Molecular Basis of Cerebral Vasospasm: What Can We Learn from Transcriptome and Temporal Gene Expression Profiling in Intracranial Aneurysm?

Cerebral vasospasm (CV) is a significant complication following aneurysmal subarachnoid hemorrhage (aSAH), and lacks a comprehensive molecular understanding. Given the temporal trajectory of intracranial aneurysm (IA) formation, its rupture, and development of CV, altered gene expression might be a molecular substrate that runs through these clinical events, influencing both disease inception and progression. Utilizing RNA-Seq, we analyzed tissue samples from ruptured IAs with and without vasospasm to identify the dysregulated genes. In addition, temporal gene expression analysis was conducted. We identified seven dysregulated genes in patients with ruptured IA with vasospasm when compared with those without vasospasm. We found 192 common genes when the samples of each clinical subset of patients with IA, that is, unruptured aneurysm, ruptured aneurysm without vasospasm, and ruptured aneurysm with vasospasm, were compared with control samples. Among these common genes, TNFSF13B, PLAUR, OSM, and LAMB3 displayed temporal expression (progressive increase) with the pathological progression of disease that is formation of aneurysm, its rupture, and consequently the development of vasospasm. We validated the temporal gene expression pattern of OSM at both the transcript and protein levels and OSM emerges as a crucial gene implicated in the pathological progression of disease. In addition, RSAD2 and ATP1A2 appear to be pivotal genes for CV development. To the best of our knowledge, this is the first study to compare the transcriptome of aneurysmal tissue samples of aSAH patients with and without CV. The findings collectively provide new insights on the molecular basis of IA and CV and new leads for translational research.

Primary Rosai-Dorfman disease of the central nervous system: A clinical, histological, and molecular appraisal.

Rosai-Dorfman disease (RDD) is characterized by clonal proliferation of S-100 positive histiocytes and variable emperipolesis. It commonly affects cervical lymph nodes. Central nervous system (CNS) involvement is extremely rare. We attempted to evaluate the Cyclin D1 expression and frequency of KRAS and BRAF mutations in the RDD involving the CNS. All patients with histopathologically diagnosed RDD involving CNS were recruited from 2011 to 2022. All cases were subjected to immunohistochemistry for CD68, CD163, S100, CD1a, GFAP, CD207, EMA, ALK, BRAFV600E, IgG4, IgG, and CyclinD1. The real-time polymerase chain reaction (RT-PCR) for hotspot mutation analysis of KRAS (exons 2, 3, and 4) and BRAF (V600E) was conducted on formalin-fixed paraffin-embedded tissue using a commercial kit (EntroGen). A total of seven cases were included. The median age was 31 years, with six men and one woman. It showed spinal cord (n = 4) and intracranial (n = 3) involvement. Histologically, all cases showed histiocyte-rich inflammation with evidence of emperipolesis. These histiocytes were positive for S100, CD68, CD163, and Cyclin D1, whereas negative for CD1a, CD207, and EMA. BRAF V600E was expressed in a single case. None of the control cases (demyelination and infarction) with histiocytic infiltrate showed Cyclin D1 expression. Four RDD cases showed increased IgG4-positive plasma cells (>10/HPF) and IgG4/IgG ratio (>40%). BRAF V600E mutation was detected in one case (14.28%), while none showed KRAS mutation. RDD involving CNS is extremely rare and diagnostically challenging. Nuclear Cyclin D1 expression along with S-100 positivity in the tumor cells is a strong diagnostic clue. BRAF and KRAS mutations are rare in CNS RDD.

Pediatric primary intracranial angiosarcoma with epithelioid differentiation: a surgeon's dilemma.

Angiosarcoma is a rare form of soft tissue sarcoma originating from endothelial tissue, accounting for < 1% of all sarcomas. Primary epithelioid angiosarcomas of the central nervous system (CNS) are even more elusive, with only four reports described in the literature. In this article, we describe the first case in pediatric population, with a brief literature review regarding this entity. A 13-year-old girl presented to emergency services with raised intracranial pressure. MRI demonstrated a heterogenous lesion in the temporal lobe. She underwent emergency craniotomy and subtotal excision of the tumor. Eventually the patient developed multiple infarcts and succumbed post operatively. Pre-operative diagnosis on radiology is difficult considering the rarity of this entity and heterogeneity in radiological appearance. One needs to have a high degree of suspicion to consider angiosarcoma as a radiological differential. Overall prognosis remains poor. Early adjuvant treatment may improve overall survival.

Dysregulated Genes and Signaling Pathways in the Formation and Rupture of Intracranial Aneurysm.

Intracranial aneurysm (IA) has the potential to rupture. Despite scientific advances, we are still not in a position to screen patients for IA and identify those at risk of rupture. It is critical to comprehend the molecular basis of disease to facilitate the development of novel diagnostic strategies. We used transcriptomics to identify the dysregulated genes and understand their role in the disease biology. In particular, RNA-Seq was performed in tissue samples of controls, unruptured IA, and ruptured IA. Dysregulated genes (DGs) were identified and analyzed to understand the functional aspects of molecules. Subsequently, candidate genes were validated at both transcript and protein level. There were 314 DGs in patients with unruptured IA when compared to control samples. Out of these, SPARC and OSM were validated as candidate molecules in unruptured IA. PI3K-AKT signaling pathway was found to be an important pathway for the formation of IA. Similarly, 301 DGs were identified in the samples of ruptured IA when compared with unruptured IAs. CTSL was found to be a key candidate molecule which along with Hippo signaling pathway may be involved in the rupture of IA. We conclude that activation of PI3K-AKT signaling pathway by OSM along with up-regulation of SPARC is important for the formation of IA. Further, regulation of Hippo pathway through PI3K-AKT signaling results in the down-regulation of YAP1 gene. This along with up-regulation of CTSL leads to further weakening of aneurysm wall and its subsequent rupture.

Morphology of intra tumoral cystic vestibular schwannoma and their response to gammaknife radiosurgery.

BACKGROUND: Cystic vestibular schwannoma (CVS) traditionally considered as poor responder to gammaknife radiosurgery (GKRS). Their longterm radiobiological behavior is less known. Here we discuss 38 cases with intra tumoral cyst CVS primarily treated with GKRS. Tumor morphology was assessed to understand their response to GKRS. METHODS: Total 38 patients(21 male and 17 female with median age of 41.7 years) of CVS treated with GKRS were retrospectively analysed. Tumors were divided as predominantly (greater than50% of total tumor volume) cystic or solid. They were subclassified as type 1 (predominantly cystic CVS, single cyst), type 2 (predominantly solid CVS, single cysts), type 3 (multicystic CVS). The entire cyst was incorporated for radiosurgery. The results were compared with volume matched control of 58 solid tumors(SVS). RESULT: The median tumor volume of CVS was 5.8 cc. The median tumor volume reduction was 44.5 % at a median follow-up of 68.5 months (30-110 months). Median tumor volume reduction was 68.5 %, 34.0%, 11.0.%, 30.5% at a median follow up of 52.5months, 66 months, 78.6 months, 96.5 months for type 1 CVS, type 2 CVS, type 3 CVS and SVS respectively. One patient with multicystic CVS showed increased tumor volume and expired after 9 months of surgery.The tumor volume reduction in type 1CVS was statistically significant as compared to type 3 CVS and SVS. However the tumor volume reduction among other groups did not differ significantly. CONCLUSION: Intra tumoral cystic components respond better to gammaknife radiosurgery in CVS. Tumor with single cyst respond better than multicystic vestibular schwannoma.

Decompressive Hemi Craniectomy in Malignant Middle Cerebral Artery Infarction: Adding Years of Quality Life or Mere Existence?

Background: In spite of advancements in treatment options for MCA infarct, there is a definite role of decompressive hemicraniectomy. When compared with best medical management, it decreases mortality and improves functional outcome. But does surgery improve quality of life in terms of independence, cognition or it merely leads to increased survival? Objective: Outcome of 43 consecutive patients of MMCAI who underwent DHC was studied. Materials and Methods: Functional outcome was evaluated based on mRS and GOS in addition to survival advantage. The patient's proficiency in performing ADL was evaluated. MMSE and MOCA were performed to evaluate the neuropsychological outcome. Results: In-hospital mortality was 18.6%, and by 3 months, 67.5% of patients survived. During follow-up, nearly 60% of patients showed improvement in functional outcome when evaluated based on mRS and GOS. No patient could reach to the level of independent existence. Only eight patients could perform MMSE and five had good score (>24). All were young and had a right-sided lesion. None of the patients could perform well in MOCA. Conclusion: DHC improves survival and functional outcome. Cognition remains poor in the majority of the patients. These patients, though survive the stroke, remain dependent on care givers.

Laccase mediated delignification of wasted and non-food agricultural biomass: Recent developments and challenges.

Utilization of microbial laccases is considered as the cleaner and target specific biocatalytic mechanism for the recovery of cellulose and hemicelluloses from nonfood and wasted agricultural, lignocellulosic biomass (LCB). The extent of lignin removal by laccase depends on the biochemical composition of biomass and the redox potential (E0) of the biocatalyst. Intensive research efforts are going on all over the world for the recognition of appropriate and easily available agricultural lignocellulosic feedstocks to exploit maximally for the production of value-added bioproducts and biofuels. In such circumstances, laccase can play a major role as a leading biocatalyst and potent substitute for chemical based deconstruction of the lignocellulosic materials. The limited commercialization of laccase at an industrial scale has been feasible due to its full working efficiency mostly expressed in the presence of cost intensive redox mediators only. Although, recently there are some reports that came on the mediator free biocatalysis of enzyme but still not considerably explored and neither understood in depth. The present review will address the various research gaps and shortcomings that acted as the big hurdles before the complete exploitation of laccases at an industrial scale. Further, this article also reveals insights on different microbial laccases and their diverse functional environmental conditions that affect the deconstruction process of LCB.

Phytoremediation of radioactive elements, possibilities and challenges: special focus on agricultural aspects.

The radioactive contamination has been reported frequently from agricultural lands and ground water. The main reason behind the radioactive pollution is unprotected mining of radioactive elements, unsafe discard of nuclear industrial waste, military applications, dumping of medically used radioisotopes, globally situated (>400) nuclear power plants and use of phosphate fertilizers in farming. Radionuclides are well known potent carcinogens that may cause the various types of cancers to human and animals due to the long exposure to radioactive contaminated sites. To get rid of from the radioactive pollution there is a need of practically successful and cost effective bioremediation technologies that should able to decontaminate the effected lands and water to benefit the mankind. Microbial and phytoremediation are well studied methods for decreasing or gradually eliminating the radioactive contaminants. In this review, we discussed the different strategies of microbial and phytoremediation of radionuclides and recent advancements, that can play the major role in bioremediation of soil and water.

Different remediation technologies based on physical (precipitation, extraction and membrane separation technologies) and chemical (chemical extraction and leaching, hydrolysis, etc.) methods to remediate the radioactive compounds from soils and water are being developed and evaluated. Most of these technologies are cost intensive and only applicable to little contaminated sites. On the other hand phytoremediation and microbial bioremediation are scientifically proven for applying at large scale and economical. Phytoremediation is one of the bioengineering treatments in which terrestrial and aquatic plants have been successfully used for cleaning the radioactive pollutants from diverse environments. Present review article is a updating the recent developments came in the different bioremediation methods. Moreover aim of this manuscript is also emerging the research gaps and identified the future research frontiers to unlock the complexity of phyto and microbial remediation advancements. Although several plants and numerous bacteria and fungi have been identified as the potential radioactive accumulator but their complete mechanism of bioremediation is still unknown. Present article will help the researchers to understand the process of bioremediation of radionuclides in more depths and will aware about the requirements of the coming future.HighlightsPhyto and microbial bioremediation of radioactive elements, possibilities and challenges.Causes of radioactive contamination in soil and water.Nanophytoremediation is an advanced technology of phytoremediation.Drawbacks of phytoremediation.

Propofol versus Desflurane in Moyamoya Disease Patients-A Pilot Study.

Objectives The choice of inhalational or intravenous anesthetic agents is debatable in neurosurgical patients. Desflurane, a cerebral vasodilator, may be advantageous in ischemic cerebral pathologies. Hence, we planned to compare desflurane and propofol in patients with moyamoya disease (MMD) with the objective of comparing neurological outcomes. Materials and Methods This prospective pilot trial was initiated after institutional ethics committee approval. Patients with MMD undergoing revascularization surgery were randomized into two groups receiving either desflurane or propofol intraoperatively. Neurological outcomes were assessed using a modified Rankin score (mRS) at discharge and an extended Glasgow outcome score (GOS-E) at 1 month. Intraoperative parameters, including hemodynamic parameters, end-tidal carbon dioxide, entropy, intraoperative brain relaxation scores (BRS), and rescue measures for brain relaxation, were compared. Statistical Analysis The normality of quantitative data was checked using Kolmogorov-Smirnov tests of normality. Normally distributed data were compared using unpaired t -tests, skewed data using Mann-Whitney U tests, and categorical variables using chi-squared tests. Results A total of 17 patients were randomized, 10 in the desflurane and 7 in the propofol group. mRS (1.3 ± 0.6 and 1.14 ± 0.4, p = 0.450) and GOS-E (6.7 ± 0.6 and 6.85 ± 0.5, p = 0.45) were comparable between desflurane and propofol groups, respectively. BRS was significantly higher in the desflurane group (3.6 ± 0.5) compared to the propofol group (2.1 ± 0.3, p = 0.001), with a significant number of patients requiring rescue measures in the desflurane group (70%, p < 0.001). Other outcome parameters were comparable ( p > 0.05). Conclusion We conclude that postoperative neurological outcomes were comparable with using either an anesthetic agent, desflurane, or propofol in MMD patients undergoing revascularization surgery. Maintenance of anesthesia with propofol had significantly superior surgical field conditions.

Surgical Outcome Analysis of Large and Giant Petroclival Meningiomas with Special Reference to Quality of Life Issues.

Background: Management strategies for petroclival menigiomas remain controversial. Objectives: We share our experience in management of large and giant true petroclival meniongiomas with special emphasis on patient reported quality of life parameters. Methods: This is a single center study of 47 patients between 2008 and 2018. All patients were checked for tumor specific parameters, clinical parameters, extent of surgical excision, and outcome, as assessed by Karnofsky performance score (KPS), Glasgow outcome score, clinical status, and by SF-36 questionnaire. Results: 32/47 patients' data were assessed. Symptoms included headache (62.5%), involvement of 5th nerve (47%), facial nerve (40.6%), lower cranial nerves (37.5%), cerebellar signs (84%), and long tract signs in (50%) of patients. The mean preoperative KPS was 83.75+/-6.59. Surgical approaches included retromastoid suboccipital craniotomy (50%), Kawase's approach (31.25%), and others in 18.25% patients. 40.625% (n = 13) had a gross total excision, near total resection (NTR) was achieved in 53.125% (n = 17), and 6.25% (n = 2) had a subtotal excision (STE). In 13 patients who had gross total resection (GTR), there were 12 (70.5%) new neurological deficits, while among the 19 patients with NTR, only 5 (29.5%) new neurological deficits were seen. No new onset neurological deficit was seen in patients with STE of tumor. Patient assessed QoL parameters were worse in patients with GTR and best in patients with NTR/STE + GKRS. Conclusion: In patients of large/giant petroclival meningiomas, NTE/STE with adjuvant GKRS provided better preservation of quality of life.

Setting up a Neurosurgical Skills Laboratory and Designing Simulation Courses to Augment Resident Training Program.

Background: The surgical skill practice in neurosurgery is being compromised in the recent past owing to the duty time constraint, patient safety concerns, and medico-legal issues. Surgical practice outside the operating room is essential to enhance a resident's operative skills and to gain confidence. Objective: To discuss the experience of establishing an 'in-house neurosurgery skills laboratory' and various training sessions conducted with cadaveric and non-cadaveric simulation modules. Methods: A skills laboratory was set up in the existing resident teaching hall with nine workstations. Each station has been equipped with an operating table, surgeon's chair, basic microscope, endoscope, high-speed drill system, and a suction machine. Vascular anastomosis, high-speed drilling, and basic neuroendoscopy were planned on low-cost non-cadaveric modules. Craniotomy and various surgical approaches were designed on cadaveric modules obtained from the anatomy department. Result: A total of 18 residents in divided groups during their initial three semesters had participated in the non-cadaveric simulation courses. Twenty-six residents had participated and 12 sessions were conducted on the cadaveric modules. Three workshops were conducted and 20 residents and faculty members from five other institutions had participated in the cadaveric hands-on training session. Conclusion: A well-equipped skills laboratory provides an opportunity for the residents to acquire operative expertise in a similar atmosphere to that of the operating theater. A structured program comprising various operative practice sessions should be incorporated into the resident training program.

Seasonal variation and Incidence of rupture of intracranial aneurysm : A prospective study and Literature review.

OBJECTIVES: Some studies have found an association of incidence of aneurysmal Sub arachnoid hemorrhage (aSAH) seasonal variations and weather patterns but others have refuted this. With conflicting reports in the literature, we tried to find out whether climatic conditions influence the incidence of aSAH. PATIENTS AND METHODS: This was a prospective single centre study involving patients with aSAH operated in a tertiary care hospital over one calendar year. Meteorological parameters like temperature, barometric pressure, humidity and sunshine hours were noted for 2 consecutive days prior to the ictus and on the day of ictus. RESULTS: 392 patients of aSAH who underwent clipping were enrolled. There was no significant difference in the incidence of aSAH across various seasons (p > 0.05). Pre ictus fall in temperature lead to a surge in number of cases. 241 patients (61.5%) reported were from geographical areas which had experienced a fall in temperature over preceding 2 days, with a mean fall in temperature of 1.1(SD 2.1) degree celsius (p less then 0.05). The incidence of aSAH patients in low sunshine hour seasons (1.13 patients/day) was significantly more than that in higher sunshine hour seasons (0.9 patients/day) (p less than 0.05 ). CONCLUSIONS: Seasonal variation had no direct bearing on the incidence of aSAH. Pre ictus fall in temperature lead to a rise in number of cases. Also, higher incidence of aneurysmal subarachnoid haemorrhage was seen in lower sunshine hour seasons.

Cerebral phaeohyphomycosis: The 'Dark Side' of fungal infections.

PURPOSE: Cerebral phaeohyphomycosis is a rare and fatal fungal infection of the central nervous system (CNS) caused by dematiaceous fungi. The aim of this study was to analyse the clinico- radiological presentation, pathology and outcome of cerebral phaeohyphomycosis and discuss the relevant literature. PATIENTS AND METHODS: Data of 7 patients diagnosed with cerebral phaeohyphomycosis and managed at our institute between 2014 and 2020 was collected and reviewed retrospectively. The diagnosis was established after surgery on KOH mount, Sabouraud dextrose agar, frozen section or histopathology. The clinical, radiological and pathological characteristics along with outcomes were analysed. RESULTS: Three patients with underlying comorbidities [chronic renal failure-2 and haematological malignancy -1] presented with brain abscess. The remaining 4 had no comorbidities. Two of them mimicked cystic glioma and one patient presented as intraventricular tumour. Another patient on anti- tubercular treatment for suspected pulmonary tuberculosis presented with encephalitis. Histopathology in all patients showed diffuse micro abscesses with coarse and reactive gliosis in the adjacent brain parenchyma and chronic lymphomononuclear inflammation without angioinvasion or vasculitis. Four showed granuloma formation. Antifungals were started after diagnosis. Six out of seven patients died and one was lost to follow up. CONCLUSION: Cerebral phaeohyphomycosis presents as abscesses in immunocompromised patients and mimics tumours in immunocompetent patients. KOH mount and frozen section examination is simple yet effective tool for establishing early diagnosis. Overall, the prognosis is dismal. Administering antifungals early in the course of management along with aggressive surgical excision may improve outcomes.

Outcome Following Surgical Revascularization in Patients of Moyamoya Disease with Focus on Graft Patency and Angiographic Changes.

BACKGROUND: Surgical revascularization is the mainstay of treatment in symptomatic patients of moyamoya disease (MMD). OBJECTIVE: The present study analyzed the postoperative angio-architecture in pediatric and adult patients of moyamoya disease. MATERIAL AND METHODS: Patients with MMD, both ischemic and hemorrhagic, were subjected to surgery. A superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis was attempted in all. It was augmented by an encephalo-duro-myo-synangiosis), this was labelled as the combined surgical group. In patients where a direct bypass was not possible encephalo-duro-arterio-myo-synangiosis (EDAMS) was performed and these patients were put in the indirect surgery group. In the postoperative period, MRA was performed in all patients to look for (a) graft patency, (b) regression of moyamoya vessels, and (c) degree of surgical neovascularization (as quantified on adapted Matsushima and Inaba grading system). RESULTS: Eighty-two patients underwent 131 surgical revascularization procedures. A combined surgery (STA-MCA bypass and EDAMS) was performed in 100 hemispheres and indirect surgery (EDAMS) on 31 sides. In children less than 5 years of age, STA-MCA anastomosis was possible in more than 50% of patients. Clinical improvement was seen in 85.4% of patients. Postoperative MRA demonstrated a patent bypass graft in 97% of cases. Regression of moyamoya vessels was seen in half of the cases and good surgical revascularization (type A and B) was seen in more than 80% of hemispheres in the combined surgery and indirect surgery group. CONCLUSIONS: Revascularization procedures led to a regression of moyamoya collaterals, appearance of surgical neo angiogenesis, and a graft patency rate of 97%. Surgical group with combined revascularization had a trend towards better collateral development.

Feasibility of Conducting a Virtual Exit Exam in Neurosurgery During the SARS-COV19 Pandemic.

BACKGROUND: Skills assessment forms an integral part of the exit examination in neurosurgical training programs. The established method of evaluating trainees for their clinical knowledge and surgical proficiency in the operating room is not feasible in the current time of SARS-COV19 pandemic. OBJECTIVE: The feasibility of conducting such an assessment using case modules on an online meeting platform is discussed. METHODS: Six candidates were evaluated on two consecutive days with two internal examiners located at the examination site and two external examiners situated at their own institutions elsewhere in the country. Clinical details, including images and videos of patients managed at our institute were recorded and provided to the candidates as case modules. Four sessions were conducted in the form of long and short cases, operative neurosurgery, neuroradiology, and neuropathology and a general viva-voce using "Zoom" (Zoom-Video-Communications, Inc. USA) platform. Feedback from the examinee and the examiners were obtained for any modification in the current format. RESULT: The online platform worked well without any interruption except for slight lag in the audio-visual system and occasional difficulty in using microphone and screen simultaneously. Trainees were able to interpret the clinical details and rated this format close to actual clinical evaluation. The examiners uniformly agreed that the online format for assessment was satisfactory and made some suggestions for improvement. CONCLUSION: Clinical and surgical skill evaluation is feasible using case modules and online meeting platforms. Use of original patient's data, images, videos demonstrating clinical signs, and operative procedures makes this assessment more objective.

Head injury care in a low- and middle-income country tertiary trauma center: epidemiology, systemic lacunae, and possible leads.

BACKGROUND: Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective. METHODS: This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions. RESULTS: The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity. CONCLUSIONS: The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.

Liver involvement in patients with coeliac disease: proof of causality using IgA/anti-TG2 colocalisation techniques.

AIMS: Despite clinical evidence of liver involvement in patients with coeliac disease (CeD), there is a lack of a method to prove this association. METHODS: Of 146 treatment-naive patients with CeD, 26 had liver dysfunction. Liver biopsies and corresponding small intestinal biopsies were obtained from these 26 patients. Multicolour immunohistochemical and immunofluorescence confocal microscopic studies were performed on paraffin-embedded tissue to detect the IgA/anti-TG2 deposits. Follow-up liver biopsies were taken after a gluten-free diet. RESULTS: Twenty-six out of the 146 patients (17.8%) with suspected coeliac-associated liver disease on histological examination revealed irregular sinusoidal dilatation in 15 (57.6%), steatohepatitis in 4 (15.3%), non-specific chronic hepatitis in 3 (11.5%), autoimmune hepatitis in 2 (7.6%) biopsies, including cirrhosis in one of them, irregular perisinusoidal fibrosis and changes of non-cirrhotic portal fibrosis in one biopsy each (3.8%). IgA/anti-tTG deposits were observed in 22 (84.6%) liver biopsies by dual immunohistochemistry technique, and in 24 (92.3%) by confocal immunofluorescence technique and in all corresponding duodenal biopsies (100%). Overall, IgA/anti-tTG deposits showed 100% sensitivity, 77% specificity and 85% positive predictive value for establishing an association of extraintestinal pathology and CeD using archived tissues. Follow-up liver biopsies could be obtained in five patients; four of them showed not only resolution of the histological lesions but disappearance of IgA/anti-tTG co-localisation. CONCLUSIONS: Data of the present study adds to the body of evidence that liver lesions in patients with CeD are disease related and may have been caused by a similar pathogenic mechanism that causes intestinal changes.