Histologically confirmed pineal tumors and other germ cell tumors of the brain

BACKGROUND

This study examined the outcome of patients with histologically confirmed pineal region tumors.

METHODS

One hundred thirty-five patients with histologically confirmed pineal tumors and other germ cell tumors of the brain were evaluated retrospectively. The pineal parenchymal tumors (PPTs) included 15 pineoblastomas (PB), 2 mixed PPTs, 4 PPTs with intermediate differentiation, and 9 pineocytomas. The germ cell tumors included 48 germinomas, 26 mixed germ cell tumors, 11 mature teratomas, 9 immature teratomas, 6 malignant teratomas, 2 yolk sac tumors, and 3 choriocarcinomas. Patients were treated with various combinations of chemotherapy, radiotherapy, and surgery. The duration of follow-up ranged from 0.25 to 37.3 years, with a median follow-up of 5.3 years.

RESULTS

The 5-year patient survival rate was 86% for those with mature teratomas; 86% with pineocytomas; 80% with germinomas; 67% with immature teratomas; 49% with PPTs, excluding pineocytomas; 38% with mixed germ cell tumors; and 17% with other germ cell histologies (P = 0.0001). The delivery of > 44 Gray (Gy) to germinomas and > 50 Gy to PPTs and nongerminomatous germ cell tumors (NGGCTs) other than mature and immature teratomas was associated with improved survival. A greater extent of resection was associated with a higher rate of survival in all patients with NGGCTs. The administration of chemotherapy was associated with improved survival in those patients with NGGCTs other than mature and immature teratomas.

CONCLUSIONS

Prognosis was dependent on tumor type. Obtaining a tissue diagnosis made it possible to tailor therapy according to tumor type and potentially improve the survival of patients. Survival was dependent on the dose of radiation administered to patients with PPTs, germinomas, and NGGCTs other than mature and immature teratomas. More extensive resection and the use of chemotherapy were also associated with improved survival in subgroups of patients with NGGCTs. Treatment recommendations are described in detail in the article.

Tissue and cell-type specific expression of the tuberous sclerosis gene, TSC2, in human tissues

TSC2 is a gene on chromosome 16p13.3 associated with the autosomal dominant neurocutaneous disorder, tuberous sclerosis complex (TSC). By using a partial nucleotide sequence from the cloned TSC2 and polymerase chain reaction methodology, we constructed a digoxigenin-labeled complementary DNA probe to examine TSC2 gene expression in autopsy- or biopsy-derived human tissues by in situ hybridization. TSC2 messenger RNA was widely expressed in various cell types throughout the body, including epithelia, lymphocytes, and cells with endocrine functions, e.g., adrenal cortex and anterior pituitary. It was prominently and selectively (within the central nervous system) expressed in pyramidal cells of the cerebral cortex and other motor neurons, e.g., in spinal cord and brainstem nuclei. Visceral TSC2 expression was comparable in autopsy tissues from patients with and without TSC; TSC2 messenger RNA expression was most prominent in cells with a rapid mitotic rate and turnover, e.g., epithelia and lymphocytes, with central nervous system pyramidal cells and other neurons being an obvious exception, and/or in cells with important secretory/transport functions. This widespread expression of the TSC2 gene supports the view that it encodes a protein vital to cell growth and metabolism or one that functions as a tumor/growth suppressor.

Localization of tuberous sclerosis 2 mRNA and its protein product tuberin in normal human brain and in cerebral lesions of patients with tuberous sclerosis

Tuberous sclerosis (TSC), an autosomal dominant disorder, is characterized by malformations, hamartomas and tumors in various organs including the brain. TSC is genetically linked to two loci: TSC1 on chromosome 9q34 and TSC2 on 16p13.3. TSC2 has been cloned, sequenced and encodes a protein (tuberin) which functions as a tumor suppressor. We have analyzed the distribution of TSC2 mRNA and tuberin in the brains of TSC patients and non-affected individuals using both autopsy and biopsy material. High levels of transcript and protein expression were observed in choroid plexus epithelium, ependymal cells, most brainstem and spinal cord motor neurons, Purkinje cells and the external granule cell layer of the cerebellum in both TSC and control cases. Individual balloon cells from TSC patients showed very faint expression while other glia showed no expression of either transcript or tuberin. Neocortical and hippocampal neurons expressed high levels of TSC2 transcript, but only modest levels of tuberin. The internal granule cell layer of the cerebellum expressed abundant transcript but low levels of tuberin. These observations suggest either that tuberin expression is controlled at the level of both transcription and translation or the antibody and in-situ hybridization recognize different splice variants of the TSC2 gene. In TSC patients, dysmorphic cytomegalic neurons expressed high levels of tuberin and transcript, particularly when in an 'ectopic' location. Individual cells within subependymal giant cell astrocytomas (SEGAs) and hamartomas from TSC patients expressed moderate to high levels of TSC2 transcript and tuberin. While the TSC2 transcript is widely expressed primarily within neurons, tuberin is demonstrable primarily within dysplastic/cytomegalic cells of the cortex and subependymal hamartomas/SEGAs. CNS expression of tuberin is unique in that primarily non-dividing cells express it in this location, whereas extra-CNS expression of tuberin is mainly found in actively proliferating cell types such as epithelium.

Nongerminomatous germ cell tumors of the brain

PURPOSE

This analysis was performed to determine the clinical outcome of patients with primary nongerminomatous germ cell tumors of the brain. The efficacy of various treatment options was evaluated.

METHODS AND MATERIALS

A total of 57 patients with primary nongerminomatous germ cell tumors of the brain were identified. Patient-related data were collected and analyzed retrospectively. Follow-up in surviving patients ranged from 3 to 243 months (median follow-up 36). Survival and failure rates were determined using the Kaplan-Meier method, and differences between the survival curves were evaluated using either the log rank test or the Wilcoxon test.

RESULTS

The 3-year survival rate was 86% for patients with mature teratomas, 67% for patients with immature teratomas, 44% for patients with mixed germ cell tumors, and 13% for patients with the other histologic types (p = 0.02). The 3-year survival rate was 0% for patients having biopsies alone, 32% for patients having subtotal resections, and 73% for patients having gross total resections (p = 0.0001). Patients with tumors other than mature or immature teratomas were evaluated for possible relationships between the administration of chemotherapy or radiotherapy and survival. Patients who received chemotherapy had a 3-year survival rate of 56% compared to 8% for those patients who did not receive chemotherapy (p = 0.0001) Patients who received radiotherapy had a 3-year survival rate of 46% compared to 11% for those patients who did not receive radiotherapy (p = 0.0015).

CONCLUSION

The survival of patients with primary nongerminomatous germ cell tumors of the brain is dependent on tumor histology and the extent of surgical resection. Patients with tumors other than mature or immature teratomas appear to benefit from the administration of chemotherapy and radiotherapy.

Malformations of the brain

The purpose of this article is to provide a basic outline on which the reader can hold a more elaborate and detailed knowledge of malformations of the brain. The first half of the article consists of a general approach to brain malformations; the second, the shortest possible descriptions of the common brain malformations.

Hydrocephalus, mineralizing angiopathy, hypercholesterolemia, and hyperlipoprotein (a)

A boy born at 34 weeks gestation with initially normal development presented with acute hydrocephalus at 22 months. Subsequently his development has been slow and complicated clinically by epilepsy. Upon extensive investigation, he has been found to have extremely elevated lipoprotein(a) levels, hypercholesterolemia (familial), and lesions of the cortex and meninges. Radiologic studies have disclosed a mineralizing angiopathy.

Sudden infant death syndrome: increased number of synapses in the hypoglossal nucleus

The medulla was sampled from nine cases of sudden infant death syndrome (SIDS) and from six age-matched control cases without neurological disease. Morphometric analyses were performed on serial Nissl sections through the hypoglossal nucleus on the left side of the medulla. The total volume of the nucleus and both the numerical density (Nv, cells per mm3) and total number of neurons were measured. Tissue from the remaining hypoglossal nucleus was prepared for electron microscopy using the ethanolic phosphotungstic acid method to stain synaptic contacts. Stereological analyses were performed to determine the Nv and total number of synapses. Total volume of the hypoglossal nucleus was significantly greater (36%) in SIDS cases than in controls. The Nv of neurons was significantly less than in controls (28%), although the total number of neurons did not differ significantly. The mean profile area of motor neuron cell bodies was significantly greater (30%) in SIDS cases, with no differences in the mean profile areas for interneurons or glia. The Nv of synapses did not differ significantly between SIDS cases and controls, although the total number of synapses was greater (61%) in SIDS. These abnormalities in growth indicate a greater volume of neuropil in a hypoglossal nucleus containing a normal complement of neurons. The greater number of synapses in SIDS cases is consistent with a failure to eliminate normally extraneous synapses during early development.

Sudden infant death syndrome: postnatal changes in the volumes of the pons, medulla and cervical spinal cord

The brainstem and cervical spinal cord were sampled from 45 cases of sudden infant death syndrome (SIDS), from 17 control cases without neurological disease, and from three negative control cases with abnormal growth of the central nervous system (36-98 postconceptional weeks). Morphometric analyses were performed on serial Nissl sections to determine the total volumes of the pons, nucleus pontis, medulla and cervical spinal cord. Normal development was characterized by a linear increase in the volumes of these regions during the first postnatal year. Regression analysis revealed that in SIDS cases the rates of increase in the volumes of the pons and nucleus pontis were significantly greater than in controls (56% and 83%, respectively), while growth rates did not differ significantly for the medulla and cervical spinal cord. By direct comparison, there was a significant increase in the mean volumes of the pons (33%), nucleus pontis (38%) and medulla (19%) in SIDS cases when compared to controls. No evidence of excessive edema or gliosis was noted in the brainstem by light and electron microscopy to account for the increased volumes. Subtle morphological abnormalities in brainstem neurons from SIDS cases, including an increased size of Nissl bodies in the cytoplasm of large motor neurons and the presence of paranucleolar coiled bodies, were consistent with an increased synthesis and transport of ribosomal RNA, an increased synthesis of cellular proteins and neuronal hypertrophy.

Duplication of 9P and hyperplasia of the choroid plexus: a pathologic, radiologic, and molecular cytogenetics study

Duplication of the short arm of chromosome 9 is a rare constitutional abnormality, and the presence of pathologically confirmed hyperplasia of the choroid plexus in one of two cases, and a choroid plexus papilloma in another, raises the possibility of a relationship between the 9p abnormality and abnormal growth of the choroid plexus. Molecular cytogenetic analysis using fluorescence in situ hybridization was used for detection of chromosome 9-derived material in various formalin-fixed choroid plexus abnormalities. Extra copies of chromosome 9-derived material was found in the hyperplastic choroid plexus and in a choroid plexus carcinoma. These findings suggest that there may be an association between duplication of chromosome 9 material and abnormal development of the choroid plexus.

Atelencephalic aprosencephaly

Absence of the telencephalon and diencephalon characterizes the syndrome of aprosencephaly, while in atelencephaly, only the telencephalon is absent. Atelencephalic aprosencephaly is characterized by the presence of at least a rudimentary diencephalon. Embryologically, aprosencephaly is thought to occur after the optic vesicles form but before the cerebral vesicles appear. The syndrome is quite rare, with only 10 cases previously reported. We describe two fetuses with atelencephalic aprosencephaly. A 25-week estimated gestational age fetus was born to first-cousin parents and had a prenatal ultrasonographic diagnosis of anencephaly. The second, a 19-week estimated gestational age fetus, was thought to have semilobar holoprosencephaly by prenatal ultrasound. At autopsy, neuropathologic examination in both cases showed virtual absence of the cerebral hemispheres with an incomplete diencephalon. Microscopic examination in one case revealed disorganized neuropil with a proliferative vasculopathy. The optic globes were completely formed and attached to hypoplastic optic nerves, but retinal dysplasia was apparent histologically in both cases, and bilateral colobomata were present in one case. The findings in these cases demonstrate a spectrum of congenital variations that lie between the syndromes of atelencephaly and aprosencephaly, underscoring the complexity of the congenital anomalies.

Astrocytoma with a unique telomere association

Many primary pediatric brain tumors are characterized by nonrandom cytogenetic abnormalities involving specific structural rearrangements and loss or gain of specific chromosomes. We describe a low-grade cerebellar astrocytoma with telomeric association of chromosomes 18 and 21 in a 7-year old girl. The nonrandom telomeric association of these chromosomes represents a unique cytogenetic finding in this type of pediatric brain tumor.

Unilateral cervical spinal cord lesion in a term newborn, associated with ipsilateral diaphragmatic atrophy and pulmonary hypoplasia

Two major factors can interfere with normal development of the fetal lungs: mechanical constriction resulting in decreased intrathoracic space and reduced or absent fetal breathing movements. We report a unique case in which both factors contribute to the development of lethal pulmonary hypoplasia. This full-term neonate had an isolated unilateral lesion in the cervical spinal cord resulting in ipsilateral neurogenic atrophy of the diaphragm, bilateral pulmonary hypoplasia, and lung immaturity. Evenetration of the atrophied diaphragm decreased intrathoracic space, compromising fetal lung growth. This was compounded by impaired fetal respiration due to the diaphragmatic atrophy, further aggravating pulmonary hypoplasia on the affected side. The other lung was also hypoplastic, although to a lesser degree, suggesting that its growth was also affected by either or both of these factors.

Sudden infant death syndrome: increased synaptic density in the central reticular nucleus of the medulla

The medulla was sampled from nine cases of sudden infant death syndrome (SIDS) and from six age-matched control cases without neurological disease. Morphometric analyses were performed on serial Nissl sections through the left half of each medulla to determine the total volume of the hemimedulla and the numerical density of neurons (Nv, neurons per mm3) in the central reticular nucleus. Blocks of tissue from the right half were prepared for electron microscopy using the ethanolic phosphotungstic acid (EPTA) method to stain synaptic contacts. Stereological analyses were performed to determine the Nv of synapses in the central reticular nucleus. Total volume of the hemimedulla did not differ significantly between SIDS cases and controls. However, in the central reticular nucleus of SIDS cases, the Nv of neurons was significantly less than in controls (30%), while the mean profile area of reticular neurons was significantly greater (39%). Synaptogenesis in control cases was characterized by a gradual decrease in the Nv of synapses from approximately 150 million at 40 postconceptional weeks to 110 million at 84 weeks. In SIDS cases the Nv of synapses was significantly greater (38%). These results demonstrate a disorder of synaptogenesis in the central reticular nucleus of SIDS cases. In view of previous reports of a persistence of dendritic spines on reticular neurons in SIDS, the results are consistent with a failure to eliminate normally extraneous synapses during early development.

Cytogenetic analysis of 109 pediatric central nervous system tumors

Reports of cytogenetic abnormalities in pediatric central nervous system (CNS) tumors are important for collection and comparison of large numbers of karyotypes of primary CNS neoplasms to produce statistically significant correlations. We report cytogenetic results of 119 samples of pediatric CNS tumors from 109 patients. Tumors included 33 low-grade astrocytomas, 18 high-grade astrocytomas, 14 gangliogliomas, 13 ependymomas, 17 primitive neuroectodermal tumors (PNET), three choroid plexus papillomas and carcinomas, and a miscellaneous group of 20 rare primary CNS tumors and metastases. In each group, cytogenetic results were correlated with histologic subtype and survival. The study indicated specific chromosome abnormalities in different groups of tumors. Low-grade astrocytomas showed mostly numeric abnormalities with gains of chromosome 7, high-grade astrocytomas showed differences from karyotypic changes observed in adults in lacking double minutes (dmin) and monosomy 10. The ependymoma group showed the largest proportion of abnormal karyotypes with frequent involvement of chromosome 6 and 16. Chromosome 6 was the single most common abnormal chromosome in this study, closely followed by chromosomes 1 and 11. Pediatric CNS neoplasms differ from adult tumors cytogenetically as well as histologically and biologically.

Sudden infant death syndrome: postnatal changes in the numerical density and total number of neurons in the hypoglossal nucleus

Tissue specimens from the medulla were sampled from 28 sudden infant death syndrome (SIDS) victims and from 15 control cases without neurological disease (36-95 postconceptional weeks). Morphometric analyses were performed on serial Nissl sections through the hypoglossal nucleus. The total volume of the hypoglossal nucleus, the numerical density (Nv, cells per mm3) and the total number of motor neurons, interneurons and glia were determined. Normal development was characterized by a linear increase in the volume of the hypoglossal nucleus during the first postnatal year. While the Nv of neurons decreased, the total number of neurons remained relatively constant at approximately 7,600 motor neurons and 3,100 interneurons. In SIDS cases the rate of increase in the volume of the hypoglossal nucleus was significantly greater than in controls (79%). The Nv of neurons was less than in controls (25-30%), although the total number of motor neurons and interneurons did not differ significantly. In SIDS cases the mean profile area of motor neuron cell bodies was significantly greater than in controls (29%), while the mean profile areas of interneurons and glia did not differ. These abnormalities in growth indicate a greater volume of neuropil in a hypoglossal nucleus containing a normal complement of neurons. The disproportionately rapid increase in volume of neuropil in the hypoglossal nucleus of SIDS cases may result from an increased arborization of dendrites on the motor neurons.

Continuous intrathecal baclofen treatment of severe spasms in two children with spinal-cord injury

This study reports the use of intrathecal baclofen in two ventilator-dependent children with severe spasms secondary to spinal-cord injury. Baclofen was delivered via a subcutaneously implanted, programmable pump. The children were followed for 12 and 24 months. Baclofen dramatically reduced spasms, resulting in more stable ventilation, improved ease of care, reduced distress and better integration into the community. Although effective, intrathecal baclofen represents a significant intervention; careful consideration must be given to potential complications and the need for long-term management. Full effectiveness was dependent on free CSF flow.

Surgical implications of cerebral dysgenesis

Cerebral dysgenesis encompasses varied disorders of brain development. Based on the understanding of these conditions provided by histopathologists, embryologists, radiologists and developmental pediatricians, surgeons are able to appropriately assist in the care of these patients. The surgeon can offer assessment of the ventriculomegaly that commonly accompanies cerebral dysgenesis in addition to providing methods to control hydrocephalus, to reconstruct cranial and facial malformations and to remove dysfunctional tissue. For most patients, surgical intervention is only one of the many factors that determine developmental prognosis. Based on the foundation built by other specialists, this review discusses cerebral dysgenesis from the perspective of historical and current surgical interventions.

Lethal congenital muscular dystrophy with cataracts and a minor brain anomaly: new entity or variant of Walker-Warburg syndrome?

A term newborn male with severe hypotonia and contractures was found to have dense bilateral cataracts. He died at age 3 days of respiratory failure. Amino acidopathies and disorders of peroxisome function were excluded, and results of serologic studies and placental histopathology, specifically seeking evidence of intrauterine infection, were normal. Autopsy showed changes in the skeletal muscles consistent with congenital muscular dystrophy and a small focal anomaly of the cerebral cortex. These findings either represent a new syndrome or raise further questions about broadening the spectrum of known congenital muscular dystrophy syndromes with associated eye and brain anomalies.

Centronuclear myopathy heterogeneity: distinction of clinical types by myosin isoform patterns

We studied muscles from 3 patients with centronuclear myopathy (CNM) by immunocytochemistry using myosin heavy chain (MHC)-specific monoclonal antibodies to determine whether subtypes of CNM express prenatal MHC and to assess if there is an arrest in development of these muscles. Muscle from a woman with childhood-onset CNM did not express prenatal MHC, yet this prenatal MHC was strongly expressed in the muscle fibers of 2 brothers with X-linked CNM. This finding represents the 1st immunocytochemical evidence of the expression of a prenatal myosin isoform in nonregenerating postnatal human muscle and suggests that the X-linked form of CNM differs from the other types because of a true arrest in maturation of the muscle.

Identification of somatostatin receptors by covalent labeling with a novel photoreactive somatostatin analog

We have synthesized two photoreactive derivatives of somatostatin, namely [125I-Tyr11,azidonitrobenzoyl (ANB)-Lys4]somatostatin and [125I-Tyr11,ANB-Lys9]somatostatin, and used them to characterize somatostatin receptors biochemically in several cell types. Saturation binding experiments carried out in the dark demonstrated that [125I-Tyr11,ANB-Lys4]somatostatin bound with high affinity (KD = 126 +/- 39 pM) to a single class of binding sites in GH4C1 pituitary cell membranes. The affinity of this analog was similar to that of the unsubstituted peptide [125I-Tyr11]somatostatin (207 +/- 3 pM). In contrast, specific binding was not observed with [125I-Tyr11,ANB-Lys9]somatostatin. The binding of both [125I-Tyr11,ANB-Lys4]somatostatin and [125I-Tyr11]somatostatin was potently inhibited by somatostatin (EC50 = 300 pM) whereas at 100 nM unrelated peptides had no effect. Furthermore, both pertussis toxin treatment and guanyl-5'yl imidophosphate (Gpp(NH)p) markedly reduced [125I-Tyr11,ANB-Lys4]somatostatin binding. Thus, [125I-Tyr11,ANB-Lys4]somatostatin binds to G-protein coupled somatostatin receptors with high affinity. To characterize these receptors biochemically, GH4C1 cell membranes were irradiated with ultraviolet light following the binding incubation, and the labeled proteins were identified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and autoradiography. A major band of 85 kDa was specifically labeled with [125I-Tyr11,ANB-Lys4]somatostatin but not with [125I-Tyr11,ANB-Lys9]somatostatin or [125I-Tyr11]somatostatin. The binding affinity of the 85-kDa protein for [125I-Tyr11,ANB-Lys4]somatostatin was very high (Kd = 34 pM). Labeling of this protein was inhibited competitively by somatostatin (EC50 = 140 +/- 80 pM) but not by unrelated peptides. Furthermore, this band was not labeled in pertussis toxin-treated membranes or in untreated membranes incubated with Gpp(NH)p. Finally, [125I-Tyr11,ANB-Lys4]somatostatin specifically labeled bands of 82, 75, and 72 kDa in membranes prepared from mouse pituitary AtT-20 cells, rat pancreatic acinar AR4-2J cells, and HIT hamster islet cells, respectively. Thus, [125I-Tyr11,ANB-Lys4]somatostatin represents the first photolabile somatostatin analog able to bind to receptors with high affinity. Our studies demonstrate that this novel peptide covalently labels specific somatostatin receptors in a variety of target cell types.

Sudden, unexpected, natural death in childhood

One thousand nine hundred and fifty four autopsies performed at British Columbia's Children's Hospital during a 7-year period were reviewed to determine the causes of sudden unexpected natural death in the age group from birth to 17 years. Of the 126 cases found, the largest group, 86 cases, was sudden infant death syndrome (SIDS). Nine deaths were the result of infection: 4 cases of H. influenza meningitis, 2 cases of meningococcemia, 2 cases of acute epiglottitis, and 1 case of necrotizing tracheobronchitis. Epilepsy, ruptured AV malformations, and brain tumors combined to make up an equally large group of 9 cases. Cardiac lesions were the third largest group, 6 cases. The three groups that posed the most difficulty in assigning a cause of death were (a) the group that were like SIDS yet had other confounding features, (b) the group in which metabolic death was suspected but not proven, and (c) death in epilepsy.

Ruptured intracranial aneurysm presenting as cerebral infarction in a young child

We describe a 15-month-old girl who presented with an acute hemiplegia. The sequence of events appears to have been clinically silent subarachnoid hemorrhage, vasospasm, infarction and a second lethal hemorrhage 3 months later. The old infarction was seen on computed tomography during her second illness. Autopsy confirmed the presence of a recent rupture of an intracranial aneurysm and old hemorrhage. In addition there was an unusual fibroblastic proliferation in the aneurysm wall. This case demonstrates that clinically silent subarachnoid hemorrhage, vasospasm and infarction can occur as complications of aneurysms, even in very young children.

MR imaging of periventricular leukomalacia in childhood

Eight children with clinical and radiologic abnormalities consistent with periventricular leukomalacia were investigated with MR imaging of the brain that employed both inversion-recovery and T2-weighted spin-echo imaging sequences. The more precise delineation of white and gray matter on inversion-recovery images as compared with CT allows a detailed demonstration of the anatomic features of periventricular leukomalacia; specifically, a reduced quantity of white matter in the periventricular region and centrum semiovale and, in more severe cases, cavitated infarcts that replace the immediate periventricular white matter. The T2-weighted spin-echo and short inversion time inversion-recovery images demonstrated abnormally increased signal in white matter that appeared normal on CT scans and only minimally abnormal on conventional inversion-recovery images. These abnormalities most probably represent white matter gliosis that extends beyond the immediate periventricular regions. MR recognition of cerebral white matter abnormalities associated with periventricular leukomalacia may confirm the clinical suspicion of this diagnosis in children with spastic diplegia or quadriplegia.

Two cases of Wernicke's encephalopathy in children: an underdiagnosed complication of poor nutrition

We describe the occurrence of Wernicke's encephalopathy in two children in whom the diagnosis was not suspected during life. Postmortem examination showed changes characteristic of the disease. This preventable and treatable condition is probably underdiagnosed in poorly nourished, nonalcoholic patients of all ages.

Selective brainstem injury in an asphyxiated newborn

We report the clinical, radiological, and neuropathological features of selective brainstem injury in an asphyxiated term infant. Disproportionate injury to thalamus, basal ganglia, and brainstem with relative sparing of cortex and subcortical white matter is observed occasionally after acute total asphyxia. Although this entity has been well documented neuropathologically, the specific computed tomographic findings have not been reported previously to our knowledge, and the clinical correlation is recognized rarely.

Fetal neuropathology of proliferative vasculopathy and hydranencephaly-hydrocephaly with multiple limb pterygia

We describe the third family in which fetuses have very narrow cerebral cortical mantles, enlarged ventricles, a peculiar proliferation of cerebral cortical arteries, and hypoplasia of muscle. We describe the youngest fetus yet reported. Previously this condition was interpreted as destructive, perhaps due to infection. We believe it is a primary failure of neuroectodermal cells to form in the ventricular zone with too few resulting cells in cerebral cortex and that the abnormal vascular proliferation is part of the malformation. The involvement of both sexes suggests autosomal recessive inheritance.

Isolation and characterization of monoclonal antibodies specific for the cardiac muscarinic acetylcholine receptor

A number of monoclonal antibodies were raised against the purified porcine atrial muscarinic acetylcholine receptor. The antibodies were shown to exhibit a high degree of specificity for the receptor by their ability to recognize the purified receptor but not other porcine atrial glycoproteins in enzyme-linked solid-phase immunosorptive assays and by immunoblot analyses. Several of the antibodies were able to quantitatively precipitate the muscarinic receptor in both pig and rat heart and a portion of the receptor from rat cerebellum but little if any receptor from rat cerebral cortex. Thus, these monoclonal antibodies not only exhibit specificity for the muscarinic receptor but also are specific for the cardiac receptor subtype.

Primary Ewing's sarcoma of the base of the skull

The authors report a case of primary Ewing's sarcoma of the petrous bone. The radiological features, including the computed tomographic scan and angiographic findings, are described in detail.

The growth and development of microvasculature in human cerebral cortex

Sections of the occipital cortex from 31 fetuses, infants and children, ranging in age from 15 weeks gestation to ten years postnatal, were stained to demonstrate alkaline phosphatase activity in intracortical vessels. At 15 weeks gestation intracortical positively staining vessels, assumed to be arterial precursors, were radially oriented, originating from leptomeningeal arteries. Most radial vessels coursed through the cerebral cortex without branching to vascularize the subcortical tissue. By 20 weeks gestation horizontal branches arose from radial vessels, most frequently in the lower half of the cortex. Occasionally, recurrent collaterals ascended from these horizontal branches to more superficial cortex. From 20-27 weeks gestation, the number of horizontal branches and recurrent collaterals increased in the lower half of the cortex, horizontal branches appeared in the upper half. From 27 weeks to term, shorter radial vessels, terminating in the more superficial cortical laminae increased in number. After birth a network of fine vessels, presumable precursors of capillaries, increased, particularly vascular layer 3 (neuronal lamina IV and Va). The number of radially oriented vessels per mm2 of pial surface (NA) decreased throughout development, with the most dramatic decrease occurring prenatally. In five cases of trisomy values of NA decreased less rapidly than in the normal.

Biochemical and histologic pathology in an infant with cross-reacting material (negative) pyruvate carboxylase deficiency

An infant with the acute neonatal form of pyruvate carboxylase deficiency (cross-reacting material negative) presented with severe intractable lactic acidosis within 4 h after birth. He also had hyperammonemia, hypercitrullinemia, and hyperlysinemia. Plasma glutamine was not elevated. He had a rapidly deteriorating clinical course with severe liver dysfunction, repeated septicemia and seizures; he was comatose and was on a ventilator throughout; death occurred at 8 wk of age. Skin fibroblast study confirmed the enzyme deficiency. Detailed biochemical parameters and histopathology of the brain and liver are presented. The evidence from this infant suggests that disturbances of intracellular oxaloacetate levels as a result of the primary enzyme defect might also contribute to deficiency in ATP generation which may explain the various other biochemical changes and liver pathology.

Hallervorden-Spatz disease: cysteine accumulation and cysteine dioxygenase deficiency in the globus pallidus

We describe neurochemical abnormalities found in the brains of 2 patients with autopsy-confirmed Hallervorden-Spatz (HS) disease. In 1 patient, contents of cystine and of glutathione-cysteine mixed disulfide in the globus pallidus were markedly elevated above values for appropriate control subjects. Activity of cysteine dioxygenase, which converts cysteine to cysteine sulfinic acid, was reduced in the globus pallidus, but normal in the frontal cortex and putamen of both patients. gamma-Aminobutyric acid content was markedly decreased in the globus pallidus and substantia nigra of both patients. These results suggest that cysteine accumulates locally in the globus pallidus in Hallervorden-Spatz disease as a result of an enzymatic block in the metabolic pathway from cysteine to taurine. Accumulated cysteine may chelate iron, accounting for the local increase in iron content in Hallervorden-Spatz disease. The combined excess of cysteine and ferrous iron may generate free radicals that damage neuronal membranes to cause the typical morphological changes observed in this disorder.

Screening of newborn infants for galactosemia in British Columbia

With simple microbiologic and fluorescent tests, we detected two cases of classic galactosemia, confirmed by specific enzyme assays, in the first 25 000 newborn infants in British Columbia screened for this disorder. The results were equivocally abnormal for another 31 infants, and a second blood sample was requested from each, either for repeat screening or for enzyme assays. The two infants with galactosemia were in hospital with an undiagnosed acute illness and had only a trace of non-glucose reducing substances in the urine when the screening tests were done. Screening for galactosemia fits well with our established programs of screening for phenylketonuria and hypothyroidism and costs less than $1 per infant tested.

Multiple system atrophy with neuronal intranuclear hyaline inclusions. Report of a case and review of the literature

A 31/2-year-old girl presented with frequent falls. She had an unsteady gait, delayed behavioural development absent tendon reflexes and in the legs decreased strength tone and equivocal plantar responses. She then developed ataxia, nystagmus, choreoathetosis, cranial nerve palsies, diminished strength and tone in the arms, sensory deficit in the limbs and autonomic nervous system dysfunction. She became progressively less responsive and succumbed at the age of 63/4 years. Examination of the central, peripheral and autonomic nervous system showed ubiquitous neuronal intranuclear hyaline inclusions and neuronal loss in several sites.

Respiratory arrest and cervical spinal cord infarction following lumbar puncture in meningitis

A 6-year-old child with meningitis had a respiratory arrest 20 minutes after a lumbar puncture. Thereafter she required maintenance on a ventilator, had a flaccid quadriplegia, and died 12 days later. Necropsy showed infarction of the central portion of the cord at the level of the decussation of the pyramids. The suggested mechanism of damage is compression of the arterial supply to the cord at the level of the foramen magnum by herniated cerebellar tonsils; concomitant hypotension may have contributed to production of the damage. Four similar cases, who survived with residual deficit, have also been reported. Other separate mechanisms by which the cord can be damaged in meningitis are vasculitis, thrombosis and arachnoiditis.

Mechanisms of brain damage in twins

The brains of 18 twins dying in the perinatal period showed a variety of lesions. Eleven had subependymal cell plate hemorrhage which had ruptured into the lateral ventricles in five. Five had periventricular damage. Three had anoxic neuronal damage. One acardiac monster had bilateral cerebral infarction. One pair had unequal sized brains, probably due to unequal intrauterine nutrition. Twins have a high perinatal mortality and morbidity; as well, intrauterine events may alter brain growth and development in each twin unequally, so they are an imperfect model to study the effect of genes and environment on intelligence.

On the morphogenesis of ulegyria

An 11 day old premature infant survived 8 days after a cardiac arrest. At necropsy, the infant's brain showed cortical arteries surrounded by cuffs of viable neurones, while the cortex between these arteries was necrotic. This appearance suggests that the pattern of nodules of neurones separated by radial bands of scar seen in ulegyria is probably the result of healing of similar cortical infarcts, which are oligemic intracortical boundary zone infarcts occurring when the arterial vascular bed is immature.