Inverse pattern of GABAergic system impairment in the external versus internal globus pallidus in male heroin addicts

Opioid addiction is a global problem that has been exacerbated in the USA and Europe by the COVID-19 pandemic. The globus pallidus (GP) plays a prominent neurobiological role in the regulation of behaviour as an output station of the striato-pallidal system. GABAergic large projection neurons are the main neuronal type in the external (EGP) and internal (IGP) parts of the GP, where addiction-specific molecular and functional abnormalities occur. In these neurons, glutamate decarboxylase (GAD) with isoforms GAD 65 and 67 is a key enzyme in GABA synthesis, and experimental studies suggest GAD dysregulation in the GP of heroin addicts. Our study, which was performed on paraffin-embedded brains from the Magdeburg Brain Bank, aimed to investigate abnormalities in the GABAergic function of large GP neurons by densitometric evaluation of their GAD 65/67-immunostained thick dendrites. The study revealed a bilaterally decreased fibres density in the EGP paralleled by the increase in the IGP in 11 male heroin addicts versus 11 healthy controls (significant U-test P values). The analysis of confounding variables found no interference of age, brain volume, and duration of formalin fixation with the results. Our findings suggest a dysregulation of GABAergic activity in the GP of heroin addicts, which is consistent with experimental data from animal models and plays potentially a role in the disturbed function of basal ganglia circuit in opioid addiction.

Ribosomal DNA transcription is increased in the left nucleus accumbens of heroin-dependent males

Opioid addiction is a worldwide problem accentuated in the USA and European countries by the COVID-19 pandemic. The nucleus accumbens (NAc) plays an outstanding neurobiological role in opioid addiction as a part of the striatum and key component of brain reward system. The striatal GABAergic medium spiny projection neurons (MSNs) are the main neuronal type in the NAc where addiction-specific synaptic plasticity occurs. The activity of ribosomal DNA (rDNA) transcription is crucial for neural plasticity and molecular studies suggest its increase in the NAc of heroin addicts. Silver-stained argyrophilic nucleolar organizer region (AgNOR) areas visualised in neuronal nuclei in paraffin-embedded brain sections are reliable morphological estimators of rDNA transcription and thus surrogate markers for the activity of brain regions. Our study revealed increased AgNOR areas in MSNs of the left NAc in 11 heroin addicts versus 11 healthy controls from the Magdeburg Brain Bank (U-test P = 0.007). No differences were observed in another investigated part of the striatum, namely the head of caudate nucleus, which is located closely to the NAc. The results were not confounded by significant differences in the age, brain volume and time of formalin fixation existing between compared groups. Our findings suggest an increased NAc activity in heroin addicts, which is consistent with human and animal experimental data.

Insulin-regulated aminopeptidase immunoreactivity is abundantly present in human hypothalamus and posterior pituitary gland, with reduced expression in paraventricular and suprachiasmatic neurons in chronic schizophrenia

The vasopressin- and oxytocin-degrading enzyme insulin-regulated aminopeptidase (IRAP) is expressed in various organs including the brain. However, knowledge about its presence in human hypothalamus is fragmentary. Functionally, for a number of reasons (genetic linkage, hydrolysis of oxytocin and vasopressin, its role as angiotensin IV receptor in learning and memory and others) IRAP might play a role in schizophrenia. We studied the regional and cellular localization of IRAP in normal human brain with special emphasis on the hypothalamus and determined numerical densities of IRAP-expressing cells in the paraventricular, supraoptic and suprachiasmatic nuclei in schizophrenia patients and controls. By using immunohistochemistry and Western blot analysis, IRAP was immunolocalized in postmortem human brains. Cell countings were performed to estimate numbers and numerical densities of IRAP immunoreactive hypothalamic neurons in schizophrenia patients and control cases. Shape, size and regional distribution of IRAP-expressing cells, as well the lack of co-localization with the glia marker glutamine synthetase, show that IRAP is expressed in neurons. IRAP immunoreactive cells were observed in the hippocampal formation, cerebral cortex, thalamus, amygdala and, abundantly, hypothalamus. Double labeling experiments (IRAP and oxytocin/neurophysin 1, IRAP with vasopressin/neurophysin 2) revealed that IRAP is present in oxytocinergic and in vasopressinergic neurons. In schizophrenia patients, the numerical density of IRAP-expressing neurons in the paraventricular and the suprachiasmatic nuclei is significantly reduced, which might be associated with the reduction in neurophysin-containing neurons in these nuclei in schizophrenia. The pathophysiological role of lowered hypothalamic IRAP expression in schizophrenia remains to be established.

Differential regional and cellular distribution of TFF3 peptide in the human brain

TFF3 is a member of the trefoil factor family (TFF) predominantly secreted by mucous epithelia. Minute amounts are also expressed in the immune system and the brain. In the latter, particularly the hypothalamo-pituitary axis has been investigated in detail in the past. Functionally, cerebral TFF3 has been reported to be involved in several processes such as fear, depression, learning and object recognition, and opiate addiction. Furthermore, TFF3 has been linked with neurodegenerative and neuropsychiatric disorders (e.g., Alzheimer's disease, schizophrenia, and alcoholism). Here, using immunohistochemistry, a systematic survey of the TFF3 localization in the adult human brain is presented focusing on extrahypothalamic brain areas. In addition, the distribution of TFF3 in the developing human brain is described. Taken together, neurons were identified as the predominant cell type to express TFF3, but to different extent; TFF3 was particularly enriched in various midbrain and brain stem nuclei. Besides, TFF3 immunostaining staining was observed in oligodendroglia and the choroid plexus epithelium. The wide cerebral distribution should help to explain its multiple effects in the CNS.

Increased densities of nitric oxide synthase expressing neurons in the temporal cortex and the hypothalamic paraventricular nucleus of polytoxicomanic heroin overdose victims: possible implications for heroin neurotoxicity

Heroin is one of the most dangerous drugs of abuse, which may exert various neurotoxic actions on the brain (such as gray matter loss, neuronal apoptosis, mitochondrial dysfunction, synaptic defects, depression of adult neurogenensis, as well as development of spongiform leucoencephalopathy). Some of these toxic effects are probably mediated by the gas nitric oxide (NO). We studied by morphometric analysis the numerical density of neurons expressing neuronal nitric oxide synthase (nNOS) in cortical and hypothalamic areas of eight heroin overdose victims and nine matched controls. Heroin addicts showed significantly increased numerical densities of nNOS immunoreactive cells in the right temporal cortex and the left paraventricular nucleus. Remarkably, in heroin abusers, but not in controls, we observed not only immunostained interneurons, but also cortical pyramidal cells. Given that increased cellular expression of nNOS was accompanied by elevated NO generation in brains of heroin addicts, these elevated levels of NO might have contributed to some of the known toxic effects of heroin (for example, reduced adult neurogenesis, mitochondrial pathology or disturbances in synaptic functioning).

Nardilysin in human brain diseases: both friend and foe

Nardilysin is a metalloprotease that cleaves peptides, such as dynorphin-A, α-neoendorphin, and glucagon, at the N-terminus of arginine and lysine residues in dibasic moieties. It has various functionally important molecular interaction partners (heparin-binding epidermal growth factor-like growth factor, tumour necrosis factor-α-converting enzyme, neuregulin 1, beta-secretase 1, malate dehydrogenase, P42(IP4)/centaurin-α1, the histone H3 dimethyl Lys4, and others) and is involved in a plethora of normal brain functions. Less is known about possible implications of nardilysin for brain diseases. This review, which includes some of our own recent findings, attempts to summarize the current knowledge on possible roles of nardilysin in Alzheimer disease, Down syndrome, schizophrenia, mood disorders, alcohol abuse, heroin addiction, and cancer. We herein show that nardilysin is a Janus-faced enzyme with regard to brain pathology, being probably neuropathogenic in some diseases, but neuroprotective in others.

Accidental mechanical asphyxia of children in Germany between 2000 and 2008

Accidents constitute one of the greatest risks to children, yet there are few medical reports that discuss the subject of accidental asphyxia. However, a systematic analysis of all documented cases in Germany over the years 2000-2008 has now been conducted, aiming at identifying patterns of accidental asphyxia, deducing findings, defining avoidance measures and recommending ways of increasing product safety and taking possible precautions. The analysis is based on a detailed retrospective analysis of all 91 relevant autopsy reports from 24 different German forensic institutes. A variety of demographic and morphological data was systematically collected and analysed. In 84 of the 91 cases, the sex of the victim was reported, resulting in a total of 57 boys (68 %) and 27 girls (32 %). The age spread ranged between 1 day and 14 years, with an average of 5.9 years. Most accidents occurred in the first year of life (20 %) or between the ages of 1 and 2 years (13 %). In 46 % of cases, the cause of death was strangulation, with the majority occurring in the home environment. In 31 % of all cases, the cause of death was positional asphyxia, the majority resulting from chest compression. In 23 % of cases, the cause of death was aspiration, mainly of foreign bodies. Today, accidental asphyxiation is a rare cause of death in children in Germany. Nevertheless, the majority of cases could have been avoided. Future incidence can be reduced by implementing two major precautions: increasing product safety and educating parents of potentially fatal risks. Specific recommendations relate to children's beds, toys and food.

["Natural" death of a person under the care of a custodian]

An ambulance service doctor was called to the death of a 76-year-old woman and attested cardiac arrest and psycho-organic brain syndrome as the cause of death on the death certificate. At the second external examination mandatory before cremation, extensive hematomas were detected on the right thorax and multiple haematomas in the face and on the forehead. The autopsy initially ordered by the public health officer revealed serial rib fractures and a fractured skull. After notifying the prosecutor, a forensic autopsy was ordered and death was found to have been caused by fat embolism following massive blunt force to the thorax with serial rib fractures and haematopneumothorax. After that, the adopted son, who had been appointed care custodian for the woman, and his wife were suspected, because they had given contradictory explanations for the injuries. At first, they were only suspected of failure to render assistance, but in the end they were both charged with murder. Only because of the second external examination prescribed by the law still in force could the errors of the improper first external examination be corrected.

A morphometric analysis of the septal nuclei in schizophrenia and affective disorders: reduced neuronal density in the lateral septal nucleus in bipolar disorder

The septal nuclei are assumed to play a significant role in the pathophysiology of schizophrenia and affective disorders. The aim of this study was to morphometrically characterize the septal nuclei in patients with schizophrenia, bipolar disorder, and major depressive disorder, when compared with healthy control subjects. We analyzed the septal nuclei by determining the density and size of the neurons in postmortem brains in 17 patients with schizophrenia, 8 patients with bipolar disorder, 7 patients with major depressive disorder, and 14 control subjects matched for age and gender. There was a significant reduction in the neuronal density, but not in the mean cross-sectional area, in the lateral septal nucleus (P = 0.013) in patients with bipolar disorder when compared with control subjects. There were no significant changes in the neuronal density of the septal nuclei of the medial and lateral cell groups in patients with schizophrenia and major depressive disorder when compared with control subjects. There was a significant negative correlation between neuronal density in the lateral septal nucleus and disease duration in patients with major depressive disorder (P = 0.037, r = -0.9). The histopathological abnormality of the decreased neuronal density in the lateral septal nucleus, which is an important limbic region involved in emotions, might be a neuropathological correlate of bipolar disorder.

Demonstration of disturbed activity of the lateral amygdaloid nucleus projection neurons in depressed patients by the AgNOR staining method

BACKGROUND

The aim to find a morphological biomarker of disturbed activity of the lateral amygdaloid nucleus in depression was approached by a karyometric analysis of projection neurons.

METHODS

The study was performed on paraffin-embedded brains from 19 depressed patients from both the major depressive disorder (MDD) and the bipolar disorder (BD) diagnostic groups, including 10 suicides, and 24 matched controls. The karyometric parameters of the lateral amygdaloid nucleus (La) projection neurons bilaterally were evaluated by the argyrophilic nucleolar organiser region (AgNOR) silver staining method.

RESULTS

An increased AgNOR number was found in the right La in suicides compared to controls. The intra-group comparisons between the hemispheres suggest a disturbed amygdaloid lateralisation in depressed patients. The effects were independent from psychotropic medication. There was a strong positive correlation between the nuclear area in La projection neurons and prefrontal limbic areas pyramidal neurons in the right hemisphere specific for suicide and MDD.

LIMITATIONS

A major limitation of this study is the relatively small number of cases. A further limitation is given by the lack of data on drug exposure across the entire lifespan.

CONCLUSION

The results suggest that depressed patients from both the MDD and BD diagnostic groups exhibit an increased activity of the La output neurons specific for suicidal patients. The distinctness of the diagnostic groups of mood disorders was accentuated in the correlation analysis. This putative hyperactivity was specific for the right hemisphere and psychotropic medication most likely did not counteract it.

[Suicidal extraneurocranial shot into the mouth]

A case of a 51-year-old man who killed himself with a pistol-shot into his mouth is reported. The track of the bullet passed exactly in the median level completely extraneurocranially; the cause of death was a subtotal destruction of the cervical spinal cord (C2/C3). The synoptic assessment of the scene of death, the autopsy findings, the results of the securing of evidence and the criminological investigations allowed for drawing the only conclusion that the man had committed suicide.

Demonstration of disturbed activity of external globus pallidus projecting neurons in depressed patients by the AgNOR staining method

BACKGROUND

The external globus pallidus (EGP) is thought to play the most important integrating and conveying role in the striatopallidal system involved in the transfer from motivation to action. The aim to find a morphological biomarker of disturbed EGP activity in depression was approached by the karyometric analysis of large projecting neurons.

METHODS

The study was performed on paraffin-embedded brains from 19 depressed patients from both the major depressive disorder (MDD) and the bipolar disorder (BD) diagnostic groups encompassing 10 suicides and from 24 controls. The karyometric parameters of EGP neurons bilaterally were evaluated by argyrophilic nucleolar organiser (AgNOR) silver staining method.

RESULTS

A significantly decreased AgNOR area was found in the left EGP neurons in depressed patients compared to controls. The distinctness of the diagnostic groups and suicidal vs non-suicidal patients was not shown in the statistical comparisons. The AgNOR parameter which was decreased correlated positively with the mean dose of benzodiazepines in non-suicidal patients.

LIMITATIONS

A major limitation of this study is the relatively small number of cases. A further limitation is given by the lack of data on drug exposure across the whole lifespan of patients.

CONCLUSION

The results suggest disturbed, most likely decreased, activity of the left EGP projecting neurons in depressed patients, a disturbed activity that should hypothetically be counteracted by the applied pharmacotherapy in non-suicidal patients.

Demonstration of disturbed activity of orbitofrontal pyramidal neurons in depressed patients by the AgNOR staining method

BACKGROUND

The aim to find the morphological biomarker of disturbed activity of the orbitofrontal cortex (OFC) in depression was approached by the karyometric analysis of pyramidal neurons.

METHODS

The study was performed on paraffin-embedded brains from 19 depressed patients from both major depressive disorder (MDD) and bipolar disorder (BD) diagnostic groups, including 9 suicides, and 24 matched controls. The karyometric parameters of medial OFC layer III and V pyramidal neurons bilaterally were evaluated by argyrophilic nucleolar organiser region (AgNOR) silver staining method.

RESULTS

The enlarged nuclear area was found in layer V pyramidal neurons in the right OFC in non-suicides compared to suicides and controls, which was most likely the effect of neuroleptics. The intra-group comparisons between the hemispheres suggest the disturbed orbitofrontal lateralisation in depressed patients (predominantly in suicides) with moderate distinctness of the MDD and the BD diagnostic groups.

LIMITATIONS

A major limitation of this study is a relatively small number of cases. A further limitation is given by the lack of data on drug exposure across the whole lifespan.

CONCLUSION

The results suggest disturbed activity of OFC pyramidal neurons in depression, distinct in suicide and the diagnostic groups of mood disorders. The non-suicidal patients seem to benefit from neuroleptics, which most likely increase the activity of the subpopulation of OFC pyramidal neurons.

Suicide and depression in the quantitative analysis of glutamic acid decarboxylase-Immunoreactive neuropil

BACKGROUND

Alterations of GABAergic neurotransmission are assumed to play a crucial role in the pathophysiology of mood disorders. Glutamic acid decarboxylase (GAD) is the key enzyme of GABA synthesis.

METHODS

Immunohistochemical staining of GAD 65/67 was performed in the orbitofrontal, anterior cingulate and dorsolateral prefrontal cortex (DLC), the entorhinal cortex (EC), the hippocampal formation, and the medial dorsal and lateral dorsal thalamic nuclei, with consecutive determination of GAD-immunoreactive (-ir) neuropil relative density. The study was performed on paraffin-embedded brains from 21 depressed patients (14 of whom had committed suicide) and 18 matched controls. The data were tested using Kruskal-Wallis, Mann-Whitney (U) and Spearman statistical procedures.

RESULTS

As shown by post-hoc U-tests, an increase in the relative density of GAD-ir neuropil was present in the hippocampal formation, specific for suicidal patients. The EC was the only area where non-suicidal patients also revealed an increase compared with controls. On the contrary, the DLC was the only area where a significant decrease existed, specific for non-suicidal patients. Numerous negative correlations were found between the investigated parameter and psychotropic medication.

LIMITATIONS

A major limitation of this study is the relatively small case number. A further limitation is given by the lack of data on drug exposure across the whole life span. The possible impact of unipolar-bipolar dichotomy of mood disorders on the obtained results should also be considered.

CONCLUSION

The study, revealing predominantly an increased relative density of GAD-ir neuropil, suggests the diathesis of GABAergic system specific for depressed suicidal patients.

Demonstration of decreased activity of dorsal raphe nucleus neurons in depressed suicidal patients by the AgNOR staining method

BACKGROUND

Suicide and depression are closely related yet distinct phenomena. In both these phenomena, research has focused on central serotonergic system disturbances. The dorsal raphe nucleus (DRN) is the main source of serotonergic innervation of limbic structures crucial for the regulation of emotionally influenced behaviour.

METHODS

The study was carried out on paraffin-embedded brains from 23 depressed patients (12 suicides and 11 non-suicides) and 26 matched controls without mental disorders. The karyometric parameters of DRN neurons were evaluated by the AgNOR silver staining method.

RESULTS

The significant effect of suicide on the nuclear area was found in the cumulative analysis of all DRN subnuclei (ANOVA, P=0.032). A decreased mean value of this parameter was observed in the suicides group versus controls (t-test, P=0.032). This effect was especially pronounced in the violent suicide victims (t-test, P=0.001), who also demonstrated a decreased AgNOR area versus controls (t-test, P=0.007). No significant effect of depression or polarity on AgNOR parameters was found.

LIMITATIONS

A major limitation of this study is relatively small case number. A further limitation is given by the lack of data on drug exposure across the whole life span.

CONCLUSION

Our findings suggest that hypoactivity of DRN neurons is a distinct phenomenon in depression, specific only for suicidal subgroup of depressed patients.

The changes of AgNOR parameters of anterior cingulate pyramidal neurons are region-specific in suicidal and non-suicidal depressive patients

The anterior cingulate cortex (AC) is consistently implicated in the pathophysiology of depression. While suicide has been shown in previous reports to be closely related to depression, it is still a distinct phenomenon. The aim to differentiate between depression and suicide was approached by the karyometric analysis of AC pyramidal neurons. The study was performed on paraffin-embedded brains from 20 depressive patients (10 of whom had committed suicide) and 24 matched controls. The karyometric parameters of the layer III and V pyramidal neurons of the dorsal and ventral AC were evaluated bilaterally by Argyrophilic Nucleolar Organiser (AgNOR) silver staining method. Control-specific was the increased nuclear area in ontogenetically younger pyramidal neurons layer III in the left dorsal compared with ventral AC (Wilcoxon test, P<0.01). The decreased AgNOR number per nucleus in these cells in the right ventral AC was depression-specific compared with controls (t-test, P=0.047). On the other hand, the diffuse decrease in AgNOR ratio throughout pyramidal neurons on the left side was specific for suicidal depressive patients compared with non-suicidal patients and controls (ANOVA, P=0.028). The results suggest that regionally differentiated depression- and suicide-specific disturbed function of the most important AC output cells exists in depressive patients.

Regional and cellular distribution patterns of insulin-degrading enzyme in the adult human brain and pituitary

The regional distribution and cellular localization of insulin-degrading enzyme (IDE) was studied in adult human brain and pituitary by means of immunhistochemistry. We show that the enzyme is widely but unevenly distributed in human brain, with hypothalamic neurons showing the strongest immunoreaction. Strong to moderate immunostaining for the enzyme was observed in multiple cortical areas, hippocampus, cerebellum, and brain stem. Cellularly, IDE was mainly confined to neurons, but it was also present in oligodendrocytes, choroid plexus, and some blood vessel endothelial cells. A strong immunoreaction was seen in a subset of adenohypophysial cells. Some immunolabeling was also present in the neurohypophysis. The putative importance of the distribution of the enzyme in brain and pituitary is discussed in relation to its main known substrates, insulin, Abeta, and beta-endorphin.

The changes in AgNOR parameters of dorsal raphe nucleus neurons are related to suicide

Depression has been established as the main cause of suicide and the research has concentrated on disturbed central serotonergic system in both disorders. The dorsal raphe nucleus (DRN) of brain stem is the main source of serotonergic innervation of limbic structures fundamental in the regulation of emotionally influenced behavior. The study was carried out on paraffin-embedded brains from 10 depressive patients, among them 5 suicides and 5 non-suicides and 13 matched mentally healthy controls. The karyometric parameters of DRN neurons were evaluated by AgNOR (Argyrophilic Nucleolar Organizer) silver staining method. The significant effect of suicide on nuclear area and AgNOR-ratio found in the cumulative analysis of all DRN subnuclei could be relevant for forensic diagnostic. The results suggest DRN neurons hypoactivity specific for suicide. Whether observed phenomenon is a "common trait" existing also in other diagnostic groups of mental disorders remains an open question.

Histochemical evidence for wide expression of the metalloendopeptidase nardilysin in human brain neurons

Nardilysin is a metalloendopeptidase that in vitro cleaves peptides such as dynorphin-A, somatostatin-28, alpha-neoendorphin and glucagon at the N-terminus of arginine and lysine residues in dibasic moieties. The enzyme is highly expressed in many endocrine tissues. Nardilysin has also been found in the brain. Previously, we have detected that nardilysin interacts with brain-specific proteins, i.e. p42(IP4)/centaurin-alpha1 [Stricker R, Chow KM, Walther D, Hanck T, Hersh LB, Reiser G (2006) Interaction of the brain specific protein p42(IP4)/centaurin-alpha1 with the peptidase nardilysin is regulated by the cognate ligands of p42(IP4), PtdIns(3,4,5)P(3) and Ins(1,3,4,5)P(4), with stereospecificity. J Neurochem 98:343-354]. However, very little is known about the distribution of nardilysin in the brain. The aim of the present study was to reveal its regional distribution and cellular localization in developing and adult human brain. Using immunohistochemistry and Western blot analysis we demonstrate that the enzyme is widely, but unevenly, expressed in the human brain. We found high staining intensity in the hypothalamus, neocortex and brain stem nuclei. The cellular localization is almost exclusively confined to neurons. In pre- and perinatal human brain cortex, most neurons express the enzyme. In cortical neurons nardilysin protein was found to be partially co-localized with parvalbumin but not calretinin. No co-expression was seen with somatostatin-28 immunoreactivity. A considerable overlap was revealed between p42(IP4) and nardilysin. Our data support the hypothesis that nardilysin might possibly play a role in brain development, whereas its putative function in brain peptide metabolism remains to be clarified further.

Volumetric analysis of septal region in schizophrenia and affective disorder

MRI and post-mortem studies indicate an increased prevalence of cavum septi pellucidi (CSP) in schizophrenia and affective disorder. The aim of this study was to characterize the CSP and the septal tissue among patients with schizophrenia, patients with affective disorder, and control subjects. The volumes of CSP and septal tissue were measured in post-mortem brains in 42 patients with schizophrenia, 14 patients with affective disorder, and 17 normal control cases by planimetry of serial sections. Enlargements of CSP (>100 mm(3)) were found in eight of the 42 (19%) patients with schizophrenia. There were no significant differences in CSP volumes between patients with affective disorder and controls. Enlarged CSP in schizophrenia were not associated with reduced septal tissue volumes. By contrast, a significant positive correlation between volumes of CSP and septal tissue volumes in patients with schizophrenia (P = 0.03) and in control cases (P < 0.01) was found, but not in patients with affective disorder (P = 0.53). The finding of enlarged CSP in schizophrenia strongly supports the hypothesis of an early developmental abnormality in this key structure of the limbic system.

Fibromuscular dysplasia of the basilar artery: an unusual case with medico-legal implications

A 28-year-old male car driver was reported to suddenly loose the control over his vehicle, to hit the right and middle crash barrier, and to be unconscious as the car came to a halt in a position at right angles to the road. The car was hit in its left side by an automobile with high velocity, and the 28-year-old driver died. Examination of the brain revealed a massive isolated basal subarachnoid hemorrhage and a complete tearing of the basilar artery. A macroscopically detectable aneurysm was not found. However, histological examination of the large arteries at the base of the brain showed (i) fibromuscular dysplasia (FMD) mostly involving the basilar artery (ii) with a ruptured micro-aneurysm in its upper third part. The observations of the eye witnesses that the driver initially lost control over his car were judged in favour of the accused to be due to that rupture of the micro-aneurysm, while complete transverse tearing of the basilar artery occurred during the car crash due to hyperextension and rotation of his neck. Intracranial FMD is a rare cause in the differential diagnosis of isolated basal subarachnoid hemorrhage. The medico-legal implications of this entity are described in the presented case.

Dysregulation of GABAergic Neurotransmission in Mood Disorders: A Postmortem Study

Alterations of GABAergic neurotransmission are assumed to play a crucial role in the pathophysiology of mood disorders. Gamma-aminobutyric acid (GABA) acts via binding to A and B receptors, whereas the B receptor is G protein-coupled. Glutamic acid decarboxylase (GAD) is the key enzyme of GABA synthesis. Immunohistochemical staining of GAD 65/67-immunoreactive neurons was performed in dorsolateral prefrontal cortex, orbitofrontal cortex, anterior cingulate cortex, superior temporal cortex, hippocampus formation, and mediodorsal thalamus with consecutive determination of neuronal density in 20 brains of patients with mood disorders (P) and 19 controls (C). In the patients' group were 11 patients with bipolar disorder (BD) and 9 patients with major depressive disorder (MDD). The data were tested statistically using analysis of variance (ANOVA) and post hoc Tukey tests. ANOVA revealed significant differences among the groups (C, BD, MDD) in dorsolateral prefrontal cortex, orbitofrontal cortex, superior temporal cortex, and hippocampus. Post hoc tests demonstrated higher neuronal densities in unipolar patients compared with bipolar patients and controls in dorsolateral prefrontal cortex, superior temporal cortex, and hippocampus. In the orbitofrontal cortex, a higher neuronal density was found in bipolar and unipolar patients compared with controls. In mood disorder patients, dose equivalents of antidepressants given prior to death correlated positively with the neuronal density in superior temporal cortex and hippocampus. The current data on GAD 65/67 point to a dysregulation of the GABAergic system in mood disorders. Possibly, existing deficits of GABAergic neurotransmission will be compensated or overcompensated by antidepressants. Additionally, albeit speculative, an imbalance between GABA production and transport might be of relevance.

Perforation of the pulmonary artery by a bronchial wall stent

Implantation of stents into the bronchial walls is a newly developed method to treat lung emphysema, which is now being tested clinically. During this procedure, a bronchoscope carrying a Doppler ultrasonography head is placed into a segmental bronchus and the blood vessels running in parallel to the bronchus are localized. Once a safe location without blood vessels is found, the bronchial wall is perforated and a stent is placed within the wall to improve the expiratory volume of these "bypasses" to the adjacent lung parenchyma. We observed a fatal complication with this method in a 60-year-old man. The bronchial wall and the pulmonary artery were perforated by one of the stents inducing massive bleeding, which could not be stopped. The patient died due to aspiration of blood in combination with massive loss of blood. The general risk to perforate the pulmonary artery during this procedure cannot be estimated from this single observation but should be considered regarding the legal and clinical aspects.

Volume deficits of subcortical nuclei in mood disorders A postmortem study

Structural changes in subcortical nuclei may underlie clinical symptoms of mood disorders. The goal was to determine whether macrostructural changes exist in brain areas assumed to be involved in regulation of mood and whether such changes differ between major depressive disorder and bipolar disorder. A case-control design was used to compare volumes of all major subcortical nuclei. Brains of patients with major depressive disorder (n = 9) or bipolar disorder (n = 11) or of individuals without a neuropsychiatric disorder (n = 22) were included. Exclusion criteria were a history of substance abuse or histological signs of neurodegenerative disorders. Volumes of the striato-pallidal nuclei, of the hypothalamus, thalamus, amygdala, hippocampus and basal limbic forebrain were determined in the right and left hemisphere by planimetry of 20 mum whole brain serial paraffin sections. Comparisons between patients with bipolar disorder, major depressive disorder and controls showed a significant (Lambda = 0.35, F(20,56) = 1.93, P = 0.028) overall difference in volumes of all investigated regions with strong effect sizes ( f > 0.40) contributed by the hypothalamus, external pallidum, putamen and thalamus. As compared to controls, a strong effect size (f > 0.40) was found in the bipolar group for smaller volumes of the hypothalamus, external pallidum, putamen and thalamus,whereas in patients with major depressive disorder a strong effect size was only found for a smaller volume of the external pallidum. In conclusion our data suggest that pathways presumably involved in mood regulation have structural pathology in affective disorders with more pronounced abnormalities in bipolar disorder.

Differences in activation of the dorsal raphe nucleus depending on performance of suicide

The serotonergic system has been implicated in the pathogenesis of mood disorders as well as in suicidal behavior. It is unknown, however, whether raphe neurons, which are mostly serotonergic, show altered activity in patients with mood disorders who complete suicide as compared to those without suicidal behavior. In order to measure cellular markers of serotonergic activity in the dorsal raphe nucleus in brains of 12 people with mood disorders and of 12 controls (C), stereological measurements were carried out of nucleolar organizer regions (AgNORs) and of serotonergic neuron numbers. Six patients died from suicide (S) and the other six patients died from natural causes (NS). Results were assessed using ANOVA and post hoc Tukey-HSD tests looking for effects of diagnostic group (S, NS, C). Results show that in the rostral subnuclei of the dorsal raphe there was a significant effect of diagnostic group on the ratios of the nucleolar organizer regions to nuclear area (NOR ratio) and a nearly significant effect on numbers of serotonergic neurons. Post hoc tests revealed larger values for those dependent variables in S compared to NS. Dose equivalents of antidepressants correlated positively with NOR ratios and numbers of serotonergic neurons in the rostral part of the dorsal raphe. In conclusion, the present data suggest that there are functional differences in the dorsal raphe of patients with mood disorders depending on suicidal behavior. Antidepressants appear to contribute to cellular activation in the rostral part of the dorsal raphe.

Circumscribed numerical deficit of dorsal raphe neurons in mood disorders

BACKGROUND

Neurocircuits comprising limbic, striato-pallidal and thalamo cortical brain areas are assumed to be involved in the pathophysiology of mood disorders. All these brain regions receive serotonergic afferents arising from the rostral raphe, mainly the dorsal raphe. Although serotonergic systems appear to be involved in the pathology of mood disorders, there is uncertainty as to whether structural alterations in raphe nuclei exist alongside a functional dysregulation of the serotonergic system.

METHODS

In the brains of 12 patients with mood disorders (major depressive disorder N= 6, bipolar disorder N = 6) and 12 normal subjects we performed a morphometric post-mortem study on neuronal morphology in all subnuclei of the dorsal raphe nucleus using Nissl stained 20 microm axial serial sections of the brainstem.

RESULTS

The number of neurones of the ventrolateral subnucleus of the dorsal raphe was reduced by 31 % in patients with mood disorders compared with non-psychiatric control subjects. Ventrally located subnuclei of the rostral dorsal raphe (ventrolateral, ventral, interfascicular) taken together also showed a smaller number of neurones. Neurone numbers of the dorsal and the caudal subnucleus and volumes of all single subnuclei appeared to be unchanged. Analysis of morphological neuronal types revealed a smaller number of triangular neurones in the ventrolateral subnucleus. Numbers of ovoid and round neurones in the ventrolateral subnucleus also showed a trend to reduction. No correlation was found between neurone numbers in any subnucleus of the dorsal raphe and duration of illness. Neurone numbers did not differ in any subnucleus between patients with unipolar and those with bipolar affective disorder.

CONCLUSIONS

Results indicate that patients with primary mood disorders have a circumscribed numerical neuronal deficiency in the dorsal raphe. This structural deviation may contribute to impaired serotonergic innervation of brain regions which are involved in the pathology of mood disorders.

Unusual explanation for the death of a car passenger

After collision of a car with the left rearside against a steel mast the 19-year-old front seat passenger was found comatose on the seat. CT imaging showed a depression fracture parietal on the left with an intracerebral haemorrhage on the opposite side. The cause of the injury was unknown to the surgeons at the time of operation. Despite neurosurgical intervention the patient died 24 h after the accident. The post-mortem showed an additional depression fracture at the base of the skull in the right temporal region arousing suspicion of an impalement injury. Only inspection of the car by the forensic pathologists revealed the gas pressure telescopic shock absorber to be the cause of the head injury.

Non-lethal penetrating cardiac injury from a crossbow bolt

Crossbow injuries to the thorax are nowadays uncommon. The type of arrowhead used determines not only the form of entrance wound but often the outcome of these injuries. We report the case of a 38-year-old man who attempted to commit suicide by firing a bolt from a sport crossbow into his heart. Although the bolt penetrated the mediastinum causing a deep intraseptal myocardial lesion and the pre-operative diagnostic procedure delayed the necessary operation, the patient survived.

Fatal fat embolism in acute hepatic necrosis with associated fatty liver

We report two cases of generalized nonviolent hepatogenic fat embolism. A 63-year-old woman was sent to the hospital with suspected mushroom poisoning. Shock symptoms occurred quickly and could not be treated effectively; the patient died 24 h after admission. Postmortem examination showed acute yellow dystrophy of the liver with a severe preexisting fatty liver. Any intoxication including Amanita phalloides could be excluded. In all probability, a fulminant viral hepatitis caused liver dystrophy, and the decay of the fatty liver cells led to generalized fat embolism as the cause of death. The second patient, a 46-year-old man, was reported to have suffered from an acute illness while in prison and died after having been transferred to the local hospital. Histological examinations showed an acute liver dystrophy probably caused by fulminant viral hepatitis with fatty degeneration. In this case, the cause of death was also found to be generalized fat embolism.

On the role of human herpesvirus 6 in viral latency in nervous tissue and in cerebral lymphoma

Latent infections by human herpesvirus 6 (HHV6) in nervous tissue and its role in human disease are poorly understood. For the present study, an improved PCR method has been applied to brain tissue samples from 5 different brain regions from 20 forensic post-mortem cases without neurologic involvement. Spleen tissue from these cases as well as 5 cerebral lymphoma tissue samples were also examined. HHV6 DNA was detected in 3 of 20 brains. The viral sequences could be amplified from cortical brain tissue from these 3 cases. In one of these cases, HHV6 DNA was detectable in two separate tissue samples. PCR was negative in brain lymphoma and spleen tissue. These findings point toward HHV6 latency in brain tissue and might thus support the reported glial tropism of this virus. No role could be found for HHV6 in the pathogenesis of cerebral lymphoma.

Penetrating spinal injury inflicted by screwdriver: unusual morphological findings

A 50-year-old female victim died of recurrent pulmonary embolism, 3 months after having received multiple screwdriver stab wounds in the neck and upper spine. Autopsy showed that one stab had penetrated the middle part of the cervical spinal cord and thus caused an incomplete tetraplegia. In the region of the healed spinal cord and the affected meninges, a considerable amount of hair and textile fibres surrounded by foreign body giant cells and elastic fibres of spinal ligament were found, all of which had been carried into the stab canal by the blunt tip of the screwdriver. In addition to the primary clinical findings, this unusual transportation of matter into the depth of the stab canal allowed identification of the murder weapon.

[Prevalence of alcohol in fatalities in forensic medicine]

Blood alcohol tests were carried out at the Institute of Forensic Medicine of the University of Hamburg in 1,000 sudden unexpected natural deaths and non-natural deaths (590 males, 410 females) during the first six months of 1989. In 18.6% of the cases (142 males, 44 females) a blood alcohol concentration of more than 0.1% was found. The blood alcohol concentration ranged from 0.1 to 1% in 87 cases; in 99 cases the blood alcohol concentration exceeded 1%; there were 17 fatalities with more than 3%. More than 95% of blood alcohol concentration values exceeding 2.5% were found in the age group of 40-69 years. As expected positive blood alcohol estimations and especially high blood alcohol concentrations were found in non-natural deaths. However, many cases with relevant blood alcohol findings had been classified as "sudden natural death" and were not investigated by autopsy. In 74 cases alcohol blood tests were ordered by the police.

Hepatitis C in deceased drug addicts

Needle sharing among drug addicts leads to the transmission of infectious diseases such as hepatitis B and AIDS. After development of a test system based on gene technology against the hepatitis C virus (HCV), drug addicts have been regarded as an important reservoir for hepatitis C. In our study 113 (40.1%) out of 282 addicts who died from drug abuse in Hamburg between 1988 and 1990 had antibodies against HCV (anti-HCV). The prevalence of anti-HCV differed in various age groups; the highest prevalence was found in addicts aged 30-34 years. Co-infections with hepatitis B and hepatitis C virus were found in 57 drug addicts (59.4%) out of 96 deceased with antibodies to hepatitis B (anti-HBc), whereas only 8 out of 23 HIV-infected were anti-HCV positive (34.8%).

[Fatalities in the bathtub]

A retrospective analysis concerning deaths in the bathtub was carried out in the Institute of Legal Medicine in Hamburg. The study includes 245 death cases between 1971 and 1988 (1% of all autopsies). 66 cases proved to be natural deaths, 76 were classified as suicides, 39 as accidents and 13 as homicides; 51 fatalities remained unclear with respect to one of these groups. Among the natural deaths sudden cardiac deaths were dominating (n = 39), among the suicides the intoxications (n = 37) and electrocutions (n = 20), and among the accidents the intoxications by carbon monoxide (n = 17) and electrocutions (n = 12). Out of 13 homicides only 2 were committed directly in the bathtub: One by drowning of a child and one by electric current via a hair dryer; in the other cases the dead body was put into the bathtub post mortem. About 50% of the victims were alcoholized. Signs of drowning were present in about 40% of all cases; the most frequent finding was emphysema aquosum.

[Complete airway obstruction by a prosthesis powder. The problem of protecting the airway in emergency service]

An extraordinary occurrence of death is reported due to blocking of the entrance of the larynx by a denture adhesive. The improper usage of this material by a mentally disturbed woman of 66 years of age caused her death by suffocation. In such a case an intubation can involve a transfer of the viscous material to the larynx. Therefore a coniotomy or a tracheotomy should be performed.

Death caused by drug addiction: a review of the experiences in Hamburg and the situation in the Federal Republic of Germany in comparison with the literature

Based on criminological experiences and pathomorphological, serological and toxicological studies of more than 300 fatalities, an overview is given of drugs, their intravenous abuse and drug deaths in Hamburg and the Federal Republic of Germany. The number of drug deaths has increased dramatically in Hamburg, where there were more than 50 cases each year in 1987 and 1988. In the F.R.G. approximately 400 cases are registered per annum. The percentage of female intravenous drug abusers is growing and the age of the decedents is increasing. The mean was formerly 25 years, but is now 30 years. Among the histopathological findings, foreign-body granulomas are of special value; infectious diseases, especially hepatitis B and HIV-infection, have to be investigated serologically and morphologically. The prevalence of HIV-1 antibodies among drug deaths in Hamburg is approximately 15%, in comparison with approximately 50% in Berlin. The "supply" of heroin has apparently become so copious that nearly all deaths are caused by overdosage with this substance. An international agreement about a definition of a drug death is a prerequisite for nationwide analyses.

[Hepatitis in drug poisonings]

In the period between 1983 and 1987 autopsies were carried out on 120 drug victims at the Institute for Forensic Medicine in Hamburg, and 93 cases were serologically tested for hepatitis B. It was found that 50 cases (54%) were positive for anti-HBc, 39 (42%) for anti-HBs, and 5 cases (5%) for HBsAg. The prevalence of hepatitis-B-virus markers was dependent upon the age of the victims. In 81% inflammatory alterations of the liver (including unspecific reactive hepatitis) were diagnosed histologically. The pathogenesis of these serological and pathomorphological findings is discussed. Drug addicts are a group at risk for hepatitis B, and it can spread on account of the epidemiological connection with other risk groups, e.g., prostitutes and homosexuals. Postmortem serological investigations for hepatitis markers proved to be a well-established and reproducible means of differentiating histopathological liver alterations.