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This model elucidates the magnitude of entorhinal verrucae in normal controls and AD and relates their size to disease severity.


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  4. Introduction.

These results demonstrate a significant correlation between entorhinal verrucae size and AD pathology and points to a specific morphological marker in normal controls and mild AD. Most of the neocortical and cingulate samples were obtained from the same control cases as medial temporal samples. We further describe demographic and diagnosis information in Table 1.

Demographic and diagnostic information for the cases studied. All cases have verrucae rating assessment and number sign denotes cases that have additional quantitative verrucae measurements. Images were collected on a 7. Images were acquired with flip angles 10, 20 and 30 degrees and three FLASH images were averaged to generate a mean for each flip angle.

Three-dimensional isosurfaces of the entorhinal cortex were reconstructed from the MR volume with two different software packages to test reliability of our method. Although the visualization tools in Freeview and Amira implement different volume rendering schemes, both produced satisfactory isosurfaces.

For convenience with our Linux based MRI volumes, we used Freeview for all measurements in this report.

Rhanni N. Herzfeld, M.D.

Throughout this report, we use the terms isosurface and surface interchangeably. We selected verrucae that were measured using a systematic random sampling method. Each individual box or square was 2. Each surface reconstruction was zoomed so that the total grid 30 squares covered the entorhinal surface at approximately the level of the amygdala where the grid was overlaid with the top aligned at the medial border of EC nearly parallel with the hippocampal fissure in every case.

Visibly identifiable verrucae were labeled within each randomly selected grid square i. We used a random number generator to determine which ten counting squares to label per case. Each case required approximately thirty minutes for manual labeling. Height measurements were determined as the maximum perpendicular distance from the fitted plane at the base of the verruca to the isosurface see schemata in Figure 3d. Width was determined as the maximum diameter of the label and surface area was calculated as the sum of labeled triangles.

Volume measures the space above the base fitting plane and was computed as the sum volumes of the polyhedra obtained by projecting each of the surface triangles onto the base fitting plane. We obtained very slight differences in verrucae measurements between Amira and Freeview and attribute this variation to the different tessellation algorithms employed by each software package.

These differences were not significant when compared using an independent samples t-test. Gross brain showing anterior parahippocampal gyrus a corresponds to 3D isosurface reconstruction from ex vivo MRI b in same case.

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Both the gross specimen and MRI reconstruction show entorhinal verrucae labeled in blue in c on the surface of the entorhinal cortex. Schemata of single verruca d shows label and algorithm metrics used to derive verrucae measurements.


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  • Verrucae surface reconstructions were validated with photography of gross brains and a qualitative verrucae rating scale was developed for reliability. The qualitative rating protocol was created to assess verrucae magnitude in graded categories.

    Nigel Laing – Research Output — the UWA Profiles and Research Repository

    Examples illustrate each rating category through gross photographs Figure 1. Five qualitative categories demonstrate verrucae ratings in photographs. A drawing to outline medial temporal surface anatomy in a. Short dotted line in a represents tentorial notch. All cases were stained with Nissl thionin for healthy cell bodies and thioflavine S to assess the presence of neurofibrillary tangles and senile plaques.

    Nissl staining was performed as previously published [ 4 ] and thioflavine S was performed according to Van Hoesen [ 55 ]. Briefly, Nissl stains were pretreated and defatted. Subsequently, the sections were stained with 0. Slides were dehydrated in ascending ethanol series, cleared in xylene and coverslipped with Permount Fisher, Fair Lawn, NJ. Thioflavine S sections were defatted and stained in 0. Louis MO and coverslipped with water soluble mounting media. Braak and Braak staging determined the severity of neurofibrillary tangles in distinct and cumulative cortices. Briefly, each stage is summarized, stage I represents neurofibrillary tangles in perirhinal cortex layer II-III , stage II displays neurofibrillary tangles in entorhinal cortex layer II , stage III adds entorhinal layer IV and CA1, stage V includes all hippocampal CA fields and subiculum and finally stage VI occurs when neocortical areas and dentate gyrus contain neurofibrillary tangles [ 10 ].

    Mann Whitney U was used to compare other cortical surfaces to entorhinal cortex. Mann Whitney U was also used to compare verrucae rating with gender, and to compare quantitative and qualitative verrucae measures between control and AD cases. From ex vivo MRI volumes of medial temporal lobe samples, we created surface reconstructions and found that entorhinal islands layer II colocalized with surface verrucae labeled in blue in all cases that showed visible islands and verrucae i. Each 2D image is shown with a partial surface reconstruction in coronal, sagittal and axial planes Fig.

    Islands were observed as spherical intensities in all views Fig. These data confirm the spatial relationship between entorhinal islands in layer II and surface elevations and adds a 3D modularity. Entorhinal cortex surface reconstructions with labeled verrucae blue shown with corresponding coronal a , sagittal b , and axial c MR images of medial temporal lobe.

    Note that that entorhinal islands bright spots on the MRI colocalize with labeled entorhinal verrucae blue on the surface. In fact, we found that the surface reconstruction improved detection of verrucae. We observed that the surface reconstructions yielded better visualization because the reconstruction improved shadowing that highlighted individual verruca and we had the ability to manually rotate the surface to illuminate all angles while evaluation with the gross photographs required more than one photo. A cognitively normal brain with entorhinal verrucae is illustrated in Figure 3 to show the pipeline of our model.

    We labeled all individual verrucae on the entorhinal surface to show the extent of verrucae in a cognitively normal case Fig. Blue labels highlight individual verruca where entorhinal verrucae were primarily observed at the level of the amygdala and hippocampal head and to a lesser extent at posterior levels. We developed code to quantitatively evaluate the size of an individual verruca. An individual verruca schemata is shown in Fig.

    The blue label in Fig. To further characterize the entorhinal verrucae, we labeled randomly selected verrucae in each case. In sum, the reconstructed verrucae resembled those visually observed in the gross brain and verrucae quantitative measures showed a significant change in mild AD compared to controls. To corroborate our measurement model, we imaged eight additional sample blocks from various other cortices and modalities such as, cingulate, frontal, occipital, parietal, temporal and motor.

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    Since visible verrucae were not present in neocortical samples, we modeled our labels after the approximate width of our EC verrucae data to reproduce similar sized patches. We reconstructed the surfaces and randomly selected labels using the same methods as above and we found that these cortical surfaces were significantly different from entorhinal cortex in height. All heights were constrained to positive numbers and we restricted our samples and measurements to gyri i. Thus, entorhinal surfaces show significant differences from other neocortical tissue and demonstrate a more rugged topography compared to other cortical areas.

    Mean entorhinal verrucae height measures from six control cases 0. These cortical regions were measured as a control surface and all heights measured less than 0. Error bars represent standard error. As a supplement to quantitative verrucae measurements, we also developed a qualitative rating scale for reliability and to avoid scanning all cases in Fomblin liquid. Fomblin is a proton free liquid used to minimize background effects and helped to generate a clean isosurface. The rating scale described in methods ranges from where rating 1 denotes a flat surface and 5 indicates several large verrucae.

    Validation of the qualitative verrucae ratings with quantitative verrucae measures provides evidence of the accuracy of our entorhinal verrucae measurements. We examined qualitative verrucae ratings with an inter-rater reliability test to evaluate the strength of our ratings.

    Two raters evaluated verrucae size on gross photographs and assigned a rating within on verrucae size protocol. The raters utilized and referred to the same verrucae rating protocol described in the methods. Next, we compared photographs and surface reconstructions in normal control Fig. We rated verrucae based on qualitative protocol and tested the verrucae ratings against pathological diagnosis. We confirmed that the MRI reconstructions represented the verrucae precisely and provided validation for the gross or photographic surfaces. Our rating results corroborate our quantitative measurements described above where we quantified verrucae size in a subset of cases.

    Gross brain specimen shows entorhinal cortex surface in a control case a , validated with the ex vivo MRI surface reconstruction in b. With a significant difference in quantitative verrucae measures between controls and mild AD samples, we next examined the pathological marker in AD. To assess pathological diagnosis, we stained for neurofibrillary tangles and amyloid plaques with thioflavine S and staged each case based on Braak and Braak criteria for neurofibrillary tangles and amyloid plaques.

    We observed that most cases, even cognitively normal cases, contained a few isolated NFTs. Diagnosis and Braak and Braak stage are listed in Table 1. After staining and staging, we compared verrucae rating to Braak and Braak stage and found that verrucae ranking negatively correlated to Braak and Braak staging Fig. Furthermore, we also found that verrucae ratings were significantly different when comparing normal controls to AD severity in increments.

    Within the normal control group, we did not observe a relationship between verrucae and age, gender, post mortem interval nor fixation in paraformaldehyde or formalin. Post-mortem interval is the time that passes between death and time of fixation of the brain. We were unable to examine laterality with our sample set because we did not obtain both hemispheres. We scrutinized the samples to determine whether formalin or paraformaldehyde had an effect on verrucae size but did not observe a difference qualitatively. As described above, we observed a height difference in verrucae between normal controls and AD samples in our quantitative measurements that were all within the formalin-fixed group which precludes technical differences between fixatives.

    In addition, we did not observe any tissue differences between fixatives and all cases were well preserved. All cases sectioned and stained properly and nothing remarkable was observed in MRI or histology concerning fixation. In a previous study, we demonstrated that layer II islands are visible in the entorhinal cortex using ex vivo MRI [ 4 ] and that these islands could be used to localize entorhinal cortex in vivo [ 18 ]. Here we built on this model, and created entorhinal surface reconstructions to quantify spatial and morphometric properties of the verrucae.

    Utilizing ex vivo MRI, we confirmed that entorhinal islands colocalize with entorhinal verrucae, that is, that each island is beneath a verruca, as originally detailed previous neuroanatomical studies [ 30 , 40 , 44 , 54 , 55 ]. We validated our model with qualitative assessment in the gross specimen and showed that verrucae measurements accurately reflect their true size. The validated models were then used to demonstrate that entorhinal surfaces in control cases differed significantly from other cortical regions.

    Finally, with this morphometric model, we determined that entorhinal verrucae in control cases were significantly larger than mild AD cases, and that verrucae size significantly and negatively correlated to Braak and Braak stage determined by NFTs in all stages. The novelties of our study include unique application of imaging methods on entorhinal surface reconstructions i.

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    Neuropath : n/a

    Distal myopathies Laing, N. SYN: motor dapsone n.. This most common of the chronic complications of diabetes can affect either the peripheral or the autonomic nervous system , or both. Peripheral neuropathies can cause bilaterally symmetric hypesthesia , hyperesthesia , paresthesia , loss of temperature and vibratory sense , or causalgia. Involvement of the autonomic nervous system may be manifested by postural hypotension , gastroparesis , alternating diarrhea and constipation , and impotence.

    The pathogenesis of chronic diabetic n. Symptoms tend to progress , and the response to treatment is unpredictable. In contrast , cranial nerve palsies due to microangiopathy in diabetes mellitus often resolve spontaneously. Other rare clinical types occur.


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