The neuropathological findings of developmental and epileptic encephalopathy-43 (DEE43) and delineation of a the molecular spectrum of novel case.

Developmental and epileptic encephalopathies (DEE) constitute an expanding group of severely disabling and, most frequently, drug-resistant disorders starting in the first year of life. Among them, there is DEE43, caused by dominant mutations in the GABRB3 gene. We present first neuropathological findings in a novel, molecularly confirmed case with the fatal course. The neuropathological analysis revealed co-existing developmental anomalies and retardation of myelination resulting from disturbed early brain growth as well as lesions caused by epileptic hypoxic-ischemic episodes. Developmental anomalies included misplaced neurons in the cerebellar white matter, heterotopic neurons in the cortical molecular layer and in the molecular layer of the hippocampal dentate gyrus, dysmorphic cerebellar dentate nuclei and inferior olivary nuclei in the medulla oblongata. The migrational and maturational disorders leading to the neuronal network dysfunction could be the cause of both the lack of development and the ineffectiveness of antiepileptic treatment in children affected by DEE. Giving the presented neuropathological description and based on the literature, we discuss the pathomechanism of the disease, to improve current understanding of both the lack of development and the ineffectiveness of treatment of affected children.

POLG gene mutation. Clinico-neuropathological study.

We present a female patient with a mutation of the POLG gene (POLG DNA polymerase gamma, catalytic subunit; *174763) in which the clinical course suggested a mitochondrial disease, a neuropathological examination identified the syndrome more closely, and a genetic test confirmed the disease. Apart from the morphological lesions typical of Alpers-Huttenlocher syndrome, rarely observed symmetrical degenerative changes in the accessory olivary nuclei were found. It was unusual in the clinical course of the disease that pancreatitis was diagnosed before symptoms of liver failure appeared.

Loss of SMPD4 Causes a Developmental Disorder Characterized by Microcephaly and Congenital Arthrogryposis.

Sphingomyelinases generate ceramide from sphingomyelin as a second messenger in intracellular signaling pathways involved in cell proliferation, differentiation, or apoptosis. Children from 12 unrelated families presented with microcephaly, simplified gyral pattern of the cortex, hypomyelination, cerebellar hypoplasia, congenital arthrogryposis, and early fetal/postnatal demise. Genomic analysis revealed bi-allelic loss-of-function variants in SMPD4, coding for the neutral sphingomyelinase-3 (nSMase-3/SMPD4). Overexpression of human Myc-tagged SMPD4 showed localization both to the outer nuclear envelope and the ER and additionally revealed interactions with several nuclear pore complex proteins by proteomics analysis. Fibroblasts from affected individuals showed ER cisternae abnormalities, suspected for increased autophagy, and were more susceptible to apoptosis under stress conditions, while treatment with siSMPD4 caused delayed cell cycle progression. Our data show that SMPD4 links homeostasis of membrane sphingolipids to cell fate by regulating the cross-talk between the ER and the outer nuclear envelope, while its loss reveals a pathogenic mechanism in microcephaly.

Clinico-pathological correlation in case of BRAT1 mutation.

The clinical picture of BRCA1-associated protein required for ATM activation-1 (BRAT1) comprises retractable early-onset epileptic encephalopathy, progressive microcephaly, and early demise. Both, inter- and intrafamilial variations of features of BRAT1-associated disease have been described. Here, the familial case of a brother and sister with homozygous pathogenic variants in BRAT1 is presented with special emphasis on differences in seizure type/onset and central nervous system lesions. The neuropathology is extensively discussed and hypotheses put forward that may shed light on etiology of brain symptomatology within the context of BRAT1 mutations.

Commitment of protein p53 and amyloid-beta peptide (Aß) in aging of human cerebellum.

Protein p53 is known to induce the cell cycle arrest and apoptosis in response to a variety of cellular distress signals and DNA damage. A recent study has demonstrated that in blood cells of aging subjects, p53 may induce early pathological changes that precede the amyloidogenic cascade. However, it is not clear whether p53 participates in the local deposition of amyloid-beta peptide (Aß) in the nerve tissue of normal aging subjects. Therefore, in the present study, we analyse the distribution of both (Aß and p53) proteins in the cerebellum of individuals without any history of dementia or other neurological illness who died suddenly in traffic accidents. We found that in the subjects at the beginning of their aging process (60-65 years of age) Aß deposits were localized in subependymal areas of the cerebellar cortex and such deposits were not linked to the presence of p53 in the nerve tissue. In groups of subjects over 65 years of age, numerous Aß diffuse plaques were scattered throughout the cerebellar cortex. In these subjects, p53 protein was detected in the cytoplasm or in the nucleus of the cerebellar nerve cells. All the results lead to the conclusion that in nerve tissue p53 participates in the process of neurodegeneration and then it is involved in the deposition of A in the nerve tissue.

Toll-like receptor 2 (TLR2) is a marker of angiogenesis in the necrotic area of human medulloblastoma.

Angiogenesis plays a key role in the progression of malignant tumors. In recent years, anti-angiogenic drugs have been shown to be effective against tumors. However, some tumors are able to adopt escape mechanisms, suggesting that the vascular network in these tumors may be formed or may function in a different way. Medulloblastomas are tumors characterized by poor prognosis and low patient survival rates. These tumors rarely metastasize, but the reason why they almost always recur locally is not known. Central to mediating neoplastic changes is the interaction between cell surface receptors and their cognate ligands, which through intracellular signaling induce alternations in gene expression. In this context, the aim of our present study was to examine in medulloblastoma the distribution of Toll-like receptor 2 (TLR2) and receptor for advanced glycosylation end-product (RAGE), and mast cells associated with the tumor neovascularization process. Immunohistochemical study with a battery of specific antibodies was used. The results show that in the tumor necrotic area, TLR2 participates in all steps of vascular network formation, but in regions where the tumor was not affected by necrosis, the capillary network was TLR2 immunonegative. The TLR2 vascular network of the necrotic area was not associated with RAGE and mast cells. However, in the region of the medulloblastoma not affected by necrosis, the RAGE receptor was present in the endothelium of all capillaries, and mast cells were numerous only in the perivascular space of large brain and meningeal vessels at the border of the tumor. In conclusion, our results show that the receptor of innate immunity TLR2 plays an important role in recognition of ligands delivered by dying necrotic medulloblastoma cells and participates in tumor neovascularization. Moreover, the results show that the RAGE receptor and mast cells operate in different medulloblastoma regions and influence different parts of the tumor vascular network.

Holoprosencephaly with agenesia of the prosencephalic ventricle.

Malformations of the forebrain are characterized by abnormalities in size, shape, and arrangement of the cerebral hemispheres and ventricles. We present the morphological picture of a brain with failure of the forebrain complementary to holoprosencephaly coexisting with absence of the anterodorsal part of the prosencephalic ventricles. The anomaly can be graded within the holoprosencephalic spectrum due to the main morphological features. However, such alterations as aplasia of the forebrain ventricles and prominent leptomeningeal gliomesodermal proliferation are related to atelencephaly. The observations confirm the common pathogenic mechanism of aprosencephaly/atelencephaly and holoprosencephaly. The malformation corresponds to a wide continuous spectrum with no clear-cut boundaries of abnormal formation of the prosencephalon.

Methyl-CpG binding protein 2, receptors of innate immunity and receptor for advanced glycation end-products in human viral meningoencephalitis.

Inflammation is a normal host defense reaction to infections and tissue injury. In pathology, the process of inflammation is deregulated by various environmental factors, prolonged activation of Toll-like receptors (TLRs), induction of epigenetic machinery or expression of receptors for advanced glycation end-products (RAGE). In the present study, we examined immunoexpression of proteins participating in the above-mentioned mechanisms, in the brain of patients with viral meningoencephalitis. The results showed that depending on the period of the disease, the process of inflammation is deregulated in different ways. In an early period of viral meningoencephalitis, we found numerous so-called microglial nodules which were strongly immunopositive to methyl-CpG protein 2 (MeCP2). This protein is an epigenetic factor important for methylation of DNA; therefore, our results suggest that cells collected in the nodules may participate in modification of the host defense reaction. Moreover, in the early period of viral meningoencephalitis, we found that Purkinje cells of the cerebellum contain TLR3 or TLR9 receptors that can recognize viral pathogens and may activate a self-destructive mechanism in these neurons. In the later (advanced) period of viral meningoencephalitis, despite some of the above observations, RAGE protein was detected in the brain of adult and aging patients. It means that in this period of the disease, the inflammatory process may be deregulated by numerous post-translationally modified proteins that are transported to the brain after binding with activated RAGE. In addition, young patients appeared more susceptible to viral infections than adult and aging patients, because most of them died during the early period of meningoencephalitis.

Crosstalk in human brain between globoid cell leucodystrophy and zinc-α-2-glycoprotein (ZAG), a biomarker of lipid catabolism.

Zinc-alpha-2-glycoprotein (ZAG) is a protein identified as a lipid-mobilizing factor participating in a lipid catabolism. In spite of intensive studies conducted during last five decades, the role of this protein in processes of neurodegeneration remains unclear. The aim of our study was to examine the presence of ZAG protein in the brain of patients with Krabbe's disease, which is considered as a psychosine lipidosis caused by a mutation of a known gene. We found intracellular and extracellular localization of ZAG in the brain of Krabbe's disease patients but in the brain of control age-matched patients, ZAG was not detected. Distribution of ZAG in the brain suggests that the influx of ZAG into the brain involved a blood-brain barrier mechanism and adenoreceptors localized on astrocytes and some neurons.

Morphological evidence of the beneficial role of immune system cells in a rat model of surgical brain injury.

The blood-brain barrier prevents infiltration of peripheral immunocompetent cells into the CNS under physiological conditions. Following brain trauma there is reported a rapid and massive immunological response. Our earlier data indicated that surgical brain injury causes breaking of brain parenchyma integrity and results in cell changes and death, astrogliosis and disruption of blood vessels. The aim of the present studies was to investigate and characterize immunocompetent cells entering brain damaged parenchyma in the early period following the injury in a rat model of surgical damage. In the investigations we used light and electron microscopy techniques. Four days following the lesion many monocytes and macrophages were detected in the injured parenchyma. We also found many activated microglial cells with phagosomes within the cytoplasm. The phagocytes digest the cellular debris and clean up the parenchyma. The data suggest the beneficial role of immunocompetent cells following surgical injury.

Congenital glioblastoma coexisting with vascular developmental anomaly.

Congenital central nervous tumours form a unique group of neoplasms. They are different from other tumour groups not only due to the onset time but also to their histopathology, anatomic location, and biologic behaviour. Congenital glioblastoma is one of the rarest types of congenital brain tumours and is uncommon in the prenatal period. We report a rare case of congenital glioblastoma detected prenatally by ultrasound examination and magnetic resonance imaging at 26 gestational weeks. Based on MRI findings and consultation of a team of specialists, pregnancy was terminated at 28 weeks. The newborn presented hydrops foetal. The child died shortly after birth due to cardiorespiratory insufficiency. At autopsy a large tumour with a spongy-like appearance was found. The tumour involved nearly the whole right cerebral hemisphere and led to marked hydrocephalus. In the histological and immunohistochemical examination, the tumour presented features of glioblastoma. Neoplastic cells were immunopositive for GFAP, S-100 protein and negative for neuronal markers. Frequent mitoses and high MIB-1 labelling index were seen in the tumour areas. The coexistence of tumour and vascular developmental anomaly was stated. The conglomerates of numerous, distended, thin-walled foetal-like blood vessels were located beside the tumour tissue, which presented disturbance in differentiation and maturation of the vascular net. Such coexistence of malignant glioma with vascular developmental anomaly is unique.

Diagnostic difficulties in Krabbe disease: a report of two cases and review of literature.

Globoid cell leukodystrophy (GLD, also known as Krabbe disease), whose pathophysiology is still not completely elucidated, is an inherited, metabolic, and neurodegenerative disease, caused by the deficiency of ß-galactocerebrosidase (GALC) or in very rare cases by lack of active saposin A. We describe two patients, in whom first MRI changes were not suggestive of GLD. Additionally, in Patient 1, the residual ß-galactocerebrosidase activity was rather high leading to difficulties in the diagnosing process. Molecular analysis of the GALC and PSAP genes in Patient 1, and of the GALC gene in Patient 2 confirmed the diagnosis of Krabbe disease. We have detected a novel mutation in the GALC gene in Patient 2, a deletion in exon 16, leading to the STOP codon (c.1851delT, p.Y617X). This deletion interrupts the reading frame prematurely: codon 617 is replaced by a STOP codon. A careful clinical description of presented patients is followed by a discussion of radiological, biochemical, genetic, and neuropathological studies. It concludes with a discussion of the potential difficulties encountered when diagnosing patients with rare diseases. In Patient 1 the postmortem examination of CNS revealed the presence of globoid cells grouped in multiple clusters seen in the white matter near the vessels. We would like to emphasize that proper clinical-radiological-biochemical co-operation and exchange of information between parents and specialists is a key issue in the diagnosis of rare and difficult neurological diseases, in particular, if the clinical picture is inconclusive.

Toll-like receptors as an innate immunity bridge to neuroinflammation in medulloblastoma.

The relationship between inflammation, immunity and cancer is widely accepted but mechanisms mediating this relationship remain unknown. Our present study was undertaken to examine the presence and distribution of Toll-like receptors (TLRs) in necrotic areas of medulloblastoma. These receptors fulfil the criteria postulated for the receptors of innate immunity and signalling from TLRs induces synthesis of various pro-inflammatory cytokines, enzymes and mediators. The study was performed on human medulloblastoma samples containing areas of necrosis within the tumour and/or within the normal nerve tissue at the periphery of the tumour. Proteins of four TLRs: TLR 2, 3, 4 and 9 were detected in the tissue with the immunohistochemical method using the specific antibodies. Two types of necrotic areas were found. In the first type, the area of dead cells was surrounded by undifferentiated medulloblastoma cells. A lot of these cells expressed TLR 2 and TLR 3 antigens. TLR 2 was also expressed on the wall of de novo formed blood vessels that fill tumour regions already cleared from dead cells. The second type of necrotic areas were found at the periphery of the tumour and composed of normal nerve tissue cells. TLR 2, TLR 3 and TLR 9 were detected in hypertrophic glia cells. Our findings show a new function of TLRs as sensors of pathogens released by medulloblastoma dead cells. This new function may provide a key link connecting innate immunity, neuroinflammation and angiogenesis in the tumour.

Cerebellar cortical neurons misplaced in the white matter due to disturbed migration during development of human brain.

The normal laminar organisation of the cerebellar cortex is the result of the precisely controlled migration, differentiation and maturation of the neurons. Occasionally the migrating neurons lose their proper way of migration and form nests of grey matter in the improper place. The aim of this study was to investigate the morphological features of the lost neurons in the cerebellar white matter during development, with particular emphasis on their localisation, arrangement and differentiation. We analyzed 31 fetal and infantile brains, aged from 28 gestational weeks to 18 postnatal months. We observed different morphological patterns of cerebellar heterotopias. Clusters of grey matter reflecting the cerebellar cortical pattern with well-defined molecular layer and altered granular and Purkinje cells were most frequently observed. The compact heterotopias were composed of bands or whirls of spindle and round granule cells situated closely together, while Purkinje neurons were completely disorganised. The ectopic cortex in the white matter with a normal layered structure containing all the components of the cerebellar cortex was localised by the large vessels. Aggregations of Purkinje cells scattered in the white matter without accompanying granule cells were observed. The evaluation of the biological features of the misplaced cerebellar cortical components showed high activity of neurons.

Immunodistribution of amyloid beta protein (Aß) and advanced glycation end-product receptors (RAGE) in choroid plexus and ependyma of resuscitated patients.

RAGE (receptor for advanced glycation end-products) participates in the influx transport of glycated Aß (amyloid beta) from the blood to the brain. Because little is known of the RAGE operating in brain barriers such as those in the choroid plexus and ependyma, the aim of the present study was to examine the immunodistributions of RAGE and Aß peptides in the choroid plexus where the blood-cerebrospinal fluid barrier (B-CSF) is located, and in ependyma of the brain ventricles associated with functions of the cerebrospinal fluid-brain barrier (CSF-B). The study was performed on patients over 65 years successfully resuscitated after cardiac arrest with survival a few weeks. The control group consisted of age-matched individuals who were not resuscitated and died immediately after cardiac arrest. In resuscitated patients, but not in controls, RAGE receptors were localized in choroid plexus (CP) epithelial cells and in ependymal cells bordering the brain ventricles. These cells form the B-CSF and CSF-B barriers. The presence of Aß was detected within the CP blood vessels and in the basement membrane of the CP epithelium. In numerous cytoplasmic vacuoles of CP epithelial and ependymal cells Aß protein was found and our observations suggest that the contents of those vacuoles were undergoing progressive digestion. The results demonstrated that CP epithelium and ependymal cells, equipped with RAGE receptors, not only play an important role in the creation of amyloid deposits in the brain but are also places where Aß may be utilized. The RAGE transportation system should be a main target in the therapy of brain amyloidosis, a well-known risk factor of Alzheimer disease.

Association of mast cells with calcification in the human pineal gland.

Increased pineal calcifications and decreased pineal melatonin biosynthesis, both age related, support the notion of a pineal bio-organic timing mechanism. The role of calcification in the pathogenesis of pineal gland dysfunction remains unknown but the available data document that calcification is an organized, regulated process, rather than a passive aging phenomenon. The cellular biology and micro-environmental conditions required for calcification remain poorly understood but most studies have demonstrated evidence that mast cells are strongly implicated in this process. The aim of the present study was to examine the phenotype of mast cells associated with early stages and with the progressive development of calcification in the human pineal gland. The study was performed on pineal samples of 170 fetuses and children whose brains were autopsied and diagnosed during 1998-2002. The representative cerebral and pineal specimens were stained with haematoxylin and eosin or the von Kossa staining technique and for the distribution of mast cell tryptase, mast cell chymase, histamine H4 receptor and vascular network using biotinylated Ulex europaeus agglutinin. Tryptase mast cells were found in all stages of pineal gland development independently of the presence of local tissue lesions. All of them were always localized in the close vicinity of the blood vessels and expressed immunoreactivity to histamine H4 receptor antibody. Immunolocalization of mast cells by chymase antibody (and following dual immunostaining with both chymase and tryptase antibodies) demonstrated that these cells were few in number and were located in the subcapsular region of the gland. In our study, all functional mast cells that underwent activation and were co-localized with deposits of calcium did not contain chymase. All of them were stained with tryptase and represent the MC-T phenotype. Tryptase mast cells and extracellular tryptase were often associated with areas of early and more advanced stages of calcification. Our results lead to the conclusion that the tryptase mast cells play a major role in the pineal calcification process as sites where this process starts and as a source of production of numerous biologically active substances including tryptase that participate in calcification.

Calbindin positive Purkinje cells in the pathology of human cerebellum occurring at the time of its development.

Development of cerebellum continues over an extremely long period of time extending from the early embryonic phase until the first postnatal years. During an extended time of maturation the cerebellum is vulnerable to harmful agents. A group of cytoplasmic proteins that may protect cells against injury are the calcium binding proteins, among others calbindin. The distribution of this protein is not well known in cerebellar pathology, thus in the present study the localisation and appearance of calbindin expressing Purkinje cells in different pathological conditions occurring at the time of cerebellar development was examined. The investigations were carried out on human maturing cerebellar cortex (age range 30 gestational weeks - 2 years) of cases with paraneoplastic cerebellar degeneration and cerebellar neuronal migration disturbances. The Purkinje cells located in cerebellar heterotopias and dysgenesias were morphologically well developed and strongly immunostained with calbindin antibody. In paraneoplastic cerebellar degeneration the progressive decrease of calbindin content and disintegration of Purkinje cells were observed. Our results show that intrauterine harmful agents that disturb migration of the cerebellar neurons do not affect the content of calbindin in misoriented neurons and that this protein may play a role in development of Purkinje cells located in heterotopias and cerebellar dysgenesias. The progressive decrease of calbindin content in the Purkinje cells undergoing degeneration and death during paraneoplastic changes in the cerebellum also supports the hypothesis that this protein is very important component of intracellular homeostasis in cerebellar neurons.

Astroglia and microglia in cerebellar neuronal migration disturbances.

Between the neuronal and glial cells there is a close relationship conditioning a tight morphological correlation and proper functional interplay. Disturbed interaction between glial and neuronal components leads to inappropriate neural circuits. The reflection of the failure of neural circuit organisation is the picture of morphological changes of neurons and glia. The appearance of microglia and astroglia was analysed in a defectively formed cellular network due to cerebellar neuronal migration disturbances. Focal disruption of neuron migration leads to their differentiation in an abnormal position manifested as heterotopias and cortical anomalies. Neurons that had lost their proper migratory way and heterotopically settled in the white matter were encircled by GFAP-positive astrocytes, with morphology appropriate for surrounding white matter. The microglial cells infiltrated the parenchyma within the heterotopic neurons playing a role in their elimination. In the cerebellar cortical malformations astrocytes were grouped near the Purkinje cells. In the minimal cortical dysplasia the increased number of astrocytes supported the neurons. Impaired morphological components of the glial-pial barrier were observed. In the massive cortical malformations a few degenerated astrocytes followed the disarranged Purkinje cells, while microglia and Bergmann glia fibres were not present. Absence of cells supporting and organizing the cerebellar cortex had an effect on loss of Purkinje cell shape, their disorientation and abnormal position. The appearance and localisation of the astroglia and microglia in the abnormal cerebellar circuitry due to migration disturbances is dependent on the pathomechanism of the anomalies.

Faulty position of cerebellar cortical neurons as a sequel of disturbed neuronal migration.

The object of our report is the presentation of the morphological picture of cerebellar cortex malformation as a sequel of disturbed neuronal migration. In the disarranged tissue, cavities with a network of meningeal tissue and embedded pathological vessels were noted. The external granule cells did not form a proper external granule layer, but moved deeper, forming irregular aggregates. Abnormally aggregated external granular cells invaded the cerebellar tissue. Abnormal Purkinje cell positioning and a disarranged molecular layer were observed. The normal layered pattern of the cerebellar cortex was disorganized. The presented cases represent a spectrum of morphological changes which are the consequence of aberrant migration. Against a background of vascular pathology affecting the meningoglial network the migration pathways were disrupted. The defective movement of neurons and their faulty maturation resulted in disturbances of cortical layering, and defects of cerebellar folia formation.

Inflammatory and reparative tissue reaction in developing human central nervous system.

Morphologic features of inflammatory reactions in the immature central nervous system (CNS) develop in the second half of pregnancy. The cells composing the infiltrations arise early during development but their presence in circulation and final localization in fully mature inflammatory reactions is prolonged in time. The aim of this work was to compare the picture of inflammatory infiltrations in a group of fetal brains following various infections and aseptic injuries. It was found that numerous granulocytes appeared in bacterial infections, but not in aseptic lesions of the brain. The young maturing blood cells and granulocytes demonstrate the subsequent stages in the development of the inflammatory reaction. The changes depend on the character of the injurious factor and the level of maturation of the CNS. The topography of maturing brain lesions due to infections and anoxic/ischemic damage was similar and localized most often in the periventricular white matter.