CNS Pathology Lab Case Studies

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CNS Pathology LabCase Studies

• Dr. Gilbert
• WebPath

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• Case 2
• History
• This 61 year old alcoholic male was sitting on a
  bar stool when he was noted to suddenly fall to
  the floor. He was unable to arise and the
  paramedics were called. When they arrived, he was
  able to answer questions and he stated that he
  had a severe headache. Upon arrival to the
  hospital the admitting physical examination
  demonstrated a right hemiparesis. The patient
  became increasingly somnolent after admission.
• Further history
• In spite of supportive care, the patient became
  comatose and died two hours after admission.

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Slide 1.1This is a CT scan of the patient's head
upon admission.
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Slide 1.2This is a coronal section of the brain
and midbrain at autopsy.
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Questions

1. What are possible causes of this acute incident?
2. What treatment could have prevented this event?
3. Is there any treatment after the event occurs?

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Answers

• What are possible causes of this acute incident?
• There are several possibilities. Because of the
  acuteness of the symptoms, one should think of a
  vascular problem, either due to trauma or to
  underlying vessel disease. This man could have
  suffered a skull fracture and epidural hemorrhage
  upon hitting the floor. Embolic stroke,
  hypertensive bleed (from long-standing
  hypertension), or bleed from a vascular
  malformation are all possible. Bleeding into a
  tumor is another possibility.
• What treatment could have prevented this event?
• Treatment of hypertension with antihypertensive
  medication over the years has produced a marked
  reduction in the incidence of hypertensive bleeds
  in the brain.
• Is there any treatment after the event occurs?
• Evacuation of the blood from a hypertensive
  bleed in this location is rarely helpful.
  Hypertensive bleeds into the cerebellum can be
  life saving, if evacuation is performed before
  tonsillar herniation and brainstem compression.

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• Case 2
• History
• This 81 year old man was in good health until
  developing a cough with the production of yellow
  sputum. He complained to his relatives of a
  headache the day before admission. He was found
  stuporous by his son on the day of admission. In
  the emergency room, the physical examination
  demonstrated an elderly man who was not
  responding very well to questions. His
  temperature was 99.7 degrees F, respirations 16,
  pulse 100 and weak, and blood pressure 110/50.
  His neck was stiff. A lumbar puncture revealed
  cloudy cerebrospinal fluid with a marked
  pleocytosis with 1500 WBC's (90 of them PMN's),
  decreased glucose, and mildly elevated protein.
• Further history
• The patient does not respond to treatment and
  dies.

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Slide 2.1This is a gross photograph of his
brain.
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Slide 2.2This is a microscopic photograph with
HE staining of the subarachnoid space.
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Questions

• What is the diagnosis? What is the most likely
  organism in this man?
• What would be your treatment?
• What is a possible cause of death in this man?

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Answers

• What is the diagnosis? What is the most likely
  organism in this man?
• Acute meningitis is the diagnosis. The most
  likely organisms are bacteria meningitis in this
  age group is most commonly caused by
  Streptococcus pneumoniae.
• What would be your treatment?
• Immediate institution of intravenous penicillin.
  
• What is a possible cause of death in this man?
• Uncal and tonsillar herniation with brainstem
  compression can occur because of brain edema.

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• Case 3
• History
• This 68 year old man was noted by his family to
  have become forgetful in the months before being
  seen by his family physician. He was brought to
  his physician by his son because he had been
  found wandering in the streets. On physical
  examination, he was unable to remember any
  objects after five minutes and, although an avid
  football fan, he was unable to recount the
  previous Monday night's game which he had watched
  with his son. A CT scan was obtained and showed
  mild cerebral atrophy.

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Slide 3.1This is the gross appearance of the
brain from a man who died from the same disease
suffered by this patient.
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Slide 3.2This is a microscopic section of brain
stained with HE.
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Slide 3.3This is another microscopic section of
brain stained with a silver stain. In the center
there is a senile plaque.
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Questions

• What is the apparent diagnosis?
• What other tests would you order on this man?
• What are the major causes of dementia?

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Answers

• What is the apparent diagnosis?
• Dementia is the most likely diagnosis, although
  depression in the elderly must be ruled out.
• What other tests would you order on this man?
• Thyroid funtion tests, vitamin B12 level, and
  serologic test for syphilis (e.g., VDRL) will
  help rule out more treatable causes of dementia.
  A toxicology screen will help rule out possible
  unknown drugs.
• What are the major causes of dementia?
• Alzheimer's disease, multi-infarct dementia,
  hydrocephalus, chronic subdural, and diffuse Lewy
  body disease are major causes for dementia.
  Pick's disease is uncommon. Dementia can be seen
  late in Parkinson's disease. Alzheimer's disease
  is by far the most common.

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• Case 4
• History
• This 58 year old alcoholic male developed
  increasing weakness on his right side over
  several days. Upon admission he was mildly
  agitated and complaining of a headache. His right
  arm and leg were weak and there was flattening of
  the nasolabial fold on the right. He denied any
  recent head trauma. A head CT scan was obtained.

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Slide 4.1This is the CT scan.
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Slide 4.2This is a gross photograph of a similar
lesion in a patient who died.
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Questions

1. What are the possible causes for his weakness?
2. Why did the patient deny any history of recent
   trauma?
3. What age groups commonly present with this type
   of lesion after head trauma?
4. What blood vessels are rupture to produce this
   lesion?

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Answers

• What are the possible causes for his weakness?
• A progressive stroke due to vascular occlusion
  on the left side or an enlarging subdural are
  possible causes in spite of the negative history
  of trauma. An intraparenchymal tumor or abscess
  are other possibilities.
• Why did the patient deny any history of recent
  trauma?
• With his history of alcoholism, he most likely
  was intoxicated (drunk) at the time and did not
  remember striking his head.
• What age groups commonly present with this type
  of lesion after head trauma?
• Subdural hematomas are most commonly seen in the
  very young and the very old. Alcoholics commonly
  present with subdurals because of their
  propensity to fall.
• What blood vessels are rupture to produce this
  lesion?
• The crossing dural veins are ruptured. Because
  of the slower accumulation of blood, the patient
  may not present acutely with the symptoms of a
  space occupying mass. Chronic subdurals are
  thought to be caused mainly by minor movements of
  the head, tearing the small vessels taking part
  in the resorption of the original clot.

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• Case 5
• History
• This 52 year old man had presented at age 37 with
  blurred vision. This lasted for several weeks.
  Five years later he suffered an episode ofright
  leg weakness which resolved over several months.
  Over the ensuing 10 years he developed
  dysarthria, internuclear ophthalmoplegia, and
  paraplegia with spasticity. He became bedridden
  and died of a pulmonary embolus. At the time of
  his initial evaluation, a spinal tap revealed a
  normal CSF pressure, 6 cells (all lymphocytes),
  an elevated protein, and a normal glucose.
  Protein electrophoresis revealed an elevation in
  IgG. An MRI was performed six years before his
  death and showed several T2 bright images in the
  white matter of the cerebral hemispheres.

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Slide 5.1This is a CT scan from another patient
with the same disease.
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Slide 5.2This is a gross photograph of the brain
from this patient.
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Slide 5.3This is a microscopic section with
myelin stain of one of the lesions.
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Slide 5.4This is a microscopic section with a
silver stain for axons of one of the lesions.
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Slide 5.5On this HE stained microscopic
section, note the perivascular lymphocytes in the
lesion.
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Answers

• What is the most likely diagnosis?
• Multiple sclerosis.
• What other test would help in confirming your
  diagnosis? What would you tell the patient about
  the prognosis?
• CSF agarose gel electrophoresis to look for
  oligoclonal bands. Visual evoked responses and
  brain stem evoked responses may demonstrate
  abnormalities not noted on examination. The
  prognosis varies with each patient and many
  patients do not progress to severe disabilities.
  Many patients have periods of remission.

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• Case 6
• History
• This 50 year old female was in her normal state
  of good health when she began to notice a funny
  feeling in her left hand. Over the ensuing weeks
  she began to notice a continual nagging headache
  which was partially relieved with Tylenol. On the
  morning of admission she had a grand mal seizure
  witnessed by her husband. Upon arrival at the
  emergency room she was awake and slightly
  disoriented but could give a good history. On
  physical examination there was mild weakness of
  the left arm and leg with paresthesias of the
  left hand.

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Slide 6.1This is an enhanced MRI scan of the
right hemisphere as seen sagittally.
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Slide 6.2This is an HE stained microscopic
section of the biopsy taken from the lesion.
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Slide 6.3This is a gross photograph of a similar
lesion from an elderly man who died.
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Questions

• What are possible causes for these symptoms?
• What would be part of your workup on this
  patient?

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Answers

• What are possible causes for these symptoms?
• Since the symptoms progressed over weeks, tumor
  or abscess should be considered. A chronic
  subdural is another possibility.
• What would be part of your workup on this
  patient?
• A scan to rule out a localized lesion. CT scans
  are better at identifying intracranial
  hemorrhages, while MRI scans are better at
  identifying neoplasms.

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• Case 7
• History
• This 25 year old female was admitted to the
  hospital for left sided focal seizures and
  obtundation. She had complained of increasing
  headaches over the weeks prior to admission.
  There was also some clumsiness of her left hand
  and leg. She noted clonic jerking of her right
  arm lasting approximately five minutes which
  resolved with some weakness in her arm. Twenty
  minutes later, a similar episode occurred. On
  admission she was barely responsive and had a
  temperature of 100 degrees F. She had a right
  hemiparesis.

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Slide 7.1This is an enhanced head CT scan.
Describe the lesion present.
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Slide 7.2This is a gross photograph of a section
of brain from another patient with the same
problem.
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Slide 7.3This is a microscopic section with
connective tissue (trichrome) stain of the lesion
after some months have passed.
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Questions

1. What are the possible causes for this type of
   presentation?
2. What studies would help define this situation?
3. What further studies would help define the
   etiology of the lesion in the brain?
4. How would you treat her disease? What is the
   prognosis?

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Answers

• What are the possible causes for this type of
  presentation?
• Because of the fever one would think of
  infection. With the focality of the symptoms and
  the progression of symptoms over several weeks,
  an abscess would be suspected. Tumor would also
  have to be considered.
• What studies would help define this situation?
• Scans would help localize a lesion and define
  what type of lesion was present.
• What further studies would help define the
  etiology of the lesion in the brain?
• Blood cultures might isolate an organism. An
  echocardiogram might localize the source of
  infection. A chest x-ray might also help localize
  a source of infection.
• How would you treat her disease? What is the
  prognosis?
• Antibiotics specific to the organism would be
  given. If subsequent scans did not show
  improvement, surgical drainage could be
  considered. The prognosis with response to
  therapy is good.

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• Case 8
• History
• This 55 year old man presented with the acute
  onset of left sided headache and mild right leg
  paresis. On CT scan a focal area of hemorrhage
  was seen near the gray white junction in the mid
  left frontal area. There was a questionable
  lesion in the right parietal lobe, but this was
  not well defined. It was decided to evacuate the
  lesion because of the mild mass effect and
  symptoms.
• Further history
• On questioning, the patient admitted to noting
  some blood-tinged urine in the weeks prior to his
  admission. He did not have any dysuria or
  urgency. A CT scan of the abdomen revealed a
  large mass in the right kidney.

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Slide 8.1This T1 weighted post-contrast MRI scan
in coronal view demonstrates the lesion. The mass
lesion is brightly enhancing and could represent
either blood or a neoplasm.
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Slide 8.2This microscopic section shows the
cellular portion of the lesion evacuated and sent
to surgical pathology.
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Slide 8.3This gross section of the brain is from
another individual with the same disease. There
is a well circumscribed hemorrhagic lesion in the
cortex with some surrounding edema.
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Questions

• 1. What are the possible etiologies for this
  lesion? What would be your follow-up after the
  discovery of the lesion?
• 2. What is the most likely diagnosis which
  explains both lesions? What is the treatment?

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Answers

• What are the possible etiologies for this lesion?
  What would be your follow-up after the discovery
  of the lesion?
• Primary or metastatic tumor are possible
  etiologies. Follow-up consists of a more thorough
  exam and history to see if there is a primary
  tumor elsewhere in the body. Special stains can
  be done on the biopsy tissue to discern whether
  it is primary or metastatic. In general, well
  circumscribed tumors in brain are metastatic. The
  pattern of clear cells would suggest renal cell
  carcinoma.
• 2. What is the most likely diagnosis which
  explains both lesions? What is the treatment?
• A renal cell carcinoma is the most likely
  diagnosis. Surgical removal of the kidney and a
  search for possible other metastatic sites is
  indicated.