Small cerebral hemispheres in adults with Down's syndrome: contributions of developmental arrest and lesions of Alzheimer's disease

Morphometric analysis was used to measure cross-sectional areas of cerebral structures in middle-aged patients with Down's syndrome (N = 5) for comparison with data obtained from individuals with senile dementia of the Alzheimer type (N = 16) and neuropathologically normal controls (N = 14). Down's syndrome was distinguished from Alzheimer's disease by the 19% lower mean brain weight which was associated with more pronounced reductions in the areas of both cortex and white matter. However, the differences were most striking in the anterior frontal and anterior temporal regions where the effects of arrested neurodevelopment are grossly evident. In addition, in Down's syndrome the amygdala was significantly smaller than in Alzheimer's disease. In both Down's syndrome and Alzheimer's disease, shrinkage of the cortical ribbon was associated with abundant neuritic plaques and neurofibrillary tangles, while white matter atrophy was associated with histopathological evidence of axonal degeneration. These findings suggest that in Down's syndrome the reduction in volume in the posterior portion of the cerebrum relative to controls is largely due to acquired lesions of Alzheimer's disease, whereas anteriorly and within certain subcortical nuclei, the effects of both Alzheimer's disease and arrested neurodevelopment are manifested. Moreover, the finding of white matter lesions in Down's syndrome corroborates the notion that white matter degeneration is a fundamental component of the Alzheimer's disease process.     

Cortical somatostatin, neuropeptide Y, and NADPH diaphorase neurons: normal anatomy and alterations in Alzheimer's disease

Somatostatin and neuropeptide Y are two neuropeptides that are of particular interest in Alzheimer's disease because they are reported to be depleted in cerebral cortex. In the present study we examined somatostatin, neuropeptide Y, and nicotinamide adenine dinucleotide phosphate (NADPH) diaphorase neurons in nine cortical regions in both normal and Alzheimer's disease brains. These three neurochemical markers show a high degree of co-localization (greater than 90%) in nonpyramidal neurons that are primarily distributed in cortical layers II-III, V-VI, and, most prominently, in infracortical white matter. The highest cell density was in temporal and parietal association cortex. The major morphological abnormality in Alzheimer's disease brains was a marked pruning and distortion of fiber plexuses with an apparent reduction in fiber density. In contrast, perikaryal density was preserved except for a reduction in parietal association cortex. Approximately 10 to 15% of senile plaques in the inferior temporal gyrus contained abnormal neurites. Additional abnormal collections of neurites without plaque cores were frequently found in layers II-III and V-VI. Neuropeptide Y and somatostatin were co-localized in abnormal neurites, suggesting an origin from local intrinsic neurons in which the two peptides are co-localized. Double immunofluorescence staining for both tau protein, a major antigenic component of paired helical filaments, and either somatostatin or neuropeptide Y showed that these neurons do not contain tau-immunoreactive neurofibrillary tangles. The morphological correlate of reduced somatostatin and neuropeptide Y content in Alzheimer's disease brain therefore appears to be a distortion and reduction in fiber plexuses. In addition, it is apparent that these neurons can develop widespread morphological abnormalities in the absence of neurofibrillary tangle formation.     

Tau epitopes are incorporated into a range of lesions in Alzheimer's disease

The neuronal microtubule-associated phosphoprotein, tau, has been identified as a major antigenic component of paired helical filaments in Alzheimer's disease (AD). The extent and distribution of altered tau antigens in AD brain, other than those found in neurofibrillary tangles (NFT) and senile plaque (SP) neurites, has not been widely discussed. We have examined tau immunoreactivity in AD using the monoclonal antibody (MAb), 5E2, raised against human fetal tau. Four types of abnormalities were recognized by MAb 5E2, each having some counterpart in Bielschowsky silver impregnations: 1) NFT; 2) thickened neurites in SP; 3) diffuse perikaryal staining seen in some neurons apparently lacking NFT; and 4) a dispersed network of randomly oriented thickened neurites not clustered into discrete plaques but found in NFT- and SP-rich cerebral cortex. These four alterations could also be recognized using three different polyclonal antibodies which had strong tau immunoreactivity but were optimally shown by MAb 5E2. Our findings demonstrate the complexity of altered tau-immunoreactive neuronal elements and emphasize the widespread abnormality of microtubule-associated proteins in AD cortex.     

Re-examination of ex-boxers' brains using immunohistochemistry with antibodies to amyloid β-protein and tau protein

Summary A histopathological study was carried out on the brains of eight ex-boxers (ages 56 to 83) using conventional histological staining methods and immunocytochemistry with antibodies to amyloid -protein and the PHF-related tau protein. All cases showed a large number of tau-immunoreactive neurofibrillary tangles and also -protein immunoreactive senile plaques in the cortex. In the areas with many neurofibrillary tangles, neuropil threads with tau-immunoreactivity were also observed, and some of the senile plaque lesions were surrounded by abnormal neurites with tau-immunoreactivity. Moreover, three cases revealed -protein-type cerebrovascular amyloid deposits on both leptomeningeal and cortical blood vessels. The present observations indicate that the cerebral pathology of dementia pugilistica is very similar to that of Alzheimer's disease and suggest that these two disorders share some common etiological and pathogenic mechanisms.Supported by grants from the Intractable Disease Division, Ministry of Health and Welfare, Primary Amyloidosis Research Committee and Kanae Foundation of New Medicine, and a grant-in-aid for Scientific Research from the Ministry of Education, Science and Culture, Japan     

Microtubular reorganization and dendritic growth response in Alzheimer's disease

Cytoskeletal disruption is a key pathological feature of Alzheimer's disease (AD). We used refined immunocytochemical techniques to define the range of abnormalities affecting the microtubule system in AD hippocampus. Minimal tau and tubulin immunoreactivity was granular and accumulated in otherwise normal neuronal perikarya. As tau-reactive neurofibrillary tangles formed, granular tau and tubulin staining diminished, and ubiquitin reactivity developed. In regions of high neurofibrillary tangle density, microtubule-associated protein 2 (MAP2) histochemical features of remaining nontangled neurons included apical dendritic degeneration with proliferation of basal dendrites. In addition to perisomatic dendritic proliferation, there was massive sprouting of tau-immunoreactive distal dystrophic neurites. Sprouting proximal dendrites and dystrophic neurites often demonstrated growth-cone-like lamellipodia and filopodia. Degeneration of the perisomatic proliferating dendrites was characterized by the accumulation of fibrillar tau immunoreactivity. The colocalization of MAP2 and tau in growth structures recapitulated their codistribution in developing neurites. The data suggest that extensive plasticity and growth response occur in tandem with neuronal degeneration in AD, and that reorganization of the cytoskeletal microtubule system may underlie these proliferative changes.     

Senile plaque neurites fail to demonstrate anti-paired helical filament and anti-microtubule-associated protein-tau immunoreactive proteins in the absence of neurofibrillary tangles in the neocortex

Summary Although much work has been directed recently towards unravelling the protein chemistry of neurofibrillary tangle (NFT) and senile plaque (SP) components in Alzheimer's disease, the pathogeneses of these lesions remains largely unknown and the problem of their relationship is unresolved. In particular, although paired helical filaments (PHF) have long been documented in SP neurites, we do not know if they are of pathogenetic relevance for the formation of the SP. To investigate the relationship between NFT and SP, we examined antigenic properties of proteins in SP neurites in neocortical tissues of patients with senile dementia of Alzheimer type, in the presence or absence of NFT in the same cortical area. We used two polyclonal antibodies directed against PHF and microtubule-associated protein (MAP)-tau and three monoclonal antibodies (MAbs) (RT97, BF10, 147) to phosphorylated epitopes of human neurofilament polypeptides, as well as the Gallyas silver impregnation method which specifically stains PHF in NFT and neurites. The main finding of our investigations consists in a differential pattern of immunoreactivity of SP neurites depending on the presence or absence of NFT in the neocortex. In the presence of NFT, there were numerous neuropil threads and SP neurites containing Gallyas-positive, as well as anti-PHF- and anti-tau-labelled material. In the absence of NFT in the neocortex there was a striking absence of any Gallyas-positive or PHF- and tau-immunoreactive structure in the cortical neuropil and in SP neurites, irrespective of the maturation stage of the SP. In contrast with these results, the number of neurites labelled by MAbs RT97, BF10 and 147 in SP and in the neuropil was apparently unaffected by the presence or absence of NFT. Amyloid in SP, remained consistently unstained by all antibodies of the panel as well as by the Gallyas stain. Our findings indicate that PHF and tau polypeptides are facultative components of SP neurites and suggest that the development of SP may occur independently of PHF pathology in neocortical neurons.Supported by the Wellcome Trust and the Medical Research Council     

A case of familial juvenile Alzheimer's disease with apallic state at the relatively early stage and various neurological features--a clinicopathological study

A case of familial juvenile Alzheimer's disease with apallic state at the relatively early stage and various neurological features was reported. A 33-year-old woman showed a progressive dementia followed by apallic state at the relatively early stage, and died of cardiac failure at the age of 45. Neurological examination disclosed chorea, myoclonus, rigidity, pyramidal sign, and generalized convulsion. Neuropathologically, extensive senile changes such as senile plaques, neurofibrillary tangles, and granurovascular degenerations were observed in the brain, chiefly in the cerebral cortex and limbic system. The present case was characterized by a severe neuronal loss in the subcortical gray matter such as the caudate nucleus, dentate nucleus, substantia nigra, and thalamus as well as a marked myelin loss and axonal damages in the cerebral white matter. This case suggested a combination of multisystemic degeneration and a primary degeneration of the cerebral white matter. The additional peculiar aspects in this case were the senile plaques and amyloid angiopathy in the cerebellar cortex, and the senile plaques and grumose degeneration in the cerebellar dentate nucleus. In the clinicopathological standpoint, the apallic state in this case could be attributed to a severe degeneration of the cerebral white matter in addition to the cerebral cortical deterioration. Furthermore, the occurrence of chorea and myclonus might be contributed to the severe degeneration of the caudate nucleus and to the degeneration of the dentate nucleus, particularly to the grumose degeneration, respectively.     

Progressive transformation of the cytoskeleton associated with normal aging and Alzheimer's disease.

Transitional and end-stage forms of neurofibrillary tangles associated with normal aging and Alzheimer's disease were identified using thioflavine staining combined with tau and neurofilament protein immunofluorescence. Normal aging was marked by transitional pathology in layer II of the entorhinal cortex but no neurofibrillary tangles in prefrontal cortex, whereas, in Alzheimer's disease cases, layer II entorhinal neurons had progressed to end-stage neurofibrillary tangles and the prefrontal cortex contained a high representation of transitional forms of the neurofibrillary tangle.     

Immunohistological study on brains of Alzheimer's disease using antibodies to fetal antigens,C-series gangliosides and microtubule-associated protein 5

Summary An immunohistological study of Alzheimer's brains was performed using antibodies to C-series gangliosides and microtubule-associated protein 5 (MAP5), and their staining patterns were compared with those of antibodies to tau and -amyloid precursor protein. Antibodies to C-series gangliosides and MAP5, both of which are known to preferentially expressed in the fetal brains, immunostained dystrophic neurites of senile plaques, neurofibrillary tangles and neuropil threads abundant in 3rd and 5th layers in the cerebral cortex, all of which are considered to be pathological hallmarks of Alzheimer's disease. The immunostaining patterns of these structures by antibodies to C-series gangliosides and MAP5 were similar to those by the antibody to tau. These three antibodies also immunostained some neurons in Alzheimer's brain, although their staining patterns were slightly different from one another; i.e., both diffuse and granular patterns were seen by the antibody to tau, but only granular pattern by the antibodies to C-series gangliosides and MAP5. These neurons immunostained by these three types of antibodies appeared to be the precursors of the classical neurofibrillary tangles, as positively stained neurons were not seen in the brains of non-demented cases. The presence of fetal antigens such as the C-series gangliosides and MAP5 in Alzheimer's brain may suggest that regeneration or sprouting of neurons is ongoing in association with the re-induction of gene expression characteristic for the brain in the early stage of development.     

Massive somatodendritic sprouting of cortical neurons in Alzheimer's disease

In addition to neurofibrillary tangles and senile plaques, antibodies to human tau revealed extensive tau-immunoreactive meshworks in layers III and V of the neocortex affected with Alzheimer's disease. The meshworks consisted of innumerable abnormally curly fibers, which were coming from somata and dendrites of pyramidal cells. Their morphological appearance suggests that those curly fibers represent somatodendritic sprouting.     

Tau protein aggregation in the frontal and entorhinal cortices as a function of aging

OBJECTIVES: The abnormal accumulation of tau protein is increasingly recognized as the neuropathological hallmark of a number of dementing illness in which frontotemporal lobar degeneration occurs. In this paper we examined the age-dependant deposition of tau protein in the frontal and entorhinal neocortices. METHODS: We examined autopsy records from 1997 to 2002 and selected 87 cases (10 in each decade from 0 to 79 years of age, 7 in 80-89 decade) with no history of dementia or other neurodegenerative diseases, and for which neurodegenerative diseases were excluded neuropathologically. Archival paraffin-embedded frontal and entorhinal cortices were examined by both Gallyas-Braak silver staining and a panel of antibodies recognizing tau protein accumulation. RESULTS: Tau neuronal aggregates were observed in both frontal and entorhinal cortices in the third decade. While the frontal neuronal tau aggregates remained infrequent in the remaining decades, the number and extent ofneuronal tau aggregates in the entorhinal cortex increased such that by the 7th decade the majority of cases showed extensive tau aggregate formation. The most consistent morphological observation was of dense, perikaryal neuronal tau-immunoreactive aggregates, similar to the total tau distribution, firstly presenting in cortical layers II and III and subsequently involving in layers IV-VI. Neuropil threads became maximal in the 9th decade in both frontal and entorhinal cortices. Astrocytic tau accumulation was first observed in both frontal and entorhinal cortices in the 6th decade, predominantly in layer I and subcortical white matter, and increased in number with aging. Extraneuronal tau reactive aggregates and coiled bodies were rarely observed in the entorhinal cortex, and when present, were scattered through layer II to VI. CONCLUSIONS: We have observed an age-dependant pattern of neuronal, extraneuronal and glial tau protein accumulation in the entorhinal cortex in individuals without neurodegenerative diseases. In contrast, tau protein aggregation is infrequently observed in the frontal cortex as a function of aging.     

Neuronal pathology in the nucleus basalis and associated cell groups in senile dementia of the Alzheimer's type: possible role in cell loss

The loss of cortical cholinergic innervation in senile dementia of the Alzheimer's type (SDAT) is associated with cell loss in the nucleus basalis and related cell groups (magnocellular basal nucleus, MBN). We examined MBN in Nissl-, acetylcholinesterase- and thioflavin S-stained sections in two cases of SDAT and in four control brains. Using these sensitive methods, senile plaques were easily demonstrated in MBN, and most MBN neurons showed neurofibrillary degeneration as an early change. Cell loss appeared to be due to maturation of neurofibrillary tangles, displacing normal cellular contents. In contrast to theories that the cell loss in MBN represents retrograde degeneration due to axonal injury in the cerebral cortex, MBN neuronal perikarya may be involved by the same primary processes as cortical neurons.     

Pathology of subcortical visual centres in relation to cortical degeneration in Alzheimer's disease

Subcortical visual centres such as the lateral geniculate nucleus, the lateral inferior pulvinar and the superior colliculus, together with the primary visual cortex and its adjacent white matter, were studied in 12 Alzheimer brains and five age-matched controls. The periodic acid methenamine technique was used for the demonstration of senile plaques and the Gallyas technique for neuro-fibrillary tangles and neuritic threads in the neuropil. In the lateral geniculate nucleus and inferior pulvinar, the presence of periodic acid methenamine-positive senile plaques was observed in variable numbers in all Alzheimer cases. In the lateral geniculate nucleus, senile plaques were encountered more often in parvocellular than in magnocellular layers, in the interlaminar zones, in the optic radiation and in the adjacent pre-geniculate nucleus. Gallyas staining did not reveal any neuro-fibrillary tangles. neuritic threads or neuritic plaques, meaning that in this thalamic region there are mainly amyloid deposits without neuritic degeneration. In the superior colliculus both amyloid and neuritic plaques, as well as neurofibrillary tangles and neuritic threads were encountered in the superficial and deep layers. In the primary visual cortex, all types of senile plaques were observed as well as a rather high number of neurofibrillary lesions in pyramidal neurons, mainly in layers 5 and 6, but also in several types of non-pyramidal neurons. In the underlying white matter there was a morphologically heterogeneous population of neurofibrillary tangle-bearing neurons and a considerable number of threads representing degenerating axons, suggesting that degeneration could follow cortico-subcortical connections. These data demonstrate that lesions in the primary visual structures and pathways are more prevalent than previously observed and could partly explain the visual disturbances in Alzheimer's disease.     

An autopsy case of diffuse neurofibrillary tangles with calcification: Early stage pathologic findings

A 66‐year‐old man with no medically remarkable past or family history gradually showed personality changes, memory disturbance, sleeplessness and abnormal behavior. Neurologic examination showed no focal signs and neither parkinsonism nor cerebellar ataxia was recognized. He died 4 years after the onset of dementia due to chronic renal failure. Neuropathologic examination revealed neuronal loss and gliosis in the temporal cortex, particularly in the subiculum, parahippocampal gyrus and entorhinal cortex, and insular cortex. NFTs were observed to be widespread in the cerebral cortex, especially the temporal cortex and brainstem, while senile plaques were not observed. Gallyas‐Braak silver staining revealed the presence of numerous NFTs, glial inclusions and neuropil threads throughout the cerebral neocortex, limbic system, hippocampus and brainstem. The subiculum showed the most severe involvement; severe atrophy, severe neuron loss, and numerous ghost tangles (extracellular NFTs) were apparent. Although NFTs contained both monoclonal anti‐3repeat‐tau antibody (RD3) and RD4 immunoreactivity, this differed between the intracellular NFTs and ghost tangles. RD3 immunoreactivity was mainly observed in ghost tangles and neuropil threads, whereas RD4 immunoreactivity was mainly observed in intracellular NFTs and glial inclusions. Calcification was also found to be widespread in the cerebral cortex and white matter, basal ganglia, thalamus, cerebellar cortex, white matter and dentate nucleus. These characteristic neuropathologic findings lead to the pathologic diagnosis of diffuse neurofibrillary tangles with calcification (DNTC). It is argued that this patient showed early stage pathologic signs of DNTC due to a short disease duration, which may provide clues regarding the progression of this rare disease.     

Tau antisera recognize neurofibrillary tangles in a range of neurodegenerative disorders

Neurofibrillary tangles occur in a number of apparently distinct neurodegenerative diseases and in normal aging of the human brain. Antibodies raised against Alzheimer's disease paired helical filaments immunolabel the tangles seen in all other tangle-associated disorders examined to date. The neuronal microtubule-associated protein, tau, has recently been identified as an antigenic component of neurofibrillary tangles and senile plaque neurites in Alzheimer's disease. Three different polyclonal antibodies with strong tau immunoreactivity are examined in this study. These antibodies were found to immunostain tangles in normal aged brain and in brains affected by a range of neurodegenerative disorders, including Down's syndrome, Alzheimer's disease plus Parkinson's disease, progressive supranuclear palsy, and the parkinsonism-dementia complex of Guam, as well as Pick bodies in Pick's disease. The findings further illustrate the relative nonspecificity of neurofibrillary lesions in neurodegenerative disorders.     

Dissociation of Alzheimer type pathology in a disconnected piece of cortex

A woman with Alzheimer’s disease died at the age of 85 years. A left sphenoid meningioma had been removed 27 years earlier. The tumor and the operation had severely altered the white matter of the frontal lobe and of the anterior part of the temporal lobe on the left side and massively disconnected a small piece of frontal cortex. There were numerous senile plaques and neurofibrillary tangles in the limbic and isocortical samples. The white matter lesions, on the operated (left) side, were associated with a lower density of neuritic plaques and of neuropil threads and with a higher density of β-amyloid (Aβ) deposits. The density of tau-positive neuritic plaques, neurofibrillary tangles and neuropil threads was close to zero, whereas the diffuse deposits of Aβ were abundant, in the small disconnected piece of cortex. In this area, the white matter was severely damaged, as in the adjoining cortex, but the continuity of the cortical ribbon was also disrupted. These data show that neuritic and Aβ pathologies may be dissociated and suggest that the neuritic alterations mainly involve cortico-cortical fibers coursing tangentially in the cortical ribbon. Received: 1 July 1996 / Revised, accepted: 29 October 1996     

Brain ubiquitin is markedly elevated in Alzheimer disease.

Levels of ubiquitin, microtubule associated protein tau and tubulin were determined by immunoassays in homogenates of cerebrum and cerebellum of Alzheimer disease and aged control cases. Ubiquitin levels increased many fold in the cerebral cortex of Alzheimer disease cases and the increase correlated strongly with the degree of neurofibrillary changes in the tissue. The increase in ubiquitin was much less remarkable in the cerebral white matter. Cerebellum which is unaffected with neurofibrillary changes in Alzheimer disease had normal levels of ubiquitin both in gray matter and in white matter. There was an appreciable increase in abnormally phosphorylated tau in an Alzheimer disease brain with severe neurofibrillary degeneration, whereas the normal tau levels were increased only slightly. Tubulin was slightly decreased in the cerebral gray matter but not in the adjacent white matter. Marked increase in brain ubiquitin in Alzheimer disease suggests the role of ubiquitin in the pathobiology of Alzheimer disease.     

Pathological tau tangles localize to focal cortical dysplasia in older patients

PURPOSE: Reactivation of neurodevelopmental processes may contribute to neurodegeneration. For example, the proteins cyclin dependent kinase 5 (cdk5) and glycogen synthase kinase 3 beta (GSK3beta), which are essential to normal cortical development, can hyperphosphorylate tau and might contribute to the pathogenesis of Alzheimer's disease. Focal cortical dysplasia (FCD) is an important neurodevelopmental cause of refractory human epilepsy within which dysplastic neurons exhibit increased immunoreactivity for cdk5 and GSK3beta as well as neurofilamentous accumulations. We therefore hypothesized that the developmentally abnormal cortex of FCD might be more susceptible to tau-mediated neurodegeneration than adjacent histologically normal cortex. MATERIALS AND METHODS: We examined a series of 15 cases of FCD, spanning a wide age range, for beta-amyloid, pathologically phosphorylated tau and neurofibrillary tangles using silver staining, immunohistochemistry for tau, AT8, RD3, RD4 and two-dimensional cell counting. RESULTS: Beta-amyloid plaques, aberrantly phosphorylated tau and neurofibrillary tangles are only found in older patients. The hyperphosphorylated tau tangles are confined to dysplastic neurons. Immunoreactivity for 3- and 4-repeat tau was again only detected within regions of FCD in older patients. With increasing age, the dysplastic cortex became hypocellular and a higher proportion of dysplastic neurons exhibited pathological tau phosphorylation. CONCLUSIONS: In older patients, FCD appears more susceptible to formation of pathologically phosphorylated tau neurofibrillary tangles than adjacent histologically normal cortex. Our results suggest a novel convergence of pathological neurodevelopment with pathological age-related neurodegeneration.     

Tauopathy with paired helical filaments in an aged chimpanzee

An enigmatic feature of age-related neurodegenerative diseases is that they seldom, if ever, are fully manifested in nonhuman species under natural conditions. The neurodegenerative tauopathies are typified by the intracellular aggregation of hyperphosphorylated microtubule-associated protein tau (MAPT) and the dysfunction and death of affected neurons. We document the first case of tauopathy with paired helical filaments in an aged chimpanzee (Pan troglodytes). Pathologic forms of tau in neuronal somata, neuropil threads, and plaque-like clusters of neurites were histologically identified throughout the neocortex and, to a lesser degree, in allocortical and subcortical structures. Ultrastructurally, the neurofibrillary tangles consisted of tau-immunoreactive paired helical filaments with a diameter and helical periodicity indistinguishable from those seen in Alzheimer's disease. A moderate degree of Abeta deposition was present in the cerebral vasculature and, less frequently, in senile plaques. Sequencing of the exons and flanking intronic regions in the genomic MAPT locus disclosed no mutations that are associated with the known human hereditary tauopathies, nor any polymorphisms of obvious functional significance. Although the lesion profile in this chimpanzee differed somewhat from that in Alzheimer's disease, the copresence of paired helical filaments and Abeta-amyloidosis indicates that the molecular mechanisms for the pathogenesis of the two canonical Alzheimer lesions--neurofibrillary tangles and senile plaques--are present in aged chimpanzees.     

Sporadic Pick's disease: a tauopathy characterized by a spectrum of pathological tau isoforms in gray and white matter

Pick's disease is characterized neuropathologically by distinct tau-immunoreactive intraneuronal inclusions known as Pick bodies and by insoluble tau proteins with predominantly three microtubule-binding repeat tau isoforms. However, recent immunohistochemical studies showed that the antibody specific for exon 10, which encodes the fourth microtubule-binding repeat, detected other tau lesions in Pick's disease. To better define the spectrum of tau pathology in Pick's disease, we used biochemical, immunohistochemical, and ultrastructural techniques to analyze the tau isoform composition in 14 Pick's disease brains. Western blot analysis showed that both three and four microtubule-binding repeat pathological tau isoforms are present in gray and white matter of various brain regions. Using phosphorylation-dependent anti-tau antibodies, we show that major tau phosphoepitopes are present in sarcosyl-insoluble gray and white matter regions of Pick's disease brains. Also, for the first time to our knowledge, we demonstrated that isoforms with four microtubule-binding repeat tau isoforms are present in Pick bodies from selected brains. Isolated tau filaments were straight or twisted and formed by three microtubule-binding repeat or four microtubule-binding repeat tau isoforms. Major tau phosphorylation-dependent and exon 10-specific epitopes were present in filaments. Therefore, Pick's disease is characterized by an accumulations of Pick bodies in the hippocampal region and cortex as well as the presence of three and four microtubule-binding repeat tau pathology in both cortical gray and white matter that distinguish this tauopathy from other neurodegenerative disorders.