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Santos Silva C, Correia Rodrigues C, Fortuna Baptista M, Oliveira Santos M, Gromicho M, Carvalho V, Correia Guedes L, de Carvalho M. Upper motor neuron signs in primary lateral sclerosis and hereditary spastic paraplegia. Muscle Nerve 2024; 70:152-156. [PMID: 38687249 DOI: 10.1002/mus.28100] [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: 12/03/2023] [Revised: 04/14/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION/AIMS The frequency and distribution of upper motor neuron (UMN) signs in primary lateral sclerosis (PLS) are unknown. We aimed to study the spectrum of UMN signs in PLS and compare it with hereditary spastic paraplegia (HSP). METHODS We retrospectively analyzed the frequency of different UMN signs, including hyperreflexia (limbs and jaw), limb and tongue spasticity, Babinski, and Hoffman signs, in PLS patients at first observation and compared this respect to onset region and symptom duration. We also compared PLS versus HSP patients. RESULTS We included 34 PLS and 20 HSP patients, with a median symptom duration at first visit of 3.0 (interquartile range, IQR = 4.0) and 19.0 (IQR = 22.0) years, respectively. In PLS patients, hyperreflexia of upper (UL) (88.2%) and lower (LL) (91.2%) limbs, and LL spasticity (79.4%) were the most common findings. Spasticity of LL was significantly (p = .012) more frequent in LL-spinal onset subgroup, tongue spasticity in bulbar-onset subgroup (p = .021), and Hoffman sign in UL-spinal onset subgroup (p = .024). The PLS subgroup with shorter disease duration had a higher frequency of abnormal jaw jerk reflex (p = .037). Compared with HSP, PLS patients had a higher frequency of UL hyperreflexia (88.2% vs. 42.1%, p < .001) and UL spasticity (44.1% vs. 0.0%, p < .001). Asymmetric distribution of UMN signs was present in PLS and not in HSP. DISCUSSION In PLS, UL UMN signs are nearly always present and UMN sign distribution appears to be associated with onset region. At first observation, bulbar involvement, asymmetrical distribution of UMN signs and UL spasticity may indicate PLS versus HSP.
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Affiliation(s)
- Cláudia Santos Silva
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Catarina Correia Rodrigues
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
| | - Maria Fortuna Baptista
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
| | - Miguel Oliveira Santos
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Marta Gromicho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Vanessa Carvalho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Leonor Correia Guedes
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mamede de Carvalho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Di Lazzaro V, Ranieri F, Bączyk M, de Carvalho M, Dileone M, Dubbioso R, Fernandes S, Kozak G, Motolese F, Ziemann U. Novel approaches to motoneuron disease/ALS treatment using non-invasive brain and spinal stimulation: IFCN handbook chapter. Clin Neurophysiol 2024; 158:114-136. [PMID: 38218077 DOI: 10.1016/j.clinph.2023.12.012] [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: 10/13/2023] [Revised: 11/28/2023] [Accepted: 12/17/2023] [Indexed: 01/15/2024]
Abstract
Non-invasive brain stimulation techniques have been exploited in motor neuron disease (MND) with multifold objectives: to support the diagnosis, to get insights in the pathophysiology of these disorders and, more recently, to slow down disease progression. In this review, we consider how neuromodulation can now be employed to treat MND, with specific attention to amyotrophic lateral sclerosis (ALS), the most common form with upper motoneuron (UMN) involvement, taking into account electrophysiological abnormalities revealed by human and animal studies that can be targeted by neuromodulation techniques. This review article encompasses repetitive transcranial magnetic stimulation methods (including low-frequency, high-frequency, and pattern stimulation paradigms), transcranial direct current stimulation as well as experimental findings with the newer approach of trans-spinal direct current stimulation. We also survey and discuss the trials that have been performed, and future perspectives.
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Affiliation(s)
- Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy.
| | - Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Marcin Bączyk
- Department of Neurobiology, Poznań University of Physical Education, Królowej Jadwigi Street 27/39, 61-871 Poznań, Poland
| | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine-JLA, Egas Moniz Study Centre, Faculty of Medicine, University of Lisbon, Lisbon 1649-028, Portugal; Department of Neurosciences and Mental Health, CHULN, Lisbon, Portugal
| | - Michele Dileone
- Faculty of Health Sciences, UCLM Talavera de la Reina, Toledo, Spain; Neurology Department, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Raffaele Dubbioso
- Neurophysiology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Sofia Fernandes
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016-Lisboa, Portugal
| | - Gabor Kozak
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Francesco Motolese
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Ulf Ziemann
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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Schito P, Russo T, Domi T, Mandelli A, Pozzi L, Del Carro U, Carrera P, Agosta F, Quattrini A, Furlan R, Filippi M, Riva N. Clinical Features and Biomarkers to Differentiate Primary and Amyotrophic Lateral Sclerosis in Patients With an Upper Motor Neuron Syndrome. Neurology 2023; 101:352-356. [PMID: 36927885 PMCID: PMC10449441 DOI: 10.1212/wnl.0000000000207223] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/09/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES Differentiation between primary (PLS) and amyotrophic lateral sclerosis (ALS) entails relevant consequences for prognosis and management but is mostly unreliable at early stages. The objectives of the study are (1) to determine the features at onset that could help to differentiate between PLS and ALS, (2) to evaluate the diagnostic performance of an integrated serum biomarker panel, and (3) to identify the prognostic factors for patients presenting with upper motor neuron (UMN) syndrome. METHODS We selected and retrospectively analyzed the clinical data of patients presenting with UMN syndrome. At the first evaluation, when available, serum biomarkers were measured using ultrasensitive single molecule array. RESULTS The study population included 55 patients with PLS and 50 patients with ALS. Patients with PLS presented a longer time to first neurologic evaluation (PLS: 35.0 months, interquartile range [IQR] 17.0-38.0 months; ALS: 12.5 months, IQR 7.0-21.3 months; p < 0.01) and lower levels of neurofilament light chain (NfL) (PLS: 81.8 pg/mL, IQR 38.4-111.1 pg/mL; ALS: 155.9 pg/mL, IQR 85.1-366.4 pg/mL; p = 0.01). Two patients with PLS and 3 patients with ALS carried the C9orf72 expansion. NfL resulted an independent predictor of final diagnosis (odds ratio 1.01, 95% CI 1.00-1.02; p = 0.04) and an independent prognostic factor (hazard ratio 1.01, 95% CI 1.00-1.01; p < 0.01). DISCUSSION NfL might help to differentiate patients with PLS from patients with ALS and to predict prognosis in patients with UMN syndrome.
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Affiliation(s)
- Paride Schito
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Tommaso Russo
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Teuta Domi
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Mandelli
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Laura Pozzi
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ubaldo Del Carro
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paola Carrera
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Federica Agosta
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Angelo Quattrini
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Furlan
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Massimo Filippi
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nilo Riva
- From the Experimental Neuropathology Unit (P.S., T.R., T.D., L.P., A.Q., N.R.), Institute of Experimental Neurology (INSPE), Division of Neuroscience, San Raffaele Scientific Institute; Neurology Unit (P.S., T.R., M.F.), Neurophysiology Unit (P.S., U.D.C., M.F.), and Neurorehabilitation Unit (P.S., M.F.), IRCCS San Raffaele Scientific Institute; Clinical Neuroimmunology Unit (A.M., R.F.), Division of Neuroscience, Institute of Experimental Neurology, San Raffaele Scientific Institute; Division of Genetics and Cell Biology (P.C.), Unit of Genomics for Human Disease Diagnosis, Laboratory of Clinical Molecular Biology, IRCCS Ospedale San Raffaele; Neuroimaging Research Unit (F.A., M.F.), Institute of Experimental Neurology, Division of Neuroscience, IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University (F.A., M.F.); and 3rd Neurology Unit and Motor Neuron Disease Centre (N.R.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
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