Intracranial Malignant Peripheral Nerve Sheath Tumors Not Associated with a Cranial Nerve: Systematic Review and Illustrative Case.

OBJECTIVE: Primary intracranial malignant peripheral nerve sheath tumors (MPNSTs) not associated with cranial nerves are rare and aggressive neoplasms. The rarity of presentation has precluded rigorous analysis of diagnosis, risk factors, treatment, and survival. We analyzed every reported case through exhaustive literature review. In addition, we present our own experience managed with resection, radiotherapy, and first use of targeted therapy in a tumor of this type for a BRAF mutation identified during next-generation sequencing. METHODS: Two databases, PubMed and Embase, and crossed references were queried for intracranial MPNSTs not associated with a cranial nerve. Extracted variables included demographics, risk factors, tumor characteristics, interventions, and outcomes. Univariate and multivariate analysis was performed to identify factors with survival benefit. RESULTS: A total of 56 patients (including the present case) were included from 743 literature results. There was a male/female ratio of 1.5:1 and mean diagnosis age of 29.7 ± 21.8 years. Seventy-one percent of cases were sporadic and 23% neurofibromatosis type 1 related. Median survival was 29 ± 22.1 months with 1-year survival of 60%. Factors associated on univariate analysis with reduced survival were subtotal resection (P = 0.05), older age (P = 0.023), triton histology (P < 0.001), and early recurrence (≤6 months) (P = 0.018). On multivariate analysis, gross total resection reduced mortality risk (P = 0.011), whereas triton histology (P = 0.017) and infratentorial tumor location (P = 0.037) increased mortality. CONCLUSIONS: We present a systematic review of intracranial MPNSTs not associated with a cranial nerve. These tumors have poor prognosis and benefit from aggressive resection, multimodal treatment, and close follow-up. Next-generation sequencing can show molecular alterations for potential targeted therapy.

Photomicrograph-Based Neuropathology Consultation in Tanzania.

OBJECTIVES: Since neuropathologic diagnosis in the developing world is hampered by limitations in technical infrastructure, trained laboratory personnel, and subspecialty-trained pathologists, the use of telepathology for diagnostic support, second-opinion consultations, and ongoing training holds promise as a means of addressing these challenges. This study aims to assess the utility of static teleneuropathology in improving neuropathologic diagnoses in low- and middle-income countries. METHODS: Consecutive neurosurgical biopsy and resection specimens obtained at Muhimbili National Hospital in Tanzania between July 1, 2018, and June 30, 2019, were selected for retrospective, blinded static-image neuropathologic review followed by on-site review by an expert neuropathologist. RESULTS: A total of 75 neuropathologic cases were reviewed. The agreement of static images and on-site glass diagnosis was 71% with strict criteria and 88% with less stringent criteria. This represents an overall improvement in diagnostic accuracy from 36% by general pathologists to 71% by a neuropathologist using static telepathology (or from 76% to 88% with less stringent criteria). CONCLUSIONS: Telepathology offers a promising means of providing diagnostic support, second-opinion consultations, and ongoing training to pathologists practicing in resource-limited countries. Moreover, static digital teleneuropathology is an uncomplicated, cost-effective, and reliable way to achieve these goals.

Online Adaptive Image Reconstruction (OnAIR) Using Dictionary Models.

Sparsity and low-rank models have been popular for reconstructing images and videos from limited or corrupted measurements. Dictionary or transform learning methods are useful in applications such as denoising, inpainting, and medical image reconstruction. This paper proposes a framework for online (or time-sequential) adaptive reconstruction of dynamic image sequences from linear (typically undersampled) measurements. We model the spatiotemporal patches of the underlying dynamic image sequence as sparse in a dictionary, and we simultaneously estimate the dictionary and the images sequentially from streaming measurements. Multiple constraints on the adapted dictionary are also considered such as a unitary matrix, or low-rank dictionary atoms that provide additional efficiency or robustness. The proposed online algorithms are memory efficient and involve simple updates of the dictionary atoms, sparse coefficients, and images. Numerical experiments demonstrate the usefulness of the proposed methods in inverse problems such as video reconstruction or inpainting from noisy, subsampled pixels, and dynamic magnetic resonance image reconstruction from very limited measurements.

A Review of Neuropathological Features of Familial and Adult Hemophagocytic Lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a hematological disorder that can be due to genetic (primary HLH) causes or excessive activation of the immune system in association with infection, malignancy, rheumatologic disorders, or immune suppression (secondary HLH). Hemophagocytic lymphohistiocytosis remains an under-recognized condition among neuropathologists, especially the secondary forms, where it may be diagnosed only at brain biopsy or autopsy due to confounding comorbidities. The CNS is frequently affected, but neuropathological features are underappreciated. We place our own experience with HLH in context with review of neuropathological features from the literature. A 10-year database search for cases from our pediatric and adult hospitals with re-review of neuropathological features revealed 1 biopsy and 5 autopsies. Literature that reported neuropathological features was tabulated and 8 adult and 12 pediatric cases were identified. Children had predominantly secondary HLH: 5/12 co-associated with Epstein Barr (or dual) viral infections, 3/12 with malignancy. One biopsy showed florid lymphohistiocytic infiltrates and hemophagocytosis and served as first diagnosis; 2/5 CNS autopsies had originally been reported as negative for HLH, but on re-review had subtle lymphohistiocytic infiltrates with hemophagocytosis confined to leptomeninges. In conclusion, the neuropathological features are highly variable in HLH; features such as focal erythrophagocytosis may be histologically subtle in early phases, but should be sought.

A Phase 1 Dose-Escalation Study of Oral 5-Aminolevulinic Acid in Adult Patients Undergoing Resection of a Newly Diagnosed or Recurrent High-Grade Glioma.

BACKGROUND: The utility of oral 5-aminolevulinic acid (5-ALA)/protoporphyrin fluorescence for the resection of high-grade gliomas is well documented. This drug has received regulatory approval in Europe but awaits approval in the United States. OBJECTIVE: To identify the appropriate dose and toxicity or harms of 5-ALA used for enhanced intraoperative visualization of malignant brain tumors, reported from a single medical center in the United States. METHODS: Prior to craniotomy for resection of a presumed high-grade glioma, individuals were given oral 5-ALA as part of a rapid dose-escalation scheme. At least 3 patients were selected for each dose level from 10 to 50 mg/kg in 10 mg/kg increments. Adverse events, intensity of tumor fluorescence, and results of biopsies in areas of tumor and the tumor bed under white light and deep blue light were recorded. RESULTS: A total of 19 patients were studied in this phase 1 study. Serious adverse events were unrelated to the ingestion of 5-ALA. At the highest dose level studied (50 mg/kg), 2 out of 6 patients were observed to have transient dermatologic redness and peeling. These were grade 1 adverse events, which were not serious enough to be dose limiting. Patients at higher dose levels (>40 mg/kg) were more likely to have strong tumor fluorescence. There were no instances of false positive fluorescence. CONCLUSION: The use of 5-ALA for brain tumor fluorescence is safe and effective to a dose of 50 mg/kg. Dose-limiting toxicity was not reached in this study.

Low-Rank and Adaptive Sparse Signal (LASSI) Models for Highly Accelerated Dynamic Imaging.

Sparsity-based approaches have been popular in many applications in image processing and imaging. Compressed sensing exploits the sparsity of images in a transform domain or dictionary to improve image recovery fromundersampledmeasurements. In the context of inverse problems in dynamic imaging, recent research has demonstrated the promise of sparsity and low-rank techniques. For example, the patches of the underlying data are modeled as sparse in an adaptive dictionary domain, and the resulting image and dictionary estimation from undersampled measurements is called dictionary-blind compressed sensing, or the dynamic image sequence is modeled as a sum of low-rank and sparse (in some transform domain) components (L+S model) that are estimated from limited measurements. In this work, we investigate a data-adaptive extension of the L+S model, dubbed LASSI, where the temporal image sequence is decomposed into a low-rank component and a component whose spatiotemporal (3D) patches are sparse in some adaptive dictionary domain. We investigate various formulations and efficient methods for jointly estimating the underlying dynamic signal components and the spatiotemporal dictionary from limited measurements. We also obtain efficient sparsity penalized dictionary-blind compressed sensing methods as special cases of our LASSI approaches. Our numerical experiments demonstrate the promising performance of LASSI schemes for dynamicmagnetic resonance image reconstruction from limited k-t space data compared to recent methods such as k-t SLR and L+S, and compared to the proposed dictionary-blind compressed sensing method.

A Unique Case of Intravascular Lymphoma Mimicking Encephalomyeloradiculoneuropathy.

INTRODUCTION: Angiotropic lymphoma is a rare large B-cell lymphoma involving the intravascular compartment without local tissue or vessel wall infiltration. CASE REPORT: A 48-year-old male presented with 8 months of progressive paraparesis and bowel and bladder incontinence. Initial cerebrospinal fluid analysis showed high protein, lymphocytic pleocytosis, high IgG synthesis, but no oligoclonal bands. Brain imaging at presentation was unrevealing. Electromyography revealed evidence of bilateral lumbosacral radiculoplexopathy [R>L]. A trial of intravenous solumedrol resulted in significant improvement in weakness. He had multiple hospital admissions for worsening lower extremity weakness, altered mental status, and new-onset upper extremity weakness. Magnetic resonance imaging of the spine revealed abnormal hyperintense T2 signal at T7-T8 level. Visual-evoked potentials revealed significant slowing of conduction in both optic nerves. Repeat electromyography showed a moderate to severe motor axonal polyneuropathy with secondary demyelination in the upper and lower extremities. A working diagnosis of encephalomyeloradiculoneuritis was made because of signs of polyradiculopathy, peripheral neuropathy and myelopathy. Patient had 3 trials of intravenous solumedrol with transient improvement in symptoms. The magnetic resonance imaging brain on his sixth hospital admission revealed multiple areas of restricted diffusion throughout the brain parenchyma. The patient underwent a right frontal lobe biopsy, which showed large CD-20 neoplastic lymphocytes within small arteries, veins, and capillaries with no extension to surrounding brain parenchyma. The findings were consistent with intravascular large B-cell lymphoma. CONCLUSION: Angiotropic lymphoma is a rare disease with frequent involvement of central nervous system and skin that can present with neurological involvement of both the peripheral and central nervous system.

Reactive astrocytes promote the metastatic growth of breast cancer stem-like cells by activating Notch signalling in brain.

Brain metastasis of breast cancer profoundly affects the cognitive and sensory functions as well as morbidity of patients, and the 1 year survival rate among these patients remains less than 20%. However, the pathological mechanism of brain metastasis is as yet poorly understood. In this report, we found that metastatic breast tumour cells in the brain highly expressed IL-1ß which then 'activated' surrounding astrocytes. This activation significantly augmented the expression of JAG1 in the astrocytes, and the direct interaction of the reactivated astrocytes and cancer stem-like cells (CSCs) significantly stimulated Notch signalling in CSCs. We also found that the activated Notch signalling in CSCs up-regulated HES5 followed by promoting self-renewal of CSCs. Furthermore, we have shown that the blood-brain barrier permeable Notch inhibitor, Compound E, can significantly suppress the brain metastasis in vivo. These results represent a novel paradigm for the understanding of how metastatic breast CSCs re-establish their niche for their self-renewal in a totally different microenvironment, which opens a new avenue to identify a novel and specific target for the brain metastatic disease.

Novel deletion of lysine 7 expands the clinical, histopathological and genetic spectrum of TPM2-related myopathies.

The ß-tropomyosin gene encodes a component of the sarcomeric thin filament. Rod-shaped dimers of tropomyosin regulate actin-myosin interactions and ß-tropomyosin mutations have been associated with nemaline myopathy, cap myopathy, Escobar syndrome and distal arthrogryposis types 1A and 2B. In this study, we expand the allelic spectrum of ß-tropomyosin-related myopathies through the identification of a novel ß-tropomyosin mutation in two clinical contexts not previously associated with ß-tropomyosin. The first clinical phenotype is core-rod myopathy, with a ß-tropomyosin mutation uncovered by whole exome sequencing in a family with autosomal dominant distal myopathy and muscle biopsy features of both minicores and nemaline rods. The second phenotype, observed in four unrelated families, is autosomal dominant trismus-pseudocamptodactyly syndrome (distal arthrogryposis type 7; previously associated exclusively with myosin heavy chain 8 mutations). In all four families, the mutation identified was a novel 3-bp in-frame deletion (c.20_22del) that results in deletion of a conserved lysine at the seventh amino acid position (p.K7del). This is the first mutation identified in the extreme N-terminus of ß-tropomyosin. To understand the potential pathogenic mechanism(s) underlying this mutation, we performed both computational analysis and in vivo modelling. Our theoretical model predicts that the mutation disrupts the N-terminus of the α-helices of dimeric ß-tropomyosin, a change predicted to alter protein-protein binding between ß-tropomyosin and other molecules and to disturb head-to-tail polymerization of ß-tropomyosin dimers. To create an in vivo model, we expressed wild-type or p.K7del ß-tropomyosin in the developing zebrafish. p.K7del ß-tropomyosin fails to localize properly within the thin filament compartment and its expression alters sarcomere length, suggesting that the mutation interferes with head-to-tail ß-tropomyosin polymerization and with overall sarcomeric structure. We describe a novel ß-tropomyosin mutation, two clinical-histopathological phenotypes not previously associated with ß-tropomyosin and pathogenic data from the first animal model of ß-tropomyosin-related myopathies.

Von Willebrand Factor permeates small vessels in CADASIL and inhibits smooth muscle gene expression.

BACKGROUND AND PURPOSE: CADASIL (cerebral autosomal dominant arteriopathy subcortical infarcts and leukoencephalopathy) is a genetic disorder hallmarked by ischemic stroke and vascular dementia. Characteristic pathological changes in the vasculature include thickening of small arteries and accumulation of heterogeneous material within the vessel wall. We tested whether endothelial von Willebrand factor (vWF) accumulates in CADASIL vessels and whether exposure of smooth muscle cells to vWF alters the expression of smooth muscle gene expression. METHODS: Brain sections obtained at autopsy from six North American CADASIL patients were examined using immunohistochemistry for vWF and IgG. Rat aortic smooth muscle cells (A7R5 cells) were tested for binding to infrared-tag labeled vWF. Finally, A7R5 cells were exposed to vWF, and expression of mature smooth muscle marker genes was analyzed by quantitative reverse transcriptase PCR. RESULTS: vWF is expressed in the penetrating arterial walls in all CADASIL samples. IgG, a marker of serum extravasation, was present only in a minority of arterial walls. vWF binds to smooth muscle cells in vitro, and low concentrations of vWF rapidly activate c-fos, EGR, TSP1, and c-myc while specifically inhibiting RNA encoding smooth muscle actin, calponin, and SM22. CONCLUSIONS: These data demonstrate that vWF, likely produced by the endothelium, permeates the vessel wall of CADASIL brains. Exposure of smooth muscle cells to vWF results in reduction of specific RNAs required for normal vascular homeostasis. This is the first report of accumulation of a protein within CADASIL vessels that inhibits vascular gene expression and implicates a role for vWF beyond hemostasis.

Identifying behaviors in crowd scenes using stability analysis for dynamical systems.

method is proposed for identifying five crowd behaviors (bottlenecks, fountainheads, lanes, arches, and blocking) in visual scenes. In the algorithm, a scene is overlaid by a grid of particles initializing a dynamical system defined by the optical flow. Time integration of the dynamical system provides particle trajectories that represent the motion in the scene; these trajectories are used to locate regions of interest in the scene. Linear approximation of the dynamical system provides behavior classification through the Jacobian matrix; the eigenvalues determine the dynamic stability of points in the flow and each type of stability corresponds to one of the five crowd behaviors. The eigenvalues are only considered in the regions of interest, consistent with the linear approximation and the implicated behaviors. The algorithm is repeated over sequential clips of a video in order to record changes in eigenvalues, which may imply changes in behavior. The method was tested on over 60 crowd and traffic videos.

Musashi1 antigen expression in human fetal germinal matrix development.

Musashi1 is a highly conserved protein found in neural progenitor cells. We examined the expression dynamics of Musashi1 in conjunction with other representative neural progenitor antigenic determinants (Ki-67 and nestin) during 8 different stages of the developing human fetal germinal matrix. Our results indicate that Musashi1 is a useful marker for immature cells in periventricular areas inhabited by stem cells, progenitor cells, and differentiating cells.

Lineage-negative bone marrow cells travel bidirectionally in the olfactory migratory stream but maintain hematopoietic phenotype.

The mammalian olfactory system is a physiologically plastic region of the brain with the potential to support implanted stem cells. We performed direct injection of lineage-negative (lin-neg), green fluorescent protein-positive (GFP+) bone marrow cells into the olfactory bulb to assess cell survival and motility within the central nervous system (CNS). Before direct injection of 100,000 lin-neg cells, some of the C57/Bl mice received 1,000 cGy brain irradiation with the aim of disabling the endogenous reservoir of periventricular neural progenitor cells. Brain harvest took place up to 2 weeks after cell implantation. Brains were evaluated for presence of GFP positivity via fluorescence microscopy. Many GFP+ cells were identified within the turbinate neuroepithelium, olfactory bulb, and frontal lobe. Most of the cells that had traveled from the implantation site adopted an elongated, arborizing morphology consistent with cellular extensions arrayed in the direction of the rostral migratory stream (RMS). No difference was seen in brain-irradiated versus non-irradiated mice. Antibody staining revealed that these cells did not take on a neural, glial, or endothelial phenotype, while largely retaining their hematopoietic lineage as demonstrated by CD45 positivity.

Intrinsic hematopoietic stem cell/progenitor plasticity: Inversions.

Traditional concepts indicate that stem cells give rise to progenitor cells in a hierarchical system. We studied murine engraftable stem cells (ESCs) and progenitors in in vitro and found that ESC and progenitors exist in a reversible continuum, rather then a hierarchy. B6.SJL and BALB/c marrow cells were serially cultured with thrombopoietin (TPO), FLT-3 ligand (FLT-3L), and steel factor through cell cycle. Progenitors (high-proliferative potential colony-forming cells (HPP-CFC) and colony-forming unit culture (CFU-c)) and ESC capacity was determined. The cell cycle status of purified lineage(negative)rhodamine(low)Hoechst(low) stem cells was determined under the same conditions using tritiated thymidine incorporation and cell counts. We found an inverse relationship between progenitors and ESC, which occurred during the first cell cycle transit and was reversible. We have termed these progenitor/stem cell inversions and found that these inversions were consistently seen at 28-32 h of culture, representing early S-phase. We observed 13 major reversible increases in progenitor numbers from one time-point to another during the first cell cycle transit; this was coupled with 11 major ESC decreases and in 2 instances ESC were at baseline. These studies indicate that primitive marrow cells reversibly shift from ESC to progenitors without differentiation occurring. They exist as a fluctuating continuum.

Differentiation hotspots: the deterioration of hierarchy and stochasm.

The conception of the present-day model of hematopoiesis was begun by the work of Professor Ernst Neumann in the 19th century when he established that immature blood cells in the bone marrow migrate out into the blood vessels. Here was the birth of the hierarchical model of hematopoiesis. Jumping 135 years into the present day, recent data suggests that the stem cell regulation is not based on the classic hierarchical model, but instead more on a functional continuum. Presumptively, chromatin remodeling with cycle transit underlies changes in gene expression. This implies that the differentiative potential of primitive stem cells should also shift with cycle transit. This model proposes a less rigid system, at least in the early stem cell and progenitor compartments in which the functional characteristics of stem cells change as they go through cycle transit. We have shown that hematopoietic stem cells reversibly shift their engraftment phenotype with cytokine induced cell cycle transit. Other shifts include adhesion protein expression, cytokine receptor expression, gene expression, and progenitor phenotype. We have also found differentiation "hotspots", culture times (reflective of cell cycle state) at which stem cell differentiation was directed toward a specific lineage. This data inaugurates the end of a pure stochastic model. This work complements existing scientific work without discounting it and adds an additional dimension of complexity (or simplicity) to the process of hematopoiesis.

Giant trichophytobezoar in a pediatric patient with trichotillomania.

We report a case of a 13-year-old girl with trichotillomania. A plain abdominal radiograph and axial CT scan revealed a well-defined mass within the stomach. Gastrotomy was performed and a 19 x 11 x 2-cm trichophytobezoar was delivered intact.

Methotrexate-related nonnecrotizing multifocal axonopathy detected by beta-amyloid precursor protein immunohistochemistry.

We describe a 64-year-old woman with biphenotypic leukemia involving the meninges who received 2 doses of intrathecal methotrexate. Soon after treatment, the patient developed postural rigidity and a marked decline in mental status. The patient died of respiratory failure 1 month after methotrexate treatment was initiated. At autopsy, the brain was grossly normal. Routine microscopy showed no evidence of leukemic infiltrates or necrotizing lesions. However, when stained with beta-amyloid precursor protein, multifocal axonal injury was evident in the brain, spinal cord, and nerve roots. Our findings show that immunohistochemical staining for beta-amyloid precursor protein can effectively demonstrate axonal injury associated with methotrexate neurotoxicity, even when conventional staining procedures are negative. This technique may therefore reveal a possible pathologic substrate for some of the neurological complications seen in patients with methotrexate neurotoxicity.