The Vascular Access Questionnaire: assessing patient-reported views of vascular access

BACKGROUND

The use of central venous catheters for vascular access in hemodialysis (HD) patients is associated with an increased risk of complications compared to arteriovenous fistulas (AVF). Despite this, catheter use remains high and patient satisfaction may be an important driver of catheter use.

METHODS

We developed the Vascular Access Questionnaire (VAQ) to measure patient-reported views of their vascular access. Chronic HD patients at two centers were asked to rate how bothered they were by 17 access-related problems. VAQ symptom scores were compared between patients using catheters and those using fistulas for vascular access.

RESULTS

Two hundred and twenty-two patients were eligible for the study. Symptom score was not different between patients using catheters and those using fistulas (p=0.36). However, patients using fistulas were more likely to be at least moderately bothered by pain, bleeding, bruising, swelling, and the appearance of their access than patients using catheters. Elderly patients reported lower symptom scores with catheters than fistulas.

CONCLUSIONS

Patients appear to be primarily concerned with the appearance of their access and cannulation-related complications, particularly the elderly. Better education about the risk of adverse events with catheters and the implementation of measures aimed at reducing cannulation-related complications may help to increase fistula rates and improve patient satisfaction with their vascular access.

Home care assistance and the utilization of peritoneal dialysis

Peritoneal dialysis (PD) may be declining because the elderly often have barriers to self-care PD. The objective of this study was to determine whether the availability of home care increases utilization of PD. In 134 incident chronic dialysis patients (median age 73), 108 (81%) had at least one medical or social condition, which was a potential barrier to self-care PD. Eighty percent of patients living in regions where home care was available were considered eligible for PD compared to 65% in regions without home care (P=0.01, adjusted). Each barrier reduced the probability of being eligible for PD by 26% (odds ratio 0.74, per condition, P=0.02) adjusted for age, sex, predialysis care, in-patient start, and availability of home care. In regions with and without home care, 59 and 58% of eligible patients choose PD when they were offered it (P=NS). The utilization of PD in the incident end-stage renal disease (ESRD) population living in regions with and without home care was 47 and 37%, respectively (P=0.27). The mean rate of home care visits over the first year was 4.3 per week (maximum available was 14 per week). Of the 22 assisted patients, 15 required chronic support, five graduated to self-care, and two started with self-care but later required assistance. Adverse events were similar between assisted PD and traditional modalities. Barriers to self-care PD are very common in the elderly ESRD population but home care assistance significantly increases the number of patients who can be safely offered PD.

Clinical, neuropathological and genetic aspects of the tuberous sclerosis complex

Tuberous sclerosis complex (TSC) is an autosomal dominant syndrome in which patients develop hamartomatous lesions in the nervous system and a host of other organs. While considerable experience has been gained in defining the clinical spectrum of TSC, a number of nosological questions remain. Neuropathological studies have continued to refine our knowledge of the nervous system abnormalities that characterize TSC. Molecular genetic studies have implicated two chromosomal regions in the genesis of TSC, one on chromosome 9q and the other on chromosome 16p. The chromosome 16p gene, designated TSC2, has been cloned, although its function remains speculative. The identification of the TSC1 gene on chromosome 9q, along with functional studies and mutational analyses of both TSC genes, will likely provide fascinating insights into the pathogenesis of TSC.

An improved approach to prepare human brains for research

We describe two protocols for preparing human brains collected for research and diagnosis. In both protocols, one half brain is processed for research and the other for neuropathological evaluation. Clinical, neuropathological and tissue mRNA retention data are used for sample categorization. In protocol 1, coronal, whole hemisphere slices cut at standardized landmarks are frozen with a cooling device at -90 degrees C, which yields discrete anatomical structures. In selected instances, small blocks of brain are frozen at -160 degrees C in liquid nitrogen vapor. Cooling device or liquid nitrogen vapor frozen samples are suitable for in situ hybridization, protein blotting or immunohistochemistry. Morphological freezing artifacts are minimal. In protocol 2, one half brain is frozen en bloc on dry ice; this tissue is suitable for regional evaluation of gene expression or neurochemistry. Morphological freezing artifacts are severe. In both protocols, the other half brain is fixed in formalin prior to sectioning and diagnostic evaluation. The standardized selection of paraffin blocks from each brain allows precise diagnoses to be established, including identification of dangerous infectious processes; moreover, it makes it possible to produce a set of uniformly selected blocks and slides for comparative studies. These protocols lead to standardized tissue preparation for research and reduce variables impairing interpretation and comparison of data.

The nosology of Creutzfeldt-Jakob disease and conditions related to the accumulation of PrPCJD in the nervous system

Although typical cases of Creutzfeldt-Jakob disease are readily recognized pathologically and clinically, variant forms often pose a diagnostic challenge. From the 1920's, when this disease was first characterized, until quite recently diagnosis relied heavily on morphologic changes. New advances in immunoassays and PrP gene analysis now provide important adjuncts in recognizing the spectrum of disorders of PrP metabolism associated with these transmissible encephalopathies.

Deep sylvian fissure meningioma without dural attachment in an adult: case report

Meningiomas are thought to arise from arachnoid cap or meningothelial cells that not only cluster on the surface of pacchionian granulations but also can cover the arachnoid membrane in other locations. This frequent apposition to the dura mater probably accounts for the usual attachment of the neoplasm to this layer. We report a deep sylvian fissure meningioma without dural attachments in the right hemisphere of an adult patient. The patient initially presented with simple partial seizures. Magnetic resonance imaging revealed a contrast-enhancing circular mass in the superior aspect of the insular region, deep to the inferior parietal lobule. Surgical exploration confirmed the absence of dural attachments. Microscopically, the tumor was found to be a sparsely cellular meningioma with an extensive collagenous matrix. A survey of the literature reveals that the majority of cases of meningiomas without dural attachments occur either in children or below the tentorium. Extremely rare cases of supratentorial meningiomas without dural attachment have been described in adults. The uncommon locations of these tumors at sites distant from the dura mater is postulated to reflect the rare occurrence of arachnoidal cap cells in the Virchow-Robin spaces along the cerebral vasculature or in pial layers distant from the dura mater.

In situ polymerase chain reaction demonstration of JC virus in progressive multifocal leukoencephalopathy, including an index case

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease that is caused by JC papovavirus. The virus can be demonstrated in brains with PML using a variety of techniques. In situ polymerase chain reaction (PCR) is a new method that combines the sensitivity of PCR with the histological localization of in situ hybridization. We here show that in situ PCR can detect JC virus in archival tissue sections of 3 cases of PML, including 1 of the original cases described in 1958 and 1 case that was fixed in formalin for 7 weeks. JC virus DNA was amplified directly on tissue and demonstrated in the characteristic enlarged oligodendrocytes and bizarre astrocytes. These data illustrate the utility of the in situ PCR technique in detecting JC virus in archival sections, including those fixed for prolonged periods, and provide a historical footnote to the original report of PML.

The development of neuropathology at the Massachusetts General Hospital and Harvard Medical School

Few institutions have shaped neuropathology as a discipline as profoundly as Massachusetts General Hospital (MGH) and Harvard Medical School. Their fascination over many decades is due to a unique accumulation of excellent, intellectually stimulating neurologists with a sincere interest in the morphologic and pathogenetic basis of nervous system diseases. Their approach was strictly case oriented and clinico-pathological conferences were developed to the highest standard. In this review, the foundations of neuropathology in Boston are recounted.

Proliferative and degenerative changes in striatal spiny neurons in Huntington's disease: a combined study using the section-Golgi method and calbindin D28k immunocytochemistry

Dysmorphic alterations of dendritic arbors and spines in spiny striatal neurons were identified in section-Golgi impregnations of moderate and severe grades of Huntington's disease (HD). These alterations could be characterized as either proliferative or degenerative changes. Proliferative changes included prominent recurving of distal dendritic segments, short-segment branching along dendrites, and increased numbers and size of dendritic spines. Degenerative alterations consisted of truncated dendritic arborizations, occasional focal dendritic swellings, and marked spine loss. Proliferative changes were found primarily in moderate grades of HD, while degenerative changes were predominantly found in severe grades. Cytopathologic changes increased with neuropathologic severity. Similar morphologic alterations were observed in calbindin D28k (Calb) stained neurons in HD striatum. The immunoreactive intensity of Calb staining was increased in the distal dendrites of positive neurons in HD striatum. The present findings provide morphologic and quantitative evidence that confirms an early and marked involvement of spiny striatal neurons in HD and suggest that neuronal growth, rather than degeneration, may be the harbinger of cell death in this disorder.

Phosphorylated neurofilament epitopes in the achromasic neurons of corticonigral degeneration

By employing monoclonal phosphorylated neurofilaments antibody, we studied the abnormally pale-staining neurons in 3 cases of corticonigral degeneration by the avidin-biotin immunoperoxidase method. For comparison, the central chromatolysis in anterior horn cells secondary to cervical spine fracture and "ballooned" neurons in a case of Pick's disease and a case of Alzheimer's disease were studied with similar procedure. Achromasic neurons in the case of corticonigral degeneration and ballooned neurons in Pick's disease and Alzheimer's disease showed positive immunostaining, while neurons with central chromatolysis secondary to axonal injury did not. Our observations show that the achromasic neurons in corticonigral degeneration contain phosphorylated neurofilaments which share common antigenic characteristics with ballooned neurons in Pick's disease and Alzheimer's disease. The absence of positive immunostaining in reactive central chromatolysis suggests that despite the similarities in appearance with the usual histopathologic stains this cytoplasmic change is pathogenetically different from that in the other neuronal disorders mentioned above.

Decreased neuronal and increased oligodendroglial densities in Huntington's disease caudate nucleus

Decreased density of neurons was found throughout the head of the caudate nucleus in Huntington's disease (HD), with the most severe neuronal loss early in the disease in the medial region. The density of reactive astrocytes is inversely proportional to the neuronal loss. In cases of mild Huntington's disease which had no identifiable abnormality on conventional neuropathologic evaluation (grade 0), there is a reduction in neuron density without an accompanying reactive astrocytosis. The pattern for decrease in neurons and accompanying astrocytosis suggests that the earliest changes occur in the most medial portion of the head of the caudate nucleus and subsequently sweep laterally across the caudate nucleus to the internal capsule. An increased density of oligodendrocytes is observed in the head of the caudate nucleus for the lower grades (0, 1 and 2). The decreased neuronal and increased oligodendroglial densities may be of significance in understanding the pathogenesis of HD. These altered densities, observed in the absence of reactive astrocytosis, suggest that these changes may not represent recent effects of disease, but rather that HD gene expression may influence brain cell densities from early in the life of the gene carrier.

Secondary optic nerve tumors

Secondary tumors of the optic nerve are more common than primary optic nerve tumors. The involvement of the optic nerve may arise from direct invasion from intraocular malignancies, from hematopoietic malignancy, from meningeal carcinomatosis, or from distant primary tumors. Orbital tumors rarely invade the optic nerve, and brain tumors involve it only in their late stages.

Cerebral amyloid angiopathy without and with cerebral hemorrhages: a comparative histological study

To identify those factors associated with cerebral hemorrhage among brains with cerebral amyloid angiopathy (CAA), we undertook a comparative postmortem histopathological study of amyloid-containing vessels in the brains of patients with and without hemorrhage. Those without hemorrhage were represented by the following two groups: (1) elderly patients from a large general hospital (n = 66; age range, 75-107 years) and (2) patients with various neuropsychiatric disorders (n = 70; age range, 27-96 years). CAA was found in 45% of the first group and in 54% of the second group. The findings in these patients were compared with those in 17 brains in which both CAA and cerebral hemorrhage were present. We found that CAA was more severe in the brains with cerebral hemorrhage than in those without, and that fibrinoid necrosis was seen only in the brains with cerebral hemorrhage (12 of the 17 brains). Microaneurysms occurred only in the presence of severe, rather than moderate or mild, CAA. Serial sections in 2 brains of patients with cerebral hemorrhage showed fibrinoid necrosis, microaneurysms, and vascular rupture in close association with the hemorrhage. In 2 patients, hemorrhage was precipitated by trauma, and in 1, it was secondary to metastatic carcinoma. The features of brains from patients with CAA that are most consistently related to cerebral hemorrhage are (1) a severe degree of CAA and (2) the presence of fibrinoid necrosis, with or without microaneurysms.

Type-specific identification of herpes simplex and varicella-zoster virus antigen in autopsy tissues

To identify antigens of herpes simplex virus (HSV) types 1 and 2 and varicella-zoster virus (VZV) in human tissue, polyclonal antisera and an immunoperoxidase method were used to examine formalin-fixed, paraffin-embedded tissues from autopsy cases and experimentally infected animals. These antisera readily distinguished between HSV and VZV antigen, with no evident cross-reactivity. Antiser ato HSV-1 and HSV-2 were more strongly reactive with antigen of the homologous virus than with that of heterologous virus. This difference in immunoreactivity was used to discriminate between HSV-1 and HSV-2 antigens in experimentally infected animal tissues containing HSV antigens of known type and, by extrapolation, to distinguish between these antigens in human autopsy tissues. Thus, with appropriate antisera and tissue controls, HSV-1, HSV-2, and VZV can be identified in paraffin sections.

Clinicopathologic correlations of cranial magnetic resonance imaging of periventricular white matter

We studied clinical, imaging, and autopsy data on 7 patients who underwent magnetic resonance imaging (MRI) during life. Small periventricular zones of increased T2 signal corresponded to a periventricular cap consisting of subependymal glial accumulations, with some loss of the ependymal lining, and a surrounding pale-staining area of finely textured myelin and axons with an altered glial pattern. The fine-fiber zone is identifiable anatomically as the subcallosal fasciculus. This histologic pattern of subependymal glial accumulations and fine fibers is normal and is often associated with fibrotic small blood vessels. More extensive subcortical MRI changes corresponded, in 1 case, to multiple sclerosis, and in another to subcortical arteriosclerotic encephalopathy (Binswanger's disease) with widespread fiber loss and lacunar changes. Wallerian degeneration secondary to infarction occurred in some areas of MRI abnormality.

Peduncular hallucinosis associated with isolated infarction of the substantia nigra pars reticulata

We report the clinicopathological study of an 83-year-old man who abruptly developed complex visual hallucinations, disordered sleep, and mild cognitive impairment that persisted until his death 6 months later. Postmortem neuropathological examination including serial sections through the diencephalon, midbrain, and pons disclosed isolated bilateral infarcts confined to the medial substantia nigra pars reticulata. The findings suggest that destruction of the pars reticulata may be the essential feature to the development of peduncular hallucinosis.

Primary intracranial leiomyosarcoma. Case report

A case of primary intracranial leiomyosarcoma is presented, with clinical, radiological, light microscopic, immunohistochemical, and ultrastructural data. The histogenesis is discussed and the literature on smooth-muscle tumors of the central nervous system is reviewed.

Intravascular lymphomatosis (malignant angioendotheliomatosis). A B-cell neoplasm expressing surface homing receptors

We report the clinical and immunohistochemical features of six cases of intravascular lymphomatosis. All patients presented with symptoms referable to central nervous system (CNS) involvement. In two patients, the diagnosis was made on brain biopsy specimens. In the remaining four cases, diagnosis was made at autopsy. Three of the four autopsied patients had focal extravascular lymphoma, diffuse large cell type. In all five cases tested, immunohistochemical stains on paraffin-embedded sections confirmed the lymphoid nature of the malignant cells. Stains on frozen sections in one case, and on paraffin-embedded tissue in the other four cases, demonstrated B-lymphocyte lineage. In the remaining case, electron microscopy confirmed the lymphoid nature of the tumor cells. All three cases tested expressed the Hermes 3-defined homing receptor antigen and lacked peanut agglutinin receptors. Our results are consistent with other reports confirming the lymphoid nature of so-called malignant angioendotheliomatosis. Our limited analysis of surface receptor molecules suggests that the expression of the homing receptor for high endothelial venules is not in itself responsible for the unusual intravascular location of these cells.

Preclinical Creutzfeldt-Jakob disease discovered at autopsy in a human growth hormone recipient

An adolescent girl with idiopathic hypothalamic dysfunction and hypopituitarism was treated with human growth hormone between 1969 and 1979, dying of parainfluenza pneumonia 2 months after her last hormone treatment. Although she had no signs of progressive neurologic disease, reexamination of autopsy material revealed a focus of spongiform change and astrogliosis in the corpus striatum. Thus, this growth hormone recipient, who died of intercurrent infection, was unexpectedly found to be in an early, preclinical phase of Creutzfeldt-Jakob disease.

Clinical and neuropathologic assessment of severity in Huntington's disease

Clinical records were evaluated for 163 Huntington's disease patients in whom postmortem brain specimens had been graded for degree of neuropathologic involvement in the striatum. Juvenile/adolescent onset (4 to 19 years of age) was associated with very severe neuropathologic involvement produced by an apparent rapid degenerative process. Cases of early (20 to 34 years) and midlife (35 to 49 years) onset had respectively less severe striatal involvement, suggesting a slower degenerative progression. High correlations among the grade of neuropathologic involvement, cell counts of neurons, and a rating of physical disability suggest that each represents a common underlying degenerative process of the disease. The relationship between the age at onset and the extent of neuropathologic involvement suggests that a single mechanism may determine both onset and rate of degenerative disease progression.

Sparing of acetylcholinesterase-containing striatal neurons in Huntington's disease

The present study demonstrates that large aspiny neurons, containing the enzyme acetylcholinesterase (AChE), are relatively preserved in the caudate nucleus and putamen in Huntington's disease (HD). Although histochemical evidence indicates that AChE and choline acetyltransferase (ChAT) co-localize within the same striatal neurons, measurements of ChAT activity showed significant reductions in enzyme activity, as others have reported. Reduced ChAT activity in the presence of presence of persistent AChE-positive neurons may be a consequence of loss of synaptic terminals resulting from the death of spiny neurons. The selectivity of neuronal sparing in HD may be related to the patterns of synaptic contact or a paucity of excitatory amino acid receptors on striatal aspiny neurons.

Subacute encephalomyelitis of AIDS and its relation to HTLV-III infection

Subacute encephalitis, characterized by demyelination, gliosis of the gray and white matter, focal necrosis, microglial nodules, atypical oligodendrocyte nuclei, and multinucleation of cells, was present in 27 of 30 (90%) autopsied patients with acquired immune deficiency syndrome (AIDS) or AIDS-related complex. Subacute encephalitis was mainly distributed in the frontal (58%) and temporal (69%) lobes, basal ganglia (77%), amygdala (80%), and hippocampus (64%). Ten (37%) with moderate or severe subacute encephalitis were demented; 82% with mild subacute encephalitis had no recognized neurologic disorder. Human T-lymphotropic virus type III (HTLV-III) was isolated from neural tissue or CSF in 11 of 13 patients, 10 with subacute encephalitis, and 1 without CNS lesions. We conclude that subacute encephalitis is common in AIDS patients and is most likely caused by CNS infection with HTLV-III.

Neuropeptide Y, somatostatin, and reduced nicotinamide adenine dinucleotide phosphate diaphorase in the human striatum: a combined immunocytochemical and enzyme histochemical study

Neuropeptide Y and somatostatin immunoreactive neurons and processes were examined in human striatum using both immunofluorescence and avidin biotin immunoperoxidase methods. Reduced nicotinamide adenine dinucleotide phosphate diaphorase activity was histochemically determined by the reduction of nitro blue tetrazolium. Immunofluorescence using a monoclonal anti-somatostatin antibody and a polyclonal anti-neuropeptide Y antibody, followed by diaphorase histochemistry, showed that these three neurochemical markers are co-localized in a single population of medium-sized aspiny intrinsic neurons. Cells were evenly distributed in clusters throughout the striatum, but fiber density was higher in the nucleus accumbens and ventromedial regions of the caudate and putamen. Double-stained reduced nicotinamide adenine dinucleotide phosphate diaphorase-acetylcholinesterase sections demonstrated that these neurons are located in zones of high acetylcholinesterase activity, often at the interface of these zones with regions of low enzyme activity. These biochemically distinctive neurons are uniquely situated to modulate activity between striatal compartments. Our findings provide new information about the modular organization of the striatum and extend these observations in human brain.

NMR-neuropathologic correlation in stroke

True, three-dimensional proton nuclear magnetic resonance imaging at 0.147 tesla was performed postmortem on 2 patients embodying various stroke syndromes, including chronic (4 and 15 years) infarction, subacute (within 1 week) bland infarction, acute (2 days) hemorrhagic infarction, and hematoma secondary to ruptured aneurysm. A third patient, with subcortical arteriosclerotic encephalopathy, so-called Binswanger's disease, was examined antemortem using a 0.6 tesla scanner. Nuclear magnetic resonance images were reconstructed at levels matching the pathologic specimens. Qualitative and, when available, quantitative comparisons between the results of nuclear magnetic resonance imaging and pathology were carried out. Areas of qualitatively prolonged T1 and T2 relaxation times on nuclear magnetic resonance imaging were more extensive than the corresponding areas of chronic infarction noted pathologically and were determined to be infarcts plus the adjacent areas of Wallerian degeneration. Hemorrhagic infarction, without evidence of blood on computed tomography, was found to have mildly prolonged T1 and T2 relaxation times, between those of normal brain and chronic infarction; a 10-day-old hematoma had a very short T1, slightly shorter than that of white matter, and a mildly prolonged T2, with values between those of white and gray matter. Subcortical arteriosclerotic encephalopathy was found to have areas of prolonged T1 and T2 relaxation times involving almost the entire white matter of the corona radiata.

Morphologic and histochemical characteristics of a spared subset of striatal neurons in Huntington's disease

We have previously found that a biochemically distinct subset of neurons, containing nicotinamide adenine dinucleotide phosphate diaphorase (NADPH-d), is selectively resistant to the degenerative process that affects the striatum in Huntington's disease (HD). We report the morphologic and histochemical characteristics of these striatal neurons and their distribution with respect to the histochemical compartments as defined by acetylcholinesterase (AChE) activity. Sections of striatum were stained histochemically for NADPH-d and AChE and immunocytochemically for somatostatin and neuropeptide Y-like immunoreactivity. The diaphorase end-product was contained within medium-sized neurons which corresponded morphologically to a category of aspiny interneurons. Combined techniques showed that NADPH-d, somatostatin, and neuropeptide Y coexisted within the same neurons in controls and patients with HD. The density of these neurons was greater in the ventral putamen and the nucleus accumbens than in the remainder of the striatum. The distinctive AChE pattern of high and low enzyme activity was altered in HD. The AChE-rich matrix zone was markedly reduced in size, while the total area of zones of low enzyme activity was not different from that found in control striatum. The relation between these AChE chemical compartments and the distribution of preserved diaphorase neurons remained intact; NADPH-d neurons were predominantly observed in the matrix zone.

Topography of enkephalin, substance P and acetylcholinesterase staining in Huntington's disease striatum

The distribution of Met-enkephalin (Enk) and substance P (SP) was examined in the striatum of Huntington's disease (HD) patients using immunoperoxidase techniques. Both Enk- and SP-like immunoreactivities (ir) were strikingly diminished in the dorsal caudate nucleus and putamen, while patchy staining persisted in the ventral putamen and nucleus accumbens. This was in sharp contrast to the patch-matrix pattern of acetylcholinesterase (AChE) staining which persisted throughout the entire striatum in HD. The regional loss of Enk- and SP-ir parallels the pattern of neuronal depletion in HD. The disparity between AChE staining and Enk- and SP-ir in HD suggests that AChE-positive neurons or fibers are resistant to the destructive process in areas where intrinsic neuronal populations are depleted.

MR and CT of occult vascular malformations of the brain

The need for improved specificity in the diagnosis of "occult" vascular malformations led to the use of MR in suspected cases in order to determine MR's potential for improved diagnostic accuracy. Six patients with six lesions histologically diagnosed as vascular malformation after partial (1) or complete (5) microsurgical excision were studied by CT, MR, and selective magnification subtraction angiography. In all cases, the cerebral lesions were apparently solitary and were visible as focal lesions on both CT and MR. Since angiography failed to reveal the pathologic blood vessels of the lesions, and no arteriovenous shunting was evident, these lesions were termed vascular malformations occult to angiography (VMOTA). Angiography revealed a mass effect in only two cases. MR did not reveal additional vascular malformations missed by CT. In each case, MR, which was performed in an attempt to support the diagnosis suggested by CT, did in fact do so by revealing signal abnormalities indicative of nonacute hemorrhage within the lesion on T1- and T2-weighted pulse sequences. Although, as on CT, MR features of these lesions were found to be nonspecific, the MR criteria reinforced the probable diagnosis of VMOTA in an additional 30 cases that had shown similar nonspecific CT features. In this second group, excluded from this study, in which histologic verification was not obtained because of perceived hazards of surgery, the increased assurance regarding the diagnosis led to proton-beam therapy without histologic verification in 18 cases. It is concluded that MR can provide significant improvement in the accuracy of diagnosing VMOTA beyond that obtainable just by plain and contrast-enhanced CT.

Gilles de la Tourette's syndrome. A postmortem neuropathological and immunohistochemical study

Immunocytochemical studies of the human forebrain have shown that enkephalin-like, dynorphin-like and substance-P-like immunoreactivity (respectively ELI, DLI, and SPI) normally present in unique pattern (now termed woolly fibers) in the globus pallidus and substantia nigra, in which their concentration is at its densest. Quantitative determinations moreover indicate that the levels of all 3 peptides are higher in the globus pallidus and substantia nigra than in any other region of the brain. We report here the distribution of immunoreactivity of these 3 peptides in the brain of a patient showing the typical clinical manifestations of Gilles de la Tourette's syndrome (TS); a disease for which no characteristic or consistent neuropathological features have been discerned. In the case described here neuropathological examination by means of the usual histopathological methods showed no abnormalities to which the patient's illness could be ascribed. ELI- and SPLI-positive woolly fibers were densely stained and of normal distribution. DLI-staining was, however, considerably less dense throughout the brain than normal. The most striking finding was the total absence of DLI-positive woolly fibers in the dorsal part of the external segment of the globus pallidus; the ventral pallidum showed very faint staining. These observations, which indicate a decrease of dynorphin in striatal fibers projecting to the globus pallidus, are, to our knowledge, the first evidence of a distinct pathological change in the brain in TS.

Keyhole aqueduct syndrome

Communicating syringes confined to the brain stem are extraordinarily rare. Two patients, presenting with signs and symptoms of cerebellar dysfunction, later developed evidence of brain-stem disease with dysarthria, nystagmus, deafness, and internuclear ophthalmoplegia. The condition of both patients had been diagnosed clinically as multiple sclerosis, but at autopsy they had a striking keyhole-shaped syrinx in the midbrain and upper pons, which communicated with the aqueduct and fourth ventricle without associated syringomyelia. In addition, both patients had marked atrophy and gliosis of the cerebellum, one with extension of the syrinx into cerebellar folia. The unique character of these lesions coupled with the similarity of the clinical features of the cases prompted us to name this disorder--"keyhole aqueduct syndrome."

Relapsing central and peripheral demyelinating diseases. Unusual pathologic features

We treated a patient who had a demyelinating peripheral neuropathy and a central nervous system inflammatory demyelinating disease. The unusual pathologic feature of dense infiltrates of atypical macrophages was observed in many areas of the brain; otherwise the process had several features in common with either multiple sclerosis or chronic relapsing experimental allergic encephalomyelitis. The illness followed "swine-flu" inoculation; exacerbation followed pneumococcal vaccination.

Myoclonus epilepsy in two brothers. Clinical features and neuropathology of a unique syndrome

We report 2 brothers with progressive ataxia, seizures, myoclonus, supranuclear ophthalmoplegia, progressive visual loss and embolic strokes. The epilepsy and myoclonus came on many years after the onset of the ataxia. In the more severely affected brother the myoclonus was often unilateral and focal but ultimately involved both sides of the body. His sibling had only unilateral myoclonus after a contralateral middle cerebral artery stroke. When focal, persistent and unilateral, the myoclonus in both brothers was clinically similar to epilepsia partialis continua except that muscles of the trunk and proximal limbs were the most affected. It was exacerbated by movement of the affected part but was otherwise not stimulus sensitive. The more severely affected brother had a pigmentary retinopathy and a cardiac fibromyxoid valvulopathy. In his sibling, visual loss was not fully investigated and the heart was not examined at autopsy though he had a longstanding heart murmur. Neuropathological studies showed pancerebellar cortical atrophy, cell loss in the inferior olivary nuclei and old right middle cerebral artery infarctions in both brothers. Biochemical assays for known metabolic diseases were negative. We suggest that this syndrome represents a unique autosomal recessive form of progressive myoclonus epilepsy of unclear aetiology. It is distinguished from other familial myoclonus epilepsies by the presence of early onset cerebellar ataxia, supranuclear ophthalmoplegia, pigmentary retinopathy and possibly cardiac valvulopathy with subsequent cerebral emboli.

Septic thrombosis of the dural venous sinuses

From 1940 to 1984, 19 cases of septic dural-sinus thrombosis have been diagnosed at the Massachusetts General Hospital, and some 136 cases have been reported from other institutions. Septic thrombosis most frequently involves the cavernous sinuses (96 cases). Facial or sphenoid air sinus infection often precede cavernous-sinus disease. In addition to the classical signs of proptosis, chemosis, and oculomotor paralysis, isolated sixth-nerve palsy and hypo- or hyperesthesia of the fifth nerve may be found. The major pathogens associated with cavernous-sinus infection include Staphylococcus aureus, other gram-positive organisms, and anaerobes. Septic lateral-sinus thrombosis (64 cases) is almost exclusively a complication of otitis media and/or mastoid infection. Organisms causing this infection include Proteus species, Escherichia coli, S. aureus, and anaerobes. Septic thrombosis of the superior sagittal sinus (23 cases) most frequently accompanies bacterial meningitis or air sinus infection. Causative organisms include Streptococcus pneumoniae, S. aureus, other streptococci, and Klebsiella species. Because septic dural-sinus thrombosis is rare, this disease is frequently misdiagnosed. Evaluation should include lumbar puncture, air sinus films, and computed tomographic scan with contrast. Other helpful diagnostic tests may include carotid angiography, and dynamic brain scan. Orbital venography is the most definitive study in cases of chronic cavernous-sinus thrombosis. Therapy should include intravenous antibiotics and early surgical drainage of purulent exudate in the air sinuses or mastoid regions. Retrospective analysis suggests that treatment with heparin may reduce mortality in carefully selected cases of septic cavernous-sinus thrombosis. Anticoagulation is not recommended in other forms of septic dural-sinus thrombosis. Mortality in the antibiotic-era remains high, particularly in patients with septic thrombosis of the cavernous (30%) and superior sagittal (78%) sinuses.

Immunodiagnostics of malignant diseases. II. The electrophoretic mobility test in the diagnosis of gynecological malignancies

We applied the electrophoretic mobility test (EMT) to 117 patients. 49 patients suffered from gynecological malignant tumors of different types and eleven had a carcinoma in situ. 57 patients served as a control group, 26 of whom were clinically healthy volunteers and 31 had benign gynecological diseases. In the EMT all malignant cases had inhibition values of at least-5% or even more. All other tested persons, the so-called non-malignant or healthy cases, had an inhibition of less than -5% or even an acceleration of the tanned sheep erythrocytes stabilized with sulfosalicylic acid (ETS).

Neuropathological classification of Huntington's disease

In postmortem brain specimens from 163 clinically diagnosed cases of Huntington's disease (HD) the striatum exhibited marked variation in the severity of neuropathological involvement. A system for grading this severity was established by macroscopic and microscopic criteria, resulting in five grades (0-4) designated in ascending order of severity. The grade correlates closely with the extent of clinical disability as assessed by a rating scale. In five cases of clinically diagnosed HD there were no discernible neuropathological abnormalities (grade 0), suggesting that the anatomical changes lag behind the development of clinical abnormalities. In eight cases, neuropathological changes could only be recognized microscopically (grade 1). The earliest changes were seen in the medial paraventricular portions of the caudate nucleus (CN), in the tail of the CN, and in the dorsal part of the putamen. Counts of neurons in the CN reveal that 50% are lost in grade 1 and that 95% are lost in grade 4; astrocytes are greatly increased in grades 2-4. These studies indicate that analyses of the CN in grade 4 would reflect mainly its astrocytic composition with a component of remote neurons projecting to the striatum. Because of the relative preservation of the lateral half of the head of the CN in grades 1-2, these regions would reflect early cellular and biochemical changes in HD.

Selective sparing of a class of striatal neurons in Huntington's disease

A distinct subpopulation of striatal aspiny neurons, containing the enzyme nicotinamide adenine dinucleotide phosphate diaphorase, is preserved in the caudate nucleus in Huntington's disease. Biochemical assays confirmed a significant increase in the activity of this enzyme in both the caudate nucleus and putamen in postmortem brain tissue from patients with this disease. The resistance of these neurons suggests that the gene defect in Huntington's disease may be modifiable by the local biochemical environment. This finding may provide insight into the nature of the genetically programmed cell death that is a characteristic of the disease.

Prognostic value of round cell (lymphocyte) infiltration in malignant gliomas

The biopsy specimens of 342 patients with malignant glioma were evaluated to determine the extent and prognostic significance of round cell infiltration within these representative tissues: (a) tumor, (b) peritumoral, (c) hypervascular, (d) necrotic, and (e) normal tissue. Thirty-six percent of all biopsy specimens showed at least one tissue area with round cell infiltration. Patients in age groups 0 to 25 years and 71 years and older tended to show less round cell infiltration than did patients 41 to 55 years old. The presence of round cell infiltration in tissue was associated with a poor prognosis. Patients showing any infiltration had mean survival times of 8.4 months as opposed to 11.9 months for those showing no infiltration. The relationship between round cell infiltration and poor prognosis is true, irrespective of postoperative therapy, sex, and age.

Prenatal intramedullary gliofibroma. A light and electron microscope study

A case of an unusual congenital intramedullary tumor of the spinal cord is reported. A paraplegic 11-day-old boy with hypotonia and atrophy of the abdominal and lower-extremity muscles showed a complete myelographic block between T-5 and T-8. Surgical exploration disclosed an elongated tumor mass within the spinal cord, that blended with the surrounding nervous-system tissue. Light and electron microscopy showed that the tumor was composed of intermingled well differentiated astrocytes and fibroblasts. These two cell types often were surrounded by the same basal lamina. There were no intercellular junctions. Gliofibrils were abundant, and the interstitial spaces contained abundant collagen and reticulin fibers. There were no histological signs of malignancy. We conclude that this is a case of prenatally arising gliofibroma.

Schwann cell remyelination of demyelinated axons in spinal cord multiple sclerosis lesions

To investigate remyelination in multiple sclerosis lesions, we immunostained spinal cord sections from patients with multiple sclerosis and neurological normal (control) patients with antisera to P0 protein, a major constituent of peripheral nervous system myelin, and myelin basic protein, which is found in both central and peripheral nervous system myelin. In sections from five of the eight patients with no clinical or pathological evidence of neurological disease, P0 immunostaining was confined to peripheral myelin sheaths in dorsal and ventral roots. They were intensely stained, and peripheral--central nervous system transition zones were clearly demarcated. Sections from the other three control patients contained a few P0-stained sheaths in the central nervous system near root entry zones or among marginal glia near the dorsal sulcus. Spinal cord sections from six of the ten patients with multiple sclerosis contained clusters of myelin sheaths immunostained by P0 antiserum. These regenerating sheaths of peripheral nervous system origin were most numerous in large lesions and were commonly located in central areas or peripherally near root entry zones. The sheaths were observed frequently in areas of active demyelination and appeared morphologically normal even when surrounded by debris-filled macrophages. Near margins of small inactive plaques were a few basic protein--stained oligodendroglia extending processes to thin basic protein--stained sheaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Localized brainstem ischemic damage and Ondine's curse after near-drowning

A 19-year-old man was a victim of near-drowning in fresh water. After he was resuscitated, examination showed nystagmus, absent gag reflex, diminished facial sensation, dysmetria of all limbs, and failure of automatic respiration. His intellect was perfectly preserved. Eight months later, he died suddenly, and the essential neuropathologic findings were limited to the lower brainstem. There was marked neuronal depletion bilaterally in the nucleus gracilis, nucleus cuneatus, nucleus of the tractus solitarius, nucleus ambiguus, and nucleus retroambiguus; several other lower-brainstem nuclei showed evidence of damage, but to lesser extent. The neuropathologic findings seem to have been an unusual consequence of anoxia-ischemia and support previous concepts of the anatomical localization of the human respiratory centers.