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Pavey NA, Menon P, Peterchev AV, Kiernan MC, Vucic S. Abnormalities of cortical stimulation strength-duration time constant in amyotrophic lateral sclerosis. Clin Neurophysiol 2024; 164:161-167. [PMID: 38901111 DOI: 10.1016/j.clinph.2024.05.014] [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: 01/28/2024] [Revised: 04/23/2024] [Accepted: 05/26/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVES Strength-duration time constant (SDTC) may now be determined for cortical motor neurones, with activity mediated by transient Na+ conductances. The present study determined whether cortical SDTC is abnormal and linked to the pathogenesis of amyotrophic lateral sclerosis. METHODS Cortical SDTC and rheobase were estimated from 17 ALS patients using a controllable pulse parameter transcranial magnetic stimulation (cTMS) device. Resting motor thresholds (RMTs) were determined at pulse widths (PW) of 30, 45, 60, 90 and 120 µs and M-ratio of 0.1, using a figure-of-eight coil applied to the primary motor cortex. RESULTS SDTC was significantly reduced in ALS patients (150.58 ± 9.98 µs; controls 205.94 ± 13.7 µs, P < 0.01). The reduced SDTC correlated with a rate of disease progression (Rho = -0.440, P < 0.05), ALS functional rating score (ALSFRS-R) score (Rho = 0.446, P < 0.05), and disease duration (R = 0.428, P < 0.05). The degree of change in SDTC was greater in patients with cognitive abnormalities as manifested by an abnormal total Edinburgh Cognitive ALS Screen score (140.5 ± 28.7 µs, P < 0.001) and ALS-specific subscore (141.7 ± 33.2 µs, P = 0.003). CONCLUSIONS Cortical SDTC reduction was associated with a more aggressive ALS phenotype, or with more prominent cognitive impairment. SIGNIFICANCE An increase in transient Na+ conductances may account for the reduction in SDTC, linked to the pathogenesis of ALS.
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Affiliation(s)
- Nathan A Pavey
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Concord Hospital, Sydney, Australia
| | - Parvathi Menon
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Concord Hospital, Sydney, Australia
| | - Angel V Peterchev
- Department of Biological Sciences, Dartmouth College, Hanover, NH, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Psychiatry and Behavioural Sciences, Duke University, Durham, NC, USA; Department of Electrical and Computer Engineering, Duke University, Durham, NC, USA; Department of Neurosurgery, Duke University, Durham, NC, USA
| | | | - Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School, University of Sydney, Concord Hospital, Sydney, Australia.
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Higashihara M, Pavey N, Menon P, van den Bos M, Shibuya K, Kuwabara S, Kiernan MC, Koinuma M, Vucic S. Reduction in short interval intracortical inhibition from the early stage reflects the pathophysiology in amyotrophic lateral sclerosis: A meta-analysis study. Eur J Neurol 2024; 31:e16281. [PMID: 38504632 DOI: 10.1111/ene.16281] [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: 10/29/2023] [Revised: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND AND PURPOSE Cortical hyperexcitability has been identified as a diagnostic and pathogenic biomarker of amyotrophic lateral sclerosis (ALS). Cortical excitability is assessed by transcranial magnetic stimulation (TMS), a non-invasive neurophysiological technique. The TMS biomarkers exhibiting highest sensitivity for cortical hyperexcitability in ALS remain to be elucidated. A meta-analysis was performed to determine the TMS biomarkers exhibiting the highest sensitivity for cortical hyperexcitability in ALS. METHODS A systematic literature review was conducted of all relevant studies published in the English language by searching PubMed, MEDLINE, Embase and Scopus electronic databases from 1 January 2006 to 28 February 2023. Inclusion criteria included studies reporting the utility of threshold tracking TMS (serial ascending method) in ALS and controls. RESULTS In total, more than 2500 participants, incorporating 1530 ALS patients and 1102 controls (healthy, 907; neuromuscular, 195) were assessed with threshold tracking TMS across 25 studies. Significant reduction of mean short interval intracortical inhibition (interstimulus interval 1-7 ms) exhibited the highest standardized mean difference with moderate heterogeneity (-0.994, 95% confidence interval -1.12 to -0.873, p < 0.001; Q = 38.61, p < 0.05; I2 = 40%). The reduction of cortical silent period duration along with an increase in motor evoked potential amplitude and intracortical facilitation also exhibited significant, albeit smaller, standardized mean differences. CONCLUSION This large meta-analysis study disclosed that mean short interval intracortical inhibition reduction exhibited the highest sensitivity for cortical hyperexcitability in ALS. Combined findings from this meta-analysis suggest that research strategies aimed at understanding the cause of inhibitory interneuronal circuit dysfunction could enhance understanding of ALS pathogenesis.
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Affiliation(s)
- Mana Higashihara
- Department of Neurology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Nathan Pavey
- Brain and Nerve Research Center, University of Sydney, Sydney, New South Wales, Australia
| | - Parvathi Menon
- Brain and Nerve Research Center, University of Sydney, Sydney, New South Wales, Australia
| | - Mehdi van den Bos
- Brain and Nerve Research Center, University of Sydney, Sydney, New South Wales, Australia
| | - Kazumoto Shibuya
- Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Satoshi Kuwabara
- Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Matthew C Kiernan
- Neuroscience Resarch Australia, University of New South Wales, Sydney, New South Wales, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Masayoshi Koinuma
- Faculty of Pharmaceutical Sciences, Teikyo Heisei University, Tokyo, Japan
- Healthy Aging Innovation Center, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Steve Vucic
- Brain and Nerve Research Center, University of Sydney, Sydney, New South Wales, Australia
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Dharmadasa T, Pavey N, Tu S, Menon P, Huynh W, Mahoney CJ, Timmins HC, Higashihara M, van den Bos M, Shibuya K, Kuwabara S, Grosskreutz J, Kiernan MC, Vucic S. Novel approaches to assessing upper motor neuron dysfunction in motor neuron disease/amyotrophic lateral sclerosis: IFCN handbook chapter. Clin Neurophysiol 2024; 163:68-89. [PMID: 38705104 DOI: 10.1016/j.clinph.2024.04.010] [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: 10/01/2023] [Revised: 02/08/2024] [Accepted: 04/14/2024] [Indexed: 05/07/2024]
Abstract
Identifying upper motor neuron (UMN) dysfunction is fundamental to the diagnosis and understanding of disease pathogenesis in motor neuron disease (MND). The clinical assessment of UMN dysfunction may be difficult, particularly in the setting of severe muscle weakness. From a physiological perspective, transcranial magnetic stimulation (TMS) techniques provide objective biomarkers of UMN dysfunction in MND and may also be useful to interrogate cortical and network function. Single, paired- and triple pulse TMS techniques have yielded novel diagnostic and prognostic biomarkers in MND, and have provided important pathogenic insights, particularly pertaining to site of disease onset. Cortical hyperexcitability, as heralded by reduced short interval intracortical inhibition (SICI) and increased short interval intracortical facilitation, has been associated with the onset of lower motor neuron degeneration, along with patterns of disease spread, development of specific clinical features such as the split hand phenomenon, and may provide an indication about the rate of disease progression. Additionally, reduction of SICI has emerged as a potential diagnostic aid in MND. The triple stimulation technique (TST) was shown to enhance the diagnostic utility of conventional TMS measures in detecting UMN dysfunction in MND. Separately, sophisticated brain imaging techniques have uncovered novel biomarkers of neurodegeneration that have bene associated with progression. The present review will discuss the utility of TMS and brain neuroimaging derived biomarkers of UMN dysfunction in MND, focusing on recently developed TMS techniques and advanced neuroimaging modalities that interrogate structural and functional integrity of the corticomotoneuronal system, with an emphasis on pathogenic, diagnostic, and prognostic utility.
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Affiliation(s)
- Thanuja Dharmadasa
- Department of Neurology, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Nathan Pavey
- Brain and Nerve Research Center, The University of Sydney, Sydney, Australia
| | - Sicong Tu
- Brain and Mind Centre, The University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Australia
| | - Parvathi Menon
- Brain and Nerve Research Center, The University of Sydney, Sydney, Australia
| | - William Huynh
- Brain and Mind Centre, The University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Australia
| | - Colin J Mahoney
- Brain and Mind Centre, The University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Australia
| | - Hannah C Timmins
- Brain and Mind Centre, The University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Australia
| | - Mana Higashihara
- Department of Neurology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, Tokyo, Japan
| | - Mehdi van den Bos
- Brain and Nerve Research Center, The University of Sydney, Sydney, Australia
| | - Kazumoto Shibuya
- Neurology, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Satoshi Kuwabara
- Neurology, Chiba University, Graduate School of Medicine, Chiba, Japan
| | - Julian Grosskreutz
- Precision Neurology, Excellence Cluster Precision Medicine in Inflammation, University of Lübeck, University Hospital Schleswig-Holstein Campus, Lübeck, Germany
| | - Matthew C Kiernan
- Brain and Mind Centre, The University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Australia
| | - Steve Vucic
- Brain and Nerve Research Center, The University of Sydney, Sydney, Australia.
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Vucic S, de Carvalho M, Bashford J, Alix JJP. Contribution of neurophysiology to the diagnosis and monitoring of ALS. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:87-118. [PMID: 38802184 DOI: 10.1016/bs.irn.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
This chapter describes the role of neurophysiological techniques in diagnosing and monitoring amyotrophic lateral sclerosis (ALS). Despite many advances, electromyography (EMG) remains a keystone investigation from which to build support for a diagnosis of ALS, demonstrating the pathophysiological processes of motor unit hyperexcitability, denervation and reinnervation. We consider development of the different diagnostic criteria and the role of EMG therein. While not formally recognised by established diagnostic criteria, we discuss the pioneering studies that have demonstrated the diagnostic potential of transcranial magnetic stimulation (TMS) of the motor cortex and highlight the growing evidence for TMS in the diagnostic process. Finally, accurately monitoring disease progression is crucial for the successful implementation of clinical trials. Neurophysiological measures of disease state have been incorporated into clinical trials for over 20 years and we review prominent techniques for assessing disease progression.
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Affiliation(s)
- Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Mamede de Carvalho
- Instituto de Medicina Molecular João Lobo Antunes, Centro de Estudos Egas Moniz, Faculty of Medicine, Universidade de Lisboa, Lisboa, Portugal; Department of Neurosciences, CHULN, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
| | - James Bashford
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - James J P Alix
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom.
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5
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Vucic S, Stanley Chen KH, Kiernan MC, Hallett M, Benninger DH, Di Lazzaro V, Rossini PM, Benussi A, Berardelli A, Currà A, Krieg SM, Lefaucheur JP, Long Lo Y, Macdonell RA, Massimini M, Rosanova M, Picht T, Stinear CM, Paulus W, Ugawa Y, Ziemann U, Chen R. Clinical diagnostic utility of transcranial magnetic stimulation in neurological disorders. Updated report of an IFCN committee. Clin Neurophysiol 2023; 150:131-175. [PMID: 37068329 PMCID: PMC10192339 DOI: 10.1016/j.clinph.2023.03.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/28/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
The review provides a comprehensive update (previous report: Chen R, Cros D, Curra A, Di Lazzaro V, Lefaucheur JP, Magistris MR, et al. The clinical diagnostic utility of transcranial magnetic stimulation: report of an IFCN committee. Clin Neurophysiol 2008;119(3):504-32) on clinical diagnostic utility of transcranial magnetic stimulation (TMS) in neurological diseases. Most TMS measures rely on stimulation of motor cortex and recording of motor evoked potentials. Paired-pulse TMS techniques, incorporating conventional amplitude-based and threshold tracking, have established clinical utility in neurodegenerative, movement, episodic (epilepsy, migraines), chronic pain and functional diseases. Cortical hyperexcitability has emerged as a diagnostic aid in amyotrophic lateral sclerosis. Single-pulse TMS measures are of utility in stroke, and myelopathy even in the absence of radiological changes. Short-latency afferent inhibition, related to central cholinergic transmission, is reduced in Alzheimer's disease. The triple stimulation technique (TST) may enhance diagnostic utility of conventional TMS measures to detect upper motor neuron involvement. The recording of motor evoked potentials can be used to perform functional mapping of the motor cortex or in preoperative assessment of eloquent brain regions before surgical resection of brain tumors. TMS exhibits utility in assessing lumbosacral/cervical nerve root function, especially in demyelinating neuropathies, and may be of utility in localizing the site of facial nerve palsies. TMS measures also have high sensitivity in detecting subclinical corticospinal lesions in multiple sclerosis. Abnormalities in central motor conduction time or TST correlate with motor impairment and disability in MS. Cerebellar stimulation may detect lesions in the cerebellum or cerebello-dentato-thalamo-motor cortical pathways. Combining TMS with electroencephalography, provides a novel method to measure parameters altered in neurological disorders, including cortical excitability, effective connectivity, and response complexity.
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Affiliation(s)
- Steve Vucic
- Brain, Nerve Research Center, The University of Sydney, Sydney, Australia.
| | - Kai-Hsiang Stanley Chen
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Matthew C Kiernan
- Brain and Mind Centre, The University of Sydney; and Department of Neurology, Royal Prince Alfred Hospital, Australia
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, Bethesda, Maryland, United States
| | - David H Benninger
- Department of Neurology, University Hospital of Lausanne (CHUV), Switzerland
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, Rome, Italy
| | - Paolo M Rossini
- Department of Neurosci & Neurorehab IRCCS San Raffaele-Rome, Italy
| | - Alberto Benussi
- Centre for Neurodegenerative Disorders, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alfredo Berardelli
- IRCCS Neuromed, Pozzilli; Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Antonio Currà
- Department of Medico-Surgical Sciences and Biotechnologies, Alfredo Fiorini Hospital, Sapienza University of Rome, Terracina, LT, Italy
| | - Sandro M Krieg
- Department of Neurosurgery, Technical University Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Jean-Pascal Lefaucheur
- Univ Paris Est Creteil, EA4391, ENT, Créteil, France; Clinical Neurophysiology Unit, Henri Mondor Hospital, AP-HP, Créteil, France
| | - Yew Long Lo
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, and Duke-NUS Medical School, Singapore
| | | | - Marcello Massimini
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Milan, Italy; Istituto Di Ricovero e Cura a Carattere Scientifico, Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Mario Rosanova
- Department of Biomedical and Clinical Sciences University of Milan, Milan, Italy
| | - Thomas Picht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Cluster of Excellence: "Matters of Activity. Image Space Material," Humboldt University, Berlin Simulation and Training Center (BeST), Charité-Universitätsmedizin Berlin, Germany
| | - Cathy M Stinear
- Department of Medicine Waipapa Taumata Rau, University of Auckland, Auckland, Aotearoa, New Zealand
| | - Walter Paulus
- Department of Neurology, Ludwig-Maximilians-Universität München, München, Germany
| | - Yoshikazu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Japan
| | - Ulf Ziemann
- Department of Neurology and Stroke, Eberhard Karls University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany; Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Otfried-Müller-Straße 27, 72076 Tübingen, Germany
| | - Robert Chen
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, Division of Neurology-University of Toronto, Toronto Canada
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Vucic S, Pavey N, Haidar M, Turner BJ, Kiernan MC. Cortical hyperexcitability: Diagnostic and pathogenic biomarker of ALS. Neurosci Lett 2021; 759:136039. [PMID: 34118310 DOI: 10.1016/j.neulet.2021.136039] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 03/04/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023]
Abstract
Cortical hyperexcitability is an early and intrinsic feature of both sporadic and familial forms of amyotrophic lateral sclerosis (ALS).. Importantly, cortical hyperexcitability appears to be associated with motor neuron degeneration, possibly via an anterograde glutamate-mediated excitotoxic process, thereby forming a pathogenic basis for ALS. The presence of cortical hyperexcitability in ALS patients may be readily determined by transcranial magnetic stimulation (TMS), a neurophysiological tool that provides a non-invasive and painless method for assessing cortical function. Utilising the threshold tracking TMS technique, cortical hyperexcitability has been established as a robust diagnostic biomarker that distinguished ALS from mimicking disorders at early stages of the disease process. The present review discusses the pathophysiological and diagnostic utility of cortical hyperexcitability in ALS.
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Affiliation(s)
- Steve Vucic
- Western Clinical School, University of Sydney, Sydney, Australia.
| | - Nathan Pavey
- Western Clinical School, University of Sydney, Sydney, Australia
| | - Mouna Haidar
- Florey Institute of Neuroscieace and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Bradley J Turner
- Florey Institute of Neuroscieace and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
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Rawji V, Latorre A, Sharma N, Rothwell JC, Rocchi L. On the Use of TMS to Investigate the Pathophysiology of Neurodegenerative Diseases. Front Neurol 2020; 11:584664. [PMID: 33224098 PMCID: PMC7669623 DOI: 10.3389/fneur.2020.584664] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022] Open
Abstract
Neurodegenerative diseases are a collection of disorders that result in the progressive degeneration and death of neurons. They are clinically heterogenous and can present as deficits in movement, cognition, executive function, memory, visuospatial awareness and language. Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation tool that allows for the assessment of cortical function in vivo. We review how TMS has been used for the investigation of three neurodegenerative diseases that differ in their neuroanatomical axes: (1) Motor cortex-corticospinal tract (motor neuron diseases), (2) Non-motor cortical areas (dementias), and (3) Subcortical structures (parkinsonisms). We also make four recommendations that we hope will benefit the use of TMS in neurodegenerative diseases. Firstly, TMS has traditionally been limited by the lack of an objective output and so has been confined to stimulation of the motor cortex; this limitation can be overcome by the use of concurrent neuroimaging methods such as EEG. Given that neurodegenerative diseases progress over time, TMS measures should aim to track longitudinal changes, especially when the aim of the study is to look at disease progression and symptomatology. The lack of gold-standard diagnostic confirmation undermines the validity of findings in clinical populations. Consequently, diagnostic certainty should be maximized through a variety of methods including multiple, independent clinical assessments, imaging and fluids biomarkers, and post-mortem pathological confirmation where possible. There is great interest in understanding the mechanisms by which symptoms arise in neurodegenerative disorders. However, TMS assessments in patients are usually carried out during resting conditions, when the brain network engaged during these symptoms is not expressed. Rather, a context-appropriate form of TMS would be more suitable in probing the physiology driving clinical symptoms. In all, we hope that the recommendations made here will help to further understand the pathophysiology of neurodegenerative diseases.
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Affiliation(s)
| | | | | | | | - Lorenzo Rocchi
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
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Lack of evidence for interhemispheric inhibition in the lower face primary motor cortex. Clin Neurophysiol 2019; 130:1917-1925. [DOI: 10.1016/j.clinph.2019.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 07/01/2019] [Accepted: 07/17/2019] [Indexed: 11/18/2022]
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Menon P, Yiannikas C, Kiernan MC, Vucic S. Regional motor cortex dysfunction in amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2019; 6:1373-1382. [PMID: 31402622 PMCID: PMC6689694 DOI: 10.1002/acn3.50819] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The pathophysiological processes underlying amyotrophic lateral sclerosis (ALS) need to be better understood, although cortical dysfunction has been implicated. Previous transcranial magnetic stimulation (TMS) studies have assessed cortical dysfunction from the hand. The aim of the present study was to determine whether cortical dysfunction was evident across representations of three body regions, and to relate these changes to clinical features of ALS. METHODS In this cross-sectional study, threshold tracking TMS was undertaken in 60 sporadic ALS patients, with motor evoked potential (MEP) responses recorded over the hand (abductor pollicis brevis), lower limb (tibialis anterior), and bulbar (trapezius) regions. The cross-sectional findings were compared to 28 age- and gender-matched controls. RESULTS Cortical dysfunction was evident across the representation of the three body regions, although the degree and nature of the dysfunction varied. Cortical hyperexcitability, as heralded by reduced short interval intracortical inhibition (SICI), was evident in all cortical regions (hand, P < 0.01; leg, P < 0.05; bulbar, P < 0.05) in ALS patients when compared with healthy control subjects. Importantly, features of cortical hyperexcitability seemed more prominent in clinically affected body regions and correlated with functional disability and muscle weakness. Cortical inexcitability was more prominent in the leg (P < 0.001) and bulbar regions (P < 0.01) when compared with controls. INTERPRETATION The nature of cortical dysfunction varied across the body regions in ALS, with cortical hyperexcitability being more prominent in the upper limbs while cortical inexcitability was more evident in the lower limbs and bulbar regions. The findings suggest a heterogeneity of cortical pathophysiological processes in ALS.
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Affiliation(s)
- Parvathi Menon
- Westmead HospitalSydneyNew South WalesAustralia
- University of SydneySydneyNew South WalesAustralia
| | - Con Yiannikas
- University of SydneySydneyNew South WalesAustralia
- Concord HospitalSydneyNew South WalesAustralia
| | - Matthew C. Kiernan
- University of SydneySydneyNew South WalesAustralia
- Brain and Mind InstituteSydneyNew South WalesAustralia
| | - Steve Vucic
- Westmead HospitalSydneyNew South WalesAustralia
- University of SydneySydneyNew South WalesAustralia
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10
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Superconditioning TMS for examining upper motor neuron function in MND. Exp Brain Res 2019; 237:2087-2103. [PMID: 31175383 DOI: 10.1007/s00221-019-05573-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/30/2019] [Indexed: 01/09/2023]
Abstract
We used transcranial magnetic stimulation (TMS) of motor cortex, including a novel four-pulse superconditioning (TMSsc) paradigm, in repeated examinations of motor-evoked potentials (MEPs) in eight subjects with motor neuron disease (MND), including seven with amyotrophic lateral sclerosis (ALS). The goals were: (1) to look for evidence of cortical hyperexcitability, including a reduction in short-interval intracortical inhibition (SICI); and (2) to examine the utility of using TMSsc for quantifying upper motor neuron function during MND progression. Testing of abductor pollicis brevis (APB) and tibialis anterior (TA) muscles bilaterally was carried out every 3 months in MND subjects for up to 2 years; results were compared to those from a cohort of 15 control subjects. Measures of SICI were not significantly different between control and MND subjects for either APB or TA muscles. Other measures of cortical excitability, including TMS threshold and MEP amplitude, were consistent with lowered cortical excitability in MND subjects. Certain combinations of superconditioning TMS were capable of causing stronger inhibition or facilitation of MEPs compared to dual-pulse TMS, for both APB and TA target muscles. Moreover, there were multiple cases in which target muscles unresponsive to strong single-pulse TMS, whether at rest or when tested with an active contraction, showed an MEP in response to TMSsc optimized for facilitation. Our findings suggest that a multi-faceted neurophysiologic protocol for examining upper motor neuron function in MND subjects might benefit from inclusion of TMSsc testing.
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Vucic S, van den Bos M, Menon P, Howells J, Dharmadasa T, Kiernan MC. Utility of threshold tracking transcranial magnetic stimulation in ALS. Clin Neurophysiol Pract 2018; 3:164-172. [PMID: 30560220 PMCID: PMC6275211 DOI: 10.1016/j.cnp.2018.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/17/2018] [Accepted: 10/29/2018] [Indexed: 12/21/2022] Open
Abstract
Upper motor neuron [UMN] and lower motor neuron [LMN] dysfunction, in the absence of sensory features, is a pathognomonic feature of amyotrophic lateral sclerosis [ALS]. Although the precise mechanisms have yet to be elucidated, one leading hypothesis is that UMN precede LMN dysfunction, which is induced by anterograde glutamatergic excitotoxicity. Transcranial magnetic stimulation (TMS) is a neurophysiological tool that provides a non-invasive and painless assessment of cortical function. Threshold tracking methodologies have been recently adopted for TMS, whereby changes in threshold rather than motor evoked potential (MEP) amplitude serve as outcome measures. This technique is reliable and provides a rapid assessment of cortical function in ALS. Utilisng the threshold tracking TMS technique, cortical hyperexcitability was demonstrated as an early feature in sporadic ALS preceding the onset of LMN dysfunction and possibly contributing to disease spread. Separately, cortical hyperexcitability was reported to precede the clinical onset of familial ALS. Of further relevance, the threshold tracking TMS technique was proven to reliably distinguish ALS from mimicking disorders, even in the presence of a comparable degree of LMN dysfunction, suggesting a diagnostic utility of TMS. Taken in total, threshold tracking TMS has provided support for a cortical involvement at the earliest detectable stages of ALS, underscoring the utility of the technique for probing the underlying pathophysiology. The present review will discuss the physiological processes underlying TMS parameters, while further evaluating the pathophysiological and diagnostic utility of threshold tracking TMS in ALS.
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Affiliation(s)
- Steve Vucic
- Western Clinical School, University of Sydney, Sydney, Australia
| | | | - Parvathi Menon
- Western Clinical School, University of Sydney, Sydney, Australia
| | - James Howells
- Brain and Mind Centre, University of Sydney and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
| | - Thanuja Dharmadasa
- Brain and Mind Centre, University of Sydney and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
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Lenglet T, Camdessanché JP. Amyotrophic lateral sclerosis or not: Keys for the diagnosis. Rev Neurol (Paris) 2017; 173:280-287. [PMID: 28461025 DOI: 10.1016/j.neurol.2017.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a degenerative motor neuron disease (MND) which prognosis is poor. Early diagnosis permit to set up immediately adapted treatment and cares. Available diagnostic criteria are based on the detection of both central and peripheral motor neuron injury in bulbar, cervical, thoracic and lumbar regions. Electrodiagnostic (EDX) tests are the key tools to identify peripheral motor neuron involvement. Needle examination records abnormal activities at rest, and looks for neurogenic pattern during muscle contraction. Motor unit potentials morphology is modified primary to recruitment. Motor evoked potentials remain the test of choice to identify impairment of central motor neurons. In the absence of diagnostic biomarker of ALS and among essential investigations of suspected MND, a careful clinical and neurophysiological work-up is essential to rule out the differential diagnosis.
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Affiliation(s)
- T Lenglet
- Département de neurophysiologie clinique, Hôpital de la Salpêtrière, Assistance Publique-Hôpitaux de Paris, France; Centre Référent Maladies du Motoneurone et SLA, Hôpital de la Salpêtrière, Assistance Publique-Hôpitaux de Paris, France
| | - J-P Camdessanché
- Service de Neurologie, Hôpital Nord, CHU de Saint-Etienne, France; Centre Référent Maladies du Motoneurone et SLA, CHU de Saint-Etienne, France.
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Vucic S, Kiernan MC. Transcranial Magnetic Stimulation for the Assessment of Neurodegenerative Disease. Neurotherapeutics 2017; 14:91-106. [PMID: 27830492 PMCID: PMC5233629 DOI: 10.1007/s13311-016-0487-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a noninvasive technique that has provided important information about cortical function across an array of neurodegenerative disorders, including Alzheimer's disease, frontotemporal dementia, Parkinson's disease, and related extrapyramidal disorders. Application of TMS techniques in neurodegenerative diseases has provided important pathophysiological insights, leading to the development of pathogenic and diagnostic biomarkers that could be used in the clinical setting and therapeutic trials. Abnormalities of TMS outcome measures heralding cortical hyperexcitability, as evidenced by a reduction of short-interval intracortical inhibition and increased in motor-evoked potential amplitude, have been consistently identified as early and intrinsic features of amyotrophic lateral sclerosis (ALS), preceding and correlating with the ensuing neurodegeneration. Cortical hyperexcitability appears to form the pathogenic basis of ALS, mediated by trans-synaptic glutamate-mediated excitotoxic mechanisms. As a consequence of these research findings, TMS has been developed as a potential diagnostic biomarker, capable of identifying upper motor neuronal pathology, at earlier stages of the disease process, and thereby aiding in ALS diagnosis. Of further relevance, marked TMS abnormalities have been reported in other neurodegenerative diseases, which have varied from findings in ALS. With time and greater utilization by clinicians, TMS outcome measures may prove to be of utility in future therapeutic trial settings across the neurodegenerative disease spectrum, including the monitoring of neuroprotective, stem-cell, and genetic-based strategies, thereby enabling assessment of biological effectiveness at early stages of drug development.
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Affiliation(s)
- Steve Vucic
- Westmead Clinical School, University of Sydney, Sydney, Australia
| | - Matthew C Kiernan
- Bushell Chair of Neurology, Brain and Mind Centre, University of Sydney, Camperdown, Australia.
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Mcilduff CE, Yim SJ, Pacheck AK, Rutkove SB. Optimizing electrical impedance myography of the tongue in amyotrophic lateral sclerosis. Muscle Nerve 2016; 55:539-543. [DOI: 10.1002/mus.25375] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 07/17/2016] [Accepted: 08/08/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Courtney E. Mcilduff
- Department of Neurology; Beth Israel Deaconess Medical Center; 330 Brookline Avenue, CC-810 Boston Massachusetts 02215 USA
| | - Sung J. Yim
- Department of Neurology; Beth Israel Deaconess Medical Center; 330 Brookline Avenue, CC-810 Boston Massachusetts 02215 USA
| | - Adam K. Pacheck
- Department of Neurology; Beth Israel Deaconess Medical Center; 330 Brookline Avenue, CC-810 Boston Massachusetts 02215 USA
| | - Seward B. Rutkove
- Department of Neurology; Beth Israel Deaconess Medical Center; 330 Brookline Avenue, CC-810 Boston Massachusetts 02215 USA
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15
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New insights into the clinical neurophysiological assessment of ALS. Neurophysiol Clin 2016; 46:157-63. [PMID: 27364772 DOI: 10.1016/j.neucli.2016.05.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 05/25/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022] Open
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Kakeda S, Yoneda T, Ide S, Miyata M, Hashimoto T, Futatsuya K, Watanabe K, Ogasawara A, Moriya J, Sato T, Okada K, Uozumi T, Adachi H, Korogi Y. Zebra sign of precentral gyri in amyotrophic lateral sclerosis: A novel finding using phase difference enhanced (PADRE) imaging-initial results. Eur Radiol 2016; 26:4173-4183. [PMID: 26822372 DOI: 10.1007/s00330-016-4219-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 01/02/2016] [Accepted: 01/13/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We compared the precentral gyri (PG) on the PADRE of patients with amyotrophic lateral sclerosis (ALS) and healthy subjects (HSs) in order to determine whether it is possible to discriminate between ALS patients and HSs on an individual basis. METHODS First, two radiologists reviewed the appearance of the normal PG and that of ALS patients on PADRE in a non-blinded manner, and deviations from the appearance of the normal PG were recorded. Next, based on the presence of PG abnormalities on PADRE, we performed an observer performance study using 16 ALS patients and 16 HSs. RESULTS The radiologists were able to consensually define the PG as abnormal on PADRE when a low-signal-intensity layer was observed in the gray matter of the PG; a three- or four-layer organization (zebra sign) was characterized by the low-signal-intensity layer. The observer performance study demonstrated that the sensitivity, specificity, and accuracy of PG abnormalities on PADRE for discriminating ALS patients from HSs were 94 %, 94 %, and 94 %, respectively, for reviewers 1 and 2. CONCLUSIONS It was possible to discriminate between ALS patients and HSs based on the presence of PG abnormalities on PADRE, which may reflect upper motor neuron impairment in ALS. KEY POINTS • PADRE reveals low-signal-intensity layer in the PG of ALS • By PADRE findings on PG, we can discriminate ALS from HSs • PADRE may be a useful method for detecting UMN impairment in ALS.
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Affiliation(s)
- Shingo Kakeda
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - Tetsuya Yoneda
- Department of Medical Physics in Advanced Biomedical Sciences, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoru Ide
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Mari Miyata
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Tomoyo Hashimoto
- Department of Neurology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Koichiro Futatsuya
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Keita Watanabe
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Atsushi Ogasawara
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Junji Moriya
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Toru Sato
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Kazumasa Okada
- Department of Neurology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Takenori Uozumi
- Department of Neurology, Wakamatsu Hospital of the University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Hiroaki Adachi
- Department of Neurology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
| | - Yukunori Korogi
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
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17
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Brown KE, Neva JL, Ledwell NM, Boyd LA. Use of transcranial magnetic stimulation in the treatment of selected movement disorders. Degener Neurol Neuromuscul Dis 2014; 4:133-151. [PMID: 32669907 PMCID: PMC7337234 DOI: 10.2147/dnnd.s70079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/23/2014] [Indexed: 11/23/2022] Open
Abstract
Transcranial magnetic stimulation (TMS) is a valuable technique for assessing the underlying neurophysiology associated with various neuropathologies, and is a unique tool for establishing potential neural mechanisms responsible for disease progression. Recently, repetitive TMS (rTMS) has been advanced as a potential therapeutic technique to treat selected neurologic disorders. In healthy individuals, rTMS can induce changes in cortical excitability. Therefore, targeting specific cortical areas affected by movement disorders theoretically may alter symptomology. This review discusses the evidence for the efficacy of rTMS in Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis, and multiple sclerosis. It is hoped that gaining a more thorough understanding of the timing and parameters of rTMS in individuals with neurodegenerative disorders may advance both clinical care and research into the most effective uses of this technology.
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Affiliation(s)
| | - Jason L Neva
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Lara A Boyd
- Graduate Program in Rehabilitation Science.,Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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18
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Camdessanché JP, Lenglet T. Place des explorations électrophysiologiques dans la sclérose latérale amyotrophique. Presse Med 2014; 43:563-8. [DOI: 10.1016/j.lpm.2014.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 03/21/2014] [Accepted: 03/24/2014] [Indexed: 10/25/2022] Open
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Cattaneo L, Pavesi G. The facial motor system. Neurosci Biobehav Rev 2013; 38:135-59. [PMID: 24239732 DOI: 10.1016/j.neubiorev.2013.11.002] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 10/18/2013] [Accepted: 11/02/2013] [Indexed: 12/23/2022]
Abstract
Facial movements support a variety of functions in human behavior. They participate in automatic somatic and visceral motor programs, they are essential in producing communicative displays of affective states and they are also subject to voluntary control. The multiplicity of functions of facial muscles, compared to limb muscles, is reflected in the heterogeneity of their anatomical and histological characteristics that goes well beyond the conventional classification in single facial muscles. Such parcellation in different functional muscular units is maintained throughout the central representation of facial movements from the brainstem up to the neocortex. Facial movements peculiarly lack a conventional proprioceptive feedback system, which is only in part vicariated by cutaneous or auditory afferents. Facial motor activity is the main marker of endogenous affective states and of the affective valence of external stimuli. At the cortical level, a complex network of specialized motor areas supports voluntary facial movements and, differently from upper limb movements, in such network there does not seem to be a prime actor in the primary motor cortex.
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Affiliation(s)
- Luigi Cattaneo
- Center for Mind/Brain Sciences, University of Trento, Via delle Regole 101, Mattarello, Trento 38123, Italy.
| | - Giovanni Pavesi
- Department of Neuroscience, University of Parma, Via Gramsci 14, Parma 43100, Italy
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20
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Vucic S, Ziemann U, Eisen A, Hallett M, Kiernan MC. Transcranial magnetic stimulation and amyotrophic lateral sclerosis: pathophysiological insights. J Neurol Neurosurg Psychiatry 2013; 84:1161-70. [PMID: 23264687 PMCID: PMC3786661 DOI: 10.1136/jnnp-2012-304019] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disorder of the motor neurons in the motor cortex, brainstem and spinal cord. A combination of upper and lower motor neuron dysfunction comprises the clinical ALS phenotype. Although the ALS phenotype was first observed by Charcot over 100 years ago, the site of ALS onset and the pathophysiological mechanisms underlying the development of motor neuron degeneration remain to be elucidated. Transcranial magnetic stimulation (TMS) enables non-invasive assessment of the functional integrity of the motor cortex and its corticomotoneuronal projections. To date, TMS studies have established motor cortical and corticospinal dysfunction in ALS, with cortical hyperexcitability being an early feature in sporadic forms of ALS and preceding the clinical onset of familial ALS. Taken together, a central origin of ALS is supported by TMS studies, with an anterograde transsynaptic mechanism implicated in ALS pathogenesis. Of further relevance, TMS techniques reliably distinguish ALS from mimic disorders, despite a compatible peripheral disease burden, thereby suggesting a potential diagnostic utility of TMS in ALS. This review will focus on the mechanisms underlying the generation of TMS measures used in assessment of cortical excitability, the contribution of TMS in enhancing the understanding of ALS pathophysiology and the potential diagnostic utility of TMS techniques in ALS.
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Affiliation(s)
- Steve Vucic
- Sydney Medical School Westmead, University of Sydney, Sydney, New South Wales, Australia.
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21
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Ahdab R, Créange A, Saint-Val C, Farhat WH, Lefaucheur JP. Rapidly progressive amyotrophic lateral sclerosis initially masquerading as a demyelinating neuropathy. Neurophysiol Clin 2013; 43:181-7. [PMID: 23856174 DOI: 10.1016/j.neucli.2013.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 04/30/2013] [Accepted: 05/01/2013] [Indexed: 11/17/2022] Open
Abstract
Rare cases of demyelinating neuropathy have been described in association with amyotrophic lateral sclerosis (ALS). We report two patients with typical ALS whose initial electroneuromyographic (ENMG) presentation could suggest the existence of a process of motor nerve fiber demyelination. However, subsequent ENMG examinations and the fatal course of the disease in a few months rather supported severe ongoing axonal degeneration at the origin of motor nerve conduction abnormalities. Repeated examinations could be required to distinguish between ENMG features of concomitant demyelinating neuropathy and rapidly progressive motor neuron loss in ALS.
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Affiliation(s)
- R Ahdab
- EA 4391, faculté de médecine de Créteil, université Paris Est Créteil, Créteil, France
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22
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Vucic S, Kiernan MC. Utility of transcranial magnetic stimulation in delineating amyotrophic lateral sclerosis pathophysiology. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:561-575. [PMID: 24112924 DOI: 10.1016/b978-0-444-53497-2.00045-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disorder of the motor neurons in the motor cortex, brainstem, and spinal cord. The clinical phenotype of ALS is underscored by a combination of upper and lower motor neuron dysfunction. Although this phenotype was observed over 100 years ago, the site of ALS onset and the pathophysiological mechanisms underlying the development of motor neuron degeneration remain to be elucidated. Transcranial magnetic stimulation (TMS) enables noninvasive assessment of the functional integrity of the motor cortex and its corticomotoneuronal projections. To date, TMS studies have established cortical dysfunction in ALS, with cortical hyperexcitability being an early feature in sporadic forms of ALS and preceding the clinical onset of familial ALS. Taken together, a central origin of ALS is supported by TMS studies, with an anterograde dying-forward mechanism implicated in ALS pathogenesis. Of further relevance, TMS techniques reliably distinguish ALS from mimic disorders, despite a compatible peripheral disease burden, thereby suggesting a potential diagnostic utility of TMS in ALS. This chapter reviews the mechanisms underlying the generation of TMS parameters utilized in assessment of cortical excitability, the contribution of TMS in enhancing the understanding of ALS pathophysiology, and the potential diagnostic utility of TMS techniques in ALS.
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Affiliation(s)
- Steve Vucic
- Sydney Medical School Westmead, University of Sydney, Sydney, Australia; Neuroscience Research Australia, Sydney, Australia
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Abstract
Central motor conduction time (CMCT) is the time taken for neural impulses to travel through the central nervous system on their way to the target muscles. When the motor cortex is stimulated with transcranial magnetic stimulation (TMS), CMCT is calculated by subtracting the peripheral conduction time from the motor evoked potential latency elicited by motor cortical TMS. CMCT in infants and children reaches adult level at about age of 6 years for the lower limbs. The alterations of CMCT in various neurological conditions are reviewed in this chapter. Prolongation of CMCT occurs due to slowing of conduction through rapidly conducting corticospinal fibers, as seen in various disorders such as demyelinating diseases (multiple sclerosis, MS), amyotrophic lateral sclerosis, structural lesions in the corticospinal tract such as stroke and compressive myelopathy, and neurodegenerative disorders including multiple system atrophy and progressive supranuclear palsy. As CMCT is prolonged in certain clinical conditions, it is of diagnostic value in some neurological disorders such as myelopathy, amyotrophic lateral sclerosis, and MS when used together with other clinical and electrophysiological measures. It could also be used as a prognostic marker in some of neurological conditions, such as myelopathy and MS.
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Affiliation(s)
- Kaviraja Udupa
- Division of Neurology, Department of Medicine, University of Toronto and Division of Brain Imaging & Behaviour Systems - Neuroscience, Toronto Western Research Institute, Toronto, Canada
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Bede P, Bokde ALW, Byrne S, Elamin M, Fagan AJ, Hardiman O. Spinal cord markers in ALS: diagnostic and biomarker considerations. ACTA ACUST UNITED AC 2012; 13:407-15. [PMID: 22329869 DOI: 10.3109/17482968.2011.649760] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Despite considerable involvement of the spinal cord in amyotrophic lateral sclerosis (ALS), current biomarker research is primarily centred on brain imaging and CSF proteomics. In clinical practice, spinal cord imaging in ALS is performed primarily to rule out alternative conditions in the diagnostic phase of the disease. Quantitative spinal cord imaging has traditionally been regarded as challenging, as it requires high spatial resolution while minimizing partial volume effects, physiological motion and susceptibility distortions. In recent years however, as acquisition and post-processing methods have been perfected, a number of exciting and promising quantitative spinal imaging and electrophysiology techniques have been developed. We performed a systematic review of the trends, methodologies, limitations and conclusions of recent spinal cord studies in ALS to explore the diagnostic and prognostic potential of spinal markers. Novel corrective techniques for quantitative spinal cord imaging are systematically reviewed. Recent findings demonstrate that imaging techniques previously used in brain imaging, such as diffusion tensor, functional and metabolic imaging can now be successfully applied to the human spinal cord. Optimized electrophysiological approaches make the non-invasive assessment of corticospinal pathways possible, and multimodal spinal techniques are likely to increase the specificity and sensitivity of proposed spinal markers. In conclusion, spinal cord imaging is an emerging area of ALS biomarker research. Novel quantitative spinal modalities have already been successfully used in ALS animal models and have the potential for development into sensitive ALS biomarkers in humans.
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Affiliation(s)
- Peter Bede
- Trinity College Institute of Neuroscience, Centre for Advanced Medical Imaging, St James's Hosiptal, Dublin, Ireland.
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25
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Assessment of motor pathways by magnetic stimulation in human and veterinary medicine. Vet J 2011; 187:174-81. [DOI: 10.1016/j.tvjl.2009.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 12/09/2009] [Accepted: 12/11/2009] [Indexed: 11/22/2022]
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Kollewe K, Münte TF, Samii A, Dengler R, Petri S, Mohammadi B. Patterns of cortical activity differ in ALS patients with limb and/or bulbar involvement depending on motor tasks. J Neurol 2010; 258:804-10. [DOI: 10.1007/s00415-010-5842-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 11/15/2010] [Accepted: 11/17/2010] [Indexed: 11/24/2022]
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Measures of bulbar and spinal motor function, muscle innervation, and mitochondrial function in ALS rats. Behav Brain Res 2010; 211:48-57. [PMID: 20211206 DOI: 10.1016/j.bbr.2010.03.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 02/19/2010] [Accepted: 03/02/2010] [Indexed: 01/31/2023]
Abstract
Symptom onset in amyotrophic lateral sclerosis (ALS) may occur in the muscles of the limbs (spinal onset) or those of the head and neck (bulbar onset). Most preclinical studies have focused on spinal symptoms, despite the prevalence of and increased morbidity and mortality associated with bulbar disease. We measured lick rhythm and tongue force to evaluate bulbar disease in the SOD1-G93A rat model of familial ALS. Body weight and grip strength were measured concomitantly. Testing spanned the early (maturation), middle (pre-symptomatic), and late (symptomatic and end-stage) phases of the disease. We measured a persistent tongue motility deficit that became apparent in the early phase of the disease, providing behavioral evidence of bulbar pathology. At end-stage, however, cytochrome oxidase (CO) activity was normal in the hypoglossal nucleus, and in the tongue, neuromuscular innervation, citrate synthase (CS) protein levels and activity, and uncoupling protein 3 (UCP3) protein levels remained unchanged. Interestingly, significant denervation and atrophy were evident in the end-stage sternomastoid muscle, providing peripheral anatomical evidence of bulbar pathology. Changes in body weight and grip strength occurred in the late phase of the disease. Extensive atrophy and denervation were observed in the end-stage gastrocnemius muscle. In contrast to our findings in the tongue, CS protein levels were decreased in the extensor digitorum longus (EDL) and soleus, although CS activity was maintained or increased. UCP3 protein was decreased also in the EDL. These data provide evidence of differential effects in muscles that were more or less affected by disease.
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Mohammadi B, Kollewe K, Samii A, Krampfl K, Dengler R, Münte TF. Decreased brain activation to tongue movements in amyotrophic lateral sclerosis with bulbar involvement but not Kennedy syndrome. J Neurol 2009; 256:1263-9. [DOI: 10.1007/s00415-009-5112-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 02/17/2009] [Accepted: 03/17/2009] [Indexed: 11/30/2022]
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Nelles M, Block W, Träber F, Wüllner U, Schild HH, Urbach H. Combined 3T diffusion tensor tractography and 1H-MR spectroscopy in motor neuron disease. AJNR Am J Neuroradiol 2008; 29:1708-14. [PMID: 18701582 DOI: 10.3174/ajnr.a1201] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Diagnostic confidence in motor neuron disease may be improved by the use of advanced MR imaging techniques. Our aim was to assess the accuracy (sensitivity/specificity) and agreement of combined (1)H-MR spectroscopy (proton MR spectroscopy) and diffusion tensor imaging (DTI) at 3T in patients with suspected motor neuron disease regarding detection of upper motor neuron (UMN) dysfunction. MATERIALS AND METHODS Eighteen patients with suspected motor neuron disease were studied with MR spectroscopy/DTI and clinically rated according to the El-Escorial and ALSFRS-R scales. For MR spectroscopy, absolute N-acetylaspartate (NAA), choline (Cho), and phosphocreatine (PCr) concentrations and relative NAA/Cho and NAA/PCr ratios of corresponding volumes of interest within the primary motor cortex were calculated. For DTI, fractional anisotropy (FA) and mean diffusivity (MD) were measured bilaterally at the level of the precentral gyrus, corona radiata, internal capsule, cerebral peduncles, pons, and pyramid. FA and MD statistics were averaged on the corticospinal tracts (CSTs) as a whole to account for a region-independent analysis. RESULTS MR spectroscopy indicated NAA reduction beyond the double SD of controls in 6 of 8 patients with clinical evidence for UMN involvement. Congruently, the mean FA of these patients was significantly lower in the upper 3 regions of measurements (P < .01). Overall, MR spectroscopy and DTI were concordant in all except 3 cases: 1 was correctly excluded from motor neuron disease by DTI (genetically proved Kennedy syndrome), whereas MR spectroscopy indicated CST involvement. MR spectroscopy and DTI each were false-positive for CST affection in 1 patient with lower motor neuron involvement only. CONCLUSION Combined MR spectroscopy/DTI at 3T effectively adds to the detection of motor neuron disease with a high degree of accordance.
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Affiliation(s)
- M Nelles
- Department of Radiology, University of Bonn Medical Center, Bonn, Germany.
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30
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Chen R, Cros D, Curra A, Di Lazzaro V, Lefaucheur JP, Magistris MR, Mills K, Rösler KM, Triggs WJ, Ugawa Y, Ziemann U. The clinical diagnostic utility of transcranial magnetic stimulation: Report of an IFCN committee. Clin Neurophysiol 2008; 119:504-532. [DOI: 10.1016/j.clinph.2007.10.014] [Citation(s) in RCA: 348] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2007] [Revised: 10/12/2007] [Accepted: 10/18/2007] [Indexed: 12/11/2022]
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Cho JY, Sung JJ, Min JH, Lee KW. Clinical utility of trapezius muscle studies in the evaluation of amyotrophic lateral sclerosis. J Clin Neurosci 2006; 13:908-12. [PMID: 17049243 DOI: 10.1016/j.jocn.2006.01.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2005] [Accepted: 01/06/2006] [Indexed: 10/24/2022]
Abstract
Needle electromyography (EMG) and determining the motor evoked potential (MEP) of the genioglossus (tongue) are difficult to perform in evaluation of the craniobulbar region in patients with amyotrophic lateral sclerosis (ALS). Needle EMG and MEP determination in the upper trapezius were carried out in 17 consecutive ALS patients. The needle EMG parameters recorded included abnormal spontaneous activity and motor unit action potential morphology. An upper motor neuron lesion was presumed when either response to cortical stimulation was absent, or the central conduction time was delayed (>mean + 2 SD). Of the 12 patients with limb-onset ALS, using needle EMG, 11 were found to have abnormalities in the upper trapezius, and only five in the tongue. Three of the six patients with isolated limb involvement had abnormal MEP findings. In conclusion, electrophysiological studies of the upper trapezius are useful in ALS patients without bulbar symptoms.
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Affiliation(s)
- Joong-Yang Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine, Ilsan, Korea
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Quelle est la place des autres examens complémentaires ? Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75166-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Osei-Lah AD, Mills KR. Optimising the detection of upper motor neuron function dysfunction in amyotrophic lateral sclerosis?a transcranial magnetic stimulation study. J Neurol 2004; 251:1364-9. [PMID: 15592732 DOI: 10.1007/s00415-004-0545-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2003] [Revised: 04/21/2004] [Accepted: 05/10/2004] [Indexed: 11/24/2022]
Abstract
Evidence of upper motor neuron (UMN) dysfunction is essential in making the diagnosis of amyotrophic lateral sclerosis (ALS). Central motor conduction (CMC) abnormalities detected using transcranial magnetic stimulation (TMS) are presumed to reflect UMN dysfunction. CMC is, however, often normal in patients with classical sporadic ALS. The aim of the study was to determine whether the utility of the CMC measure in ALS could be enhanced. We measured CMC to four pairs of muscles (abductor digiti minimi (ADM), biceps, vastus medialis (VM) and abductor hallucis (AH) in 20 controls and 25 ALS patients. The commonest abnormality detected in the ALS patients was an absent MEP, found in 11 patients (44 %) and in 25 of 200 muscles examined. Studying a minimum of three muscles increased the probability of detecting UMN dysfunction. Weakness in the muscle as well as selecting a distal rather than a proximal muscle was significantly associated with an abnormal CMC. Interside differences in CMC were significantly more pronounced in the patient group. In 30% of patients a significant interside difference in AH CMC time was the sole abnormality, suggesting mild UMN dysfunction on the side with the longer CMC.
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Affiliation(s)
- Abena D Osei-Lah
- Department of Clinical Neurophysiology, Guy's, King's and St. Thomas' School of Medicine, London, SE5 9RS, UK
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Cudkowicz M, Qureshi M, Shefner J. Measures and markers in Amyotrophic Lateral Sclerosis. Neurotherapeutics 2004. [DOI: 10.1007/bf03206611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disorder characterized by loss of spinal and cortical motor neurons, leading to progressive weakness and ultimately, death. Clinically, there appears to be an anatomic focus at disease onset, from which the disease then spreads. Because the focus of initial symptoms and the subsequent direction of spread can vary from patient to patient, disease monitoring is difficult, especially in a clinical trial, in which outcome measures must be identical and able to capture progression of all types. Thus, the search for markers of disease progression is especially important in ALS. Many approaches have been taken, from voluntary strength assessment and functional rating scales to physiological and pathological sampling of affected portions of nervous system. No proposed marker has been demonstrated to meet the desired criteria of biological meaning, sensitivity to disease progression, clear relationship to overall prognosis and survival, and ease of measurement. However, progress is being made in all of these regards.
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Affiliation(s)
- Merit Cudkowicz
- Neurology Clinical Trial Unit, Massachusetts General Hospital, Charlestown, Massachusetts 02129, USA.
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Abstract
The cranial motor neurons innervate muscles that control eye, jaw, and facial movements of the vertebrate head and parasympathetic neurons that innervate certain glands and organs. These efferent neurons develop at characteristic locations in the brainstem, and their axons exit the neural tube in well-defined trajectories to innervate target tissues. This review is focused on a subset of cranial motor neurons called the branchiomotor neurons, which innervate muscles derived from the branchial (pharyngeal) arches. First, the organization of the branchiomotor pathways in zebrafish, chick, and mouse embryos will be compared, and the underlying axon guidance mechanisms will be addressed. Next, the molecular mechanisms that generate branchiomotor neurons and specify their identities will be discussed. Finally, the caudally directed or tangential migration of facial branchiomotor neurons will be examined. Given the advances in the characterization and analysis of vertebrate genomes, we can expect rapid progress in elucidating the cellular and molecular mechanisms underlying the development of these vital neuronal networks. Developmental Dynamics 229:143-161, 2004.
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Affiliation(s)
- Anand Chandrasekhar
- Division of Biological Sciences, University of Missouri, Columbia, Missouri, USA.
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Nollet H, Van Ham L, Deprez P, Vanderstraeten G. Transcranial magnetic stimulation: review of the technique, basic principles and applications. Vet J 2003; 166:28-42. [PMID: 12788015 DOI: 10.1016/s1090-0233(03)00025-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Transcranial magnetic stimulation is rapidly developing as a powerful, non-invasive tool for studying the descending motor tracts in humans. The applications of the test in animals are for the moment restricted to small animals. However, this non-invasive, sensitive and painless technique appears promising as a test of motor tract function in horses where the neurological examination is mainly restricted to clinical evaluation and some ancillary tests, such as radiography, cerebrospinal fluid analysis and electromyography. In this review, we want to discuss the history, basic principles, technique and applications of transcranial magnetic stimulation in humans and small animals and indicate the possibilities for its use in horses. Since the great portion of this review is based on human studies, it is worthwhile to mention that the reports being described are from humans unless otherwise specified.
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Affiliation(s)
- H Nollet
- Department of Internal Medicine and Clinical Biology of Large Animals, Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, 9820, Merelbeke, Belgium.
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Urban PP. Chapter 35 Transcranial magnetic stimulation in brainstem lesions and lesions of the cranial nerves. ACTA ACUST UNITED AC 2003; 56:341-57. [PMID: 14677411 DOI: 10.1016/s1567-424x(09)70238-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Affiliation(s)
- Peter P Urban
- Department of Neurology, University of Mainz, Langenbeckstr. 1, D-55101 Mainz, Germany.
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