Forensic aspects of post-mortem histological detection of amniotic fluid embolism.

Amniotic fluid embolism (AFE) continues to be one of the most feared and devastating complications of pregnancy. A reliable diagnosis can be made only upon histological examination. A detection of AFE every now and then has a relevant implication on medico-legal aspects of intrapartum or post-partum maternal death. However, there are only isolated reports in the literature concerning the detection interval of amniotic fluid elements after their transfer into the lungs. The objective of this study was to determine how long after the onset of clinical symptoms the elements of amniotic fluid may be detectable in the pulmonary circulation. An autopsy, as well as a histological and toxicological examination of 29 women, who died intrapartum or post-partum were performed. AFE was diagnosed in seven women (25%). The maximum survival time of the women with AFE and also the detection interval of AF in the pulmonary vasculature was 36 h. In the lungs of the women who did not die of AFE, amniotic fluid components were not found. Thus, there is no evidence for a physiologic occurrence of AFE. In women who die some days or even weeks after delivery as a consequence of a haemorrhagic shock following post-partum genital bleeding ensuing from uterine atony, AFE should be considered as a cause of a coagulopathy.

Cellular glycoconjugates and their potential endogenous receptors in the cerebral microvasculature of man: a glycohistochemical study.

Protein-carbohydrate interactions are supposed to play a pivotal role in mediation of recognitive interactions, relevant to cellular interactions and transport. The brain microvasculature is the site of numerous cell-cell and cell-matrix recognitive interactions. Assuming carbohydrate-protein interactions play important physiological roles here, then specific carbohydrate-binding proteins should be prominent components of this microvasculature, in addition to the wealth of endogenous glycoconjugates reported by other authors. Human brain and brain tumor microvessels were analyzed histochemically for expression of endogenous sugar-binding proteins using a panel of biotin-conjugated, chemically glycosylated probes with specificities for alpha-/beta-D-galactosides and -D-glucosides, alpha-L-fucosides, alpha-D-mannosides, and beta-D-xylosides, and for expression of endogenous glycoconjugates using a panel of biotin-conjugated plant lectins with specificities for fucoside, galactoside, mannoside and glucoside moieties. Wax-embedded aldehyde- or Bouin-fixed tissues or acetone-fixed frozen sections were examined. Blood-brain barrier function was checked by ascertaining immunohistochemically the extravasation of serum albumin in these tissues. Microvessels in normal human brain tissues (with intact blood-brain barrier) contained abundant endogenous sugar-binding proteins with specificities for beta-galactosides, alpha-mannosides and beta-xylosides, and lesser amounts of proteins binding alpha-galactosides, alpha-fucosides and glucosides. Endogenous glycoconjugates bearing beta-galactoside, alpha-D-mannoside/alpha-D-glucoside or alpha-L-fucoside moieties were also abundant. In brain tumors (with defective blood brain barrier) the microvessels contained altered patterns of endogenous sugar-binding proteins, particularly noticeable in glioblastomas, in which there were notable alterations in galactoside-binding proteins in the microvessels.

Microglia and the development of spongiform change in Creutzfeldt-Jakob disease.

Recent in vitro experiments suggest that neurotoxicity of the prion protein is dependent on the presence of microglia. We have studied 11 cases of Creutzfeldt-Jakob disease (CJD) using immunocytochemistry in combination with computerized image analysis to clarify the relationship between spongiform change and microglial activation. MHC class II-positive microglia were almost exclusively confined to cortical gray matter where the neuropil area occupied by these cells exceeded that of controls more than 350-fold. In cortical regions with a bimodal distribution of spongiform degeneration, the presence of class II-positive microglia correlated well with the presence of vacuolation in layer V, but significantly less with spongiform change in layers II and III. In areas where spongiform degeneration affected the entire depth of the cortex, activated microglia were predominantly located in the inner one-half of the cortex or were evenly distributed throughout all cortical laminae. Here, microglia exhibited atypical, tortuous cell processes and occasionally intracytoplasmic vacuoles, suggesting that microglia themselves may become a disease target. Taken together, our results provide indirect evidence against an early causative involvement of microglia in the development of spongiform change. At later stages, however, diseased microglia could produce harmful factors which mediate both astrogliosis and neuronal injury.

Cerebral involvement in graft-versus-host disease after murine bone marrow transplantation.

Neurologic manifestation of graft-versus-host disease (GvHD) after allogeneic bone marrow transplantation (BMT) has until now been limited to rare neuromuscular syndromes. Investigating cerebral findings using a murine BMT model, the authors found parenchymal lymphocytic inflammation, microglia activation, and mild cerebral angiitis-like changes in allogeneic transplanted animals but not in syngeneic controls. These findings suggest that cerebral involvement during GvHD may be a new neurologic complication after BMT.

Growth inhibition of experimental glioma grafts by monoclonal antibody treatment.

The effects of 14AC1 monoclonal antibody (McAb) on 79FR-G-41 rat glioma cells in vitro, on the formation of metastases in lung by antibody coated glioma cells, and on the growth of glioma grafts in BALB/c-nu/nu mice were investigated. The 14AC1 antibodies - isotyped as IgG2a - were obtained from a hybridoma clone established after fusion of X63-Ag8.653 myeloma cells and spleen cells of BALB/c mice hyperimmunized with 79FR-G-41 glioma cells. Antibody treatment of glioma cells in vitro caused evident cell surface alterations and pronounced growth depression of most cells. However, a few tumor cells remained unchanged in morphology and continued to proliferate. Moreover, 14AC1 antibodies drastically reduced lung metastasis by pretreated and i.v. delivered glioma cells. Additionally, 14AC1 antibodies suppressed the growth of transplanted rat gliomas in nude mice as evidenced by a longer latency period and a smaller volume of glioma grafts in treated than in control tumor bearers. Nevertheless, glioma grafts showed accelerated growth after termination of antibody treatment. Further experimental investigation is required in order to identify the precise mechanisms of the effects of McAbs on tumor cells in vitro and in vivo.

Monoclonal antibodies against human astrocytomas and their reactivity pattern.

The establishment of hybridomas after fusion of X63-Ag8.653 mouse myeloma cells and splenocytes from BALB/c mice hyperimmunized against human astrocytomas is presented. The animals were primed with 5 X 10(6) chemically modified uncultured or cultured glioma cells. Six weeks after the last immunization step an intrasplenal booster injection was administrated and 3 days later the spleen cells were prepared for fusion experiments. According to the specificity analysis of the generated antibodies 7 hybridoma products (MUC 7-22, MUC 8-22, MUC 10-22, MUC 11-22, MUC 14-22, MUC 15-22 and MUC 2-63) react with gliomas, neuroblastomas and melanomas as well as with embryonic and fetal cells but do not recognize non-neurogenic tumors. The selected monoclonal antibodies (McAbs) of IgG1 and IgG2a isotypes are not extensively characterized but these antibodies have been demonstrated to be reactive with a panel of glioma cell lines with varying patterns of antigen distribution. Using the McAbs described above and a series of cryosections of glioma biopsies and paraffin sections of the same material as well as glioma cultures established from these, variable antigenic profiles among glioma cell populations could be demonstrated. From these results it is evident that there is not only a distinct degree of antigenic heterogeneity among and within brain tumors, but also that the pattern of antigenic expression can change continuously. Some of the glioma associated antigens recognized by the selected antibodies persist after fixation with methanol/acetone and Karnovsky's fixative and probably are oncoembryonic/oncofetal antigen(s). The data suggest that the use of McAbs recognizing tumor associated oncofetal antigens in immunohistochemistry facilitates objective typing of intracranial malignancies and precise analysis of fine needle brain/tumor biopsies in a sensitive and reproducible manner.

Primary intracranial metatypical basal cell carcinoma: case report.

OBJECTIVE AND IMPORTANCE: A case of primary intracranial metatypic basal cell carcinoma in a 20-year-old man is described. CLINICAL PRESENTATION: A 20-year-old man presented with palsies of the left cranial nerves VI through XII, including complete facial and vestibulocochlear nerve palsy and signs of cerebellar dysfunction, which included left-sided brachydiadochokinesis and nystagmus when looking to the left. There was no evidence of extracranial tumor manifestation. Imaging showed a tumor located in the left pyramidal bone, filling the left cerebellopontine cistern and compressing the brain stem with an extension into the middle cranial fossa as far as the internal carotid artery. INTERVENTION: Subtotal tumor removal was accomplished by a combined neurosurgical-otolaryngological procedure through a transpetrosal approach. A histopathological examination revealed a metatypical basal cell carcinoma. Postoperatively, a total dose of 60 Gy of radiation therapy was administered over a period of 6 weeks. CONCLUSION: Although it is rare, primary intracranial basal cell carcinoma should be considered in the differential diagnosis of tumors of the temporal bone.

Inducible nitric oxide synthase: a possible key factor in the pathogenesis of chronic vasospasm after experimental subarachnoid hemorrhage.

OBJECT: The role of nitric oxide (NO) in the pathogenesis of cerebral vasospasm after subarachnoid hemorrhage (SAH) is not well understood. Nitric oxide is a well-established vasodilatory substance; however, in SAH, NO may become a major source for the production of injurious free-radical species, leading to chronic cerebral vasospasm. Reactive overproduction of NO to counteract vascular narrowing might potentiate the detrimental effects of NO. The focus of the present study is to determine the extent of reactive induction of inducible nitric oxide synthase (iNOS) after experimental SAH. METHODS: Chronic vasospasm was induced in male Wistar rats by an injection of autologous blood (100 microl) into the cisterna magna followed by a second injection 24 hours later. A control group of 10 animals was treated with injections of 0.9% sodium chloride solution. Vasospasm was verified by pressure-controlled angiography after retrograde cannulation of the external carotid artery 7 days later. In 11 of 15 animals radiographic evidence of cerebral vasospasm was seen. The animals were perfusion fixed and their brains were removed for immunohistochemical assessment. With the aid of a microscope, staining for iNOS was quantified in 40-microm floating coronal sections. Immunohistochemical staining for iNOS was markedly more intense in animals with significant angiographic evidence of vasospasm. Virtually no staining was observed in control animals. Seven days after the second experimental SAH, labeling of iNOS was found in endothelial cells, in vascular smooth-muscle cells, and, above all, in adventitial cells. Some immunohistochemical staining of iNOS was observed in rod cells (activated microglia), in glial networks, and in neurons. CONCLUSIONS: The present study demonstrates induction of iNOS after experimental SAH.

Fluorescence-guided resection of glioblastoma multiforme by using 5-aminolevulinic acid-induced porphyrins: a prospective study in 52 consecutive patients.

OBJECT: It has been established that 5-aminolevulinic acid (5-ALA) induces the accumulation of fluorescent porphyrins in glioblastoma multiforme (GBM), a phenomenon potentially exploitable to guide tumor resection. In this study the authors analyze the influence of fluorescence-guided resection on postoperative magnetic resonance (MR) imaging and survival in a series of patients who underwent surgery in the authors' department. METHODS: Fifty-two consecutive patients with GBM received oral doses of 5-ALA (20 mg/kg body weight) 3 hours before induction of anesthesia. Intraoperatively, tumor fluorescence was visualized using a modified operating microscope. Fluorescing tissue was removed whenever it was considered safely possible. Residual enhancement on early postoperative MR imaging was quantified and related to each patient's characteristics to determine which factors influenced resection. Survival was analyzed using the Kaplan-Meier method and multivariate analysis was performed in which the Karnofsky Performance Scale (KPS) score, residual fluorescence, patient age, and residual enhancement on MR images were considered. Intraoperatively, two fluorescence qualities were perceived: solid fluorescence generally reflected coalescent tumor, whereas vague fluorescence mostly corresponded to infiltrative tumor. Complete resection of contrast-enhancing tumor was accomplished in 33 patients (63%). Residual intraoperative tissue fluorescence left unresected for safety reasons predicted residual enhancement on MR images in 18 of the 19 remaining patients. Age, residual solid fluorescence, and absence of contrast enhancement in MR imaging were independent explanatory factors for survival, whereas the KPS score was significant only in univariate analysis. No perioperative deaths and one case of permanent morbidity were encountered. CONCLUSIONS: The observations in this study indicate the usefulness of 5-ALA-induced tumor fluorescence for guiding tumor resection. The completeness of resection, as determined intraoperatively from residual tissue fluorescence, was related to postoperative MR imaging findings and to survival in patients suffering from GBM.

Antigenic heterogeneity of human brain tumors defined by monoclonal antibodies.

The antigenic profiles of human gliomas and in vitro established cell lines were investigated using the monoclonal antibodies (MABs) MUC 8-22 and MUC 2-63. The reactivity with tissue samples and cytospin preparations obtained from 45 brain tumors was estimated by the indirect immunoperoxidase technique. In addition, computer-assisted cytofluorometry was used to quantify the intensity and distribution of antibody-binding. Various degrees of antibody-binding among and within gliomas and glioma-derived cell lines were observed. The data show that a variable percentage of cells are not labeled with the employed MABs. The spectrum of reactivity of the selected antibodies was independent of the histological grading of gliomas. However, there were significant differences in various stages of subcultivation of glioma lines. In most cases, the heterogeneity of antigen expression decreased during successive in vitro propagation of glioma cells. The extent of variation in staining intensity values differed within cell populations and reflected the antigenic heterogeneity of human brain tumors. The findings presented here suggest that the use of MABs which recognize glioma-associated antigens facilitates the objective analysis of brain tumors and is of potential value for immunohistochemical application in surgical neuropathology.

Morphometry of intraluminal side-to-side differences in human basal cerebral arteries.

Intraindividual variability of Doppler frequencies in the basal cerebral arteries is higher than the variability in perfusion measurements. Since Doppler frequency is dependent on vessel diameter, we measured intraluminal vessel diameters post mortem. In 73 human cadavers, we measured fresh pairs of rings of the terminal internal carotid artery, the anterior and the middle cerebral artery. Mean intraluminal diameters (+/- standard deviation) for the respective vessel segments were 2.8 +/- 0.49 mm (2.72 +/- 0.49 mm), 1.61 +/- 0.37 mm (1.63 +/- 0.39 mm) and 2.10 +/- 0.38 mm (2.10 +/- 0.41 mm). The left/right ratio was 1.04 +/- 0.13, 1.05 +/- 0.35 and 1.02 +/- 0.17. Intraindividual asymmetries in intraluminal vessel diameters might be an additional factor in the interpretation of intracranial Doppler frequency measurements.

[Nuclear magnetic resonance tomographic appearance of disseminated encephalomyelitis in relation to clinical diagnosis]. / Kernspintomographisches Erscheinungsbild der Encephalomyelitis disseminata in Abhängigkeit von der klinischen Diagnosestellung.

The MRI findings in 149 patients with a clinical diagnosis of disseminated encephalomyelitis (D.E.) were related to the diagnostic criteria of McAlpine (definite, probable, possible). The most common pattern in all three groups was a mixed peri- and para-ventricular distribution of foci. The findings in 'possible' D.E., compared with 'definite' D.E., showed fewer confluent lesions, but were characterised by peri- and para-ventricular as well as solitary foci. The results of the present study permit better classification and evaluation of the MRI findings if the clinical diagnosis of D.E. is only suspected (probable or possible).

Generalized mitochondrial microangiopathy and vascular cytochrome c oxidase deficiency. Occurrence in a case of MELAS syndrome with mitochondrial cardiomyopathy-myopathy and combined complex I/IV deficiency.

The pathophysiological significance of the mitochondrial microangiopathy in MELAS (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes) syndrome was evaluated in an autopsy study of a nearly 13-year-old girl who had suffered from multiple infarctlike lesions in the brain, a mitochondrial myopathy-cardiomyopathy, and a generalized mitochondrial microangiopathy. Cytochemically, defects of cytochrome c oxidase (complex IV) were visualized by light and electron microscopy in the skeletal and heart muscle and in the altered vessels, as well as in single bile duct cells, with the activity of the hepatocytes being diffusely reduced, whereas in the brain, the cytochemical activity was only slightly diminished. Biochemical studies revealed a 50% reduction of both NADH (the reduced from of nicotinamide-adenine dinucleotide) dehydrogenase (complex I) and complex IV in the skeletal muscle. In the brain, complex I was diminished to 20%, whereas complex IV was only slightly below the low-normal range. Immunohistochemical studies with the use of subunit-specific antiserum samples against cytochrome c oxidase showed a varying protein profile, with loss of both mitochondrially and nuclearly derived subunits being most pronounced in the heart muscle and lesser in the skeletal muscle. In the brain, liver, bile ducts, and especially the vessels, no loss of enzyme protein content was observed. The results illustrate heterogeneous tissue expression of respiratory chain defects in MELAS syndrome and indicate that vascular cytochrome c oxidase deficiency may be involved in the cerebral manifestation of the disease, whereas in other organs like the heart, a similar pathogenetic importance of the microangiopathy cannot be verified.

Non-specific granulomas of the pituitary: report of six cases treated surgically.

Granulomatous lesions of the pituitary gland are very rare. In our department, six patients with these lesions have been operated on since 1988. The records of these patients were analysed and are reported in the following. Three of the patients were admitted because of severe and rapid development of visual disturbances caused by a suprasellar extending lesion. Endocrinological examination most often found posterior lobe insufficiency, was followed by anterior lobe dysfunction. CT and MRI demonstrated a cystic lesion with semiliquid content, where mild contrast enhancement of the walls of the tumor was observed in all cases. Surgery was performed using the transphenoidal approach. Rapid relief of visual impairment was observed in the three patients with chiasmal compression. In one patient, recurrent chiasm syndrome due to lesion regrowth required additional surgery with transcranial resection of the capsule. Unfortunately, visual impairment persisted postoperatively in one eye. Endocrinological follow-up demonstrated unchanged or even worsened pituitary functions in all cases. Our study revealed no consistent predictive preoperative finding. Therefore, we consider an indication for decompression surgery to be given in all patients with chiasmal syndrome and for diagnostic surgery for all patients with intrasellar lesions.

Diagnosis of primary cerebral lymphoma with particular reference to CT-guided stereotactic biopsy.

In establishing the histological diagnosis of primary cerebral lymphoma, stereotactic brain tumour biopsy is the method of choice as the mainstay of therapy is radiation and chemotherapy. This study describes the histopathology and diagnostic immunohistochemistry of 54 primary brain lymphomas in a mainly non-AIDS population. The stereotactic biopsies were performed using the Leksell CT stereotactic frame and a spiral needle which procured about 10-mm-long tissue cylinders. Usually, three successive biopsy cylinders were taken along the target trajectory. Histological examination revealed the prevalence of high-grade non-Hodgkin's lymphoma of the polymorphous centroblastic type. The series did not include any low-grade lymphomas or T-cell lymphomas. L-26 immunohistochemistry resulted in a positive staining of the blasts, thus confirming the B-cell origin of primary brain lymphomas. Small reactive T-lymphocytes and monohistiocytic cells were also found within and at the periphery of the lymphomas and in areas of degeneration. In the biopsies of nine patients, who had shown significant reduction of the lesions on the CT scans, after corticosteroid medication, regressive tissue changes were predominant and consisted of T-lymphocytes, macrophages, and occasionally bizarre reactive astrocytes.

Synaptic stripping in the human facial nucleus.

An autopsy case of severe peripheral facial nerve paresis with disconnection of synapses from facial motor neurons is reported. A 77-year-old man presented with left-sided otitis media and subsequent development of facial nerve paresis. Three months later, the patient died of an acute gastrointestinal bleeding from a chronic duodenal ulcer. Gross inspection of the brain revealed non-stenosing arteriosclerotic vascular changes and a single small cystic lesion in the right putamen. Microscopically, marked chromatolytic changes were observed in the left facial nucleus. Immunocytochemistry for synaptophysin revealed a marked loss of afferent synaptic contacts from somatic and stem dendritic surface membranes of all chromatolytic motor neurons. Wrapping of a number of neurons by newly formed glial fibrillary acidic protein-positive astrocytic cell processes could be detected in the regenerating facial motor nucleus. In addition, expression of HLA-DR was increased on a small number of microglia and perivascular cells. These changes were absent from the contralateral, normal-appearing facial nucleus. To our knowledge, this case provides the first evidence for disconnection of synapses following peripheral nerve lesioning in humans. Occurrence of synaptic stripping is likely to explain nuclear hyperexcitability and failure of recovery of complex fine motor movements that are commonly observed following peripheral injury to the facial nerve.

[Listeriosis in malignant diseases]. / Listeriose bei malignen Erkrankungen.

Listeriosis occurred in two patients, a 46-year-old woman and a 41-year-old man, in the course of an underlying malignant disease. The woman had a metastasizing pancreatic apudoma, requiring partial pancreas resection with splenectomy. After the end of cytostatic treatment she developed headaches and fever up to 40 degrees C. Listeria monocytogenes was demonstrated in the blood and cerebrospinal fluid. She went into coma on the day after hospital admission and, despite antibiotic administration, she died on the fourth day of treatment. The 41-year-old man was suspected of having an angioimmunoblastic lymphoma. Severe haemolytic anaemia (haemoglobin 4.4 g/dl) was treated with glucocorticoids, massive blood transfusions and splenectomy, at first without success. During immunosuppressive treatment with prednisone and cyclophosphamide the haemoglobin rose. But he was still feverish with nocturnal sweating. Neurological symptoms of motor aphasia, cranial nerve deficits and incomplete hemiparesis rapidly developed. Computed tomography revealed a focus in the internal capsule. Blood culture grew Listeria. The focal encephalitis healed with minor sequelae after antibiotic treatment. Both patients had hypogammaglobulinaemia, but no granulocytopenia. It is stressed that listeriosis should be included in the differential diagnosis in cases of septicaemia or cerebral infection occurring in the course of malignant disease.

Accuracy of stereotactic brain tumor biopsy: comparison of the histologic findings in biopsy cylinders and resected tumor tissue.

Appropriate treatment for intracranial mass lesions depends upon accurate morphological diagnosis. In 47 of 360 patients the findings in stereotactically obtained tissue cylinders were compared with tumor resection (n = 38) or autopsy (n = 9) tissue material to define the accuracy of our stereotactic biopsy method. These biopsies were performed using the LEKSELL CT stereotactic frame and a spiral needle which procured about 10-mm-long tissue cylinders. Usually, three to four successive biopsy specimens were taken along the target trajectory placed through the whole lesion and its margins according to the CT imagings. Final morphological diagnosis was exclusively based on the histological findings of permanent paraffin sections. In 42 cases (89%), the histological results in biopsy and resection/autopsy tissue were identical, including mainly cases of low and high grade gliomas as well as some brain lymphomas, metastases, and cases of inflammatory brain lesions (aspergillosis, toxoplasmosis). In 3 patients with a diagnosis of brain lymphoma and low grade glioma on the basis of the surgical specimens, stereotactic biopsy revealed only unspecific reactive tissue changes. In two cases of the early part of the study, sampling errors occurred. This study provides evidence for the high diagnostic accuracy of the established stereotactic biopsy method which is characterized by representative tissue sampling and histological processing of the specimens.