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Mijajlovic M, Bozovic I, Pavlovic A, Rakocevic-Stojanovic V, Gluscevic S, Stojanovic A, Basta I, Meola G, Peric S. Transcranial brain parenchyma sonographic findings in patients with myotonic dystrophy type 1 and 2. Heliyon 2024; 10:e26856. [PMID: 38434309 PMCID: PMC10907768 DOI: 10.1016/j.heliyon.2024.e26856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 02/06/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction Myotonic dystrophy type 1 (DM1) and 2 (DM2) are genetically determined progressive muscular disorders with multisystemic affection, including brain involvement. Transcranial sonography (TCS) is a reliable diagnostic tool for the investigation of deep brain structures. We sought to evaluate TCS findings in genetically confirmed DM1 and DM2 patients, and further correlate these results with patients' clinical features. Methods This cross-sectional study included 163 patients (102 DM1, 61 DM2). Echogenicity of the brainstem raphe (BR) and substantia nigra (SN) as well as the diameter of the third ventricle (DTV) were assessed by TCS. Patients were evaluated using the Hamilton Depression Rating Scale, Fatigue Severity Scale and Daytime Sleepiness Scale. Results SN hyperechogenicity was observed in 40% of DM1 and 34% of DM2 patients. SN hypoechogenicity was detected in 17% of DM1 and 7% of DM2 patients. BR hypoechogenicity was found in 36% of DM1 and 47% of DM2 subjects. Enlarged DTV was noted in 19% of DM1 and 15% of DM2 patients. Older, weaker, depressive, and fatigued DM1 patients were more likely to have BR hypoechogenicity (p < 0.05). DTV correlated with age and disease duration in DM1 (p < 0.01). In DM2 patients SN hyperechogenicity correlated with fatigue. Excessive daytime sleepiness was associated with hypoechogenic BR (p < 0.05) and enlarged DVT (p < 0.01) in DM2 patients. Conclusions TCS is an easy applicable and sensitive neuroimaging technique that could offer new information regarding several brainstem structures in DM1 and DM2. This may lead to better understanding of the pathogenesis of the brain involvement in DM with possible clinical implications.
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Affiliation(s)
- Milija Mijajlovic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivo Bozovic
- Neurology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandra Pavlovic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Faculty of Special Education and Rehabilitation, University of Belgrade, Belgrade, Serbia
| | - Vidosava Rakocevic-Stojanovic
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sanja Gluscevic
- Neurology Clinic, Clinical Center of Montenegro, Podgorica, Montenegro
| | | | - Ivana Basta
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Giovanni Meola
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Neurorehabilitation Sciences, Casa Di Cura del Policlinico, Milan, Italy
| | - Stojan Peric
- Neurology Clinic, University Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Koscik TR, van der Plas E, Long JD, Cross S, Gutmann L, Cumming SA, Monckton DG, Shields RK, Magnotta V, Nopoulos PC. Longitudinal changes in white matter as measured with diffusion tensor imaging in adult-onset myotonic dystrophy type 1. Neuromuscul Disord 2023; 33:660-669. [PMID: 37419717 PMCID: PMC10529200 DOI: 10.1016/j.nmd.2023.05.010] [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: 11/19/2022] [Revised: 05/17/2023] [Accepted: 05/31/2023] [Indexed: 07/09/2023]
Abstract
Myotonic dystrophy type 1 is characterized by neuromuscular degeneration. Our objective was to compare change in white matter microstructure (fractional anisotropy, radial and axial diffusivity), and functional/clinical measures. Participants underwent yearly neuroimaging and neurocognitive assessments over three-years. Assessments encompassed full-scale intelligence, memory, language, visuospatial skills, attention, processing speed, and executive function, as well as clinical symptoms of muscle/motor function, apathy, and hypersomnolence. Mixed effects models were used to examine differences. 69 healthy adults (66.2% women) and 41 DM1 patients (70.7% women) provided 156 and 90 observations, respectively. There was a group by elapsed time interaction for cerebral white matter, where DM1 patients exhibited declines in white matter (all p<0.05). Likewise, DM1 patients either declined (motor), improved more slowly (intelligence), or remained stable (executive function) for functional outcomes. White matter was associated with functional performance; intelligence was predicted by axial (r = 0.832; p<0.01) and radial diffusivity (r = 0.291, p<0.05), and executive function was associated with anisotropy (r = 0.416, p<0.001), and diffusivity (axial: r = 0.237, p = 0.05 and radial: r = 0.300, p<0.05). Indices of white matter health are sensitive to progression in DM1. These results are important for clinical trial design, which utilize short intervals to establish treatment efficacy.
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Affiliation(s)
- Timothy R Koscik
- Arkansas Children's Research Institute, University of Arkansas for Medical Sciences, 13 Children's Way, Little Rock, AR 72202-3591, USA
| | - Ellen van der Plas
- Arkansas Children's Research Institute, University of Arkansas for Medical Sciences, 13 Children's Way, Little Rock, AR 72202-3591, USA
| | - Jeffrey D Long
- Department of Psychiatry, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; Department of Biostatistics, College of Public Health, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Stephen Cross
- Arkansas Children's Research Institute, University of Arkansas for Medical Sciences, 13 Children's Way, Little Rock, AR 72202-3591, USA
| | - Laurie Gutmann
- Department of Neurology, School of Medicine, Indiana University, 362W 15th St, Indianapolis, IN 46202, USA
| | - Sarah A Cumming
- Institute of Molecular, Cell and Systems Biology, University of Glasgow, Glasgow G12 8QQ, UK
| | - Darren G Monckton
- Institute of Molecular, Cell and Systems Biology, University of Glasgow, Glasgow G12 8QQ, UK
| | - Richard K Shields
- Department of Radiology, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Vincent Magnotta
- Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA
| | - Peggy C Nopoulos
- Department of Psychiatry, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; Department of Neurology, School of Medicine, Indiana University, 362W 15th St, Indianapolis, IN 46202, USA; Department of Pediatrics, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Wang PY, Kuo TY, Wang LH, Liang WH, Wang GS. Loss of MBNL1-mediated retrograde BDNF signaling in the myotonic dystrophy brain. Acta Neuropathol Commun 2023; 11:44. [PMID: 36922901 PMCID: PMC10018927 DOI: 10.1186/s40478-023-01540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023] Open
Abstract
Reduced brain volume including atrophy in grey and white matter is commonly seen in myotonic dystrophy type 1 (DM1). DM1 is caused by an expansion of CTG trinucleotide repeats in the 3' untranslated region (UTR) of the Dystrophia Myotonica Protein Kinase (DMPK) gene. Mutant DMPK mRNA containing expanded CUG RNA (DMPK-CUGexp) sequesters cytoplasmic MBNL1, resulting in morphological impairment. How DMPK-CUGexp and loss of MBNL1 cause histopathological phenotypes in the DM1 brain remains elusive. Here, we show that BDNF-TrkB retrograde transport is impaired in neurons expressing DMPK-CUGexp due to loss of cytoplasmic MBNL1 function. We reveal that mature BDNF protein levels are reduced in the brain of the DM1 mouse model EpA960/CaMKII-Cre. Exogenous BDNF treatment did not rescue impaired neurite outgrowth in neurons expressing DMPK-CUGexp, whereas overexpression of the cytoplasmic MBNL1 isoform in DMPK-CUGexp-expressing neurons improved their responsiveness to exogenous BDNF. We identify dynein light chain LC8-type 2, DYNLL2, as an MBNL1-interacting protein and demonstrate that their interaction is RNA-independent. Using time-lapse imaging, we show that overexpressed MBNL1 and DYNLL2 move along axonal processes together and that MBNL1-knockdown impairs the motility of mCherry-tagged DYNLL2, resulting in a reduced percentage of retrograde DYNLL2 movement. Examination of the distribution of DYNLL2 and activated phospho-TrkB (pTrkB) receptor in EpA960/CaMKII-Cre brains revealed an increase in the postsynaptic membrane fraction (LP1), indicating impaired retrograde transport. Finally, our neuropathological analysis of postmortem DM1 tissue reveals that reduced cytoplasmic MBNL1 expression is associated with an increase in DYNLL2 and activated pTrkB receptor levels in the synaptosomal fraction. Together, our results support that impaired MBNL1-mediated retrograde BDNF-TrkB signaling may contribute to the histopathological phenotypes of DM1.
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Affiliation(s)
- Pei-Ying Wang
- Institute of Biomedical Sciences, Academia Sinica, 128, Section 2, Academia Rd. Nangang, Taipei, 115, Taiwan
| | - Ting-Yu Kuo
- Institute of Biomedical Sciences, Academia Sinica, 128, Section 2, Academia Rd. Nangang, Taipei, 115, Taiwan
| | - Lee-Hsin Wang
- Institute of Biomedical Sciences, Academia Sinica, 128, Section 2, Academia Rd. Nangang, Taipei, 115, Taiwan
| | - Wen-Hsing Liang
- Institute of Biomedical Sciences, Academia Sinica, 128, Section 2, Academia Rd. Nangang, Taipei, 115, Taiwan
| | - Guey-Shin Wang
- Institute of Biomedical Sciences, Academia Sinica, 128, Section 2, Academia Rd. Nangang, Taipei, 115, Taiwan. .,Taiwan International Graduate Program in Molecular Medicine, National Yang Ming Chiao Tung University and Academia Sinica, Taipei, Taiwan. .,Taiwan International Graduate Program in Interdisciplinary Neuroscience, National Yang Ming Chiao Tung University and Academia Sinica, Taipei, Taiwan.
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Rossi S, Silvestri G. Fluid Biomarkers of Central Nervous System (CNS) Involvement in Myotonic Dystrophy Type 1 (DM1). Int J Mol Sci 2023; 24:ijms24032204. [PMID: 36768526 PMCID: PMC9917343 DOI: 10.3390/ijms24032204] [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: 12/27/2022] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Myotonic dystrophy type 1 (DM1), commonly known as Steinert's disease (OMIM #160900), is the most common muscular dystrophy among adults, caused by an unstable expansion of a CTG trinucleotide repeat in the 3' untranslated region (UTR) of DMPK. Besides skeletal muscle, central nervous system (CNS) involvement is one of the core manifestations of DM1, whose relevant cognitive, behavioral, and affective symptoms deeply affect quality of life of DM1 patients, and that, together with muscle and heart, may profoundly influence the global disease burden and overall prognosis. Therefore, CNS should be also included among the main targets for future therapeutic developments in DM1, and, in this regard, identifying a cost-effective, easily accessible, and sensitive diagnostic and monitoring biomarker of CNS involvement in DM1 represents a relevant issue to be addressed. In this mini review, we will discuss all the papers so far published exploring the usefulness of both cerebrospinal fluid (CSF) and blood-based biomarkers of CNS involvement in DM1. Globally, the results of these studies are quite consistent on the value of CSF and blood Neurofilament Light Chain (NfL) as a biomarker of CNS involvement, with less robust results regarding levels of tau protein or amyloid-beta.
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Affiliation(s)
- Salvatore Rossi
- Department of Neuroscience, Università Cattolica del Sacro Cuore–Sede di Roma, Largo F. Vito 1, 00168 Rome, Italy
| | - Gabriella Silvestri
- Department of Neuroscience, Università Cattolica del Sacro Cuore–Sede di Roma, Largo F. Vito 1, 00168 Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
- Correspondence:
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Morin A, Funkiewiez A, Routier A, Le Bouc R, Borderies N, Galanaud D, Levy R, Pessiglione M, Dubois B, Eymard B, Michon CC, Angeard N, Behin A, Laforet P, Stojkovic T, Azuar C. Unravelling the impact of frontal lobe impairment for social dysfunction in myotonic dystrophy type 1. Brain Commun 2022; 4:fcac111. [PMID: 35611304 PMCID: PMC9123843 DOI: 10.1093/braincomms/fcac111] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 01/14/2022] [Accepted: 05/13/2022] [Indexed: 01/18/2023] Open
Abstract
Abstract
Myotonic dystrophy type 1 is an autosomal dominant multisystemic disorder affecting muscular and extra muscular systems, including the central nervous system. Cerebral involvement in myotonic dystrophy type 1 is associated with subtle cognitive and behavioural disorders, of major impact on socio-professional adaptation. The social dysfunction and its potential relation to frontal lobe neuropsychology remain under-evaluated in this pathology. The neuroanatomical network underpinning that disorder is yet to disentangle. Twenty-eight myotonic dystrophy type 1 adult patients (mean age: 46 years old) and 18 age and sex-matched healthy controls were included in the study. All patients performed an exhaustive neuropsychological assessment with a specific focus on frontal lobe neuropsychology (motivation, social cognition and executive functions). Among them, 18 myotonic dystrophy type 1 patients and 18 healthy controls had a brain MRI with T1 and T2 Flair sequences. Grey matter segmentation, Voxel-based morphometry and cortical thickness estimation were performed with Statistical Parametric Mapping Software SPM12 and Freesurfer software. Furthermore, T2 white matter lesions and subcortical structures were segmented with Automated Volumetry Software. Most patients showed significant impairment in executive frontal functions (auditory working memory, inhibition, contextualization and mental flexibility). Patients showed only minor difficulties in social cognition tests mostly in cognitive Theory of Mind, but with relative sparing of affective Theory of Mind and emotion recognition. Neuroimaging analysis revealed atrophy mostly in the parahippocampal and hippocampal regions and to a lesser extent in basal ganglia, regions involved in social navigation and mental flexibility, respectively. Social cognition scores were correlated with right parahippocampal gyrus atrophy. Social dysfunction in myotonic dystrophy type 1 might be a consequence of cognitive impairment regarding mental flexibility and social contextualization rather than a specific social cognition deficit such as emotion recognition. We suggest that both white matter lesions and grey matter disease could account for this social dysfunction, involving, in particular, the frontal-subcortical network and the hippocampal/arahippocampal regions, brain regions known, respectively, to integrate contextualization and social navigation.
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Affiliation(s)
- Alexandre Morin
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Service de Neurologie, CHU Rouen, Centre National de Référence Maladie d’Alzheimer du sujet jeune, 76000 Rouen, France
| | - Aurelie Funkiewiez
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Département de Neurologie, Institut de la Mémoire et de la Maladie d’Alzheimer, Centre National Démences Rares, Hôpital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Alexandre Routier
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
| | - Raphael Le Bouc
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Urgences cérébro-vasculaires, Hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Nicolas Borderies
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
| | - Damien Galanaud
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Service de Neuroradiologie, Hôpital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Richard Levy
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Département de Neurologie, Institut de la Mémoire et de la Maladie d’Alzheimer, Centre National Démences Rares, Hôpital Pitié-Salpêtrière, APHP, 75013 Paris, France
- Unité de Neuro-Psychiatrie Comportementale (IHU), Hôpital de la Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Mathias Pessiglione
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
| | - Bruno Dubois
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Département de Neurologie, Institut de la Mémoire et de la Maladie d’Alzheimer, Centre National Démences Rares, Hôpital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Bruno Eymard
- Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hospital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Claire-Cecile Michon
- Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hospital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Nathalie Angeard
- U1129, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Institut de Myologie, Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France
| | - Anthony Behin
- Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hospital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Pascal Laforet
- Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hospital Raymond Poincaré, APHP, 92380 Garches, France
| | - Tanya Stojkovic
- Centre de référence des maladies neuromusculaires Nord/Est/Ile de France, Institut de Myologie, Hospital Pitié-Salpêtrière, APHP, 75013 Paris, France
| | - Carole Azuar
- Institut du Cerveau et de la Moelle épinière (ICM), UMRS 975, ICM-INSERM 1127, 75013 Paris, France
- Département de Neurologie, Institut de la Mémoire et de la Maladie d’Alzheimer, Centre National Démences Rares, Hôpital Pitié-Salpêtrière, APHP, 75013 Paris, France
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Rosado Bartolomé A, Puertas Martín V, Domínguez González C, Ramos Miranda M. Alteración cognitiva en la distrofia miotónica tipo 1 (enfermedad de Steinert). Semergen 2022; 48:208-213. [DOI: 10.1016/j.semerg.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 01/27/2022] [Accepted: 01/30/2022] [Indexed: 11/28/2022]
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White matter integrity changes and neurocognitive functioning in adult-late onset DM1: a follow-up DTI study. Sci Rep 2022; 12:3988. [PMID: 35256728 PMCID: PMC8901711 DOI: 10.1038/s41598-022-07820-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/21/2022] [Indexed: 12/04/2022] Open
Abstract
Myotonic Dystrophy Type 1 (DM1) is a multisystemic disease that affects gray and white matter (WM) tissues. WM changes in DM1 include increased hyperintensities and altered tract integrity distributed in a widespread manner. However, the precise temporal and spatial progression of the changes are yet undetermined. MRI data were acquired from 8 adult- and late-onset DM1 patients and 10 healthy controls (HC) at two different timepoints over 9.06 years. Fractional anisotropy (FA) and mean diffusivity (MD) variations were assessed with Tract-Based Spatial Statistics. Transversal and longitudinal intra- and intergroup analyses were conducted, along with correlation analyses with clinical and neuropsychological data. At baseline, reduced FA and increased MD values were found in patients in the uncinate, anterior-thalamic, fronto-occipital, and longitudinal tracts. At follow-up, the WM disconnection was shown to have spread from the frontal part to the rest of the tracts in the brain. Furthermore, WM lesion burden was negatively correlated with FA values, while visuo-construction and intellectual functioning were positively correlated with global and regional FA values at follow-up. DM1 patients showed a pronounced WM integrity loss over time compared to HC, with a neurodegeneration pattern that suggests a progressive anterior–posterior disconnection. The visuo-construction domain stands out as the most sensitive neuropsychological measure for WM microstructural impairment.
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Abstract
Myotonic Dystrophy Type I (DM1) patients demonstrate widespread and variable brain structural alterations whose etiology is unclear. We demonstrate that inactivation of the Muscleblind-like proteins, Mbnl1 and Mbnl2, initiates brain structural defects. 2D FSE T2w MRIs on 4-month-old Mbnl1+/-/Mbnl2-/- mice demonstrate whole-brain volume reductions, ventriculomegaly and regional gray and white matter volume reductions. Comparative MRIs on 2-month-old Mbnl1-/-, Mbnl2-/- and Mbnl1-/-/Mbnl2+/- brains show genotype-specific reductions in white and gray matter volumes. In both cohorts, white matter volume reductions predominate, with Mbnl2 loss leading to more widespread alterations than Mbnl1 loss. Hippocampal volumes are susceptible to changes in either Mbnl1 or Mbnl2 levels, where both single gene and dual depletions result in comparable volume losses. In contrast, the cortex, inter/midbrain, cerebellum and hindbrain regions show both gene and dose-specific volume decreases. Our results provide a molecular explanation for phenotype intensification in congenital DM1 and the variability in the brain structural alterations reported in DM1.
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Liu J, Guo ZN, Yan XL, Yang Y, Huang S. Brain Pathogenesis and Potential Therapeutic Strategies in Myotonic Dystrophy Type 1. Front Aging Neurosci 2021; 13:755392. [PMID: 34867280 PMCID: PMC8634727 DOI: 10.3389/fnagi.2021.755392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 10/20/2021] [Indexed: 12/17/2022] Open
Abstract
Myotonic dystrophy type 1 (DM1) is the most common muscular dystrophy that affects multiple systems including the muscle and heart. The mutant CTG expansion at the 3′-UTR of the DMPK gene causes the expression of toxic RNA that aggregate as nuclear foci. The foci then interfere with RNA-binding proteins, affecting hundreds of mis-spliced effector genes, leading to aberrant alternative splicing and loss of effector gene product functions, ultimately resulting in systemic disorders. In recent years, increasing clinical, imaging, and pathological evidence have indicated that DM1, though to a lesser extent, could also be recognized as true brain diseases, with more and more researchers dedicating to develop novel therapeutic tools dealing with it. In this review, we summarize the current advances in the pathogenesis and pathology of central nervous system (CNS) deficits in DM1, intervention measures currently being investigated are also highlighted, aiming to promote novel and cutting-edge therapeutic investigations.
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Affiliation(s)
- Jie Liu
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Zhen-Ni Guo
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Xiu-Li Yan
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Shuo Huang
- Department of Neurology, Stroke Center & Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
- China National Comprehensive Stroke Center, Changchun, China
- Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
- *Correspondence: Shuo Huang,
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Hanoun S, Sun Y, Ebrahimi F, Ghasemi M. Speech and language abnormalities in myotonic dystrophy: An overview. J Clin Neurosci 2021; 96:212-220. [PMID: 34789418 DOI: 10.1016/j.jocn.2021.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 09/30/2021] [Accepted: 10/24/2021] [Indexed: 12/26/2022]
Abstract
Myotonic dystrophy (DM) is an autosomal dominant neuromuscular and multisystem disease that is divided into two types, DM1 and DM2, according to mutations in DMPK and CNBP genes, respectively. DM patients may manifest with various speech and language abnormalities. In this review, we had an overview on speech and language abnormalities in both DM1 and DM2. Our literature search highlights that irrespective of age, all DM patients (i.e. congenital, juvenile, and adult onset DM1 as well as DM2 patients) exhibit various degrees of speech impairments. These problems are related to both cognitive dysfunction (e.g. difficulties in written and spoken language) and bulbar/vocal muscles weakness and myotonia. DM1 adult patients have also a significant decrease in speech rate and performance due to myotonia and flaccid dysarthria, which can improve with warming up. Weakness, tiredness, and hypotonia of oral and velopharyngeal muscles can cause flaccid dysarthria. Hearing impairment also plays a role in affecting speech recognition in DM2. A better understanding of different aspects of speech and language abnormalities in DM patients may provide better characterization of these abnormalities as markers that can be potentially used as outcome measures in natural history studies or clinical trials.
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Affiliation(s)
- Sakhaa Hanoun
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA 01655, USA; Department of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Yuyao Sun
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Farzad Ebrahimi
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA; Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mehdi Ghasemi
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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De Serres-Bérard T, Pierre M, Chahine M, Puymirat J. Deciphering the mechanisms underlying brain alterations and cognitive impairment in congenital myotonic dystrophy. Neurobiol Dis 2021; 160:105532. [PMID: 34655747 DOI: 10.1016/j.nbd.2021.105532] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/24/2021] [Accepted: 10/11/2021] [Indexed: 12/13/2022] Open
Abstract
Myotonic dystrophy type 1 (DM1) is a multisystemic and heterogeneous disorder caused by the expansion of CTG repeats in the 3' UTR of the myotonic dystrophy protein kinase (DMPK) gene. There is a congenital form (CDM1) of the disease characterized by severe hypotonia, respiratory insufficiency as well as developmental delays and intellectual disabilities. CDM1 infants manifest important brain structure abnormalities present from birth while, in contrast, older patients with adult-onset DM1 often present neurodegenerative features and milder progressive cognitive deficits. Promising therapies targeting central molecular mechanisms contributing to the symptoms of adult-onset DM1 are currently in development, but their relevance for treating cognitive impairment in CDM1, which seems to be a partially distinct neurodevelopmental disorder, remain to be elucidated. Here, we provide an update on the clinical presentation of CDM1 and review recent in vitro and in vivo models that have provided meaningful insights on its consequences in development, with a particular focus on the brain. We discuss how enhanced toxic gain-of-function of the mutated DMPK transcripts with larger CUG repeats and the resulting dysregulation of RNA-binding proteins may affect the developing cortex in utero. Because the methylation of CpG islets flanking the trinucleotide repeats has emerged as a strong biomarker of CDM1, we highlight the need to investigate the tissue-specific impacts of these chromatin modifications in the brain. Finally, we outline promising potential therapeutic treatments for CDM1 and propose future in vitro and in vivo models with great potential to shed light on this disease.
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Affiliation(s)
- Thiéry De Serres-Bérard
- LOEX, CHU de Québec-Université Laval Research Center, Quebec City, Canada; CERVO Brain Research Center, Institut universitaire en santé mentale de Québec, Quebec City, Canada
| | - Marion Pierre
- CERVO Brain Research Center, Institut universitaire en santé mentale de Québec, Quebec City, Canada
| | - Mohamed Chahine
- CERVO Brain Research Center, Institut universitaire en santé mentale de Québec, Quebec City, Canada; Department of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada.
| | - Jack Puymirat
- LOEX, CHU de Québec-Université Laval Research Center, Quebec City, Canada; Department of Medicine, Faculty of Medicine, Université Laval, Quebec City, Canada
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12
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Longitudinal study in patients with myotonic dystrophy type 1: correlation of brain MRI abnormalities with cognitive performances. Neuroradiology 2020; 63:1019-1029. [PMID: 33237431 DOI: 10.1007/s00234-020-02611-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Myotonic dystrophy type 1 (DM1) is a muscular dystrophy with neurological, cognitive, and radiological abnormalities. The developmental or degenerative nature of these abnormalities, and their progression over time, remains unclear. The aim of this study is to perform a longitudinal assessment of imaging and cognitive performances in a group of patients with DM1. METHODS A longitudinal observational study was conducted in a group of 33 DM1 patients. All patients underwent cognitive and MRI evaluation, including the use of structural and diffusion tensor imaging techniques, at baseline and follow-up evaluation (4 years). Longitudinal changes in white matter lesion (WML), volumetric analysis, and diffusivity values were assessed and correlated with neuropsychological test findings. RESULTS An increase in WML was observed in 16 patients (48.5%). An increase in ventricular system volume and a decrease in volume of the left thalamus, caudates, putamen, and hippocampus were observed (p < 0.001). Global cortical volume showed a significant decrease (p < 0.001), although no changes were observed in white matter volume. A significant increase in mean diffusivity and decrease in fractional anisotropy for the white matter were found (p < 0.001). Neuropsychological evaluation showed a significant deterioration in test performance that measures working memory (Letter-Number Sequencing, p = 0.049) and visuospatial skills (Benton Visual Retention Test, p = 0.001). These findings were significantly associated with WML load (working memory p = 0.002 and visuospatial skills p = 0.021) and mean diffusivity increase (visuospatial skills p = 0.003 in the corpus callosum and working memory p = 0.043 in the right cerebral white matter). CONCLUSION White matter and grey matter involvement in DM1 patients is progressive. Patients experience a worsening in cognitive impairment that correlates with white matter involvement. These findings support the neurodegenerative nature of this disease.
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13
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Labayru G, Jimenez‐Marin A, Fernández E, Villanua J, Zulaica M, Cortes JM, Díez I, Sepulcre J, López de Munain A, Sistiaga A. Neurodegeneration trajectory in pediatric and adult/late DM1: A follow-up MRI study across a decade. Ann Clin Transl Neurol 2020; 7:1802-1815. [PMID: 32881379 PMCID: PMC7545612 DOI: 10.1002/acn3.51163] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To characterize the progression of brain structural abnormalities in adults with pediatric and adult/late onset DM1, as well as to examine the potential predictive markers of such progression. METHODS 21 DM1 patients (pediatric onset: N = 9; adult/late onset: N = 12) and 18 healthy controls (HC) were assessed longitudinally over 9.17 years through brain MRI. Additionally, patients underwent neuropsychological, genetic, and muscular impairment assessment. Inter-group comparisons of total and voxel-level regional brain volume were conducted through Voxel Based Morphometry (VBM); cross-sectionally and longitudinally, analyzing the associations between brain changes and demographic, clinical, and cognitive outcomes. RESULTS The percentage of GM loss did not significantly differ in any of the groups compared with HC and when assessed independently, adult/late DM1 patients and their HC group suffered a significant loss in WM volume. Regional VBM analyses revealed subcortical GM damage in both DM1 groups, evolving to frontal regions in the pediatric onset patients. Muscular impairment and the outcomes of certain neuropsychological tests were significantly associated with follow-up GM damage, while visuoconstruction, attention, and executive function tests showed sensitivity to WM degeneration over time. INTERPRETATION Distinct patterns of brain atrophy and its progression over time in pediatric and adult/late onset DM1 patients are suggested. Results indicate a possible neurodevelopmental origin of the brain abnormalities in DM1, along with the possible existence of an additional neurodegenerative process. Fronto-subcortical networks appear to be involved in the disease progression at young adulthood in pediatric onset DM1 patients. The involvement of a multimodal integration network in DM1 is discussed.
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Affiliation(s)
- Garazi Labayru
- Personality, Assessment and psychological treatment department; Psychology FacultyUniversity of the Basque Country (UPV/EHU)San SebastiánGipuzkoaSpain
- Neuroscience AreaBiodonostia Research Institute, OsakidetzaDonostia‐San SebastiánGipuzkoaSpain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)Institute Carlos IIIMadridSpain
| | - Antonio Jimenez‐Marin
- Biocruces‐Bizkaia Health Research InstituteBarakaldoBizkaiaSpain
- Biomedical Research Doctorate ProgramUniversity of the Basque Country (UPV/EHU)LeioaSpain
| | - Esther Fernández
- OsatekDonostia University HospitalDonostia‐ San SebastiánGipuzkoaSpain
| | - Jorge Villanua
- OsatekDonostia University HospitalDonostia‐ San SebastiánGipuzkoaSpain
| | - Miren Zulaica
- Neuroscience AreaBiodonostia Research Institute, OsakidetzaDonostia‐San SebastiánGipuzkoaSpain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)Institute Carlos IIIMadridSpain
| | - Jesus M. Cortes
- Biocruces‐Bizkaia Health Research InstituteBarakaldoBizkaiaSpain
- Cell Biology and Histology DepartmentUniversity of the Basque Country (UPV/EHU)LeioaSpain
- IKERBASQUEThe Basque Foundation for ScienceBilbaoSpain
| | - Ibai Díez
- Gordon Center for Medical ImagingDepartment of RadiologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Neurotechnology LaboratoryTecnalia Health DepartmentDerioSpain
| | - Jorge Sepulcre
- Gordon Center for Medical ImagingDepartment of RadiologyMassachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Adolfo López de Munain
- Neuroscience AreaBiodonostia Research Institute, OsakidetzaDonostia‐San SebastiánGipuzkoaSpain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)Institute Carlos IIIMadridSpain
- Neurology DepartmentDonostia University HospitalDonostia‐ San SebastiánGipuzkoaSpain
- Neuroscience DepartmentUniversity of the Basque Country (UPV/EHU)Donostia‐San SebastiánGipuzkoaSpain
| | - Andone Sistiaga
- Personality, Assessment and psychological treatment department; Psychology FacultyUniversity of the Basque Country (UPV/EHU)San SebastiánGipuzkoaSpain
- Neuroscience AreaBiodonostia Research Institute, OsakidetzaDonostia‐San SebastiánGipuzkoaSpain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED)Institute Carlos IIIMadridSpain
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14
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Biere J, Okkersen K, van Alfen N, Kessels RPC, Gouw AA, van Dorst M, van Engelen B, Stam CJ, Raaphorst J. Characterization of EEG-based functional brain networks in myotonic dystrophy type 1. Clin Neurophysiol 2020; 131:1886-1895. [PMID: 32590320 DOI: 10.1016/j.clinph.2020.05.014] [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: 05/28/2019] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In the autosomal dominant, multisystem, chronic progressive disease myotonic dystrophy type 1 (DM1), cognitive deficits may originate from disrupted functional brain networks. We aimed to use network analysis of resting-state electro-encephalography (EEG) recordings of patients with DM1 and matched unaffected controls to investigate changes in network organization in large-scale functional brain networks and correlations with cognitive deficits. METHODS In this cross-sectional study, 28 adult patients with genetically confirmed DM1 and 26 age-, sex- and education-matched unaffected controls underwent resting-state EEG and neuropsychological assessment. We calculated the Phase Lag Index (PLI) to determine EEG frequency-dependent functional connectivity between brain regions. Functional brain networks were characterized by applying concepts from graph theory and compared between-groups. Network topology was evaluated using the minimum spanning tree (MST). We evaluated correlations between network metrics and neuropsychological tests that showed statistically significant between-group differences. RESULTS Functional connectivity estimated as whole-brain median PLI for DM1 patients versus healthy controls was higher in theta band (0.141 [0.050] versus 0.125 [0.018], p = 0.029), and lower in the upper alpha band (0.154 [0.048] versus 0.182 [0.073], p = 0.038), respectively. Functional MST-constructed networks in DM1 patients were significantly dissimilar from healthy controls in the delta, (p = 0.009); theta, (p = 0.009); lower alpha, (p = 0.036); and upper alpha, (p = 0.008) bands. In evaluation of local MST network measures, trends toward networks with higher global integration in the theta band and lower global integration in the upper alpha band were observed. Compared to unaffected controls, DM1 patients performed worse on tests of attention, motor function, executive function and visuospatial memory. Visuospatial memory correlated with the global median PLI in the upper alpha band; the Stroop interference test correlated with betweenness centrality in this band. CONCLUSION This study supports the hypothesis that brain changes in DM1 give rise to disrupted functional network organization, as modelled with EEG-based networks. Further study may help unravel the relations with clinical brain-related DM1 symptoms. SIGNIFICANCE EEG network analysis has potential to help understand brain related DM1 phenotypes. FUNDING This work was supported by the European Community's Seventh Framework Programme (FP7/2007-2013) under grant agreement n° 305697 (OPTIMISTIC) and the Marigold Foundation.
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Affiliation(s)
- Joost Biere
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Kees Okkersen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Nens van Alfen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Roy P C Kessels
- Department of Neuropsychology and Rehabilitation Psychology, Radboud University Medical Center, Nijmegen, the Netherlands; Center for Cognition, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Kapittelweg 29, 6525 EN Nijmegen, the Netherlands; Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands.
| | - Alida A Gouw
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Maud van Dorst
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands; Vincent van Gogh Institute for Psychiatry, Venray, the Netherlands.
| | - Baziel van Engelen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Cornelis J Stam
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Joost Raaphorst
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Neurology, Academic University Medical Center, Amsterdam, the Netherlands.
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15
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Angelini C, Pinzan E. Advances in imaging of brain abnormalities in neuromuscular disease. Ther Adv Neurol Disord 2019; 12:1756286419845567. [PMID: 31105770 PMCID: PMC6503605 DOI: 10.1177/1756286419845567] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/05/2019] [Indexed: 01/18/2023] Open
Abstract
Brain atrophy, white matter abnormalities, and ventricular enlargement have been described in different neuromuscular diseases (NMDs). We aimed to provide a comprehensive overview of the substantial advancement of brain imaging in neuromuscular diseases by consulting the main libraries (Pubmed, Scopus and Google Scholar) including the more common forms of muscular dystrophies such as dystrophinopathies, dystroglycanopathies, myotonic dystrophies, facioscapulohumeral dystrophy, limb-girdle muscular dystrophy, congenital myotonia, and congenital myopathies. A consistent, widespread cortical and subcortical involvement of grey and white matter was found. Abnormalities in the functional connectivity in brain networks and metabolic alterations were observed with positron emission tomography (PET) and single photon emission computed tomography (SPECT). Pathological brain changes with cognitive dysfunction seemed to be frequently associated in NMDs. In particular, in congenital muscular dystrophies (CMDs), skeletal muscular weakness, severe hypotonia, WM abnormalities, ventricular dilatation and abnormalities in cerebral gyration were observed. In dystroglycanopathy 2I subtype (LGMD2I), adult patients showed subcortical atrophy and a WM periventricular involvement, moderate ventriculomegaly, and enlargement of subarachnoid spaces. Correlations with clinical features have been observed with brain imaging characteristics and alterations were prominent in congenital or childhood onset cases. In myotonic dystrophy type 2 (DM2) symptoms seem to be less severe than in type 1 (DM1). In Duchenne and Becker muscular dystrophies (DMD, BMD) cortical atrophy is associated with minimal ventricular dilatation and WM abnormalities. Late-onset glycogenosis type II (GSD II) or Pompe infantile forms are characterized by delayed myelination. Only in a few cases of oculopharyngeal muscular dystrophy (OPMD) central nervous system involvement has been described and associated with executive functions impairment.
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Affiliation(s)
- Corrado Angelini
- Fondazione Ospedale San Camillo IRCCS, Via
Alberoni 70, Venezia, 30126, Italia
| | - Elena Pinzan
- Fondazione Ospedale San Camillo IRCCS, Venezia,
Italia
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16
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Park JS, Song H, Jang KE, Cha H, Lee SH, Hwang SK, Park D, Lee HJ, Kim JY, Chang Y. Diffusion tensor imaging and voxel-based morphometry reveal corticospinal tract involvement in the motor dysfunction of adult-onset myotonic dystrophy type 1. Sci Rep 2018; 8:15592. [PMID: 30349069 PMCID: PMC6197259 DOI: 10.1038/s41598-018-34048-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/09/2018] [Indexed: 12/30/2022] Open
Abstract
Magnetic resonance imaging (MRI) studies have demonstrated that patients with myotonic dystrophy type 1 (DM1) exhibit gray and white matter abnormalities that are correlated with various genetic and neuropsychological measures. However, few MRI studies have focused on the correlations between brain abnormalities and overall motor function including gait performance. Here, we investigated the correlations between brain abnormalities, as assessed with MRI including diffusion tensor imaging (DTI), and motor performance, as assessed with the Medical Research Council sum score (MRCSS), 6-minute walk test (6MWT), and hand grip power, in patients with DM1. Eighteen patients with DM1 and twenty healthy controls participated in this study. The MRCSS and 6MWT reflect patients’ general motor performance, particularly gait, while hand grip reflects the presence of myotonia. We found significant relationships between DTI parameters in the corticospinal tract (CST) and genetic factors and motor performance in patients with DM1. These findings suggest that CST involvement reflecting deterioration of the motor tracts may play a significant role in clinical myotonia. Further, a direct relationship between the cortical gray matter volume and DTI measures in the CST suggests that white matter abnormalities in the CST are strongly associated with volume reductions in the sensorimotor cortex of patients with DM1.
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Affiliation(s)
- Jin-Sung Park
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea.,Department of Neurology, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Huijin Song
- Institute of Biomedical Engineering Research, Kyungpook National University, Daegu, Korea
| | - Kyung Eun Jang
- Department of Medical & Biological Engineering, Kyungpook National University, Daegu, Korea
| | - Hyunsil Cha
- Department of Medical & Biological Engineering, Kyungpook National University, Daegu, Korea
| | - Sang-Hoon Lee
- Department of Medical & Biological Engineering, Kyungpook National University, Daegu, Korea
| | - Su-Keong Hwang
- Department of Pediatrics, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Donghwi Park
- Department of Rehabilitation, Daegu Fatima Hospital, Daegu, Korea
| | - Hui Joong Lee
- Department of Radiology, Kyungpook National University Hospital, Daegu, Korea.,Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jun-Young Kim
- Department of Orthopaedic Surgery, Daegu Catholic University College of Medicine, Daegu, Korea
| | - Yongmin Chang
- Department of Radiology, Kyungpook National University Hospital, Daegu, Korea. .,Department of Molecular Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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17
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Hamilton MJ, McLean J, Cumming S, Ballantyne B, McGhie J, Jampana R, Longman C, Evans JJ, Monckton DG, Farrugia ME. Outcome Measures for Central Nervous System Evaluation in Myotonic Dystrophy Type 1 May Be Confounded by Deficits in Motor Function or Insight. Front Neurol 2018; 9:780. [PMID: 30333784 PMCID: PMC6176265 DOI: 10.3389/fneur.2018.00780] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/30/2018] [Indexed: 01/18/2023] Open
Abstract
Background: Central nervous system involvement in myotonic dystrophy type 1 (DM1) is associated with cognitive deficits, impaired social performance and excessive somnolence, which greatly impact quality of life. With the advent of clinical trials in DM1, there is a pressing need to identify outcome measures for quantification of central symptoms that are feasible and valid. In this context, we sought to evaluate neuropsychological and self-reported measures currently recommended by expert consensus, with particular reference to their specificity for central nervous system involvement in a moderate-sized DM1 cohort. Methods: Forty-five adults with DM1 and 20 controls completed neuropsychology assessments and symptom questionnaires. Those without contraindication also underwent MRI brain, from which global gray matter volume and white matter lesion volume were quantified. CTG repeat was measured by small pool PCR, and was screened for the presence of variant repeat sequences. Results: The neuropsychology test battery was well tolerated and detected impairment across various domains in the DM1 group vs. controls. Large effect sizes in the Stroop and Trail Making Tests were however attenuated by correction for basic speed, which could be influenced by dysarthria and upper limb weakness, respectively. Low mood was strongly associated with increased self-reporting of central symptoms, including cognitive impairment. Conversely, self-reported cognitive impairment did not generally predict poorer performance in neuropsychology assessments, and there was a trend toward greater self-reporting of low mood and cognitive problems in those with milder white matter change on MRI. Global gray matter volume correlated with performance in several neuropsychology assessments in a multivariate model with age and sex, while white matter lesion volume was associated with executive dysfunction reported by a proxy. Screening for variant repeats was positive in three individuals, who reported mild muscle symptoms. Conclusions: Identification of outcome measures with good specificity for brain involvement in DM1 is challenging, since complex cognitive assessments may be compromised by peripheral muscle weakness and self-reported questionnaires may be influenced by mood and insight. This highlights the need for further large, longitudinal studies to identify and validate objective measures, which may include imaging biomarkers and cognitive measures not influenced by motor speed.
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Affiliation(s)
- Mark J Hamilton
- West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow, United Kingdom.,Institute of Molecular, Cell and Systems Biology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - John McLean
- Department of Neuroradiology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Sarah Cumming
- Institute of Molecular, Cell and Systems Biology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Bob Ballantyne
- West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Josephine McGhie
- Institute of Molecular, Cell and Systems Biology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ravi Jampana
- Department of Neuroradiology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Cheryl Longman
- West of Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jonathan J Evans
- Institute of Health and Wellbeing, Gartnavel Royal Hospital, University of Glasgow, Glasgow, United Kingdom
| | - Darren G Monckton
- Institute of Molecular, Cell and Systems Biology, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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18
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Minnerop M, Gliem C, Kornblum C. Current Progress in CNS Imaging of Myotonic Dystrophy. Front Neurol 2018; 9:646. [PMID: 30186217 PMCID: PMC6110944 DOI: 10.3389/fneur.2018.00646] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/18/2018] [Indexed: 01/18/2023] Open
Abstract
Neuroimaging in myotonic dystrophies provided a major contribution to the insight into brain involvement which is highly prevalent in these multisystemic disorders. Particular in Myotonic Dystrophy Type 1, conventional MRI first revealed hyperintense white matter lesions, predominantly localized in the anterior temporal lobe. Brain atrophy and ventricle enlargement were additional early findings already described almost 30 years ago. Since then, more advanced and sophisticated imaging methods have been applied in Myotonic Dystrophy Types 1 and 2. Involvement of actually normal appearing white matter and widespread cortical affection in PET studies were key results toward the recognition of diffuse and not only focally localized brain pathology in vivo. Later, structural abnormalities of both, gray and white matter, have been found in both forms of the disorder, albeit more prominent in myotonic dystrophy type 1. In Type 1, a consistent widespread cortical and subcortical involvement of gray and white matter affecting all lobes, brainstem and cerebellum was observed. Spectroscopy studies gave additional evidence of neuronal and glial damage in both types. Central questions regarding the origin and spatiotemporal evolution of the CNS involvement and its relevance for clinical symptoms had already been raised 30 years ago, however are still not answered. Results of correlation analyses between neuroimaging and clinical parameters are diverse and with few exceptions not well reproducible across studies. It may be related to the fact that most of the reported studies included only small numbers of subjects, sometimes even not separating Myotonic Dystrophy Type 1 from Type 2. But this heterogeneity may also support the current point of view that the clinical impairments are not simply linked to specific and regionally circumscribed structural or functional brain alterations. It seems more convincing that disturbed networks build the functional and structural substrate of clinical symptoms in these disorders as it is proposed in other neuropsychiatric diseases. Consecutively, structural and functional network analyses may provide additional information regarding the link between brain pathology and clinical symptoms. Up to now, only cross-sectional neuroimaging studies have been published. To analyze the temporal evolution of brain affection, longitudinal studies are urgently needed, and systematic natural history data would be useful to identify potential biomarkers for therapeutic studies.
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Affiliation(s)
- Martina Minnerop
- Institute of Neuroscience and Medicine (INM-1), Research Center Juelich, Juelich, Germany.,Department of Neurology and Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Center for Movement Disorders and Neuromodulation, Heinrich-Heine University, Düsseldorf, Germany
| | - Carla Gliem
- Department of Neurology, University Hospital of Bonn, Bonn, Germany
| | - Cornelia Kornblum
- Department of Neurology, University Hospital of Bonn, Bonn, Germany.,Center for Rare Diseases Bonn (ZSEB), University Hospital of Bonn, Bonn, Germany
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19
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Altered power spectral density in the resting-state sensorimotor network in patients with myotonic dystrophy type 1. Sci Rep 2018; 8:987. [PMID: 29343751 PMCID: PMC5772436 DOI: 10.1038/s41598-018-19217-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/27/2017] [Indexed: 11/08/2022] Open
Abstract
Myotonic dystrophy type 1 (DM1) is a multisystemic disease that involves the brain with several neurological symptoms. Although there were few imaging studies on DM1, no studies have investigated functional alterations in the sensorimotor network at rest in patients with DM1. In the current study, a power spectral density (PSD) analysis of resting-state fMRI data was performed to assess possible alteration in spontaneous neural activity of the sensorimotor network in patients with DM1. Compared to healthy controls, patients with DM1 showed higher PSD responses in the orbitofrontal cortex, parahippocampus and basal ganglia (corrected P < 0.05). Patients with DM1 showed higher PSD responses in white matter structures associated with motor function (corrected P < 0.05). Furthermore, correlation analysis indicated that the brain regions showing PSD differences were correlated with measures of motor performance (P < 0.05). In gray matter, our findings suggest that motor disability in DM1 is not an isolated deterioration of the motor power but a multimodal dysfunction that also involves the visual system. In addition, the widespread PSD alteration in white matter structures suggest that motor deficits in DM1 involve motor movement structures as well as structures important for its coordination and regulation.
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20
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Zu T, Cleary JD, Liu Y, Bañez-Coronel M, Bubenik JL, Ayhan F, Ashizawa T, Xia G, Clark HB, Yachnis AT, Swanson MS, Ranum LPW. RAN Translation Regulated by Muscleblind Proteins in Myotonic Dystrophy Type 2. Neuron 2017; 95:1292-1305.e5. [PMID: 28910618 DOI: 10.1016/j.neuron.2017.08.039] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 05/31/2017] [Accepted: 08/25/2017] [Indexed: 10/18/2022]
Abstract
Several microsatellite-expansion diseases are characterized by the accumulation of RNA foci and RAN proteins, raising the possibility of a mechanistic connection. We explored this question using myotonic dystrophy type 2, a multisystemic disease thought to be primarily caused by RNA gain-of-function effects. We demonstrate that the DM2 CCTG⋅CAGG expansion expresses sense and antisense tetrapeptide poly-(LPAC) and poly-(QAGR) RAN proteins, respectively. In DM2 autopsy brains, LPAC is found in neurons, astrocytes, and glia in gray matter, and antisense QAGR proteins accumulate within white matter. LPAC and QAGR proteins are toxic to cells independent of RNA gain of function. RNA foci and nuclear sequestration of CCUG transcripts by MBNL1 is inversely correlated with LPAC expression. These data suggest a model that involves nuclear retention of expansion RNAs by RNA-binding proteins (RBPs) and an acute phase in which expansion RNAs exceed RBP sequestration capacity, are exported to the cytoplasm, and undergo RAN translation. VIDEO ABSTRACT.
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Affiliation(s)
- Tao Zu
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA
| | - John D Cleary
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA
| | - Yuanjing Liu
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA
| | - Monica Bañez-Coronel
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA
| | - Jodi L Bubenik
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA
| | - Fatma Ayhan
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA
| | - Tetsuo Ashizawa
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Neurology, University of Florida, Gainesville, FL 32610, USA; McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA; Neurological Institute, Houston Methodist Hospital, Houston, TX 77030, USA
| | - Guangbin Xia
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Neurology, University of Florida, Gainesville, FL 32610, USA; McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| | - H Brent Clark
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Anthony T Yachnis
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Maurice S Swanson
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA; Genetics Institute, University of Florida, Gainesville, FL 32610, USA
| | - Laura P W Ranum
- Center for NeuroGenetics, University of Florida, Gainesville, FL 32610, USA; Department of Molecular Genetics and Microbiology, University of Florida, Gainesville, FL 32610, USA; Department of Neurology, University of Florida, Gainesville, FL 32610, USA; Genetics Institute, University of Florida, Gainesville, FL 32610, USA.
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Okkersen K, Monckton DG, Le N, Tuladhar AM, Raaphorst J, van Engelen BGM. Brain imaging in myotonic dystrophy type 1: A systematic review. Neurology 2017; 89:960-969. [PMID: 28768849 DOI: 10.1212/wnl.0000000000004300] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/30/2017] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To systematically review brain imaging studies in myotonic dystrophy type 1 (DM1). METHODS We searched Embase (index period 1974-2016) and MEDLINE (index period 1946-2016) for studies in patients with DM1 using MRI, magnetic resonance spectroscopy (MRS), functional MRI (fMRI), CT, ultrasound, PET, or SPECT. From 81 studies, we extracted clinical characteristics, primary outcomes, clinical-genetic correlations, and information on potential risk of bias. Results were summarized and pooled prevalence of imaging abnormalities was calculated, where possible. RESULTS In DM1, various imaging changes are widely dispersed throughout the brain, with apparently little anatomical specificity. We found general atrophy and widespread gray matter volume reductions in all 4 cortical lobes, the basal ganglia, and cerebellum. The pooled prevalence of white matter hyperintensities is 70% (95% CI 64-77), compared with 6% (95% CI 3-12) in unaffected controls. DTI shows increased mean diffusivity in all 4 lobes and reduced fractional anisotropy in virtually all major association, projection, and commissural white matter tracts. Functional studies demonstrate reduced glucose uptake and cerebral perfusion in frontal, parietal, and temporal lobes, and abnormal fMRI connectivity patterns that correlate with personality traits. There is significant between-study heterogeneity in terms of imaging methods, which together with the established clinical variability of DM1 may explain divergent results. Longitudinal studies are remarkably scarce. CONCLUSIONS DM1 brains show widespread white and gray matter involvement throughout the brain, which is supported by abnormal resting-state network, PET/SPECT, and MRS parameters. Longitudinal studies evaluating spatiotemporal imaging changes are essential.
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Affiliation(s)
- Kees Okkersen
- From the Department of Neurology (K.O., N.L., A.M.T., J.R., B.G.M.v.E.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands; and Institute of Molecular, Cell and Systems Biology (D.G.M.), College of Medical, Veterinary and Life Sciences, University of Glasgow, UK.
| | - Darren G Monckton
- From the Department of Neurology (K.O., N.L., A.M.T., J.R., B.G.M.v.E.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands; and Institute of Molecular, Cell and Systems Biology (D.G.M.), College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Nhu Le
- From the Department of Neurology (K.O., N.L., A.M.T., J.R., B.G.M.v.E.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands; and Institute of Molecular, Cell and Systems Biology (D.G.M.), College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Anil M Tuladhar
- From the Department of Neurology (K.O., N.L., A.M.T., J.R., B.G.M.v.E.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands; and Institute of Molecular, Cell and Systems Biology (D.G.M.), College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Joost Raaphorst
- From the Department of Neurology (K.O., N.L., A.M.T., J.R., B.G.M.v.E.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands; and Institute of Molecular, Cell and Systems Biology (D.G.M.), College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
| | - Baziel G M van Engelen
- From the Department of Neurology (K.O., N.L., A.M.T., J.R., B.G.M.v.E.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands; and Institute of Molecular, Cell and Systems Biology (D.G.M.), College of Medical, Veterinary and Life Sciences, University of Glasgow, UK
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Gourdon G, Meola G. Myotonic Dystrophies: State of the Art of New Therapeutic Developments for the CNS. Front Cell Neurosci 2017; 11:101. [PMID: 28473756 PMCID: PMC5397409 DOI: 10.3389/fncel.2017.00101] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/27/2017] [Indexed: 12/12/2022] Open
Abstract
Myotonic dystrophies are multisystemic diseases characterized not only by muscle and heart dysfunction but also by CNS alteration. They are now recognized as brain diseases affecting newborns and children for myotonic dystrophy type 1 and adults for both myotonic dystrophy type 1 and type 2. In the past two decades, much progress has been made in understanding the mechanisms underlying the DM symptoms allowing development of new molecular therapeutic tools with the ultimate aim of curing the disease. This review describes the state of the art for the characterization of CNS related symptoms, the development of molecular strategies to target the CNS as well as the available tools for screening and testing new possible treatments.
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Affiliation(s)
- Genevieve Gourdon
- Institut National de la Santé et de la Recherche Médicale UMR1163Paris, France.,Laboratory CTGDM, Institut Imagine, Université Paris Descartes-Sorbonne Paris CitéParis, France
| | - Giovanni Meola
- Department of Biomedical Sciences for Health, Policlinico San Donato (IRCCS), University of MilanMilan, Italy
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Smith CA, Gutmann L. Myotonic Dystrophy Type 1 Management and Therapeutics. Curr Treat Options Neurol 2016; 18:52. [DOI: 10.1007/s11940-016-0434-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Baldanzi S, Cecchi P, Fabbri S, Pesaresi I, Simoncini C, Angelini C, Bonuccelli U, Cosottini M, Siciliano G. Relationship between neuropsychological impairment and grey and white matter changes in adult-onset myotonic dystrophy type 1. NEUROIMAGE-CLINICAL 2016; 12:190-7. [PMID: 27437180 PMCID: PMC4939389 DOI: 10.1016/j.nicl.2016.06.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 06/01/2016] [Accepted: 06/13/2016] [Indexed: 01/18/2023]
Abstract
Myotonic dystrophy type 1 (DM1) has a wide phenotypic spectrum and potentially may affect central nervous system with mild to severe involvement. Our aim was to investigate grey matter (GM) and white matter (WM) structural alterations in a sample of adult-onset DM1 patients and to evaluate relationship with clinical and cognitive variables. Thirty DM1 patients underwent neuropsychological investigation and 3T-MRI protocol. GM and WM changes were evaluated calculating brain parenchymal fraction (BPF), voxel-based morphometry (VBM), white matter lesion load (LL% and Fazekas scale) and tract based spatial statistical (TBSS). Patients showed main impairment in tests exploring executive and mnesic domains with visuo-spatial involvement, significantly related to BPF. VBM revealed clusters of widespread GM reduction and TBSS revealed areas of decreased fractional anisotropy (FA) and increased radial diffusivity (RD), mean diffusivity (MD) and axial diffusivity (AD) in patients compared to a group of matched healthy controls. Multiple regression analyses showed areas of significant negative relationship between left temporal atrophy and verbal memory, between RD and mnesic and visuo-spatial cognitive domains, and between AD and verbal memory. TBSS results indicate that the involvement of normal appearance WM, beyond the signal changes detected with conventional MR imaging (Fazekas scale and LL%), was associated with neuropsychological deficit. These data suggest that disrupted complex neuronal networks can underlie cognitive-behavioural dysfunctions in DM1. We performed VBM and TBSS analyses in a sample of adult-onset DM1 patients. The relationship between neuroimaging variables and cognitive profile was studied. Global atrophy correlated with executive and visuo-spatial abilities. TBSS revealed associations between DTI indexes and cognitive performances. Disrupted complex neuronal networks can underlie cognitive dysfunction in DM1.
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Affiliation(s)
- Sigrid Baldanzi
- Department of Clinical and Experimental Medicine, University of Pisa, via Savi 10, 56126 Pisa, Italy
| | - Paolo Cecchi
- Neuroradiology Unit, S.Chiara Hospital, via Roma 67, 56126 Pisa, Italy
| | - Serena Fabbri
- Neuroradiology Unit, S.Chiara Hospital, via Roma 67, 56126 Pisa, Italy
| | - Ilaria Pesaresi
- Neuroradiology Unit, S.Chiara Hospital, via Roma 67, 56126 Pisa, Italy
| | - Costanza Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, via Savi 10, 56126 Pisa, Italy
| | - Corrado Angelini
- Fondazione Ospedale S.Camillo, IRCCS, Via Alberoni 70, 30126 Lido Venice, Italy
| | - Ubaldo Bonuccelli
- Department of Clinical and Experimental Medicine, University of Pisa, via Savi 10, 56126 Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, S.Chiara Hospital, via Roma 67, 56126 Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, via Savi 10, 56126 Pisa, Italy
| | - Gabriele Siciliano
- Department of Clinical and Experimental Medicine, University of Pisa, via Savi 10, 56126 Pisa, Italy
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