PATH WONK

Interesting case - 1.29.2012

2012-01-29T16:53:00.000-08:00

Here's a case that I've been wanting to post for awhile, but I held out for some time, as I wanted to include the slide in the first annual "LLUMC Holiday Neuropathology Challenge" (Thanks to Dr. Jack Raisanen at UTSW for the inspiration!). Now that the competition is over, and the champions have been announced, I can go ahead and share the case.

This was an autopsy brain from a 8-year-old male who died from sequelae of congenital heart disease. At one point, a possible intracranial vascular malformation was suspected, so he underwent cerebral angiography, which was negative. His terminal course was characterized by circulatory collapse. Examination of the histologic sections from the midbrain disclosed the abnormality below...

The remainder of the brain parenchyma was free of inflammation, hypoxic/ischemic changes, etc...

This lesion is quite the "head scratcher". This is one of those "lesions" that is difficult to recognize for those who are uninitiated, but is quite characteristic (i.e. an "Aunt Minnie").

Click here for the diagnosis...

Interesting case - 12.27.2011

2011-12-27T20:42:00.000-08:00

Here's a consult case that came through recently. This patient was a 52-year-old male with a skull base mass anterior to the foramen magnum. Surgical resection yielded the following specimen...

This tumor carries a quite short differential diagnosis. Routine histology will get you 90% of the way... Immunohistochemical stains will "seal the deal". Prior to reading the case discussion, one should formulate your differential diagnosis and decide which immunostains that you would order...

Click here for the diagnosis...

Interesting case - 12.10.2011

2011-12-10T07:02:00.001-08:00

I am still amazed at the number of interesting and strange CNS tumors that I have encountered here at the new job. The hospital, while not especially large, is exceedingly busy, and serves as a major referral center for the inland and surrounding desert communities of Southern California. Even on general sign out days, it often seems that even "simple" cases present unique diagnostic challenges. Enough musing; on to the case...

This patient was a 13-year-old female who presented with progressively worsening headaches and difficulty concentrating at school. The results of subsequent neuroimaging are shown below...

Sagittal T1 Post

Sagittal T2

Coronal T2

Obviously, neurosurgery was consulted shortly thereafter. Intraoperatively, the tumor was found to be well-circumscribed, predominantly intraventricular, and firm. Selected photomicrographs below demonstrate the diagnostic histopathologic features...

H&E - low magnification

H&E - high magnification

No hints necessary. Special stains were performed, the results of which you will soon know.

Click here for the diagnosis...

Interesting case - 11.2.2011

2011-11-02T21:04:00.000-07:00

I apologize. It's been awhile since I posted an interesting case. I am fortunate that I see plenty of interesting cases. I've been saving them and adding them to my collection. The hard part is finding time to post them. It's odd how little time that there is left in the day after working. Enough excuses. Here's another case...

This patient was a 35-year-old female who presented with nonspecific complaints of headache and a single unwitnessed possible seizure. Her past medical history was noncontributory. An MRI demonstrated the following abnormality...

Coronal T2

Coronal T1 post-contrast

Sagittal T1 post-contrast

Neurosurgery was consulted; a stereotactic biopsy was undertaken shortly thereafter.

H&E

Your mission, should you choose to accept it, is to arrive at the correct diagnosis. If your computer is windows-based, it will self-destruct in 10,9,8,7... (<-- if you didn't get the joke, it's a satire of the old mission impossible TV show to poke fun of PCs...)

Bonus points for naming the eponymously-named cells which suggest the proper etiology.

Hint - remembering the entire radiologic differential diagnosis for ring-enhancing lesions in the CNS will significantly narrow the differential diagnosis.

Click here for the case discussion...

Sweet words...

2011-10-20T21:34:00.000-07:00

The following words from the ABP endow me with the full powers of a neuropathologist...

I'm glad it's over with. It already seems like it was eons ago. Now I can relax for ten years or so...

Neuropath boards are over!!!

2011-09-09T14:56:00.000-07:00

I just finished taking the neuropathology boards in Tampa, Florida. That was an interesting experience. In a sense, I do think that it is an adequate test for licensure purposes... It proves that if one can make esoteric diagnoses on a single low-power, low-resolution, barely-representative image in the complete absence of relavent clinical details, one can easily make an adequate diagnosis on a well-stained actual glass slide using a real microscope...

Glad it's over! Hope I don't have to do it again too soon...

Interesting case - 9.3.2011

2011-09-04T08:38:00.000-07:00

Here's another case that came through the UTSW neuropathology service, kindly provided by Dr. Mathis...

This patient was a 17-year-old female with a long seizure history. An EEG demonstrated an epileptogenic focus in the region of the left temporal lobe, which corresponded to a non-enhancing mass in the lateral aspect of the left temporal lobe (unfortunately imaging unavailable). Surgical resection yielded the following pathology specimen...

H&E; low power

H&E; intermediate power

H&E; high power

GFAP immunostain

Synaptophysin immunostain

CD31 immunostain

Epithelial membrane antigen (EMA) immunostain

No good hints here. Key elements in the history and recognition of the unique growth pattern are key to the diagnosis in this case...

Click here for the diagnosis...

Interesting case - 8.7.2011

2011-08-07T20:45:00.000-07:00

This is another case provided by my former neuropathology co-fellow, now colleague Derek Mathis M.D.

This was an 18-year-old female who was found to have mass in foramen magnum, impinging on the cervicomedullary junction. Neurosurgical intervention followed shortly.

Sagittal T1

Sagittal T1, post-gadolinium

H&E, intermediate magnification

H&E, high magnification

Mystery immunostain

It's not a difficult diagnosis to make. The diagnosis hinges upon recognizing a focal yet interesting feature of the neoplastic cells, and remembering why the "mystery immunostain"would use a red chromogen.

Click here for the diagnosis

Interesting case - 7.28.2011

2011-07-27T20:51:00.000-07:00

For numerous reasons, it's been awhile since I posted a case... Here's a case that I had when I was a first year path resident. It's near and dear to my heart, so I held on to it for awhile.

This patient was a 46-year-old female with a several month history of rapidly-progressive cognitive decline. Neuroimaging demonstrated numerous foci of white-matter T2 and FLAIR signal abnormalities scattered throughout the cerebral hemispheres; gadolinium administration revealed numerous, ill-defined small foci of contrast enhancement. The antemortem clinical differential diagnosis included nearly all known causes of human disease, including infection, ADEM, AHLE, metastatic carcinoma (remote history of breast carcinoma). Despite aggressive clinical interventions, the patient expired after a several-week stay in the hospital.

Sectioning of the brain demonstrated (sadly, images not available) irregular, ill-defined areas of softening and hemorrhage in the hemispheric white matter. In areas, the gray-white junction was effaced.

Low power (H&E); frontal lobe

Low power (LFB); frontal lobe, white matter

High power (H&E); frontal lobe

High power (H&E); frontal lobe, neocortex

High power (H&E); high power, frontal lobe leptomeninges

No hints needed here. This case qualifies as an "Aunt Minnie". If you've seen it before, the diagnosis is unquestionable. If not, good luck...

Click here for the diagnosis...

Interesting case - 7.1.2011

2011-07-01T09:45:00.000-07:00

Unfortunately, all vacations must come to an end. The AANP meeting in Seattle went quite well, and did a good job of highlighting the potential diagnostic pitfalls of muscle biopsies (i.e. scared a lot of people). It was really nice to get back home though. I just finished "checking out" at UT Southwestern, so I am no longer employed by UT Southwestern. Next up, I start my new job in Southern California on Tuesday. And so the adventure continues...

On to the case. I've been holding on to this case for quite awhile, as I didn't want to spoil the presentation of the case at the AANP diagnostic slide session. Now that is over, I can share what I thought was a fantastic case. This patient was an adolescent female with an 11-year history of tremor, gait instability, dysarthria, tongue fasiculations, and temperature instability. The immediate preterminal period was characterized by disabling dyskinesias, choking and aspiration, and progressive cognitive decline.

Gross brain; vertex

Coronal section, level of nucleus accumbens

Cross sections, brain stem and cerebellum

Substantia nigra, low-power; H&E

Subthalamic nucleus; H&E

Anterior horn, spinal cord; H&E

Cerebellar cortex; H&E

Substantia nigra; H&E

This is a classic "Aunt Minnie" diagnosis. If you've seen if before, the diagnosis is not difficult. If not, head scratching and shuffling pages ensues... Never fear, helpful immunostains will be provided!

Click here for the diagnosis...

On vacation...

2011-06-19T20:18:00.000-07:00

Just so you know, I'm not slacking off. I took my family on a last hurrah before starting work... We're taking the long route (i.e. Pacific Coast Highway) up to the AANP meeting in Seattle. I'll pick back up when I get back...

Interesting case - 5.26.2011

2011-05-26T09:00:00.000-07:00

Continuing the theme, here is another contribution by my co-fellow, Derek Mathis, MD. It's an interesting case that is not normally considered to fall under the umbrella of neuropathology per se, but it can involve structures that are near and dear to the brain (and rarely the brain parenchyma itself).

This is my last month of my neuropathology fellowship at UTSW. I saved up all of my vacation for the last year, and am taking my family on a road trip to see the West coast and Canadian Rockies for nearly all of June. I'll be bringing my wife and kids to the AANP meeting in Seattle. Afterwards, I'll be joining the Pathology faculty at Loma Linda University (my alma mater) in beautiful Southern California (Yay!!). Needless to say, I won't be posting from our campsites; I'll wait until I'm settled in before resuming. Hope to see some of you in Seattle!

Here's the case... A 29-year-old male presented to his primary care physician complaining of headache and a mass on his left forehead. Neuroimaging was followed by neurosurgical intervention...

Sagittal T1

Coronal T1 post-gadolinium

H&E; low-magnification

H&E; medium-magnification

H&E; high-magnification

There are immunostains on this case that you'll get to see. First, you should formulate your differential diagnosis and determine what panel of immunostains you would order...

Click here for the diagnosis...

Interesting case - 5.14.2011

2011-05-14T19:02:00.000-07:00

This case is courtesy of my co-fellow, Derek Mathis, M.D. Derek is an Air Force pathologist who decided to take a few years off his real job and join us in the riveting world of neuropathology. Derek's been a great guy to share an office with. He has introduced me to the world of high finance, and is trying to convince me to take my money out of my mattress. I'm trying to introduce him to the world of liberal politics. It's not going so well... On to the case...

This patient was a 14-year-old female with a heterogenous mass with scant irregular enhancement involving the left cerebellar hemisphere.

Axial T1 post-contrast

Hematoxylin and eosin

Synaptophysin immunostain

Microtubular associated protein 2 (MAP2) immunostain

There's no getting around it; this case is a real doozy. The location, histologic appearance, and immunoprofile are classic. That being said, as one of my fellows taught me during my first year of training, everything is "classic" for something. One thing that may help is that this tumor combines histologic and immunophenotypic characteristics from several other neoplasms, both supratentorial and infratentorial. And, remember that in the CNS, MAP2 serves as a marker of neural differentiation, among other uses.

Click here for the diagnosis...

Interesting case - 5.1.2011

2011-05-01T08:42:00.000-07:00

It's been awhile since my last post. I'm going to pull the "I'm really quite busy right now" excuse on this one. My family and I are getting ready for a fast-approaching move to California (i.e. packing, selling house, applying for licenses, etc), where I finally am going to start work in earnest. It's amazing how much of one's life is dedicated to just getting to this point.

This is a case from our neuropathology consultation service... The patient was a 92-year-old male with a long history of various "psychologic disturbances". While cognitive decline was noted, behavioral abnormalities dominated the clinical picture. He was eventually admitted to a psychiatric facility by his family, where his neuropsychiatric function relentlessly progressed. He died 18 years after his initial (psychiatric) diagnosis.

Gross brain; lateral

Gross brain; medial

Gross brain; anterior aspect of superior temporal gyrus

Gross brain; coronal frontal and temporal lobe sections

H&E; dentate gyrus

H&E; temporal lobe neocortex

H&E; cornu Ammonis

Phosphotau (AT8); dentate gyrus

3R tau; dentate gyrus

4R tau; dentate gyrus

Thioflavine S; dentate gyrus

There are a couple of key points to notice; the severe involvement of some gyri, with the sparing of adjacent gyri, and the "lobar" pattern of involvement is characteristic. The histology is also "classic". One can make a definitive diagnosis on one slide; the key is knowing which one.

Click here for the diagnosis...

Interesting case - 4.14.2011

2011-04-14T07:11:00.000-07:00

This patient was a 47-year-old female with a several month history of a presumed demyelinating disorder. She was brought to the emergency department with fever, generalized weakness, and acute mental status decline. Neuroimaging obtained at the acute presentation showed significant signal abnormalities (see below); not pictured are images of the spine, which revealed extensive, confluent FLAIR signal abnormality in the spinal cord. Her condition deteriorated over the next few days despite aggressive medical intervention.

Axial T2 FLAIR

Autopsy brain, midsagittal section

Coronal section at level of thalamus

Axial sections of brain stem

LFB/PAS/H (Myelin = blue), internal capsule

H&E, internal capsule

LFB/PAS/H, internal capsule

LFB/PAS/H, optic nerve

LFB/PAS/H, dorsolateral spinal cord

LFB/PAS/H, ventral spinal cord

H&E, dorsolateral spinal cord

The etiologic categorization in this case is not difficult. Giving it a precise name may be, as the presentation, distribution of the lesions, and histologic features are unique to a specific entity. Pay particular attention to the areas most severly affected, with the caveat that one of the areas of involvement may represent a so-called "red herring".

Click here for the diagnosis...

Interesting case - 4.6.2011

2011-04-06T12:21:00.000-07:00

Here is another case that belongs to the "look at it now, because you're never going to see it again" category. A bonus is the fact that this is a textbook case of what it is...

This patient was a 19-year-old female with progressive cognitive decline, blindness, and muscle weakness following an apparently normal childhood. Several "cerebral infarcts" were documented in the last few years.

Axial T2

Brain, external (lateral)

Brain, external (dorsal)

Brain, coronal (level of thalamus)

Brain, coronal (occipital lobes)

Brain, H&E, crest of gyrus, occipital lobe

Brain, H&E, depth of sulcus, occipital lobe

Brain, H&E, cavitary lesions in crest of gyrus

Brain, H&E, adjacent to cavitary lesion

Quadriceps femoris, H&E, cryostat

Quadriceps femoris, Gomori trichrome, cryostat

Quadriceps femoris, succinate dehydrogenase (SDH), cryostat

Quadriceps femoris, COX/SDH combo, cryostat

Quadriceps femoris, oil red O (ORO), cryostat

Quadriceps femoris, electron microscopy

This case is particularly challenging on a few levels. First, proper work-up of this case required utilization of techniques unfamiliar to many pathologists, namely enzyme histochemistry on frozen muscle and ultrastructural examination. Secondly, to arrive at the correct diagnosis, the clinical presentation, as well as the findings in the brain and skeletal muscle, must be considered. Nonetheless, it is a great case with classic pathologic features...

As far a guidance, I would emphasize paying particular attention to the distribution of the lesions in the cerebral parenchyma. The muscle biopsy speaks for itself, but only if you are familiar with the function of the particular stains. Electron microscopy was interesting, but I wouldn't spend too much time pontificating on the particulars...

Click here for the diagnosis...

Interesting case - 3.28.2011

2011-03-28T11:04:00.000-07:00

Here's a case that my friend from medical school sent me, to whom I am exceedingly grateful. This one qualifies as a "look at it now, cause you're never going to see it again" category.

The patient was a 5-month old female with a 6 cm well-circumscribed, irregularly-pigmented mass in the anterior aspect of the right mandible.

There really aren't any good hints here. As is the case in every challenging pathologic diagnosis, the key to the diagnosis is gleaning the appropriate information from the clinical, gross, and microscopic examination; immunohistochemistry functions to confirm or reject the initial impression.

Click here for the diagnosis...

Interesting case - 3.23.2011

2011-03-23T19:03:00.000-07:00

In this case, if one tries really hard, one could combine elements of the clinical history and gross appearance of the lesion and arrive at the correct diagnosis without the assistance of histopathology. This patient was a 52-year-old woman with a history of a solid organ transplant two years prior. Presented with fulminant respiratory failure and subsequent multi-organ dysfunction. Aside from examination of the CNS, examination of the lung sections was most helpful.

Ok, now you've arrived at your preliminary diagnosis. What stain would you order to highlight the features of interest?

Also, If you picked up on the "not quite so obvious" diagnosis in the gross images, good for you. If not, you may want to give it one more try prior to proceeding to the diagnosis...

Click here for the diagnosis...

Interesting case - 3.11.2011

2011-03-11T14:03:00.000-08:00

This case is not nearly as esoteric as those shown recently. Consider it a "breather".

This patient was a 32-year-old male who presented with headaches of increasing severity. Neuroimaging prompted neurosurgical intervention, who in turn summoned neuropathology from the bowels of the hospital.

Axial FLAIR

Axial T1 post-gadolinium

H&E

CAM 5.2

CEA

Hint: this is an exercise in subtyping intracranial neoplasia.

Click here for the diagnosis

Interesting case - 3.7.2011

2011-03-07T07:22:00.000-08:00

Here's a case that belongs in the "only see it once" category of neuropathologic diagnoses. It's probably not the most efficient use of your neocortex, but it is interesting nonetheless.

The patient was a 15-year-old male with progressive cognitive decline and Parkinsonism. Pertinently, he had a vague history of several family members who died of a similar, yet undiagnosed neurologic condition.

Globus pallidus

Substantia nigra

Iron stain, globus pallidus

The key to the diagnosis in this case is in the gross appearance of paired deep structures, and obviously the microscopic appearance.

Click here for the diagnosis...

Interesting case - 3.1.2011

2011-03-01T17:00:00.000-08:00

Here is a case that gets the point across without needing histology.

The decedent was a 52-year-old alcoholic female who fell unwitnessed while inebriated. Complaining of a severe headache, she went to bed to "sleep it off". She was found unresponsive in bed the next morning. Autopsy revealed a large right-sided subdural hemorrhage.

No hints are needed for this case. Here are a couple of questions to consider prior to proceeding to the case diagnosis...

1) The history already disclosed the presence of a subdural hemorrhage. Without having the clinical history or dura to examine, how would one determine the relative age of the subdural hemorrhage based solely on the appearance of the brain?

2) What are the significant gross findings demonstrated in the photographs, and what is their pathogenesis and/or clinical significance? Note that several eponyms will be invoked.

Click here for the diagnosis...

Interesting case - 2.24.2011

2011-02-24T19:04:00.000-08:00

Here is a case from our archives, from a brain cutting many moons ago (one of the first really cool cases for me as a neuropathology fellow). Hope you enjoy!

This was a 48-year-old epileptic female who suddenly coded during a routine surgical procedure. The patient was followed routinely for what some would consider "significant" cutaneous lesions.

Hint: The radiolographic appearance, as well as a clue in clinical history, is highly characteristic of this condition.

Click here for the diagnosis...

Interesting case - 2.11.2011

2011-02-11T17:47:00.000-08:00

Now that everything is thawing out here in Texas, it's time to bring out another case. This was a fascinating example of an entity rarely seen outside of textbooks and study sets that came through our hospital braincutting recently.

The patient was an 18-month-old male with a history of progressive lethargy, developmental delay, and hypotonia. In the later stages, the clinical picture was dominated by hypothermia, seizuress and bulbar dysfunction.

Coronal T2

Axial T2 FLAIR

Putamen- Low Power

Putamen- High Power

Medial thalamus

Substantia nigra

Superior colliculus

Periaqueductal gray

Pontine tegmentum

Here's a hint: the distribution of the lesions, as well as the sparing of a subset of cells within the areas of parenchymal damage are characteristic of this rare entity.

Click here for the diagnosis...

Interesting case - 2.7.2011

2011-02-07T10:45:00.000-08:00

This case came through our hospital brain cutting service some months ago. The patient was a 15-year-old boy who presented to the hospital with nonspecific complaints, including headache. His clinical condition subsequently declined precipitously.

Don't forget to look for all of the significant gross findings...

Click here for the diagnosis...

Interesting case - 1.31.2011

2011-01-31T13:25:00.000-08:00

This case hails from the land of pediatric neuropathology.

This patient was a 7-year-old male with a history of a resection of a "low-grade glioma, NOS" 6 years prior. Subsequently monitored with periodic MRI, where he was noted to have multiple, slowly-growing enhancing nodules in the surgical resection cavity, prompting a neurosurgical encounter...

Don't let the heterogenous nature of the material confuse you. There is one diagnosis which explains the pleomorphic histopathologic features...

Click here for the diagnosis...

Interesting case - 1.26.2011

2011-01-26T09:03:00.000-08:00

Here is a case which came through our service last week. Here's a hint... This case violates one of the cardinal rules that we are taught as pathology residents...

This patient was a 44-year-old male who presented with large lump on his scalp. Additional clinical history included a resection of a skin tumor approximately two years ago. An MRI demonstrated the following lesion.

Axial T2

Axial FLAIR

Axial T1 post-gadolinium

He subsequently underwent neurosurgical intervention...

Click here for the diagnosis.

Interesting case - 1.20.2011

2011-01-20T10:48:00.000-08:00

This case illustrates a diagnosis that we don't see very often on the muscle biopsy service.

This patient was a 78-year-old male with a three-year history of progressive upper and lower extremity weakness. On statin for hyperlipidemia. The clinical impression was either an inflammatory or toxic myopathy.

H&E, cryostat

Gomori trichrome, cryostat

Crystal violet, cryostat

Texas red filter, fluorescent microscopy

Click here for the diagnosis...

Interesting case- 1.16.2011

2011-01-16T07:08:00.000-08:00

In this case, the macroscopic appearance is sufficient to make the correct diagnosis... That's a good thing, as I can post this case from home (I'm off work until Tuesday for MLK day)...

This was a 23-year-old female who died suddenly and unexpectedly in her sleep. Aside from a seizure disorder, her provided medical history was unremarkable...

Click here for the diagnosis...

Interesting case - 1.11.2011

2011-01-11T10:48:00.000-08:00

Here are some images from a recent braincutting...

Can you name the gross finding? What information can you infer about the findings in the brain from the appearance of the skull?

Thanks to Theresa Kinard, M.D. for providing the excellent photographs and bringing the case for consultation.

Click here for the diagnosis...

Interesting case - 1.10.2011

2011-01-10T12:27:00.000-08:00

Here's a real head-scratcher of a case... If I were assign cases to a category, this one belongs in the category of "obfuscated clinical histories". Once again, this one is a good case to pause and consider your differential diagnosis at each step...

62-year-old male who presented with a rapidly evolving decline in mental status. Neuroimaging revealed a significant abnormality, which prompted a neurosurgical biopsy. Pertinent clinical history available at the time of biopsy included a marked peripheral eosinophilia, multiple abdominal lesions, and retroperitoneal lymphadenopathy. Prior surgical biopsies and fine needle aspirations, including flow cytometry, had all been nondiagnostic. Multiple services were consulted, including infectious disease, as the patient had a recent travel history to South America. There was a high suspicion for a parasitic infection, and the patient received both antibiotic therapy and systemic corticosteroids...

AXIAL T2 FLAIR

CORONAL T1 POSTCONTRAST

SAGITTAL T1 FLAIR

FROZEN SECTION

****

PAUSE!!!!

****

The intraoperative frozen section consisted primarily of necrotic debris and an inflammatory infiltrate heavily enriched in eosinophils... Several rounded structures with a thick, brightly-eosinophilic periphery were noted. Could these be degenerating parasites? If not, how do you explain their presence?

****

Below are images from the permanent sections...

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PERMANENT SECTION

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The following H&E demonstrates the sole small focus of atypical cells in a biopsy consisting of multiple blocks as part of multiple specimens... Following are a set of immunostains which should help you to arrive at the correct diagnosis... This would be another good time to contemplate your pathologic differential diagnosis, and consider which immunostains you would order to confirm the diagnosis...

****

PERMANENT SECTION

CAM5.2

LCA (CD45)

L26 (CD20)

CD3

KI-1 (CD30)

MIB1

ALK1

Click here for the diagnosis...

Food For Thought...

2011-01-04T19:45:00.000-08:00

In regards to the last interesting case (January 4, 2011), Professor Mark Cohen, M.D., at the Case Western Reserve University brought the following article to my attention...

http://www.ncbi.nlm.nih.gov/pubmed/20034093

If you can download the article and take the time to read it, it raises some fascinating points as to the pathogenesis of the particular entity (and it's only two pages!).

Interesting case - 1.4.2011

2011-01-04T12:57:00.000-08:00

Happy New Year to one and all! Much thanks for Jeong Han, M.D., Ph.D. for bringing us this interesting case...

This patient was a 6-month male who was noted to have several facial dysmorphisms, including right microphthalmia, asymmetric nares, and a nevus below the right eye. An MRI demonstrated the following abnormality, which initiated a subsequent neurosurgical intervention...

Hint: The histologic findings are quite subtle. It may help to know that the radiologists nailed the diagnosis, as the appearance on neuroimaging is classic.

Click here for the diagnosis...

Interesting case - 12.31.2010

2010-12-31T17:15:00.000-08:00

Here is the last case of 2010. Enjoy, and have a happy new year!

76-year-old man with a brain mass...

****

PAUSE!!!

The following immunostain is highly suggestive of the diagnosis. This would be a good place to consider the pathologic differential diagnoses, and consider which immunostains one would order to confirm the diagnosis...

Proceed when ready...

****

CK20

Click here for the diagnosis...

Courville Neuropathology Museum

2010-12-28T12:24:00.000-08:00

I recently visited my alma mater, Loma Linda University School of Medicine (LLUSM). I was talking with their neuropathologist, Ravi Raghavan, M.D., who told me that there was an amazing collection of neuropathology specimens housed in the basement of the basic science building. It was an amazing discovery!

The collection was amassed by Cyril Brian Courville, M.D. (1900-1968), a neurologist, neurosurgeon, and neuropathologist, who was the chairman of the Loma Linda University Department of Nervous Diseases, as it was known at the time. Through the years, Dr. Courville worked with both Dr. Harvey Cushing and Santiago Ramon y Cajal. Aside from collecting interesting neuropathology specimens, he published hundreds of scientific articles, wrote eighteen books; he also collected weapons, armor, and skulls demonstrating injury in combat.

Dr. Courville's collection of neuropathology specimens, housed in the Neuropathology Museum in the basement of the LLUSM basic science building, comprises approximately 60,000 specimens, including whole brains, sectioned brains, spinal cords, skulls, kodachromes, and microscope slides. The brains are organized by age and type of injury (i.e. trauma, vascular, neoplastic, metabolic, infectious, developmental, etc). Most of the specimens are mounted in plexiglass containers and are labeled with the corresponding diagnosis. It's a great treasure trove of macroscopic neuropathology, as many of the diagnoses are rarely seen by the modern practitioner outside of pathology textbooks. If anyone with an interest in neuropathology were to find oneself in the southern California region, it would definitely worth the effort to find this hidden gem. And, best of all, the admission is free!

Cyril Brian Courville, M.D. (1900-1968)

Interesting case - 12.23.2010

2010-12-23T07:58:00.000-08:00

This case was a recent neurosurgical biopsy specimen read by Dr. Hatanpaa. The histology and neuroimaging are exquisite (and high yield for the boards)!

41-year-old male with progressively severe headaches.

Click here for diagnosis

Interesting case - 12.20.2010

2010-12-20T12:17:00.000-08:00

Here's an interesting case from brain cutting a few weeks ago... Much thanks to Mihail Firan M.D. for bringing us such an interesting case...

35-year-old female with diagnosis of HIV/AIDS and dementia, who presented with altered mental status, hypothermia, and seizures. A CT scan demonstrated cerebral edema and hydrocephalus. Grossly, the brain showed cerebral edema and slight opacification of the leptomeninges.

Ventral

Dorsal

Medial Temporal Lobe

Medial Temporal Lobe: medium power

Medial Temporal Lobe: high power

GMS

PAS

Mucicarmine

Click here for diagnosis...

Interesting case - 11.30.2010

2010-11-30T12:39:00.000-08:00

This is quite possible one of the best examples of what this is that most will see. I was fortunate enough to be on service when the case came through, courtesy of Dr. Michael Arnold, M.D., Ph.D.

11-year-old female with a 7-year history of slowly progressive motor and sensory deficits. The diagnosis was made solely on the radiologic appearance, and treatment was undertaken.

Click here for diagnosis