THEME 4 IMAGING, ELECTROPHYSIOLOGY AND MARKERS OF DISEASE PROGRESSION

P77 NEUROIMAGING IN ALS AS A FEASIBLE STRATEGY FOR CLINICAL THERAPY: TARGETS AND LIMITS

Cova L¹

Bossolasco P¹

Diana V¹

Micotti E²

Sitia L²

Giardino D¹

Moscatelli D³

Bigini P²

Silani V^1,4

^aIRCCS Istituto Auxologico Italiano, Milan, Italy

^bMario Negri Institute for Pharmacological Research, Milan, Italy

^cDepartment of Chimica Materiali e Ingegneria Chimica G. Natta, Politecnico di Milano, Milan, Italy

^dDepartment of Pathophysiology and Transplanation, “Dino Ferrari” Centre, Universita` degli Studi di Milano, Milan, Italy

Email address for correspondence: [email protected]

Keywords: SPIOn, migration, stem cell

Background: In the absence of effective pharmacological treatments for amyotrophic lateral sclerosis (ALS), a novel promising therapeutic strategy resides in stem cell (SC) transplantation for the replacement and/or protection of damaged neurons. An important, still unsolved, challenge is the imaging of SCs to monitor their fate and interactions with host tissue after transplantation. A common technique consists of cell labelling with small paramagnetic iron oxide nanoparticles (SPIOn), detectable by magnetic resonance imaging (MRI).

Objectives: The aims of the present study were to monitor the advantages and enlighten the limits of the clinically approved SPIOn labelling from in vitro to in vivo, in the pathological Wobbler mice, a well-characterized ALS animal model.

Methods: Nanoparticles, composed by carboxydextran and paramagnetic iron oxide, were loaded in human foetal SCs for 72 hours in conjunction with a suitable live cell DNA dye. SCs were labelled with SPIOn and their motility was evaluated by a specific cell migration assay. Thereafter, cells were intracerebroventricularly injected in Wobbler mice and monitored at different times (24h, 2, 6 and 8 weeks after graft).

Results: We observe that the double labelling did not interfere with cell proliferation and survival. However, we also found that SPIOn labelling significantly reduce SC migration. Motility impairment was directly proportional to loaded SPIOn amount while the migration rate of labelled cells was only partially restored by a degenerative surrounding. After injection in mice, MRI analysis showed a consistent signal confined in the whole ventricular compartments until the 2^nd week after graft. In the following 6 and 8 weeks it decreased, but remained still visible in the same regions. Ex vivo studies confirmed that the MRI signal overlapped with Hoechst 33258 labelling in mice without relevant differences.

Discussion and conclusion: The overall results obtained revealed that (1) biological properties of SCs resulted unaffected by double labelling; (2) SPIOn labelling could affect cell motility in a dose-dependent manner, shedding the light on another important parameter that could be crucial for the creation of novel protocols applicable to clinic; (3) an ongoing degenerative environment could partially restore normal motility; (4) in vivo, transplanted cells diffused in the whole ventricular system with a reduced, but still detectable, MRI signal over time; and (5) the macroscopic localization of SCs appeared not influenced by the pathological state affecting Wobbler mice.

Altogether, our results demonstrate that establishment of an optimal SPIOn dose, enabling both an excellent visualization of grafted cell by imaging and the maintenance of migration ability, appears fundamental to improve the effects of SC therapy. Alternative dyes (ie genetic or near infrared emitting tracers) should be investigated in pre-clinical settings as they may be more suitable for the future clinical treatments of ALS patients.

P78 NEUROIMAGING CORRELATES OF IMPAIRED MOTOR FUNCTION IN AMYOTROPHIC LATERAL SCLEROSIS

Koritnik B^1,2

Pecaric Meglic N²

Sirnik A²

Zidar J¹

^eInstitute of Clinical Neurophysiology

^fClinical Institute of Radiology; University Medical Centre Ljubljana, Ljubljana, Slovenia

Email address for correspondence: [email protected]

Keywords: fMRI, VBM, biomarker

Background: Neuroimaging studies in patients with ALS have shown differences in brain structure and function compared to healthy subjects. It is, however, not known whether and to what extent these changes relate to the functional measures of the disease.

Objectives: To correlate structural and functional magnetic resonance imaging data to functional measures of the disease.

Methods: Functional magnetic resonance imaging (fMRI) and voxel-based morphometry (VBM) were performed in eight ALS patients (age range: 46–82 years) on a Siemens Trio 3T scanner. For fMRI, a visuo-motor handgrip task at the 30% of the individual maximum force was used. Image pre-processing and statistical analysis was done using SPM8. A second level random effects analysis was used with a cluster-level significance p < 0.05 (FDR-corrected). A range of disease measures was tested in regression models: age, disease duration, ALS Functional Rating Scale (ALS-FRS), handgrip strength, upper motor neuron burden and compound muscle action potential (CMAP) amplitude.

Results: Group fMRI activations included contralateral primary sensorimotor cortex, lateral premotor cortex, posterior parietal cortex and supplementary motor area. Disease duration, ALS-FRS, handgrip strength and CMAP amplitude showed some statistically significant correlations with fMRI activity. There was no effect of age and upper motor neuron burden on fMRI activations. VBM measures (cortical grey matter density) correlated with ALS-FRS and not with other functional measures.

Conclusions: Cortical fMRI activity in ALS patients correlates to a certain extent with some of the disease measures. In general, fMRI activations decreased with disease duration and loss of function. Structural cortical changes showed only weak correlation with disease measures. Using functional and structural neuroimaging as a biomarker for ALS disease progression seems a possibility but there are some methodological issues to be considered. Longitudinal studies of larger groups of patients at different stages of the disease are warranted.

P79 TRACKING DISEASE PROGRESSION BY MRI: CLINICAL FEATURES OF AMYOTROPHIC LATERAL SCLEROSIS CORRELATE WITH FOCAL CORTICAL THINNING OF THE MOTOR CORTEX

Schuster CH¹

Kasper E¹

Machts J⁴

Bittner DM⁵

Kaufmann J⁵

Benecke R²

Teipel S^1,3

Vielhaber S^4,5

Prudlo J^2,1

^gGerman center of neurodegenerative diseases, Rostock, Germany

^hDepartment of Neurology, University Hospital Rostock, Rostock, Germany

ⁱDepartment of Psychosomatic Medicine, University of Rostock, Rostock, Germany

^jGerman center of neurodegenerative diseases (DZNE), Magdeburg, Germany

^kUniversity Hospital Magdeburg, Magdeburg, Germany

Email address for correspondence: [email protected]

Keywords: cortical thickness, phenotypes, biomarker

Background and objectives: Amyotrophic lateral sclerosis (ALS) is characterised by degeneration of upper (UMN) and lower motor neurons (LMN). A tool to objectively quantify disease pathology in the brain would serve as both a surrogate endpoint and as a risk marker for future clinical trials. The aim of the present study was to relate clinical variables to cortical thinning of the primary motor cortex (PMC) measured by magnetic resonance imaging (MRI).

Methods: The PMC was defined as region of interest in high-resolution structural MRI scans. We related vertex-wise measures of cortical thinning to UMN involvement, bulbar/limb onset, the total ALS functional rating scale (ALSFRS-R), and its bulbar and upper limb subscore. In total, 93 ALS patients were recruited, 60 classical ALS, 17 with UMN dominant ALS, and 16 with pure LMN dominant ALS variants and compared to 67 age- and gender-matched healthy controls. The analyses were then repeated for the average cortical thickness of the PMC.

Results: Vertex-wise analysis revealed bilateral thinning of bulbar regions of the motor homunculus when UMN signs were found at the brainstem level, and in hand and arm regions when UMN signs were detected at the spinal level. The site of disease onset (bulbar/limb) exhibited the most pronounced thinning in the corresponding part of the motor cortex. UMN dominant ALS patients demonstrated the most distinct thinning followed by classical ALS patients. LMN dominant ALS variants did not differ from healthy controls. Analysing the average thickness confirmed these results. Moreover, the ALSFRS-R score correlated positively with thinning of the left superior PMC and the bulbar subscore with thinning of the bilaterally inferior PMC.

Discussion and conclusion: Focal morphological changes within the PMC correspond to clinically measured impairments and to the disease phenotype. Measuring cortical thickness may offer an objective in vivo marker of upper motor neuron involvement. Longitudinal data may clarify the sequential order of the clinically measurable changes and the morphological alterations in the brain, as described above.

P80 POOLING OF DTI METRICS DERIVED FROM DIFFERENT MR-PROTOCOLS: AN EX POST FACTO METHODOLOGICAL PILOT STUDY IN ALS

Müller H-P

Gorges M

Roßkopf J

Ludolph A C

Kassubek J

University of Ulm, Ulm, Germany

Email address for correspondence: [email protected]

Keywords: diffusion tensor imaging, pooling of data, ex post facto approach

Introduction: Diffusion tensor imaging (DTI)-based metrics are increasingly used for analyzing ALS associated white matter (WM) alterations. The objective of this retrospective study was to analyze if DTI-based metrics derived from different diffusion weighted magnetic resonance (MR) protocols could be pooled in order to obtain large study samples for DTI analysis at the group level in ALS.

Methods: Two-hundred DTI data sets from patients with ALS and controls were collected from the database of the Department of Neurology, University of Ulm. Data were recorded within 8 years between 2005 and 2013. In control data, statistical analysis of fractional anisotropy, mean diffusivity, axial and radial diffusivity was performed in predefined regions of interests (ROIs), prone to be affected in ALS such as corticospinal tracts (CST) and corpus callosum (CC), together with regions that are probably not affected in ALS. Statistical comparison in terms of average FA-values and coefficients of variance (COV) (1) was performed for subgroups of control data that had been acquired by use of different MR-protocols, that is protocols with 13, 31 and 52 gradient directions, respectively. The same statistical methodology was then applied to the corresponding ALS patient subgroups. All analyses were performed by the Tensor Imaging and Fiber Tracking (TIFT) software (2).

Results: The statistical analyses of DTI-based metrics allowed to set up criteria for pooling DTI data that were derived from different MR-protocols. The criteria were based on F-statistics on averaged FA-values as well as on COV. Out of the total number of more than 200 DTI data sets greater than 70 % could be used for pooling and further analyses at the group level.

Conclusion: In summary, the retrospective statistical analysis was able to set up criteria for pooling of data that were recorded with different MR-protocols. The methodology is prone to be applied on the task of pooling multicenter DTI data that usually include differences in MRI protocols due to local scanner-specific conditions.

References:

• Müller HP, Grön G, Sprengelmeyer R, Kassubek J et al. Evaluating multicenter DTI data in Huntington's disease on site specific effects: an ex post facto approach. Neuroimage Clinical 2013;2:161–167.
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• Müller HP, Unrath A, Ludolph AC, Kassubek J. Preservation of diffusion tensor properties during spatial normalization by use of tensor imaging and fibre tracking on a normal brain database. Phys Med Biol 2007;52: N99–109.
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P81 DIFFUSION TENSOR TRACTOGRAPHY ANALYSIS OF THE CORPUS CALLOSAL FIBERS IN AMYOTROPHIC LATERAL SCLEROSIS

Kim J-E¹

Oh JS²

Sung J-J³

Lee K-W³

Song IC⁴

Hong Y-H⁵

^lDepartment of Neurology, Seoul Medical Center, Seoul, Republic of Korea

^mDepartment of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea

ⁿDepartment of Neurology

^oDepartment of Radiology

^pDepartment of Neurology; Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea

Email address for correspondence: [email protected]

Keywords: corpus callosum, diffusion tensor imaging, tractography

Background: Involvement of the corpus callosum (CC) was reported to be a consistent feature of amyotrophic lateral sclerosis (ALS). We examined the CC pathology using diffusion tensor tractography (DTT) analysis to identify the precise fiber bundles involved in ALS patients.

Methods: Diffusion tensor imaging was obtained from 14 sporadic ALS patients, and 16 age-matched, healthy controls. We performed whole brain tractography with multiple-ROI approach, and extracted CC fiber bundles in two different ways based on functional and structural relevance, that is, cortical ROI selection based on Brodmann area (BA), and on the sulcal-gyral pattern of cortical gray matter using FreeSurfer.

Results: The mean fractional anisotropy (FA) value was significantly reduced in ALS patients compared to controls in the callosal fibers interconnecting the primary motor (BA4), supplementary motor (BA6) and dorsolateral prefrontal cortex (BA9/46), but not the primary sensory cortex (BA 1, 2, 3), Broca area (BA 44/45) and orbitofrontal cortex (BA 11/47). The FreeSurfer ROI approach revealed very similar pattern of abnormalities. In addition, mean FA value of the callosal fibers interconnecting the primary motor area showed a significant correlation with disease severity, as assessed by revised Amyotrophic Lateral Sclerosis Functional Rating Scale, and clinical extent of upper motor neuron signs.

Conclusion: Our findings suggest that there may be some degree of selectivity or gradient in the CC pathology in ALS. The CC fibers interconnecting the primary motor and dorsolateral prefrontal cortex may be preferentially involved in ALS.

P82 PATH OF INTEREST-BASED DTI METRICS ANALYSIS ON AFFECTED TRACT STRUCTURES IN THE BRAINS OF ALS PATIENTS

Kassubek J

Müller H-P

Del Tredici K

Brettschneider J

Braak H

Ludolph A C

University of Ulm, Ulm, Germany

Email address for correspondence: [email protected]

Keywords: diffusion tensor imaging, fiber tracking, individual level analysis

Introduction: In many studies, diffusion tensor imaging (DTI) has proven its applicability to identify ALS-associated patterns of brain alterations at the group level by voxel-wise comparison and whole brain-based spatial statistics (1). A different approach is the analysis of brain pathways identified by fiber tracking (FT) techniques (2). The objective of this study was to apply a new methodological FT-based approach to automatically analyze pathways that are prone to be involved in ALS by DTI-based FT.

Methods: From the database of the Department of Neurology, University of Ulmone-hundred and 26 DTI data sets from patients with ALS (N = 83) and controls (N = 53) investigated by the identical DTI acquisition protocol (1.5T) were analyzed using the following procedure. After stereotaxic normalization (under preservation of the intra-voxel directional information) of DTI data, starting seeds and target seeds for the FTs were defined. The structures to be analyzed included the corticospinal tract (CST) and other pathways known to become involved in the course of ALS. Out of all possible paths of the starting seed region, bundles of interest (BOIs) were defined as those paths that ended in the target seed region. The median path in each BOI was defined as path of interest (POI). The mean fractional anisotropy (FA) values underlying the defined BOIs and POIs were used for characterization of the pathway. All analyses were performed by the Tensor Imaging and Fiber Tracking (TIFT) software (3).

Results: The statistical analyses of BOIs and POIs allowed to automatically separate ALS and controls at p < 0.01 for various pathways.

Conclusion: The new technique of automatically defined BOIs and POIs at individual single subject level allows for individual analysis of predefined tract structures in neurodegenerative diseases with predefined affectated WM structures such as ALS.

References:

• Kassubek J, Ludolph AC, Müller HP. Neuroimaging of motor neuron diseases. Ther Adv Neurol Disord 2012; 5:119–27.
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• Müller HP, Unrath A, Sperfeld AD, Ludolph AC, Riecker A, Kassubek J. Diffusion tensor imaging and tractwise fractional anisotropy statistics: quantitative analysis in white matter pathology. Biomed Eng Online 2007;6:42.
   PubMed Web of Science ®Google Scholar
• Müller HP, Unrath A, Ludolph AC, Kassubek J. Preservation of diffusion tensor properties during spatial normalization by use of tensor imaging and fibre tracking on a normal brain database. Phys Med Biol 2007;52: N99–109.
   Web of Science ®Google Scholar

P83 DISSOCIATION OF STRUCTURAL AND FUNCTIONAL MOTOR SYSTEM INTEGRITY ACROSS THE AMYOTROPHIC LATERAL SCLEROSIS – FRONTO-TEMPORAL DEMENTIA CONTINUUM

Bae J¹

Ferguson M¹

Tan R¹

Lam B¹

Menon P³

Mioshi E^1,2

Simon N¹

Burrell JR¹

Vucic S³

Hodges JR^1,2

Kiernan MC^1,2

Hornberger M^1,2

^qNeuroscience Research Australia, Randwick, NSW, Australia

^rUniversity of New South Wales, Randwick, NSW, Australia

^sWestmead Hospital, Sydney, Australia

Email address for correspondence: [email protected]

Keywords: voxel-based morphometry, diffusion tensor imaging, threshold-tracking transcranial magnetic stimulation

Background: There is increasing evidence that amyotrophic lateral sclerosis (ALS) and fronto-temporal dementia (FTD) lie on a disease continuum. While cognitive deficits in ALS are increasingly recognised and shared with FTD, motor system dysfunction in the ALS-FTD continuum has been virtually unexplored.

Objective: To investigate the structural and functional motor system changes across the ALS-FTD continuum.

Methods: Seventy-nine individuals (ALS = 25, bvFTD = 17, controls = 37) participated in this study. Structural changes were assessed using a region of interest imaging approach of voxel-based morphometry (VBM) grey matter motor system regions and their diffusion tensor imaging (DTI) white matter connections. To elucidate the functional motor system changes, we conducted threshold-tracking transcranial magnetic stimulation (TMS) and measured neurophysiological index to measure both upper and lower motor neuron involvement. In a final analysis, we cross-correlated the structural and functional motor system data via covariation analyses. All results are reported at p < 0.05 corrected for family-wise error (FWE) or false discovery rate (FDR) multiple comparison correction.

Results: Structural results showed that in comparison to controls, ALS patients had substantially more white matter changes in corticospinal and motor cortical regions, while grey matter changes were mostly constrained to the cerebellum. BvFTD patients showed substantial grey and white matter changes across virtually all motor system regions, with the exception of the brainstem which was less affected than remaining regions. Direct comparison of ALS and bvFTD showed greater grey and white matter motor system changes in bvFTD compared to ALS, including in the motor cortex. By contrast, the functional motor systems integrity results revealed the opposite picture with ALS being worse affected than bvFTD and both patient groups showing increased excitability of upper motor neuron than controls. Cross-correlation analysis revealed that grey matter in motor cortical and cerebellar regions correlated with the excitability data for ALS, while bvFTD showed mostly supplementary motor and motor cortical areas related to these scores. Similarly, both ALS and bvFTD showed white matter integrity in the motor cortical areas covarying with TMS excitability, but bvFTD showed additionally more corticalspinal tract involvement on the level of the internal capsule while ALS showed corticalspinal involvement on the level of the brainstem.

Discussion: These findings reveal a dissociation of structural and functional motor system integrity across the ALS-FTD continuum, with bvFTD patients showing more structural motor system changes, while ALS having more functional motor system changes. Interestingly, cross-correlation of structural and functional data revealed further a neural dissociation of different motor system regions and tract covarying with the TMS excitability across both patient groups.

Conclusion: These findings suggest that structural and functional motor integrity measures do not converge for both pathologies, which will inform future diagnosis of motor system changes in both diseases.

Acknowledgements:

MNDRIA, ARC and NHMRC

P84 CORPUS CALLOSUM INVOLVEMENT IN AMYOTROPHIC LATERAL SCLEROSIS: A PROBABILISTIC TRACTOGRAPHY STUDY USING Q-BALL IMAGING

Trojsi F^1,2

Corbo D^2,3

Caiazzo G^2,3

Piccirillo G^1,2

Esposito F^2,4

Monsurrò MR^1,2

Tedeschi G^1,2

^tDepartment of Medical, Surgical, Neurological, Metabolic and Aging Sciences, Second University of Naples, Naples, Italy

^uMRI Research Center SUN-FISM – Second University of Naples, Naples, Italy

^vNeurological Institute for Diagnosis and Care “Hermitage Capodimonte”, Naples, Italy

^wDepartment of Medicine and Surgery, University of Salerno, Baronissi, Italy

Email address for correspondence: [email protected]

Keywords: fiber tracking, corpus callosum, q-ball imaging

Background: Diffusion tensor imaging (DTI)-based tractography has become a useful tool to investigate early corticospinal tract (CST) damage in amyotrophic lateral sclerosis (ALS). However, DTI model has shown some shortcomings in resolving individual fiber orientations within voxels containing fibers with more than one orientation. To overcome this limitation, fiber tracking packages that apply multi-tensorial algorithms, such as Q-ball imaging (QBI), have been proposed as effective alternative approaches.

Objectives: We explored WM tract abnormalities in phenotypically heterogeneous ALS cases aiming to establish a consistent WM signature of disease using QBI tracking algorithm.

Methods: Probabilistic tractography analysis was performed in 20 ALS patients (10 men and 10 women) and 20 age and sex-matched healthy controls. Diffusion-weighted datasets were loaded into QBI model using Diffusion Toolkit, a tool of Trackvis software package. Corpus callosum (CC) and CSTs were segmented in regions of interest (ROIs); genu, body and splenium for CC, and superior and inferior tracts for CSTs, from which WM tracts length (tl), fiber volume and density, and generalized fractional anisotropy (GFA) were extracted. Tractography parameters were correlated with clinical indices of pyramidal impairment (Upper Motor Neuron score), disease disability (ALS Functional Rating Scale-Revised) and progression (48-ALSFRS-R/months of disease duration).

Results: In ALS patients compared to controls, fiber density and volume were found significantly decreased, and tl significantly increased in all ROIs (p < 0.05, corrected). With regard to correlation analysis with clinical indices, in the body of CC pyramidal impairment was inversely related to fiber density (p = 0.01) and tl (p = 0.05). In the splenium of CC, clinical disability (p = 0.013) and disease progression rate (p = 0.02) were inversely related to tl. In the superior tracts of left CST disease progression rate was inversely related to fiber density (p = 0.01).

Discussion and conclusion: Callosal involvement confirms to be a consistent feature of ALS pathology, significantly related to both upper motor neuron dysfunction and clinical disability. Specifically, structural damage of CC body might reflect pyramidal dysfunction, while structural changes of CC splenium may be associated with the grade of disease disability and progression. These findings indicate bilateral cortical impairment with an inter-hemispheric spread of the degenerative process. Moreover, the role of the increased fiber length observed in ALS patients might be attributable to compensatory mechanisms in response to impaired motor skills. This intriguing clue may provide further value to the hypothesis of structural brain plasticity triggered by the neurodegenerative process in ALS.

P85 RESTING STATE FUNCTIONAL CONNECTIVITY ALTERATIONS IN PRIMARY LATERAL SCLEROSIS

Agosta F¹

Canu E¹

Inuggi A¹

Chiò A²

Riva N¹

Silani V³

Falini A¹

Comi G¹

Filippi M¹

^xSan Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy

^yUniversity of Torino, Torino, Italy

^zUniversity of Milano, Milan, Italy

Email address for correspondence: [email protected]

Keywords: primary lateral sclerosis, resting state fMRI, tractography

Background: Like amyotrophic lateral sclerosis (ALS), primary lateral sclerosis (PLS) is a clinical diagnosis without established biomarkers. Analysis of resting state (RS) functional MRI (fMRI) reveals the temporal correlation between the low-frequency spontaneous fluctuations in the resting brain. These form functionally distinct networks that are related to specific sensory, motor, and cognitive brain functions. RS fMRI alterations have been observed in ALS patients.

Objective: To investigate RS functional connectivity of the sensorimotor and extramotor brain networks in patients with PLS, and to explore whether the RS functional connectivity alterations are related to patient clinical and cognitive status, and white matter (WM) tract damage.

Methods: RS functional MRI and diffusion tensor (DT) MRI were obtained from 24 PLS patients and 26 healthy controls. RS functional MRI was analyzed using independent component analysis and dual-regression technique. Using probabilistic tractography, the corticospinal tracts, corpus callosum (genu, body, splenium, and motor callosal fibers) and superior longitudinal fasciculi were obtained and tract mean FA values were calculated.

Results: Compared with controls, PLS patients showed an increased functional connectivity within the sensorimotor, frontal and left frontoparietal networks spanning the pre- and postcentral, medial and dorsal frontal, insular and superior temporal regions. Patients with more severe physical disability and more rapid rate of disease progression presented higher sensorimotor connectivity values. The increased functional connectivity within the frontal network was associated with executive dysfunction. In addition, where the functional connectivity values were higher, greater was the structural damage to network-specific WM tracts.

Conclusions: This study shows clinically meaningful increased RS functional connectivity in PLS. Our findings raise the possibility that functional connectivity increases have a direct link with the pathogenesis of the disease.

Acknowledgements:

This study was partially supported by a grant from the Italian Ministry of Health (Grant #RF-2010-2313220).

P86 EXTRAMOTOR PATHOLOGY IS ASSOCIATED WITH COGNITIVE DEFICITS IN PRIMARY LATERAL SCLEROSIS PATIENTS

Canu E¹

Agosta F¹

Galantucci S¹

Riva N¹

Chiò A²

Messina S³

Iannaccone S¹

Calvo A²

Silani V³

Copetti M⁴

Falini A¹

Comi G¹

Filippi M¹

^aaSan Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy

^abUniversity of Torino, Torino, Italy

^acUniversity of Milano, Milano, Italy

^adIRCCS-Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy

Email address for correspondence: [email protected]

Keywords: primary lateral sclerosis, cognition, diffusion tensor MRI

Background: In early studies cognition was reported to be normal in primary lateral sclerosis (PLS). More recently, frontal lobe dysfunction syndrome in some PLS patients has been reported. Diffusion tensor (DT) MRI is currently unrivalled as a neuroimaging marker of upper motor neuron involvement and has the potential to provide an objective in vivo assessment of the extra-motor brain damage in motor neuron diseases.

Objective: The aim of this study was to determine the patterns of WM damage in PLS patients with cognitive impairment (PLS-ci) and those that are cognitively unimpaired (PLS-cu).

Methods: DT MRI scans were obtained from 26 PLS patients and 35 healthy controls (HC). All PLS patients underwent a neuropsychological battery of tests. The WM integrity was assessed using tract-based spatial statistics (TBSS) and the diffusion mean values were extracted from motor and extra-motor WM tracts using probabilistic tractography.

Results: Ten PLS patients had abnormal scores in at least one neuropsychological test and were considered PLS-ci. Compared with HC, both groups of patients had a pattern of WM alterations in the corticospinal tract and body of the corpus callosum. Furthermore, compared with HC, PLS-ci patients showed an extra-motor damage involving the bilateral superior and inferior longitudinal fasciculi. The diffusion mean values of the extra-motor tracts were found to be altered in PLSci patients compared with both HC and PLS-cu groups.

Conclusions: This is the first study evaluating the relationship between cognitive performance and WM tract damage in PLS patients. PLS patients with abnormal cognition experience more extensive WM alterations than those with a preserved cognitive status. These results contribute to a better understanding and characterization of extra-motor clinical manifestations in motor neuron diseases.

Acknowledgements:

This study was partially supported by a grant from the Italian Ministry of Health (Grant #RF-2010-2313220).

P87 CORTICAL MOTOR REPRESENTATION MAPPING BY NAVIGATED TRANSCRANIAL MAGNETIC STIMULATION and VOXEL-BASED MORPHOMETRY. WHAT IS CLOSER TO THE TRUTH?

Chervyakov A¹

Bakulin I²

Bryukhov V¹

Konovalov R¹

Savitskaya N¹

Poydashevaa¹

Arkhipov I²

Gavrilov A²

Zakharova M¹

Piradov M¹

^aeResearch Center of Neurology, Russian Academy of Medical Science, Moscow, Russia

^afM.V. Lomonosov Moscow State University, Moscow, Russia

Email address for correspondence: [email protected]

Keywords: transcranial magnetic stimulation, voxel-based morphometry, brain mapping

Background: Navigated transcranial magnetic stimulation (nTMS) is a technique for the diagnosis of upper motor neuron function in ALS and in vivo motor areas of brain mapping. Another in vivo technique for gray matter atrophy detection is voxel-based morphometry (VBM). Both methods reflect the state of the gray matter: structurally (VBM), functionally (nTMS).

Objectives: To compare cortical motor areas and volume of gray matter measured by VBM.

Methods: The study involved 31 ALS patients (mean age 54.6 ± 12.2 years, ranging from 31 to 88 years old) and 24 healthy volunteers (mean age 39.5 ± 13.48 years). All respondents were right-handed. For ALS patients the median time from onset to inclusion in the study was 12 months. The patients’ neurological status was evaluated using the revised ALS Functional Rating Scale (ALSFRS-R). The region of onset was bulbar in 12 patients, lower limb in 11 patients and upper limb in seven patients. Navigated TMS (NBS eXimia Nexstim) investigations including measurement of resting motor threshold and area maps size of m. abductor pollicis brevis (APB) cortical representation were performed for all participants. VBM was performed on ALS patients using 1.5 T Siemens Magnetom Avanto (3D T1 MPRAGE) and SPM8 on MATLAB platform for post processing statistical analysis.

Results: We find a significant difference between sizes of the cortical maps in ALS patients and healthy volunteers (p = 0,001, U-test). The volume of cortical motor maps of APB in healthy volunteers was equal to 83 (64, 102) mm³ for the left hemisphere and 72 (48, 118) mm³ for the right. In ALS patients, map volume was equal to – 37 [(2, 60) mm³ and 28 (6, 50) mm³, respectively. Individual maps obtained for ALS patients were located in the anterior central gyrus, posterior central gyrus and the premotor cortex region. In several ALS patients (with recent ALS onset or relatively benign course), we observed broadening of individual cortical representations: motor evoked potentials were registered in response to stimulation of the frontal and temporal parasagittal regions. There were significant correlations between the ALSFRS-R and the strength of the contralateral APB with the map size in both right and left hemispheres. The inverse correlation between the map size and the motor threshold was also significant (p < 0.001).The area maps are not dependent on disease duration and site of onset. There was a significant correlation between the map size and precentral gyrus VBM volume in left but not in right hemisphere (p = 0.02 and p = 0.3, respectively).

Conclusions: nTMS and VBM are methods which both describe the condition of cortical motor neurons. The combination of these two techniques in future research could help in the study of neurodegeneration pathogenesis, diagnosis and prognosis.

P88 NEAR-INFRARED SPECTROSCOPY-BASED RESTING STATE ANALYSIS REVEALS ALTERED FUNCTIONAL CONNECTIVITY IN ALS-PATIENTS WITH AND WITHOUT COGNITIVE IMPAIRMENT

Veit M¹

Machts J¹

Abdulla S^1,2

Kollewe K³

Petri S³

Dengler R³

Heinze HJ²

Vielhaber S^1,2

Kopitzki K²

^agGerman Centre for Neurodegenerative Diseases, Magdeburg, Germany

^ahDepartment of Neurology, Otto-von-Guericke-University, Magdeburg, Germany

^aiDepartment of Neurology, Hannover Medical School, Hannover, Germany

Email address for correspondence: [email protected]

Keywords: cognition, resting state fMRI, near infrared spectroscopy

Background: Extramotor involvement, especially evidenced by executive dysfunction, has been demonstrated in ALS-patients repeatedly (1,2). fMRI-based resting state analyses revealed altered activation in functional networks for ALS-patients, specifically in sensorimotor and default mode networks (3). The latter have been assumed to be associated with cognitive impairment, but have not yet been investigated using near-infrared spectroscopy (NIRS) during the resting state.

Objectives: This study aims to investigate alterations in functional connectivity (FC) in ALS via resting state NIRS-based upon patients’ cognitive performance.

Methods: Using a NIRS system consisting of 16 measurement channels, positioned over bilateral prefrontal, temporal and occipital regions, resting state NIRS data were obtained, allowing measurement of homologous and fronto-posterior FC. During measurement participants lay down for 15–20 minutes, keeping their eyes closed in a darkened room. This was done for 33 ALS-patients and 30 age-matched healthy controls (HC). Patients performed a neuropsychological battery of tests comprising Auditory Verbal Learning Test, Complex Figure Test, Digit Span, Trail Making Test, Category fluency and Phonemic verbal fluency, and Stroop Test. They were assigned to groups of pure ALS, executive impaired ALS (ALS-Ex) and non-executive impaired ALS (ALS-NECI) according to the classification suggested by Phukan et al. (2). Data were analysed applying random permutation statistics to identify channel pairs revealing modulations in averaged coherence values in the low frequency (0.06–0.08 Hz) and very low frequency (0.009–0.02 Hz) bands.

Results: Homologous and fronto-posterior connectivity were reduced in ALS-patients compared to HC, as indicated by reduced averaged coherence values for low frequency bands. Comparisons among ALS subgroups revealed that ALS-Ex patients showed generally increased homologous and fronto-posterior connectivity compared to ALS patients without executive impairment (ALS-NECI). Non-executive cognitive impaired ALS patients showed reduced FC between right and left motor cortex.

Discussion and conclusion: These results suggest that ALS is associated with an alteration of functional brain networks, showing patterns of both decreased and increased FC. Those effects are in line with previous studies that used task fMRI (4) or resting state fMRI (3, 5). Increased FC in the ALS Ex group could be an indicator for neuronal compensation or decreased intracortical inhibition, a phenomenon observed previously in sensorimotor areas in ALS. Decreased connectivity between motor cortices in ALS-NECI could be related with patient motor disability but has to be proven further.

Therefore, we consider that resting state NIRS could be used as an economic and sensitive tool to reflect functional changes of cognitive impairment.

References:

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P89 FRACTIONAL ANISOTROPY LOSS IN ALS EVOLVES AS A FUNCTION OF DISEASE SEVERITY BUT LIMB- AND BULBAR-ONSET DIFFER QUANTITATIVELY WHEN MATCHED FOR SEVERITY STAGE

Cardenas-Blanco A¹

Machts J¹

Acosta-Cabronero J¹

Abdulla S^2,1

Kollewe K³

Petri S³

Dengler R³

Heinze HJ^2,4

Vielhaber S^2,1

Nestor P¹

^ajGerman Center for Neurodegenerative Diseases, Magdeburg, Germany

^akDepartment of Neurology, Otto-von-Guericke University, Magdeburg, Germany

^alDepartment of Neurology, Hannover Medical School, Hannover, Germany

^amLeibniz Institute for Neurobiology, Magdeburg, Germany

Email address for correspondence: [email protected]

Keywords: DTI, fractional anisotropy, imaging

Background: Diffusion tensor MRI studies in Amyotrophic Lateral Sclerosis (ALS) have become popular but the method’s true biological worth remains unclear. Studies are somewhat confounded by small, often heterogeneous, groups and inconsistent methodology.

Objective: To understand the evolution of fractional anisotropy (FA) changes in a substantial ALS cohort using a standardized methodology.

Method: N = 45 cases with ‘classic’ ALS participated in this study; those with dementia, flail limb, or PLS were excluded to maximize clinical homogeneity. Patients and age-matched controls (n = 29) were scanned on a 3T scanner; diffusion data were analyzed using Tract-Based Spatial Statistics focusing exclusively on FA. First, cases were stratified into three sub-groups according to the ALS functional rating scale (1) (ALSFRS-R; mild/moderate/severe: n = 16/15/14; range = 46–43/ 42-36/35-22) to test whether FA reliably tracks clinical severity. The results led to a hypothesis that bulbar-onset (ALS-b) behaves differently in terms of FA perturbation and ALSFRS-R score compared to limb-onset (ALS-l). This was tested by stratifying only the ALS-l cases into mild and advanced groups (n = 13/group) and by contrasting ALS-b and ALS-l groups that were strictly matched for power (n = 14/group) and ALSFRS-R score (mean/range): ALS-b = 39.9/29–46, ALS-l = 39.2/27–46, p = 0.6.

Results: The initial stratification by ALSFRS-R score found that the most severe sub-group had the most severe FA reduction (involving corticospinal tracts and body of corpus callosum). The mild and moderate sub-groups showed less severe FA reduction with FA loss worse in the mild compared to the moderate group. Analyzing those with ALS-l only showed clear progression of FA loss from mild to severe. Matched for ALSFRS-R and power, ALS-b showed far worse FA reduction compared to ALS-l even though the ALS-b group had shorter symptom duration (mean months/range = 18/4-50 versus 31/7-81). There were no qualitative differences in lesion distribution for any analyses, only lesion severity varied.

Discussion: The most advanced sub-group in the first analysis had the greatest FA reductions, but paradoxically, FA reductions were worse in the mild compared to the moderate sub-group. Although this could have potentially indicated that the ALSFRS-R lacked construct-validity or that FA changes follow a non-linear evolution, the data suggested a more plausible, third possibility in which an over-representation of ALS-b drove the effect in the mild stratum. This hypothesis was confirmed by comparing ALS-b and precisely matched ALS-l sub-groups. Stratifying ALS-l revealed clear progression of FA loss with advancing disease.

Conclusion: FA has strong potential as a severity biomarker in ALS. There is a critical confound, however, regarding ALS-l versus ALS-b that must be considered in cross-sectional studies. ALS-b appears to be a truly more aggressive variant when FA loss and symptom duration are considered but effects the same regions as ALS-l.

Reference:

• Cedarbaum J, Stambler N, Malta E et al. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. J. Neurol. Sci. 1999; 169 (1–2);13–21.
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P90 ORIGIN OF FASCICULATIONS IN ALS AND BENIGN FASCICULATION SYNDROME

De Carvalho M^1,2

Swash M^2,3

^anDepartment of Neurosciences, Hospital de Santa Maria, Lisbon, Portugal

^aoTranslational Clinical Neurophysiology Unit, Instituto de Medicina Molecular and Institute of Physiology, Faculty of Medicine, University of Lisbon, Lisbon, Portugal

^apDepartments of Neurology and Neuroscience, Royal London Hospital, Queen Mary University of London, London, UK

Email address for correspondence: [email protected]

Keywords: benign fasciculations, fasciculation potentials, electromyography

Background: The site of origin of the fasciculation potentials (FPs) in ALS and other disorders has proven difficult to determine. Most evidence favors distal origin, but central origin cannot be discarded. The origin of benign FPs (BFPs) has not been investigated.

Objectives: We aimed to study the origin of FPs in ALS and in subjects with benign FPs with a novel approach.

Methods: We studied 52 ALS patients, mean age 59.6 ± 10.1 years, means disease duration 11.1 ± 5.7 months, referred for diagnostic testing. All had one tibialis anterior (TA) of normal strength. We studied 11 patients with BFPs, mean age 58.5 ± 11.7 years. These patients had normal motor unit potential (MUP) analysis and no progression to other disorders. We classified the TA muscles in the ALS patients as with or without neurogenic change, according to MUP analysis. Recordings were made from two adjacent sites in the TA muscle using two concentric needle electrodes placed at least 1cm apart perpendicular to the vertical axis of the muscle. The peroneal nerve was stimulated at low intensity at the fibular head to confirm that the two electrodes were recording from MUs innervated by different axons. Between 6 and 8 pairs of recording sites were used in each subject. We quantified the number of FPs recorded in time-locked fashion at both of the two sites in each recording.

Results: Thirty-two ALS patients showed neurogenic change in the TA muscle. In these patients, 1096 FPs were recorded; 941 (85.7%) of these were recorded from only one of the recording site – the remaining 155 (14.3%) were recorded time-locked. Twenty ALS patients had TA muscles with normal MUPs, 544 FPs were recorded, 394 (72.7%) were recorded from only one site and 150 (27.3%) were recorded time-locked from both sites. In the 11 subjects with BFPs, 234 FPs were recorded; 129 (55.1%) FPs from only one electrode; 105 (44.9%) from the two sites. The probability of recording time-locked FPs was greater in the BFPs group than in the two groups of ALS patients (p < 0.0001, chi-square test). The probability of time-locked FPs in the two recording sites was significantly greater in the ALS group without neurogenic changes than in ALS with neurogenic changes (p < 0.0001, chi-square test).

Discussion and conclusion: Our results show that time-locked FPs recorded from two MUs innervated by different axons in a muscle, are more common in benign fasciculation than in ALS. In addition, in ALS, time-locked FPs were more common in TA muscles not yet involved by denervation and reinnervation than in muscles in which there was chronic partial denervation. We conclude that the origin of FPs changes over disease progression in ALS.

P91 SYMPTOM SPREAD IN PRIMARY LATERAL SCLEROSIS IS CONSISTENT WITH PATHOLOGY THAT SPREADS THROUGH AXONAL PATHWAYS AND TO CONTIGUOUS BRAIN REGIONS

Flynn L

Stephen M

Floeter MK

NINDS, NIH, Bethesda, Md, USA

Email address for correspondence: [email protected]

Keywords: primary lateral sclerosis, symptom progression, chart review

Background: Two opposing theories have been proposed to explain how disease spreads in motor neuron disease as symptoms progress from one body region to another. One proposes that degeneration occurs in CNS areas with axonal connections, while the other proposes a prion-like spreading of misfolded proteins. The sequence of symptom progression in primary lateral sclerosis, which selectively affects upper motor neurons, can test these proposals. Local spreading of misfolded proteins should produce symptoms in contiguous somatotopic areas of the motor strip, whereas spread through network connections would involve spread to non-contiguous areas, for example, via the corpus callosum.

Objectives: To determine whether the spread of clinical symptoms is consistent with spread to contiguous areas or through axonal connections in PLS.

Methods: Charts of 45 patients followed at NIH for a clinical diagnosis of PLS were reviewed. Each instance of symptom onset in an additional body region was categorized as consistent with contiguous spread, through axonal connections, possibly contiguous, or unrelated/undetermined.

Results: In the 45 patients, there were 152 instances where symptoms progressed to additional body regions. One hundred and sixteen instances could be classified as axonal or contiguous spread according to a set of classification rules. Seventy-seven instances were consistent with contiguous spread, and 39 were consistent with axonal spread. The first instance of symptom spread was approximately equally divided between instances classified as contiguous or axonal. Symptoms began in a lower extremity in 37 patients; in 22 of these patients, the next symptoms involved the other leg, which we classified as axonal spread. However, in some patients the arm ipsilateral to the first leg became symptomatic about the same time as the contralateral leg, and that spread was classified as contiguous. Following the initial instance, subsequent instances of symptom progression were predominantly classified as contiguous. There was no difference between the average time for instances of axonal and contiguous spread (2.17 ± 1.8 vs. 2.42 ± 1.77 years, respectively).

Discussion: Symptom spread in PLS is consistent with a mixture of pathology that spreads through axonal pathways and contiguous brain regions. The predominance of axonal spread early in the disease course is partly due to the common occurrence of symptoms in one leg followed by the other. Later in the course of the disease, instances classified as contiguous spread were more prevalent, although the average interval for symptom spread was the same for axonal and contiguous instances.

Conclusions: In PLS, symptom spread from one body region to another is consistent with a mixture of spread through axonal pathways, especially early in the disease, and local spread to adjacent cortical regions, particularly later in the course of the disease.

P92 ALTERED GLOBAL AND LOCAL RESTING STATE BEHAVIOUR IN AMYOTROPHIC LATERAL SCLEROSIS AT BASELINE AND DISEASE PROGRESSION

Machts J¹

Zhang B⁶

Kaufmann J³

Kasper E²

Schuster CH²

Prudlo J²

Veit M¹

Abdulla S^1,3

Kollewe K⁴

Petri S⁴

Dengler R⁴

Heinze H-J^3,5

Vielhaber S^3,1

Walter M^6,5

^aqGerman Center for Neurodegenerative Diseases, Magdeburg, Germany

^arGerman Center for Neurodegenerative Diseases, Rostock, Germany

^asDepartment of Neurology

^atDepartment of Psychiatry ,Otto-von-Guericke University, Magdeburg, Germany

^auDepartment of Neurology, Hannover Medical School, Hannover, Germany

^avLeibniz Institute of Neurobiology, Magdeburg, Germany

Email address for correspondence: [email protected]

Keywords: MRI, resting state fMRI, disease progression

Background: ALS is primarily characterized by degeneration of neurons in the motor cortex (M1). Task motor fMRI studies suggested a cortical reorganization, where activity of sensorimotor network regions (4) was enhanced but decayed with increasing weakness (3). So far, there is no investigation on resting state behaviour in the course of the disease.

Objectives: This study aimed to investigate functional connectivity (FC) and spontaneous fluctuations via resting state MRI measures in the progression of the disease.

Methods: Eighty-one ALS-Patients and 68 controls (HC) underwent a resting state scan (3T). FC for regions of interest of the left and right M1 and fractional amplitude of low-frequency fluctuation (fALFF) (5) were calculated voxelwise for patients and HC, and correlated with ALSFRS-R scores in patients. After 3–6 months, 42 patients were measured again and maps for FC and fALFF were compared to baseline. Significant clusters were corrected for multiple comparisons (p < 0.05).

Results: ALS patients showed significantly higher FC seeded from right M1 with the ipsilateral and contralateral precentral gyrus and supplemental motor area (SMA) in comparison to HC. Decreased FC from right M1 with the default mode network was observed for ALS patients compared to HC. FC of both M1 towards contralateral precentral gyri correlated positively with patients’ disease severity as well as fALFF in left and right premotor cortex. There was an inverse correlation between patient ALSFRS-R score and fALFF in the cerebellum. Longitudinal decreases of FC of M1 were found towards ipsilateral SMA and contralateral precentral gyrus while fALFF decreased in the left precentral gyrus at follow-up.

Discussion and conclusion: We demonstrate that alterations of motor FC in ALS coincide with altered local fluctuation amplitudes in M1 and the cerebellum in dependence of the clinical severity. Such network alterations are in accordance to previous studies that used resting state fMRI (1,2), considering therefore rsfMRI as a useful biomarker for disease severity and progression.

References:

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P93 DISTAL ULNAR AND MEDIAN NERVE APPEARANCE IN ALS PATIENTS WITH DIFFERENT PHENOTYPES – A PROSPECTIVE ULTRASOUND STUDY

Schreiber S^1,2

Abdulla S¹

Debska-Vielhaber G¹

Machts J²

Feistner H¹

Galazky I¹

Oldag A¹

Goertler M¹

Petri S³

Kollewe K³

Kropf S¹

Heinze HJ^1,2

Dengler R³

Vielhaber S^1,2

^awOtto-von-Guericke University, Magdeburg, Germany

^axGerman Center for Neurodegenerative Diseases (DZNE) within the Helmholtz Association, Magdeburg, Germany

^ayClinic for Neurology, Hannover Medical School, Hannover, Germany

Email address for correspondence: [email protected]

Keywords: high-resolution ultrasound, PLS, ulnar nerve

Background: Amyotrophic lateral sclerosis (ALS) is characterized by a progressive axonal degeneration of the upper and lower motor neurons. In primary axonal neuropathies high-resolution ultrasound revealed increased cross-sectional areas (CSA) and fascicle diameters (FD) of peripheral nerves. Indeed, considering ALS and its clinical phenotypes, the sonographic nerve appearance and the diagnostic value of high-resolution ultrasound have not been determined so far.

Methods: CSA and FD of the median and ulnar nerves at the forearm and wrist were investigated sonographically (12-MHz-probe) in 68 patients with ALS (bulbar phenotype n = 15, classic subtype n = 19, lower motor neuron disease variant (LMND) n = 19, upper motor neuron disease variant (UMND) n = 15), in six patients with primary lateral sclerosis (PLS) and in 18 matched healthy controls. All patients obtained electrophysiological measurements of the median and ulnar nerves.

Results: Patients and controls with carpal and/or cubital tunnel syndromes were excluded from statistical analyses. Compared to the healthy volunteers all ALS patients exhibited significant reductions of the ulnar nerve CSA at their forearm and wrist which was applying to all investigated phenotypes. Contrary, in the PLS group the ulnar nerve CSA did not differ from those values detected in the controls. There were no differences of the median nerve CSA as well as of the median and ulnar nerves’ FD between the ALS phenotypes, PLS and control groups. Preliminary analyses revealed an inverse association between age, duration of illness and ulnar CSA in ALS. Concomitantly, corresponding to their ulnar pathology detected by high-resolution ultrasound, about 40% of all ALS patients exhibited increased ulnar distal motor latencies and in about 20% reduced motor action potential amplitudes were detected.

Conclusions: All ALS phenotypes apart from PLS exhibit a relatively uniform sonographical appearance predominantly of the distal ulnar nerve potentially facilitating an easier clinical discrimination between, for example, the UMN-dominant variant of ALS and PLS, a spastic syndrome of slow progression.

P94 A RETROSPECTIVE STUDY OF ELECTROMYOGRAPHY OF THE TRAPEZIUS MUSCLE AT TIME OF DIAGNOSIS AS A PREDICTOR OF EARLY RESPIRATORY IMPAIRMENT IN ALS PATIENTS

Hegedus J

White C

Korngut L

University of Calgary, Calgary, Alberta, Canada

Email address for correspondence: [email protected]

Keywords: EMG, respiration, prognostication

Background: In ALS, death is usually secondary to respiratory failure (1, 2). Recent studies have shown that decreased motor responses of the phrenic nerve are important prognostic factors for respiratory failure (3) but phrenic testing is not routinely performed and is technically difficult. Tests which are easier to administer and more tolerable to patients may be more useful in at the early identification of those at risk of early respiratory failure (4).

Objective: To examine for an association between the presence of active denervation on electromyography (EMG) of the trapezius muscle and reduced respiratory function in newly diagnosed patients with ALS.

Methods: This study is a retrospective chart review. The charts of all deceased patients the Calgary ALS and Motor Neuron Disease Clinic from 2006–2010 were considered for this study.

Patients who had been diagnosed as having clinically definite; clinically probable; clinically probable (laboratory-supported); clinically possible; clinically suspected ALS according to the El-Escorial diagnostic criteria for ALS were eligible for the study. Patients having both EMG studies of the trapezius and forced vital capacity (FVC) testing upon presentation were included. The proportion of patients with trapezius denervation who had reduced FVC (less than 90% of predicted) was calculated. FVC at the last clinic visit was also recorded, allowing the calculation of rate of change in FVC over during the period of active disease.

Results: We reviewed 197 deceased ALS patient charts and identified 42 reporting electromyography of the trapezius muscle. Signs of denervation were observed in 19/42 (45.2%) of as evidenced by the presence of fibrillations or positive sharp waves. Reduced FVC was observed in 28/42 (66.7%) at presentation. Patients with active denervation of the trapezius muscle at time of presentation were not more likely to demonstrate reduced FVC at presentation but had a statistically greater rate of FVC decline then those without denervation (p = 0.0078).

Discussion and conclusion: There is evidence of denervation in the trapezius muscle upon first presentation with ALS in a significant proportion of the patients. The correlation between trapezius denervation and increased rate of FVC decline may prove to be a good predictor of future respiratory compromise in ALS.

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P95 DECREASED PLASMA LEVELS OF FIBRONECTIN IN AMYOTROPHIC LATERAL SCLEROSIS

Oketa Y

Mikami H

Watanabe T

Suzuki M

Ono S

Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan

Email address for correspondence: [email protected]

Keywords: fibronectin, plasma

Background: Fibronectin (FN) is a large glycoprotein (440 kDa) present in many tissues and in most body fluids. Important properties of FN include its ability to bind to the cell surface and the fact that it has other binding sites to recognize the collagen molecules and other connective components. In this way, FN is believed to be involved in the interaction of cells with the extracellular matrix, and thus influence both morphologic properties and differentiation. Recent investigations have shown that increased levels of serum type III procollagen and serum hyaluronic acid, and decreased levels of serum 7S collagen are associated with amyotrophic lateral sclerosis (ALS). All of these factors are known to be involved in the metabolism of connective tissues. However, there have been no published studies of plasma FN in ALS.

Objectives: To study plasma levels of FN in ALS.

Methods: Our subjects were 28 patients with ALS, 18 control subjects with other neurological diseases (control group A) and 21 healthy adults (control group B). Plasma FN concentration was determined by turbidimetric immunoassay. FN was reacted with monospecific antibody in aqueous solution. The immunocomplexes which were formed caused some turbidity. Turbidity was found to be linearly dependent on FN concentration up to an absorbance reading of 200/cm at 340 nm.

Results: In ALS patients and control groups A and B serum levels of FN were 186.6 ± 93.3 μg/dl, 271.7 ± 122.6 μg/dl, and 325.7 ± 114.4 μg/dl, respectively. Serum FN levels were significantly lower (p < 0.02 and p < 0.001, respectively) in ALS patients than in control groups A and B. There was no marked difference (0.1 < p < 0. 5) in serum levels of FN between control groups A and B. There was a significant negative correlation (r = − 0.70, p < 0.001) between serum FN levels and duration of illness in ALS patients, but there was no such correlation in control group A. No relationship was found between concentrations of serum FN and dysphasia, muscle power, and severity of disability in ALS patients or control group A.

Discussion and conclusion: The low values of plasma FN in ALS patients may be accounted for by increased catabolism of FN mediated by the presence of altered homeostasis. The postulated causes of the decreased plasma FN levels include altered turnover, increased consumption, altered tissue distribution, and decreased production of this substance, and there is as yet no consensus on this subject. As indicated above, decreased plasma FN levels may be related to the pathogenesis of ALS. The measurement of plasma FN may be useful as a supplementary and noninvasive test in the diagnosis of ALS.

P96 PLASMA NEUROFILAMENTS AS A BIOMARKER OF DISEASE PROGRESSION IN ALS: INSIGHTS FROM LONGITUDINAL STUDIES IN MICE AND MAN

Lu C^1,2

Petzold A³

Topping J¹

Allen K⁴

Fish M⁵

Orrell R^6,7

Howard R⁶

Greensmith L²

Malaspina A^1,8

^azCentre for Neuroscience & Trauma, Blizard Institute, QMUL, London, UK

^baSobell Department

^bbDepartment of Neuroinflammation

^bcBasildon and Thurrock University Hospitals, Basildon, Essex, UK

^bdClinical Trials Unit, Musgrove Park Hospital, Taunton, Somerset, UK

^beNational Hospital for Neurology and Neurosurgery, London, UK

^bfDepartment of Clinical Neuroscience, UCL Institute of Neurology, London, UK

^bgNorth-East London and Essex MND Care and Research Centre, London, UK

Email address for correspondence: [email protected]

Keywords: neurofilament heavy chain, biomarker, disease progression

Background: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder for which there is no effective treatment. Clinical trials in ALS are hindered by the lack of reliable biomarkers to enable an early diagnosis and monitoring of disease progression. There is therefore an urgent need to develop biomarkers for ALS.

Objectives: To determine whether plasma neurofilament heavy chain (NfH) levels are a biomarker of disease progression in mouse models and ALS patients.

Methods: Blood was drawn from SOD1^G93A mice at various disease stages, when neuromuscular function and motor neuron survival were also assessed. ALS patients (n = 136) were evaluated in clinic and blood samples taken every 3 months. Disease progression was evaluated using the ALS Functional Rating Scale_Revised (ALSFRS_R). Controls include healthy controls and neurological disease controls (n = 104). Plasma NfH levels were determined using an in-house ELISA method. A cross-sectional study of NfH levels at baseline sampling as well as a longitudinal study of serial samples from ALS patients was undertaken.

Results: In SOD1^G93A mice, we observed a significant increase in plasma NfH levels as disease progressed, which correlated with the decrease in functional and morphological read-outs of disease. In contrast, in a cross-sectional study of 136 clinically heterogeneous ALS patients and 104 controls, we found comparable levels of plasma NfH levels. Longitudinal analysis of plasma NfH levels showed that patients with a shorter diagnostic latency and disease duration progressed faster and had higher plasma NfH levels during the early stages of the disease which declined later on with disease progression. Paradoxically, low levels of plasma NfH correlated with a poor prognosis. Importantly, in our large heterogeneous ALS cohort, we found that changes in plasma NfH levels did not predict disease progression. Contrary to expectations, plasma NfH levels do not always increase as disease progresses in ALS patients, possibly as a result of NfH aggregate formation and cleavage. Initial analyses reveal the presence of auto-antibodies to NfH in ALS patient plasma, suggesting that the immune response may influence measurement of plasma NfH.

Discussion: Our results shown that plasma NfH levels are a good biomarker of disease progression in SOD1^G93A mice, which exhibit a well characterised, aggressive disease phenotype. However, in clinically heterogeneous ALS patients, changes in plasma NfH levels during disease progression are more complex. Our data suggest that the asymptomatic phase of ALS and the delay to diagnosis or to baseline sampling have a significant impact on NfH measurements performed in the symptomatic phase of the disease of ALS individuals.

Conclusions: The diagnostic delay from disease onset to diagnosis has a significant and confounding impact on the analysis of plasma-based biomarkers for ALS, including NfH as well as other pathologically relevant neurochemical markers in ALS.

P97 EOSINOPHIL-DERIVED NEUROTOXIN AS A BIOMARKER FOR AMYOTROPHIC LATERAL SCLEROSIS

Hwang CS^1,2

Liu GT^3,4

Chang HT^3,4

^bhDepartment of Neurology, Taipei City Hospital, Taipei, Taiwan

^biInstitute of Molecular and Cellular Biology & Department of Medical Science, National Tsing Hua University, Hsinchu, Taiwan

^bjGraduate Institute of Molecular Systems Biomedicine, China Medical University, Taichung, Taiwan

^bkGraduate Institute of Basic Medical Science and Ph.D. Program for Aging China Medical University, Taichung, Taiwan

Email address for correspondence: [email protected]

Keywords: eosinophil-derived neurotoxin, neuroinflammation, biomarker

Background: Oxidative stress and neuroinflammation have been implicated in the pathophysiology of amyotrophic lateral sclerosis (ALS). There are prevalent danger signals involved in ALS. Many inflammatory molecules including interleukin-6, interferon-γ, tumor necrosis factor-α, and nitric oxide have been reported to be elevated in the serum of ALS patients. Members of damage-associated molecular patterns, including reactive oxygen species, eosinophil-derived neurotoxin (EDN), and eosinophil cationic protein (ECP) may also participate in its pathogenic processes. Herein, we hypothesized that two important danger signals, EDN and ECP, may elevate in ALS patients and be used as biomarkers for ALS.

Methods: Forty-four ALS patients, 39 patients with Alzheimer’s disease (AD), 40 patients with Parkinson’s disease (PD), and 44 age-matched healthy controls were recruited from Taipei City Hospital – Zhongxiao Branch. Detailed clinical data of these patients were registered. 10ml venous blood was collected from each participant. The concentration of serum ECP and EDN was measured using an enzyme-linked immunosorbent assay. ANOVA, Bonferroni multiple comparison test, and Spearman rank correlation were used for statistical analysis.

Results: The average EDN levels of ALS, AD, PD patients, and healty controls were 24.1 ± 24.5 ng/ml, 15.4 ± 17.4 ng/ml, 15.8 ± 15.2 ng/ml, and 21.1 ± 27.4 ng/ml, respectively. Averaged EDN level of ALS patients was significantly increased 2.17 fold as compared with that of healthy controls (p < 0.05). There was no significant correlation between the levels EDN and various clinical parameters of ALS patients. The serum EDN level of ALS patients was significantly increased 1.61 and 1.84 fold as compared with that of AD and PD patients, respectively. There was no significant difference for ECP levels between patients with ALS, AD, PD and healthy controls. Meanwhile, there was no significant correlation between ECP levels and each clinical parameter. Hence, EDN, but not ECP, may serve as an indicator for ALS. Receiver operating characteristic analysis of EDN for diagnosis of ALS showed best performance with 88.53% accuracy, 77.27% sensitivity, 84.09% specificity when cut-off value was set at 23.43 ng/ml. The value of area under the curve was 0.8264.

Conclusion: Our study showed EDN levels were significantly elevated in ALS patients. We propose that EDN may participate in the pathogenesis of ALS and may serve as a biomarker for ALS.

P98 SERUM FERRITIN IS ELEVATED IN AMYOTROPHIC LATERAL SCLEROSIS PATIENTS

Su X¹

Clardy S¹

Lawson R²

Stephens H¹

Simmons Z¹

Connor J¹

^blPenn State College of Medicine, Hershey, PA, USA

^bmNortheast ALS Consortium, Boston, MA, USA

Email address for correspondence: [email protected]

Keywords: serum ferritin, iron metabolism, biomarker

Background: Dysregulated iron metabolism may play a role in ALS pathophysiology. Polymorphisms in the HFE iron regulatory gene have been shown to increase ALS risk, and iron dyshomeostasis negatively impacts pathways implicated in ALS, including oxidative stress.

Objectives: To analyze levels of serum ferritin, a marker of iron metabolism, in ALS patients as well as healthy and diseased controls, and to determine if ferritin levels impact survival.

Methods: An IRB-approved, retrospective analysis was performed of data from 137 ALS patients, 152 healthy controls, and 80 patients with other neurological diseases seen at a university-based multidisciplinary ALS clinic or who provided samples to the Northeast ALS Consortium. Gender, age, site of onset, and, for selected patients, date of symptom onset as well as death was recorded. Survival time was defined as the duration from symptom onset to death. Serum ferritin levels were measured using standard clinical laboratory procedures. One-way ANOVA was used to compare serum ferritin levels between groups, whereas Spearman correlation was used to measure the association between serum levels and survival time. Serum ferritin levels were categorized into high and low groups, and survival analysis was performed using Kaplan–Meier logrank statistics and Cox proportional hazards regression.

Results: Age was significantly different in ALS patients (mean 60.5 years) compared to that of healthy (mean: 44.1) and diseased controls (mean: 52.1). However, age was not associated with serum ferritin levels (R-squared 0.063, canonical correlation). Gender proportions were significantly different in ALS patients (65.3% males) compared to that of healthy (32.5% males) and diseased controls (38.5% males), and gender significantly affected serum ferritin levels (Male: mean = 224.8 ng/ml and Female: mean = 90.0 ng/ml p < 0.001). Therefore, serum ferritin comparisons between groups were stratified for gender. In males, serum ferritin levels were significantly higher in ALS patients (mean: 286.6 ng/ml) than those of either healthy (mean: 160.8 ng/ml, p < 0.001) or diseased controls (mean: 164.5, p = 0.003). In females, serum ferritin levels were significantly higher in ALS patients (mean: 142.6 ng/ml) than those of either healthy (mean: 69.3 ng/ml, p < 0.001) or diseased controls (mean: 77.5, p < 0.001). However, serum ferritin levels were not associated with survival times in either males (R²: 0.001) or females (R²: 0.069). ALS patients were categorized into low and high ferritin groups by median values (200.0 ng/ml, males; 123.0 ng/ml, females). Ferritin status did not significantly impact survival by Kaplan–Meier logrank tests or Cox regression in either gender.

Discussion and conclusion: These results suggest altered iron metabolism in ALS patients, effects that are not simply due to presence of neurological disease. However, serum ferritin alone may be insufficient to reflect or predict disease progression and survival.

P99 URINARY EXTRACELLULAR DOMAIN OF NEUROTROPHIN RECEPTOR P75 MEASUREMENTS AS A NOVEL BIOMARKER FOR MOTOR NEURON DISEASE

Shepheard SR¹

Chataway T¹

Schultz D²

Rush RA¹

Rogers M-L¹

^bnFlinders University, Flinders Medical Science & Technology, Human Physiology & Centre for Neuroscience, Adelaide, South Australia, Australia

^boDepartment of Neurology, Flinders Medical Centre, Adelaide, South Australia, Australia

Email address for correspondence: [email protected]

Keywords: biomarkers, human urine, ELISA

Background: Objective biomarkers for motor neuron disease (MND) would aid diagnosis and facilitate the discovery of new treatments. Sources of biomarkers such as urine that are easily obtained should be investigated, as the invasive nature of CSF sampling is problematic for MND patients and especially healthy controls (1). p75NTR re-expression after nerve injury and cleavage of the extracellular domain of p75NTR (p75NTRECD) is part of a homeostatic program that removes defective neurons, axons and synapses upon injury and degeneration (2). In MND patients, p75NTR is up-regulated in motor neurons and Schwann cells post-mortem, but not in healthy controls (3, 4). We have previously found p75NTRECD in urine of MND mice and patients (5). We now ask whether levels of urinary p75NTRECD serve as a useful diagnostic and progression biomarker for MND.

Methods: A quantitative sandwich ELISA was used to detect p75NTRECD in the pg/ml range. Mass spectrometry and western blotting (WB) of urinary p75NTRECD after immunoprecipitation (IP) confirmed p75NTRECD in MND patient urine. Urine and neurological data were collected from 26 patients with sporadic MND, 12 healthy controls and 19 patients with non-MND diseases including Parkinson's disease (PD) and Multiple Sclerosis (MS). p75NTRECD was also measured multiple times from a cohort of 14 MND patients.

Results: The presence of p75NTRECD in urine of MND patients was confirmed by IP/WB and mass spectrometry. Urinary p75NTRECD levels measured by ELISA predict MND from healthy controls with high levels of sensitivity and specificity. The mean value for urinary extracellular p75NTRECD from 26 MND patients was 7.45 ± 0.53 (ng p75NTR/mg creatinine) significantly higher (p < 0.001) than 12 healthy control patients (2.5 ± 0.22) and 19 patients with other neurological diseases (4.7 ± 0.31; PD and MS). Urinary p75NTRECD tested over 3-month intervals in 14 MND patients is being performed with preliminary data indicating that p75NTRECD levels increase with a decline in the amyotrophic lateral sclerosis functional rating scale-revised (ALSFRSr). In addition, high urinary p75NTRECD appears to be prognostic for decreased survival time (n = 9).

Discussion and conclusion: These findings indicate urinary p75NTRECD offers utility as a biomarker MND. In addition, preliminary results indicate that it may be useful as a progression and prognostic marker. p75NTRECD should now be evaluated in large population studies.

Acknowledgements:

We would like to thank the patients and control subjects who participated. This study was supported by the Motor Neuron Disease Research Institute of Australia (MLR, RAR) and a Flinders University PhD scholarship supported by Australian Rotary Health (SRS).

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P100 IRISIN, A NEWLY IDENTIFIED MYOKINE AS A CANDIDATE MARKER OF METABOLIC INVOLVEMENT IN ALS

Weydt P¹

Böhm B²

Ludolph AC¹

Süssmuth S¹

^bpNeurology, Ulm University, Ulm, Germany

^bqInternal Medicine I, Ulm University, Ulm, Germany

Email address for correspondence: [email protected]

Keywords: irisin, biomarker, pgc-1a

Background: The development and ascertainment of biomarkers of disease onset and progression is a key objective of clinical ALS research and an important prerequisite for therapeutic trials. In addition to this identification of biomarkers might offer insights in to disease pathogenesis. Transcriptional processes regulated by peroxisome proliferator-activated receptor gamma (PPARg) coactivator-1 alpha (PGC-1a), which are critical for metabolic regulation and mitochondrial biogenesis, have been shown to be impaired in ALS and other neurodegenerative diseases. Therefore monitoring function of the PGC-1a system is of great potential interest in ALS. A protein which is under the direct transcriptional control of PGC-1a is the newly identified hormone called Irisin. Irisin is 112 amino acids long and is a cleavage product of the precursor protein FNDC5. It exists in at least four isoforms. It was originally described in 2012 as a myokine that signals metabolic information from the muscle to the adipose tissue and mediates many of the beneficial metabolic effects of exercise, for example, improved glucose tolerance. Irisin has thus been dubbed the ‘exercise hormone’ and it can be detected in blood serum.

Methods: Western blot analysis and ELISA were used to measure Irisin blood levels. An in-house ELISA for detection and quantification of Irisin in serum was developed in the Department of Internal Medicine I, Ulm University. Patient groups consisted of patients with motor neuron disease (MND) (n = 10; 41.6–74.6 years); patients with Huntington's disease, HD (n = 5; 39.7–54.3 years), and age-matched normal controls without any neurological disease.

Results: Irisin serum levels were found to be reduced in HD and ALS compared to those of controls. Irisin is a candidate marker of metabolic pathway involvement in ALS and HD. The metabolic dysregulation is of potential relevance for understanding of the disease pathogenesis.

Discussion: Further studies are needed to study the regulation of Irisin levels and to elucidate the mechanisms underlying these effects.

P101 AN IMPROVED MOTOR UNIT NUMBER INDEX (MUNIX) AS BIOMARKER FOR ALS

Kobor I

Stein F

Khomenko A

Baldaranov D

Johannesen S

Bruun T-H

Bogdahn U

Schulte-Mattler W

Department of Neurology, Regensburg, Germany

Email address for correspondence: [email protected]

Keywords: motor unit number estimation, motor unit number index, neurodegeneration

Objective: Biomarker improvement and validation of the new non-invasive neurophysiological method MUNIX (motor unit number index). The reliability, practicability and inter-rater-variability of potential improvements to MUNIX were determined and compared to two established Motor Unit Number Estimation (MUNE) methods.

Methods: Forty healthy subjects and 18 patients with amyotrophic lateral sclerosis (ALS) were studied prospectively at single point or multiple points in time. MUNIX results were compared with incremental stimulation MUNE (IS-MUNE) at abductor digiti minimi muscles (ADM), and with spike-triggered averaging MUNE (STA-MUNE) at trapezius muscles (TRA). In contrast to the original MUNIX method, we recorded a continuous electromyogram during increasing muscle contraction to reduce the influence of both patient’s compliance and investigator bias. Moreover, baseline correction for CMAP was implemented and the influence of the parameter settings (filters, number of data points, and rectifying) was systematically studied.

Results: The best parameter setting includes high pass-filter 10Hz, low pass-filter 3000Hz, number of data points 1000, and rectification of the signals. This leads to an improved correlation between MUNE and MUNIX, up to r = 0.80 for ADM and r = 0.7 for TRA. The inter-rater-variability is expected to be below 10% and therefore considerable better than for IS-MUNE/STA-MUNE.

Conclusion: The improved MUNIX needs minimum patient cooperation, and provides stable results easily and quickly. Improved MUNIX is suggested as an excellent biomarker alternative to the established MUNE methods in distal and as well as in proximal muscles.

References:

• Nandedkar SD, Nandedkar DS, Barkhaus PE, Stalberg EV. Motor unit number index (MUNIX). IEEE Trans. Biomed. Eng. 2004;51:2209–11.
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P102 “REPORTING BIOMARKER” DEVELOPMENT: UPDATE IN ALS PATIENTS TREATED WITH G-CSF-MOBILIZED HEMATOPOIETIC STEM CELLS

Khomenko A¹

Baldaranov D¹

Johannesen S¹

Kobor I¹

Grassinger J²

Stein F¹

Rösl J¹

Kollewe K³

Dengler R³

Ludolph AC⁴

Kassubek J⁴

Deppe M⁵

Schuierer G⁶

Bruun TH¹

Schulte-Mattler W¹

Bogdahn U¹

^brDepartment of Neurology

^bsDepartment of Neuroradiology University of Regensburg, Regensburg, Germany

^btDepartment of Haematology and Internal Oncology, University Hospital Regensburg, Regensburg, Germany

^buClinic for Neurology Medizinische Hochschule Hannover, Hannover, Germany

^bvNeurological University clinic, Ulm, Germany

^bwUniversity of Muenster Department of Neurology, Muenster, Germany,

Email address for correspondence: [email protected]

Objective: Treatment development in neurodegeneration is demanding because of time slots for evaluating effects and multiple confounders. We selected prolonged open label ‘compassionate use’ autologous BM stem cell mobilization in human ALS-patients to pre-validate ‘reporting biomarkers’ for disease modulation and safety evaluation.

Methods: Twenty ALS patients were treated with s.c. rec-hu-G-CSF, in a conventional 5/28 days or a 1/7 days × 4 (each = 1 cycle) outpatient regimen: 5–10 μg/kg BW were given daily plus riluzole. Patients with a median age of 48 yrs (25–75y, 13m and 7f,) were evaluated by ALS-FRS-R every 4 weeks. As reporting biomarkers we assessed (1) hypothenar muscle motor unit number estimates (MUNE, Mc Comas) and (2) cranial MRI-DTI to delineate microstructural FAI-changes as sign of axonal damage/repair in motor cortex and pyramidal tracts every 12 weeks, and (3) BM function including stem cell differentiation profile, smears and blood counts, Burst forming and colony forming units (BFU-E, CFU-E, CFU-GM, CFU-GEMM) pre- and post-mobilization. Safety included abdominal sonography, determination of BW, pulmonary function, and clinical chemistry.

Results: Both application modes (5/28: 15 treatment cycles (4–31) and 1/7x4: 11.5 cycles (4–16)) were safe with no obvious difference in efficacy. Side effects were very mild and tolerance was good. No differences were detected when compared to an ALS population treated with riluzole only. Clinical outcome revealed some longer stabilisations, unrelated to age or disease dynamics. Median overall survival in application mode 5/28 was 2.9 years. MUNE correlated to disease progression (p < 0.01) and DTI-FAI (p < 0.003), and showed increases in individual patients. DTI-/FAI-values over time indicated decrease in most patients, in some minor improvement. BM function was complex, and correlations to effects are still ongoing. Median overall survival could not yet be determined.

Discussion: Prolonged treatment with G-CSF is feasible and safe in ALS patients; however, prospective study data are needed. MUNE, DTI and BM function parameters are probably very useful biomarkers.

P103 THE FEATURES OF SERUM LIPID AND SURVIVAL IN ALS PATIENTS: A STUDY FROM SOUTHWEST CHINA

Huang R

Zheng Z

Guo X

Shang H

Department of Neurology, West China Hospital, SiChuan University, Chengdu Sichuan, China

Email address for correspondence: [email protected]

Keywords: amyotrophic lateral sclerosis, serum lipid, survival time

Background: To investigate the associations between fasting serum lipid and survival in Chinese ALS patients.

Methods: Four hundred and thirteen ALS patients (241 males and 172 females) were included in the study. All the patients were regularly followed up from 2004 to 2013. Fasting serum lipid concentration of all the subjects, consisted of total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglyceride (TG) were measured at the time of first visit. Information including survival time, and revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALS-FRS) were collected by follow-up.

Results: ALS patients with high triglyceride serum levels had longer survival time compared with ALS patients with lower triglyceride serum levels (p < 0.05). We found a median prolonged life expectancy by 5.66 months for patients with serum triglyceride levels above the median of 1.47mmol/L. A meta-analysis indicated that there were no significant differences in mean total cholesterol, triglycerides, LDL and the LDL/HDL ratio between ALS patients and controls.

Conclusion: High triglyceride serum levels may prolong survival time and maybe a potential prognostic factor in ALS patients.

Acknowledgements:

The authors thank the patients and their families for their participation in the study. The present study was supported by the National Science Fund of China (Grant No. 30973149) and the Science and Technology Bureau Fund of Sichuan Province (No. 2010SZ0069).

P104 VIDEOFLUOROGRAPHIC MARKERS IN SPINAL AND BULBAR MUSCULAR ATROPHY (SBMA): A STUDY OF 111 JAPANESE PATIENTS

Banno H^1,2

Katsuno M¹

Suzuki K¹

Tanaka S³

Suga N¹

Hashizume A¹

Mano T¹

Araki A¹

Fujimoto Y⁴

Nakashima T⁴

Yamamoto M³

Sobue G¹

^bxDepartment of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan

^byDepartment of Neurology, Massachusetts General Hospital, Boston, MA, USA

^bzDepartment of Health Science, Aichi Gakuin University, Aichi, Japan

^caDepartment of Otorhinolaryngology, Nagoya University Graduate school of Medicine, Nagoya, Japan

Email address for correspondence: [email protected]

Keywords: SBMA, videofluorography, dysphagia

Objective: SBMA is a lower motor neuron disease characterized by weakness and atrophy of limb, facial, and oropharyngeal muscles. Dysphagia is a major symptom of SBMA and often leads to life-threatening events such as aspiration pneumonia and suffocation. Although bulbar dysfunction is an important prognostic factor in SBMA, pathophysiology of dysphagia remains elusive. The purpose of this study is to clarify the characteristics of dysphagia in spinal and bulbar muscular atrophy (SBMA) using videofluorography (VFG) and investigate the relationship between bulbar palsy and other clinical phenotypes of the disease.

Methods: We performed VFG examination on 111 consecutive genetically confirmed SBMA patients and analyzed quantitative and qualitative data. In each VFG study, swallowing of 3 ml liquid barium was viewed in the lateral plane and was analyzed using Logemann’s videofluorographic examination of swallowing worksheet. The VFG findings were compared with 53 healthy age-matched controls using t-test and chi-square test. Quantitative VFG data were also compared with patient genetic background such as CAG repeat length, and with other motor functional measures such as ALSFRS-R using Pearson’s correlation coefficient.

Results: All the patients examined demonstrated qualitative abnormalities in VFG. Most pertinent abnormal findings include nasal penetration, vallecular residue after swallow and insufficient tongue movement (p < 0.05 for each). Quantitative analyses showed that ALSFRS-R bulbar components correlated with oral residue and piecemeal deglutition.

Conclusion: Dysphagia in SBMA is characterized by impaired tongue movement in the oral phase followed by vallecular residue and piecemeal deglutition.