A case of myelinoclastic diffuse sclerosis in an adult

We report a case of rapidly progressive cerebral demyelinating disease in a previously healthy 40-year-old woman. This case satisfies the diagnostic criteria for myelinoclastic diffuse sclerosis (MDS), but is unusual in the age of onset. This is the 1st case of MDS in an adult with full documentation of clinical, biochemical, radiographic, and pathologic features.

Evaluation of selective liver denervation methods

This study compares four methods of hepatic denervation and defines the rate and physiological significance of reinnervation. Five groups of rats were prepared: 10 underwent orthotopic liver transplantation. In nine rats a 90% aqueous phenol solution was applied circumferentially to the portal vein. Thirteen rats underwent microsurgical denervation; 28 received different doses of 6-hydroxydopamine (6-HODA) administered as a single intraportal injection [50 (n = 10), 75 (n = 6), and 100 mg/kg (n = 6)]. Twelve rats were studied as controls. Rats were killed 1, 4, and 8 wk after surgery to determine liver tissue content of norepinephrine (NE). Changes in mean arterial pressure (MAP) in response to hepatic nerve stimulation, which was supramaximum in intensity and frequency, were measured before rats were killed. NE content in controls ranged from 121 to 204 ng/g and MAP increased by 30-38 mmHg after electrical stimulation. At 1, 4, and 8 wk after treatment the liver NE content was less than 1, 2.3, and 20.2 ng/g in the transplant group; less than 1, 2.7, 4.1 ng/g in the phenol group; and 17.2, less than 1, and 3 ng/g in the surgically denervated group. In the 6-HODA group, values were 18.9, 47, and 61.5 ng/g (50 mg/kg); 5.7, 20.2, and 15 ng/g (75 mg/kg); and 7.7, 2.5, and 17.5 ng/g (100 mg/kg). When the level of NE was undetectable, MAP increase after stimulation was 0-18% that of controls. When NE content was 15-23% of normal, MAP increased 49-62% regardless of the denervation technique.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial border zone necrosis of the spinal cord

A 74-year-old man developed necrosis of the spinal cord following an episode of severe hypotension associated with dissection of the aorta. The area of necrosis was confined to the arterial border zone between the anterior and posterior spinal arteries, and involved both gray and white matter symmetrically. The periphery of the cord was spared. Only the lower thoracic cord, which represents a border zone between segmental radicular arteries, was involved. Extensive arterial border zone necrosis was also present in the cerebral cortex and cerebellum. The fact that arterial border zone necrosis is much less common in the spinal cord than in the brain suggests that its development requires a local compromise of the spinal cord circulation in addition to systemic arterial hypotension.

Sural nerve biopsy in chronic inflammatory demyelinating polyradiculoneuropathy

We compared histologic features of sural nerve biopsies in 14 patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) with those in other forms of neuropathy. In CIDP endoneurial pericapillary cellular infiltrates were found in 4 patients (29%), onion bulbs in 5 patients (36%), and predominant demyelination in 7 patients (50%). None of these abnormalities was specific, but cellular infiltrates and onion bulbs appear to be diagnostically useful when combined with clinical information. To detect macrophage infiltration of myelin, cell nuclei were counter-stained in 20 teased fiber preparations. Nine patients with CIDP had a significantly higher mean number of cells per centimeter of teased fiber than 11 patients with other neuropathies. Despite overlap, significant infiltration of myelin detected by this method suggests CIDP in an appropriate clinical setting.

Neuroimaging of scuba diving injuries to the CNS

Diving accidents related to barotrauma constitute a unique subset of ischemic insults to the CNS. Victims may demonstrate components of arterial gas embolism, which has a propensity for cerebral involvement, and/or decompression sickness, with primarily spinal cord involvement. Fourteen patients with diving-related barotrauma were studied with MR imaging of the brain and spinal cord and with CT of the brain. In four patients with presumed cerebral gas embolism, cranial MR was abnormal in three patients while CT was abnormal in only one. Twelve patients had decompression sickness and spinal cord symptoms. MR documented spinal cord abnormalities in three patients. However, scans obtained early in our study were frequently limited by technical constraints. MR of the brain is more sensitive than conventional CT scanning techniques in detecting and characterizing foci of cerebral ischemia caused by embolic barotrauma to the CNS. Although spinal MR may be less successful in the localization of spinal cord lesions related to decompression sickness, these lesions were previously undetectable by other neuroimaging methods.

Pyrrole oxidation and protein cross-linking as necessary steps in the development of gamma-diketone neuropathy

It has been well documented that the gamma-diketone HD1 is the ultimate toxic metabolite of n-hexane. Furthermore, it has been shown that the pathogenetic mechanism by which HD exerts its neurotoxic effects is through binding to protein lysly residues and cyclization to pyrroles. The present study sought to determine whether the presence of pyrrole residues on NF1 proteins is sufficient to cause the NF-filled axonal swellings associated with n-hexane and other gamma-diketone neuropathies or whether pyrrole oxidation and protein cross-linking also have to occur in order for neurotoxicity to develop. We synthesized the HD analogue AcHD1 and assessed its rate of pyrrole formation in vitro, the ease of oxidation of its resulting pyrroles, and its ability to cross-link proteins in vitro. The in vivo effects of AcHD on rats were examined following daily ip1 injections. AcHD was found to have a rate of pyrrole formation comparable to that of the potent HD analogue DMHD1 at 35 degrees C. The pyrrole derived from AcHD was more resistant to oxidation than that derived from the neurotoxic compound HD. AcHD did not cross-link proteins in vitro. Pyrrole derivatives were demonstrated on hemoglobin isolated from animals treated with HD, DMHD, and AcHD. Cross-linked spectrin was detected in animals treated with HD and DMHD but not with AcHD. Rats receiving 0.1 or 0.25 mmol of AcHD/kg/day did not reach the end point of hindlimb paralysis observed in the gamma-diketone neuropathies, and the NF-filled axonal swellings seen following exposure to the neurotoxic gamma-diketones were not observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Occlusion of the basilar artery within a fracture of the clivus. Case report

Following a 15-foot fall from a roof, a 70-year-old man became comatose and developed signs of pontine dysfunction. There was a severely comminuted fracture of the distal left femur suggesting that he had landed in an upright position. It was clinically unclear whether the fall was secondary to a pontine infarct; however, an autopsy revealed a fracture of the clivus which had entrapped and occluded the basilar artery, causing death. These findings, and those in similar cases, suggest that this entity results from a force transmitted in an axial direction.

Evidence that pyrrole formation is a pathogenetic step in gamma-diketone neuropathy

Previous studies from this laboratory have demonstrated that the addition of methyl groups at the 3 and 4 positions of the 2,5-hexanedione (2,5-HD) molecule results both in more rapid pyrrole formation and in enhanced neurotoxicity. In order to define more clearly the relationship between rates of pyrrole formation and neurotoxicity, the dl and meso diastereomers of 3,4-dimethyl-2,5-hexanedione (DMHD), 3,4-diethyl-2,5-hexanedione (DEHD), and 3,4-diisopropyl-2,5-hexanedione (DiPHD) were synthesized and purified. The rates of pyrrole formation were compared with that of unsubstituted 2,5-HD, and rates of in vitro crosslinking were determined. Each of the compounds was administered to rats to determine relative neurotoxicity. Hindlimb paralysis was reached after a total administered dose of 1.6 mmol/kg of dl-DMHD, while 5.9 mmol/kg of meso-DMHD was required. Paralysis was not achieved with either diastereomer of DEHD or DiPHD, although both produced systemic toxicity. Histologic sections of spinal cords and anterior roots from rats treated with DMHD revealed large neurofilament-filled axonal swellings, while more distal sections contained axons undergoing Wallerian-type degeneration. Neither axonal swellings nor Wallerian-type degeneration were seen in sections from spinal cord or peripheral nerve of rats treated with DEHD or DiPHD. The rates of pyrrole formation were in the order dl-DMHD greater than meso-DMHD greater than 2,5-HD greater than dl-DEHD greater than meso-DEHD greater than dl-DiPHD greater than meso-DiPHD, while in vitro crosslinking rates were in the order dl-DMHD greater than meso-DMHD greater than dl-DEHD greater than meso-DEHD greater than 2,5-HD greater than dl-DiPHD greater than meso-DiPHD. Cyclic voltammetry showed that the autoxidation of pyrroles derived from DMHD, DEHD, and DiPHD occurred more readily than that derived from 2,5-HD. In addition, we report for the first time the segregation of axoplasmic organelles in animals treated with DMHD, providing further evidence that the neurofilamentous axonopathies caused by such compounds as beta,beta'-iminodipropionitrile (IDPN), 2,5-HD and CS2 share a common underlying mechanism. The strong correlations between rates of pyrrole formation, rates of in vitro crosslinking and relative neurotoxicity are seen as evidence that pyrrole formation is a step in the pathogenetic sequence of gamma-diketone neuropathy.

dl- versus meso-3,4-dimethyl-2,5-hexanedione: a morphometric study of the proximo-distal distribution of axonal swellings in the anterior root of the rat

The neurotoxicity of the dl and meso diastereomers of the gamma-diketone 3,4-dimethyl-2,5-hexanedione (DMHD) was studied to determine if the difference in rates of pyrrole derivatization would influence the clinical and morphological appearance of the neuropathy associated with these gamma-diketones. Two groups of rats received 0.2 mmol/kg/day intraperitoneal injections of their respective diastereomer, and two groups of control rats received comparable volumes of water. The dl-DMHD treated group reached the clinical end-point of hindlimb paralysis in a period of time threefold shorter than the meso-DMHD treated group, paralleling the in vitro kinetics of pyrrole formation with a model amine. A computerized morphometric analysis of cross-sectional axonal areas along the lengths of L4 and L5 anterior roots revealed that the dl-DMHD treated rats had axonal swellings more proximal and of smaller caliber than the meso-DMHD treated rats. 14C-labeled dl and meso diastereomers were synthesized and used to determine relative ability of the diastereomers to gain access to the nervous system. There was approximately 25% more dl-DMHD in the brain after 2 hr. The brain:serum ratios of the diastereomers, however, were equivalent. The more distal location of the neurofilament-filled swellings after meso-DMHD intoxication corroborates previous findings regarding toxicant potency and location of axonal swellings and suggests that the rate of neurofilament crosslinking determines the location of swellings along the length of the axon in the neurofilamentous axonopathies.

Hyperbaric oxygen accelerates the neurotoxicity of 2,5-hexanedione

The molecular pathogenesis of n-hexane neurotoxicity has been postulated to proceed as follows: The gamma-diketone metabolite, 2,5-hexanedione (HD), reacts with lysyl-amino groups on neurofilaments to form imines. The imines cyclize to form pyrroles. The pyrroles autoxidize, resulting in covalent protein-protein crosslinking within or between neurofilaments. A resultant impairment of neurofilament transport is proposed to lead to neurofilament-filled axonal swellings. This experiment was designed to test whether oxidation is a necessary pathogenetic step in vivo by comparing time of onset of paralysis of an HD treated group of rats to that of a group receiving HD plus oxygen under high pressure (OHP). The group of rats receiving the hyperbaric oxygen treatment reached the endpoint of hindlimb paralysis significantly sooner than the group receiving none. The fact that OHP does accelerate HD neuropathy points towards an oxidative step in the molecular pathogenesis of gamma-diketone neuropathy.

In vitro evidence that covalent crosslinking of neurofilaments occurs in gamma-diketone neuropathy

We have postulated that the toxic neuropathies associated with neurofilament-filled axonal swellings have a common pathogenesis, the covalent crosslinking of neurofilaments during anterograde transport. The newly described gamma-diketone, 3,4-dimethyl-2,5-hexanedione (DMHD), is a more potent analogue of the toxic metabolite of n-hexane, 2,5-hexanedione. The axonal swellings observed in DMHD toxicity are in the proximal axon, as seen in intoxication with beta, beta'-iminodipropionitrile, rather than in the distal axon, where neurofilamentous swellings are observed in n-hexane, carbon disulfide, and acrylamide neurotoxicity. In these studies, 14C-labeled DMHD and 2-butanone were synthesized and allowed to react with peripheral nerve. Only 14C-labeled DMHD resulted in stable radiolabeled protein polymers, which were retained by nitrocellulose filters with pore sizes as large as 12 microns. More specific evidence for covalent crosslinking of neurofilaments was obtained when DMHD was allowed to react with peripheral nerve in which the neurofilaments had been pulse-labeled with L-[35S]methionine.

3,4-Dimethyl-2,5-hexanedione impairs the axonal transport of neurofilament proteins

Accumulations of neurofilaments are observed in a variety of neurological disorders, and their pathogenesis is a fundamental problem of neuropathology. 2,5-Hexanedione (HD) neurotoxicity provides an extensively studied model of axonal neurofibrillary changes in which the pathogenetic mechanisms have been conjectural. Chronic exposure to HD results in neurofilament-filled swellings in the distal regions of large axons of exposed humans and experimental animals. In this report we describe the changes produced by a potent analogue of HD, 3,4-dimethyl-2,5-hexanedione ( DMHD ), in slow axonal transport in the rat sciatic motor axons. Young rats received 0.6 mmol/kg of DMHD for 5 days before [35S]methionine was injected into the lumbar ventral horns. Slow axonal transport of the neurofilament proteins, tubulin, and selected slow component b (SCb) proteins in DMHD -treated animals was compared to the profiles found in age-matched control animals. DMHD administration reduced the rate of transport of the neurofilament proteins 75 to 90%, while tubulin and the SCb proteins were only modestly retarded. No alterations in electrophoretic mobilities of slowly transported proteins were found, nor were any proteins accelerated in transport. These findings were systematically compared to the changes produced by administration of beta,beta'- immino - dipropionitrile (IDPN) (2.0 gm/kg, i.p.), an agent known to impair neurofilament transport. Although slightly less severe, the changes produced by DMHD were nearly identical to those of IDPN. In correlative morphological studies, the neurofilamentous changes were also comparable. The results indicate that DMHD and IDPN share the capacity to interfere selectively with neurofilament transport and thereby share pathogenetic mechanisms. DMHD provides a new agent for exploration of the organization and transport of the neuronal cytoskeleton.

The effect of 3,4-dimethyl substitution on the neurotoxicity of 2,5-hexanedione. I. Accelerated clinical neuropathy is accompanied by more proximal axonal swellings

The neurotoxicity of the gamma-diketone, 3,4-dimethyl-2,5-hexanedione, was studied in rats and compared to the known neurotoxicity of the parent compound, 2,5-hexanedione. The test compound was found to be 20 to 30 times more potent on a molar basis than hexanedione. In addition, unlike the distal axonal changes associated with hexanedione, the neurofilamentous swellings following exposure to the dimethyl analog occurred more proximally in the axon, with a preponderance in the anterior horn and lateral tracts of the spinal cord, and in the anterior roots. Since alkyl substitution causes branched-chain compounds to cyclize more rapidly than unbranched analogs, the greater neurotoxicity of the dimethyl compound implicates pyrrole formation in the pathogenesis of n-hexane neuropathy. Furthermore, the location of the axonal swellings induced with 3,4-dimethyl 2,5-hexanedione suggests that there is a common mechanism of injury for the entire class of neurofilament neuropathies, providing a continuum between the intraspinal swellings of beta, beta'-iminodipropionitrile (IDPN) and the distal axonopathies of 2,5-hexanedione, carbon disulfide, and acrylamide. In addition, lower doses of 3,4-dimethyl-2,5-hexanedione for longer periods of time led to a shift in the location of the axonal swellings to include more distal sites. These observations support the hypothesis that covalent crosslinking of the stable neurofilament is the primary event in the molecular pathogenesis of these toxic neuropathies, and that the rate of crosslinking of neurofilaments determines the proximodistal location of the axonal swelling.

The effect of 3,4-dimethyl substitution on the neurotoxicity of 2,5-hexanedione. II. Dimethyl substitution accelerates pyrrole formation and protein crosslinking

3,4-Dimethyl-2,5-hexanedione and 2,5-hexanedione were reacted with model amines to yield N-substituted 2,3,4,5-tetramethylpyrroles and 2,5-dimethylpyrroles, respectively. When compared to the unsubstituted parent compound 2,5-hexanedione, 3,4-dimethyl-2,5-hexanedione was found to cyclize approximately eight times as rapidly on a molar basis at 37 degrees C, with an activation energy of 3290 cal/mole less than 2,5-hexanedione. In addition, 1-benzyl-2,3,4,5-tetramethylpyrrole oxidized more readily than 1-benzyl-2,5-dimethylpyrrole with a difference in the half-wave potentials of 0.29 V. Both gamma-diketones led to progressive crosslinking of proteins in vitro, with the dimethyl substitution accelerating this process by a factor of 40. The formation of pyrrolyl derivatives in vivo was demonstrated by the characteristic absorption spectra obtained following reaction of erythrocyte proteins from intoxicated rats with Ehrlich's reagent. There was progressive formation of protein-bound dimethylpyrroles following exposure to 2,5-hexanedione and formation of tetramethylpyrroles following exposure to 3,4-dimethyl-2,5-hexanedione in vivo. Preparations of axonal pads also demonstrated pyrrole derivatization in vivo. In addition, spectrin preparations of erythrocytes from intoxicated rats showed a large amount of high molecular weight protein (400,000 Da), corresponding to dimerized spectrin. Thus, 3,4-dimethyl-2,5-hexanedione, which is 20 to 30 times more potent on a molar basis than 2,5-hexanedione in leading to a neurofilamentous neuropathy, is associated with more rapid pyrrole formation and protein crosslinking in vitro, and it has been demonstrated that these processes occur in vivo. These observations support the hypothesis that pyrrole formation and autoxidation occur following exposure to gamma-diketones, leading to covalent crosslinking of proteins in vivo, a process which may explain the pathogenesis of neurofilament accumulation in these neuropathies.

The spatio-temporal pattern of the axonopathy associated with the neurotoxicity of 3,4-dimethyl-2,5-hexanedione in the rat

The neurotoxicity of the gamma-diketone 3,4-dimethyl-2,5-hexanedione(DMHD) was studied to determine the distribution of the neuropathologic changes and the temporal sequence during the intoxication period and following five and 15 weeks of recovery. Intoxication with 3,4-dimethyl-2,5-hexanedione at a daily dose of 0.25 mmoles/kg led to a profound clinical neuropathy, resulting in paralysis of all four limbs after 12-15 days. The cumulative toxic dose for this gamma-diketone was 3-4 mmoles/kg, indicating that dimethyl substitution increased the neurotoxicity of gamma-diketones by a factor of 20-30. The neuropathy was characterized histologically by giant axonal swellings in the proximal axon of the lower motor neuron in a distribution similar to IDPN (beta,beta'-iminodipropionitrile)-neuropathy, with swellings in the anterior horn, intraspinal anterior root, and the proximal anterior root. These swellings developed from six to 12 days of intoxication and were still evident after 15 weeks of recovery. The fact that dimethyl substitution of 2,5-hexanedione accelerated the neuropathy and was characterized by proximal axonal swellings has two important implications: 1) that formation of pyrrole derivatives may be an important step in the pathogenesis of gamma-diketone neuropathies, and 2) that the neurofilament neuropathies may represent a continuum of toxic neuropathies in which the rate of action of the neurotoxin ultimately determines the proximo-distal location of the axonal swellings.

In vitro and in vivo studies of the molecular pathogenesis of n-Hexane neuropathy

In vivo intoxication of rats with 2,5-hexanedione and 3,4-dimethyl-2,5-hexanedione, which results in axonal swellings filled with neurofilaments, has been combined with in vitro exposure of proteins and model amines to the gamma-diketones in attempts to explain the molecular pathogenesis of n-hexane neuropathy and related neurofilament neuropathies. The heretofore untested gamma-diketone, 3,4-dimethyl-2,5-hexanedione is proposed as a "missing link" between beta, beta'-iminodipropionitrile, which produces proximal aggregates of neurofilaments, and 2,5-hexanedione, acrylamide, and carbon disulfide, which result in neurofilament-filled swellings in the distal axon.