma# Meningioma# Metastatic Tumors
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Central: Ad 1. Gliomas: Astrocytoma
Mitosis
Grade 1-2 ( Moderate pleomorphism)
Grade 3-4
Endothelial cells kapiler proliferasi, lumen sempit
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Central: Ad 2. Gliomas: Oligodendroglioma
• Fried egg appearance (round blue nuclei with clear cytoplasm/halo)
Sering dengan:• Calcium deposition in
the media of a small vessel.
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Central: Ad 3. Gliomas: Ependymoma
• Cytologically bland, ephitelium like tumor cells forming prominent rosettes
• Characteristic: Perivascular pseudorosettes
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Central: Ad 4. Medulloblastoma
Within the cerebellum.
•Small round blue cells rosettes (Homer Wright rosettes).•Malignant neoplasm.•Radiosensitive.
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Central: Ad 5. Meningioma
Hyaline bodies Psammoma bodiesWhorled pattern
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Central: Ad 6. Metastatic Tumors
From breast
From bronchus
Edema
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B. PERIPHERAL NERVOUS SYSTEM:
# Schwannoma
# Neurofibroma
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Peripheral: Ad 1. Schwannoma• Left: “Antoni A”
pattern:• Palisading of
tumor cell nuclei, surrounding pink areas (Verocay bodies)
• Right: “Antoni B” pattern:• Looser stroma,
fewer cells, myxoid change
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Peripheral: Ad 2. Neurofibroma
• Bundles of wavy, elongated spindle cells
• A lot of intervening pink collagen