Friday, September 12, 2014

PBS's Frontline Spotlights Neuropathology in Documentary Film

In the film, which premieres Tuesday, Oct. 8 beginning at 9 pm EST, FRONTLINE investigates the hidden story of the NFL’s response to head injuries. Through interviews with former players, scientists and neuropatholgists, it examines what the NFL knew about the risks of chronic traumatic encephalopathy (CTE), and when it knew it. Dr. Bennet Omalu, the first neuropathologist to draw a connections between playing football and the development of CTE, is featured in this remarkable documentary.

See a six-minute preview of the film here.

Dr. Bennet Omalu, the first pathologist to posit the connection between CTE and playing football

Thanks to Dr. Doug Shevlin sending me this link.

Tuesday, September 9, 2014

Amyloid-beta and neurofilament in 3D

Three-dimensional immunohistological visualization of Aβ (green) and neurofilament (red) in a 500-micron thick block of human post-mortem Alzheimer disease tissue.
From:Kunie A, et al. Inside Alzheimer brain with CLARITY: senile plaques, neurofibrillary tangles and axons in 3D. Acta Neuropathologica. , Volume 128, Issue 3, pp 457-459.

Thanks to Dr. Mark Cohen of Case Western for sending me the link.

Monday, September 8, 2014

Best Post of June 2014: Higgins Leads Athena's Quest for More Specific Epilepsy Diagnoses

The next in our "Best of the Month" series is from Thursday, June 5, 2014:

Joseph J. Higgins, MD
Last month I had an opportunity to sit down with Joseph J. Higgins, MD at the American Academy of Neurology Annual Meeting in Philadelphia. Dr. Higgins is Athena Diagnostics' recently named medical director for neurology.
Among the topics we discussed is Athena's new advances in helping clinicians diagnose autoimmune epilepsy disorders. A growing body of evidence points to an autoimmune etiology for a proportion of drug-resistant epilepsy cases. Dr. Higgins, with the horsepower of Athena's parent company Quest Diagnostics behind him, is leading the way in making auto-antibody testing available to patients with intractable epilepsy. While patients with pathogenic auto-antibodies often experience heightened adverse effects and typically respond poorly to conventional treatment, they can respond very well to immunomodulatory therapy. Autoantibodies to surface proteins that influence neuronal excitability have been found in the serum and cerebral spinal fluid of well over 10% of patients with epilepsy—whether the epilepsy was newly-diagnosed or established. In many cases, once identified, autoimmune epilepsy can be slowed, halted, or even reversed with adjunctive immunotherapy. Testing to establish an accurate diagnosis is an important part of selecting an optimal treatment plan. In a recent study (see reference below), 81% of adult patients diagnosed with autoimmune epilepsy experienced significant improvement in seizure status when immunotherapy was used in combination with anti-epileptic medications; 67% achieved complete seizure freedom.

Among the clinical syndromes that can be investigated using CSF auto-antibody assays are Morvan's Syndrome (by testing for VGKC complex, predominantly CASPR2) and NMDA Receptor Antibody Encephalitis (by testing for NMDA receptor, NR1 subunit). Dr. Higgins is at the forefront of personalized epilepsy treatment. Athena's advances in this field will ultimately improve patient outcomes while reducing medical costs. 

Reference: Quek AM, Britton JW, McKeon A, et al. Autoimmune epilepsy: clinical characteristics and response to immunotherapy. Arch Neurol 2012;69:582-93.

Monday, August 25, 2014

Best Post of May 2014: Primary Progressive Aphasia (non-fluent/agrammatic variant) in a patient with Pick disease

The next in our "Best of the Month" series is from May 14, 2014:

I recently performed an autopsy on a 67-year-old man had a seven-year history of progressive difficulty with halting speech. His wife described him as seeming to be “groping for words”. Three years after initial presentation, he demonstrated profound difficulty both initiating and finishing sentences. His verbal communication was marked by jumbled grammatical errors in which he put words in the wrong order and tense. For example, when asked by his neurologist to recount his activities over the day, he responded: “Go I… the grocery store… to.” He had no difficulty with naming objects or understanding their use. He had only mild amnestic deficits and no visuospatial difficulties. During the last months of his life, he began to become more rigid in his personality and more socially withdrawn. 
The clinical diagnosis in this patient is primary progressive aphasia, non-fluent/agrammatic variant. The pathologic diagnosis is frontotemporal lobar degeneration with 3R tau inclusions (FTLD-tau), commonly known as Pick disease.  The clinical presentation of FTLD can be divided into two types: the behavioral variant (bvFTLD) and primary progressive aphasia (PPA). Neurologists subclassify PPA into three subtypes: semantic variant (sv-PPA), non-fluent/agrammatic variant (na-PPA), and logopenic/phonologic variant (lv-PPA). While sv-PPA and na-PPA generally correspond to FTLD pathology, lv-PPA typically corresponds to Alzheimer disease (AD) pathology (and is accordingly referred to as the “language variant” of AD).  The syndrome of na-PPA is characterized by predominant language dysfunction in which there is a disordering of words in sentences, an inability to repeat complex words (e.g., saying “castaphory” when asked to repeat back the word “catastrophe”), inability to construct complex sentences, and other deficits in grammar and phonology.  In contrast, a diagnosis of sv-PPA is given to patients who exhibit a general deficit in their ability to understand word and object meaning. Patients with sv-PPA also show difficulty in naming objects and understanding what they are used for. A diagnosis of bvFTLD is ruled out as this patient only showed behavioral changes only late in the disease course

Pick disease was demonstrated pathologically by the presence of 3R tau positive Pick bodies (see photomicrograph) in the frontal and temporal lobes as well as the dentate fascia of the hippocampus, cornu Ammonis of the hippocampus, presubiculum, cingulate gyrus, insula, and inferior parietal lobe.

3R tau positive Pick body in the inferior temporal gyrus

For the practicing neuropathologist, FTLD’s are not yet classified on a molecular basis (although some day they surely will be),  but rather according to the particular protein aggregation which is detected using immunohistochemistry. The five possible FTLD subtypes, based on specific associated protein aggregations, are represented in the following table: 
FTLD type
Associated Protein Aggregation
Tau (can be further subclassified into 3-repeat [3R], 4-repeat [4R], or 3R+4R tau)
Transactive response DNA-binding protein of 43 kDa (TDP-43)
Fused in sarcoma (FUS)
Ubiquitin (with UPS standing for ubiquitin-proteasome system)
No immunoreactivity
In 80% of cases of sv-PPA, the underlying histopathology is that of FTLD-TDP; while in the majority of na-PPA cases, the pathologic substrate is FTLD-tau.  Although not denoting a specific clinical syndrome, the term “Pick disease” has come to denote FTLD-tau, particularly referring to aggregation of the tau isoform in which there are three repeats (3R) of the phosphate-binding domain.


Sieben A, Van Langenhove T, Engelborghs S, et al. The genetics and neuropathology of frontotemporal lobar degeneration. Acta Neuropathol. 2012;124(3):353-372.

Zdenek R, Matej R. Current Concepts in the Classification and Diagnosis of Frontotemporal Lobar Degenerations: A Practical Approach. Arch Pathol Lab Med. 2014;138:132-138.

Thursday, August 21, 2014

35-year-old woman who died after a presumed seizure episode

A 35-year-old woman died after a witness saw her "foaming at the mouth". A seizure was presumed to have occurred by emergency personnel. At autopsy, there was mild dilatation of the lateral and third ventricles:

This translucent mass was identified in the third ventricle:

Histological examination of the cyst contents revealed:

Although no ciliated epithelium was identified within the specimen, there were columnar cells with a pseudostratified configuration:

However, the majority of the cyst lining was flattened, simple epithelium:

Diagnosis?  (Please post to comments)

Tuesday, August 19, 2014

Dr. Peter Cummings Challenges Neuropathologists to Ice Bucket Challenge

Peter Cummings, MD
Dr. Peter Cummings has challenged his neuropathology colleagues to take the ALS ice bucket challenge. The good doctor dumps a bucket of ice water on his head in this video. If you are unfamiliar with the viral phenomenon of the ice bucket challenge, here's a New York Times article describing it. Now, grab a bucket!

Monday, August 18, 2014

Best Post of April 2014: Nobel Laureate Prusiner Tells His Story

The next in our  "Best of the Month" series is from April 8, 2014:

Just published by Yale University Press: Stanley Prusiner's new book, Madness and Memory: The Discovery of Prions - A New Biological Principle of Disease, is now available for purchase. Although I am not personally a big fan of Dr. Oliver Sacks's work, his blurb on Prusiner's book is worth reading: “Stanley Prusiner is a brilliant scientist whose boldness and tenacity enabled him, against all odds and despite near-universal skepticism, to discover and prove the importance of a new class of disease-producing agents—prions—a discovery as fundamental as that of bacteria and viruses. Prions, by subverting the brain’s own proteins, may play a crucial role in Alzheimer’s, Parkinson’s, and other neurodegenerative diseases—and perhaps afford a clue to their prevention. Madness and Memory is the story of one of the most important discoveries in recent medical history, and it is also a vivid and compelling portrait of a life in science." Special thanks to Dr. Mark Cohen for alerting me to the publication of this new account of a seminal discovery in biological science.

The bookish Dr. Mark Cohen