H. Cartwright

The cerebral cortex is damaged in chronic alcoholics

There is some controversy in the literature concerning whether chronic alcohol consumption damages the cerebral cortex. While decreased neuronal density in specific cortical regions is well described in chronic alcoholics, a recent study by Badsberg Jensen and Pakkenberg using unbiased stereological methods questions whether neurodegeneration occurs. In order to assess selective neurodegeneration in the cerebral cortex of chronic alcoholics, regional volumes and unbiased estimates of regional neuronal number (including neuronal identification with calcium-binding proteins) were calculated for 14 chronic alcoholics and 21 controls. Cases were carefully screened to exclude any interfering pathologies. Lifetime and maximum daily alcohol consumption was determined, and homogeneous groups were identified (four chronic alcoholics with Wernickes encephalopathy and Korsakoffs psychosis, four chronic alcoholics with Wernickes encephalopathy alone, six chronic alcoholics without Wernickes encephalopathy or Korsakoffs psychosis, and 21 controls). Brain volume analysis revealed that discrete regions were significantly smaller in the chronic alcoholics compared to controls. As previously shown, white matter regions (particularly in the frontal lobe) were the most significantly reduced in volume. Alcoholics with Wernickes encephalopathy (either alone or in combination with Korsakoffs psychosis) had significantly smaller white matter volumes than controls or alcoholics without these complications. Medial temporal lobe regions and the thalamus were also reduced in volume. Regression analyses revealed that the volume of both the white matter and thalamus negatively correlated with alcohol consumption. Consistent with the interpretation of previous neuronal density studies, selective neuronal loss was found in the superior frontal association cortex of chronic alcoholics, while no loss occurred from the motor cortex. The number of parvalbumin-, calbindin- and calretinin-immunoreactive neurons was found to be unaltered in chronic alcoholics, suggesting that the neurodegeneration is confined to the non-GABAergic pyramidal neurons. As neurodegeneration was observed in all alcoholic groups, damage to the frontal association cortex is not restricted to alcoholics with the amnesia of Korsakoffs psychosis. These results are consistent with the notion that chronic alcohol consumption is associated with selective neuronal vulnerability. The selective frontal neurodegeneration and the frontal focus of white matter atrophy are supported by neuropsychological, regional blood flow, and magnetic resonance imaging studies of frontal lobe dysfunction in chronic alcoholics and may correlate with abnormalities in working memory.

Degeneration of the Centré median-parafascicular complex in Parkinson's disease

Two major noncortical inputs to the striatum originate from the substantia nigra and the thalamic centré median–parafascicular complex. Although it is established that in Parkinsons disease there is degeneration of the nigral dopaminergic neurons, there has been little analysis of the glutamatergic centré median–parafascicular complex. We therefore evaluated these and neighboring thalamic nuclei (for specificity of any changes) in 9 Parkinsons disease patients and 8 age‐matched controls. Degeneration in the substantia nigra and centré median–parafascicular complex was estimated by using quantitative neuronal counts. On average, 70% of the pigmented nigral neurons degenerated and there was 30% to 40% neuronal loss in the centré median–parafascicular complex in Parkinsons disease. Thalamic degeneration was marked in neuronal subpopulations (50% loss of parvalbumin‐positive neurons in the parafascicular, and 70% loss of non–parvalbumin‐positive neurons in the centré median nuclei). In contrast, adjacent thalamic nuclei did not degenerate, which supports a selective neurodegeneration of the centré median–parafascicular complex. Our results show that the thalamic centré median–parafascicular complex is an additional nondopaminergic site of neurodegeneration in Parkinsons disease. Because this thalamic region provides important sensorimotor feedback to the striatum, degeneration of this region is likely to exacerbate the clinical signs and symptoms of Parkinsons disease. Ann Neurol 2000;47:345–352

Specific A10 dopaminergic nuclei in the midbrain degenerate in Parkinson's disease.

Using unbiased quantitative techniques, we evaluated the effect of Parkinsons disease on the regional size and the number of tyrosine hydroxylase-producing neurons and all neurons in the midbrain A8 and A10 dopaminergic cell groups located adjacent to the substantia nigra. Seven patients with Lewy body Parkinsons disease were evaluated and compared with five controls. Four of the patients with Parkinsons disease had additional neuropathology, and the effect of concomitant pathology on A10 populations was also determined. Degeneration was not observed in the A8 regions of any patient, and only certain A10 nuclei were affected by the disease. The parabrachial pigmented nucleus situated dorsal to the substantial nigra, and the parapeduncular nucleus located rostromedially were significantly reduced by 40-50% in patients with Parkinsons disease. Few differences were found between patients with or without additional pathology, suggesting a similar pathogenic mechanism to that observed in the substantia nigra of these patients. However, patients with additional pathology also had serotonergic cell loss in the caudal linear nucleus. There was a reduction in tyrosine hydroxylase immunoreactivity but no overt neurodegeneration in other A10 regions, suggesting the disease may also influence the production of dopamine in some surviving neurons.

α-Synucleinopathy phenotypes

α-Synucleinopathies are neurodegenerative diseases characterised by the abnormal accumulation of α-synuclein aggregates in neurons, nerve fibres or glial cells. While small amounts of these α-synuclein pathologies can occur in some neurologically normal individuals who do not have associated neurodegeneration, the absence of neurodegeneration in such individuals precludes them from having a degenerative α-synucleinopathy, and it has yet to be established whether such individuals have a form of preclinical disease. There are three main types of α-synucleinopathy, Parkinsons disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA), with other rare disorders also having α-synuclein pathologies, such as various neuroaxonal dystrophies. Multiple clinical phenotypes exist for each of the three main α-synucleinopathies, with these phenotypes differing in the dynamic distribution of their underlying neuropathologies. Identifying the factors involved in causing different α-synuclein phenotypes may ultimately lead to more targeted therapeutics as well as more accurate clinical prognosis.

Midbrain neuropathology in idiopathic Parkinson's disease and diffuse Lewy body disease

We have quantified midbrain cell loss in idiopathic Parkinsons disease (PD) compared with controls; six patients had PD with onset before 70 years, five patients had late onset PD (>70 years) and nine patients had diffuse Lewy body disease. The pattern of cell loss in these last two groups has not been previously described. No age associated neuronal loss was seen in controls. There was cell loss and reduced area of the pars compacta in all cases but no difference in the pattern of cell loss, which was predominantly ventral. The amount of cell loss in the dorsolateral cluster correlated with the duration of Parkinsonian symptoms, while greater cell loss in the dorsomedial cluster correlated with the presence of tremor and the absence of early dementia. These results suggest that the topography of midbrain pathology does not assist in differentiating these overlapping syndromes.

Progressive supranuclear palsy affects both the substantia nigra pars compacta and reticulata.

We have analyzed the neuropathology of the substantia nigra in four cases of progressive supranuclear palsy compared with age-matched controls and patients with Parkinsons disease. Although there are many reports of severe dopaminergic cell loss in progressive supranuclear palsy, the fate of the GABAergic pars reticulata neurones remains unclear. Serial section analysis and fractional counts of pars compacta neurones (identified by their neuromelanin pigment) and pars reticulata neurones (identified using parvalbumin immunohistochemistry) were performed, and the type and distribution of neuropathology were described. Severe neurodegeneration within the dopaminergic pars compacta was seen in all cases of progressive supranuclear palsy and all cases of Parkinsons disease compared with controls. Lewy body pathology was found only in cases of Parkinsons disease, while neurofibrillary tangles were seen only in cases of progressive supranuclear palsy. Tau-positive astrocytes and neuropil threads were occasionally seen in controls and cases of Parkinsons disease (particularly those of advanced age) but were extremely numerous in all cases of progressive supranuclear palsy. There was a similar decrease in parvalbumin immunoreactivity within the pars reticulata in both progressive supranuclear palsy and Parkinsons disease. However, there was a striking 70% reduction in the number of pars reticulata neurones in progressive supranuclear palsy, with no cell loss observed in Parkinsons disease compared with controls. Our results show that both the dopaminergic pars compacta and the GABAergic pars reticulata are significantly damaged in cases of progressive supranuclear palsy. The distribution of neurodegeneration in patients with Parkinsons disease and progressive supranuclear palsy is discussed with respect to the current theories on pathophysiology in basal ganglia circuitry.

Quantitative analysis of the variability of substantia nigra pigmented cell clusters in the human

At present there is no consensus concerning the internal organization of the human substantia nigra, despite its pivotal role in neurodegenerative conditions. We have quantitatively analysed the variability in the pattern of clusters of melanin-pigmented neurons in the human substantia nigra using serial section analysis and computer reconstructions. The substantia nigra pars compacta showed a bilaminar organization consisting of the pars medialis and pars lateralis, as well as dorsal and ventral tiers as described previously [D. A. McRitchie et al. (1995) J. comp. Neurol. (in press)]. Both the dorsal and ventral tiers could be further subdivided into three mediolateral cell columns based on position and cell density. The presence and arrangement of these cell clusters was most variable in transverse sections (the plane currently used for diagnostic neuropathology). Quantitative assessment of the topographical pattern of cell loss within single transverse sections of the human substantia nigra should therefore be treated with some caution. In contrast, the full rostrocaudal extent of the cell columns could be seen in horizontal sections. Thus, consistent samples of larger numbers of pigmented neurons per region were found in this section plane, although only two cell columns were found in most sections. Our results show that greater quantitative reliability can be achieved with horizontal sections of the substantia nigra.

Idiopathic generalized epilepsy Lack of significant microdysgenesis

Background: The idiopathic generalized epilepsies (IGE) are classically regarded as due to a functional abnormality. However, microscopic microdysgenetic changes have been reported in the majority of cases by one group. Objective: To independently evaluate the microscopic microdysgenetic changes in a controlled, blinded study. Methods: Five brains with IGE and five age-matched control brains were collected. Blocks were taken from nine standardized Brodmann areas, both hippocampi, and cerebellum. Slides were examined independently by two neuropathologists blinded to patient group, who qualitatively scored microdysgenetic features on standardized data sheets. The results were compared and any discrepancies were rescored by the pathologists together using a double-header microscope. Quantitative neuronal profile counts in the molecular layer in standardized Brodmann areas of frontal cortex and in deep frontal white matter were performed. Results: Microdysgenetic features in nine Brodmann areas, hippocampi, and cerebellum were not increased in brains from subjects with IGE compared with control brains. Quantitative neuronal profile counts in the molecular layer of frontal cortex and deep frontal white matter were not increased in IGE compared with controls. Conclusions: This controlled, blinded study did not replicate the results of previous reports of microdysgenesis in IGE. Although factors such as syndrome heterogeneity and sample size may explain the discrepancy, technical factors could also play a role. The current ion channel hypothesis for the pathogenesis of IGE does not preclude microscopic or ultramicroscopic abnormalities and the search for these should continue.

Ubiquitin-positive achromatic neurons in corticobasal degeneration

A 66-year-old woman presented with an alien limb syndrome without dementia. The course of her illness was unremitting and at autopsy 6 years later her diagnosis was confirmed as corticobasal degeneration without Alzheimer-type pathology. Although the presence of ballooned achromatic cortical neurons and cell loss from the substantia nigra distinguishes such patients, the site and density of achromatic neurons has not previously been quantified. We show that immunohistochemistry for the cell stress protein ubiquitin selectively stains these achromatic neurons, whereas they do not stain for abnormally phosphorylated tau protein. Phosphorylated neurofilament antibodies recognise both ballooned and non-ballooned neurons. In this case, high densities of ubiquitin-positive ballooned neurons were found in frontal cortical regions with the highest densities in layers V and VI of the anterior cingulate cortex. In addition, high densities of ubiquitin-positive ballooned neurons were found in the insular cortex, claustrum and amygdala. These results confirm past reports of frontal pathology, but show that there is also considerable pathology in insular and parahippocampal cortical regions and some subcortical regions. Our findings suggest that the distribution and staining characteristics of ballooned neurons in corticobasal degeneration may help to differentiate these cases pathologically, while the absence of dementia appears to be an important clinical criterion.

Neuropathology of α-synuclein propagation and braak hypothesis

Parkinsons disease is a progressive neurodegenerative disorder with multiple factors contributing to increasing severity of pathology in specific brain regions. The Braak hypothesis of Lewy pathology progression in Parkinsons disease proposes a systematic spread of α‐synuclein that can be staged, with the later stages correlating with clinical aspects of the disease. The spread of pathology through the different stages suggests progression, a theory that has proven correct from evidence of pathology in healthy neurons grafted into the brains of patients with Parkinsons disease. Progression of pathology occurs on a number of levels, within a cell, between nearby cells, and then over longer distances throughout the brain, and evidence using prion proteins suggests two dissociable mechanisms—intracellular toxicity versus a nontoxic infectious mechanism for propagation. In Parkinsons disease, intracellular changes associated with mitochondria and lysosome dysfunction appear important for α‐synuclein propagation, with high stress conditions favoring mitochondrial cell death mechanisms. Functional neurons appear necessary for propagation. Unconventional exocytosis releases α‐synuclein under stress conditions, and endocytic uptake occurs in nearby cells. This cell‐to‐cell transmission of α‐synuclein has been recapitulated in both cell culture and animal models, but the timeframe of transmission is considerably shorter than that observed in transplanted neurons. The time course of Lewy pathology formation in patients is consistent with the long time course observed in grafted neurons, and the restricted neuronal loss in Parkinsons disease is potentially important for the propagation of α‐synuclein through relatively intact circuits.