Lack of effect of oral choline supplement on the concentrations of choline metabolites in human brain

'Citicoline' and support of the memory function: Evaluation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006

Following an application from Egde Pharma Sp. z o.o, submitted for authorisation of a health claim pursuant to Article 13(5) of Regulation (EC) No 1924/2006 via the Competent Authority of Poland, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on the scientific substantiation of a health claim related to citicoline and memory. The Panel considers that the food, citicoline (cytidine 5-diphosphocholine, CDP-Choline) inner salt, is sufficiently characterised. Improvement, maintenance or reduced loss of memory is a beneficial physiological effect for middle-aged or elderly adults encountering age-associated subjective memory impairment. The applicant identified three pertinent human intervention studies in healthy individuals that investigated the effect of citicoline on memory. In weighing the evidence, the Panel took into account that only one randomised controlled trial in healthy participants showed a beneficial effect of citicoline on episodic memory when consumed at doses of 500 mg/day for 12 weeks, whereas this effect has not been observed in another study using citicoline at doses of 1 g/day for 3 months or supported by data obtained in patients with dementia using doses of 1 g/day for 12 weeks and 12 months. No convincing evidence of a plausible mechanism by which citicoline or any of its components (in addition to their endogenous synthesis) could exert an effect on memory in humans has been provided. The Panel concludes that a cause-and-effect relationship has not been established between the consumption of citicoline (CDP-Choline) inner salt and improvement, maintenance or reduced loss of memory in middle-aged or elderly adults encountering age-associated subjective memory impairment.

Citicoline for Supporting Memory in Aging Humans

Citicoline is the generic name of CDP-choline, a natural metabolite present in all living cells. Used in medicine as a drug since the 1980-s, citicoline was recently pronounced a food ingredient. When ingested, citicoline breaks down to cytidine and choline, which become incorporated into their respective normal metabolic pathways. Choline is a precursor of acetylcholine and phospholipids; these is a neurotransmitter pivotal for learning and memory and important constituents of neuronal membranes and myelin sheaths, respectively. Cytidine in humans is readily converted to uridine, which exerts a positive effect on synaptic function and supports the formation of synaptic membranes. Choline deficiency has been found to be correlated with memory dysfunction. Magnetic resonance spectroscopy studies showed that citicoline intake improves brain uptake of choline in older persons, suggestive of that it shall help in reversing early age-related cognitive changes. In randomized, placebo-controlled trials of cognitively normal middle-aged and elderly persons, positive effects of citicoline on memory efficacy were found. Similar effects of citicoline on memory indices were also found in patients suffering from mild cognitive impairment and some other neurological diseases. Altogether, the aforementioned data provide complex and unambiguous evidence supporting the claim that oral citicoline intake positively influences memory function in humans who encounter age-related memory impairment also in the absence of any detectable neurological or psychiatric disease.

Every hit matters: White matter diffusivity changes in high school football athletes are correlated with repetitive head acceleration event exposure

Recent evidence of short-term alterations in brain physiology associated with repeated exposure to moderate intensity subconcussive head acceleration events (HAEs), prompts the question whether these alterations represent an underlying neural injury. A retrospective analysis combining counts of experienced HAEs and longitudinal diffusion-weighted imaging explored whether greater exposure to incident mechanical forces was associated with traditional diffusion-based measures of neural injury—reduced fractional anisotropy (FA) and increased mean diffusivity (MD). Brains of high school athletes (N = 61) participating in American football exhibited greater spatial extents (or volumes) experiencing substantial changes (increases and decreases) in both FA and MD than brains of peers who do not participate in collision-based sports (N = 15). Further, the spatial extents of the football athlete brain exhibiting traditional diffusion-based markers of neural injury were found to be significantly correlated with the cumulative exposure to HAEs having peak translational acceleration exceeding 20 g. This finding demonstrates that subconcussive HAEs induce low-level neurotrauma, with prolonged exposure producing greater accumulation of neural damage. The duration and extent of recovery associated with periods in which athletes do not experience subconcussive HAEs now represents a priority for future study, such that appropriate participation and training schedules may be developed to minimize the risk of long-term neurological dysfunction.

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Brain volumes evidencing injury are larger in football athletes than controls.

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Spatial extent of decreased FA correlates with head acceleration event exposure.

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Spatial extent of increased MD correlates with head acceleration event exposure.

900MHz 1H-/13C-NMR analysis of 2-hydroxyglutarate and other brain metabolites in human brain tumor tissue extracts

PURPOSE

To perform in vitro high-resolution 900 MHz magnetic resonance spectroscopy (NMR) analysis of human brain tumor tissue extracts and analyze for the oncometabolite 2-hydroxyglutarate (2HG) and other brain metabolites, not only for 1H but also for 13C with indirect detection by heteronuclear single quantum correlation (HSQC).

MATERIAL AND METHODS

Four surgically removed human brain tumor tissue samples were used for extraction and preparation of NMR samples. These tissue samples were extracted with 4% perchloric acid and chloroform, freeze-dried, then dissolved into 0.28 mL of deuterium oxide (D2O, 99.9 atom % deuterium) containing 0.025 wt % sodium 3-(trimethylsilyl)propionate-2,2,3,3-d4 (TSP). All samples were adjusted to pH range of 6.9-7.1 before finally transferred to 5 mm Shigemi™ NMR microtube. NMR experiments were performed on Bruker DRX 900 MHz spectrometer with 1H/13C/15N Cryo-probe™ with Z-gradient, without further temperature control for the samples. All chemical shift values were presented relative to TSP at 0.00 ppm for both 1H and 13C. 1H 1D, 1H-13C HSQC, 1H-1H correlation spectroscopy (COSY) and 1H-13C heteronuclear multiple bond correlation (HMBC) spectra were acquired and analyzed.

RESULTS

2-hydroxyglutarate, an oncometabolite associated with gliomas with IDH mutations, was successfully detected and assigned by both 1H-13C HSQC and 1H-1H COSY experiments as well as 1H 1D experiments in two of the tissue samples. In particular, to our knowledge this work shows the first example of detecting 900 MHz 13C-NMR spectral lines of 2-hydroxyglutarate in human brain tumor tissue samples. In addition to the oncometabolite 2-hydroxyglutarate, at least 42 more metabolites were identified from our series of NMR experiment.

CONCLUSION

The detection of 2-hydroxyglutarate and other metabolites can be facilitated by homonuclear and heteronuclear two-dimensional 900 MHz NMR spectroscopy even in case of real tumor tissue sample extracts without physical separation of metabolites.

Oral administration of choline does not affect metabolic characteristics of gliomas and normal-appearing white matter, as detected with single-voxel (1)H-MRS at 1.5 T

INTRODUCTION

The present study was done for evaluation of the possible influence of the oral administration of choline on metabolic characteristics of gliomas detected with proton magnetic resonance spectroscopy ((1)H-MRS).

MATERIALS AND METHODS

Thirty patients (22 men and eight women; mean age 38 +/- 15 years) with suspicious intracranial gliomas underwent single-voxel long-echo (TR 2,000 ms, TE 136 ms, 128-256 acquisitions) (1)H-MRS of the tumor, peritumoral brain tissue, and distant normal-appearing white matter before and several hours (median, 3 h; range, 1.2-3.7 h) after ingestion of choline with prescribed dose of 50 mg/kg (median actual dose, 52 mg/kg; range, 48-78 mg/kg). Investigations were done using 1.5 T clinical magnetic resonance imager. The volume of the rectangular (1)H-MRS voxel was either 3.4 or 8 cm(3). At the time of both spectroscopic examinations, similar voxels' positioning and size and technical parameters of (1)H-MRS were used. Surgery was done in 27 patients within 1 to 68 days thereafter. In all cases, more than 80% resection of the neoplasm was attained.

RESULTS

There were 12 low-grade gliomas and 15 high-grade gliomas. MIB-1 index varied from 0% to 51.7% (median, 13.8%). Statistical analysis did not disclose significant differences of any investigated metabolic parameter of the tumor, peritumoral brain tissue and distant normal-appearing white matter between two spectroscopic examinations.

CONCLUSION

Single-voxel (1)H-MRS at 1.5 T could not detect significant changes of the metabolic characteristics of gliomas, peritumoral brain tissue, and distant normal-appearing white matter after oral administration of choline.

The in-depth evaluation of suspected mitochondrial disease

Mitochondrial disease confirmation and establishment of a specific molecular diagnosis requires extensive clinical and laboratory evaluation. Dual genome origins of mitochondrial disease, multi-organ system manifestations, and an ever increasing spectrum of recognized phenotypes represent the main diagnostic challenges. To overcome these obstacles, compiling information from a variety of diagnostic laboratory modalities can often provide sufficient evidence to establish an etiology. These include blood and tissue histochemical and analyte measurements, neuroimaging, provocative testing, enzymatic assays of tissue samples and cultured cells, as well as DNA analysis. As interpretation of results from these multifaceted investigations can become quite complex, the Diagnostic Committee of the Mitochondrial Medicine Society developed this review to provide an overview of currently available and emerging methodologies for the diagnosis of primary mitochondrial disease, with a focus on disorders characterized by impairment of oxidative phosphorylation. The aim of this work is to facilitate the diagnosis of mitochondrial disease by geneticists, neurologists, and other metabolic specialists who face the challenge of evaluating patients of all ages with suspected mitochondrial disease.

Mitochondrial dysfunction in bipolar disorder: evidence from magnetic resonance spectroscopy research

Magnetic resonance spectroscopy (MRS) affords a noninvasive window on in vivo brain chemistry and, as such, provides a unique opportunity to gain insight into the biochemical pathology of bipolar disorder. Studies utilizing proton ((1)H) MRS have identified changes in cerebral concentrations of N-acetyl aspartate, glutamate/glutamine, choline-containing compounds, myo-inositol, and lactate in bipolar subjects compared to normal controls, while studies using phosphorus ((31)P) MRS have examined additional alterations in levels of phosphocreatine, phosphomonoesters, and intracellular pH. We hypothesize that the majority of MRS findings in bipolar subjects can be fit into a more cohesive bioenergetic and neurochemical model of bipolar illness that is both novel and yet in concordance with findings from complementary methodological approaches. In this review, we propose a hypothesis of mitochondrial dysfunction in bipolar disorder that involves impaired oxidative phosphorylation, a resultant shift toward glycolytic energy production, a decrease in total energy production and/or substrate availability, and altered phospholipid metabolism.

Valeurs contrôles obtenues avec une séquence press 135 ms en neurospectroscopie monovoxel du proton

The clinical value of MR spectroscopy is now well established and this technique has been added to the current French classification of medical acts (CCAM). This paper presents a set of normal control values for 3 metabolite ratios obtained using a PRESS sequence with a TE of 135 ms at 1.5T: NAA/Cho, NAA/Cr and Cho/CR. Spectroscopy data acquisition were obtained from the following 12 anatomical regions: parieto-occipital white matter, centrum semiovale, frontal white matter, thalamus, basal ganglia, cerebellum (hemisphere, including dentate nucleus), brain stem (including pons, medulla and midbrain), anterior and posterior temporal lobe, parietal, occipital and pre-frontal cortices. The presented data allow radiologists equipped with a similar MR system to implement a clinical spectroscopy program without undergoing research protocols in order to obtain control values.

Oral choline increases choline metabolites in human brain

Choline, a precursor of acetylcholine and phosphatidylcholine, is largely obtained from the diet. Animal studies demonstrate increased choline metabolites in brain following oral administration. Several proton magnetic resonance spectroscopy ((1)H-MRS) reports differ as to whether similar increases are observable in human subjects. This study was designed to minimize intra-subject variance and thereby maximize the ability to determine if a significant increase in brain choline can be detected after choline ingestion. (1)H-MRS was performed continuously for 2.5 h on 11 healthy young males following choline ingestion. Nine of the original subjects returned for identical scans without choline ingestion. Following oral choline, there was a statistically significant increase in the choline signal (Cho) measured from the left putamen, representing choline-containing compounds, as measured against creatine (Cr) or N-acetylaspartate (NAA). The mean increase in Curve maxima (C(max)) is 6.2% for Cho/Cr and 3.0% for Cho/NAA. The Mean Time to C(max) (T(max)) was approximately 2 h after ingestion. A 3-6% increase in Cho by MRS likely corresponds to a 10-22% increase in phosphocholine, similar to findings in animal studies. In conclusion, a significant increase in choline-containing compounds in human brain can be detected by (1)H-MRS after choline ingestion in young subjects.

Choline in the aging brain

Proton magnetic resonance spectroscopy has been increasingly utilized in brain research to monitor non-invasively metabolites such as N-acetyl aspartate (NAA), creatine (Cr) and choline (Cho). We present here studies of the effect of aging on the ratios of these metabolites measured in the rat brain in vivo and on choline transport and lipid synthesis in rat brain slices, in vitro. The in vivo studies indicated that the ratios of Cho/NAA and Cho/Cr increased in the aged hippocampus, whereas the ratio of Cr/NAA was similar in the aged and adult hippocampus. These three ratios remained similar in the cortex of adult and aged rats. The in vitro studies revealed that in the aged cortex and the aged hippocampus the activity of the low-affinity choline uptake increased, possibly compensating for a decrease in the high-affinity uptake activity and the rate of choline diffusion. The incorporation of choline into phospholipids exhibited high and low affinity kinetics which were not modified by aging.

Role of phospholipase A(2) on the variations of the choline signal intensity observed by 1H magnetic resonance spectroscopy in brain diseases

Phospholipase A(2) catalyzes the hydrolysis of membrane glycerophospholipids leading to the production of metabolites observable by both 1H and 31P magnetic resonance spectroscopy. The signal of choline-containing compounds (Cho) observed by 1H magnetic resonance spectroscopy is constituted of metabolites of phosphatidylcholine, especially phosphocholine (PCho) and glycerophosphocholine (GPCho). The phosphomonoester (PME) and phosphodiester (PDE) signals observed by 31P magnetic resonance spectroscopy are, respectively, precursors and catabolites of phospholipids. A large number of brain diseases have been reported to cause variations in the intensity of the Cho, PME and PDE signals. Changes in the activity of phospholipase A(2) have been measured in many brain diseases. In this review, the relationships between the results of 1H and 31P magnetic resonance spectroscopy and the phospholipase A(2) assays are analyzed. In many brain diseases, the variation in the Cho signal intensity can be correlated with a stimulation or inhibition of the phospholipase A(2) activity.

Proton NMR chemical shifts and coupling constants for brain metabolites

Proton NMR chemical shift and J-coupling values are presented for 35 metabolites that can be detected by in vivo or in vitro NMR studies of mammalian brain. Measurements were obtained using high-field NMR spectra of metabolites in solution, under conditions typical for normal physiological temperature and pH. This information is presented with an accuracy that is suitable for computer simulation of metabolite spectra to be used as basis functions of a parametric spectral analysis procedure. This procedure is verified by the analysis of a rat brain extract spectrum, using the measured spectral parameters. In addition, the metabolite structures and example spectra are presented, and clinical applications and MR spectroscopic measurements of these metabolites are reviewed.

Brain biochemistry using magnetic resonance spectroscopy: relevance to psychiatric illness in the elderly

Magnetic resonance spectroscopy (MRS) allows for the noninvasive study of cerebral biochemistry. It has been used to investigate cerebral metabolic changes associated with mental illness in vivo and in vitro. In this review, we will discuss the application of MRS to psychiatric illness in the elderly. Following a brief description of the basic principles of MRS, the use of phosphorus (31P) and proton (1H) MRS to enable a better understanding of normal brain aging, dementia (Alzheimer's disease, multiple subcortical infarct dementia, Down syndrome, frontotemporal dementia, vascular dementia, age-associated memory impairment, and other dementias), major depression, and electroconvulsive therapy is detailed.

Developmental changes in choline- and ethanolamine-containing compounds measured with proton-decoupled (31)P MRS in in vivo human brain

Cerebral phosphorylated metabolites, possibly involved in membrane and myelin sheath metabolism, were measured and quantified using proton-decoupled (31)P ({(1)H}-(31)P) MRS in 32 children and 28 adults. Age-dependent changes were determined for phosphorylethanolamine (PE), phosphorylcholine (PC), glycerophosphorylethanolamine (GPE), glycerophosphorylcholine (GPC), and phosphocreatine (PCr) concentrations. In the neonate, PE dominates the spectrum and decreases with age along with PC, whereas GPE, GPC, and PCr increase in concentration with postnatal age. PE (1.23 +/- 0.13 mM) and GPE (0.57 +/- 0.08 mM) co-resonate with choline in (1)H MRS. Together with PC (0.57 +/- 0.12 mM) and GPC (0. 94 +/- 0.13 mM) these four metabolites accounted for all of the visible (1)H MRS choline in normal adult brain. Children with diseases that affect myelination were found to have abnormal ¿(1)H¿-(31)P MRS. The new quantitative assay may provide novel insights in determining and monitoring normal and abnormal brain maturation noninvasively. Magn Reson Med 42:643-654, 1999.

Molecular aspects of magnetic resonance imaging and spectroscopy

Magnetic resonance imaging (MRI) is a well known diagnostic tool in radiology that produces unsurpassed images of the human body, in particular of soft tissue. However, the medical community is often not aware that MRI is an important yet limited segment of magnetic resonance (MR) or nuclear magnetic resonance (NMR) as this method is called in basic science. The tremendous morphological information of MR images sometimes conceal the fact that MR signals in general contain much more information, especially on processes on the molecular level. NMR is successfully used in physics, chemistry, and biology to explore and characterize chemical reactions, molecular conformations, biochemical pathways, solid state material, and many other applications that elucidate invisible characteristics of matter and tissue. In medical applications, knowledge of the molecular background of MRI and in particular MR spectroscopy (MRS) is an inevitable basis to understand molecular phenomenon leading to macroscopic effects visible in diagnostic images or spectra. This review shall provide the necessary background to comprehend molecular aspects of magnetic resonance applications in medicine. An introduction into the physical basics aims at an understanding of some of the molecular mechanisms without extended mathematical treatment. The MR typical terminology is explained such that reading of original MR publications could be facilitated for non-MR experts. Applications in MRI and MRS are intended to illustrate the consequences of molecular effects on images and spectra.

Neither short-term nor long-term administration of oral choline alters metabolite concentrations in human brain

BACKGROUND

This study reexamined conflicting proton magnetic resonance spectroscopy (MRS) reports of increased or unaffected choline-containing compounds (Cho) in human brain in response to a single dose of 50 mg/kg choline bitartrate.

METHODS

The present work was based on a well-established strategy for quantitative proton MRS (2.0 T, STEAM localization sequence, TR/TE/TM = 6000/20/10 ms, LCModel automated spectral evaluation) that allows the determination of cerebral metabolite concentrations rather than T1-weighted resonance intensity ratios. Moreover, the investigations were extended to a possible long-term effect of oral choline by monitoring the continuous ingestion of 2 x 16 g of lecithin per day for 4 weeks. Six young healthy volunteers participated in each study and metabolite concentrations were determined in standardized locations in gray matter, white matter, cerebellum, and thalamus.

RESULTS

Neither for short-term nor for long-term administration of choline do the data reveal statistically significant deviations from the basal concentrations of Cho, total N-acetyl-containing compounds (neuronal markers), total creatine, and myo-inositol (glial marker) in any of the investigated brain regions.

CONCLUSIONS

Previous reports of increased Cho are not confirmed.

In vivo magnetic resonance spectroscopy of human fetal neural transplants

To better define the survival and cellular composition of human fetal neurotransplants in vivo, we performed quantitative 1H MRS to determine the concentration of the neuronal amino acid [N-acetylaspartate] within MRI-visible grafts. In all, 71 grafts in 38 patients [24 Parkinson's disease (PD), 14 Huntington's disease (HD)] were examined, as well as 24 untreated PD and HD patients and 13 age-matched normal controls. MRI appearances of edema were present in three out of 71 grafts, the remainder being consistent with histologically identified viable neural transplant tissue. N-acetylaspartate (NAA), creatine, choline, myoinositol and glutamine plus glutamate (Glx) were identified in all post-transplant putamens, with abnormal metabolites, lactate and/or lipid detectable in only three patients. Of 71 grafts, 19 occupied more than 60% of the MRS-examined volume (VOI) (mean 84.2 +/- 3%; range 61-100%). In those, [NAA] was 8.50 +/- 0.99 mM in eight PD spectra and 6.59 +/- 0.81 mM in 11 HD spectra, and was not significantly different from controls. In contrast, transplanted fetal neurones contain less than 0.4 mM of the neuronal amino acid NAA. This suggests that established fetal neurotransplants in the human putamen of both PD and HD patients are populated by adult neurones, axons and dendrites.

Quantitative proton-decoupled 31P MRS of the schizophrenic brain in vivo

Quantitative proton MR spectroscopy (MRS) and proton-decoupled phosphorus MRS were applied in the parietal cortex of 13 schizophrenic subjects (11 drug-treated and 2 neuroleptic-naive) and 15 normal control subjects. Significantly increased concentrations of glycerophosphorylcholine (1.18 +/- 0.16 vs. 0.93 +/- 0.14 mmol/kg brain; p < 0.001), glycerophosphoethanolomine (0.70 +/- 0.19 vs. 0.59 +/- 0.07 mmol/kg; p < 0.04), and phosphocreatine (3.73 +/- 0.39 vs. 3.41 +/- 0.13 mmol/kg; p < 0.007), but no differences in N-acetylaspartate, total creatine, or myo-inositol, were determined in treated schizophrenic subjects. Identical abnormalities were found in two neuroleptic-naive patients. These results provide new evidence of disordered cerebral membrane and high energy phosphate metabolism in schizophrenia.