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Cabona C, Ferraro PM, Scialò C, Bandettini Di Poggio M, Novi G, Gemelli C, Vignolo M, Rao F, Capovilla M, Marogna M, Mandich P, Origone P, Schenone A, Caponnetto C. Clinical epidemiology of amyotrophic lateral sclerosis in Liguria, Italy: a ten year follow up study. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:104-111. [PMID: 37737151 DOI: 10.1080/21678421.2023.2260842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE This article presents an updated analysis of the LIGALS register, a prospective study conducted over a ten-year period (2009-2018) in Liguria, Italy, aimed at evaluating the incidence, prevalence, clinical presentation, and management of amyotrophic lateral sclerosis (ALS). METHODS We calculated the mean annual crude incidence rate of ALS, assessed the point prevalence of ALS on January 1, 2018, and analyzed demographic factors, clinical characteristics, and clinical management strategies. Data analysis included Cox regression analysis to identify predictors of survival. RESULTS The mean annual crude incidence rate of ALS was 3.16/100,000 per year (CI 95%) while the point prevalence of ALS on January 1, 2018, was 9.31/100,000 population (CI 95%). Among the patients, 6.5% were familial ALS, while 93.5% were sporadic cases. Clinical management strategies, including percutaneous endoscopic gastrostomy (PEG) and noninvasive ventilation (NIV), were employed. The study observed a stable frequency of NIV initiation and PEG placement over time, with a growing trend toward earlier PEG positioning. The mean survival from symptom onset was 39 months, whereas from diagnosis, it was 26 months. Cox regression analysis identified several predictors of survival, including gender, age at onset and diagnosis, site of onset, diagnostic category, phenotype, and diagnostic delay. CONCLUSIONS This comprehensive analysis provides valuable insights into the long-term trends in ALS epidemiology and clinical management in Liguria, Italy. It underscores the importance of continued research efforts in understanding and addressing the challenges posed by ALS, particularly in terms of early diagnosis and optimizing clinical interventions to improve patient outcomes.
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Affiliation(s)
| | | | - Carlo Scialò
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | | | - Giovanni Novi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | | | - Fabrizio Rao
- Centro Clinico NeMO, Ospedale la Colletta, Arenzano, Italy
| | | | - Maura Marogna
- Azienda Sanitaria Locale 3 Genovese, Genova, Italy, and
| | - Paola Mandich
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genova, Italy
| | - Paola Origone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genova, Italy
| | - Angelo Schenone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health, University of Genoa, Genova, Italy
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Mohammadi S, Ghaderi S, Fatehi F. MRI biomarkers and neuropsychological assessments of hippocampal and parahippocampal regions affected by ALS: A systematic review. CNS Neurosci Ther 2024; 30:e14578. [PMID: 38334254 PMCID: PMC10853901 DOI: 10.1111/cns.14578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Amyotrophic lateral sclerosis (ALS) is a progressive motor and extra-motor neurodegenerative disease. This systematic review aimed to examine MRI biomarkers and neuropsychological assessments of the hippocampal and parahippocampal regions in patients with ALS. METHODS A systematic review was conducted in the Scopus and PubMed databases for studies published between January 2000 and July 2023. The inclusion criteria were (1) MRI studies to assess hippocampal and parahippocampal regions in ALS patients, and (2) studies reporting neuropsychological data in patients with ALS. RESULTS A total of 46 studies were included. Structural MRI revealed hippocampal atrophy, especially in ALS-FTD, involving specific subregions (CA1, dentate gyrus). Disease progression and genetic factors impacted atrophy patterns. Diffusion tensor imaging (DTI) showed increased mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD), and decreased fractional anisotropy (FA) in the hippocampal tracts and adjacent regions, indicating loss of neuronal and white matter integrity. Functional MRI (fMRI) revealed reduced functional connectivity (FC) between the hippocampus, parahippocampus, and other regions, suggesting disrupted networks. Perfusion MRI showed hypoperfusion in parahippocampal gyri. Magnetic resonance spectroscopy (MRS) found changes in the hippocampus, indicating neuronal loss. Neuropsychological tests showed associations between poorer memory and hippocampal atrophy or connectivity changes. CA1-2, dentate gyrus, and fimbria atrophy were correlated with worse memory. CONCLUSIONS The hippocampus and the connected regions are involved in ALS. Hippocampal atrophy disrupted connectivity and metabolite changes correlate with cognitive and functional decline. Specific subregions can be particularly affected. The hippocampus is a potential biomarker for disease monitoring and prognosis.
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Affiliation(s)
- Sana Mohammadi
- Neuromuscular Research Center, Department of Neurology, Shariati HospitalTehran University of Medical SciencesTehranIran
- Department of Medical Sciences, School of MedicineIran University of Medical SciencesTehranIran
| | - Sadegh Ghaderi
- Neuromuscular Research Center, Department of Neurology, Shariati HospitalTehran University of Medical SciencesTehranIran
- Department of Neuroscience and Addiction Studies, School of Advanced Technologies in MedicineTehran University of Medical SciencesTehranIran
| | - Farzad Fatehi
- Neuromuscular Research Center, Department of Neurology, Shariati HospitalTehran University of Medical SciencesTehranIran
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Ai Y, Li F, Hou Y, Li X, Li W, Qin K, Suo X, Lei D, Shang H, Gong Q. Differential cortical gray matter changes in early- and late-onset patients with amyotrophic lateral sclerosis. Cereb Cortex 2024; 34:bhad426. [PMID: 38061694 DOI: 10.1093/cercor/bhad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/11/2023] [Accepted: 10/14/2023] [Indexed: 01/19/2024] Open
Abstract
Age at onset may be an important feature associated with distinct subtypes of amyotrophic lateral sclerosis (ALS). Little is known about the neuropathological mechanism of early-onset ALS (EO-ALS) and late-onset ALS (LO-ALS). Ninety ALS patients were divided into EO-ALS and LO-ALS group, and 128 healthy controls were matched into young controls(YCs) and old controls (OCs). A voxel-based morphometry approach was employed to investigate differences in gray matter volume (GMV). Significant age at onset-by-diagnosis interactions were found in the left parietal operculum, left precentral gyrus, bilateral postcentral gyrus, right occipital gyrus, and right orbitofrontal cortex. Post hoc analysis revealed a significant decrease in GMV in all affected regions of EO-ALS patients compared with YCs, with increased GMV in 5 of the 6 brain regions, except for the right orbitofrontal cortex, in LO-ALS patients compared with OCs. LO-ALS patients had a significantly increased GMV than EO-ALS patients after removing the aging effect. Correspondingly, GMV of the left postcentral gyrus correlated with disease severity in the 2 ALS groups. Our findings suggested that the pathological mechanisms in ALS patients with different ages at onset might differ. These findings provide unique insight into the clinical and biological heterogeneity of the 2 ALS subtypes.
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Affiliation(s)
- Yuan Ai
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Fei Li
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Yanbing Hou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Xiuli Li
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Wenbin Li
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Kun Qin
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Xueling Suo
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Du Lei
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
| | - Qiyong Gong
- Department of Radiology and Huaxi MR Research Center (HMRRC), Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Wuhou District, Chengdu, Sichuan 610041, China
- Department of Radiology, West China Xiamen Hospital of Sichuan University, 699 Jinyuan Xi Road, Jimei District, Xiamen, Fujian 361021, China
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Li C, Lin J, Jiang Q, Yang T, Xiao Y, Huang J, Hou Y, Wei Q, Cui Y, Wang S, Zheng X, Ou R, Liu K, Chen X, Song W, Zhao B, Shang H. Genetic Modifiers of Age at Onset for Amyotrophic Lateral Sclerosis: A Genome-Wide Association Study. Ann Neurol 2023; 94:933-941. [PMID: 37528491 DOI: 10.1002/ana.26752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/03/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVE Age at onset (AAO) is an essential clinical feature associated with disease progression and mortality in amyotrophic lateral sclerosis (ALS). Identification of genetic variants and environmental risk factors influencing AAO of ALS could help better understand the disease's biological mechanism and provide clinical guidance. However, most genetic studies focused on the risk of ALS, while the genetic background of AAO is less explored. This study aimed to identify genetic and environmental determinants for AAO of ALS. METHODS We performed a genome-wide association analysis using a Cox proportional hazards model on AAO of ALS in 10,068 patients. We further conducted colocalization analysis and in-vitro functional exploration for the target variants, as well as Mendelian randomization analysis to identify risk factors influencing AAO of ALS. RESULTS The total heritability of AAO of ALS was ~0.16 (standard error [SE] = 0.03). One novel locus rs2046243 (CTIF) was significantly associated with earlier AAO by ~1.29 years (p = 1.68E-08, beta = 0.10, SE = 0.02). Functional exploration suggested this variant was associated with increased expression of CTIF in multiple tissues including the brain. Colocalization analysis detected a colocalization signal at the locus between AAO of ALS and expression of CTIF. Causal inference indicated higher education level was associated with later AAO. INTERPRETATION These findings improve the current knowledge of the genetic and environmental etiology of AAO of ALS, and provide a novel target CTIF for further research on ALS pathogenesis and potential therapeutic options to delay the disease onset. ANN NEUROL 2023;94:933-941.
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Affiliation(s)
- Chunyu Li
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Junyu Lin
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Qirui Jiang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Tianmi Yang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Xiao
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Jingxuan Huang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Yanbing Hou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Qianqian Wei
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Yiyuan Cui
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Shichan Wang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoting Zheng
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Ruwei Ou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Kuncheng Liu
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Xueping Chen
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Song
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Bi Zhao
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, National Clinical Research Center for Geriatric, West China Hospital, Sichuan University, Chengdu, China
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Li C, Wei Q, Hou Y, Lin J, Ou R, Zhang L, Jiang Q, Xiao Y, Liu K, Chen X, Yang T, Song W, Zhao B, Wu Y, Shang H. Genome-wide analyses identify NEAT1 as genetic modifier of age at onset of amyotrophic lateral sclerosis. Mol Neurodegener 2023; 18:77. [PMID: 37872557 PMCID: PMC10594666 DOI: 10.1186/s13024-023-00669-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Patients with amyotrophic lateral sclerosis (ALS) demonstrate great heterogeneity in the age at onset (AAO), which is closely related to the course of disease. However, most genetic studies focused on the risk of ALS, while the genetic background underlying AAO of ALS is still unknown. METHODS To identify genetic determinants influencing AAO of ALS, we performed genome-wide association analysis using a Cox proportional hazards model in 2,841 patients with ALS (Ndiscovery = 2,272, Nreplication = 569) in the Chinese population. We further conducted colocalization analysis using public cis-eQTL dataset, and Mendelian randomization analysis to identify risk factors for AAO of ALS. Finally, functional experiments including dual-luciferase reporter assay and RT-qPCR were performed to explore the regulatory effect of the target variant. RESULTS The total heritability of AAO of ALS was ~ 0.24. One novel locus rs10128627 (FRMD8) was significantly associated with earlier AAO by ~ 3.15 years (P = 1.54E-08, beta = 0.31, SE = 0.05). This locus was cis-eQTL of NEAT1 in multiple brain tissues and blood. Colocalization analysis detected association signals at this locus between AAO of ALS and expression of NEAT1. Furthermore, functional exploration supported the variant rs10128627 was associated with upregulated expression of NEAT1 in cell models and patients with ALS. Causal inference suggested higher total cholesterol, low-density lipoprotein, and eosinophil were nominally associated with earlier AAO of ALS, while monocyte might delay the AAO. CONCLUSIONS Collective evidence from genetic, bioinformatic, and functional results suggested NEAT1 as a key player in the disease progression of ALS. These findings improve the current understanding of the genetic role in AAO of ALS, and provide a novel target for further research on the pathogenesis and therapeutic options to delay the disease onset.
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Affiliation(s)
- Chunyu Li
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Qianqian Wei
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Yanbing Hou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Junyu Lin
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Ruwei Ou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Lingyu Zhang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Qirui Jiang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Yi Xiao
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Kuncheng Liu
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Xueping Chen
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - TianMi Yang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Wei Song
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Bi Zhao
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Ying Wu
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, National Clinical Research Center for Geriatric, Sichuan University, Chengdu, China.
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Gianferrari G, Martinelli I, Simonini C, Zucchi E, Fini N, Caputo M, Ghezzi A, Gessani A, Canali E, Casmiro M, De Massis P, Curro' Dossi M, De Pasqua S, Liguori R, Longoni M, Medici D, Morresi S, Patuelli A, Pugliatti M, Santangelo M, Sette E, Stragliati F, Terlizzi E, Vacchiano V, Zinno L, Ferro S, Amedei A, Filippini T, Vinceti M, Mandrioli J. Insight into Elderly ALS Patients in the Emilia Romagna Region: Epidemiological and Clinical Features of Late-Onset ALS in a Prospective, Population-Based Study. Life (Basel) 2023; 13:life13040942. [PMID: 37109471 PMCID: PMC10144747 DOI: 10.3390/life13040942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
Few studies have focused on elderly (>80 years) amyotrophic lateral sclerosis (ALS) patients, who represent a fragile subgroup generally not included in clinical trials and often neglected because they are more difficult to diagnose and manage. We analyzed the clinical and genetic features of very late-onset ALS patients through a prospective, population-based study in the Emilia Romagna Region of Italy. From 2009 to 2019, 222 (13.76%) out of 1613 patients in incident cases were over 80 years old at diagnosis, with a female predominance (F:M = 1.18). Elderly ALS patients represented 12.02% of patients before 2015 and 15.91% from 2015 onwards (p = 0.024). This group presented with bulbar onset in 38.29% of cases and had worse clinical conditions at diagnosis compared to younger patients, with a lower average BMI (23.12 vs. 24.57 Kg/m2), a higher progression rate (1.43 vs. 0.95 points/month), and a shorter length of survival (a median of 20.77 vs. 36 months). For this subgroup, genetic analyses have seldom been carried out (25% vs. 39.11%) and are generally negative. Finally, elderly patients underwent less frequent nutritional- and respiratory-supporting procedures, and multidisciplinary teams were less involved at follow-up, except for specialist palliative care. The genotypic and phenotypic features of elderly ALS patients could help identify the different environmental and genetic risk factors that determine the age at which disease onset occurs. Since multidisciplinary management can improve a patient's prognosis, it should be more extensively applied to this fragile group of patients.
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Affiliation(s)
- Giulia Gianferrari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Ilaria Martinelli
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, 41124 Modena, Italy
- Clinical and Experimental Medicine Ph.D. Program, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Cecilia Simonini
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, 41124 Modena, Italy
| | - Elisabetta Zucchi
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, 41124 Modena, Italy
- Neuroscience Ph.D. Program, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Nicola Fini
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, 41124 Modena, Italy
| | - Maria Caputo
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Andrea Ghezzi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Annalisa Gessani
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, 41124 Modena, Italy
| | - Elena Canali
- Department of Neurology, IRCCS Arcispedale Santa Maria Nuova, 42123 Reggio Emilia, Italy
| | - Mario Casmiro
- Department of Neurology, Faenza and Ravenna Hospital, 48100 Ravenna, Italy
| | | | | | | | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, 40126 Bologna, Italy
| | - Marco Longoni
- Department of Neurology, Infermi Hospital, 48018 Rimini, Italy
- Department of Neurology, Bufalini Hospital, 47521 Cesena, Italy
| | - Doriana Medici
- Department of Neurology, Fidenza Hospital, 43036 Parma, Italy
| | | | | | - Maura Pugliatti
- Department of Neurosciences, University of Ferrara, 44121 Ferrara, Italy
- Department of Neurology, St. Anna Hospital, 44124 Ferrara, Italy
| | | | - Elisabetta Sette
- Department of Neurology, St. Anna Hospital, 44124 Ferrara, Italy
| | - Filippo Stragliati
- Department of General and Specialized Medicine, University Hospital of Parma, 43126 Parma, Italy
| | - Emilio Terlizzi
- Department of Neurology, G. Da Saliceto Hospital, 29121 Piacenza, Italy
| | - Veria Vacchiano
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, 40126 Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, 40126 Bologna, Italy
| | - Lucia Zinno
- Department of General and Specialized Medicine, University Hospital of Parma, 43126 Parma, Italy
| | - Salvatore Ferro
- Department of Hospital Services, Emilia Romagna Regional Health Authority, 40127 Bologna, Italy
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Tommaso Filippini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Research Centre in Environmental, Genetic and Nutritional Epidemiology-CREAGEN, University of Modena and Reggio Emilia, 41125 Modena, Italy
- School of Public Health, University of California Berkeley, Berkeley, CA 94704, USA
| | - Marco Vinceti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Research Centre in Environmental, Genetic and Nutritional Epidemiology-CREAGEN, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA 02118, USA
| | - Jessica Mandrioli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41125 Modena, Italy
- Department of Neurosciences, Azienda Ospedaliero Universitaria di Modena, 41124 Modena, Italy
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7
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Milella G, Introna A, Mezzapesa DM, D'Errico E, Fraddosio A, Ucci M, Zoccolella S, Simone IL. Clinical Profiles and Patterns of Neurodegeneration in Amyotrophic Lateral Sclerosis: A Cluster-Based Approach Based on MR Imaging Metrics. AJNR Am J Neuroradiol 2023; 44:403-409. [PMID: 36958798 PMCID: PMC10084907 DOI: 10.3174/ajnr.a7823] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/20/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE The previous studies described phenotype-associated imaging findings in amyotrophic lateral sclerosis (ALS) with a prior categorization of patients based on clinical characteristics. We investigated the natural segregation of patients through a radiologic cluster-based approach without a priori patient categorization using 3 well-known prognostic MR imaging biomarkers in ALS, namely bilateral precentral and paracentral gyrus cortical thickness and medulla oblongata volume. We aimed to identify clinical/prognostic features that are cluster-associated. MATERIALS AND METHODS Bilateral precentral and paracentral gyri and medulla oblongata volume were calculated using FreeSurfer in 90 patients with amyotrophic lateral sclerosis and 25 healthy controls. A 2-step cluster analysis was performed using precentral and paracentral gyri (averaged pair-wise) and medulla oblongata volume. RESULTS We identified 3 radiologic clusters: 28 (31%) patients belonged to "cluster-1"; 51 (57%), to "cluster 2"; and 11 (12%), to "cluster 3." Patients in cluster 1 showed statistically significant cortical thinning of the analyzed cortical areas and lower medulla oblongata volume compared with subjects in cluster 2 and cluster 3, respectively. Patients in cluster 3 exhibited significant cortical thinning of both paracentral and precentral gyri versus those in cluster 2, and this latter cluster showed lower medulla oblongata volume than cluster 3. Patients in cluster 1 were characterized by older age, higher female prevalence, greater disease severity, higher progression rate, and lower survival compared with patients in clusters 2 and 3. CONCLUSIONS Patients with amyotrophic lateral sclerosis spontaneously segregate according to age and sex-specific patterns of neurodegeneration. Some patients with amyotrophic lateral sclerosis showed an early higher impairment of cortical motor neurons with relative sparing of bulbar motor neurons (cluster 3), while others expressed an opposite pattern (cluster 2). Moreover, 31% of patients showed an early simultaneous impairment of cortical and bulbar motor neurons (cluster 1), and they were characterized by higher disease severity and lower survival.
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Affiliation(s)
- G Milella
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - A Introna
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - D M Mezzapesa
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - E D'Errico
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - A Fraddosio
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - M Ucci
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
| | - S Zoccolella
- Azienda Sanitaria Locale Bari (S.Z.), San Paolo Hospital, Bari, Italy
| | - I L Simone
- From the Neurology Unit (G.M., A.I., D.M.M., E.D., A.F., M.U., I.L.S.), Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro," Bari, Italy
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Sako W, Haji S, Abe T, Osaki Y, Matsumoto Y, Harada M, Izumi Y. M1/precuneus ratio as a surrogate marker of upper motor neuron sign in ALS. J Neurol Sci 2023; 445:120548. [PMID: 36640663 DOI: 10.1016/j.jns.2023.120548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/04/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To investigate whether primary motor cortex (M1) volume measured with an automated approach in MRI reflects upper motor neuron dysfunction and whether it can serve as a potential diagnostic and/or disease-tracking biomarker for amyotrophic lateral sclerosis (ALS). METHODS In this retrospective study, we enrolled 95 subjects, including 33 possible or laboratory supported probable ALS, 26 probable or definite ALS (Prob/Def), 2 primary lateral sclerosis patients, 8 progressive muscular atrophy patients, 19 normal controls (NC) and 7 ALS patients having a second structural MRI scan. Some subjects also underwent functional MRI. We calculated M1, primary sensory cortex, precuneus volumes, and total gray matter volume (TGMV) with FreeSurfer. The sensorimotor network (SMN) was identified using independent component analysis. RESULTS The M1/precuneus ratio showed a significant difference between the NC and Prob/Def groups (p < 0.05). The diagnostic accuracy of the M1/precuneus ratio was moderate for distinguishing Prob/Def from NC (cutoff = 1.00, sensitivity = 0.42, specificity = 0.90). Two of eight cases without upper motor neuron dysfunction could be diagnosed with ALS using M1/precuneus ratio as a surrogate marker. A negative correlation between M1/precuneus ratio and functional activity was found in Brodmann area 6 in the SMN in all subjects. TGMV tended to decrease with disease progression (p = 0.04). INTERPRETATION The M1/precuneus volume ratio, associated with the SMN, may have potential as a surrogate biomarker of upper motor neuron dysfunction in ALS. Furthermore, TGMV may serve as an ALS disease-tracking biomarker.
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Affiliation(s)
- Wataru Sako
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan; Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan.
| | - Shotaro Haji
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Takashi Abe
- Department of Radiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yusuke Osaki
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yuki Matsumoto
- Department of Radiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Masafumi Harada
- Department of Radiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yuishin Izumi
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Toh C, Keslake A, Payne T, Onwuegbuzie A, Harding J, Baster K, Hoggard N, Shaw PJ, Wilkinson ID, Jenkins TM. Analysis of brain and spinal MRI measures in a common domain to investigate directional neurodegeneration in motor neuron disease. J Neurol 2023; 270:1682-1690. [PMID: 36509983 PMCID: PMC9971079 DOI: 10.1007/s00415-022-11520-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/26/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) of the brain and cervical spinal cord is often performed in diagnostic evaluation of suspected motor neuron disease/amyotrophic lateral sclerosis (MND/ALS). Analysis of MRI-derived tissue damage metrics in a common domain facilitates group-level inferences on pathophysiology. This approach was applied to address competing hypotheses of directionality of neurodegeneration, whether anterograde, cranio-caudal dying-forward from precentral gyrus or retrograde, dying-back. METHODS In this cross-sectional study, MRI was performed on 75 MND patients and 13 healthy controls. Precentral gyral thickness was estimated from volumetric T1-weighted images using FreeSurfer, corticospinal tract fractional anisotropy (FA) from diffusion tensor imaging using FSL, and cross-sectional cervical cord area between C1-C8 levels using Spinal Cord Toolbox. To analyse these multimodal data within a common domain, individual parameter estimates representing tissue damage at each corticospinal tract level were first converted to z-scores, referenced to healthy control norms. Mixed-effects linear regression models were then fitted to these z-scores, with gradients hypothesised to represent directionality of neurodegeneration. RESULTS At group-level, z-scores did not differ significantly between precentral gyral and intracranial corticospinal tract tissue damage estimates (regression coefficient - 0.24, [95% CI - 0.62, 0.14], p = 0.222), but step-changes were evident between intracranial corticospinal tract and C1 (1.14, [95% CI 0.74, 1.53], p < 0.001), and between C5 and C6 cord levels (0.98, [95% CI 0.58, 1.38], p < 0.001). DISCUSSION Analysis of brain and cervical spinal MRI data in a common domain enabled investigation of pathophysiological hypotheses in vivo. A cranio-caudal step-change in MND patients was observed, and requires further investigation in larger cohorts.
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Affiliation(s)
- C Toh
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - A Keslake
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - T Payne
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - A Onwuegbuzie
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - J Harding
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - K Baster
- School of Mathematics and Statistics, University of Sheffield, Sheffield, UK
| | - N Hoggard
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - P J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - I D Wilkinson
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - T M Jenkins
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK.
- Royal Perth Hospital, Victoria Square, Perth, WA, 6000, Australia.
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Ueno T, Haga R, Arai A, Tomiyama M. Slow vital capacity as a useful indicator of the prognosis after percutaneous endoscopic gastrostomy in patients with amyotrophic lateral sclerosis. Acta Neurol Scand 2022; 146:578-585. [PMID: 35975358 DOI: 10.1111/ane.13683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/06/2022] [Accepted: 07/27/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Forced vital capacity (FVC) is recommended as a respiratory function test in patients with amyotrophic lateral sclerosis (ALS). However, in ALS associated with orofacial palsy, FVC may be an unreliable test. Slow vital capacity (SVC) is an easier and more reliable test even in cases with bulbar symptoms. However, it remains unclear whether respiratory function tests using SVC and FVC are associated with prognosis after percutaneous endoscopic gastrostomy (PEG) placement. This study aimed to confirm whether both SVC and FVC are related to prognosis after PEG placement in patients with ALS. MATERIALS AND METHODS We conducted this retrospective observational cohort study of 69 consecutive patients diagnosed with sporadic ALS who underwent PEG placement between July 2007 and February 2020. We analyzed the association with mortality 6 months after PEG placement and evaluated long-term prognosis. RESULTS Forty-four patients met the inclusion criteria. In cases with decreased SVC (p < .01) and FVC (p < .01), a significant difference was observed in mortality 6 months after PEG placement, with an optimal cut-off of SVC ≤57.4% (sensitivity, 0.828; specificity, 0.867) and FVC ≤57.3% (sensitivity, 0.828; specificity, 0.867). Multivariate analysis showed that onset age ≥ 65 years (p < .05), SVC ≤57.4% (p < .01), and FVC ≤57.3% (p < .01) were associated with survival after PEG placement. CONCLUSIONS SVC, like FVC, is an important prognostic factor after PEG placement in patients with ALS, and there is a possibility that evaluation using SVC can complement respiratory function testing even in cases where the evaluation of FVC is limited.
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Affiliation(s)
- Tatsuya Ueno
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Rie Haga
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Akira Arai
- Department of Neurology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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18F-FDG-PET correlates of aging and disease course in ALS as revealed by distinct PVC approaches. Eur J Radiol Open 2022; 9:100394. [PMID: 35059473 PMCID: PMC8760536 DOI: 10.1016/j.ejro.2022.100394] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/23/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
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Ingannato A, Bagnoli S, Mazzeo S, Bessi V, Matà S, Del Mastio M, Lombardi G, Ferrari C, Sorbi S, Nacmias B. Neurofilament Light Chain and Intermediate HTT Alleles as Combined Biomarkers in Italian ALS Patients. Front Neurosci 2021; 15:695049. [PMID: 34539331 PMCID: PMC8446383 DOI: 10.3389/fnins.2021.695049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To study the possible implication of the two biomarkers, intermediate alleles (IAs) of the Huntingtin (HTT) gene and neurofilament light chain (NfL) levels in plasma, in amyotrophic lateral sclerosis (ALS) patients. Methods We analyzed IAs in a cohort of 106 Italian ALS patients and measured the plasma NfL levels in 20% of the patients of the cohort. We correlated the two biomarkers with clinical phenotypes. Results Intermediate alleles were present in 7.5% of the patients of our cohort, a frequency higher than that reported in general population. Plasma NfL levels increased with age at onset (p < 0.05). Patients with bulbar onset (BO) had higher plasma NfL concentration (CI −0.61 to −0.06, p = 0.02) and a later age at onset of the disease (CI −24.78 to −4.93, p = 0.006) with respect to the spinal onset (SO) form. Additionally, two of the patients, with IAs and plasma NfL concentration lower with respect to normal alleles’ carriers, presented an age at onset higher than the mean of the entire cohort. Conclusion According to our findings, plasma NfL and IAs of HTT gene may represent potential biomarkers in ALS, providing evidence of a possible implication in clinical phenotype.
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Affiliation(s)
| | - Silvia Bagnoli
- NEUROFARBA Department, University of Florence, Florence, Italy
| | | | - Valentina Bessi
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Sabrina Matà
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e Degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Monica Del Mastio
- SOD Neurologia 1, Dipartimento Neuromuscolo-Scheletrico e Degli Organi di Senso, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Camilla Ferrari
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Sandro Sorbi
- NEUROFARBA Department, University of Florence, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Benedetta Nacmias
- NEUROFARBA Department, University of Florence, Florence, Italy.,IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy
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Park HR, Yang EJ. Oxidative Stress as a Therapeutic Target in Amyotrophic Lateral Sclerosis: Opportunities and Limitations. Diagnostics (Basel) 2021; 11:diagnostics11091546. [PMID: 34573888 PMCID: PMC8465946 DOI: 10.3390/diagnostics11091546] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/14/2021] [Accepted: 08/25/2021] [Indexed: 12/20/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease (MND) and Lou Gehrig’s disease, is characterized by a loss of the lower motor neurons in the spinal cord and the upper motor neurons in the cerebral cortex. Due to the complex and multifactorial nature of the various risk factors and mechanisms that are related to motor neuronal degeneration, the pathological mechanisms of ALS are not fully understood. Oxidative stress is one of the known causes of ALS pathogenesis. This has been observed in patients as well as in cellular and animal models, and is known to induce mitochondrial dysfunction and the loss of motor neurons. Numerous therapeutic agents have been developed to inhibit oxidative stress and neuroinflammation. In this review, we describe the role of oxidative stress in ALS pathogenesis, and discuss several anti-inflammatory and anti-oxidative agents as potential therapeutics for ALS. Although oxidative stress and antioxidant fields are meaningful approaches to delay disease progression and prolong the survival in ALS, it is necessary to investigate various animal models or humans with different subtypes of sporadic and familial ALS.
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