Central pontine myelinolysis and Rosenthal fibers of the brainstem. Association with emaciation and prolonged intravenous hyperalimentation

The clinical spectrum of late-onset Alexander disease: a systematic literature review

Following the discovery of glial fibrillary acidic protein (GFAP) mutations as the causative factor of Alexander disease (AxD), new case reports have recently increased, prompting a more detailed comprehension of the clinical features of the three disease subtypes (infantile, juvenile and adult). While the clinical pattern of the infantile form has been substantially confirmed, the late-onset subtypes (i.e., juvenile and adult), once considered rare manifestations of AxD, have displayed a wider clinical spectrum. Our aim was to evaluate the clinical phenotype of the adult and juvenile forms by reviewing the previously reported cases. Data were collected from previously published reports on 112 subjects affected by neuropathologically or genetically proven adult and juvenile Alexander disease. Although the late-onset forms of AxD show a wide clinical variability, a common pattern emerges from comparing previously reported cases, characterized by pseudo-bulbar signs, ataxia, and spasticity, associated with atrophy of the medulla and upper cervical cord on neuroimaging. Late-onset AxD cases can no longer be considered as rare manifestations of the disease. The clinical pattern usually reflects the topographic localization of the lesions, with adult cases displaying a predominant infratentorial localization of the lesions. Juvenile cases show clinical and radiological features which are intermediate between adult and infantile forms.

Identification of GFAP gene mutation in hereditary adult-onset Alexander's disease

Alexander's disease, a leukodystrophy characterized by Rosenthal fibers (RFs) in the brain, is categorized into three subtypes: infantile, juvenile, and adult. Although most are sporadic, occasional familial Alexander's disease cases have been reported for each subtype. Hereditary adult-onset Alexander's disease shows progressive spastic paresis, bulbar or pseudobulbar palsy, palatal myoclonus symptomatologically, and prominent atrophy of the medulla oblongata and upper spinal cord on magnetic resonance imaging. Recent identification of GFAP gene mutations in the sporadic infantile- and juvenile-onset Alexander's disease prompted us to examine the GFAP gene in two Japanese hereditary adult-onset Alexander's disease brothers with autopsy in one case. Both had spastic paresis without palatal myoclonus, and magnetic resonance imaging showed marked atrophy of the medulla oblongata and cervicothoracic cord. The autopsy showed severely involved shrunken pyramids, but scarce Rosenthal fibers (RFs). Moderate numbers of Rosenthal fibers (RFs) were observed in the stratum subcallosum and hippocampal fimbria. In both cases, we found a novel missense mutation of a G-to-T transition at nucleotide 841 in the GFAP gene that results in the substitution of arginine for leucine at amino acid residue 276 (R276L). This is the first report of identification of the causative mutation of the GFAP gene for neuropathologically proven hereditary adult-onset Alexander's disease, suggesting a common molecular mechanism underlies the three Alexander's disease subtypes.

Infantile and juvenile presentations of Alexander's disease: a report of two cases

We describe 2 new cases of Alexander's disease, the first to be reported in Belgium. The first patient, a 4-year-old girl, presented with progressive megalencephaly, mental retardation, spastic tetraparesis, ataxia and epilepsy: post-mortem examination showed widespread myelin loss with Rosenthal fibers (RFs) accumulation throughout the neuraxis. She was the third of heterozygotic twins, the 2 others having developed normally and being alive at age 5 years. The second patient developed at age 10 years and over a decade spastic paraparesis, palatal myoclonus, nystagmus, thoracic hyperkyphosis and thoraco-lumbar scoliosis with radiological findings of bilateral anterior leukoencephalopathy. Brain stereotactic biopsy at age 16 years demonstrated numerous RFs. With these 2 cases, we review the literature on the various clinico-pathological conditions reported as Alexander's disease. We discuss the nosology of this entity and the pathogeny of RFs formation and dysmyelination. Clues to the diagnosis of this encephalopathy in the living patient are briefly described.

Does arterial recanalization improve outcome in carotid territory stroke?

BACKGROUND AND PURPOSE

We sought to determine whether early (< 8 hours) or delayed (8 to 24 hours) recanalization after stroke may be an independent variable in the improvement of clinical outcome in patients with occlusion of the middle cerebral artery.

METHODS

We prospectively studied 77 patients by combined Scandinavian Stroke Scale score at admission, repeated computed tomography and angiography before and after thrombolytic treatment at < 8 hours after stroke onset, and transcranial Doppler ultrasound 24 hours later. We tested an association between clinical and neuroradiological baseline characteristics, recanalization, and outcome as assessed by the modified Rankin Scale 4 weeks after stroke and determined the effect of recanalization on mortality and good outcome (Rankin Scale grades 0 to 3) by multiple logistic regression analyses.

RESULTS

Recanalization rates at 8 and 24 hours after stroke correlated with sites of occlusion (middle cerebral artery branch, 73% and 73%, trunk, 27% and 38%, respectively; intracranial internal carotid artery bifurcation, 14% and 14%; P = .002), collaterals (good, 43% and 51%, respectively; scarce, 17% and 19%, respectively; P = .01), and Scandinavian Stroke Scale score at admission (P = .002). Six of 6 patients with delayed recanalization had good outcomes. Recanalization at < 8 hours after symptom onset had no independent predictive value for good outcome (P = .69). Recanalization at 24 hours increased the proportion of good outcomes from 23% to 75% in a subgroup of patients. Recanalization did not independently affect mortality (P > .15).

CONCLUSIONS

Even if delayed, arterial recanalization may improve clinical outcome in a subgroup of patients with middle cerebral artery occlusion.

A familial disorder associated with palatal myoclonus, other brainstem signs, tetraparesis, ataxia and Rosenthal fibre formation

Three siblings presented with a progressive neurological disorder beginning in the third decade of life and characterised by palatal myoclonus, nystagmus, bulbar weakness and spastic tetraparesis. There was no evidence of intellectual deterioration or seizures. CT scan showed marked brainstem atrophy in two patients and basal ganglia calcification in one. MRI scan in one showed high signal in the brainstem and periventricular region and cerebral biopsy in this patient showed myelin loss and the presence of Rosenthal fibres. A similar disease affected the siblings' mother, maternal aunt and two of the aunt's daughters, suggesting an autosomal dominant mode of transmission of what appears to be a unique genetic disorder.

Alexander's disease with Rosenthal fibre formation in an adult

The case of a woman who had a mild mental and physical handicap all her life is described. At the age of 39 years she began a progressive deterioration which terminated with her death after a year. CT scanning revealed basal ganglia calcification and at necropsy there was evidence of widespread generalised myelin loss with extensive Rosenthal fibre formation. The hypothesis that this may be an adult form of Alexander's disease is discussed.

Central pontine myelinolysis with extrapontine lesions

An autopsy case of central pontine myelinolysis (CPM) was reported. The patient, a 48-year-old man, with a long history of alcoholic intake appeared in a hospital with the diagnosis of alcoholic hepatitis and the neurologic symptoms of delirium tremens. During the hospital course he fell into "locked in" with concomitant development of marked hyponatremia (92 mEq/1). An autopsy revealed typical CPM and the extra-pontine myelinolytic lesions distributed symmetrically in the thalami, subthalamic nuclei, and lateral geniculate bodies. Spongiosis was also found in the deep layer of the cerebral cortex and in the putamen. It was suggested that CPM occur in close association with marked hyponatremia and the extrapontine involvement be likely to manifest in the deep layer of the cerebral cortex, putamen, thalamus, and lateral geniculate body, where the myelin cylinders form an interlacing network embedding large neurons and oligodendrocytes.

Malignant histiocytosis and encephalomyeloradiculopathy complicating coeliac disease

A 62 year old Irish woman with an eight year history of probable coeliac disease developed brain stem signs, unilateral facial numbness and weakness, wasting and anaesthesia in both lower limbs. Over the next two years, a progressive deterioration in neurological function and in intestinal absorption, and the development of anaemia led to a suspicion of malignancy. Bone marrow biopsy revealed malignant histiocytosis. Treatment with cytotoxic drugs led to a transient, marked improvement in intestinal structure and function, and in power of the lower limbs. Relapse was associated with bone marrow failure, resulting in overwhelming infection. Post mortem examination confirmed the presence of an unusual demyelinating encephalomyelopathy affecting the brain stem and the posterior columns of the spinal cord.

Primary necrosis of corpus callosum with dystrophic astrogliosis and Rosenthal-like fiber formation. The first Chinese case of Marchiafava-Bignami's disease (MBD)

The first Chinese case of MBD is reported as an incidental finding in a non-alcoholic who died from syphilitic heart disease complicated by subacute endocarditis. The extensive necrotic and demyelinating lesion of the body of corpus callosum presents no sandwich appearance. The core of the corpus callosum shows dystrophic astrogliosis with Rosenthal-like fibers and Alzheimer astrocytes, while only reactive astrogliosis is observed in its subpia and subependyma. The development of dystrophic astrogliosis in which gemistocytosis is believed to be the central theme, with the presence of Rosenthal-like fibers and Alzheimer astrocytes in this case denotes possibly a severe metabolic derangement of the affected astroglia. The presence of the subpial and subependymal reactive astrogliosis of the body of corpus callosum to the dystrophic astrogliosis of its core suggests that the same injury may lead to different responses in different subtypes of astrocytes of the same anatomic locus.

Diffuse Rosenthal fiber formation in adults. A case report

A 20-year-old woman was admitted to the Hospital because of tetraparesis and respiratory failure, requiring mechanical ventilation. No disturbances of consciousness were associated. She had a residual left lower limb paresis from the age of 14, lasting unchanged until this final episode of bulbar paralysis. She did not recover: death occurred 3 months later. Neuropathological examination revealed Rosenthal fibers in the gray and white matter with typical perivascular and subpial distribution. Areas of mild demyelination were found in the periventricular white matter of the centrum ovale and in the hilum of the nucleus dentatus. In the brain stem the highest density of Rosenthal fibers was found in the medulla where the deposits extended deeply into parenchyma. The relationship of this case with Alexander's disease is discussed.

Rosenthal fibers formation in the central nervous system. Its relation to Alexander's disease

Subpial and subependymal gliosis with abundant Rosenthal fiber (RF) formation are described in two patients. In one, the process appeared as a narrow band over the entire neuraxis and was not accompanied by neurologic manifestations. In the other, the changes were mostly restricted to the lower medulla and upper cervical cord and displayed invasive features. The glial proliferation with RF in the second patient was associated with an inflammatory component, dense collagen deposition, perivascular Schwannosis and demyelination. Involvement of some of the medullary nuclei and their tracts may explain the patient's vague bulbar symptomatology. The underlying cause which led to astrocytic proliferation with excessive RF in these two patients remains elusive. Possible factors contributing to this phenomenon are discussed in the context of Alexander's disease.

[Electron microscopic and neurochemical study of Alexander's disease (author's transl)]

The authors report the results of a cerebral and of a neuromuscular biopsies and of the autopsy findings in another infantile case of Alexander's disease in a girl. They review the 17 previously reported cases of this disease and the various etiopathogenic hypotheses mentioned. The presence of numerous, sometimes abnormal enlarged mitochondria and of abundant membranous cytoplasmic bodies in the astrocytic cytoplasm seems to be unreported elsewhere. Peripheral nerve changes are mentioned for the first time.

Enlargement of subarachnoid spaces and lateral ventricles in pediatric patients undergoing chemotherapy

This retrospective study investigated the possible adverse effects of cancer therapy on the brain. Cranial computed tomographic scans of 76 patients with non-central nervous system malignancies and 25 patients with leukemia had enlarged lateral ventricles and/or cortical sulci in 19% and 40%, respectively. Leukemic patients, especially those with meningeal involvement, had the most frequent and most severe abnormalities.

Alexander's disease presenting as astrocytoma

A case of progressive fibrinoid degeneration of astrocytes is described. Symptoms began with convulsions at the age of 6 weeks and cerebral tumour was suspected because of enlargement of the head, increased intracranial tension, and marked proliferation of astrocytes in the brain biopsy which was interpreted as an astrocytoma. Fibres and granules staining deeply with PTAH are a constant feature of the few cases so far described. The aetiology is unknown but an inherited metabolic defect of astrocytes may be responsible.