Takeda Shigeki, Onda Kiyoshi, Yoshida Yuichi
Department of Pathology, Niigata Neurosurgical Hospital, Niigata, Japan.
Department of Neurosurgery, Niigata Neurosurgical Hospital, Niigata, Japan.
Neuropathology. 2018 Jun 6. doi: 10.1111/neup.12476.
Neuropathological examinations of the brain in cases of brain death are usually insufficient because of autolysis. We examined a case of sporadic-type cerebral amyloid angiopathy-related hemorrhage (sCAA-H) in a 74-year-old Japanese woman who had been clinically established as brain dead 7 days before cardiac arrest. The brain was macerated, and a huge hematoma was evident in the right parieto-occipital region. Ordinary neuropathological examination was unable to clarify where the hematoma was located in the brain parenchyma or the subarachnoid space (SAS). Immunohistochemistry for amyloid-β (Aβ) and synaptophysin revealed that: (i) the hematoma affected the cerebral sulcus, cerebral cortex (CC) and subcortical white matter; (ii) the CC was destroyed at the depth of the cerebral sulcus; (iii) in three 6-μm-thick sections, ruptured Aβ-positive vessels were seen only in the intrasulcal hematoma and not in the CC or intracerebral hematoma; and (iv) in the CC adjacent to the intrasulcal hematoma, a few macrophages were observed, indicating a fresh infarct of the CC. These findings indicate that sCAA-H occurred first in the cerebral sulcus due to rupture of multiple meningeal vessels, as had been documented in our previous reports. The present study shows that even in an autolytic dead brain, immunohistochemistry is more useful than ordinary staining methods. Other than double-barreled vessels, several vascular changes such as fibrinoid degeneration, segmental dilatation (so-called micro-aneurysmal dilatation), and hyalinous onion-like change of the intima were seen in the intrasulcal hematoma, SAS and CC. Interestingly these vascular changes were not observed in the ruptured Aβ-positive vessels. More detailed studies will be needed to examine the correlation between these vascular changes and vessel rupture.
由于自溶作用，脑死亡病例的脑部神经病理学检查通常并不充分。我们检查了一名74岁日本女性的散发性脑淀粉样血管病相关性出血（sCAA-H）病例，该患者在心脏骤停前7天临床诊断为脑死亡。脑部已浸软，右侧顶枕区可见巨大血肿。普通神经病理学检查无法明确血肿位于脑实质还是蛛网膜下腔（SAS）。淀粉样β蛋白（Aβ）和突触素的免疫组织化学显示：（i）血肿累及脑沟、大脑皮质（CC）和皮质下白质；（ii）脑沟深处的CC被破坏；（iii）在三个6μm厚的切片中，仅在脑沟内血肿中可见破裂的Aβ阳性血管，而在CC或脑内血肿中未见；（iv）在与脑沟内血肿相邻的CC中，观察到少量巨噬细胞，提示CC有新鲜梗死。这些发现表明，如我们之前报告所述，sCAA-H首先因多条脑膜血管破裂发生于脑沟。本研究表明，即使在自溶的死亡大脑中，免疫组织化学也比普通染色方法更有用。除双管血管外，在脑沟内血肿、SAS和CC中还可见到其他血管变化，如纤维蛋白样变性、节段性扩张（所谓的微动脉瘤样扩张）和内膜透明样洋葱样改变。有趣的是，在破裂的Aβ阳性血管中未观察到这些血管变化。需要更详细的研究来检查这些血管变化与血管破裂之间的相关性。
