Brain biopsies requiring Creutzfeldt-Jakob disease precautions in the Republic of Ireland 2005-2016.

AIMS: Creutzfeldt-Jakob disease (CJD) risk precautions are required when performing brain biopsies on patients with a dementing illness and in 'risk' groups. The impact on a diagnostic neuropathology service is considerable. We sought to determine if better case selection might reduce the necessity for application of CJD risk precautions. METHODS: We reviewed the clinical information, contributory investigations and final neuropathologic diagnosis in a cohort of patients (n = 21), referred to the National CJD Surveillance Centre between January 1, 2005, and December 31, 2016. RESULTS: Of this 21-patient cohort, five were positive for CJD, four belonged to the 'at risk of CJD' category requiring brain surgery, while the remaining 12 were referred to the National CJD Surveillance Unit with CJD as part of their differential diagnosis. CJD was confirmed in 5/21 (three sporadic [s]CJD, one variant [v]CJD and one iatrogenic [i] CJD). CJD was clinically probable in 4/5 proven CJD patients (80%). The patients (n = 4) in the 'at risk of CJD' group were diagnosed with tumour (n = 2), inflammation (n = 1) and non-specific changes (n = 1). Of the remaining 12 patients (in whom CJD was included in the differential diagnosis), the final neuropathologic diagnoses included tumour (n = 2), neurodegenerative (n = 2), inflammatory (n = 1), metabolic (n = 2), vascular (n = 2) and non-specific gliosis (n = 3). CONCLUSIONS: More often than not, the clinical suspicion of CJD was not borne out by the final neuropathological diagnosis. Failure by clinicians to adhere to the recommended CJD investigation algorithm impacts adversely on the neuropathology workload and causes unnecessary concern among operating theatre, laboratory and nursing personnel.

Temporal stability of MGMT promoter methylation in glioblastoma patients undergoing STUPP protocol.

Epigenetic silencing of O-6-methylguanine-DNA methyltransferase (MGMT) promoter via methylation in a glioblastoma (GBM), has been correlated with a more favourable response to alkylating chemotherapeutic agents such as temozolomide. The use of global methylation surrogates such as Long Interspersed Nucleotide Element 1 (LINE1) may also be valuable in order to fully understand these highly heterogeneous tumours. In this study, we analysed both original and recurrent GBMs in 22 patients (i.e. 44 tumours), for both MGMT and LINE1 methylation status. In the 22 patients: 14 (63.6%) displayed MGMT methylation stability in the recurrent GBM versus 8 (36.4%), with instability of methylation status. No significant differences in overall and progression free survival was evident between these two groups. LINE1 methylation status remained stable for 12 (54.5%) of recurrent GBM patients versus 9 (41%) of the patients with instability in LINE1 methylation status (p = 0.02), resulting in an increase in overall survival of the stable LINE1 group (p = 0.04). The results obtained demonstrated major epigenetic instability of GBMs treated with temozolomide as part of the STUPP protocol. GBMs appear to undergo selective evolution post-treatment, and have the ability to recur with a newly reprogrammed epigenetic status. Selective targeting of the altered epigenomes in recurrent GBMs may facilitate the future development of both prognostic biomarkers and enhanced therapeutic strategies.

Intravascular large B-cell lymphoma presenting clinically as rapidly progressive dementia.

BACKGROUND: In patients presenting with rapidly progressive dementia, prion disease may enter the differential diagnosis. The commonest malignancies masquerading as prion disease are primary CNS lymphoma and intravascular large B-cell lymphoma, both rare and difficult to diagnose without brain biopsy. CASE PRESENTATION: This 82-year-old lady with a past history of hypertension, presented with rapidly progressive cognitive impairment and ataxia. The possibility of sCJD was raised. Brain biopsy was carried out. Western blot for prion protein was negative. Brain biopsy showed intravascular large B-cell lymphoma. She died shortly afterwards. CONCLUSION: The clinical presentation of intravascular large B-cell lymphoma is diverse. Patients may present as in this case with dementia, seizures, and myoclonus leading to a clinical diagnosis of sCJD. The diagnosis here was made at biopsy but is made at autopsy in over 50% of cases.

Comparative genomic and proteomic analysis of high grade glioma primary cultures and matched tumor in situ.

Developing targeted therapies for high grade gliomas (HGG), the most common primary brain tumor in adults, relies largely on glioma cultures. However, it is unclear if HGG tumorigenic signaling pathways are retained under in-vitro conditions. Using array comparative genomic hybridization and immunohistochemical profiling, we contrasted the epidermal and platelet-derived growth factor receptor (EGFR/PDGFR) in-vitro pathway status of twenty-six primary HGG cultures with the pathway status of their original HGG biopsies. Genomic gains or amplifications were lost during culturing while genomic losses were more likely to be retained. Loss of EGFR amplification was further verified immunohistochemically when EGFR over expression was decreased in the majority of cultures. Conversely, PDGFRα and PDGFRß were more abundantly expressed in primary cultures than in the original tumor (p<0.05). Despite these genomic and proteomic differences, primary HGG cultures retained key aspects of dysregulated tumorigenic signaling. Both in-vivo and in-vitro the presence of EGFR resulted in downstream activation of P70s6K while reduced downstream activation was associated with the presence of PDGFR and the tumor suppressor, PTEN. The preserved pathway dysregulation make this glioma model suitable for further studies of glioma tumorigenesis, however individual culture related differences must be taken into consideration when testing responsiveness to chemotherapeutic agents.

The contribution of alcohol to fatal traumatic head injuries in the forensic setting.

Excessive drinking increases the risk of dying unnaturally. In the Republic of Ireland such deaths are referred to the State Pathologist. Blood alcohol concentration (BAC) is routinely measured. We created a database of cases presenting to the State Pathologist over a nine year period (2000-2008 inclusive) to evaluate the relationship between alcohol and fatal traumatic brain injuries (FTBI). Of a total of 1778 cases, 332 (275 Male [M]; 57 Female [F]) died of head injuries. Fatalities were highest in males aged 36-50 (N = 97) and 26-35 (N = 73). Assaults (N = 147), falls (N = 95), road traffic accidents (RTA) (N = 50) and suicide (N = 15) were the commonest modes of presentation. A positive blood alcohol concentration (BAC) was found in 36% of assaults, 41% of falls and 40% of suicides. In the RTA group BAC was positive in 59% of pedestrians, 33% of drivers and 14% of passengers. Alcohol clearly plays a significant role in FTBI in the forensic setting.

Is the contribution of alcohol to fatal traumatic brain injuries being underestimated in the acute hospital setting?

Alcohol consumption in Ireland has nearly doubled during the period 1989-2001. To evaluate the relationship of alcohol to fatal head injuries in the acute hospital setting we created a data base of all fatal traumatic brain injuries in the Department of Neuropathology at Beaumont Hospital over a ten year period (1997-2006 inclusive). 498 cases were identified (351 males: 147 females). Fatalities were highest in males aged 19-25 years (N=101) and 51-70 years (N=109). Falls (N=210) and road traffic accidents (N=183) were the commonest modes of presentation. 36/210 (17%) falls had positive blood alcohol testing, 9/210 (4.3%) had documentation of alcohol in notes but no testing, 35/210 (16.7%) tested negative for alcohol and 130/210 (61.9%) were not tested. The RTA group (N=183) comprised drivers (n=79), passengers (n=47) and pedestrians (n=57). 65/79 (82.2%) of drivers were males aged 19-25 years. Blood alcohol was only available in 27/79 (34.1%) drivers and was positive in 13/27 (48.1%). 14/75 (18.7%) pedestrians were tested for alcohol, 4/14 (28.6%) were positive. Overall 142/183 (77.6%) of the RTA group were not tested. The contribution of alcohol to fatal traumatic brain injuries is probably being underestimated due to omission of blood alcohol concentration testing on admission to hospital. Absence of national guidelines on blood alcohol testing in the emergency department compounds the problem.

Facial nerve schwannoma of the internal auditory canal.

BACKGROUND: Facial nerve schwannoma of the internal auditory canal is a very rare tumour. AIM: While Bell's palsy is the commonest cause of a facial paresis, more serious causes should be excluded if recovery is delayed. METHOD: A case report of a young man who presented with a long standing facial palsy. CONCLUSION: Any facial palsy that does not show evidence of recovery within six weeks should be investigated radiologically to exclude a tumour.

July 2004: 40-year-old man with headaches and dyspnea.

A 40-year-old man had a 6-week history of severe frontal headaches and dry cough. Chest x-ray showed hilar adenopathy with bilateral parenchymal infiltrates. A diagnosis of atypical pneumonia was made. Four weeks later he was admitted with persistent headache. Infectious screen was negative. Brain MR post contrast, revealed cerebellar enhancement and swelling with moderate tonsillar herniation; findings which precluded the performance of a lumbar puncture. High resolution CT thorax confirmed hilar abnormalities; shown by microscopy to represent non caseating granulomata. A presumptive diagnosis of sarcoidosis was reached. Despite an initial symptomatic improvement his headache persisted. Repeat MRI, eleven days after admission, showed reduced cerebellar enhancement and swelling with no change in the degree of tonsillar herniation. He deteriorated acutely and died two weeks after admission. Autopsy revealed cerebral oedema with tonsillar herniation secondary to cryptococcal meningitis variety neoformans. There was no evidence of neurosarcoid. Active and inactive sarcoid was identified in the lungs and hilar nodes with no evidence of systemic sarcoid. Focal evidence of cryptococcal pneumonitis was present in the lung as a necrotic focus. A strong index of clinical suspicion is necessary to diagnose the rare association of cryptococcus complicating sarcoidosis.

Herpes simplex encephalitis occurring after chemotherapy, surgery, and stereotactic radiotherapy for medulloblastoma.

Reactivation of latent herpes simplex virus (HSV) in the trigeminal ganglion most commonly gives rise to recurrent herpes labialis and rarely to herpes simplex encephalitis. The mechanisms underlying reactivation of latent trigeminal HSV are complex. Here we report the case history of a 25-year-old woman who developed a fatal, bilateral necrotizing destructive temporal lobe lesion following surgical removal of a cerebellar medulloblastoma and combined radiotherapy and chemotherapy for recurrent tumor. Neuropathologic examination of the brain revealed minimal inflammatory changes, but immunohistochemistry was positive for HSV protein, and HSV deoxyribonucleic acid (DNA) was recovered from formalin-fixed paraffin-embedded brain tissue. The temporal proximity of the surgery, chemotherapy, and radiotherapy to the onset of disease suggests that these factors may have acted as triggers that precipitated conversion of latent HSV to overt HSV.

Acute demyelination, neuropathological diagnosis, and clinical evolution.

A retrospective analysis of 14 patients who presented with a progressively expanding mass lesion(s) shown at biopsy/autopsy to represent acute demyelination was carried out. The aims of this study were to determine the optimal neuropathological approach to diagnosis and to determine the clinical evolution of this condition. Subsequent investigations and clinical outcome studies confirmed MS in 10 cases. Two patients had received an incorrect neuropathologic diagnosis of astrocytoma resulting in cranial irradiation. Key histologic parameters in establishing a diagnosis of acute demyelination were a predominance of lipid filled macrophages, macrophage alignment along axons, and an absence of oligodendroglial inclusions. Axonal injury was present in all cases and a lymphocytic/plasma cell infiltrate was sparse in areas of demyelination. Neuroimaging revealed single lesions in 10 patients and multiple lesions in 4 patients. Two patients were lost to follow-up, 3 died within 18 months of diagnosis, 8 had a relapsing remitting clinical course, and 1 patient had a chronic progressive course. In conclusion, a dense lymphocytic and plasma cell infiltrate is unusual in acute human demyelination. Although axonal injury is a frequent histologic finding in acute demyelination, it does not preclude a favorable clinical outcome.

Crystalloid inclusions in brain macrophages and hemopoietic tissue in GFAP-IL3 mice resemble inclusions identified in multiple sclerosis.

Crystalloid inclusions or "pole bodies" observed in brain macrophages in human demyelinating disease represent a morphological enigma. Similar inclusions were detected in brain macrophages from the GFAP-IL3 mouse, a transgenic murine model for macrophage mediated demyelination. Mice also showed inclusions in hematopoietic tissue. They appear to be related to phagocytosis and secretion, respectively, as evidenced by the fact that in phagocytosing cells they often merged with lysozomes and that affected cells showed empty channels open to the interstitium. Based on ultrastructural and immunolocalization studies using chaperonin-10, lysozyme, and cathepsin the authors suggest that these inclusions are consistent with phagocytosis-related secretory products. This study may provide insight into the nature and significance of similar macrophage inclusions recently identified in multiple sclerosis.

Extradural haematoma--a preventable cause of death.

Traumatic extradural haematoma (EDH) complicates 1-4% of all head injuries and is a major factor contributing to morbidity and mortality. Clinical awareness and early diagnosis are the keys to successful management. With the advent of computerised tomographic (CT) scanning a trend towards 'zero mortality' has been reported. We report four adolescent cases presenting with mild head injury (Glascow Coma Score 13-15) who subsequently died as a result of EDH. We suggest that excessive delay both in recognising the condition and the subsequent referral and transfer are factors contributing to the mortality of these patients.

Response of glia, mast cells and the blood brain barrier, in transgenic mice expressing interleukin-3 in astrocytes, an experimental model for CNS demyelination.

Transgenic mice overexpressing cytokines facilitate analysis of the effects of these immunomodulators on indigenous cells of the central nervous system. This study examines morphological aspects of demyelination and permeability changes, in a recently described transgenic model (termed GFAP-IL3). GFAP-IL3 mice develop progressive motor disease at approximately 5 months. Lesions identified after disease onset, showed activation of microglia, astroglial proliferation with phagocytosis of lipids, and immigration of macrophages and mast cells into neural parenchyma. Lymphocytes failed to appear until the later stages of the disease. Later, cerebellar and brain stem white matter contained focal demyelinating lesions with intense macrophage infiltration and a proliferative astrocytosis. Dystrophic axonal changes were noted, in addition to demyelination in heavily infiltrated lesions. Mast cells, variably present in the thalamus and meninges of wild type mice, were greatly increased at these sites in GFAP-IL3 mice. Blood-brain barrier (BBB) defects were documented with leakage of intravenously injected horseradish peroxidase. Mast cell infiltration into the CNS and their degranulation at the site of injury, may represent initial events in a spontaneous process of macrophage mediated demyelination in which glial cells and macrophages are both involved in the phagocytic process.

Histological parameters as predictors of prognosis in childhood brain tumors.

Using histological parameters with high recognition reliability, we retrospectively analyzed all newly diagnosed patients under the age of 16 years (n = 100) with brain and spinal cord tumors presenting to the National Neuroscience Centres of the Richmond and Beaumont Hospitals, Dublin, Ireland, between 1985 and 1990, allowing analysis of 5-year survival in all cases. Tumor histology was reviewed by two neuropathologists blinded to previous histological diagnosis and to the site of lesion. We found that certain histological features such as very low cell density and microcyst formation had a positive effect on prognosis. Mitoses and pleomorphism had a negative effect on prognosis, whereas necrosis and meningeal involvement had no effect on prognosis. It is suggested that identification of reliably recognized histological features rather than assignation of tumors to particular diagnostic categories may be a more reliable predictor of tumor behavior in the pediatric age-group.

MCP-1, MCP-2 and MCP-3 expression in multiple sclerosis lesions: an immunohistochemical and in situ hybridization study.

Chemokines are low molecular weight chemotactic cytokines that have been shown to play a central role in the perivascular transmigration and accumulation of specific subsets of leukocytes at sites of tissue damage. Two major families have been defined depending on the positioning of four conserved cysteines. The CXC chemokines predominantly attract neutrophils, whereas the CC chemokines predominantly attract monocytes and other leukocyte cell types. Members of the monocyte chemotactic protein (MCP)-1 family form a major component of the CC family of chemokines and are considered the principal chemokines involved in the recruitment of monocytes/macrophages and activated lymphocytes. In this study we addressed the expression and distribution of MCP-1, -2 and -3 in multiple sclerosis (MS) lesions of differing ages and levels of inflammatory activity using immunohistochemistry and in situ hybridization. In acute and chronic-active MS lesions immunoreactivity for MCP-1, -2 and -3 was prominent throughout the lesion center with reactivity diminishing abruptly at the lesion edge. Hypertrophic astrocytes were strongly reactive and inflammatory cells showed variable reactivity. Outside of the lesion only hypertrophic astrocytes were reactive. The results obtained by in situ hybridization for MCP-1 were in agreement with those obtained by immunostaining. In more chronic lesions immunoreactivity for MCP-1, -2 and -3 was considerably diminished, and in chronic-silent lesions immunoreactivity was restricted to a few scattered reactive astrocytes. Normal control brains showed no immunoreactivity for MCP-1, -2 and -3. Although the cellular distribution of all three members of this family was similar, antibodies to MCP-3 gave prominent staining of the extracellular matrix that was not noted for MCP-1 and -2. These results support the conclusion that members of the MCP family of chemokines are involved in the development of MS lesions in the central nervous system.

Pathogen-free granulomatous diseases of the central nervous system.

Pathogen-free granulomatous diseases (PFGD) of the central nervous system (CNS) are a group of disorders with protean clinical and pathological findings. Failure to identify a causative organism leads to considerable diagnostic difficulty. The neuropathology records between 1985 and 1995 were retrospectively reviewed, and the medical records of all patients in whom a diagnosis of PFGD of the CNS was made were retrieved. Patients in whom an infective agent was shown either by culture, special staining techniques, or by immunohistochemical methods were excluded. We identified 11 patients (eight male, three female) who fulfilled the pathological criteria for this condition. Average age at diagnosis was 38.7 years (range, 17 to 78). Neurological symptoms were the presenting feature in nine patients. Neuroimaging findings included hydrocephalus (54.5%), meningeal enhancement (45.5%), and mass lesions (45.5%). Seven patients had antemortem CNS biopsies (brain/meninges [n = 6], spinal [n = 1]), which showed noncaseating granulomas. Eight patients died (mortality rate: 72.7%). Postmortem examination showed granulomatous involvement of the leptomeninges and cerebral parenchyma in all cases with systemic involvement in 50%, chiefly in the form of noncaseating granulomas of the hilar nodes. Six patients fulfilled the clinical, radiological, and pathological diagnostic criteria for neurosarcoidosis. The remaining five patients had an unclassifiable pathogen-free granulomatous disease of the CNS. PFGD of the CNS are associated with a poor prognosis. Although neurosarcoidosis may account for some of the cases, there remains an unclassifiable subgroup that continues to be a diagnostic and management challenge.

Immunohistochemical evaluation of merosin deficiency in congenital muscular dystrophies.

OBJECTIVES: To determine the prevalence of merosin deficiency in cases of unclassified congenital muscular dystrophy and to determine the temporal stability of merosin epitopes in fixed and stored archival material. MATERIALS AND METHODS: Using an antibody to human merosin we retrospectively studied 12 cases of undiagnosed muscular dystrophy from our files to determine the prevalence of merosin deficiency. Where fresh muscle was not available, unstained stored cryostat sections or destained archival stored sections were incubated with the merosin antibody. RESULTS: Two of the 12 cases of undiagnosed muscular dystrophy were merosin-deficient. No difference in intensity of merosin staining was found between freshly cut cryostat sections and unstained stored cryostat sections. There was no difference in the intensity of merosin staining in sections archived for up to 10 years. CONCLUSIONS: We conclude that 16% of unclassified muscular dystrophies in our study are due to merosin deficiency and that merosin antigenicity remains intact in archival stored muscle tissue, facilitating retrospective evaluation of patients in whom frozen muscle is not available. To our knowledge, this latter observation has not been reported previously.

Merosin-deficient congenital muscular dystrophy and cortical dysplasia.

Congenital muscular dystrophy (CMD) encompasses a heterogenous group of muscle disorders with autosomal recessive inheritance, characterized by muscular weakness and hypotonia at birth or within the first few months of life and developmental delay. Merosin-deficient CMD is a clinically distinct form which may be associated with significant abnormalities of the brain detectable by neuroimaging. We report two siblings of consanguineous parents with merosin-deficient CMD in an Irish family who in addition to the characteristic white matter abnormalities on neuroimaging, had occipital dysplasia. Clinical, electrophysiological muscle biopsy findings and neuroimaging were very similar in both cases. Although merosin-deficient CMD with white matter abnormalities on neuroimaging is well documented in the literature, the association with occipital dysplasia has only rarely been reported. The appearance of an identical cortical defect in these siblings suggests an underlying genetic mechanism.

Effects of seven days of galactose feeding and aldose reductase inhibition on mast cells and vessel morphometry in rat sciatic nerve.

The association between mast cells and vessel morphometry in sciatic nerve was examined after seven days in animals fed a diet of 40% D-galactose and compared to control rats and to galactose-fed animals treated with the aldose reductase inhibitor, Tolrestat. Electron microscopy revealed an increase in the total number of mast cells and the number of degranulated mast cells in galactose-fed animals (7.8 +/- 2.9; 2.6 +/- 2.9; mean +/- SD) compared to controls (4.6 +/- 2.1; degranulated mast cells were not seen in any control nerves) and Tolrestat-treated, galactose-fed animals (4.4 +/- 2.5; 0.1 +/- 0.4). Although no significant differences were noted in the numbers of vessels between the three groups, an index of vasoconstriction was significantly increased in the galactose-fed animals (0.115 +/- 0.048; mean +/- SD) compared to controls (0.068 +/- 0.011) and Tolrestat-treated, galactose-fed animals (0.075 +/- 0.20). These data suggest that mast cell degranulation is associated with the vascular constriction induced by seven days of galactose intoxication and that both may be prevented by inhibiting aldose reductase.