A typical presenile dementia. Report of an anatomo-clinical case and review of the literature

Frontotemporal lobar degeneration with TAR DNA-binding protein 43 (TDP-43): its journey of more than 100 years

Frontotemporal lobar degeneration (FTLD) with TDP-43-immunoreactive inclusions (FTLD-TDP) is a neurodegenerative disease associated with clinical, genetic, and neuropathological heterogeneity. An association between TDP-43, FTLD and amyotrophic lateral sclerosis (ALS) was first described in 2006. However, a century before immunohistochemistry existed, atypical dementias displaying behavioral, language and/or pyramidal symptoms and showing non-specific FTLD with superficial cortical neuronal loss, gliosis and spongiosis were often confused with Alzheimer's or Pick's disease. Initially this pathology was termed dementia lacking distinctive histopathology (DLDH), but this was later renamed when ubiquitinated inclusions originally found in ALS were also discovered in (DLDH), thus warranting a recategorization as FTLD-U (ubiquitin). Finally, the ubiquitinated protein was identified as TDP-43, which aggregates in cortical, subcortical, limbic and brainstem neurons and glial cells. The topography and morphology of TDP-43 inclusions associate with specific clinical syndromes and genetic mutations which implies different pathomechanisms that are yet to be discovered; hence, the TDP-43 journey has actually just begun. In this review, we describe how FTLD-TDP was established and defined clinically and neuropathologically throughout the past century.

Late-onset sporadic progressive subcortical gliosis

We report two sporadic cases of progressive subcortical gliosis (PSG) with onset after age 60. The presentation included slowly progressive dementia with memory loss, geographic disorientation, and personality change. Both were diagnosed clinically as Alzheimer's disease (AD) and both met NINCDS-ADRDA criteria for probable AD. Autopsy revealed generalized atrophy, predominantly involving the white matter of the frontal and temporal lobes. Microscopically, prominent fibrillary astrocytosis was present in the subcortical white matter and in the subpial and deep layers of the overlying cerebral cortex. Mild cortical neuron loss accompanied the gliosis, but no myelin loss was evident. Amyloid deposits and neuronal cytoskeletal inclusions were absent.

Clinical characteristics of familial and sporadic Creutzfeldt-Jakob disease in Finland

The clinical features of 44 Finnish patients with Creutzfeldt-Jakob disease (CJD) were analyzed with special emphasis on the differences between the sporadic and familial forms. The 32 sporadic patients comprised all neuropathologically verified cases of CJD in 1974-89 in Finland. The 12 familial patients were members of the same pedigree where CJD has been linked with a mutation at codon 178 of the PRNP gene. The median age at the onset of the disease was 62.5 years and median duration 4.5 months in sporadic patients, and 49 years and 20.5 months in familial CJD, respectively. 90 percent of both sporadic and familial patients had myoclonus. Typical periodic EEG change was seen in 72% of sporadic patients, whereas the familial patients showed only a progressive slowing of EEG.

Dementia of frontal lobe type: neuropathology and immunohistochemistry

Brains from 12 patients dying with a clinical diagnosis of frontal lobe dementia have been examined at post mortem. In pathological terms four groups were encountered. Groups A and B showed severe frontal and temporal lobe atrophy characterised histologically in group A by severe neuronal loss, spongiform change of the superficial laminae, and mild astrocytosis; in group B severe neuronal loss was accompanied by intense gliosis but with little or no spongiform change. Two patients in this latter group also showed inclusions in frontal cortex and hippocampus typical of "Pick bodies"; such patients were considered as having classic "Pick's disease". Group C patients showed severe striatal atrophy with variable cortical (frontal or temporal) involvement, with histological changes similar to patients in groups A and B. The single patient in group D showed mild frontotemporal atrophy with spongiform degeneration of the superficial laminae of the cortex and nigral damage, and was considered to have motor neuron disease with dementia. This study is consistent with previous reports showing that the clinical syndrome of frontal lobe dementia is pathologically heterogeneous. However, the nosological relationships within these pathological variants, and between them and conditions such as progressive aphasia were similar histopathological changes are present, remain uncertain.

The topographic distribution of brain atrophy in frontal lobe dementia

The topographic distribution of brain atrophy was quantified by image analysis of fixed brain slices from ten patients dying with dementia of frontal type (DFT) and from six other patients dying with dementia of frontal type with motor neurone disease (DFT + MND). In both groups the atrophy was maximal within frontal, anterior temporal and anterior parietal regions of cortex, although other structures such as the amygdala, caudate nucleus, thalamus and hippocampus were also affected. The magnitude of the atrophy was much greater, in all affected regions, in DFT alone than in DFT + MND. Grey and white matter were affected equally in DFT alone although in DFT + MND a preferential white matter involvement was noted. No differences in the topographic distribution of the atrophy was observed in cases of DFT showing a spongiform degeneration of the cortex compared to those showing a gliotic degeneration with, or without, Pick cells and Pick bodies.

Some immunohistochemical features of argyrophilic grain dementia with normal cortical choline acetyltransferase levels but extensive subcortical pathology and markedly reduced dopamine

Detailed immunohistochemical and biochemical studies are reported on two cases of progressive dementia showing no Alzheimer-type pathology but extensive argyrophilic grains as described previously by Braak and Braak. These cases had no specific clinical features, and the pathology of these brains showed subcortical gliosis (proliferation of astrocytes and microglia) without significant neuronal losses. Interesting novel immunohistochemical findings were the profuse appearance of complement-activated oligodendrocytes and oligodendroglial microtubular masses. Their appearance seems to indicate oligodendroglial reactions to widespread damage of myelinated axons. Cortical levels of choline acetyltransferase were normal, but striatal levels of dopamine and its metabolites were markedly reduced. This disease may be consistent with the criteria for progressive subcortical gliosis.

A case of progressive subcortical gliosis presenting clinically as Steele-Richardson-Olszewski syndrome

A patient presenting with the characteristic clinical features of Steele-Richardson-Olszewski syndrome is described, in whom neuropathological examination revealed atypical features, including extensive cortical and subcortical gliosis. The clinical and pathological features are discussed with particular reference to Creutzfeldt-Jacob disease and it is proposed that the case should be classified as progressive subcortical gliosis.

Progressive subcortical gliosis of Neumann: a clinicopathologic study of two cases with review

A clinico-pathological report is given of two cases of progressive dementia of fronto-temporal type associated with variable cortical neuronal loss and extensive subcortical and deep white matter gliosis. There was minimal demyelination of white matter, significant gliosis of thalamus and inferior olivary nuclei. The authors review the condition of progressive subcortical gliosis, compare such changes with white matter changes in other dementias, examine the relationship to Kraepelin's disease, contrast the disorder with atypical Pick's dementia, progressive dementia with motor neuron disease and Creutzfeldt-Jakob dementia.

Sleep abnormalities with REM disorder in experimental Creutzfeldt-Jakob disease in cats: a new pathological feature

Alterations in sleep organization were studied during the clinical phase of experimental Creutzfeldt-Jakob disease (CJD) in cats. Twenty months after intracerebral inoculation of a CJD agent, cats developed clinical signs including behavioral changes, diminished grooming activity, dysmetria, startle reflex, myoclonus, and unusual sleep abnormalities. Rapid eye movement (REM) sleep displayed a new and irreversible organization, with a continuous and constant pseudoperiodic pattern of rapid eye movements, synchronous with diffuse bursts of cortical abnormalities and with ponto-geniculo-occipital (PGO) wave activity. Computer analysis revealed a constant morphology of cortical bursts and their temporal relationship with ocular episodes. Induction of PGO wave activity with benzoquinolizine derivative Ro 4-1284 demonstrated the PGO-dependent nature of the cortical alterations. Abnormal unresponsive states were observed during REM sleep phases and arousal thresholds were increased in CJD cats during REM sleep. The percentages of wakefulness and slow-wave sleep were reversed in these animals. Preliminary neuropathological observations included discrete to minimal spongiosis of cerebral gray matter and a remarkably focalized intracytoplasmic vacuolation in neurons of the raphé system. Our findings suggest that particular neuronal systems involved in sleep regulation are impaired in CJD cats.

Nonspecific dementia, cortical blindness, and Congophilic angiopathy. A clinicopathological report

Postmortem examination of an elderly male with cortical blindness and features of both cortical and subcortical dementia revealed extensive neuronal dropout most marked in the occipital cortex, moderate gliosis, rare neuritic plaques, no neurofibrillary tangles, and extensive Congophilic angiopathy. The unprecedented association of Congophilic angiopathy with nonspecific dementia provides further support for the concept that Congophilic angiopathy is usually a nonspecific manifestation of neuronal degeneration and of little clinical significance except when it results in intracerebral hemorrhage.

Dialysis encephalopathy: neuropathologic aspects

The clinical, epidemiologic, electroencephalographic, and toxicologic features of dialysis encephalopathy (DE) have been clarified, but the neuropathologic and clinicopathologic aspects of the disease have remained obscure. In three cases of DE associated with a dialysate of high aluminum content, spongy change restricted to the upper layers of the cerebral cortex was found. The spongy change was distributed through the cerebral cortex bilaterally and diffusely, but the left hemisphere was involved more severely and extensively than the right hemisphere, and the opercular portions of the frontal and temporal lobes were affected more than the remainder of those lobes. This topographic distribution correlated with the clinical defects in higher cortical functions, including aphasia. The spongy change consisted of vacuoles in the neuropil and inside nerve cell bodies. The vacuoles in the neuropil were located in dendrites, astrocytic processes, and, possibly, other structures. Thus, DE is a disease of neurons and astrocytes of the cerebral cortex. Although spongy change of the upper layers of the cerebral cortex is a nonspecific abnormality, when it occurs in the distribution described and in the absence of other diffuse cerebral diseases, it is characteristic of DE.

Dementia and motor neuron disease: morphometric, biochemical, and Golgi studies

In three patients dementia without neurofibrillary tangles or Pick bodies antedated amyotrophy by several years. The motor neuron disorder in two patients was characterized by terminal bulbar symptoms; in one it was similar to classic amyotrophic lateral sclerosis. In two patients, quantitative studies of selected regions of the cortex using a computerized image analyzer disclosed, as in patients with senile dementia of Alzheimer type, a marked reduction in the number of neurons, especially those larger than 90 mu 2. The findings differed from those in Alzheimer dementia, however, in that the cells in the substantia innominata were not reduced and the levels of choline acetyltransferase and somatostatin-like immunoreactivity, determined in one patient, were within normal limits. A variable degree of sponginess of the upper layers of the cortex was attributed to attrition of pyramidal cell dendrites, observed in the one patient in whom Golgi study was successful. Because of severe degeneration of the substantia nigra in all three, the disease in these patients may represent a subset of motor neuron disease or a multisystem atrophy.