Review: Vascular dementia: clinicopathologic and genetic considerations.

The incidence and severity of cerebrovascular disease (CVD) increase with advancing age, as does the risk of developing Alzheimer's disease (AD). Not surprisingly, heterogeneous forms of CVD may coexist with AD changes in the 'ageing brain'. These include angiopathies (affecting both large and small arteries) that result from 'classical' risk factors (hypertension, smoking and diabetes) and others (cerebral amyloid angiopathy) that are biochemically closely linked to AD. The morphologic consequences of these various vascular diseases are infarcts and/or haemorrhages of varying sizes within the brain, which lead to neurocognitive decline that may mimic AD - though the vascular abnormalities are usually detectable by neuroimaging. More subtle effects of CVD may include neuroinflammation and biochemical 'lesions' that have no reliable morphologic correlate and thus escape the attention of even an experienced Neuropathologist. The pathogenesis of hippocampal injury resembling ischaemic change - commonly seen in the brains of geriatric subjects - remains controversial. In recent years, genetically determined forms of microangiopathy (e.g. CADASIL, CARASIL, Trex1-related microangiopathies, CARASAL, familial forms of cerebral amyloid angiopathy or CAA) have provided interesting cellular and molecular clues to the pathogenesis of sporadic microvascular disease such as arteriolosclerosis and AD-related CAA.

MRI shows more severe hippocampal atrophy and shape deformation in hippocampal sclerosis than in Alzheimer's disease.

While hippocampal atrophy is a key feature of both hippocampal sclerosis (HS) and Alzheimer's disease (AD), the pathology underlying this finding differs in these two conditions. In AD, atrophy is due primarily to loss of neurons and neuronal volume as a result of neurofibrillary tangle formation. While the etiology of HS is unknown, neuron loss in the hippocampus is severe to complete. We compared hippocampal volume and deformations from premortem MRI in 43 neuropathologically diagnosed cases of HS, AD, and normal controls (NC) selected from a longitudinal study of subcortical ischemic vascular disease (IVD Program Project). HS cases (n = 11) showed loss of neurons throughout the rostral-caudal extent of the hippocampus in one or both hemispheres. AD cases (n = 24) met NIA-Reagan criteria for high likelihood of AD. Normal control cases (n = 8) were cognitively intact and showed no significant AD or hippocampal pathology. The mean hippocampal volumes were significantly lower in HS versus AD groups (P < .001). Mean shape deformations in the CA1 and subiculum differed significantly between HS versus AD, HS versus NC, and AD versus NC (P < .0001). Additional study is needed to determine whether these differences will be meaningful for clinical diagnosis of individual cases.

Co-registration of In-Vivo Human MRI Brain Images to Postmortem Histological Microscopic Images.

Certain features such as small vascular lesions seen in human MRI are detected reliably only in postmortem histological samples by microscopic imaging. Co-registration of these microscopically detected features to their corresponding locations in the in-vivo images would be of great benefit to understanding the MRI signatures of specific diseases. Using non-linear Polynomial transformation, we report a method to co-register in-vivo MRIs to microscopic images of histological samples drawn off the postmortem brain. The approach utilizes digital photographs of postmortem slices as an intermediate reference to co-register the MRIs to microscopy. The overall procedure is challenging due to gross structural deformations in the postmortem brain during extraction and subsequent distortions in the histological preparations. Hemispheres of the brain were co-registered separately to mitigate these effects. Approaches relying on matching single-slices, multiple-slices and entire volumes in conjunction with different similarity measures suggested that using four slices at a time in combination with two sequential measures, Pearson correlation coefficient followed by mutual information, produced the best MRI-postmortem co-registration according to a voxel mismatch count. The accuracy of the overall registration was evaluated by measuring the 3D Euclidean distance between the locations of microscopically identified lesions on postmortem slices and their MRI-postmortem co-registered locations. The results show a mean 3D displacement of 5.1 ± 2.0 mm between the in-vivo MRI and microscopically determined locations for 21 vascular lesions in 11 subjects.

A standardized method for brain-cutting suitable for both stereology and MRI-brain co-registration.

We have developed an agar-embedding method for brain-slicing that minimizes the geometrical distortions which arise from handling and slicing the fixed postmortem brain. To facilitate postmortem brain-magnetic resonance imaging (MRI) co-registration, each hemisphere is processed separately. We embed the fixed brain hemisphere with reference markers in agar. The block containing the brain and markers is sliced at a fixed interval using a rotary slicer. Each slice is photographed with a high-resolution digital camera. The digital images are realigned as a 3-dimensional volume via a control point-based registration method for multi-slice registration. The realigned multiple slices of the reconstructed postmortem hemisphere are then co-registered to corresponding slices of an in vivo reference MRI-volume. We illustrate these postmortem MRI-brain co-registration methods to correlate in vivo T2-weighted MRI hyperintensities in gray and white matter with underlying pathology. For design-based stereology, the volume of interest (VOI) is defined using reproducible anatomical boundaries. This method is suitable for stereologic measures of structures ranging from defined nuclei to whole brain.

Neuropathologic substrates of ischemic vascular dementia.

Ischemic vascular dementia (IVD) is a relatively uncommon entity, in the course of which multiple ischemic brain lesions result in progressive cognitive and memory impairment. Ischemic brain lesions may also aggravate the neuropsychologic deficit of Alzheimer disease (AD). In this review we summarize our experience based upon autopsy examination of the central nervous system in 20 patients (age range 68-92 years) enrolled in a longitudinal investigation of structural, neurochemical, functional neuroimaging, and neuropsychologic components of IVD, especially dementia associated with cerebral microvascular disease. While cystic infarcts were present in the CNS of 5 patients, the most commonly observed neuropathologic abnormalities were lacunar infarcts and microinfarcts--both types of lesion were encountered in over half of patients' brains. Evidence of (remote) hippocampal injury was found in 11/20 patients. Severe atherosclerosis and arterio/ arteriolosclerosis were both associated with the occurrence of multiple lacunar infarcts. Pronounced cerebral amyloid angiopathy (CAA) was noted in a single patient, who also showed other microscopic changes of severe AD. While fairly unusual as a nosologic entity, IVD appears to correlate with widespread small ischemic lesions distributed throughout the CNS. We furthermore propose an approach to quantifying the burden of ischemic vascular and parenchymal disease that may be associated with a dementia syndrome. A brief review of neuropathologic features of vascular dementia (both familial and sporadic) is presented.

Cerebral amyloid angiopathy in Alzheimer disease is associated with apolipoprotein E4 and cortical neuron loss.

Pathological correlations were sought between cerebral amyloid angiopathy (CAA) and other classical neurodegenerative changes in 101 consecutive cases of autopsy-confirmed Alzheimer disease (AD). Some degree of CAA was found in at least one area of the brain in 81% of the cases; severe CAA was found in at least one brain region in 29% of the cases. In a subset of 42 cases for which genomic DNA was available, greater severity of CAA was associated more with cases that were homozygous for apolipoprotein epsilon4 than in cases with only one or no epsilon4 alleles (Fisher's exact test, p = 0.005). In all brain regions, severity of CAA was inversely correlated with numbers of neurons. This correlation was statistically significant in the temporal lobe (r = -0.29,p = 0.004) and the frontal lobe (r = -0.22, p = 0.02). Our findings suggest that two factors may modify the severity of AD pathology: Apolipoprotein E4 may accentuate the vascular deposition of beta-amyloid, and severe CAA may accelerate neuronal loss.

Increased apolipoprotein E mRNA in the hippocampus in Alzheimer disease and in rats after entorhinal cortex lesioning.

The distribution of apolipoprotein E (ApoE) mRNA was characterized in the hippocampus of humans with Alzheimer disease (AD) and in rats with experimental lesions (unilateral ablation of the entorhinal cortex) that model selected features of AD. In both AD and the lesion model, we observed a shift in the location of astrocytes containing prevalent ApoE mRNA from the neuropil to regions with densely packed neurons. The increased abundance of ApoE mRNA in astrocytes close to neuron cell bodies could be indicative of lipid uptake in regions where neurons are degenerating or where synaptic remodeling is taking place.

Vascular basement membrane pathology and Alzheimer's disease.

We have previously demonstrated that the capillary vascular basement membrane (VBM) is pathologically altered in Alzheimer's disease (AD). This microangiopathy is highlighted by the immunocytochemical localization of the three principal intrinsic VBM components: heparan sulfate proteoglycan, collagen type IV, and laminin. These three VBM components also immunolable amyloid deposits and senile plaque-associated glial processes. The present study examines the ultrastructure of the VBM in one brain region severely affected (temporal gyrus) and one relatively spared (cerebellum) from the lesions of AD in both AD and neurological control cases. The cross-sectional area as well as the width of the VBM were found to be greater in AD cortical capillaries. In addition, we found ultrastructural evidence for the activation of microglial-related perivascular cells, and their apparent extravasation through the VBM, findings consistent with the hypothesis that these cells are being recruited as part of a disease-related immune response. The recruitment of these "resting" microglial-like cells from their intra-VBM location to plaques and tangles in AD may explain (1) the thickening and vacuolization of the VBM; (2) the specificity of this VBM alteration to brain regions where there are plaques and tangles; and (3) the source of some of the large number of activated microglia in these affected areas. Thus, while VBM alterations may not be specific to AD, these changes appear to be specifically related to the disease process.

Physical aggression is associated with preservation of substantia nigra pars compacta in Alzheimer disease.

OBJECTIVE: To investigate specific neuropathologic correlates of agitation and physical aggression in Alzheimer disease (AD). DESIGN: Neuronal counts in the nucleus basalis, locus ceruleus, and substantia nigra were compared in the brains of patients with pathologically definite AD with or without histories of agitation or interpersonal violence. SETTING: Alzheimer disease center of a university department of neurology. MAIN OUTCOME MEASURES: Neuron densities in the nucleus basalis and absolute neuron counts in the locus ceruleus and substantia nigra pars compacta. RESULTS: The patients with AD who had histories of unequivocal interpersonal violence had significantly greater neuron counts in the substantia nigra pars compacta than did the nonviolent patients with AD. This finding remained significant after multiple clinical and neuropathologic variables were adjusted for. Neuropathologic findings in the nucleus basalis and locus ceruleus were not different between violent and nonviolent patients. CONCLUSION: Preservation of pigmented substantia nigra neurons may be a risk factor for physical aggression in AD.

Limited responses of neuronal mRNAs to unilateral lesions of the rat entorhinal cortex.

Following unilateral electrolytic lesioning of the rat entorhinal cortex, we assessed changes in messenger RNA (mRNA) levels for four neuron-associated proteins, GAP-43, SCG10, 68 kDa neurofilament (NF68), and alpha 1-tubulin that encode proteins of importance to synaptic remodelling. The mRNA levels for GAP-43 and SCG10 were reduced in the septal nuclei, while those of SCG10 and alpha 1-tubulin were elevated in the hippocampus; at most, the changes ranged from -40% to +50% of controls. Changes in NF68 mRNA levels were not significant. Correlations were found between mRNA for SCG10 and both GAP-43 and NF68. In view of these modest changes in most mRNA levels examined, we suggest that post-translational regulation may also be important in responses to injury.

Transforming growth factor-beta 1 induces neuronal and astrocyte genes: tubulin alpha 1, glial fibrillary acidic protein and clusterin.

Transforming growth factor-beta 1 was studied as a possible regulator of messenger RNAs in astrocytes and neurons that increase after hippocampal deafferentation by perforant path transection: tubulin alpha 1, clusterin and glial fibrillary acidic protein messenger RNA. Because transforming growth factor-beta 1 messenger RNA is increased after this lesion, we examined which messenger RNA lesion responses could be induced by transforming growth factor-beta 1 alone. Porcine transforming growth factor-beta 1 infused into the lateral ventricle elevated the messenger RNAs for tubulin alpha 1, clusterin and glial fibrillary acidic protein 24 h after infusion in the ipsilateral hippocampus. As assayed by nuclear run-on, the transcription of glial fibrillary acidic protein RNA was increased in the ipsilateral hippocampus after perforant path transection and in primary rat astrocyte cultures by transforming growth factor-beta 1. In contrast, transforming growth factor-beta 1 did not change apolipoprotein-E messenger RNA or transcription, or growth associated protein-43 messenger RNA levels. We conclude that transforming growth factor-beta 1 increases subsets of neuronal and astrocyte messenger RNAs coding for cytoskeletal proteins that are also elevated in response to experimental lesions and Alzheimer's disease. This suggests that transforming growth factor-beta 1 might be a local organizing factor of neuronal and astrocyte responses to brain injury.

Inability to detect beta-amyloid protein precursor mRNA in Alzheimer plaque-associated microglia.

A close association between Alzheimer senile plaques and microglia (the resident mononuclear phagocytic system cells of the brain) is well documented. To determine whether microglia contain detectable beta-amyloid protein precursor (beta-APP) mRNA, the present study combined immunocytochemistry (LN3 antibody to label microglia) with in situ hybridization (full-length cRNA probe to detect all forms of beta-APP mRNA). We report that immunolabeled microglia, including those clustered around senile plaques, generally lack detectable beta-APP mRNA--suggesting that microglia are not synthesizing the plaque-associated amyloid. The possibility that, analogous to the process in other forms of amyloidosis, the resident mononuclear phagocytic cells ingest an amyloidogenic precursor and secrete amyloid was not examined. Recent demonstrations of interactions between immune-related factors and Alzheimer lesions suggest that beta-APP and its breakdown products, along with microglia and their secretory products, may work synergistically in an AD pathogenetic cascade.

Studies of the enteric nervous system in Alzheimer disease and other dementias of the elderly: enteric neurons in Alzheimer disease.

Studies of the myenteric (Auerbach) plexus of esophagus, stomach, small intestine, colon, and rectum, by microdissection and pointcount morphometry, for 18 patients with Alzheimer disease (AD), eight with other types of dementia of the elderly, non-demented elderly patients, and younger control patients, show a normal loss of enteric neurons and plexus mass with age, comparable to that reported by others for rats and guinea pigs. Values for patients with AD or other non-AD dementias did not differ from those for elderly controls. Enteric neurons in AD or the other dementias studied showed no definite stain with ALZ-50, a monoclonal antibody to a derivative of the microtubule-associated protein tau, which stains degenerating cerebral neurons in AD. Although the processes in the central nervous system in AD affect some neurons derived from the neural plate, the results of this study suggest that the enteric neurons, which are of neural crest origin, are not affected in AD. Enteric neurons, at least by the methods of this study, do not provide a useful peripheral marker for AD.

Neuropathologic diagnosis of Alzheimer disease: interrater reliability in the assessment of senile plaques and neurofibrillary tangles.

A diagnosis of definite Alzheimer disease (AD) is made when there is a history of progressive dementia combined with the pathologic findings of numerous senile plaques and neurofibrillary tangles in neocortex. Recent studies have shown, however, that there may be significant interrater variability in the quantitation of these histopathologic lesions. In the present two-center study, interrater reliability and test-retest reliability for plaque and tangle counts were examined when histologic staining and sampling were controlled. We report similar levels of reliability for plaque and tangle counts in 35 cases of AD, nine normal elderly controls and six non-AD dementias: Pearson correlations for interrater reliability ranged from 0.68 to 0.88, and from 0.97 to 0.99 for test-retest reliability. Using quantitative cut-points, concordance between laboratories for experimental diagnoses of AD versus non-AD made on the basis of these lesion counts ranged from 84 to 92% (kappa scores: 0.69-0.84). The agreement between these experimental diagnoses and the clinicopathologic diagnoses of record ranged from 74 to 86% (kappa scores: 0.50-0.71). Thus, under optimal conditions, a moderate to substantial degree of interrater reliability can be attained in the pathologic diagnosis of AD.

Reliability and usefulness of a new immunochemical assay for Alzheimer's disease.

OBJECTIVE: To assess the reliability and usefulness of a new sandwich enzyme-linked immunoassay (ALZ-EIA) that detects Alzheimer's disease-associated proteins in the diagnosis of Alzheimer's disease. DESIGN: The reliability of the assay was assessed between two laboratories. Sensitivity and specificity of a diagnostic algorithm based on the results of the ALZ-EIA were determined using the Consortium to Establish a Registry for Alzheimer's Disease neuropathological diagnoses as the "gold standard." SETTING: Autopsy cases were obtained from a teaching hospital with a specialized Alzheimer Disease Diagnostic and Treatment Center. CASES: Brain tissue was selected from 24 cases with dementia and 10 normal controls. MAIN OUTCOME MEASURES: Optical density measurements from the ALZ-EIA in the hippocampus and three neocortical regions. RESULTS: A 95% concordance in ALZ-EIA activity was found between the two laboratories, and an 85% concordance was found between ALZ-EIA and the Consortium to Establish a Registry for Alzheimer's Disease diagnoses. Perfect agreement was obtained for "typical" Alzheimer's disease cases (those with plaques and tangles), while discrepancies occurred for "atypical" cases (those with predominantly plaques or tangles). CONCLUSIONS: The ALZ-EIA provides a highly reliable method of assessing neurofibrillary degeneration. Its clinical usefulness as a diagnostic test would be enhanced by the availability of a complementary assay for beta-amyloid.

Sulfated glycoprotein-2 is increased in rat hippocampus following entorhinal cortex lesioning.

Thios study showed responses of sulfated glycoprotein-2 (SGP-2) in the rat hippocampus after deafferenting lesion. SGP-2 is a plasma protein that also occurs in many peripheral tissues. In some circumstances, elevations of SGP-2 mRNA are associated with cell degeneration and responses to injury. This study used entorhinal cortex lesions (ECL) to partially deafferent the hippocampus by damaging the perforant path and to induce synaptic remodeling. SGP-2 mRNA is increased in hippocampal astrocytes after ECL. Western blot analysis of soluble hippocampal proteins identified 3 major forms of rat SGP-2 protein: a precursor (61 kDa) and 2 reduced subunits at 39.5 and 35 kDa. These forms increased at 4 days post ECL ipsilaterally to the lesion. By immunocytochemistry (ICC), SGP-2 showed an increased immunoreactivity on the lesioned side by 2 days post ECL that continued through 14 days post ECL. Besides immunopositive astrocytes, punctate immunochemical reaction products occurred among the degenerating fibers of the perforant path. We conclude that changes of SGP-2 protein in the hippocampus after ECL occur roughly in parallel with increases of SGP-2 mRNA. The punctate immuno-deposits could represent secreted SGP-2 and may be useful as a marker for degenerating pathways.

Pathologic correlates of dementia in Parkinson's disease.

Histopathologic studies of the cerebral cortex, hippocampus, and three subcortical nuclei were performed in four patients with Parkinson's disease whose mental status had been evaluated by neuropsychologic testing. Clinicopathologic correlations suggest that dementia with marked visuospatial disturbance as well as severe aphasia may be associated with severe neuronal loss in subcortical nuclei, without significant numbers of plaques or tangles in the hippocampus and cerebral cortex. Furthermore, memory loss may not be consistently related to neuronal loss in the nucleus basalis of Meynert, particularly in non-Lewy body parkinsonism.

Stability of neuronal number in the human nucleus basalis of Meynert with age.

Numbers of neurons in the nucleus basalis of Meynert were estimated in seventeen non-demented patients who died of chronic hepatic or cardiopulmonary disease. Neurons were counted at the site of maximal neuronal density (SMND). This site was chosen by reviewing serial sections around the decussation of the anterior commissure and appeared to be comparable in different individuals. No correlation between numbers of neurons and age could be found. It appears that no uniform neuronal loss occurs in the nucleus basalis with age. Taken together with biochemical studies of cerebral cortical choline acetyltransferase activity, these findings suggest that there is no overall change in cholinergic input to cerebral cortex with age.

Human leukemic cells resistant to 5-fluoro-2'-deoxyuridine contain a thymidylate synthetase with lower affinity for nucleotides.

A line of human lymphocytic leukemia cells (CCRF-CEM) has been obtained which is 140-fold resistant to the potent cell growth inhibitor 5-fluoro-2'-deoxyuridine (FdUrd). The cells were also 11-fold cross-resistant to 5-fluorouracil. In contrast to several previous studies involving FdUrd-resistant mouse cells, thymidylate synthetase levels were not substantially elevated in these FdUrd-resistant human leukemic cells. Thymidine kinase activity was also unchanged in the resistant cells, although the levels of 5-fluoro-2'-deoxyuridylate (FdUMP), the potent inhibitor of thymidylate synthetase, generated at equimolar doses of FdUrd were about 40% lower than in the sensitive cells. Studies of the kinetics of FdUMP binding to thymidylate synthetase isolated from the FdUrd-resistant cells disclosed a considerably higher dissociation constant (Kd = 1.0 X 10(-9) M) for the ternary covalent enzyme . FdUMP . 5,10-methylene tetrahydrofolate complex compared to the value obtained with enzyme from sensitive cells (Kd = 4.4 X 10(-11) M). The thymidylate synthetase from the FdUrd-resistant cells also showed 17-fold weaker binding of 2'-deoxyuridylate, even though the Km value for 2'-deoxyuridylate was 3-fold lower compared to the enzyme from FdUrd-sensitive cells. The turnover number of the altered enzyme was 1.8-fold higher than that for the normal enzyme but the rate constants for the release of FdUMP from the ternary complex, which is also an enzyme-catalyzed reaction, were identical for both enzymes. Electrophoresis of the radiolabeled ternary complexes on nondenaturing gels showed small but reproducible differences in migration rates. These results demonstrate that the mechanism of resistance to FdUrd in this cell line involves an alteration in the target enzyme, thymidylate synthetase, which causes it have a lower affinity for nucleotides.

Large-scale and small-scale methods for the preparation of 5,10-methylenetetrahydrofolate.

Two procedures have been developed for the synthesis and isolation of 5,10-methylenetetrahydrofolate, the cofactor for the reaction catalyzed by thymidylate synthetase, one of which can be used for large-scale preparations of the cofactor and the other for small-scale syntheses especially suitable for obtaining the radiolabeled cofactor. The large-scale procedure involves treatment of folic acid with dithionite to give dihydrofolate, which is then converted to tetrahydrofolate by dihydrofolate reductase (L. casei). The small-scale method involves a direct enzymatic reduction of folic acid to tetrahydrofolate by dihydrofolate reductase, and has been used to prepare the double-labeled 5,10-[14C]methylene[3',5',7,9-3H]tetrahydrofolate. In both procedures, after the reduction steps have been performed, the tetrahydrofolate is treated in situ with formaldehyde prior to purification by DEAE-cellulose chromatography, thus allowing the isolation of 5,10-methylenetetrahydrofolate as a dry powder after lyophilization. This product is active in the enzyme reaction without the further addition of excess formaldehyde as in previous procedures. The cofactor prepared in this manner has much improved stability toward oxidation compared to free tetrahydrofolate.