MR diffusion imaging in Pelizaeus-Merzbacher disease

High b-value and diffusion tensor imaging in a canine model of dysmyelination and brain maturation

Recent studies in rodents have demonstrated that diffusion imaging is highly sensitive to differences in myelination. These studies suggest that demyelination/dysmyelination cause increases in the radial diffusivity from diffusion tensor imaging (DTI) measurements and decreases in the restricted diffusion component from high b-value diffusion-weighted imaging experiments. In this study, the shaking pup (sh pup), a canine model of dysmyelination, was studied on a clinical MRI scanner using a combination of conventional diffusion tensor imaging and high b-value diffusion-weighted imaging methods. Diffusion measurements were compared between control dogs and sh pups in the age range 3 months to 16 months, which is similar to the period of early childhood through adolescence in humans. The study revealed significant group differences in nearly all diffusion measures with the largest differences in the zero-displacement probability (Po) from high b-value DWI and the radial diffusivity from DTI, which are consistent with the observations from the published rodent studies. Age-related changes in Po, FA, mean diffusivity, radial diffusivity and axial diffusivity were observed in whole brain white matter for the control dogs, but not the sh pups. Regionally, age-related changes in the sh pup white matter were observed for Po, mean diffusivity and radial diffusivity in the internal capsule, which may be indicative of mild myelination. These studies demonstrate that DWI may be used to study myelin abnormalities and brain development in large animal models on clinical MRI scanners, which are more amenable to translation to human studies.

Childhood white matter disorders: quantitative MR imaging and spectroscopy

PURPOSE

To prospectively investigate whether quantitative magnetic resonance (MR) parameters, including magnetization transfer ratio (MTR), apparent diffusion coefficient (ADC), fractional anisotropy (FA), and MR spectroscopic metabolite concentrations, allow for discrimination between different types of pathologic conditions that underlie signal intensity abnormalities in white matter.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. Forty-one patients (19 male, 22 female; mean age, 15.4 years) and 41 control subjects (25 male, 16 female; mean age, 11.3 years) were included. Twelve patients had a hypomyelinating disorder; 14, a demyelinating disorder; five, a disorder characterized by myelin vacuolation; and 10, a disorder characterized by cystic degeneration. Regions of interest were selected within the parietal white matter and were transferred to the corresponding sections of the generated ADC, FA, and MTR maps to extract quantitative measurements. Linear discriminant analysis and univariate analysis of covariance were used for statistical evaluation.

RESULTS

Linear discriminant analysis showed that 95% of patients were correctly classified by using total creatine, choline-containing compounds, myo-inositol, MTR, and ADC. In the hypomyelination group, all MR parameters were close to normal, with the exception of elevated total creatine (P = .03) and myo-inositol (P < .001) levels and decreased MTR values (P < .001). In the demyelination group, the levels of choline-containing compounds (P = .02) and myo-inositol (P < .001) were highly elevated. In the myelin vacuolation and cystic degeneration groups, high ADC values (P < .001) and variable decreases in all MR spectroscopic metabolites were seen. MTR was significantly reduced (P < .001) in the cystic degeneration group.

CONCLUSION

Quantitative MR techniques can be used to discriminate between different types of white matter disorders and to classify white matter lesions of unknown origin with respect to underlying pathologic conditions.

A case of complicated spastic paraplegia 2 due to a point mutation in the proteolipid protein 1 gene

Pelizaeus-Merzbacher disease (PMD) is a rare X-linked dysmyelinating disorder resulting from mutation of the proteolipid protein gene (PLP1). Clinical features of PMD include progressive psychomotor developmental delay, nystagmus, spastic quadriplegia, dystonia, and cerebellar ataxia. PMD is clinically classified into three subtypes according to the severity of the disease: connatal, transitional, and classic forms. Patients with PMD have been identified with duplication, point mutations, and deletion of PLP1. In addition, spastic paraplegia 2 (SPG2) is allelic to PMD and typically caused by missense mutations in the second extracellular domain of PLP1 or in the PLP1-specific region that is spliced out during formation of the DM20 isoform. The authors describe a Korean boy diagnosed with SPG2 caused by a mutation that results in a Pro215Leu substitution in the second extracellular domain. Analysis of phenotypes resulting from mutations affecting PLP1 has been valuable in identifying functional domains of this still incompletely understood major myelin protein. Null mutations and mutations affecting the PLP1-specific domain cause peripheral neuropathy. The PLP1-specific domain also is important in the long-term maintenance of axonal integrity. This patient's phenotype was relatively mild, in contrast with other mutations at position 215 of PLP1 that cause severe PMD. One of these severe mutations is also a missense mutation substituting an aliphatic residue, alanine, for proline. The distinct severity difference between the Pro215Leu and Pro215Ala substitutions suggests that this region of the protein is very sensitive to subtle structural changes and likely plays a critical role in PLP1 function.

Pelizaeus-Merzbacher disease and spastic paraplegia type 2: two faces of myelin loss from mutations in the same gene

Pelizaeus-Merzbacher disease and X-linked spastic paraplegia type 2 are two sides of the same coin. Both arise from mutations in the gene encoding myelin proteolipid protein. The disease spectrum for Pelizaeus-Merzbacher disease and spastic paraplegia type 2 is extraordinarily broad, ranging from a spastic gait in the pure form of spastic paraplegia type 2 to a severely disabling form of Pelizaeus-Merzbacher disease featuring hypotonia, respiratory distress, stridor, nystagmus, and profound myelin loss. The diverse disease spectrum is mirrored by the underlying pathogenesis, in which a blockade at any stage of myelin proteolipid protein synthesis and assembly into myelin spawns a unique phenotype. The continuing definition of pathogenetic mechanisms operative in Pelizaeus-Merzbacher disease and spastic paraplegia type 2, together with advances in neural cell transplant therapy, augurs well for future treatment of the severe forms of Pelizaeus-Merzbacher disease.

Diffusion-weighted MR imaging in the brain in children: findings in the normal brain and in the brain with white matter diseases

PURPOSE

To establish quantitative standards for age-related changes in diffusion restriction of cerebral white matter in healthy children and to compare data with results in children with white matter diseases.

MATERIALS AND METHODS

Diffusion-weighted magnetic resonance (MR) imaging was performed in 44 children (age range, 7 days to 7.5 years) without brain abnormalities and in 13 children with proved leukodystrophy. Apparent diffusion coefficient (ADC) and apparent anisotropy (AA) were measured in 11 regions of interest within white matter. Age-related changes were analyzed with regression analysis.

RESULTS

During normal brain myelination, ADCs in different anatomic regions were high at birth (range, 1.04 x 10(-9) m(2)/sec +/- 0.05 [SD] to 1.64 x 10(-9) m(2)/sec +/- 0.09) and low after brain maturation (range, 0.75 x 10(-9) m(2)/sec +/- 0.02 to 0.92 x 10(-9) m(2)/sec +/- 0.02). AA was low at birth (range, 0.05 +/- 0.01 to 0.52 +/- 0.04) and high after brain maturation (range, 0.25 +/- 0.02 to 0.85 +/- 0.03). Age relationship could be expressed with monoexponential functions for all anatomic regions. Anisotropy preceded the myelination-related changes at MR imaging. ADC and AA in four children with Pelizaeus-Merzbacher disease were identical with results in healthy newborn children and showed no age dependency. In peroxisomal disorders, Krabbe disease, and mitochondriopathy, demyelination on T1- and T2-weighted MR images led to expected findings at diffusion-weighted MR imaging, with high ADC and low AA, whereas in Canavan disease and metachromatic leukodystrophy, the opposite findings were revealed, with low ADC within the demyelinated white matter.

CONCLUSION

During early brain myelination, diffusion restriction in normal white matter increases. Anisotropy precedes myelination changes that are visible at MR imaging. Compared with T1- and T2-weighted MR imaging, diffusion-weighted MR imaging in white matter diseases reveals additional information.

Differentiation of dys- and demyelination using diffusional anisotropy

We attempted differential diagnosis of dysmyelination and demyelination in childhood using magnetic resonance diffusion weighted imaging. Pelizaeus-Merzbacher disease, one of the dysmyelination disorders, demonstrated diffuse high intensity of the cerebral white matter on T2-weighted images, which demonstrated diffusional anisotropy on diffusion weighted images. On the other hand, high intensity lesions on T2-weighted images in Krabbe disease, one of the demyelination disorders, lost diffusional anisotropy. Another demyelination disorder, Alexander disease-related disorder, also lost its diffusional anisotropy. In contrast to relatively high signal of the lesions on diffusion-weighted images in Krabbe disease (high signal type), the lesions in Alexander disease-related disorder showed low signal on diffusion-weighted images (low signal type). These results suggest that diffusion-weighted images will be clinically useful to differentiate dysmyelination from demyelination; both of them demonstrate similar high intensity lesions of the white matter on T2-weighted images.

X-Linked Developmental Defects of Myelination: From Mouse Mutants to Human Genetic Diseases

Molecular cloning of the major myelin-specific genes and a systematic analysis of mouse mutants have led to the identification of molecular defects in human genetic diseases that affect myelination. In the central nervous system, Pelizaeus-Merzbacher disease (PMD) and X-linked spastic paraplegia (SPG-2) are clinically distinct with respect to the severity of motor dysfunction but involve the same gene for myelin proteolipid protein (PLP). Spontaneous mouse mutants of the PLP gene, such as jimpy and rumpshaker, provide faithful models of these human diseases and allow a detailed analysis of PLP dysfunction. Hypomyelination in jimpy and, presumably, in PMD is largely the result of abnormally increased oligodendrocyte death and a lack of terminal differentiation. In rumpshaker, a model for X-linked spastic paraplegia, myelinating oligodendrocytes appear normal in number but fail to assemble myelin correctly. Recently, PLP-transgenic mice have provided experimental evidence that increasing the normal PLP gene dosage (e.g., by a gene duplication) is by itself sufficient to cause PMD. The latter is strikingly similar to the peripheral neuropathy Charcot-Marie-Tooth disease frequently associated with a duplication of the myelin protein gene PMP-22.

Differentiation between dysmyelination and demyelination using magnetic resonance diffusional anisotropy

Using magnetic resonance (MR) diffusion-weighted method, we examined the optic and the trigeminal nerves of jimpy and twitcher mice, considered to be animal models of Pelizaeus-Merzbacher disease, hypomyelination disorder, and Krabbe disease, demyelination disorder, respectively. In jimpy mice, diffusional anisotropy of optic nerve did not show a significant difference compared to age-matched control mice, suggesting that diffusional anisotropy does exist in absence of multiple layers of myelin sheath. In twitcher mice, diffusional anisotropy was attenuated remarkably in the optic and trigeminal nerves. Loss of axonal straightness on longitudinal section confirmed by electron microscopy appeared to be the principal explanation for it. It is further suggested that this MR diffusion-weighted imaging method enables us to differentiate hypomyelination from demyelination in vivo.