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From the Entorhinal Region Via the Prosubiculum to the Dentate Fascia: Alzheimer Disease-Related Neurofibrillary Changes in the Temporal Allocortex

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From the Entorhinal Region Via the Prosubiculum to the Dentate Fascia: Alzheimer Disease-Related Neurofibrillary Changes in the Temporal Allocortex J Neuropathol Exp Neurol Vol. 79, No. 2, February 2020, pp. 163–175 doi: 10.1093/jnen/nlz123 ORIGINAL ARTICLE From the Entorhinal Region via the Prosubiculum to the Dentate Fascia: Alzheimer Disease-Related Neurofibrillary Changes in the Temporal Allocortex Heiko Braak, MD and Kelly Del Tredici, MD, PhD without manifest heritability. Particularly, susceptible are late- Abstract developing and late-maturing projection neurons that gener- The pathological process underlying Alzheimer disease (AD) ate—in relation to the size of their cell body—a long and unfolds predominantly in the cerebral cortex with the gradual appear- sparsely myelinated axon (3, 8). With minor exceptions, local ance and regional progression of abnormal tau. Intraneuronal tau pa- circuit neurons are resistant (3). The predictable pattern of the thology progresses from the temporal transentorhinal and entorhinal tau lesions makes it possible to track the progression and to regions into neocortical fields/areas of the temporal allocortex. Here, distinguish different neuropathological stages (9–12). The based on 95 cases staged for AD-related neurofibrillary changes, we lesions include AT8-immunopositive nonargyrophilic pretan- propose an ordered progression of abnormal tau in the temporal allo- gles (13–15) that convert into argyrophilic filamentous accu- cortex. Initially, abnormal tau was limited to distal dendritic segments mulations of abnormal tau in dendrites (neuropil threads followed by tau in cell bodies of projection neurons of the transento- [NTs]) (16, 17), and cell somata (neurofibrillary tangles rhinal/entorhinal layer pre-a. Next, abnormal distal dendrites accumu- [NFTs]) (9, 18). Abnormal tau in axons generally resists con- lated in the prosubiculum and extended into the CA1 stratum oriens version into argyrophilic tau except in terminal axons of neu- and lacunosum. Subsequently, altered dendrites developed in the ritic plaques (3). The present study presents a sequence of CA2/CA3 stratum oriens and stratum lacunosum-moleculare, com- neuronal involvement within the temporal allocortex with a bined with tau-positive thorny excrescences of CA3/CA4 mossy cells. focus on the earliest changes, namely, the development of ab- Finally, granule cells of the dentate fascia became involved. Such a normal tau in distal segments of dendrites (15, 19). progression might recapitulate a sequence of transsynaptic spreading Unidirectional connectivities are known to exist in the of abnormal tau from 1 projection neuron to the next: From pre-a cells temporal allocortex that begin in the dentate fascia (df) and to distal dendrites in the prosubiculum and CA1; then, from CA1 or project via mossy fibers, Schaffer collaterals, and the prosubicular pyramids to CA2 principal cells and CA3/CA4 mossy ammonic-subicular pathway to the subiculum ([20]; see also cells; finally, from CA4 mossy cells to dentate granule cells. The Supplementary Data). Here, we propose a progression of tau lesions are additive: Those from the previous steps persist. lesions that proceeds in the opposite direction, namely, from Key Words: Alzheimer disease, Ammon’s horn, Dendritic tau, the entorhinal cortex to the prosubiculum and CA1, and, from Neurofibrillary, Neuropil threads, Pretangles, Thorny excrescences. there, to CA2-CA4 and then the df. This sequence suggests the existence of connectivities within the temporal allocortex that are still partially uncertain (Fig. 1). INTRODUCTION Sporadic Alzheimer disease (sAD) is a human tauopathy MATERIALS AND METHODS that selectively involves specific neuronal types while sparing Study Cohort others (1–4). Generally speaking, familial cases, which in- This retrospective study was conducted in compliance clude early- and late-onset types, account for <3% of all AD with university ethics committee guidelines as well as with cases (5–7), whereas the remainder are sporadic (idiopathic) German federal and state law governing human tissue usage. Informed written permission for autopsy was obtained from all patients and/or their next of kin. The cohort included From the Department of Neurology, Clinical Neuroanatomy, Center for Bio- medical Research, University of Ulm, Ulm, Germany (HR, KDT). 95 individuals (52 females, 43 males, age range 34– Send correspondence to: Heiko Braak, MD, Clinical Neuroanatomy, Center 97 6 13.1 years of age; mean age 74.5 years). The postmortem for Biomedical Research, Helmholtzstrasse 8/1, 89081 Ulm, Germany; interval to autopsy ranged from 5 to 107 hours, with a median E-mail: [email protected] of 41 hours for all cases. All brains were staged for tau pathol- This study was supported, in part, by the Hans & Ilse Breuer Foundation (Frankfurt am Main). ogy corresponding to NFT stages I–VI (Roman numerals) and The authors have no duality or conflicts of interest to declare. Ab phases 0–5 (Arabic numerals) (9, 12, 21). Individuals Supplementary Data can be found at academic.oup.com/jnen. with neuropathologically confirmed preclinical or clinical VC 2020 American Association of Neuropathologists, Inc. 163 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please [email protected] Braak and Del Tredici J Neuropathol Exp Neurol • Volume 79, Number 2, February 2020 FIGURE 1. Summary diagram of temporal lobe allocortical connectivities. The direction of the main efferent projections is indicated by the red arrow at the far left. Granule cells of the dentate fascia project via mossy fibers to CA3 and CA4 projection neurons. Axons of these cells contribute to the alveus and give off Schaffer collaterals to CA1 pyramidal cells. These, in turn, project via the ammonic-subicular pathway to the prosubiculum/subiculum, and subicular efferents reach the deep layer pri-a of the entorhinal region (short red arrows). Outer layers of the entorhinal and transentorhinal regions project via the perforant path (blue arrow) to the Ammon’s horn and predominantly to the dentate fascia. The progression of the sAD-associated pathology is indicated by the green arrow at the far right. Shorter green arrows between the boxes indicate the here hypothesized projections from pre-a cells to the prosubiculum and both the stratum oriens and stratum lacunosum of CA1, as well as the hypothetical projections from prosubicular and/or CA1 pyramidal cells to the stratum oriens, stratum lacunosum, and to thorny excrescences of CA3/CA4 projection neurons. Question marks indicate uncertainties regarding the existence of these connections. A known pathway is given off from CA3/CA4 mossy cells to the inner one-third of the dentate molecular layer. synucleinopathies or frontotemporal lobar dementia-TDP sAD (28–30) and for TDP-43 proteinopathy (31). An APOE were excluded from the study. Other exclusionary criteria genotyping was performed using a seminested polymerase were the presence of tauopathies other than sAD, for example, chain reaction assay and restriction isotyping with restriction argyrophilic grain disease (22), Niemann-Pick disease type C enzyme HhaI, as elsewhere (32). Genomic DNA was (23), subacute sclerosing panencephalitis, progressive supra- extracted from formaldehyde-fixed and paraffin-embedded nuclear palsy, Pick disease, or corticobasal degeneration (24). brain or liver specimens. A summary of the demographic and neuropathological data, including NFT and Ab stages, apolipoprotein E status, and the presence of hippocampal sclerosis, is provided for all cases in Tissue Fixation, Embedding, and Sectioning the Table. Hippocampal (or Ammon’s horn) sclerosis, which The brains were fixed by immersion in a 4% aqueous so- is marked by severe neuronal loss and gliosis in sector CA1 lution of formaldehyde for 14 days prior to dissection. The fol- and/or the subiculum, is considered a neurodegenerative sub- lowing tissue blocks required for neuropathological diagnosis strate of cognitive decline (25–27). and staging were dissected: 2 transversally cut blocks through the temporal lobe, the first through the uncal portion of the hippocampus, including the adjoining parahippocampal and Genetic Analysis occipito-temporal gyri, the second through the hippocampus Apolipoprotein E status was available for all individuals at the latitude of the lateral geniculate body. A third block was studied (Table). The e4 allele is a major genetic risk factor for cut from basal portions of the occipital lobe. The cut was 164 J Neuropathol Exp Neurol • Volume 79, Number 2, February 2020 Tau Pathology in Temporal Allocortex of Alzheimer Disease TABLE. Demographic and Neuropathological Data From the 95 Cases Studied Case Gender Age NFT Stage Ab Phase APOE AGD TDP-43 HS 1 Female 34 I 0 3/4 0 0 0 2 Female 55 I 0 3/3 0 0 0 3 Male 58 I 1 3/4 0 0 0 4 Male 60 I 1 3/3 0 0 0 5 Male 61 I 0 3/3 0 0 0 6 Female 65 I 0 3/4 0 0 0 7 Male 69 I 0 3/3 0 0 0 8 Male 82 I 0 3/4 0 0 0 9 Male 37 II 0 3/3 0 0 0 10 Female 48 II 0 3/3 0 0 0 11 Male 53 II 0 3/4 0 0 þ 12 Female 56 II 0 3/4 0 0 0 13 Male 56 II 0 3/3 0 0 0 14 Male 56 II 0 3/3 0 0 0 15 Male 61 II 0 3/3 0 0 0 16 Male 61 II 0 3/3 0 0 0 17 Male 62 II 0 3/3 0 0 0 18 Female 62 II 0 3/3 0 0 0 19 Male 62 II 0 3/3 0 0 0 20 Male 62 II 2 3/4 0 0 0 21 Female 63 II 0 2/3 0 0 0 22 Male 64 II 0 3/3 0 0 0 23 Male 64 II 0 3/3 0 0 þ 24 Male 64 II 1 3/4 0 0 0 25 Male 65 II 0 3/3
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    Free Neuropathology 1:25 (2020) Kurt A. Jellinger doi: https://doi.org/10.17879/freeneuropathology-2020-2945 page 1 of 20 Reflections Neuropathology through the ages My life between neurology and neuropathology 1 Kurt A. Jellinger 1 Institute of Clinical Neurobiology, Vienna, Austria Address for correspondence: Kurt A. Jellinger · Institute of Clinical Neurobiology · Alberichgasse 5/13 · A-1150 Vienna · Austria [email protected] Additional resources and electronic supplementary material: supplementary material Submitted: 12 August 2020 · Accepted: 12 August 2020 · Copyedited by: Katy Lawson · Published: 27 August 2020 Keywords: Neuropathology, Clinical neurology, Vienna, Personal reflections Introduction enced by my late mother, my beloved wife Elisa- beth, colleagues, patients, friends, and students When the editors of Free Neuropathology, whom I met during my professional and private life. Werner and Tibor, approached me about writing an autobiography for the journal, similar in scope to This essay is intended to encourage young col- Sam Ludwin’s excellent piece two years ago [1], I leagues to not concentrate exclusively on experi- confess that I had reservations about writing an mental neuropathology without also considering autobiography, because I never wanted to talk the practical part of the neurosciences since there about myself. However, after a lengthy hesitation is an urgent need to inspire young neurologists to and eager discussions with my wife and my former pursue a double career as both a clinician and neu- scholar and friend, Hans Lassmann, I realized with a roscientist in order to promote progress in the neu- certain degree of doubt that, on the threshold of rosciences. age 90 years, I could perhaps provide some thoughts about the bridges between clinical neu- Why the appeal of clinical neurology rology and neuropathology for those who might be and neuropathology? interested in the experiences of an old neuroscien- tist.
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