Tuesday, February 26, 2013

Review by Dr. Mark Cohen of "Neuropathology: A Volume in the High Yield Pathology Series", edited by Yachnis and Rivera-Zengotita

Mark L. Cohen, MD
I am honored to present a guest post by the inimitable Dr. Mark Cohen of the illustrious Case Western Reserve University. Dr. Cohen not only reviews a great new neuropathology textbook, but illustrates yet again why he is widely known as the Maxwell Smart of Neuropathology.

(Not really) Full disclosure
Self-annihilating conflicts of interest, as follows:
  1. Long-standing professional relationship with unbridled admiration for lead editor Tony Yachnis, both as a person and as a pathologist (he's not the Moderator of the world-famous Diagnostic Slides Session of the American Association of Neuropathologists, as well as their President-Elect, for nothing).
  2. I have contributed to several publications that compete within the same niche, and from which I have amassed a small fortune (recently enabling me to purchase new windshield wipers for my ‘99 Corolla).

Several weeks ago, I received the following teaching evaluation from an anonymous medical student: "One of the worst lecturers that I had the misfortune of experiencing in medical school. Powerpoints were poorly constructed in terms of high yield content...”. So, when our host Dr. Moore blogged about the impending publication of Neuropathology: A Volume in the High Yield Pathology Series, I sprinted to my laptop to pre-order a copy.

Anthony T. Yachnis, MD, MS
The book arrived safely last night (albeit buried in several inches of snow), and I was not disappointed. Best described as Text-Atlas, it weighs in at 351 pages, which is roughly half that of both Perry & Brat’s Practical Surgical Neuropathology and Prayson’s Neuropathology, second edition. In addition, it represents something of a revolutionary approach in that it was primarily written by trainees in pathology, neuropathology, dermatopathology, hematopathology and neurosurgery. This team-based approach (a testament to Captain Tony’s coaching skills) has produced a neuropathology text “of the people, by the people, and for the people”, as well as resulting in a textbook which is remarkably up to date (including such topics as Natalizumab-related PML). In addition to an introduction to basic neuropathological reactions, subjects covered include developmental disorders (both malformative and acquired), cerebrovascular disorders, trauma, brain tumors, infectious diseases, neurodegenerative disorders, demyelinating diseases, toxic/metabolic disorders, and neuromuscular disorders. For a book of this size, the scope of the topics covered is remarkably comprehensive, and they are extensively, if not exhaustively, illustrated. The pictures, especially the gross photographs, are of uniformly high quality (which appears to be maintained in the on-line version, unlike another high-profile textbook I reviewed a few years ago). In addition to the beautifully photographed gross specimens, pictures include histochemistry, immunohistochemistry, and neuroimaging, as appropriate. The vast majority of the photographs are reproduced at 3.25 x 2.5 inches, which is more than adequate to appreciate the features described in the figure legends. With rare exceptions, arrows are not included within the photomicrographs (which I feel is appropriate, but has gotten me in trouble with certain journals, publishers, and students). As is the practice within this series of textbooks, as well as in many other currently published pathology books, the text is entirely bulleted (a practice which I personally dislike, but which is executed quite well here). Another feature that the reader should be aware of is that (no doubt as part of the philosophy of “high-yield pathology”) there are no references.

Marie Rivera-Zengotita, MD
As an academic neuropathologist, do I have criticisms? (Do bears sh...?). Besides minor quibbles with organization (I probably would have included Natilizumab-associated PML within the Infections section rather than as part of multiple sclerosis) and such Talmudic issues as whether brain invasive meningiomas are truly atypical or not really atypical, but still WHO Grade II, I think that the improvements that I would suggest are largely outside the purview of the authors and editors. Specifically, the titling typography and design layout is nothing short of hideous, and, although the pictures are of adequate size, the presence of many nearly blank pages certainly makes me wish that those spaces had been filled by larger format photographs. In addition, a few of the topics are presented sans photographs, which detracts somewhat from the flow of the textbook (although the authors had the good sense of not trying to illustrate mixed oligoastrocytomas). All in all, however, I think that the book succeeds in its aspirations of presenting "high yield neuropathology".

The editors hope that the volume will be useful for trainees in pathology, neurology, neurosurgery, neuroradiology, neuro-oncology and related fields; as well as being a practical reference for practicing pathologists -- including neuropathologists requiring quick access to the field. As I was reading through the text, I kept this in mind, and triaged these groups as follows:

  1. Neurology and neurosurgery residents should run, not walk, to order a copy, as Board examinations are near at hand, and this book provides a perfect study guide for preparation. Neuropathology fellows should also obtain a copy for studying, although at this moment they have time to walk to their laptops or bookstore.
  2. Neuroradiologists and anatomic pathologists should obtain a copy to keep as a quick reference
  3. Neuro-oncologists will probably gravitate towards more specialized textbooks (such as the recent addition to the Diagnostic Pathology series edited by PCB et al.)
  4. As far as practicing neuropathologists go, I think we all need a copy as we generally find ourselves in one of two situations:
    1. A private practice or group setting without instantaneous access to literature databases. For this group, I think the book fulfills its goal as a quick access to diseases with which we may have become unacquainted during our time in practice.
    2. A large academic medical center with broadband access to literature databases. In this position, our quick access will generally be on-line. On the other hand, we should all have a copy to lend to clinical rotators as an expression of our great goodwill. (Another minor weakness of the book is that there is no RFID device by which we can geolocate our books once they have left our offices. On the other hand, the included on-line access assures that even as our copies disappear, we will still have access from our computers).

Unfortunately, while I feel this book will definitely help to guide me in the revision of my medical student lectures, it is by itself not appropriate for medical student study. To paraphrase Jack Nicholson as Col Nathan R. Jessup, USMC in A Few Good Men: You want high yield? You can’t handle high-yield!

Luckily, for those who can handle the truth, Neuropathology: A Volume in the High Yield Pathology Series will provide a valuable and lasting resource.

Wednesday, February 13, 2013

A Primer on Perinatal Telencephalic Leukoencephalopathy

In my last post, it was correctly pointed out by two astute readers that the Netter figure demonstrating brain malformations included an entity which is NOT a brain malformation: perinatal telencephalic leukoencephalopathy (PTL). PTL results from a perinatal hypoxic insult and is not a malformation per se, as the term "malformation" should really be reserved for anatomic abnormalities resulting from developmental defects. The cerebral white matter in the fetus and neonate is particularly susceptible to injury as it is metabolically highly active. Ischemia of the germinal matrix, subependymal region, and periventricular white matter can lead to periventricular leukomalacia that may even calcify and result in periventricular mineralization (1). At its most extreme, PTL may take the form of hemispheric multicystic leukomalacia in which the cerebral hemispheric white matter is replaced by multiloculated cysts separated by strands of fibroglial tissue.(2)

1. Fuller, Gregory N. and Goodman, J. Clay. Practical Review of Neuropathology. Lippincott 2001. Page 315.
2. Haberland, Catherine. Clinical Neuropathology: Text and Atlas. Demos Publishing 2007. Page 303.

Neuropathology Blog is Signing Off

Neuropathology Blog has run its course. It's been a fantastic experience authoring this blog over many years. The blog has been a source...