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'''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.
[[Image:MCA-Stroke-Brain-Human-2.JPG|thumb|right|Gross image showing changes of a [[stroke]]. (WC/Marvin 101)]]
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]].


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]].
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.


==Neuroanatomy==
==Neuroanatomy==
Line 8: Line 9:


==Neuroradiology==
==Neuroradiology==
Enhancing vs. non-enhancing:
Key factors to consider in evaluation:
*If it is tumour... enhancing usu. high grade, non-enhancing usu. low grade.
# Location.
# Number of lesions - single versus multiple.
# Cystic versus solid lesion.
# Enhancement.
 
==Lesion location==
In neuroradiology and neuropathology, real estate is crucial. Lesion location can often narrow your differential.
 
Cortical lesions (gray matter):
* [[Oligodendroglioma]].
* [[DNET]].
* [[Ganglioglioma]].
* [[Pleomorphic xanthoastrocytoma]].
* Extraventricular [[ependymoma]].
 
Cortical-subcortical junction:
* [[brain metastasis|Metastases]].
* Abscesses (hematogenous spread).
 
Subcortical lesions (white matter):
* [[Glioblastoma]].
* Diffuse gliomas.
* Demyelinating plaques.
 
Deep gray matter lesions (e.g. basal ganglia):
* Gliomas.
* [[Hypertensive hemorrhage]]
 
Cerebellar lesions:
* [[Medulloblastoma]].
* [[Pilocytic astrocytoma]].
* [[AT/RT]].
 
Intraventricular lesions:
* [[Ependymoma]].
* [[Subependymoma]].
* [[Pilocytic astrocytoma]].
* [[Central neurocytoma]].
* Rosette forming glioneuronal tumour of the fourth ventricle.
 
Suprasellar (above the pituitary):
* [[Craniopharyngioma]].
* [[Germinoma]].
* [[Pilomyxoid astrocytoma]].
 
==Number of lesions==
If ''single'' lesion = think primary, neoplastic
If ''multiple'' lesions = think metastatic, neoplastic or infectious
'''NB: glioblastoma can be multifocal''' (and the foci can be quite far apart)
 
==Cystic vs. solid lesions==
Some tumours are classically cystic with a small solid component (so-called cyst with a mural nodule) -- e.g. pilocytic astrocytoma, ganglioglioma, hemangioblastoma
 
==Enhancing vs. non-enhancing:==
*In adults, enhancing generally = high grade.
*In pediatrics, it often depends on the pattern.
Two main patterns to be mindful of -- ring enhancing lesions, and cystic lesions with a mural nodule.


===Ring enhancing lesions===
===Ring enhancing lesions===
In [[HIV]]/AIDS patients... mass on CT if infection:
In [[HIV]]/AIDS patients... mass on CT if infection:
*Toxoplasmosis - most common.<ref>MUN. Feb 3, 2009.</ref>
*[[Toxoplasmosis]] - most common.<ref>MUN. Feb 3, 2009.</ref>


Ring enhancing lesion (DDx) - mnemonic ''MAGICAL DR'':<ref>TN2005 NS7.</ref>
Ring enhancing lesion (DDx) - mnemonic ''MAGICAL DR'':<ref>{{Ref TN2005 |NS7}}</ref>
*Metstasis.
*Metstasis.
*Abscess.
*Abscess.
*Glioblastoma.
*[[Glioblastoma]].
*Infarct.
*[[Infarct]].
*Contusion.
*Contusion.
*AIDS-related.
*AIDS-related.
*Lymphoma + HIV assoc. disease (toxoplasma).
*[[Lymphoma]] + [[HIV]] assoc. disease (toxoplasma).
*Demyelination (e.g. multiple sclerosis).
*Demyelination (e.g. [[multiple sclerosis]]).
*Resolving hematoma.
*Resolving hematoma.
===Cyst with enhancing mural nodule===
*hemangioblastoma (#1 in adults)
*pilocytic astrocytoma (#1 in peds)
*pleomorphic xanthoastrocytoma
*ganglioglioma


==Grossing==
==Grossing==
Line 33: Line 96:


Exceptions:<ref>R. Kiehl. 8 November 2010.</ref>
Exceptions:<ref>R. Kiehl. 8 November 2010.</ref>
*Sausage shape lesion of filum terminale = myxopapillary ependymoma.
*Sausage shape lesion of filum terminale = [[myxopapillary ependymoma]].
*Soft & tan colour = pituitary adenoma.
*Soft & tan colour = [[pituitary adenoma]].


==Normal histology==
==Normal histology==
Line 42: Line 105:
==Histopathology==
==Histopathology==
===Neuronal changes===
===Neuronal changes===
*Central chromatolysis.<ref>URL: [http://www.neuropathologyweb.org/chapter1/chapter1aNeurons.html http://www.neuropathologyweb.org/chapter1/chapter1aNeurons.html]. Accessed on: 22 December 2010.</ref>
====Anoxic neurons====
**Central clearing.
*[[AKA]] ''red neurons''.
***Nucleus and Nissl substance are pushed to cell periphery.
 
**DDx: (traumatic) axonal injury,<ref name=pmid8909880>{{cite journal |author=Holland GR |title=Experimental trigeminal nerve injury |journal=Crit. Rev. Oral Biol. Med. |volume=7 |issue=3 |pages=237–58 |year=1996 |pmid=8909880 |doi= |url=}}</ref>  vitamin deficiency ([[pellagra]]).<ref name=pmid15577526>{{cite journal |author=Piercecchi-Marti MD, Pélissier-Alicot AL, Leonetti G, Tervé JP, Cianfarani F, Pellissier JF |title=Pellagra: a rare disease observed in a victim of mental and physical abuse |journal=Am J Forensic Med Pathol |volume=25 |issue=4 |pages=342–4 |year=2004 |month=December |pmid=15577526 |doi= |url=}}</ref>
Features:
*Intensely red cytoplasm.
*Pyknosis = nuclear shrinkage + darker staining.
 
=====Images=====
<gallery>
Image:Alzheimer_type_II_astrocyte_high_mag_cropped.jpg | Anoxic neurons (WC)
Image:AcuteStroke_HE400x.jpg | Neurons in an acute stroke. (WC)
</gallery>
www:
*[http://neuropathology-web.org/chapter2/images2/2-anoxic.png Anoxic neurons (neuropathologyweb.org)].<ref>URL: [http://neuropathology-web.org/chapter2/chapter2aHIE.html http://neuropathology-web.org/chapter2/chapter2aHIE.html]. Accessed on: 10 December 2014.</ref>
*[http://moon.ouhsc.edu/kfung/iacp-olp/APAQ-Images/N1-MS-01-16.gif Anoxic neurons (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/N1-MS-01-16-Ans.htm http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/N1-MS-01-16-Ans.htm] and [http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/n1-ms-01.htm http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/n1-ms-01.htm]. Accessed on: 31 October 2010.</ref>
 
====Central chromatolysis====
Features:<ref>URL: [http://www.neuropathologyweb.org/chapter1/chapter1aNeurons.html http://www.neuropathologyweb.org/chapter1/chapter1aNeurons.html]. Accessed on: 22 December 2010.</ref>
*Central clearing.
**Nucleus and Nissl substance are pushed to cell periphery.
 
DDx:  
*Axonal injury (traumatic).<ref name=pmid8909880>{{cite journal |author=Holland GR |title=Experimental trigeminal nerve injury |journal=Crit. Rev. Oral Biol. Med. |volume=7 |issue=3 |pages=237–58 |year=1996 |pmid=8909880 |doi= |url=}}</ref>   
*Vitamin deficiency ([[pellagra]]).<ref name=pmid15577526>{{cite journal |author=Piercecchi-Marti MD, Pélissier-Alicot AL, Leonetti G, Tervé JP, Cianfarani F, Pellissier JF |title=Pellagra: a rare disease observed in a victim of mental and physical abuse |journal=Am J Forensic Med Pathol |volume=25 |issue=4 |pages=342–4 |year=2004 |month=December |pmid=15577526 |doi= |url=}}</ref>
 
=====Images=====
<gallery>
Image:Central_chromatolysis_-_intermed_mag_-_cropped.jpg | Central chromatolysis - intermed. mag. (WC)
Image:Central_chromatolysis_-_nf_-_very_high_mag.jpg | Central chromatolysis - NF stain - very high mag. (WC)
</gallery>
====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:
Images:
*[http://commons.wikimedia.org/wiki/File:Central_chromatolysis_-_intermed_mag_-_cropped.jpg Central chromatolysis - intermed. mag. (WC)].
*[http://frontalcortex.com/gallery/pics/gliageek_VWMDx200.jpg Axonal swelling (frontalcortex.com)].<ref>URL: [http://frontalcortex.com/?page=oll&topic=24&qid=602 http://frontalcortex.com/?page=oll&topic=24&qid=602]. Accessed on: 3 November 2010.</ref>
*[http://en.wikipedia.org/wiki/File:Central_chromatolysis_-_nf_-_very_high_mag.jpg Central chromatolysis - NF stain - very high mag. (WC)].
*[http://www.neuropathologyweb.org/chapter3/images3/3-pvlaxonsweling.jpg Axonal swelling (neuropathologyweb.org)].
 
=====IHC=====
*APP.
 
Image:
*[http://vet.sagepub.com/content/37/6/677/F7.expansion.html Axonal swelling - APP (sagepub.com)].<ref>{{cite journal |author=Finnie JW, Manavis J, Blumbergs PC, Kuchel TR |title=Axonal and neuronal amyloid precursor protein immunoreactivity in the brains of guinea pigs given tunicamycin |journal=Vet. Pathol. |volume=37 |issue=6 |pages=677–80 |year=2000 |month=November |pmid=11105962 |doi= |url=http://vet.sagepub.com/content/37/6/677.full}}</ref>


===Glial changes===
===Glial changes===
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**Classically described as "funnel-shaped" in benign astrocytes.<ref>MUN. 15 November 2010.</ref>
**Classically described as "funnel-shaped" in benign astrocytes.<ref>MUN. 15 November 2010.</ref>
*Peripheral nucleus.
*Peripheral nucleus.
*Image: [http://commons.wikimedia.org/wiki/File:Reactive_astrocytes_-_lfb_-_high_mag.jpg Reactive astrocytes - high mag. (WC)].
<gallery>
Image:Reactive_astrocytes_-_lfb_-_high_mag.jpg | Reactive astrocytes - high mag. (WC)
</gallery>


Alzheimer type II astrocyte:<ref>URL: [http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html]. Accessed on: 2 July 2010.</ref>
Alzheimer type II astrocyte:<ref>URL: [http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html]. Accessed on: 2 July 2010.</ref>
Line 65: Line 170:
*Indistinct cytoplasm.
*Indistinct cytoplasm.
*Found in the context of ''hepatic encephalopathy'' in basal ganglia and lower layers of cortex.<ref name=Ref_Klatt202>{{Ref Klatt|202}}</ref>
*Found in the context of ''hepatic encephalopathy'' in basal ganglia and lower layers of cortex.<ref name=Ref_Klatt202>{{Ref Klatt|202}}</ref>
*Images:  
*Images:
**[http://commons.wikimedia.org/wiki/File:Alzheimer_type_II_astrocyte_high_mag.jpg Alzheimer type II astrocytes (WC)].
**[http://neuroquiz.com/?page=image&topic=1&qid=2714 Alzheimer type II astrocytes (neuroquiz.com)].
**[http://neuroquiz.com/?page=image&topic=1&qid=2714 Alzheimer type II astrocytes (neuroquiz.com)].
**[http://www.neuropathologyweb.org/chapter10/images10/10-AlzIIl.jpg Alzheimer type II astrocytes (neuropathologyweb.org)] .
**[http://www.neuropathologyweb.org/chapter10/images10/10-AlzIIl.jpg Alzheimer type II astrocytes (neuropathologyweb.org)] .
<gallery>
Image:Alzheimer_type_II_astrocyte_high_mag.jpg| Alzheimer type II astrocytes. (WC)
</gallery>


Creutzfeldt cell:<ref name=Ref_PSNP18>{{Ref PSNP|18}}</ref>  
Creutzfeldt cell:<ref name=Ref_PSNP18>{{Ref PSNP|18}}</ref>  
*Astrocyte that mimics a mitoses; has moderate (identifiable) cytoplasm.
*Astrocyte that mimics a mitoses; has moderate (identifiable) cytoplasm.
*Finding associated with demyelinating disease.
*Finding associated with demyelinating disease.
*Image: [http://path.upmc.edu/cases/case336/images/fig03.jpg Crutzfeldt cell (upmc.edu)].<ref>URL: [http://path.upmc.edu/cases/case336.html http://path.upmc.edu/cases/case336.html]. Accessed on: 15 January 2012.</ref>


Gemistocytic astrocytes:<ref>URL: [http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html]. Accessed on: 7 November 2010.</ref>
Gemistocytic astrocytes:<ref>URL: [http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html http://www.neuropathologyweb.org/chapter1/chapter1bAstrocytes.html]. Accessed on: 7 November 2010.</ref>
Line 85: Line 193:
Bergmann gliosis (in the cerebellum):<ref name=Ref_PSNP18>{{Ref PSNP|18}}</ref>  
Bergmann gliosis (in the cerebellum):<ref name=Ref_PSNP18>{{Ref PSNP|18}}</ref>  
*Thin layer of cells (2-3 cells) with open nuclei that are larger than granular cell layer nuclei; seen with Purkinje cell loss.
*Thin layer of cells (2-3 cells) with open nuclei that are larger than granular cell layer nuclei; seen with Purkinje cell loss.
**Images:
 
***[http://commons.wikimedia.org/wiki/File:Bergmann_gliosis_-_intermed_mag.jpg Bergmann gliosis - intermed. mag. (WC)].
<gallery>
***[http://commons.wikimedia.org/wiki/File:Bergmann_gliosis_-_high_mag.jpg Bergmann gliosis - high mag. (WC)].
Image:Bergmann_gliosis_-_intermed_mag.jpg | Bergmann gliosis - intermed. mag. (WC)
***[http://commons.wikimedia.org/wiki/File:Metastatic_adenocarcinoma_-_cerebellum_-_intermed_mag.jpg Bergmann gliosis due to compression by metastasis - intermed mag. (WC)].
Image:Bergmann_gliosis_-_high_mag.jpg | Bergmann gliosis - high mag. (WC)
***[http://tpx.sagepub.com/content/35/5/676/F5.expansion.html Bergmann gliosis (sagepub.com)].
Image:Metastatic_adenocarcinoma_-_cerebellum_-_intermed_mag.jpg | Bergmann gliosis due to compression by metastasis - intermed mag. (WC)
</gallery>
Image:
*[http://tpx.sagepub.com/content/35/5/676/F5.expansion.html Bergmann gliosis (sagepub.com)].


====Reactive change vs. malignancy====
====Reactive change vs. malignancy====
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*'''S'''atellitosis, perineuronal.
*'''S'''atellitosis, perineuronal.
**Large "crowds" of glial cells associated with nuclei.
**Large "crowds" of glial cells associated with nuclei.
===Inflammatory===
DDx:
*Autoimmune - [[Multiple sclerosis]].
*Neoplastic - [[Neuropathology tumours#CNS lymphoma|CNS lymphoma]].
*Infectious - [[HSV]].
====Encephalitis====
see also:
* [[Viruses]]
* [[Microorganisms]]
=====General=====
DDx:
*Viral encephalitis (Neurotrophic viruses):<ref>{{Cite journal  | last1 = Ludlow | first1 = M. | last2 = Kortekaas | first2 = J. | last3 = Herden | first3 = C. | last4 = Hoffmann | first4 = B. | last5 = Tappe | first5 = D. | last6 = Trebst | first6 = C. | last7 = Griffin | first7 = DE. | last8 = Brindle | first8 = HE. | last9 = Solomon | first9 = T. | title = Neurotropic virus infections as the cause of immediate and delayed neuropathology. | journal = Acta Neuropathol | volume = 131 | issue = 2 | pages = 159-84 | month = Feb | year = 2016 | doi = 10.1007/s00401-015-1511-3 | PMID = 26659576 }}</ref>
** Eteroviruses are the most common cause of aseptic meningitis.
***Coxackie Virus.
***Enteric cytopathic human orphan (ECHO) virus.
** Human Herpesviruses (HSV1, HSV2, VZV, CMV, EBV, Roseola)
*** HSV encephalitis has high mortality without acyclovir treatment.
*** Childhood cerebellitis mainly associated with varicella.
*** VZV is the second most common viral meningitis after enterovirus.
** Measles virus(worldwide more than 100.000 deaths annually).
***Is linked to [[acute demyelinating encephalomyelitis]] (ADEM) and Subacute sclerosing encephalitis (SSPE).
** Seasonal influenza A virus (highest patogenic potential: avian influenza H5N1).
** Polio and Non-Polio Enterovirus (mostly children).
***Although massive eradication: Polio still existent in Pakistan, Afghanistan, Nigeria.
** Rabies virus
** Tick-borne encephalitis virus (Europe, Siberia, Russian far-east).
** West-Nile virus (US, Southern europe).
** St. Louis encephalitis virus (US).
** Japanese encephalitis virus (South, south-east asia, high disability rate).
** La Crosse virus (esp. children, midwest & eastern US).
** Borna disease virus (VSBV-1).
** Equine encephalitis viruses (EEEV, VEEV, WEEV, CHIKV).
*Paraneoplastic syndromes.
*Autoimmune antibody-mediated limbic encephalitis (NMDAR).
*Purulent bacterial encephalitis
**Streptococcus, [[Actinomyces]] ....
*Septic metastatic encephalitis
**microabscesses, local astrogliosis, two or more granulocytic infiltrates without relation to vessel.<ref>{{Cite journal  | last1 = Tauber | first1 = SC. | last2 = Bunkowski | first2 = S. | last3 = Brück | first3 = W. | last4 = Nau | first4 = R. | title = Septic metastatic encephalitis: coexistence of brain damage and repair. | journal = Neuropathol Appl Neurobiol | volume = 37 | issue = 7 | pages = 768-76 | month = Dec | year = 2011 | doi = 10.1111/j.1365-2990.2011.01196.x | PMID = 21696418 }}</ref>
*Septic embolic encephalitis
**Embolic endocarditis, Stroke-like lesions.<ref>{{Cite journal  | last1 = Bitsch | first1 = A. | last2 = Nau | first2 = R. | last3 = Hilgers | first3 = RA. | last4 = Verheggen | first4 = R. | last5 = Werner | first5 = G. | last6 = Prange | first6 = HW. | title = Focal neurologic deficits in infective endocarditis and other septic diseases. | journal = Acta Neurol Scand | volume = 94 | issue = 4 | pages = 279-86 | month = Oct | year = 1996 | doi =  | PMID = 8937541 }}</ref>
*Non-purulent bacterial encephalitis
** [[Tuberculosis]]...
=====Gross=====
*Frontal and temporal lobe - most common for HSV encephalitis.<ref>{{Ref APBR|416 Q47}}</ref>
=====Microscopic=====
Features:<ref name=pmid20051019>{{Cite journal  | last1 = Takei | first1 = H. | last2 = Wilfong | first2 = A. | last3 = Malphrus | first3 = A. | last4 = Yoshor | first4 = D. | last5 = Hunter | first5 = JV. | last6 = Armstrong | first6 = DL. | last7 = Bhattacharjee | first7 = MB. | title = Dual pathology in Rasmussen's encephalitis: a study of seven cases and review of the literature. | journal = Neuropathology | volume = 30 | issue = 4 | pages = 381-91 | month = Aug | year = 2010 | doi = 10.1111/j.1440-1789.2009.01079.x | PMID = 20051019 }}</ref>
*Perivascular inflammation.
*Microglia.
*+/-Neuronophagia.
**Phagocytosis of neurons.<ref>URL: [http://medical-dictionary.thefreedictionary.com/neuronophagia http://medical-dictionary.thefreedictionary.com/neuronophagia]. Accessed on: 11 April 2012.</ref>
*+/-Viral cytopathic changes.
*+/-Perineuronal inflammation.
Notes:
*Hemorrhage<ref name=pmid18246335>{{Cite journal  | last1 = Vossough | first1 = A. | last2 = Zimmerman | first2 = RA. | last3 = Bilaniuk | first3 = LT. | last4 = Schwartz | first4 = EM. | title = Imaging findings of neonatal herpes simplex virus type 2 encephalitis. | journal = Neuroradiology | volume = 50 | issue = 4 | pages = 355-66 | month = Apr | year = 2008 | doi = 10.1007/s00234-007-0349-3 | PMID = 18246335 }}</ref> and necrosis - characteristic of HSV encephalitis.
Image:
*[http://neuropathology-web.org/chapter5/images5/5-21l.jpg HSV encephalitis (neuropathology-web.org)].<ref>URL: [http://neuropathology-web.org/chapter5/chapter5dViruses.html http://neuropathology-web.org/chapter5/chapter5dViruses.html]. Accessed on: 27 January 2012.</ref>
=====IHC=====
IHC stains for:
*Viral etiologies, e.g. [[HSV]], [[CMV]].
*Parasites, e.g. [[toxoplasma]].
*[[Fungi]], e.g. PASD.
<gallery>
File:CNS_lymphocytic_encephalitis_frozen_section.jpg | Intraoperative appearance of a lymphocytic encephalitis (WC/jensflorian)
File:CNS_lymphocytic_encephalitis_FFPE_section.jpg | Perivascular inflammation in a lymphocytic encephalitis (WC/jensflorian)
File:HSV_hemorrhagic_encephalitis.jpg | Hemorrhage in HSV encephalitis (WC/jensflorian)
File:HSV_necrotizing_encephalitis.jpg | HSV encephalitis, higher magnification (WC/jensflorian)
File:Cmv_status_verrucosus.jpg | Neonatal brain with migration disturbances due to CMV infection (WC/jensflorian)
File:Cmv_neuronal_inclusions.jpg | Neuronal nuclear inclusions in a neonatal CMV infection (WC/jensflorian)
File:Rabies encephalitis PHIL 3368 lores.jpg | Rabies encephalitis (CDC.gov)
File:Rabies negri bodies brain.jpg | Negri bodies in Purkinje cells (CDC.gov)
</gallery>
====Vasculitis====
DDx Cerebral vasculitis / angiitis:
*[[Systemic lupus erythematosus]] (SLE)
*[[Rheumatoid arthritis]].
*Medications and drugs (amphetamine, cocaine and heroin).
*Paraneoplastic(lymphomas, leukemia and lung cancer).
*[[Granulomatosis_with_polyangiitis]]
*[[Giant cell arteritis]]
*[[Takayasu's arteritis]]
*[[Polyarteritis nodosa]]
*Beta-amyloid-related angiitis (ABRA)
<gallery>
File:ABRA_HE_40x.jpg | Beta-amyloid related angitis, HE (WC)
File:ABRA_beta-amyloid_40x.jpg |  Beta-amyloid related angiitis, abeta IHC (WC)
File:Giant cell arteritis -- low mag.jpg | Giant cell arteritis, HE (WC)
</gallery>


===Architecture===
===Architecture===
====All things rosette====
====Rosettes====
*Rosette = circular/flower-like arrangement of cells.<ref name=pmid16551982>{{cite journal |author=Wippold FJ, Perry A |title=Neuropathology for the neuroradiologist: rosettes and pseudorosettes |journal=AJNR Am J Neuroradiol |volume=27 |issue=3 |pages=488–92 |year=2006 |month=March |pmid=16551982 |doi= |url=}}</ref>
*Rosette = circular/flower-like arrangement of cells.<ref name=pmid16551982>{{cite journal |author=Wippold FJ, Perry A |title=Neuropathology for the neuroradiologist: rosettes and pseudorosettes |journal=AJNR Am J Neuroradiol |volume=27 |issue=3 |pages=488–92 |year=2006 |month=March |pmid=16551982 |doi= |url=}}</ref>


*Perivascular pseudorosette = circular/flower-like arrangement of cells with blood vessel at the centre.<ref name=pmid16551982>{{cite journal |author=Wippold FJ, Perry A |title=Neuropathology for the neuroradiologist: rosettes and pseudorosettes |journal=AJNR Am J Neuroradiol |volume=27 |issue=3 |pages=488–92 |year=2006 |month=March |pmid=16551982 |doi= |url=}}</ref>
*Perivascular pseudorosette = circular/flower-like arrangement of cells with blood vessel at the centre.<ref name=pmid16551982>{{cite journal |author=Wippold FJ, Perry A |title=Neuropathology for the neuroradiologist: rosettes and pseudorosettes |journal=AJNR Am J Neuroradiol |volume=27 |issue=3 |pages=488–92 |year=2006 |month=March |pmid=16551982 |doi= |url=}}</ref>
**Ependymoma.
**[[Ependymoma]].
**[[Medulloblastoma]], PNET.  
**[[Medulloblastoma]], PNET.  
**Central neurocytoma.
**[[Central neurocytoma]].
**[[Glioblastoma]]s.
**[[Glioblastoma]]s.


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***Image: [http://moon.ouhsc.edu/kfung/IACP-OLP/APAQ-Images/N1-TU-01-17.gif Medulloblastoma (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/IACP-OLP/APAQ-Text/N1-TU-01.htm#17 http://moon.ouhsc.edu/kfung/IACP-OLP/APAQ-Text/N1-TU-01.htm#17]. Accessed on: 3 December 2010.</ref>
***Image: [http://moon.ouhsc.edu/kfung/IACP-OLP/APAQ-Images/N1-TU-01-17.gif Medulloblastoma (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/IACP-OLP/APAQ-Text/N1-TU-01.htm#17 http://moon.ouhsc.edu/kfung/IACP-OLP/APAQ-Text/N1-TU-01.htm#17]. Accessed on: 3 December 2010.</ref>
**PNET (can be thought of as a supratentorial medulloblastoma) .
**PNET (can be thought of as a supratentorial medulloblastoma) .
**Neuroblastoma


*Flexner-Wintersteiner rosette = rosette with empty centre (donut hole).<ref name=pmid16551982/>
*Flexner-Wintersteiner rosette = rosette with empty centre (donut hole).<ref name=pmid16551982/>
**Retinoblastomas.
**[[Retinoblastoma]]s.
**Pineoblastomas.
**[[Pineoblastomas]].
**Medulloepitheliomas.
**[[Medulloepithelioma]]s.


*True ependymal rosette = surrounds a space.<ref name=pmid16551982/>
*True ependymal rosette = surrounds a space.<ref name=pmid16551982/>
**Ependymoma.
**[[Ependymoma]].


*Pineocytomatous/neurocytic rosette = irregular rosette with a large meshwork of fibers (neuropil) at the centre.<ref name=pmid16551982>{{cite journal |author=Wippold FJ, Perry A |title=Neuropathology for the neuroradiologist: rosettes and pseudorosettes |journal=AJNR Am J Neuroradiol |volume=27 |issue=3 |pages=488–92 |year=2006 |month=March |pmid=16551982 |doi= |url=}}</ref>
*Pineocytomatous/neurocytic rosette = irregular rosette with a large meshwork of fibers (neuropil) at the centre.<ref name=pmid16551982>{{cite journal |author=Wippold FJ, Perry A |title=Neuropathology for the neuroradiologist: rosettes and pseudorosettes |journal=AJNR Am J Neuroradiol |volume=27 |issue=3 |pages=488–92 |year=2006 |month=March |pmid=16551982 |doi= |url=}}</ref>
**Similar to Homer-Wright rosette.
**Similar to Homer-Wright rosette.
**[[Pineocytoma]].
**[[Pineocytoma]].
**Neurocytoma.
**[[Neurocytoma]].
**[[RGNT]] - Rosette forming glioneuronal tumor of the IVth ventricle.
 
*Radial (cartwheel) profiles = neoplastic cells anchoring to stromal vessels, shorter processes than in ependymal pseudorosettes
**[[Astroblastoma]].
**[[Glioblastoma]].
 
*Multilayered rosettes
**[[Ependymomblastoma]]s.
**[[Medulloepithelioma]]s.
 
*Meningeothelial rosettes
**[[Meningioma]] - a rare pattern.<ref>{{Cite journal  | last1 = Liverman | first1 = C. | last2 = Mafra | first2 = M. | last3 = Chuang | first3 = SS. | last4 = Shivane | first4 = A. | last5 = Chakrabarty | first5 = A. | last6 = Highley | first6 = R. | last7 = Hilton | first7 = DA. | last8 = Byrne | first8 = NP. | last9 = Wesseling | first9 = P. | title = A clinicopathologic study of 11 rosette-forming meningiomas: a rare and potentially confusing pattern. | journal = Acta Neuropathol | volume = 130 | issue = 2 | pages = 311-3 | month = Aug | year = 2015 | doi = 10.1007/s00401-015-1456-6 | PMID = 26106026 }}</ref>
 
<gallery>
Image:Neuroblastoma Homer Wright rosettes HE.jpg | Homer-Wright rosettes (WC).
Image:RGNT HE 2.jpg | Neurocytic rosettes (WC).
Image:Ependymoma H&E.jpg | Perivascular pseudorosette (WC).
Image:Ependymoblastoma ETMRjpg.jpg | Multilayered rosettes (WC).
Image:Ependymoblastomatous Rosette.jpg | Ependymoblastous rosettes (WC/Marvin101).
Image:Ependymoma true ependymal rosettes and pseudorosettes.jpg | True ependymal rosettes and pseudorosettes (WC).
Image:Astroblastoma HE Specimen.jpg | Radial (cartwheel) profiles (WC).
</gallery>


====Other====
====Other important histological features====
*Rosenthal fibres = worm-like or corkscrew-like (brightly) eosinophilic bodies; 10-40 micrometers.
*Rosenthal fibres = worm-like or corkscrew-like (brightly) eosinophilic bodies; 10-40 micrometers.
**Key feature: variable thickness; helps separate from RBCs.
**Key feature: variable thickness; helps separate from RBCs.
**Well-seen on trichrome stains.
**Well-seen on trichrome stains.  
**Images: [http://en.wikipedia.org/wiki/File:Rosenthal_HE_40x.jpg Rosenthal fibres (WP)], [http://commons.wikimedia.org/wiki/File:Rosenthal_fibers.jpg Rosenthal fibres - smear (WC/AFIP)].
<gallery>
*Eosinophilic granular bodies = related to Rosenthal fibres; round cytoplasmic hyaline droplets in astrocytes.<ref>{{Ref MBNP|11}}</ref>
Image:Rosenthal_HE_40x.jpg | Rosenthal fibres. (WP)
**Image: [http://commons.wikimedia.org/wiki/File:Pilocytic_Micro.jpg EGBs (WC/AFIP)].
Image:Rosenthal_fibers.jpg | Rosenthal fibres - smear (WC/AFIP)
</gallery>
*Eosinophilic granular bodies = related to Rosenthal fibres; round cytoplasmic hyaline droplets in [[astrocyte]]s.<ref>{{Ref MBNP|11}}</ref>
<gallery>
File:Pilocytic Micro.jpg | Eosinophilic granular bodies in pilocytic astrocytoma smear (WC/AFIP)
File:PXA HE x20.jpg | Eosinophilic granular body in a pleomorphic xanthoastrocytoma (WC/jensflorian)
</gallery>
 
*Pseudopalisading - picket fence-like alignment of cells; long axis of cells perpendicular to interface with other structures/cells.
*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.  
**Pseudopalisading of tumour cells (around necrotic regions) is seen in [[glioblastoma]].  
<gallery>
File:GBM pseudopalisading necrosis.jpg | Pseudopalisading necrosis in a glioblastoma (WC/jensflorian)
</gallery>
 
*Perivascular lymphocytic cuffing - Lymphocytes surrounding vessels.
** Seen in many inflammatory conditions including MS.
** Often seen in [[ganglioglioma]] and [[pleomorphic xanthoastrocytoma]].
** Less common in some gemistocytic [[astrocytoma]].
*** No association with survival. <ref>{{Cite journal  | last1 = Rossi | first1 = ML. | last2 = Jones | first2 = NR. | last3 = Candy | first3 = E. | last4 = Nicoll | first4 = JA. | last5 = Compton | first5 = JS. | last6 = Hughes | first6 = JT. | last7 = Esiri | first7 = MM. | last8 = Moss | first8 = TH. | last9 = Cruz-Sanchez | first9 = FF. | title = The mononuclear cell infiltrate compared with survival in high-grade astrocytomas. | journal = Acta Neuropathol | volume = 78 | issue = 2 | pages = 189-93 | month =  | year = 1989 | doi =  | PMID = 2750489 }}</ref>
<gallery>
File:Ganglioglioma lymphocytic cuffing PAS.jpg | Lymphocytic cuffing in [[ganglioglioma]] (WC/jensflorian)
</gallery>


Note:  
Note:  
*Good set of articles: [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=PureSearch&db=PubMed&details_term=Neuropathology%20for%20the%20neuroradiologist Neuropathology for radiologists (ncbi.nlm.nih.gov)].
*Good set of articles: [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=PureSearch&db=PubMed&details_term=Neuropathology%20for%20the%20neuroradiologist Neuropathology for radiologists (ncbi.nlm.nih.gov)].
===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:
*[http://frontalcortex.com/gallery/pics/gliageek_VWMDx200.jpg Axonal swelling (frontalcortex.com)].<ref>URL: [http://frontalcortex.com/?page=oll&topic=24&qid=602 http://frontalcortex.com/?page=oll&topic=24&qid=602]. Accessed on: 3 November 2010.</ref>
*[http://www.neuropathologyweb.org/chapter3/images3/3-pvlaxonsweling.jpg Axonal swelling (neuropathologyweb.org)].
====IHC====
*APP.
Image:
*[http://vet.sagepub.com/content/37/6/677/F7.expansion.html Axonal swelling - APP (sagepub.com)].<ref>{{cite journal |author=Finnie JW, Manavis J, Blumbergs PC, Kuchel TR |title=Axonal and neuronal amyloid precursor protein immunoreactivity in the brains of guinea pigs given tunicamycin |journal=Vet. Pathol. |volume=37 |issue=6 |pages=677–80 |year=2000 |month=November |pmid=11105962 |doi= |url=http://vet.sagepub.com/content/37/6/677.full}}</ref>


===Inclusion bodies===
===Inclusion bodies===
*Negri bodies.
*Negri bodies.
**Cytoplasmic inclusions; classically in Purkinje cells of the cerebellum, pyramidal cells of Ammon's horn.
**Cytoplasmic inclusions; classically in Purkinje cells of the cerebellum, pyramidal cells of Ammon's horn.
**Rabies.
**[[Rabies]].  
**Image: [http://commons.wikimedia.org/wiki/File:Rabies_encephalitis_Negri_bodies_PHIL_3377_lores.jpg Negri bodies (WC/CDC)].
<gallery>
Image:Rabies_encephalitis_Negri_bodies_PHIL_3377_lores.jpg | Negri bodies. (WC/CDC)
</gallery>
*Owl eye inclusions.
**Basiopilic neuronal inclusions in enlarged cells, typically seen in CMV encephalitis
<gallery>
Image:CMV encephalitis owl eye inclusions HE stain.jpg | Owl eye inclusions
</gallery>


*Lewy bodies.
*Lewy bodies.
**Eosinophilic cytoplasmic inclusion - composed mostly of alpha-synuclein.<ref name=pmid15235805>{{cite journal |author=Marui W, Iseki E, Kato M, Akatsu H, Kosaka K |title=Pathological entity of dementia with Lewy bodies and its differentiation from Alzheimer's disease |journal=Acta Neuropathol. |volume=108 |issue=2 |pages=121–8 |year=2004 |month=August |pmid=15235805 |doi=10.1007/s00401-004-0869-4 |url=}}</ref>
**Eosinophilic cytoplasmic inclusion - composed mostly of alpha-synuclein.<ref name=pmid15235805>{{cite journal |author=Marui W, Iseki E, Kato M, Akatsu H, Kosaka K |title=Pathological entity of dementia with Lewy bodies and its differentiation from Alzheimer's disease |journal=Acta Neuropathol. |volume=108 |issue=2 |pages=121–8 |year=2004 |month=August |pmid=15235805 |doi=10.1007/s00401-004-0869-4 |url=}}</ref>
**Image: [http://commons.wikimedia.org/wiki/File:Lewy_Koerperchen.JPG Lewy body (WC)].
<gallery>
 
Image:Lewy_Koerperchen.JPG | Lewy body. (WC)
</gallery>
====Table of inclusions====
====Table of inclusions====
{| class="wikitable"  
{| class="wikitable sortable"  
| Feature  
! Feature  
| Appearance
! Appearance
| Associated disease
! Associated disease
| Comment
! Comment
| Image
! Image
|-
|-
| Grumous bodies<br>[[AKA]] granular bodies
| Grumose bodies<br>[[AKA]] granular bodies
| granular and eosinophilic ~50 micrometers
| granular and eosinophilic ~50 micrometers
| neurodegenerative disease, neuroaxonal dystrophies, aging
| neurodegenerative disease, neuroaxonal dystrophies, aging
Line 186: Line 426:
| Cowdry type 1<br>AKA Cowdry type A  
| Cowdry type 1<br>AKA Cowdry type A  
| eosinophilic & round + halo
| eosinophilic & round + halo
| herpes simplex virus
| [[herpes simplex virus]]
| can be confused with <br>Lewy body, Marinesco body  
| can be confused with <br>Lewy body, Marinesco body  
| ?Image
| ?Image
Line 192: Line 432:
| Lewy body  
| Lewy body  
| round cytoplasmic eosinophilic<br> body +/- pale halo
| round cytoplasmic eosinophilic<br> body +/- pale halo
| Parkinsons disease, dementia with Lewy bodies
| [[Parkinson disease]], dementia with Lewy bodies
| morphology dependent on <br>location in brain; +ve for alpha-synuclein, <br>alpha-B crystallin, ubiquitin
| morphology dependent on <br>location in brain; +ve for alpha-synuclein, <br>alpha-B crystallin, ubiquitin
| [http://commons.wikimedia.org/wiki/File:Lewy_Koerperchen.JPG], [http://firstaidteam.com/usmlerximages/v/USMLERxLewy+bodies.gif.html]
| [[Image:Lewy_Koerperchen.JPG |thumb|center|150px|]], [http://firstaidteam.com/usmlerximages/v/USMLERxLewy+bodies.gif.html]
|-  
|-  
| Lafora body
| Lafora body
| round
| round
| myoclonic epilepsy
| myoclonic [[epilepsy]]
| look like corpora amylacea; location: dentate nucleus, liver, skeletal muscle, sweat glands
| look like corpora amylacea; location: dentate nucleus, liver, skeletal muscle, sweat glands
| ?Image
| ?Image
Line 212: Line 452:
| rabies
| rabies
| found in hippocampal neurons and Purkinje cells
| found in hippocampal neurons and Purkinje cells
| [http://commons.wikimedia.org/wiki/File:Rabies_encephalitis_Negri_bodies_PHIL_3377_lores.jpg]
| [[Image:Rabies_encephalitis_Negri_bodies_PHIL_3377_lores.jpg|thumb|center|150px|]]
|-  
|-  
| Hirano body
| Hirano body
| concentric calcification/rod-shaped bright eosinophilic; overlap edge of neuron
| concentric calcification/rod-shaped bright eosinophilic; overlap edge of neuron
| Alzheimer d., Pick d.<ref name=Ref_MBNP5>{{Ref MBNP|5}}</ref>
| Alzheimer disease, Pick disease<ref name=Ref_MBNP5>{{Ref MBNP|5}}</ref>
| actin crystals, may look like capillaries; location: CA1 of hippocampus  
| actin crystals, may look like capillaries; location: CA1 of hippocampus  
| [http://faculty.washington.edu/alexbert/MEDEX/Fall/adhirano.jpg]<ref name=pakmednet>URL: [http://www.pakmed.net/academic/age/alz/alz030.htm http://www.pakmed.net/academic/age/alz/alz030.htm]. Accessed on: 12 November 2010.</ref>
| [http://faculty.washington.edu/alexbert/MEDEX/Fall/adhirano.jpg]<ref name=pakmednet>URL: [http://www.pakmed.net/academic/age/alz/alz030.htm http://www.pakmed.net/academic/age/alz/alz030.htm]. Accessed on: 12 November 2010.</ref>
Line 228: Line 468:
| Granulovacuolar degeneration
| Granulovacuolar degeneration
| cytoplasmic vacuoles 4-5 micrometers
| cytoplasmic vacuoles 4-5 micrometers
| ageing, Alzheimer's disease, <br>Pick's disease
| ageing, [[Alzheimer's disease]], <br>Pick's disease
| main found in Ammon horn<ref name=Ref_MBNP5>{{Ref MBNP|5}}</ref>
| main found in Ammon horn<ref name=Ref_MBNP5>{{Ref MBNP|5}}</ref>
| [http://faculty.washington.edu/alexbert/MEDEX/Fall/adgvd.jpg]<ref name=alexbert>URL: [http://faculty.washington.edu/alexbert/MEDEX/Fall/NeuroPath_Obj.htm http://faculty.washington.edu/alexbert/MEDEX/Fall/NeuroPath_Obj.htm]. Accessed on: 13 November 2010.</ref>
| [http://faculty.washington.edu/alexbert/MEDEX/Fall/adgvd.jpg]<ref name=alexbert>URL: [http://faculty.washington.edu/alexbert/MEDEX/Fall/NeuroPath_Obj.htm http://faculty.washington.edu/alexbert/MEDEX/Fall/NeuroPath_Obj.htm]. Accessed on: 13 November 2010.</ref>
Line 234: Line 474:
| Pick bodies
| Pick bodies
| round, homogenous, intracytoplasmic, ~10 micrometers
| round, homogenous, intracytoplasmic, ~10 micrometers
| Pick's disease
| [[Pick's disease]]
| pyramidal neurons, dentate <br>granule cells (hippocampus); +ve for tau, tubulin, ubiquitin  
| pyramidal neurons, dentate <br>granule cells (hippocampus); +ve for tau, tubulin, ubiquitin  
| [http://s212.photobucket.com/albums/cc74/cat_at_uw/Osler%20-%20Neuropath/?action=view&current=Picks60x.jpg&mediafilter=images]
| [http://s212.photobucket.com/albums/cc74/cat_at_uw/Osler%20-%20Neuropath/?action=view&current=Picks60x.jpg&mediafilter=images]
Line 240: Line 480:
| Bunina body
| Bunina body
| size of Nissl granules, eosinophilic
| size of Nissl granules, eosinophilic
| ALS
| [[amyotrophic lateral sclerosis]] (ALS)
| EM: membrane-bound bodies; ubiquitin +ve  
| EM: membrane-bound bodies; ubiquitin +ve  
| [http://pathol.umin.ac.jp/gakubu/exam/2006jpg/19.jpg]
| [http://pathol.umin.ac.jp/gakubu/exam/2006jpg/19.jpg]
Line 266: Line 506:
Standard work-up:
Standard work-up:
*GFAP.
*GFAP.
*p53.
*MAP2C. <ref>{{Cite journal  | last1 = Blümcke | first1 = I. | last2 = Müller | first2 = S. | last3 = Buslei | first3 = R. | last4 = Riederer | first4 = BM. | last5 = Wiestler | first5 = OD. | title = Microtubule-associated protein-2 immunoreactivity: a useful tool in the differential diagnosis of low-grade neuroepithelial tumors. | journal = Acta Neuropathol | volume = 108 | issue = 2 | pages = 89-96 | month = Aug | year = 2004 | doi = 10.1007/s00401-004-0873-8 | PMID = 15146346 }}</ref>
*Ki-67.
*Ki-67 (MIB-1).
 
Useful additional markers:
*IDH1(R132H) in Astrocytic/Oligodendroglial tumors. <ref>{{Cite journal  | last1 = Paulus | first1 = W. | title = GFAP, Ki67 and IDH1: perhaps the golden triad of glioma immunohistochemistry. | journal = Acta Neuropathol | volume = 118 | issue = 5 | pages = 603-4 | month = Nov | year = 2009 | doi = 10.1007/s00401-009-0600-6 | PMID = 19847448 }}</ref>
*ATRX in mixed gliomas. <ref>{{Cite journal  | last1 = Reuss | first1 = DE. | last2 = Sahm | first2 = F. | last3 = Schrimpf | first3 = D. | last4 = Wiestler | first4 = B. | last5 = Capper | first5 = D. | last6 = Koelsche | first6 = C. | last7 = Schweizer | first7 = L. | last8 = Korshunov | first8 = A. | last9 = Jones | first9 = DT. | title = ATRX and IDH1-R132H immunohistochemistry with subsequent copy number analysis and IDH sequencing as a basis for an "integrated" diagnostic approach for adult astrocytoma, oligodendroglioma and glioblastoma. | journal = Acta Neuropathol | volume = 129 | issue = 1 | pages = 133-46 | month = Jan | year = 2015 | doi = 10.1007/s00401-014-1370-3 | PMID = 25427834 }}</ref>
*EMA in Ependymal tumors. <ref>{{Cite journal  | last1 = Hasselblatt | first1 = M. | last2 = Paulus | first2 = W. | title = Sensitivity and specificity of epithelial membrane antigen staining patterns in ependymomas. | journal = Acta Neuropathol | volume = 106 | issue = 4 | pages = 385-8 | month = Oct | year = 2003 | doi = 10.1007/s00401-003-0752-8 | PMID = 12898159 }}</ref>
*OLIG-2 usually -ve in Ependymomas. <ref>{{Cite journal  | last1 = Ishizawa | first1 = K. | last2 = Komori | first2 = T. | last3 = Shimada | first3 = S. | last4 = Hirose | first4 = T. | title = Olig2 and CD99 are useful negative markers for the diagnosis of brain tumors. | journal = Clin Neuropathol | volume = 27 | issue = 3 | pages = 118-28 | month =  | year =  | doi =  | PMID = 18552083 }}</ref><ref>{{Cite journal  | last1 = Otero | first1 = JJ. | last2 = Rowitch | first2 = D. | last3 = Vandenberg | first3 = S. | title = OLIG2 is differentially expressed in pediatric astrocytic and in ependymal neoplasms. | journal = J Neurooncol | volume = 104 | issue = 2 | pages = 423-38 | month = Sep | year = 2011 | doi = 10.1007/s11060-010-0509-x | PMID = 21193945 }}</ref>
===Neuronal===
===Neuronal===
*Synaptophysin.
*Synaptophysin.
Line 282: Line 526:
=Brain tumours=
=Brain tumours=
{{main|Neuropathology tumours}}
{{main|Neuropathology 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.
Tumours are a big part of neuropathology.  The most common brain tumour (in adults) is a metastasis.  The most common primary tumours originating in the brain (in adults) are [[glioma]]s. More than 50% of these are classified as [[glioblastoma]] which has a horrible prognosis.


=Non-tumour=
=Non-tumour=
==Vascular disorders==
===Cerebral hemorrhage===
:See: ''[[Intracranial hematoma]]'' for intracranial bleeds
Includes discussion of:
*[[Epidural hematoma]].
*[[Subdural hematoma]].
*[[Subarachnoid hematoma]].
*[[Intracerebral hematoma]]s.
===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]]).<ref name=pmid11819006>{{Cite journal  | last1 = Parizel | first1 = PM. | last2 = Makkat | first2 = S. | last3 = Jorens | first3 = PG. | last4 = Ozsarlak | first4 = O. | last5 = Cras | first5 = P. | last6 = Van Goethem | first6 = JW. | last7 = van den Hauwe | first7 = L. | last8 = Verlooy | first8 = J. | last9 = De Schepper | first9 = AM. | title = Brainstem hemorrhage in descending transtentorial herniation (Duret hemorrhage). | journal = Intensive Care Med | volume = 28 | issue = 1 | pages = 85-8 | month = Jan | year = 2002 | doi = 10.1007/s00134-001-1160-y | PMID = 11819006 }}</ref>
*Often fatal.<ref name=pmid11098635>{{Cite journal  | last1 = Fujimoto | first1 = Y. | last2 = Aguiar | first2 = PH. | last3 = Freitas | first3 = AB. | last4 = de Andrade | first4 = AF. | last5 = Marino Júnior | first5 = R. | title = Recovery from Duret hemorrhage: a rare complication after craniotomy--case report. | journal = Neurol Med Chir (Tokyo) | volume = 40 | issue = 10 | pages = 508-10 | month = Oct | year = 2000 | doi =  | PMID = 11098635 }}</ref>
====Gross====
*Extravasated blood in midbrain and pons - usu. ventral (anterior) and paramedian (adjacent to the midline).<ref name=pmid11819006/>
Image:
*[http://library.med.utah.edu/WebPath/jpeg5/CNS037.jpg Duret hemorrhage (med.utah.edu)].<ref>URL: [http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/npfrm.html http://library.med.utah.edu/WebPath/EXAM/IMGQUIZ/npfrm.html]. Accessed on: 4 December 2011.</ref>
====Microscopic====
Features:
*RBC extravasation.
*+/-Hemosiderin-laden macrophages.
*+/-Ischemic neurons.
===Cerebral amyloid angiopathy===
====General====
*Abbreviated ''CAA''.
*Disease of the old.
*Strong association with ''[[lobar haemorrhage]]'' (bleeds of the cerebellar cortex and cerebral cortex).<ref name=pmid16982664>{{cite journal |author=Thanvi B, Robinson T |title=Sporadic cerebral amyloid angiopathy--an important cause of cerebral haemorrhage in older people |journal=Age Ageing |volume=35 |issue=6 |pages=565–71 |year=2006 |month=November |pmid=16982664 |doi=10.1093/ageing/afl108 |url=}}</ref>
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.<ref name=pmid17297004>{{Cite journal  | last1 = Haacke | first1 = EM. | last2 = DelProposto | first2 = ZS. | last3 = Chaturvedi | first3 = S. | last4 = Sehgal | first4 = V. | last5 = Tenzer | first5 = M. | last6 = Neelavalli | first6 = J. | last7 = Kido | first7 = D. | title = Imaging cerebral amyloid angiopathy with susceptibility-weighted imaging. | journal = AJNR Am J Neuroradiol | volume = 28 | issue = 2 | pages = 316-7 | month = Feb | year = 2007 | doi =  | PMID = 17297004 | URL = http://www.ajnr.org/content/28/2/316.long }}</ref>
====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.<ref name=pmid19225408>{{Cite journal  | last1 = Schröder | first1 = R. | last2 = Deckert | first2 = M. | last3 = Linke | first3 = RP. | title = Novel isolated cerebral ALlambda amyloid angiopathy with widespread subcortical distribution and leukoencephalopathy due to atypical monoclonal plasma cell proliferation, and terminal systemic gammopathy. | journal = J Neuropathol Exp Neurol | volume = 68 | issue = 3 | pages = 286-99 | month = Mar | year = 2009 | doi = 10.1097/NEN.0b013e31819a87f9 | PMID = 19225408 }}
</ref>
====Images====
<gallery>
Image:Cerebral_amyloid_angiopathy_-_very_high_mag.jpg |CAA - congo red - very high mag. (WC)
Image:Cerebral_amyloid_angiopathy_-_low_mag.jpg |CAA - congo red - low mag. (WC)
Image:Cerebral_amyloid_angiopathy_-2b-_amyloid_beta_-_high_mag.jpg |CAA - beta-amyloid - high mag. (WC)
</gallery>
====Stains====
*[[Congo red]].
====IHC====
*Abeta-amyloid (AKA beta-amyloid).
===Cerebral amyloid angiopathy associated with inflammation (I-CAA)===
* Cognitive decline.
* Microbleedings in MRI.
* Responsive to steroids.
* Abeta deposits in vessels.
* Perivascular lymphocytic infiltrate (but no vasculitis!).
* Giant cells may be present.
===Vascular malformations===
{{Main|Vascular malformations}}
Types:<ref name=pmid17076525>{{cite journal |author=Prayson RA, Kleinschmidt-DeMasters BK |title=An algorithmic approach to the brain biopsy--part II |journal=Arch. Pathol. Lab. Med. |volume=130 |issue=11 |pages=1639–48 |year=2006 |month=November |pmid=17076525 |doi= |url=}}</ref>
*[[Vascular_malformations#Arteriovenous_malformation|Arteriovenous malformation]].
*Varix.
*Venous angioma.
*[[Vascular_malformations#Cavernous_hemangioma|Cavernous hemangioma]]  (Cavernoma).
*Capillary teleangiectasia.
Also see: ''[[Sturge-Weber syndrome]]''.
===Atherosclerosis===
{{Main|Vascular_disease#Atherosclerosis}}
*Intracranial atherosclerosis most common at circle of Willis.
*Macroscopic yellow discoloration.
*Luminal stenosis and eccentric intimal thickening.
<gallery>
File:Carotid Plaque (121061911).jpg|Plaque of the carotid bifurcation (Ed Uthman).
</gallery>
===Other large arterial diseases===
*[[Vascular_disease#Fibromuscular_dysplasia|Fibromuscular dysplasia]].
*Moyamoya disease.
**Progressive stenosis of basal intracranial arteries and abnormal vascularization.
*[[Aortic dissection|Arterial dissection]].
*[[Giant cell arteritis]].
*[[Takayasu's arteritis]].
*[[Antiphospholipid antibody syndrome|Antiphospholipid antibody]] mediated thrombosis.
===Microangiopathy===
*Defined as Small vessel disease (<300µm in transverse section).
*Includes atherosclerosis and cerebral amyloid angiopathy.
Other causes:
*Primary angitis of the CNS (PACNS).
*[[Polyarteritis nodosa]].
*[[Granulomatosis with polyangiitis]] (Wegener's granulomatosis).
*[[Lymphomatoid granulomatosis]].
*Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (commonly abbreviated ''CADASIL'').
{{Main|Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy}}
===Hypoxic-ischemic encephalopathy===
*Abbreviated ''HIE''.
{{Main|Hypoxic-ischemic encephalopathy}}
**Hypoxia: reduction in oxygen supply or utilization.
**Ischemia: reduction in blood supply.
===Cerebrovascular accident===
*Abbreviated ''CVA''.
*[[AKA]] ''stroke''.
{{Main|Cerebrovascular accident}}
*Stroke includes:
**Infarction (ischemia in defined vascular distribution persisting for at least 24hrs).
**Intracrebral hemorrhage (focal blood accumulation in the brain parenchyma).
**Subarachnoid hemorrhage (SAH).
**Cerebral venous thrombosis (CVT).
==Alcohol & CNS==
==Alcohol & CNS==
===Clinical===
===Clinical===
Line 312: Line 682:
General:
General:
*Due to thiamine deficiency.
*Due to thiamine deficiency.
**Malnourishment often accompanies [[alcoholism]].


Features:
Features:<ref name=pmid3929155>{{Cite journal  | last1 = Torvik | first1 = A. | title = Two types of brain lesions in Wernicke's encephalopathy. | journal = Neuropathol Appl Neurobiol | volume = 11 | issue = 3 | pages = 179-90 | month =  | year =  | doi =  | PMID = 3929155 }}</ref>
*Neurons preserved - '''key'''.
*Neurons of mammillary bodies preserved - '''key'''.
*Loss of myelin.
*Loss of myelin.
*Hemorrhage.
*Hemorrhage.
*Spongiosis.
*Edema.
*Reactive blood vessels.
*Reactive blood vessels.


Note:
*The thalamus and inferior olives show neuronal loss.<ref name=pmid3929155/>


====Common non-specific findings====
====Common non-specific findings====
Line 334: Line 707:
*+/-Decreased level of consciousness.
*+/-Decreased level of consciousness.


Etiology:
CSF findings:
{| class="wikitable sortable"
! Type
! Glucose
! Protein
! Cells
! Cytopathology
|-
| Bacterial, acute
| low
| high
| neutrophils
| [[File:Purulent_CSF.jpg|100px|center|]][[CSF_cytopathology#Acute_bacterial_meningitis|Cytophathology]]
|-
| Viral
| normal
| slight elevation
| lymphocytes
| [[CSF_cytopathology#Viral_meningitis|Cytophathology]]
|}
 
 
 
====Etiology====
*Infectious.
*Infectious.
**Bacterial.
**Bacterial.
Line 341: Line 737:
*Autoimmune.
*Autoimmune.
*Toxic.
*Toxic.
*Aseptic - see ''[[Mollaret's meningitis]]''.
Bacterial meningitis - most probably cause by age:<ref>{{Ref PCPBoD8|666-7}}</ref>
{| class="wikitable sortable"
! Age
! Organism
|-
| Neonate
| ''Escherichia coli'', ''Group B Streptococcus''
|-
| Infants, children
| ''Streptococcus pneumoniae''
|-
| Adolescents, young adults
| ''Neisseria meningitidis''
|-
| Elderly
| ''Streptococcus pneumoniae'', ''Listeria monocytogenes''
|}


===Gross===
===Gross===
Line 349: Line 764:
*+/-Cerebral edema.
*+/-Cerebral edema.


Image:
====Image====
*[http://en.wikipedia.org/wiki/File:Streptococcus_pneumoniae_meningitis,_gross_pathology_33_lores.jpg Meningitis (WP)].
<gallery>
Image:Streptococcus_pneumoniae_meningitis,_gross_pathology_33_lores.jpg | Streptococcus Meningitis. (WC/Dr. Edwin P. Ewing, Jr.)
File:Haemophilus influenzae meningitis 5003 lores.jpg | Hemophilus influenza Meningitis. (WC/CDC)
File:Pneumococcal meningitis.jpg | Pneumococcus Meningitis. (WC/Dr. Yale Rosen)
File:Meningitis-MRI.JPG | Bacterial Meningitis MRI (WC/MBq)
</gallery>


===Microscopic===
===Microscopic===
Features:
Features:
*Inflammation of the meninges.
*Inflammation of the meninges:
*Infectious meningitis:
**+/-[[Neutrophil]]s.
**Microorganisms (bacteria, fungi).
**+/-Lymphocytes.
**+/-[[Plasma cell]]s.
*+/-Microorganisms (infectious meningitis):  
**Bacteria.
**[[Fungi]], e.g. [[aspergillosis]] (may be intravascular).
 
Main DDx:
*[[Lymphoma]].
 
====Image====
<gallery>
Image:Meningitis_Histopathology.jpg | Bacterial meningitis. (WC/Marvin101)
</gallery>


==Abscess==
==Cerebral abscess==
===General===
===General===
*May mimic malignancy clinically.
*May mimic malignancy clinically.
Line 367: Line 799:
**Fibrosing brain: pale (lighter pink than normal brain tissue), dense.
**Fibrosing brain: pale (lighter pink than normal brain tissue), dense.


Image: [http://www.pathconsultddx.com/pathCon/largeImage?pii=S1559-8675(06)70787-2&figureId=fig1 Cerebral abscess (pathconsultddx.com)].
Images:  
*[http://pathology.class.kmu.edu.tw/ch01/4-1.jpg Cerebral abscess - very low mag. (kmu.edu.tw)].<ref>URL: [http://pathology.class.kmu.edu.tw/ch01/Slide4.htm http://pathology.class.kmu.edu.tw/ch01/Slide4.htm]. Accessed on: 1 January 2012.</ref>
*[http://pathology.class.kmu.edu.tw/ch01/4-5.jpg Cerebral abscess - low mag. (kmu.edu.tw)].


==Neurodegenerative diseases==
==Neurodegenerative diseases==
{{Main|Neurodegenerative diseases}}
{{Main|Neurodegenerative diseases}}
This is a hueueuge topic.  It is covered its own article and includes a general discussion of dementia.
This is a hueueuge topic.  It is covered in its own article and includes a general discussion of dementia.
 
==Malformation of cortical development(MCD) ==
===Lissencephaly===
* Greek: ‘lissos': smooth and ‘enkephalos': brain.
* Absent (agyria) or decreased (pachygyria) convolutions.
* Cortical thickening
* Smooth cerebral surface
* Subtypes with different layering: 2-layered, 3-layered, and 4-layered forms.
* Heterotopic neurons in a pattern suggestive of laminar organization.
* 14 LIS mutations account for 90% of all cases.<ref name="pmid27781032">{{cite journal |authors=Parrini E, Conti V, Dobyns WB, Guerrini R |title=Genetic Basis of Brain Malformations |journal=Mol Syndromol |volume=7 |issue=4 |pages=220–233 |date=September 2016 |pmid=27781032 |pmc=5073505 |doi=10.1159/000448639 |url=}}</ref>
 
===Polymicrogyria===
* Abnormal cortical lamination.
* Abnormally small and partly fused gyri.
* Can be unilateral, bilateral and symmetrical.
* Intellectual disability.
* Sometimes severe encephalopathy.
* Pharmacoresistant epilepsy
* Cortical lamination can be unlayered or four-layered.
** Unlayered:  Unorganized radial distribution of neurons.
** Four-layered:  Molecular layer, outer neuronal layer, nerve fiber layer, and inner neuronal layer.
* 1q trisomy in unilateral cases.<ref name="pmid32979071">{{cite journal |authors=Kobow K, Jabari S, Pieper T, Kudernatsch M, Polster T, Woermann FG, Kalbhenn T, Hamer H, Rössler K, Mühlebner A, Spliet WGM, Feucht M, Hou Y, Stichel D, Korshunov A, Sahm F, Coras R, Blümcke I, von Deimling A |title=Mosaic trisomy of chromosome 1q in human brain tissue associates with unilateral polymicrogyria, very early-onset focal epilepsy, and severe developmental delay |journal=Acta Neuropathol |volume=140 |issue=6 |pages=881–891 |date=December 2020 |pmid=32979071 |doi=10.1007/s00401-020-02228-5 |url=}}</ref>


==Epilepsy==
==Epilepsy==
===General===
{{Main|Epilepsy}}
*Seizure that are "idiopathic", i.e. no brain tumour, no mass lesion, no brain injury.
===Focal cortical dysplasia (FCD)===
*Most common form: ''temporal lobe epilepsy''.<ref>URL: [http://emedicine.medscape.com/article/342150-overview http://emedicine.medscape.com/article/342150-overview]. Accessed on: 20 November 2010.</ref>
*Localized malformations of the cortex.
*Frequently associated with epilepsy in children.
*Includes cortical dyslamination, cytoarchitectural changes and white matter abnormalities.
*Current consensus: ILAE classification scheme 2011 <ref>{{Cite journal  | last1 = Blümcke | first1 = I. | last2 = Aronica | first2 = E. | last3 = Miyata | first3 = H. | last4 = Sarnat | first4 = HB. | last5 = Thom | first5 = M. | last6 = Roessler | first6 = K. | last7 = Rydenhag | first7 = B. | last8 = Jehi | first8 = L. | last9 = Krsek | first9 = P. | title = International recommendation for a comprehensive neuropathologic workup of epilepsy surgery brain tissue: A consensus Task Force report from the ILAE Commission on Diagnostic Methods. | journal = Epilepsia | volume = 57 | issue = 3 | pages = 348-58 | month = Mar | year = 2016 | doi = 10.1111/epi.13319 | PMID = 26839983 }}
</ref>(based on previous classification by Palmini 2004):


===Microscopic===
Features:<ref>MUN. 15 November 2010.</ref>
*Mesial temporal sclerosis = scarring of the medial temporal lobe.
**Involves: hippocampus, parahippocampal gyrus and amygdala.
***Hippocampus: CA1 and CA4 affected.


Notes:
*Type I FCD (focal)
*Changes in CA1 & CA4 of the hippocampus - DDx:
**Ia: Abnormal radial cortical lamination.
**Epilpsy.
**Ib: Abnormal tangential cortical lamination.
**Dementia.
**Ic: Abnormal radial and tangential cortical lamination.


==Cysts==
===General===
*All are "benign", but some may be fatal due to spatial constraints.


===List of cysts===
*Type II FCD (focal)
*Colloid cyst.<ref>MUN. 11 Mar 2009.</ref>
**IIa: Presence of dysmorphic neurons.
**Columnar epithelium.
**IIb: Presence of dysmorphic neurons and balloon cells.
*Arachnoid cyst - considered precursor of meningioma.
**Psammoma bodies.
**Clumps of cells.
**Whorled pattern.
*Dermoid cyst.
**Skin + adnexal structures.
**... think of ovarian dermoid.
*Epidermoid.
*Choriod cyst.
**?


*Neuroenteric cyst.
*Epithelial cyst.


==Stroke==
*Type III FCD (associated with other lesion)
===Gross===
**IIIa: FCD associated with [[Epilepsy#Hippocampal_sclerosis|hippocampal sclerosis]].
*Soft/mushy brain.
**IIIb: FCD adjacent to a brain tumor.
*Older infarcts.
**IIIc: FCD adjacent to vascular malformation.
**A "roof" is present - a thin submeningeal layer is preserved by the CSF.<ref>MUN. 16 December 2009.</ref>
**IIIc: FCD associated with previous injury (trauma, inflammation...).
***"Roof" is absent in trauma.
**Cavity - in older infarcts.
***''Multiple sclerosis'' does not cavitate.
*Laminar necrosis = (thin) chalky line replaces grey mater.<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/neurotest/Q03-Ans.htm http://moon.ouhsc.edu/kfung/jty1/neurotest/Q03-Ans.htm]. Accessed on: 26 October 2010.</ref>
**[[AKA]] ''pseudolaminar necrosis'' - as it is not localized to a specific layer of the cortex.<ref>MUN. 26 November 2010.</ref>


==Hypoxic-ischemic encephalopathy==
===General===
*Often due to ''cardiac arrest'', i.e. global ischemia.
*Triple watershed area = parieto-occipital cortex, extrastriate occipital cortex.


===Microscopic===
<gallery>
Features:
File:FCDIIa dysmorphic neurons HE.jpg|Dysmorphic neurons in FCD (HE)
*Hippocampal ischemic changes:
File:FCDIIa neuronal heterotopia neun.jpg|Heterotopic neurons (NeuN)
**Loss of neurons in CA1, CA3 and CA4 +/- "cavitation".
</gallery>
***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".<ref>URL: [http://www.neuropathologyweb.org/chapter2/chapter2aHIE.html http://www.neuropathologyweb.org/chapter2/chapter2aHIE.html]. Accessed on: 12 July 2010.</ref>
**Shrunken neurons with intensely eosinophilic cytoplasm and pyknotic (shrunken) nuclei.
*Pseudolaminar necrosis - (uncontrolled) cell death in the cerebral cortex in a band-like pattern,<ref>Hypoxic and Ischemic Encephalopathy. neuropathology.neoucom.edu. Accessed on: 29 December 2010.</ref> with a relative preservation of cells immediately adjacent to the meninges.


Images:
===Hamartia===
*Anoxic neurons:
* Small collection of ectopic glioneuronal cells.
**[http://www.neuropathologyweb.org/chapter2/images2/2-1HIE.jpg Anoxic neurons (neuropathologyweb.org)].
**Morpholology resembling oligodendroglial-like cells. <ref>{{Cite journal  | last1 = Kasper | first1 = BS. | last2 = Stefan | first2 = H. | last3 = Buchfelder | first3 = M. | last4 = Paulus | first4 = W. | title = Temporal lobe microdysgenesis in epilepsy versus control brains. | journal = J Neuropathol Exp Neurol | volume = 58 | issue = 1 | pages = 22-8 | month = Jan | year = 1999 | doi =  | PMID = 10068310 }}</ref>
**[http://commons.wikimedia.org/wiki/File:Alzheimer_type_II_astrocyte_high_mag_cropped.jpg Anoxic neurons (WC)].
* Mostly amygdala, less common in hippocampus or temporal lobe.
**[http://moon.ouhsc.edu/kfung/iacp-olp/APAQ-Images/N1-MS-01-16.gif Anoxic neurons (ouhsc.edu)].<ref>URL: [http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/N1-MS-01-16-Ans.htm http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/N1-MS-01-16-Ans.htm] and [http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/n1-ms-01.htm http://moon.ouhsc.edu/kfung/iacp-olp/apaq-text/n1-ms-01.htm]. Accessed on: 31 October 2010.</ref>
* Can coexist with focal cortical dysplasia.
*Hippocampal ischemic changes:
**[http://www.neuropathologyweb.org/chapter2/images2/2-hippoHIE.jpg Hippocampus in HIE (neuropathologyweb.org)].<ref>URL: [http://www.neuropathologyweb.org/chapter2/chapter2aHIE.html http://www.neuropathologyweb.org/chapter2/chapter2aHIE.html]. Accessed on: 14 January 2011.</ref>
*Pseudolaminar necrosis:
**[http://commons.wikimedia.org/wiki/File:Cortical_pseudolaminar_necrosis_-_lfb_-_very_low_mag.jpg Pseudolaminar necrosis - very low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Cortical_pseudolaminar_necrosis_-_lfb_-_intermed_mag.jpg Pseudolaminar necrosis - intermed. mag. (WC)].


Notes:
==Demyelination==
*Neurons of ''subiculum'' in adults - usu. normal (as they are resistant to ischemic changes).


==Multiple sclerosis==
===Multiple sclerosis===
===General===
*Abbreviated ''MS''.
*A bread 'n butter disease of neurology in Canada.
{{Main|Multiple sclerosis}}


Clinical:
===Osmotic demyelination syndrome===
*CSF: oligoclonal bands of immunoglobulin.<ref>{{Ref PBoD8|1311}}</ref>
{{Main|Osmotic demyelination syndrome}}
*Previously known as ''central pontine myelinolysis'' (abbreviated ''CPM'').


===Radiologic/Gross===
===Acute disseminated encephalomyelitis===
Features:<ref>URL: [http://library.med.utah.edu/kw/ms/path.html http://library.med.utah.edu/kw/ms/path.html]. Accessed on: 12 July 2010.</ref>
*Abbreviated ''ADEM''.
*White matter lesions.
{{Main|Acute disseminated encephalomyelitis}}
**Cerebrum (classically): periventricular distribution.
**Optic nerves (optic neuritis) - classic presentation.


===Microscopic===
===Neuromyelitis optica===
Features:<ref>URL: [http://library.med.utah.edu/kw/ms/path.html http://library.med.utah.edu/kw/ms/path.html]. Accessed on: 12 July 2010.</ref>
*Abbreviated ''NMO''.
*Perivascular inflammation.
*Demyelination.
**Subcortical myelinated fibers are often spared.


Classification of MS lesions:
General:
*Early active.
*Rare autoimmune disease - once considered a variant of [[multiple sclerosis]].
*Inactive.  
**Autoantibodies directed at aquaporin-4.<ref name=pmid22087205>{{Cite journal  | last1 = Kim | first1 = W. | last2 = Kim | first2 = SH. | last3 = Kim | first3 = HJ. | title = New insights into neuromyelitis optica. | journal = J Clin Neurol | volume = 7 | issue = 3 | pages = 115-27 | month = Sep | year = 2011 | doi = 10.3988/jcn.2011.7.3.115 | PMID = 22087205 }}</ref>
*Early remyelinating.  
*Late remyelinating.


==Cerebral amyloid angiopathy==
Diagnosis:
===General===
*NMO-IgG.
*Abbreviated ''CAA''.
*Disease of the old.
*Strong association with ''[[lobar haemorrhage]]''.<ref name=pmid16982664>{{cite journal |author=Thanvi B, Robinson T |title=Sporadic cerebral amyloid angiopathy--an important cause of cerebral haemorrhage in older people |journal=Age Ageing |volume=35 |issue=6 |pages=565–71 |year=2006 |month=November |pmid=16982664 |doi=10.1093/ageing/afl108 |url=}}</ref>
**Cerebellar cortex.
**Cerebral cortex.


Etiology:
Clinical - preferentially:
*[[Amyloid]] deposition in the basal lamina of smooth muscle (in the cerebellar cortex and cerebral cortex).
*Eye (optic neuritis).
*Spinal cord (myelitis).


===Microscopic===
Microscopic:
Features:
*Inflammation - lymphocytes, macrophages.
*Amorphous, acellular eosinophilic material within walls of small arteries.
*Reactive astrocytes.
**This is a high power diagnosis with congo red staining.


Special stains:
Images:
*[[Congo red]].
*[http://path.upmc.edu/cases/case637.html Neuromyelitis optica - several images (upmc.edu)].
*Abeta-amyloid (AKA beta-amyloid).


Notes:
IHC:
*Amyloidosis is seen in all individuals with Alzheimer's disease; the amount of amyloid is what differs -- in CAA it is lots and lots.
*Mixed lymphocyte population with CD3 > CD20.
*The white matter is typically spared by CAA.<ref name=pmid19225408>{{Cite journal  | last1 = Schröder | first1 = R. | last2 = Deckert | first2 = M. | last3 = Linke | first3 = RP. | title = Novel isolated cerebral ALlambda amyloid angiopathy with widespread subcortical distribution and leukoencephalopathy due to atypical monoclonal plasma cell proliferation, and terminal systemic gammopathy. | journal = J Neuropathol Exp Neurol | volume = 68 | issue = 3 | pages = 286-99 | month = Mar | year = 2009 | doi = 10.1097/NEN.0b013e31819a87f9 | PMID = 19225408 }}
*Aquaporin-4 loss.
</ref>


Images:
===Progressive multifocal leukoencephalopathy===
*[http://commons.wikimedia.org/wiki/File:Cerebral_amyloid_angiopathy_-_very_high_mag.jpg CAA - congo red - very high mag. (WC)].
*Abbreviated ''PML''.
*[http://commons.wikimedia.org/wiki/File:Cerebral_amyloid_angiopathy_-_low_mag.jpg CAA - congo red - low mag. (WC)].
{{Main|Progressive multifocal leukoencephalopathy}}


==Vascular malformations==
{{Main|Vascular malformations}}
Types:<ref name=pmid17076525>{{cite journal |author=Prayson RA, Kleinschmidt-DeMasters BK |title=An algorithmic approach to the brain biopsy--part II |journal=Arch. Pathol. Lab. Med. |volume=130 |issue=11 |pages=1639–48 |year=2006 |month=November |pmid=17076525 |doi= |url=}}</ref>
#Arteriovenous malformation.
#*Most important clinically - highest risk of bleeding.
#Varix.
#*One large (dilated) vein.
#Venous angioma.
#*Many small veins.
#Caverous malformation.
#*Vessels are back-to-back (no intervening parenchyma).


Also see: ''[[Sturge-Weber syndrome]]''.


=Paediatric pathology=
=Cysts=
===Joubert syndrome===
===General===
*Malformation of the cerebellar vermis.<ref name=ninds_joubert>[http://www.ninds.nih.gov/disorders/joubert/joubert.htm http://www.ninds.nih.gov/disorders/joubert/joubert.htm]</ref>
*All are "benign", but some may be fatal due to spatial constraints.


===Epidemiology===
===List of cysts===
*Autosomal recessive - mutation in a number of genes including NPHP1, AHI1, and CEP290.<ref name=ninds_joubert/>  
*[[Colloid cyst]].
**Columnar epithelium.
*Arachnoid cyst - considered precursor of [[meningioma]].
**[[Psammoma bodies]].
**Clumps of cells.
**Whorled pattern.
*[[Dermoid cyst]].
**Skin + adnexal structures.
**... think of ovarian dermoid.
*Epidermoid cyst.
*Choroid plexus cyst.
*Neuroenteric cyst.
**Foregut cyst with connection to dura.<ref>URL: [http://bhj.org/journal/2003_4502_april/neurentericcyst_373.htm http://bhj.org/journal/2003_4502_april/neurentericcyst_373.htm]. Accessed on: 19 December 2011.</ref>
***Gastrointestinal tract epithelium.
***Usually seen with vertebral anomalies.
*Epithelial cyst.
*Cyst with a mural nodule tumor of the brain.
**Commonly seen in: <ref>{{Cite journal  | last1 = Raz | first1 = E. | last2 = Zagzag | first2 = D. | last3 = Saba | first3 = L. | last4 = Mannelli | first4 = L. | last5 = Di Paolo | first5 = PL. | last6 = D'Ambrosio | first6 = F. | last7 = Knopp | first7 = E. | title = Cyst with a mural nodule tumor of the brain. | journal = Cancer Imaging | volume = 12 | issue =  | pages = 237-44 | month = Aug | year = 2012 | doi = 10.1102/1470-7330.2012.0028 | PMID = 22935908 }}</ref>
**[[Hemangioblastoma]]
**[[Craniopharyngioma]]
**[[Ganglioglioma]]
*Others.


=Weird stuff=
==Colloid cyst==
==Acute disseminated encephalomyelitis==
===General===
===General===
*Thought to be autoimmune; often associated with/preceded by by viral illness.<ref name=pmid17438235>{{cite journal |author=Tenembaum S, Chitnis T, Ness J, Hahn JS |title=Acute disseminated encephalomyelitis |journal=Neurology |volume=68 |issue=16 Suppl 2 |pages=S23–36 |year=2007 |month=April |pmid=17438235 |doi=10.1212/01.wnl.0000259404.51352.7f |url=}}</ref>
Classic presentation:<ref name=pmid15228889>{{Cite journal | last1 = Spears | first1 = RC. | title = Colloid cyst headache. | journal = Curr Pain Headache Rep | volume = 8 | issue = 4 | pages = 297-300 | month = Aug | year = 2004 | doi =  | PMID = 15228889 }}</ref>
*May mimic multiple sclerosis.
*Headache - may be relieved by lying down.
*Abbreviated "ADEM".
*Can cause [[sudden natural death]].<ref name=pmid14716130>{{Cite journal  | last1 = Kava | first1 = MP. | last2 = Tullu | first2 = MS. | last3 = Deshmukh | first3 = CT. | last4 = Shenoy | first4 = A. | title = Colloid cyst of the third ventricle: a cause of sudden death in a child. | journal = Indian J Cancer | volume = 40 | issue = 1 | pages = 31-3 | month =  | year =  | doi =  | PMID = 14716130 }}</ref>


Treatment:
===Gross===
*Steroids.
*Fluid filled cyst - classically in the third ventricle.
*Plasmapheresis.


Diagnosis:
====Images====
*Need to r/o infection (with lumbar puncture).
<gallery>
*No old plaques on imaging (MRI).
Image:Human brain showning a colloid cyst in the third ventricle.jpg| Colloid cyst at autopsy. (Shaktawat ''et al.''<ref name=pmid16867192>{{Cite journal  | last1 = Shaktawat | first1 = SS. | last2 = Salman | first2 = WD. | last3 = Twaij | first3 = Z. | last4 = Al-Dawoud | first4 = A. | title = Unexpected death after headache due to a colloid cyst of the third ventricle. | journal = World J Surg Oncol | volume = 4 | issue =  | pages = 47 | month =  | year = 2006 | doi = 10.1186/1477-7819-4-47 | PMID = 16867192 }}</ref>)
</gallery>
www:
*[http://www.ajnr.org/content/21/8/1470/F3.expansion.html Colloid cyst of third ventricle (ajnr.org)].<ref name=pmid11003281/>


===Microscopic===
===Microscopic===
Features:<ref>{{Ref PBoD8|1312}}</ref>
Features:<ref name=pmid11003281>{{Cite journal  | last1 = Armao | first1 = D. | last2 = Castillo | first2 = M. | last3 = Chen | first3 = H. | last4 = Kwock | first4 = L. | title = Colloid cyst of the third ventricle: imaging-pathologic correlation. | journal = AJNR Am J Neuroradiol | volume = 21 | issue = 8 | pages = 1470-7 | month = Sep | year = 2000 | doi =  | PMID = 11003281 }}</ref>
*Myelin loss with sparing of axons.
*Simple epithelium with ciliated cells and goblet cells.
*Inflammation:
**Early: neutrophils.
**Late: mononuclear cells (lymphocytes, plasma cells).
*Lipid-laden macrophages.


DDx
====Images====
*Multiple sclerosis.
<gallery>
**Age of lesions differs.
Image:Colloid_Cyst_HE_40x.jpg | Colloid cyst. (WC)
*Acute necrotizing hemorrhagic encephalomyelitis (ANHE).
</gallery>
www:
*[http://www.ajnr.org/content/21/8/1470/F4.expansion.html Colloid cyst (ajnr.org)].<ref name=pmid11003281/>


==Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)==
=Paediatric pathology=
==Kernicterus==
===General===
===General===
*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 }}
*Due to hyperbilirubinemia.<ref name=pmid7063283>{{Cite journal  | last1 = Turkel | first1 = SB. | last2 = Miller | first2 = CA. | last3 = Guttenberg | first3 = ME. | last4 = Moynes | first4 = DR. | last5 = Godgman | first5 = JE. | title = A clinical pathologic reappraisal of kernicterus. | journal = Pediatrics | volume = 69 | issue = 3 | pages = 267-72 | month = Mar | year = 1982 | doi = | PMID = 7063283 }}</ref>
</ref>
*Causes strokes in 40-50 year-old.
*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>


====Etiology====
===Gross===
*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>
*Yellow staining:<ref name=npw>URL: [http://neuropathology-web.org/chapter3/chapter3eBilirubinencephalopathy.html http://neuropathology-web.org/chapter3/chapter3eBilirubinencephalopathy.html]. Accessed on: 30 May 2012.</ref>
**Diagnosis: proven ''Notch 3'' mutation.
**Basal ganglia.<ref name=pmid10920171>{{Cite journal  | last1 = Hansen | first1 = TW. | last2 = Hervieux | first2 = JF. | last3 = Orth | first3 = J. | last4 = Schmorl | first4 = CG. | last5 = Baumes | first5 = JB. | title = Pioneers in the scientific study of neonatal jaundice and kernicterus. | journal = Pediatrics | volume = 106 | issue = 2 | pages = E15 | month = Aug | year = 2000 | doi = | PMID = 10920171 }}</ref>
**Hippocampus.<ref name=pmid15091133>{{Cite journal  | last1 = Paksoy | first1 = Y. | last2 = Koç | first2 = H. | last3 = Genç | first3 = BO. | title = Bilateral mesial temporal sclerosis and kernicterus. | journal = J Comput Assist Tomogr | volume = 28 | issue = 2 | pages = 269-72 | month =  | year =  | doi =  | PMID = 15091133 }}</ref>
**Subthalamic nucleus.


===Microscopic===
Note:
Features:
*May not be specific.<ref name=pmid7063283/>  
*+/-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====
Image:
*Notch 3: smooth muscle and pericytes punctate +ve.<ref name=pmid12861102/>
*[http://www.flickr.com/photos/neonatal-box/6275988844/ Kernicterus (flickr.com)].


Image: [http://commons.wikimedia.org/wiki/File:CADASIL_-_very_high_mag.jpg Notch 3 staining in CADASIL (WC)].
===Microscopic===
Features - similar to [[HIE]]:<ref name=npw/>
*+/-Red neurons.
*+/-Gliosis.


Notes:
==Joubert syndrome==
*No cortical involvement -- this is unlike ''multiple sclerosis''.
*Malformation of the cerebellar vermis.<ref name=ninds_joubert>[http://www.ninds.nih.gov/disorders/joubert/joubert.htm http://www.ninds.nih.gov/disorders/joubert/joubert.htm]</ref>


DDx:
===Epidemiology===
*[[Amyloidosis]].
*Autosomal recessive - mutation in a number of genes including NPHP1, AHI1, and CEP290.<ref name=ninds_joubert/>
*[[Binswanger's disease]] - multi-infarct dementia affecting subcortical white matter.
**Often diagnosed as ''Alzheimer's disease'' in the past.
 
====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).


=See also=
=See also=
Michael
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