Journal of the Neurological Sciences 158 (1998) 5–14

Decade of the brain: neurological advances 1

Lord Walton of Detchant

President, World Federation of Neurology, Oxford OX2 6 PS, England

Received 30 September 1997; accepted 26 November 1997

Abstract

In the last half century, neurological developments have been phenomenal and have escalated in this decade of the brain. Many
infective disorders have been conquered, but AIDS has posed new challenges. Neuropharmacology has transformed the management of
parkinsonism and epilepsy. New imaging techniques such as CT, NMR, PET and ultrasonic scanning have presented us with remarkable
images of the nervous system in health and disease. Steroids control many autoimmune disorders; beta-interferon and other new drugs
have begun to influence multiple sclerosis. Intensive care has saved many of those with head injury or acute neurological disorders, and
we have greatly improved methods of rehabilitation. There are still many incurable neurological disorders but none are untreatable.
Today’s discovery in basic science brings tomorrow’s improvement in patient care, as is clearly shown by molecular genetics. Some
neurological and neuromuscular diseases in which the causal gene or genes have been located and characterised and in which the missing
or abnormal gene product has been identified will be mentioned, as well as the prospects of carrier detection, antenatal diagnosis and gene
therapy.  1998 Elsevier Science B.V.

1. Introduction 2. Clinical neuroscience: a quarter century of

In this my final year as President of the World Federa-
tion of Neurology, and in the seventh year of the Decade
of the Brain, I regard it as a singular honour and privilege
to have been invited to give this plenary lecture and to
attempt to highlight some of the major advances in our
discipline which have been made possible by develop-
ments in neuroscience during my professional lifetime (of
now some 52 years) and which are likely to yet further
transform our understanding of neurological disorders well
into the next millennium. And may I, at the outset, express
my personal sincere gratitude first to our Argentinean hosts
for the excellence of their planning and organisation and to
the officers, chairmen and members of committees and
delegates of the WFN who have given me such unfailing
support over the last eight years.
1
The inaugural lecture, delivered at the XVI World Congress of Neurolo-
gy, Buenos Aires, Argentina, September 1997.
progress
The conquest of many once devastating infective dis-
orders such as poliomyelitis and smallpox is now largely a
matter of history, but as new antibiotics and vaccines have
been discovered, so nature has posed new challenges.
AIDS, which may seriously damage the nervous and
neuromuscular systems, represents one such infective
disorder which presents the medical profession with yet
another difficult mountain to climb, but combinations of
new antiviral agents bring hope for the future. Stroke,
especially ischaemic stroke, continues to be a major killer
and crippler [1]. Most advances have related to prevention,
as relatively little can be done once the stroke occurs.
Trials of remedies such as calcium antagonists or tissue-
type plasminogen activator have shown only marginal
benefit in acute stroke. However, prevention by treatment
with aspirin in patients suffering transient ischaemic
attacks, or by carotid endarterectomy in individuals with
suitably severe degrees of carotid stenosis [2] have each

0022-510X / 98 / $19.00  1998 Elsevier Science B.V. All rights reserved.

PII: S0022-510X( 97 )00317-1
6 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
constituted major advances. Perhaps above all, new tech-
niques of imaging, including CT, NMR and PET scanning
and the use of sophisticated ultrasonic techniques including
the Doppler method, have presented us with images of the
nervous system and of the effects of pathological processes
upon it undreamt of only a few years ago [3]. And NMR
spectroscopy has given invaluable information about meta-
bolic changes in brain and muscle in health and disease.
While many such techniques are expensive, both in capital
and in revenue costs, the benefit to patients and the
avoidance of the suffering resulting from older methods
such as pneumoencephalography and ventriculography
have outweighed the cost to society if assessed in both
financial and social terms. Interventional neuroradiology
has much more to give, not least in the treatment of
intracranial aneurysms, and advanced clinical neuro-
physiological techniques have also enhanced our diagnos-
tic capability. New and improved methods of intensive
care have saved many who would formerly have died from
head injury or severe paralysing disorders. The identifica-
tion of new neurotransmitters, along with neurophar-
macological and neurochemical research, has led to the
introduction of many new drugs, including increasingly
effective anticonvulsants [4,5], while steroids, plas-
mapheresis and other immunological techniques have
proved beneficial in many autoimmune disorders of the
muscular and neuromuscular systems.
Pain relief has been transformed and we have available
much improved techniques of rehabilitating patients recov-
ering from acute neurological illness and of improving the
lifestyle and longevity of many with progressive and as yet
incurable conditions. The range of new appliances and of
physical and communication aids developed by bioen-
gineering expertise is striking. In neurology there are still
many incurable diseases but none are untreatable. All can
have their effects modified by pharmacological, physical or
psychological intervention.
There is another incontrovertible truism which sadly
does not always convince health care providers and / or
research funding agencies. It is that today’s discovery in
basic laboratory science brings tomorrow’s practical de-
velopment in patient care. In no field is this more evident
than in molecular biology and molecular genetics and in
the burgeoning area of gene therapy. As it would be
impossible to highlight in this talk even the major develop-
ments in all these sciences which are influencing clinical
practice, I must be selective.
I therefore propose to mention first some neurological
disorders in which the causal gene has been located and its
effects identified, secondly to comment upon new knowl-
edge relating to dementia, especially to Alzheimer’s dis-
ease, and thirdly to refer briefly to new developments in
multiple sclerosis and some other neurological disorders.
Finally, I shall turn to exciting developments in neuro-
muscular disease, with particular reference to the inflam-
matory myopathies and to the muscular dystrophies.
3. Molecular genetics and neurological disease
3.1. Gene mapping
As mapping of the human genome (the HUGO project)
proceeds apace through international collaborative effort,
we learn almost monthly that yet another gene has been
located, and many have been fully characterised and
sequenced. A table published in Neuromuscular Disorders
(Vol. 6, No. 5, 1996) presents, by way of example, a
selective list of some important neuromuscular disorders in
which gene mapping has been achieved within the last few
years. In relatively few do we yet know the nature of the
missing or abnormal gene product. However, in some
recessively inherited disorders, gene deletions or point
mutations clearly result in the absence of an important
structural protein, while, by contrast, in some autosomal
dominant conditions (such as myotonic dystrophy, Hunting-
ton’s chorea and various cerebellar ataxias including
Machado–Joseph disease) there are abnormal nucleotide
triplet repeats, whose extent can often be correlated with
age of onset and disease severity. These discoveries are
inevitably taking us further towards identifying the ulti-
mate cause of many such disorders and we may anticipate
that in some, effective treatment will soon be devised,
either through gene therapy or through some other means,
such as cell transplantation, of circumventing the genetic
defect. The subject has been reviewed by Yates [6], Hurko
[7], Joynt and Kurlan [8] and Sharma and Baynes [9].
4. Alzheimer’s disease and some other dementias
As knowledge accumulates, it is increasingly clear that
Alzheimer’s disease, whether occurring in the presenium
or in the senium, is not a single entity [10]. And diffuse
Lewy body dementia, with or without clinical evidence of
Parkinsonism, may closely mimic the condition, as may
the rare familial dementia due to a frameshift in the
caeruloplasmin gene [11]. Diagnosis from multi-infarct
dementia can usually be achieved by scanning, but distinc-
tion from other dementias, including the frontal lobe type,
is more difficult in the absence of a specific marker.
Hence, despite the increasing use of NMR and PET
imaging, along with refined psychometric tests, clinical
diagnosis remains imprecise and is probably correct in no
more than 85–90% of cases of dementia. This may have
prejudiced conclusions drawn from some epidemiological
studies based upon clinical diagnosis. Nevertheless, knowl-
edge of pathogenesis is accumulating apace. It is agreed
that the histological hallmarks of the disease are neuro-
fibrillary tangles and senile plaques in the cerebral cortex.
Tomlinson et al. [12,13] found similar but less severe
changes in brains of nondemented elderly people and also
defined a quantitative relationship between the severity of
dementia and the numerical incidence of these changes.
 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
Later, Bowen et al. [14] and Perry et al. [15] showed that
acetylcholine and choline acetyltransferase activity were
markedly reduced in the cerebral cortex. It was later shown
that paired helical filaments in the plaques are associated
with hyperphosphorylated tau protein [16].
The senile plaques in amyloid disease contain an
amyloid b-protein, the so-called A4 protein or b A4
peptide. From its primary amino acid sequence, the cDNA
clone has been isolated and has been shown to encode for
a much larger 770 amino acid protein called the amyloid
precursor protein (APP) of which six transcripts have been
isolated, four containing the b A4 moiety. The physiologi-
cal role of APP in the brain is as yet unclear but is the
subject of intensive research [17]. Recent research has also
indicated that APP expression is abnormal in head injury
and stroke, in which the release of interleukin 1 may lead
to progressive cell stress.
In familial Alzheimer’s disease, responsible genes, also
related to the genetic abnormality in Down’s syndrome,
were identified on chromosome 21 in both exons 7 and 17
[18,19]. In early-onset Alzheimer’s disease, however, there
is evidence that other genes lie on chromosomes 1 and 14;
that on chromosome 14, called presenilin-1 (PS-1), associ-
ated with 5 missense mutations (amino acid substitutions),
is now known to account for about 70% of early-onset
familial cases [6]. It has also been shown that apolipo-
protein E (apoE4) homozygotes carry a high risk of
developing Alzheimer’s disease relatively early in life,
whereas those who are homozygous for apoE3 are more
likely to develop the condition later. While the use of the
apoE4 marker in genetic counselling and in diagnosis was
once postulated, its relationship to the disease is not
precise enough, especially since recent work has suggested
a possible relationship between apoE4 and Lewy body
disease and also frontal lobe dementia [20–22].
In therapy, choline, lecithin, eserine, tacrine, donepezil
and rivastigmine have all been tried, the latter three
remedies proving effective in delaying progression of the
disease to some extent [23–25]. But the cost effectiveness
of such treatment has been questioned [26]. Work is now
proceeding to examine the role of acetyl-L-carnitine [27]
and of free radical scavengers. Nerve growth factors such
as brain-derived neurotrophic factor (BDNF) and
neurotrophin-3 (r1 T-3) are also being studied, as are drugs
which stimulate nicotinic receptors or others which inhibit
b A4 peptide enzymes and calcium entry. Even antiinflam-
matory remedies such as indomethacin and other NSAIDS
may have a protective effect or may confer marginal
benefit [23,28].
5. Multiple sclerosis
It is now agreed [29,30] that in multiple sclerosis (MS)
there is an underlying genetic susceptibility. Against such
a background an environmental factor, which may be one
7
of several different viruses, triggers an autoimmune pro-
cess. Myelin-reactive T cells then act upon the myelin in
the central nervous system but also increase the per-
meability of the blood / brain barrier, leading to perivascu-
lar inflammatory cell infiltration which in turn increases
the extent of the demyelination. However, treatment of the
disease with steroids, with intravenous immunoglobulin
and with immunosuppressive agents such as azathioprine
has given disappointing results.
Among the new drugs recently introduced in treatment
have been interferon beta-1a and beta-1b, of which the
latter has seemed marginally more effective [31,32], but
recent reports have favoured beta-1a. Interferon alpha-2a
has also been tested but does not seem to confer any
lasting benefit [33]. Useful guidelines covering the use of
the interferons have now been published [34] and despite
published reservations about the cost-effectiveness of these
remedies [35], their value in reducing relapses in remit-
ting–relapsing disease is now amply confirmed [36].
Another new agent, copolymer 1, is a synthetic poly-
peptide consisting of L-alanine, L-glutamic acid, L-lysine
and L-tyrosine. It is thought to work either by producing
antigen-suppressor cells specific for myelin basic protein,
or more probably by interfering with T-cell activation by
competing with myelin basic protein for the major his-
tocompatibility complex class 2 binding sites responsible
for antigen presentation. In a study of the effects of this
remedy by Johnson and others [37] the relapse rate was cut
by 24%, and the percentage of patients who developed
worsening neurological disability was also reduced in a
randomised, double-blind, placebo-controlled trial involv-
ing 251 patients.
Linomide, a synthetic immunomodulator that increases
natural killer cell activity, has also been used [38,39] but it
produces unacceptable side-effects. The potential value of
the chimeric anti-CD4 antibody is as yet unconfirmed.
6. Some other neurological disorders
6.1. Neurotransmitters
Nitric oxide (NO), the molecule of the decade, has now
been shown to be a neurotransmitter [40]. Relaxation of
arterial muscle is brought about by several messenger
molecules, one of which is acetylcholine. It had always
been thought that acetylcholine in the blood acted directly
upon muscle cells, causing relaxation, but in the 1980s
acetylcholine was shown to release an endothelium-derived
relaxing factor from the endothelium of blood vessels; this
was eventually identified as nitric oxide, which diffuses
into the surrounding muscle in the arterial wall and triggers
muscle relaxation. Glyceryl trinitrate, the vasodilator, is
transformed into nitric oxide in the body. The role of nitric
oxide has also proved to be very much more ubiquitous
than originally thought.
8 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
It is involved in stimulation of macrophages dealing
with infection and has an important role in type 1 diabetes,
in septic shock, in arming the immune system, in prevent-
ing premature birth, and in treating impotence. There is
also good evidence emerging to indicate that as a neuro-
transmitter it may play a part in the control of memory.
Indeed NO as a diffusible messenger is long-lasting,
playing an important role in modulating neuronal firing
behaviour and being involved in synaptic plasticity. NO
synthase (NOS) is a regulator of cerebral blood flow and
NO appears to be involved in learning, pain, sleep, feeding
and sexual function [41].
Of equal interest and importance is the fact that excitat-
ory amino acid systems are of fundamental importance in
the pathogenesis of several neurological diseases [42,43].
In particular, glutamate is the predominant excitatory
transmitter in mammals, acting upon at least four major
subtypes of receptor, namely the NMDA, AMPA and
kainate (KA) receptors, and also metabotropic receptors,
upon which I shall not comment further. However, AMPA
receptors are responsible for much of the fast excitatory
neurotransmission in the nervous system and several
selective antagonists for the AMPA receptor have been
developed. The NMDA receptors are more complex, and
the KA receptors are as yet not well understood, though
they have a high affinity for kainate, an analogue of
glutamate. Glutamate is clearly an excitotoxin and it seems
that a relative excess of this substance can under certain
circumstances contribute to neuronal death in Huntington’s
disease, Alzheimer’s disease, Parkinson’s disease and
amyotrophic lateral sclerosis. Clearly, too, glutamate plays
a fundamental role in epilepsy; glutamate receptor antago-
nists are powerful anticonvulsants, but they also appear to
reduce brain damage after ischaemia and trauma in animal
models. This is because, as an excitotoxin, glutamate may
contribute to cellular calcium overload, to increased lipid
peroxidation and to the release of free radicals. There is
also growing evidence to indicate that oxidative stress due
to increased free radical production and / or defective
antioxidant defences (as with superoxide dismutase in
familial amyotrophic lateral sclerosis and glutathione in
Parkinson’s disease) may be central to some neurode-
generative processes. All of this evidence has raised the
possibility of new forms of treatment being introduced, not
only for ischaemia, stroke, epilepsy and head injury, but
also perhaps for some of the neurodegenerative diseases
which I have mentioned.
Calcium antagonists have been shown to have limited
benefit in limiting ischaemic damage, and free radical
scavengers have also been tried, though the commonest of
these, namely vitamin E and ascorbic acid, do not seem
very effective. However, work is now in progress upon the
role of NMDA and AMPA receptor antagonists. Glutamate
antagonists such as lamotrigine are clearly effective in
treating epilepsy.
6.2. Cytokines
Much interest has also been aroused by recent work on
cytokines, a heterogeneous group of polypeptide mediators
or intercellular messengers, classically associated with
activation of the immune system and inflammatory re-
sponses. They include the interleukins and interferons and
it is clear that this class of substances plays an important
role in providing communication signals between the
immune system and the brain. Their role in neurological
disease and dysfunction will surely be further clarified in
the next century, but it is already evident that cytokine-
based treatment, as with the interleukins and interferons,
will be invaluable in treating inflammatory, immune and
infective conditions [44].
6.3. Parkinsonism and motor neurone disease
In Parkinsonism, as in ischaemia and stroke, free radical
production or defective antioxidation involving glutathione
may contribute to nigral cell death. Studies reported in the
last 3 months have located the gene for familial Parkinson-
ism on chromosome 4 [45]. Ubiquitin staining, which is
positive in the nigral cells and in cells throughout the
cortex in patients with Lewy body dementia, indicates
protein degradation. Annual crude death rates from Parkin-
son’s disease in Norway confirm the increased survival of
individuals since levodopa was introduced [46]. Some
evidence suggested that selegiline as an initial treatment in
do novo parkinsonian patients might be effective and
might delay the necessity for giving levodopa [47], and
indeed it was thought earlier that selegiline might exert a
neuroprotective action and prolong longevity. However,
recent work [48,49] has failed to demonstrate any such
effect. Experimental studies using glial-derived neuro-
trophic factor (GDNF) in MPTP-induced Parkinsonism in
animals have raised the possibility of using this preparation
in human subjects.
Ubiquitin, despite being indicative of protein degra-
dation, has been discovered in normal motor end-plates in
the postjunctional region. However, it accumulates in
excess in anterior horn cells in cases of motor neurone
disease and in these neurones there is increased activity of
proline endopeptidase and pyroglutamyl aminopeptidase
[50]. In familial cases of this condition there is evidence of
an altered encoding of copper / zinc / magnesium-controlled
superoxide dismutase and the gene responsible has been
localised to chromosome 21q [3]. There is now evidence
that the apoE2 / 3 genotypes may be protective, while
apoE4 is associated with earlier onset, bulbar involvement
and greater severity [51].
A possible role of glutamate in motor neurone disease
has been postulated, though glutamate antagonists such as
lamotrigine have not been shown to be of any benefit and
nor have an array of antioxidants [52]. However, trials of
 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
riluzole, which modulates glutamate transmission, suggest
that this remedy may be of some benefit in cases present-
ing with bulbar involvement, but this remains to be
confirmed. Recent work has suggested that neurotrophin-3
or ciliary neurotrophic factor may ultimately prove to be of
benefit.
6.4. The stiff-man syndrome
Another interesting finding is the recent discovery that
the stiff-man syndrome, a rare disorder of unknown
aetiology in which progressive rigidity, spasms and con-
tinuous motor activity occurs, may be due to dysfunction
of GABAergic inhibition of alpha motor neurones. Au-
toantibodies to GABAergic neurones have been identified
in some cases and the condition is believed to be au-
toimmune, responding to treatment by plasmapheresis [53].
6.5. Creutzfeldt– Jakob disease
In Creutzfeldt–Jakob disease, which is associated with
an isoform of the host-encoded prion protein [54], it is now
clear that not only is the condition closely related to the
autosomal dominant Gerstmann–Straussler–Scheinker
syndrome, but that genetic factors influence susceptibility
to the disease and also its duration, age of onset, clinical
signs and clinical presentation, as well as the distribution
and type of lesions in both sporadic and familial CJD [55].
The relevant gene (or genes) lie on the short arm of
chromosome 20 and 12 point mutations have been iden-
tified especially at codons 102, 117, 178 and 200. The
so-called new variant, which may be related to bovine
spongiform encephalopathy (BSE), is associated with
methionine homozygosity at codon 129 [56,57]. The
closely related condition of familial fatal insomnia has
been found to be related to a polymorphism at codon 129
[58]. Mutations have also been identified in a group af
Libyan Jews who are highly susceptible to this disease
[59]; it was once thought that this was because they ate
sheep’s eyes as a delicacy and hence might have been
infected by the scrapie agent, but this is now known not to
be so as a substitution of lysine for glutamate has been
found in codon 200. And of great interest is that the apoE4
marker is an important risk factor relating to the develop-
ment of Creutzfeldt–Jakob disease, as it is in Alzheimer’s
disease [60] and perhaps in Parkinsonism and Lewy body
disease [61].
6.6. Huntington’ s disease
Since the gene for Huntington’s chorea was identified on
chromosome 4.16.3 in 1993, it was found that the mutation
causes an unstable cytosine–adenine–guanine (CAG) tri-
nucleotide repeat. It appears that the abnormal triplet
repeat causes excessive glutamine residues to be inserted
9
into proteins, leading to the formation of insoluble
proteinaceous aggregates. An abnormal protein called
huntingtin has been found to be widespread throughout the
brain in affected individuals. A huntingtin-associated pro-
tein (HAP-1) has also been identified and may prove to be
a target for future experimental therapy. In the meantime,
preliminary work which could lead to treatment with
transplanted fetal caudate neurones is in progress. And
work done in France and the USA and reported in Nature
in March 1997 has suggested that human ciliary neuro-
trophic factor, delivered by intrastriatal implants of ge-
netically modified hamster cells encapsulated in porous
membranes may produce clinical improvement.
7. Neuromuscular disease
7.1. Myotonic dystrophy
The mutation causing myotonic dystrophy is an unstable
CTG trinucleotide repeat in a gene at chromosome 19p
13.3 which encodes for a protein with putative serine–
threonine kinase activity [62]. The number of repeats
correlates with the severity and age of onset of the disease,
early onset being related to a larger number. No such
repeats are found, however, in the rare proximal myotonic
myopathic syndrome for which no gene location has yet
been identified [63]. The finding of pathological tau
proteins, tau 55, 64 and 69, in the brains of patients with
myotonic dystrophy is reminiscent of certain features of
Alzheimer’s disease [62].
7.2. Myositis – pathogenesis and therapeutic trials
The role of T-cell mediated cytotoxicity in polymyositis
and of an autoimmune, humoral vasculopathy in dermato-
myositis are now fully accepted [64–66]. No single virus
or other infective agent has been shown to be consistently
responsible for initiating the autoimmune process but the
part played by HTLV-1 [67] seems to be of growing
importance, while HIV also accounts for a few cases.
In patients who are resistant to corticosteroids, many
other forms of treatment are available for both poly-
myositis and dermatomyositis and for related conditions
such as sarcoid, granulomatous myositis and localised
nodular myositis. They include other immunosuppressive
drugs, plasmapheresis (in dermatomyositis) or total body
irradiation. Immunomodulatory therapy with intravenous
immunoglobulins has been shown to be useful [68,69] but
because of side-effects, fortunately few of which are
serious [70], it cannot be tolerated by all patients; hence its
place in treatment is still to be defined [69] and it is still
very expensive.
10 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
7.3. Inclusion body myositis
Previous work suggesting a possible role of the mumps
virus in the aetiology of this condition has not been
confirmed and no causal virus has been isolated. However,
Askanas, Engel and others [71,72] demonstrated ubiquitin
in the postjunctional area of the end-plates of normal
human individuals and also found it in the filaments and
microtubules associated with the vacuoles and inclusions
in inclusion body myositis. They also identified amyloid,
prion-related protein, phosphorylated tau, b-amyloid pro-
tein, a-antichymotrypsin and apoE4 immunoreactive de-
posits. This interesting finding postulates a curious rela-
tionship between this disorder of muscle on the one hand
and Alzheimer’s disease on the other. Clearly there is a
link here which must be further explored. Unfortunately,
immunosuppressive therapy produces little or no benefit in
this condition and despite one or two promising prelimin-
ary reports about the value of IVIgG, the effects of this
remedy are still uncertain [73].
7.4. Emery–Dreifuss, facioscapulohumeral, limb-girdle
and congenital muscular dystrophies
While much international interest has been aroused by
work on the Duchenne and Becker type muscular
dystrophies upon which I shall concentrate in the conclud-
ing section of my lecture, developments in knowledge of
the other muscular dystrophies has been no less striking.
Thus in the relatively benign form of muscular dystrophy
with progressive contractures called the Emery–Dreifuss
type, due to a mutation on the long arm of the X-
chromosome, the missing protein, now called emerin, has
been identified and, as it is very much smaller than
dystrophin, the missing protein in Duchenne dystrophy, the
prospect of gene therapy in the future will clearly arise. In
autosomal dominant facioscapulohumeral (FSH) dystrophy
the gene has been mapped to chromosome 4q35; a
polymorphic fragment is made up of D424 (3.3 Kb)
tandem repeats. It probably does not encode a protein with
any direct association with FSHD but there is a clear
correlation between the size of deletions at this locus on
the one hand and age of onset of the disease on the other
[74].
The situation in respect of limb-girdle dystrophy
(LGMD) is even more complicated as about seven sub-
varieties have been recognised, related to at least five
genes lying on chromosomes 2, 5, 13, 15 and 17 [75].
Many appear to be due to deficiency of specific sar-
coglycans, glycoproteins which bind dystrophin; thus
adhalin is deficient in LGMD2D, calpain 3 in LGMD2A
[76].
It has also been discovered that one form of congenital
muscular dystrophy is due to a deficiency of merosin,
causing disruption of the muscle basal lamina [77] and that
a variable clinical phenotype may be dependent on con-
sequential variable deficiency of laminin-a2 [78,79]. Pre-
natal diagnosis by studying laminin-a2 chain expression in
trophoblast samples obtained by chorionic villus sampling
is now possible [80].
These are but a few of the manifold discoveries which
are being made almost daily by scientific endeavour in
these disorders, discoveries which already contribute to
improved management of patients and families and which
will surely lead to more effective treatment in the future.
7.5. Duchenne and Becker muscular dystrophy
In my former research laboratories in Newcastle upon
Tyne, a major breakthrough came in 1975 when Cullen
and Fulthorpe [81], using electron microscopy, studied the
earliest structural changes occurring in the muscle fibres of
patients with preclinical Duchenne dystrophy. Under
phase-contrast illumination, in unfixed muscle fibres they
found multiple contraction bands which were clearly
responsible for fibre hyalinisation. In plastic-embedded
fibres stained with toluidine blue, these areas might be very
localised, involving only a small segment of a fibre in
transverse section, usually adjacent to the sarcolemma;
they and Bradley also found a marked excess of calcium in
these areas.
They concluded that in Duchenne dystrophy there was
probably a defect in the plasma membrane allowing the
ingress of calcium from the extracellular space, which
activated calcium-activated neutral proteases which then
led to the breakdown and digestion of muscle fibres.
Pennington [82] confirmed that such calcium-activated
proteases were present in excess. Almost simultaneously
Mokri and Engel [83], also using electron microscopy,
demonstrated focal defects in the plasma membrane which
they called ‘‘the delta lesion’’.
But the greatest impetus to research came from molecu-
lar biology. In 1987, through work in many laboratories,
including some in Holland, Toronto and Oxford to name
but three, but ultimately through the energy, industry and
expertise of Drs Kunkel, Hoffman and their colleagues at
the Boston Children’s Hospital, the gene for Duchenne
muscular dystrophy was finally isolated, localised and
characterised in the Xp 21 region of the female X-chromo-
some. It has proved to be one of the largest genes known
in human genetics with a length of about 2 megabases
[84,85]. Furthermore, the genes for Duchenne and Becker
dystrophy are allelic, clinical expression depending, at
least in part, upon the number and extent of the deletions
within the gene. This gave us a much more precise and
accurate means of identifying the female carriers of these
X-linked genes in most affected families. It also led to
accurate antenatal diagnosis of both affected Duchenne
boys and of female carriers, through chorionic villus
sampling to which I shall refer again.
Identification of the gene led to isolation of the missing
gene product, namely dystrophin [85] which is totally
 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
absent in almost all cases of Duchenne dystrophy and
much reduced in the Becker variety. Further work showed
that dystrophin is a vital structural component of the
plasma membrane of the skeletal muscle fibre [86]; it thus
appears that the earlier observations of Cullen, Fulthorpe,
Mokri and Engel upon the pathogenesis of muscle fibre
breakdown have been largely vindicated. The absence of
dystrophin renders the plasma membrane incompetent and
leads on to the breakdown process which I have outlined
[87]. There is some evidence that long-term treatment with
prednisone or prednisolone may slow down this break-
down process a little, but because of side-effects, relatively
few neurologists recommend this as a routine treatment.
Much research is now concentrating upon methods of
attempting to repair the membrane defect by means of
gene therapy in affected children identified at birth.
Fortunately, a naturally-occurring X-linked muscular
dystrophy has been identified in the mdx mouse [88] and
yet another in strains of golden retrievers and rottweilers
[89]. These afflictions are in many respects comparable to
the human disease. The Duchenne gene transcript is
lacking [90] and dystrophin is absent from the muscle cells
of affected animals. Cardiomyopathy like that of Duchenne
dystrophy occurs in the dogs [91] and in carriers of the
X-linked canine disorder mosaic expression of dystrophin
comparable to that found in the muscle of human female
carriers has been found [92]. Experiments in gene replace-
ment are being undertaken in such animals. While myo-
blast transfer [93] has been found to restore dystrophin
partially and temporarily in dystrophic mice, this technique
has not proved helpful in human subjects [1,94].
A new dimension was added through the work of Acsadi
and others in 1991 [95]. Previous studies had shown that
after pure plasmid DNA was injected into rodent muscle,
the cells expressed reporter genes. They showed that a
12-kb full-length human dystrophin cDNA gene and a
6.3-kb Becker-like gene could be expressed in cultured
cells and in vivo. When the human dystrophin expression
plasmids were injected intramuscularly into dystrophin-
deficient mdx mice, the human dystrophin proteins per-
sisted in the cytoplasm and sarcolemma of myofibres.
Those myofibres expressing human dystrophin contained
an increased percentage of peripheral nuclei. Since then,
work exploring the potential prospects of gene therapy has
moved forward rapidly. Miniconstructs of the dystrophin
gene have been prepared and a variety of different (mainly
viral) vectors to which such constructs can be spliced have
been prepared; the hope is that if problems of immune
rejection can be overcome, such vectors can be used to
carry the minidystrophin gene into the muscle cells
throughout the body. In Becker dystrophy, unlike the
Duchenne type, rejection of the dystrophin construct
should not arise as small amounts are normally present in
the muscle. Both retroviruses and adenoviruses have been
used; at present it seems that adeno-associated virus (AAV)
vectors from the human parvovirus are favoured, produc-
11
ing relatively little immune response and proving more
advantageous than other adenoviruses or naked plasmid
DNA [96].
An alternative possibility may in future be the prospect
of upregulating utrophin, a normal constituent of the
muscle fibre membrane, present in Duchenne boys but
localised in them, as in normal subjects, in the region of
the neuromuscular junction. It is believed that if this
protein could be upregulated and encouraged to diffuse
along the sarcolemma, it might, at least in part, replace the
missing dystrophin [97]. Prof. Kay Davies of Oxford is
leading these studies. I firmly believe we shall have an
effective treatment within 10 years.
In the meantime, however, there is a prospect of
prevention of Duchenne dystrophy through embryo re-
search. Carrier detection, as already mentioned, is 95–98%
accurate in informative families. Such carriers in the past
could only be advised that if they fell pregnant, they
should undergo amniocentesis at the fourteenth week and
then have an abortion if the fetus was male. Now, with
chorionic cell biopsy at eight or nine weeks, it is possible
not only to sex the unborn fetus but, using current
molecular biological techniques, to demonstrate whether or
not, in a male, the abnormal gene is present. And now [98]
prenatal diagnosis can even be achieved using a single
nucleated erythrocyte obtained from maternal blood.
Hence selective abortion of affected males is now feasible.
Even though chorionic cell biopsy does carry limited
clinical risks [99], most carriers regard these as acceptable.
Of even greater importance is the fact that in vitro
fertilisation and pre-embryo biopsy is now likely soon to
make preimplantation diagnosis possible. The Human
Fertilisation and Embryology Act, which received the
royal assent after its final passage through both Houses of
Parliament in the UK in 1990, allows research on the
human embryo up to 14 days after fertilisation. Without
this Act, and the establishment of a Human Fertilisation
and Embryology Authority to license such work, all
research of vital importance to the infertile and to carriers
of the gene responsible for Duchenne dystrophy and those
causing many other crippling inherited disorders would
have been prevented by law.
When several female ova, released into the uterus at the
time of ovulation, are fertilised by sperm, the process of
cell division begins and within the first few days floating
free in the uterus are 4 to 6 groups of undifferentiated but
pluripotential cells, each forming what I prefer to call a
conceptus or a pre-embryo rather than an embryo. The
term ‘‘pluripotential’’ means that it is impossible at first to
identify which cells will form the membranes and placenta
and which will later form an identifiable embryo from
which a fetus will develop. By about the fourth or fifth
day, the conceptus becomes a blastocyst [100] in which
there is a nodule or cluster of cells called the inner cell
mass from which the embryo later derives, and an outer
ring of cells which will form the membranes and the
12 Lord Walton of Detchant / Journal of the Neurological Sciences 158 (1998) 5 – 14
placenta. But no such blastocyst is yet attached to, or
embedded in the wall of the uterus and about 80% of them
are spontaneously aborted. About one in five begins to
attach to the uterine wall at about the seventh day,
subsequently receiving a blood supply from the maternal
circulation; later, at about the fourteenth day, that specific
linear arrangement of cells within the basal cell mass
which constitutes the primitive streak appears.
Work done in the last few years by Prof. (now Lord)
Winston at Hammersmith and by others has shown that it
is now feasible, without damage to subsequent develop-
ment of the embryo, to carry out blastocyst biopsy after in
vitro fertilisation by removal of a single cell at about the
fourth or fifth day; that single cell can now be removed
from the part which will form the membranes and the
placenta. Sexing of the conceptus is now commonly
performed and Professor Winston and his colleagues have
found it possible to identify in single cells not only the sex
of the conceptus but also whether or not various disease
genes (such as that for cystic fibrosis) are present. As yet,
the size of the Duchenne gene has made it difficult to
achieve preimplantation diagnosis of this disease, but this
will surely soon be possible. This will make it feasible for
such carrier women to have normal sons and non-carrier
daughters, a prospect undreamed of a few years ago.
I understand and appreciate the sincerity of those who
believe that human life begins at conception and that any
experiment on what they regard as a human life, or what
can become one, is to them abhorrent. I am, however,
personally satisfied, as are many eminent theologians
including the former Archbishop of York, Lord Soper, the
Rev. Prof. Gordon Dunstan and the Rev. Dr Norman Ford,
a distinguished Australian Roman Catholic theologian
[101] that individuation of the human embryo does not
begin until the primitive streak appears at the fourteenth
day. I therefore am in no doubt that Parliament was right to
accept the Human Fertilisation and Embryology Act,
which passed both Houses with very large majorities. The
work it is making possible will, I believe, bring inestim-
able benefits to human health, not least to the families of
patients with Duchenne dystrophy and to those in which
other serious inherited diseases are present.
8. Conclusions
Mr. Chairman, in expressing yet again my indebtedness
to you and to all of those concerned in the planning and
organisation of this World Congress, including of course
your very generous sponsors, I thank you for the oppor-
tunity you have given me of delivering this plenary lecture.
I hope that in my very selective survey I have been able to
convince you that burgeoning developments in neuro-
science in this Decade of the Brain, and perhaps above all
in molecular genetics, have already had a substantial
impact upon our practice of clinical neurology. Without
doubt, in the next millennium further developments in this
rapidly evolving field will bring new hope to many of our
patients. At last they will see increasing prospects of new
and effective treatments being introduced for some of
those progressive and disabling neurological disorders
which are at present incurable. As my Presidency of the
World Federation of Neurology draws to a close, I am
confident that the future of our specialty could not possibly
be more exciting.
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