Alterations in nitrogen monoxide-synthesizing cortical neurons in amyotrophic lateral sclerosis with dementia.

Cognitive impairment in the absence of lesions indicative of Alzheimer's disease and other dementing conditions has long been recognized in a subgroup of patients with motor neuron disease MND), including amyotrophic lateral sclerosis. However, the mechanisms underlying this cognitive deterioration and its relationship with the relatively selective involvement of motor neurons remains elusive. We used histo- and immunocytochemical labeling methods to study the nitrogen monoxide (NO; a.k.a. nitric oxide) synthase (NOS)-/NADPH diaphorase-containing neurons (NOSN) in three patients with MND and dementia (MND+D), two patients with MND without dementia, and 19 controls that included patients with Alzheimer and non-Alzheimer dementias. Patients with MND+D, but not those with MND without dementia, exhibit numerous dystrophic perikarya and neurites throughout all sensory, motor, association, and limbic neocortices examined. Interestingly, affected NOSN appear to correspond to some subtypes (smooth stellate and spiny neurons), while other neurons containing the same molecular phenotype (such as layer I local circuit neurons and layer II granule cells) are either spared or significantly less affected. These observations indicate that cognitive impairment and dementia in MND may be due, at least in part, to a pancortical involvement of certain types of NOSN. Consequently, the elucidation of the factors that make NOSN vulnerable in MND, and the prevention or pharmacological palliation of their loss, may eventually help to prevent or ameliorate cognitive impairment in MND and may also shed some light on the nature of the insult that targets motor neurons.

Monocytes become macrophages; they do not become microglia: a light and electron microscopic autoradiographic study using 125-iododeoxyuridine.

This light and electron microscopic autoradiographic study of stab injuries in the spinal cord of mice evaluated the ultrastructural characteristics of cells labeled by incorporation of the thymidine analogue 125I-5-iodo-2'-deoxyuridine (I-UdR), injected one day prior to injury. I-UdR was used instead of tritiated thymidine (H-TdR) because H-TdR can be reutilized and is therefore not a suitable pulse label for long-term studies of cell migration. Using serial thick and thin sections for autoradiography 614 labeled cells were identified. Labeled cells included 545 monocytes/macrophages, 50 lymphocytes, 17 pericytes, one endothelial cell, and one arachnoid cell. No labeled cell had the morphology of microglia. We concluded that macrophages in stab injuries of the spinal cord of mice are derived from blood monocytes. Blood-derived lymphocytes are also involved in the reaction to spinal cord stab injury. Microglia are not blood-derived and are not seen as a transitional form in the differentiation of monocytes to macrophages.

Phenotypic and pathologic evaluation of the myd mouse. A candidate model for facioscapulohumeral dystrophy.

Facioscapulohumeral dystrophy (FSHD) is an autosomal dominant disease of unknown pathogenesis which is characterized by weakness of the face and shoulder girdle. It is associated with a sensorineural hearing loss which may be subclinical. FSHD has been mapped to the distal most portion of 4q35, although the gene has not yet been identified. Distal 4q has homology with a region of mouse chromosome 8 to which a mouse mutant, myodystrophy (myd), has been mapped. Muscle from homozygotes for the myd mutation appears dystrophic, showing degenerating and regenerating fibers, inflammatory infiltrates, central nuclei, and variation in fiber size. Brainstem auditory evoked potentials reveal a sensorineural hearing loss in myd homozygotes. Based on the homologous genetic map locations, and the phenotypic syndrome of dystrophic muscle with sensorineural hearing loss, we suggest that myd represents an animal model for the human disease FSHD.

Vascular smooth muscle hyperplasia underlies the formation of glomeruloid vascular structures of glioblastoma multiforme.

The origin of the vascular hyperplasia seen in glioblastoma multiforme is a matter of debate. To test the predominant hypothesis that these glomeruloid structures are of endothelial origin the following study was undertaken. Seven glioblastomas containing prominent glomeruloid vascular structures were stained with Ulex europaeus agglutinin I (UEA-1) and with antibodies against factor VIII/related antigen (fVIII/RAg), glial fibrillary acidic protein (GFAP), S-100 protein, muscle specific alpha-actin (MSA) and smooth muscle specific alpha-actin (SMSA). The GFAP and S-100 antibodies stained the neoplastic glial component of each tumor but did not bind to vascular cells. Endothelial cells lining the lumina of normal vessels and the lumina of glomeruloid vascular structures stained positively with both UEA-1 and fVIII/RAg antibody. No other cells were found to be stained by UEA-1 or by fVIII/RAg antibody. Smooth muscle cells of the normal vasculature stained positively exclusively with anti-MSA and anti-SMSA antibodies. The same pattern of positive actin antibody staining was seen in the majority of cells forming the glomeruloid structures; however, the cells lining the vascular lumina did not bind the MSA and SMSA antibodies. These data strongly suggest that the vascular proliferation resulting in glomeruloid structures is due in large measure to smooth muscle hyperplasia.

Smooth muscle can comprise the sarcomatous component of gliosarcomas.

The sarcomatous component of gliosarcomas is thought by many to originate from the vascular proliferation seen in glioblastoma multiforme and has, therefore, been assumed to be endothelial. Immunohistochemical staining of four gliosarcomas has led us to an alternate theory. Pathologically all four tumors were composed of at least two cell types; the first had a stellate, glial appearance and the second was either spindled or polygonal in shape. Polygonal cells were associated with glomeruloid vascular structures in some areas. Both components of each neoplasm were cytologically malignant. Glial fibrillary acidic protein and S-100 antibodies stained most of the glial-appearing cells and some of the spindled cells, but not the polygonal cells. Muscle specific alpha-actin and smooth muscle specific alpha-actin antibodies stained only the malignant spindled and polygonal cells and normal vascular smooth muscle. Ulex europaeus agglutinin I and anti-factor VIII/related antigen antibody stained only cells lining vascular lumina. The staining results suggest that the malignant mesenchymal component of these tumors is of smooth muscle origin. Having demonstrated elsewhere that glomeruloid vascular structures of glioblastoma multiforme contain smooth muscle cells, we propose here that gliosarcomas can represent one end of the spectrum of glioma-induced vascular smooth muscle proliferation.

Experimental autoimmune inflammatory myopathy.

We report an experimental model of autoimmune inflammatory myopathy. Splenic cells from two inbred murine strains (BALB/c and SJL/J) are activated (immunized) in vitro by co-culture with their respective syngeneic skeletal muscle myotubes. Subsequent injection of the activated splenocytes with or without B. pertussis into the respective syngeneic hosts results in inflammatory myopathy in the SJL/J mice but never in the BALB/c mice. The muscle inflammation is very similar in appearance to human autoimmune inflammatory myopathies. The myositis is not effector cell-skeletal muscle specific because splenocytes activated by co-culture with smooth muscle will also elicit skeletal muscle lesions. Both strains of skeletal muscle appear to express class II (Ia) antigens and the splenocytes from both strains appear to be equally activated. Thus we postulate that the difference in the expression of myositis between the two strains is in the effector phase of the disease. Since SJL/J mice have vasoactive amine sensitive vascular systems and BALB/c do not, it is likely that activated splenocytes emigrate from muscle microvessels in the SJL/J strain whereas they cannot do so in the BALB/c strain. The most significant contribution of this model may be in its potential for addressing a sine qua non of cellular autoimmune disease, i.e. lymphocyte migration from the vascular compartment into the target tissue. Finally, the data support a cellular more than a humoral pathogenesis in this model.

The neuropathology of a chromosome 17-linked autosomal dominant parkinsonism and dementia ("pallido-ponto-nigral degeneration").

A group of similar autosomal dominant hereditary neurodegenerative disorders have been linked to chromosome 17 in thirteen kindreds. One of these disorders, known as pallido-ponto-nigral degeneration (PPND), is characterized by extensive degeneration of the globus pallidus and substantia nigra as well as accumulation of abnormally phosphorylated tau proteins. The authors now present comprehensive data on the cellular and molecular pathology of PPND, allowing its classification among chromosome 17-linked neurodegenerative disorders as well as its classification among sporadic and other familial tauopathies. First, we showed that PPND is characterized by abundant ballooned neurons in neocortical and subcortical regions as well as by tau-rich inclusions in the cytoplasm of neurons and oligodendroglia morphologically similar to those seen in corticobasal degeneration (CBD), but in a distribution pattern resembling progressive supranuclear palsy (PSP). Second, we demonstrated that antibodies to phosphorylation-independent (Alz50, 133, 304, Tau-2, T-46) as well as phosphorylation-dependent (AT8, PHF-6, 12E8, PHF-1, T3P, pS422) epitopes in human tau proteins stain these glial and neuronal inclusions as intensely as they stain CBD or PSP inclusions. Third, we probed PPND brain by Western blots using some of the same anti-tau antibodies to reveal 2 tau immunobands with molecular weights of 69 kD and 64 kD in gray and white matter extracts, as reported for both PSP and CBD. Finally, electron microscopy showed that these abnormal tau proteins formed flat twisted ribbons with a maximum diameter of 20 nanometers (nm) and a periodicity of about 200 nm, resembling those reported in CBD. Based on this, we conclude that PPND is a hereditary neurodegenerative disorder characterized by neuronal and glial tau-rich inclusions formed from aggregated filaments and hyperphosphorylated tau proteins and, hence, can be subcategorized into the tauopathy group of chromosome 17-linked neurodegenerative disorders. Further, since the morphologic and biochemical lesions of PPND overlap with those seen in sporadic CBD and PSP, we speculate that these disorders share common pathogenetic mechanisms.

Non-specific esterase activity in reactive cells in injured nervous tissue labeled with 3H-thymidine or 125iododeoxyuridine injected before injury.

Tritiated thymidine (3H-TdR) injected before a stab wound of the spinal cord or transection of the hypoglossal nerve has resulted in many labeled reactive cells in the CNS after injury, most of which have the ultrastructural features of microglia. To test for the possible origin of these labeled cells from monocytes, we examined them for the presence of sodium fluoride- (NaF) sensitive non-specific esterase (NSE), an enzyme characteristic of monocytes. Some of the labeled cells in stab wounds had NaF-sensitive NSE, but no such cells were found in the nucleus of the injured hypoglossal nerve. To test for the possibility that the NSE-negative labeled cells had been labeled by reutilization of 3H-TdR, we used 125I-5-iodo-2'-deoxyuridine (125I-UdR), a thymidine analogue with a much lower rate of reutilization, to label blood mononuclear cells prior to either a spinal cord stab wound or hypoglossal axotomy. The number of labeled cells was decreased in the spinal cord wound, but more than half were NSE-negative. No labeled blood mononuclear cells were found in the hypoglossal nucleus, although there was no decrease in the hyperplasia of unlabeled non-neuronal cells. When 125I-UdR was injected on the fourth day after hypoglossal axotomy, or when both 3H-TdR and 125I-UdR were injected simultaneously before hypoglossal axotomy, many labeled cells were found in the hypoglossal nucleus, indicating that 125I-UdR can be used by the reactive cells and that it did not inhibit their proliferation. Therefore, the microglial cells that proliferate in response to peripheral nerve injury are not recently derived from any type of circulating large blood mononuclear cell. The most likely explanation for the presence of the 3H-TdR-labeled cells in the nucleus of the injured hypoglossal nerve is that they were proliferating intrinsic cells labeled by reutilization of 3H-TdR.

Computed tomographic and postmortem study of a nonhemorrhagic thalamic infarction.

A 70-year-old man had a stroke and became unconscious. High-resolution computed tomography (CT) with 5-mm cuts disclosed bilateral thalamic infarctions, larger on the left than the right. He died one week later, and a postmortem examination was performed. By plotting the CT on templates constructed to show the different vascular territories of the thalamus, the infarctions were predicted to be in the territories of the interpeduncular profunda arteries. Comparing sagittal reconstructions to the Schaltenbrand and Wahren atlas, the following thalamic nuclei were thought to be involved: dorsomedial, parafascicular, and centrum medianum bilaterally; and reticular, ventroanterior, and ventrolateral on the left. Pathologic study confirmed these findings. We believe that it is possible to predict the vascular territory of thalamic infarctions by plotting the CT on templates showing the different vascular territories of the thalamus. Sagittal reconstructions of CT scans also permit the determination of thalamic nuclei involved in a lesion.

Molecular genetics of holoprosencephaly.

Holoprosencephaly (HPE) is a common developmental defect of the human forebrain and midface. Pathological studies have identified different categories of severity of the brain and craniofacial malformations observed in HPE, although the variable clinical spectrum of HPE extends in unbroken sequence from alobar HPE and cyclopia to clinically unaffected carriers in familial HPE. The etiology of HPE is extremely heterogeneous including both environmental and genetic causes. Here we focus on molecular aspects of HPE in light of the recent identification of some of the genes causing human HPE and other candidate genes involved in forebrain development, through different approaches, such as positional cloning and functional cloning, based on animal models. These approaches will aid in the identification of additional genes involved in HPE and in a better understanding of the molecular genetics of brain development.

Warfarin-related purple toes syndrome and cholesterol microembolization.

The "purple toes syndrome" is a rare complication of oral anticoagulant therapy. Four patients who presented with "purple toes syndrome" several weeks after warfarin therapy was initiated are described. The diagnosis of cholesterol microembolization was made by biopsy in three cases. Malignant hypertension and renal failure developed in two patients who died within three to six months of onset of purple toes. Postmortem examination in one of these patients showed widespread cholesterol microembolization. Renal failure has not developed in the other two patients, who are doing well. These biopsy and autopsy results suggest that the warfarin-related "purple toes syndrome" is due to cholesterol microembolization.

The role of radiation therapy in the management of ependymomas of the spinal cord.

Twenty patients with biopsy-proven ependymomas of the spinal cord were treated between 1960 and 1984-7 with surgery only, 3 with radiation therapy only, and 10 with surgery and postoperative radiation therapy. Of these, 2 patients developed recurrent tumor at the primary site, 3 developed a recurrent tumor in the thecal sac, and 1 developed distant metastasis. The absolute 5- and 10-year survival rates were 95% (19/20) and 86% (12/14), respectively. None of 13 patients who were treated with radiation therapy only or combined surgery and postoperative radiation therapy developed recurrent tumor at the primary site, and none of 7 patients who received thecal sac irradiation developed thecal sac recurrences. In contrast, 2 of 7 patients (29%) treated with surgery alone developed recurrent tumor at the primary site, and 3 of 13 patients (23%) who received no thecal sac irradiation developed a recurrent tumor in the thecal sac. The failure rates following surgery were greatest in patients who had tumor removed in a piecemeal fashion (43%, 6/14). The results show that radiation therapy is probably not necessary if the tumor has been removed completely in an en bloc fashion. However, radiation therapy is needed if the tumor has been incompletely removed or removed in a piecemeal fashion. If the tumor has been removed in a piecemeal fashion, the radiation portals should be extended to include the thecal sac. Histologic subtypes influenced the pattern of recurrence. Myxopapillary ependymomas and high grade cellular ependymomas appear to be more likely to recur in the thecal sac. However, no big difference could be detected in local recurrence.

Case of multivertebral anomalies, cloacal dysgenesis, and other anomalies presenting prenatally as cystic kidneys.

We describe a newborn boy on whom prenatal ultrasonography demonstrated intrauterine growth retardation, multiple vertebral anomalies, cystic kidneys, and oligohydramnios. Autopsy findings included multiple vertebral anomalies, cloacal dysgenesis (imperforate anus, vesicorectal fistula, and bilateral renal dysplasia), sacral absence, single umbilical artery, pulmonary hypoplasia, scoliosis, and hexadactyly of the left thumb. Although our case resembles a previously described case, a definitive diagnosis could not be made. The differential diagnosis included a variant of spondylocostal dysostosis and the VATER association.

Brainstem subarachnoid respiratory epithelial cysts: report of two cases and review of the literature.

Two cystic lesions that were lined by pseudostratified ciliated columnar epithelium containing goblet cells are described. Both lesions were found in the subarachnoid space between the vertebrobasilar arterial system and the brainstem. One cyst was an incidental finding in a patient who died of orbital phycomycosis. The cyst was filled with clear mucinous material. The second cyst presented as a mass adjacent to the brainstem in a woman who had progressive brainstem dysfunction. This lesion showed transition from pseudostratified ciliated columnar epithelium with goblet cells to papillary stratified squamous epithelium, histologic features essentially identical to those of squamous papillomas of the nasal cavity. This lesion was filled with squamous debris. The proposed origin of these lesions is discussed.

Cytochemical demonstration of neuromelanin in black pigmented adrenal nodules.

Retrospective review of 363 consecutive autopsy reports in which adrenal examination was noted reveal 8 cases of pigmented adrenal nodules. Black pigmented adrenal nodules have been reported infrequently both as incidental autopsy findings and in association with Cushing's syndrome. The nature of the pigment in these lesions has been assumed to be lipofuscin. Gross and histologic study of seven cases and electron microscopic study of two cases suggest the presence of a neuromelanin component in the pigment, a previously unreported finding in the adrenal cortex. Review of the clinical records of the patients suggested no associations with specific underlying disorders. The prevalence the authors report (2.2%) is less than that of a previous prospective study.

Neoplastic angioendotheliomatosis: immunopathologic and morphologic evidence for intravascular malignant lymphomatosis.

Neoplastic angioendotheliomatosis (NAE) is a rare entity characterized by multifocal, intravascular proliferation of large pleomorphic cells within small vessels of most organs, with a particular affinity for the central nervous system. Clinically, patients with NAE present with focal neurologic signs and a progressive decline in mental status, followed by death in a few months. The histogenesis of NAE is controversial but has been previously thought to represent a malignant proliferation of endothelial cells. Three autopsy cases with clinical and histologic features of NAE were investigated by electron microscopic, standard histochemical, and immunohistochemical technics that included the use of three panleukocyte monoclonal antibodies (PLA), the endothelial-cell-specific reagents, FVIII-RAG anti-sera and Ulex europaeus agglutinin (UEA), and muramidase. The NAE cells in all three cases were stained positively by the PLA, whereas the adjacent endothelial cells and not the NAE cells were stained by FVIII-RAG and UEA. Muramidase by immunoperoxidase technic and nonspecific esterase (chloracetate) were not present in NAE cells. These results indicate that NAE is a leukocyte-derived neoplasm and not a malignant endothelial cell neoplasm. Based on these findings and on a review of the literature, it is proposed that NAE represents intravascular malignant lymphomatosis (IML). IML appears to be a primary manifestation and/or a major secondary form of disseminated malignant lymphoma. This would explain the spectrum of findings in previously reported cases.

Black thyroid syndrome: exaggeration of a normal process?

Coal-black thyroid discoloration usually is identified in patients receiving chronic minocycline therapy. This report concerns the use of light microscopic, electron microscopic, and energy dispersion spectroscopy of thyroid pigments in three separate situations: minocycline-associated black thyroid; idiopathic black thyroid; and normally pigmented thyroid glands. One of the pigments, which is found in each situation, is best described as neuromelanin. This melanin pigment, like lipofuscin, appears to accumulate with advancing age. Pigment accumulation, therefore, is a normal process in the thyroid gland. Accelerated pigment accumulation occurs with minocycline therapy but can uncommonly be seen without associated minocycline treatment. Possible mechanisms for the development of these pigments in normal and black thyroid glands are discussed. Minocycline-associated pigment is also described in substantia nigra and atherosclerotic plaques.

Isolated central nervous system angiitis first presenting as spontaneous intracranial hemorrhage.

Two cases of isolated central nervous system angiitis presenting as spontaneous intracranial hemorrhage are reported. The usefulness and limitations of cortical/leptomeningeal biopsy in this condition is described. Emphasis is placed on the clinical awareness of this unusual association to ensure early recognition and prompt management with immunosuppressive therapy.

Diagnostic yield in CT-guided stereotactic biopsy of gliomas.

Twenty-seven patients underwent 29 computerized tomography (CT)-guided stereotactic biopsy procedures for untreated or recurrent malignant astrocytomas. Biopsies were obtained from the hypodense center, enhancing margin, and hypodense periphery as seen on contrast-enhanced CT scans, with diagnostic yields of (number of biopsies yielding tumor/number of biopsies obtained): 34/61 (56%), 68/101 (67%), and 8/22 (36%) from these three zones, respectively. Although tumor was identified in all three zones, diagnostic yield was significantly higher in the hypodense center and enhancing margin. Comparison of patients with untreated tumors to those with recurrent tumors demonstrated no statistical difference in tumor distribution, although there was a trend toward a higher yield from the hypodense periphery in the recurrent tumor group. Tumor was found up to 15 mm beyond the CT-enhancing margin, in addition to extending beyond the area of abnormality on T2-weighted magnetic resonance images. These findings suggest that serial stereotactic biopsies should be targeted to the hypodense center and enhancing margin for improved diagnostic yield. Biopsy material obtained from the hypodense periphery that demonstrates tumor also indicates that a tumor volume beyond the confines of the CT-enhancing margin should be considered when calculating dosimetry for interstitial radiation.

Quantitative assessment of ALZ-50 immunoreactivity in Alzheimer's disease.

A quantitative assay for ALZ-50 immunoreactivity was evaluated in samples of superior temporal gyrus taken at autopsy from 13 Alzheimer patients and 11 controls. The assayable immunoreactivity appears to be stable for at least 24 hours postmortem but was lost with formalin fixation. The mean value of the Alzheimer patients was tenfold higher than that of the controls (P less than .002). The values of four Alzheimer samples overlapped with the low levels seen in controls, but no controls had elevated levels. In this sample population, therefore, the assay had a sensitivity of 69% and specificity of 100%.