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Neurobiology of Aging
journal homepage: www.elsevier.com/locate/neuaging
Department of Neurology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
Department of Radiology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
c
Department of Psychiatry, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 12 June 2014
Received in revised form 14 August 2014
Accepted 1 September 2014
Available online 6 September 2014
The aim of this study was to assess the involvement of deep gray matter, hippocampal subelds, and
ventricular changes in patients with amyotrophic lateral sclerosis (ALS). A total of 112 ALS patients and
60 healthy subjects participated. High-resolution T1-weighted images were acquired using a 3T MRI
scanner. Thirty-nine patients underwent a follow-up scan. Volumetric and shape analyses of subcortical
structures were performed, measures were correlated with clinical parameters, and longitudinal changes
were assessed. At baseline, reduced hippocampal volumes (left: p 0.007; right: p 0.011) and larger
inferior lateral ventricles (left: p 0.013; right: p 0.041) were found in patients compared to healthy
controls. Longitudinal analyses demonstrated a signicant decrease in volume of the right cornu
ammonis 2/3 and 4/dentate gyrus and left presubiculum (p 0.002, p 0.045, p < 0.001), and a signicant increase in the ventricular volume in the lateral (left: p < 0.001; right: p < 0.001), 3rd (p < 0.001)
and 4th (p 0.001) ventricles. Larger ventricles were associated with a lower ALSFRS-R score (p 0.021).
In conclusion, ALS patients show signs of neurodegeneration of subcortical structures and ventricular
enlargement. Subcortical involvement is progressive and correlates with clinical parameters, highlighting
its role in the neurodegenerative process in ALS.
2015 Elsevier Inc. All rights reserved.
Keywords:
Amyotrophic lateral sclerosis
Magnetic resonance imaging
Longitudinal
Basal ganglia
Hippocampal subelds
1. Introduction
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive upper and lower motor neuron
degeneration (Kiernan et al., 2011). Although progressive motor
neuron degeneration is the hallmark feature of ALS, widespread
extramotor brain involvement can be found as well (Agosta et al.,
2007; Verstraete et al., 2014). It has been shown that ALS affects a
subnetwork in the brain including white matter connections with
subcortical structures such as the thalamus, caudate nucleus, putamen, globus pallidus, and hippocampus (Verstraete et al., 2014).
These ndings may suggest involvement of these structures in the
underlying neurodegenerative process in ALS.
Magnetic resonance imaging (MRI) is a noninvasive, sensitive
method allowing in vivo study of volume changes of structures
within the brain. Most neuroimaging studies have focused on the
* Corresponding author at: Department of Neurology, G03.228, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. Tel.: 31 88
7557939; fax: 31 30 2542100.
E-mail address: L.H.vandenBerg@umcutrecht.nl (L.H. van den Berg).
1
Authors contributed equally.
0197-4580/$ e see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.neurobiolaging.2014.09.002
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Age
Gender (male:female)
Handedness (left:right)c
ALSFRS-R score
Site of onset (%)
Bulbar
Cervical
Lumbosacral
Disease progression rate
(points decrease/month)d
El Escorial criteria (%)
Denite
Probable
Probable laboratory
supported
Possible
Disease duration (months)
Type (sporadic:familial ALS)
C9orf repeat expansion
Died
Healthy
controls
Baseline
(n 112)
Follow-up
(n 39)
Baseline
(n 60)
60.4 (24e78)
86:26
18:86
41 (29e48)
24 (21)
55 (49)
33 (30)
0.5 (02.6)e
3 (8)
24 (62)
12 (31)
0.6 (0.5 to 3)f
13 (12)
48 (43)
35 (31)
4 (10)b
19 (49)b
10 (26)b
16 (14)
14.2 (4e75)
105:7
7/112
77/112
6 (15)b
18.5 (10e82)
37:2
5/39
23/39
0/60
1077
Table 2
Age- and gender-adjusted subcortical volume differences in study subjectsa
Left
Thalamus
Caudatus
Putamen
Pallidum
Hippocampus
Amygdala
Accumbens
Right
Thalamus
Caudatus
Putamen
Pallidum
Hippocampus
Amygdala
Accumbens
Ventricles
Left lateral
Left inferior lateral
Right lateral
Right inferior lateral
Third
Fourth
Hippocampal subelds
Left
CA1
CA2/3
CA4/DG
Presubiculum
Subiculum
Right
CA1
CA2/3
CA4/DG
Presubiculum
Subiculum
Difference
p Valueb
6621 83
3673 54
5562 67
1678 26
3892 58
1615 31
577 15
6475 61
3642 39
5497 49
1655 19
3697 42
1572 23
545 11
146 103
32 67
65 83
23 32
195 71
43 39
32 19
0.159
0.636
0.435
0.468
0.007**
0.274
0.091
6474 83
3730 55
5326 70
1575 21
4034 54
1831 35
688 13
6304 60
3645 40
5325 51
1528 16
3861 40
1816 25
678 10
170 102
85 69
2 87
47 26
173 67
16 43
10 16
0.098
0.216
0.984
0.078
0.011*
0.719
0.561
13,337 1036
556 61
11,502 817
501 45
1481 74
1986 90
14,766 757
742 45
12,951 598
615 33
1617 54
2162 66
1429 1284
186 76
1449 1014
114 56
136 92
176 111
0.273
0.013*
0.155
0.041*
0.144
0.117
4 6
28 20
14 11
29 11
23 13
0.509
0.162
0.209
0.009**
0.091
5 6
15 18
10 10
21 11
24 13
0.417
0.409
0.329
0.052
0.062
335
972
549
491
646
5
16
9
9
11
346 5
1027 15
572 8
473 9
643 10
331
944
535
462
624
4
12
7
6
8
341 3
1012 11
562 6
452 6
618 8
Hippocampal atrophy is present on both sides and enlarged inferior lateral ventricles. Atrophy of the left presubiculum was statistically signicant; on the right side
there was a tendency to atrophy in ALS patients (p 0.052). Values are in mean
standard error.
Key: ALS, ALS patients; CA, cornu ammonis; CO, healthy controls; DG, dentate gyrus.
* p < 0.05
** p < 0.01.
a
Volumes are reported in mm3.
b
p Values were completely randomly permutated 10,000 times.
1078
Fig. 1. Thalamic shape. Comparison of thalamic shape of ALS patients with healthy subjects. The orange areas indicate affected aspects. These areas correspond closely to the
intramedullary laminae of the thalamus. (For interpretation of the references to color in this Figure, the reader is referred to the web version of this article.)
1079
Table 3
Correlations between subcortical structures and clinical parameters in study subjects
At baseline, higher ventricular volume is associated with lower ALSFRS-R score. Survival is shorter in patients with smaller basal ganglia, larger ventricular volume, and smaller
limbic structures (see also Fig. 2).
Key: ALSFRS-R, revised ALS Functional Rating Scale; PC1, principal component 1 (representing basal ganglia); PC2, principal component 2 (representing ventricles); PC3,
principal component 3 (representing both hippocampi and amygdalas).
* p < 0.05.
** p < 0.01.
a
Progression rate (48 ALSFRS-R score)/disease duration (in months).
b
Covariates were age and gender.
c
Values are hazard ratio (95% condence interval).
d
Covariates were age at onset and bulbar onset.
is likely that subcortical structures play a role in the neurodegenerative process of ALS. In addition, shorter survival was related to
smaller basal ganglia and limbic structures and larger ventricles, but
multivariate analyses showed that age at onset was associated more
strongly with survival than the above-mentioned PCs.
Only 1 study reported a detailed cross-sectional analysis of the
deep gray matter in 39 ALS patients (Bede et al., 2013). Hippocampal atrophy at baseline was comparable in these studies, suggesting a role of the hippocampus in the neurodegenerative process
and clinical phenotype of ALS patients. The shape analysis of the
thalami was largely comparable in this study and in our examination (Bede et al., 2013). In our study in 112 ALS patients, however, a
change in thalamic shape was not observed to be accompanied by
volume changes of the entire thalamus. Neither shape nor
morphometric analysis showed (regional) atrophy of other DGM,
whereas the above-mentioned study did report atrophy of the
caudate nucleus, accumbens area, and putamen. A possible explanation for this difference is the shorter disease duration in our
study (14 vs. 26 months). A subgroup analysis (n 26) was performed (mean disease duration standard deviation: 24.3
10.4 months) to further elucidate this difference. With respect to
the DGM, the right hippocampus (p 0.028) showed a signicant
difference in this specic subgroup. This comparison is, however,
hampered because of the relatively small sample size and different
distribution of the data, and because other demographic characteristics such as ALSFRS-R score and disease progression were not
available for comparison. Although our longitudinal analysis
showed a tendency for the putamen, caudate nucleus, and right
accumbens area to decrease in volume, these decreases did not
reach statistical signicance (Fig. 2). This rst longitudinal analysis
of subcortical structures also showed progressive ventricular
enlargement and decreasing volumes of some hippocampal subelds, indicating progressive neurodegeneration. Hippocampal
subelds have not previously been studied in vivo, but the nding
of hippocampal subeld degeneration is supported by post mortem
histological research (Takeda et al., 2009; Zu et al., 2013), and the
present study shows that it can also be detected in vivo at a relatively early stage of the disease.
Ventricular enlargement at baseline was restricted to the temporal parts of the ventricular system (in line with hippocampal
atrophy) and progressed during follow-up to signicant enlargement of both lateral ventricles and third and fourth ventricles.
These results suggest that neurodegeneration in the temporal lobe
is an early characteristic of ALS and is present before progressive
neurodegeneration becomes visible in ventricular enlargement in
the rest of the brain. Ventricular enlargement is a common feature
1080
Fig. 2. Longitudinal analysis of subcortical structures. The x-axis shows the number of the magnetic resonance imaging (MRI) scan (1 rst scan; 2 second scan). The y-axis
shows the volumes normalized to healthy subjects, meaning that 100% was the mean subcortical volume of healthy subjects at baseline. This gure shows signicantly smaller
volumes of both hippocampi and signicantly larger volumes of both inferior lateral ventricles in ALS patients at baseline. After a follow-up of 5.5 months (on average), the volumes
of the right CA2/3 and CA4/DG decreased signicantly. In addition, volumes of nearly all ventricles increased signicantly during follow-up. The colors in the graphs correspond to
the colors in the pictures of subcortical structures and hippocampal subelds. Error bars indicate standard errors. Abbreviations: CA, cornu ammonis; DG, dentate gyrus; Sub,
subiculum; Presub, presubiculum. *p < 0.05; **p < 0.01; ***p < 0.001. (For interpretation of the references to color in this Figure, the reader is referred to the web version of this
article.)
(Van der Werf et al., 2000; Zarei et al., 2010). Surprisingly, no shape
alteration was observed in the nucleus connected with the motor
cortex, the ventral lateral nucleus.
Although a relatively large number of patients and controls were
studied in detail, several limitations of this study should be taken
into account. First, no follow-up of healthy controls was performed.
Normal aging has, however, been extensively studied, and shows
that DGM volume usually decreases by less than 0.5% and ventricle
size increases by less than 3% in 6 months in healthy subjects (Fjell
et al., 2009). It is therefore highly unlikely that the volume changes
in this study are due to normal aging (e.g., interior lateral ventricles
of ALS patients increased to 130%e140% the size of normal subjects
in 6 months) (Fjell et al., 2009). Second, males were somewhat
overrepresented in this study, based on what is known from
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