Acta Neuropathol (1992) 84:207 - 210
Acta Nmopathologga (~) Springer-Verlag1992
Case reports
Spinal cord vascular and leptomeningeal amyloid [ -protein deposition in a case with cerebral amyloid angiopathy* T. Tokuda 1, S. Ikeda 1, K. Maruyama 1, N. Yanagisawa 1, and N. Ito 2 Departments of 1Medicine (Neurology), and 2pathology, Shinshu University School of Medicine, Matsumoto 390, Japan Received September 20, 1991/Revised, accepted February 17, 1992
Summary. Cerebral amyloid angiopathy (CAA) is characterized by the deposition of amyloid fibrils on leptomeningeal and cortical blood vessels, and the incidence of this disorder increases with age. However, this form of vascular amyloid deposition rarely involves tissues outside of the brain. A 71-year-old woman first developed some deterioration in memory, and soon afterwards suffered from recurrent episodes of subcortical hemorrhage. Histopathological examination of this case revealed typical pathology of Alzheimer's disease with an extensive appearance of [3-protein type C A A , and additionally, the spinal leptomeningeal vessels and the pia-arachnoid membranes were also affected by amyloid B-protein deposits. The spinal cord involvement associated with C A A and Alzheimer's disease is unusual, and the present case provides additional important information on the pathogenesis of disorders with B-protein deposition including Alzheimer's disease.
tomatic elderly individuals. In these conditions, amyloid deposition is usually seen in the walls of leptomeningeal and cortical blood vessels of the brain [15, 24-26]. Additionally, C A A is also recognized as a cause of spontaneous cerebral hemorrhage in normotensive elderly persons [24-26]. However, the origin of B-protein has still not been determined, and the pathogenesis of the B-protein-type amyloid deposition in cerebrovascular walls has not been established. In this communication we report immunohistochemical evidence of amyloid B-protein deposits on the spinal cord leptomeningeal vessels and the pia-arachnoid membranes seen in an elderly d e m e n t e d woman with a history of recurrent cerebral hemorrhages, possibly caused by an autopsy-proven CAA. This form of spinal cord amyloid B-protein deposition has not often been described in aged individuals including patients with Alzheimer's disease.
Key words: Cerebral amyloid angiopathy - Amyloid B-protein - Alzheimer's disease - Spinal leptomeningeal vessels
Material and methods Case report
Cerebral amyloid angiopathy (CAA) is one of the cardinal brain lesions in patients with Alzheimer's disease [6, 15], whose amyloid fibrils of C A A are known to consist mainly of B-protein [5]. Furthermore, ~protein-type C A A has also been identified in persons with various other conditions [2, 4, 23]: adult Down's syndrome, Dutch-type hereditary cerebral hemorrhage with amyloidosis, dementia pugilistica, sporadic cerebral amyloid angiopathy with no significant n u m b e r of neurofibrillary tangles or senile plaques, and in asymp* Supported by a grant from the Intractable Disease Division, Ministry of Health and Welfare, Primary Amyloidosis Research Committee and a grant-in-aid for Scientific Research from the Ministry of Education, Science and Culture, Japan Correspondence to: S. Ikeda (address see above)
The patient was a 71-year-old right-handed woman who had been suffering from memory impairment for several months, and suddenly developed severe headache and gait disturbance. The patient was admitted to our hospital. She had no family history of dementia or cerebral hemorrhage. Her blood pressure was 120/60 mmHg and other general physical findings were unremarkable. Neurological examination revealed prosopagnosia, visuospatial agnosia, nuchal stiffness, left homonymous hemianopsia and hyperreflexia with Babinski sign in her left side.The routine blood, urine and cerebrospinal fluid were normal. She had neither coagulation disturbances nor autoimmune abnormalities. Brain CT disclosed a hemorrhagic lesion in the right parieto-occipital area. The cerebral angiography showed no vasculitis, aneurysms or arteriovenous malformations. In the following 2 years she developed severe memory impairment, personality change and hallucinations, and then these symptoms gradually worsened.When she was 72 years old, she complained of headache and became confused in putting on her clothes, her condition being diagnosed as dressing apraxia. An intracerebral hemorrhage was again detected in the right parieto-temporal region with CT. At the
208 age of 73, she suddenly developed severe headache and vomiting, then became comatose. She was readmitted to our hospital. CT revealed multiple hemorrhagic lesions in the bilateral cerebral hemispheres with subarachnoidal and intraventricular hemorrhages. She died of respiratory failure on the 10th day in hospital.
Specimen processing At autopsy the brain was removed and cut horizontally and fixed in 10 % buffered formalin. Tissue samples were routinely taken from cerebrum, cerebellum, brain stem and spinal cord. They were embedded in paraffin and cut into serial sections, which were stained with hematoxylin and eosin, alkaline Congo red, modified Bielshowsky's silver impregnation and by immunohistochemical methods.
Irnmunohistochemistry Immunoperoxidase staining was carried out using the avidin-biotin peroxidase technique described previously [9], and some sections were pretreated with 98% formic acid [13] to enhance the immunoreactivity of amyloid related proteins. The primary reagents were a monoclonal antibody 4D12/2/6 [1] raised against a synthetic peptide consisting of residues 8-17 of 13-protein and an affinity-purified rabbit antiserum to the amino-terminal octapeptide of human cystatin C (AG8206) [14]. The sections were immunostainedwith either 1 : 1000-diluted 4D12/2/6 ascites fluid or 1:500-diluted anti-cystatin C antiserum. The immunospecificityof the staining produced with these antibodies has been well characterized [1, 9, 14, 16].
Microscopic examination disclosed mild neuronal loss and gliosis diffusely affecting the cerebral cortex. There were numerous argyrophilic neurofibrillary tangles (NFTs) and senile plaques throughout the neocortex and hippocampus (Fig. 2A), and the subcortical gray matter was less involved with these lesions. In addition, there was severe deposition of Congophilic amyloid in both leptomeningeal and cortical blood vessels (Fig. 2B): some heavily amyloid-laden vessels showed medial thickness and/or double barreling of vascular walls, but there were no other significant vascular changes including aneurysmal formation or obliteration.These vascular amyloid deposits were also observed in the leptomeningeal vessels of cerebellum and spinal cord. In the spinal cord, the vessels located in the ventral part were more frequently affected (Fig. 3A, B). There was no difference in the severity and the pattern of vascular wall amyloid deposition among cervical, thoracic and lumbar segments examined. Immunohistochemical staining revealed that all the cerebrovascular and senile plaque amyloid deposits were invariably immunoreactive to the anti-~-protein antibody (Fig. 2B), and after formic acid pretreatment the immunoreactivity of these amyloid deposits was greatly intensified with the appearance of many early (diffuse) plaque lesions [10] (Fig. 2B, insert). In addition, some vessels with ~-protein immunoreactivitywere also stained with the anti-eystatin C antiserum (data not shown). However, the immunoreaction with this antibody was in general weaker than that with
Pathological findings The brain weighed 1300 g. Gross examination of the brain revealed subarachnoidal hemorrhage in both parietal and temporal lobes with bilateral tonsilar herniation. On the horizontally cut surface, both cerebral hemispheres showed subcortical hematomas: a recent small hematoma was located in the border-area of left frontal and parietal lobes, and within the right parieto-occipital region there was a large hematoma, which extended to the overlying leptomeninges as well as to the body of the lateral ventricle (Fig. 1). Slight atherosclerotic changes were seen in the cerebral arteries but neither aneurysms nor arteriovenous malformations were detected.
Fig. 2A, B. Neocortical findings. A Bielshowsky's silver staining
Fig. 1. Gross appearance of the brain. Horizontal section showing
of parietal cortex reveals many typical core-containing senile plaques. Insert shows neurofibrillary tangle-bearing neurons seen in the same section. B Immunostaining of the same block by anti-~-protein antibody. Most vessels in the subarachnoid space and superficial cortex are involved with [3-protein type cerebral amyloid angiopathy. Insert fi-protein immunostaining with formic acid pretreatment discloses immunoreactive plaque lesions. Bars
subcortical hematomas in both cerebral hemispheres
A, B = 100 ~m
209 anti-[3-protein antibody, and the detailed findings of CAA with dual immunoreactivity (including the present case) have been reported previously by us [16]. In the spinal cord vascular wall amyloid deposits were consistently immunoreactive to anti-[3-protein antibody but were not stained by anti-cystatin C antiserum (Fig. 3A, B). Moreover, Congo red-negative pia-arachnoid membranes in some areas were immunostained with anti-[3-protein antibody, and formic acid pretreatment resulted in a strong intensification of this immunohistochemical reaction, showing a coarse granular appearance of the entire leptomeninges involved (Fig. 3B). However, no immunoreactive lesions were observed in the intraspinal parenchyma.
Fig. 3A-C. Spinal cord lesions. Immunostaining with anti-~3protein antibody after formic acid pretreatment. A Ventral part of cervical cord (C5); B similar part of thoracic cord (Th6). Subarachnoidal vessels show B-protein immunoreactivity, mainly in outer media to adventitia, lnserl B A poralized view of a Congo red-stained section reveals amyloid angiopathy in the same vessel shown in B. C Dorsal part of cervical cord: leptomeniges discloses ~-protein immunoreactivity with a coarse granular appearance. Bars A-C = 100 ~tm
Discussion The present case first developed an impairment of cognitive ability and subsequently repeated episodes of subcortical cerebral hemorrhage occurred. Routine histopathological examination of the brain disclosed the presence of many NFTs and senile plaques with CAA. On the basis of these clinical and pathological findings the patient was diagnosed as having Alzheimer's disease. Additionally, C A A (severely involving leptomeningeal and cortical blood vessels) was considered to be a causative lesion for the cerebral hemorrhages, since the patient was a normotensive aged woman who lacked any other causes leading to recurrent intracranial hemorrhages. The most striking finding in the present case is amyloid [3-protein deposition on the spinal cord, showing a selective involvement of the subarachnoidal vessels and pia-arachnoid membranes. The latter leptomeningeal immunoreactive lesion was not visible in the sections stained with Congo red and, therefore, it still remains uncertain whether or not this spinal cord lesion is composed of genuine amyloid fibrils or p-proteinimmunoreactive material without amyloid fibril structures [10, 20]. There have been a few studies investigating amyloid deposition on the spinal cord in aged individuals: Yamada et al. [26] described that among 123 autopsy brains obtained from elderly patients, including 70 cases with CAA, only one spinal cord showed amyloid angiopathy of meningeal vessels, and H a r t et al. [8] reported a spinal cord vascular malformation with [3-protein amyloid deposits in a 76-year-old patient. However, there is no mention of pia-arachnoid membrane lesions in these reports. Accordingly, the peculiar form of spinal cord amyloid [3-protein deposition (involvement of subarachnoidal vessels and leptomeninges) observed in the present case is a previously unknown pathology in the central nervous system of patients affected by C A A and/or Alzheimer's disease. It has been already established that [3-protein is the main component of the amyloid fibrils of both senile plaques and C A A seen in aged persons including patients with Alzheimer's disease and its related disorders [2, 5, 17]. Suggestions as to the origin of amyloid p-protein precursors (APPs) [11, 12, 18, 21] have included circulating serum proteins [7], the vascular wall itself [19], and intrinsic brain cellular constituents (especially neurons) [3, 22]. However, the pathological mechanism of B-protein amyloid deposits in the brain remains unclear. The present study provides immunohistochemical evidence that in [3-protein-deposition diseases the processing of APPs leading to the formation of [3-protein amyloid fibrils may occur in a more extensive area of central nervous system than previously recognized. Further studies are required to clarify the details of amyloid deposits in brain and spinal cord in relation to ageing.
Acknowledgements. We would like to express our appreciation to Dr. D. Allsop for the 4D12/2/6 antibody, and for reading and correcting the manuscript. The AG8206 antibody was kindly provided by Dr. A. O. Grubb.
210
References 1. Allsop D, Landon M, Kidd M, Lowe JS, Reynolds OR Gardner A (1986) Monoclonal antibodies raised against a subsequence of senile plaque core protein react with plaque cores, plaque periphery and cerebrovascular amyloid in Alzheimer's disease. Neurosci Lett 68:252-256 2. Castafio EM, Frangione B (1988) Human amyloidosis, Alzheimer's disease and related disorders. Lab Invest 58:122-132 3. Chou W-G, Zain SB, Rehman S, Tate-Ostroff B (1990) Alzheimer cortical neurons containing abundant amyloid mRNA. Relationship to amyloid deposition and senile plaques. J Psychiatr Res 24:37-50 4. Coria E Castafio EM, Frangione B (1987) Brain amyloid in normal aging and cerebral amyloid angiopathy is antigenically related to Alzheimer's disease 6-protein. Am J Pathol 129:422-428 5. Glenner GG, Wong CW (1984) Alzheimer's disease: initial report of the purification and characterization of a novel cerebrovascular amyloid protein. Biochem Biophys Res Commun 120:885-890 6. Glenner GG, Henry JH, Fujihara S (1981) Congophilic angiopathy in the pathogenesis of Alzheimer's degeneration. Ann Pathol 1:120-129 7. Glenner GG, Wong CW, Quaranta V, Eanes ED (1984) The amyloid deposits in Alzheimer's disease: their nature and pathogenesis. Appl Pathol 2:357-369 8. Hart MN, Merz R Bennett-Gray J, Menezes AH, Goeken JA, Schelper RL, Wisniewski HM (1988) [3-amyloid protein of Alzheimer's disease is found in cerebral and spinal cord vascular malformations. Am J Pathol 132:167-172 9. Ikeda S, Allsop D, Glenner GG (1989) Morphology and distribution of plaque and related deposits in the brains of Alzheimer's disease and control cases. An immunohistochemical study using amyloid [3-protein antibody. Lab Invest 60:113-122 10. Ikeda S, Yanagisawa N, Allsop D, Glenner GG (1990) Early senile plaques in Alzheimer's disease demonstrated by histochemistry, immunocytochemistry and electron microscopy. Hum Pathol 21:1221-1226 11. Kang J, Lemaire H-G, Unterbeck A, Salbaum JM, Masters CL, Grzeschik K-H, Multhaup G, Beyreuther K, Miiller-Hill B (1987) The precursor of Alzheimer's disease amyloid A4 protein resembles a cell-surface receptor. Nature 325:733-736 12. Kitaguchi N,Takahashi Y, TokushimaY, Shiojiri S, Ito H (1988) Novel precursor of Alzheimer's disease amyloid protein shows protease inhibitory activity. Nature 331:530-532 13. KitamotoT, Ogomori K,Tateishi J, Prusiner SB (1987) Formic acid pretreatment enhances immunostaining of cerebral and systemic amyloids. Lab Invest 57:230-236
14. L6fberg H, Grubb AO, Nilsson EK, Jensson O, Gudmundsson G, Blondal H, Arnason A, Thorsteinsson L (1987) Immunohistochemical characterization of the amyloid deposits and quantitation of pertinent cerebrospinal fluid proteins in hereditary cerebral hemorrhage with amyloidosis. Stroke 18:431-440 15. Mandybur TI (1975) The incidence of cerebral amyloid angiopathy in Alzheimer's disease. Neurology 25:120-126 16. Maruyama K, Ikeda S, Ishihara T, Allsop D, Yanagisawa N (1990) Immunohistochemical characterization of cerebrovascular amyloid in 46 autopsied cases using antibodies to protein and cystatin C. Stroke 21:397-403 17. Masters CL, Simms G,Weinman NA, Multhaup G, McDonald BL, Beyreuther K (1985) Amyloid plaque core protein in Alzheimer disease and Down syndrome. Proc Natl Acad Sci USA 82:4245-4249 18. Ponte R Gonzalez-De Whitt P, Schilling J, Miller J, Hsu D, Greenberg B, Davis K, Wallace W, Lieberburg I, Fuller E Cordell B (1988) A newA4 amyloid mRNA contains a domain homologous to serine proteinase inhibitors. Nature 331: 525 -527 19~ Tagliavini G, Ghiso J, Timmers WE Giaccone G, Bugiani O, Frangione B (1990) Coexistence of Alzheimer's amyloid precursor protein and amyloid protein in cerebral vessel walls. Lab Invest 62:761-767 20. Tagliavini F, Giaccone G, Verga L, Ghiso J, Frangione B, Bugiani O (1991) Alzheimer's patients: preamyloid deposits are immunoreactive with antibodies to the extracellular domains of the amyloid precursor protein. Neurosci Lett 128:117-120 21. Tanzi RE, McClatchey AI, Lamperti ED, Villa-Komaroff L, Gusella JF, Neve RL (1988) Protease inhibitor domain encoded by an amyloid protein precursor mRNA associated with Alzheimer's disease. Nature 331:528-530 22. Tate-Ostroff, Majocha RE, Marotta CA (1989) Identification of cellular and extracellular sites of amyloid precursor protein extracytoplasmie domain in nomal and Alzheimer's disease brains. Proc Natl Acad Sci USA 86:745-749 23. Tokuda T, Ikeda S,Yanagisawa N, IharaY, Glenner GG (1991) Re-examination of ex-boxers' brains using immunohistochemistry with antibodies to amyloid ~-protein and tau protein. Acta Neuropathol 8-2:280-285 24. Tomonaga M (1981) Cerebral amyloid angiopathy in the elderly. J Am Geriatr Soc 29:151-157 25. Vinters HV (1987) Cerebral amyloid angiopathy. A critical review. Stroke 18:311-324 26. Yamada M, Tsukagoshi H, Otomo E, Hayakawa M (1987) Cerebral amyloid angiopathy in the aged. J Neurol 234:371-376
Acta Nmopathologga (~) Springer-Verlag1992
Case reports
Spinal cord vascular and leptomeningeal amyloid [ -protein deposition in a case with cerebral amyloid angiopathy* T. Tokuda 1, S. Ikeda 1, K. Maruyama 1, N. Yanagisawa 1, and N. Ito 2 Departments of 1Medicine (Neurology), and 2pathology, Shinshu University School of Medicine, Matsumoto 390, Japan Received September 20, 1991/Revised, accepted February 17, 1992
Summary. Cerebral amyloid angiopathy (CAA) is characterized by the deposition of amyloid fibrils on leptomeningeal and cortical blood vessels, and the incidence of this disorder increases with age. However, this form of vascular amyloid deposition rarely involves tissues outside of the brain. A 71-year-old woman first developed some deterioration in memory, and soon afterwards suffered from recurrent episodes of subcortical hemorrhage. Histopathological examination of this case revealed typical pathology of Alzheimer's disease with an extensive appearance of [3-protein type C A A , and additionally, the spinal leptomeningeal vessels and the pia-arachnoid membranes were also affected by amyloid B-protein deposits. The spinal cord involvement associated with C A A and Alzheimer's disease is unusual, and the present case provides additional important information on the pathogenesis of disorders with B-protein deposition including Alzheimer's disease.
tomatic elderly individuals. In these conditions, amyloid deposition is usually seen in the walls of leptomeningeal and cortical blood vessels of the brain [15, 24-26]. Additionally, C A A is also recognized as a cause of spontaneous cerebral hemorrhage in normotensive elderly persons [24-26]. However, the origin of B-protein has still not been determined, and the pathogenesis of the B-protein-type amyloid deposition in cerebrovascular walls has not been established. In this communication we report immunohistochemical evidence of amyloid B-protein deposits on the spinal cord leptomeningeal vessels and the pia-arachnoid membranes seen in an elderly d e m e n t e d woman with a history of recurrent cerebral hemorrhages, possibly caused by an autopsy-proven CAA. This form of spinal cord amyloid B-protein deposition has not often been described in aged individuals including patients with Alzheimer's disease.
Key words: Cerebral amyloid angiopathy - Amyloid B-protein - Alzheimer's disease - Spinal leptomeningeal vessels
Material and methods Case report
Cerebral amyloid angiopathy (CAA) is one of the cardinal brain lesions in patients with Alzheimer's disease [6, 15], whose amyloid fibrils of C A A are known to consist mainly of B-protein [5]. Furthermore, ~protein-type C A A has also been identified in persons with various other conditions [2, 4, 23]: adult Down's syndrome, Dutch-type hereditary cerebral hemorrhage with amyloidosis, dementia pugilistica, sporadic cerebral amyloid angiopathy with no significant n u m b e r of neurofibrillary tangles or senile plaques, and in asymp* Supported by a grant from the Intractable Disease Division, Ministry of Health and Welfare, Primary Amyloidosis Research Committee and a grant-in-aid for Scientific Research from the Ministry of Education, Science and Culture, Japan Correspondence to: S. Ikeda (address see above)
The patient was a 71-year-old right-handed woman who had been suffering from memory impairment for several months, and suddenly developed severe headache and gait disturbance. The patient was admitted to our hospital. She had no family history of dementia or cerebral hemorrhage. Her blood pressure was 120/60 mmHg and other general physical findings were unremarkable. Neurological examination revealed prosopagnosia, visuospatial agnosia, nuchal stiffness, left homonymous hemianopsia and hyperreflexia with Babinski sign in her left side.The routine blood, urine and cerebrospinal fluid were normal. She had neither coagulation disturbances nor autoimmune abnormalities. Brain CT disclosed a hemorrhagic lesion in the right parieto-occipital area. The cerebral angiography showed no vasculitis, aneurysms or arteriovenous malformations. In the following 2 years she developed severe memory impairment, personality change and hallucinations, and then these symptoms gradually worsened.When she was 72 years old, she complained of headache and became confused in putting on her clothes, her condition being diagnosed as dressing apraxia. An intracerebral hemorrhage was again detected in the right parieto-temporal region with CT. At the
208 age of 73, she suddenly developed severe headache and vomiting, then became comatose. She was readmitted to our hospital. CT revealed multiple hemorrhagic lesions in the bilateral cerebral hemispheres with subarachnoidal and intraventricular hemorrhages. She died of respiratory failure on the 10th day in hospital.
Specimen processing At autopsy the brain was removed and cut horizontally and fixed in 10 % buffered formalin. Tissue samples were routinely taken from cerebrum, cerebellum, brain stem and spinal cord. They were embedded in paraffin and cut into serial sections, which were stained with hematoxylin and eosin, alkaline Congo red, modified Bielshowsky's silver impregnation and by immunohistochemical methods.
Irnmunohistochemistry Immunoperoxidase staining was carried out using the avidin-biotin peroxidase technique described previously [9], and some sections were pretreated with 98% formic acid [13] to enhance the immunoreactivity of amyloid related proteins. The primary reagents were a monoclonal antibody 4D12/2/6 [1] raised against a synthetic peptide consisting of residues 8-17 of 13-protein and an affinity-purified rabbit antiserum to the amino-terminal octapeptide of human cystatin C (AG8206) [14]. The sections were immunostainedwith either 1 : 1000-diluted 4D12/2/6 ascites fluid or 1:500-diluted anti-cystatin C antiserum. The immunospecificityof the staining produced with these antibodies has been well characterized [1, 9, 14, 16].
Microscopic examination disclosed mild neuronal loss and gliosis diffusely affecting the cerebral cortex. There were numerous argyrophilic neurofibrillary tangles (NFTs) and senile plaques throughout the neocortex and hippocampus (Fig. 2A), and the subcortical gray matter was less involved with these lesions. In addition, there was severe deposition of Congophilic amyloid in both leptomeningeal and cortical blood vessels (Fig. 2B): some heavily amyloid-laden vessels showed medial thickness and/or double barreling of vascular walls, but there were no other significant vascular changes including aneurysmal formation or obliteration.These vascular amyloid deposits were also observed in the leptomeningeal vessels of cerebellum and spinal cord. In the spinal cord, the vessels located in the ventral part were more frequently affected (Fig. 3A, B). There was no difference in the severity and the pattern of vascular wall amyloid deposition among cervical, thoracic and lumbar segments examined. Immunohistochemical staining revealed that all the cerebrovascular and senile plaque amyloid deposits were invariably immunoreactive to the anti-~-protein antibody (Fig. 2B), and after formic acid pretreatment the immunoreactivity of these amyloid deposits was greatly intensified with the appearance of many early (diffuse) plaque lesions [10] (Fig. 2B, insert). In addition, some vessels with ~-protein immunoreactivitywere also stained with the anti-eystatin C antiserum (data not shown). However, the immunoreaction with this antibody was in general weaker than that with
Pathological findings The brain weighed 1300 g. Gross examination of the brain revealed subarachnoidal hemorrhage in both parietal and temporal lobes with bilateral tonsilar herniation. On the horizontally cut surface, both cerebral hemispheres showed subcortical hematomas: a recent small hematoma was located in the border-area of left frontal and parietal lobes, and within the right parieto-occipital region there was a large hematoma, which extended to the overlying leptomeninges as well as to the body of the lateral ventricle (Fig. 1). Slight atherosclerotic changes were seen in the cerebral arteries but neither aneurysms nor arteriovenous malformations were detected.
Fig. 2A, B. Neocortical findings. A Bielshowsky's silver staining
Fig. 1. Gross appearance of the brain. Horizontal section showing
of parietal cortex reveals many typical core-containing senile plaques. Insert shows neurofibrillary tangle-bearing neurons seen in the same section. B Immunostaining of the same block by anti-~-protein antibody. Most vessels in the subarachnoid space and superficial cortex are involved with [3-protein type cerebral amyloid angiopathy. Insert fi-protein immunostaining with formic acid pretreatment discloses immunoreactive plaque lesions. Bars
subcortical hematomas in both cerebral hemispheres
A, B = 100 ~m
209 anti-[3-protein antibody, and the detailed findings of CAA with dual immunoreactivity (including the present case) have been reported previously by us [16]. In the spinal cord vascular wall amyloid deposits were consistently immunoreactive to anti-[3-protein antibody but were not stained by anti-cystatin C antiserum (Fig. 3A, B). Moreover, Congo red-negative pia-arachnoid membranes in some areas were immunostained with anti-[3-protein antibody, and formic acid pretreatment resulted in a strong intensification of this immunohistochemical reaction, showing a coarse granular appearance of the entire leptomeninges involved (Fig. 3B). However, no immunoreactive lesions were observed in the intraspinal parenchyma.
Fig. 3A-C. Spinal cord lesions. Immunostaining with anti-~3protein antibody after formic acid pretreatment. A Ventral part of cervical cord (C5); B similar part of thoracic cord (Th6). Subarachnoidal vessels show B-protein immunoreactivity, mainly in outer media to adventitia, lnserl B A poralized view of a Congo red-stained section reveals amyloid angiopathy in the same vessel shown in B. C Dorsal part of cervical cord: leptomeniges discloses ~-protein immunoreactivity with a coarse granular appearance. Bars A-C = 100 ~tm
Discussion The present case first developed an impairment of cognitive ability and subsequently repeated episodes of subcortical cerebral hemorrhage occurred. Routine histopathological examination of the brain disclosed the presence of many NFTs and senile plaques with CAA. On the basis of these clinical and pathological findings the patient was diagnosed as having Alzheimer's disease. Additionally, C A A (severely involving leptomeningeal and cortical blood vessels) was considered to be a causative lesion for the cerebral hemorrhages, since the patient was a normotensive aged woman who lacked any other causes leading to recurrent intracranial hemorrhages. The most striking finding in the present case is amyloid [3-protein deposition on the spinal cord, showing a selective involvement of the subarachnoidal vessels and pia-arachnoid membranes. The latter leptomeningeal immunoreactive lesion was not visible in the sections stained with Congo red and, therefore, it still remains uncertain whether or not this spinal cord lesion is composed of genuine amyloid fibrils or p-proteinimmunoreactive material without amyloid fibril structures [10, 20]. There have been a few studies investigating amyloid deposition on the spinal cord in aged individuals: Yamada et al. [26] described that among 123 autopsy brains obtained from elderly patients, including 70 cases with CAA, only one spinal cord showed amyloid angiopathy of meningeal vessels, and H a r t et al. [8] reported a spinal cord vascular malformation with [3-protein amyloid deposits in a 76-year-old patient. However, there is no mention of pia-arachnoid membrane lesions in these reports. Accordingly, the peculiar form of spinal cord amyloid [3-protein deposition (involvement of subarachnoidal vessels and leptomeninges) observed in the present case is a previously unknown pathology in the central nervous system of patients affected by C A A and/or Alzheimer's disease. It has been already established that [3-protein is the main component of the amyloid fibrils of both senile plaques and C A A seen in aged persons including patients with Alzheimer's disease and its related disorders [2, 5, 17]. Suggestions as to the origin of amyloid p-protein precursors (APPs) [11, 12, 18, 21] have included circulating serum proteins [7], the vascular wall itself [19], and intrinsic brain cellular constituents (especially neurons) [3, 22]. However, the pathological mechanism of B-protein amyloid deposits in the brain remains unclear. The present study provides immunohistochemical evidence that in [3-protein-deposition diseases the processing of APPs leading to the formation of [3-protein amyloid fibrils may occur in a more extensive area of central nervous system than previously recognized. Further studies are required to clarify the details of amyloid deposits in brain and spinal cord in relation to ageing.
Acknowledgements. We would like to express our appreciation to Dr. D. Allsop for the 4D12/2/6 antibody, and for reading and correcting the manuscript. The AG8206 antibody was kindly provided by Dr. A. O. Grubb.
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References 1. Allsop D, Landon M, Kidd M, Lowe JS, Reynolds OR Gardner A (1986) Monoclonal antibodies raised against a subsequence of senile plaque core protein react with plaque cores, plaque periphery and cerebrovascular amyloid in Alzheimer's disease. Neurosci Lett 68:252-256 2. Castafio EM, Frangione B (1988) Human amyloidosis, Alzheimer's disease and related disorders. Lab Invest 58:122-132 3. Chou W-G, Zain SB, Rehman S, Tate-Ostroff B (1990) Alzheimer cortical neurons containing abundant amyloid mRNA. Relationship to amyloid deposition and senile plaques. J Psychiatr Res 24:37-50 4. Coria E Castafio EM, Frangione B (1987) Brain amyloid in normal aging and cerebral amyloid angiopathy is antigenically related to Alzheimer's disease 6-protein. Am J Pathol 129:422-428 5. Glenner GG, Wong CW (1984) Alzheimer's disease: initial report of the purification and characterization of a novel cerebrovascular amyloid protein. Biochem Biophys Res Commun 120:885-890 6. Glenner GG, Henry JH, Fujihara S (1981) Congophilic angiopathy in the pathogenesis of Alzheimer's degeneration. Ann Pathol 1:120-129 7. Glenner GG, Wong CW, Quaranta V, Eanes ED (1984) The amyloid deposits in Alzheimer's disease: their nature and pathogenesis. Appl Pathol 2:357-369 8. Hart MN, Merz R Bennett-Gray J, Menezes AH, Goeken JA, Schelper RL, Wisniewski HM (1988) [3-amyloid protein of Alzheimer's disease is found in cerebral and spinal cord vascular malformations. Am J Pathol 132:167-172 9. Ikeda S, Allsop D, Glenner GG (1989) Morphology and distribution of plaque and related deposits in the brains of Alzheimer's disease and control cases. An immunohistochemical study using amyloid [3-protein antibody. Lab Invest 60:113-122 10. Ikeda S, Yanagisawa N, Allsop D, Glenner GG (1990) Early senile plaques in Alzheimer's disease demonstrated by histochemistry, immunocytochemistry and electron microscopy. Hum Pathol 21:1221-1226 11. Kang J, Lemaire H-G, Unterbeck A, Salbaum JM, Masters CL, Grzeschik K-H, Multhaup G, Beyreuther K, Miiller-Hill B (1987) The precursor of Alzheimer's disease amyloid A4 protein resembles a cell-surface receptor. Nature 325:733-736 12. Kitaguchi N,Takahashi Y, TokushimaY, Shiojiri S, Ito H (1988) Novel precursor of Alzheimer's disease amyloid protein shows protease inhibitory activity. Nature 331:530-532 13. KitamotoT, Ogomori K,Tateishi J, Prusiner SB (1987) Formic acid pretreatment enhances immunostaining of cerebral and systemic amyloids. Lab Invest 57:230-236
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