2-Deoxy-2-[18 F]fluoro-d-glucose positron emission tomography, cortical thickness and white matter graph network abnormalities in brains of patients with amyotrophic lateral sclerosis and frontotemporal dementia suggest early neuronopathy rather than axonopathy.

BACKGROUND AND PURPOSE: Amyotrophic lateral sclerosis (ALS) is a motor neuron disorder, although extra-motor degeneration is well recognized, especially in frontotemporal regions manifested as ALS with frontotemporal dementia (ALS-FTD). Previous neuroimaging studies of the brains of ALS-FTD patients have measured abnormalities of either grey matter (GM) or white matter (WM) structures but not of both together. Therefore, the aim was to evaluate both GM and WM in the same ALS-FTD patient using functional and structural neuroimaging. By doing so, insights could be gained into whether neurodegeneration in ALS-FTD is primarily a neuronopathy or axonopathy. METHODS: After high-resolution brain 2-deoxy-2-[18 F]fluoro-D-glucose (18 F-FDG) positron emission tomography (PET) and magnetic resonance imaging (MRI) scans were obtained in ALS-FTD patients and in age- and sex-matched neurological controls, changes in metabolic rate, cortical thickness (CT) and WM network analysis using graph theory were analyzed. RESULTS: Significant reductions in 18 F-FDG PET metabolism, CT and WM connections were observed in motor and extra-motor brain regions of ALS-FTD patients compared to controls. Both CT and underlying WM networks were abnormal in frontal, temporal, parietal and occipital lobes of ALS-FTD patients with 86 of 90 brain regions showing reductions of CT. CONCLUSION: Abnormalities in significantly fewer WM networks underlying the affected cortical regions suggest that neurodegeneration in brains of ALS-FTD patients is primarily a 'neuronopathy' rather than an 'axonopathy.'

Assessment of bulbar function in amyotrophic lateral sclerosis: validation of a self-report scale (Center for Neurologic Study Bulbar Function Scale).

BACKGROUND AND PURPOSE: Impaired bulbar functions of speech and swallowing are among the most serious consequences of amyotrophic lateral sclerosis (ALS). Despite this, clinical trials in ALS have rarely emphasized bulbar function as an endpoint. The rater-administered Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) or various quality-of-life measures are commonly used to measure symptomatic benefit. Accordingly, we sought to evaluate the utility of measures specific to bulbar function in ALS. METHODS: We assessed bulbar functions in 120 patients with ALS, with clinicians first making direct observations of the degree of speech, swallowing and salivation impairment in these subjects. Clinical diagnosis of bulbar impairment was then compared with ALSFRS-R scores, speech rate, time to swallow liquids and solids, and scores obtained when patients completed visual analog scales (VASs) and the newly-developed 21-question self-administered Center for Neurologic Study Bulbar Function Scale (CNS-BFS). RESULTS: The CNS-BFS, ALSFRS-R, VAS and timed speech and swallowing were all concordant with clinician diagnosis. The self-report CNS-BFS and ALSFRS-R bulbar subscale best predicted clinician diagnosis with misclassification rates of 8% and 14% at the optimal cut-offs, respectively. In addition, the CNS-BFS speech and swallowing subscales outperformed both the bulbar component of the ALSFRS-R and speech and swallowing VASs when correlations were made between these scales and objective measures of timed reading and swallowing. CONCLUSIONS: Based on these findings and its relative ease of administration, we conclude that the CNS-BFS is a useful metric for assessing bulbar function in patients with ALS.

Similarities in the ultrastructural distribution of nerve growth factor receptor-like immunoreactivity in cerebellar Purkinje cells of the neonatal and colchicine-treated adult rat.

The intracellular distribution of nerve growth factor receptor immunoreactivity was examined by electron microscopy in the cerebellum of adult and postnatal day 12 rats. The very faint immunostaining in Purkinje cells of naive adult animals was greatly amplified after colchicine treatment. Neonatal cerebellum, in contrast, contained prominent immunoreactivity in both Purkinje cells and germinal cells of the external granular layer. Intracellular distribution of the nerve growth factor receptor reaction product was very similar in Purkinje cells of both neonatal and colchicine-treated adult animals. It was consistently present along the perikaryal cell membrane, in segments of the rough endoplasmic reticulum and Golgi complex. Numerous membrane-bound aggregates of immunoreactive vesicles resembling multivesicular bodies (secondary lysosomes) were scattered throughout the cell soma, although less frequently in neonatal rats. Bulbous expansions along the proximal axons of colchicine-treated Purkinje cells were filled with such immunoreactive multivesicular bodies. These cells also displayed evidence of nerve growth factor receptor internalization in the form of immunoreactive coated vesicles situated near the cell membrane. In addition to the staining in Purkinje cells, neonatal cerebellum contained high amounts of nerve growth factor receptor reaction product along the cell membrane of germinal cells in the external granular layer. Although Purkinje cells of naive adult animals possessed little or no cell membrane-related nerve growth factor receptor immunoreactivity, reaction product was sometimes seen in cisternae of the rough endoplasmic reticulum and Golgi apparatus. These findings provide electron microscopic immunocytochemical evidence of nerve growth factor receptor synthesis, internalization, and catabolism in noncholinergic neurons of the central nervous system.

Detection of cortical neuron loss in motor neuron disease by proton magnetic resonance spectroscopic imaging in vivo.

We performed proton magnetic resonance spectroscopic imaging (1H-MRSI) in patients with motor neuron disease (MND) to evaluate the distribution and extent of cortical neuron damage or loss as reflected by decreased N-acetyl (NA) to creatine (Cr) resonance intensity ratios. We examined premotor (superior frontal gyrus), primary motor (precentral gyrus), primary sensory (postcentral gyrus), and parietal (superior parietal gyrus/precuneus) neocortical regions of 12 patients with MND and six normal control subjects. Patients with MND were representative of three syndromes: amyotrophic lateral sclerosis (ALS) with definite lower motor neuron and upper motor neuron signs, MND with probable upper motor neuron signs (PUMNS), and progressive spinal muscular atrophy (PSMA) with lower motor neuron signs only. Compared with healthy controls, ALS patients had a significant decrease in NA/Cr resonance intensity ratios, most prominently in the primary motor cortex (p < 0.001) but also, to varying degrees, in primary sensory (p < 0.01), posterior premotor, and parietal (p < 0.05) regions. Patients classified as ALS-PUMNS showed less prominent reduction in NA/Cr ratios in the same regions; patients with PSMA had normal cortical NA/Cr ratios. Sequential studies in one patient suggested that 1H-MRSI could document progression of the NA/Cr abnormality. Decreased NA/Cr ratios on 1H-MRSI provide an index of cortical motor neuron loss and/or dysfunction in MND patients. Clinical applications of 1H-MRSI could include documenting the extent of upper motor neuron involvement, aiding diagnosis of syndromes presenting with an ALS-like picture, and monitoring disease progression.

1H-MRS evidence of neurodegeneration and excess glutamate + glutamine in ALS medulla.

OBJECTIVE: To determine whether short echo-time (TE) proton magnetic resonance spectroscopic imaging (1H-MRSI) can detect in vivo differences in signal intensities of specific metabolites in the medulla of patients with ALS compared with healthy individuals and whether these metabolites could be useful surrogate markers of disease. BACKGROUND: 1H-MRSI can detect N-acetylaspartate + N-acetylaspartylglutamate (abbreviated NAx), which is localized to neurons, and glutamate (Glu) + glutamine (Gln), abbreviated Glx, which may be important in ALS pathogenesis. The medulla is an ideal region to study ALS because of its high density of nuclei and fiber tracts that frequently undergo degeneration, even when more rostral brain regions show minimal pathology. METHODS: Ten patients with ALS and seven healthy control subjects underwent short TE 1H-MRSI on a 1.5 T clinical imaging system. Signal intensities of NAx and Glx were normalized to creatine-phosphocreatine and compared between groups. RESULTS: Compared with normal subjects, the medulla of patients with ALS had 17% lower NAx (p = 0.03) and 55% higher Glx (p = 0.02) signals. Bulbar symptoms, represented by the ALS Functional Rating Scale, correlated with Glx (r = -0.68, p = 0.03) but not NAx (r = 0.22, p = 0.53). CONCLUSION: There is in vivo 1H-MRSI evidence of neuronal degeneration or loss and excess Glu + Gln in the medulla of patients with ALS. Although this cross-sectional study cannot identify which change occurred first, the higher Glx signal in the medulla of patients with more dysarthria and dysphagia is consistent with the hypothesis of Glu excitotoxicity in ALS pathogenesis. Longitudinal 1H-MRSI studies of the medulla (and other brain regions) in more patients with ALS are required to confirm these findings and to determine whether such metabolite changes will be useful in monitoring disease progression, in clinical diagnosis, and in understanding the pathogenesis of ALS.

Distribution of nerve growth factor receptor-like immunoreactivity in the adult rat central nervous system. Effect of colchicine and correlation with the cholinergic system--I. Forebrain.

Nerve growth factor receptor, as recognized by the monoclonal antibody 192-IgG, was localized to multiple regions of the adult rat forebrain. Immunoreactive cell bodies and fibers were seen in both sensory and motor regions which are known to contain cholinergic and non-cholinergic neurons. Specifically, nerve growth factor receptor immunoreactivity was present in cells lining the olfactory ventricle, rostral portion of the lateral ventricle, in basal forebrain nuclei, caudate putamen, globus pallidus, zona incerta and hypothalamus. Immunoreactive cells which were situated subpially along the olfactory ventricle and anterior portions of the lateral ventricle, and in the arcuate nucleus resembled neuroglia but could not definitively identified at the light microscopic level. Animals pretreated with intracerebroventricular colchicine displayed significantly increased nerve growth factor receptor immunoreactivity in all previously positive neurons and particularly in the medial preoptic area and ventral premammillary nucleus of the hypothalamus. In such animals, receptor immunoreactivity also appeared in previously non-immunoreactive cells of the hippocampal CA3 region and polymorph layer of the dentate gyrus as well as in the mitral cell layer of the olfactory bulb. Nerve growth factor receptor-immunoreactive fibers and varicosities were seen in the olfactory bulb, piriform cortex, neocortex, amygdala, hippocampus, thalamus, olivary pretectal nucleus and hypothalamus. In most regions, such fiber-like immunoreactive structures likely represented axon terminals, although in some areas, neuroglial or extracellular localizations could not be excluded. In this context, diffuse, non-fibrillar receptor immunoreactivity occurred in the lateral habenular nucleus and medial terminal nucleus of the accessory optic tract. Furthermore, intense nerve growth factor receptor immunoreactivity occurred along certain regions of the pial surface on the ventral surface of the brain. The distribution of nerve growth factor receptor-immunoreactive cell bodies and fibers in multiple sensory and motor nuclei suggests wide-spread influences of nerve growth factor throughout the adult rat forebrain. There is a high degree of overlap with regions containing choline acetyltransferase immunoreactivity. However, significant disparities exist suggesting that certain nerve growth factor receptor-containing non-cholinergic neurons of the rat forebrain may also be affected by nerve growth factor.

Distribution of nerve growth factor receptor-like immunoreactivity in the adult rat central nervous system. Effect of colchicine and correlation with the cholinergic system--II. Brainstem, cerebellum and spinal cord.

Multiple nuclei and fiber tracts in the adult rat brainstem and spinal cord were found to contain nerve growth factor receptor-related protein, as recognized by the monoclonal antibody 192-IgG. Both cholinergic and non-cholinergic sensory and motor regions demonstrated immunoreactive cell bodies and fibers. Nerve growth factor receptor-immunoreactive cells were seen in the mesencephalic nucleus of trigeminal nerve, superior colliculus, parabrachial, prepositus hypoglossal, raphe, dorsal and ventral cochlear, interstitial nucleus of the vestibular nerve, ambiguus and reticular nuclei, cerebellum and ventral spinal cord. Immunoreactive cells resembling neuroglia were distributed subpially along the superior colliculus. Intracerebroventricular injection of colchicine resulted in significantly increased nerve growth factor receptor immunoreactivity in all previously positive neurons and especially in certain neurons of the cochlear and ambiguus nuclei. It also resulted in the visualization of receptor immunoreactivity in certain neurons which were normally non-immunoreactive including cerebellar Purkinje cells, neurons of the central gray, locus coeruleus, facial, dorsal motor vagal and hypoglossal nuclei. In normal animals, nerve growth factor receptor-immunoreactive fibers and varicosities occurred in the trigeminal nerve nuclei, pontine, vestibular, parabrachial, facial, hypoglossal, dorsal motor vagal, solitary, gracile and cuneate nuclei and spinal cord. Although most fiber-like immunoreactive structures were probably axons and nerve terminals, neuroglial or extracellular localizations could not be excluded in some areas. For example, the medial nucleus of the inferior olive and most cerebellar nuclei contained diffuse non-fibrillar receptor immunoreactivity. The presence of nerve growth factor receptor-like immunoreactivity in cell bodies and fibers of several sensory and motor areas of the adult rat brainstem, cerebellum and spinal cord suggests multifocal actions of nerve growth factor or a nerve growth factor-like substance. Although the degree of overlap between nerve growth factor receptor- and choline acetyltransferase-containing regions in the brainstem is not as great as in the forebrain, our findings suggest a potential influence of nerve growth factor or nerve growth factor-like substances on cholinergic systems outside the forebrain. Furthermore, the disparities which occur imply that non-cholinergic nerve growth factor receptor-containing neurons of the brainstem, cerebellum and spinal cord may be affected by such trophic substances.

Long-term protective effects of human recombinant nerve growth factor and monosialoganglioside GM1 treatment on primate nucleus basalis cholinergic neurons after neocortical infarction.

Neocortical infarction induces biochemical and morphological retrograde degenerative changes in cholinergic neurons of the rat nucleus basalis magnocellularis [Sofroniew et al. (1983) Brain Res. 289, 370-374]. In the present study, this lesion model has been reproduced in the non-human primate (Cercopithecus aethiops) to investigate whether degenerative changes affecting the cortex surrounding the lesioned area and the ipsilateral basal forebrain are prevented by the early administration of recombinant human nerve growth factor alone or in combination with the monosialoganglioside GM1. Six months after surgery and treatment, the monkeys were processed either for biochemistry (choline acetyltransferase assay) or immunocytochemistry. In lesioned vehicle-treated animals, choline acetyltransferase activity significantly decreased by 28% in the cortex surrounding the injured area and by 31% in the ipsilateral nucleus basalis of Meynert when compared with values of sham-operated monkeys. These biochemical changes were fully prevented with the administration of nerve growth factor alone or in combination with the monosialoganglioside GM1. The morphometrical analysis revealed a significant shrinkage of cholinergic neurons (61 +/- 1.4% of sham-operated cell size) and loss of neuritic processes (59 +/- 10% of sham-operated values) within the intermediate nucleus basalis region of lesioned vehicle-treated animals. Although a protection of the cholinergic cell bodies within the nucleus basalis was found with both treatments, a significant recovery of the neuritic processes (84 +/- 7.2% of sham-operated values) was assessed only in the double-treated monkeys. These results indicate that the early administration of nerve growth factor alone or in combination with the monosialoganglioside GM1 induces a long-term protective effect on the nucleus basalis cholinergic neurons in cortical injured non-human primates.

Primate nucleus basalis of Meynert p75NGFR-containing cholinergic neurons are protected from retrograde degeneration by the ganglioside GM1.

The effects of unilateral devascularizing lesions of the neocortex in primates (Cercopithecus aethiops) on the immunoreactivity of choline acetyltransferase and the low-affinity nerve growth factor receptor (p75NGFR) were investigated in cell bodies of the nucleus basalis of Meynert. Choline acetyltransferase enzymatic activity was measured in the dissected ipsi- and contralateral nucleus basalis of Meynert as well as in the remaining cortex adjacent to the lesion. Cortically lesioned animals displayed a shrinkage of p75NGFR-immunoreactive cholinergic cell bodies in only the intermediate portion of the nucleus basalis of Meynert as well as a depletion of choline acetyltransferase activity in this cellular complex. In contrast, cortically lesioned monkeys treated with monosialoganglioside did not reveal a significant loss of choline acetyltransferase activity or shrinkage of nucleus basalis of Meynert cholinergic neurons, but rather a modest hypertrophy. These results are discussed in relation to a possible use of putative trophic agents in the repair of the damaged central nervous system.

Cellular and subcellular localization of nerve growth factor receptor-like immunoreactivity in the rat CNS.

The cellular actions of nerve growth factor (NGF) are known to be mediated through specific binding sites located on the cell membrane-bound NGF receptor (NGFr). Binding studies have revealed a high and a low affinity form of the NGFr although only the high affinity form is internalized. Most of the identified physiological effects of NGF appear to require internalization of the NGF-NGFr complex although details of subsequent events are still unclear. Since the relatively recent discovery that NGF exerts neurotrophic effects on cholinergic neurons of the rat basal forebrain, in addition to its previously known actions on sympathetic and sensory neurons of the peripheral nervous system, numerous morphological studies have localized the NGFr to such neurons in the forebrain. While the cellular localization of high affinity binding-sites using [(125)I]NGF radioautography has limitations of morphological resolution, NGFr immunoreactivity (IR) demonstrated by a monoclonal antibody, 192-IgG, may represent an epitope common to both low and high affinity forms of the NGFr and, possibly, one occurring in other related neurotrophic factor receptors. We have demonstrated NGFr-IR in neurons not only of the cholinergic basal forebrain nuclei but also of several other regions in the rat central nervous system, several of which are non-cholinergic. The use of colchicine to block the somatofugal transport of NGFr has revealed NGFr-IR in specific non-cholinergic neuronal populations where otherwise little or none is seen. These findings expand on the notion that NGF effects are not restricted to cholinergic neurons. Immunoelectron microscopy of nucleus basalis magnocellularis neurons has allowed identification of the subcellular sites of NGFr protein synthesis, modification, packaging and possible catabolism. We have also observed NGFr-IR within coated vesicles suggesting receptor internalization. Our ultrastructural observations demonstrate the utility of 192-IgG in studying the intracellular compartmentalization of NGFr reaction product and provide further evidence that 192-IgG labels an epitope common to both the low and high affinity NGFr.

Neuronal pathology in the wobbler mouse brain revealed by in vivo proton magnetic resonance spectroscopy and immunocytochemistry.

Proton magnetic resonance spectroscopy (1H-MRS) was used to measure the in vivo signal of N-acetylaspartate (NAA), a putative neuronal marker, in the brain of the mutant wobbler mouse, a model of motor neuron disease. The ratio of NAA to creatine-phosphocreatine, an internal standard, was significantly lower in five affected wobbler mice (0.79+/-0.05; mean+/-s.d.) than in five unaffected littermates (0.98+/-0.10, p = 0.006). Ubiquitin and phosphorylated heavy neurofilament immunoreactivities were increased in cortical neurons of affected animals. This is the first demonstration of cerebral neuronal pathology in the wobbler mouse, supporting its use as a model of amyotrophic lateral sclerosis. In vivo IH-MRS and correlative postmortem study of wobbler mouse brain will allow temporal monitoring of neuronal degeneration and responsiveness to neuroprotective pharmacotherapies.

Purkinje cells of adult rat cerebellum express nerve growth factor receptor immunoreactivity: light microscopic observations.

Adult rat cerebellum was examined for the presence of nerve growth factor receptor (NGFr) immunoreactivity (IR) using the monoclonal antibody 192-IgG. In normal animals, light NGFr-IR was observed consistently in Purkinje cells and molecular layer throughout the flocculonodular lobe. However, animals treated with intracerebroventricular colchicine 7-72 h prior to analysis displayed a graded increase of IR in Purkinje cells of all regions with progressively longer survival times. These findings demonstrate the usefulness of colchicine in revealing accumulation of NGFr in adult CNS neurons where previously not visualized and suggest responsiveness of a non-cholinergic neuronal population to nerve growth factor (NGF).

Neocortical infarction in subhuman primates leads to restricted morphological damage of the cholinergic neurons in the nucleus basalis of Meynert.

The aim of the present study was to investigate the long-term effect of cortical infarction on the subhuman primate (Cercopithecus aethiops) basal forebrain. The lesion, carried out by cauterizing the pial blood vessels supplying the left fronto-parieto-temporal neocortex, induced retrograde degenerative processes within the ipsilateral nucleus basalis of Meynert. The morphometrical analysis revealed that significant shrinkage of cholinergic neurons and loss of neuritic processes were localized within the intermediate regions of the nucleus basalis. The average cross-sectional areas of choline acetyltransferase-immunoreactive neurons in the intermedio-ventral (Ch4iv) and intermedio-dorsal (Ch4id) nucleus basalis were decreased to 62.5 +/- 9.5 and 58.0 +/- 8.6%, respectively, of the sham-operated values. Although an apparent loss of Nissl-stained magnocellular neurons in Ch4iv and Ch4id was found by applying a quantitative analysis based on a perikaryal-size criterion, data obtained by the quantification of immunostained material failed to reveal any significant decrease of cholinergic cell density. Results are discussed in view of future application of this ischemic model to study processes of retrograde degeneration following cortical target removal and to assess potential neurotrophic and neuroprotective properties of pharmacologic agents.

Loss of substance P and enkephalin immunoreactivity in the human substantia nigra after striato-pallidal infarction.

Post-mortem neuropathological material from 3 patients with striato-pallidal infarction provided the first immunohistochemical evidence for substance P- and enkephalin-containing nerve fibre projections from the striato-pallidum to the substantia nigra in the human. The nigra corresponding to the normal side showed abundant substance P and enkephalin immunoreactivity whose patterns of immunostaining were notably similar. In contrast, the substantia nigra ipsilateral to the striato-pallidal infarction showed a decrease in substance P and enkephalin immunoreactivity which was proportional to the extent of the infarction. This suggests that much of the substance P and enkephalin immunoreactivity in the nigra is present in nerve fibres projecting from the striato-pallidum. Furthermore, the similar distribution of remaining substance P and enkephalin immunoreactivity in corresponding areas of the nigra of the infarcted side indicates that the origins and/or projections of nerve fibres containing these two neuropeptides may be closely approximated anatomically. Depletion of substance P immunoreactivity in the pars reticulata of the substantia nigra in a fourth patient with anterior striatal infarction suggests a topographic projection for substance P immunoreactive fibres from the striatum. There is some evidence in one patient with cognitive and behavioural abnormalities to support the suggestion that the basal ganglia may be involved in non-motor functions.

Immunoelectron microscopic evidence of nerve growth factor receptor metabolism and internalization in rat nucleus basalis neurons.

Nerve growth factor receptor (NGFr) immunoreactive neurons of the adult rat nucleus basalis magnocellularis were examined by electron microscopy. Prominent NGFr immunoreactivity (IR) was consistently present along the perikaryal cell membrane and frequently in intracellular sites of protein synthesis and modification such as the rough endoplasmic reticulum and Golgi apparatus, respectively. Immunoperoxidase reaction product was also seen along the nuclear membrane. Membrane-bound aggregates of immunoreactive vesicles were scattered throughout the perikaryon, being more concentrated in the perinuclear region and in the proximal neurites. These may represent either aggregates of receptor-containing vesicles on their way to/from the cell membrane or secondary lysosomes where NGFr reaction product is degraded. Immunostained cytoplasmic vesicles which possessed an electron-dense coat and were adjacent to or contiguous with the plasmalemma probably represented internalized receptor. This ultrastructural study of the subcellular distribution of NGFr-IR in basal forebrain neurons therefore demonstrates sites of receptor metabolism and potential receptor-ligand interaction.

Demonstration of substance P immunoreactivity in the nucleus dorsalis of human spinal cord.

Substance P immunoreactivity has been detected in varicosities around cell bodies of the nucleus dorsalis (Clarke's column) of the human spinal cord. This immunostaining probably represents neuropeptide immunoreactivity either in the nerve terminals of spinal interneurone, descending projections or in the primary dorsal root afferents which have been shown previously to synapse with the neurones of Clarke's column. The presence of substance P immunoreactivity in the human nucleus dorsalis suggests a role of substance P in the transmission of proprioceptive and exteroceptive information from the lower trunk and limbs to the cerebellum.

Loss of substance P immunoreactivity in the nucleus of the spinal trigeminal tract after intradural tumour compression of the trigeminal nerve.

The peptide, substance P (SP), is suspected of being a mediator of nociception. Immunoreactive SP is conspicuously present in areas of the mammalian central nervous system which receive nociceptive input. We have observed that compression of the trigeminal nerve by an intradural tumour deposit results in the ipsilateral depletion of SP immunoreactivity in human spinal trigeminal nucleus. These results expand previous experimental animal studies which associate this peptide with a subpopulation of primary sensory neurones and, in addition, demonstrate a correlation between the levels of SP immunoreactivity and premortem clinical sensory alterations.

MR spectroscopy in amyotrophic lateral sclerosis/motor neuron disease.

Proton magnetic resonance spectroscopy (1H-MRS) and proton magnetic resonance spectroscopic imaging (1H-MRSI) have been used to identify neuronal dysfunction and/or loss in vivo in patients with various neurological diseases, including amyotrophic lateral sclerosis/motor neuron disease (ALS/MND). Both long and short echo time (TE) proton spectroscopy reveal the brain metabolites choline (Cho), creatine/phosphocreatine (Cr), and N-acetyl (NA) groups. Because NA groups are localized to mature neurons and Cr is homogeneously distributed throughout the brain, the NA/Cr ratio is considered an index of neuronal integrity. Long TE proton spectroscopic studies have revealed significantly decreased NA/Cr values in the sensorimotor cortex and brainstem of patients with ALS, consistent with neuronal dysfunction and/or loss. The amount of NA/Cr decrease appears to be directly proportional to the degree of clinical upper motor neuron deficit. Short TE 1H-MRS and 1H-MRSI also reveal other metabolites such as glutamate (Glu) and glutamine (Gln), which have been implicated in the ALS/MND disease process. Preliminary results of short TE 1H-MRSI of the medulla in patients with ALS/MND have revealed significantly decreased NA/Cr values and abnormally elevated Glu+Gln/Cr ratios, compared to control individuals. The latter values were higher in patients with more rapid disease. Although it is unclear whether the elevation of Glu+Gln/Cr precedes or follows the neuronal (and axonal) degeneration in the medulla of these patients, its occurrence provides in vivo evidence of abnormal glutamate metabolism in the CNS parenchyma of patients with ALS/MND.

Combined thyrotroph and lactotroph cell hyperplasia simulating prolactin-secreting pituitary adenoma in long-standing primary hypothyroidism.

Primary hypothyroidism accompanies more than 50% of clinically significant pituitary thyrotroph adenomas. Hypothyroidism may also produce pituitary enlargement secondary to thyrotroph hyperplasia and present with a sellar mass and hyperprolactinemia. Three hypothyroid patients who presented with presumed prolactin-producing adenomas are reported. Although laboratory and radiologic abnormalities of pituitary enlargement may resolve after corrective thyroid therapy, our patients showed no such response and underwent operation. Histologic examination revealed no adenomas, but thyrotroph and lactotroph hyperplasia were present. Thyrotroph hyperplasia probably results from lack of negative feedback of thyroid hormone upon the anterior pituitary. Whether this is due to hypothalamic release of thyrotropin-releasing hormone (TRH) or another mechanism is unclear. Lactotroph hyperplasia may result from excess TRH, which stimulates lactotrophs with resultant hyperprolactinemia, or from reduced hypothalamic dopamine, thereby facilitating prolactin secretion. This study suggest that (a) hyperprolactinemia in hypothyroidism is not necessarily due to the "stalk section effect" secondary to pituitary enlargement, and (b) patients with primary hypothyroidism and sellar mass should initially be managed medically so that potentially reversible pituitary hyperplasia is not mistaken for adenoma.