Vitamin B12 deficiency: Characterization of psychometrics and MRI morphometrics

Vitamin B12 Levels Association with Functional and Structural Biomarkers of Central Nervous System Injury in Older Adults

OBJECTIVE

Vitamin B12 (B12) plays a critical role in fatty- and amino-acid metabolism and nucleotide synthesis. While the association between B12 deficiency and neurological dysfunction is well-known, the exact threshold for adequacy remains undefined in terms of functional impairment and evidence of injury. The objective was to assess whether B12 levels within the current normal range in a cohort of healthy older adults may be associated with measurable evidence of neurological injury or dysfunction.

METHODS

We enrolled 231 healthy elderly volunteers (median age 71.2 years old) with a median B12 blood concentration of 414.8 pmol/L (as measured by automated chemiluminescence assay). We performed multifocal visual evoked potential testing, processing speed testing, and magnetic resonance imaging to assess neurological status. Moreover, we measured serum biomarkers of neuroaxonal injury, astrocyte involvement, and amyloid pathology.

RESULTS

Low (log-transformed) B12, especially decreased holo-transcobalamin, was associated with visual evoked potential latency delay (estimate = -0.04; p = 0.023), processing speed impairment (in an age-dependent manner; standardized β = -2.39; p = 0.006), and larger volumes of white matter hyperintensities on MRI (β = -0.21; p = 0.039). Remarkably, high levels of holo-haptocorrin (biologically inactive fraction of B12) correlated with serum levels of Tau, a biomarker of neurodegeneration (β = 0.22, p = 0.015).

INTERPRETATION

Healthy older subjects exhibit neurological changes at both ends of the measurable "normal" B12 spectrum. These findings challenge our current understanding of optimal serum B12 levels and suggest revisiting how we establish appropriate nutritional recommendations. ANN NEUROL 2025.

Neuroimaging Findings in Vitamin B12-Deficient Infants With Neurologic Features

Background:Vitamin B₁₂ deficiency causes serious neurologic problems among infants. However, its neuroradiologic correlate is still largely obscure. Methodology: This prospective study was conducted on patients aged 6 months to 2 years. All children with proven vitamin B₁₂ deficiency were planned to undergo magnetic resonance imaging (MRI) and magnetic resonance spectroscopy of the brain. Results: A total of 35 patients (63% female) were enrolled. Twenty-six (74%) patients had significant findings on brain MRI scan, commonest of which were thinning of corpus callosum and prominence of extra-axial spaces in 28.6% children, cerebral atrophy in 17%, and diffuse symmetrical hyperintensity of white matter in 5.7% patients. Using logistic regression, it was found that odds of abnormal neuroimaging findings were higher in children below 12 months, in females, and in patients with developmental regression, but none of them were statistically significant. Conclusion: Most of the infants with vitamin B₁₂ deficiency have abnormal neuroimaging findings.

Neurovascular Correlates of Cobalamin, Folate, and Homocysteine in Dementia

BACKGROUND

Cobalamin (Cbl) and folate are common supplements clinicians prescribe as an adjuvant therapy for dementia patients, on the presumption of their neurotrophic and/or homocysteine (Hcy) lowering effect. However, the treatment efficacy has been found mixed and the effects of Cbl/folate/Hcy on the human brain remain to be elucidated.

OBJECTIVE

To explore the neurovascular correlates of Cbl/folate/Hcy in Alzheimer's disease (AD) and subcortical ischemic vascular dementia (SIVD).

METHODS

Sixty-seven AD patients and 57 SIVD patients were prospectively and consecutively recruited from an outpatient clinic. Multimodal 3-Tesla magnetic resonance imaging was performed to quantitatively evaluate cerebral blood flow (CBF) and white matter integrity. The relationship between neuroimaging metrics and the serum levels of Cbl/folate/Hcy was examined by using the Kruskal-Wallis test, partial correlation analysis, and moderation analysis, at a significance level of 0.05.

RESULTS

As a whole, CBF mainly associated with Cbl/folate while white matter hyperintensities exclusively associated with Hcy. As compared with AD, SIVD exhibited more noticeable CBF correlates (spatially widespread with Cbl and focal with folate). In SIVD, a bilateral Cbl-moderated CBF coupling was found between medial prefrontal cortex and ipsilateral basal ganglia, while in the fronto-subcortical white matter tracts, elevated Hcy was associated with imaging metrics indicative of increased injury in both axon and myelin sheath.

CONCLUSIONS

We identified the neurovascular correlates of previously reported neurotrophic effect of Cbl/folate and neurotoxic effect of Hcy in dementia. The correlates exhibited distinct patterns in AD and SIVD. The findings may help improving the formulation of supplemental Cbl/folate treatment for dementia.

B Vitamin Supplementation Slows Cognitive Decline in Mild Cognitive Impairment Patients with Frontal Lobe Atrophy

BACKGROUND

The effects of B vitamins on mild cognitive impairment (MCI) patients' cognition have been mixed, suggesting the existence of moderating factors.

OBJECTIVE

A post hoc analysis of a negative B vitamin trial was performed to examine the potential modulating effect of regional brain atrophy on the cognitive response to B vitamins in MCI patients.

METHODS

In the 24-month randomized trial, 279 MCI outpatients took 500μ#x03BC;g methylcobalamin and 400μ#x03BC;g folic acid once per day or placebo tablets once per day. Sixty-four aspirin users were excluded from analysis as aspirin use has been found to have significant negative interaction effects. Subjects were followed up at months 12 and 24. The primary cognitive outcome was clinical dementia rating scale sum of boxes (CDR_SOB). In a subgroup of 83 subjects, MRI brain scans were performed at baseline to estimate regional brain atrophy ratios.

RESULTS

Among the trial subjects who had MRI data, B vitamin supplementation had no significant effect on CDR_SOB, despite having significant homocysteine lowering effects. The atrophy ratio of the left frontal lobe significantly moderated the effect of B vitamin supplementation on CDR_SOB, after adjusting for confounders, in that B vitamin supplementation was associated with lower CDR_SOB scores (i.e., better cognitive function) at the 24th month among those patients with above median atrophy ratios, but not among those with lower atrophy ratios, in the left frontal lobe.

CONCLUSION

B vitamins may be more effective in slowing down cognitive decline in MCI patients with atrophy in the left frontal lobe.

Neuropsychiatric manifestations in vitamin B12 deficiency

Vitamin B12 deficiency can have distressing neuropsychiatric symptoms. It can have an etiological role in clinical presentations like depression, anxiety, psychosis, dementia, and delirium, requiring screening of at-risk populations. Few mechanisms that underlie the neuropsychiatric manifestations of B12 deficiency include alteration in one-carbon metabolism, genetic vulnerability, and alteration in folate metabolism. Maintaining a high serum B12 level in elderly can be protective against Alzheimer's disease (AD). In an established AD, its deficiency is associated with higher cognitive decline and risk for delirium. The other mental changes associated with B12 deficiency include apathy, agitation, impaired concentration, insomnia, persecutory delusions, auditory and visual hallucinations, and disorganized thought-process. Besides serum vitamin B12, plasma methylmalonic acid (MMA) and homocysteine helps in diagnosis. The chapter focuses on early recognition and effective treatment of these neuropsychiatric manifestations of vitamin B12 deficiency.

Cognitive dysfunction and psychosis: expanding the phenotype of SPG7

Spastic paraplegia type 7 (SPG7) is one of the most common forms of autosomal recessive hereditary spastic paraplegia, which can lead to a hybrid spastic-ataxic phenotype. Recently, novel complicated forms of SPG7, including cognitive and social impairment phenotypes, have been reported. We present a SPG7 case with two pathogenic variants in compound heterozygosity in the SPG7 gene, featuring a cerebellar cognitive affective syndrome with psychosis not yet described in the literature.

Clinical and imaging characteristics of subacute combined degeneration complicated with white matter lesions in the brain: a report of five cases

PURPOSE

To report five cases of subacute combined degeneration (SCD) with brain involvement and explore its clinical and imaging characteristics.

METHODS

A retrospective study was performed on the clinical data and brain MRI of five patients with subacute combined degeneration with brain involvement (out of 107 cases with SCD in total). White matter lesions (WML) assessment was performed qualitatively using Fazekas scale score.

RESULTS

The main symptoms in four patients were weakness in both lower extremities and unstable walking (limb weakness in three patients, dizziness in three patients, and blurred vision in one patient). One patient had memory loss and cognitive dysfunction. The MMSE scale indicated mild dementia in one patient. On head MRI (Magnetic Resonance Imaging), multifocal and symmetrical high signals of T2WI and FLAIR were observed in the frontal lobe and periventricular white matter in four patients, while another patient showed preferential atrophy in frontal regions. Fazekas scale scores ranged from 1-6.

CONCLUSION

Adult subacute combined degeneration seldom involves the brain. Multifocal and symmetrical high signal white matter lesions can be found on FLAIR and T2WI, as well as frontal atrophy on head MRI.

Tc-99m-ECD SPECT as the measure for therapeutic response in patients with cobalamin deficiency: Two case reports

BACKGROUND

Cobalamin (Cbl) is an essential vitamin for human health. While an increasing body of evidence supports the negative impact of Cbl deficiency on cognition, the causality has yet to be determined, and the reported therapeutic responses after Cbl supplement therapy have been inconsistent. Besides, few reports have described neuroimaging characteristics associated with the therapeutic response.

METHODS

To describe and compare technetium-99m ethyl cysteinate dimer single-photon emission computed tomography (Tc-99m-ECD SPECT) findings in 2 patients with Cbl deficiency with distinct therapeutic responses.

RESULTS

Case 1 scored 12/30 in the mini-mental state examination (MMSE) and 34/100 in the cognitive abilities screening instrument (CASI). Profound deficits in mental manipulation, drawing, short-term/long-term memory, and verbal fluency were noted. Case 2 scored 24/30 in the MMSE and 78/100 in the CASI, mainly due to impaired mental manipulation, abstract thinking, and borderline performance in short-term memory and verbal fluency. While both cases showed widespread hypoperfusion within bilateral frontotemporal regions and thalamus on Tc-99m-ECD SPECT, Case 2 demonstrated relatively preserved radio-uptake in the frontal regions, especially the anterior cingulate cortex (ACC) and prefrontal cortex (PFC), consistent with the better therapeutic response (Case 1: 12/30 to 11/30 in the MMSE; Case 2: 24/30 to 28/30 in the MMSE).

CONCLUSION

Given that the ACC integrates the limbic system and frontosubcortical circuits and the PFC governs executive function, the extent and severity of hypofrontality may be responsible for the worse prognosis. Our Tc-99m-ECD SPECT observations revealed that the negative impact on cerebral metabolic tone is relevant to the severity of Cbl deficiency, and the functional integrity of the ACC and PFC is highly associated with the preservation of global cognitive function in our cases with Cbl deficiency.

Effect of vitamin B12 and omega-3 fatty acid supplementation on brain neurotrophins and cognition in rats: A multigeneration study

Vitamin B12 and omega-3 fatty acids are important nutrients required for neuronal functioning. We have demonstrated the beneficial effects of vitamin B12 and omega-3 fatty acid supplementation on brain neurotrophins and cognition in the first and second generation offspring. However, there is a need to examine if the effects are sustained in the third generation offspring. This study reports the effects of vitamin B12 and omega-3 fatty acid supplementation across three consecutive generations on brain neurotrophins like brain derived neurotrophic factor (BDNF); nerve growth factor (NGF) and cognitive performance in the third generation male offspring. Three successive generations of Wistar rats were assigned the following groups throughout pregnancy, lactation and adulthood: i) Control, ii) vitamin B12 deficient (BD), iii) vitamin B12 deficient + omega-3 fatty acid (BDO), iv) vitamin B12 supplemented (BS) and v) vitamin B12 supplemented + omega-3 fatty acid (BSO). The BD group demonstrated lower (p < 0.01) NGF in the cortex but not BDNF levels although the cognition was impaired (p < 0.01). In contrast, in the BDO group, higher NGF levels were observed in the hippocampus and animals demonstrated improved (p < 0.01) cognitive performance. Vitamin B12 supplementation showed comparable BDNF levels in the hippocampus while their levels were lower in the cortex as compared to the control (p < 0.05). These animals showed more reference and working memory errors (p < 0.01) as compared to the control group. A combined supplementation of vitamin B12 and omega-3 fatty acid showed higher (p < 0.01) levels of DHA and NGF in the hippocampus, higher BDNF in both hippocampus and cortex and improved cognitive performance. Our findings have implications for fortification of foods with vitamin B12 and omega-3 fatty acids in improving brain development.