Brain-reactive antibodies and disease.

Autoimmune diseases currently affect 5-7% of the world's population; in most diseases there are circulating autoantibodies. Brain-reactive antibodies are present in approximately 2-3% of the general population but do not usually contribute to brain pathology. These antibodies penetrate brain tissue only early in development or under pathologic conditions. This restriction on their pathogenicity and the lack of correlation between serum titers and brain pathology have, no doubt, contributed to a delayed appreciation of the contribution of autoantibodies in diseases of the central nervous system. Nonetheless, it is increasingly clear that antibodies can cause damage in the brain and likely initiate or aggravate multiple neurologic conditions; brain-reactive antibodies contribute to symptomatology in autoimmune disease, infectious disease, and malignancy.

Caspr2-reactive antibody cloned from a mother of an ASD child mediates an ASD-like phenotype in mice.

Autism spectrum disorder (ASD) occurs in 1 in 68 births, preferentially affecting males. It encompasses a group of neurodevelopmental abnormalities characterized by impaired social interaction and communication, stereotypic behaviors and motor dysfunction. Although recent advances implicate maternal brain-reactive antibodies in a causative role in ASD, a definitive assessment of their pathogenic potential requires cloning of such antibodies. Here, we describe the isolation and characterization of monoclonal brain-reactive antibodies from blood of women with brain-reactive serology and a child with ASD. We further demonstrate that male but not female mice exposed in utero to the C6 monoclonal antibody, binding to contactin-associated protein-like 2 (Caspr2), display abnormal cortical development, decreased dendritic complexity of excitatory neurons and reduced numbers of inhibitory neurons in the hippocampus, as well as impairments in sociability, flexible learning and repetitive behavior. Anti-Caspr2 antibodies are frequent in women with brain-reactive serology and a child with ASD. Together these studies provide a methodology for obtaining monclonal brain-reactive antibodies from blood B cells, demonstrate that ASD can result from in utero exposure to maternal brain-reactive antibodies of single specificity and point toward the exciting possibility of prognostic and protective strategies.

Preserved corticospinal conduction without voluntary movement after spinal cord injury.

STUDY DESIGN: Case report. OBJECTIVES: To identify preserved corticomotor connection in chronic spinal cord injury (SCI) in the absence of clinically observable movement. SETTING: Rehabilitation Hospital and Medical Research Institute, NY, USA. METHODS: The motor-evoked potential (MEP) response to transcranial magnetic stimulation (TMS) was recorded using surface electromyography from the right biceps brachii, extersor carpi radialis (ECR), flexor carpi radialis (FCR) and abductor pollicis brevis (APB) muscles in a 31-year-old male traumatic SCI chronic patient-ASIA B, injury level C5. Motor power scores were additionally obtained from a clinician blinded to the results of TMS. RESULTS: TMS could consistently elicit MEPs of normal latency, phase and amplitude, in the severely affected ECR muscle but not the similarly affected FCR muscle. The response in proximal and unaffected biceps muscle was larger than the healthy subject, whereas no response was obtained in the distal APB muscle as expected. CONCLUSION: TMS can identify residual pathways not apparent from clinical assessment alone, which may have prescriptive value for rehabilitation.

Moving towards a cure: blocking pathogenic antibodies in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is characterized by the presence of autoantibodies that can mediate tissue damage in multiple organs. The underlying aetiology of SLE autoantibodies remains unknown, and treatments aimed at eliminating B cells, or limiting their function, have demonstrated limited therapeutic benefit. Thus, the current therapies for SLE are based on the concept of nonspecific immunosuppression and consist of nonsteroidal anti-inflammatory drugs (NSAIDS), corticosteroids, anti-malarials and cytotoxic drugs, all of which have serious adverse side effects including organ damage. The major auto-specificity in SLE is double-stranded (ds) DNA. Many anti-dsDNA antibodies cross-react with non-DNA antigens that may be the direct targets for their pathogenic activity. Studying anti-dsDNA antibodies present in SLE patients and in animal models of lupus, we have identified a subset of anti-dsDNA antibodies which is pathogenic in the brain as well as in the kidney. We have recently demonstrated that specific peptides, or small molecules, can protect target organs from antibody-mediated damage. Thus, it might be possible to treat the aspects of autoimmune disease without inducing major immunosuppression and ensuing infectious complications.

A subset of lupus anti-DNA antibodies cross-reacts with the NR2 glutamate receptor in systemic lupus erythematosus.

In systemic lupus erythematosus, antibodies against double-stranded DNA are a major contributor to renal disease. We have previously demonstrated that the pentapeptide Asp/Glu-Trp-Asp/Glu-Tyr-Ser/Gly is a molecular mimic of double-stranded DNA. This sequence is also present in the extracellular domain of murine and human NMDA (N-methyl-D-aspartate) receptor subunits NR2a and NR2b. Here we show that the NR2 receptor is recognized by both murine and human anti-DNA antibodies. Moreover, anti-DNA antibodies with this cross-reactivity mediate apoptotic death of neurons in vivo and in vitro. Finally, we show that the cerebrospinal fluid of a patient with systemic lupus erythematosus contains these antibodies and also mediates neuronal death via an apoptotic pathway. These observations indicate that lupus antibodies cross-react with DNA and NMDA receptors, gain access to cerebrospinal fluid and may mediate non-thrombotic and non-vasculitic abnormalities of the central nervous system.

Raised corticomotor excitability of M1 forearm area following anodal tDCS is sustained during robotic wrist therapy in chronic stroke.

PURPOSE: Anodal transcranial direct current stimulation (tDCS) can transiently increase corticomotor excitability of intrinsic hand muscles and improve upper limb function in patients with chronic stroke. As a preliminary study, we tested whether increased corticomotor excitability would be similarly observed in muscles acting about the wrist, and remain present during robotic training involving active wrist movements, in six chronic stroke patients with residual motor deficit. METHODS: Transcranial magnetic stimulation (TMS) generated motor evoked potentials (MEP) in the flexor carpi radialis (FCR) and provided a measure of corticomotor excitability and short-interval cortical inhibition (SICI) before and immediately after a period of tDCS (1 mA, 20 min, anode and TMS applied to the lesioned hemisphere), and robotic wrist training (1hr). RESULTS: Following tDCS, the same TMS current strength evoked an increased MEP amplitude (mean 168 +/- 22%SEM; p < 0.05), that remained increased after robot training (166 +/- 23%; p < 0.05). Conditioned MEPs were of significantly lower amplitude relative to unconditioned MEPs prior to tDCS (62 +/- 6%, p < 0.05), but not after tDCS (89 +/- 14%, p = 0.40), or robot training (91 +/- 8%, p = 0.28), suggesting that the increased corticomotor excitability is associated with reduced intracortical inhibition. CONCLUSION: The persistence of these effects after robotic motor training, indicates that a motor learning and retraining program can co-exist with tDCS-induced changes in cortical motor excitability, and supports the concept of combining brain stimulation with physical therapy to promote recovery after brain injury.

Cognitive interaction after staged callosal section: evidence for transfer of semantic activation.

Sensory and cognitive functions were assessed in a right-handed male before and after partial and complete callosal commissurotomy. After the initial posterior section was made, there was no evidence of interhemispheric sensory transfer, although the left hemisphere did have access to stimulus-related semantic and episodic information from the right hemisphere. After the callosum was completely sectioned, this exchange was no longer observed.

Molecular mimicry: anti-DNA antibodies bind microbial and nonnucleic acid self-antigens.

Although cells of the innate immune response have a variety of pattern recognition receptors that are triggered by blood classes of markers, a critical feature of the adaptive immune response is antigenic specificity. Yet it is becoming increasingly clear that the specificity of lymphocyte receptors admits of some laxity. Cross-reactivity may, in fact, be necessary for lymphocyte survival as antigen receptor signaling maintains cellular viability in the absence of antigen activation. Studies of molecular mimicry have revealed many instances in which antibodies to microbial antigens bind also to self-antigens; in some cases, this cross-reactivity has pathogenic potential. In this chapter, we describe cross-reactivity between two self-antigens, DNA and NMDA receptors, and how antibodies with specificity for DNA in patients with splenic lupus may cause central nervous system damage by virtue of binding also to neuronal receptors. This example serves as a reminder that cross-reactivity may exist among self-antigens as well as between foreign and self-antigens.

Bile salt alteration of ion transport across jejunal mucosa.

The effect of conjugated dihydroxy and trihydroxy bile salts on electrolyte transport across isolated rabbit jejunal mucosa was studied. Both taurochenodeoxycholic acid and taurocholic acid increased the short-circuit current (Isc) in bicarbonate-Ringer solution but not in a bicarbonate-free, chloride-free solution. Taurochenodeoxycholic acid was significantly more effective than taurocholic acid in increasing Isc. The presence of theophylline prevented the taurochenodeoxycholic acid- and taurocholic acid-induced increase in Isc. Transmural ion fluxes across jejunal mucosa demonstrated that 2 mM taurochenodeoxycholic acid decreased net Na+ absorption, increased net Cl- secretion and increased the residual flux (which probably represents HCO3- secretion). These studies support the hypothesis that cyclic AMP may be a mediator of intestinal electrolyte secretion.

Ibuprofen protects ischemia-induced neuronal injury via up-regulating interleukin-1 receptor antagonist expression.

The inflammatory response accompanies and exacerbates the developing injury after cerebral ischemia. Ibuprofen, a non-steroidal anti-inflammatory drug, has been shown to attenuate injuries in animal models of various neurological diseases. In the present study, we investigated ibuprofen's neuroprotective effects in rats exposed to transient forebrain ischemia and in cultures exposed to oxygen glucose deprivation (OGD). Rats treated with ibuprofen after transient forebrain ischemia displayed long-lasting protection of CA1 hippocampal neurons. There were selective increases in interleukin-1 receptor antagonist gene and protein expression in ibuprofen-treated OGD microglia. Furthermore, treatment with ibuprofen in neuron/microglia co-cultures increased the number of surviving HC2S2 neurons against OGD whereas IL-1ra neutralizing antibody reversed the ibuprofen-induced neuroprotection. The data indicate that ibuprofen-induced IL-1ra secretion is involved in neuroprotection against ischemic conditions.

Early c-Fos induction after cerebral ischemia: a possible neuroprotective role.

The role of c-Fos in neurodegeneration or neuroprotection after cerebral ischemia is controversial. To investigate whether early c-Fos induction after ischemia is associated with neuroprotection, rats were subjected to 10 minutes of transient forebrain ischemia and c-Fos expression was examined. Resistant dentate granule cells and neurons in CA2-4 displayed more robust immunoreactivity than vulnerable neurons in the CA1 region of hippocampus during early hours of reperfusion. By 6 hours after reperfusion, c-Fos immunoreactivity was greatly diminished in all areas of the hippocampus. Administration of N-acetyl-O-methyldopamine (NAMDA), a compound previously shown to protect CA1 neurons against ischemia, increased c-Fos immunoreactivity in the CA1 vulnerable region at 6 hours after ischemia and protected SK-N-BE(2)C neurons from oxygen glucose deprivation. Further in vitro study showed that NAMDA potentiated phorbol-12 myristate-13 acetate (PMA)-induced c-Fos expression, AP1 binding activity, and late gene expression determined by chloramphenicol acetyltransferase (CAT) activity from AP1 containing tyrosine hydroxylase promoter-CAT fusion gene in SK-N-BE(2)C neurons. In vivo and in vitro results showed that a neuroprotectant, NAMDA, in concert with another stimulus (for example, ischemia or PMA) up-regulates c-Fos expression and suggested that the early rise of NAMDA-induced c-Fos expression in vulnerable CA1 neurons may account for neuroprotection by means of up-regulating late gene expression for survival.

An animal model of human-type memory loss based on aging, lesion, forebrain ischemia, and drug studies with the rat.

The goals of this research were to develop a within-subject test of spatial working memory and performance for the rat in a T-maze, based on a delayed alternation, or "win-shift" foraging strategy. Using this model, specific aims were to compare the effects of: (1) age, (2) basal forebrain, medial septal, and amygdala lesions, (3) four vessel occlusion (4-VO), forebrain ischemia, and (4) physostigmine, scopolamine, arecoline, piracetam, and clonidine on memory and performance of young middle-aged, and old rats. Aging significantly impaired working memory and performance of Long-Evans rats. Memory of septal and basal forebrain, but not of amygdala lesioned rats was significantly impaired without effects on performance. Transient, 4-VO forebrain ischemia produced significant memory impairment, without effects on performance, and highly selective CA1 cell loss in the hippocampus. Physostigmine enhanced working memory in middle-aged and old rats. Scopolamine impaired memory in young, middle-aged, and old rats. Physostigmine reversed the scopolamine impairments of working memory. Arecoline enhanced memory in old rats without effects on performance. Piracetam and clonidine had no direct effects on memory, but piracetam increased and clonidine decreased speed of performance. From the aging, lesion, ischemia, and drug studies it was concluded that there was a convergence of evidence from 4 different approaches for a critical role for the hippocampus, particularly the CA1 fields, in spatial working memory.

The characterization of an amnesic syndrome following hypoxic ischemic injury.

We used clinical analysis and criteria derived from the experimental studies of classic amnesic syndromes to characterize the amnesia that follows hypoxic ischemic brain injury from cardiac or respiratory arrest. The results show that patients with hypoxic ischemic amnesia have several neuropsychological features in common with other amnesics, including intact short-term memory, severely depressed free recall, and less depressed recognition of visual and verbal material. Unlike amnesics with alcoholic Korsakoff's syndrome, they are oriented and do not confabulate. Hypoxic ischemic brain injury is a common hospital occurrence, and a study of the characteristics of the amnesia that can occur after such injury should enlarge our understanding of the amnesic syndromes.

Confusional states following posterior cerebral artery infarction.

Four patients with left-sided posterior cerebral artery infarction developed acute confusional states. Fifteen additional patients with confusion following unilateral posterior cerebral artery infarction were identified from a review of the literature; in 14 the lesion was left sided. Destruction or disconnection of dominant hemisphere neocortex from limbic structures, resulting in impairment of focal attention, loss of linguistically organized memory, and/or disruption of temporal sequencing may be responsible for this syndrome.

Can left-handed writing posture predict cerebral language laterality?

In terms of cerebral lateralization of function, left-handed persons represent a more heterogeneous group than right-handed persons. Some evidence suggests that left-handed subgroups can be identified on the basis of the following two types of writing posture: (1) inverted posture that indicates ipsilateral hemisphere language capability and (2) straight writing posture that indicates contralateral hemisphere language capability. A direct test of this hypothesis with an intracarotid amobarbital sodium injection failed to support these predictions. For clinical decisions in which the hemisphere subserving language is necessary, one should rely on direct assessment with the use of the amobarbital injection technique.

The effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke.

BACKGROUND: We used MIT-Manus, a robot designed to provide interactive, goal-directed motor activity for clinical neurologic applications. OBJECTIVE: To test whether this robotic manipulation of the impaired limb influenced motor recovery in patients with hemiplegia. METHODS: Sequential patients with a history of a single stroke and hemiplegia (N = 20) hospitalized on the same acute care rehabilitation floor were enrolled in a standard rehabilitation program supplemented by either robot-aided therapy or sham robot-aided therapy. These 2 groups were comparable in age, initial physical impairment, and time between onset of the stroke and enrollment in the trial. Patients, clinical team members, and the clinical evaluator were blinded to the treatment group assignments. Standardized assessment tools measured outcomes. RESULTS: Impairment and disability declined in both groups between hospital admission and discharge. The robot-treated group showed a greater degree of improvement in all 3 measures of motor recovery, and the change in motor status measured in the proximal upper limb musculature was significant (P = .002). No adverse events resulted from robot-assisted therapy. CONCLUSIONS: These results suggest that robotic manipulation of the impaired limb may favorably add to recovery following stroke and that robotics may provide new strategies for neurologic rehabilitation.

Classical "parietal" neglect syndrome after subcortical right frontal lobe infarction.

The classical unilateral neglect syndrome is usually associated with lesions of the nondominant inferior parietal lobe. Symptoms typically include a disturbance of orienting and attending to sensory events. We examined three patients with a "parietal" neglect syndrome: CT-documented infarctions that involved only the subcortical right frontal lobe and basal ganglia. There was no CT abnormality in the nondominant parietal lobe. Our data support the view that for polymodal cortical association areas such as the parietal lobe, which connect a variety of distant cerebral areas including the frontal lobe and basal ganglia, damage in a part of the network may be associated with different aspects of the neglect syndrome.

Dementia with bilateral medial temporal lobe ischemia.

Neuropathologic examination of two patients with dementia showed chronic bilateral medial temporal lobe ischemic damage that included the hippocampus (particularly the CA-1 region), subiculum, and amygdala. Both patients had several myocardial infarctions, and the relatively circumscribed cerebral injury may have resulted from one or more episodes of global hypoxic ischemia. Focal hippocampal injury has been associated with amnesia. The additional damage to medial temporal lobe structures may have caused the dementia.

Impaired syntactic comprehension and production in Broca's aphasia: CT lesion localization and recovery patterns.

Three of 50 patients with left hemisphere stroke manifested Broca's aphasia associated with deficits in syntactic processing. CT demonstrated anterior infarcts in two patients and a posterior infarct in the third. Two years later, all three patients showed improved syntactic production, but only the patient with the posterior lesion performed significantly above change on a sentence comprehension test requiring syntactic manipulations in the absence of semantic constraints. Prospective investigations combining psycholinguistic analyses and brain imaging techniques may provide empiric data relevant to neurologic models of language and ultimately may contribute to patient prognostication and rehabilitation.