Perineurial calcification

Clinicopathologic Features and Calcium Deposition Patterns in Calciphylaxis: Comparison With Gangrene, Peripheral Artery Disease, Chronic Stasis, and Thrombotic Vasculopathy

Diagnosis of calciphylaxis is crucial, yet its distinction from other vascular diseases can be challenging. Although vascular calcification and thrombosis are hallmarks of calciphylaxis, the incidence and patterns of these features in other vascular diseases have not been well characterized. The specificity of fine calcium deposits in vessel walls (identifiable on von Kossa [VK] stain only) and other extravascular calcifications is not entirely clear. We retrospectively examined the clinicopathologic features in calciphylaxis (n=27), gangrene and viable skin at amputation margin (n=20 each), chronic stasis (n=22), and thrombotic vasculopathy (n=19) to identify useful discriminators. Calcification of subcutaneous small vessels appreciable on hematoxylin and eosin stain was relatively specific for calciphylaxis, although sensitivity was low (56%). VK detected fine calcium deposits in vessel walls not appreciable on hematoxylin and eosin, however, specificity was limited by frequent finding of similar deposits in peripheral artery disease. Combining calcium deposits detected by VK and thrombosis of subcutaneous small vessels resulted in optimal sensitivity (85%) and specificity (88%) for calciphylaxis. Similar observations applied to medium-sized vessel calcification. Calcification of eccrine gland basement membranes, elastic fibers, and perineurium did not effectively distinguish calciphylaxis from other groups. Diffuse dermal angiomatosis was exclusively found in calciphylaxis in this study. In conclusion, VK is useful in enhancing the detection of vascular calcification and avoiding the false-negative diagnosis, but this finding requires concomitant subcutaneous small vessel thrombosis to support a diagnosis of calciphylaxis. Diffuse dermal angiomatosis should increase suspicion for underlying calciphylaxis and prompt deeper sampling in the appropriate clinical setting.

Structural Nerve Remodeling at 3-T MR Neurography Differs between Painful and Painless Diabetic Polyneuropathy in Type 1 or 2 Diabetes

Background The pathophysiologic mechanisms underlying painful symptoms in diabetic polyneuropathy (DPN) are poorly understood. They may be associated with MRI characteristics, which have not yet been investigated. Purpose To investigate correlations between nerve structure, load and spatial distribution of nerve lesions, and pain in patients with DPN. Materials and Methods In this prospective single-center cross-sectional study, participants with type 1 or 2 diabetes volunteered between June 2015 and March 2018. Participants underwent 3-T MR neurography of the sciatic nerve with a T2-weighed fat-suppressed sequence, which was preceded by clinical and electrophysiologic tests. For group comparisons, analysis of variance or the Kruskal-Wallis test was performed depending on Gaussian or non-Gaussian distribution of data. Spearman correlation coefficients were calculated for correlation analysis. Results A total of 131 participants (mean age, 62 years ± 11 [standard deviation]; 82 men) with either type 1 (n = 45) or type 2 (n = 86) diabetes were evaluated with painful (n = 64), painless (n = 37), or no (n = 30) DPN. Participants who had painful diabetic neuropathy had a higher percentage of nerve lesions in the full nerve volume (15.2% ± 1.6) than did participants with nonpainful DPN (10.4% ± 1.7, P = .03) or no DPN (8.3% ± 1.7; P < .001). The amount and extension of T2-weighted hyperintense nerve lesions correlated positively with the neuropathy disability score (r = 0.37; 95% confidence interval [CI]: 0.21, 0.52; r = 0.37; 95% CI: 0.20, 0.52, respectively) and the neuropathy symptom score (r = 0.41; 95% CI: 0.25, 0.55; r = 0.34; 95% CI: 0.17, 0.49, respectively). Negative correlations were found for the tibial nerve conduction velocity (r = -0.23; 95% CI: -0.44, -0.01; r = -0.37; 95% CI: -0.55, -0.15, respectively). The cross-sectional area of the nerve was positively correlated with the neuropathy disability score (r = 0.23; 95% CI: 0.03, 0.36). Negative correlations were found for the tibial nerve conduction velocity (r = -0.24; 95% CI: -0.45, -0.01). Conclusion The amount and extension of T2-weighted hyperintense fascicular nerve lesions were greater in patients with painful diabetic neuropathy than in those with painless diabetic neuropathy. These results suggest that proximal fascicular damage is associated with the evolution of painful sensory symptoms in diabetic polyneuropathy. © RSNA, 2019 Online supplemental material is available for this article.

Disruption of peripheral nerve development in a zebrafish model of hyperglycemia

Diabetes mellitus-induced hyperglycemia is associated with a number of pathologies such as retinopathy, nephropathy, delayed wound healing, and diabetic peripheral neuropathy (DPN). Approximately 50% of patients with diabetes mellitus will develop DPN, which is characterized by disrupted sensory and/or motor functioning, with treatment limited to pain management. Zebrafish ( Danio rerio) are an emerging animal model used to study a number of metabolic disorders, including diabetes. Diabetic retinopathy, nephropathy, and delayed wound healing have all been demonstrated in zebrafish. Recently, our laboratory has demonstrated that following the ablation of the insulin-producing β-cells of the pancreas (and subsequent hyperglycemia), the peripheral nerves begin to show signs of dysregulation. In this study, we take a different approach, taking advantage of the transdermal absorption abilities of zebrafish larvae to extend the period of hyperglycemia. Following 5 days of 60 mM d-glucose treatment, we observed motor axon defasciculation, disturbances in perineurial glia sheath formation, decreased myelination of motor axons, and sensory neuron mislocalization. This study extends our understanding of the structural changes of the peripheral nerve following induction of hyperglycemia and does so in an animal model capable of potential DPN drug discovery in the future.

NEW & NOTEWORTHY Zebrafish are emerging as a robust model system for the study of diabetic complications such as retinopathy, nephropathy, and impaired wound healing. We present a novel model of diabetic peripheral neuropathy in zebrafish in which the integrity of the peripheral nerve is dysregulated following the induction of hyperglycemia. By using this model, future studies can focus on elucidating the underlying molecular mechanisms currently unknown.

Acute effects of hyperglycemia on the peripheral nervous system in zebrafish (Danio rerio) following nitroreductase-mediated β-cell ablation

Diabetic peripheral neuropathy (DPN) is estimated to affect 50% of diabetic patients. Although DPN is highly prevalent, molecular mechanisms remain unknown and treatment is limited to pain relief and glycemic control. We provide a novel model of acute DPN in zebrafish ( Danio rerio) larvae. Beginning 5 days postfertilization (dpf), zebrafish expressing nitroreductase in their pancreatic β-cells were treated with metronidazole (MTZ) for 48 h and checked for β-cell ablation 7 dpf. In experimental design, this was meant to serve as proof of concept that β-cell ablation and hyperglycemia are possible at this time point, but we were surprised to find changes in both sensory and motor nerve components. Compared with controls, neurod+ sensory neurons were often observed outside the dorsal root ganglia in MTZ-treated fish. Fewer motor nerves were properly ensheathed by nkx2.2a+ perineurial cells, and tight junctions were disrupted along the motor nerve in MTZ-treated fish compared with controls. Not surprisingly, the motor axons of the MTZ-treated group were defasciculated compared with the control group, myelination was attenuated, and there was a subtle difference in Schwann cell number between the MTZ-treated and control group. All structural changes occurred in the absence of behavioral changes in the larvae at this time point, suggesting that peripheral nerves are influenced by acute hyperglycemia before becoming symptomatic. Moving forward, this novel animal model of DPN will allow us to access the molecular mechanisms associated with the acute changes in the hyperglycemic peripheral nervous system, which may help direct therapeutic approaches.

Deficiency in monocarboxylate transporter 1 (MCT1) in mice delays regeneration of peripheral nerves following sciatic nerve crush

Peripheral nerve regeneration following injury occurs spontaneously, but many of the processes require metabolic energy. The mechanism of energy supply to axons has not previously been determined. In the central nervous system, monocarboxylate transporter 1 (MCT1), expressed in oligodendroglia, is critical for supplying lactate or other energy metabolites to axons. In the current study, MCT1 is shown to localize within the peripheral nervous system to perineurial cells, dorsal root ganglion neurons, and Schwann cells by MCT1 immunofluorescence in wild-type mice and tdTomato fluorescence in MCT1 BAC reporter mice. To investigate whether MCT1 is necessary for peripheral nerve regeneration, sciatic nerves of MCT1 heterozygous null mice are crushed and peripheral nerve regeneration was quantified electrophysiologically and anatomically. Compound muscle action potential (CMAP) recovery is delayed from a median of 21 days in wild-type mice to greater than 38 days in MCT1 heterozygote null mice. In fact, half of the MCT1 heterozygote null mice have no recovery of CMAP at 42 days, while all of the wild-type mice recovered. In addition, muscle fibers remain 40% more atrophic and neuromuscular junctions 40% more denervated at 42 days post-crush in the MCT1 heterozygote null mice than wild-type mice. The delay in nerve regeneration is not only in motor axons, as the number of regenerated axons in the sural sensory nerve of MCT1 heterozygote null mice at 4 weeks and tibial mixed sensory and motor nerve at 3 weeks is also significantly reduced compared to wild-type mice. This delay in regeneration may be partly due to failed Schwann cell function, as there is reduced early phagocytosis of myelin debris and remyelination of axon segments. These data for the first time demonstrate that MCT1 is critical for regeneration of both sensory and motor axons in mice following sciatic nerve crush.

Mechanisms of diabetic neuropathy: Schwann cells

As ensheathing and secretory cells, Schwann cells are a ubiquitous and vital component of the endoneurial microenvironment of peripheral nerves. The interdependence of axons and their ensheathing Schwann cells predisposes each to the impact of injury in the other. Further, the dependence of the blood-nerve interface on trophic support from Schwann cells during development, adulthood, and after injury suggests these glial cells promote the structural and functional integrity of nerve trunks. Here, the developmental origin, injury-induced changes, and mature myelinating and nonmyelinating phenotypes of Schwann cells are reviewed prior to a description of nerve fiber pathology and consideration of pathogenic mechanisms in human and experimental diabetic neuropathy. A fundamental role for aldose-reductase-containing Schwann cells in the pathogenesis of diabetic neuropathy, as well as the interrelationship of pathogenic mechanisms, is indicated by the sensitivity of hyperglycemia-induced biochemical alterations, such as polyol pathway flux, formation of reactive oxygen species, generation of advanced glycosylation end products (AGEs) and deficient neurotrophic support, to blocking polyol pathway flux.

The nerve biopsy: indications, technical aspects, and contribution

This chapter discusses the indications for biopsying a peripheral nerve and the factors involved in justifying this decision and then deciding which nerve to take. There is a table summarizing some of the causes of neuropathy and attempting to relate these to the probability that nerve biopsy would be helpful in diagnosis. The surgical procedure for the nerve biopsy is described including aftercare and possible complications. The techniques involved in processing and staining the nerve are discussed. This section includes the possibilities of creating artefactual damage by mishandling or poor technique, and how to avoid these. Modification to the standard resin processing schedule to allow the teasing out of individual nerve fibers is briefly described, as are methods for measuring fiber density, fiber size and myelin thickness. There is also a brief discussion of the applications of immunohistochemistry. This is followed by a section on interpretation by light and electron microscopy in which some of the more important diagnostic features are described and illustrated, as are nonspecific morphological findings. Interpretation of teased fiber preparations is discussed. Finally, some common causes of incorrect interpretation are mentioned.

Microscopic anatomy: normal structure

A peripheral nerve trunk is composed of nerve fascicles supported in a fibrous collagenous sheath and defined by concentric layers of cells (the perineurium) that separate the contents (the endoneurium) from its fibrous collagen support (the epineurium). In the endoneurium are myelinated and unmyelinated fibers that are axons combined with their supporting Schwann cells to provide physical and electrical connections with end-organs such as muscle fibers and sensory endings. Axons are tubular neuronal extensions with a cytoskeleton of neurotubules and tubulin along which organelles and proteins can travel between the neuronal cell body and the axon terminal. During development some axons enlarge and are covered by a chain of Schwann cells each associated with just one axon. As the axons grow in diameter, the Schwann cells wrap round them to produce a myelin sheath. This consists of many layers of compacted Schwann cell membrane plus some additional proteins. Adjacent myelin segments connect at highly specialized structures, the nodes of Ranvier. Myelin insulates the axon so that the nerve impulse can jump from one node to the next. The region adjacent to the node, the paranodal segment, is the site of myelin terminations on the axolemma. There are connections here between the Schwann cell and the axon via a complex chain of proteins. The Schwann cell cytoplasm in the adjacent segment, the juxtaparanode, contains most of the Schwann cell mitochondria. In addition to the node, continuity of myelin lamellae is broken at intervals along the internode by helical regions of decompaction known as Schmidt-Lanterman incisures; these are seen as paler conical segments in suitably stained microscopical preparations and provide a pathway between the adaxonal and abaxonal cytoplasm. Smaller axons without a myelin sheath conduct very much more slowly and have a more complex relationship with their supporting Schwann cells that has important implications for repair.

Suffocation of Nerve Fibers by Living Nanovesicles: A Model Simulation−Part II

Nanobacteria may cause peripheral neuropathy by adhesion to the perineurium. This hypothesis receives support from five independent observations: (1) identification of perineurial apatite in diabetic patients with peripheral neuropathy, (2) massive presence of nanobacteria in a diabetic patient, (3) beneficial effect of lasers on peripheral neuropathy, (4) model simulation indicating that perineurial deposition and attachment of nanobacteria is encouraged by both their size and chemical nature, and (5) transient inhibition of neural function by apatite. Initial deposition of (stressed) nanobacteria is promoted by a slime thought to consist of proteins, calcium, and phosphate, and is most likely followed by an immobilization phase, mediated by a bioadhesive capacity of the apatite. Proteomics may hold the key to control both attachment processes.

Suffocation of Nerve Fibers by Living Nanovesicles: A Model Simulation

A model using nanospheres to allow the simulation of the nonspecific interaction of nanobacteria (NB), one with another or with body tissues, is established. Depending primarily on their concentrations and stress levels, these apatite nanovesicles may nucleate thrombogenic conglomerates in blood, or self-assemble to dense nanoclay layers on surfaces in the body. Partial or total encapsulation of nerve fiber bundles by such mineral layers may interrupt the metabolic exchanges between the surrounded tissue and its immediate environment and may restrict signaling processes. The presented model could provide detailed insight into plaque formation triggered by NB, and the parameters encouraging it.

Perineurium talin immunoreactivity decreases in diabetic neuropathy

We studied the immunolocalization of Dp116 (a 116 kDa protein product of the dystrophin gene), vinculin, talin, vimentin, desmin, spectrin and titin in the sural nerve biopsies of 25 patients with peripheral neuropathies of different origin. 4 patients presented with HMSN type 1, 4 with HMSN type 2, 2 with HNPP, 4 with CIDP, 5 with chronic axonal neuropathy of unknown origin, 3 with vasculitic neuropathy, 3 with diabetic neuropathy. Expression and localization of Dp116, vinculin, vimentin, desmin, spectrin and titin did not differ from normal control cases. Spectrin and titin immunoreactivities were absent and desmin was occasionally found in few epineurial vessels. A thin rim of Dp116 binding surrounded the outermost layer of myelin sheaths. Perineurium and epineurial vessels stained deeply for vinculin. Vimentin immunoreactivity was seen in all endoneurial, perineurial and epineurial cells. Immunoreactivity for talin was normally found at endoneurial and epineurial vessel walls, perineurial cells and epineurial fibroblasts in all the sural nerves except diabetic nerves. In the latter, whereas talin binding was normal in the vessel walls and epineurial fibroblasts, it was markedly reduced in the perineurium. On immunoblot, two bands at 235 and 190 kDa were found in the sural nerves with the antibody anti-talin, and both were reduced only in the patients with diabetic neuropathy. We postulate that decreased perineurium talin in diabetic polyneuropathy may be related to the known alterations of the tight junctions of the perineurial cells, which have been proposed to be a contributory factor to impaired permeability barrier properties.

Calcification of cervical ganglia: case report

We describe a 44-year-old woman with progressive cervical pain in whom plain films of the cervical spine showed only minor syndesmophyte formation when the patient first presented. However, after 5 weeks, repeat films demonstrated heavy symmetrical calcification of the cervical dorsal root ganglia. A review of the literature did not reveal a previous description of these findings.

Posttraumatic osseous tunnel formation causing sciatic nerve entrapment

Sciatic nerve entrapment in an osseous tunnel has only been reported twice previously. We describe a 19-year-old man evaluated for left lower limb pain and weakness that began one and one half years after sustaining stab wounds to the left buttock and midline back near the T11 vertebrae. The patient had sciatica and demonstrated motor and sensory deficits on physical exam. Electrodiagnostic studies demonstrated a localized injury to the sciatic nerve in the proximal thigh. Radiographic studies of the left pelvis and femur showed an 8 to 10cm linear opacification overshadowing the left femoral head and anatomic neck. An arteriogram of the left leg demonstrated a 3 x 4cm lobulated aneurysm arising from the distal portion of the inferior gluteal artery. Surgical exploration revealed the sciatic nerve to be encased in cylindrical bone. The ectopic bone was removed and the sciatic nerve released. The patient had gradual improvement with a nearly complete neurological recovery by three months after surgery.

[A case of primary intraneural ossification of the ulnar nerve]

The authors report a case of ossification of the ulnar nerve at the elbow. The dense bone tissue spread into the interfascicular space while the epineurium and the fasciculi were undamaged. The pathological tissue was removed and the patient recovered. No similar report has been found in the literature.

Spontaneous mineralization of the sciatic nerve of senescent rats

A spontaneous mineralization of the sciatic nerve of senescent specific pathogen-free-bred rats (aged 42 months) is reported. Deposits were found in the endoneurium of different branches of the nerve at mid-thigh level. They appeared as small discrete deposits or as large tubular-shaped concretions, probably formed by the growth and merger of the smaller deposits. Some of the concretions were found in close proximity to blood vessels. Deposits consisted of dense aggregations of randomly entangled spicules spreading within bundles of collagen fibrils. Calcium was detected by histochemistry and X-ray dispersion microanalysis. Phosphorus was also found, possibly associated with calcium to form hydroxyapatite.

Disruption of cellular elements and water in neurotoxicity: studies using electron probe X-ray microanalysis

Regulation of elements and water in nerve cells is a complex, multifaceted process which appears to be vulnerable to neurotoxic events. However, much of our knowledge concerning the potential role of elements in nerve cell injury is limited by the relatively gross level of corresponding analyses. If we are to confirm and understand the proposed role, more precise and detailed information is needed. As indicated in this commentary, research employing electron probe microanalysis and digital X-ray imaging has begun to provide this necessary information. Recent EPMA studies of nerve and glial cells in the peripheral and central nervous systems have shown that each cell type and their corresponding morphologic compartments exhibit unique distributions of elements and water. The use of microprobe analysis has allowed us to document precisely how elements and water redistribute in morphological compartments of damaged nerve cells. Accumulating evidence from EPMA studies suggests that, rather than being an epiphenomenon, intracellular changes in diffusible elements might mediate the functional and structural consequences of neurotoxic insult. It is also evident from this research that elements other than Ca might play a pertinent role in the injury response and that changes in intraneuronal elemental composition might develop according to a specific temporal pattern, e.g., transection-induced sequential alterations in axonal K, Na, Cl, and Ca. Therefore, rather than conducting end-point studies, longitudinal investigations are necessary to define the sequential pattern of elemental perturbation associated with a given neurotoxic event. Such research can also help identify the role of individual elements in the injury response. Future microprobe studies should be combined with measurements of ion levels (e.g., using fura-2 or ion selective electrodes) to provide a comprehensive and dynamic view of elemental deregulation. In addition, parallel biochemical studies should be performed to determine mechanisms of elemental disruption and possible biochemical and metabolic consequences of this disruption. Although evidence presented in this commentary suggests that each type of neurotoxic event produces a characteristic pattern of decompartmentalization, further work is necessary to confirm this possibility. Finally, based on a presumed involvement of elements in nerve injury, efforts are currently underway in several laboratories to develop appropriate pharmacological therapies for certain chemical- and trauma-induced neuropathological conditions (Dretchen et al., 1986; El-Fawal et al., 1989; Beattie et al., 1989).(ABSTRACT TRUNCATED AT 400 WORDS)

Taxol-induced neuropathy after nerve crush: long-term effects on Schwann and endoneurial cells

The present investigation is a continuation of previous studies showing taxol-induced changes up to 4 weeks after a nerve crush. To evaluate the long-term cellular response to taxol, we have extended our morphological analysis of these changes in the taxol-treated nerve crush for up to 40 weeks after a single injection of taxol (PI). The results showed that Schwann cells exhibited a long-lasting and marked response when taxol was injected into the crushed peripheral nerve. During the first 2 months PI, taxol-induced giant axonal bulbs showed the formation of primitive nodes of Ranvier as a result of Schwann cell invaginations. The Schwann cell invaginations developed into nodes of Ranvier after 3-4 months PI together with the recovery of axonal bulbs. Ultrastructurally, cytoplasmic microtubule-related abnormalities were numerous up to 3 months PI and microtubules were seen to enclose degenerative myelin. Taxol-induced abnormalities in Schwann cells did not prevent their ability to produce myelin sheaths, although the accumulation of microtubules between myelin lamellae caused swellings of Schmidt-Lanterman incisures and paranodal myelin loops. Abnormal, extracellular collagen-like 5-nm-thin fibrils were noted closely associated with Schwann cells up to 10 weeks PI. Endoneurial cells, present as long rows without interconnections were noted in areas devoid of axonal sprouts up to 6-8 weeks PI. These cells showed marked cytoplasmic elongations and were covered by thickened basal lamina and contained several microtubule-related cytoplasmic structures, some of which have not been described previously. Taxol, when injected into crushed sciatic nerve induced a long-lasting response upon the Schwann cells with several ultrastructural abnormalities which correlate with changes in myelination and the development of nodes of Ranvier. These findings suggest that normal microtubule turnover is necessary for Schwann cells during nerve fiber regeneration.