[Myelopathy caused by hypertrophy of the posterior longitudinal ligament of the cervical spine in a patient with long-term hemodialysis]

A 48-year-old female was admitted to our hospital because of progressive gait deterioration over a period of 4 months. She had been treated by hemodialysis for 14 years after bilateral nephrectomy. She originally suffered achondroplasia. Otherwise she was a healthy woman. Neurological examination showed weakness and hypesthesia below C5, accelerated deep tendon reflexes and inability in walking. T1 weighted magnetic resonance imaging revealed severe cord compression from C4 to C6 due to an epidural isointensity mass located in the ventral surface of the dura. This mass was enhanced by a contrast medium. Anterior decompression followed by an autogenous vertebral bone graft at C4/5 and C5/6 was performed. The posterior longitudinal ligament was remarkably thickened resulting in severe cord compression. Histologically this thick ligament contained amyloid deposition both in the superficial and deep layers. Ossification was not noticed in the ligament. Diagnosis of hypertrophy of the posterior longitudinal ligament (HPLL) was made. HPLL is known to be frequently associated with herniated intervertebral discs or segmental ossification of the posterior longitudinal ligament (OPLL). Myelopathy in this patient with long-term hemodialysis was aggravated by HPLL without ossification due to imbalance of systemic metabolism such as amyloidosis. The authors report a unique case of HPLL caused by amyloidosis as one of the complications of chronic hemodialysis with special emphasis on its pathophysiology and management.

Morphologic features of the normal human cadaveric spinal cord

STUDY DESIGN

The cross-sectional area and diameter of the normal cadaveric spinal cord at each segmental level were measured, and the morphologic features were presented.

OBJECTIVES

To provide accurate anatomic descriptions and morphometric data of the human spinal cord.

SUMMARY OF BACKGROUND DATA

There is a large individual variation in human spinal cord size, and no authorized standard of measurement has been established. There have been few detailed descriptions of the normal morphologic features of the spinal cord.

METHODS

The authors measured the cross-sectional area and diameter of the spinal cord at each segment from C2 and S3 in 12 cadaveric specimens, and the morphologic features of each segment were described.

RESULTS

The relative ratio of the cross-sectional area of each segment to that of the C3 segment was similar in all the specimens examined despite a large individual variation in absolute cord size. Each segment had distinct qualitative and quantitative morphologic features.

CONCLUSIONS

The normal cross-sectional area of the spinal cord at any segment in an individual is calculable from measurements of a given single normal segment. This value appears to be an appropriate and practical standard of measurement of the normal morphologic features of the spinal cord.

Morphometric study of myelinated fibers in human cervical spinal cord white matter

STUDY DESIGN

Using human autopsy spinal cord specimens, morphologic measurements of myelinated nerve fibers were performed, focusing on the regions that include the main white matter conduction paths. The hemilateral spinal cord morphology was also measured, and its relation with the component myelinated nerve fibers determined.

OBJECTIVES

To determine the relation between spinal cord transverse area in the normal lower cervical spine, the site most vulnerable to chronic compressive myelopathy, and myelinated nerve fibers.

SUMMARY OF BACKGROUND DATA

Considerable interindividual variation normally is observed in the morphology of the spinal cord transverse area. The influence of this variation on the composition of the white matter myelinated nerve fibers is obscure.

METHODS

The C7 segments from seven cadavers were resected, and from magnified photographs of paraffin-embedded specimens, the hemilateral spinal cord area and funicular area were measured. Nerve fiber morphology was measured using Epon-embedded specimens. Three regions that included the main conduction paths were sampled, and magnified photographs obtained. The nerve fiber transverse morphology was measured using the ellipse conversion method, and the myelinated nerve density and fiber area were determined.

RESULTS

Marked interindividual variations were found in both the hemilateral spinal cord transverse area and funicular area. A positive correlation was noted between the two, with the spinal cord transverse area large in the cases with a large funicular area. For fiber density and area, histograms were constructed that showed characteristic distribution patterns in each region. By dividing each region into two components (i.e., small- and large-diameter fibers), it was found that the interindividual variation in large-diameter fiber density was small, clarifying that the absolute number of large-diameter fibers compared to fiber density is more strongly dependent on the funicular area.

CONCLUSIONS

The absolute number of large-diameter myelinated fibers is smaller in cross-sections of thin as compared to those of thick spinal cord. When elucidating the pathophysiology of compressive myelopathy, it is necessary to study not only the circumstances surrounding the spinal cord, but this kind of factor intrinsic to the spinal cord itself.

Significance of MIB-1, PCNA indices, and p53 protein over-expression in intramedullary tumors of the spinal cord

Due to the low incidence of intramedullary spinal cord tumors there have been few reports considering its proliferative kinetics. In this study, expression of two cell cycle related antigens (PCNA and MIB-1) were immunohistochemically examined by the percentage of positively stained cells were recorded as PCNA and MIB-1 indices. In addition, over-expression of p53 protein was also investigated in 19 cases of intrameduallary spinal cord tumors. In astrocytic tumors and ependymomas, statistically significant correlations were observed between PCNA and MIB-1 indices (R = 0.98). In hemangioblastoma cases, a similar correlation was not observed between PCNA and MIB-1 indices. The MIB-1 indices of hemangioblastoma cases were less than 1.56 while PCNA indices were more than 14.63 despite long-term survival occurred in all cases. The PCNA index in hemangioblastoma was significantly greater (p < 0.01) than all other types of tumors except for glioblastomas. Thus, interpretation of PCNA index must be made with caution in regard to the subgroup of the tumor histology. Over-expression of the p53 protein was observed only in glioblastoma cases. The MIB-1 index appears to be a useful method for predicting the outcome of all cases with intramedullary tumors of the spinal cord.

Dopamine-derived endogenous 1(R),2(N)-dimethyl-6,7-dihydroxy- 1,2,3,4-tetrahydroisoquinoline, N-methyl-(R)-salsolinol, induced parkinsonism in rat: biochemical, pathological and behavioral studies

Dopamine-derived 1-methyl-6,7-dihydroxy-1,2,3,4-tetrahydroisoquinoline (salsolinol, Sal) and related compounds were examined for their selective neurotoxicity to dopamine neurons by injection into the rat striatum. Among salsolinol analogs examined, only N-methyl-(R)- salsolinol (NM(R)Sal) induced behavioral changes very similar to those in Parkinson's disease: hypokinesia, stiff tail, limb twitching at rest and postural abnormality. Biochemical analysis showed that after NM(R)Sal injection, NM(R)Sal itself and its oxidation product, 1-2-dimethyl-6,7-dihydroxyisoquinolinium ion (DMDHIQ+) accumulated in the striatum, and also in the substantia nigra definite amount of DMDHIQ+ was detected. Dopamine and noradrenaline were reduced in the striatum and more markedly in the substantia nigra, whereas serotonin and its metabolite were not affected. Morphological analysis revealed selective reduction of tyrosine hydroxylase (TH)-containing neurons in the substantia nigra after continuous NM(R)Sal administration in the striatum. These results demonstrate the selective cytotoxicity of NM(R)Sal to the dopamine neurons in the substantia nigra, and the possible involvement of this 6,7-dihydroxy-isoquinoline in the pathogenesis of Parkinson's disease is discussed.

Identification of 3-nitro-L-tyrosine, a product of nitric oxide and superoxide, as an indicator of oxidative stress in the human brain

3-Nitro-L-tyrosine synthesized from L-tyrosine by peroxynitrite, a product of superoxide and nitric oxide, was identified for the first time in human brains. By quantitative analysis using high-performance liquid chromatography with multi-electrochemical detectors, 3-nitro-L-tyrosine concentration in the gray matter was higher in the cerebrum than in the cerebellum; 0.96 and 0.29 nmol/g wet weight, respectively. On the other hand, L-tyrosine concentration was not different. 3-Nitro-L-tyrosine in the brain may be used as an indicator of oxidative stress induced by reactive oxygen species and nitric oxide.

[Sociomedical study of centenarians in Nagoya City]

The purpose of this study was to assess the background to the longevity of 36 centenarians in Nagoya city and to compare 14 institutionalized centenarians out of those 36 with 202 individuals in the 70-99 age group in our special nursing home, particularly with regard to blood chemistry and immunity tests. The reasons for their social longevity in terms of profile appeared to be attention to eating habits, abstention from smoking and drinking, occupations with adequate exercise. The incidence of dementia was 65.6% among them. We evaluated centenarians from the viewpoint of Hasegawa's Dementia Scale (HDS) and comprehensive functional assessment of the elderly consisted of the revised version of Hasegawa's Dementia Scale (HDSR), and examination of activity of daily living (ADL), physical perception, and social life. All were positively associated. Thus centenarians independent of physical assistance demonstrated significantly higher systolic blood pressure, and respective scores for HDS, HDSR, ADL, physical perception and social life than their dependent counterparts, were less likely to be institutionalized and suffered from fewer disorders. In particular none were diagnosed as positive for cerebral hemorrhage, infarction and dementia. Age demonstrated significant positive or negative correlation with the following values in blood chemistry and immunity tests: blood cell counts, hemoglobin concentration, hematocrit value, albumin, total protein, total cholesterol, low density lipoprotein cholesterol, creatinine, blood cell nitrogen, uric acid, helper T cell, and IgA immunoglobulin.

[Pathology of intravascular malignant lymphomatosis]

On the basis of six necropsied cases of intravascular malignant lymphomatosis (IML), we elucidated its pathological characteristics. In the brain of IML, multiple softened areas of various size were observed, dominantly in the white matter of the cerebral hemisphere, which showed bilateral distribution with no relation to the supply area of the large vessels and intermingled fresh and old lesions. The spinal cord was one of the most often involved areas in IML, particularly at the lumbosacral segmental level. The origin of the tumor cells, based upon the findings that the tumor cell of all our cases were positive for SL-26, LN1, and LN2, were considered to be B-cell. We speculated that not only the circulatory failure due to the tumor cells which filled the vascular lumen, but also circulatory disturbances due to thrombosis, thickening of the intima and angiitis were significant findings for the necrosis in IML. IML is an important disease as the fourth type of central nervous system involvement due to malignant lymphoma, in addition to primary malignant lymphoma of the brain, meningeal lymphomatosis, compression of the spinal cord caused by extradural metastasis of lymphoma.

Distribution of neuronal cytoplasmic inclusions in multiple system atrophy

Neuronal cytoplasmic inclusions (NCIs) were demonstrated by means of silver staining (Gallyas staining) in the central nervous systems of 18 deceased patients with multiple system atrophy (MSA) - 6 with olivopontocerebellar atrophy (OPCA), 6 with striatonigral degeneration (SND) and 6 with Shy-Drager syndrome (SDS). We observed NCIs in the cerebral cortex, putamen, pons, medulla oblongata and spinal cord, and especially in the putamen and pons of all cases with MSA. No NCIs were observed in the cerebellum and midbrain. The findings were common to all 3 subtypes of MSA. NCIs were not present in patients with other neurodegenerative disorders and non-neurological disorders. Our findings indicate that NCIs represent a special neuronal alteration characteristic of MSA and support the theory that OPCA, SND and SDS represent manifestations of a single condition i.e. MSA.

Age-related alteration of proline hydroxylase and collagen-binding heat shock protein (HSP47) expression in human fibroblasts

Changes in the expression of alpha and beta subunits of proline 4-hydroxylase (PH alpha and PH beta) and HSP47, implicated as a molecular chaperone specific for procollagen processing, were examined in human embryonal fibroblasts in relation to in vitro aging. For this purpose a model with treatments causing the decreased hydroxylation of proline residues in procollagens was used. In cells at a low population doubling level (PDL) induction of PH alpha, PH beta, and HSP47 by depletion of ascorbate or addition of alpha-alpha' dipyridyl could be clearly demonstrated by immunoprecipitation and Northern blotting. In contrast, the induction of PH alpha and HSP47 expression was markedly attenuated in high PDL cells, indicating an age-related decrease in response to procollagen retention in the ER caused by hypohydroxylation of proline residues of procollagens.

[Neuroimaging and pathology of the spinal cord in compressive cervical myelopathy]

Magnetic resonance imaging (MRI) has enabled us to see the spinal intramedullary pathology as differences in signal intensity. Intramedullary high intensity lesions were observed on T2-weighted MRI in patients with cervical spondylotic myelopathy (20.0%) and ossification of the posterior longitudinal ligament (OPLL) of the cervical spine (25.7%). The frequency of this findings was proportional to the clinical severity of myelopathy and degree of spinal cord compression. The pathophysiological basis of such signal abnormality was presumed to vary from acute edema to chronic myelomalacia. The intramedullary lesion on MRI is considered to be the main site of lesion responsible for the neurological symptom because of a good correlation between the neurological level and high intensity level. We found from nine autopsy cases of OPLL that there are distinct differences in severity and extent of pathological changes between the spinal cord with a boomerang-shaped cross-section and that with a triangular-shaped cross-section. In the boomerang-shaped cases, major pathological changes were restricted to the gray matter and the white matter was relatively well preserved. Secondary wallerian degeneration was restricted to the fasciclus cuneatus the fibers of which were derived from the affected segments. In the cases of a triangular shape, pathological changes were more severe, both white and gray matter were involved. There were severe pathological changes over more than one segment, and both descending degeneration of the lateral pyramidal tracts and ascending degeneration of the posterior column, including the fasciclus gracilis, were observed. In conclusion, it is clinically very important to understand the pathological basis of the compressed spinal cord on neuroimages.

Clinical and neuropathological features of a neurodegenerative disorder in the central nervous system with progressive head drooping (Kubisagari)

The clinical and neuropathological features of a case of a neurodegenerative disorder with pronounced and progressive head drooping, in Japanese Kubisagari, are reported. This female patient died at the age of 72 years after an approximately 20-year history of peculiar posture with progressive head drooping (Kubisagari) and lordosis (bowed posture), parkinsonism, dysphonia and slight muscle wasting of the face, tongue, neck, and distal portions of the upper extremities. She did not display mental deterioration until the terminal stage of the illness. A simple macroscopic inspection formalin-fixed sections of the central nervous system (CNS) showed prominent atrophic frontal and temporal lobes, brownish discoloration of the putamen and an atrophic pyramidal tract. Light microscopy revealed severe neuron loss with fibrillary gliosis at both the above-mentioned lobes and the putamen. Both the facial and hypoglossal nuclei had almost disappeared. Motor neurons in the spinal cord were moderately to markedly decreased. Neither Bunina nor Lewy bodies, senile plaque, nor Pick's argyrophilic neuronal inclusions were observed, but very occasionally ubiquitin-positive neurons were found in the temporal cortex. In conclusion, the hitherto-unrecognized neuropathological findings in the CNS corresponding to progressive head drooping (Kubisagari) suggest that this is a neurodegenerative disorder of the CNS, possibly an atypical form of amyotrophic lateral sclerosis.

Elevated cerebrospinal fluid levels of manganese superoxide dismutase in bacterial meningitis

We examined the mechanism of increase of manganese superoxide dismutase (Mn SOD) in the cerebrospinal fluid (CSF) in bacterial meningitis (BM). The elevated levels of Mn SOD in the CSF in BM, measured with an enzyme immunoassay method, were more prominent than those in aseptic meningitis (AM) and encephalitis (EN). In AM and EN Mn SOD levels well correlated with levels of neuron-specific enolase and S-100b protein, which are markers of damages to nervous tissues, but did not with any of them in BM. CSF concentrations of tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 alpha (IL-1 alpha) were higher in BM than in AM and EN. From the serial measurements in BM, the peak values of these cytokines chronologically preceded or corresponded to those of Mn SOD. Immunohistochemically, a large number of the glial cells were stained for Mn SOD in the cerebral cortex from a patient with BM. By contrast, in the normal cerebral cortex, the glial cells were negative for Mn SOD staining. These results suggest that the marked increase of Mn SOD in the CSF in BM may be related to the increase of such cytokines as TNF-alpha and IL-1 alpha and that these cytokines may play a role in the induction of Mn SOD in nervous tissues.

Clinical, neurophysiologic, and neuropathological features of an infant with brain damage of total asphyxia type (Myers)

An infant who demonstrated clinical features compatible with total asphyxia is reported. Immediately after birth, the patient manifested severe hypotonia and total absence of cranial nerve functions. Magnetic resonance imaging revealed abnormal intensity of the thalamus and putamen, and atrophy of the brainstem. Late components of brainstem auditory evoked potential were absent, but electroencephalography was normal. Postmortem autopsy revealed destructive lesions of the brainstem tegmentum, thalamus, basal ganglia, and spinal cord, but preserved cerebral cortex; findings consistent with those of total asphyxia as reported by Myers, and attributable to prenatal insult.

Adhesive substrates influence acid-productive activities of cultured rabbit osteoclasts: cultured osteoclasts with large vacuoles have enhanced acid-productive activities

Since acid secretion of polarized osteoclasts on the bone surface has an important role in bone resorption, we examined the acid-productive activities of osteoclasts by measuring the pH of acidic organelles such as endosomes, lysosomes, and vacuoles in cultured rabbit osteoclasts with FITC-dextran as a fluorescent pH probe. The average pH value of acidic organelles of osteoclasts cultured on plain glass coverslips was 5.3 +/- 0.2. The pH of the acidic organelles correlated well with the size and amount of the vacuoles in the cells. Using this FITC-dextran method, we also examined the effects of adhesive substrates, such as type I collagen, vitronectin, and dentine, on the acid-productive activities of osteoclasts and found that the pH value of acidic organelles of osteoclasts cultured on dentine slices was significantly lower than that of osteoclasts cultured on plain glass coverslips. Likewise, in the case of the osteoclasts cultured on type I collagen- or vitronectin-coated glass coverslips, the pH values of acidic organelles were slightly lower and the proportion of osteoclasts having large vacuoles was increased compared with the cells cultured on the plain glass coverslips. These results indicate that osteoclasts containing large vacuoles have high acid-productive activities, and adhesive substrates such as type I collagen and vitronectin influence the formation of large vacuoles in cultured osteoclasts.

[Two siblings of familial amyotrophic lateral sclerosis with multisystemic degeneration characterized by mild involvement of the middle root zone of the posterior column, Clarke's nuclei and spinocerebellar tract]

The aim of this study is to clarify the clinicopathological characteristics of the multisystem degeneration seen in two male siblings with familial amyotrophic lateral sclerosis (FALS). A similar neurological disorder affected their elder sister and paternal uncle, but not their parents. The older brother (case 1) developed muscular weakness at 50 years of age and the younger brother (case 2), at 42 years of age. The duration of illness was 19 months in case 1 and 31 months in case 2. The clinical picture was the common (suspended) form in case 1 and the pseudopolyneuritic form in case 2. Pyramidal tract sign was obscure in both cases and cerebellar sign, sensory disturbance, sphincter disturbance and oculomotor palsy were not observed in either case. Neuropathological examination revealed similar findings in the two cases: 1) marked loss of lower motor neurons in the spinal anterior horn and motor nuclei of the lower brain stem in both cases, with neuronal loss of Onuf's nuclei in case 2; 2) very mild involvement in Clarke's nuclei, the dorsal and ventral spinocerebellar tracts and the middle root zone of the posterior column; 3) relatively well preserved Betz cells in the upper motor cortex with the appearance of a few macrophages, and mild changes in the pyramidal tract of the spinal cord; and 4) mild degenerative changes in the pallidoluysian system and the dentatorubral system. The most characteristic pathological findings common to both cases were the extremely mild involvement of the middle root zone of the posterior column, Clarke's nuclei and spinocerebellar tracts. The pattern of lower motor neuron system degeneration paralleled the development of clinical features. Genetic studies demonstrated no mutations in exons 1, 2 and 4 of Cu/Zn-binding superoxide dismutase gene. We emphasized the existence of mild involvement of middle root zone of posterior column, Clarke's nuclei and spinocerebellar tract in FALS with multisystemic degeneration.

[An autopsied case of dominantly affecting upper motor neuron with atrophy of the frontal and temporal lobes--with special reference to primary lateral sclerosis]

In this paper, the autopsy findings of a 78-year-old man mimicking primary lateral sclerosis (PLS) are reported. His clinical symptoms were slowly progressive spasticity, pseudobulbar palsy and character change. He died of sepsis 32 months after protracting the disease. The autopsy revealed severe atrophy of the frontal and temporal lobes. The histological findings were severe neuronal loss with gliosis in the precentral gyrus and left temporal lobe tip, loss of Betz cell, prominent demyelination throughout of the corticospinal tract, axonal swelling in the cerebral peduncule, severe degeneration of the amygdala, mild degeneration of the Ammon horn, normal substantia nigra, a few neuronal cells with central chromatolysis in the facial nerve nucleus and very mild neuronal cell loss in the spinal anterior horn. The anterior horn cell only occasionally demonstrated Bunina body by H & E and cystatin-C stainings, as well as, skein-like inclusion by ubiquitin staining. Thus, this is a case of uncommon amyotrophic lateral sclerosis (ALS) dominantly affecting the upper motor neuron including the motor cortex and temporal limbic system. In analysis of nine cases of putative primary lateral sclerosis in the literature, six cases showed loss of Betz cell in the precentral gyrus, and four cases very mild involvement of the lower motor neuron such as central chromatolysis and eosinophilic inclusion body. Degeneration of the limbic system was observed in two cases. We indicated a possible subgroup with concomitant involvement in the motor cortex and temporal lobe in motor neuron disease dominantly affecting the upper motor neuron.

[An autopsy case of gliomatosis cerebri with marked swelling of the spinal cord]

We report a 26-year-old male with diffuse infiltration of neoplastic glial cell to the bilateral hemisphere, basal ganglia, cerebellum, brain stem and markedly swollen spinal cord. Initial complaints were general malaise and disturbance of eye movements. The patient died after 30 months. The characteristics of this case included diffuse severe swelling of the brain stem and spinal cord (from the cervical to thoracic levels) shown on MRI without marked change of the hemispheres, cerebellum or basal ganglia. This is a rare case report of spinal swelling that was visually and radiologically apparent, although at present 11 cases of gliomatosis cerebri with histologically proven invasion to the spinal cord. From these facts, it is thought that this case is important from the aspect of the differential diagnosis of the spinal cord lesions.

Primary sensory neurons in X-linked recessive bulbospinal neuropathy: histopathology and androgen receptor gene expression

Pathology of the primary sensory neurons was examined in 7 autopsied patients and 6 biopsied sural nerves from the patients with X-linked recessive bulbospinal neuronopathy (SBMA). Large myelinated fibers in the central rami (L-4 posterior root, L-4, T-7, and C-6 segment of the fasciculus gracilis), and in the peripheral rami (sural nerve) were diminished in a distally accentuated manner, while small myelinated and unmyelinate fibers were well preserved in number. Demylinating process and axonal atrophy was ubiquitous. The diameter frequency histograms of the dorsal root ganglion (DRG) neurons showed a decrease in the number of large diameter neurons and an increase in the number of small diameter neurons without substantial loss of whole number of neurons, which suggested that neuronal size was atrophied. These data suggested central and peripheral distal axonopathy with neuronal atrophy was the process of sensory neuron involvement. Expression of mutant androgen receptor mRNA with elongated CAG repeat in the DRG and sural nerve supported the view that sensory nerve involvement is the primary process in SBMA.

Effects of acetazolamide on the sleep apnea syndrome and its therapeutic mechanism

Twenty male patients with sleep apnea syndrome were treated with acetazolamide (AZM), a carbonic anhydrase inhibitor. In 14 of the patient a significant decrease was found in the number of apnea, apnea index and % apnea time (percentage of time spent with apnea to the total sleep time) with improvement in sleep structure, clinical symptoms, such as insomnia, daytime excessive sleepiness and snoring. A significant decrease was also observed in arterial blood pH and HCO-3 in the 14 improved patients. On the other hand, no improvement occurred in the parameters of sleep apnea and sleep with AZM in the remaining six patients. Moreover, metabolic acidosis and an improvement in arterial blood gases did not occur with AZM in the six patients.

[A 115-year-old woman: the oldest individual in Japan]

The purpose of this study was to assess the background to the longevity of a 115-year-old woman who was the oldest individual in Japan as of September, 1994. The secrets of her social and medical profile appeared to be hereditary factors, well-balanced meals, no smoking or drinking, sufficient sleep and adequate exercise. From the viewpoints of psychological aspects and comprehensive functional assessment of the elderly, she clearly has a tenacious personality. Furthermore, she has maintained independence in her activities of daily living, and did not suffer from senile dementia until 107 years of age. From the medical standpoint, she has suffered from transient hypertension, but her left ventricle function has remained within the normal echocardiography range and no greatly abnormal values have been observed in blood chemistry tests. She has suffered from pneumonia and urinary tract infection many times since the age of 109, and on these occasions she was promptly admitted to our hospital and received appropriate medical treatment. We consider that this also played an important role in her longevity.

Spinal cord morphology and pathology in ossification of the posterior longitudinal ligament

We analysed nine autopsy cases of ossification of the posterior longitudinal ligament (OPLL) to elucidate the relationship between morphology and pathology of the spinal cord. The cross-sectional shape of the spinal cord at the most severely affected segment was classified into two categories: boomerang (convex lateral surfaces and concave anterior surface) and triangular (angular lateral surfaces and flat anterior surface). In the cases with a boomerang shape, even when the compression was severe, major pathological changes were restricted to the grey matter and the white matter was relatively well preserved. No secondary descending degeneration of the lateral columns was seen, and ascending degeneration of the posterior column was restricted to the fasciculus cuneatus whose fibres were derived from the affected segments. In the cases with a triangular shape, pathological changes were more severe, both white matter and grey matter were involved, and only the anterior columns were free of pathological changes. There were severe pathological changes over more than one segment, and both descending degeneration of the lateral pyramidal tracts and ascending degeneration of the posterior column, including the fasciculus gracilis, were observed. The transverse area of the spinal cord was > 60% of normal in most of the cases with a boomerang shape, but it was reduced to < 60% of normal in more than one segment in the cases with a triangular shape. The compression ratio of the spinal cord (sagittal diameter/transverse diameter x 100%) was not related to pathological changes. In conclusion, a triangular-shaped spinal cord with transverse area of < 60% of normal in more than one segment appeared to be associated with severe and irreversible pathological changes in cases of OPLL.

[An autopsy case of intravascular malignant lymphomatosis with intracranial lymphomatous mass lesions]

A 50-year-old man was admitted to our hospital, because of weakness in his right leg. On admission, he had generalized hyperreflexia and positive Babinski signs bilaterally. After admission, weakness in his left leg and confusion developed. A cerebrospinal fluid examination revealed increases in cell counts and protein but was negative for malignant cells. Blood chemistry was normal except for elevated LDH. A bone marrow biopsy yielded lymphoma cells. Successive T2-weighted cranial MRI showed a progressively expanding high signal area in the right parieto-occipital lobe. His confusional state improved after chemotherapy; however, two months later another cranial CT showed multiple enhanced mass lesions. The patient died 20 months after the onset of illness. Postmortem examination revealed widespread intravascular aggregates of malignant lymphomatous cells in the cerebrum, lungs and kidney, as well as multiple infarcts without atherosclerosis in the cerebrum. These pathological findings are compatible with those of intravascular malignant lymphomatosis. In addition, extravascularly expanding tumor cells formed multiple nodular lesions in the cerebral hemisphere. An immunohistochemical study showed that the tumor cells were positive for B-cell marker L26. Intracranial lymphomatous mass lesion rarely occurs in cases of intravascular malignant lymphomatosis. In the present case, tumor cells were presumably restricted to intravascular spaces, occluded them and resulted in ischemic lesions in the cerebrum in the early phase, but they expanded extravascularly and developed mass lesions in the terminal stages. In conclusion, intravascular malignant lymphomatosis is considered to be phenotypes of malignant lymphoma. This is the first case of intravascular malignant lymphomatosis associated with intracranial lymphomatous mass lesions in Japan.

[Role of institutions for the elderly in senile dementia]

The purpose of this study was to assess the role of institutions for the elderly, and special nursing homes in particular, with regard to senile dementia. The subjects consisted of 81 cases who were institutionalized in our special nursing home from early November, 1992 to late October, 1993. Of these, 37 cases (45.7%) showed clinical dementia at the time of institutionalization. The severity and respective percentages of dementia were as follows: slight degree 32.4%, moderate degree 27.0% and severe degree 40.6%. The severity of dementia demonstrated significant correlation with age. Hasegawa's Dementia Scale, activity of daily living and physical conditions. The admission rate (40.5%) of the demented group for physical diseases was significantly higher than that (22.7%) of the non-demented group. The majority of families of both groups first sought advice at institutions other than our special nursing home and the welfare office in the city, prior to being institutionalized. The referral rate from such institutions was far higher than that for direct entry from their homes. We consider that special nursing homes, in addition to carrying for daily living requirements, should pay great attention to physical diseases in patients suffering from senile dementia, and cooperate with medical institutes, particularly referring hospitals, and other welfare and health facilities, in this regard.