Cook R.A., Stewart B. Colour Atlas of Anatomical Pathology

NERVOUS

SYSTEM

Fig. 11.53

Effects

of

raised

intracranial

pressure

-

Figs

11.50-11.55

Fig. 11.50

Tonsillar

herniation

of the

cerebellum.

The

groove

made

by the

foramen magnum

can be

seen. There

had

been increased intracranial pressure,

and

this forced

the

cerebellar

tonsils

through

the

foramen magnum causing

pressure

on the

brain stem

-

'coning'.

Fig. 11.51

Uncal

herniation.

The

same brain

as in

Figure

11.50.

The

brain

is

viewed

on its

undersurface

and the

left

uncus

is

more prominent than

the

right.

It has

herniated medially,

causing stretching

of the

posterior communicating artery,

and

would have caused stretching

of the

sixth nerve

as

well.

The

tonsillar herniation

of the

cerebellum

is

also apparent.

Fig. 11.52

Multiple

brain-stem

haemorrhages.

Another

complication

of

raised intracranial pressure

and

frequently

the

final

cause

of

death. (Brain-stem haemorrhage

may

also result

from external trauma.)

Fig. 11.53

Recent

infarction

of

both

occipital

lobes

due

to

occlusion

of

both

posterior

cerebral

arteries

caused

by

compression

of the

arteries against

the

free

edge

of the

tentorium cerebelli

by

raised intracranial pressure.

Fig. 11.54 Coronal section

of the

brain, showing

the

distribution

of

this infarction. Note

the

infarction

of the

posterior

end of the

thalamus because

it is

supplied

by

branches

of the

posterior cerebral artery.

Fig. 11.55

Infarction

of the

cerebral

peduncles,

which

are

also

supplied

by

small branches

of the

posterior cerebral

arteries.

Many

of the

small branches

of

this artery,

and of the

other arteries forming

the

circle

of

Willis,

can be

seen

in

this

photograph.

Fig. 11.54

Fig. 11.55

251

NERVOUS

SYSTEM

Fig. 11.58

252

Fig.

11.56

Fig. 11.57

NERVOUS

SYSTEM

Fig. 11.56

Sagittal

sinus

thrombosis.

F/2. There

is

thrombus

in the

sagittal sinus

and in the

cortical veins that

drain

into

it. In

this case

the

thrombosis

was a

result

of

dehydration from diarrhoea.

Fig. 11.57

Cortical

vein

thrombosis.

Thrombosis

of the

cortical veins draining into

the

sagittal sinus.

Fig. 11.58

Sagittal

sinus

and

cortical

vein

thrombosis.

Vertical

slice through

the

brain, showing infarction

and

liquefaction

of

brain substance drained

by the

cortical veins.

This

infarction

is in the

region

of the

precentral gyrus.

Fig. 11.59

Right

orbital

cellulitis.

M/41. This

is a

serious

infection

because

the

orbital veins drain directly through

the

orbital fissure into

the

cavernous sinus. This

man

recovered

after

treatment with antibiotics.

Fig. 11.60

Thrombosis

of the

right

cavernous

sinus.

F/6. There

is

infarction

of the

adjacent brain

due to

occlusion

of

the

veins that drain into

the

cavernous sinus. This followed

unsuccessful treatment

of

orbital cellulitis.

Fig.

11.59

Fig.

11.60

253

NERVOUS

SYSTEM

254

Fig.

11.61

Fiq.

11.62

NERVOUS

SYSTEM

Fig.

11.63

Fig.

11.64

Fig. 11.61 Normal

brain.

Slice

of

brain showing

the

normal

internal deep cerebral veins running between

the

head

of the

caudate nucleus

and the

thalamus.

Can you

identify

all the

anatomical structures

in

this slice

of

brain?

Fig. 11.62

Deep

cerebral

vein

thrombosis.

F/3. Infarction

of

white matter

in

both hemispheres

in the

region

of the

internal

capsules resulting from thrombosis

of

branches

of the

deep

cerebral

veins. This occurred during

an

episode

of

hypotension

following open heart surgery.

Fig. 11.63 Extradural

haemorrhage.

M/16. This resulted

from

rupture

of the

right middle meningeal artery following

a

head

injury.

The

classic history

in

such cases

is:

injury; quickly

becomes unconscious; recovery (apparently normal)

an

hour

or

so

later; unconscious again.

Fig. 11.64

Subdural

haemorrhage

resulting

from

rupture

of

veins

following

a

head

injury.

M/3.

Fig. 11.65

Intracerebral

haemorrhage.

M/50. Hypertension.

Death followed

a few

hours after

the

sudden onset

of

unconsciousness. Haemorrhage fills

the

third

and

both lateral

ventricles.

The

insert

is a CT

scan

of

this patient taken

on

admission

to

hospital.

It

shows

the

haemorrhage.

Fig. 11.65

255

NERVOUS

SYSTEM

Fig. 11.67

Fig. 11.66

Pontine

haemorrhage.

F/42. Hypertension.

Fig. 11.67

Intracerebellar

haemorrhage.

M/82.

Hypertension. This

is the

least common type

of

hypertensive

haemorrhage.

Fig. 11.68

Acute

gastric

erosions.

M/57.

A

well recognized

complication

of

intracerebral haemorrhage.

256

Fig.

11.66

Fig. 11.68

NERVOUS SYSTEM

Fig. 11.69

Multiple

haemorrhages

through

both

hemispheres.

F/16.

The

patient

had

acute myeloblastic

leukemia

and

died

as a

result

of a

bleeding diathesis.

The

fact

that

the

haemorrhages

are

multiple indicates

a

bleeding disorder

rather

than rupture

of a

major vessel. These

two

brain slices

follow

in

sequence,

the

upper

one

first. They

are

both viewed

from

the

anterior aspect.

Fig. 11.70 Haemorrhage

into

the

spinal

cord.

M/61. This

resulted from

a

road traffic accident.

257

Fig.

11.70

NERVOUS

SYSTEM

Fig. 11.71

Fig. 11.71 Berry

aneurysm

on the

anterior communicating

artery.

M/48.

The

aneurysm

bled,

causing subarachnoid

haemorrhage. Surgical clips were applied

to the

base

of the

aneurysm

to

control

the

bleeding. Note

the

arteries forming

the

circle

of

Willis. (The letters

are

explained

in the

legend

to

Figure

11.74.)

Fig. 11.72

Subarachnoid

haemorrhage

in the

spinal cord

following

rupture

of a

berry

aneurysm.

F/33.

The

white spinal

cord,

seen

at the

upper

end of the

photograph,

is

encased

by

blood

filling

the

subarachnoid space.

The

classic presentation

is a

sudden

onset

of

severe headache, followed quickly

by

unconsciousness.

Clinical examination shows marked neck stiffness.

258

Fig.

11.72

NERVOUS

SYSTEM

Fig.

11.73

Fig. 11.73 Ruptured aneurysm

on the

right

internal

carotid

artery

at the

point

where

it

becomes

the

middle

cerebral

artery- F/57.

It had

caused subarachnoid

haemorrhage

and had

extended into

the

optic nerve.

The

aneurysms

illustrated

in

Figures 11.71

and

11.73

are the

commonest sites

for

intracerebral aneurysms.

259

Fig.

11.74

Fig. 11.74

Large

unruptured

aneurysm

of the

basilar

artery,

an

incidental

finding.

F/61.

In

this photograph

the

pons

and

brain stem (medulla oblongata)

are

viewed

in

situ

as

the

brain

was

being removed during postmortem examination.

At

the top of the

photograph

one

sees

the

optic

nerves

(A)

optic chiasm (which

has

been removed).

The

third

nerves

(B) are

present lateral

to the

middle cerebral arteries.

The

thin fourth nerve

(C) can be

seen

on the

left side beneath

the

third nerve.

The

fifth nerve

(D) can be

seen

on the

right side

beneath

the

dura mater

on the

surface

of the

petrous temporal

bone (E).

The

middle cerebral arteries

(F) are

lateral

to the

pituitary

fossa.

The

bone

of the

posterior

surface

of the

pituitary

fossa forms

the

clivus

and

extends downwards into

the

foramen

magnum.

The

brain stem (medulla oblongata) extends into

the

foramen

magnum

and

becomes

the

spinal cord.

The

aneurysm

is

in the

basilar

artery, which

runs

on the

of the

pons.

On the

right side

of the

photograph

the

seventh

(larger)

and

eighth (smaller) nerves

(G) are

passing into

the

petrous

temporal bone.

The

origin

of the

thick fifth nerve from

the

middle

of

the

pons

(H) can be

seen

on the

left side

of the

photograph.

The

ninth, tenth, eleventh

and

twelfth nerves

(I)

arise from

the

brain stem

and can be

seen

in the

foramen magnum

on the

right

side

of the

photograph.

Refer

to

Figure

11.71.

Here

we see the

first (olfactory) nerves

(J)

on the

inferior surface

of the

medial portion

of the

frontal

lobes. These nerves

end in a

bulb

- the

olfactory

bulb.

This

is

better seen

in the

nerve

on the

right

of the

photograph.

The

optic

nerve

and

optic

chiasm

can be

seen (K).

Immediately

behind

the

optic nerve

is the

stalk

of the

pituitary gland (L). Through

the

hole

in

the

leptomeninges

the two

mamillary bodies

can be

seen.

The

beginnings

of the two

middle cerebral arteries from

the

terminations

of the

internal carotid arteries

can be

seen (M).

The

third nerves

can be

seen passing

on the

medial side

of the

cerebral peduncle (N).

The

thin fourth nerve

can be

seen passing

on

the

lateral

surface

of the

cerebral

peduncle

on the

left side

of

the

photograph.

The

right sixth

nerve

(O) can be

seen arising

from

the

lower border

of the

pons

in

Figure 11.83.

The

third,

fourth

and

sixth nerves pass anteriorly

in the

lateral wall

of the

cavernous

sinus,

and

thence

to the

orbit.

It is

easy

to

understand

how the

nerves

can be

stretched whenever there

is

raised intracranial pressure,

and

compressed

by an

aneurysm

or

a

tumour

in

their course from

the

brain stem

to the

points where

they exit

the

skull.

260

NERVOUS SYSTEM

Cook R.A., Stewart B. Colour Atlas of Anatomical Pathology

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