GENERAL PATHOLOGY LABORATORY : ISCHEMIC

STROKE
Group 4

Bacon, Jereel Hope

Chan Baquero, Vic Benson
Clerino, Mark Christian
Ibona, Hanzel
Jowak, Halima
Noynay, Riddle
Ong, Mary Madelene
Pidor, Marica
Ramos, Walidah U.
Usman, Hadja Yasmin

MEDICINE 2-A

Presentation of Case:

An 81-year-old man unable to move his right arm or leg and unable to
speak.
The patient had a stroke about a year before with profound
weakness of his left arm and leg.

Brain Autopsy results:

Patchy parenchymal loss and severe cerebrovascular atherosclerosis

Multifocal parenchymal lesions on coronal sections of the cerebral
hemispheres and some of which were centred at the depths of sulci
Some lesions were granular or crumbly and some were cystic
A large lesion in the left lateral frontal lobe and nearly the entire pons
were simply softened

DIFFERENTIAL DIAGNOSIS

FINAL DIAGNOSIS

Ischemic stroke
- occurs when a blood vessel that supplies blood to the brain is
blocked by a blood clot
-presence of severe atherosclerosis
- may happen in two ways:
thrombotic stroke
embolic stroke
-symptoms
muscle weakness, hemiparesis, aphasia
PATHOPHYSIOLOGY

TREATMENT AND MANAGEMENT

1. Fibrinolytic Therapy fibrinolytics restore cerebral blood flow in patient and
may lead to improvement or resolution of neurologic deficits. Unfortunately,
fibrinolytics may also cause symptomatic intracranial haemorrhage. (ex. tPA)
2. Intra-arterial Reperfusion theoretically, intra-arterial delivery may produce
higher local concentration of the fibrinolytic agent at lower doses (and thus
lower risk of systemic blee) and allow a longer therapeutic window.
3. Antiplatelet Agents Aspirin, 323mg orally within 24-48 hours of ischemic
stroke onset. The benefit of aspirin is modest but statistically significant and
appears principally to involve the reduction of recurrent stroke
4. Blood pressure control Thresholds for antihypertensive treatment in acute
ischemic stroke patients who are not fibrinolysis candidate, are systolic blood
pressure higher than 220mm Hg or diastolic pressure of 120 mm Hg. In those
patients, a reasonable goal is to lower blood pressure by 15% during the first
24 hours.
5. Mechanical Thrombectomy Mechanical clot disruption is an alternative for
patients in whom fibrinolysis is ineffective or contraindicated.
6. Medications medications for the management of ischemic stroke can be
distributed into following categories:
Anticoagulation
Reperfusion
Antiplatelet
Neuroprotective
PROGNOSIS
In the Framingham and Rochester stroke studies, the overall mortality rate at

30 days after stroke was 28%, he mortality rate at 30 days after ischemic
stroke was 19%, and the 1-year survival rate for patient with ischemic stroke
was 77%. However, the prognosis after acute ischemic stroke varies greatly
in individual patients, depending on the stroke severity and on the patients
premorbid condition, age, and post stroke complications.

QUESTIONS AND GUIDE TO DISCUSSION

1. REVIEW THE ANATOMY AND HISTOLOGY OF THE ORGAN
INVOLVED
The brain is made of three main parts:
1. Forebrain- consists of the cerebrum, thalamus, and hypothalamus (part of
the limbic system).
2. Midbrain- consists of the tectum and tegmentum

3. Hindbrain- is made of the cerebellum, pons and medulla.

Often the midbrain, pons, and medulla are referred to together as the
brainstem.

Cerebrum: The cerebrum or cortex is the largest part of the human

brain, associated with higher brain function such as thought and
action. The cerebral cortex is divided into four sections, called "lobes":
the frontal lobe, parietal lobe, occipital lobe, and temporal lobe.
Frontal Lobe- associated with reasoning, planning, parts of
speech, movement, emotions, and problem solving
Parietal Lobe- associated with movement, orientation,
recognition, perception of stimuli
Occipital Lobe- associated with visual processing
Temporal Lobe- associated with perception and recognition of
auditory stimuli, memory, and speech

A deep furrow divides the cerebrum into two halves, known as the left and
right hemispheres.

Cerebellum: The cerebellum, or "little brain", is similar to the cerebrum

in that it has two hemispheres and has a highly folded surface or
cortex. This structure is associated with regulation and coordination of
movement, posture, and balance.
Brain Stem: This structure is responsible for basic vital life functions
such as breathing, heartbeat, and blood pressure.
The brain stem is made of the midbrain, pons, and medulla.
Midbrain/ Mesencephalon- the rostral part of the brain stem,
which includes the tectum and tegmentum. It is involved in
functions such as vision, hearing, eye movement, and body
movement.
Pons- It is involved in motor control and sensory analysis.
Important for the level of consciousness and for sleep. Some
structures within the pons are linked to the cerebellum, thus are
involved in movement and posture.
Medulla Oblongata- this structure is the caudal-most part of the
brain stem, between the pons and spinal cord. It is responsible
for maintaining vital body functions, such as breathing and heart
rate.

Blood Vessels of the Brain

Blood is supplied to the brain, face, and scalp via two major sets of vessels:
the right and left common carotid arteries and the right and left vertebral
arteries.

Circle of Willis
Is a part of the cerebral circulation and is composed of the following arteries:

Anterior cerebral artery (left and right)

Anterior communicating artery
Internal carotid artery (left and right)
Posterior cerebral artery (left and right)
Posterior communicating artery (left and right)
Basilar artery

The cranial nerves:

Twelve large nerves exit the bottom of the brain to supply function to the
senses such as hearing, vision, and taste
1. The Olfactory Nerve
2. The Optic Nerve
3. The Oculomotor Nerve
4. The Trochlear Nerve
5. The Trigeminal Nerve
6. The Abducens Nerve
7. The Facial Nerve
8. The Auditory Nerve
9. The Glossopharyngeal Nerve
10.
The Vagus Nerve
11.
The Spinal Accessory Nerve
12.
The Hypoglossal Nerve
Histology of Brain
Cerebellum Cortex, 40x, Scanning Objective, Silver stain

Cerebellar cortex, 400z, high power objective, Silver Stain

The brain is enveloped by a connective tissue called meninges to protect the

central nervous system. It has three layers: dura mater which is the outer
layer and it is closed to the skull. The inbetween is the arachnoid meninges
which forms a spider-web like appearance and the inner layer is the pia
matter which adheres to the brain and descends down into lines sulci.
The visible layers in the cortex are the molecular layer and the granular layer
with the pyramidal cells. The pyramidal cells initiate conscious motor activity.
The largest is called the BETZ CELL. The dendrites of pyramidal cells collect
information leading to initiation of motor impulse. The astrocytes supply
nutrients to neurons and aids to the formation of blood brain barrier. The
dendritic collaterals collect impulse towards the cell body and the axon
conducts electrical impulses away from the cell body. Towards the center of
the cerebrum is the medulla which has the white matter.
Cerebellum, 40x, scanning objective, silver stain

Cerebellar cortex, 100x, Low power objective, Silver stain

The structure of the cerebellum is more refined and the sulci is deeper and
also the gyru is narrower. It is also called folia. There three layers visible in
the cerebellar cortex: Molecular layer, Purkinje cell layer and the granular
layer. The purkinje cell layer controls motor movement. It has a GABA
neurotransmitter which has inhibitory actions which reduces transmission of
nerve impulse.

2. Understand how these cells respond to injury

Cellular Adaptations
New and altered steady states may be achieved with excessive physiologic
stress or some pathological stimuli.
Adaptations are reversible changes in the size, number, phenotype,
metabolic activity, or functions of cells in response to changes in their
environment. Such adaptations may take several distinct forms:
1. Hypertrophy- refers to an increase in the size of cells that result in an
increase in the size of the affected organ.

2. Hyperplasia- is defined as an increase in the number of cells in an

organ or tissue in response to a stimulus.
3. Atrophy- is defined as a reduction in the size of an organ or tissue due
to a decrease in cell size and number.
4. Metaplasia is a reversible change in which one differentiated cell type
(epithelial or mesenchymal) is replaced by another cell type.
Cellular Swelling
This is usually an early and common manifestation of non-lethal hypoxic
injury.
This is caused by the failure of Na+, K+-ATPase; resulting in sodium entering
the cell and potassium leaving, and an isosmotic gain of water.
The endoplasmic reticulum balloons out as does the mitochondria.
This increase in water volume is known as "hydropic change" or "vacuolar
change" if there is a formation of vacuoles.
These changes are reversible if oxygenation is restored.

Intracellular Accumulations
Various substances can accumulate in cells and sometimes result in cell
injury.
This sort of cell injury is usually reversible. However, depending on the
intensity and duration of the accumulation, it may become irreversible.

Cell Death
When the injury to the cell is irreparable, it will eventually lead to cell death.
There are two important patterns of cell death:
o Apoptosis- is a pathway of cell death that is induced by a tightly
regulated suicide program in which cells destined to die activate
intrinsic enzymes that degrade the cells own nuclear DNA and nuclear
and cytoplasmic proteins.

o Necrosis- Necrosis has been considered an accidental and

unregulated form of cell death resulting from damage to cell
membranes and loss of ion homeostasis.

3. Given the gross finding of the organ, identify type of necrosis

involved in this case
Liquefactive necrosis (or colliquative necrosis)
-

A type of necrosis which results in a transformation of the tissue into a liquid

viscous mass.[1] Often it is associated with focal bacterial or fungal
infections. In liquefactive necrosis, the affected cell is completely digested by
hydrolytic enzymes, resulting in a soft, circumscribed lesion consisting of pus
and the fluid remains of necrotic tissue. Dead leukocytes will remain as a
creamy yellow pus.[1] After the removal of cell debris by white blood cells, a
fluid filled space is left. It is generally associated with abscess formation and
is commonly found in the central nervous system.
For unclear reason, hypoxic death of cells within the central nervous system
can result in liquefactive necrosis. This is a process in which lysosomes turn
tissues into pus as a result of lysosomal release of digestive enzymes. Loss of
tissue architecture means that the tissue can be liquefied. This process is not
associated with bacterial action or infection. Ultimately, in a living patient
most necrotic cells and their contents disappear.

Cystic parenchymal lesion

Granular parenchymal lesion

Severe Cerebrovascular Atheroscleros

5. Discuss the mechanism of cell injury and cell death with emphasis to
ischemic cell injury?

Upon brain autopsy, there were severe cerebrovascular atherosclerosis.

Atherosclerosis happens when there is a damage to the endothelium caused
by high blood pressure, smoking, or high cholesterol causing an entry of LDL
into the walls of the artery.

When this happens the white blood cells are originally sent by the body's
immune system to clean up LDL cholesterol pockets. When they stick to an
artery they secrete a molecule called netrin-1, this stops normal migration of
the macrophages out of the arteries. As a result, what you have left is a
mixture of clumped up cholesterol pockets and white blood cells, this is the
plaque that can disrupt blood flow.
LEADING TO:

Hypoxia
injury

(= decrease of oxygen supply) -most common cause of cell

-occurs usually as a result of ischemia (= loss of blood supply), which

occurs for example when arterial flow suffers from atherosclerosis or
thrombotic occlusion of arteries - most common cause of hypoxia
-is due to inadequate oxygenation, for example in cardiorespiratory
failure
-is caused by loss of oxygen-carrying capacity of the blood, either due
to anemia (decreased capacity of the blood for oxygen), or after poisoning
with carbon monoxide (CO)= loss of the carrying capacity of the blood
depending on the severity of hypoxia- the cell may undergo
-adaptation
-injury
-cell death

As the oxygen tension within the cell decreases, there is loss of

oxidative phosphorylation and decreased generation of ATP. The depletion of
ATP results in failure of the sodium pump, with loss of potassium, influx of
sodium and water, and cell swelling. There is progressive loss of glycogen
and decreased protein synthesis. There may be severe functional
consequences at this stage. If hypoxia continues, worsening ATP depletion
causes further morphologic deterioration. The cytoskeleton disperses,
resulting in the loss of ultrastructural features such as microvilli and the
formation of "blebs" at the cell surface. "Myelin figures," derived from plasma
as well as organellar membranes, may be seen within the cytoplasm or
extracellularly. They are thought to result from dissociation of lipoproteins
with unmasking of phosphatide groups, promoting the uptake and
intercalation of water between the lamellar stacks of membranes. At this
time, the mitochondria are usually swollen, owing to loss of volume control
by these organelles; the endoplasmic reticulum remains dilated; and the
entire cell is markedly swollen, with increased concentrations of water,

sodium, and chloride and a decreased concentration of potassium. If oxygen

is restored, all of these disturbances are reversible.

6. Discuss the causes of cell injury with emphasis to this

particular case. Is this reversible or irreversible?

If ischemia persists, irreversible injury and necrosis ensue. Irreversible injury

is associated morphologically with severe swelling of mitochondria, extensive
damage to plasma membranes, and swelling of lysosomes. Large, flocculent,
amorphous densities develop in the mitochondrial matrix. Death is mainly by
necrosis. After death, cell components are progressively degraded, and there
is widespread leakage of cellular enzymes into the extracellular space and,
conversely, entry of extracellular macromolecules from the interstitial space
into the dying cells. Finally, the dead cell may become replaced by large
masses composed of phospholipids in the form of myelin figures. These are
then either phagocytosed by other cells or degraded further into fatty acids.
Calcification of such fatty acid residues may occur with the formation of
calcium soaps.

7. Describe the morphologic alterations in cell injury. What are

the different patterns of tissue necrosis?
Morphology of cell injury
1.- Ultrastructural changes include:
cellular swelling - it is near-universal manifestation of cell injury
formation of cytoplasmic blebs and distortion of microvilli
deterioration of cell attachments
mitochondrial changes- occur very rapidly in ischemic injury, but are
delayed in some types of chemical injury.
early after ischemia- swelling of mitochondrias due to changes in ions
small to large size amorphous densities in mitochondrias- these consist of
lipids or lipid-protein complexes- dense granules rich in calcium (appear early
after reperfusion)
endoplasmic reticulum- changes of ER occur early after injury due to
changes in ion and water regulation - detachment of ribosomes and
disaggregation of polysomes -result in decrease of proteosynthesis
progressive fragmentation of ER - results in formation of myelin figures derived from plasma and organelle membranes (lipoproteins)
alterations of lysosomes in cell injury- generally appear later
lysosomes become swollen, and after the onset of lethal injury lysosomes
rupture and this event causes leakage of the lysosomal enzymes at this
stage= irreversible cell injury
heterophagy- is the uptake of materials from the external
environment by phagocytosis.
examples: phagocytosis and degradation of bacteria by leukocytes, removal
of necrotic debris by macrophages, reabsorption of protein
autophagy- is the phagocytosis by lysosomes of deteriorating
intracellular orgtanelles, including mitochondria and endoplasmic reticulum.
Autophagy is particularly pronounced in cells undergoing atrophy. Lysosomes
with undigested debris- are called autophagic vacuoles and may persist
within the cells as residual bodies or may be extruded from the cell

2- Light microscopic changes.

Reversible changes-in classic pathology nonlethal injury to cells were
termed degenerations, dystrophies, but today it is common to designate
them reversible injuries or regressive changes
two patterns can be recognized by light microscopy:
1-cellular swelling- appears whenever the cell is not capable of
maintaining ionic and water homeostasis
it is near-universal change in cell injury

-is the first manifestation of cell injury

-it may be sometimes difficult to appreciate with the light microscopy
alone, better evident at the level of organgrossly: the organ becomes paler, it shows an increased turgor, increased
weight
microscopically: enlargment of cells
- if water continues to accumulate-small clear vacuoles appear within
the cytoplasm (=distended segment of ER) =hydropic change or vacuolar
degeneration, for example: epithelial cells of renal tubuli

2-fatty change- is more often encountered in the cells involved in fat

metabolism, such as hepatocytes - Not so universal reaction as cell
swelling.
- refers to any abnormal accumulation of fat within parenchymal cells
-different mechanisms account for fatty change - later will be discussed
-fatty change is most commonly seen in the liver, heart, muscle,etc.
-although fatty change is an indicator of nonlethal injury, in many situations
is encountered in cells adjacent to those that have died and undergone
necrosis
Cell death is an irreversible change in the cell associated with its end
We can distinguish two different types of cell death, that differ one from
another in many aspects, particularly
-in morphologic changes
-in pathogenesis
- they have different causes
- different meaning and significance
These are-apoptosis
-necrosis

TYPES OF CELL DEATH - necrosis and apoptosis

APOPTOSIS
-Distinctive type of cell death- occurs in physiological and
embryological processes and appears to be a phenomenon whereby tissues
control cell population numbers
-apoptosis also occurs in pathological processes, such as
inflammation and cancer, in an attempt by the body to arrest cell
proliferation and tissue damage
-Apoptosis- recognized as special type of cell death only recently
Apoptosis- should be differentiated from common necrosis- differs both in its
biochemistry and in its morphology
Its designation apoptosis- it is a word from Greek language, which
originally refers to falling of leaves from trees in the autumn

Sequence of events in apoptosis

1- elevation of cellular calcium and rapid reduction of volume of the
cell
2- activation of calcium-dependent enzyme endonuclease which
cleaves DNA
3- fragmentation of DNA and marked condensation of both nucleus and
cytoplasm
4- formation of apoptotic bodies- small apoptotic bodies are composed
of fragments of nuclei with condensed chromatin, larger apoptotic bodies are
composed of both fragments of nuclei and condesed cytoplasm with
preserved organelles
5- apoptotic bodies are rapidly phagocytosed by epithelial cells in
neibourghood or by macrophages - cell dying by apoptosis are recognized
and phagocytosed soon after initiation of apoptosis ( role of vitronectin
receptor- belongs to the family of so called integrins= adhesive cell surface
and extracellular matrix proteins with important functions in cell-cell and
cell-matrix interactions)
Morphologic changes in apoptosis
rapid volume reduction and formation of cytoplasmic blebs -shrinkage
necrosis
loss of cell - cell contacts
formation of apoptotic bodies
phagocytosis of apoptotic bodies by macrophages, within which they
undergo hydrolytic phagocytic degradation
Significance of apoptosis
= programmed cell death, cell suicide, since it appears as apparently active
process- it requires energy and protein synthesis. Apoptosis is dependent on
gene activation and new protein synthesis. It is thought that the process is
regulated by a number of apoptosis-associated genes. These include bcl-2
protein, which inhibits apoptosis and therefore extends cell survival, p-53
protein which normally stimulates apoptosis but mutated or absent favors
cell survival.
-it requires activation of enzyme
apoptosis seems to be responsible for cell destruction in numerous
physiologic events -apoptosis leads to removing of unwanted cells
physiological apoptosis:
occurs in a number of situations
-is involved in normal tissue turnover
-in hormone-induced atrophy (endometrium in menstrual cycle,
mammary gland in menopause)
- in developing tissues,
-programmed cell destruction in embryogenesis, for example formation
of digits
pathological apoptosis:
apoptosis may be involved in response to pathologic stimuli,

-such as viral infection (for example- Councilman bodies in liver cells in

viral hepatitis)
-tumor regression induced by chemotherapy
-probably the most interesting aspect is spontaneous occurrence of
apoptosis in solid tumors of various types which is now being studied very
intensively - involvement of apoptosis in tumor growth

NECROSIS is the most common pattern of cell death

in contrast to apoptosis- necrosis may be defined as the morphologic

changes that following the cell death in a living tissue or organ resulting from
the progressive degradative activity of catalytic enzymes
These enzymes are derived either from dying cells themselves=
autolysis
or from lysosomal enzymes of leukocytes, referrred to as= heterolysis
-Apoptosis is a death of isolated cell/cells and typically is not
associated with tissue reaction, in contrast morphologic changes of necrosis
are typically caused by tissue reactivity, such as active increase in blood
supply of the tissue surrounding necrosis,
-infiltration of the vicinity of necrotic area by inflammatory cells,
especially by leukocytes
-circumscription of the necrotic focus and subsequent healing
Necrosis is the sum of the morphologic changes that follow cell death in
living tissue or organ.
These changes result from progressive degradative activity of
enzymes of lethally injured cells (autolysis and heterolysis) on one hand sideand denaturation of structural proteins
two principal processes influence the changes of necrosis:
1-enzymatic digestion of the cell
2-denaturation of proteins
DEAD CELL MORPHOLOGY:
-

cytoplasm- increased eosinophilia-attributable in part to the loss of

normal cytoplasmic basophilia caused by the RNA and in part by
increased binding of eosin to denatured intracytoplasmic proteins
more glassy appearance of the cell cytoplasm-due mainly to the loss of
glycogen particles
- nucleus- nuclear changes can be reversible -clumping of the
chromatin with large aggregates attached to the nuclear membrane
or irreversible1.- pyknosis = nucleus progressively shrinks and becomes dense
mass of tightly packed chromatin

2.- karyolysis = progressive dissolution of nuclear chromatin due to

action of DNAases of lysosomal origin
3.- karyorrhexis = nucleus may break up to many clumps
Causes of necrosis:
Identical as those of cell injury in general terms, such as mechanical,
chemical, physical, infectious agents, and hypoxia/anoxia

MORPHOLOGICAL TYPES OF NECROSIS

1.- COAGULATIVE NECROSIS
-most common pattern of necrosis, is characteristic of hypoxic cell death
macroscopic appearance: firm consistency, yellowish colour, dry appearance
of the cut section
-this pattern of necrosis-most commonly results from sudden severe
ischemia (is encountered mostly in solid organs, such as kidney, heart,
spleen, adrenal gland)
pathogenesis: Coagulative necrosis implies preservation of the basic outline
of coagulated cells for several days
- nucleus usually disappears, but the shape of cell is preserved
-Presumably, the pattern of coagulative necrosis results from severe
intracellular acidosis which denaturates not only of structural proteins, but
also enzymes (this block rapid proteolysis of the cell)
finally, the necrotic cell breaks into fragments that are removed by
phagocytosis of the cellular debris (by proteolytic enzymes of leukocytes and
macrophages, immigrating into the necrotic focus)
The best example of coagulative necrosis- myocardial infarction
gross appearance of acute myocardial infarct changes with time
fewer than 8-10 hours- ischemic area is slightly paler, hardly
discernable
even early infarct can be visualized by various histochemic reactions that
may show depletion of oxidative enzymes from infarcted area
microscopic appearance - in early acute infarction- cell swelling
pyknosis, eosinophilia of cytoplasm
by 18-24 hours -the infarct becomes apparent grossly - pale, more
sharply circumscribed, hyperemic bordermicroscopically: total necrosis with loss of nuclei, heavy infiltrate of
leukocytes, macrophages
by 3-7 days -more apparent hyperemia at the border of infarct, yellowbrown color, soft consistency
end of 1st week - infarct becomes circumscribed by highly vascularized
scar tissue
microscopically: there is a prominent fibrovascular reaction in margins
6th week - total replacement by scar = myofibrosis
2. LIQUEFACTIVE NECROSIS

-results from the rapid action of hydrolytic enzymes and occurs always
when autolysis and heterolysis prevail over denaturation of proteins
-characteristic of ischemic necrosis of brain, pancreas
also common in bacterial lesions - due to activity of enzymes of bacterial and
leukocytic origin good example of liquefactive necrosis is brain infarction
gross morphology- necrotic area becomes very soft and fluidy- these
changes are first detectable at about 12 hours
within 2-3 day softening and discoloration become more apparent
in large infarcts- there is marked swelling, tissue liquefaction results in
subsequent pseudocystic degeneration
no fibrous scar is formed, necrotic area changes into postmalatic
pseudocyst (postnecrotic pseudocyst) =cystic space filled with debris, fluid

3. FAT NECROSIS
-this refers to necrosis in adipose tissue -due to action of activated
lipases
most common-in acute pancreatic necrosis, in which active pancreatic
enzymes cause focal necrosis of the pancreas and the adipose tissue
throughout the abdomen
-lipases are activated and released and destroy not only pancreatic
tissue itself but also fat cells in the pancreas and also fat cells throughout the
peritoneal cavity - Balser necrosis= sharply circumscribed foci of
enzymatic necroses of fat tissue with shadowy outlines surrounded by a zone
of inflammation
the released fatty acids then complex with calcium to create calcium soaps
to the naked eye the necrotic foci appear opaque and chalky white or
yellowish
4. CASEOUS NECROSIS
-another distinctive type of necrosis that is a combination of
coagulative and liquefactive necrosis. It is encountered in tuberculousis.
Gross morphology:
caseous necrosis appears grossly as soft, friable, whitish-gray debris
resembling cheesy materialhence the term caseous necrosis.
This appearance has been attributed to the specific lipopolysaccharides of
the capsule of the agent, tuberculous bacillus (Mycobacterium tuberculosis)the exact interactions with dead cells are not completely understood.
Microscopy:
Histologically, caseous necrosis appears as amorphous eosinophilic material
with cell debris
The caseous necrosis is surrounded by specific granulomatous inflammatory
reaction (epithelioid histiocytes, giant cells of Langhans type, lymfocytes,
plasmacytes).
5. FIBRINOID NECROSIS

-is a type of connective tissue necrosis seen particularly in

autoimmune disease collagen and smooth muscle are affected (for examplein polyarteriitis nodosa- fibrinoid necrosis affects blood vessel walls)
-fibrinoid necrosis is characterized by loss of normal structure of
collagen fibres
-causing teh change of tinctorial features of collagen-bright eosinophilia
which resembles fibrin- derived from plasmatic fibrinogen

GANGRENOUS NECROSIS
-it is not a distinctive type of necrosis, it is a necrosis secondary
modified usually by the attack of bacterial agents. The term gangrene is
commonly used in clinical practise to describe a condition when extensive
tissue necrosis is complicated by bacterial infection.
There are three major types of gangrene:
dry gangrene
wet gangrene
gas gangrene
-dry gangrene- necrotic tissue appears black and dry and is sharply
demarcated from viable tissue
most commonly it occurs in extremities as a result of ischemic coagulative
necrosis doe to arterial obstruction
When the coagulative pattern prevails - dry gangrene develops
when liquefaction is more pronounced- wet gangrene develops
-wet gangrene- results from severe bacterial inection of necrotic area
most commonly it occurs in the extremities due to arterial obstruction, but
also in the internal organs, such as intestine- most common example- in
acute suppurative appendicitis
grossly- tissue is swollen, reddish-black with extensive liquefaction
wet gangrene is severe complication associated with high mortality rate
-gas ganrene- is a wound infection caused by Clostridium perfringens
and other types of Clostridia
-it is characterized by extensive necrosis and tissue destruction and
production of gas by fermentative action of bacteria
grossly- appearance similar as in wet gangrene with additional presence of
gas in tissues
crepitus- a sound that can be detected by palpation of necrotic tissues
gas gangrene is associated with a high mortality rate
NECROSIS and APOPTOSIS

NECROSIS

APOPTOSIS

Stimuli

hypoxia, toxins

physiologic and
pathologic

Histology

cellular swelling,
coagulation necrosis,
disruption of organelles

single cells,chromatin
condensation, apoptotic
bodies

DNA
breakdown

random, diffuse

internucleosomal

Mechanisms

ATP depletion, membrane gene activation,

injury, free radical
endonuclease
damage

Tissue
reaction

inflammation

no inflammation,
phagocytosis of apoptotic
bodies

8. Discuss and differentiate each type as to its causes,

mechanism, gross and microscopic finding and give examples.
Causes of cell injury range from gross mechanical external causes to mild
endogenous causes as genetic lack of enzymes etc.
Virtually all forms of tissue injuries start with molecular or structural
alterations in cells.
Under normal conditions, the cells are in:

homeostastatic steady state

Normal cell is confined to relatively narrow range of functions and structure
by its genetic programme to handle normal physiologic demands.
Cells react to adverse influence by
1- adapting
2- sustaining reversible injury
3- suffering irreversible cellular injury- cell death
More excessive stimuli (either physiologic or pathologic) may cause cellular
adaptation -in order to reach

altered steady state

- for example, excessive work stress causes an increase in muscle

mass that reflects the increase in size of the individual muscle fiber, results
in higher level of metabolic activity and new equilibrium is reachedhypertrophy
- on the other hand- atrophy- is adaptative response in which there is
a decrease in the size and function of the cells- and results from a slow longlasting decrease of blood supply
if the limits of adaptative mechanisms are exceeded or when no
adaptative response is possible- cell injury

Reversible cell injury denotes pathologic changes that can be reversed

when the stimulus is removed and the cellular injury has been mild. Cell
injury is reversible only up to certain point.

Irreversible cell injury denotes pathologic changes that are permanent

and cause cell death, they cannot be reversed to normal state

for example: if the blood suply to heart muscles is cut off for 10-15 minutesthe myocardial cell experiences injury but it can recover to normal function,
if the blood flow is cut off for longer period- the myocardial fiber diesnecrosis
CAUSES OF CELL INJURY

Hypoxia
injury

(= decrease of oxygen supply) -most common cause of cell

-occurs usually as a result of ischemia (= loss of blood supply), which

occurs for example when arterial flow suffers from atherosclerosis or
thrombotic occlusion of arteries - most common cause of hypoxia
-is due to inadequate oxygenation, for example in cardiorespiratory
failure
-is caused by loss of oxygen-carrying capacity of the blood, either due
to anemia (decreased capacity of the blood for oxygen), or after poisoning
with carbon monoxide (CO)= loss of the carrying capacity of the blood
depending on the severity of hypoxia- the cell may undergo
-adaptation
-injury
-cell death
for example: -if femoral artery is narrowed (due to atherosclerotic or
atherothrombotic reduction of the lumen of the affected vessel)- skeletal
muscles of the leg decrease in size= atrophy. This reduction in size of cell
mass may achieve a new balance on the lower level, but severe and
prolonged hypoxia will induce severe injury and cell death.

physical agents - many forms of physical energy may give rise to cell
and tissue injury, such as mechanical trauma, extremes of temperature,
sudden changes in atmosphere pressure, electromagnetic energy,
radiation and electric shock

The most important and frequent in clinical practice are consequences of

mechanical forces (traffic accidents).
Changes in atmosphere pressure and hypotermia are relatively uncommon
causes of injury, but hypertermia (burns) are encountered more often.
Radiation injury- have also assumed importance as potential causes of
widespread destruction

chemical agents -the list of chemicals that may cause cell and tissue
injury includes
-poisons-arsenic, cyanide, mercuric salts,etc
-air pollutants
-insecticides and herbicides
-alcohol, narcotic drugs
-variety of therapeutic drugs and even oxygen in high concentrations

infectious agents- these agents range from the submicroscopic viruses,

rickettsiae to bacteria, fungi and higher forms of parasites.

immunologic reactions -immune system works in a defense against

biologic agents. Immune reactions may, however cause cell injury
-first- so called anaphylactic reaction - to a foreign protein or drug

-second- reactions to endogenous self-antigens are responsible for a

number of so called autoimmune diseases
genetic derangements-genetic defects cause a number of diseases
Genetic injury may result in severe defects and congenital
malformations (Downs syndrome) or in mild derangements and errors of
metabolism (lack of a distinctive enzyme ), etc.
nutritional disbalances- even now nutritional errors continue to be major
cause of cell injury.
-protein-calorie deficiencies- chiefly among underprivileged population
-deficiencies of specific vitamins
-nutritional excesses have become important in cell injury among
overprivileged population (excess in lipids-predispose to atherosclerosis,
cause obesity, influence diabetes mellitus).
GENERAL MECHANISMS OF CELL INJURY.

Four intracellular systems are particularly vulnerable to cell injury:

1. maintenance of the integrity of cell membrane (upon which the
osmotic homeostasis of the cell is dependent)
2. aerobic respiration involving
production of ATP (mitochondria)

oxidative

phosphorylation

and

3. synthesis of functional and structural proteins (Golgi)

4. preservation of the genetic apparatus of the cell (nucleus)

Important aspects of cell injury:

-the following factors influence severity of injury, consequences of cell injury
depend both on cell and the injurious agent, and other factors

1- wide-spread effect of changes-whatever the first point of injury in the

cell is - wide-range secondary effects. Above mentioned four vulnerable
systems are closely related, thus injury at one of them leads to
widespread secondary effects

for example-impairment of aerobic respiration disrupts the energy-dependent

sodium pump- results in loss of ionic and fluid balance- causes alterations in
the intracellular content of water and ions- cell swelling

2- time factor- morphologic changes of cell injury become apparent only

after some critical time.

for example- light microscopic changes characteristic of cell death do not

occur in the myocardium until 10-12 hours after total injury- but irreversible
injury actually occurs within 20-60 minutes!!

3- cell susceptibility to injury- reactions of the cells to pathologic stimuli

depend on the type of the cell. The consequences of cell injury depend on
the type, state and adaptability of the cell.

Important factors in the cell are:

-nutritional state, hormonal status, metabolic activity and demands of
the cell. How vulnerable is the cell when exposed to hypoxia?
- high susceptibility-neurons (3-5 minutes)
- intermediate- myocardium, hepatocytes, renal epithelial cell (20-120
minutes)
- low susceptibility- fibroblasts, epidermis, skeletal muscles ( many hours)

4- reactions of the cell to pathologic stimuli depend on the type of injury,

its duration, its severity, thus short ischemia may induce reversible injury,
while more prolonged ischemia might lead either to cell death or to slow
irreversible injury.

 MECHANISMS OF CELL INJURY IN HYPOXIC INJURY.

reversible cell injury

Hypoxia first causes loss of phosphorylation in mitochondria- results in
decrease of production of energy rich-ATP - loss of ATP (which is a energy
source) has widespread effects on many systems in the cellfor example-heart muscle stops to contract within 60 seconds after coronary
occlusion (noncontractility does not mean the cell death)
the decrease in cellular ATP stimulates increase of anaerobic glycolysis= the
other source how to generate energy for the cell
glycogen is rapidly depleted, glycolysis results in accumulation of lactic acids
- it reduces pH intracellularly - at this point, there is also early clumping of
nuclear chromatin
energy-dependent sodium pump slows down the activity - sodium pump
keeps normally the concentration of potassium (K+) significantly higher
intracellularly.
Failure of active transport through the cell membrane causes that sodium
(Na+) accumulates within the cell and potassium diffuses out of the cell - it
leads to important movement of water intracellularly=
morphologic changes in reversible cell injury
-cellular swelling -due to accumulation of catabolites of metabolism
and water intracellularly
-loss of microvilli
-blebs
swelling of cisternae of endoplasmic reticulum -detachment of ribosomes
from the granular ER due to disruptions of energy-dependent interactions
between membranes
myelin figures- derived from plasma or from membranes of organelles. They
are thought to results from dissociation of lipoproteins.
All the above mentioned changes are reversible if oxygenation is restored.

irreversible cell injury

-if ischemia persists, irreversible injury develops. Irreversible injury is
marked by severe mitochondrial vacuolization, extensive damage to plasma
membranes, swelling of ribosomes, swelling of ribosomes. Injury to
lysosomal membranes leads to leakage of lysosomal enzymes into the
cytoplasm,
there is no universal biochemical point of no return, transitions from
reversible injury to cell death.

 critical events for irreversible cell injury:

-1- ATP depletion
inability to reverse mitochondrial dysfunction
phosphorylation and production of energy )

(lack

of

oxidative

-2- Cell membrane demage

-the earliest phase of irreversible injury is associated with functional and
structural defects in cell membranes
-great deal of evidence indicates that cell membrane damage is a central
factor in the pathogenesis of irreversible injury
-intact cell membranes are essencial to the maintenance of normal cell
permeability and volume- loss of membrane integrity causes massive influx
of calcium from the extracellular space- resulting in mitochondrial
dysfunction, inhibition of intracellular enzymes, denaturation of proteins
2. CHEMICAL INJURY
chemicals induce cell injury by one of two major mechanisms:
1-some chemicals act directly by chemical bindings with some critical
molecules or cellular organelles
for example: mercuric chloride poisoning (mercury binds directly to
sulphydryl groups of cell membranes)--GIT and kidney
or anticancer drugs and some antibiotic drugs also induce cell damage by
direct cytotoxic effects
-2-other chemicals are not biologically active but convert into reactive toxic
metabolits (role of free radicals for example)
3. INJURY INDUCED BY VIRUSES
viruses induce cellular changes by two general mechanisms:
1-cytolytic and cytopathic viruses cause various degrees of cellular injury
and cell death
2-oncogenic viruses stimulate host cell to proliferate and may induce tumors
Cytopathic effects of viruses cause injury by two major mechanisms:
-first is direct cytopathic effect, in which rapidly replicating virus
particles interfere with some aspects of cell metabolism and cause cellular
damage.
Most directly cytopathic viruses have a high degree of cell specificity= viral
tropism, caused by presence of membrane receptors on host cells, which

interact with viral strucutresallow to attack to the host cellto enter the
host cell and cause the injury by active reduplication of virus particles
-second mechanism involves the induction of an immunological
response-destruction of the cell by either antibody or cell-mediated
reactions, for example the damage and death of hepatocytes caused by
hepatitis B viruses are mediated by cytolysis induced by T-lymfocytes
The nature of cell response to viral replication depends on the host cell and
type of virus and can have several forms:
1-cell lysis-apparently due to rapid viral replication
2-some viruses can cause cytoskeletal damage (for example disruption of
vimentin)
3-cell may response by formation of giant multinucleate cells, due to cellcell fusion, for example in measles or herpes virus infection
4-some viruses infected cells develop inclusion bodies, which contain
virions or viral proteins in nuclei or cytoplasm
9. Discuss the features of necrosis and apoptosis

Definition

Cell Size
Plasma
membrane
Nucleus
Effect on
inflammatio
n
Cellular
contents
Cause of
Appearance

Mechanism

TWO PRICIPAL TYPES OF CELL DEATH

Necrosis
Apoptosis
Is a pathway of cell death that is
induced by a tightly regulated
suicide program in which cells
destined to die activate enzymes
that degrade the cells own nuclear
DNA and nuclear and cytoplasmic
proteins.
Enlarged (Swelling)
Reduced (shrinkage)
Loss of membrane integrity;
Intact; altered structure, especially
Damage is severe; Disrupted
orientation of lipids
Pyknosis -> Karyorrhexis ->
Fragmentation into nucleosome-size
Karyolysis
fragments
Elicit inflammation in the
No inflammmmatory reaction
surrounding tissue
Leakage of cellular contents
Denaturation of intracellular proteins
Enzymatic digestion (from the
lysosomes of the dying cell)
Lysosomal enzymes enter the

Intact; may be released in apoptotic

bodies
Activation of caspaces
DNA & Protein breakdown
Membrane Alterations and
Recognition by Phagocytes
Cells DNA or proteins are damaged

cytoplasm and digest the cell

Disease

ALWAYS pathological process;

Invariably pathologic (culmination of
irreversible cell injury)

Morphology

eosinophilia in H&E stains

Loss of cytoplasmic RNA
Glassy homogenous appearance
Loss of glycogen particles
Vacuolated and appears moth-eaten
Karyolysis basophilia of the
chromatin
Pyknosis nuclear shrinkage and
basophilia
Karyorrhexis pyknotic nucles
undergoes fragmentation

beyond repair, the cell kills itself;

Rapid removal of the cellular debris.
May serve many normal function
Can progress to necrosis -> May be
pathologic after some forms of cell
injury, esp DNA damage
Not necessarily associated with cell
injury
Cell Shrinkage
Chromatin condensation
Formation of cytoplasmic bleps and
apoptotic bodies
Phagocytosis of apoptotic cells or
cell bodies, usually by macrphages

10.
Discuss the clinic-pathologic correlation of ischemic cell
injury in this particular case
Ischemia Nutrient & O2 supply often due to blood flow & also by a
venous drainage; both aerobic & anaerobic energy generation affected
Mechanisms of Ischemic Cell injury:
O2 tension
Loss of oxid phosphorylation
Depletion of ATP
Na+ pump failure
(loss of K+, influx of H2O, Na+ & Ca++)
swelling, progressive glycogen loss &
protein synthesis
irreversible injury & necrosis