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tah ir9 9 - Un ite dV RG vip .pe rsi an ss. ir tah ir9 9 - Un ite dV RG vip .pe rsi an ss. ir Textbook of Stroke Medicine Second Edition tah ir9 9 - Un ite dV RG vip .pe rsi an ss. ir tah ir9 9 - Un ite dV RG vip .pe rsi an ss. ir Textbook of Stroke Medicine Second Edition Edited by Michael Brainin MD PhD Professor and Chair, Department of Clinical Neuroscience and Preventive Medicine, Danube University Krems, Krems, Austria Wolf-Dieter Heiss MD PhD Professor of Neurology, Emeritus Director, Max Planck Institute for Neurological Research and Department of Neurology, University of Cologne, Cologne, Germany Editorial Assistant Susanne Tabernig MD Vienna, Austria tah ir9 9 - Un ite dV RG vip .pe rsi an ss. ir Library of Congress Cataloging in Publication data Textbook of stroke medicine / edited by Michael Brainin, Wolf-Dieter Heiss ; editorial assistant, Suzanne Tabernig. – Second edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-107-04749-5 I. Brainin, M. (Michael), editor of compilation. II. Heiss, W.-D. (Wolf-Dieter), 1939 December 31- editor of compilation. III. Tabernig, Suzanne, editor of compilation. [DNLM: 1. Stroke. WL 355] RC388.5 616.801–dc23 2013048020 Michael Brainin & Wolf-Dieter Heiss 2013 ISBN-13: 9781107047495 tah ir9 9 - Un ite dV RG vip .pe rsi an ss. ir Contents List of contributors vii Preface ix Section 1 – Etiology, pathophysiology, and imaging 1. Neuropathology and pathophysiology of stroke 1 Konstantin-A. Hossmann and Wolf-Dieter Heiss 2. Common causes of ischemic stroke 33 Bo Norrving 3. Neuroradiology 45 (A) Imaging of acute ischemic and hemorrhagic stroke: CT, perfusion CT, CT angiography 45 Patrik Michel (B) Imaging of acute ischemic and hemorrhagic stroke: MRI and MR angiography 49 Jochen B. Fiebach, Patrik Michel, and Jens Fiehler (C) Multimodal imaging-guided acute stroke treatment based on CT and MR imaging 54 Patrik Michel 4. Imaging for prediction of functional outcome and for assessment of recovery 64 Wolf-Dieter Heiss 5. Ultrasound in acute ischemic stroke 82 László Csiba Section 2 – Clinical epidemiology and risk factors 6. Basic epidemiology of stroke and risk assessment 102 Jaakko Tuomilehto 7. Common risk factors and prevention 119 Michael Brainin, Yvonne Teuschl, and Karl Matz 8. Cardiac diseases relevant to stroke 140 Claudia Stöllberger and Josef Finsterer Section 3 – Diagnostics and syndromes 9. Common stroke syndromes 155 Céline Odier and Patrik Michel 10. Less common stroke syndromes 169 Wilfried Lang 11. Intracerebral hemorrhage 188 Corina Epple, Michael Brainin, and Thorsten Steiner 12. Subarachnoid hemorrhage 206 Philipp Lichti and Thorsten Steiner 13. Cerebral venous thrombosis 222 Jobst Rudolf 14. Behavioral neurology of stroke 236 José M. Ferro, Isabel P. Martins, and Lara Caeiro 15. Stroke and dementia 255 Barbara Casolla and Didier Leys 16. Ischemic stroke in the young and in children 266 Valeria Caso and Didier Leys Section 4 – Therapeutic strategies and neurorehabilitation 17. Stroke units and clinical assessment 285 Danilo Toni and Ángel Chamorro 18. Acute therapies for stroke 294 Richard E. O’Brien and Kennedy R. Lees v 19. Interventional intravascular therapies for stroke 311 Pasquale Mordasini, Jan Gralla, and Gerhard Schroth 20. Management of acute ischemic stroke and its late complications 326 Natan M. Bornstein and Eitan Auriel 21. Infections in stroke 342 Achim J. Kaasch and Harald Seifert 22. Secondary prevention 356 Hans-Christoph Diener, Sharan K. Mann, and Gregory W. Albers 23. Neurorehabilitation practice for stroke patients 371 Sylvan J. Albert and Jürg Kesselring Index 399 Contents vi Contributors Gregory W. Albers, MD Department of Neurology, Stanford University Medical Center, Stanford, CA, USA Sylvan J. Albert, MD, MSc Department of Neurology and Neurorehabilitation, Rehabilitation Centre, Valens, Switzerland Eitan Auriel, MD Department of Neurology, Elias Sourasky Medical Centre, Tel-Aviv, Israel Natan M. Bornstein, MD Department of Neurology, Elias Sourasky Medical Centre, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel Michael Brainin, MD, PhD Department of Clinical Neuroscience and Preventive Medicine, Danube University Krems, Krems, Austria Lara Caeiro, PhD, Mcs Department of Neurosciences, Hospital de Santa Maria and Instituto de Medicina Molecular, University of Lisboa, Portugal Valeria Caso, MD, PhD Department of Internal Medicine, Stroke Unit, University of Perugia, Perugia, Italy Barbara Casolla, MD Department of Neurology, Sapienza University, Rome, Italy Ángel Chamorro, MD, PhD Neurology Service, Jefe dela Unidad de Ictus Hospital Clinico, Barcelona, Spain László Csiba, MD, PhD, DSc Department of Neurology, University of Debrecen, Health Science Center, Debrecen, Hungary Hans-Christoph Diener, MD, PhD Department of Neurology, University Hospital Essen, University Duisberg Essen, Germany Corina Epple, MD Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany José M. Ferro, MD, PhD Department of Neurosciences, Hospital de Santa Maria and Instituto de Medicina Molecular, University of Lisboa, Portugal Jochen B. Fiebach, MD Department of Neurology, Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany Jens Fiehler, MD Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Josef Finsterer, MD, PhD Department of Internal Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria Jan Gralla, MD, MSc University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland Wolf-Dieter Heiss, MD, PhD Max Planck Institute for Neurological Research and Department of Neurology, University of Cologne, Cologne, Germany Konstantin-A. Hossmann, MD, PhD Max Planck Institute for Neurological Research, Cologne, Germany vii Achim J. Kaasch, MD Institute for Medical Microbiology, Immunology and Hygiene, Medical Center, University of Cologne, Cologne, Germany Jürg Kesselring, MD Department of Neurology and Neurorehabilitation, Rehabilitation Centre, Valens, Switzerland Wilfried Lang, MD Neurologische Abteilung, KH der Barmherzigen Brüder Wien, Vienna, Austria Kennedy R. Lees, MD Division of Cardiovascular and Medical Sciences, University of Glasgow and Western Infirmary, Glasgow, UK Didier Leys, MD, PhD Department of Neurology, Stroke Department, University of Lille, Lille, France Philipp Lichti, MD Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany Sharan K. Mann, MD Department of Neurology, Stanford University Medical Center, Stanford, CA, USA Isabel P. Martins, MD, PhD Department of Neurosciences, Hospital de Santa Maria and Instituto de Medicina Molecular, University of Lisboa, Portugal Karl Matz, MD Department of Neurology, Landesklinikum Tulln, Tulln, Austria Patrik Michel, MD Neurology Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland Pasquale Mordasini, MD, MSc University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland Bo Norrving, MD, PhD Department of Clinical Sciences, Division of Neurology, Lund University, Sweden Richard E. O’Brien, MD, FRCPEdin, MBChB City Hospitals Sunderland NHS Foundation Trust,Sunderland Royal Hospital, Sunderland, UK Céline Odier, MD Neurology Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland Jobst Rudolf, MD, PhD Department of Neurology, General Hospital “Papageorgiou,” Thessaloniki, Greece Gerhard Schroth, MD University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland Harald Seifert, MD Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany Thorsten Steiner, MD, PhD, MME Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany and Department of Neurology, University of Heidelberg, Heidelberg, Germany Claudia Stöllberger, MD Department of Internal Medicine, Krankenanstalt Rudolfstiftung, Vienna, Austria Yvonne Teuschl, PhD Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria Danilo Toni, MD Emergency Department Stroke Unit, Department of Neurological Sciences, University “La Sapienza,” Rome, Italy Jaakko Tuomilehto, MD, PhD Centre for Vascular Prevention, Danube University Krems, Krems, Austria; Diabetes Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland; King Abdulaziz University, Jeddah, Saudi Arabia; and Instituto de Investigacion Sanitaria del Hospital Universario LaPaz (IdiPAZ), Madrid, Spain List of contributors viii Preface This book is designed to improve the teaching and learning of stroke medicine in postgraduate educa- tional programs. It is targeted at “beginning special- ists,” either medical students with a deeper interest or medical doctors entering the field of specialized stroke care. Therefore, the text contains what is con- sidered essential for this readership but, in addition, goes into much greater depth, e.g. the coverage of less frequent causes of stroke, and describing the more technical facets and settings of modern stroke care. The textbook leads the reader through the many causes of stroke, its typical manifestations, and the practical management of the stroke patient. We have tried to keep the clinical aspects to the fore, giving relative weight to those chapters that cover clinically important issues; however, the pathological, patho- physiological and anatomical background is included where necessary. The book benefits from the experi- ence of many specialized authors, thereby providing expert coverage of the various topics by international authorities in the field. In places this leads to some differences of opinion in the approach to particular patients or conditions; as editors we have tried not to interfere with the individual character of each chapter, leaving only duplicate presentations when they were handled from different topological or didactic aspects, e.g. on genetic or rarer forms of diseases. The development of this textbook has been trig- gered by the “European Master in Stroke Medicine Programme” held at Danube University in Austria. This program has been fostered by the European Stroke Organisation and has been endorsed by the World Stroke Organization. This book has been shaped by the experiences of the lecturers – most of them also leading authors for our chapters – and the feedback of our students during several runs of this course. Thus, we hope to satisfy the needs of students and young doctors from many different countries, both within and outside Europe. Finally, we would like to thank Dr. Susanne Taber- nig for her expert editorial assistance and her diligent and expert help in summarizing the chapters’ contents. Thanks also to Nick Dunton and his team at CambridgeUniversity Press for their help and patience. Michael Brainin Wolf-Dieter Heiss ix Section 1 Chapter 1 Etiology, pathophysiology, and imaging Neuropathology and pathophysiology of stroke Konstantin-A. Hossmann andWolf-Dieter Heiss The vascular origin of cerebrovascular disease All cerebrovascular diseases (CVDs) have their origin in the vessels supplying or draining the brain. There- fore, the knowledge of pathological changes occurring in the vessels and in the blood are essential for under- standing the pathophysiology of the various types of CVD and for planning of efficient therapeutic strat- egies. Changes in the vessel wall lead to obstruction of blood flow, by interacting with blood constituents they may cause thrombosis and blockade of blood flow in this vessel. In addition to vascular stenosis or occlusion at the site of vascular changes, disruption of blood supply and consecutive infarcts can also be produced by emboli arising from vascular lesions situated proximally to otherwise healthy branches located more distal in the arterial tree or from a source located in the heart. At the site of occlusion, opportunity exists for thrombus to develop in ante- rograde fashion throughout the length of the vessel, but this event seems to occur only rarely. Changes in large arteries supplying the brain, including the aorta, are mainly caused by atheroscler- osis. Middle-sized and intracerebral arteries can also be affected by acute or chronic vascular diseases of inflammatory origin due to subacute to chronic infec- tions, e.g. tuberculosis and lues, or due to collagen disorders, e.g. giant cell arteritis, granulomatous angiitis of the central nervous system, panarteritis nodosa, and even more rarely systemic lupus erythe- matosus, Takayasu’s arteritis, Wegener granulomato- sis, rheumatoid arteritis, Sjögren’s syndrome, or Sneddon and Behçet’s disease. In some diseases affecting the vessels of the brain the etiology and pathogenesis are still unclear, e.g. moyamoya disease and fibromuscular dysplasia, but these disorders are characterized by typical locations of the vascular changes. Some arteriopathies are hereditary, such as CADASIL (cerebral autosomal dominant arteriopa- thy with subcortical infarcts and leukoencephalopa- thy), in some such as cerebral amyloid angiopathy a degenerative cause has been suggested. All these vas- cular disorders can cause obstruction, and lead to thrombosis and embolizations. Small vessels of the brain are affected by hyalinosis and fibrosis; this “small-vessel disease” can cause lacunes and, if wide- spread, is the substrate for vascular cognitive impair- ment and vascular dementia. Atherosclerosis is the most widespread disorder leading to death and serious morbidity including stroke [1]. The basic pathological lesion is the ather- omatous plaque, and the most commonly affected sites are the aorta, the coronary arteries, the carotid artery at its bifurcation, and the basilar artery. Arteriosclerosis, a more generic term describing hardening and thickening of the arteries, includes as additional types Mönkeberg’s sclerosis which is char- acterized by calcification in the tunica media and arteriolosclerosis with proliferative and hyaline changes affecting the arterioles. Atherosclerosis starts at young age, lesions accumulate and grow through- out life and become symptomatic and clinically evi- dent when end organs are affected [2]. Atherosclerosis: atheromatous plaques, most commonly in the aorta, the coronary arteries, the bifurcation of the carotid artery and the basilar artery. The initial lesion of atherosclerosis has been attrib- uted to “fatty streaks” and the “intimal cell mass.” Those changes already occur in childhood and ado- lescence and do not necessarily correspond to the future sites of atherosclerotic plaques. Fatty streaks Textbook of Stroke Medicine, Second Edition, ed. Michael Brainin and Wolf-Dieter Heiss. Published by Cambridge University Press. © Michael Brainin and Wolf-Dieter Heiss 2014. 1 are focal areas of intra cellular lipid collection in both macrophages and smooth muscle cells. Various con- ceptshave been proposed to explain the progression of such precursor lesions to definite atherosclerosis [2, 3], most remarkable of which is the response-to- injury hypothesis postulating a cellular and molecular response to various atherogenic stimuli in the form of an inflammatory repair process [4]. This inflamma- tion develops concurrently with the accumulation of minimally oxidized low-density lipoproteins (LDLs) [5, 6], and stimulates vascular smooth muscle cells (VSMCs), endothelial cells, and macrophages [7], and as a result foam cells aggregate with an accumulation of oxidized LDL. In the further stages of arthero- sclerotic plaque development VSMCs migrate, prolif- erate, and synthesize extracellular matrix components on the luminal side of the vessel wall, forming the fibrous cap of the atherosclerotic lesion [8]. In this complex process of growth, progression, and finally rupture of an atherosclerotic plaque a large number of matrix modulators, inflammatory mediators, growth factors, and vasoactive substances are involved. The complex interactions of these many factors are dis- cussed in the special literature [5–9]. The fibrous cap of the atherosclerotic lesion covers the deep lipid core with a massive accumula- tion of extracellular lipids (atheromatous plaque), or fibroblasts and extracellular calcifications may con- tribute to a fibrocalcific lesion. Mediators from inflam- matory cells at the thinnest portion of the cap surface of a vulnerable plaque – which is characterized by a larger lipid core and a thin fibrous cap – can lead to plaque disruption with formation of a thrombus or hematoma or even to total occlusion of the vessel. During the development of atherosclerosis the entire vessel can enlarge or constrict in size [10]. However, once the plaque covers >40% of the vessel wall, the artery no longer enlarges, and the lumen narrows as the plaque grows. In vulnerable plaques thrombosis forming on the disrupted lesion further narrows the vessel lumen and can lead to occlusion or be the origin of emboli. Less commonly, plaques have reduced collagen and elastin with a thin and weakened arterial wall, resulting in aneurysm forma- tion which when ruptured may be the source of intracerebral hemorrhage (Figure 1.1). Injury hypothesis of progression to atherosclerosis: fatty streaks (focal areas of intra cellular lipid collection) ! inflammatory repair process with stimulation of vascular smooth muscle cells ! atheromatous plaque. Thromboembolism: immediately after plaque rupture or erosion, subendothelial collagen, the lipid core, and procoagulants such as tissue factor and von Wille- brand factor are exposed to circulating blood. Platelets rapidly adhere to the vessel wall through the platelet glycoproteins (GP) Ia/IIa and GP Ib/IX [11] with subsequent aggregation to this initial monolayer through linkage with fibrinogen and the exposed GP IIb/IIIa on activated platelets. As platelets are a source of nitric oxide (NO), the resulting deficiency of bioac- tive NO, which is an effective vasodilator, contributes Figure 1.1. The stages of development of an atherosclerotic plaque. (1) LDL moves into the subendothelium and (2) is oxidized by macrophages and smooth muscle cells (SMC). (3) Release of growth factors and cytokines (4) attracts additional monocytes. (5) Macrophages and (6) foam cell accumulation and additional (7) SMC proliferation result in (8) growth of the plaque. (9) Fibrous cap degradation and plaque rupture (collagenases, elastases). (10) Thrombus formation. IL-1 ¼ interlenkin-1; MCP-1 ¼ Monocyte chemotactic protein-1. (Modified with permission from Faxon et al. [5].) Section 1: Etiology, pathophysiology, and imaging 2 to the progression of thrombosis by augmenting platelet activation, enhancing VSMC proliferation and migration, and participating in neovasculariza- tion [12]. The activated platelets also release adeno- sine diphosphate (ADP) and thromboxane A2 with subsequent activation of the clotting cascade. The growing thrombus obstructs or even blocks the blood flow in the vessel. Atherosclerotic thrombi are also the source for embolisms, which are the primary pathophysiological mechanism of ischemic strokes, especially from carotid artery disease or of cardiac origin. Rupture or erosion of atheromatous plaques! adhesion of platelets ! thrombus ! obstruction of blood flow and source of emboli. Small-vessel disease usually affects the arterioles and is associated with hypertension. It is caused by suben- dothelial accumulation of a pathological protein, the hyaline, formed from mucopolysaccharides and matrix proteins, which leads to narrowing of the lumen or even occlusion of these small vessels. Often it is associated with fibrosis, which affects not only arterioles, but also other small vessels and capillaries and venules. Lipohyalinosis also weakens the vessel wall, predisposing for the formation of “miliary aneurysms.” Small-vessel disease results in two patho- logical conditions: status lacunaris (lacunar state) and status cribrosus (état criblé). Status lacunaris is char- acterized by small irregularly shaped infarcts due to occlusion of small vessels; it is the pathological sub- strate of lacunar strokes and vascular cognitive impairment and dementia. In status cribrosus small round cavities develop around affected arteries due to disturbed supply of oxygen and metabolic sub- strate. These “criblures” together with miliary aneur- ysms are the sites of vessel rupture causing typical hypertonic intracerebral hemorrhages [13–16]. A second type of small-vessel disease is characterized by the progressive accumulation of congophilic, βA4 immunoreactive, amyloid protein in the walls of small- to medium-sized arteries and arterioles. Cere- bral amyloid angiopathy is a pathological hallmark of Alzheimer’s disease and also occurs in rare genet- ically transmitted diseases, e.g. CADASIL and Fabry’s disease [17]. For a more detailed discussion of the etiology and pathophysiology of the various specific vascular disorders see [18–20]. Small-vessel disease: subendothelial accumulation of hyaline in arterioles. Types of acute cerebrovascular diseases Numbers relating to the frequency of the different types of acute CVD are highly variable depending on the source of data. The most reliable numbers come from the in-hospital assessment of stroke in the Framingham study determining the frequency of completed stroke: 60% were caused by athero- thrombotic brain infarction, 25.1% by cerebral embolism, 5.4% by subarachnoid hemorrhage, 8.3% by intracerebral hemorrhage, and 1.2% by undefined diseases. In addition, transient ischemic attacks (TIAs) accounted for 14.8% of the total cerebrovascular events [21]. Ischemic strokes result from a critical reduction of regional cerebral blood flow (rCBF) lasting beyond a critical duration, and are caused by atherothrombotic changes of the arteries supplying the brain or by emboli from sources in the heart, the aorta, or the large arteries. The pathological substrate of ischemic stroke is ischemic infarction of brain tissue, the loca- tion, extension, and shape of which depend on the size of the occluded vessel, the mechanism of arterial obstruction, and the compensatory capacity of the vascular bed. Occlusion of arteries supplying defined brain territories by atherothrombosis or embolization lead to territorial infarcts of variable size: they may be large – e.g. the whole territory supplied by the middle cerebral artery (MCA) – or small, if branches of large arteries are occluded or if compensatory collateral perfusion – e.g. via the circle of Willis or leptomenin- geal anastomoses – is efficient in reducing the area of critically reduced flow (Figure 1.2) [14, 16]. In a smaller number of cases infarcts can also develop at the borderzones between vascular territories,when several large arteries are stenotic and the perfusion in these “last meadows” cannot be constantly main- tained above the critical threshold of morphological integrity [22]. Borderzone infarctions are a subtype of the low-flow or hemodynamically induced infarctions which are the result of critically reduced cerebral perfusion pressure in far-downstream brain arteries. The more common low-flow infarctions affect sub- cortical structures within a vascular bed with pre- served but marginal irrigation [23]. Lacunar infarcts reflect disease of the vessels penetrating the brain to supply the capsule, the basal ganglia, thalamus, and paramedian regions of the brainstem [24]. Most often they are caused by lipohyalinosis of deep arteries (small-vessel disease); less frequent causes are stenosis Chapter 1: Neuropathology and pathophysiology of stroke 3 of the MCA stem and microembolization to penetrant arterial territories. Pathologically these lacunes are defined as small cystic trabeculated scars about 5 mm in diameter, but they are more often observed on magnetic resonance images, where they are accepted as lacunes up to 1.5 cm diameter. The classic lacunar syndromes include pure motor, pure sensory, and sensorimotor syndromes, sometimes ataxic hemi- paresis, clumsy hand, dysarthria, and hemichorea/ hemiballism, but higher cerebral functions are not involved. A new classification of stroke subtypes is mainly oriented on the most likely cause of stroke: atherosclerosis, small-vessel disease, cardiac source, or other cause [25]. Territorial infarcts are caused by an occlusion of arteries supplying defined brain territories by atherothrombosis or embolizations. Borderzone infarcts develop at the borderzone between vascular territories and are the result of a critically reduced cerebral perfusion pressure (low-flow infarctions). Lacunar infarcts are mainly caused by small-vessel disease. Hemorrhagic infarctions, i.e. “red infarcts” in contrast to the usual “pale infarcts,” are defined as ischemic infarcts in which varying numbers of blood cells are found within the necrotic tissue. The size can range from a few petechial bleeds in the gray matter of cortex and basal ganglia to large hemorrhages involv- ing the cortical and deep hemispheric regions. Hem- orrhagic transformation frequently appears during the second and third phase of infarct evolution, when macrophages appear and new blood vessels are formed in tissue consisting of neuronal ghosts and proliferating astrocytes. However, the only significant difference between “pale” and “red infarcts” is the intensity and extension of the hemorrhagic compon- ent, since in at least two-thirds of all infarcts petechial hemorrhages are microscopically detectable. Macro- scopically, red infarcts contain multifocal bleedings which are more or less confluent and predominate in cerebral cortex and basal ganglia, which are richer in capillaries than the white matter[26]. If the hemor- rhages become confluent intrainfarct hematomas might develop, and extensive edema may contribute to mass effects and lead to malignant infarction. The frequency of hemorrhagic infarctions in anatomical studies ranged from 18% to 42% [27], with a high incidence (up to 85% of hemorrhagic infarcts) in cardioembolic stroke [28]. Figure 1.2. Various types and sizes of infarcts due to different hemodynamic patterns a. Total territorial infarct due to defective collateral supply b. Core infarct, meningeal anastomosis supply peripheral zones c. Territorial infarct in center of supply area, due to branch occlusion d. Borderzone infarction in watershed areas due to stenotic lesions in arteries supplying neighboring areas e. Lacunar infarctions due to small-vessel disease. (Modified with permission from Zülch [14].) Section 1: Etiology, pathophysiology, and imaging 4 Mechanisms for hemorrhagic transformation are manifold and vary with regard to the intensity of bleeding. Petechial bleeding results from diapedesis rather than vascular rupture. In severe ischemic tissue vascular permeability is increased and endothelial tight junctions are ruptured. When blood circulation is spontaneously or therapeutically restored, blood can leak out of these damaged vessels. This can also happen with fragmentation and distal migration of an embolus (usually of cardiac origin) in the damaged vascular bed, explaining delayed clinical worsening in some cases. For the hemorrhagic transformation the collateral circulation might also have an impact: in some instances reperfusion via pial networks may develop with the diminution of peri-ischemic edema at borderzones of cortical infarcts. Risk of hemorrhage is significantly increased in large infarcts, with mass effect supporting the importance of edema for tissue damage and the deleterious effect of late reperfusion when edema resolves. In some instances also the rupture of the vascular wall secondary to ischemia-induced endothelial necrosis might cause an intra-infarct hematoma. Vascular rupture can explain very early hemorrhagic infarcts and early intrainfarct hematoma (between 6 and 18 hours after stroke), whereas hemorrhagic trans- formation usually develops within 48 hours to 2 weeks. Hemorrhagic infarctions are defined as ischemic infarcts in which varying amounts of blood cells are found within the necrotic tissue. They are caused by leakage from damaged vessels, due to increased vascular permeability in ischemic tissue or vascular rupture secondary to ischemia Intracerebral hemorrhage (ICH) occurs as a result of bleeding from an arterial source directly into the brain parenchyma and accounts for 5–15% of all strokes [29, 30]. Hypertension is the leading risk factor, but in addition advanced age, race and also cigarette smoking, alcohol consumption, and high serum cholesterol levels have been identified. In a number of instances ICH occurs in the absence of hypertension, usually in atypical locations. The causes include small vascular malformations, vasculitis, brain tumors, and sympathomimetic drugs (e.g. cocaine). ICH may also be caused by cerebral amyloid angiopathy and rarely damage is elicited by acute changes in blood pressure, e.g. due to exposure to cold. The occurrence of ICH is also influenced by the increasing use of antithrombotic and thrombolytic treatment of ischemic diseases of the brain, heart, and other organs [31, 32]. Spontaneous ICH occurs predominantly in the deep portions of the cerebral hemispheres (“typical ICH”) [33]. Its most common location is the putamen (35–50% of cases). The subcortical white matter is the second most frequent location (approx. 30%). Hemorrhages in the thalamus are found in 10–15%, in the pons in 5–12%, and in the cerebellum in 7% [34]. Most ICHs originate from the rupture of small, deep arteries with diameters of 50 to 200 μm which are affected by lipohyalinosis due to chronic hyper- tension. These small-vessel changes lead to weakening of the vessel wall and miliary microaneurysm and consecutive small local bleedings, which might be followed by secondary ruptures of the enlarging hematoma in a cascade or avalanche fashion [35]. After active bleeding has started it can continue for a number of hours with enlargement of hema- toma that is frequently associated with clinical deterioration [36]. Putaminal hemorrhages originate from a lateral branch of the striate arteries at the posterior angle, resulting in an ovoid mass pushing the insular cortex laterally and displacing or involving the internal capsule. From this initial putaminal-claustral loca- tion a large hematoma may extend to the internal capsule and lateral ventricle, into the corona radiata, and into the temporal white matter. Putaminal ICHs are considered the typical hypertensive hemorrhages. Caudate hemorrhage, a less common formof bleeding from distal branches of lateral striate arter- ies, occurs in the head of the caudate nucleus. This bleeding soon connects to the ventricle and usually involves the anterior limb of the internal capsule. Thalamic hemorrhages can involve most of this nucleus and extend into the third ventricle medially and the posterior limb of the internal capsule laterally. The hematoma may press on or even extend into the midbrain. Larger hematomas often reach the corona radiata and the parietal white matter. Lobar (white matter) hemorrhages originate at the cortico-subcortical junction between gray and white matter and usually spread along the fiber bundles in the parietal and occipital lobes. The hematomas are close to the cortical surface and usually not in direct contact with deep hemisphere structures or the ven- tricular system. As atypical ICHs they are not neces- sarily correlated with hypertension. Chapter 1: Neuropathology and pathophysiology of stroke 5 Cerebellar hemorrhages usually originate in the area of the dentate nucleus from rupture of distal branches of the superior cerebellar artery and extend into the hemispheric white matter and into the fourth ventricle. The pontine tegmentum is often com- pressed. A variant, the midline hematoma, originates from the cerebellar vermis, always communicates with the fourth ventricle, and frequently extends bilaterally into the pontine tegmentum. Pontine hemorrhages from bleeding of small para- median basilar perforating branches cause medially placed hematomas involving the basis of the pons. A unilateral variety results from rupture of distal long circumferential branches of the basilar artery. These hematomas usually communicate with the fourth ventricle, and extend laterally and ventrally into the pons. The frequency of recurrent ICHs in hypertensive patients is rather low (6%) [37]. Recurrence rate is higher with poor control of hypertension and also in hemorrhages due to other causes. In some instances multiple simultaneous ICHs may occur, but also in these cases the cause is other than hypertension. In ICHs, the local accumulation of blood des- troys the parenchyma, displaces nervous structures, and dissects the tissue. At the bleeding sites fibrin globes are formed around accumulated platelets. After hours or days extracellular edema develops at the periphery of the hematoma. After 4 to 10 days the red blood cells begin to lyse, granulocytes and thereafter microglial cells arrive, and foamy macro- phages are formed, which ingest debris and hemosi- derin. Finally, the astrocytes at the periphery of the hematoma proliferate and turn into gemistocytes with eosinophylic cytoplasma. When the hematoma is removed, the astrocytes are replaced by glial fibrils. After that period – extending to months – the residue of the hematoma is a flat cavity with a reddish lining resulting from hemosiderin-laden macrophages [34]. Intracerebral hemorrhage (ICH) occurs as a result of bleeding from an arterial source directly into the brain parenchyma, predominantly in the deep portions of the cerebral hemispheres (typical ICH). Hypertension is the leading risk factor, and the most common location is the putamen. Cerebral venous thrombosis (CVT) can develop from many causes and due to predisposing conditions. CVT is often multifactorial, when various risk factors and causes contribute to the development of this dis- order [38]. The incidence of septic CVT has been reduced to less than 10% of cases, but septic cavernous sinus thrombosis is still a severe, however, rare prob- lem. Aseptic CVT occurs during puerperium and less frequently during pregnancy, but may also be related to use of oral contraceptives. Among the non- infectious causes of CVT congenital thrombophilia, particularly prothrombin and factor V Leiden gene mutations, as well as antithrombin, protein C, and protein S deficiencies must be considered. Other con- ditions with risk for CVT are malignancies, inflamma- tory diseases, and systemic lupus erythematosus. However, in 20–35% of CVT the etiology remains unknown. The fresh venous thrombus is rich in red blood cells and fibrin and poor in platelets. Later on, it is replaced by fibrous tissue, occasionally with reca- nalization. The most common location of CVT is the superior sagittal sinus and the tributary veins. Whereas some thromboses, particularly of the lateral sinus, may have no pathological consequences for the brain tissue, occlusion of large cerebral veins usually leads to a venous infarct. These infarcts are located in the cortex and adjacent white matter and often are hemorrhagic. Thrombosis of the superior sagittal sinus may lead only to brain edema, but usually causes bilateral hemorrhagic infarcts in both hemispheres. These venous infarcts are different from arterial infarcts: cytotoxic edema is absent or mild, vasogenic edema is prominent, and hemorrhagic transformation or bleeding is usual. Despite this hemorrhagic component heparin is the treatment of choice. Cerebral venous thrombosis can lead to a venous infarct. Venous infarcts are different from arterial infarcts: cytotoxic edema is absent or mild, vasogenic edema is prominent, and hemorrhagic transformation or bleeding is usual. Cellular pathology of ischemic stroke Acute occlusion of a major brain artery causes a stereotyped sequel of cellular alterations which evolve over a protracted period of time and which depend on the topography, severity, and duration of ischemia [39]. The most sensitive brain cells are neurons, followed – in this order – by oligodendrocytes, astro- cytes, and vascular cells. The most vulnerable brain regions are hippocampal subfield CA1, neocortical Section 1: Etiology, pathophysiology, and imaging 6 layers 3, 5, and 6, the outer segment of striate nucleus, and the Purkinje and basket cell layers of cerebellar cortex. If blood flow decreases below the threshold of energy metabolism, the primary pathology is necrosis of all cell elements, resulting in ischemic brain infarct. If ischemia is not severe enough to cause primary energy failure, or if it is of so short duration that energy metabolism recovers after reperfusion, a delayed type of cell death may evolve which exhibits the morphological characteristics of necrosis, apop- tosis, or a combination of both. In the following, primary and delayed cell death will be described separately. Primary ischemic cell death In the core of the territory of an occluded brain artery the earliest sign of cellular injury is neuronal swelling or shrinkage, the cytoplasm exhibiting microvacuolation (MV) which ultrastructurally has been associated with mitochondrial swelling [40]. These changes are potentially reversible if blood flow is restored before mitochondrial membranes begin to rupture. One to two hours after the onset of ische- mia, neurons undergo irreversible necrotic alterations (red neuron or ischemic cell change). In conven- tional hematoxylin-eosin-stained brain sections such neurons are characterized by intensively stained eosi- nophilic cytoplasma, formation of triangular nuclear pyknosis, and direct contact with swollen astrocytes (Figure 1.3). Electron-microscopically mitochondria exhibit flocculent densities which represent denatu- rated mitochondrial proteins. Ischemic cell change must be distinguished from artifactual dark neurons which stain with all (acid or basic) dyes and are not surrounded by swollen astrocytes [41]. Control Necrotic changes Dark neuron artifact sham surgery red neuron 1 day 3 days sham surgery 4 hours ghost neuron 2 hours Acute ischemic changes shrinkageswelling Light-microscopical characteristics of rat infarction Figure 1.3. Light-microscopical evolution of neuronal changes after experimental middle cerebral occlusion. (Modifiedwith permission from Garcia et al. [126].) Chapter 1: Neuropathology and pathophysiology of stroke 7 With ongoing ischemia, neurons gradually loose their stainability with hematoxylin, they become mildly eosinophilic, and, after 2–4 days, transform to ghost cells with hardly detectable pale outline. Interestingly, neurons with ischemic cell change are mainly located in the periphery and ghost cells in the center of the ischemic territory, which suggests that manifestation of ischemic cell change requires some residual or restored blood flow whereas ghost cells may evolve in the absence of flow [39]. Primary ischemic cell death induced by focal ischemia is associated with reactive and secondary changes. The most prominent alteration during the initial 1–2 hours is perivascular and perineuronal astrocytic swelling, after 4–6 hours the blood–brain barrier breaks down, resulting in the formation of vasogenic edema, after 1–2 days inflammatory cells accumulate throughout the ischemic infarct, and within 1.5–3 months cystic transformation of the necrotic tissue occurs together with the development of a peri-infarct astroglial scar (Figure 1.4) Delayed neuronal death The prototype of delayed cell death is the slowly progressing injury of pyramidal neurons in the CA1 sector of the hippocampus after a brief episode of global ischemia [42]. In focal ischemia delayed neur- onal death may occur in the periphery of cortical infarcts or in regions which have been reperfused before ischemic energy failure becomes irreversible. Cell death is also observed in distant brain regions, notably in the substantia nigra and thalamus. The morphological appearance of neurons during the interval between ischemia and the manifestation of delayed cell death exhibits a continuum that ranges from necrosis to apoptosis with all possible combinations of cytoplasmic and nuclear morph- ology that are characteristic for the two types of cell death [43]. In its pure form, necrosis combines karyorrhexis with massive swelling of endoplasmic reticulum and mitochondria, whereas in apoptosis mitochondria remain intact and nuclear fragmenta- tion with condensation of nuclear chromatin gives way to the development of apoptotic bodies. A frequently used histochemical method for the visualization of apoptosis is terminal deoxyribonu- cleotidyl transferase (TdT)-mediated dUTP-biotin nick-end labeling (TUNEL assay), which detects DNA strand breaks. However, as this method may also stain necrotic neurons, a clear differentiation is not possible [44]. A consistent ultrastructural finding in neurons undergoing delayed cell death is disaggregation of Figure 1.4. Transformation of acute ischemic alterations into cystic infarct. Note pronounced inflammatory reaction prior to tissue cavitation. PMN ¼ polymorphonuclear leukocyte. (Modified with permission from Petito [39].) Section 1: Etiology, pathophysiology, and imaging 8 ribosomes, which reflects the inhibition of protein synthesis at the initiation step of translation [45]. Light-microscopically, this change is equivalent to tigrolysis, visible in Nissl-stained material. Disturb- ances of protein synthesis and the associated endo- plasmic reticulum (ER) stress are also responsible for cytosolic protein aggregation and the formation of stress granules [46]. In the hippocampus, stacks of accumulated ER may become visible but in other areas this is not a prominent finding. Pathology of the neurovascular unit The classical pathology of ischemic injury differenti- ates between the sensitivity of the various cell types of brain parenchyma with the neurons as the most vulnerable elements. The molecular analysis of injury evolution, however, suggests that ischemia initiates a coordinated multi-compartmental response of brain cells and vessels, also referred to as the neurovascular unit [47]. This unit includes microvessels (endothelial cells, basal lamina matrix, astrocytic endfeet, peri- cytes, and circulating blood elements), the cell body and main processes of astrocytes, the nearby neurons together with their axons, and supporting cells, notably microglia and oligodendrocytes. It provides the framework for the bi-directional communication between neuron and supplying microvessel. Under physiological conditions, the most prominent func- tion is the neurovascular coupling for maintaining adequate supply of brain nutrients and clearance of waste products. Pathophysiological disturbances of microcirculation, conversely, provoke coincidental microvessel–neuron responses, possibly mediated by alterations in the matrix of the vascular and non- vascular compartments of the ischemic territory. Severe ischemia induces primary cell death due to necrosis of all cell elements. Not so severe or short-term ischemia induces delayed cell death with necrosis, apoptosis, or a combination of both. The neurovascular unit provides the conceptual framework for the propagation of injury from microvessels to neurons. Animal models of stroke According to the Framingham study, 65% of strokes that result from vascular occlusion present lesions in the territory of the MCA, 2% in the anterior and 9% in the posterior cerebral artery territories; the rest is located in brainstem, cerebellum, in watershed, or multiple regions. In experimental stroke research, this situation is reflected by the preferential use of MCA occlusion models. Transorbital middle cerebral artery occlusion: this model was introduced in the 1970s for the production of stroke in monkeys [48] and later modified for use in cats, dogs, rabbits, and even rats. The procedure is technically demanding and requires microsurgical skills. The advantage of this approach is the possibility to expose the MCA at its origin from the internal carotid artery without retracting parts of the brain. Vascular occlusion can thus be performed without the risk of brain trauma. On the other hand, removal of the eyeball is invasive and may evoke functional disturbances which should not be ignored. Surgery may also cause generalized vasospasm which may interfere with the collateral circulation and, hence, induce variations in infarct size. The procedure there- fore requires extensive training before reproducible results can be expected. The occlusion of the MCA at its origin interrupts blood flow to the total vascular territory, including the basal ganglia which are supplied by the lenticulo- striate arteries. These MCA branches are end-arteries which in contrast to the cortical branches do not form collaterals with the adjacent vascular territories. As a consequence, the basal ganglia are consistently part of the infarct core whereas the cerebral cortex exhibits a gradient of blood flow which decreases from the peripheral towards the central parts of the vascular territory. Depending on the steepness of this gradient, a cortical core region with the lowest flow values in the lower temporal cortex is surrounded by a variably sized penumbra which may extend up to the parasagittal cortex. Transcranial occlusion of the middle cerebral artery: post- or retro-orbital transcranial approaches for MCA occlusion are mainly used in rats and mice because in these species the main stem of the artery appears on the cortical surface rather close to its origin from the internal carotid artery [49]. In con- trast to transorbital MCA occlusion, transcranial models do not produce ischemic injury in the basal ganglia because the lenticulostriate branches origin- ate proximal to the occlusion site. Infarcts, therefore, are mainly located in the temporo-parietal cortex with a gradient of declining flow values from the periph- eral to the central parts of the vascular territory. Filament occlusion of the middle cerebral artery: the presently most widely used procedure for MCA Chapter 1: Neuropathologyand pathophysiology of stroke 9 occlusion in rats and mice is the intraluminal filament occlusion technique, first described by Koizumi et al. [50]. A nylon suture with an acryl-thickened tip is inserted into the common carotid artery and ortho- gradely advanced, until the tip is located at the origin of the MCA. Modifications of the original technique include different thread types for isolated or com- bined vascular occlusion, adjustments of the tip size to the weight of the animal, poly-L-lysine coating of the tip to prevent incomplete MCA occlusion, or the use of guide-sheaths to allow remote manipulation of the thread for occlusion during polygraphic record- ings or magnetic resonance imaging. The placement of the suture at the origin of the MCA obstructs blood supply to the total MCA sup- plied territory, including the basal ganglia. It may also reduce blood flow in the anterior and posterior cere- bral arteries, particularly when the common carotid artery is ligated to facilitate the insertion of the thread. As this minimizes collateral blood supply from these territories, infarcts are very large and produce massive ischemic brain edema with a high mortality when experiments last for more than a few hours. For this reason, threads are frequently withdrawn 1–2 hours following insertion. The resulting reperfusion sal- vages the peripheral parts of the MCA territory, and infarcts become smaller [51]. However, the pathophy- siology of transient MCA occlusion differs basically from that of the clinically more relevant permanent occlusion models, and neither the mechanisms of infarct evolution nor the pharmacological responsive- ness of the resulting lesions replicate that of clinical stroke [52]. Transient filament occlusion is also an inappro- priate model for the investigation of spontaneous or thrombolysis-induced reperfusion. Withdrawal of the intraluminal thread induces instantaneous reperfu- sion whereas spontaneous or thrombolysis-induced recanalization results in slowly progressing recir- culation. As post-ischemic recovery is greatly influ- enced by the dynamics of reperfusion, outcome and pharmacological responsiveness of transient filament occlusion is distinct from most clinical situations of reversible ischemia, where the onset of reperfusion is much less abrupt. Clot embolism of middle cerebral artery: MCA embolism with autologous blood clots is a clinically highly relevant but also inherently variable stroke model which requires careful preparation and place- ment of standardized clots to induce reproducible brain infarcts [53]. The most reliable procedure for clot preparation is thrombin-induced clotting of auto- logous blood within calibrated tubings, which results in cylindrical clots that can be dissected in segments of equal length. Selection of either fibrin-rich (white) or fibrin-poor (red) segments influences the speed of spontaneous reperfusion and results in different outcome. Clots can also be produced in situ by microinjection of thrombin [54] or photochemically by ultraviolet illumination of the MCA following injection of rose Bengal [55]. The main application of clot embolism is for the investigation of experimental thrombolysis. The drug most widely used is human recombinant tissue plas- minogen activator (rtPA) but the dose required in animals is much higher than in humans, which must be remembered when possible side-effects such as rtPA toxicity are investigated. The hemodynamic effect, in contrast, is similar despite the higher dose and adequately reproduces the slowly progressing recanalization observed under clinical conditions. A recent development of clinical stroke treatment and possibly the central challenge for future animal research is interventional thrombectomy [56]. The animal most widely used for this research is the swine but as in this species the carotid access to the anterior cerebral vasculature is impeded by a rete mirabile, clot embolism and retrieval is carried out via the internal maxillary or lingual artery [57]. Angiographic studies confirm that clot retrieval using either aspiration or removable stent devices results in immediate recana- lization but a detailed pathophysiological analysis of post-ischemic reperfusion is not yet available. It is, therefore, premature to speculate whether this treat- ment and its effect on post-ischemic recovery can also be replicated in smaller animals by technically simpler mechanical occlusion models, such as transient fila- ment occlusion. Various procedures for artery occlusion models, mostly middle cerebral artery occlusion models, were developed to study focal ischemia in animals. Hemodynamics of stroke Normal regulation of blood flow In the intact brain, CBF is tightly coupled to the metabolic requirements of tissue (metabolic regula- tion) but the flow rate remains essentially constant over a wide range of blood pressures (autoregulation). Section 1: Etiology, pathophysiology, and imaging 10 An important requirement for metabolic regula- tion is the responsiveness of blood vessels to carbon dioxide (CO2 reactivity), which can be tested by the application of carbonic anhydrase inhibitors or CO2 ventilation. Under physiological conditions, blood flow doubles when CO2 rises by about 30 mmHg, and is reduced by one-third when CO2 declines by 15 mmHg. The vascular response to CO2 depends mainly on the changes of extracellular pH but it is also modulated by other factors such as prostanoids, NO, and neurogenic influences. Autoregulation of CBF is the remarkable capacity of the vascular system to adjust its resistance in such a way that blood flow is kept constant over a wide range of cerebral perfusion pressures (80–150 mmHg). The range of autoregulation is shifted to the right, i.e. to higher values, in patients with hypertension and to the left during hypercarbia. The mechanism of autoregulation is complex [58]. The dominating factor is a pressure-sensitive direct myogenic response initiated by the activation of stretch-sensitive cation channels of vascular smooth muscle. In addition, a flow-sensitive indirect smooth muscle response is initiated by changes in the shear stress of endothelial cells, which result in activation of various signal transduction pathways. Other influ- ences are mediated by metabolic and neurogenic factors but these may be secondary effects and are of lesser significance. Metabolic regulation: cerebral blood flow is coupled to metabolic requirements of tissue by a vascular response to changes in CO2. Autoregulation: cerebral blood flow is kept constant over a wide range of cerebral perfusion pressures. Disturbances of flow regulation Focal cerebral ischemia is associated with tissue acid- osis which leads to vasoparalysis and, in consequence, to a severe disturbance of the regulation of blood flow [59]. In the center of the ischemic territory, CO2 reactivity is abolished or even reversed, i.e. blood flow may decrease with increasing arterial pCO2. This paradoxical “steal” effect has been attributed to the rerouting of blood to adjacent non-ischemic brain regions in which CO2 reactivity remains intact. Stroke also impairs autoregulation but the dis- turbance is more severe with decreasing rather than with increasing blood pressure. This is explained by the fact that in the ischemic tissue a decrease of local brain perfusion pressure cannot be compensated by further vasorelaxation whereas an increase may shift the local perfusion pressure into the autoregulatory range and cause vasoconstriction. An alternative explanation is “false autoregulation” due to brain edema which causes an increase in local tissue pres- sure that precludes a rise of the actual tissue perfusion pressure. Failure of cerebral autoregulation can be demonstrated in such instances by dehydratingthe brain in order to reduce brain edema. After transient ischemia, vasorelaxation persists for some time, which explains the phenomenon of post-ischemic hyperemia or luxury perfusion. During luxury perfusion, oxygen supply exceeds oxygen require- ments of the tissue, as reflected by the appearance of red venous blood. With the cessation of tissue acido- sis, vascular tone returns, and blood flow declines to or below normal. At longer recirculation times auto- regulation – but not CO2 reactivity – may recover, resulting in persisting failure of metabolic regulation. This is one of the reasons why primary post-ischemic recovery may be followed by delayed post-ischemic hypoxia and secondary metabolic failure [60]. Disturbances of flow regulation through ischemia: tissue acidosis leads to vasorelaxation, CO2 reactivity is abolished or even reversed, and autoregulation is impaired. Disturbances of microcirculation With the increasing understanding of the pathobiol- ogy of the neurovascular unit, microcirculatory disturbances are recognized to contribute to the evo- lution of ischemic brain injury [61]. Such disturb- ances develop at the capillary level within the first hour of focal ischemia and may persist even after full reversal of vascular occlusion (incomplete microcir- culatory reperfusion). The dominating pathology is the narrowing of the capillary lumen, induced by constriction of pericytes and swelling of pericapillary astrocytic endfeet. The capillaries are filled with aggregated red blood cells, leukocytes, and fibrin/ platelet deposits, the high viscosity of which adds to the increased vascular resistance of the reduced capillary lumen. The mechanism of microcirculatory impairment is multifactorial. Pericytes constrict in response to the generation of reactive oxygen species (ROS), swelling of astrocytic endfeet is due to cytotoxic brain edema, and leukocyte adhesion to the vessel wall is part of the Chapter 1: Neuropathology and pathophysiology of stroke 11 inflammatory response mediated by the generation of chemoattractants, cytokines, and chemokines. Finally, the activation of proteolytic enzymes contributes to the dismantlement of basal lamina and results in damage of the blood–brain barrier, an increase in interstitial tissue pressure, and the risk of hemor- rhagic transformation. The impairment of microcirculation is equivalent to a reduction of nutritional blood flow. During per- manent vascular occlusion it aggravates the effect of primary ischemia, particularly in the borderzone of the infarct, and after transient vascular occlusion it prevents adequate reoxygenation despite recanaliza- tion of the supplying artery. It is still unresolved to what extent microcirculatory impairment contributes to or originates from ischemic injury but there is general consent that microvascular protection is a requirement for successful stroke treatment [62]. Focal brain ischemia is aggravated by microcirculatory disturbances which may persist despite recanalization. Anastomotic steal phenomena The brain is protected against focal disturbances of blood flow by the collateral circulation, which pro- vides a subsidiary network of vascular channels when principal conduits fail [63]. However, the connection of ischemic and non-ischemic vascular territories by anastomotic channels may divert blood from one brain region to another, depending on the magnitude and direction of the blood pressure gradients across the anastomotic connections (for review see Tode and McGraw [64]). The associated change of regional blood flow is called “steal” if it results in a decrease in flow, or “inverse steal” if it results in an improvement in flow. Inverse steal has also been referred to as the Robin Hood syndrome in analogy to the legendary hero who took from the rich and gave to the poor. Steals are not limited to a particular vascular ter- ritory and may affect both the extra- and intracerebral circulation. Examples of extracerebral steals are the subclavian, the occipital-vertebral, and the ophthal- mic steal syndrome. Intracerebral steal occurs across collateral pathways of brain, notably the circle of Willis and Heubner’s network of pial anastomoses. The pathophysiological importance of steal has been disputed but as it depends on the individual hemody- namic situation it may explain unintended effects when flow is manipulated by alterations of arterial pCO2 or vasoactive drugs. Most authors, therefore, do not recommend such manipulations for the treatment of stroke. “Steal”: decrease in focal blood flow when blood is diverted from one brain region to another by anastomotic channels; “inverse steal” if that results in an improvement in flow. The concept of ischemic penumbra Energy requirements of brain tissue The energy demand of the central nervous tissue is very high and therefore sufficient blood supply to the brain must be maintained constantly. A normal adult male’s brain containing about 130 billion neurons (21.5 billion in the neocortex) [65] comprises only 2% of total body mass, yet consumes at rest approxi- mately 20% of the body’s total basal oxygen consump- tion supplied by 16% of the cardiac blood output. The brain’s oxygen consumption is almost entirely for the oxidative metabolism of glucose, which in normal physiological conditions is the almost exclusive sub- strate for the brain’s energy metabolism (Table 1.1) [66]. Glucose metabolized in neuronal cell bodies is mainly to support cellular vegetative and house- keeping functions, e.g. axonal transport, biosynthesis of nucleic acids, proteins, and lipids, as well as other energy-consuming processes not related directly to the generation of action potentials. Therefore, the rate of glucose consumption of neuronal cell bodies is essentially unaffected by neuronal functional acti- vation. Increases in glucose consumption (and regional blood flow) evoked by functional activation are confined to synapse-rich regions, i.e. the neuropil, which contains axonal terminals, dendritic processes, and also the astrocytic processes that envelop the synapses. The magnitudes of these increases are lin- early related to the frequency of action potentials in Table 1.1. Cerebral blood flow (CBF), oxygen utilization (CMRO2), and metabolic rates of glucose (CMRGIc) in man (approximated values) Cortex White matter Global CBF (ml/100 g/min) 65 21 47 CMRO2 (μmol/100 g/min) 230 80 160 CMRGlc (μmol/100 g/min) 40 20 32 Section 1: Etiology, pathophysiology, and imaging 12 the afferent pathways, and increases in the projection zones occur regardless of whether the pathway is excitatory or inhibitory. Energy requirements of func- tional activation are due mostly to stimulation of the Na+/K+-ATPase activity to restore the ionic gradients across the cell membrane and the membrane poten- tials following spike activity, and are rather high com- pared to the basal energy demands of neuronal cell bodies (Figure 1.5) [67]. In excitatory glutamatergic neurons, which account for 80% of the neurons in the mammalian cortex, glucose utilization during activation is medi- ated by astrocytes which by anaerobic glycolysis pro- vide lactate to the neurons where it is used for oxidative metabolism [68]. Overall, 87% of the total energy consumed is required for signaling, mainly action potential propagation and postsynaptic ion fluxes, and only 13% is expended in maintaining membrane resting potential (Figure 1.5) [69]. The mechanisms by which neurotransmitters other than glutamate influence blood flow and energy metabolism in the brain are still not understood [70]. A normal adult male’s brain comprises only 2% of total body mass, yet consumes at rest approximately 20% of the body’s total basal oxygen consumption. Glucose is the almost exclusivesubstrate for the brain’s energy metabolism; 87% of the total energy consumed is required for signaling, mainly action potential propagation and postsynaptic ion fluxes. Viability thresholds of brain ischemia The different amounts of energy required for the generation of membrane potential and the propaga- tion of electrical activity are reflected by different thresholds of oxygen consumption and blood flow that must be maintained to preserve neuronal function and morphological integrity. Flow values below normal but above the threshold of neuronal function are referred to as “benign oligemia.” The flow range between the thresholds of neuronal function and morphological integrity is called the “ischemic penumbra” [71]. It is characterized by the preservation of membrane polarization and the potential of functional recovery without morpho- logical damage, provided that local blood flow can be re-established [72, 73]. The “infarct core” is the area in which blood flow declines below the thresh- old of morphological integrity and in which tissue necrosis evolves. According to the classical concept of viability thresholds, functional activity – reflected by the amplitudes of spontaneous and evoked electrical activity – begins to decline at flow values below 50% of control and is completely suppressed at about 30% of control [71]. In awake monkeys these values cor- respond to the progression of neurological injury from mild paresis at 22 ml/100 g/min to complete paralysis at 8 ml/100 g/min. Morphological damage AstrocyteGlutamate-releasingpresynaptic terminal Glycolysis Glucose Lactate Glucose Capillary 34% postsynaptic ion fluxes 3% glial resting potential 3% glutamate recycling 47% action potential propagation 3% presynaptic Ca2+ 10% neuronal resting potential Glu Glu EAAT Oxidative phosphorylation Gln Gln Postsynaptic site (a) (b) Na+/K+-ATPase Na+ Na+ K+ NMDAR lonotropic glutamate receptor Figure 1.5. (a) Schematic representation of the mechanism for glutamate-induced glycolysis in astrocytes during physiological activation [127]. (b). Distribution of energy expenditure in rat cortex at a mean spike rate of 4 Hz: most energy is required for activity, only 13% is used for maintenance of resting potentials of neurons and glial cells [69,128]. EAAT ¼ excitatory amino-acid transporter; NMDAR ¼ N-methyl- D-aspartate receptor. Chapter 1: Neuropathology and pathophysiology of stroke 13 evolves as soon as cell membranes depolarize (“ter- minal” depolarization) and occurs at flow values below 15–20% of control. Biochemically, functional suppression is associated with the inhibition of pro- tein synthesis at about 50% and the development of lactacidosis at 30–40% of control, whereas membrane depolarization and morphological injury correspond to the breakdown of energy metabolism and the loss of adenosine triphosphate (ATP) at about 18% of control (Figure 1.6). A more detailed picture of the dynamics of injury evolution is obtained by the simultaneous recording of local blood flow and spontaneous unit activity of cortical neurons [74]. According to these measure- ments, unit activity disappeared at a mean value of 18 ml/100 g/min but the large variability of the func- tional thresholds of individual neurons (6–22 ml/ 100 g/min) indicates differential vulnerability even within small cortical sectors. This explains the gradual development of neurological deficits, which may be related to differences in single cell activity with regu- lar or irregular discharges at flow levels above the threshold of membrane failure. Whereas neuronal function is impaired immedi- ately when flow drops below the threshold, the devel- opment of irreversible morphological damage is time dependent. Based on recordings from a considerable number of neurons during and after ischemia of varying degree and duration it was possible to con- struct a discriminant curve representing the worst possible constellation of residual blood flow and dur- ation of ischemia still permitting neuronal recovery (Figure 1.7). These results broaden the concept of the ischemic penumbra: the tissue fate – potential of recovery or irreversible damage – is determined not only by the level of residual flow but also by the duration of the flow disturbance. Each level of decreased flow can, on average, be tolerated for a defined period of time; flow between 17 and 20 ml/ 100 g/min can be tolerated for prolonged but yet undefined periods of time. As a rule used in many experimental models, flow rates of 12 ml/100 g/min lasting for 2–3 hours lead to large infarcts, but indi- vidual cells may become necrotic after shorter periods of time and at higher levels of residual flow. The ischemic penumbra is the range of perfusion between the flow threshold for preservation of function and the flow threshold for preservation of morphological integrity. It is characterized by the potential for functional recovery without morphological damage. Imaging of penumbra Based on the threshold concept of brain ischemia, the penumbra can be imaged on quantitative flow maps using empirically established flow thresholds. A more Figure 1.6. Diagrammatic representation of viability thresholds of focal brain ischemia. EEG ¼ electroencephalogram; OEF ¼ oxygen extraction fraction; SEP ¼ somatosensory evoked potential. Section 1: Etiology, pathophysiology, and imaging 14 Figure 1.7. (A) Activity of a single neuron during graded ischemia before, during, and after reversible MCA occlusion. (B) Recovery of neuronal function after a limited period of ischemia. (C) Diagram of CBF thresholds required for the preservation of function and morphology of brain tissue. The activity of individual neurons is blocked when flow decreases below a certain threshold (upper dashed line) and returns when flow is raised again above this threshold. The fate of a single cell depends on the duration for which CBF is impaired below a certain level. The solid line separates structurally damaged from functionally impaired, but morphologically intact tissue, the “penumbra.” The upper dashed line distinguishes viable from functionally impaired tissue. EP ¼ evoked potentials. (Modified with permission from Heiss and Rosner [129]). Chapter 1: Neuropathology and pathophysiology of stroke 15 precise approach is the imaging of threshold- dependent biochemical disturbances to demarcate the mismatch between disturbances which occur only in the infarct core and others which also affect the penumbra (Figure 1.8) [75]. Under experimental con- ditions themost reliable way to localize the infarct core is the loss of ATP on bioluminescent images of tissue ATP content. A biochemical marker of core plus pen- umbra is tissue acidosis or the inhibition of protein synthesis. The penumbra is the difference between the respective lesion areas. The reliability of this approach is supported by the precise colocalization of gene tran- scripts that are selectively expressed in the penumbra, such as the stress protein hsp70, or the documentation of the gradual disappearance of the penumbra with increasing ischemia time [76]. Non-invasive imaging of the penumbra is possible using positron emission tomography (PET) or mag- netic resonance imaging (MRI). Widely used PET parameters are the increase in oxygen extraction or the mismatch between reduced blood flow and the preservation of vitality markers, such as flumazenil binding to central benzodiazepine receptors [77]. An alternative PET approach is the use of hypoxia markers such as 18F-misonidazole (F-MISO), which is trapped in viable hypoxic but not in normoxic or necrotic tissue [78]. The best-established MRI approach for penumbra imaging is the calculation of mismatch maps between the signal intensities of perfusion (PWI)and diffusion- weighted images (DWI), but its reliability has been questioned [79]. An alternative method is quanti- tative mapping of the apparent diffusion coefficient (ADC) of water, which reveals a robust correlation with the biochemically characterized penumbra for ADC values between 90% and 77% of control [80]. Recently MR stroke imaging has been performed by combining PWI, DWI, and pH-weighted imaging (pHWI) [81]. The mismatch between DWI and pHWI detects the penumbra, and that between PWI and pHWI the area of benign oligemia, i.e. a region in which flow reduction is not severe enough to cause metabolic disturbances. Diffusion kurtosis imaging (DKI), an extension of diffusion imaging, demarcates the regions with structural damage that cannot be salvaged upon reperfusion [82]. Finally, new developments in MR molecular imaging are of increasing interest for stroke research [83]. These methods make use of contrast-enhanced probes that trace gene transcription or of intracellular conjugates that reflect the metabolic status and/or bind to stroke markers. The number of molecules that can be identified by these methods rapidly expands and greatly facilitates the regional analysis of stroke injury. Non-invasive imaging of the penumbra is possible using positron emission tomography (PET) or magnetic resonance imaging (MRI). Mechanisms of infarct expansion With the advent of non-invasive imaging evidence has been provided that brain infarcts grow (Figure 1.9). This growth is not due to the progression of ischemia because the activation of collateral blood supply and spontaneous thrombolysis tend to improve blood flow over time. Infarct progression can be differenti- ated into three phases. During the acute phase tissue Figure 1.8. Biochemical imaging of infarct core, penumbra, and benign oligemia after experimental middle cerebral artery occlusion. The core is identified by ATP depletion, the penumbra by the mismatch between the suppression of protein synthesis and ATP depletion (top) or by the mismatch between tissue acidosis and ATP (bottom), and benign oligemia by the reduction of blood flow in the absence of biochemical alterations. (Modified with permission from Hossman and Mies [130]). Section 1: Etiology, pathophysiology, and imaging 16 injury is the direct consequence of the ischemia- induced energy failure and the resulting terminal depolarization of cell membranes. At flow values below the threshold of energy metabolism this injury is established within a few minutes after the onset of ischemia. During the subsequent subacute phase, the infarct core expands into the peri-infarct penumbra until, after 4–6 hours, core and penumbra merge. The reasons for this expansion are peri-infarct spreading depressions and a multitude of cell biological disturb- ances, collectively referred to as molecular cell injury. Moreover, a delayed phase of injury evolves which may last for several days or even weeks. During this phase secondary phenomena such as vasogenic edema, inflammation, and possibly programmed cell death may contribute to a further progression of injury. The largest increment of infarct volume occurs during the subacute phase in which the infarct core expands into the penumbra. Using multiparametric imaging techniques for the differentiation between core and penumbra, evidence could be provided that in small rodents submitted to permanent occlusion of the MCA at its origin, the penumbra equals the volume of the infarct core at 1 hour, but after 3 hours more than 50% and between 6 and 8 hours almost all of the penumbra has disappeared and is now part of the irreversibly damaged infarct core [76]. In larger animals the infarct core may be heterogeneous with multiple mini-cores surrounded by multiple mini- penumbras but these lesions also expand and eventu- ally progress to a homogeneous defect with a similar time course [84]. Brain infarcts evolve in three phases: � acute phase, within a few minutes after the onset of ischemia; terminal depolarization of cell membranes; � subacute phase, within 4–6 hours; spreading depression and molecular cell injury, the infarct core expands into the peri-infarct penumbra; � delayed phase, several days to weeks; vasogenic edema, inflammation, and possibly programmed cell death. In the following, the most important mediators of infarct progression will be discussed. Peri-infarct spreading depression A functional disturbance contributing to the growth of the infarct core into the penumbra zone is the generation of peri-infarct spreading depression-like depolarizations (Figure 1.9) [85]. These depolariza- tions are initiated at the border of the infarct core and spread over the entire ipsilateral hemisphere. During spreading depression the metabolic rate of the tissue markedly increases in response to the Figure 1.9. Relationship between peri- infarct spreading depressions (above) and infarct growth (below) during permanent focal brain ischemia induced by occlusion of the middle cerebral artery in rat. The effect of spreading depressions on electrical brain activity (EEG) and blood flow (LDF) are monitored by DC recording of the cortical steady potential, and infarct growth by MR imaging of the apparent diffusion coefficient (ADC) of brain water. (Modified with permission from Hossmann [131,132]). Chapter 1: Neuropathology and pathophysiology of stroke 17 greatly enhanced energy demands of the activated ion exchange pumps. In the healthy brain the associated increase of glucose and oxygen demands are coupled to a parallel increase of blood flow but in the peri- infarct penumbra this flow response is suppressed or even reversed [86]. As a result, a misrelationship arises between the increased metabolic workload and the low oxygen supply, leading to transient epi- sodes of hypoxia and the stepwise increase in lactate during the passage of each depolarization. The pathogenic importance of peri-infarct depo- larizations for the progression of ischemic injury is supported by the linear relationship between the number of depolarizations and infarct volume. Cor- relation analysis of this relationship suggests that during the initial 3 hours of vascular occlusion each depolarization increases the infarct volume by more than 20%. This is probably one of the reasons that glutamate antagonists, which are potent inhibitors of spreading depression, reduce the volume of brain infarcts [87]. Peri-infarct spreading depressions are depolarizations initiated at the border of the infarct core and may contribute to progression of ischemic injury. Molecular mechanisms of injury progression In the borderzone of permanent focal ischemia or in the core of the ischemic territory after transient vas- cular occlusion, cellular disturbances may evolve that cannot be explained by a lasting impairment of blood flow or energy metabolism. These disturbances are referred to as molecular injury, where the term “molecular” does not anticipate any particular injury pathway (for reviews see [88], [89]). The molecular injury cascades (Figure 1.10) are interconnected in complex ways, which makes it difficult to predict their relative pathogenic importance in different ischemia models. In particular, molecular injury induced by transient focal ischemia is not equivalent to the alter- ations that occur in the penumbra of permanent ischemia. Therefore, the relative contribution of the following injury mechanisms differs in different types of ischemia. Acidotoxicity: during ischemia oxygen depletion and the associated activation of anaerobic glycolysis cause an accumulation of lactic acid which, depending on the severity of ischemia, blood glucose levels, and the degree of ATP hydrolysis, results in a decline of intracellular pH to between 6.5 and below 6.0.
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