bs_bs_banner
Neuropathology 2014; 34, 555–570
Sympos i um : D e fi n i t i o n a n d D i ff e r e n t i a l s – H o w t o
D isti ngui s h D i s e a s e - S p e c i fi c C h a n g e s o n M i c r o s c o p y
Astrocytic inclusions in progressive supranuclear
palsy and corticobasal degeneration
Mari Yoshida
Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan
Tufted astrocytes (TAs) in progressive supranuclear palsy
(PSP) and astrocytic plaques (APs) in corticobasal degen-
eration (CBD) have been regarded as the pathological
hallmarks of major sporadic 4-repeat tauopathies. To
better define the astrocytic inclusions in PSP and CBD and
to outline the pathological features of each disease, we
reviewed 95 PSP cases and 30 CBD cases that were con-
firmed at autopsy. TAs exhibit a radial arrangement of thin,
long, branching accumulated tau protein from the cyto-
plasm to the proximal processes of astrocytes. APs show a
corona-like arrangement of tau aggregates in the distal
portions of astrocytic processes and are composed of fuzzy,
short processes. Immunoelectron microscopic examination
using quantum dot nanocrystals revealed filamentous tau
accumulation of APs located in the immediate vicinity of
the synaptic structures, which suggested synaptic dysfunc-
tion by APs. The pathological subtypes of PSP and CBD
have been proposed to ensure that the clinical phenotypes
are in accordance with the pathological distribution and
degenerative changes. The pathological features of PSP
are divided into 3 representative subtypes: typical PSP
type, pallido-nigro-luysian type (PNL type), and CBD-like
type. CBD is divided into three pathological subtypes:
typical CBD type, basal ganglia- predominant type, and
PSP-like type. TAs are found exclusively in PSP, while
APs are exclusive to CBD, regardless of the pathological
subtypes, although some morphological variations exist,
especially with regard to TAs. The overlap of the patho-
logical distribution of PSP and CBD makes their clinical
diagnosis complicated, although the presence of TAs and
Correspondence: Yoshida Mari, MD, PhD, Institute for Medical
Science of Aging, Aichi Medical University, 1-1 Yazakokarimata,
Nagakute, Aichi 480-1195, Japan. Email: myoshida@aichi-med-u.ac.jp
Received 16 April 2014; revised 15 June 2014 and accepted 15 June
2014.
© 2014 Japanese Society of Neuropathology
doi:10.1111/neup.12143
APs differentiate these two diseases. The characteristics of
tau accumulation in both neurons and glia suggest a differ-
ent underlying mechanism with regard to the sites of tau
aggregation and fibril formation between PSP and CBD:
proximal-dominant aggregation of TAs and formation of
filamentous NFTs in PSP in contrast to the distal-
dominant aggregation of APs and formation of less fila-
mentous pretangles in CBD.
Key words: astrocytic plaque, corticobasal degeneration,
fibril formation, progressive supranuclear palsy, tufted
astrocyte.
INTRODUCTION
Progressive supranuclear palsy (PSP)1 and corticobasal
degeneration (CBD)2 have been regarded as distinct
clinicopathological entities with hyperphosphorylated four
repeat (4R) tau aggregation in neurons and glia, although
the recent recognitions of many clinical similarities have
increasingly raised more difficulties in the clinical diagnosis
of these two disorders. However, microscopic cellular tau
pathology has been used to distinguish PSP from CBD.3–5
PSP is defined primarily by tau-positive neurofibrillary
tangles (NFTs), coiled bodies, threads, and tufted
astrocytes, in contrast to the ballooned neurons, pretangles,
threads, and astrocytic plaques that are characteristic of
CBD (Table 1). Because PSP and CBD frequently present
similar pathological distributions (Table 1, Fig. 1), a patho-
logical diagnosis may be difficult without the discrimina-
tion of abnormal tau inclusions and particularly of the most
characteristic and obvious tau morphology, that of
astrocytic inclusions.6 Therefore, it is important to reevalu-
ate and differentiate between tufted astrocytes (TAs) and
astrocytic plaques (APs) and to discuss the pathogenesis of
these types of inclusions. To address these issues, we
reviewed the morphology and differential distribution of
556 M Yoshida

Table 1 Diagnostic pathological findings in progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD)
Lesion
Neuronal loss & gliosis
Ballooned or achromatic neurons
Gallyas/4R-tau positive lesions
Neuronal inclusions
Threads and coiled bodies
Astrocytic inclusions
4R-tau, 4 repeat tau; NFTs, neurofibrillary tangles.
PSP
Distribution
Affected cortices (variable)
Globus pallidus
Subthalamic nucleus
Substantia nigra
Brainstem tegmentum
Dentate nucleus
Pons and medulla (variable)
NFTs > Pretangles
Substantia nigra, oculomotor complex, locus
ceruleus, pons, brainstem nuclei, dentate
nucleus, globus pallidus, subthalamic
nucleus
Striatum, thalamus, basal nucleus of Meynert
Affected Cortices (variable)
Spinal cord
Threads and coiled bodies
Brainstem, cerebellar white matter, globus
pallidus, subthalamic nucleus, striatum,
thalamus, gray matter and white matter,
spinal cord
Tufted astrocytes
Affected cortices, striatum, brainstem
CBD
Affected cortices/subcortical white matter
(gliosis)
Globus pallidus (variable)
Subthalamic nucleus (variable)
Substantia nigra
Striatum (caudate and putamen) (gliosis)
Brainstem tegmentum (variable)
Dentate nucleus (variable)
Pons and medulla (variable)
Affected cortices
Pretangles >> NFTs
Affected cortices, substantia nigra, globus
pallidus, subthalamic nucleus
Striatum, thalamus, basal nucleus of Meynert
Brainstem nuclei and dentate nucleus
Spinal cord
Threads >> coiled bodies
Subcortical white matter and gray matter,
globus pallidus, subthalamic nucleus,
striatum, thalamus, brainstem, spinal cord
Astrocytic plaques
Affected cortices, striatum

pathologic lesions of 95 neuropathologically confirmed cerebellar involvement (PSP-C).12,13 The PSP-Richardson

PSP cases and 30 CBD cases that were registered at the
Institute for Medical Science of Aging, Aichi Medical Uni-
versity. Our focus was on the pathogenesis of astrocytic
inclusions, their disease specificity, and their morphological
variations.
PROGRESSIVE SUPRANUCLEAR
PALSY (PSP)
PSP is a progressive neurodegenerative disorders,described
by Steele, Richardson and Olszewski in 1964.1 It is the
second most common form of parkinsonism after Parkin-
son’s disease. Clinical features include abnormal gait, and
postural instability, and recurrent falls, supranuclear
ophthalmoparesis, cognitive and behavioral changes,
pseudobulbar features and dystonia.
Clinical aspects
As noted previously, pathologically confirmed cases of PSP
have exhibited some variation of the clinical and pathologi-
cal features. Therefore, clinical subtypes were proposed to
classify PSP: PSP-Richardson, PSP-parkinsonism (PSP-
P),7,8 PSP-pure akinesia with gait freezing (PSP-PAGF),9
PSP-primary progressive aphasia,10,11 and PSP-predominant
type is the prototypical form of PSP that is defined by early
falls, early cognitive dysfunction, abnormalities of gaze and
postural instabilities. PSP-P represents asymmetric onset,
tremor, early bradykinesia, non-axial dystonia and a
response to levodopa. Individuals with PSP-PAGF present
with the gradual onset of freezing of gait or speech, absent
limb rigidity and tremor, a lack of sustained response to
levodopa, and no dementia or ophthalmoplegia in the first 5
years of disease. PSP-primary progressive aphasia is defined
by the presence of primary progressive aphasia, or progres-
sive nonfluent aphasia. Individuals with PSP-C develop
cerebellar-predominant ataxia as the initial and principal
symptom.
Neuropathology
Neuropathological diagnostic criteria
The pathological criteria for the diagnosis of PSP are well
established and include specific neuronal loss with gliosis
and neurofibrillary tangles (NFTs) in the subcortical
and brainstem nuclei and in the cerebellar dentate nucleus
with the pathological accumulation of abnormally
phosphorylated microtubule-associated protein tau into
filamentous deposits.14 The NINDS diagnostic criteria for
PSP and related disorders are pertinent for typical PSP,

© 2014 Japanese Society of Neuropathology

Astrocytic inclusions in PSP and CBD 557

Fig. 1 The group of pathological subtypes in PSP (A) and CBD (B). (A) The pathological subtypes in PSP is generally divided into three
representative types: typical PSP type, pallido-nigro-luysian type (PNL type), and CBD-like type, according to the distribution of the
lesions and the severity. The spinocerebellar degeneration (SCD)-like type is associated with severe degeneration of the dentate nucleus,
superior cerebellar peduncles, cerebellar cortex, white matter and pontine tegmentum and base, which are frequently associated with
frontal involvement. The PNL type shows relatively restricted changes in pallido-nigro-luysian lesions. The CBD-like type is accompanied
by more severe, asymmetrical cortical changes and a variable degeneration of the basal ganglia, brainstem and cerebellar dentate nucleus.
(B) The pathological subtypes of CBD is generally divided into three representative types: typical CBD type, basal ganglia-predominant
type, and PSP-like type, according to the distribution of the lesions and the severity. The typical CBD type shows dominant cortical
involvement with laterality in the posterior frontoparietal or perisylvian areas. Some cases exhibit anterior frontal-dominant cortical
degeneration, such as frontotemporal lobar degeneration. The basal ganglia-predominant type reveals severe involvement of the pallidum
and subthalamic nucleus, with relatively mild cortical degeneration without distinct laterality. The PSP-like type shows severe degeneration
of the brainstem and dentate nucleus similar to that seen in PSP, in addition to the variable cortical involvement.

which conforms to the original description, and atypical
PSP, which consists of histologic variants where the severity
or distribution of abnormalities, or both, deviate from the
typical pattern; these criteria are also relevant for combined
PSP, in which typical PSP is accompanied by concomitant
infarcts in the brainstem, basal ganglia, or both.3,12 Micro-
scopic findings include a high density of NFTs and neuropil
threads in at least three of the following areas: the pallidum,
subthalamic nucleus, substantia nigra, or pons. In addition, a
low to high density of NFTs or neuropil threads is found in
at least three of the following areas: the striatum, oculomo-
tor complex, medulla, or dentate nucleus. A clinical history

© 2014 Japanese Society of Neuropathology

558 M Yoshida

that is compatible with PSP is also required for diagnosis
according to this set of criteria. These criteria have come to
define the typical clinicopathological PSP cases. However,
based on these criteria, it was recommended that atypical
PSP should be excluded as a PSP subtype because further
neuropathological studies of this entity were needed.
Neuropathological reevaluation of PSP cases
Among 95 pathologically confirmed PSP cases, 25 cases
were associated with other significant diseases. Two of
these cases were associated with Alzheimer’s disease, 12
with Parkinson’s disease or dementia with Lewy bodies
(DLB), 1 with multiple system atrophy, 1 with SCA6 and
DLB, 1 with amyotrophic lateral sclerosis, 1 with traumatic
brain injury, 4 with cerebrovascular disease, 1 with gliob-
lastoma, and 2 cases were without detailed information.
With the exception of these 25 cases, 70 cases were
analyzed and had the following characteristics: a mean age
at onset of 67 years (range 39–92 years), a mean disease
duration of 8 years (range 1–28 years), and a mean age at
death of 75 years (range 49–106 years). PSP is a sporadic
disease, although approximately 7% of affected individuals
have a family history of neurological disorders, including
parkinsonism or dementia.
Macroscopic and microscopic findings
The macroscopic examination of the brain in typical PSP
reveals mild frontal atrophy including precentral gyrus,
particularly in the convexity (Fig. 2A). The brainstem and
cerebellum are mildly atrophic. The globus pallidus and
subthalamic nucleus usually show a brownish atrophy. The
third ventricle may be enlarged. The tegmentum of the
midbrain and pons also shows atrophy. The substantia
nigra shows discolored, while the locus ceruleus is often
relatively preserved. The cerebellar dentate nucleus, and
the superior cerebellar peduncle are atrophic.
The microscopic findings indicate neuronal loss and
gliosis with NFTs, which appear globose in appearance, in
the basal ganglia, thalamus, brainstem, and cerebellum
(Table 1, Fig. 3). The thalamus has mild to moderate
neuronal loss and gliosis, while the putamen and the
caudate show mild gliosis. The most affected nuclei are the
globus pallidus, subthalamic nucleus and substantia nigra.
The affected regions of the brainstem are as follows: mid-
brain tegmentum including the superior colliculus,
periaqueductal gray matter, oculomotor nuclei, locus
ceruleus, pontine tegmentum, pontine nuclei, medullary
tegmentum and the inferior olivary nucleus. The dentate
nucleus usually exhibits grumose degeneration. The
superior cerebellar peduncles are atrophic, and the cer-
ebellar cortex may show mild loss of Purkinje cells with
mild atrophy of the white matter. The medullary tegmen-
tum may be atrophic with myelin pallor. The cerebral cor-
tices show mild gliosis especially in the premotor and
precentral gyrus in the convexity. The spinal cord, espe-
cially the cervical segment, is usually involved, particularly
in the medial division of the anterior horn and intermedi-
ate gray matter.15–17 Transverse sections of the spinal cord
often show myelin pallor in the anterolateral funiculus in
the cervical and thoracic segments. Immunohistochemistry
for phosphorylated tau or modified Gallyas silver staining
reveals NFTs, pretangles in neurons, tufted astrocytes,
coiled bodies in oligodendrocytes, and threads (Table 1,
Fig. 3).
Tufted astrocytes
TAs are defined as radial arrangements of thin and long
branching fibers without collaterals that course continu-
ously through the cytoplasm to the distal processes of
astrocytes (Fig. 3d–j,m,n).6,18 “Tufts of abnormal fiber,” as
described in PSP by Hauw et al.,19 is the root of the nomen-
clature for “tufted astrocytes,” although their cellular char-
acterization was not mentioned in their study. Tufted
astrocytes were described by Hauw et al.19 as star-like tufts
of fibers devoid of degenerative features and without
amyloid cores that are clearly distinguishable with Bodian
stain as well as with tau immunocytochemistry. The
astrocytic nature of the cells that contain the tufted-type
inclusions was confirmed by the double-labeling of sections
with antibodies to GFAP, CD44 and abnormal tau.20–22
Cytoplasmic staining is usually not conspicuous within TAs

▶
Fig. 2 Macroscopic findings of typical PSP type (A), pallido-nigro-luysian (PNL)- type (B) and CBD-like type (C).
(A) Macroscopic findings in coronal sections of typical PSP show mild frontal atrophy in the convexity (a), atrophy of the pallidum and
subthalamic nucleus (a, arrow), atrophy of the brainstem tegmentum (b), loss of pigment in the substantia nigra (b, arrow) with
preservation of pigment in the locus ceruleus, and atrophy of the cerebellar dentate nucleus (c). Bar = 2 cm.
(B) Macroscopic findings in PNL-type PSP reveal severe atrophy of the pallidum and the subthalamic nucleus (a) and depigmentation of
the substantia nigra (b), with relative preservation of the brainstem tegmentum (b) and cerebellar dentate nucleus (c). The PNL-type
sometimes shows atypical TAs, which demonstrates proximal dominant tau accumulations (d, e). d, Gallyas silver stain; e, AT8
immunohistochemistry; a, b, c, bar = 2 cm; e, bar = 10 μm.
(C) Macroscopic findings in CBD-like type PSP indicate left side-predominant degeneration of the cerebral cortices and the basal ganglia
(a–d) with relatively mild atrophy of the brainstem (e). Microscopically typical TAs are observed in the basal ganglia and cerebral cortices
(f, g). a, c, Klüver-Barrera stain; b, d, Holzer stain; f, Gallyas silver stain; g, AT8 immunohistochemistry; bar = 10 μm.

© 2014 Japanese Society of Neuropathology

Astrocytic inclusions in PSP and CBD 559

© 2014 Japanese Society of Neuropathology

560 M Yoshida

© 2014 Japanese Society of Neuropathology

Astrocytic inclusions in PSP and CBD 561

Fig. 3 Major microscopic findings in PSP. Microscopic findings include globose-type neurofibrillary tangles visualized with H&E stain (a),
Bodian stain (b), and phosphorylated tau immunohistochemistry (c). Typical TAs have phosphorylated tau (d, g, j), 4 repeat tau (e, h) and
Gallyas-positive (f, i) radiating proximal branches with variable cytoplasmic tau accumulation. Differential structures are oligodendroglial
coiled bodies and threads (k) and tau accumulation in senile plaques (l),and globular glial inclusions in globular glial tauopathies (m).Double
immunostaining for AT8 (brown) and GFAP (red) in TAs shows tau-positive radiating filamentous processes from the GFAP-positive
cytoplasm (n) or more abundant tau accumulation in the proximal portion in the cytoplasm (o). a, H&E stain; b, Bodian stain; f, i, Gallyas
silver stain; c, d, g, i–m, AT8 immunohistochemistry; e, h, RD4 immunohistochemistry; n, o, double immunostaining for AT8 (brown) and
GFAP (red). Bar = 10 μm.
◀

after either Gallyas-Braak (GB) silver stain or anti-tau
immunohistochemistry; however, upon careful examina-
tion, some TAs revealed positive staining in the perikaryon
after anti-tau immunohistochemistry (Fig. 3g). Electron
microscopy demonstrated that astrocytes with abundant
glial filaments formed loose bundles of straight 15 nm
tubules in the perikaryon.23 Fibers with a diameter
of approximately 20–25 nm were also described.21
Immunoelectron microscopy recognized TAs as central
nucleus surrounded by radiating AT8-immunoreactive
processes.24 TAs are commonly found in the premotor, sup-
plement, and motor cortex in the convex areas, the basal
ganglia, thalamus, and brainstem tegmentum, and are rec-
ognized as a distinctive pathological marker of PSP.25 With
regard to disease specificity, it is strongly believed that the
4R tau-positive TAs are more common in PSP. It is prob-
able that tufted astrocytes are the pathognomonic hall-
mark of PSP.6,25,26
Correlation between TAs and
clinicopathological features
Based on the distribution of neuronal loss with gliosis and
tau positive neuronal and glial inclusions, the pathological
topography of 68 out of 70 PSP cases (except for 2 cases
within one year’s disease duration), were divided grossly
into 3 representative subtypes: typical PSP type, pallido-
nigro-luysian type (PNL-type), and CBD-like type
(Fig. 1A,2). The typical PSP type (50 out of 68 cases,
73%) represents the prototypical pathological distribu-
tion, which involves the pallidum, subthalamic nucleus,
substantia nigra, brainstem tegmentum, cerebellar dentate
nucleus, thalamus and the cerebral cortices to a mild or
moderate degree (Fig. 2A). SCD-like type (11 cases, 16%)
involves severe degeneration of the dentate nucleus and
atrophy of the pontocerebellum with tau accumulation
(Fig. 1A). Because the SCD-like type normally develops
into a typical PSP type, this type seems to be of similar
etiology as the typical PSP type. The PNL-type (12 cases,
18%) demonstrates lesions that are relatively confined to
the pallidum, subthalamic nucleus and substantia nigra
(Fig. 1A,2B). CBD-like type (6 cases, 9%) reveals promi-
nent asymmetrical cortical involvement that is associated
with mild to moderate involvement of the brainstem and
the cerebellar dentate nucleus (Fig. 1A,2C).
The pathology of the different subtypes wholly corre-
sponds to the clinical phenotypes: pathologically typical
PSP type corresponds to PSP-Richardson, pathological
PNLA-types to PSP-PAGF or some PSP-P clinical phe-
notypes, and CBD-like type to PSP-corticobasal syn-
drome (CBS).27 Therefore, the clinical phenotypes depend
on the topographical distribution and the degree of
degeneration. Furthermore transitional pathology also
exists among those pathological subtypes in their distri-
bution and severity.
In all subtypes,TAs are almost always invariably present.
In the typical PSP type, TAs are usually prominent in the
frontal cortices and in the striatum.6 In the CBD-like type,
more prominent TAs are seen in the affected cerebral cor-
tices. In the PNLA type, typical TAs are less prominent, and
atypical astrocytic tau inclusions are sometimes observed
(Fig. 2B). These astrocytes in the striatum develop marked
proximal dominant tau accumulation, but these atypical
astrocytic tau inclusions are always accompanied by a few
typical TAs (Fig. 3d–f).TAs in the cerebral cortices develop
alongside NFT formations and other glial structures such as
coiled bodies and threads, although TAs are already found
early in PSP cases (within one year) and are even found in
cases without formation of significant NFTs or other glial
inclusions. Therefore, TAs do not necessarily accompany
neuronal loss and reactive gliosis, but rather, they reflect
intrinsic tau aggregation in astrocytes.28
Differential structures are tau-positive dystrophic
neurites that surround senile plaques, thorn-shaped
astrocytes, astrocytic plaques, coiled bodies, threads, and
globular glial inclusions in globular glial tauopathies,29
although these structures are generally well-differentiated
based on each of their characteristic distributions and mor-
phology, or by using immunohistochemistry to detect tau
or Aβ (Fig. 3k–o).
CORTICOBASAL DEGENERATION (CBD)
CBD is a rare, progressive neurological disorder character-
ized by widespread hyperphosphorylated 4R tau pathology
in neurons and glia in both cortical and subcortical areas.4
The clinical presentation originally described by Rebeiz
et al. involves asymmetric motor dysfunction including
prominent involuntary movements.2 Additional reports

© 2014 Japanese Society of Neuropathology

562 M Yoshida

have described similar patients who, in addition, demon- cal diseases: one with motor neuron disease with TDP-43
strated supranuclear gaze palsy and Parkinsonian proteinopathy, one with DLB, and one demonstrated a
features.27,30–32 Although the combination of asymmetric clinical history of cerebral palsy. The 27 cases that were
motor disturbances with cortical sensory loss and apraxia analyzed had a mean age at onset of 63 years (range 51–79
without marked cognitive dysfunction has been thought to years), a mean disease duration of 6 years (range 3–13
be specific for CBD, neuropathologically documented years), and a mean age at death of 69 years (range 54–
presentations as PSP and Parkinson’s disease make ante- 86 years). Although CBD is most often a sporadic
mortem diagnosis of CBD difficult.33–35 disease, approximately 7% of affected individuals have a
family history of neurological disorders, including PSP or
dementia.
CLINICAL ASPECTS
In light of advances in the understanding of CBD, new
Macroscopic and microscopic findings
guidelines have recently proposed 4 CBD phenotypes:
CBS, which presents as an asymmetric movement disorder Typical macroscopic findings (Fig. 4A) include hemia-
combined with lateralized higher cortical features, trophy or bilateral asymmetrical cortical atrophy, which
frontal behavioral-spatial syndrome (FBS), a nonfluent/ predominates in the perirolandic area, posterior-frontal to
agrammatic variant of primary progressive aphasia the parietal area, anterior frontal, or in the perisylvian
(naPPA), and progressive supranuclear palsy syndrome area. Coronal sections demonstrate thinning of cortical
(PSPS).36 ribbons associated with rarefaction of subcortical white
matter in the affected cortices. Medial temporal structures
Neuropathology are relatively preserved, but the brainstem and cerebellum
Neuropathological diagnostic criteria may show variable atrophy. The substantia nigra consist-
ently shows severe depigmentation, with variable atrophy
Due to the uncertainty and heterogeneity of the clinical of the basal ganglia including the globus pallidus and the
criteria for the diagnosis of CBD, neuropathological subthalamic nucleus.
examination is the gold standard used to make a definitive The characteristic pathological hallmark of CBD is the
diagnosis. Clear pathological criteria have been proposed swollen achromatic neuron, or ballooned cell (Table 1,
that were not adversely influenced by clinical information.5 Fig. 5a) that is present in affected cortical areas; however,
These criteria emphasize tau-immunoreactive lesions in ballooned neurons are nonspecific, and their quantity may
neurons, glia, and cell processes in the neuropathologic vary according to the severity of the cortical involvement.
diagnosis of CBD, although cortical atrophy, ballooned Neuronal loss and gliosis are seen in the affected cortices,
neurons, and degeneration of the substantia nigra have and typically, the degeneration of subcortical white matter
been emphasized in previous descriptions. The minimal is severe (Fig. 4Ac,d). Prominent cell loss and gliosis occur
pathologic features required for a diagnosis of CBD are in the substantia nigra and are associated with varying
cortical and striatal tau-positive neuronal and glial lesions, degeneration of the globus pallidus and, to a lesser extent,
especially APs and thread-like lesions in both white matter of the subthalamic nucleus.The caudate and putamen show
and gray matter; neuronal loss in focal cortical regions and mild to moderate gliosis.
in the substantia nigra are also prerequisites for a diagnosis The pathological hallmarks of CBD are hyperphos-
of CBD (Table 1). phorylated 4R tau- positive neuronal and glial inclusions,
pretangles, NFTs, threads, APs, and coiled bodies (Table 1,
Reevaluation of the neuropathology in CBD cases
Fig. 5). Immunohistochemistry for the detection of hyper-
Among the 30 pathologically confirmed CBD cases from phosphorylated tau reveals these abnormal tau aggregates,
our institute, 3 cases were associated with other neurologi- but they are most conspicuous after GB silver staining.
▶
Fig. 4 Macroscopic findings in typical CBD (A) and PSP-like CBD (B). (A) Macroscopic findings in typical CBD show right side-
predominant bilateral cerebral atrophy (a). A coronal section demonstrates right side-predominant frontal atrophy, thinning of cortical
ribbons and subcortical white matter, and atrophy of the globus pallidus and subthalamic nucleus associated with atrophy of the putamen
and caudate (b). Medial temporal structures are relatively preserved. The same specimens as in panel (b) demonstrate right side-
predominant atrophy of cortical and basal ganglia with reduced Klüver-Barrera staining of subcortical white matter including U-fibers (c),
and this is shown by Holzer staining to be accompanied with fibrous gliosis (d). Bar = 2 cm. (B) Macroscopic findings in PSP-like CBD
indicate severe atrophy of the pallidum and subthalamic nucleus with relatively mild degeneration of the cerebral cortices and subcortical
white matter (a, b) and severe depigmentation of the substantia nigra accompanied by atrophy of the brainstem tegmentum (c, d) and
dentate nucleus (e). Microscopically, astrocytic plaques are found in the basal ganglia and cerebral cortices (f). In the pontine nucleus,
numerous pretangles, threads and neurites are found (g). b, d, e, Klüver-Barrera staining and Holzer stain. a, c, bar = 2 cm; f, bar = 10 μm;
g, bar = 50 μm.

© 2014 Japanese Society of Neuropathology

Astrocytic inclusions in PSP and CBD 563

© 2014 Japanese Society of Neuropathology

564 M Yoshida

Fig. 5 Major microscopic findings in CBD. Microscopic findings in CBD include ballooned neurons (a), numerous tau-positive threads
in cortical and subcortical structures (b), pretangles (c) and APs (d). An AP has Gallyas-positive (e) and 4R tau-positive (f) filamentous
structures associated with collaterals (g) in a coronal arrangement. A double-immunofluorescence study of APs indicates a tau-positive
coronal arrangement of filaments (h, red) located into the distal portion of GFAP-positive astrocytic processes (green), which are shown
merged only within the distal portions (i). a, H&E; b, c, d, g, AT8; e, Gallyas silver stain; f, RD4 immunohistochemistry; h, i, double-
immunofluorescence for tau (red) and GFAP (green). a, d, g, bar = 10 μm; b, bar = 50 μm; c, f, bar = 20 μm. e, bar = 100 μm.

© 2014 Japanese Society of Neuropathology

Astrocytic inclusions in PSP and CBD 565

Fig. 6 Ultrastructural characterization of AP. Lower magnification of an AP, indicate Q dot-labeled AT8-positive short filaments (black
arrow) loosely bundled near the synaptic structures and glial filaments (white arrow) (a). Higher magnification (b) indicates Q dot-labeled
tau-positive short filamentous structures (black arrow) are inserted into a narrow gap near the synaptic structures. These short filamentous
structures may represent the collateral structures of APs.

Although threads, pretangles and APs are highly specific scopic examination was performed using the pre-
for CBD, APs are almost exclusively seen in CBD and are embedding Q-dots immunolabeling, which was modified
considered a diagnostic hallmark. from the previously reported method.38–40 It revealed that
an AP contained a randomly arranged bundle of straight
Definition and differentials of astrocytic plaques and twisted tubules in 15–20 nm diameter and the tau-
positive filaments were densely immunolabeled with
APs are not visualized in hematoxylin-eosin staining, but
Q-dots (Fig. 6). Some of these filaments are located in a
GB silver staining and tau immunohistochemistry reveal
narrow hollow near synaptic structures (Fig. 6b). These
their distinctive morphology. APs exhibit a corona-like
findings suggested that the bush-like or collateral appear-
arrangement and are composed of fuzzy, short processes
ance of tau-positive APs may reflect the collaterals of distal
with tapered ends and fine collaterals, which were more
astrocytic processes, which serve as a cover layer for the
evident on GB silver staining (Fig. 5d–g). No cytoplasmic
dendritic and perikaryal surfaces of certain neurons, and
staining was observed within the APs.6
groups of, or individual synapses.41 The location of filamen-
APs were first identified by Feany and Dickson 37 using
tous tau accumulation of APs in the immediate vicinity of
immunohistochemistry and laser confocal microscopy.
the synaptic structures suggest that APs may impair syn-
They demonstrated that the nonamyloid cortical plaques
aptic functions. APs were most abundant in the prefrontal
of CBD are actually collections of abnormal tau in the
and premotor areas in the cerebral cortex of brains from
distal processes of astrocytes, which were defined as APs.
individuals diagnosed with CBD, but many APs were also
These glial cells express both vimentin and CD44, markers
observed in the caudate nucleus.42 They are rarely seen in
of astrocyte activation.
white matter with numerous tau-positive threads, despite
Differential structures are threads, TAs, other tau-
severe gliosis. This also suggests that the morphology of the
positive astrocytic inclusions and senile plaques. Threads
processes of protoplasmic astrocytes in the gray matter
are fine, thin filamentous structures that are abundant in
may be closely related to the corona-like structures of APs
the cerebral cortices, subcortical white matter, basal
(Figs 7,8). The origin of tau-positive filaments in APs is still
ganglia, and brain stem; they are not corona-like in appear-
unknown. The density of APs is variable according to the
ance and do not have collaterals or a bush-like appearance.
degree and extent of the disease of the affected cortices.
Senile plaques are composed of amyloid β accompanied by
Even when the degeneration of the cerebral cortices is
tau-positive dystrophic neurites. TAs in PSP have been
mild, a small number of typical APs are enough for a diag-
described previously.
nosis of CBD.
Using double immunofluorescence staining, APs were
found to be partially demonstrated colocalization with
Correlation between APs and
GFAP and tau in the distal portion of GFAP- positive
clinicopathological features
asrtrocytic processes (Fig. 5h,i). Colocalization of GFAP
and tau was not clearly observed in the cytoplasm or in the Based on the distribution of neuronal loss with gliosis and
proximal processes of astrocytes. Immunoelectron micro- tau positive neuronal and glial inclusions in the 27 CBD

© 2014 Japanese Society of Neuropathology

566 M Yoshida

Fig. 7 Schematic illustration of tau accumulation in TAs of PSP and APs of CBD. In TAs (a), radially arranged filamentous tau
aggregation (red lines) occurs in the cytoplasm and proximal processes of astrocytes. In APs (b), annularly distributed tau aggregation
(green lines) is formed in the most distal portion of the astrocytic processes associated with collaterals. (Modified diagram reproduced with
the permission of Igaku-Shoin from “A Guide to Neuropathology” by Hirano A, p205, Tokyo, 1981)40

cases, pathological topography was grossly divided into 3
representative subtypes: typical CBD type, basal ganglia
predominant type, and PSP-like type (Fig. 1B). Typical
CBD type (15 out of 27 cases, 56%) represents prototypical
CBD and involves asymmetrical degeneration of the cer-
ebral cortices and subcortical white matter, substantia
nigra, pallidum, and the subthalamic nucleus, from a mod-
erate to a severe extent (Fig. 1B). In the typical CBD type,
the cortical distribution was predominantly in the posterior
frontoparietal and perisylvian areas in 10 cases (37%), and
in the anterior frontal area in 5 cases (19%). The PSP-like
type (9 cases, 33%) revealed prominent involvement of the
basal ganglia, brainstem and cerebellar dentate nucleus
with mild to moderate involvement of the cerebral cortices
without obvious laterality (Fig. 1B,4B). The basal ganglia-
predominant type (3 cases, 11%) demonstrated relatively
confined lesions to the pallidum, subthalamic nucleus,
and the substantia nigra, with mild degeneration of the
cerebral cortices, white matter, brainstem and cerebellum
(Fig. 1B).43
The pathological subtypes wholly correspond to the
clinical phenotypes: pathologically typical CBD type with
posterior frontoparietal or perisylvian cortical lesions cor-
responds to CBD with clinical CBS; similarly, the patho-
logical PSP-like type corresponds to CBD with clinical PSP
syndrome. The pathologically typical CBD type with ante-
rior frontal involvement corresponds to the clinical pheno-
type FBS, and the basal ganglia-predominant type
demonstrates atypical parkinsonism or PSPS. Therefore,
clinical phenotypes depend on the topographical distribu-
tion and degree of degeneration of the cerebral cortices,
basal ganglia, and brainstem. In fact, we analyzed cases that
exhibited borderline pathology between those pathologi-
cal subtypes.
APs are exclusively seen in all CBD subtypes, although
the density is variable according to the cerebral regions
that are affected. APs are usually prominent in the
frontoparietal cortices and in the striatum, especially in the
caudate.43 In the typical CBD type, more prominent APs
are recognized in the affected cerebral cortices and in the
striatum. In the PSP-like type or the basal ganglia- pre-
dominant type, APs are located in the putamen and
caudate and to a lesser extent in the cerebral cortices. APs
typically associate with pretangles and threads.
UNDERLYING MECHANISM
Although PSP and CBD are independent 4R tauopathies,
highly overlapping pathological distributions seem to influ-
ence clinical diagnostic practices. The microscopic tau
pathology allows for the clear discrimination of distinct-
ive tau aggregates in neurons and glia between the two

© 2014 Japanese Society of Neuropathology

Astrocytic inclusions in PSP and CBD 567

Fig. 8 Schematic illustration of tau accumulation in neurons and glia in PSP and CBD. In PSP (left panel), filamentous tau aggregation
(red lines) is produced in the form of globose-type NFTs, TAs, and coiled bodies within the soma and proximal processes of neurons and
glia. In CBD (right panel) less fibrillar tau aggregation (yellow lines) is produced and thus the majority of aggregates appear in the form
of pretangles, APs, and threads within the cytoplasm of the soma and the distal processes of neurons and glia.

diseases. In this review, colocalization of TAs and APs was
not found, although colocalization of TAs and APs as well
as the coexistence of PSP and CBD in the same family
were reported in some cases.44–46 In the TAs of PSP, tau
accumulates in the proximal portion of astrocytic processes
and the perikaryon, in contrast to tau accumulation in the
distal processes of astrocytes in the APs of CBD (Fig. 7).
Tau accumulation of APs in the immediate vicinity of the
synaptic structures suggests synaptic dysfunction by APs,
which may provide the different pathophysiological
mechanism from that of AD with predominant neuronal
tau accumulation. Immunoelectron microscopic examina-
tion In Furthermore, in PSP, neuronal tau aggregates form
a fibrillar, globose type of NFT, while in CBD, less filamen-
tous tau accumulates in neurons as pretangles (Fig. 8).47,48
On immunoblots of sarkosyl-insoluble brain extracts, a
33-kDa band predominated in the low molecular weight
tau fragments in PSP, whereas two closely related bands of
approximately 37 kDa predominated in CBD. These
results suggest that despite the identical composition of the
tau isoforms, distinct proteolytic processing of abnormal
tau occurs in these two diseases.49
CONCLUSIONS
Astrocytic inclusions in PSP and CBD are briefly reviewed
along with the pathological characteristics of tau aggrega-
tion and the pathological diversity of PSP and CBD. The
different sites of tau aggregation in astrocytes and the dif-
ferent extent of fibril formation in neurons might help
differentiate these two 4R tauopathies (Fig. 8).
Addendum
Dr. Nakano I. from Tokyo Metropolitan Neurological Hos-
pital questioned the certainty of immunoelectron micro-
scopic findings and the relationship between the APs and
vessels. The double immunohistochemistry analysis of
vimentin and AT8 in the frontal cortices of CBD patients
indicated that the processes of astrocytes within APs rarely

© 2014 Japanese Society of Neuropathology

568
Fig. 9 Perivascular orientation of APs. Double immunohisto-
chemistry for vimentin (violet) and AT8 (brown) of the frontal
cortices in CBD indicates that the astrocytic processes radiate
continuously to AT8-positive APs (white arrow) and rarely
contact vessels (V), although some of the processes attached to
the vessels showed AT8-positive staining (black arrow). V, vessel;
A, astrocyte; bar = 10 μm.
contact vessels. Tau deposition into the perivascular foot
processes was not remarkable, although some of the pro-
cesses attached to the vessels demonstrated AT8-positive
staining (Fig. 9).50
COI
The author declares no competing interests.
ACKNOWLEDGMENTS
This work was presented in part at the 54th Annual Meeting
of the Japanese Society of Neuropathology (Tokyo, Japan,
2013) and was supported by grants from the Collaborative
Research Project [2012-2308 to MY] of the Brain Research
Institute, Niigata University and grants-in-aid from the
Research Committee of CNS Degenerative Diseases,
the Ministry of Health, Labour and Welfare of Japan. The
author acknowledges Dr. S. Tatsumi, Dr. M. Mimuro, and
Dr. Y. Iwasaki, and also thanks K. Koutani, T. Mizuno,
C. Sano and C. Uno for excellent technical assistance.
REFERENCES
1. Steele J, Richardson C, Olszewski J. Progressive
supranuclear palsy. Arch Neurol 1964; 10: 333–359.
2. Rebeiz JJ, Kolodny EH, Richardson EP Jr.
Corticodentatonigral degeneration with neuronal
achromasia: a progressive disorder of the late adult
life. Trans Am Neurol Assoc 1967; 92: 23–26.
M Yoshida
3. Hauw JJ, Daniel SE, Dickson D et al. Preliminary
NINDS neuropathologic criteria for Steele-
Richardson-Olszewski syndrome (progressive
supranuclear palsy). Neurology 1994; 44: 2015–2019.
4. Nukina N, Quan Y, Nakano I, Otomo E. Widespread
tau abnormality in a case of cortico-basal degenera-
tion. (In Japanese with English abstract. Rinsho
Shinkeigaku 1992; 32: 1093–1101.
5. Dickson DW, Bergeron C, Chin SS et al. Office of rare
diseases neuropathologic criteria for corticobasal
degeneration. J Neuropathol Exp Neurol 2002; 61: 935–
946.
6. Komori T, Arai N, Oda M et al. Astrocytic plaques and
tufts of abnormal fibers do not coexist in corticobasal
degeneration and progressive supranuclear palsy. Acta
Neuropathol 1998; 96: 401–408.
7. Williams DR, de Silva R, Paviour DC et al. Character-
istics of two distinct clinical phenotypes in path-
ologically proven progressive supranuclear palsy:
Richardson’s syndrome and PSP-parkinsonism. Brain
2005; 128: 1247–1258.
8. Williams DR, Holton JL, Strand C, Pittman A, de Silva
R et al. Pathological tau burden and distribution distin-
guishes progressive supranuclear palsy-parkinsonism
from Richardson’s syndrome. Brain 2007; 130: 1566–
1576.
9. Williams DR, Holton JL, Strand K et al. Pure akinesia
with gait freezing: a third clinical phenotype of pro-
gressive supranuclear palsy. Mov Disord 2007; 22:
2235–2241.
10. Mochizuki A, Ueda Y, Komatsuzaki Y, Tsuchiya K,
Arai T, Shoji S. Progressive supranuclear palsy
presenting with primary progressive aphasia –
Clinicopathological report of an autopsy case. Acta
Neuropathol 2003; 105: 610–614.
11. Josephs KA, Boeve BF, Duffy JR et al. Atypical pro-
gressive supranuclear palsy underlying progressive
apraxia of speech and nonfluent aphasia. Neurocase
2005; 11: 283–296.
12. Kanazawa M, Shimohata T, Toyoshima Y et al. Cer-
ebellar involvement in progressive supranuclear palsy:
a clinicopathological study. Mov Disord 2009; 24: 1312–
1318.
13. Iwasaki Y, Mori K, Ito M, Tatsumi S, Mimuro M,
Yoshida M. An autopsied case of progressive
supranuclear palsy presenting with cerebellar ataxia
and severe cerebellar involvement. Neuropathology
2013; 33: 561–567.
14. Litvan I, Hauw JJ, Bartko JJ et al. Validity and reli-
ability of the preliminary NINDS neuropathologic
criteria for progressive supranuclear palsy and
related disorders. J Neuropathol Exp Neurol 1996; 55:
97–105.
© 2014 Japanese Society of Neuropathology
Astrocytic inclusions in PSP and CBD
15. Kato T, Hirano A, Weinberg MN, Jacobs AK.
Spinalcord lesion in progressive supranuclear palsy:
somenew observations. Acta Neuropathol 1986; 71:
11–14.
16. Kikuchi H, Doh-ura K, Kira J, Iwai T. Preferential
neurodegeneration in the cervical spinal cord of pro-
gressive supranuclear palsy. Acta Neuropathol 1999;
97: 577–584.
17. Iwasaki Y, Yoshida M, Hashizume Y, Hattori M, Aiba
I, Sobue G. Widespread spinal cord involvement in
progressive supranuclear palsy. Neuropathology 2007;
27: 331–340.
18. Arai N, Oda M. A variety of glial pathological struc-
tures by the modified Gallyas-Braak method. Neuro-
pathology 1996; 16: 133–138.
19. Hauw JJ, Verny M, Delaere P, Cervera P, He Y,
Duyckaerts C. Constant neurofibrillary changes in the
neocortex in progressive supranuclear palsy. Basic dif-
ferences with Alzheimer’s disease and aging. Neurosci
Lett 1990; 119: 182–186.
20. Yamada T, McGeer PL, McGeer EG. Appearance of
paired nucleated, tau-positive glia in patients with pro-
gressive supranuclear palsy brain tissue. Neurosci Lett
1992; 135: 99–102.
21. Yamada T, Calne DB, Akiyama H, McGeer EG,
McGeer PL. Further observations on tau-positive glia
in the brains with progressive supranuclear palsy. Acta
Neuropathol 1993; 85: 308–315.
22. Nishimura T, Ikeda K, Akiyama H et al. Immunohisto-
chemical investigation of tau-positive structures in
the cerebral cortex of patients with progressive
supranuclear palsy. Neurosci Lett 1995; 201: 123–
126.
23. Nishimura M, Namba Y, Ikeda K, Oda M. Glial
fibrillary tangles with straight tubules in the brains of
patients with progressive supranuclear palsy. Neurosci
Lett 1992; 143: 35–38.
24. Arima K. Ultrastructural characteristics of tau fila-
ments in tauopathies: immuno-electron microscopic
demonstration of tau filaments in tauopathies. Neuro-
pathology 2006; 26: 475–483.
25. Iwasaki Y, Yoshida M, Hattori M et al. Distribution of
tuft-shaped astrocytes in the cerebral cortex in pro-
gressive supranuclear palsy. Acta Neuropathol 2004;
108: 399–405.
26. Yoshida M. Cellular tau pathology and immunohisto-
chemical study of tau isoforms in sporadic tauopathies.
Neuropathology 2006; 26: 457–470.
27. Boeve BF, Maraganore DM, Parisi JE et al. Pathologic
heterogeneity in clinically diagnosed corticobasal
degeneration. Neurology 1999; 53: 795–800.
28. Togo T, Dickson DW. Tau accumulation in astrocytes
in progressive supranuclear palsy is a degenerative
© 2014 Japanese Society of Neuropathology
569
rather than a reactive process. Acta Neuropathol 2002;
104: 398–402.
29. Ahmed Z, Bigio H, Budka H et al. Globular glial
tauopathies (GGT): consensus recommendations. Acta
Neuropathol 2013; 126: 537–544.
30. Gibb WR, Luthert PJ, Marsden CD. Corticobasal
degeneration. Brain 1989; 112: 1171–1192.
31. Riley DE, Lang AE, Lewis A et al. Cortical-basal gan-
glionic degeneration. Neurology 1990; 40: 1203–
1212.
32. Josephs KA, Tang-Wai DF, Edland SD et al. Correla-
tion between antemortem magnetic resonance imaging
findings and pathologically confirmed corticobasal
degeneration. Arch Neurol 2004; 61: 1881–1884.
33. Mizuno T, Shiga K, Nakata Y et al. Discrepancy
between clinical and pathological diagnoses of CBD
and PSP. J Neurol 2005; 252: 687–697.
34. Murray R, Neumann M, Forman MS et al. Cognitive
and motor assessment in autopsy-proven corticobasal
degeneration. Neurology 2007; 68: 1274–1283.
35. Ling H, O’Sullivan SS, Holton JL et al. Does
corticobasal degeneration exist ? A clinicopathological
re-evaluation. Brain 2010; 133: 2045–2057.
36. Armstrong MJ, Litvan I, Lang AE et al. Criteria for the
diagnosis of corticobasal degeneration. Neurology
2013; 80: 496–503.
37. Feany MB, Dickson DW. Widespread cytoskeletal
pathology characterizes corticobasal degeneration.
Am J Pathol 1995; 146: 1388–1396.
38. Heines MA, Guyot-Sionnest P. Synthesis and charac-
terization of strongly luminsecing ZnS-capped CdSe
nanocrystals. J Phys Chem 1996; 100: 468–471.
39. Giepmans BN, Deerinck TJ, Smarr BL, Jones YZ,
Ellisman MH. Correlated light and electron micro-
scopic imaging of multiple endogenous proteins using
Quantum dots. Nat Methods 2005; 2: 743–749.
40. Uematsu M, Adachi E, Nakamura A, Tsuchiya K,
Uchihara T. Atomic identification of fluorescent
Q-dots on tau-positive fibrils in 3D-reconstructed Pick
bodies. Am J Pathol 2012; 180: 1394–1397.
41. Hirano A. A guide to neuropathology. IGAKU-
SHOIN Tokyo, 1981.
42. Hattori M, Hashizume Y, Yoshida M et al. Distribution
of astrocytic plaques in the corticobasal degeneration
brain and comparison with tuft-shaped astrocytes
in the progressive supranuclear palsy brain. Acta
Neuropathol 2003; 106: 143–149.
43. Hattori M, Yoshida M, Ojika K, Yuasa H, Mitake S
et al. An autopsy case of corticobasal degeneration
without prominent cortical pathology – an imitator of
progressive supranuclear palsy (in Japanese with
English astract). Rinsho Shinkeigaku 2000; 40: 372–
377.
570
44. Katsuse O, Iseki E, Arai T et al. 4-repeat tauopathy
sharing pathological and biochemical features of
corticobasal degeneration and progressive sup-
ranuclear palsy. Acta Neuropathol 2003; 106: 251–
260.
45. Tan CF, Piao YS, Kakita A et al. Frontotemporal
dementia with co-occurrence of astrocytic plaques and
tufted astrocytes, and severe degeneration of the cer-
ebral white matter: a variant of corticobasal degenera-
tion? Acta Neuropathol 2005; 109: 329–338.
46. Tuite PJ, Clark HB, Bergeron C et al. Clinical and
pathologic evidence of corticobasal degeneration and
progressive supranuclear palsy in familial tauopathy.
Arch Neurol 2005; 62: 1453–1457.
M Yoshida
47. Uchihara T, Mitani K, Mori H, Kondo H, Yamada M,
Ikeda K. Abnormal cytoskeletal pathology peculiar to
corticobasal degeneration is different from that of
Alzheimer’s disease or progressive supranuclear palsy.
Acta Neuropathol 1994; 88: 379–383.
48. Ikeda K. Basic pathology of corticobasal degeneration.
Neuropathology 1997; 17: 127–133.
49. Arai T, Ikeda K, Akiyama H et al. Identification of
amino-terminally cleaved tau fragments that distin-
guish progressive supranuclear palsy from corticobasal
degeneration. Ann Neurol 2004; 55: 72–79.
50. Shibuya K, Yagishita S, Nakamura A, Uchihara T.
Perivascular orientation of astrocytic plaques and tuft-
shaped astrocytes. Brain Res 2011; 1404: 50–54.
© 2014 Japanese Society of Neuropathology