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Milella G, Zoccolella S, Giugno A, Filardi M, Urso D, Nigro S, Tafuri B, Tamburrino L, Gnoni V, Logroscino G. The impact of upper and lower motor neuron burden on diagnostic certainty, and clinical course of spinal-onset amyotrophic lateral sclerosis: a cluster-based approach. J Neurol 2023; 270:4868-4875. [PMID: 37338613 DOI: 10.1007/s00415-023-11827-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/10/2023] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Upper motor neuron (UMN) and lower motor neuron (LMN) involvement represent the core clinical features of amyotrophic lateral sclerosis (ALS). Several studies divided patients into prevalent UMN and LMN impairment phenotypes to investigate the association between motor systems impairments and ALS clinical course. However, this distinction was somehow heterogeneous and significantly affected the comparability across studies. AIMS This study aimed to investigate whether patients spontaneously segregate based on the extent of UMN and LMN involvement without a-priori categorization and to identify potential clinical and prognostic features of different clusters. METHODS Eighty-eight consecutive spinal-onset ALS patients were referred to an ALS tertiary center between 2015 and 2022. UMN and LMN burden was assessed with the Penn Upper Motor Neuron scale (PUMNS) and the Devine score, respectively. PUMNS and LMN scores were normalized into 0-1 and analyzed using a two-step cluster analysis and the Euclidean distance measure. The Bayesian Information Criterion was used to determine the cluster number. Demographic and clinical variables were tested for differences among the clusters. RESULTS Three distinct clusters emerged at cluster analysis. Patients in "cluster-1" showed moderate UMN and severe LMN involvement, corresponding to the typical ALS phenotype. Patients in "cluster-2" showed mild LMN and severe UMN damage, corresponding to a predominant UMN phenotype, while "cluster-3" patients showed mild UMN and moderate LMN damage, corresponding to a predominant LMN phenotype. Patients in "cluster-1" and "cluster-2" showed a higher prevalence of definite ALS than those in "cluster-3" (61% and 46 vs 9%, p < 0.001). "Cluster-1" patients had a lower median ALSFRS-r score compared to both "cluster-2" and 3 patients (27 vs 40 and 35, < 0.001). "Cluster-1" (HR: 8.5; 95% CI 2.1-35.1 and p = 0.003) and 3 (HR: 3.2; 95% CI 1.1-9.1; p = 0.03) were associated with shorter survival than those in "cluster-2". CONCLUSIONS Spinal-onset ALS can be categorized into three groups according to LMN and UMN burden. The UMN burden is related to higher diagnostic certainty and broader disease spread, while LMN involvement is associated with higher disease severity and shorter survival.
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Affiliation(s)
- Giammarco Milella
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
| | - Stefano Zoccolella
- Neurology Unit, ASL Bari, San Paolo Hospital, Bari, Italy.
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy.
| | - Alessia Giugno
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Marco Filardi
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Daniele Urso
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Salvatore Nigro
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Benedetta Tafuri
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Ludovica Tamburrino
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Valentina Gnoni
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
| | - Giancarlo Logroscino
- Department of Translational Biomedicine and Neurosciences (DiBraiN), University of Bari Aldo Moro, Bari, Italy
- Center for Neurodegenerative Diseases and the Aging Brain at Pia Fondazione "Card. G. Panico", University of Bari, Tricase (Lecce), Italy
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Castro J, Swash M, de Carvalho M. The cutaneous silent period as a measure of upper motor neuron dysfunction in amyotrophic lateral sclerosis. Neurophysiol Clin 2023; 53:102843. [PMID: 36716610 DOI: 10.1016/j.neucli.2022.102843] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/17/2022] [Accepted: 12/17/2022] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES We investigated the cutaneous silent period (CutSP) as a measure of upper motor neuron (UMN) dysfunction in amyotrophic lateral sclerosis. METHODS The onset latency, duration, and amount of EMG suppression of the CutSP were compared with clinical UMN signs in 24 patients with amyotrophic lateral sclerosis (ALS). UMN signs were quantified using a clinical index and transcranial magnetic stimulation (TMS). Central motor conduction time (CMCT), cortical motor threshold and motor evoked potential amplitudes were assessed as measures of UMN dysfunction. CutSP was studied in abductor digit minimi (ADM) and tibialis anterior (TA) EMG recordings following stimulation of the 5th finger and sural nerves respectively. Non-parametric tests and binomial logistic regression were applied to evaluate the data. RESULTS CutSP onset latency was increased in ALS patients, compared to healthy controls, both for ADM and TA muscles. In limbs with clinical UMN signs or abnormal TMS findings, the CutSP onset latency was particularly increased. There was a significant positive correlation between CutSP onset latency and the UMN score in both upper and lower limbs. In TA muscles there was also a negative correlation between CutSP onset latency and EMG suppression. The logistic regression model based on CutSP parameters correctly classified more than 70% of the cases regarding the presence of clinical signs of UMN lesion, in both upper and lower limbs. The results were not significant for TMS. CONCLUSION We conclude that upper limb CutSP changes associates with UMN lesion in ALS. This neurophysiological measurement merits further investigation in ALS.
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Affiliation(s)
- José Castro
- Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal.
| | - Michael Swash
- Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Departments of Neurology and Neuroscience, Barts and the London School of Medicine, Queen Mary University of London, United Kingdom
| | - Mamede de Carvalho
- Instituto de Fisiologia, Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa Norte, Lisbon, Portugal
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Marzoughi S, Pfeffer G, Cashman N. Primary lateral sclerosis. Handb Clin Neurol 2023; 196:89-99. [PMID: 37620095 DOI: 10.1016/b978-0-323-98817-9.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Like motor neuron diseases (MNDs) refer to a constellation of primarily sporadic neurodegenerative diseases characterized by a progressive loss of upper and/or lower motor neurons. Primary lateral sclerosis (PLS) is considered a neurodegenerative disorder that is characterized by a gradually progressive course affecting the central motor systems, designated by the phrase "upper motor neurons." Despite significant development in neuroimaging, neurophysiology, and molecular biology, there is a growing consensus that PLS is of unknown etiology. Currently there is no disease-modifying treatment for PLS, or prospective randomized trials being carried out, partly due to the rarity of the disease and lack of significant understanding of the underlying pathophysiology. Consequently, the approach to treatment remains largely symptomatic. In this chapter we provide an overview of primary lateral sclerosis including clinical and electrodiagnostic considerations, differential diagnosis, updates in genetics and pathophysiology, and future directions for research.
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Affiliation(s)
- Sina Marzoughi
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gerald Pfeffer
- Department of Neurosciences, Division of Neurology, University of Calgary, Calgary, AB, Canada
| | - Neil Cashman
- Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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de Carvalho M, Swash M. Upper and lower motor neuron neurophysiology and motor control. Handb Clin Neurol 2023; 195:17-29. [PMID: 37562869 DOI: 10.1016/b978-0-323-98818-6.00018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
This chapter considers the principles that underlie neurophysiological studies of upper motor neuron or lower motor neuron lesions, based on an understanding of the normal structure and function of the motor system. Human motor neurophysiology consists of an evaluation of the active components of the motor system that are relevant to volitional movements. Relatively primitive motor skills include locomotion, much dependent on the spinal cord central pattern generator, reaching, involving proximal and distal muscles activation, and grasping. Humans are well prepared to perform complex movements like writing. The role of motor cortex is critical for the motor activity, very dependent on the continuous sensory feedback, and this is essential for adapting the force and speed control, which contributes to motor learning. Most corticospinal neurons in the brain project to brainstem and spinal cord, many with polysynaptic inhibitory rather than excitatory connections. The monosynaptic connections observed in humans and primates constitute a specialized pathway implicated in fractional finger movements. Spinal cord has a complex physiology, and local reflexes and sensory feedback are essential to control adapted muscular contraction during movement. The cerebellum has a major role in motor coordination, but also consistent roles in sensory activities, speech, and language, in motor and spatial memory, and in psychological activity. The motor unit is the final effector of the motor drive. The complex interplay between the lower motor neuron, its axon, motor end-plates, and muscle fibers allows a relevant plasticity in the movement output.
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Affiliation(s)
- Mamede de Carvalho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa-Norte, Lisbon, Portugal; Faculdade de Medicina-Instituto de Medicina Molecular-Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal.
| | - Michael Swash
- Faculdade de Medicina-Instituto de Medicina Molecular-Centro de Estudos Egas Moniz, Universidade de Lisboa, Lisbon, Portugal; Department of Neurology, Barts and London School of Medicine, Queen Mary University of London and Royal London Hospital, London, United Kingdom
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Grapperon AM, Verschueren A, Jouve E, Morizot-Koutlidis R, Lenglet T, Pradat PF, Salachas F, Bernard E, Delstanche S, Maertens de Noordhout A, Guy N, Danel V, Delval A, Delmont E, Rolland AS, Pulse Study Group, Jomir L, Devos D, Wang F, Attarian S. Assessing the upper motor neuron in amyotrophic lateral sclerosis using the triple stimulation technique: A multicenter prospective study. Clin Neurophysiol 2021; 132:2551-2557. [PMID: 34455313 DOI: 10.1016/j.clinph.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/16/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the relevance of transcranial magnetic stimulation (TMS) using triple stimulation technique (TST) to assess corticospinal function in amyotrophic lateral sclerosis (ALS) in a large-scale multicenter study. METHODS Six ALS centers performed TST and conventional TMS in upper limbs in 98 ALS patients during their first visit to the center. Clinical evaluation of patients included the revised ALS Functional Rating Scale (ALSFRS-R) and upper motor neuron (UMN) score. RESULTS TST amplitude ratio was decreased in 62% of patients whereas conventional TMS amplitude ratio was decreased in 25% of patients and central motor conduction time was increased in 16% of patients. TST amplitude ratio was correlated with ALSFRS-R and UMN score. TST amplitude ratio results were not different between the centers. CONCLUSIONS TST is a TMS technique applicable in daily clinical practice in ALS centers for the detection of UMN dysfunction, more sensitive than conventional TMS and related to the clinical condition of the patients. SIGNIFICANCE This multicenter study shows that TST can be a routine clinical tool to evaluate UMN dysfunction at the diagnostic assessment of ALS patients.
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Affiliation(s)
- Aude-Marie Grapperon
- APHM, Timone University Hospital, Referral Center for Neuromuscular Diseases and ALS, ERN Euro-NMD Center, Marseille, France
| | - Annie Verschueren
- APHM, Timone University Hospital, Referral Center for Neuromuscular Diseases and ALS, ERN Euro-NMD Center, Marseille, France
| | - Elisabeth Jouve
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, Department of Clinical Pharmacology and Pharmacovigilance, CIC-CPCET, Marseille, France
| | | | - Timothée Lenglet
- Department of Neurophysiology, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - François Salachas
- Referral Center for ALS, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Emilien Bernard
- Service des pathologies neuromusculaires et du motoneurone, Hospices Civils de Lyon, France
| | - Stéphanie Delstanche
- University of Liège, Centre Hospitalier Régional de la Citadelle, Department of Neurology, Liège, Belgium
| | | | - Nathalie Guy
- CRC SLA et maladie du neurone moteur, U1107-neurodol-UCA, CHU de Clermont-Ferrand, France
| | - Véronique Danel
- University of Lille, Expert center for ALS, CHU-Lille, Lille Neuroscience & Cognition, INSERM, UMR-S1172, LICEND, ACT4ALS-MND network, France
| | - Arnaud Delval
- Department of Clinical Neurophysiology, CHU-Lille, U1172 Lille Neuroscience & Cognition, University of Lille, France
| | - Emilien Delmont
- APHM, Timone University Hospital, Referral Center for Neuromuscular Diseases and ALS, ERN Euro-NMD Center, Marseille, France
| | - Anne-Sophie Rolland
- University of Lille, Expert center for ALS, CHU-Lille, Lille Neuroscience & Cognition, INSERM, UMR-S1172, LICEND, ACT4ALS-MND network, France
| | | | - Laurent Jomir
- Service des pathologies neuromusculaires et du motoneurone, Hospices Civils de Lyon, France
| | - David Devos
- University of Lille, Expert center for ALS, CHU-Lille, Lille Neuroscience & Cognition, INSERM, UMR-S1172, LICEND, ACT4ALS-MND network, France
| | - François Wang
- CHU de Liège, Department of Clinical Neurophysiology, Liège, Belgium
| | - Shahram Attarian
- APHM, Timone University Hospital, Referral Center for Neuromuscular Diseases and ALS, ERN Euro-NMD Center, Marseille, France.
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Cathcart SJ, Appel SH, Peterson LE, Greene EP, Powell SZ, Arumanayagam AS, Rivera AL, Cykowski MD. Fast Progression in Amyotrophic Lateral Sclerosis Is Associated With Greater TDP-43 Burden in Spinal Cord. J Neuropathol Exp Neurol 2021; 80:754-763. [PMID: 34383907 PMCID: PMC8433592 DOI: 10.1093/jnen/nlab061] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Upper and lower motor neuron pathologies are critical to the autopsy diagnosis of amyotrophic lateral sclerosis (ALS). Further investigation is needed to determine how the relative burden of these pathologies affects the disease course. We performed a blinded, retrospective study of 38 ALS patients, examining the association between pathologic measures in motor cortex, hypoglossal nucleus, and lumbar cord with clinical data, including progression rate and disease duration, site of symptom onset, and upper and lower motor neuron signs. The most critical finding in our study was that TAR DNA-binding protein 43 kDa (TDP-43) pathologic burden in lumbar cord and hypoglossal nucleus was significantly associated with a faster progression rate with reduced survival (p < 0.02). There was no correlation between TDP-43 burden and the severity of cell loss, and no significant clinical associations were identified for motor cortex TDP-43 burden or severity of cell loss in motor cortex. C9orf72 expansion was associated with shorter disease duration (p < 0.001) but was not significantly associated with pathologic measures in these regions. The association between lower motor neuron TDP-43 burden and fast progression with reduced survival in ALS provides further support for the study of TDP-43 as a disease biomarker.
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Affiliation(s)
- Sahara J Cathcart
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Stanley H Appel
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Leif E Peterson
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Ericka P Greene
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Suzanne Z Powell
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Anithachristy S Arumanayagam
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Andreana L Rivera
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
| | - Matthew D Cykowski
- From the Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas, USA (SJC, SZP, ASA, ALR, MDC); University of Nebraska Medical Center, Omaha, Nebraska, USA (SJC); Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, MDC); Institute of Academic Medicine at the Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR, MDC); Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, USA (SHA, EPG, SZP, ALR); NXG Logic, LLC, Houston, Texas, USA (LEP)
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Nelson MES, Orr M. Digital rectal stimulation as an intervention in persons with spinal cord injury and upper motor neuron neurogenic bowel. An evidenced-based systematic review of the literature. J Spinal Cord Med 2021; 44:525-532. [PMID: 31809250 PMCID: PMC8288126 DOI: 10.1080/10790268.2019.1696077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context: Need for evidential support of practice guideline recommendations for management of neurogenic bowel management in adults with spinal cord injury.Objective: To determine evidence for digital rectal stimulation (DRS) as an intervention in the management of upper motor neuron neurogenic bowels (UMN-NB) in persons with spinal cord injury (SCI).Methods: A systematic review of the literature including research articles and practice guidelines evaluating upper motor neuron neurogenic bowel treatments and the use of digital rectal stimulation was performed using OvidMedline, PubMed and the Cochrane database and included research articles and practice guidelines. Limitations were made related to English language, patient age and focus on spinal cord injured patients. Strength of evidence was assessed using the Johns Hopkins Nursing evidence-based practice model.Results: Eleven articles were included in the systematic review. Only one used DRS as a primary intervention. There was moderate evidence for DRS in persons with SCI and UMN-NB. There was evidence of the physiologic effect of DRS and support for combining DRS with other treatment regimens.Conclusion: There is insufficient evidence to promote any one intervention for the management of UMN-NB. The promotion of DRS, and education as to the proper technique for DRS should remain an emphasis of education of home management of UMN-NB in persons with SCI. Future research should focus on the use of standardized, validated tools to evaluate management techniques for UMN-NB.
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Affiliation(s)
- Mary Elizabeth S. Nelson
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA,Correspondence to: Mary Elizabeth S. Nelson, DNP, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, HUB 4th floor, 8701 Watertown Plank Rd., Milwaukee, WI53226, USA; Ph: 414-955-1915.
| | - Merle Orr
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Alhardallo M, El Ansari W, Baco AM. Second ever reported case of central cause of unilateral foot drop due to cervical disc herniation: Case report and review of literature. Int J Surg Case Rep 2021; 83:105928. [PMID: 34004565 PMCID: PMC8141523 DOI: 10.1016/j.ijscr.2021.105928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/21/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Foot drop is defined as a weakness in the ankle and foot dorsiflexors. A disruption of the neural pathway starting from the motor prefrontal cortex and ending in the peroneal nerve can lead to foot drop. Foot drop due to lower motor neuron injury is well documented. However, foot drop due to a central cause of cervical disc prolapse is very rare. CASE PRESENTATION A 55-year-old male presenting with neck pain, right and left arms radicular pain and numbness, and unilateral right foot drop following cervical disc prolapse. The patient presented with upper motor neuron lesion signs. MRI showed cervical disc prolapse at two levels, confirming central cause of foot drop. The patient underwent anterior cervical decompression and fusion surgery. DISCUSSION Following decompression and fusion of involved cervical spine disc pathology, the patient had complete recovery of his right foot drop. CONCLUSIONS Central causes, although rare, should be considered in the differential diagnosis of foot drop. Causes could be due to the compression effect of the cortico-spinal tract of the cervical spinal cord. Satisfactory results can be achieved upon correcting the causative lesion.
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Affiliation(s)
- Mutaz Alhardallo
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Walid El Ansari
- Department of Surgery, Hamad General Hospital, Doha, Qatar; College of Medicine, Qatar University, Doha, Qatar; School of Health and Education, University of Skövde, Skövde, Sweden.
| | - Abdul Moeen Baco
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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Couratier P, Lautrette G, Luna JA, Corcia P. Phenotypic variability in amyotrophic lateral sclerosis. Rev Neurol (Paris) 2021; 177:536-543. [PMID: 33902945 DOI: 10.1016/j.neurol.2021.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
Clinically, ALS phenotypes depend on the areas of the body that are affected, the different degrees of involvement of upper and lower motor neurons, the degrees of involvement of other systems, particularly cognition and behavior, and rates of progression. Phenotypic variability of ALS is characteristic and can be declined on the distribution of motor manifestations but also on the presence of extra-motor signs present in a variable manner in ALS patients. Neuropathologically, ALS is defined by the loss of UMN and LMN and the presence of two representative motor neuronal cytoplasmic inclusions, Bunina bodies and 43kDa Transactivation Response DNA Binding Protein (TDP-43) - positive cytoplasmic inclusions. The distribution of cytopathology and neuronal loss in patients is variable and this variability is directly related to phenotypic variability. Key regulators of phenotypic variability in ALS have not been determined. The functional decrement of TDP-43, and region-specific neuronal susceptibility to ALS, may be involved. Due to the selective vulnerability among different neuronal systems, lesions are multicentric, region-oriented, and progress at different rates. They may vary from patient to patient, which may be linked to the clinicopathological variability across patients.
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Affiliation(s)
- P Couratier
- Service de neurologie, centre de référence maladies rares SLA et autres maladies du neurone moteur, CHU de Limoges, Limoges, France; Inserm, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, université de Limoges, CHU de Limoges, Limoges, France; Fédération des Centres SLA de Limoges et Tours, Litorals, Limoges, France.
| | - G Lautrette
- Service de neurologie, centre de référence maladies rares SLA et autres maladies du neurone moteur, CHU de Limoges, Limoges, France; Fédération des Centres SLA de Limoges et Tours, Litorals, Limoges, France
| | - J A Luna
- Inserm, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, GEIST, université de Limoges, CHU de Limoges, Limoges, France
| | - P Corcia
- Fédération des Centres SLA de Limoges et Tours, Litorals, Limoges, France; Centre de référence maladies rares SLA et autres maladies du neurone moteur, CHU Bretonneau, Tours, France
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10
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Bilić H, Hančević M, Sitaš B, Bilić E. A rare case of parasagittal meningioma causing isolated foot drop: case report and review of the literature. Acta Neurol Belg 2021; 121:555-559. [PMID: 31786742 DOI: 10.1007/s13760-019-01255-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 11/25/2019] [Indexed: 11/25/2022]
Abstract
Foot drop represents a very common reason for a neurologist referral and is often first seen in emergency departments or by a general practitioner. This condition is defined as weakness of ankle dorsiflexion (mainly through tibialis anterior muscle weakness). The most common causes include lower motor neuron lesion, with L4-L5 radiculopathy and peroneal neuropathy being the most frequent ones. Classical diagnostic pathway includes a thorough medical history, detailed neurological examination, radiological studies (MRI of the lumbosacral spine), EMG and nerve conduction studies, and a battery of laboratory tests. The absence of abnormal radiological and neurophysiological findings when searching for the most common causes of foot drop, should raise a red flag and broaden the diagnostic yield for central nervous system pathology (upper motor neuron, UMN) as a possible cause of foot drop. Central causes of isolated foot drop are very rare, with less than 20 cases reported in literature so far, and seven of them being a meningioma. We present a case of a 79-year-old female patient with an isolated foot drop (with no UMN signs on the initial examination) and parasagittal meningioma. Central causes of foot drop should be suspected when foot drop is associated with UMN signs on examination (hyperreflexia of the patellar or ankle jerk and extensor plantar reflex) and when standard diagnostic work-up (MRI of the lumbar spine, EMG and NCS, standard laboratory screening for most common causes of foot drop) is negative or inconclusive. Although very rare, central lesions present a far more serious cause of foot drop and require a more urgent diagnostic work up and a potential neurosurgical referral and treatment. Keeping in mind the possible central causes of foot drop would eliminate unnecessary diagnostic work up and avoid delayed diagnosis and treatment.
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Affiliation(s)
- Hrvoje Bilić
- Department of Neurology, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.
| | - Mirea Hančević
- Department of Neurology, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Barbara Sitaš
- Department of Neurology, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Ervina Bilić
- Department of Neurology, Clinical Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
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11
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Zoccolella S, Introna A, Milella G, Mastronardi A, Iliceto G, D'Errico E, Fraddosio A, Simone IL. Subclinical upper motor neuron involvement at the diagnosis may predict disease progression in a cohort of lower motor neuron syndromes from Southern Italy. J Neurol Sci 2021; 425:117392. [PMID: 33838499 DOI: 10.1016/j.jns.2021.117392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/06/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Only few epidemiological studies on survival of Lower Motor Neuron (LMN) phenotype (LMNP) are available and with controversial results. AIMS To prospectively evaluate a cohort of LMNP patients and assess the possible contribute on survival or disease's progression according to the presence of subclinical Upper Motor Neuron (UMN) impairment at the diagnosis. METHODS Forty LMNP among 176 consecutive incident ALS cases observed in our tertiary center from the ALS-Apulia Register were enrolled in the study. Each patient underwent to a neurophysiological study with transcranial magnetic stimulation (TMS) at diagnosis. The primary outcome was the impact of abnormalities at TMS on survival time (from symptoms onset or diagnosis to death, tracheostomy or 30 June 2020, as censoring time). Secondary outcome was time to reach the King's 4 stage. RESULTS Approximately one half of LMNP reached the primary outcome during the study period. No difference was found in median survival times and 4 years survival rates according to the presence of TMS impairment. On the other hand, a shorter median time to reach the King's 4 from onset was observed in the group of LMNP with TMS abnormalities (16 months versus 50 months; p = 0.008). Consistently, TMS abnormalities were associated with a 3.5 times higher risk for reaching King's 4 stage (Hazard Ratio: 3.5; 95% Confidence Interval: 1.1-10.9; p = 0.03). CONCLUSION Our data suggest a role of TMS abnormalities as potential indicator of disease progression and multidistrectual involvement in patients with pure clinical LMN phenotype at the diagnosis.
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Affiliation(s)
| | - Alessandro Introna
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Giammarco Milella
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Antonella Mastronardi
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Giovanni Iliceto
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Eustachio D'Errico
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Angela Fraddosio
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Isabella Laura Simone
- Neurology Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70100 Bari, Italy
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12
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Ghosh R, Dubey S, Chatterjee S, Kanti Ray B, Benito-León J. Mixed Upper and Lower Motor Neuron Damage in Japanese Encephalitis Virus Infection. Case Rep Neurol 2020; 12:482-488. [PMID: 33568983 PMCID: PMC7841720 DOI: 10.1159/000510711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/05/2020] [Indexed: 11/19/2022] Open
Abstract
Cerebral manifestations in Japanese B encephalitis are well known. However, there are very few studies focusing on extra-cerebral manifestations, among which focal anterior horn cell involvement is exceedingly rare. We herein report a case of Japanese B encephalitis with focal anterior horn cell involvement and unfurl how stepwise clinical approach and targeted investigations helped to solve the diagnostic conundrum. A 27-year-old female was admitted with fever, headache, altered sensorium, and convulsions. She tested positive for Japanese B encephalitis-IgM. Following conservative management, she regained consciousness after 5 days when neurological examination revealed marked cognitive impairment, medial convergence of eyeballs, upward gaze restriction, upper limbs dystonia with brisk tendon jerks, and flaccid paraparesis. A repeat neurological examination, on day 15 of admission, showed marked wasting and intermittent fasciculation in both lower limbs. Brain magnetic resonance imaging showed asymmetrical (right > left) bilateral thalamic and midbrain lesions, hyperintense on T2 and T2-fluid-attenuated inversion recovery (FLAIR)-weighted imaging with mild diffusion restriction on diffusion-weighted imaging and apparent diffusion coefficient map, suggestive of encephalitis. Nerve conduction study revealed decreased compound muscle action potentials exclusively in lower limbs with intact sensory nerve action potentials. Electromyogram showed chronic denervation potentials and presence of spontaneous activity in lower limbs, but not in upper limbs, indicative of focal anterior horn cell involvement. Prognosis of Japanese B encephalitis does not only depend on cerebral sequelae. Anterior horn cell involvement can dictate poor outcome and can easily be missed if not carefully dealt with.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, India
| | - Souvik Dubey
- Department of Neuromedicine, Bangur institute of Neurosciences, Kolkata, India
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur institute of Neurosciences, Kolkata, India
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
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13
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Finegan E, Siah WF, Shing SLH, Chipika RH, Chang KM, McKenna MC, Doherty MA, Hengeveld JC, Vajda A, Donaghy C, Hutchinson S, McLaughlin RL, Hardiman O, Bede P. Imaging and clinical data indicate considerable disease burden in 'probable' PLS: Patients with UMN symptoms for 2-4 years. Data Brief 2020; 32:106247. [PMID: 32944602 PMCID: PMC7481824 DOI: 10.1016/j.dib.2020.106247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/12/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022] Open
Abstract
Primary lateral sclerosis (PLS) is an adult-onset upper motor neuron disease manifesting in progressive spasticity and gradually resulting in considerably motor disability. In the absence of early disease-specific diagnostic indicators, the majority of patients with PLS face a circuitous diagnostic journey. Until the recent publication of consensus diagnostic criteria, 4-year symptom duration was required to establish the diagnosis. The new diagnostic criteria introduced the category of ‘probable PLS’ for patients with a symptom duration of 2–4 years. “Evolving diagnostic criteria in primary lateral sclerosis: The clinical and radiological basis of "probable PLS" [1]. This dataset provides radiological metrics in a cohort of ‘probable PLS’ patients, ‘definite PLS’ patients and age-matched healthy controls. Region-of-interest radiological data include diffusivity metrics in the corticospinal tracts and corpus callosum as well as mean cortical thickness values in the pre- and para-central gyri in each hemisphere. Our data indicate considerable grey matter and relatively limited white matter involvement in ‘probable PLS’ which supports the rationale for this diagnostic category as a clinically useful entity. The introduction of this diagnostic category will likely facilitate the timely recruitment of PLS patients into research studies and pharmacological trials before widespread neurodegenerative change ensues.
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Affiliation(s)
- Eoin Finegan
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
| | - We Fong Siah
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
| | - Stacey Li Hi Shing
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
| | | | - Kai Ming Chang
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Electronics and Computer Science, University of Southampton, Southampton, United Kingdom
| | - Mary Clare McKenna
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
| | - Mark A. Doherty
- Complex Trait Genomics Laboratory, Smurfit Institute of Genetics, Trinity College Dublin, Ireland
| | - Jennifer C. Hengeveld
- Complex Trait Genomics Laboratory, Smurfit Institute of Genetics, Trinity College Dublin, Ireland
| | - Alice Vajda
- Complex Trait Genomics Laboratory, Smurfit Institute of Genetics, Trinity College Dublin, Ireland
| | - Colette Donaghy
- Department of Neurology, Western Health & Social Care Trust, Belfast, United Kingdom
| | | | - Russel L. McLaughlin
- Complex Trait Genomics Laboratory, Smurfit Institute of Genetics, Trinity College Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Ireland
- Corresponding author.
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14
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Tokimura R, Murakami T, Ugawa Y. Central motor conduction time reveals upper motor neuron involvement masked by lower motor neuron impairment in a significant portion of patients with amyotrophic lateral sclerosis. Clin Neurophysiol 2020; 131:1896-1901. [PMID: 32593964 DOI: 10.1016/j.clinph.2020.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/13/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We retrospectively investigated the utility of the central motor conduction time (CMCT) in detecting upper motor neuron (UMN) involvements in patients with amyotrophic lateral sclerosis (ALS). METHODS Fifty-two ALS patients and 12 disease control patients participated in this study. Surface electromyograms were recorded from the first dorsal interosseous (FDI) and tibialis anterior (TA) muscles. We stimulated the motor cortex, brainstem, and spinal nerve using transcranial magnetic stimulation (TMS) in order to measure the cortical, brainstem, and spinal latencies. We divided the ALS patients into 2 subgroups (with UMN impairment vs. without UMN impairment) and calculated the rates of abnormal CMCT prolongation judged by their comparison with the normal ranges obtained by the measurement in the control patients. RESULTS The CMCTs in the FDI and TA were abnormally prolonged in over 40% of the ALS patients with UMN impairment and in nearly 30% of those without UMN impairment. CONCLUSIONS CMCT shows UMN dysfunction in ALS patients without clinical UMN impairment. SIGNIFICANCE TMS still has diagnostic utility in a significant portion of ALS patients.
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Affiliation(s)
- Ryo Tokimura
- Department of Neurology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan.
| | - Takenobu Murakami
- Department of Neurology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan; Department of Neurology, Tottori Prefectural Kousei Hospital, 150 Higashishowacho, Kurayoshi, Japan
| | - Yoshikazu Ugawa
- Department of Neurology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, Japan; Department of Human Neurophysiology, Fukushima Medical University, 1 Hikarigaoka, Fukusima, Japan
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15
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Geser F, Fellner L, Haybaeck J, Wenning GK. Development of neurodegeneration in amyotrophic lateral sclerosis: from up or down? J Neural Transm (Vienna) 2020; 127:1097-1105. [PMID: 32500222 DOI: 10.1007/s00702-020-02213-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/23/2020] [Indexed: 12/19/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurological disease associated with neurodegeneration and intracellular pathological 43-kDa transactive response sequence DNA-binding protein (TDP-43) positive inclusions. The various clinical symptoms, such as motor disorders and cognitive impairment, reflect the degeneration of certain areas of the nervous system. Since the discovery of the significance of pathological TDP-43 for human disease including ALS, there has been an increasing number of studies reporting on the distribution and severity of neurodegeneration. These have rekindled the old debate about whether the first or second motor neuron is the primary site of degeneration in ALS. To shed light on this question, the following is a review of the relevant neuropathological studies.
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Affiliation(s)
- F Geser
- Department of Neurology, Hegau-Bodensee-Klinikum Singen, Virchowstr. 10, 78224, Singen (Hohentwiel), Germany.
| | - L Fellner
- Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Haybaeck
- Department of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neuropathology, Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - G K Wenning
- Division of Neurobiology, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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16
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Sugiyama A, Sato N, Kimura Y, Shigemoto Y, Suzuki F, Morimoto E, Takahashi Y, Matsuda H, Kuwabara S. Exploring the frequency and clinical background of the "zebra sign" in amyotrophic lateral sclerosis and multiple system atrophy. J Neurol Sci 2019; 401:90-94. [PMID: 31075684 DOI: 10.1016/j.jns.2019.04.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/08/2019] [Accepted: 04/23/2019] [Indexed: 11/28/2022]
Abstract
In amyotrophic lateral sclerosis (ALS), the "zebra sign" in the precentral gyrus on phase difference enhanced magnetic resonance imaging (PADRE) recently has been reported as a possible imaging biomarker for upper motor neuron (UMN) involvement. A previous study has shown that the "zebra sign" allowed us to differentiate patients with ALS from healthy subjects with excellent accuracy. We validated the usefulness of the sign for differentiating patients with ALS from healthy subjects and investigated whether the "zebra sign" can be observed other neurodegenerative disorders with UMN involvement. The "zebra sign" on PADRE was assessed in 26 patients with ALS, 26 with multiple system atrophy (MSA) and 26 healthy controls, and the sign was observed in 50%, 23%, and no subjects, respectively. ALS patients with the "zebra sign" demonstrated a higher UMN burden score than those without the sign. The "zebra sign" on PADRE is not specific to ALS, also present in MSA, but might reflect the degeneration of the UMN within the motor cortex in neurodegenerative disorders.
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Affiliation(s)
- Atsuhiko Sugiyama
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan; Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Noriko Sato
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan.
| | - Yukio Kimura
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoko Shigemoto
- Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Fumio Suzuki
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Emiko Morimoto
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuji Takahashi
- Department of Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Hiroshi Matsuda
- Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
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17
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Calancie B, Young E, Watson ML, Wang D, Alexeeva N. Superconditioning TMS for examining upper motor neuron function in MND. Exp Brain Res 2019; 237:2087-103. [PMID: 31175383 DOI: 10.1007/s00221-019-05573-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/30/2019] [Indexed: 01/09/2023]
Abstract
We used transcranial magnetic stimulation (TMS) of motor cortex, including a novel four-pulse superconditioning (TMSsc) paradigm, in repeated examinations of motor-evoked potentials (MEPs) in eight subjects with motor neuron disease (MND), including seven with amyotrophic lateral sclerosis (ALS). The goals were: (1) to look for evidence of cortical hyperexcitability, including a reduction in short-interval intracortical inhibition (SICI); and (2) to examine the utility of using TMSsc for quantifying upper motor neuron function during MND progression. Testing of abductor pollicis brevis (APB) and tibialis anterior (TA) muscles bilaterally was carried out every 3 months in MND subjects for up to 2 years; results were compared to those from a cohort of 15 control subjects. Measures of SICI were not significantly different between control and MND subjects for either APB or TA muscles. Other measures of cortical excitability, including TMS threshold and MEP amplitude, were consistent with lowered cortical excitability in MND subjects. Certain combinations of superconditioning TMS were capable of causing stronger inhibition or facilitation of MEPs compared to dual-pulse TMS, for both APB and TA target muscles. Moreover, there were multiple cases in which target muscles unresponsive to strong single-pulse TMS, whether at rest or when tested with an active contraction, showed an MEP in response to TMSsc optimized for facilitation. Our findings suggest that a multi-faceted neurophysiologic protocol for examining upper motor neuron function in MND subjects might benefit from inclusion of TMSsc testing.
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18
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de Carvalho M, Swash M. Motor unit recruitment in myopathy: The myopathic EMG reconsidered. J Electromyogr Kinesiol 2019; 45:41-5. [PMID: 30798164 DOI: 10.1016/j.jelekin.2019.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 12/11/2022] Open
Abstract
Motor unit recruitment is abnormal in myopathies. We have addressed this subject by recording motor unit potentials (MUPs) using a standard concentric needle electrode in tibialis anterior muscles of clinically normal strength in a group of patients with myopathy (15 with myositis and 4 with facioscapulohumeral muscular dystrophy Type 1). In each recording site, a minimal voluntary contraction was sought in order to activate only 2 MUPs. At least 5 pairs of MUPs were recorded in each muscle. We analysed the recruitment rate of the first activated MUP and the mean consecutive difference (MCD) of firing frequency between the individual MUPs of each recruited pair. Results were compared with 30 healthy control subjects. In myopathy the first recorded MUs fired at similar rates to controls (8.2 vs 8.0 Hz, respectively), but the MCD of the firing rate difference between the first two recruited MUPs was less than in controls (median difference 1.78 Hz vs median difference 2.47 Hz, p = 0.02). This change suggests increased lower motor neuron excitability as a functional adaptation, since muscle strength was normal in the studied muscles. These findings are consistent with spinal cord adaptation to the functional changes associated with myopathic muscle disease, although a primary muscle fibre feedback sensing mechanism could also be involved.
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19
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Zucchi E, Bedin R, Fasano A, Fini N, Gessani A, Vinceti M, Mandrioli J. Cerebrospinal Fluid Neurofilaments May Discriminate Upper Motor Neuron Syndromes: A Pilot Study. NEURODEGENER DIS 2018; 18:255-261. [PMID: 30428468 DOI: 10.1159/000493986] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/19/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients presenting with upper motor neuron (UMN) signs may widely diverge in prognosis, ranging from amyotrophic lateral sclerosis (ALS) to primary lateral sclerosis (PLS) and hereditary spastic paraplegia (hSP). Neurofilaments are emerging as potential diagnostic and prognostic biomarkers for ALS, but the diagnosis of UMN syndromes still relies mostly on clinical long-term observation and on familiarity or genetic confirmation. OBJECTIVES To test whether phosphorylated neurofilament heavy chain (pNfH) may discriminate different UMN syndromes at diagnosis and to test their prognostic role among these diseases. METHODS We measured the cerebrospinal fluid (CSF) and serum pNfH of 30 patients presenting with UMN signs and diagnosed with ALS, hSP, and PLS, plus 9 healthy controls (HC). RESULTS ALS patients had higher levels of pNfH in CSF and serum compared to HC (p < 0.001 and p < 0.001 in CSF and serum, respectively) and PLS (p = 0.015 and p = 0.038) and hSP (p = 0.003 and p = 0.001) patients. PLS and hSP patients had similar CSF and serum pNfH concentrations, but a higher CSF pNfH concentration, compared to HC (p = 0.002 and p = 0.003 for PLS and hSP, respectively). Receiver operating characteristic curves for discriminating ALS from PLS and hSP showed an area under the curve of 0.79 for CSF and 0.81 for serum. In multivariable survival analysis including relevant clinical factors CSF pNfH represented the strongest variable predicting survival (HR 40.43; 95% CI 3.49-467.79, p = 0.003) independently of clinical group. CONCLUSIONS Despite some statistical instability of the results due to limitations in sample size, our study supports the role of CSF pNfH as a prognostic biomarker for motor neuron diseases presenting with UMN signs. A potential power to discriminate between ALS and other UMN syndromes at presentation, and between all of the examined MND and HC, has been detected for both CSF and serum pNfH.
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Affiliation(s)
- Elisabetta Zucchi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Antonio Fasano
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Nicola Fini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Annalisa Gessani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Marco Vinceti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy.,Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Jessica Mandrioli
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy, .,Azienda Ospedaliero Universitaria di Modena, Modena, Italy,
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20
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Nakane S, Fujita K, Azuma S, Urushihara R, Kamada M, Harada M, Izumi Y, Kaji R. CSF cystatin C and diffusion tensor imaging parameters as biomarkers of upper motor neuron degeneration in amyotrophic lateral sclerosis. Clin Neurol Neurosurg 2018; 172:162-8. [PMID: 30016754 DOI: 10.1016/j.clineuro.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 07/04/2018] [Accepted: 07/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The establishment of biomarkers for amyotrophic lateral sclerosis (ALS) will be useful for early diagnosis and may provide evidence about pathogenesis. To elucidate whether high-field magnetic resonance (MR) findings and multimodal analysis of cerebrospinal fluid (CSF) levels of cystatin C could be indicators of upper motor neuron (UMN) involvement in ALS. PATIENTS AND METHODS Patients with ALS (n = 20), multiple sclerosis (n = 15), immune mediated chronic polyneuropathy (n = 17), and acute polyneuropathy (n = 12) were included in this retrospective study. Clinical indices including UMN signs were assessed, and 3.0-Tesla diffusion tensor imaging and MR spectroscopy were performed in patients with ALS. CSF levels of cystatin C were measured using enzyme-linked immunosorbent assay. RESULTS MR findings indicated that decreased anisotropy, increased diffusion, and increased myo-inositol/creatine ratio were also significantly correlated with UMN involvement in patients with ALS. The CSF cystatin C levels were significantly lower in patients with ALS than in the other three groups. The reduction of CSF cystatin C levels was significantly correlated with clinical UMN involvement (r = -0.505, p = 0.023). CONCLUSIONS Reduced cystatin C in CSF can reflect UMN involvement as shown in high-field MR of ALS, potentially providing a new biomarker for UMN degeneration in ALS.
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Lenglet T, Camdessanché JP. Amyotrophic lateral sclerosis or not: Keys for the diagnosis. Rev Neurol (Paris) 2017; 173:280-287. [PMID: 28461025 DOI: 10.1016/j.neurol.2017.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/06/2017] [Accepted: 04/07/2017] [Indexed: 10/19/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a degenerative motor neuron disease (MND) which prognosis is poor. Early diagnosis permit to set up immediately adapted treatment and cares. Available diagnostic criteria are based on the detection of both central and peripheral motor neuron injury in bulbar, cervical, thoracic and lumbar regions. Electrodiagnostic (EDX) tests are the key tools to identify peripheral motor neuron involvement. Needle examination records abnormal activities at rest, and looks for neurogenic pattern during muscle contraction. Motor unit potentials morphology is modified primary to recruitment. Motor evoked potentials remain the test of choice to identify impairment of central motor neurons. In the absence of diagnostic biomarker of ALS and among essential investigations of suspected MND, a careful clinical and neurophysiological work-up is essential to rule out the differential diagnosis.
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Affiliation(s)
- T Lenglet
- Département de neurophysiologie clinique, Hôpital de la Salpêtrière, Assistance Publique-Hôpitaux de Paris, France; Centre Référent Maladies du Motoneurone et SLA, Hôpital de la Salpêtrière, Assistance Publique-Hôpitaux de Paris, France
| | - J-P Camdessanché
- Service de Neurologie, Hôpital Nord, CHU de Saint-Etienne, France; Centre Référent Maladies du Motoneurone et SLA, CHU de Saint-Etienne, France.
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Shirani A, Newton BD, Okuda DT. Finger tapping impairments are highly sensitive for evaluating upper motor neuron lesions. BMC Neurol 2017; 17:55. [PMID: 28327094 PMCID: PMC5361720 DOI: 10.1186/s12883-017-0829-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/03/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Identifying highly sensitive and reliable neurological exam components are crucial in recognizing clinical deficiencies. This study aimed to investigate finger tapping performance differences between patients with CNS demyelinating lesions and healthy control subjects. METHODS Twenty-three patients with multiple sclerosis or clinically isolated syndrome with infratentorial and/or cervical cord lesions on MRI, and 12 healthy controls were videotaped while tapping the tip of the index finger against the tip and distal crease of the thumb using both the dominant and non-dominant hand. Videos were assessed independently by 10 evaluators (three MS neurologists, four neurology residents, three advanced practice providers). Sensitivity and inter-evaluator reliability of finger tapping interpretations were calculated. RESULTS A total of 1400 evaluations (four videos per each of the 35 subjects evaluated by 10 independent providers) were obtained. Impairments in finger tapping against the distal thumb crease of the non-dominant hand, identified by neurologists, had the greatest sensitivity (84%, p < 0.001) for detecting impairment. Finger tapping against the thumb crease was more sensitive than the thumb tip across all categories of providers. The best inter-evaluator reliability was associated with neurologists' evaluations for the thumb crease of the non-dominant hand (kappa = 0.83, p < 0.001). CONCLUSIONS Impaired finger tapping against the distal thumb crease of the non-dominant hand was a more sensitive technique for detecting impairments related to CNS demyelinating lesions. Our findings highlight the importance of precise examinations of the non-dominant side where impaired fine motor control secondary to an upper motor injury might be detectable earlier than the dominant side.
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Affiliation(s)
- Afsaneh Shirani
- Department of Neurology and Neurotherapeutics, Clinical Center for Multiple Sclerosis, Multiple Sclerosis & Neuroimmunology Imaging Program, Neuroinnovation Program, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Braeden D Newton
- Department of Neurology and Neurotherapeutics, Clinical Center for Multiple Sclerosis, Multiple Sclerosis & Neuroimmunology Imaging Program, Neuroinnovation Program, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Darin T Okuda
- Department of Neurology and Neurotherapeutics, Clinical Center for Multiple Sclerosis, Multiple Sclerosis & Neuroimmunology Imaging Program, Neuroinnovation Program, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA.
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Huynh W, Simon NG, Grosskreutz J, Turner MR, Vucic S, Kiernan MC. Assessment of the upper motor neuron in amyotrophic lateral sclerosis. Clin Neurophysiol 2016; 127:2643-60. [PMID: 27291884 DOI: 10.1016/j.clinph.2016.04.025] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 04/22/2016] [Accepted: 04/27/2016] [Indexed: 02/07/2023]
Abstract
Clinical signs of upper motor neuron (UMN) involvement are an important component in supporting the diagnosis of amyotrophic lateral sclerosis (ALS), but are often not easily appreciated in a limb that is concurrently affected by muscle wasting and lower motor neuron degeneration, particularly in the early symptomatic stages of ALS. Whilst recent criteria have been proposed to facilitate improved detection of lower motor neuron impairment through electrophysiological features that have improved diagnostic sensitivity, assessment of upper motor neuron involvement remains essentially clinical. As a result, there is often a significant diagnostic delay that in turn may impact institution of disease-modifying therapy and access to other optimal patient management. Biomarkers of pathological UMN involvement are also required to ensure patients with suspected ALS have timely access to appropriate therapeutic trials. The present review provides an analysis of current and recently developed assessment techniques, including novel imaging and electrophysiological approaches used to study corticomotoneuronal pathology in ALS.
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Statland JM, Barohn RJ, McVey AL, Katz JS, Dimachkie MM. Patterns of Weakness, Classification of Motor Neuron Disease, and Clinical Diagnosis of Sporadic Amyotrophic Lateral Sclerosis. Neurol Clin 2015; 33:735-48. [PMID: 26515618 DOI: 10.1016/j.ncl.2015.07.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
When approaching a patient with suspected motor neuron disease (MND), the pattern of weakness on examination helps distinguish MND from other diseases of peripheral nerves, the neuromuscular junction, or muscle. MND is a clinical diagnosis supported by findings on electrodiagnostic testing. MNDs exist on a spectrum, from a pure lower motor neuron to mixed upper and lower motor neuron to a pure upper motor neuron variant. Amyotrophic lateral sclerosis (ALS) is a progressive mixed upper and lower motor neuron disorder, most commonly sporadic, which is invariably fatal. This article describes a pattern approach to identifying MND and clinical features of sporadic ALS.
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Affiliation(s)
- Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA.
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA
| | - April L McVey
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA
| | - Jonathan S Katz
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA; Department of Neurology, California Pacific Medical Center, 475 Brannan Street, Suite 220, San Francisco, CA 94107, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA
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Chakraborty S, Gupta A, Nguyen T, Bourque P. The "Motor Band Sign:" Susceptibility-Weighted Imaging in Amyotrophic Lateral Sclerosis. Can J Neurol Sci 2015; 42:260-3. [PMID: 25971894 DOI: 10.1017/cjn.2015.40] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kim KW, Park JS, Koh EJ, Lee JM. Cerebral infarction presenting with unilateral isolated foot drop. J Korean Neurosurg Soc 2014; 56:254-6. [PMID: 25368770 PMCID: PMC4217064 DOI: 10.3340/jkns.2014.56.3.254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/07/2014] [Accepted: 09/06/2014] [Indexed: 11/27/2022] Open
Abstract
Weakness of the dorsiflexor muscles of the ankle or toe, referred to as foot drop, is a relatively common presentation. In most cases, foot drop is caused by a lower motor neuron disease such as peroneal peripheral neuropathy, L4-5 radiculopathic sciatic neuropathy, or polyneuropathy. Although upper motor neuron lesions can present as foot drop, the incidence is very rare. Here, we report an extremely rare case in which foot drop was the only presenting symptom of cerebral infarction.
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Affiliation(s)
- Ki-Wan Kim
- Department of Neurosurgery, Research Institute of Clinical Medicine, Institute for Medical Science, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Jung-Soo Park
- Department of Neurosurgery, Research Institute of Clinical Medicine, Institute for Medical Science, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Eun-Jeong Koh
- Department of Neurosurgery, Research Institute of Clinical Medicine, Institute for Medical Science, Chonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Jong-Myong Lee
- Department of Neurosurgery, Research Institute of Clinical Medicine, Institute for Medical Science, Chonbuk National University Medical School and Hospital, Jeonju, Korea
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