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Colombo E, Gentile F, Maranzano A, Doretti A, Verde F, Olivero M, Gagliardi D, Faré M, Meneri M, Poletti B, Maderna L, Corti S, Corbo M, Morelli C, Silani V, Ticozzi N. The impact of upper motor neuron involvement on clinical features, disease progression and prognosis in amyotrophic lateral sclerosis. Front Neurol 2023; 14:1249429. [PMID: 37822527 PMCID: PMC10562695 DOI: 10.3389/fneur.2023.1249429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/13/2023] [Indexed: 10/13/2023] Open
Abstract
ObjectivesIn amyotrophic lateral sclerosis (ALS) both upper (UMNs) and lower motor neurons (LMNs) are involved in the process of neurodegeneration, accounting for the great disease heterogeneity. We evaluated the associations of the burden of UMN impairment, assessed through the Penn Upper Motor Neuron Score (PUMNS), with demographic and clinical features of ALS patients to define the independent role of UMN involvement in generating disease heterogeneity, predicting disease progression and prognosis.MethodsWe collected the following clinical parameters on a cohort of 875 ALS patients: age and site of onset, survival, MRC scale, lower motor neuron score (LMNS), PUMNS, ALSFRS-R, change in ALSFRS-R over time (DFS), MITOS and King’s staging systems (KSS). Transcranial magnetic stimulation was performed on a subgroup of patients and central motor conduction time (CMCT) and cortical silent period (CSP) were calculated.ResultsWe observed that patients with an earlier age at onset and bulbar onset had higher PUMNS values. Higher values were also associated to lower ALSFRS-R and to higher DFS scores, as well as to higher MITOS and KSS, indicating that a greater UMN burden correlates with disease severity. Conversely, we did not appreciate any association between UMN involvement and survival or markers of LMN impairment. Moreover, PUMNS values showed a positive association with CMCT and a negative one with CSP values.InterpretationOur results suggest that the burden of UMN pathology, assessed through PUMNS, has an important independent role in defining clinical characteristics, functional disability, disease progression and prognosis in ALS patients. We also support the role of TMS in defining severity of UMN involvement.
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Affiliation(s)
- Eleonora Colombo
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Francesco Gentile
- Neurology Residency Program, Università degli Studi di Milano, Milan, Italy
| | - Alessio Maranzano
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Alberto Doretti
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Federico Verde
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
- “Dino Ferrari” Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Marco Olivero
- Neurology Residency Program, Università degli Studi di Milano, Milan, Italy
| | - Delia Gagliardi
- “Dino Ferrari” Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Faré
- Department of Neurology, San Gerardo Hospital ASST, Monza, Italy
- School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Megi Meneri
- “Dino Ferrari” Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Poletti
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Luca Maderna
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Stefania Corti
- “Dino Ferrari” Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa di Cura Igea (CCI), Milan, Italy
| | - Claudia Morelli
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Vincenzo Silani
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
- “Dino Ferrari” Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Nicola Ticozzi
- Department of Neurology and Laboratory of Neuroscience, IRCCS Istituto Auxologico Italiano, Milan, Italy
- “Dino Ferrari” Center, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Tahedl M, Tan EL, Siah WF, Hengeveld JC, Doherty MA, McLaughlin RL, Hardiman O, Finegan E, Bede P. Radiological correlates of pseudobulbar affect: Corticobulbar and cerebellar components in primary lateral sclerosis. J Neurol Sci 2023; 451:120726. [PMID: 37421883 DOI: 10.1016/j.jns.2023.120726] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION Pseudobulbar affect (PBA) is a distressing symptom of a multitude of neurological conditions affecting patients with a rage of neuroinflammatory, neurovascular and neurodegenerative conditions. It manifests in disproportionate emotional responses to minimal or no contextual stimulus. It has considerable quality of life implications and treatment can be challenging. METHODS A prospective multimodal neuroimaging study was conducted to explore the neuroanatomical underpinnings of PBA in patients with primary lateral sclerosis (PLS). All participants underwent whole genome sequencing and screening for C9orf72 hexanucleotide repeat expansions, a comprehensive neurological assessment, neuropsychological screening (ECAS, HADS, FrSBe) and PBA was evaluated by the emotional lability questionnaire. Structural, diffusivity and functional MRI data were systematically evaluated in whole-brain (WB) data-driven and region of interest (ROI) hypothesis-driven analyses. In ROI analyses, functional and structural corticobulbar connectivity and cerebello-medullary connectivity alterations were evaluated separately. RESULTS Our data-driven whole-brain analyses revealed associations between PBA and white matter degeneration in descending corticobulbar as well as in commissural tracts. In our hypothesis-driven analyses, PBA was associated with increased right corticobulbar tract RD (p = 0.006) and decreased FA (p = 0.026). The left-hemispheric corticobulbar tract, as well as functional connectivity, showed similar tendencies. While uncorrected p-maps revealed both voxelwise and ROI trends for associations between PBA and cerebellar measures, these did not reach significance to unequivocally support the "cerebellar hypothesis". CONCLUSIONS Our data confirm associations between cortex-brainstem disconnection and the clinical severity of PBA. While our findings may be disease-specific, they are consistent with the classical cortico-medullary model of pseudobulbar affect.
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Affiliation(s)
- Marlene Tahedl
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - Ee Ling Tan
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - We Fong Siah
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | | | - Mark A Doherty
- Smurfit Institute of Genetics, Trinity College Dublin, Dublin, Ireland
| | | | - Orla Hardiman
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - Eoin Finegan
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland; Department of Neurology, St James's Hospital, Dublin, Ireland.
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Gondim FDAA, Pinto WBVDR, Chieia MAT, Correia CDC, Cunha FMB, Dourado MET, França Júnior MC, Marques Júnior W, Oliveira ASB, Rodrigues CL, Silva DJD, Dias-Tosta E. Definitions, phenomenology, diagnosis, and management of the disorders of laughter and crying in amyotrophic lateral sclerosis (ALS): Consensus from ALS and Motor Neuron Disease Scientific Department of the Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:764-775. [PMID: 37647907 PMCID: PMC10468253 DOI: 10.1055/s-0043-1771176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
The spectrum of neuropsychiatric phenomena observed in amyotrophic lateral sclerosis (ALS) is wide and not fully understood. Disorders of laughter and crying stand among the most common manifestations. The aim of this study is to report the results of an educational consensus organized by the Brazilian Academy of Neurology to evaluate the definitions, phenomenology, diagnosis, and management of the disorders of laughter and crying in ALS patients. Twelve members of the Brazilian Academy of Neurology - considered to be experts in the field - were recruited to answer 12 questions about the subject. After exchanging revisions, a first draft was prepared. A face-to-face meeting was held in Fortaleza, Brazil on 9.23.22 to discuss it. The revised version was subsequently emailed to all members of the ALS Scientific Department from the Brazilian Academy of Neurology and the final revised version submitted for publication. The prevalence of pseudobulbar affect/pathological laughter and crying (PBA/PLC) in ALS patients from 15 combined studies and 3906 patients was 27.4% (N = 1070), ranging from 11.4% to 71%. Bulbar onset is a risk factor but there are limited studies evaluating the differences in prevalence among the different motor neuron diseases subtypes, including patients with and without frontotemporal dementia. Antidepressants and a combination of dextromethorphan and quinidine (not available in Brazil) are possible therapeutic options. This group of panelists acknowledge the multiple gaps in the current literature and reinforces the need for further studies.
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Affiliation(s)
- Francisco de Assis Aquino Gondim
- Universidade Federal do Ceará, Departamento de Clínica Médica, Núcleo de Desenvolvimento e Pesquisa de Medicamentos, Fortaleza CE, Brazil
| | - Wladimir Bocca Vieira de Rezende Pinto
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia/Ebserh, Setor de Investigações nas Doenças Neuromusculares, São Paulo SP, Brazil
| | - Marco Antônio Troccoli Chieia
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia/Ebserh, Setor de Investigações nas Doenças Neuromusculares, São Paulo SP, Brazil
| | | | | | | | | | - Wilson Marques Júnior
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências, Ribeirão Preto SP, Brazil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia/Ebserh, Setor de Investigações nas Doenças Neuromusculares, São Paulo SP, Brazil
| | | | - Delson José da Silva
- Universidade Federal de Goiás, Hospital das Clínicas, Unidade de Neurologia e Neurocirurgia/Ebserh, Goiânia GO, Brazil
| | - Elza Dias-Tosta
- Comissão de Ética da Academia Brasileira de Neurologia, São Paulo SP, Brazil
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Gilmore M, Elman L, Babu S, Andres P, Floeter MK. Measuring disease progression in primary lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 21:59-66. [PMID: 33602016 DOI: 10.1080/21678421.2020.1837179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Quantitative measures of disease severity are essential outcome measures for clinical trials. The slow progression of disease in primary lateral sclerosis (PLS) requires clinical measures that are sensitive to changes occurring within the time frame of a clinical trial. Proposed clinical outcome measures include the PLS functional rating scale (PLSFRS), burden scores derived from clinical examination findings, and quantitative measures of motor performance. The PLSFRS has good inter-rater reliability and showed greater longitudinal change over 6- and 12-months compared to the revised ALS functional rating scale. Examination-based upper motor neuron burden (UMNB) scales also have good reliability, and longitudinal studies are in process. Quantitative measures of strength, dexterity, gait, and speech have the potential to provide objective and precise measures of clinical change, but have been the least studied in persons with PLS.
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Affiliation(s)
- Madison Gilmore
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Lauren Elman
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Suma Babu
- Sean M Healy & AMG Center for ALS, Massachusetts General Hospital, Boston, MA, USA
| | - Patricia Andres
- Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Mary Kay Floeter
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
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Makary MM, Weerasekara A, Rodham H, Hightower BG, Tseng CEJ, Chan J, Chew S, Paganoni S, Ratai EM, Zürcher NR, Hooker JM, Atassi N, Babu S. Comparison of Two Clinical Upper Motor Neuron Burden Rating Scales in ALS Using Quantitative Brain Imaging. ACS Chem Neurosci 2021; 12:906-916. [PMID: 33576234 DOI: 10.1021/acschemneuro.0c00772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Several clinical upper motor neuron burden scales (UMNSs) variably measure brain dysfunction in amyotrophic lateral sclerosis (ALS). Here, we compare relationship of two widely used clinical UMNSs in ALS (Penn and MGH UMNSs) with (a) neuroimaging markers of brain dysfunction and (b) neurological impairment status using the gold-standard functional measure, the revised ALS Functional Rating Scale (ALSFRS-R). MGH UMNS measures hyperreflexia alone, and Penn UMNS measures hyperreflexia, spasticity, and pseudobulbar affect. Twenty-eight ALS participants underwent both Penn and MGH UMNSs, at a matching time-point as a simultaneous [11C]PBR28 positron emission tomography (PBR28-PET)/Magnetic Resonance scan and ALSFRS-R. The two UMNSs were compared for localization and strength of association with neuroimaging markers of: (a) neuroinflammation, PBR28-PET and MR Spectroscopy metabolites (myo-inositol and choline) and (b) corticospinal axonal loss, fractional anisotropy (FA), and MR Spectroscopy metabolite (N-acetylaspartate). Among clinical UMN manifestations, segmental hyperreflexia, spasticity, and pseudobulbar affect occurred in 100, 43, and 18% ALS participants, respectively. Pseudobulbar affect did not map to any specific brain regional dysfunction, while hyperreflexia and spasticity subdomains significantly correlated and colocalized neurobiological changes to corticospinal pathways on whole brain voxel-wise analyses. Both UMNS total scores showed significant and similar strength of association with (a) neuroimaging changes (PBR28-PET, FA, MR Spectroscopy metabolites) in primary motor cortices and (b) severity of functional decline (ALSFRS-R). Hyperreflexia is the most frequent clinical UMN manifestation and correlates best with UMN molecular imaging changes in ALS. Among Penn UMNS's subdomains, hyperreflexia carries the weight of association with neuroimaging markers of biological changes in ALS. A clinical UMN scale comprising hyperreflexia items alone is clinically relevant and sufficient to predict the highest yield of molecular neuroimaging abnormalities in ALS.
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Affiliation(s)
- Meena M. Makary
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
- Systems and Biomedical Engineering Department, Faculty of Engineering, Cairo University, Giza, 12613, Egypt
| | - Akila Weerasekara
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Haley Rodham
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Baileigh G. Hightower
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Chieh-En J. Tseng
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Sheena Chew
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Sabrina Paganoni
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
- Department of PM&R, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts 02129, United States
| | - Eva-Maria Ratai
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Nicole R. Zürcher
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Jacob M. Hooker
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Nazem Atassi
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
- Sanofi Genzyme, Cambridge, Massachusetts 02142, United States
| | - Suma Babu
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
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Ranieri F, Mariotto S, Dubbioso R, Di Lazzaro V. Brain Stimulation as a Therapeutic Tool in Amyotrophic Lateral Sclerosis: Current Status and Interaction With Mechanisms of Altered Cortical Excitability. Front Neurol 2021; 11:605335. [PMID: 33613416 PMCID: PMC7892772 DOI: 10.3389/fneur.2020.605335] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
In the last 20 years, several modalities of neuromodulation, mainly based on non-invasive brain stimulation (NIBS) techniques, have been tested as a non-pharmacological therapeutic approach to slow disease progression in amyotrophic lateral sclerosis (ALS). In both sporadic and familial ALS cases, neurophysiological studies point to motor cortical hyperexcitability as a possible priming factor in neurodegeneration, likely related to dysfunction of both excitatory and inhibitory mechanisms. A trans-synaptic anterograde mechanism of excitotoxicity is thus postulated, causing upper and lower motor neuron degeneration. Specifically, motor neuron hyperexcitability and hyperactivity are attributed to intrinsic cell abnormalities related to altered ion homeostasis and to impaired glutamate and gamma aminobutyric acid gamma-aminobutyric acid (GABA) signaling. Several neuropathological mechanisms support excitatory and synaptic dysfunction in ALS; additionally, hyperexcitability seems to drive DNA-binding protein 43-kDA (TDP-43) pathology, through the upregulation of unusual isoforms directly contributing to ASL pathophysiology. Corticospinal excitability can be suppressed or enhanced using NIBS techniques, namely, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), as well as invasive brain and spinal stimulation. Experimental evidence supports the hypothesis that the after-effects of NIBS are mediated by long-term potentiation (LTP)-/long-term depression (LTD)-like mechanisms of modulation of synaptic activity, with different biological and physiological mechanisms underlying the effects of tDCS and rTMS and, possibly, of different rTMS protocols. This potential has led to several small trials testing different stimulation interventions to antagonize excitotoxicity in ALS. Overall, these studies suggest a possible efficacy of neuromodulation in determining a slight reduction of disease progression, related to the type, duration, and frequency of treatment, but current evidence remains preliminary. Main limitations are the small number and heterogeneity of recruited patients, the limited “dosage” of brain stimulation that can be delivered in the hospital setting, the lack of a sufficient knowledge on the excitatory and inhibitory mechanisms targeted by specific stimulation interventions, and the persistent uncertainty on the key pathophysiological processes leading to motor neuron loss. The present review article provides an update on the state of the art of neuromodulation in ALS and a critical appraisal of the rationale for the application/optimization of brain stimulation interventions, in the light of their interaction with ALS pathophysiological mechanisms.
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Affiliation(s)
- Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Raffaele Dubbioso
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Naples, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, Rome, Italy
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Reliable and efficient scale to assess upper motor neuron disease burden in amyotrophic lateral sclerosis. Muscle Nerve 2019; 61:508-511. [DOI: 10.1002/mus.26764] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/25/2019] [Accepted: 11/12/2019] [Indexed: 12/13/2022]
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Finegan E, Chipika RH, Li Hi Shing S, Hardiman O, Bede P. Pathological Crying and Laughing in Motor Neuron Disease: Pathobiology, Screening, Intervention. Front Neurol 2019; 10:260. [PMID: 30949121 PMCID: PMC6438102 DOI: 10.3389/fneur.2019.00260] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 12/11/2022] Open
Abstract
Pathological crying and laughing (PCL) has significant quality-of-life implications in amyotrophic lateral sclerosis (ALS); it can provoke restrictive life-style modifications and lead to social isolation. Despite its high prevalence and quality of life implications, it remains surprisingly understudied. Divergent pathophysiological models have been proposed, centered on corticobulbar tract degeneration, prefrontal cortex pathology, sensory deafferentation, and impaired cerebellar gate-control mechanisms. Quantitative MRI techniques and symptom-specific clinical instruments offer unprecedented opportunities to elucidate the anatomical underpinnings of PCL pathogenesis. Emerging neuroimaging studies of ALS support the role of cortico–pontine–cerebellar network dysfunction in context-inappropriate emotional responses. The characterization of PCL-associated pathophysiological processes is indispensable for the development of effective pharmacological therapies.
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Affiliation(s)
- Eoin Finegan
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Rangariroyashe H Chipika
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Stacey Li Hi Shing
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Togrol RE, Demir S. Reliability, validity and validation of the CNS emotional lability scale for pseudobulbar affect on multiple sclerosis in Turkish patients. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1472905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rıfat Erdem Togrol
- Department of Neurology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Serkan Demir
- Department of Neurology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
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Thakore NJ, Pioro EP. Laughter, crying and sadness in ALS. J Neurol Neurosurg Psychiatry 2017; 88:825-831. [PMID: 28572273 PMCID: PMC5629932 DOI: 10.1136/jnnp-2017-315622] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/16/2017] [Accepted: 04/12/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pseudobulbar affect (PBA) is prevalent in amyotrophic lateral sclerosis (ALS), but there is limited information on its associations and course. OBJECTIVES Explore prevalence, associations, course and manifestations of PBA in outpatient cohort of patients with ALS and examine its relationship to depression. METHODS Self-reported measures of PBA and depression (Center for Neurologic Study-Lability Scale (CNS-LS) and Patient Health Questionnaire (PHQ-9), respectively) were obtained from consecutive patients with ALS using tablet devices in waiting rooms (Knowledge Program). RESULTS PBA (CNS-LS ≥13) was seen in 209/735 patients (28.4%). PBA was associated with bulbar onset and dysfunction, upper motor neuron dysfunction, cognitive impairment, depression and lower quality of life. A multivariable model that included lower bulbar and gross motor subscores, female gender, younger age and shorter duration of disease predicted PBA with 74% accuracy. CNS-LS scores increased only slowly with time. Women with PBA reported more crying than men. Crying (but not laughter) correlated with depression, and crying was associated with poorer quality of life. Exploratory factor analysis of pooled questions of CNS-LS and PHQ-9 identified three underlying factors (laughter, crying and depression) loaded on appropriate questions of the respective instruments. CONCLUSION This study identifies associations of PBA and additionally finds PBA (especially crying-predominant PBA) more prevalent in women with ALS. Although the two self-report instruments (CNS-LS and PHQ-9) discriminate well between PBA and depression, there is significant overlap between depression and crying in PBA. Studies of PBA should stratify for gender, examine crying and laughter as separate outcomes and adjust for depression.
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Affiliation(s)
- Nimish J Thakore
- Department of Neurology, Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erik P Pioro
- Department of Neurology, Neuromuscular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Pathological laughing and crying in amyotrophic lateral sclerosis is related to frontal cortex function. J Neurol 2016; 263:1788-95. [DOI: 10.1007/s00415-016-8201-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 06/09/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
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12
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Woo JH, Wang S, Melhem ER, Gee JC, Cucchiara A, McCluskey L, Elman L. Linear associations between clinically assessed upper motor neuron disease and diffusion tensor imaging metrics in amyotrophic lateral sclerosis. PLoS One 2014; 9:e105753. [PMID: 25144708 PMCID: PMC4140827 DOI: 10.1371/journal.pone.0105753] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 07/28/2014] [Indexed: 12/02/2022] Open
Abstract
Objective To assess the relationship between clinically assessed Upper Motor Neuron (UMN) disease in Amyotrophic Lateral Sclerosis (ALS) and local diffusion alterations measured in the brain corticospinal tract (CST) by a tractography-driven template-space region-of-interest (ROI) analysis of Diffusion Tensor Imaging (DTI). Methods This cross-sectional study included 34 patients with ALS, on whom DTI was performed. Clinical measures were separately obtained including the Penn UMN Score, a summary metric based upon standard clinical methods. After normalizing all DTI data to a population-specific template, tractography was performed to determine a region-of-interest (ROI) outlining the CST, in which average Mean Diffusivity (MD) and Fractional Anisotropy (FA) were estimated. Linear regression analyses were used to investigate associations of DTI metrics (MD, FA) with clinical measures (Penn UMN Score, ALSFRS-R, duration-of-disease), along with age, sex, handedness, and El Escorial category as covariates. Results For MD, the regression model was significant (p = 0.02), and the only significant predictors were the Penn UMN Score (p = 0.005) and age (p = 0.03). The FA regression model was also significant (p = 0.02); the only significant predictor was the Penn UMN Score (p = 0.003). Conclusions Measured by the template-space ROI method, both MD and FA were linearly associated with the Penn UMN Score, supporting the hypothesis that DTI alterations reflect UMN pathology as assessed by the clinical examination.
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Affiliation(s)
- John H. Woo
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Sumei Wang
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Elias R. Melhem
- Department of Radiology, University of Maryland, Baltimore, Maryland, United States of America
| | - James C. Gee
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Andrew Cucchiara
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Leo McCluskey
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Lauren Elman
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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Mitsumoto H, Factor-Litvak P, Andrews H, Goetz RR, Andrews L, Rabkin JG, McElhiney M, Nieves J, Santella RM, Murphy J, Hupf J, Singleton J, Merle D, Kilty M, Heitzman D, Bedlack RS, Miller RG, Katz JS, Forshew D, Barohn RJ, Sorenson EJ, Oskarsson B, Filho JAMF, Kasarskis EJ, Lomen-Hoerth C, Mozaffar T, Rollins YD, Nations SP, Swenson AJ, Shefner JM, Andrews JA, Koczon-Jaremko BA. ALS Multicenter Cohort Study of Oxidative Stress (ALS COSMOS): study methodology, recruitment, and baseline demographic and disease characteristics. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15:192-203. [PMID: 24564738 PMCID: PMC4310702 DOI: 10.3109/21678421.2013.864312] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract In a multicenter study of newly diagnosed ALS patients without a reported family history of ALS, we are prospectively investigating whether markers of oxidative stress (OS) are associated with disease progression. Methods utilize an extensive structured telephone interview ascertaining environmental, lifestyle, dietary and psychological risk factors associated with OS. Detailed assessments were performed at baseline and at 3-6 month intervals during the ensuing 30 months. Our biorepository includes DNA, plasma, urine, and skin. Three hundred and fifty-five patients were recruited. Subjects were enrolled over a 36-month period at 16 sites. To meet the target number of subjects, the recruitment period was prolonged and additional sites were included. Results showed that demographic and disease characteristics were similar between 477 eligible/non-enrolled and enrolled patients, the only difference being type of health insurance among enrolled patients. Sites were divided into three groups by the number of enrolled subjects. Comparing these three groups, the Columbia site had fewer 'definite ALS' diagnoses. This is the first prospective, interdisciplinary, in-depth, multicenter epidemiological investigation of OS related to ALS progression and has been accomplished by an aggressive recruitment process. The baseline demographic and disease features of the study sample are now fully characterized.
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Affiliation(s)
- Hiroshi Mitsumoto
- Eleanor and Lou Gehrig MDA/ALS Research Center Department of Neurology Columbia University Medical Center 710 West 168 St, New York, NY 10032
| | - Pam Factor-Litvak
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | - Howard Andrews
- Data Coordinating Center (DCC), Mailman School of Public Health Biostatistics Department, Columbia University
| | - Raymond R. Goetz
- New York State Psychiatric Institute & Department of Psychiatry, Columbia University
| | - Leslie Andrews
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University
| | - Judith G. Rabkin
- New York State Psychiatric Institute & Department of Psychiatry, Columbia University
| | - Martin McElhiney
- New York State Psychiatric Institute & Department of Psychiatry, Columbia University
| | - Jeri Nieves
- Department of Epidemiology, Mailman School of Public Health, Columbia University
- Clinical Research Center, Helen Hayes
| | - Regina M. Santella
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University
| | - Jennifer Murphy
- Department of Neurology, University of California, San Francisco
| | - Jonathan Hupf
- Eleanor and Lou Gehrig MDA/ALS Research Center Department of Neurology Columbia University Medical Center 710 West 168 St, New York, NY 10032
| | - Jess Singleton
- Eleanor and Lou Gehrig MDA/ALS Research Center Department of Neurology Columbia University Medical Center 710 West 168 St, New York, NY 10032
| | - David Merle
- Data Coordinating Center (DCC), Mailman School of Public Health Biostatistics Department, Columbia University
| | - Mary Kilty
- Department of Epidemiology, Mailman School of Public Health, Columbia University
| | | | | | | | | | - Dallas Forshew
- Forbes Norris ALS Center, California Pacific Medical Center
| | | | | | | | | | | | | | | | | | - Sharon P. Nations
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern
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Primitive reflexes in amyotrophic lateral sclerosis: prevalence and correlates. J Neurol 2014; 261:1196-202. [DOI: 10.1007/s00415-014-7342-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 04/03/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022]
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15
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Brettschneider J, Toledo JB, Van Deerlin VM, Elman L, McCluskey L, Lee VMY, Trojanowski JQ. Microglial activation correlates with disease progression and upper motor neuron clinical symptoms in amyotrophic lateral sclerosis. PLoS One 2012; 7:e39216. [PMID: 22720079 PMCID: PMC3375234 DOI: 10.1371/journal.pone.0039216] [Citation(s) in RCA: 182] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 05/17/2012] [Indexed: 01/29/2023] Open
Abstract
Background/Aims We evaluated clinicopathological correlates of upper motor neuron (UMN) damage in amyotrophic lateral sclerosis (ALS), and analyzed if the presence of the C9ORF72 repeat expansion was associated with alterations in microglial inflammatory activity. Methods Microglial pathology was assessed by IHC with 2 different antibodies (CD68, Iba1), myelin loss by Kluver-Barrera staining and myelin basic protein (MBP) IHC, and axonal loss by neurofilament protein (TA51) IHC, performed on 59 autopsy cases of ALS including 9 cases with C9ORF72 repeat expansion. Results Microglial pathology as depicted by CD68 and Iba1 was significantly more extensive in the corticospinal tract (CST) of ALS cases with a rapid progression of disease. Cases with C9ORF72 repeat expansion showed more extensive microglial pathology in the medulla and motor cortex which persisted after adjusting for disease duration in a logistic regression model. Higher scores on the clinical UMN scale correlated with increasing microglial pathology in the cervical CST. TDP-43 pathology was more extensive in the motor cortex of cases with rapid progression of disease. Conclusions This study demonstrates that microglial pathology in the CST of ALS correlates with disease progression and is linked to severity of UMN deficits.
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Affiliation(s)
- Johannes Brettschneider
- Center for Neurodegenerative Disease Research, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America.
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Abstract
Numerous neurologic diseases affect voice production either through direct effects on the larynx or by affecting muscles involved with support or resonation of the voice. Voice changes can be the initial presenting symptoms of neurodegenerative disorders, especially in patients who have increased awareness of their vocal quality. Some patients present to the otolaryngologist before the neurologist. The otolaryngologist must have an understanding and familiarity with laryngeal manifestations of neurodegenerative diseases to make the appropriate diagnosis in a timely fashion. Moreover, the otolaryngologist can play a significant role in the care of patients who have neurodegenerative disease. Video procedures for neurolaryngologic evaluation accompany this content online.
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Affiliation(s)
- Adam D Rubin
- Lakeshore Professional Voice Center, Lakeshore Ear, Nose and Throat Center, 21000 E. Twelve Mile Road, Suite 111, Saint Clair Shores, MI 48081, USA.
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Abstract
Involuntary emotional expression disorder (IEED) is a syndrome in which emotional or affective motor control becomes dysregulated as a result of brain damage from neurological disease or as a result of brain injury. A debilitating disorder with persistent symptoms, IEED has a significant impact upon the lives of patients and caregivers, but is often overlooked or misdiagnosed. IEED is a clinically well-defined disorder, and specific criteria may be used when making a diagnosis. It must be distinguished from depression or other psychological and neurological conditions. Several assessment scales have been validated for use in IEED, in order to evaluate the baseline severity and to track the course of the disorder and response to treatment.
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Affiliation(s)
- Jeffrey L Cummings
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA, USA
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Abstract
Because treatments are not yet powerful enough to reverse the symptoms of amyotrophic lateral sclerosis (ALS), randomized placebo-controlled trials remain the gold standard for testing new therapies. To date, only one drug, riluzole, has been shown to slow the course of ALS, albeit in a very modest way. Since the approval of riluzole almost 10 years ago, there have been a number of negative trials, and we still await the discovery of a medication with a truly meaningful effect. With each study, our sophistication in trial design grows, but hurdles remain, including how to use transgenic animal models optimally, which outcome measures most accurately reflect changes in the disease, and how to reduce the often high dropout rates in trials of ALS. This article is devoted to the recent evolution of clinical trials in ALS and discusses specific trials conducted during the past 5 years.
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Affiliation(s)
- Paul H Gordon
- Eleanor and Lou Gehrig MDA/ALS Research Center, Neurological Institute, 9th Floor, 710 West 168th Street, New York, NY 10032, USA.
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