Quantitative changes of sural nerves in various neurological diseases

Abnormal cortical brain integration of somatosensory afferents in ALS

OBJECTIVES

Infraclinical sensory alterations have been reported at early stages of amyotrophic lateral sclerosis (ALS). While previous studies mainly focused on early somatosensory evoked potentials (SEPs), late SEPs, which reflect on cortical pathways involved in cognitive-motor functions, are relatively underinvestigated. Early and late SEPs were compared to assess their alterations in ALS.

METHODS

Median and ulnar nerves were electrically stimulated at the wrist, at 9 times the perceptual threshold, in 21 ALS patients without clinical evidence of sensory deficits, and 21 age- and gender-matched controls. SEPs were recorded at the Erb point using surface electrodes and using a needle inserted in the scalp, in front of the primary somatosensory area (with reference electrode on the ear lobe).

RESULTS

Compared to controls, ALS patients showed comparable peripheral (N9) and early cortical component (N20, P25, N30) reductions, while the late cortical components (N60, P100) were more depressed than the early ones.

CONCLUSIONS

The peripheral sensory alteration likely contributed to late SEP depression to a lesser extent than that of early SEPs.

SIGNIFICANCE

Late SEPs may provide new insights on abnormal cortical excitability affecting brain areas involved in cognitive-motor functions.

Visualization of Sensory Neurons and Their Projections in an Upper Motor Neuron Reporter Line

Visualization of peripheral nervous system axons and cell bodies is important to understand their development, target recognition, and integration into complex circuitries. Numerous studies have used protein gene product (PGP) 9.5 [a.k.a. ubiquitin carboxy-terminal hydrolase L1 (UCHL1)] expression as a marker to label sensory neurons and their axons. Enhanced green fluorescent protein (eGFP) expression, under the control of UCHL1 promoter, is stable and long lasting in the UCHL1-eGFP reporter line. In addition to the genetic labeling of corticospinal motor neurons in the motor cortex and degeneration-resistant spinal motor neurons in the spinal cord, here we report that neurons of the peripheral nervous system are also fluorescently labeled in the UCHL1-eGFP reporter line. eGFP expression is turned on at embryonic ages and lasts through adulthood, allowing detailed studies of cell bodies, axons and target innervation patterns of all sensory neurons in vivo. In addition, visualization of both the sensory and the motor neurons in the same animal offers many advantages. In this report, we used UCHL1-eGFP reporter line in two different disease paradigms: diabetes and motor neuron disease. eGFP expression in sensory axons helped determine changes in epidermal nerve fiber density in a high-fat diet induced diabetes model. Our findings corroborate previous studies, and suggest that more than five months is required for significant skin denervation. Crossing UCHL1-eGFP with hSOD1^G93A mice generated hSOD1^G93A-UeGFP reporter line of amyotrophic lateral sclerosis, and revealed sensory nervous system defects, especially towards disease end-stage. Our studies not only emphasize the complexity of the disease in ALS, but also reveal that UCHL1-eGFP reporter line would be a valuable tool to visualize and study various aspects of sensory nervous system development and degeneration in the context of numerous diseases.

Changes of unmyelinated nerve fibers in sural nerve in amyotrophic lateral sclerosis, Parkinson's disease and multiple system atrophy

Quantitative changes in unmyelinated nerve fibers (UMNFs) of sural nerves in patients of amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD) and multiple system atrophy (MSA) were evaluated using autopsy materials whose pathological diagnosis had been confirmed by careful postmortem examinations. Ordinary ALS cases demonstrated no involvement in cutaneous UMNFs; however, the patients with long survival due to the application of ventilatory support showed bimodality in UMNF diameter histograms, and a patient with involvement of systems other than motor pathways showed an abnormal value in two indices: a low percentage of subunits containing axon(s) and a high mean number of Schwann cell profiles per axon. A significant reduction of the mean value of UMNF density (21%) was found in PD patients. Because the density of myelinated nerve fibers did not show any significant decrease as compared with age-matched controls, the change of nerve fibers in peripheral nervous system was considered to be confined to UMNFs in PD. Elderly PD cases showed enhanced changes in the ageing process, as expressed by the two indices described above. In MSA, the mean value of UMNF density was significantly decreased (23%), and this decrease almost paralleled that of myelinated nerve fiber density. Abnormal values for the two indices described above were found and two out of four cases demonstrated bimodality in the diameter histogram of UMNFs. Unlike MSA, ALS and PD have not been included in the disorders with cutaneous UMNF involvement. Our results supply the first evidence of morphological changes in cutaneous UMNFs in PD cases. In ordinary ALS cases, the emergence of such morphological changes is suggested in cases with long survival.

Serum IgG antibodies to a 35-kDa P0-related glycoprotein in motor neuron disease

Using an immunoblot technique we found a significantly higher frequency of serum IgG antibodies to a 35-kDa peripheral nerve myelin glycoprotein in patients with motor neuron disease (MND) (39% of 70) than in patients with neuropathy (13% of 61), other neurological disease (9% of 32) and normal subjects (5% of 20) (P < 0.005 in all cases), but not with multiple sclerosis (MS) (20% of 30) or non-neural immune diseases (25% of 32). Most positive patients had antibody titers of 1:200 or 1:2000 while higher titers were only found in seven patients with MND, one with chronic inflammatory demyelinating neuropathy, two with MS, two with non-neural immune diseases and one with stroke. The reacting protein had a higher molecular mass than P0 and was only faintly bound by an anti-P0 antiserum, but had the same N-terminal amino acid sequence of P0. The difference in molecular mass between P0 and the 35-kDa protein and the IgG reactivity of one patient's IgG with the 35-kDa protein persisted after its deglycosylation and dephosphorylation. Although there is no evidence that these antibodies are pathogenic, their frequent occurrence in MND and other immune-mediated conditions supports the hypothesis of an activation of the immune system in MND.

Progressive sensory nerve dysfunction in amyotrophic lateral sclerosis: a prospective clinical and neurophysiological study

Sensory nerve function was determined in 19 patients with amyotrophic lateral sclerosis (ALS), using a battery of clinical and neurophysiological tests. This assessment was repeated on 12 patients after intervals of 6-18 months. Twelve controls were also studied. In the ALS group, only 2 patients had noticed mild sensory symptoms and none had sensory signs. Between successive studies the vibration thresholds increased, but not to a significant degree. ALS patients showed a significant fall in amplitude of the sensory nerve action potentials in the median, radial, and sural nerves (P < 0.04); sensory nerve conduction velocity did not alter. The median nerve somatosensory evoked potential N19 latency showed a highly significant increase (P < 0.008). Significant subclinical deterioration in sensory nerve function occurs in ALS, and parallels the progressive motor decline. Neuronal degeneration in ALS is not restricted to motor neurons.

Involvement of peripheral sensory fibers in amyotrophic lateral sclerosis: electrophysiological study of 64 cases

We report electrophysiological findings of conduction along peripheral sensory fibers in 64 patients with amyotrophic lateral sclerosis. Distribution of the values of action potential amplitudes and conduction velocities of peripheral afferent fibers were significantly lower than in normal age-matched controls. Sensory action potential amplitudes (SAPas) were more affected than sensory conduction velocities (SCVs). When single patients were considered, SAPas were slightly but significantly reduced in 22% of the cases (median nerve 17%, ulnar nerve 11%, and sural nerve 22%). A parallel decrease in SCVs and MCVs in 14 patients in whom the study was repeated over a period of time was also found. All these electrophysiological findings are due to progressive neuronopathy of peripheral sensory fibers. A pathogenetic mechanism is proposed.

Age-dependent changes in cat masseter nerve: an electrophysiological and morphological study

The present study was undertaken to determine the manner in which aging affects the function and structure of the masseter nerve in old cats. Electrophysiological data demonstrated a significant decrease in the conduction velocity of the action potential in old cats compared with that observed in adult cats. Light microscopic analyses revealed an age-dependent decrease in axon diameter. Electron microscopic observations of the masseter nerve in the aged cats revealed a disruption of the myelin sheaths and a pronounced increase in collagen fibers in the endoneurium and perineurium. These morphological changes are discussed and then related to the decrease in conduction velocity which was observed in the electrophysiological portion of this study.

Sensory nerve pathology in amyotrophic lateral sclerosis

A detailed morphometric study was performed on sural nerve biopsies to determine the consistency of sensory nerve pathology in amyotrophic lateral sclerosis (ALS) and to seek a correlation between the severity of peripheral nerve pathology and disease duration. Nerve biopsies from patients with ALS consistently showed evidence of early axonal atrophy, increased remyelination and a shift in the diameter distributions curve towards smaller fiber diameters. Importantly, the severity of sensory nerve pathology in ALS patients correlated with disease duration. The peripheral nerve sodium pump concentration of patients was not reduced. It is concluded that an ingravescent dorsal root ganglion neuronopathy is seen in the incipient stages of ALS, preferentially affecting the largest neurons and resulting in turn in progressive axonal atrophy, secondary demyelination-remyelination and finally in nerve fiber degeneration. Etiologically, a parallel involvement of motor and sensory neurons suggests a more widespread metabolic disturbance in ALS than simply "sick" motor neurons.

Magnetic resonance imaging in motor neuron disease

Magnetic resonance imaging (MRI) of the brain was evaluated in 20 patients with motor neuron disease (MND) and in a control group of 11 healthy people. Bilateral increased signal areas of various sizes in the centrum semiovale, corona radiata, internal capsule, pedunculi of midbrain, pons, medulla and even in the frontal lobe, topographically related with the corticospinal tract, were found in 8 out of 20 patients. Three out of 4 patients with progressive bulbar paralysis and 5 out of 11 cases of amyotrophic lateral sclerosis had abnormal MRI. Such MRI abnormalities have neither been found in patients with progressive muscular atrophy nor in controls, suggesting that they may be the hallmark of pyramidal tract degeneration in motor neuron disease.

Differential diagnosis between amyotrophic lateral sclerosis and spinal muscular atrophy by skin involvement

Amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA) might be clinical variants caused by the same etiology, or different diseases altogether. We studied the skin in 12 patients with ALS and 7 patients with SMA. The "delayed return phenomenon" (DRP) was observed only in ALS patients. On light microscopy, collagen bundles in ALS dermis were seen to be less numerous, thinner and more loosely woven than in SMA. Electron microscopy revealed that in ALS (1) collagen fibers became thinner as the disease lasted longer, and (2) collagen bundles were separated by much more amorphous material. These findings were not observed in SMA. Our observations show that ALS may be distinguished from SMA by the presence of abnormal dermal collagen. Therefore, we suggest that comparable clinical and pathological skin analysis is the most important diagnostic tool in differentiating between ALS and SMA.

Radial and tibial nerve pathology of two lactating ewes with "kangaroo gait"

Radial and tibial nerves of two ewes with clinical signs of chronic "kangaroo gait" were examined by qualitative and quantitative techniques and compared to the same nerves of a clinically normal ewe in late lactation. In affected ewes, there was extensive axonal degeneration of myelinated fibres in the radial nerve. Large and small myelinated fibres were affected equally and unmyelinated fibres were normal. Nerve fibre regeneration was present. In contrast, tibial nerve changes in the "kangaroo gait" ewes were minimal. The chronic nature of the radial nerve pathology was consistent with the clinical time course of "kangaroo gait". Regeneration may account for gradual improvement with eventual recovery in most chronically affected ewes. An episode of bilateral severe compression of a proximal radial nerve site is proposed as an explanation for the neuropathy, although the specific mechanism of this trauma is not known.

Morphometry of intramuscular nerves in amyotrophic lateral sclerosis

Morphometric analysis of 90 intramuscular nerves from the biopsied biceps muscles of 16 cases of amyotrophic lateral sclerosis (ALS) were done and compared with controls. In all fascicles (large and small) of ALS, the total number and the numbers of large and small myelinated fibers were significantly reduced to 52, 16, and 64% of controls, respectively. A histogram of the largest fascicles revealed a unimodal distribution and a shift to the left, showing a single peak at 1 micron diameter. The results indicate proximal and distal involvement of the most remote portions of the nerves to the muscle in ALS and support previous suggestions of a neuronopathy.

Morphometric study of the sensory nerve in classical (or Charcot disease) and juvenile amyotrophic lateral sclerosis

Analysis of the superficial peroneal nerve sampled in 9 cases of classical amyotrophic lateral sclerosis (classical ALS, Charcot disease) and compared with 8 age-matched controls showed a very significant reduction of all myelinated fibres (P less than 0.001), affecting small-diameter (P less than 0.01) and large-diameter (P less than 0.02) fibres. Moreover, the small-diameter unmyelinated fibres were very significantly reduced (P less than 0.001) and the large-diameter fibres were highly increased (P less than 0.01). These results suggest a phenomenon of chronic axonal degeneration. Analysis of the same nerve in 7 patients suffering from juvenile ALS and compared with 4 age-matched controls showed a significant reduction (P less than 0.05) of myelinated fibres. The small-diameter and overall unmyelinated fibres were not significantly reduced while the large-diameter fibres, were significantly increased (P less than 0.01). The same analysis of 4 patients presenting an early-onset ALS compared with 3 controls showed lesions of a severity half-way between that of the classical and the juvenile form. Our study showed that the lesions of the sensory nerve are of the same type in classical ALS and in juvenile ALS, but of differing severity. The nosologic place of juvenile ALS compared with classical ALS and with heredodegenerative diseases of the nervous system is discussed.

Light and ultrastructural studies in sural biopsies of the pseudopolyneuropathic form of ALS

The aim of this work was to study the neuropathological picture of the sural nerve in the pseudopolineuropathic form of A.L.S. Five patients were considered: in all cases the clinical and electromyographic follow-up excluded other diseases. EMG-studies were repeatedly performed: they showed the progressive evolution of the spinal anterior horn cell pathology from lower spinal to cervical levels. The sural nerve was processed according to the procedure used in our laboratory for light and ultrastructural examination. Quantitative analysis of myelinated fiber density was carried out on photographic enlargement and reported on histograms. The light and ultrastructural examination showed a severe loss of myelinated fibers; the decrease affected all types of fibers, but predominated in the largest ones. In the axons there was an increase of mitochondria, dilation of the small vesicles and increase in the number of neurofilaments. It is our opinion that all histopathologic data obtained in the sural nerve biopsy in this form of A.L.S. reveal a clear involvement of the sensory neurons of the spinal ganglia and the results can be useful for the study of precocius lesions in the A.L.S.

The peripheral neuropathy in Machado-Joseph disease

Peripheral nerve biopsies were taken from 11 patients with Machado-Joseph disease (MJD), a heredo-degenerative disease within the group of autosomal dominant ataxias. On the basis of the clinical symptoms, 2 patients were found to suffer from type I, 4 from type II and 5 from type III. All cases shared the same pathological features, which consisted of a reduction in density of myelinated and unmyelinated fibres and an increase in endoneurial collagen. It was also observed that some Schwann cells were not related to axons, whilst others showed numerous budding processes. The intensity of the changes varied considerably: it was mild in type I and II and severe in type III. Peripheral nerve changes in MJD are compared with those previously described in other forms of heredo-ataxias. It is concluded that involvement of peripheral nerves is a significant feature in this group of diseases and that peripheral nerve biopsy could be useful in the identification of the subtypes of MJD.

Somatosensory evoked potentials in motor neuron disease

We studied median somatosensory evoked potentials (SEPs) in an unselected series of 30 patients with sporadic motor neuron disease (MND). SEPs were affected in 17 patients (57%), with a higher incidence of abnormality in amyotrophic lateral sclerosis and bulbar palsy than in progressive muscular atrophy. In a majority of patients, simultaneous bilateral stimulation of the median nerve revealed a delay or absence of scalp-recorded central N32 and/or N60, leaving the earlier peaks intact. In the remaining cases, the N19 peak was asymmetrically prolonged. These findings suggest common involvement of somatosensory pathways in MND, either at cortical or subcortical levels, and correlate with neuropathologic reports of neuronal degeneration beyond the primary motor system.

Amyotrophic lateral sclerosis: Part 1. Clinical features, pathology, and ethical issues in management

Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disease of the motor system in adults that occurs in sporadic, familial, and Western Pacific forms. Involvement of non-motor pathways has been increasingly recognized, both clinically and pathologically. Although the usual course is relentlessly progressive with death in half the cases within three years from onset, it can sometimes be protracted. Degeneration and loss of large motor neurons in the cerebral cortex, brainstem, and cervical and lumbar spinal cord are characteristic. Marked reduction in the number of large myelinated fibers is notable in the cervical and lumbar ventral roots. Peripheral nerves show reduced numbers of large myelinated fibers, acute axonal degeneration at all levels, and distal axonal atrophy. Motor end-plates reveal small or absent nerve terminals. Subclinical non-motor system involvement includes neuronal loss in Clarke's nucleus and dorsal root ganglia, degeneration of non-motor tracts in the spinal cord, loss of receptors in the dorsal horns of the spinal cord, and myelinated fiber loss with segmental demyelination in sensory and mixed nerves. The serious implications of the diagnosis of ALS make it mandatory to exclude similar potentially treatable disorders. Management should be multidisciplinary, and discussions with the patient and family members should be frank and frequent. Discussions about ventilatory support should take place early in the disease so that death from respiratory failure can be prevented, when that is desired, and conversely to obviate the discontent and anger that accompany involuntary life on a ventilator.

Somatosensory evoked potentials in amyotrophic lateral sclerosis

Forty five patients with amyotrophic lateral sclerosis were investigated, by means of somatosensory evoked potentials, in order to detect the presence of subclinical sensory changes. Cervical SEPs from the median nerve and cortical SEPs from the median and tibial nerve were recorded, showing a delay of N13 and subsequent components; the latency of the first constant cortical potential was also increased in many patients. Only the SEPs from the tibial nerve showed a decrease of amplitude. These results suggest a pathological slowing of conduction along the central sensory pathways in amyotrophic lateral sclerosis.

Morphometric and biochemical studies of peripheral nerves in amyotrophic lateral sclerosis

Phrenic nerves of 11 patients with amyotrophic lateral sclerosis studied postmortem contained only 33% of the normal number of large myelinated fibers (9 controls; p less than 0.001). In the phrenic nerves of these patients, there were 18% fewer large myelinated fibers in the distal segment than in the proximal segment (p less than 0.025). The ratio of axonal circumference to myelin lamellae in large myelinated fibers in the distal segment was 34% greater than that in control fibers (p less than 0.002). The proportion of acute axonal degeneration was the same at all levels (48.0 +/- 13.7%). Sural nerves of 21 patients with amyotrophic lateral sclerosis had more acute axonal degeneration and 30% fewer myelinated fibers (p less than 0.05) than controls; evidence of degeneration also extended to unmyelinated fibers. The amount of axonal transport of acetylcholinesterase in 9 sural nerves determined in vitro was reduced by 24% (p less than 0.05) and the apparent transport rate was reduced by 44% (p less than 0.01) compared with 4 controls. These findings show that in amyotrophic lateral sclerosis a small degree of dying-back change and of distal axonal atrophy is superimposed on the degeneration of motor neuron cell bodies, and that the disease effects spread beyond the motor neurons.

Observations on normal skeletal muscle of mature dogs: a cytochemical, histochemical, and morphometric study

Cytochemical, histochemical, and morphometric features of skeletal muscle were evaluated in 140 specimens from five appendicular muscles of 28 dogs which were free of neuromuscular disease. Dogs ranged from six months to 15 years of age. Evidence of degeneration and regeneration, cell reactions and architectural change was found but with an incidence of less than 1% of the total myofiber population in any muscle. The number of fibers with internal nuclei never exceeded 1%. The only changes that appeared to be age-related were fiber size variation associated with the presence of small angular type IIA fibers in muscles of dogs seven years of age and older. Percentages of type I, type IIA, and type IIC fibers remained relatively constant in the various muscles in the age range examined. Type I fibers predominated in medial head of triceps brachii and superficial digital flexor muscles, whereas type IIA fibers were more numerous in biceps femoris and long head of triceps brachii muscles. An approximately equal ratio was found in gastrocranius muscles. In any given muscle, type IIC fibers represented less than 2% of the fibers. Statistically significant differences were found in values for fiber size between groups of dogs weighing more than (mean diameter range = 40 to 50 microns) and less than (mean diameter range = 30 to 40 microns) 15 kilograms.

Age-related changes in peripheral nerves of the dog. II. A morphologic and morphometric study of cross-sectional nerve

Qualitative histologic studies and quantitative measurements were made on cross-sectional preparations of common peroneal and ulnar nerves of 32 neuromuscular disease-free dogs from birth to 15 years of age, to provide normative data not available previously. Minimal lesions were seen in nerves of dogs from birth to seven years; however, in older dogs, the incidence of axonal degeneration and segmental demyelination and remyelination increased. Total fiber density of both nerves was over 40,000 fibers/mm2 at birth and declined rapidly during the first six to nine months to level off at about 10,000 fibers/mm2 by one year of age. Density of small (less than 5 micrometers) and large (greater than or equal to 5 micrometers) diameter fibers attained adult values by one year of age. The frequency distribution of the myelinated fibers was unimodal at birth and became bimodal between three and six months of age. The peak of the small and large fiber groups occurred at 3 micrometers and 6 micrometers, respectively. Larger diameter fibers (10 micrometers to 12 micrometers) reached adult values between nine months and one year of age. A 2.5 fold increase in mean fiber diameter occurred during the first year of life. There was no statistically significant change in any histometric parameter after maturity (approximately one year of age).

Peripheral neuropathy in spinocerebellar degenerations

Nerve conduction studies have been performed in 19 subject with hereditary spinocerebellar degenerations other than Friedreich ataxia. Clinically, they may be classified as olivopontocerebellar atrophy or cerebello-olivary degeneration. In 9 patients, sensory conduction was abnormal, and in the whole group there was a significant impairment of sensory conduction and mild slowing of motor conduction in the lateral popliteal nerve. Sural nerve biopsies were performed on 5 patients. In 3 cases there was a mild to moderate reduction of myelinated fibers of all diameters; unmyelinated fibers were normal. In 1 patient from a kindred with a spinocerebellar degeneration in which the inheritance was autosomal dominant, neuropathological findings at autopsy confirmed the clinical diagnosis of the Menzel type of olivopontocerebellar atrophy; there was a degeneration of dorsal root ganglion and anterior horn cells as well as of myelinated fibers of all diameters in the sural nerve.

Fatty acid composition of myelin lipids (cerebrosides, sulphatides and sphingomyelin) from normal human sural nerve, and changes in peripheral neuropathy

Fatty acids of cerebrosides, sulphatides and sphingomyelin from normal human sural nerve, by comparison with brain, show a diminution of long-chained fatty acids as well as unsaturated fatty acids. The findings in brachial plexus are intermediate. In cases of peripheral neuropathy from various causes sphingomyelin fatty acid composition reveals pronounced loss of long-chained fatty acids, a phenomenon that is probably unspecific and may be associated with all forms of demyelination. Problems associated with the limited amount of nervous tissue available from biopsy specimens are discussed.