Case History
82-year-old with a psychiatric history.
What is the most appropriate diagnosis?
A. Focal cortical dysplasia type IIb
B. Tuberous Sclerosis complex
C. Normal cortex
D. Grey matter heterotopia
Answer: C. Normal cortex
Discussion:
The giant pyramidal neurons are motor neurons from the primary motor cortex of the precentral gyrus. They are called Betz cells or pyramidal cells of Betz.
The distractions of FCD type II b, Tuberous Sclerosis Complex, and Picks disease all have “balloon cells” which are rather large but lack the normal features of neurons (Nissl substance, lipofuscin, pyramidal arch, ect). Grey matter heterotopia is a migration error and does not have normal cortical layering. Amyotrophic lateral sclerosis can involve the cortex and is related to frontal temporal degeneration, but that is not seen here, and the spinal cord would be the place to look for that one.
Case contributed by: Brandon Maveal, M.D., Neuropathology Fellow, UAB Pathology