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Of Common Postgrad Med J: first published as 10.1136/pgmj.42.483.5 on 1 January 1966. Downloaded from POSTGRAD. MED. J. (1966), 42, 5 CURRENT VIEWS ON THE PATHOGENESIS OF COMMON "STROKES" F. J. FAWCETT, M.B., M.'R.C.P. W. THoMAS SMITH, M.D., M.C.Path. Lecturer in Pathology Reader in . Neuropathology University"I ofI Birmingham- I THE TITLE of th(is review is deliberately pro- out the 19th and early 20th centuries it was vocative and only becomes meaningful when the widely held that;cerebral infarcts were simply term "stroke" is defined. According to "A explained by occlusion of the supplying artery, New English Dictionary" (Murray, 1919) a this belief being reinforced by Cohn'heim's "stroke" is "an apoplectic or .... paralytic description in 1872 of clearly defined vascular seizure"; apoplexy is described as "a malady territories and by the belief in end-arteries. ..... usually caused 'by an effusion of blood The role of anastomotic channels was seldom or serum in the brain ... ". The survey will considered. The clinical and pathological be arbitrarily restricted to current views on features of occlusion of all main arteries were pathological aspects of commoner seizures ca,refully documented and many tantalizing classifiable as apoplectic by the above definition. syndromes, beloved of examiners, were at- "Effusions of blood" undoubtedly means tributed to occlusion of specific braniches of cerebral haemorrhage, and "effusions of the circle of Willis. Occasional dissenters such serum" would seem to refer to forms of as Nothnagel '(1877) noted that relevant arteries cerebral infarction such as acute colliquaition were not always occluded in brains showing or more chronic encystation ("apoplectic cyst"). infarction. The possibility of resorption of "Paralytic seizures" due to other causes are thrombus and the concept of reactive vaso- thus outside our selfimposed terms of refer- spasm to explain these discrepancies were by copyright. ence. The account will be further limited by neither generally accepted nor confirmed. confining it to the three varieties of apoplectic The importance of the carotid arteries has stroke 'that have attracted most attention in long been known and the word carotid is an recent years. These are: cerebral infarction adaptation of the Greek term for "to stupefy"; related 'to atheromatous disease of the intra- Galen showed that carotid compression could cranial and/or carotid and vertebral arteries; cause "carus" or insensilbilhity. Todd (1844), subarachnoid haemorrhage and other con- Gull,(1855) and Ramsay Hunt (1914) recognised sequences of ruptured berry ("congenital") the importance of carotid occlusion in the aneurysm of the circle of Willis; and massive pathogenesis of cerebral infarction but the http://pmj.bmj.com/ intracerebral bleeding 'associated with systemic knowledge that bilateral occlusion was con- arterial hypertension. Infarotion resulting from sistent with survival and that carotid ligation unusual forms of arterial disease or from was not necessarily associated with cerebral emrboli of cardiac origin, and bleeding due to lesions temporarily discredited the former haemorrhagic disorders, trauma, tumours etc. avant-garde observations. The advent of are'therefore not included. arteriography in the 1930's istimulated con- Cerebral siderable interest in internall carotid artery Infarction thrombosis, the clinical syndrome first being on September 30, 2021 by guest. Protected Historical reported by iMoniz, Lima and de Lacerda Though Morgagni (1761) distinguished bet- (1937). However, it was only recently that the ween cerebral 'haemorrhage ("sanguineous carotid and vertebral systems together with the stroke") and cerebral softening '("non-sanguine- circle of Willis were considered as an integral ous stroke") many years elapsed before the unit in a detailed clinical and pathological cause of infarction was suspected. Abercrombie investigation by 'Hutchinson and Yates (1957) (1828) defined its ischaemic nature and held and Yates and Hutchinson '(1961). that the effects of local arterial 'lesions and of extracranial factors were important. Through- The role of carotico-vertebral stenosis Based on a Joint communication presented at a Symposium on Cerebro-vascular Disease, organised Yates and Hutchinson fully investigated 100 by the Board iof Graduate Studies of the Faculty of cases in which the clinical picture suggested Medicine, University of Birmingham, on June 26th, that cerebral ischaemia had either caused or 1965. contributed to death; cases recognised as intra- Postgrad Med J: first published as 10.1136/pgmj.42.483.5 on 1 January 1966. Downloaded from 6 POSTGRADUATE MEDICAL JOURNAL January, 1966 cranial haemorrhage or cerebral embolism by arterial disease; both of these effects could complicating heart disease were excluded. Theey bring about temporary disturbances of cerebral examined the whole cerebrovascular system, function, especially when associated with sludg- including the carotid and vertebral arteries and ing of blood in the capillary bed. These conclu- circle of Willis, together with the brain. Because sion were in general supported by the findings of the technical difficulties involved in removing of McGee, McPhedran and Hoffman (1962); the intraosseous and intracranial parts of the Baker, Dahl and Sandler (1963); and Fisher, vertebral and internal carotid arteries at Gore, Okabe and White '(1965). necropsy thhis procedure had been neglected in The significance of non-occlusive stenosis previious work on cerebral infarction. The in reducing blood-flow has been questioned impressive results of 'Hutchinson and Yates by Mitchell and Schwartz (1965) on the grounds showed that atheromatous diseases of the extra- that the series of Hutchinson and Yates (1957), cranial arteries iis of paramount significance in selected because of cliical evidence of cerebral the pathogenesis of cerebral ischaemia and ischaemia, did not show a signilficantly different infarction. They found occlusion and/or serious prevalence of carotico-vertebral stenosis from stenosis of one or more neck arteries in 58 that found in their own entirely unselected of the 100 cases; in 18 only the carotids and necropsy series. Amongst 93 adults over the in 7 only the vertebrals were affected but in age of 35 only 27 'had clinical evidence of 33 both were affected. In 35 cases there were "strokes". They found stenoses at some point in all 74 separate infarcts; all but 3 of these along the vessels in 90%/, of men and 85% of 35 cases showed significant stenosis (defined women which were severe in 43%/O of men and as 50% or more reduction of lumen) or 35% of women. Furthermore, severe narrow- occlusion of the extracranial arteries; only ings were present in the carotid sinus in one 19 of these same cases (showing 22 of the man in 7 and in the vertebral arteries in one infarcts) were associated with significant changes man in 4. Mitchell and Schwartz commented in ithe intracranial arteries. Thus, in 16 (46%) that 90% of the peripheral resistance in the by copyright. of the cases with infarcts signfificant dfisease cerebral circulation is contributed by the of the intracranial arteries was excluded. The smaller "intracranial vessels and considerable site of the disease in the internal carotid reduction in the calibre of the major neck arteries was most commonly the carotid sinus. arteries can occur before their narrowing be- In the vertebral arteries atherosclerosis was comes a controlling factor in brain blood-flow. somewhat more widespread but also tended They argued that their own findings showed to involve the proximal 2 cm. In 19 cases the relation between carotico-vertebral stenosis showing thrombotic occlusion of one or more and "strokes" to be uncertain and suggested extracranial arteries all but 4 showed cerebral that the stenosed segments do not usually http://pmj.bmj.com/ infarction, and 2 of these almost certainly seriously impair blood-flow but are more im- died before gross changes had time to develop. portant 'as a source of emboli which block the Yates and Hutchinson noted that distortion smaller cerebral vessels. They also claimed that and obstruction of diseased vertebral arteries as the frequency of "strokes" and of carotico- could 'be produced or aggravated by osteo- vertebral stenosis are both correlated with age, arthritis of the cervical spine as subsequently it is inevitable that there will be a correlation appraised by Brain (1963). They also em- between them, even if causally unrelated. It phasised the role of general systemic factors is unfortunate that Mitchell and Schwartz on September 30, 2021 by guest. Protected such as anaemia and blood loss, anoxia, hypo- neither specified the variety of "stroke" to tension and traumatic shock, and concluded which they alluded, nor described whether that cerebral infarction rarely had a single cerebral infarction, massive haemorrhage or cause; it was usually the result of a combination other lesions were found post mortem in the of systemic disease and inadequacy of total small number of cases on which they based cerebral blood-flow due to stenosis or occlu- their conclusions; they also ignored the more sion of extracranial or intracranial cerebral detailed report of Ytates and Hutchinson (1961). arteries, or both, infarction being commoner The role of cervical artery stenosis in massive with extracranial ithan intracranial arteriopathy. haemorrhagic strokes could be of paradoxical They further suggested that atheroma of the significance, and even protect the bra'in
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