[When to look for rare causes of cerebral small vessel disease?]

The majority of small vessel diseases is related to vascular risk factors or sporadic amyloid angiopathy, but a minority is caused by genetic, immune, or infectious diseases. In this article, we propose a pragmatic approach for the diagnosis and treatment of rare causes of cerebral small vessel disease.

Etiology, 3-Month Functional Outcome and Recurrent Events in Non-Traumatic Intracerebral Hemorrhage

Background and Purpose Knowledge about different etiologies of non-traumatic intracerebral hemorrhage (ICH) and their outcomes is scarce.Methods We assessed prevalence of pre-specified ICH etiologies and their association with outcomes in consecutive ICH patients enrolled in the prospective Swiss Stroke Registry (2014 to 2019). Results We included 2,650 patients (mean±standard deviation age 72±14 years, 46.5% female, median National Institutes of Health Stroke Scale 8 [interquartile range, 3 to 15]). Etiology was as follows: hypertension, 1,238 (46.7%); unknown, 566 (21.4%); antithrombotic therapy, 227 (8.6%); cerebral amyloid angiopathy (CAA), 217 (8.2%); macrovascular cause, 128 (4.8%); other determined etiology, 274 patients (10.3%). At 3 months, 880 patients (33.2%) were functionally independent and 664 had died (25.1%). ICH due to hypertension had a higher odds of functional independence (adjusted odds ratio [aOR], 1.33; 95% confidence interval [CI], 1.00 to 1.77; <i>P</i>=0.05) and lower mortality (aOR, 0.64; 95% CI, 0.47 to 0.86; <i>P</i>=0.003). ICH due to antithrombotic therapy had higher mortality (aOR, 1.62; 95% CI, 1.01 to 2.61; <i>P</i>=0.045). Within 3 months, 4.2% of patients had cerebrovascular events. The rate of ischemic stroke was higher than that of recurrent ICH in all etiologies but CAA and unknown etiology. CAA had high odds of recurrent ICH (aOR, 3.38; 95% CI, 1.48 to 7.69; <i>P</i>=0.004) while the odds was lower in ICH due to hypertension (aOR, 0.42; 95% CI, 0.19 to 0.93; <i>P</i>=0.031).Conclusions Although hypertension is the leading etiology of ICH, other etiologies are frequent. One-third of ICH patients are functionally independent at 3 months. Except for patients with presumed CAA, the risk of ischemic stroke within 3 months of ICH was higher than the risk of recurrent hemorrhage.

Preparing for a Second Attack: A Lesion Simulation Study on Network Resilience After Stroke

Background:

Does the brain become more resilient after a first stroke to reduce the consequences of a new lesion? Although recurrent strokes are a major clinical issue, whether and how the brain prepares for a second attack is unknown. This is due to the difficulties to obtain an appropriate dataset of stroke patients with comparable lesions, imaged at the same interval after onset. Furthermore, timing of the recurrent event remains unpredictable.

Methods:

Here, we used a novel clinical lesion simulation approach to test the hypothesis that resilience in brain networks increases during stroke recovery. Sixteen highly selected patients with a lesion restricted to the primary motor cortex were recruited. At 3 time points of the index event (10 days, 3 weeks, 3 months), we mimicked recurrent infarcts by deletion of nodes in brain networks (resting-state functional magnetic resonance imaging). Graph measures were applied to determine resilience (global efficiency after attack) and wiring cost (mean degree) of the network.

Results:

At 10 days and 3 weeks after stroke, resilience was similar in patients and controls. However, at 3 months, although motor function had fully recovered, resilience to clinically representative simulated lesions was higher compared to controls (cortical lesion P =0.012; subcortical: P =0.009; cortico-subcortical: P =0.009). Similar results were found after random ( P =0.012) and targeted ( P =0.015) attacks.

Conclusions:

Our results suggest that, in this highly selected cohort of patients with lesions restricted to the primary motor cortex, brain networks reconfigure to increase resilience to future insults. Lesion simulation is an innovative approach, which may have major implications for stroke therapy. Individualized neuromodulation strategies could be developed to foster resilient network reconfigurations after a first stroke to limit the consequences of future attacks.

Association of the COVID-19 Outbreak with Acute Stroke Care in Switzerland

Background and purpose

In Switzerland, the COVID‐19 incidence during the first pandemic wave was high. Our aim was to assess the association of the outbreak with acute stroke care in Switzerland in spring 2020.

Methods

This was a retrospective analysis based on the Swiss Stroke Registry, which includes consecutive patients with acute cerebrovascular events admitted to Swiss Stroke Units and Stroke Centers. A linear model was fitted to the weekly admission from 2018 and 2019 and was used to quantify deviations from the expected weekly admissions from 13 March to 26 April 2020 (the “lockdown period”). Characteristics and 3‐month outcome of patients admitted during the lockdown period were compared with patients admitted during the same calendar period of 2018 and 2019.

Results

In all, 28,310 patients admitted between 1 January 2018 and 26 April 2020 were included. Of these, 4491 (15.9%) were admitted in the periods March 13–April 26 of the years 2018–2020. During the lockdown in 2020, the weekly admissions dropped by up to 22% compared to rates expected from 2018 and 2019. During three consecutive weeks, weekly admissions fell below the 5% quantile (likelihood 0.38%). The proportion of intracerebral hemorrhage amongst all registered admissions increased from 7.1% to 9.3% (p = 0.006), and numerically less severe strokes were observed (median National Institutes of Health Stroke Scale from 3 to 2, p = 0.07).

Conclusions

Admissions and clinical severity of acute cerebrovascular events decreased substantially during the lockdown in Switzerland. Delivery and quality of acute stroke care were maintained.

The neural correlates of intermanual transfer

Intermanual transfer of motor learning is a form of learning generalization that leads to behavioral advantages in various tasks of daily life. It might also be useful for rehabilitation of patients with unilateral motor deficits. Little is known about neural structures and cognitive processes that mediate intermanual transfer. Previous studies have suggested a role for primary motor cortex (M1) and the supplementary motor area (SMA). Here, we investigated the functional neuroanatomy of intermanual transfer with a special emphasis on functional connectivity within the motor network and between motor regions and attentional networks, including the fronto-parietal executive control network and visual attention networks. We designed a finger tapping task, in which young, heathy subjects trained the non-dominant left hand in the MRI scanner. Behaviorally, transfer of sequence learning was observed in most cases, independently of the trained hand's performance. Pre- and post-training functional connectivity patterns of cortical motor seeds were investigated using generalized psychophysiological interaction analyses. Transfer was correlated with the strength of connectivity between the left premotor cortex and structures within the dorsal attention network (superior parietal cortex, left middle temporal gyrus) and executive control network (right prefrontal regions) during pre-training, relative to post-training. Changes in connectivity within the motor network, and more particularly between trained and untrained M1, as well as between the SMA and untrained M1, correlated with transfer after training. Together, these results suggest that the interplay between attentional, executive and motor networks may support processes leading to transfer, whereas, following training, transfer translates into increased connectivity within the motor network.

Periinfarct rewiring supports recovery after primary motor cortex stroke

After stroke restricted to the primary motor cortex (M1), it is uncertain whether network reorganization associated with recovery involves the periinfarct or more remote regions. We studied 16 patients with focal M1 stroke and hand paresis. Motor function and resting-state MRI functional connectivity (FC) were assessed at three time points: acute (<10 days), early subacute (3 weeks), and late subacute (3 months). FC correlates of recovery were investigated at three spatial scales, (i) ipsilesional non-infarcted M1, (ii) core motor network (M1, premotor cortex (PMC), supplementary motor area (SMA), and primary somatosensory cortex), and (iii) extended motor network including all regions structurally connected to the upper limb representation of M1. Hand dexterity was impaired only in the acute phase (P = 0.036). At a small spatial scale, clinical recovery was more frequently associated with connections involving ipsilesional non-infarcted M1 (Odds Ratio = 6.29; P = 0.036). At a larger scale, recovery correlated with increased FC strength in the core network compared to the extended motor network (rho = 0.71;P = 0.006). These results suggest that FC changes associated with motor improvement involve the perilesional M1 and do not extend beyond the core motor network. Core motor regions, and more specifically ipsilesional non-infarcted M1, could hence become primary targets for restorative therapies.

Abstract P345: Perfusion-Guided Bridging Therapy in Strokes With Unknown Time of Onset and Large Vessel Occlusion

Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown.

Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume< 70ml; mismatch ratio >= 1.8 and mismatch volume >= 15ml), and iv) treated < 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months.

Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax > 6s) was 119 ml (80-151) and infarcted core (CBF ratio <30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78).

Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated <4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.

Abstract P357: Deep Learning Building on Prior Ischemic Core Segmentation Improves Prediction of Infarction After Stroke

Introduction: Imaging studies are used to guide patient selection for acute stroke treatment. Perfusion CT (pCT) is widely used to identify the acute ischemic core and penumbra, but the prediction of the final infarct remains challenging. With the advent of machine learning, algorithms learning the prediction of the final lesion from imaging data collected in the acute phase have been proposed. We aimed to investigate whether machine learning methods that integrate prior ischemic core segmentation improve the prediction of the final infarct after stroke.

Methodology: We retrospectively included all stroke patients admitted to the Geneva University Hospital for intravenous and/or endovascular treatment from 01.2016 to 12.2017. All patients had acute pCT and follow-up MRI. An Attention-Gated 3D Unet was used as the baseline model on which the effect of access to a threshold-based ischemic core segmentation was tested. To ensure the efficient integration of information contained in voxels from the ischemic core, we extended the baseline model with a bayesian skip connection allowing only the prior to bypass most of the network. This modifies the model’s task to predict divergence from the prior representation. All models were evaluated for the prediction of the final infarct on follow-up MRI, given acute pCT maps as input. The output of each model was compared to finals lesions manually delineated by expert neurologists. Dice score was used to assess performance.

Results: A total of 144 patients were included. Median hypoperfused tissue volume (Tmax > 6s) was 60 ml [17-134], median ischemic core (relative CBF < 38%) volume was 23 ml [17-33] and median final infarct volume was 13 ml [3-38]. Dice score for the threshold based ischemic core segmentation was 0.1. The baseline model with and without prior segmentation as input achieved a Dice score of 0.19. Adding the proposed bayesian skip connection lead to a more efficient integration of the prior segmentation ensuring faster convergence and better performance with a final Dice score of 0.21.

Conclusion: The evaluated deep learning model can effectively leverage the information contained in a prior segmentation of the ischemic core to enhance the learning process and improve the prediction of the final infarct after stroke.

Abstract 25: Periinfarct Rewiring Supports Recovery After Primary Motor Cortex Stroke

Background and Purpose: After stroke restricted to the primary motor cortex (M1), it is uncertain whether network reorganization associated with motor recovery involves the periinfarct or more remote brain regions. In humans, the challenge is to recruit patients with similar lesions in size and location.

Methods: We studied 16 patients with focal M1 stroke and hand paresis. Motor function and resting-state MRI functional connectivity (FC) were studied at three time points: acute (<10 days), early subacute (3 weeks), and late subacute (3 months). FC correlates of motor recovery were investigated at three spatial scales, i) ipsilesional non-infarcted M1, ii) core motor network (including M1, premotor cortex (PMC), supplementary motor area (SMA), and primary somatosensory cortex), and iii) extended motor network including all regions structurally connected to the upper limb representation of M1.

Results: Hand dexterity was impaired only in the acute phase ( P =0.036). At a small spatial scale, improved dexterity was associated with increased FC involving mainly the ipsilesional non-infarcted M1 and contralesional motor regions (cM1: rho=0.732; P =0.004; cPMC: rho=0.837, P <0.001; cSMA: rho=0.736; P =0.004). At a larger scale, motor recovery correlated with the relative increase in total FC strength in the core motor network compared to the extended motor network (rho=0.71; P =0.006).

Conclusions: FC changes associated with motor improvement involve the perilesional M1 and do not extend beyond the core motor network. The ipsilesional non-infarcted M1 and core motor regions could hence be primary targets for future restorative therapies.

Integrating regional perfusion CT information to improve prediction of infarction after stroke

Physiological evidence suggests that neighboring brain regions have similar perfusion characteristics (vascular supply, collateral blood flow). It is largely unknown whether integrating perfusion CT (pCT) information from the area surrounding a given voxel (i.e. the receptive field (RF)) improves the prediction of infarction of this voxel. Based on general linear regression models (GLMs) and using acute pCT-derived maps, we compared the added value of cuboid RF to predict the final infarct. To this aim, we included 144 stroke patients with acute pCT and follow-up MRI, used to delineate the final infarct. Overall, the performance of GLMs to predict the final infarct improved when using RF for all pCT maps (cerebral blood flow, cerebral blood volume, mean transit time and time-to-maximum of the tissue residual function (Tmax)). The highest performance was obtained with Tmax (glm(Tmax); AUC = 0.89 ± 0.03 with RF vs. 0.78 ± 0.02 without RF; p < 0.001) and with a model combining all perfusion parameters (glm(multi); AUC 0.89 ± 0.02 with RF vs. 0.79 ± 0.02 without RF; p < 0.001). These results suggest that prediction of infarction improves by integrating perfusion information from adjacent tissue. This approach may be applied in future studies to better identify ischemic core and penumbra thresholds and improve patient selection for acute stroke treatment.

Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation

OBJECTIVE

The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes.

METHODS

This was a cohort study of consecutive patients (2014-2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0-2) at 3 months.

RESULTS

Of 8,179 patients (mean [SD] age, 79.8 [9.6] years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, [interquartile range 2-11]) compared with VKA (6, [2-14]) and controls (7, [3-15], p < 0.001; quantile regression: β -2.1, 95% confidence interval [CI] -2.6 to -1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 [63%]; adjusted odds ratio [aOR] 0.67; 95% CI 0.50-0.90) and particularly in patients on DOACs (69 of 464 [15%]; aOR 0.06; 95% CI 0.05-0.08) compared with controls (1,544 of 2,504 [74%]). sICH after IVT occurred in 3.6% (2.6-4.7%) of controls, 9 of 195 (4.6%; 1.9-9.2%; aOR 0.93; 95% CI 0.46-1.90) patients on VKA and 2 of 65 (3.1%; 0.4-10.8%, aOR 0.56; 95% CI 0.28-1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3-month outcome (aOR 1.24; 1.01-1.51).

INTERPRETATION

Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42-53.

Complex movement disorder in a patient with heterozygous YY1 mutation (Gabriele-de Vries syndrome)

YY1 mutations cause Gabriele-de Vries syndrome, a recently described condition involving cognitive impairment, facial dysmorphism and intrauterine growth restriction. Movement disorders were reported in 5/10 cases of the original series, but no detailed description was provided. Here we present a 21-year-old woman with a mild intellectual deficit, facial dysmorphism and a complex movement disorder including an action tremor, cerebellar ataxia, dystonia, and partial ocular apraxia as the presenting and most striking feature. Whole-exome sequencing revealed a novel heterozygous de novo mutation in YY1 [NM: 003403.4 (YY1): c.907 T > C; p.(Cys303Arg)], classified as pathogenic according to the ACMG guidelines.

Evolution of the neurochemical profiles in the G93A-SOD1 mouse model of amyotrophic lateral sclerosis

In vivo ¹H magnetic resonance spectroscopy (¹H-MRS) investigations of amyotrophic lateral sclerosis (ALS) mouse brain may provide neurochemical profiles and alterations in association with ALS disease progression. We aimed to longitudinally follow neurochemical evolutions of striatum, brainstem and motor cortex of mice transgenic for G93A mutant human superoxide dismutase type-1 (G93A-SOD1), an ALS model. Region-specific neurochemical alterations were detected in asymptomatic G93A-SOD1 mice, particularly in lactate (-19%) and glutamate (+8%) of brainstem, along with γ-amino-butyric acid (-30%), N-acetyl-aspartate (-5%) and ascorbate (+51%) of motor cortex. With disease progression towards the end-stage, increased numbers of metabolic changes of G93A-SOD1 mice were observed (e.g. glutamine levels increased in the brainstem (>+66%) and motor cortex (>+54%)). Through ALS disease progression, an overall increase of glutamine/glutamate in G93A-SOD1 mice was observed in the striatum (p < 0.01) and even more so in two motor neuron enriched regions, the brainstem and motor cortex (p < 0.0001). These ¹H-MRS data underscore a pattern of neurochemical alterations that are specific to brain regions and to disease stages of the G93A-SOD1 mouse model. These neurochemical changes may contribute to early diagnosis and disease monitoring in ALS patients.

SOD1 silencing in motoneurons or glia rescues neuromuscular function in ALS mice

Objective

Amyotrophic lateral sclerosis is an incurable disorder mainly characterized by motoneuron degeneration. Mutations in the superoxide dismutase 1 (SOD1) gene account for 20% of familial forms of the disease. Mutant SOD1 exerts multiple pathogenic effects through the gain of toxic properties in both neurons and glial cells. Here, we compare AAV-based gene therapy suppressing expression of mutant SOD1 in either motoneurons or astrocytes.

Methods

AAV vectors encoding microRNA against human SOD1 were administered to ^G93ASOD1 mice either by intracerebroventricular injections in pups or by lumbar intrathecal injections in adults. Vector systems were designed to suppress SOD1 expression predominantly in either spinal motoneurons or astrocytes. Electrophysiological and behavioral tests were performed on treated animals to evaluate disease progression.

Results

Following vector injection in ^G93ASOD1 pups, efficient silencing of SOD1 expression was achieved in motoneurons and/or astrocytes. Most complete protection of motor units was obtained when targeting human SOD1 predominantly in motoneurons. Suppressing SOD1 mainly in astrocytes led to preserved muscle innervation despite only partial protection of spinal motoneurons. In both cases, injection in pups led to full recovery of neuromuscular function and significantly prolonged survival. Vector injections in adult mice also achieved significant protection of neuromuscular function, which was highest when motoneurons were targeted.

Interpretation

These results suggest that AAV-mediated SOD1 silencing is an effective approach to prevent motoneuron degeneration caused by SOD1 mutation. AAV vectors suppressing SOD1 in motoneurons delay disease onset and show effective neuroprotection. On the other hand, AAV-based SOD1 silencing in astrocytes rescues neuromuscular function following initial denervation.

Intracerebroventricular injection of adeno-associated virus 6 and 9 vectors for cell type-specific transgene expression in the spinal cord

In the context of motoneuron diseases, gene delivery as an experimental or therapeutic approach is hindered by the challenge to specifically target cell populations that are widely distributed along the spinal cord. Further complicating the task, transgenes often need to be delivered to motoneurons and/or glial cells to address the non-cell-autonomous mechanisms involved in disease pathogenesis. Intracerebroventricular (ICV) injection of recombinant adeno-associated viruses (AAVs) in newborn mice allows distributing viral vectors throughout the central nervous system while limiting undesired transduction of peripheral organs. Here, we show that by combining the appropriate set of AAV serotype and promoter, specific transgene expression can be achieved in either motoneurons or astrocytes along the whole mouse spinal cord. ICV injection of recombinant AAV6 with the cytomegalovirus (cmv) promoter preferentially targets motoneurons, whereas AAV9 particles combined with the astrocyte-specific gfaABC₁D promoter lead to significant transgene expression selectively targeted to astrocytes. Importantly, ICV coinjection of both AAV6-cmv and AAV9-gfaABC₁D results in segregated expression of two different transgenes in motoneurons and astrocytes, respectively. Relevance of viral vector delivery via the cerebrospinal fluid was further investigated in young nonhuman primates. Intracisternal injection of recombinant AAV6-cmv led to robust cervical transduction of motoneurons, highlighting the potential of this approach for gene therapy and modeling of motoneuron diseases.

A spastic paraplegia mouse model reveals REEP1-dependent ER shaping

Axonopathies are a group of clinically diverse disorders characterized by the progressive degeneration of the axons of specific neurons. In hereditary spastic paraplegia (HSP), the axons of cortical motor neurons degenerate and cause a spastic movement disorder. HSP is linked to mutations in several loci known collectively as the spastic paraplegia genes (SPGs). We identified a heterozygous receptor accessory protein 1 (REEP1) exon 2 deletion in a patient suffering from the autosomal dominantly inherited HSP variant SPG31. We generated the corresponding mouse model to study the underlying cellular pathology. Mice with heterozygous deletion of exon 2 in Reep1 displayed a gait disorder closely resembling SPG31 in humans. Homozygous exon 2 deletion resulted in the complete loss of REEP1 and a more severe phenotype with earlier onset. At the molecular level, we demonstrated that REEP1 is a neuron-specific, membrane-binding, and membrane curvature-inducing protein that resides in the ER. We further show that Reep1 expression was prominent in cortical motor neurons. In REEP1-deficient mice, these neurons showed reduced complexity of the peripheral ER upon ultrastructural analysis. Our study connects proper neuronal ER architecture to long-term axon survival.

Astrocyte-neuron co-culture on microchips based on the model of SOD mutation to mimic ALS

Amyotrophic lateral sclerosis (ALS) is the most common motor neuron disease. ALS is believed to be a non-cell autonomous condition, as other cell types, including astrocytes, have been implicated in disease pathogenesis. Hence, to facilitate the development of therapeutics against ALS, it is crucial to better understand the interactions between astrocytes and neural cells. Furthermore, cell culture assays are needed that mimic the complexity of cell to cell communication at the same time as they provide control over the different microenvironmental parameters. Here, we aim to validate a previously developed microfluidic system for an astrocyte-neuron cell culture platform, in which astrocytes have been genetically modified to overexpress either a human wild-type (WT) or a mutated form of the super oxide dismutase enzyme 1 (SOD1). Cortical neural cells were co-cultured with infected astrocytes and studied for up to two weeks. Using our microfluidic device that prevents direct cell to cell contact, we could evaluate neural cell response in the vicinity of astrocytes. We showed that neuronal cell density was reduced by about 45% when neurons were co-cultured with SOD-mutant astrocytes. Moreover, we demonstrated that SOD-WT overexpressing astrocytes reduced oxidative stress on cortical neurons that were in close metabolic contact. In contrast, cortical neurons in metabolic contact with SOD-mutant astrocytes lost their synapsin protein expression after severe glutamate treatment, an indication of the toxicity potentiating effect of the SOD-mutant enzyme.