Genetics of amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease characterized by upper and lower motor neuron damage in the bulbar and spinal territories. Although the pathophysiology of ALS is still unknown, the involvement of genetic factors is no longer a subject of debate. Familial ALS (fALS) accounts for 10-20% of cases. Since the identification of the SOD1 gene, more than 20 genes have been described, of which four can explain >50% of familial cases. This review is an update focused on major aspects of the field of ALS genetics concerning both causative and susceptibility factors.

A phase II-III trial of olesoxime in subjects with amyotrophic lateral sclerosis.

BACKGROUND AND PURPOSE: To assess the efficacy and safety of olesoxime, a molecule with neuroprotective properties, in patients with amyotrophic lateral sclerosis (ALS) treated with riluzole. METHODS: A double-blind, randomized, placebo-controlled, multicenter trial of 18 months' duration was conducted in 512 subjects, with probable or definite ALS and a slow vital capacity (SVC) ≥70%, receiving 330 mg olesoxime daily or matching placebo and 50 mg riluzole twice a day in all. The primary intention-to-treat (ITT) outcome analysis was 18 months' survival. Secondary outcomes were rates of deterioration of the revised ALS functional rating scale (ALSFRS-R), focusing on the 9-month assessment, SVC and manual muscle testing. Blood levels, safety and tolerability of olesoxime were also assessed. RESULTS: At 18 months, 154 of the 512 ITT patients had died (79 of 253 placebo, 75 of 259 olesoxime). Estimated overall survival according to Kaplan-Meier analysis was 67.5% (95% CI 61.0%-73.1%) in the placebo group and 69.4% (95% CI 63.0%-74.9%) in the olesoxime group; hence survival was not significantly different between treatment arms (P = 0.71, stratified bulbar/spinal log-rank). The other efficacy end-points evaluated were also negative, with the exception of a small difference in ALSFRS-R global score at 9 months in favor of olesoxime but not sustained after 18 months' treatment nor evident in either the stratified bulbar or spinal subpopulations. Treatment did not raise any safety concerns. CONCLUSIONS: Olesoxime, although well tolerated, did not show a significant beneficial effect in ALS patients treated with riluzole.

[Analysis of clinical pathway in changing and disabling neurological diseases]. / Analyse du parcours de santé au cours des maladies neurologiques handicapantes et évolutives.

Neurological diseases are characterized by the complexity of care and by a constant and changing disability. More and more frequently, their impact on the clinical pathway remains unknown. Seven postgraduate rehabilitation students (Master coordination du handicap, université Pierre-et-Marie-Curie, Paris) reconstructed the clinical pathway of 123 patients with various neurological diseases: multiple sclerosis, Alzheimer disease, amyotrophic lateral sclerosis, spinal trauma, Parkinson disease and brain tumors. There was a significant correlation between disease duration and the number of specialists involved in care, the number of prescribed drugs and the number of short-term hospitalizations; there was no correlation with age. This result suggests that with time an increasing number of complications related to the initial neurological disease developed. Hospitalization in rehabilitation units was highly correlated with the degree of disability and also with the help received by the patients during the course of their disease. This result suggests that these hospitalizations were a direct consequence of burn out among relatives. General practitioners (GP) were highly involved only during the initial part of the pathway, and their involvement rapidly declined thereafter, suggesting a probable relation with the specificities and the complexity of care for neurological diseases which induces a progressive transfer of responsibilities from the GP to the hospital. Social care was always incomplete and occurred too late during the course of the disease. The feeling by the patients that their care pathway was chaotic was highly correlated with the quality of the information given to the patient at the time of the announcement of their disease. This study confirms that cares for neurological diseases is highly specific and that expert centers and coordination networks are in a key position to ensure an efficient care pathway.

Elevated levels of IFNγ and LIGHT in the spinal cord of patients with sporadic amyotrophic lateral sclerosis.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a paralytic and fatal neurodegenerative disorder caused by the gradual loss of both upper and lower motoneurons. There is compelling evidence from ALS experimental models that neuroinflammation actively contributes to motoneuron damage. We recently proposed that interferon gamma (IFNγ), a potent proinflammatory cytokine, induces motoneuron death by eliciting the activation of the lymphotoxin beta receptor (LT-ßR) through its ligand LIGHT. Here, we explore the pertinence of this non-cell-autonomous mechanism in human ALS. METHODS: The levels and expression pattern of IFNγ, LIGHT, and LT-ßR were investigated by Western blot and immunohistochemical analysis in spinal cord of patients with sporadic ALS. RESULTS: We observed significant increased levels of IFNγ in human ALS spinal cords compared to control cases. We found that large ventral horn neurons as well as glial cells were immunoreactive for IFNγ in sporadic ALS spinal cord. We further observed that LIGHT and LT-ßR were expressed mainly by motoneurons in both ALS and control cases, and while LT-ßR levels remained constant between ALS and control cases, LIGHT levels were increased in human ALS spinal cords. CONCLUSION: These findings in sporadic ALS cases, which are consistent with the observation made in ALS experimental models, propose that the IFNγ-triggered LIGHT/LT-ßR-mediated death pathway may contribute to human ALS pathogenesis.

Contribution of TARDBP mutations to sporadic amyotrophic lateral sclerosis.

AIMS AND BACKGROUND: Mutations in the TARDBP gene, which encodes the TAR DNA binding protein (TDP-43), have been described in individuals with familial and sporadic amyotrophic lateral sclerosis (ALS). We screened the TARDBP gene in 285 French sporadic ALS patients to assess the frequency of TARDBP mutations in ALS. RESULTS: Six individuals had potentially deleterious mutations of which three were novel including a Y374X truncating mutation and P363A and A382P missense mutations. This suggests that TARDBP mutations may predispose to ALS in approximately 2% of the individuals followed in this study. CONCLUSION: Our findings, combined with those from other collections, brings the total number of mutations in unrelated ALS patients to 17, further suggesting that mutations in the TARDBP gene have an important role in the pathogenesis of ALS.

[Primary lateral sclerosis: the era of international diagnosis criteria]. / La sclérose latérale primitive : l'avènement de critères consensuels internationaux.

Since Charcot's first description, primary lateral sclerosis (PLS) remains a rare clinical syndrome, a neuropathological phenotype of motor system degeneration. In turn, PLS has been described as belonging to the large spectrum of motoneuron diseases or to the diverse degenerative diseases of the nervous system. Clinically, it is characterized by progressive pyramidal involvement in patients who present insidiously progressive gait disorders and, on examination, have relatively symmetrical lower limb weakness, increased muscle tone, pathologic hyper-reflexia, and exaggerated extensor plantar responses. Pinprick, light touch, and temperature sensations are preserved. Viewed in another way, PLS mimicks progressive hereditary spastic paraparesis (HSP) and the "central" phenotype of amyotrophic lateral sclerosis (ALS). PLS is considered "idiopathic" and, depending on the presence or absence of similarly affected family members, the syndrome of idiopathic HSP and ALS are labeled "hereditary" or "apparently sporadic". The juvenile form of PLS and early age at onset in cases of HSP complicate our understanding of the relationship between these two disorders. Guidelines for diagnosis and genetic counseling have been published for HSP and ALS. Recently, since the first international workshop, guidelines for diagnosis of PLS propose a classification system, e.g. for heterogeneous HSP into "pure PLS", complicated or "plus PLS", symptomatic PLS and upper motor neuron-dominant ALS. However, when reviewing known cases of PLS drawn from the literature, rigorous retrospective application of these new PLS criteria raises an unanswered question: does pure PLS exist?

[Parkinson disease and amyotrophic lateral sclerosis. Tauopathies, TDP-43 and SOD mutations]. / Syndromes parkinsoniens et sclérose latérale amyotrophique Tauopathies, TDP-43 et mutations SOD.

In addition to a large number of clinical descriptions of atypical cases, recent pathological, biochemical and genetic studies challenge the view that amyotrophic lateral sclerosis (ALS) is a disorder restricted to the pyramidal motor system. Relations between ALS, Parkinson disease, fronto-temporal dementia, progressive supranuclear paralysis, and cortico-basal degeneration have now been identified. We propose a review of the topic and discuss the contribution of various clinical and pathological features leading to consider motoneuron diseases as neurodegenerative processes included in a broad spectrum of tauopathies.

A decrease in blood cholesterol after gastrostomy could impact survival in ALS.

Although the global benefits of gastrostomy have been proven in amyotrophic lateral sclerosis (ALS), the impact on biological parameters has not been explored yet. The aim of this preliminary work was to evaluate the modification of biological parameters in patients with ALS undergoing gastrostomy. We retrospectively collected clinical and biological data from 44 patients having undergone gastrostomy at three time points (T0, T1 and T2: before, at the time of and after gastrostomy). We examined the relationship between the biological parameters and disease progression. Variations of the concentrations of total cholesterol significantly differed before (T1-T0) vs those after gastrostomy (T2-T1; P=0.0044). The variations of total cholesterol and low-density lipoprotein cholesterol concentrations after gastrostomy were negatively associated with survival (P=0.0002). This study showed for the first time that patients with ALS fed quite exclusively by gastrostomy had decreased blood cholesterol after gastrostomy. We suggest that a restoration of normal lipid metabolism should be planned in patients with ALS.

[Ethical aspects for substitute decisions and their reversion in amyotrophic lateral sclerosis]. / Aspects éthiques des décisions de suppléance et leur réversibilité.

Related to its clinical characteristics, amyotrophic lateral sclerosis (ALS) is a paradigm of the ethical difficulties due to a chronic and relentless fatal disease. Its fatal evolution in relation with a respiratory failure, but mainly the choices imposed by the respiratory insufficiency at the end of live, makes that the medical team faces very difficult situations. These situation can be solved only case per case, with repeated discussion with the patients and its relatives. The appeal to the shared dossier becomes essential in this approach. It makes easier the communication, and the appropriation and sharing of information and knowledge that are necessary to anticipate the end of life decisions. ALS sparks off constantly renewed dilemmas.

Characteristics of microtubules at the different stages of neuronal differentiation and maturation.

The developing nervous system has proved to be a very powerful tool to analyze how MT are involved in basic biological processes such as cell proliferation, cell migration, cell shaping, and transport. A better knowledge of the basic events occurring during neurogenesis also affords us the possibility of establishing the basis of experiments and trying to solve unanswered and important questions. Despite the considerable value of cell culture, we need to use more discrete regions of the developing brain in situ in order to analyze the MT and their modifications into cells developing their "natural" environment. One major problem remains the question of the mode of assembly and disassembly, that is, the behavior of MT in living cells. Dynamic instability and/or treadmilling are accurate interpretations of the dynamics of MT at least in vitro or in cell culture, but we do need more information on what happens in situ and in vitro. One of the main tasks of cell biologists is to devise satisfactory tests to approach this fundamental question. In this view, pharmacological manipulation of embryos treated in whole-embryo culture systems might be a possible way. Microtubules are ubiquitous cell components. However, the extensive heterogeneity of MAP and tubulin in the CNS confers on the neurons a wide range of capabilities of assembly of these proteins and suggests that the neuron has a unique potential of a relation between MT composition and cell function. We have seen that each major event during neurogenesis is related to a specific series of modifications of the MT components. It remains to be determined if there is a causal or just a correlative relationship between the appearance of specific isotypes and the occurrence of specific events and/or functions. We have also to determine the exact spatial and temporal relations among the different isotypes of MT proteins, tubulin, and MAP. Is there a close correspondence between a tubulin and a MAP isotype? Can the appearance of one isotype of tubulin influence the appearance and the assembly of a specific MAP, or vice versa? Recent results obtained with the Tyr- and Glu-MT shed light on these questions and suggest a whole series of possibilities for cells to modulate the structure, behavior, and function of MT in specific domains of the neuron or in specific regions of the brain, by only a minute modification of the molecule of tubulin. Microtubule protein heterogeneity raises also a number of questions.(ABSTRACT TRUNCATED AT 400 WORDS)

Postnatal modifications of the dendritic tree of cells in the inferior colliculus of the cat. A quantitative Golgi analysis.

Postnatal modifications of dendrites have been quantitatively studied by network analysis of the dendritic tree in the two central nuclei of the inferior colliculus in the cat. This analysis revealed cells with two types of branching patterns suggesting two different modes of growth. The predominant pattern is characterized by dichotomous branching on random segments (DR cells). However, a purely collateral branching pattern is particular to certain cells (CB cells). These two branching patterns were found in both nuclei of the IC in adult and young cats, but the exact significance of these two cell types remains unclear. The dendritic trees of cells in kittens differed from those of the adult cat. Also, the types of modification were different in the two functionally distinct nuclei of the inferior colliculus that we studied. The most dramatic modifications were observed in the dendritic tree of DR cells in the central nucleus, which receives fibers from the auditory nuclei in the brainstem. Two parameters were modified: the mean number of terminal segments and the mean total length of segments. Both parameters increased in the sagittal plane and decreased in the frontal plane. These modifications indicate a reorientation of the dendritic tree in the sagittal plane, along the incoming axons from the auditory nuclei. As these afferents become functionally mature only after birth, this spatial remodeling of the dendrites seems closely related to functional maturation of secondary auditory axons. In the dorsomedial nucleus that receives fibers from the auditory cortices, the dendritic tree of DR cells also undergoes spatial reorientation. This is more evident in the horizontal plane and with respect to the incoming axons. Our results suggest that the characteristic orientation of the dendritic tree of cells observed in the inferior colliculus of the adult cat is established only after the first postnatal weeks. This orientation seems to result from an active process of remodeling concomitant with the functional maturation of afferents, a fact already established for various cell types in the nervous system.

An analysis of extended survival in patients with amyotrophic lateral sclerosis treated with riluzole.

BACKGROUND: In an attempt to better understand and define the progression of amyotrophic lateral sclerosis (ALS), we developed a classification of 5 discrete health states that reflect patients' activities of daily living. These health states were used to determine whether patients with ALS who are treated with riluzole differed from those treated with placebo. SETTING: Clinics for patients with ALS. DESIGN: Placebo-controlled trial of riluzole treatment in 959 patients with ALS. INTERVENTIONS: Treatment with riluzole or placebo. MAIN DEPENDENT MEASURES: A Cox model was used to assess whether, from the initial randomization to the end of an 18-month follow-up, there was a difference in the times of transition into subsequent health states between patients treated with riluzole and those treated with placebo. RESULTS: Our analysis showed a significant difference in the time to transit between the riluzole and the placebo groups in less severely affected cases, ie, state 2 and state A (the milder states) of ALS. CONCLUSION: Patients receiving riluzole remained in the milder health states longer (P<.05).

Deletions causing spinal muscular atrophy do not predispose to amyotrophic lateral sclerosis.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a rapidly progressive, invariably lethal disease resulting from the premature death of motor neurons of the motor cortex, brainstem, and spinal cord. In approximately 15% of familial ALS cases, the copper/zinc superoxide dismutase gene is mutated; a juvenile form of familial ALS has been linked to chromosome 2. No cause has been identified in the remaining familial ALS cases or in sporadic cases and the selective neurodegenerative mechanism remains unknown. Deletions in 2 genes on chromosome 5q, SMN (survival motor neuron gene) and NAIP (neuronal apoptosis inhibitory protein gene), have been identified in spinal muscular atrophy, a disease also characterized by the loss of motor neurons. These genes are implicated in the regulation of apoptosis, a mechanism that may explain the cell loss found in the brains and spinal cords of patients with ALS. OBJECTIVE: To determine whether the mutations causing neurodegeneration in spinal muscular atrophy are present in patients with ALS in whom the copper/zinc superoxide dismutase gene is not mutated. PATIENTS AND METHODS: Patients in whom ALS was diagnosed were screened for mutations in the SMN and NAIP genes by single strand conformation analysis. RESULTS: We found 1 patient with an exon 7 deletion in the SMN gene; review of clinical status confirmed the molecular diagnosis of spinal muscular atrophy. No mutations were found in the remaining patients. CONCLUSION: The SMN and NAIP gene mutations are specific for spinal muscular atrophy and do not predispose individuals to ALS.

Modifications of microtubule proteins in ALS nerve precede detectable histologic and ultrastructural changes.

Fast axonal transport is altered in nerves from amyotrophic lateral sclerosis (ALS) patients. Microtubules are involved in axonal transport. We analyzed the possibility of an involvement of microtubule modifications underlying the alterations in transport using biochemical and morphologic analysis of intercostal nerves from ALS and control patients. In intercostal nerves displaying no morphologic signs of acute neuronal degeneration, two-dimensional gels showed modifications of the group of beta tubulins and abnormal spots of proteins, some appearing to be closely related to tau proteins. These results suggest that microtubule proteins are modified in ALS before ultrastructural axonal degeneration, but the significance of these abnormalities remains hypothetical.

A double-blind, placebo-controlled trial of high doses of gangliosides in amyotrophic lateral sclerosis.

We performed a 3-month, double-blind, placebo-controlled trial of 300 mg of gangliosides (Cronassial) in 40 outpatients with amyotrophic lateral sclerosis (ALS). We evaluated drug effect through physical examinations and symptom scales. Though this dosage had no major toxic effect, Cronassial treatment did not significantly benefit ALS patients.

Spinobulbar muscular atrophy can mimic ALS: the importance of genetic testing in male patients with atypical ALS.

The clinical presentation of amyotrophic lateral sclerosis (ALS) is variable and overlaps with that of other motor neuron diseases such as spinobulbar muscular atrophy (SBMA; Kennedy disease). With the identification of disease-specific mutations such as the CAG repeat expansion in the androgen receptor in SBMA, an accurate molecular diagnosis can be made in some patients with motor neuron disease. To determine the extent of misdiagnosis of ALS we screened 147 male ALS patients and 100 unrelated male patients from 100 familial ALS (FALS) kindreds for the presence of the SBMA mutation using polymerase chain reaction methods. We show that ALS was clinically misdiagnosed in 2% of sporadic cases and in two of the 100 FALS kindreds. This study underscores the difficulty in distinguishing SBMA from ALS clinically, particularly in patients who lack the classic signs of each disease.

A confirmatory dose-ranging study of riluzole in ALS. ALS/Riluzole Study Group-II.

ALS is a progressive motor neuron disease with no effective treatment. The anti-excitotoxic drug riluzole (100 mg/day) has been shown to decrease mortality and muscular deterioration in ALS patients. To confirm and extend the therapeutic effect of riluzole, we performed a double-blind, placebo-controlled, multicenter, international, dose-ranging (50, 100, 200 mg/day), stratified study in 959 ALS outpatients treated for up to 18 months. Primary efficacy criterion was survival and the effect of treatment was analyzed before (Wilcoxon and log rank tests) and after adjustment on prognostic factors (Cox model). Secondary efficacy criterion was disease progression assessed through change in functional measures. Tracheostomy-free survival rates were: 50.4% (placebo), 55.3% (50 mg riluzole) (p = 0.23, Wilcoxon test; p = 0.25, log-rank test), 56.8% (100 mg riluzole) (p = 0.05, Wilcoxon test; p = 0.076, log-rank test), and 57.8% (200 mg riluzole) (p = 0.061, Wilcoxon test; p = 0.075, log-rank test). At the end of the 18-month study, there was a significant dose-related decrease in risk of death or tracheostomy (p = 0.04). Adjustment for baseline prognostic factors showed a 35% decreased risk of death with the 100-mg dose compared with placebo (p = 0.002). No significant treatment effects were detected for the functional assessments. The most frequent dose-related adverse events included nausea, asthenia, and elevated liver enzyme levels. This study confirms the therapeutic effect of riluzole in a large representative ALS sample, over an 18-month period. Riluzole is well tolerated and decreases the risk of death or tracheostomy in ALS patients.

APOE: a potential marker of disease progression in ALS.

Although documented in AD, the role of APOE remains unclear in ALS. APOE phenotype and plasma levels were measured in 403 patients with ALS and were correlated with clinical parameters and survival time. No correlations were observed between the APOE phenotype and these variables. In contrast, APOE plasma levels were correlated with both rate of deterioration and survival time and appeared to be an important risk factor for decreased survival time with a relative risk of 0.647 (95% CI: 0.465 to 0.901; p = 0.01).

In situ analysis of the action of Navelbine on various types of microtubules using immunofluorescence.

Preliminary clinical studies demonstrated that 5' nor-anhydro-vinblastine, Navelbine (NVB) has a broader antitumor activity and fewer neurotoxic effects than vinblastine or vincristine. The tectal plate anlage of mouse embryos at the earliest stages of neuronal differentiation were used to analyze and compare the effect of NVB, vincristine and vinblastine on axonal and mitotic microtubules after culture of post-implantation embryos in a medium containing the agent. All drugs are active on mitotic microtubules at the same concentration (0.1 mumol/L), inducing a depolymerization of microtubules and a blockade of cells at metaphase. At higher concentrations. NVB is the only one of the three drugs that induces a blockade of the cells at prophase. A depolymerization of axonal microtubules occurs at higher concentrations with NVB than with the two other vinca alkaloids. These results demonstrate that NVB is as active on mitotic microtubules and less active on axonal microtubules than vincristine and vinblastine. These findings can be related to the potent antitumor effect of the drug with minor neurotoxicity.