Shunting effects in patients with idiopathic normal pressure hydrocephalus; correlation with cerebral and leptomeningeal biopsy findings

Normal Pressure Hydrocephalus (NPH) is a potentially treatable syndrome with abnormal cerebrospinal fluid dynamics. Meningeal fibrosis and/or obliteration of the subarachnoid space have been suggested as one of the patho-anatomical substrates. However, other types of adult onset dementia, predominantly Alzheimer's disease and Vascular Dementia, may mimic the clinical NPH characteristics. The purpose of the present study was to correlate cerebral parenchymal and leptomeningeal biopsy findings to the clinical outcome after CSF shunting in a prospective group of idiopathic NPH (INPH) patients. The study comprises 27 patients with INPH, diagnosed and shunted according to generally accepted clinical, imaging and hydrodynamic criteria. In all patients a frontal leptomeningeal and brain biopsy was obtained prior to the shunt insertion. Degenerative cerebral changes, most often Alzheimer (6 cases) or vascular changes (7 cases) were described in 14 out of 27 biopsies. Arachnoid fibrosis was found in 9 of the 18 biopsies containing arachnoid tissue. Overall, nine patients (33%) improved, of whom 6 presented Alzheimer or vascular changes in their biopsies. No correlation was found between clinical outcome and the presence or absence of degenerative cerebral changes and/or arachnoid fibrosis. However, a tendency towards higher improvement rates was noted in the subgroups presenting degenerative cerebral changes or arachnoid fibrosis. The results suggest that no constant morphological element exists in the syndrome of INPH. Various aetiologies may be involved in the pathogenesis and possibly in some cases co-existing: Patients may also improve by shunting despite the presence of degenerative cerebral parenchymal changes.

Epidemiology and prognosis in children treated for intracranial tumours in Denmark 1960-1984

A total of 911 Danish children under 15 years of age were treated for an intracranial tumour in the 25-five year period 1960-1984. All cases were followed up to the end of 1994 or to emigration or death if one of these came sooner. The mean annual incidence was 32.5 per million children with a slight increase over the 25 years. The male/female ratio was 1.15 and close to the M/F ratio for the entire Danish population of children. Of the tumours, 46% were located in the supratentorial and 54% in the infratentorial compartment, and 94% were verified histologically. In order of frequency the most common types were astrocytomas (all grades, 35%), medulloblastomas (20%), ependymomas (14%), and craniopharyngiomas (5%). Total removal of the tumour was performed in 277 and partial removal, including biopsy, in 490 children. In 57 patients a shunt operation only was performed, and 87 children did not have an operation or died before the correct diagnosis was established. Radiotherapy was administered in 55%. The outcome depended on extent of removal, radiation, location and histology of the tumour. Most (784 or 86%) of the children survived more than 1 month after diagnosis or operation, and 353 children (39% of the whole series, 47% of those alive more than 1 month after diagnosis) were alive at follow-up. Of the survivors 29% had a tumour in the supratentorial midline, 26% one in the lateral part of the supratentorial area, 31% a cerebellar tumour and 13% a IV ventricle tumour. It was possible for 66% of the survivors with supratentorial and 90% of those with infratentorial tumours to lead a normal life. The long-term prognosis was especially good for children with cerebellar and supratentorial astrocytomas and optic chiasma tumours. Children with juvenile cerebellar astrocytoma had the best prognosis: 90% were alive at the end of the follow-up period, as against 20% of those with medulloblastoma and 6% of those with glioblastoma. A comparison of the data from the present series and from a similar Danish series of intracranial tumours in 533 children seen in the years 1935-1959 shows no significant differences in location or histology, a slight increase in annual incidence, and improved survival rates during the 50 years in question.

Frontal brain and leptomeningeal biopsy specimens correlated with cerebrospinal fluid outflow resistance and B-wave activity in patients suspected of normal-pressure hydrocephalus

OBJECTIVE

Normal-pressure hydrocephalus (NPH) is a potentially treatable syndrome with abnormal cerebrospinal fluid dynamics. Meningeal fibrosis and/or obliteration of the subarachnoid space has been suggested as the pathoanatomic basis. The purpose of the present study was to investigate whether meningeal fibrosis causes increased resistance to cerebrospinal fluid outflow (R(out)) and/or increased B-wave activity and whether pathological changes in the brain parenchyma after brain compliance, causing increased B-wave activity.

METHODS

The study involved a group of 38 consecutively studied patients with clinical and radiological evidence of idiopathic NPH, for whom a frontal brain biopsy was obtained. For 29 patients, hydrodynamic criteria of NPH were fulfilled and a ventriculoperitoneal shunt was performed.

RESULTS

Meningeal fibrosis was found in 12 of 25 biopsies containing arachnoid tissue, but no correlation with R(out) or B-waves was found. Pathological parenchymal changes, most often Alzheimer's disease (10 cases) or vascular changes (10 cases), were found in 21 biopsies, but no correlation with B-waves or R(out) was found.

CONCLUSION

The results suggest that leptomeningeal fibrosis is not the only pathoanatomic basis of increased R(out) and/or B-wave activity in patients with NPH and that various degenerative changes in the parenchyma may be responsible for the altered cerebrospinal fluid dynamics characteristic of NPH.

Prognostic factors in oligodendrogliomas

An outcome analysis was performed on 96 patients with pure cerebral oligodendrogliomas operated in the 30-year period 1962 to 1991. The most important predictive prognostic factors were youth and no neurological deficit, demonstrated as a median survival for the group younger than 20 years of 17.5 years and for the group older than 60 years of 13 months. The group without neurological deficits had a 5-years survival of 43 per cent while the group with deficits had a 5-years survival of 5 per cent. The 5-years survival for oligodendroglioma of grade II was 46 per cent and for grade III 10 per cent. We found no effect of radiotherapy on survival, neither in the whole material or in any subgroup.

Heterogeneous cerebral glucose metabolism in normal pressure hydrocephalus

The regional cerebral metabolic rate for glucose (rCMRglu) has never been investigated in large consecutive groups of patients with normal pressure hydrocephalus (NPH), a potentially treatable form of dementia with an unpredictable outcome after shunt surgery. Using PET and 18F-2-fluorodeoxyglucose, rCMRglu was studied in 18 patients who fulfilled hydrodynamic criteria for NPH and in whom a biopsy of the frontal cortex was obtained. When compared with an age matched group of 11 healthy subjects, the patients with NPH showed a significant rCMRglu reduction in all cortical and subcortical regions of interest. Individual metabolic patterns, however, disclosed a large topographical heterogeneity. Furthermore, histopathological examination identified Alzheimer's disease or cerebrovascular disease in six cases, and no parenchymal disease or non-specific degenerative processes in the remaining 12. After separating the patients according to the histological diagnosis, the rCMRglu patterns were still heterogeneous, the abnormalities ranging from focal to diffuse in both subgroups. After shunt operation, 11 patients did not improve or worsened clinically. Six patients improved; of those, two had Alzheimer changes and two cerebrovascular changes in their biopsy. The metabolic pattern of these six patients did not differ from the rest of the NPH group. The results indicate that the NPH syndrome may be non-specifically associated with different degenerative disorders. The metabolic heterogeneity, together with the heterogeneous histopathological findings, indicate the necessity of reevaluating the pathogenesis of the NPH syndrome, and may account for the high variability in the success rate of shunt surgery series.

Histopathology and growth pattern of cystic acoustic neuromas

In a series of 571 acoustic neuromas, 23 were identified as cystic tumors. An immunohistochemical study including nervous system-associated protein (S-100), glial fibrillary acidic protein (GFAP), neurofilament protein (NF), laminin, fibronectin, vimentin, factor VIII (von Willebrand factor)-related antigen, and the nuclear antibody Ki-67 was performed. The cyst walls contained numerous S-100-positive fibrils distributed throughout the whole extent of the walls. Laminin, fibronectin, and vimentin were predominantly located around the vessel walls, factor VIII was found inside the vessels. GFAP-positive lamellae occurred in 50% of the cases near the surface of the cyst walls. Ki-67 is an antigen associated with cell proliferation. The density of Ki-67-positive cells was found to be 36 times lower in 16 noncystic controls than in the 23 cystic neuromas, indicating that the increase in tumor size in cystic acoustic neuromas may be caused by expansion of the cysts and not by an actual increase in the growth rate of the tumor cells. The data achieved in this series may contribute to better planning of the surgical approach. Because of the risk of sudden expansion of cystic elements, a wait-and-see policy should not be applied to patients with cystic acoustic neuromas.

Subcutaneous growth of human acoustic schwannomas in athymic nude mice

In order to develop an in vivo model for growth of acoustic schwannomas, we studied tumor specimens from 10 patients, transplanted into a subcutaneous pocket of 67 nude mice. The number of tumors which survived or grew was 63 (94%). Obvious macroscopic growth was observed in 22 (33%), status quo in 28 (42%), and regression of tumor size in 13 (19%). The tumor disappeared in 4 cases (6%). Serial implantation was not possible due to the small amount of neuroma tissue in the surviving tumors. In animals with obvious macroscopic growth, neovascularization was clearly demonstrated. The presence of Schwann cells in the implants was confirmed immunohistochemically. The proliferative activity in the original and implanted tumors was evaluated by the proliferating cell nuclear antigen (PCNA) and Ki-67 nuclear antigen stainings and showed good correlation between primary tumors and implants. This in vivo tumor model will open new opportunities to study the biology of acoustic tumors and to test different therapeutic modalities.

Histology and neuro-imaging in cystic acoustic neuromas

Tumor configuration and attenuation on CT scan with contrast enhancement or gadolinium-DTPA-enhanced MR depends upon tumor histology. Various elements are responsible for the density on CT or MR, e.g. blood vessels, fatty tissue, connective tissue, calcium, necrotic tissue, hemorrhage and intra- or extratumoral cyst formation. In a series of 571 acoustic neuromas we found 23 cystic tumors. The diagnosis was based on neuro-imaging examination, confirmed at surgery and finally verified histologically. Eight tumors with small or large cysts were diagnosed by CT or MR scan as intratumoral, and 15 with large cysts were diagnosed as extratumoral. We found a good correlation between the histology of cystic acoustic neuromas and the CT or MR scans. The tumors were predominantly hypodense, corresponding to the cystic areas, but also iso- or hyperdense areas were observed, corresponding to other tissue types. Antoni type B tissue and xanthomatous areas were found in all 23 cases.

Brain autopsy in organic solvent syndrome

General autopsy findings, brain weight and brain pathology were studied in 98 men and five women who had been exposed occupationally to organic solvents over several years and assessed by the Danish National Board of Industrial Injuries for chronic toxic encephalopathy. The findings were compared with a forensic control material and a hospital control material. As in the general population, the most common causes of death among the exposed workers were heart failure and other vascular diseases. Due to the composition of the material (forensic cases), the number of suicides and violent deaths was high. Atherosclerosis was the most common CNS finding, but in comparison with the two control materials, no increase in the frequency of atherosclerosis or of Alzheimer's disease was found. Brain weights of the exposed workers corresponded closely to brain weights in the control materials, after correction for body height, body weight and age. Chronic alcoholism was correlated with slightly reduced brain weight.

Localized cranial hyperostosis of meningiomas: a result of neoplastic enzymatic activity?

Cranial hyperostosis is a common secondary manifestation of intracranial meningiomas. This may occur with or without neoplastic invasion, apart or even remote from the growth. Alkaline phosphatase (AP) is one of many enzymes produced by meningiomas and is known to possess indirect ossifying properties. Meningiomatous cranial hyperostosis could possibly be mediated by a humoral mechanism. This hypothesis was tested using chemical and histochemical determination of the occurrence of the enzyme in a series of hyperostosing and non-hyperostosing meningiomas. In the hyperostosing type the content of AP was in average more than three times as high as in the non-hyperostosing type. The results thus are in favour of the induction hypothesis.

Prognostic parameters in benign astrocytomas

To elucidate the prognosis of different types of benign astrocytomas and to ascertain whether patients with partially resected benign astrocytomas, or any subtype of these, would benefit from postoperative radiotherapy, we studied retrospectively material comprising 300 patients with benign astrocytomas treated in the period 1956 to 1991. The pilocytic type of astrocytoma was found to have an outstandingly good prognosis and should be regarded as a distinct nosological entity. For the non-pilocytic supratentorial astrocytomas, a multivariate regression analysis showed that age, tumour site, Kernohan grade and lymphocytic perivascular cuffing influenced survival. The proportion of gemistocytes increased with age. After correction for age, the proportion of gemistocytes had no significant influence on survival. It was not possible to demonstrate any influence of radiotherapy on median survival time of patients with non-pilocytic supratentorial benign astrocytomas. The study emphasizes the necessity of a prospective combined multicenter analysis of the effect of radiation on benign astrocytomas.

Histologic examination of the rat central nervous system after intrathecal administration of human beta-endorphin

The objective of this study was to evaluate histologically the toxicity of human beta-endorphin on the rat central nervous system after intrathecal administration. Animals received a single injection of 5 micrograms (n = 9) or 50 micrograms (n = 10) on each of four consecutive days, while others received 50 micrograms (n = 8) as a single dose. The control groups received either physiologic saline (n = 10) during each of four consecutive days or had sham operations (n = 4). Tests for nociception (tail-flick latency), motor function, and reflexes (righting reflex, eye-blink reflex, and inclined plane) were performed 5, 15, 30, 60, and 120 min after injection. Both dosages produced a dose-dependent impact on these parameters. In the 50-micrograms group, there were no significant differences in analgesia between the first and the fourth doses injected. The 50-micrograms dose produced catalepsy in some animals. All changes returned to baseline within 24 h. One animal in the 50-micrograms group developed hind limb paralysis after a single injection. Histologic sections from brain, brain stem, and spinal cord were prepared. No changes in histology were found except for that in the paretic animal, which had anoxic changes in the hippocampus and other cortical areas. Human beta-endorphin produced no neurotoxicity. The effect on nociception, reflexes, and motor function confirmed the results of previous studies.

Pituitary histology in Cushing's disease

OBJECTIVE

We assessed pituitary histology in patients with Cushing's disease.

DESIGN

Systematic histological assessment of pituitary tissue removed at surgery.

PATIENTS

Thirty-six consecutive patients cured from Cushing's disease by transsphenoidal neurosurgery.

MEASUREMENTS

Microscopical examination of all available tissue removed at operation.

RESULTS

After selective removal of tissue supposed to represent an adenoma in 25 patients this could be histologically verified in 18. In the 11 patients who had undergone a total hypophysectomy an adenoma could be demonstrated in three patients only, despite a systematic search of the entire pituitary gland. Only in 21 of the 36 cured patients (58%) could an adenoma be verified.

CONCLUSIONS

Combining the present results with previous reports there is strong reason to believe that in some patients with Cushing's disease no histological lesion in the pituitary is verifiable.

Histopathology of intact and docked pigtails

A histological examination was performed on tails from three groups of pigs, comprising 10 amputated tail tips from day-old piglets, 10 tails from undocked fattening pigs and 20 tails from docked fattening pigs. The investigation demonstrated that peripheral nerves could be traced to the tip of the tails of day-old piglets as well as of fattening pigs. In the docked fattening pigs, the peripheral nerves were unevenly distributed and showed regressive changes. In some cases traumatic neuromas were found, indicating an increased sensitivity to pain in the amputation stump. It was, surprisingly, demonstrated that widespread inflammatory reactions could be found in the apparently healthy tails of both categories of fattening pigs, presumably due to pen-mates' chewing activities.

Entrapped, non-neoplastic adenohypophysiocytes in human pituitary adenomas

The immunoprofile of 76 human pituitary adenomas was studied with particular reference to the occurrence of entrapped, non-neoplastic pituitary cells. This phenomenon was defined as unevenly distributed, usually peripherally located cells forming less than 1% of the total cell population. The stellate contour of such passively incorporated cells departed from the more rounded shape of most principal, neoplastic cells. Thirty-six of the adenomas studied comprised one or more types of entrapped elements. According to the hormone produced, prolactin-(PRL-)cells most commonly occurred as a minor "foreign" component (seen in 23 of the adenomas), whereas growth hormone-(GH-) and adrenocorticotropic hormone-(ACTH-)cells rarely were trapped (seen in 5 and 4 of the adenomas. Entrapped follicle stimulating hormone-(FSH-), luteinizing hormone-(LH-), and thyroid-stimulating hormone-(TSH-)cells assumed an intermediate position (seen in 14, 17 and 15 of the adenomas, respectively).

Estrogen and progesterone receptors in acoustic neuromas

Acoustic neuromas are more frequent, larger, and more vascular in women, and their growth rate increases during pregnancy. Estrogen receptors were claimed to be demonstrated in these neoplasms for the first time in 1981. Since then, numerous diverging studies, using various biochemical and histochemical methods, have been published on the contents of estrogen and progesterone receptors in acoustic neuromas. We determined the content of estrogen and progesterone receptors by means of an immunohistochemical method, using monoclonal antibodies, which has proved to be reliable, reasonably sensitive, and clinically relevant in other tissues, especially in breast carcinomas. No estrogen or progesterone receptors could be found in 18 consecutive acoustic neuromas from 7 men and 11 women, ranging in age from 26 to 73 years. The results do not support preoperative hormone treatment of acoustic neuromas.

[Plasmapheresis in the treatment of peripheral HIV neuropathy]

Peripheral neuropathy following HIV infection is frequently seen among HIV-positive-, ARC- and AIDS patients who often complain of debilitating paresthesias. Indirect immunofluorescence technique showed antibodies directed either to myelin and/or axons and to endothelial cells of the blood vessels within the nerve tissue. Sural nerve biopsies from five patients showed demyelination, axonal degeneration and perivascular cellular infiltration. Two of the patients had nuclear inclusions and high anti-CMV titer. Plasma exchange was undertaken on five HIV infected patients which resulted in complete disappearance of symptoms in three, incomplete remission in one and no effect in one patient. The finding of autoantibodies against different nerve tissue components, cellular infiltration, positive effect of the plasma exchange and relapse suggests that autoimmunity may play a pathogenetic role in some of the HIV infected patients with peripheral neuropathy.

Pathology of brain and eye in the acquired immune deficiency syndrome (AIDS). A comparison of lesions in a consecutive autopsy material

During the years 1984-1987, a consecutive Danish autopsy material of 43 AIDS cases was analysed in order to investigate a possible coincidence of pathological changes in brain and eye. In the brain, nodular gliosis/encephalitis was most frequent, followed by cytomegalovirus infection, which occurred twice as frequently as toxoplasmic infection and four times as frequently as fungal infection. In the eye, cytomegalovirus infection was most frequent and the only opportunistic infection, followed by retinal gliosis and cytoid body lesion. Malignant lymphoma was present in the brain in three patients, and in the choroid in two of these. In 11 patients, no changes of the brain were found. In eight of these the eye was also without pathological findings, while three had minor changes. In 22 patients the eye was normal, but in only eight of these was the brain without changes. Eight had nodular gliosis, and four a specific infection, while multifocal leucoencephalopathy and unspecified abscess each occurred in one patient. Comparison of the three opportunistic infections--CMV, toxoplasmosis and mycosis--in the three-year period showed an overall decreasing frequency, attributed to better medical care. It is concluded that concomitance of identical pathological lesions in brain and eye is less frequent than was expected.

Malignancy criteria in computed tomography of primary supratentorial tumors in infancy and childhood

The CT findings of 11 malignant primary supratentorial tumors in children are compared with those of 38 benign tumors. The malignant tumors were more often laterally placed and surrounded by edema. Irregular tumor shape and high or "mixed" density were more frequent in the malignant group where larger tumor volume was found. The contrast enhancement pattern was also different. Thus, ring enhancement with central lucency was more often seen in the malignant tumors. Seven of the malignant tumors had both irregular shape and edema, while this combination was not present in any of the 38 benign tumors.

Neuropsychiatric studies in a family with presenile dementia different from Alzheimer and Pick disease

We have studied a family in which 14 persons among 73 are or have been suffering from presenile dementia. Post mortem examination showed atrophy but no sign of any known demential syndrome. Cerebral blood flow measured in the late stage of disease was low, but with no characteristic pattern in flow distribution. In one patient in the initial stage of disease, the cerebral blood flow was unexpectedly increased. The patients with presenile dementia in this family did not reveal pathological signs of any known demential syndrome and showed CBF-changes not earlier reported. Moreover, contrary to widely held views we have evidence that dementia may be connected to a high blood flow at least in the initial state. An increased blood flow was also seen in seven of ten well functioning first degree relatives, in some cases along with cerebral atrophy and/or psychological tests with signs of dementia. Are these people going to develop manifest dementia later in life?

Patho-anatomical studies in patients dying of AIDS

The incidence of AIDS in Denmark is the highest reported among the countries of Western Europe. This preliminary account is a report of the autopsy findings in 10 patients, 9 homosexual men and 1 woman. Our aim is to provide a detailed description of the patho-anatomical findings, as well as to compare these with corresponding results reported from the United States, with a view to establishing possible geographical differences in the disease picture. The results of the patho-anatomical studies correspond in all essentials to those from the United States. However, it must be stated that no malignant lymphomas were demonstrated in our patients, although the disease can give rise to very pronounced, possibly transitory, lesions in the lymphatic tissue, easily misinterpreted as malignant. Further features that should be emphasized are the often widespread mycobacterial infection found in the intestinal wall in protracted cases, the occurrence of CMV vasculitis, particularly in the adrenal cortex and medulla, and thromboembolic lesions, often demonstrated in a variety of tissues. The studies made so far emphasize the importance of autopsy in AIDS deaths, as it has extended our detailed knowledge of the patho-anatomical lesions associated with certain opportunistic infections. Further, the autopsy findings have been demonstrably significant either for confirming or for rejecting the clinical diagnosis. On the basis of an analysis of the cellular immunological profile in AIDS, parallels can be drawn to the conditions in certain lymphoproliferative diseases. In autopsied AIDS cases, we recommend a standard scheme covering the tissue specimens to be obtained for histological examination. Strict safety precautions should be observed against infection during autopsy.

Periphlebitis retinae in multiple sclerosis. A histopathological study of two cases

The reported findings of periphlebitis retinae (PR) at autopsy, in which brain autopsy was also performed, in 2 patients with multiple sclerosis (MS) are, so far as the authors are aware, the first histological account of this manifestation of the disease. The similarity between the cellular accumulations around the veins of the central nervous system seen in multiple sclerosis and the periphlebitic cellular accumulations here described suggests that periphlebitis is an initial event in plaque formation.

Cell density and cortex thickness in the border zone surrounding old infarcts in the human brain

Six cases of completed ischemic stroke in the middle cerebral artery territory of more than two months' duration were selected for this study of neuropathology. Coronal brain slices of the entire brain were cut for histology and stained with Klüver-Barrera's stain. Neuronal and glial cell density, and cortex thickness were measured at various distances from the border of the infarct. Corresponding counting points in the contralateral hemisphere served as control in all cases. The density of histologically intact neurons was in all cases normal at a distance of 0.5 cm or more from the border of the infarcts. In one half of the cases the border zone between infarcted and normal tissue was less than a few cells in thickness. This study of old brain infarcts confirms the commonly held view that there is an abrupt transition between infarcted and normal tissue. This observation suggests that the wide zone of low blood flow and metabolism surrounding cerebral infarcts is not caused by selective loss of neurons. Instead, we hypothesize that such change in blood flow and metabolism is the result of neuronal disconnection and cortical deactivation.

Calcified acoustic neurinoma

An unusual case history of a patient with an acoustic neurinoma is reported. The patient had a two-year history of unilateral sensori-neural hearing impairment, normal radiological appearance of the internal acoustic meatus at tomography and on CT a grossly calcified tumour in the cerebello-pontine angle, indicating pathology other than an neurinoma. Vertebral angiography was normal, and at surgery a grossly calcified tumour was found, while microscopy revealed a typical neurinoma pattern. The tumour had to be removed in two stages, both via the translabyrinthine approach, with a satisfactory post-operative condition, including near-normal facial function. It is concluded that dense calcifications in tumours in the cerebello-pontine angle do not necessarily exclude a neurinoma, and vertebral angiography is therefore not indicated routinely. However, such findings do predict difficulties at surgery.

Blood-brain and blood-spinal cord barrier permeability during the course of experimental allergic encephalomyelitis in the rat

Experimental allergic encephalomyelitis (EAE) was induced in young male Lewis rats. Blood-brain barrier permeability to radiotracers of different molecular sizes was studied at intervals after induction using a tissue sampling technique. The results were correlated to the clinical picture and to the histological appearance of the central nervous system. Significant increase in blood-brain barrier permeability to small molecules was found to precede clinical symptoms by one day in the lumbar spinal cord and to coincide with the onset of clinical disease in other regions. In all regions, increased blood-brain barrier permeability preceded the occurrence of histological lesions (perivascular cellular infiltrates). No permeability increase to large molecules could be demonstrated.

Familial aggregation of neuroectodermal and gastrointestinal tumors

A family with multiple tumors is presented. Four cases were childhood neoplasms derived from the neuroectoderm, as was a malignant melanoma in a young female and a branchiogenic cyst in her brother. He also had an early onset of an adenocarcinoma of the transverse colon. Four further cases of gastrointestinal tumors and one case of acute myelogenous leukemia had occurred in the family. One of the childhood tumors was a bilateral retinoblastoma. It is discussed as to whether the tumors in the studied family were due to a genetic factor resulting in a neuroectodermal embryopathy, or were caused by a retinoblastoma gene with a pleiotropic effect.

Secondary brain stem hemorrhage in stroke

The occurrence of secondary brain stem hemorrhage was studied in 435 autopsies from patients with recent cerebral hemorrhage, infarction or ruptured cerebral aneurysms. The frequency of secondary brain stem hemorrhage was found to be 45% in cerebral hemorrhage, 15% in cerebral infarction, and 36% in ruptured aneurysms. In the majority of cases the secondary brain stem hemorrhage occurred a few days after the onset of cerebral hemorrhage or infarction. Ruptured aneurysms showed a more widespread temporal distribution of secondary brain stem hemorrhage. The median survival time was 2 days in cases of cerebral hemorrhage, 4 days in ruptured aneurysm and 4 days in cerebral infarction. The frequency of secondary brain stem hemorrhage was significantly lower in patients younger than 20 years. No significant difference was found in its distribution between the sexes. Secondary occipital lobe infarction was present in 3.5% of the patients. It is concluded that secondary brain stem hemorrhage is a common major contribution to the cause of death in stroke.

Histopathology of eye, optic nerve and brain in a case of dominant optic atrophy

Histopathology of eye, optic nerve and brain was performed in a patient with typical signs and symptoms of dominant optic atrophy. He belonged to a previously-reported family of 152 members in which optic atrophy was demonstrable in 14 persons, and probably present in a further 8 cases. In the eyes, fibrosis of the retinal ganglion cell layer and disc was found. Ultrastructural examination showed a few remaining cells in this layer, heavy fibrosis and in particular a highly condensed inner limiting membrane. The optic nerves, the optic chiasm and optic tracts showed an increased content of collagen tissue and a decreased number of neurofibrils and myelin sheaths. In the lateral geniculate body there was massive loss of ganglion cells, fibrillary gliosis and a great quantity of fine granular lipid in the cytoplasm of the ganglion cells. No changes in the calcarine cortex were observed. Examination of the intracranial part of both vestibulocochlear nerves showed a decreased number of neurofibrils and myelin sheaths. It is concluded that the histopathological changes of the visual system are similar to those in Leber's disease, but less pronounced. The study confirms earlier theories that dominant optic atrophy is a primary degeneration of the ganglion cell layer in the retina, with ascending optic atrophy.

Meniere's disease: peripheral or central origin. A neuroanatomical study

Previous clinical and histological studies have suggested that the aetiology of Meniere's disease should be sought not only in the endolymphatic hydrops, but also in pathological changes of the brain and brain stem. Moreover, neuropsychological studies have indicated some centralization of the disease, whether it be primary or secondary. In order to elucidate this problem further we have examined the temporal bones and brains of 4 patients with Meniere's disease, who died of diseases unrelated to the inner ear or the central auditory and vestibular pathways. Endolymphatic hydrops was found in 6 temporal bones to a varying degree, as well as degeneration of the ganglion cells. The brain stem was divided by many horizontal sections from the rostral border of the superior colliculi above, to 15 mm caudal to the border between pons and medulla below. The principal nuclei and fascicles, the intra- and extraparenchymatous vessels and the leptomeninges were examined. The morphology of ganglion and glial cells was studied. Myelin sheaths were investigated for focal or diffuse demyelination, and the axons were observed. In addition, vessels and leptomeninges were studied for atherosclerosis and fibrosis. The brain autopsies did not reveal any changes, either locally or diffusely, which could support central pathoanatomical lesions as being responsible for the symptoms in Meniere's disease.

Prediction of recurrence in meningiomas after surgical treatment. A quantitative approach

The prognostic significance of nuclear count, nuclear area fraction, and mean nuclear area estimated by automatic image analysis was evaluated in benign meningiomas. One hundred thirty-two meningiomas without recurrences, 39 meningiomas that recurred, and 40 first recurrences were examined. The tumors were classified according to age and sex of patients, localization, and histology; and the correlation between these parameters and the recurrence rate was assessed. The nuclear counts were identical in paraffin sections from meningiomas without recurrences (6.1 nuclei per 1,000 micrometer 2) and in meningiomas that recurred (6.4 nuclei per 1,000 micrometer 2). The cell count in the recurrences (7.4 nuclei per 1,000 micrometer 2) was higher than in the primary tumors. The same relationship was found for the nuclear area fractions, which were identical in meningiomas without recurrences and in primary meningiomas that recurred. The nuclear area fraction was increased in recurrences. The mean nuclear areas were identical in all groups. The histological type was of little significance in prediction of recurrence rate, although bone invasion and necrosis were of some significance. We found a higher recurrence rate in parasagittal meningiomas. Meningiomas that recurred appeared in a younger age group than other meningiomas, and the recurrence rate was higher for males than for females.

Computed tomography of benign supratentorial astrocytomas of infancy and childhood

The CT findings of 15 benign supratentorial astrocytomas in children less than 15 years of age are compared with the CT findings of 19 supratentorial tumors of other histological types in the same age group. Astrocytomas were more often hypodense, lacked calcification and showed greater contrast enhancement than other tumors. Seven of the 15 astrocytomas were hypodense, without calcification and showed contrast enhancement of more than 10 Hounsfield units, whereas this coexistence was not present in any of the 19 tumors of the other histological types.

Cerebral blood flow and oxygen consumption during ethanol withdrawal in the rat

The ethanol withdrawal syndrome in man and animals is characterized by signs of CNS hyperactivity although a direct measurement of a physiological variable reflecting this CNS hyperactivity has never been performed in untreated man or in animals. We induced ethanol dependence in the rat by means of intragastric intubation with a 20% w/v ethanol solution, thus keeping the animals in a state of continuous severe intoxication for 3--4 days; during the subsequent state of withdrawal characterized by tremor, rigidity, stereotyped movements and general seizures a 25% increase in cerebral oxygen consumption (CMRO2) could be measured; this increase was not due to catecholamines originating from adrenal medulla as adrenomedullectomized animals showed a similar increase in CMRO2 (28%); the withdrawing animals showed a corresponding cerebral blood flow (CBF) increase. The elevated CMRO2 and CBF could be reduced to normal by administration of a beta-adrenergic receptor blocker (propranolol 2 mg/kg i.v.), and hence the increased CMRO2 during ethanol withdrawal could be related to catecholaminergic systems in the brain, e.g. the noradrenergic locus coeruleus system which is anatomically well suited as a general activating system. This interpretation is supported by the earlier neurochemical finding of an increased cerebral noradrenaline turnover during ethanol withdrawal. The exact mechanism underlying the increased cerebral oxygen consumption during ethanol withdrawal and the effect of propranolol on cerebral function during this condition remains to be clarified.

Incidence and long term survival of children with intracranial tumours treated in Denmark 1935-1959

The total number of children under 15 years of age with intracranial tumours in Denmark during the years 1935-1959 was found to be 533. The average incidence was 21 new cases/10(6) children/year during the 25-year period in question, and 25/10(6) children/year during the first 17 years of Danish cancer registration. The sex ratio (290 boys to 243 girls) was not significantly different from that of the child population in Denmark. In 219 cases the tumour was located in the supratentorial and in 314 in the infratentorial space. 93% of the tumours were histologically verified, with the following order of frequency for the most usual types: astrocytomas (all grades), medulloblastomas, ependymomas, and craniopharyngiomas. Follow-up was 100%. For the 345 children who survived for more than one month after operation or diagnosis, 36% were alive after 15 years. 119 patients were alive in April 1974 and these were all observed between 15-40 years after diagnosis and operation. Of these 44 had tumours in the supratentorial and 75 in the infratentorial space. 66% of the survivors with supratentorial and 90% with infratentorial tumours led a normal life. Most of the survivors had had a cerebellar astrocytoma, a supratentorial astrocytoma, an apendymoma or oligodendroglioma, but other histological diagnoses were also represented, especially in the supratentorial group. The long-term prognosis was especially bad for children with brain-stem tumours, infratentorial ependymomas and medulloblastomas.

Long-term prognosis in children with benign cerebellar astrocytoma

In 44 children with benign cerebellar astrocytoma, operated on between 1935 and 1959, two histological types could be distinguished, namely, a so-called juvenile type (31 children) and a diffuse type (13 children). All the children were followed to April, 1976, and the histological review was performed without knowledge of the survival in the single patient. For children with the juvenile type of cerebellar astrocytoma the 25-year cumulative survival rate was 94%, as against 38% for children with the diffuse type. It has thus been demonstrated that the morphological difference between the two types corresponds to a marked difference in survival rate.

Comparison of metrizamide and iodophendylate for cerebral ventriculography: a long-term ultrastructural study of the ventricular wall in the rat

Cerebral ventriculography was performed on adult albino rats to compare the effect of metrizamide and iodophendylate on the ependymal wall. The animals were killed by vascular perfusion 1 month and 4 months after ventriculography. The ependymal layer and the underlying brain tissue were examined with the electron microscope. After the use of metrizamide the tissue appeared completely normal. The use of iodophendylate provoked accumulation of phagocytozing macrophages on the ependymal wall and storage of iodophendylate in the ependyma and underlying brain tissue. These changes were present both 1 and 4 months after ventriculography.

Glial and nerve cell changes in rats with porto-caval anastomosis

Nuclear size and density were determined in brain regions with different glial--neurone composition in rats up to 35 weeks after porto-caval anastomosis. In the white matter, i.e. corpus callosum, both the total cell count and the percentage of astrocytes and oligodendrocytes were unchanged. In the corpus striatum, where the glial/neurone ratio is about 1, the number of nuclei registered as astrocytes increased, and after 35 weeks astrocytes comprised 29% of glial cells (compared with 15% in controls). However, the number of oligodendrogial nuclei decreased simultaneously, leaving the total glial number unchanged. In the animals with longest experimental period there was a 15% loss of neurones. In a region with higher glial/neurone ratio, i.e. the Purkinje cell layer, the neurones showed a similar reduction, whereas the number of Bergmann astrocyte nuclei increased less than striatal astrocytes. A small group of animals with pronounced signs of encephalopathy had a higher loss of neurones and, furthermore, the glial number in corpus striatum and callosum was reduced, due to loss of oligodendrocytes. Despite the use of perfusion fixation, the size of astrocyte nuclei increased, this was reversible, as only slight changes were seen after 35 weeks. A possible explanation of the increase in astrocyte nuclear count and decrease in oligodendroglial count could be that nuclei normally considered to be oligodendroglial are transformed into nuclei with morphological characteristics of astrocytes.

Temporal lobe epilepsy and neuropathology. Histological findings in resected temporal lobes correlated to surgical results and clinical aspects

Neuropathological findings were studied in 74 patients with drug-resistant temporal lobe epilepsy who underwent unilateral temporal lobe resection in 1960-1969 in Denmark. In 60 per cent of the patients a well-defined neuropathological abnormality was revealed (i.e. 13 cases of focal lesions, including four small tumours, 21 cases of gliosis, and 10 cases of perivascular infiltration), in 23 per cent the findings were either questionably abnormal or without structural abnormality, while in the last 18 per cent sequelae of a previous operation dominated the histology. The general trend was for the postoperative clinical outcome to be better, the more specific and circumscribed the histological abnormality. There was no correlation between the neuropathological findings and the preoperative types of seizures. Postoperative recurrence of seizures was more often observed in patients with gliosis than in those with other histological diagnoses. A positive correlation existed between a history of cerebral infection and the presence of perivascular lymphocytic and histiocytic infiltration, and gliosis was a frequent finding in patients with epilepsy of unknown aetiology. No other significant correlation was found between the neuropathological abnormalities and the clinical, hereditary, aetiological, and social aspects.

Histological changes in the central nervous system following intraventricular administration of oil-soluble contrast media. An experimental study in the rat

Following injections of iodophendylate (Pantopaque) in adult rats, the contrast medium was shown to be refrained in the dilated cerebral ventricles for at least 180 days. Histological examination revealed macrophages containing phagocytosed lipid on the ependymal lining of the ventricles, but there was no leukocytic reaction to retained or encysted contrast material. The macrophages were considered to be involved in the removal of iodophendylate. The irritative reaction in the normal central nervous system was limited, as opposed to the severe reactions previously reported in animals with inflammation of the brain and meninges.

Malignancy grade and long-term survival in brain tumours of infancy and childhood

281 histologically verified brain tumours in children were revised and reclassified according to degree of histological malignancy. Survival graphs based on 100 per cent follow-up after 15-40 years show that, of those who survived for more than 1 month after diagnosis and possible operation, 40 per cent were still alive more than 15 years later. There was a clear correlation between survival and degree of malignancy. Sixty-five per cent of those with tumours of malignancy grade I and only 3 per cent of those with malignancy grade IV were alive after 15 years.