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O'Loghlen S, Guy B, Rossiter JP, Boyd JG. Clinical Reasoning: A 37-year-old man with multiple cranial neuropathies. Neurology 2016; 86:e66-70. [PMID: 26880815 DOI: 10.1212/wnl.0000000000002381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sean O'Loghlen
- From the Divisions of General Internal Medicine (S.O., B.G.) and Neurology (J.G.B.), Department of Medicine, and the Department of Critical Care Medicine (J.G.B.), Queen's University, Kingston; and the Department of Pathology and Molecular Medicine (J.P.R.), Queen's University and Kingston General Hospital, Canada.
| | - Brent Guy
- From the Divisions of General Internal Medicine (S.O., B.G.) and Neurology (J.G.B.), Department of Medicine, and the Department of Critical Care Medicine (J.G.B.), Queen's University, Kingston; and the Department of Pathology and Molecular Medicine (J.P.R.), Queen's University and Kingston General Hospital, Canada
| | - John P Rossiter
- From the Divisions of General Internal Medicine (S.O., B.G.) and Neurology (J.G.B.), Department of Medicine, and the Department of Critical Care Medicine (J.G.B.), Queen's University, Kingston; and the Department of Pathology and Molecular Medicine (J.P.R.), Queen's University and Kingston General Hospital, Canada
| | - John Gordon Boyd
- From the Divisions of General Internal Medicine (S.O., B.G.) and Neurology (J.G.B.), Department of Medicine, and the Department of Critical Care Medicine (J.G.B.), Queen's University, Kingston; and the Department of Pathology and Molecular Medicine (J.P.R.), Queen's University and Kingston General Hospital, Canada
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Kleinschmidt-DeMasters BK, Lopes MBS, Prayson RA. An Algorithmic Approach to Sellar Region Masses. Arch Pathol Lab Med 2015; 139:356-72. [DOI: 10.5858/arpa.2014-0020-oa] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
Most sellar region masses (85%–90%) are pituitary adenomas; however, other neoplasms or even inflammatory or cystic nonneoplastic lesions may occasionally be encountered in this location. A practical, non–electron-microscopically based approach is essential for the daily practice of diagnosing and subclassifying adenomatous and nonadenomatous sellar region lesions.
Objective
To provide an algorithmic approach to sellar region masses for the pathologist and to formulate a cost-effective, limited panel of stains and immunostains that can be used in daily practice at most small to medium-sized centers.
Design
Pool collective experience of 3 neuropathologists practicing at academic medical centers with expertise in diagnosis and treatment of sellar region masses to craft a single-page algorithmic diagram and to liberally illustrate the range of lesions present in the sellar region.
Results
After formulating a differential diagnosis, the general pathologist can generate a confident final diagnosis of adenoma using 1 histochemical (reticulin) and 1 immunohistochemical (synaptophysin) stain, supplemented by 5 immunohistochemical stains (CAM5.2, follicle-stimulating hormone, growth hormone, prolactin, and adrenocorticotropic hormone), which provide subtyping of the adenoma in the overwhelming majority of examples. CAM5.2 and clinical information further help identify clinically aggressive variants such as sparsely granulated growth hormone adenomas and silent adrenocorticotropic hormone adenomas, respectively. MIB-1, thyroid transcription factor 1, and S-100 protein can be of further assistance in select cases where increased mitotic activity or possible nonadenomatous spindle cell lesions are suspected.
Conclusions
Adenomas, normal anterior or posterior gland, and nonadenomatous masses can be easily diagnosed in a nontertiary pathology laboratory setting.
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Affiliation(s)
- B. K. Kleinschmidt-DeMasters
- From the Departments of Pathology, Neurology, and Neurosurgery, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora (Dr Kleinschmidt-DeMasters)
- the Departments of Pathology and Neurosurgery, University of Virginia School of Medicine, Charlottesville (Dr Lopes)
- and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Prayson)
| | - M. B. S. Lopes
- From the Departments of Pathology, Neurology, and Neurosurgery, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora (Dr Kleinschmidt-DeMasters)
- the Departments of Pathology and Neurosurgery, University of Virginia School of Medicine, Charlottesville (Dr Lopes)
- and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Prayson)
| | - Richard A. Prayson
- From the Departments of Pathology, Neurology, and Neurosurgery, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora (Dr Kleinschmidt-DeMasters)
- the Departments of Pathology and Neurosurgery, University of Virginia School of Medicine, Charlottesville (Dr Lopes)
- and the Department of Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, Ohio (Dr Prayson)
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Tana C, Wegener S, Borys E, Pambuccian S, Tchernev G, Tana M, Giamberardino MA, Silingardi M. Challenges in the diagnosis and treatment of neurosarcoidosis. Ann Med 2015; 47:576-91. [PMID: 26469296 DOI: 10.3109/07853890.2015.1093164] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The diagnosis and treatment of neurosarcoidosis can be very challenging for several reasons. It affects clinically 5%-10% of sarcoidosis patients, but can be found in up to 25% of autopsies. These data reveal that a high percentage of asymptomatic or misdiagnosed cases can be missed at an initial diagnostic approach. Clinical and imaging findings are often non-specific since they can be found in a large number of neurological disorders. Histopathology can also be confounding if not performed by an expert pathologist and not placed in an appropriate clinical context. In this review, we discuss clinical features, laboratory findings, imaging, and histology of neurosarcoidosis, and we report current evidence regarding drug therapy. We conclude that a correct diagnostic approach should include a multidisciplinary evaluation involving clinicians, radiologists, and pathologists and that future studies should evaluate the genetic signature of neurosarcoidosis as they could be helpful in the assessment of this uncommon disease. With head-to-head comparisons of medical treatment for neurosarcoidosis still lacking due to the rarity of the disease and an increasing number of immunomodulating therapies at hand, novel therapeutic approaches are to be expected within the next few years.
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Affiliation(s)
- Claudio Tana
- a Internal Medicine Unit , Guastalla Hospital, AUSL Reggio Emilia , Reggio Emilia , Italy
| | - Susanne Wegener
- b Department of Neurology , University Hospital Zurich and University of Zurich , Zurich , Switzerland
| | - Ewa Borys
- c Department of Pathology , Loyola University Medical Center and Stritch School of Medicine, Loyola University Chicago , Maywood , Illinois , USA
| | - Stefan Pambuccian
- c Department of Pathology , Loyola University Medical Center and Stritch School of Medicine, Loyola University Chicago , Maywood , Illinois , USA
| | - Georgi Tchernev
- d Polyclinic for Dermatology and Venereology and Medical Faculty , University Hospital Lozenetz and Sofia University , Sofia , Bulgaria
| | - Marco Tana
- e Department of Medicine and Science of Aging , "G. d'Annunzio" University , Chieti , Italy
| | | | - Mauro Silingardi
- a Internal Medicine Unit , Guastalla Hospital, AUSL Reggio Emilia , Reggio Emilia , Italy
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Mikdashi JA. Primary angiitis of the central nervous system. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00164-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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King A, Maekawa S, Bodi I, Troakes C, Curran O, Ashkan K, Al-Sarraj S. Simulated surgical-type cerebral biopsies from post-mortem brains allows accurate neuropathological diagnoses in the majority of neurodegenerative disease groups. Acta Neuropathol Commun 2013; 1:53. [PMID: 24252649 PMCID: PMC3893367 DOI: 10.1186/2051-5960-1-53] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/13/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In theory, cerebral biopsies could provide the diagnosis in a significant proportion of patients with neurodegenerative diseases, however, there are considerable ethical barriers. Previous series of cerebral biopsies have shown variable diagnostic accuracy but have understandably suffered because of lack of post-mortem tissue with which to compare the diagnosis. To determine the accuracy of such biopsies in neurodegenerative disease we took small biopsy-sized samples of predominantly fresh post-mortem brain tissue from frontal and temporal lobes in 62 cases. These were processed as for a biopsy and stained for H&E, p62, tau, Aβ, α-synuclein, and TDP-43. The sections were assessed blind by 3 neuropathologists and the results compared with the final post-mortem diagnosis. RESULTS The agreement and sensitivity in most cases was good especially: controls; Alzheimer's disease (AD); multiple system atrophy (MSA); frontotemporal lobar degeneration with TDP-43 positive inclusions and/or motor neurone disease (FTLD-TDP/MND); Huntington's disease (HD); corticobasal degeneration (CBD) / microtubular associated protein tau mutation cases with CBD-like features (CBD/MAPT); and combined AD- Dementia with Lewy Bodies (AD-DLB) where the sensitivity on assessing both brain regions varied between 75-100%. There was poor sensitivity for progressive supranuclear palsy (PSP) and amyotrophic lateral sclerosis (ALS) (both 0%), but moderate sensitivity for pure DLB (60%). The temporal lobe assessment was marginally more accurate than the frontal lobe but these were only slightly worse than both combined. CONCLUSIONS The study shows that with certain caveats the cerebral biopsy in life should be a viable method of accurately diagnosing many neurodegenerative diseases.
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Flegel T, Oevermann A, Oechtering G, Matiasek K. Diagnostic yield and adverse effects of MRI-guided free-hand brain biopsies through a mini-burr hole in dogs with encephalitis. J Vet Intern Med 2012; 26:969-76. [PMID: 22708694 DOI: 10.1111/j.1939-1676.2012.00961.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 04/17/2012] [Accepted: 05/10/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND The diagnosis of encephalitis is usually presumptive based on MRI, cerebrospinal fluid analysis, or both. A definitive diagnosis based on histopathology, however, is required for optimizing treatment strategies. OBJECTIVE To investigate the diagnostic yield and adverse effects of minimally invasive brain biopsies in dogs with encephalitis. ANIMALS Seventeen dogs with suspected encephalitis, based on MR imaging and cerebrospinal fluid analysis. METHODS Retrospective study. Minimally invasive, free-hand brain biopsy specimens were taken from forebrain lesions through a 4-mm burr hole using a Sedan side-cutting needle. Routine histopathological examination was performed. The adverse effects were assessed by MRI evaluations after biopsy procedure (12/17) and by sequential neurological examinations. RESULTS The overall diagnostic yield with regard to a specific type of encephalitis was 82%. Encephalitis was evident in an additional 12%, but a specific disease could not be determined. There were no deaths caused by the biopsy procedure itself, but the indirect case fatality rate was 6%. Morbidity was 29%, including stupor, seizures, tetraparesis, hemiparesis, ataxia, and loss of conscious proprioception. All these signs resolved within 3-14 days. CONCLUSIONS AND CLINICAL IMPORTANCE Minimally invasive brain biopsy in dogs with suspected encephalitis leads to a definite diagnosis in the majority of dogs, allowing for a specific treatment. The advantages of a definite diagnosis outweigh potential case fatality rate and temporary neurological deficits.
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Affiliation(s)
- T Flegel
- Department of Small Animal Medicine, University of Leipzig, Leipzig, Germany.
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Venneti S, Robinson JL, Roy S, White MT, Baccon J, Xie SX, Trojanowski JQ. Simulated brain biopsy for diagnosing neurodegeneration using autopsy-confirmed cases. Acta Neuropathol 2011; 122:737-45. [PMID: 21959586 PMCID: PMC3575084 DOI: 10.1007/s00401-011-0880-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/22/2011] [Accepted: 09/22/2011] [Indexed: 12/12/2022]
Abstract
Risks associated with brain biopsy limit availability of tissues and the role of brain biopsy in diagnosing neurodegeneration is unclear. We developed a simulated brain biopsy paradigm to comprehensively evaluate potential accuracy of detecting neurodegeneration in biopsies. Postmortem tissue from the frontal, temporal and parietal cortices and basal ganglia from 73 cases including Alzheimer's disease (AD), Lewy body disease (LBD), frontotemporal lobar degeneration-TDP43 (FTLD-TDP), multiple system atrophy (MSA), Pick's disease (PiD), corticobasal degeneration (CBD) and progressive supranuclear palsy (PSP) were evaluated using H&E and immunostains. Brain biopsy was simulated in a blinded manner by masking each slide with opaque tape except for an area measuring 10 mm in diameter. Diagnoses obtained from frontal cortex only or all 4-brain regions were then compared with autopsy diagnoses. Diagnostic sensitivity in frontal cortex was highest in FTLD-TDP (88%), AD (80%) and LBD (79%); intermediate for MSA (71%), CBD (66%) and PiD (66%) and lowest for PSP (0%) (average 64%). Specificity was 43%. Sensitivities were enhanced with all 4-brain regions: FTLD-TDP (100%), AD (80%), LBD (100%), MSA (100%), CBD (83%), PiD (100%) and PSP (88%) (average 92%). Specificity was 71%. Simulated brain biopsy addressed limitations of standard brain biopsies such as tissue availability and lack of autopsy confirmation of diagnoses. These data could inform efforts to establish criteria for biopsy diagnosis of neurodegenerative disorders to guide care of individuals who undergo biopsy for enigmatic causes of cognitive impairment or when evidence of an underlying neurodegenerative disease may influence future therapy.
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Affiliation(s)
- Sriram Venneti
- Division of Neuropathology, Department of Pathology, and Laboratory Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Maloney 3rd Floor, 36th and Spruce Streets, Philadelphia, PA 19104-4283, USA
| | - John L. Robinson
- Institute on Aging and Center for Neurodegenerative Disease Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Subhojit Roy
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Matthew T. White
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer Baccon
- Department of Pathology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Sharon X. Xie
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John Q. Trojanowski
- Division of Neuropathology, Department of Pathology, and Laboratory Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Maloney 3rd Floor, 36th and Spruce Streets, Philadelphia, PA 19104-4283, USA. Institute on Aging and Center for Neurodegenerative Disease Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Abstract
Intraoperative consultation remains an invaluable tool in the initial evaluation of surgically excised specimens. Good communication is required between the pathologist and surgeon to obtain the best care for their mutual patient. Intraoperative consultation (frozen section, FS) provides a preliminary diagnosis for the surgeon and aids in guiding his/her subsequent surgical approach. For the pathologist, it serves to assess tissue adequacy in the context of the clinical and imaging features of the patient. FS can guarantee that the surgeon is in the desired anatomic location, but most often serves to ensure that adequate amounts of abnormal, and likely diagnostic, tissue will be available to the pathologist to render a final diagnosis on permanent sections. The preliminary evaluation of tissue at the time of intraoperative FS also guides the pathologist in the ordering of ancillary studies, some of which need to be performed on fresh or frozen tissues and must be sent at the time of the intraoperative consultation. This brief review will specifically focus on the role of the pathologist who is called to perform a FS for a neurosurgical specimen. We will discuss (1) the goals of the neurosurgeon for the intraoperative consultation, (2) how to achieve optimal communication between neurosurgeon and pathologist at the time of the FS, (3) what constitutes reasonable and unreasonable expectations by the neurosurgeon for the FS, (4) choices of techniques that can be used by the pathologist, (5) what tissue should be triaged, and (6) common discrepancies between FS and permanent section diagnoses in central nervous system disorders. The published literature on FS and permanent section discrepancies will be briefly reviewed so that pathologists will understand that some difficulties are inherent in neurosurgical specimens and are not specific to their practice, or to a given pathologist. Hopefully, this knowledge will enhance pathologists' confidence as they negotiate how best to handle this time-sensitive, and sometimes angst-producing, task.
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Plesec TP, Prayson RA. Frozen section discrepancy in the evaluation of nonneoplastic central nervous system samples. Ann Diagn Pathol 2009; 13:359-66. [DOI: 10.1016/j.anndiagpath.2009.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 05/25/2009] [Accepted: 05/27/2009] [Indexed: 12/01/2022]
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Hernández-Rodríguez J, Molloy ES, Calabrese LH, Prayson RA, Langford CA. Arteriovenous malformation of the brain mimicking primary central nervous system vasculitis. Scand J Rheumatol 2008; 37:481-4. [PMID: 18830901 DOI: 10.1080/03009740802179719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the diagnosis of primary central nervous system (CNS) vasculitis, it is crucial to rule out clinical, angiographic, and pathological mimics. We report a case of arteriovenous malformation (AVM) mimicking primary CNS vasculitis. A young male presented with intracerebral haemorrhage and no other clinical, laboratory, or angiographic features suggesting vasculitis. Cerebral biopsy showed perivascular inflammation and slight infiltration of the muscular layer of cerebral vessels by chronic inflammatory cells close to the haemorrhagic areas. These findings led to a diagnosis of CNS vasculitis. The patient was initially treated with corticosteroids, but 10 months after the discovery and surgical repair of the AVM, the patient is not receiving any immunosuppressant and has not developed any features of cerebral or systemic vasculitis.
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Affiliation(s)
- J Hernández-Rodríguez
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH 44195, USA.
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