Morphological and morphometric features of the brain in children with cerebral palsy complicated by epilepsy Текст научной статьи по специальности «Клиническая медицина»

Morphological and morphometry features of the brain in children with cerebral palsy complicated by epilepsy

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Artykova Mavlyuda Abdurahmanovna Senior Researcher of Tashkent Institute of Postgraduate Medical Education, Uzbekistan, Chief physician of Bukhara Regional Children's Mental Hospital of the Republic of Uzbekistan E-mail: [email protected]

Morphological and morphometric features of the brain in children with cerebral palsy complicated by epilepsy

Abstract: Cerebral palsy (CP) is one of the most severe pediatric neurological diseases. Numerous studies are devoted to the diagnosis and treatment of this disease, but the morphological status of the brain in children with CP complicated by epilepsy has not been studied. The aim of this study is to investigate the morphological and morphometric features of the brain of deceased children with CP associated with epilepsy. The morphometric studies were performed in 32 cases with hyperkinetic, double hemiplegia and hemiplegic forms of CP in the central gyrus of the frontal lobe and the hypothalamus of the affected hemisphere. Morphological findings revealed a greater degree of immaturity of the brain of children with CP and seizures that may underlie the defect of brake mechanisms of the brain, which causes the occurrence of epileptic foci.

Key words: cerebral palsy, epilepsy, brain morphology, histological and morphometric studies.

Cerebral disorders in children is one of the urgent topics of modern neurology. The rate of congenital abnormalities of the central nervous system in newborn infants ranges from 0.74 to 1.89 cases per 1000 births, while in the general structure of all congenital defects of the nervous system accounts 10-20% [1, 2, 9].

Cerebral palsy (CP) is one of the most severe neurological diseases of pediatric age [3, 6, 10]. Numerous studies address mainly the issues of diagnosis and treatment of this pathology [4, 5, 7, 8]. However, the morphological status of the brain in children with cerebral palsy complicated by epilepsy has not been studied.

The purpose of this study is to investigate morphological and morphometric features of the brain in children with epilepsy.

Materials and Methods

Morphometric studies were performed in 32 patients with hyperkinetic form of CP, double hemiplegia and hemiplegic form in the central gyrus of the frontal lobe of the affected hemisphere and hypothalamus.

Brain tissue for histological study was processed according to standard methods. The sections were stained with hematoxylin and eosin, as well as with 0.5% solution of cresyl-violet by Nissle method, the dignity of which is stability of the results and the possibility of directional electoral identification ofspecific nerve cells with all their processes. In the preparations were determined morphological and morphometric characteristics of the cortex of the temporal lobe of both hemispheres and nuclear structures ofhypothalamic region of the brain: the thickness of the layers of the cortex, the length (height) and width of neurons in layers, the density of neurons and neuroglia in square cut in 1 mm 2.

The thickness of the layers of the cortex, the dimensions of the bodies of pyramidal neurons in layers I, II, III, IV, V, VI of the cor-

tex were measured by using ocular ruler (7x eyepiece, 20x objective, microscope Leica). There were used methods of S. M. Blinkov and I. I. Glezer (1984). The volume of bodies ofpyramidal neurons was calculated according to the formula of I. N. Bogolepov, (1978). The data were processed by methods of variation statistics.

Results of the study

The thickness of all layers of the affected areas of the cortex of the central gyrus of frontal lobe in double hemiplegic form of CP without epilepsy was significantly less, in comparison with mor-phometric parameters of the same areas of the brain in children who died because of other causes. In this case, there was significant thinning of the thickness of V large pyramidal layer by 2 times, III external pyramidal layer by 1.8 times, I, II, IV layers on average by 1.5 times. VI internal polymorphic cell layer thickens by 50%, compared to control (Table 1).

In case of double hemiplegic form of CP with epilepsy morphometric changes differed somewhat from the above data. It was noted some thickening of the external three layers of the cortex, while the thickness of IV-V layers was more thin (Photo 1). Morphometric changes of the thickness of layers of cortex of frontal lobe of brain affected hemisphere in double hemiplegia were undoubtedly associated with atrophic changes of cerebral cortex as a manifestation of CP. Thickening of the external layers in epilepsy seems to be associated with the development of secondary changes in the form of edema and blood filling of vessels (Table 1).

The study of astrocytes density in the cortex in double hemiplegia showed its slight increase in II, III, and IV layers of the cortex on average by 30-40%, as compared to the control. In epilepsy was observed more increase in astrocytes density in the same layers of

Figure 1. 2.7-year-old child, double hemiplegic cerebral palsy with epilepsy. Atrophy of the cortex, thickening of pia mater, expansion of the acellular layer of the cerebral cortex. Staining with hematoxylin and eosin, 10x10

the cortex of frontal lobe of the affected hemisphere of the brain that indicates the increase in gliosis and atrophy of nerve cells. The densities of neurons in the cortex demonstrate significant atrophy and reduction of their quantities. In this case, there was determined the tendency of uniform reduction of numbers of neurons in almost all layers of the cortex. More significant decrease in the density of

neurons was identified in the internal polymorphous cell layer by 2 times, in the internal pyramidal layer by 1.5 times, in the internal granular layer by 1.7 times and in other layers of the cortex by an average of 1.3 times (Table 1).

In double hemiplegic form of CP, increase of astrocytes density and decrease ofneurons density naturally has led to significant changes in the astrocytic index. If in the norm this indicator in all granular layers of the cortex is equal to an average of 1.35, in the pyramidal layers is equal to 1.81 and 2.16, respectively, so in this form of CP there was its increase in all layers, especially in epilepsy, amounting in the internal pyramidal layer to 3.0, in the internal granular layer to 3.19. This trend, the increase in astrocytic index was observed in the hypothalamus. If this index in the norm is equal to 2.0, in this form of CP, especially with epilepsy, it was increased to 3.12 (Table 1).

Thus, significant changes in morphometric indices of the layer thicknesses, the density of astrocytes and neurons of the frontal lobe and the hippocampus of affected hemisphere of the brain in the form of thinning of the layers, increase of astrocytes density, decrease in neurons density and enhance of the astrocytic index indicate dominated atrophic changes of the parenchymatous cells and the development of gliosis. Increase of these indicators in epilepsy proves on the accession of secondary changes in the form of plethora of vessels and edema of brain tissue (Table 1).

Table 1. - Morphometric parameters of thickness of layers, the density of astrocytes and neurons of the central gyrus of frontal lobe and the hypothalamus of the brain hemisphere affected with double hemiplegia (M±m, m, and in pieces)

№ Parameters Cortical layers Hypothalamus

I II III IV V VI

1 Thickness of cortical layers in mkm Without epilepsy 210,4±6,3 166,5±4,2 126,5±3,8 226,5±6,4 150,4±3,2 167,4±3,9

With epilepsy 221,4±4,6 P<0,05 172,5±3,8 P<0,05 132,6±2,8 P<0,01 221,4±5,7 P<0,01 144,8±3,2 P<0,05 174,6±3,6 Р<0,05

2 Density of neurons Without epilepsy 30,2±1,5 40,3±2,6 32,4±1,7 28,3±1,4 26,6±1,3 22,3±1,2 22,4±1,4

With epilepsy 28,4±1,3 P<0,01 41,4±2,3 P<0,01 30,6±1,6 P<0,05 26,4±1,4 P<0,05 30,2±2,3 P<0,05 24,5±1,5 P<0,01 20,6±1,6 P<0,01

3 Density of astrocytes Without epilepsy 44,6±2,8 71,3±4,6 82,4±4,8 94,2±6,3 66,5±3,8 62,6±3,3 66,5±3,2

With epilepsy 46,5±2,6 P<0,01 80,6±6,9 P<0,01 91,7±7,6 P<0,05 84,3±5,9 P<0,05 68,4±4,7 P<0,01 58,7±3,7 P<0,01 64,3±4,6 P<0,01

4 Astrocytic index Without epilepsy 1,54 1,76 2,54 3,32 2,50 2,81 2,97

With epilepsy 1,63 1,93 3,00 3,19 2,26 2,38 3,12

Figure 2. 7-year-old child with hemiplegic form of cerebral palsy. Massive focus of necrosis and diapedese hemorrhage in circle of necrosis. Coloring by Nissle, 10x10

The results of morphometric studies of the brain in hemiplegic form of CP showed significant changes in the form of thinning of the thickness of cortex layers in III, V pyramidal cellular layers, especially in epilepsy the thinning of these layers reached 2 times. The densities of neurons in almost all layers of the cortex somewhat reduced, compared to the norm. If we compare the cases of hemiplegic forms of CP with and without epilepsy, there was more decrease in the density of neurons due to atrophy of neurons of the internal and external pyramidal layers of the cortex. While against this increased density of astrocytes, especially in the external granular, external pyramidal, internal granular and internal pyramidal layers (Photo 2). The abovementioned morphometric changes of the density of neurons and astrocytes were accompanied by significant increase in the astrocytic index. If in the norm this indicator in almost all layers of the cortex averaged 1.35, so in this form of CP, especially with epilepsy, exceeded 2 times (Table 2).

Morphological and morphometric features of the brain in children with cerebral palsy complicated by epilepsy

The study of morphometric parameters of the hypothalamus showed that the density of neurons in this form of CP without epilepsy was 18.2±1.4, with epilepsy — 14.6±1.6 that is lower normal values in 1.4 and 1.6 times, respectively. In the nuclei of the hy-

pothalamus, it is also noted increase in astrocytes density: without epilepsy — 54.5±2.2, and with epilepsy — 56.3±3.6. Correspondingly, the astrocytic index increased, amounting to 2.98 and 3.86, respectively (Table 2).

Table 2. - Morphometric parameters of thickness of layers, the density of astrocytes and neurons of the central gyrus of frontal lobe and the hypothalamus of the brain hemisphere affected with hemiplegic form (M±m, m, and in pieces)

№ Parameters Cortical layers Hypothalamus

I II III IV V VI

1 Thickness of cortical layers in mkm Without epilepsy 217,4±7,3 174,5±3,2 138,5±3,6 234,7±7,4 155,3±2,6 147,4±2,9

With epilepsy 211,4±3,6 P<0,05 152,7±3,2 P<0,05 122,6±1,8 P<0,01 231,4±4,7 P<0,01 148,8±2,9 P<0,05 154,6±2,5 P<0,05

2 Density of neurons Without epilepsy 28,2±1,5 42,6±1,6 48,4±2,7 54,3±3,4 36,8±2,3 30,3±1,2 18,2±1,4

With epilepsy 27,8±1,3 P<0,01 40,4±2,3 P<0,01 24,6±1,6 P<0,05 31,4±2,4 P<0,05 32,6±3,3 P<0,05 28,7±1,5 P<0,01 14,6±1,6 P<0,01

3 Density of astrocytes Without epilepsy 48,3±1,8 61,3±3,6 72,4±4,8 82,2±5,3 63,5±2,8 58,4±1,9 54,5±2,2

With epilepsy 52,5±1,6 P<0,01 64,2±3,9 P<0,01 66,7±3,6 P<0,05 91,3±5,3 P<0,05 82,4±4,7 P<0,01 64,7±3,7 P<0,01 56,3±3,6 P<0,01

4 Astrocytic index Without epilepsy 1,70 1,44 1,50 1,51 1,72 1,93 2,98

With epilepsy 1,89 1,58 2,70 2,89 2,52 2,25 3,86

The study of morphometric parameters of the brain in hyperkinetic form of CP showed that, compared with the previous forms, almost all indicators were significantly low, especially in epilepsy. In this case, the thickness of cortex layers reduced, especially in the external and internal pyramidal layers upon accession of epilepsy, and amounted to 112.6±2.4 and 114.8±4.2 mcm, respectively. There was also observed significant reduction of the density of neurons in almost all layers of the cortex, 2-fold reduction in III, IV, V, VI layers. Against these changes was observed increase of astrocytes density in these layers of the cerebral cortex in this form of CP without and with epilepsy. Increase of astrocytes density was accompanied by increase in the astrocytic index of external layer up to internal layer of the cortex in the following values: 1.59, 1.90, 2.73, 3.68,

3.45, 3.59 and in epilepsy 1.60, 1.76, 2.76, 3.46, 2.81, and 2.78, respectively. These parameters are significantly higher than those of the norm (Table 3).

It was mentioned above that in hyperkinetic form of CP the significant pathomorphological changes occur in the subcortical zones of the brain. Accordingly, these changes in morphometric parameters of the hypothalamus were significantly low. Indicators of neurons density upon accession of epilepsy and without it reduced in 2 times and averaged 12.4±1.2 and 13.8±1.6 respectively. In this case, increase of astrocytes density in the nuclear structures of the hypothalamus led to significant increase in the astrocytic index, which amounted to 5.12 and 5.16, respectively, that exceed normal levels in 2-3 times (Table 3).

Table 3. - Morphometric parameters of thickness of layers, the density of astrocytes and neurons of the central gyrus of frontal lobe and the hypothalamus of the brain hemisphere affected with hyperkinetic form (M±m, m, and in pieces)

№ Parameters Cortical layers Hypothalamus

I II III IV V VI

1 Thickness of cortical layers in mkm Without epilepsy 186,4±5,3 136,5±3,2 117,5±3,5 206,5±5,4 128,4±3,6 147,4±2,9

With epilepsy 176,4±4,3 P<0,05 132,5±3,1 P<0,05 112,6±2,4 P<0,01 186,4±4,7 P<0,01 114,8±4,2 P<0,05 144,6±2,6 P<0,05

2 Density of neurons Without epilepsy 28,4±1,5 41,3±2,7 34,4±1,7 30,3±1,4 27,6±1,5 23,3±1,5 12,4±1,2

With epilepsy 26,4±1,3 P<0,01 38,7±2,3 P<0,01 31,6±1,6 P<0,05 27,4±1,4 P<0,05 31,2±2,3 P<0,05 25,5±1,4 P<0,01 13,8±1,6 P<0,01

3 Density of astrocytes Without epilepsy 45,6±2,8 78,6±5,6 94,4±5,8 112,2±6,3 94,5±3,8 84,6±3,3 64,5±3,2

With epilepsy 42,5±2,6 P<0,01 68,6±5,9 P<0,01 86,7±6,6 P<0,05 94,8±5,9 P<0,05 88,4±4,7 P<0,01 71,7±3,7 P<0,01 71,3±4,6 P<0,01

4 Astrocytic index Without epilepsy 1,59 1,90 2,73 3,68 3,45 3,59 5,12

With epilepsy 1,60 1,76 2,76 3,46 2,81 2,78 5,16

Figure 3. 8.6-year-old patient with cerebral palsy, epilepsy

and heterotopia. Extension of the acellular layer in the cortex, reduction of cells in the middle layers, formation of focus of gliosis. Staining with hematoxylin and eosin, 10x10

Thus, results of morphometric studies of the brain in some forms of CP with epilepsy showed a broad scope of significant deviations in the thickness of layers, density of neurons and astrocytes in them and the astrocytic index. Significant reduction of the thickness of pyramidal cell layers of the cortex, the density of neurons and significant increase in astrocytes density indicate the presence of atrophic changes of parenchymatous elements and the development of hyperplasia of glial cells in the cortical tissue. In mostly studied hyperkinetic form of CP significant morphological abnormalities were observed in the hypothalamus with decrease in the density

of neurons in 2 times, increase in astrocytes density in 1.5 times and significant increase of the astrocytic index as at the accession of epilepsy and without it. These morphometric parameters confirmed pathological changes in the form of atrophy, degeneration and gliosis that develop in different forms of CP in the cerebral cortex and subcortical areas of the brain (Photo 3).

Conclusions

1. Micropolygyria is the most frequent malformation of the brain in patients with cerebral palsy, morphologically manifested in the form of small, rounded gyrus with deep sulcus. In the presence of epilepsy is marked thinning of the gray matter, expansion ofven-tricles and occurrence of foci of hemorrhages, which probably are of secondary origin. Micropolygyria with cerebral palsy with epilepsy is manifested by underdevelopment of nerve cells, preserving the signs of neuroblasts, their chaotic arrangement and predominating diffuse gliosis.

2. At the cellular level, microscopic signs appeared as delay of the development and differentiation of nerve cells, appearance of acellular fields, and disorderly arrangement of nerve cells with unequal content of tiger substance. These changes are most pronounced in patients with cerebral palsy, complicated by epileptic seizures.

3. The revealed morphological findings that, in general, shows the most degree of immaturity of the brain of children with cerebral palsy and epileptic seizures may underlie the defect in brake mechanisms of the brain, which causes the appearance of epileptic foci.

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