Difference between revisions of "Neuropathology"

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==Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy==
==Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy==
*Commonly abbreviated ''CADASIL''.
*Commonly abbreviated ''CADASIL''.
===General===
{{Main|Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy}}
*Autosomal dominant disorder - as the name implies.<ref name=pmid19174371>{{Cite journal  | last1 = Tikka | first1 = S. | last2 = Mykkänen | first2 = K. | last3 = Ruchoux | first3 = MM. | last4 = Bergholm | first4 = R. | last5 = Junna | first5 = M. | last6 = Pöyhönen | first6 = M. | last7 = Yki-Järvinen | first7 = H. | last8 = Joutel | first8 = A. | last9 = Viitanen | first9 = M. | title = Congruence between NOTCH3 mutations and GOM in 131 CADASIL patients. | journal = Brain | volume = 132 | issue = Pt 4 | pages = 933-9 | month = Apr | year = 2009 | doi = 10.1093/brain/awn364 | PMID = 19174371 }}
</ref>
*Causes strokes in 40-50 year-old.
*Cerebral microbleeds - common.
**Associated with increased risk of [[intracerebral hemorrhage]].<ref name=pmid17135568>{{Cite journal  | last1 = Choi | first1 = JC. | last2 = Kang | first2 = SY. | last3 = Kang | first3 = JH. | last4 = Park | first4 = JK. | title = Intracerebral hemorrhages in CADASIL. | journal = Neurology | volume = 67 | issue = 11 | pages = 2042-4 | month = Dec | year = 2006 | doi = 10.1212/01.wnl.0000246601.70918.06 | PMID = 17135568 }}</ref>
*Characteristic MRI findings - present in asymptomatic individuals with mutation.
*Increased risk of [[heart|myocardial infarction]].<ref name=pmid12861102>{{cite journal |author=Lesnik Oberstein SA, Jukema JW, Van Duinen SG, ''et al.'' |title=Myocardial infarction in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) |journal=Medicine (Baltimore) |volume=82 |issue=4 |pages=251–6 |year=2003 |month=July |pmid=12861102 |doi=10.1097/01.md.0000085054.63483.40 |url=}}</ref>
 
Note:
*There is also an autosomal recessive form - CARASIL.<ref name=pmid21215656>{{Cite journal  | last1 = Fukutake | first1 = T. | title = Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL): from discovery to gene identification. | journal = J Stroke Cerebrovasc Dis | volume = 20 | issue = 2 | pages = 85-93 | month =  | year =  | doi = 10.1016/j.jstrokecerebrovasdis.2010.11.008 | PMID = 21215656 }}</ref>
====Etiology====
*Mutation of ''Notch 3'' gene.<ref name=pmid15537516>{{Cite journal  | last1 = Kalaria | first1 = RN. | last2 = Viitanen | first2 = M. | last3 = Kalimo | first3 = H. | last4 = Dichgans | first4 = M. | last5 = Tabira | first5 = T. | title = The pathogenesis of CADASIL: an update. | journal = J Neurol Sci | volume = 226 | issue = 1-2 | pages = 35-9 | month = Nov | year = 2004 | doi = 10.1016/j.jns.2004.09.008 | PMID = 15537516 }}</ref>
**Diagnosis: proven ''Notch 3'' mutation.
 
===Microscopic===
Features:
*+/-Subcortical infarcts.
**Patches of (non-myelinated) tissue within the white matter deep to the cortex with abundant macrophages.
*Blood vessels typically have a basophilic granularity.<ref name=pmid17076524>{{cite journal |author=Kleinschmidt-DeMasters BK, Prayson RA |title=An algorithmic approach to the brain biopsy--part I |journal=Arch. Pathol. Lab. Med. |volume=130 |issue=11 |pages=1630–8 |year=2006 |month=November |pmid=17076524 |doi= |url=}}</ref>
 
====IHC====
*Notch 3: smooth muscle and pericytes punctate +ve.<ref name=pmid12861102/>
 
Notes:
*No cortical involvement -- this is unlike ''multiple sclerosis''.
 
DDx:
*[[Amyloidosis]].
*[[Binswanger's disease]] - multi-infarct dementia affecting subcortical white matter.
**Often diagnosed as ''Alzheimer's disease'' in the past.
 
<gallery>
Image:CADASIL_-_very_high_mag.jpg | Notch 3 staining in CADASIL. (WC/Nephron)
</gallery>
====Skin biopsy diagnosis====
*Can be diagnosed on a skin biopsy.<ref name=pmid11755616 >{{cite journal |author=Joutel A, Favrole P, Labauge P, ''et al.'' |title=Skin biopsy immunostaining with a Notch3 monoclonal antibody for CADASIL diagnosis |journal=Lancet |volume=358 |issue=9298 |pages=2049–51 |year=2001 |month=December |pmid=11755616 |doi=10.1016/S0140-6736(01)07142-2 |url=}}</ref>
 
===Electron microscopy===
*Granular osmiophilic material (GOM).


==Progressive multifocal leukoencephalopathy==
==Progressive multifocal leukoencephalopathy==

Revision as of 06:52, 9 December 2014

Neuropathology is the bane of many anatomical pathologists in teaching hospitals... 'cause they have to fill in for the neuropathologist when he or she is on vacation.

This article is an introduction to neuropathology. There are separate articles for brain tumours, the pituitary gland, the spine, the eye, muscle pathologies, neurohistology and neuroanatomy.

Neuroanatomy

This is a large topic. It covered in a separate article, that also covers grossing.

Neuroradiology

Enhancing vs. non-enhancing:

  • If it is tumour... enhancing usu. high grade, non-enhancing usu. low grade.

Ring enhancing lesions

In HIV/AIDS patients... mass on CT if infection:

Ring enhancing lesion (DDx) - mnemonic MAGICAL DR:[2]

Grossing

This is covered in the neuroanatomy article.

Gross pathology

The gross usually useless for arriving at a definitive diagnosis.

Exceptions:[3]

Normal histology

This is a big topic. It is covered in a separate article called neurohistology.

Histopathology

Neuronal changes

Anoxic neurons

  • AKA red neurons.

Features:

  • Intensely red cytoplasm.
  • Pyknosis = nuclear shrinkage + darker staining.
Images

www:

Central chromatolysis

Features:[5]

  • Central clearing.
    • Nucleus and Nissl substance are pushed to cell periphery.

DDx:

Images

Axonal swellings

H&E:

  • Eosinophilic (light pink) - ground glass-like appearance.
  • Shape:
    • Round if sectioned perpendicular to axis of axon.
      • Bound by cell membrane.
      • Large ~ typically 2-4x RBC diameter.
    • Sausage-shaped if cut in along axis.

Images:

IHC
  • APP.

Image:

Glial changes

Astrocyte changes

Reactive astrocytes:

  • Approximately equally-spaced; distance between neighbouring astrocytes is ~2x (or more) the cell size.
  • Well-defined cell border.
  • Eosinophilic cytoplasm with many branching processes.
    • Classically described as "funnel-shaped" in benign astrocytes.[10]
  • Peripheral nucleus.

Alzheimer type II astrocyte:[11]

Creutzfeldt cell:[13]

  • Astrocyte that mimics a mitoses; has moderate (identifiable) cytoplasm.
  • Finding associated with demyelinating disease.
  • Image: Crutzfeldt cell (upmc.edu).[14]

Gemistocytic astrocytes:[15]

  • Distinct eosinophilic cytoplasm - with ground-glass appearance.

Tufted astrocytes:[16]

  • Cellular processes loaded with tau protein (as may be seen with tau IHC or Gallyas silver stain); Parisian-star-like appearance with special stain.
  • +/-Multinucleated.
  • A classic feature of progressive supranuclear palsy.

Other glial

Bergmann gliosis (in the cerebellum):[13]

  • Thin layer of cells (2-3 cells) with open nuclei that are larger than granular cell layer nuclei; seen with Purkinje cell loss.

Image:

Reactive change vs. malignancy

Reactive changes vs. malignancy (mnemonic MIMICS):[17]

  • MIcrovesicular pattern.
  • Mitoses.
  • Irregular spacing.
  • Calcifications.
  • Satellitosis, perineuronal.
    • Large "crowds" of glial cells associated with nuclei.

Inflammatory

DDx:

Encephalitis

General

DDx:

  • Viral encephalitis.
  • Paraneoplastic syndromes.
Gross
  • Frontal and temporal lobe - most common for HSV encephalitis.[18]
Microscopic

Features:[19]

  • Perivascular inflammation.
  • Microglia.
  • +/-Neuronophagia.
    • Phagocytosis of neurons.[20]
  • +/-Viral cytopathic changes.
  • +/-Perineuronal inflammation.

Notes:

  • Hemorrhage[21] and necrosis - characteristic of HSV encephalitis.

Image:

IHC

IHC stains for:

Architecture

Rosettes

  • Rosette = circular/flower-like arrangement of cells.[23]
  • Homer-Wright rosette = (circular) rosette with a small (~100 micrometers ???) meshwork of fibers (neuropil) at the centre.[23]
  • Flexner-Wintersteiner rosette = rosette with empty centre (donut hole).[23]
  • Pineocytomatous/neurocytic rosette = irregular rosette with a large meshwork of fibers (neuropil) at the centre.[23]

Other

  • Rosenthal fibres = worm-like or corkscrew-like (brightly) eosinophilic bodies; 10-40 micrometers.
    • Key feature: variable thickness; helps separate from RBCs.
    • Well-seen on trichrome stains.
  • Eosinophilic granular bodies = related to Rosenthal fibres; round cytoplasmic hyaline droplets in astrocytes.[25]
    • Image: [Image:Pilocytic_Micro.jpg EGBs (WC/AFIP)].
  • Pseudopalisading - picket fence-like alignment of cells; long axis of cells perpendicular to interface with other structures/cells.
    • Pseudopalisading of tumour cells (around necrotic regions) is seen in glioblastoma.

Note:

Inclusion bodies

  • Negri bodies.
    • Cytoplasmic inclusions; classically in Purkinje cells of the cerebellum, pyramidal cells of Ammon's horn.
    • Rabies.
  • Lewy bodies.
    • Eosinophilic cytoplasmic inclusion - composed mostly of alpha-synuclein.[26]

Table of inclusions

Feature Appearance Associated disease Comment Image
Grumous bodies
AKA granular bodies
granular and eosinophilic ~50 micrometers neurodegenerative disease, neuroaxonal dystrophies, aging ?Comment ?Image
Cowdry type 1
AKA Cowdry type A
eosinophilic & round + halo herpes simplex virus can be confused with
Lewy body, Marinesco body
?Image
Lewy body round cytoplasmic eosinophilic
body +/- pale halo
Parkinson disease, dementia with Lewy bodies morphology dependent on
location in brain; +ve for alpha-synuclein,
alpha-B crystallin, ubiquitin
Lewy Koerperchen.JPG
, [1]
Lafora body round myoclonic epilepsy look like corpora amylacea; location: dentate nucleus, liver, skeletal muscle, sweat glands ?Image
Lipofuscin yellow & granular aging olive, dendate ?Image
Negri body small eosinophic bodies rabies found in hippocampal neurons and Purkinje cells
Rabies encephalitis Negri bodies PHIL 3377 lores.jpg
Hirano body concentric calcification/rod-shaped bright eosinophilic; overlap edge of neuron Alzheimer disease, Pick disease[27] actin crystals, may look like capillaries; location: CA1 of hippocampus [2][28]
Neurofibrillary tangles flame-shaped cytoplasmic thingy
~30 micrometers
aging, Alzheimer's disease seen with silver stain Schematic[28], [3][29]
Granulovacuolar degeneration cytoplasmic vacuoles 4-5 micrometers ageing, Alzheimer's disease,
Pick's disease
main found in Ammon horn[27] [4][29]
Pick bodies round, homogenous, intracytoplasmic, ~10 micrometers Pick's disease pyramidal neurons, dentate
granule cells (hippocampus); +ve for tau, tubulin, ubiquitin
[5]
Bunina body size of Nissl granules, eosinophilic amyotrophic lateral sclerosis (ALS) EM: membrane-bound bodies; ubiquitin +ve [6]

Image collection: Inclusion bodies (photobucket.com).

Immunohistochemistry

General

  • S-100.
    • Sensitive... but non-specific, e.g. also stains melanoma.

Glial

  • GFAP (glial fibrillary acidic protein) - should stain perikaryon.

Glial tumours

Standard work-up:

  • GFAP.
  • p53.
  • Ki-67.

Neuronal

  • Synaptophysin.
  • Chromogranin.

Carcinoma vs. glial tumours

  • AE1/AE3 often +ve in glial tumours (e.g. astrocytomas, oligodendrogliomas); CAM5.2 is usu. -ve in glial tumours.[30]

Others

  • APP (amyloid precursor protein) - detects axonal swellings.
  • NF (neurofilament) - detects axonal swellings.

Brain tumours

Tumours are a big part of neuropathology. The most common brain tumour is a metastasis. The most common primary tumour (in adults) is glioblastoma which has a horrible prognosis.

Non-tumour

Cerebral hemorrhage

See: Intracranial hematoma for intracranial bleeds

Includes discussion of:

Duret hematoma

  • AKA Duret hemorrhage.

General

  • Bleed in the upper brainstem (midbrain and pons).
    • Thought to be due to transtentorial herniation secondary to supratentorial mass effect (e.g. supratentorial tumour, intracranial hemorrhage).[31]
  • Often fatal.[32]

Gross

  • Extravasated blood in midbrain and pons - usu. ventral (anterior) and paramedian (adjacent to the midline).[31]

Image:

Microscopic

Features:

  • RBC extravasation.
  • +/-Hemosiderin-laden macrophages.
  • +/-Ischemic neurons.

Alcohol & CNS

Clinical

  • Wernicke's encephalopathy
    • Mnemonic WACO:
      • Wernicke's.
      • Ataxia.
      • Confusion, confabulation -- Korsakoff.
      • Ocular Sx (CN IV palsy).
    • Cause: thiamine deficiency.

Pathology

Features:[34]

  • Morel's laminar sclerosis = spongy degeneration and gliosis of the cerebral cortex[35] usu. prominent in the third layer of the cortex (outer pyramidal layer) and especially in the lateral-frontal cortex.[36]
  • Central pontine myelinolysis (CPM).[37]
    • Just what it sound like - myelin loss in the central pons.
    • Classically associated with rapid correction of hyponatremia.[38]
  • Mammillary body shrinkage.[39]
  • Anterior cerebellar vermis atrophy; weak finding - as also age-related.[40]
    • Vermis atrophy is also seen in schizophrenia.[41]

Marchiafava-Bignami Disease

  • Rare.
  • Demyelination of the corpus callosum.[36]

Wernicke's encephalopathy

General:

  • Due to thiamine deficiency.

Features:[42]

  • Neurons of mammillary bodies preserved - key.
  • Loss of myelin.
  • Hemorrhage.
  • Edema.
  • Reactive blood vessels.

Note:

  • The thalamus and inferior olives show neuronal loss.[42]

Common non-specific findings

Meningitis

General

  • Definition: inflammation of the meninges (pia mater, arachnoid membranes, dura mater).

Classic clinical presentation:

  • Neck stiffness.
  • Fever.
  • +/-Headache.
  • +/-Decreased level of consciousness.

CSF findings:

Type Glucose Protein Cells
Bacterial, acute low high neutrophils
Viral normal slight elevation lymphocytes

Etiology

Bacterial meningitis - most probably cause by age:[43]

Age Organism
Neonate Escherichia coli, Group B Streptococcus
Infants, children Streptococcus pneumoniae
Adolescents, young adults Neisseria meningitidis
Elderly Streptococcus pneumoniae, Listeria monocytogenes

Gross

Features:

  • +/-Clouded appearance of the meninges.
  • +/-Pus.
  • +/-Petechiae.
  • +/-Cerebral edema.

Image

Microscopic

Features:

Main DDx:

Image

Cerebral abscess

General

  • May mimic malignancy clinically.

Microscopic

Features:

  • Sheets of neutrophils surrounded by fibrosing brain.
    • Fibrosing brain: pale (lighter pink than normal brain tissue), dense.

Images:

Neurodegenerative diseases

This is a hueueuge topic. It is covered in its own article and includes a general discussion of dementia.

Epilepsy

Cerebrovascular accident

  • Abbreviated CVA.
  • AKA stroke.

Hypoxic-ischemic encephalopathy

  • Abbreviated HIE.

General

  • Often due to cardiac arrest, i.e. global ischemia.
  • Triple watershed area = parieto-occipital cortex, extrastriate occipital cortex.

Note:

  • Hypoxia = blood decreased oxygen carrying capacity,[45] e.g. anemia.
  • Ischemia = decreased blood flow.[45]
  • Either or both = less oxygen delivery to tissue.

Microscopic

Features:

  • Hippocampal ischemic changes (in adults):
    • Loss of neurons in CA1, CA3 and CA4 +/- "cavitation".
      • Neuronal loss: No blue (nuclei) where there should be some.
      • Cavitation: bubbles/clear spaces where there should be none.
    • CA2 neurons preserved/resistant.
  • Purkinje cell loss in the cerebellum and Bergmann gliosis.
  • "Anoxic neurons".[46]
    • Shrunken neurons with intensely eosinophilic cytoplasm and pyknotic (shrunken) nuclei.
  • Pseudolaminar necrosis - (uncontrolled) cell death in the cerebral cortex in a band-like pattern,[47] with a relative preservation of cells immediately adjacent to the meninges.

Notes:

  • Neurons of subiculum in adults - usu. normal (as they are resistant to ischemic changes).

Images

Multiple sclerosis

  • Abbreviated MS.

Cerebral amyloid angiopathy

General

  • Abbreviated CAA.
  • Disease of the old.
  • Strong association with lobar haemorrhage (bleeds of the cerebellar cortex and cerebral cortex).[50]

Etiology:

  • Amyloid deposition in the basal lamina of smooth muscle (in the cerebellar cortex and cerebral cortex).

Gross

  • Bleeds typically superficial (cortex and subcortical white matter) and in the frontal lobe or parietal lobe.[51]

Microscopic

Features:

  • Amorphous, acellular eosinophilic material within walls of small arteries.
    • This is a high power diagnosis with congo red staining.

Notes:

  • Amyloidosis is seen in all individuals with Alzheimer's disease; the amount of amyloid is what differs -- in CAA it is lots and lots.
  • The white matter is typically spared by CAA.[52]

Images

Stains

IHC

  • Abeta-amyloid (AKA beta-amyloid).

Central pontine myelinolysis

  • Abbreviated CPM.
  • AKA pontine myelinolysis.

General

  • Classically in the pons, ergo "pontine" is in the name.
  • Classically midline, ergo "central" is in the name.
    • May occur elsewhere -- known as extrapontine myelinolysis.

Etiology:

  • Rapid correction of hyponatremia.[53]
  • Tacrolimus post-liver transplant.[54]
  • Associated with alcoholism and malnourishment.

Clinical:[55]

  • Decreased level of consciousness - most common.
  • Quadriplegia.
  • Poor prognosis.

Microscopic

Features:[56]

  • Myelin loss.
  • No inflammation.
  • Relative preservation of neurons.

Images:

Vascular malformations

Types:[57]

  1. Arteriovenous malformation.
    • Most important clinically - highest risk of bleeding.
  2. Varix.
    • One large (dilated) vein.
  3. Venous angioma.
    • Many small veins.
  4. Cavernous malformation.
    • Vessels are back-to-back (no intervening parenchyma).

Also see: Sturge-Weber syndrome.

Cysts

General

  • All are "benign", but some may be fatal due to spatial constraints.

List of cysts

  • Colloid cyst.
    • Columnar epithelium.
  • Arachnoid cyst - considered precursor of meningioma.
  • Dermoid cyst.
    • Skin + adnexal structures.
    • ... think of ovarian dermoid.
  • Epidermoid cyst.
  • Choroid plexus cyst.
  • Neuroenteric cyst.
    • Foregut cyst with connection to dura.[58]
      • Gastrointestinal tract epithelium.
      • Usually seen with vertebral anomalies.
  • Epithelial cyst.
  • Others.

Colloid cyst

General

Classic presentation:[59]

Gross

  • Fluid filled cyst - classically in the third ventricle.

Images

www:

Microscopic

Features:[62]

  • Simple epithelium with ciliated cells and goblet cells.

Images

www:

Paediatric pathology

Kernicterus

General

  • Due to hyperbilirubinemia.[63]

Gross

  • Yellow staining:[64]
    • Basal ganglia.[65]
    • Hippocampus.[66]
    • Subthalamic nucleus.

Note:

  • May not be specific.[63]

Image:

Microscopic

Features - similar to HIE:[64]

  • +/-Red neurons.
  • +/-Gliosis.

Joubert syndrome

  • Malformation of the cerebellar vermis.[67]

Epidemiology

  • Autosomal recessive - mutation in a number of genes including NPHP1, AHI1, and CEP290.[67]

Weird stuff

Acute disseminated encephalomyelitis

  • Abbreviated ADEM.

General

Treatment:

  • Steroids.
  • Plasmapheresis.

Diagnosis:

  • Need to r/o infection (with lumbar puncture).
  • No old plaques on imaging (MRI).

An acute form exists known as acute hemorrhagic leukoencephalitis[69] (AKA acute necrotizing hemorrhagic encephalomyelitis).

Microscopic

Features:[70]

  • Myelin loss with sparing of axons.
  • Inflammation:
    • Early: neutrophils.
    • Late: mononuclear cells (lymphocytes, plasma cells).
  • Lipid-laden macrophages.

DDx:

  • Multiple sclerosis.
    • Tend to be larger, more lymphocytes,[71] age of the lesions differ.
  • Acute necrotizing hemorrhagic encephalomyelitis (ANHE) - if one considers this a separate entity.
  • Acute necrotizing encephalopathy.[72]

Neuromyelitis optica

  • Abbreviated NMO.

General

  • Rare autoimmune disease - once considered a variant of multiple sclerosis.
    • Autoantibodies directed at aquaporin-4.[73]

Diagnosis:

  • NMO-IgG.

Clinical - preferentially:

  • Eye (optic neuritis).
  • Spinal cord (myelitis).

Microscopic

Features:

  • Inflammation - lymphocytes, macrophages.
  • Reactive astrocytes.

Images:

IHC

  • Mixed lymphocyte population with CD3 > CD20.
  • Aquaporin-4 loss.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

  • Commonly abbreviated CADASIL.

Progressive multifocal leukoencephalopathy

  • Abbreviated PML.

See also

References

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