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Background and purpose Argyrophilic grain disease (AGD) is a limbic-predominant 4R-tauopathy. AGD is thought to be an age-related disorder and is frequently detected as a concomitant pathology with other neurodegenerative conditions. There is a paucity of data on the clinical phenotype of pure AGD. In elderly patients, however, AGD pathology frequently associates with cognitive decline, personality changes, urine incontinence and cachexia. In this study, clinicopathological findings were analysed in individuals younger than 75. Methods Patients were identified retrospectively based on neuropathological examinations during 2006-2017 and selected when AGD was the primary and dominant pathological finding. Clinical data were obtained retrospectively through medical records. Results In all, 55 patients (2% of all examinations performed during that period) with AGD were identified. In seven cases (13%) AGD was the primary neuropathological diagnosis without significant concomitant pathologies. Two patients were female, median age at the time of death was 64 years (range 51-74) and the median duration of disease was 3 months (range 0.5-36). The most frequent symptoms were progressive cognitive decline, urinary incontinence, seizures and psychiatric symptoms. Brain magnetic resonance imaging revealed mild temporal atrophy. Conclusions Argyrophilic grain disease is a rarely recognized limbic tauopathy in younger individuals. Widening the clinicopathological spectrum of tauopathies may allow identification of further patients who could benefit from tau-based therapeutic strategies.

Apomorphin ist ein hochpotenter, schnell wirksamer Dopaminagonist. Die Anwendung erfolgt entweder als intermittierende Injektion (z. B. mittels Apo-go Pen) oder als Apomorphin-Infusionstherapie. Der Apo-go Pen eignet sich durch seinen schnellen Wirkungseintritt von 4–12 min, die kurze Wirkdauer von ca. 45 min und durch die subkutane Applikation besonders fur Patienten mit therapierefraktaren Offs, insbesondere morgens bzw. nach den Mahlzeiten, und fur Patienten mit schmerzhaften Dystonien. Die ubliche Wirkdosis betragt 2–6 mg bei einer maximalen Tagesdosis von 100 mg/Tag. Periphere Nebenwirkungen wie Ubelkeit, orthostatische Hypotension und neuropsychiatrische Symptome sind oft dosislimitierend und erfordern eine individuelle Dosisfindung.

Creutzfeldt-Jakob disease (CJD) is a human prion disease with different etiologies. To determine the spectrum of tau pathologies in CJD, we assessed phospho-Tau (pTau) immunoreactivities in 75 sporadic CJD cases including an evaluation of the entorhinal cortex and six hippocampal subregions. Twelve cases (16%) showed only small tau-immunoreactive neuritic profiles. Fifty-two (69.3%) showed additional tau pathology in the medial temporal lobe compatible with primary age related tauopathy (PART). In 22/52 cases the lower pTau immunoreactivity load in the entorhinal cortex as compared to subiculum, dentate gyrus or CA4 region of the hippocampus was significantly different from the typical distribution of the Braak staging. A further 11 cases (14.7%) showed widespread tau pathologies compatible with features of primary tauopathies or the gray matter type of ageing-related tau astrogliopathy (ARTAG). Prominent gray matter ARTAG was also observed in two out of three additionally examined V203I genetic CJD cases. Analysis of cerebrospinal fluid revealed prominent increase of total tau protein in cases with widespread tau pathology, while pTau (T181) level was increased only in four. This correlated with immunohistochemical observations showing less pathology with anti-pTau T181 antibody when compared to anti-pTau S202/T205, T212/S214 and T231. The frequency of tau pathologies is not unusually high in sporadic CJD and does not precisely relate to PrP deposition. However, the pattern of hippocampal tau pathology often deviates from the stages of Braak. Currently applied examination of cerebrospinal fluid pTau (T181) level does not reliably reflect primary tauopathies, PART and ARTAG seen in CJD brains.

Disease-associated proteins are thought to propagate along neuronal processes in neurodegenerative diseases. To detect disease-associated prion protein (PrPSc ) in the vagus nerve in different forms and molecular subtypes of Creutzfeldt-Jakob disease (CJD), we applied 3 different anti-PrP antibodies. We screened the vagus nerve in 162 sporadic and 30 genetic CJD cases. Four of 31 VV-2 type sporadic CJD and 7 of 30 genetic CJD cases showed vagal PrPSc immunodeposits with distinct morphology. Thus, PrPSc in CJD affects the vagus nerve analogously to α-synuclein in Parkinson disease. The morphologically diverse deposition of PrPSc in genetic and sporadic CJD argues against uniform mechanisms of propagation of PrPSc . Ann Neurol 2019;85:782-787.

Cerebrospinal fluid (CSF) cytology, i.e., the cytologic evaluation of its cellular composition, forms an integral part of the neurologist's armamentarium. Total and differential cell counts provide important first information across a spectrum of pathologic conditions involving the central nervous system and its coverings. CSF samples require immediate processing, ideally within 1 hour from collection. Upon centrifugation cytology is commonly assessed on May-Grunwald-Giemsa stains. Several additional stains are available for the identification of infectious agents such as bacteria or fungi, or the further specification of neoplastic cells by immunocytochemistry. The evaluation warrants familiarity with cytologic characteristics of cells across normal and diseased states. In normal CSF, lymphocytes and monocytes are encountered. A predominance of neutrophil granulocytes suggests bacterial meningitis and prompts search for intracellular bacteria. In contrast, in viral and chronic infections lymphocytes and monocytes prevail. Upon activation lymphocytes typically enlarge and eventually differentiate into plasma cells. Similarly, monocytes differentiate into macrophages that clear cellular debris. Macrophages that contain fragments of erythrocytes or hemoglobin degradation products are referred to as erythro- or siderophages, both of which indicate prior subarachnoid hemorrhage. Likewise, the detection of tumor cells is specific for neoplastic meningitis, although false-negative CSF cytologies are frequent. In summary, detailed morphologic workup of CSF samples provides valuable diagnostic information and is mandated in all cases with elevated cell count, computed tomography-negative suspected subarachnoid hemorrhage, and neoplastic meningitis. In all cases it needs to be interpreted in the clinical context and complements other clinical and laboratory findings.

Cerebrospinal fluid (CSF) cytology, i.e., the cytologic evaluation of its cellular composition, forms an integral part of the neurologist's armamentarium. Total and differential cell counts provide important first information across a spectrum of pathologic conditions involving the central nervous system and its coverings. CSF samples require immediate processing, ideally within 1 hour from collection. Upon centrifugation cytology is commonly assessed on May-Grunwald-Giemsa stains. Several additional stains are available for the identification of infectious agents such as bacteria or fungi, or the further specification of neoplastic cells by immunocytochemistry. The evaluation warrants familiarity with cytologic characteristics of cells across normal and diseased states. In normal CSF, lymphocytes and monocytes are encountered. A predominance of neutrophil granulocytes suggests bacterial meningitis and prompts search for intracellular bacteria. In contrast, in viral and chronic infections lymphocytes and monocytes prevail. Upon activation lymphocytes typically enlarge and eventually differentiate into plasma cells. Similarly, monocytes differentiate into macrophages that clear cellular debris. Macrophages that contain fragments of erythrocytes or hemoglobin degradation products are referred to as erythro- or siderophages, both of which indicate prior subarachnoid hemorrhage. Likewise, the detection of tumor cells is specific for neoplastic meningitis, although false-negative CSF cytologies are frequent. In summary, detailed morphologic workup of CSF samples provides valuable diagnostic information and is mandated in all cases with elevated cell count, computed tomography-negative suspected subarachnoid hemorrhage, and neoplastic meningitis. In all cases it needs to be interpreted in the clinical context and complements other clinical and laboratory findings.

Background Spreading of misfolded proteins has been suggested for neurodegenerative diseases. The hierarchical distribution of protein deposits in Alzheimer's (AD) and Parkinson's disease (PD) supports this concept. Objectives To evaluate α-synuclein and tau-deposition in the optic pathway as an excellent anatomical model, which follows a strict trajectory including a cortico-geniculate feedback connection. Methods We immunostained the optic nerve, lateral geniculate nucleus (LGN), and occipital cortex for AT8 (phosphorylated tau), α-synuclein, and disease-associated prion protein (PrP) in 47 cases with tau pathology (AD type, argyrophilic grain disease, or progressive supranuclear palsy), 16 PD, and 5 Creutzfeldt-Jakob disease (CJD) cases, respectively. Results We detected immunoreactivity for all proteins along the optic pathway. The optic nerve showed immunopositivity only in cases with tau (6/8, 75%) or α-synuclein (5/7, 71%) pathology. The LGN was involved also frequently (tau: 22/47, 46.8% ; α-synuclein: 15/16, 93.7% ; PrP 5/5, 100%). The occipital cortex was variably affected by tau or α-synuclein pathology, but always showed PrP immunoreactivity in the CJD cases. Tau pathology in the LGN correlated with tau immunoreactivity in the occipital cortex and Braak stages of neurofibrillary degeneration. In tauopathies, which do not involve the occipital cortex, like argyrophilic grain disease or progressive supranuclear palsy, tau pathology was more frequently astrocytic in the LGN. Conclusions Our results have implications 1) for the understanding of disease spreading along neural pathways and 2) for the diagnostic evaluation of the visual system in neurodegenerative proteinopathies as a potential biomarker to evaluate disease progression or subgrouping of cases.

The spectrum of mixed brain pathologies expands beyond accompanying vascular pathology in brains with Alzheimer’s disease-related pathology. Co-occurrence of neurodegenerative non-Alzheimer’s disease-type proteinopathies is increasingly recognized to be a frequent event in the brains of symptomatic and asymptomatic patients, particularly in older people. Owing to the evolving concept of neurodegenerative diseases, clinical and neuropathological diagnostic criteria have changed during the last decades. Autopsy-based studies differ in the selection criteria and also in the applied staining methods used. The present review summarizes the prevalence of mixed brain pathologies reported in recent community-based studies. In these cohorts, irrespective of the clinical symptoms, the frequency of Alzheimer’s disease-related pathology is between 19 and 67%, of Lewy body pathology is between 6 and 39%, of vascular pathologies is between 28 and 70%, of TDP-43 proteinopathy is between 13 and 46%, of hippocampal sclerosis is between 3 and 13% and, finally, of mixed pathologies is between 10 and 74%. Some studies also mention tauopathies. White-matter pathologies are not discussed specifically in all studies, although these lesions may be present in more than 80% of the aging brains. In summary, community-based neuropathology studies have shown that complex constellations of underlying pathologies may lead to cognitive decline, and that the number of possible combinations increases in the aging brain. These observations have implications for the prediction of the prognosis, for the development of biomarkers or therapy targets, or for the stratification of patient cohorts for genome-wide studies or, eventually, for therapy trials.

Introduction: Syncope and palpitations as the only initial manifestations of myotonic dystrophy type 1 (MD1) due to a CTG expansion of 50–100 repeats have not been reported. Case report: In a 55-year-old female with a family history of MD1 and a personal history of a single syncope, palpitations, and hyperCKemia, 70 CTG repeats were detected in the DMPK gene. Her brother had presented atypical clinical, electromyographic, and muscle biopsy features since the age of 35 but had been diagnosed with MD1 after he later developed typical distal myotonia. He died suddenly during an episode of syncope at the age of 53. A sister with clinical myotonia died suddenly during sleep at the age of 45 and a second sister with quadriparesis died from complications of intestinal rupture at age 52. A third sister committed suicide at age 40 after developing recurrent syncopes, while a fourth sister had hyperCKemia and foot-extensor weakness. The mother of these five affected children died suddenly from myocardial rupture. Conclusions: MD1 with