Nerve expansion in nerve regeneration: effect of time on induction of ornithine decarboxylase and Schwann cell proliferation.

We studied the effect of initiation time of nerve expansion after nerve transection on the induction of ODC activity and Schwann cell proliferation in nerve tissue under Wallerian degeneration. The levels of ODC activity and Schwann cell proliferation decreased as the initiation time of nerve expansion was delayed after nerve transection, and peak levels of ODC activity following nerve expansion preceded peak levels of Schwann cell proliferation.

MRI of the fornix and mamillary body in temporal lobe epilepsy.

We performed MRI on 27 patients with clinically proven temporal lobe epilepsy (TLE), all with prior EEG lateralisation, and 10 volunteers, studied to evaluate disparity in size arising from biological variation (group 1). Three-dimensional spoiled GRASS (3DSPGR) sequences provided 2-mm contiguous sections of the limbic system, enabling assessment of the hippocampus (HC), fornix (FN) and mamillary body (MB). Measurements of FN and MB width were made from a workstation. Any percentage difference in size was computed. In 19 cases there was unilateral abnormality in the HC (group 2); in 18 and 19 cases respectively there was a smaller FN and MB on the same side as the abnormal HC. This percentage difference in size was significantly greater than that in group 1 in the FN and MB in 17 and 17 cases respectively. Comparison of percentage difference computations for FN and MB between groups 1 and 2 showed high statistical significance (P < 0.0002). In 5 patients with clinical TLE the HC was normal on MRI (group 3). Unequal FN and MB sizes were found in 4, significant in 2. Comparison of percentage difference computations for FN and MB showed statistical significance (P < 0.0005 and P < 0.0003 respectively). There was no case of discordance between the sides of hippocampal abnormality and the smaller FN or MB or between the sides of smaller FN and MB. The strong concordance between the changes in the HC and those in the FN and MB suggests that this combination will play an important role in the assessment of TLE and limbic system abnormality.

Wallerian degeneration is required for both neuropathic pain and sympathetic sprouting into the DRG.

Chronic loose constriction of the sciatic nerve produces mechanoallodynia and thermal hyperalgesia in rats and mice, and the behaviour develops during the time in which the nerve distal to the ligature site is undergoing Wallerian degeneration. There is a sympathetic component to the pain generated by this and other rodent models of neuropathic pain, yet the site at which this sympathetic-sensory coupling remains unknown. It has been shown that following sciatic nerve transection or spinal nerve lesion, sympathetic axons invade the dorsal root ganglion (DRG) where they sometimes form pericellular baskets around mostly large diameter DRG neurons--a possible anatomical substrate for sympathetically maintained pain (SMP). The signal for the sympathetic invasion of the DRG has not yet been shown, but associated with Wallerian degeneration is the upregulation of nerve growth factor (NGF) in the distal stump of the partially injured nerve, which may be retrograde-transported to the DRG in uninjured sensory axons to induce sprouting of sympathetic axons. To investigate the role of Wallerian degeneration in the development of neuropathic pain and sympathetic sprouting in the DRG, we have made use of a strain of mouse (C57B1/Wld) in which Wallerian degeneration following nerve injury is delayed. We gave wild-type or Wld mice chronic constriction injuries (CCI) by loosely ligating the sciatic nerve with 3 ligatures, and allowed these mice to survive for a further 1, 2 or 3 weeks, during which time we assessed mechanoallodynia and thermal hyperalgesia. At the end of the testing period, the lumbar DRGs were removed for glyoxylic acid-induced fluorescence of catecholamines to determine the extent to which sympathetic axons had invaded the DRG. We found that both indices of neuropathic pain were significantly attenuated in Wld mice compared to wild-type mice, with the wild-type mice increasing in sensitivity to both thermal and mechanical stimulation in the first week post-operative (PO), while Wld mice showed marked hypoalgesia following CCI. Histological examination of the DRG showed that sympathetic sprouting into the DRG was also markedly delayed in Wld mice compared to wild-type mice: 1 week following injury, sympathetic fibres had invaded the ipsilateral DRG of wild-type mice, while sprouting in ipsilateral DRG of Wld mice was only slightly increased at 3 weeks PO. These results show that Wallerian degeneration is tightly linked to the development of both pain and sympathetic sprouting following CCI, and we speculate on the possible role of NGF as a mediator of both phenomena.

Fulminant Guillain-Barré syndrome with universal inexcitability of peripheral nerves: a clinicopathological study.

The pathological basis of nerve inexcitability in Guillain-Barré syndrome has not been established with certainty. We report the clinicopathological findings in a 67-year-old patient with fulminant Guillain-Barré syndrome who died 18 days after onset. Three serial electrophysiological studies revealed nerve inexcitability. Antibodies to Campylobacter jejuni were present but there was no antiganglioside reactivity. Spinal root sections revealed extensive and almost pure macrophage-associated demyelination with occasional presence of T lymphocytes and neutrophil leukocytes. Conversely, in femoral, median, and sural nerves the outstanding lesion was axonal degeneration, with some denuded axons remaining. Unmyelinated fibers, posterior root ganglia, and dorsal columns were preserved. Endoneurial postcapillary venules showed plump endothelial cells with loss of their tight junctions. We conclude that both primary demyelination and axonal degeneration secondary to inflammation account for nerve inexcitability. Our findings lend support to the hypothesis of increased endoneurial pressure as the cause of wallerian degeneration in nerve trunks.

The role of macrophages in Wallerian degeneration.

The present review focuses on macrophage properties in Wallerian degeneration. The identification of hematogenous phagocytes, the involvement of cell surface receptors and soluble factors, the state of activation during myelin removal and the signals and factors leading to macrophage recruitment into degenerating peripheral nerves after nerve transection are reviewed. The main effector cells in Wallerian degeneration are hematogenous phagocytes. Resident macrophages and Schwann cells play a minor role in myelin removal. The macrophage complement receptor type 3 is the main surface receptor involved in myelin recognition and uptake. The signals leading to macrophage recruitment are heterogenous and not yet defined in detail. Degenerating myelin and axons are suggested to participate. The relevance of these findings for immune-mediated demyelination are discussed since the definition of the role of macrophages might lead to a better understanding of the pathogenesis of demyelination.

Expression of neuregulins and their putative receptors, ErbB2 and ErbB3, is induced during Wallerian degeneration.

Schwann cell dedifferentiation and proliferation is a prerequisite to axonal regeneration in the injured peripheral nervous system. The neuregulin (NRG) family of growth and differentiation factors may play a particularly important role in this process, because these axon-associated molecules are potent Schwann cell mitogens and differentiation factors in vitro. We have examined Schwann cell DNA synthesis and the expression of NRGs and their receptors, the erbB membrane tyrosine kinases, in rat sciatic nerve, sensory ganglia, and spinal cord 0-30 d postaxotomy. Analysis of NRG cDNAs from these tissues revealed several novel splice variants and showed that cells endogenous to injured nerve express NRG mRNAs. A selective induction of mRNAs encoding the glial growth factor (GGF) subfamily of NRGs occurs in nerve beginning 3 d postaxotomy and thus coincides with the onset of Schwann cell DNA synthesis. In later stages of Wallerian degeneration, however, Schwann cell mitogenesis markedly decreases, whereas elevated GGF expression persists. Of the four known erbB kinases, Schwann cells express both erbB2 and erbB3 receptors over the entire interval studied. Expression of erbB2 and erbB3 is coordinately induced in response to axotomy, indicating that Schwann cell responses to NRGs may be modulated by changes in receptor density. Neuregulin (including transmembrane precursors) and erbB protein are associated with Schwann cells postaxotomy. Thus, in contrast to the concept of NRGs as axon-associated mitogens, our findings suggest that NRGs produced by Schwann cells themselves may be partially responsible for Schwann cell proliferation during Wallerian degeneration, probably acting via autocrine or paracrine mechanisms.

MRI demonstration of Wallerian degeneration in various intracranial lesions and its clinical implications.

Dynamic signal intensity changes of Wallerian degeneration (WD) are well documented in cases of stroke. These changes have been staged I-IV, depending on time-specific signal intensity changes in corticospinal tract with magnetic resonance imaging (MRI). We performed both prospective and retrospective evaluation of various intracranial lesions to look for evidence of WD and to assess its prognostic implications. Eighteen patients of acute stroke were studied prospectively. Their functional disability was evaluated by using a modified Barthel index of activity of daily living (ADL) at presentation, at 1 month and at 4 months, and was correlated with presence or absence of WD on MRI. 10/18 patients showed signal intensity changes of WD on MRI and their mean ADL score changed from 9.1 at 1 month to 11.4 at 4 months duration suggestive of moderate to severe disability after 4 months of stroke. The rest of the eight patients, where MRI did not reveal signal intensity changes of WD, the mean ADL score improved from 10.37 at 1 month to 17.5 at 4 months, suggesting significant improvement in their clinical disability. 520 patients were studied retrospectively, out of whom 31 showed signal intensity changes of WD in various intracranial lesions, i.e. infarcts (14/220), intracranial haematoma (4/147), arterio-venous malformation (1/20), tumour (6/98), multiple sclerosis (5/20) and encephalitis (1/15). Presence of WD in these intracranial lesions correlated well with persistent clinical disability. This observation has immense prognostic value, particularly in relapsing and remitting disease like multiple sclerosis. We conclude that WD can be seen secondary to any CNS insult with MRI and its presence correlates well with persistent functional disability. It thus has prognostic value.

Motor nerve terminal degeneration provides a potential mechanism for rapid recovery in acute motor axonal neuropathy after Campylobacter infection.

We investigated the possible mechanisms of paralysis and recovery in a patient with the acute motor axonal neuropathy (AMAN) pattern of the Guillain-Barré syndrome. The AMAN pattern of GBS is characterized clinically by acute paralysis without sensory involvement and electrodiagnostically by low compound motor action potential amplitudes, suggesting axonal damage, without evidence of demyelination. Many AMAN patients have serologic or culture evidence of recent Campylobacter jejuni infection. Pathologically, the most severe cases are characterized by wallerian-like degeneration of motor axons affecting the ventral roots as well as peripheral nerves, but some fatal cases have only minor changes in the roots and peripheral nerves, and some paralyzed patients with the characteristic electrodiagnostic findings of AMAN recover rapidly. The mechanism of paralysis and recovery in such cases has been uncertain. A 64-year-old woman with culture-proven Campylobacter upsaliensis diarrhea developed typical features of AMAN. She improved quickly following plasmapheresis. Her serum contained IgG anti-GM1 antibodies. The lipopolysaccharide of the organism bound peanut agglutinin. This binding was blocked by cholera toxin, suggesting that the organism contained the Gal(beta1-3)GalNAc epitope of GM1 in its lipopolysaccharide. Motor-point biopsy showed denervated neuromuscular junctions and reduced fiber numbers in intramuscular nerves. In contrast, the sural nerve biopsy was normal and skin biopsy showed normal dermal and epidermal innervation. In AMAN the paralysis may reflect degeneration of motor nerve terminals and intramuscular axons. In addition, the anti-GM1 antibodies, which can bind at nodes of Ranvier, might produce failure of conduction. These processes are potentially reversible and likely to underlie the capacity for rapid recovery that characterizes some cases of AMAN.

Ciliary neurotrophic factor immunoreactivity in rat intramuscular nerve during reinnervation through a silicone tube after severing of the rat sciatic nerve.

The immunoreactivity of ciliary neurotrophic factor (CNTF) and S100 was studied in the degenerating and regenerating intramuscular nerves after the sciatic nerve was severed. The sciatic nerves of male Wistar rats were transected at the midpoint of the thigh, and silicone tubing was used to obtain effective reinnervation. The strong immunoreactivity of CNTF and S100 was observed in the Schwann cell cytoplasm of intramuscular nerves (IMN) and at the neuromuscular junction (NMJ) on the control sections. The CNTF immunoreactivity gradually became weak and indistinct in the Schwann cell cytoplasm after the operation. However, it was recognized again in the IMN at 4 weeks after the operation. On the other hand, the S100 immunoreactivity was continuously observed except at the NMJ through the denervating and reinnervating period. At 12 weeks after the operation, the strong immunoreactivity of both CNTF and S100 was observed again. These findings suggest that the amount of CNTF protein decreased in Schwann cells of the IMN and NMJ during the denervating period and increased during the reinnervating period in proportion to the number of remyelinated Schwann cells after severing of the sciatic nerve. They also suggest that CNTF was more highly correlated than the S100 protein with the reinnervation activity of Schwann cells.

Unusual aspects of inflammation in the nervous system: Wallerian degeneration.

Wallerian degeneration in the PNS is accompanied by the rapid recruitment of monocytes, but monocytes do not invade CNS fibre tracts undergoing Wallerian degeneration. In recent years it has become apparent that the acute inflammatory response to cell degeneration in the CNS is unlike that in other tissues. We have been interested to learn why Wallerian degeneration does not provoke a typical inflammatory response. We investigated whether the vascular endothelial cells express adhesion molecules during Wallerian degeneration in PNS and CNS. We found that in the degenerating sciatic nerve there was upregulation of ICAM-1 and VCAM-1 expression on endothelial cells in the distal stump of the injured nerve as well as at the site of the lesion. However, in the degenerating optic nerve, the endothelium failed to upregulated these molecules in the distal stump of the nerve and ICAM-1 expression was only increased in the crush site. The lack of adhesion molecule expression on CNS endothelium molecules may be an explanation for the poor leukocyte recruitment during Wallerian degeneration in CNS when compared with PNS.

Myelin-stimulated macrophages release neurotrophic factors for adult dorsal root ganglion neurons in culture.

1. Our previous study demonstrated that cultured macrophages release neurotrophic factors spontaneously. In a histological study of Wallerian degeneration, macrophages phagocytosed myelin debris and expressed activated markers. 2. To investigate the role of myelin-stimulated macrophages on neurite regeneration, we prepared conditioned media from cultured mouse peritoneal macrophages which had phagocytosed a myelin fraction. This conditioned media enhanced both neurone survival and neurite regeneration of adult dorsal root ganglia (DRG) neurons compare to conditioned media from macrophage cultures without myelin. 3. The production of the neurotrophic supernatant was dose-dependent on myelin fraction and specific for myelin because supernatants from macrophages incubated with LPS (lipoplysaccharide), MDP (N-acetylmuramyl-L-alanyl-D-isoglutamine) or latex beads were not neurotrophic. 4. The neurotrophic factors from myelin-stimulated macrophages were different from spontaneously released macrophage factors as they differed in heat-sensitivity. 5. These results suggest that myelin-stimulated macrophages contribute to axon regeneration after Wallerian degeneration.

Genetic influences on cellular reactions to spinal cord injury: activation of macrophages/microglia and astrocytes is delayed in mice carrying a mutation (WldS) that causes delayed Wallerian degeneration.

Reactive changes in macrophages/microglia and astrocytes were evaluated following spinal cord injury in normal mice of the C57BL/6J strain and in mice carrying a mutation (WldS) which delays the onset of Wallerian degeneration in damaged axons. Crush injuries were produced at the T8 level by using an extradural approach; animals were allowed to survive for 2 days to 12 weeks, and spinal cords were prepared for immunocytochemistry using antibodies against Mac1 and glial fibrillary acidid protein (GFAP). In normal mice, Mac1-positive macrophages accumulated at the injury site by 4 days and immunostaining of these cells peaked at 6-8 days. Cells in the gray matter near the crush site and in the ascending dorsal column also exhibited increased Mac1 staining that was prominent at 1 week and remained high at 2-4 weeks. In mice carrying the WldS mutation, the accumulation of macrophages at the injury site and the increase in immunostaining of these cells were delayed, as were the increases in immunostaining in the gray matter and dorsal columns. Both normal and mutant mice exhibited pronounced increases in glial fibrillary acidic protein immunostaining at the edge of the crush site and for some distance both rostral and caudal to the injury; increased immunostaining was also prominent along the ascending dorsal columns. The center of the crush site, which contained connective tissue, remained completely unstained for GFAP. In normal mice, immunostaining for GFAP reached a peak at 1 week postinjury and then declined. In mice carrying the WldS mutation, increases in GFAP immunostaining did not reach a peak until 2-3 weeks postinjury. These results indicate that activation of macrophages, microglia, and astrocytes is delayed and prolonged in mice carrying the WldS mutation.

Genetic influences on cellular reactions to spinal cord injury: a wound-healing response present in normal mice is impaired in mice carrying a mutation (WldS) that causes delayed Wallerian degeneration.

Progressive tissue necrosis is a process unique to the injured mammalian spinal cord which often leads to gradually increasing cavitation and enlargement of the lesion. To evaluate the role of neuronal degeneration in initiating this response, histopathological changes were compared in C57BL and WldS (delayed Wallerian degeneration mutation) mice. The spinal cord was crushed at T8, producing a primary lesion at the site of the trauma and a secondary lesion extending rostrocaudally in the dorsal columns (where long ascending and descending fiber tracts undergo Wallerian degeneration). Cavitation was relatively mild at both sites and developed mainly at the margins of the lesions. In striking contrast to spinal cord injury in rats, progressive necrosis did not occur in mice; instead, the primary and secondary lesion sites became filled in by macrophages and fibroblasts embedded in a well-vascularized collagenous stroma. Quantitative image analysis revealed that the primary lesion decreased dramatically in size and cavitation between 2 and 3 weeks in C57BL, whereas in WldS the reduction in size and cavitation began later (at 4 weeks) and was less complete. The initial development of the secondary lesion began later and its healing was less complete in WldS than C57BL. These results are consistent with the hypothesis that neuronal damage, including Wallerian degeneration, triggers inflammatory responses leading to tissue repair. For this reason, any delay in neuronal degeneration, as in the WldS mutation, results in deficient tissue repair as reflected in the larger size of both primary and dorsal column lesions.

Whipple's disease confined to the central nervous system.

We report a 49-year-old woman with a left parietal lesion, shown on CT and MRI as an isolated ring-enhancing mass. The diagnosis of cerebral Whipple's disease was made by brain biopsy; there were no gastrointestinal symptoms nor periodic-acid Schiff-positive inclusions in the jejunal mucosa. This case illustrates atypical Whipple's disease, confined exclusively to the central nervous system.

Specific uptake of intracranial horseradish peroxidase (HRP) by microglial cells in the goldfish.

Intracranial injections of horseradish peroxidase (HRP) in the goldfish labeled a population of cells with many similarities to microglia. The fact that neither macroglia nor neurons appeared to be labeled by these injections supports this identification. The labeled cells responded to Wallerian degeneration of the optic paths by accumulating in the optic terminal zones, a cellular behavior which strongly supports their identification as microglia.

Downregulation of microglial keratan sulfate proteoglycans coincident with lymphomonocytic infiltration of the rat central nervous system.

The monoclonal antibody (MAb) 5D4 against a keratan sulfate (KS) epitope of bovine cartilage proteoglycan stains ramified microglia in the rat brain. In this study we show that 5D4-positive microglia is abundant in the normal rat spinal cord and nearly absent during both the active and recovery phase of experimental autoimmune encephalomyelitis (EAE) in myelin-immunized Lewis rats. In contrast, during Wallerian degeneration of the optic nerve the density of KS-immunoreactive microglia remains constant. KS immunoreactivity is absent from both normal and transected sciatic nerves, and spinal nerve roots. On immunoblots of spinal cord extracts MAb 5D4 stains a novel type of KS proteoglycans (KSPGs) with an apparent molecular weight mainly between 140 and 200 kd, which significantly decrease in acute EAE. Our data suggest that high levels of KSPG expression correlate to a downregulated immunophenotype of resident macrophages in the nervous system. The lack of detectable KS in peripheral nerve points to a divergent differentiation of bone marrow-derived resident macrophages in the peripheral and central nervous systems and may partially account for the rapid macrophage response to axonal injury in the peripheral nervous system. Downregulation of microglial KSPG could be a prerequisite for a rapid inflammatory response in the central nervous system.

Early nodal changes in the acute motor axonal neuropathy pattern of the Guillain-Barré syndrome.

The axonal patterns of Guillain-Barré syndrome, associated in many cases with antecedent Campylobacter jejuni infection, are now recognized as frequent causes of acute flaccid paralysis in some regions of the world. This study examined ultrastructurally the PNS of seven cases of the acute motor axonal neuropathy form of Guillain-Barré syndrome. In this disorder previous studies of advanced cases have found Wallerian-like degeneration of motor fibres in the spinal roots and peripheral nerves, with little lymphocytic inflammation or demyelination. The present study was focused on identifying early changes and establishing the sequence of changes. By electron microscopy the earliest and mildest changes consisted of lengthening of the node of Ranvier with distortion of the paranodal myelin, and in some instances with breakdown of the outermost myelin terminal loops. At this stage many nodes had overlying macrophages which extended their processes through the Schwann cell basal lamina covering the node and apposed the axolemma. Macrophage processes then extended beneath the myelin terminal loops, and the whole macrophage entered the periaxonal space at the paranode. Macrophage processes dissected the axon from the adaxonal Schwann cell plasmalemma and the macrophages advanced into the internodal periaxonal space, where they typically surrounded a condensed-appearing axon. At this stage the adaxonal Schwann cell cytoplasm regularly degenerated and disappeared, so that the periaxonal space was bounded by the innermost myelin lamella, and the axolemma of many fibres could not be seen. The internodal myelin sheath and the abaxonal Schwann cell cytoplasm remained normal. This arrangement appeared to be stable for some time, but in many fibres the axon subsequently underwent Wallerian-like degeneration. By interfering with impulse conduction, these nodal and periaxonal changes may explain paralysis in some pathologically mild cases. In addition, at early stages, these changes may be reversible, thus explaining the rapid recovery of some patients who become paralysed with acute motor axonal neuropathy. These observations, taken together with previous studies, suggest that acute motor axonal neuropathy is an antibody- and complement-mediated disorder in which the relevant epitopes are present on the nodal and internodal axolemma.

Glial reactivity in the retina of adult rats.

The present study aimed to characterize the reaction of mammalian (rat) retinal macroglia (Müller cells and astrocytes) to disturbances of their environment in the form of intraorbital section of the optic nerve, intraocular insertion of a thin glass capillary (without damage to the retina) or a combination of both. Glial reactivity was assessed through the use of a battery of antibodies which recognise four different proteins--glial fibrillary protein (GFAP) and three other proteins designated respectively MA1, 4D6 and 4H11. Retinal astrocytes did not exhibit any changes in normally expressed GFAP or MA1. By contrast, the expression of GFAP and MA1 in Müller cells increased 14 days following section of the optic nerve and/or intravitreal insertions of a glass capillary. Three days postoperatively, the expression of GFAP, but not MA1, had already increased significantly in Müller cells. 4D6 and 4H11 proteins were not expressed in astrocytes. In Müller cells, the levels of these proteins increased significantly following combined optic nerve section and intraocular insertion of a glass capillary. Thus, a mechanical disturbance of the intraocular environment constitutes a more effective stimulus in increasing the expression of some Müllerian proteins than damage to the axons of retinal ganglion cells. Such changes have important implications for various ocular treatments that involve intraocular administration of drugs, as well as for the survival/regeneration potential of retinal ganglion cells undergoing Wallerian degeneration.

Na+ channel aggregation in remyelinating mouse sciatic axons following transection.

Mouse sciatic nerves from the degeneration-resistant strain C57BL/6/Wld (Ola) were surgically injected with lysolecithin to induce focal demyelination. Three days later they were transected adjacent to the spinal cord to eliminate contact of the axons with their cell bodies. The Na+ channel distribution was assessed by immunocytochemistry and followed at several stages of remyelination. Control experiments were performed on nerves that were injected but not cut. At (3 + 4) days, namely, nerves cut 3 days post-injection and examined 4 days after cutting, axons contained fully demyelinated regions. Na+ channel clusters appeared only at heminodes and at isolated sites that are likely to represent original nodes of Ranvier. During the next few days proliferating Schwann cells adhered to the axons and extended their processes. Clusters of Na+ channels appeared at their edges, and as the Schwann cells elongated the distance between these aggregates increased. A few clusters associated with neighboring Schwann cells approached each other and appeared to coalesce at sites where presumably new nodes of Ranvier would be formed. Beyond (3 + 6) days excessive degeneration of the transected axons precluded further observations. In the uncut controls, the spatio-temporal sequence of Schwann cell proliferation and channel patch formation and movement was similar to that described above, although myelin formation was somewhat faster than in the cut axons. It is concluded that Na+ channel aggregation associated with the early stages of remyelination is not dependent upon continuous communication of the axon with its cell body and is under local control.

AIDS-associated vacuolar myelopathy. A morphometric study.

The post-mortem pathology in 20 spinal cords of human immunodeficiency virus (HIV) infected patients with vacuolar myelopathy was quantified by evaluating (i) the intensity of myelin change, vacuolation and macrophage density; and (ii) the areas of white matter covered by each feature. Severity scores were constructed for (i) the anterior, lateral, and posterior white matter columns; (ii) each level of spinal cord; and (iii) the whole spinal cord [Cord Total and Cord Average Severity Scores (CTSS, CASS)]. Astroglial activation was scored separately. In 14 cords with mild-moderate vacuolar myelopathy (CASS = 23-259), macrophages were the most prominent pathological feature, and level severity scores were higher at mid-thoracic than cervical levels (P = 0.009). In six cords with severe vacuolar myelopathy (CASS = 396-614), vacuolation, demyelination and macrophages were equally evident and thoracic and cervical level severity scores were similar. The most severe lesions showed evidence of clearing of macrophages from the collapsed centres. A clinical lower limb score correlated with the anterior (P = 0.03) and lateral (P = 0.04) column total scores and with the CTSS (P = 0.04) in the nine patients who had had both myelopathy related disability and all cord levels available. There was no significant longitudinal gradient in score severity in the posterior, lateral or anterior columns and no evidence of a dying-back phenomenon. There was no evidence of Wallerian degeneration occurring as a primary process. Astroglial activation did not correlate with the severity or duration of the vacuolar myelopathy. Detection of HIV p24 antigen in the spinal cord related to the local presence of multinucleated giant cells and to antigen expression in the brain but not with the severity of vacuolar myelopathy. The pathology in vacuolar myelopathy appeared to start in the mid-low thoracic cord, with increasing rostral involvement as the disease became more severe. The relative prominence of macrophages in mild-moderate lesions suggests they may be involved early in the pathogenesis of vacuolar myelopathy.