Introduction
a. Braak staging of LB related pathology from Braak and colleagues from 2003 [5]a
| |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Stage | dmV | irz | LC | R | SN | AC | nbM | CA2 | transent cx (mc) | TO cx (mc) | Ins cx (hc) | GC (hc) | T cx (hc) | F cx (fc) | P cx (fc) |
1 | 1–2 | IR | |||||||||||||
2 | 1–2 | IR | 0–2 | 1–2 | |||||||||||
3 | 1–3 | IR | 1–3 | 1–2 | 1–3 | 1–3 | 0–2 | ||||||||
4 | 2–3 | IR | 2–3 | 2–3 | 2–3 | IR | 1–3 | 1–2 | 1–2 | 1–2 | |||||
5 | 2–3 | IR | 2–3 | 2–3 | 2–3 | IR | 2–3 | 1–3 | 2 | 2 | 1 | 1 | 1 | ||
6 | 3 | IR | 2–3 | 2–3 | 3 | IR | 3 | 1–3 | 2–3 | 2–3 | 2 | 2 | 2 | 1 | 1 |
b. Braak staging of Lewy-body related pathology as applied in Müller and colleagues from 2005 [21]b
| |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Stage | dmV or irz | LC | R | SN | CA2 | transent cs | T cx | ||||||||
1 | ≥+ | ||||||||||||||
2 | ≥+ | ≥+ | |||||||||||||
3 | ≥+ | ≥+ | ≥+ | ≥+ | |||||||||||
4 | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | |||||||||
5 | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | ||||||||
6 | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | ≥+ | ≥++ |
c. McKeith typing of LB related pathology from McKeith and colleagues from 2005 [20]c
| |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Type | dmV | irz | LC | R | SN | AC | nbM | CA2 | transent cx (mc) | TOcx (mc) | Ins cx (hc) | GC (hc) | T cx (hc) | F cx (fc) | P cx (fc) |
Brainstem | 1–3 | 1–3 | 1–3 | 0–2 | 0–2 | 0–1 | 0–1 | ||||||||
Limbic | 1–3 | 1–3 | 1–3 | 2–3 | 2–3 | 1–3 | 1–3 | 0–2 | 0–1 | ||||||
Neocortical | 1–3 | 1–3 | 1–3 | 3–4 | 2–3 | 2–4 | 2–4 | 2–3 | 1–3 | 0–2 |
d. McKeith typing of LB related pathology as modified by Leverenz and colleagues from 2008 [18]d
| |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Type | dmV or irze
| SNe
| AC | GC | F cx | ||||||||||
Brainstem | 1+ | 1+ | 0–2 | 0–1 | 0 | ||||||||||
Limbic | 1+ | 1+ | 2+ | 1–3 | 0–1 | ||||||||||
Neocortical | 1+ | 1+ | 2+ | 2+ | 2+ | ||||||||||
Amygdala predominant | 0–1 | 0–1 | 1+ | 0–1 | 0 |
Materials and methods
Sampling of material
Case | Gender | Age at death | Cognitive impairment | Brain weight | AD related Braak stage [7] | α-synuclein immunoreactive pathology | ||
---|---|---|---|---|---|---|---|---|
Braak stage [5] | McKeith type [20] | Amygdala-predominant | ||||||
1 | Female | 70 | 1,290 | 2 | 1 | 1 | ||
2 | Male | 75 | Yes | 1,500 | 1 | 2 | 1 | |
3 | Male | 57 | 1,280 | 0 | 3 | 1 | ||
4 | Male | 70 | 1,535 | 1 | 3a
| 1 | ||
5 | Male | 76 | 1,680 | 1 | 3 | 1 | ||
6 | Male | 83 | 1,210 | 1 | 3 | 1 | ||
7 | Male | 62 | 1,505 | 0 | 4 | 1 | ||
8 | Female | 71 | Yes | 1,000 | 2 | 4 | 1 | |
9 | Female | 73 | 1,440 | 2 | 4 | 1 | ||
10 | Female | 74 | 1,260 | 2 | 4a
| 1 | ||
11 | Female | 77 | 1,345 | 1 | 4a
| 1 | ||
12 | Female | 78 | 1,480 | 2 | 4a
| 1 | ||
13 | Female | 80 | 1,560 | 0 | 4 | 1 | ||
14 | Male | 78 | 1,450 | 1 | 4 | 2 | Yesb
| |
15 | Male | 83 | Yes | 1,395 | 2 | 4 | 2 | |
16 | Male | 63 | 1,535 | 0 | 5a
| 2 | ||
17 | Female | 74 | Yes | 1,255 | 2 | 5a
| 2 | Yesb
|
18 | Male | 80 | 1,300 | 4 | 5a
| 2 | Yesb
| |
19 | Male | 76 | 1,420 | 1 | 5 | 2 | ||
20 | Male | 78 | 1,600 | 2 | 5 | 2 | Yesb
| |
21 | Male | 68 | 1,275 | 0 | 6 | 2 | ||
22 | Female | 74 | Yes | 1,305 | 6 | 6 | 2 | Yesb
|
23 | Female | 79 | Yes | 1,090 | 6 | 6a
| 2 | Yesb
|
24 | Male | 89 | 1,135 | 2 | 6a
| 2 | ||
25 | Male | 77 | 1,480 | 0 | 6 | 3 | ||
26 | Male | 67 | 1,490 | 2 | 6 | 3 | ||
27 | Male | 70 | Yes | 1,345 | 1 | 6 | 3 | |
28 | Male | 72 | 1,460 | 1 | 6 | 3 | ||
29 | Male | 73 | 1,490 | 0 | 6 | 3 | ||
30 | Male | 74 | Yes | 1,485 | 2 | 6 | 3 | |
31 | Male | 83 | Yes | 1,325 | 3 | 6 | 3 |
Immunohistochemistry
Reference assessment and construction of assessment instructions
1. | State for each sample (Fig. 2) whether or not (yes/no) the assessable region is included in the section |
2. | State for each assessable and identified region whether or not (yes/no) αS-IR pathological structures are seen. αS+ covers intracytoplasmic grains, inclusions, extracellular inclusions, aggregates, neurites, threads (Fig. 3) |
3. | State for the selected regions whether or not (yes/no) αS-IR LB-like lesions are seen. The rounded LB like inclusions may be located in a neuron or may be extracellular (Fig. 3b–j) |
4. | State for the selected regions whether or not (yes/no) αS-IR neurites are seen. LB related neurite or neuropil thread is a tiny rounded, fusiform or strip like IHC/αS+ structure in the neuropil (Fig. 3k–q) |
5. | Assess the density of αS+ in each anatomical region. It is recommended but not required to use the magnification ×100 (Fig. 4) |
0. no αS-IR in the area of interest | |
1. sparse/mild αS- IR in x100 magnification only occasional αS-IR structures are seen and in cortex only a few LB-like inclusions are seen in the whole gyrus | |
2. moderate αS-IR in x100 magnification scattered αS-IR structures are seen and in cortex patchy/intervening areas lack LB-like inclusions but neurites might be widespread | |
3. severe αS-IR in x100 magnification numerous αS-IR structures are seen and in cortex LB-like inclusions are relatively uniformly distributed with numerous neurites | |
6. | Assign a Braak stage if possible [5]. The progress from stage 1 to stage 6 is not stepwise but instead is continuous, so select a stage that is most representative |
7. | Assign a McKeith type if possible [20]. The progress from brainstem predominant to neocortical is not stepwise but instead is continuous thereby select a stage that is most descriptive |
8. | In some cases the distribution of the pathology might not be as strict as delineated by Braak and colleagues in 2003 or McKeith and colleagues from in 2005 [5, 20]. Please indicate as requested in the assessment sheet whether the distribution of the pathology in caudal to rostral direction is regular i.e. typical, or not i.e. atypical |
9. | In some cases the distribution of the pathology might not be as strict as delineated by Braak and colleagues in 2003 or McKeith and colleagues from in 2005 [5, 20]. In some cases an amygdala predominant pattern might be seen i.e. the pathology is most severe in amygdaloid complex and less pronounced in brainstem areas. State whether the assessed case should be considered as an amygdala predominant one |
Inter-observer assessment
Consensus meeting and joint assessment
Re-examining the data found in the assessment sheets
Statistical analysis and photography
Results
Case | Reference group | Braak stage Stage given by the 22 participating observers | Absolute agreement in percent | Wilcoxon rank-sum test | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 2 | 3 | 4 | 5 | 6 | Single case | One stage | Overall | Single case | One stage | Overall | ||
1 | 1 |
21
| 1 | 95 |
95
| ||||||||
2 | 2 | 8 |
14
| 64 |
64
| * | * | ||||||
3 | 3 | 1 | 7 |
11
| 3 | 50 | * | ||||||
4 | 3a
| 5 |
17
| 77 |
63
| * | |||||||
5 | 3 |
13
| 8 | 1 | 59 | * | * | ||||||
6 | 3 | 3 | 4 |
14
| 1 | 64 | * | ||||||
7 | 4 | 8 |
13
| 1 | 59 | * | |||||||
8 | 4 | 3 |
17
| 2 | 77 | * | |||||||
9 | 4 | 5 |
8
| 7 | 2 | 32 | * | ||||||
10 | 4a
| 8 |
10
| 4 | 45 |
55
| * | ||||||
11 | 4a
| 5 | 7 |
10
| 45 | * | |||||||
12 | 4a
| 5 |
10
| 6 | 1 | 45 | * | * | |||||
13 | 4 | 1 |
19
| 2 | 86 |
65
| |||||||
14 | 4b
|
13
| 4 | 5 | 59 | * | |||||||
15 | 4 |
10
| 9 | 3 | 45 | * | |||||||
16 | 5a
| 3 |
10
| 9 | 45 | * | |||||||
17 | 5a,b
| 7 |
11
| 4 | 50 | * | * | ||||||
18 | 5a,b
| 7 |
9
| 6 | 41 |
52
| * | * | |||||
19 | 5 | 3 |
12
| 7 | 55 | * | |||||||
20 | 5b
| 1 |
15
| 6 | 68 | * | |||||||
21 | 6 | 1 | 7 | 4 |
10
| 45 | * | ||||||
22 | 6b
| 4 | 5 |
13
| 59 | * | |||||||
23 | 6a,b
| 7 |
15
| 68 | * | ||||||||
24 | 6a
| 6 | 4 |
12
| 55 | * | |||||||
25 | 6 | 2 | 3 |
17
| 77 |
79
| * | ||||||
26 | 6 |
22
| 100 | * | |||||||||
27 | 6 |
22
| 100 | ||||||||||
28 | 6 | 3 |
19
| 86 | |||||||||
29 | 6 | 3 | 3 |
16
| 73 | * | |||||||
30 | 6 |
22
| 100 | ||||||||||
31 | 6 |
22
| 100 |
Case | Reference group | McKeith type Type given by the 22 participants | Absolute agreement in percent | Wilcoxon-rank-sum test *p < 0.05 | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
0 | Brainstem | Limbic | Neocortical | Single case | One type | Overall | Single case | One type | Over all | ||
1 | Brainstem |
22
| 100 | ||||||||
2 | Brainstem |
22
| 100 | ||||||||
3 | Brainstem |
21
| 1 | 95 | |||||||
4 | Brainstem |
22
| 100 | ||||||||
5 | Brainstem |
20
| 2 | 91 | |||||||
6 | Brainstem |
2
|
20
| 91 | |||||||
7 | Brainstem |
19
| 3 | 86 |
85
| ||||||
8 | Brainstem |
15
| 7 | 68 |
*
| ||||||
9 | Brainstem |
13
| 8 | 1 | 59 |
*
| |||||
10 | Brainstem |
18
| 4 | 82 | |||||||
11 | Brainstem |
20
| 2 | 91 | |||||||
12 | Brainstem |
15
| 7 | 68 |
*
| ||||||
13 | Brainstem |
16
| 6 | 73 |
*
| ||||||
14 | Limbica
| 3 |
16
| 3 | 86 |
*
| |||||
15 | Limbic | 3 |
19
| 86 |
81
| * | |||||
16 | Limbic |
19
| 3 | 86 | |||||||
17 | Limbica
| 4 |
18
| 82 | |||||||
18 | Limbica
| 2 |
18
| 2 | 86 |
73
|
*
| ||||
19 | Limbic |
21
| 1 | 95 | |||||||
20 | Limbica
| 1 |
19
| 2 | 86 | ||||||
21 | Limbic | 7 |
12
| 3 | 55 |
*
| |||||
22 | Limbica
| 3 |
10
| 9 | 45 |
*
| |||||
23 | Limbica
|
11
| 11 | 50 |
*
| ||||||
24 | Limbic | 3 |
14
| 5 | 64 |
*
| |||||
25 | Neocortical | 7 |
15
| 68 |
*
| ||||||
26 | Neocortical |
22
| 100 | ||||||||
27 | Neocortical | 1 |
21
| 95 | |||||||
28 | Neocortical | 1 | 8 |
13
| 59 |
82
|
*
| ||||
29 | Neocortical | 4 | 4 |
14
| 64 |
*
| |||||
30 | Neocortical |
22
| 100 | ||||||||
31 | Neocortical | 2 |
20
| 91 |
Case | dmV mean ± SE | SN mean ± SE | AC mean ± SE | GC mean ± SE | P cx mean ± SE |
---|---|---|---|---|---|
14 | 2.22 ± 0.09 | 2.17 ± 0.17 | 3.00 ± 0.13 | 1.57 ± 0.32 | 0.39 ± 0.22 |
17 | 1.74 ± 0.14 | 1.74 ± 0.14 | 3.00 ± 0.20 | 1.96 ± 0.31 | 0.13 ± 0.13 |
18 | 1.57 ± 0.18 | 1.83 ± 0.12 | 2.78 ± 0.11 | 2.39 ± 0.27 | 0.26 ± 0.18 |
20 | 2.48 ± 0.11 | 3.17 ± 0.12 | 3.65 ± 0.12 | 2.74 ± 0.18 | 0 |
22 | 1.96 ± 0.10 | 2.35 ± 0.10 | 3.96 ± 0.43 | 2.35 ± 0.26 | 0.13 ± 0.13 |
23 | 1.22 ± 0.21 | 1.30 ± 0.20 | 4.00 ± 0.00 | 3.26 ± 0.18 | 0.65 ± 0.26 |
T test | 0.000 | 0.000 | 0.000 | 0.000 |
Case | Braak stage | McKeith type | ||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Originala (Table 1a) Absolute agreement % | Modified by BNEb (Fig. 5) Absolute agreement % | Simplifiedc by Müller et al. (Table 1b) Absolute agreement % | Originald (Table 1c) Absolute agreement % | Modified by BNEe (Fig. 5) Absolute agreement % | Modifiedf by Leverenz et al. (Table 1d) Absolute agreement % | |||||||
Stage | Single case | Stage | Single case | Stage | Single case | Stage | Single case | Stage | Single case | Stage | Single case | |
1 | 1 | 95 | 1 | 100 | 1 | 100 | Brainstem | 100 | Brainstem | 100 | Brainstem | 100 |
2 | 2 | 64* | 2 | 95 | 2 | 95 | Brainstem | 100 | Brainstem | 100 | Brainstem | 100 |
3 | 3 | 50* | 3 | 82 | 3 | 64* | Brainstem | 95 | Brainstem | 91 | Brainstem | 91 |
4 | 3g
| 77* | 3 | 86 | 3 | 91 | Brainstem | 100 | Brainstem | 100 | Brainstem | 100 |
5 | 3 | 59* | 4 | 64* | 3 | 86 | Brainstem | 91 | Limbic | 95 | Limbic | 68* |
6 | 3 | 64* | 3 | 55* | 3 | 59* | Brainstem | 100 | Brainstem | 100 | Brainstem | 100 |
7 | 4 | 59* | 4 | 64* | 3 | 82 | Brainstem | 86 | Limbic | 73* | Limbic | 68* |
8 | 4 | 77* | 4 | 86 | 3 | 59* | Brainstem | 68* | Limbic | 100 | Limbic | 100 |
9 | 4 | 36* | 5 | 55* | 3 | 82 | Brainstem | 59* | Limbic | 86 | Limbic | 82 |
10 | 4 | 45* | 4 | 68* | 3 | 68* | Brainstem | 82 | Limbic | 82 | Limbic | 73* |
11 | 4g
| 45* | 4 | 55* | 3 | 91 | Brainstem | 91 | Limbic | 55* | Limbic | 55* |
12 | 4g
| 45* | 5 | 41* | 3 | 82 | Brainstem | 68* | Limbic | 82 | Limbic | 95 |
13 | 4 | 86 | 4 | 82 | 3 | 86 | Brainstem | 73* | Limbic | 91 | Limbic | 95 |
14 | 4h
| 59* | 5/6 | 68* | 5/6 | 55* | Limbich
| 86 | Limbic | 86 | Limbic | 73* |
15 | 4 | 45* | 4 | 64* | 4 | 41* | Limbic | 86 | Limbic | 82 | Limbic | 77* |
16 | 5/6 | 86 | 5/6 | 91 | 5/6 | 64* | Limbic | 86 | Neocortical | 64* | Neocortical | 59* |
17 | 5/6g,h
| 68* | 5/6 | 68* | 3 | 77* | Limbich
| 82 | Limbic | 95 | Limbic | 95 |
18 | 5/6g,h
| 68* | 5/6 | 82 | 4 | 36* | Limbich
| 86 | Limbic | 55* | Limbic | 64* |
19 | 5/6 | 86 | 5/6 | 95 | 5/6 | 64* | Limbic | 95 | Limbic | 68* | Limbic | 68* |
20 | 5/6h
| 95 | 5/6 | 91 | 5/6 | 68* | Limbich
| 86 | Limbic | 73* | Limbic | 73* |
21 | 5/6 | 64* | 5/6 | 100 | 3 | 73* | Limbic | 55* | Neocortical | 64* | Neocortical | 59* |
22 | 5/6h
| 82 | 5/6 | 100 | 5/6 | 100 | Limbich
| 45* | Limbic | 55* | Limbic | 59* |
23 | 5/6g,h
| 100 | 5/6 | 100 | 5/6 | 100 | Limbich
| 50* | Neocortical | 82 | Neocortical | 82 |
24 | 5/6g
| 73* | 5/6 | 91 | 5/6 | 45* | Limbic | 64* | Neocortical | 78* | Neocortical | 64* |
25 | 5/6 | 91 | 5/6 | 95 | 5/6 | 91 | Neocortical | 68* | Neocortical | 86 | Neocortical | 86 |
26 | 5/6 | 100 | 5/6 | 100 | 5/6 | 100 | Neocortical | 100 | Neocortical | 100 | Neocortical | 100 |
27 | 5/6 | 100 | 5/6 | 100 | 5/6 | 100 | Neocortical | 95 | Neocortical | 100 | Neocortical | 100 |
28 | 5/6 | 100 | 5/6 | 100 | 5/6 | 77* | Neocortical | 59* | Neocortical | 77* | Neocortical | 68* |
29 | 5/6 | 86 | 5/6 | 100 | 5/6 | 91 | Neocortical | 64* | Neocortical | 91 | Neocortical | 91 |
30 | 5/6 | 100 | 5/6 | 100 | 5/6 | 100 | Neocortical | 100 | Neocortical | 100 | Neocortical | 100 |
31 | 6 | 100 | 5/6 | 100 | 5/6 | 95 | Neocortical | 91 | Neocortical | 95 | Neocortical | 95 |
Absi
| 74 | 83 | 78 | 81 | 84 | 82 | ||||||
Absj
| 73 | 83 | 79 | 81 | 86 | 84 | ||||||
Wk
| 0.000 | 0.005 | 0.001 | 0.093 | 0.230 | 0.002 | ||||||
Wl
| 0.000 | 0.000 | 0.094 | 0.526 | 0.000 | 0.000 |