Neuropathology Lab I MHD II

Case 1

Normal brain – cerebral cortex H&E stain. Low power Q1. Identify the gray matter and the white matter

Q2. Identify the arachnoid and the subarachnoid space Identify blood vessels in the subarachnoid space

Q3. What cell type is highlighted by the blue stars Q3. What cell type is highlighted by the blue stars? What is its characteristic histologic features?

Q4. What cell type are the arrows pointing to Q4. What cell type are the arrows pointing to? Describe its characteristic histologic features. What is its function? GFAP stain

Q5 What is the predominant cell type in the high power section Q5 What is the predominant cell type in the high power section? What is its characteristic histologic features? What is its function?

Case 2

History Cc: Progressive ataxia, weakness of limbs and blurred vision with remissions and relapses of 5 years’ duration HPI: The patient is a 40-year old woman who was well until 5 years ago, when following a “flu”, she developed tremors of her arms and loss of balance while walking or standing. The symptoms improved but 6 months later she complained of blurred vision in her right eye. Approximately 1 month later she had another episode of ataxia and weakness and was seen in the ED.

Physical exam: BP 110/80; HR 80/minute and regular; respiratory rate 20/minute; temperature 990F Head/Neck: No facial asymmetry. Extraocular movements are full. Visual acuity: Right 20/200; Left 20/20. The right pupil is 5mm in diameter and does not react to direct light. Fundus exam: normal Heart, lung, abdominal exams: normal Neurological exam: Mental status – oriented to time, person, and place. The patient has ataxia and dysarthria and is unable to stand or walk without support. Motor Exam: Weakness of lower extremities, right 4/5; left 2/5; Reflexes: Deep tendon reflexes are hyperactive; Babinski sign in present on the left side. Sensory Exam: decreased vibration and position sense to both legs, pain and touch are intact

Q1 Develop a problem list Q2 Can you name a single lesion in the nervous system which could explain this patient’s neurologic findings? Why or why not?

Q3 Cite data which support of refute the following differential diagnoses: Amyotrophic lateral sclerosis (ALS) Cervical spondylosis with myelopathy Benign tumor of spinal cord Systemic Lupus Erythematosus (SLE) Multiple Sclerosis

Diagnostic evaluation: Complete blood count (CBC), Basic metabolic panel (BMP) and urinalysis are within normal limits An MRI of the brain is performed.

Q4 What is the primary abnormal finding?

Lumbar Puncture is performed: CSF examination: Protein 65mg/dL (normal 15-45 mg/dL) Glucose 70mg/dL (serum glucose 90mg/dL) Cells : Lymphocytes 50 Gammaglobulin (IgG) is increased; oligoclonal bands are identified

Q5 Interpret the CSF. Explain what “oligoclonal bands” are and the significance of their presence in this case. Q6 Based on the provided clinical and diagnostic data, what diagnosis do you favor?

Q7 Describe the gross pathologic findings Q7 Describe the gross pathologic findings. Do they correlate with the MRI findings?

Q8 Describe the gross findings.

Luxol Fast Blue stain: stains myelin blue Q9 Describe the findings. Correlate with the gross and radiologic findings. Ventricle

Q10 Identify the structure and the pathology Q10 Identify the structure and the pathology. What is its relevance to the pathologic process we are discussing? Do the findings correlate with the clinical findings? (Myelin stain)

Q11 Describe the histopathologic hallmarks of the disease Q11 Describe the histopathologic hallmarks of the disease. Describe the key findings in each of the following histologic sections (A-D)

A

B What cell type is lost in this process B What cell type is lost in this process? What is the predominant cell type in the circle?

C

D What is the cell type? What is in cytoplasm?

Case 2 Summary Q12. Describe typical location of the pathology for this disease process (where is the pathology in the CNS, brain?, spinal cord?, white matter?, grey matter?). What is the pathomechanism of the disease? What is the main pathologic process?

Case 3

HISTORY A 20 year old male college student was found in his dorm room in bed by his roommates complaining of headache, nausea, and photosensitivity. When the patient started vomiting and appeared confused, his roommates brought him to the emergency department On presentation his temperature was 40.10C. He was somnolent, but reacted to painful stimuli. He had nuchal rigidity.

Funduscopic exam is performed Patient Q1 What is the abnormality? Normal

Q2. Develop a problem list. Q3. Develop a differential diagnosis. Which diagnosis do you favor? Q4. What diagnostic tests would you order?

After further diagnostic tests, therapy was initiated After further diagnostic tests, therapy was initiated. However, the patient’s mental status worsened over the next several hours. He required intubation and mechanical ventilation.

Skin exam Q5 Describe the findings. Hospital Day 1 Hospital day 3

The patient’s condition continued to deteriorate The patient’s condition continued to deteriorate. He died on hospital day #3 despite maximal attempts at resuscitation. An autopsy was performed

Q6. Describe the gross findings. What is the arrow highlighting? What structure is the forceps on?

Q6 Describe the findings. Correlate with the gross findings. Low power H& E Section. Q6 Describe the findings. Correlate with the gross findings. 0.4X Normal

Q7 Describe the higher power histologic findings 20X

Q8 Describe the findings on high power. 40X

Q9 What is your diagnosis Q9 What is your diagnosis? Q10 Correlate the pathologic findings with the findings you suspect were likely present on examination of the CSF. Q11 What is/are the most likely etiologic agent(s) of this disease process in this patient? 10X

ADRENALS Adrenal glands. Q12 – Describe the pathologic findings. How did this process manifest clinically?

Q13 Summarize the cause of death in this patient.

Case 4

History A 34 year old man fell from his bicycle striking his head on the curb. A passerby witnessed a brief period of unconsciousness lasting approximately 30 seconds. He regained consciousness but remained somewhat confused. When paramedics arrived, he was still disoriented but was moving all extremities on command and had normally reactive pupils. He was placed on a spine board and in a stiff cervical collar and was transported to the hospital.

Physical exam: BP 126/78, HR 82/minute and regular; respiratory rate 20/minute; temperature 990F Right frontotemporal scalp hematoma was noted. Patient was confused with an initial GCS of 14.

Q1 What is your differential diagnosis? Q2 What diagnostic tests are indicated?

Q3 Describe the findings.

Q4 What is your diagnosis? Q5 What is the treatment?

Q6 What are potential complications of this disease process?

Q7. Describe the gross findings.

Q6 Describe the pathogenesis of this disease process Q6 Describe the pathogenesis of this disease process. What is the most common source of bleeding?

Case 5

Additional Examples of Traumatic Brain Injury:

Patient 1 Q1 Describe the gross findings. What may have been the cause? What clinical or physical exam findings may have been seen in this patient?

Q2. Describe the gross findings. What scenario(s) may have led to the Patient 2 Q2. Describe the gross findings. What scenario(s) may have led to the development of these findings?

Patient 3 Q3. Describe the gross findings. Be certain to comment on the particular location of the abnormal findings.

Patient 3. Q4 Describe the histologic findings on this golgi (silver) stained section.

Q5 What is the most likely mechanism/cause of patient 3’s pathology Q5 What is the most likely mechanism/cause of patient 3’s pathology? Describe the likely clinical condition of this patient.