Simplified procedure for brain cut up examination for general pathologists that emphasises the importance of good clinicopathological correlation in post-mortem CNS examination. Presented at TSL workshop in Lagos on 25 November 2014

1. BRAIN CUT UP FOR
THE GENERAL
PATHOLOGIST
Effiong E. Akang
Consultant Pathologist
University College Hospital
Ibadan, NIGERIA

2. INTRODUCTION
•CNS examination is an essential part of every full autopsy
•Brain-only autopsy not ideal, but may be indicated in a few cases
•Many general pathologists regard CNS examination to be a
daunting task (unnecessarily so).
•While neuropathologists conduct extremely detailed CNS
examinations, the same is true of other sub specialists. For
example, cardiac pathologists may take up to 70 sections of the
heart.
•Yet every self respecting pathologist undertakes a fairly thorough
examination of the heart in the average autopsy. Why not the
brain?

3. PREPARATION FOR BRAIN CUT UP
•CNS examination begins with thorough review of pertinent
clinical findings (history, examination, investigations including
neuroimaging, management and clinical course)
•CNS involvement occurs in majority of systemic illnesses;
however, primary CNS disorders are relatively uncommon. Even
so, there is an impressive list of numerous primary CNS
conditions
•Review clinical findings and cut brain in presence of managing
clinical team and certified brain aficionados (adult/paediatric
neurologist, neurosurgeon, neuroradiologist, psychiatrist) so as
to obtain maximal benefit

4. CLINICAL HISTORY
43 year old male
•Headache- 5 days (sudden onset, throbbing, generalised)
•Seizures- 4 days (began with twisting of mouth and up rolling of eyes
and spread to become generalised tonic-clonic); 5 episodes
•Vomiting- 4 days (effortless); 8 episodes
•No photophobia, phonophobia or slurring of speech. No previous
head trauma, no fever, no weight loss, no limb weakness
•Motor-cycle accident 3 years previously, but no neurological sequelae
•Smoked marijuana and drank alcohol heavily until 5 years previously
•Not a known diabetic, hypertensive or asthmatic. No family history of
similar illness. No other significant medical, social or drug history

5. PHYSICAL EXAMINATION
Young male, drowsy, not pale, anicteric, not cyanosed, afebrile, mildly
dehydrated, no palpable lymph nodes, no pedal oedema.
Glasgow Coma score- 14/15. Pupils equal bilaterally, muscle tone and
power normal globally. Reflexes normal, plantar response flexor
bilaterally, no neck stiffness, Kernig/Brudzinski signs negative.
Pulse rate 100b/m, regular, normal volume. BP- 110/80 mmHg, HS 1
and 2, no murmur.
Respiratory rate 18/min, trachea central, percussion notes resonant,
breath sounds vesicular.
Abdomen flat, moved with respiration, no tenderness, no palpable
organomegaly.
Provisional diagnosis- ?Intracranial space occupying lesion, to rule out
(1) Benign intracranial hypertension, (2) Viral encephalitis

6. INVESTIGATIONS
Random blood glucose- 187.2mg/dl (normal 45-90 mg/dl),
PCV- 39% (normal 40-54%)
Full blood count- neutrophilia and lymphopenia
Urinalysis- haematuria ++
Retroviral screening- non-reactive
CT/MRI was not available

7. MANAGEMENT AND CLINICAL COURSE
He was placed on intravenous mannitol 250ml over 30 minutes,
followed by intravenous Normal saline 1L 8hrly.
Following review by the unit senior registrar (at 9.15 pm on
14/10/14) an assessment of Adult onset seizure disorder
?Intracranial space occupying lesion was made and the patient
was administered 40 mg of diazepam into each pint for the first
litre of normal saline, Tab carbamazepam 200 mg bd, IV
diazepam 5 – 10 mg for break through seizures prn.
The patient deteriorated and died 11 hours after admission

8. CNS AUTOPSY EXAMINATION-
1- Exposure of the brain
Make full thickness ear-to-ear incision
of scalp and reflect skin flaps anteriorly
and posteriorly to expose skull bone
Use manual or electrical saw
(adult/older children) to remove skull
cap.
In neonates and infants prior to fusion
of skull sutures and closure of
fontanelles, scissors can be used to
outline and reflect four flaps (frontal
bone, occipital bone and 2 temporal
bone flaps (modified Beneke method)
Waters BL, 2009. Handbook of autopsy practice

9. CNS AUTOPSY EXAMINATION-
2A- Removal of the adult brain
Reflect dura over cerebral hemispheres
Gently lift up frontal poles and sever cranial nerves
beginning from optic to hypoglossal nerves
Transect distal brainstem/spinal cord as low as
possible and then lift out brain

10. CNS AUTOPSY EXAMINATION-
2B- Removal of the infant brain
Reflect the dura over the cerebral hemispheres
a) In cases of suspected birth trauma, remove the
hemispheres one at a time, using gravity to aid brain
removal. This way the falx cerebri and dural venous
sinuses can be examined in situ. Subsequently, the
brainstem and cerebellum are removed as a block
b) In other cases remove the brain exactly as for the adult
brain, again using gravity to aid removal

11. CNS AUTOPSY EXAMINATION-
2C- Brain smears
Prior to immersion in formalin smears may be
obtained in cases of
•Cerebral malaria (wet imprint)
•Bacterial infections (Gram stain)
•Superficial extra-axial tumours (Giemsa/Pap stain)

12. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain
The brain is usually examined after fixation in buffered
10% formalin for 1-2 weeks. If there is significant
intracranial haemorrhage, change the fixative after first 24
hours to achieve better fixation
In forensic autopsies, or in a few selected cases where a
full autopsy fails to reveal any significant changes outside
the CNS, brain may be sectioned fresh
In either case, weight of the brain must be recorded
immediately after removal from the cranial cavity

13. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain
Brain examination begins
with inspection- examine
for symmetry of the
hemispheres; gyri and
sulci; leptomeninges;
brainstem and cerebellum;
vessels of circle of Willis;
any other focal lesions

14. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain
Transect brainstem and
cerebellum
Make serial sections
beginning from frontal
lobes to occipital lobes at
1cm intervals
Arrange slices serially as
you proceed

15. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain
The brain weighs 1250 gm
(normal = 1100-1450gm),
it appears dusky in colour and
there is generalised congestion
of the leptomeninges. The right
hemisphere is bigger than the
left hemisphere, showing
narrowing of sulci and
flattening of gyri, overlying a
right frontal lobe mass lesion.

16. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain
Coronal sections of cerebral hemispheres
show a right frontal lobe encapsulated
abscess measuring 2.8 x 2.5 x 2.5 cm.
There is softening and yellowish
discolouration of the surrounding white
matter, with blurring of grey-white matter
differentiation. There is herniation of the
right cingulate gyrus and effacement of
the anterior horn of the right lateral
ventricle with deviation of the septum
pellucidum to the contralateral side.

17. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain
Transverse sections of brain stem and
sections of the cerebellum appear grossly
normal and show no focal lesion

18. CNS AUTOPSY EXAMINATION-
3- Sectioning the brain- CONSULTATION
In cases requiring neuropathological consultation (immunohistochemistry
and molecular studies for neurodegenerative or metabolic disorders)
perform autopsy within 24 hours of death. Details will vary based on
specific requirements of consultant neuropathologist
• Bisect fresh brain and preserve one half (snap freeze with liquid
nitrogen and store at -800C). Ship in dry ice. Fix second half for 1-2
weeks in buffered 10% formalin and section as described above.
Alternatively ship both halves.
• Fix fresh intact brain in buffered 10% formalin and at the time of brain
cut up preserve one half uncut and ship by courier service. The second
half is sectioned as described above. Alternatively ship intact fixed brain
in 10% formalin by courier service

19. CNS AUTOPSY EXAMINATION-
4- Removal of the spinal cord
POSTERIOR APPROACH
• Midline incision over spinous
processes, resect muscle,
bilateral laminectomy
• Useful for neck injuries,
carniocervical instability,
posterior neural tube defects
• Cons- leakage of embalming
fluids, limited dissection of
spinal nerve roots
ANTERIOR APPROACH
• Cut lateral processes, bilaterally from
upper thoracic to sacral spines. Make
transverse cuts through proximal and
distal vertebral bodies. Spinal cord
delivered by Kernohan’s method
• Useful for removal of spinal cord and
peripheral nerves in continuity, more
rapid and convenient
• Cons- likelihood of spinal cord damage

20. CNS AUTOPSY EXAMINATION-
5- Provisional anatomical diagnosis
1. Chronic pyelonephritis
2. Right frontal lobe cerebral abscess
3. Haemorrhagic gastritis
4. Pulmonary oedema

21. CNS AUTOPSY EXAMINATION-
6- Clinicopathological correlation
Adult onset seizures with raised intracranial
pressure
Brain abscess
Use of intravenous mannitol instead of high
dose corticosteroids accelerated patient’s
demise

22. SELECTED CASES- 1
• 17 year female with
ante mortem FNA
diagnosis of NHL
• Post-mortem revealed
large cell NHL with
involvement of
ovaries, kidney,
pancreas, intestines,
thyroid, scalp, skull
and dura

23. SELECTED CASES- 2
• 54 year HIV/AIDS
female with ante
mortem diagnosis of
intracranial space
occupying lesion,
?toxoplasmosis
• Post-mortem revealed
hazy leptomeninges,
with no other
significant gross lesion
• FINAL DIAGNOSIS-Neurocryptococcosis

24. SUMMARY
• CNS examination is an essential part of every full autopsy
• Should be preceded by review of clinical findings and in
presence of managing clinical team and neuro specialists
• Brain and spinal cord examination should be systematic and
detailed
• Clinicopathological correlation with clinical and other
autopsy findings is vital

25. Thanks
for
listening!