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Figure 1.
Reduced Mean Short-Interval Intracortical Inhibition (SICI) in C9orf72 Familial Amyotrophic Lateral Sclerosis (FALS)
Reduced Mean Short-Interval Intracortical Inhibition (SICI) in C9orf72 Familial Amyotrophic Lateral Sclerosis (FALS)

A, SICI was significantly reduced in patients with c9orf72 FALS when compared with asymptomatic c9orf72 expansion carriers and control participants. The reduction of SICI was comparable with that evident in patients with sporadic ALS (SALS). B, The mean SICI between interstimulus intervals of 1 to 7 milliseconds was significantly reduced in patients with FALS and patients with SALS. Error bars indicate SD values.

aP < .001.

Figure 2.
Reduced Peak Components of Short-Interval Intracortical Inhibition (SICI) in C9orf72 Familial Amyotrophic Lateral Sclerosis (FALS)
Reduced Peak Components of Short-Interval Intracortical Inhibition (SICI) in C9orf72 Familial Amyotrophic Lateral Sclerosis (FALS)

The peak SICI interstimulus interval at 1 millisecond and 3 milliseconds was significantly reduced in patients with FALS and patients with sporadic ALS (SALS) compared with asymptomatic c9orf72 expansion carriers and control participants.

aP < .001.

Figure 3.
Cortical Hyperexcitability as a Feature of C9orf72 Familial Amyotrophic Lateral Sclerosis (FALS)
Cortical Hyperexcitability as a Feature of C9orf72 Familial Amyotrophic Lateral Sclerosis (FALS)

A, Intracortical facilitation was significantly increased in patients with FALS and patients with sporadic ALS (SALS). B, Motor-evoked potential was significantly increased in patients with FALS and SALS when compared with asymptomatic c9orf72 expansion carriers and control participants. C, The cortical silent period duration was significantly reduced in patients with FALS and patients with SALS when compared with asymptomatic c9orf72 expansion carriers and control participants. D, Central motor conduction time was significantly increased in patients with FALS and patients with SALS. All P values were corrected for multiple comparisons using post hoc Bonferroni testing.

aP < .05.

bP < .01.

cP < .001.

1.
DeJesus-Hernandez  M, Mackenzie  IR, Boeve  BF,  et al.  Expanded GGGGCC hexanucleotide repeat in noncoding region of C9ORF72 causes chromosome 9p-linked FTD and ALS. Neuron. 2011;72(2):245-256.
PubMedArticle
2.
Renton  AE, Majounie  E, Waite  A,  et al; ITALSGEN Consortium.  A hexanucleotide repeat expansion in C9ORF72 is the cause of chromosome 9p21-linked ALS-FTD. Neuron. 2011;72(2):257-268.
PubMedArticle
3.
Majounie  E, Renton  AE, Mok  K,  et al; Chromosome 9-ALS/FTD Consortium; French research network on FTLD/FTLD/ALS; ITALSGEN Consortium.  Frequency of the C9orf72 hexanucleotide repeat expansion in patients with amyotrophic lateral sclerosis and frontotemporal dementia: a cross-sectional study. Lancet Neurol. 2012;11(4):323-330.
PubMedArticle
4.
Lomen-Hoerth  C, Murphy  J, Langmore  S, Kramer  JH, Olney  RK, Miller  B.  Are amyotrophic lateral sclerosis patients cognitively normal? Neurology. 2003;60(7):1094-1097.
PubMedArticle
5.
Ciura  S, Lattante  S, Le Ber  I,  et al.  Loss of function of C9orf72 causes motor deficits in a zebrafish model of amyotrophic lateral sclerosis. Ann Neurol. 2013;74(2):180-187.
PubMed
6.
Mori  K, Lammich  S, Mackenzie  IR,  et al.  hnRNP A3 binds to GGGGCC repeats and is a constituent of p62-positive/TDP43-negative inclusions in the hippocampus of patients with C9orf72 mutations. Acta Neuropathol. 2013;125(3):413-423.
PubMedArticle
7.
Donnelly  CJ, Zhang  P-W, Pham  JT,  et al.  RNA toxicity from the ALS/FTD C9ORF72 expansion is mitigated by antisense intervention. Neuron. 2013;80(2):415-428.
PubMedArticle
8.
Ling  S-C, Polymenidou  M, Cleveland  DW.  Converging mechanisms in ALS and FTD: disrupted RNA and protein homeostasis. Neuron. 2013;79(3):416-438.
PubMedArticle
9.
Ash  PE, Bieniek  KF, Gendron  TF,  et al.  Unconventional translation of C9ORF72 GGGGCC expansion generates insoluble polypeptides specific to c9FTD/ALS. Neuron. 2013;77(4):639-646.
PubMedArticle
10.
Wainger  BJ, Kiskinis  E, Mellin  C,  et al.  Intrinsic membrane hyperexcitability of amyotrophic lateral sclerosis patient-derived motor neurons. Cell Rep. 2014;7(1):1-11.
PubMedArticle
11.
Vucic  S, Ziemann  U, Eisen  A, Hallett  M, Kiernan  MC.  Transcranial magnetic stimulation and amyotrophic lateral sclerosis: pathophysiological insights. J Neurol Neurosurg Psychiatry. 2013;84(10):1161-1170.
PubMedArticle
12.
Vucic  S, Kiernan  MC.  Novel threshold tracking techniques suggest that cortical hyperexcitability is an early feature of motor neuron disease. Brain. 2006;129(pt 9):2436-2446.
PubMedArticle
13.
Vucic  S, Nicholson  GA, Kiernan  MC.  Cortical hyperexcitability may precede the onset of familial amyotrophic lateral sclerosis. Brain. 2008;131(pt 6):1540-1550.
PubMedArticle
14.
Vucic  S, Kiernan  MC.  Cortical excitability testing distinguishes Kennedy’s disease from amyotrophic lateral sclerosis. Clin Neurophysiol. 2008;119(5):1088-1096.
PubMedArticle
15.
Vucic  S, Cheah  BC, Yiannikas  C, Kiernan  MC.  Cortical excitability distinguishes ALS from mimic disorders. Clin Neurophysiol. 2011;122(9):1860-1866.
PubMedArticle
16.
de Carvalho  M, Dengler  R, Eisen  A,  et al.  Electrodiagnostic criteria for diagnosis of ALS. Clin Neurophysiol. 2008;119(3):497-503.
PubMedArticle
17.
Cedarbaum  JM, Stambler  N, Malta  E,  et al; BDNF ALS Study Group (Phase III).  The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. J Neurol Sci. 1999;169(1-2):13-21.
PubMedArticle
18.
Turner  MR, Cagnin  A, Turkheimer  FE,  et al.  Evidence of widespread cerebral microglial activation in amyotrophic lateral sclerosis: an [11C](R)-PK11195 positron emission tomography study. Neurobiol Dis. 2004;15(3):601-609.
PubMedArticle
19.
Vucic  S, Howells  J, Trevillion  L, Kiernan  MC.  Assessment of cortical excitability using threshold tracking techniques. Muscle Nerve. 2006;33(4):477-486.
PubMedArticle
20.
de Carvalho  M, Swash  M.  Nerve conduction studies in amyotrophic lateral sclerosis. Muscle Nerve. 2000;23(3):344-352.
PubMedArticle
21.
Vucic  S, Rothstein  JD, Kiernan  MC.  Advances in treating amyotrophic lateral sclerosis: insights from pathophysiological studies. Trends Neurosci. 2014;37(8):433-442.
PubMedArticle
22.
Turner  MR, Hardiman  O, Benatar  M,  et al.  Controversies and priorities in amyotrophic lateral sclerosis. Lancet Neurol. 2013;12(3):310-322.
PubMedArticle
23.
Al-Sarraj  S, King  A, Troakes  C,  et al.  p62 positive, TDP-43 negative, neuronal cytoplasmic and intranuclear inclusions in the cerebellum and hippocampus define the pathology of C9orf72-linked FTLD and MND/ALS. Acta Neuropathol. 2011;122(6):691-702.
PubMedArticle
24.
Hanajima  R, Ugawa  Y, Terao  Y,  et al.  Paired-pulse magnetic stimulation of the human motor cortex: differences among I waves. J Physiol. 1998;509(pt 2):607-618.
PubMedArticle
25.
Vucic  S, Lin  CS-Y, Cheah  BC,  et al.  Riluzole exerts central and peripheral modulating effects in amyotrophic lateral sclerosis. Brain. 2013;136(pt 5):1361-1370.
PubMedArticle
26.
Nihei  K, McKee  AC, Kowall  NW.  Patterns of neuronal degeneration in the motor cortex of amyotrophic lateral sclerosis patients. Acta Neuropathol. 1993;86(1):55-64.
PubMedArticle
27.
Turner  MR, Kiernan  MC.  Does interneuronal dysfunction contribute to neurodegeneration in amyotrophic lateral sclerosis? Amyotroph Lateral Scler. 2012;13(3):245-250.
PubMedArticle
28.
Blair  IP, Williams  KL, Warraich  ST,  et al.  FUS mutations in amyotrophic lateral sclerosis: clinical, pathological, neurophysiological and genetic analysis. J Neurol Neurosurg Psychiatry. 2010;81(6):639-645.
PubMedArticle
29.
Al-Chalabi  A, Calvo  A, Chio  A,  et al.  Analysis of amyotrophic lateral sclerosis as a multistep process: a population-based modelling study. Lancet Neurol. 2014;13(11):1108-1113.
PubMedArticle
30.
Eisen  A, Kiernan  M, Mitsumoto  H, Swash  M.  Amyotrophic lateral sclerosis: a long preclinical period? J Neurol Neurosurg Psychiatry. 2014;85(11):1232-1238.
PubMedArticle
31.
Ramesh  TM, Shaw  PJ, McDearmid  J.  A zebrafish model exemplifies the long preclinical period of motor neuron disease. J Neurol Neurosurg Psychiatry. 2014;85(11):1288-1289.
PubMedArticle
32.
Saba  L, Viscomi  MT, Caioli  S,  et al.  Altered functionality, morphology, and vesicular glutamate transporter expression of cortical motor neurons from a presymptomatic mouse model of amyotrophic lateral sclerosis. Cereb Cortex. 2015;bhu317.
PubMed
33.
Lacomblez  L, Bensimon  G, Leigh  PN, Guillet  P, Meininger  V; Amyotrophic Lateral Sclerosis/Riluzole Study Group II.  Dose-ranging study of riluzole in amyotrophic lateral sclerosis. Lancet. 1996;347(9013):1425-1431.
PubMedArticle
34.
Bensimon  G, Lacomblez  L, Meininger  V; ALS/Riluzole Study Group.  A controlled trial of riluzole in amyotrophic lateral sclerosis. N Engl J Med. 1994;330(9):585-591.
PubMedArticle
35.
Haidet-Phillips  AM, Hester  ME, Miranda  CJ,  et al.  Astrocytes from familial and sporadic ALS patients are toxic to motor neurons. Nat Biotechnol. 2011;29(9):824-828.
PubMedArticle
36.
Vucic  S, Cheah  BC, Yiannikas  C, Vincent  A, Kiernan  MC.  Corticomotoneuronal function and hyperexcitability in acquired neuromyotonia. Brain. 2010;133(9):2727-2733.
PubMedArticle
Original Investigation
November 2015

Cortical Function in Asymptomatic Carriers and Patients With C9orf72 Amyotrophic Lateral Sclerosis

Author Affiliations
  • 1Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  • 2Northcott Neuroscience Laboratory, ANZAC Research Institute, Sydney, New South Wales, Australia
  • 3Department of Neurology, Royal North Shore Hospital, Sydney, New South Wales, Australia
  • 4Brain and Mind Research Institute, University of Sydney, Sydney, New South Wales, Australia
  • 5Disciplines of Medicine and Pathology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
JAMA Neurol. 2015;72(11):1268-1274. doi:10.1001/jamaneurol.2015.1872
Abstract

Importance  The identification of the chromosome 9 open reading frame 72 (c9orf72) gene hexanucleotide repeat expansion represents a major advance in the understanding of amyotrophic lateral sclerosis (ALS) pathogenesis. The pathophysiological mechanism by which the c9orf72 gene expansion leads to neurodegeneration is not yet elucidated. Cortical hyperexcitability is potentially an important pathophysiological process in sporadic ALS and familial ALS (FALS).

Objective  To investigate whether cortical hyperexcitability forms the pathophysiological basis of c9orf72 FALS using the threshold-tracking transcranial magnetic stimulation technique.

Design, Setting, and Participants  Prospective case-control single-center study that took place at hospitals and outpatient clinics from January 1, 2013, to January 1, 2015. Clinical and functional assessments along with transcranial magnetic stimulation studies were taken on 15 patients with c9orf72 FALS and 11 asymptomatic expansion carriers of c9orf72 who were longitudinally followed up for 3 years. Results were compared with 73 patients with sporadic ALS and 74 healthy control participants.

Main Outcomes and Measures  Cortical excitability variables, including short-interval intracortical inhibition, were measured in patients with c9orf72 FALS and results were compared with asymptomatic c9orf72 carriers, patients with sporadic ALS, and healthy control participants.

Results  Mean (SD) short-interval intracortical inhibition was significantly reduced in patients with c9orf72 FALS (1.2% [1.8%]) and sporadic ALS (1.6% [1.2%]) compared with asymptomatic c9orf72 expansion carriers (10.2% [1.8%]; F = 16.1; P < .001) and healthy control participants (11.8% [1.0%]; F = 16.1; P < .001). The reduction of short-interval intracortical inhibition was accompanied by an increase in intracortical facilitation (P < .01) and motor-evoked potential amplitude (P < .05) as well as a reduction in the resting motor threshold (P < .05) and cortical silent period duration (P < .001).

Conclusions and Relevance  This study establishes cortical hyperexcitability as an intrinsic feature of symptomatic c9orf72 expansion-related ALS but not asymptomatic expansion carriers.

Introduction

Identification of increased hexanucleotide repeat expansion (GGGGCC) in the chromosome 9 open reading frame 72 (c9orf72) gene,1,2 which appears to underlie more than 40% of familial amyotrophic lateral sclerosis (FALS) and 8% of sporadic amyotrophic lateral sclerosis (SALS) cases,13 has radically altered the understanding of ALS pathogenesis, broadening the clinical heterogeneity of ALS. The c9orf72 hexanucleotide expansion underlies both ALS and frontotemporal dementia (FTD).1,2 Subtle cognitive abnormalities may be evident in as many as 50% of patients with ALS and FTD may develop in 15% of patients with ALS.4

The precise pathophysiological mechanisms by which the c9orf72 gene expansion mediates neurodegeneration in ALS has not been established,1,2 although a number of pathogenic mechanisms have been proposed, including haploinsufficiency,1,2,5 RNA-mediated toxicity,6,7 and dipeptide repeat protein toxicity related to non-ATG (RAN) translation of the expanded c9orf72 gene.8,9 Motor neuronal hyperexcitability was suggested as a potential pathophysiological mechanism in c9orf72 ALS, a process mediated by the inactivation of K+ channels.10 Importantly, a blockade of neuronal hyperexcitability by retigabine, a K+ channel activator, exerted neuroprotective benefits, identifying a putative therapeutic target in ALS.10

In patients with ALS, motor neuronal hyperexcitability may be assessed by transcranial magnetic stimulation (TMS) techniques.11 Previous TMS studies in patients with SALS and patients with FALS linked to mutations in the superoxide dismutase 1 gene have established cortical hyperexcitability as an early feature in ALS linked to the process of neurodegeneration while the level of cortical excitability was normal in asymptomatic superoxide dismutase 1 gene mutation carriers.1215 These studies highlighted the pathogenic importance of cortical hyperexcitability in ALS and suggested that the onset of ALS was potentially triggered by 1 or more factors associated with genetic mutations. Consequently, the present study used threshold-tracking TMS techniques to assess cortical function in asymptomatic c9orf72 expansion carriers, with results compared with patients with c9orf72 FALS and patients with SALS to clarify the underlying pathophysiological mechanisms in this form of FALS.

Methods
Patients

Patients were recruited from the ALS genetic database and multidisciplinary ALS clinics. Studies were undertaken on 15 patients with FALS (7 women and 8 men; mean age, 60 years; range 41-78 years), with a confirmed c9orf72 hexanucleotide expansion defined as possible or probable/definite ALS according to the Awaji criteria.16 In addition, studies were also undertaken on 11 asymptomatic c9orf72 mutation carriers (10 women and 1 man; mean age, 49 years; range 26-78 years) who were followed up for 3 years. Seventy-three patients with SALS were also assessed (45 men and 28 women; mean age, 60 years; range, 28-86 years).

Patients with ALS were clinically reviewed on a regular basis through the multidisciplinary ALS clinics. All patients were clinically staged using the Amyotrophic Lateral Sclerosis Functional Rating Scale–Revised17 and categorized according to the site of disease onset as limb- or bulbar-onset ALS. In addition, the disease duration (months) at the time of testing was recorded and muscle strength was assessed using the Medical Research Council (MRC) rating scale, with the following muscle groups assessed bilaterally, yielding a total MRC score of 90: shoulder abduction, elbow flexion, elbow extension, wrist dorsiflexion, finger abduction, thumb abduction, hip flexion, knee extension, and ankle dorsiflexion.

The degree of upper motor neuron dysfunction was assessed by a specific upper motor neuron score.18 None of the patients with ALS were receiving medications, which could have potentially interfered with neurophysiological results. Patients provided written informed consent to the procedures. The study was approved by the Sydney West Area Health Service and Human Research ethics committees.

Neurophysiological Studies

Cortical excitability was assessed by using a threshold-tracking TMS technique according to a previously reported method.19 The motor-evoked potential (MEP) response was recorded in the abductor pollicis brevis muscle. The following parameters were recorded in all participants: short-interval intracortical inhibition (SICI, %) between the interstimulus intervals (ISIs) of 1 to 7 milliseconds, intracortical facilitation (ISI of 10-30 milliseconds), resting motor threshold (%), MEP amplitude (%), cortical silent period duration (milliseconds), and central motor conduction time (milliseconds).

In the same sitting, nerve conduction studies and needle electromyography were undertaken on all participants. The compound muscle action potential (CMAP) was recorded from the abductor pollicis brevis muscle and the CMAP onset latency and peak-peak amplitude were measured. Subsequently, the neurophysiological index (NI) was derived according to a previously reported formula.20

Recordings of the compound muscle action potential (CMAP) and MEP responses were amplified and filtered (3 Hz-3 kHz), using a Cardinal Health Viking Select, version 11.1.0, Niolet-Biomedical EA-2 amplifier (Viasys Healthcare Neurocare Group) and sampled at 10 kHz using a 16-bit data acquisition card (National Instruments PCI-MIO-16E-4). Data acquisition and stimulation delivery were controlled by QTRACS software. Temperature was monitored with a purpose-built thermometer at the stimulation site.

Statistical Analysis

Cortical excitability was compared with 74 healthy control participants (37 men and 37 women; mean age, 53.1 years; range, 23-83 years). Data were assessed for normality using the Shapiro-Wilk test. The t test and Wilcoxon-Signed rank test were used to assess differences between means. Analysis of variance with post hoc testing using a Bonferroni correction (parametric data) or Kruskal-Wallis test (nonparametric data) were used for multiple comparisons. A value of P < .05 was considered statistically significant. A potential caveat was that healthy control participants were significantly younger than patients with c9orf72 expansion-related and SALS. Pearson or Spearman correlations were used to assess the relationship between parameters. Results are expressed as the mean (SD) or median with the interquartile range (IQR).

Results
Clinical Features

The clinical phenotype and level of functional impairment was similar between the 15 patients clinically affected with FALS and SALS. Specifically, the mean (SD) Amyotrophic Lateral Sclerosis Functional Rating Scale–Revised score in patients with c9orf72 FALS was 39.4 (10.1), indicating a moderate degree of impairment and was comparable with patients with SALS (41.2 [5.4]; P = .25). In addition, the mean (SD) MRC total score in patients with c9orf72 FALS was 82.6 (7.1), reaffirming a moderate degree of functional impairment and was comparable with the MRC total score in patients with SALS (80.7 [11.5]; P = .09). The median upper motor neuron score was similar in patients with c9orf72 FALS (median, 14; IQR, 10-14; SD, 6) and SALS (median, 12; IQR, 10-14; SD, 5; P = .32), signifying a presence of upper motor neuron signs in both cohorts.

At the time of TMS testing, the median disease duration in patients with FALS was 8 months (IQR, 5-12 months; SD, 12.6 months) and was comparable with patients with SALS (median, 10.5 months; IQR, 6-18 months; SD, 18.1 months). Of the patients with FALS, 40% exhibited bulbar-onset disease while 60% reported limb-onset disease, identical to that in patients with SALS. All patients were receiving riluzole at the time of assessment.

In contrast, physical examinations in all the asymptomatic c9orf72 hexanucleotide expansion carriers, including the presymptomatic carrier, were normal. Specifically, there were no upper motor neuron features, such as increased muscle tone, hyperreflexia, extensor plantar responses, positive Hoffman sign, or the presence of a jaw jerk in any patients at the time of testing.

Neurophysiological Studies

The peripheral disease burden was assessed prior to undertaking cortical excitability studies. The CMAP amplitude (patients with FALS, 6.3 mV [2.3 mV]; patients with SALS, 7.0 mV [4.0 mV]; control participants, 9.9 mV [4.3 mV]; F = 6.6; P < .001) and NI (patients with FALS, 1.5 [1.2]; patients with SALS, 1.2 [0.9]; control participants, 2.3 [0.9]; F = 10.3; P < .001) were significantly reduced in patients with FALS and patients with SALS when compared with control participants. In contrast, there was no significant difference in the CMAP amplitude and NI between asymptomatic c9orf72 hexanucleotide expansion carriers and control participants (CMAP for asymptomatic carriers, 9.2 mV [3.3 mV]; CMAP for control participants, 9.9 mV [4.3 mV]; P = .33; NI for asymptomatic carriers, 1.8 [1.3]; NI for control participants, 2.3 [0.9]; P = .20).

Cortical Excitability

Short-interval intracortical inhibition, reflected by an increase in the conditioned stimulus intensity required to track a constant target MEP of 0.2 mV, was significantly reduced in patients with FALS and patients with SALS (Figure 1A). The mean (SD) SICI, between ISI 1 and 7 milliseconds, was significantly reduced in patients with FALS and ALS when compared with control participants (patients with FALS, 1.2% [7.0%]; patients with SALS, 1.6% [10.3%]; control participants, 11.8% [8.6%]; F = 16.1, P < .001; Figure 1B) as was the SICI at ISI of 1 millisecond (patients with FALS, 0.3% [7.0%]; patients with SALS, 1.7% [6.8%]; control participants, 6.8% [10.3%]; F = 4.9; P < .005; Figure 2A) and SICI at ISI of 3 milliseconds (patients with FALS, 4.1% [9.3%]; patients with SALS, 3.5% [13.7%]; control participants, 17.2% [12.9%]; F = 18.1; P < .001; Figure 2B). In contrast, there was no significant difference in the mean (SD) SICI (asymptomatic carriers, 10.2% [6.0%]; control participants, 11.8% [8.6%]; P = .20; Figure 1B), SICI at ISI of 1 millisecond (asymptomatic carriers, 5.6% [6.6%]; control participants, 6.8% [10.3%]; P = .20; Figure 2A), and SICI at ISI of 3 milliseconds (asymptomatic carriers, 15.5% [9.6%]; control participants, 17.2% [12.9%]; P = .10; Figure 2B) between asymptomatic c9orf72 carriers and control participants.

Following SICI, a period of intracortical facilitation developed between an ISI of 10 and 30 milliseconds. Mean (SD) intracortical facilitation was increased in patients with FALS and patients with SALS (patients with FALS, −3.2% [4.3%]; patients with SALS, −4.1% [6.0%]; F = 3.3; P < .05; Figure 3A) when compared with control participants (−1.4% [6.9%]). In contrast, mean (SD) intracortical facilitation was comparable between the asymptomatic expansion carriers (−1.2% [2.0%]; P = .40) and control participants.

Single-pulse TMS disclosed a significant increase in the MEP amplitude expressed as a percentage of CMAP response in both patients with FALS and patients with SALS when compared with control participants (patients with FALS, 45.2% [25.5%]; patients with SALS, 32.2% [23.1%]; control participants, 23.4% [13.8%]; F = 3.5; P < .01; Figure 3B). In contrast, the MEP amplitude in asymptomatic expansion carriers was similar to control participants (asymptomatic expansion carriers, 24.4% [12.9%]; control participants, 23.4% [13.8%]; P = .42). In addition, the cortical silent period duration was significantly reduced in patients with FALS and patients with SALS (patients with FALS, 186.1 milliseconds [40.7 milliseconds]; patients with SALS, 173.8 milliseconds [41.9 milliseconds]; control participants, 214.1 milliseconds [33.6 milliseconds]; F = 10.8; P < .001; Figure 3C) but not in the asymptomatic expansion carriers (211.4 milliseconds [44.1 milliseconds]; P = .40).

Of further relevance, the resting motor threshold was significantly reduced in patients with c9orf72 FALS (52.2% [8.1%]) when compared with SALS, asymptomatic carriers, and control cohorts (patients with SALS, 57.2% [11.1%]; asymptomatic carriers, 58.5% [16.6%]; control participants, 60.3% [12.0%]; F = 3.4; P < .05). In addition, the central motor conduction time was significantly increased in patients with FALS and SALS (patients with FALS, 5.9 milliseconds [1.9 milliseconds]; patients with SALS, 6.6 milliseconds [1.7 milliseconds]; control participants, 5.5 milliseconds [2.6 milliseconds]; F = 4.4; P < .01, Figure 3D). In contrast, the central motor conduction time was not significantly increased in asymptomatic carriers (asymptomatic carriers, 5.2 milliseconds [2.0 milliseconds]; control participants, 5.5 milliseconds [2.6 milliseconds]; P = .30).

Correlation Studies

By combining clinical, peripheral, neurophysiological, and cortical excitability findings in the c9orf72 FALS cohort, the mean SICI (ISI, 1-7 milliseconds) significantly correlated with the CMAP amplitude (R = −0.55; P < .05), MRC upper limb score (ρ = −0.80; P < .01), and the MRC abductor pollicis brevis score (ρ = −0.46; P < .05). In addition, intracortical facilitation significantly correlated with the CMAP amplitude (R = −0.67; P < .05) as did the cortical silent period duration (R = −0.59; P < .05) and resting motor threshold (R = 0.53; P < .05). Taken together, these findings suggest the features of cortical hyperexcitability were most prominent when muscle strength and motor amplitudes were relatively preserved.

Discussion

The findings in the present study confirmed cortical hyperexcitability as an intrinsic feature of c9orf72 expansion-related ALS as well as SALS. Cortical hyperexcitability was associated by a marked reduction of short-interval intracortical inhibition and cortical silent period duration combined with an increase in MEP amplitude and intracortical facilitation. In contrast, cortical excitability was normal in the asymptomatic c9orf72 expansion carriers and was significantly different when compared with FALS and SALS cohorts. The potential mechanisms underlying these findings and their pathophysiological implications for ALS are further discussed.

Cortical Hyperexcitability and ALS Pathogenesis

Pathophysiological mechanisms underlying the development of motor neuron degeneration in ALS appear to be multifactorial, with a complex interaction between genetic factors and the dysfunction of vital molecular pathways.21 The identification of the dominantly inherited c9orf72 gene as an important genetic etiology of ALS1,2 has altered the understanding of ALS pathogenesis, building on the concept of ALS as a multisystem neurodegenerative disorder22 and emphasizing the importance of cortical mechanisms in ALS pathophysiology. This was further underscored by neuropathological studies demonstrating cortical intraneuronal inclusions evident in ALS associated with c9orf72 and frontotemporal dementia.23

Cortical hyperexcitability was a feature of c9orf72 FALS comparable with findings in the SALS cohort and evidenced by a marked reduction of SICI. Short-interval intracortical inhibition is mediated by the activation of cortical inhibitory circuits that act via γ-aminobutyric acid type A receptors as well as glutaminergic neurotransmission.11,24,25 Consequently, the reduction of SICI could have been mediated by the degeneration and dysfunction of inhibitory cortical interneurons26,27 as well as glutamate-mediated excitoxicity. A significant reduction in the cortical silent period duration and resting motor thresholds along with an increase in the MEP amplitude further supported the presence of cortical hyperexcitability in patients with c9orf72 ALS.

The findings of cortical hyperexcitability in the present c9orf72 FALS cohort were similar to previous studies in patients with FALS attributed to different genetic mutations.13,28 As such, cortical hyperexcitability appears to represent a uniform pathophysiological process in ALS irrespective of underlying genetic status. Mathematical modeling has inferred a 6-step process in ALS,29 with a prolonged prodromal period potentially extending to the perinatal period.30 Cortical hyperexcitability could represent one of the final steps in ALS pathogenesis, perhaps developing just prior to or at the onset of neuronal degeneration, a notion supported by findings of significant correlations between features of cortical hyperexcitability, motor amplitude, and muscle strength. Animal studies support this assumption, identifying neuronal hyperexcitability at a preclinical stage upstream of the spinal motor neuron.31,32

Further supporting a multistep process in ALS is the finding of normal cortical excitability in the asymptomatic c9orf72 expansion carriers similar to the findings in asymptomatic superoxide dismutase-1 gene mutation carriers.13 Consequently, the development of neuronal hyperexcitability in FALS appears to be dependent on factors other than the inheritance of genetic mutations. Identifying and modulating these triggering factors could be therapeutically significant for ALS. In addition, the findings of normal cortical excitability in the asymptomatic FALS cohorts would argue against therapeutic benefits of prophylactic riluzole.

Conclusions

It could be argued that cortical hyperexcitability was an adaptive process in response to peripheral neurodegeneration and could serve as a neuroprotective strategy. Underscoring this notion are recent animal studies suggesting that an increase in neuronal excitability may be neuroprotective.31 While this cannot be discounted in patients with ALS, it seems unlikely, given that riluzole, an antiglutaminergic agent that prolongs survival,33,34 reduces cortical hyperexcitability.25 In addition, the reduction of neuronal hyperexcitability by pharmacological agents, such as retigabine, appears to be neuroprotective,10 while normalizing astrocyte function by knocking down the expression of mutated genes and, therefore, normalizing glutamate homeostasis, appears to be neuroprotective.35 In addition, features of cortical hyperexcitability were not evident in non-ALS neuromuscular cohorts despite a comparable degree of peripheral neurodegeneration,14,15,36 further arguing against the notion that cortical hyperexcitability represents a simple compensatory mechanism. Rather, cortical hyperexcitability may serve as a final common pathway in ALS, mediating neuronal degeneration via a transsynaptic glutamate process. The identification and modulation of factors that trigger cortical hyperexcitability may prove therapeutically useful.

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Article Information

Corresponding Author: Steve Vucic, PhD, Department of Neurology, Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, New South Wales, Australia 2145 (s.vucic@neura.edu.au).

Accepted for Publication: June 17, 2015.

Published Online: September 8, 2015. doi:10.1001/jamaneurol.2015.1872.

Author Contributions: Dr Vucic had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Geevasinga, Kiernan, Vucic.

Acquisition, analysis, or interpretation of data: Geevasinga, Menon, Nicholson, Ng, Howells, Kril, Yiannikas, Vucic.

Drafting of the manuscript: Geevasinga, Kiernan, Vucic.

Critical revision of the manuscript for important intellectual content: Menon, Nicholson, Ng, Howells, Kril, Yiannikas.

Statistical analysis: Geevasinga, Howells, Vucic.

Obtained funding: Kril, Kiernan.

Administrative, technical, or material support: Geevasinga, Menon, Nicholson, Ng, Howells, Kril, Yiannikas, Vucic.

Study supervision: Menon, Yiannikas, Kiernan, Vucic.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported in part by a research grant from the Motor Neuron Disease Research Institute of Australia (Dr Geevasinga) and grants 510233, 1024915, and 1055778 from the National Health and Medical Research Council of Australia (Drs Kiernan and Vucic). Forefront, a collaborative research group dedicated to the study of frontotemporal dementia and motor neuron disease, supported this study and received the National Health and Medical Research Council of Australia Program grant 1037746 (Drs Kril and Kiernan) and the Pfizer Neuroscience grant WS2343874 (Dr Geevasinga). Tissues were received from the New South Wales Tissue Resource Centre at the University of Sydney, which is supported by the National Health and Medical Research Council of Australia, the Schizophrenia Research Institute, and grant R28AA012725 from the National Institute of Alcohol Abuse and Alcoholism (Dr Kril).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
DeJesus-Hernandez  M, Mackenzie  IR, Boeve  BF,  et al.  Expanded GGGGCC hexanucleotide repeat in noncoding region of C9ORF72 causes chromosome 9p-linked FTD and ALS. Neuron. 2011;72(2):245-256.
PubMedArticle
2.
Renton  AE, Majounie  E, Waite  A,  et al; ITALSGEN Consortium.  A hexanucleotide repeat expansion in C9ORF72 is the cause of chromosome 9p21-linked ALS-FTD. Neuron. 2011;72(2):257-268.
PubMedArticle
3.
Majounie  E, Renton  AE, Mok  K,  et al; Chromosome 9-ALS/FTD Consortium; French research network on FTLD/FTLD/ALS; ITALSGEN Consortium.  Frequency of the C9orf72 hexanucleotide repeat expansion in patients with amyotrophic lateral sclerosis and frontotemporal dementia: a cross-sectional study. Lancet Neurol. 2012;11(4):323-330.
PubMedArticle
4.
Lomen-Hoerth  C, Murphy  J, Langmore  S, Kramer  JH, Olney  RK, Miller  B.  Are amyotrophic lateral sclerosis patients cognitively normal? Neurology. 2003;60(7):1094-1097.
PubMedArticle
5.
Ciura  S, Lattante  S, Le Ber  I,  et al.  Loss of function of C9orf72 causes motor deficits in a zebrafish model of amyotrophic lateral sclerosis. Ann Neurol. 2013;74(2):180-187.
PubMed
6.
Mori  K, Lammich  S, Mackenzie  IR,  et al.  hnRNP A3 binds to GGGGCC repeats and is a constituent of p62-positive/TDP43-negative inclusions in the hippocampus of patients with C9orf72 mutations. Acta Neuropathol. 2013;125(3):413-423.
PubMedArticle
7.
Donnelly  CJ, Zhang  P-W, Pham  JT,  et al.  RNA toxicity from the ALS/FTD C9ORF72 expansion is mitigated by antisense intervention. Neuron. 2013;80(2):415-428.
PubMedArticle
8.
Ling  S-C, Polymenidou  M, Cleveland  DW.  Converging mechanisms in ALS and FTD: disrupted RNA and protein homeostasis. Neuron. 2013;79(3):416-438.
PubMedArticle
9.
Ash  PE, Bieniek  KF, Gendron  TF,  et al.  Unconventional translation of C9ORF72 GGGGCC expansion generates insoluble polypeptides specific to c9FTD/ALS. Neuron. 2013;77(4):639-646.
PubMedArticle
10.
Wainger  BJ, Kiskinis  E, Mellin  C,  et al.  Intrinsic membrane hyperexcitability of amyotrophic lateral sclerosis patient-derived motor neurons. Cell Rep. 2014;7(1):1-11.
PubMedArticle
11.
Vucic  S, Ziemann  U, Eisen  A, Hallett  M, Kiernan  MC.  Transcranial magnetic stimulation and amyotrophic lateral sclerosis: pathophysiological insights. J Neurol Neurosurg Psychiatry. 2013;84(10):1161-1170.
PubMedArticle
12.
Vucic  S, Kiernan  MC.  Novel threshold tracking techniques suggest that cortical hyperexcitability is an early feature of motor neuron disease. Brain. 2006;129(pt 9):2436-2446.
PubMedArticle
13.
Vucic  S, Nicholson  GA, Kiernan  MC.  Cortical hyperexcitability may precede the onset of familial amyotrophic lateral sclerosis. Brain. 2008;131(pt 6):1540-1550.
PubMedArticle
14.
Vucic  S, Kiernan  MC.  Cortical excitability testing distinguishes Kennedy’s disease from amyotrophic lateral sclerosis. Clin Neurophysiol. 2008;119(5):1088-1096.
PubMedArticle
15.
Vucic  S, Cheah  BC, Yiannikas  C, Kiernan  MC.  Cortical excitability distinguishes ALS from mimic disorders. Clin Neurophysiol. 2011;122(9):1860-1866.
PubMedArticle
16.
de Carvalho  M, Dengler  R, Eisen  A,  et al.  Electrodiagnostic criteria for diagnosis of ALS. Clin Neurophysiol. 2008;119(3):497-503.
PubMedArticle
17.
Cedarbaum  JM, Stambler  N, Malta  E,  et al; BDNF ALS Study Group (Phase III).  The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. J Neurol Sci. 1999;169(1-2):13-21.
PubMedArticle
18.
Turner  MR, Cagnin  A, Turkheimer  FE,  et al.  Evidence of widespread cerebral microglial activation in amyotrophic lateral sclerosis: an [11C](R)-PK11195 positron emission tomography study. Neurobiol Dis. 2004;15(3):601-609.
PubMedArticle
19.
Vucic  S, Howells  J, Trevillion  L, Kiernan  MC.  Assessment of cortical excitability using threshold tracking techniques. Muscle Nerve. 2006;33(4):477-486.
PubMedArticle
20.
de Carvalho  M, Swash  M.  Nerve conduction studies in amyotrophic lateral sclerosis. Muscle Nerve. 2000;23(3):344-352.
PubMedArticle
21.
Vucic  S, Rothstein  JD, Kiernan  MC.  Advances in treating amyotrophic lateral sclerosis: insights from pathophysiological studies. Trends Neurosci. 2014;37(8):433-442.
PubMedArticle
22.
Turner  MR, Hardiman  O, Benatar  M,  et al.  Controversies and priorities in amyotrophic lateral sclerosis. Lancet Neurol. 2013;12(3):310-322.
PubMedArticle
23.
Al-Sarraj  S, King  A, Troakes  C,  et al.  p62 positive, TDP-43 negative, neuronal cytoplasmic and intranuclear inclusions in the cerebellum and hippocampus define the pathology of C9orf72-linked FTLD and MND/ALS. Acta Neuropathol. 2011;122(6):691-702.
PubMedArticle
24.
Hanajima  R, Ugawa  Y, Terao  Y,  et al.  Paired-pulse magnetic stimulation of the human motor cortex: differences among I waves. J Physiol. 1998;509(pt 2):607-618.
PubMedArticle
25.
Vucic  S, Lin  CS-Y, Cheah  BC,  et al.  Riluzole exerts central and peripheral modulating effects in amyotrophic lateral sclerosis. Brain. 2013;136(pt 5):1361-1370.
PubMedArticle
26.
Nihei  K, McKee  AC, Kowall  NW.  Patterns of neuronal degeneration in the motor cortex of amyotrophic lateral sclerosis patients. Acta Neuropathol. 1993;86(1):55-64.
PubMedArticle
27.
Turner  MR, Kiernan  MC.  Does interneuronal dysfunction contribute to neurodegeneration in amyotrophic lateral sclerosis? Amyotroph Lateral Scler. 2012;13(3):245-250.
PubMedArticle
28.
Blair  IP, Williams  KL, Warraich  ST,  et al.  FUS mutations in amyotrophic lateral sclerosis: clinical, pathological, neurophysiological and genetic analysis. J Neurol Neurosurg Psychiatry. 2010;81(6):639-645.
PubMedArticle
29.
Al-Chalabi  A, Calvo  A, Chio  A,  et al.  Analysis of amyotrophic lateral sclerosis as a multistep process: a population-based modelling study. Lancet Neurol. 2014;13(11):1108-1113.
PubMedArticle
30.
Eisen  A, Kiernan  M, Mitsumoto  H, Swash  M.  Amyotrophic lateral sclerosis: a long preclinical period? J Neurol Neurosurg Psychiatry. 2014;85(11):1232-1238.
PubMedArticle
31.
Ramesh  TM, Shaw  PJ, McDearmid  J.  A zebrafish model exemplifies the long preclinical period of motor neuron disease. J Neurol Neurosurg Psychiatry. 2014;85(11):1288-1289.
PubMedArticle
32.
Saba  L, Viscomi  MT, Caioli  S,  et al.  Altered functionality, morphology, and vesicular glutamate transporter expression of cortical motor neurons from a presymptomatic mouse model of amyotrophic lateral sclerosis. Cereb Cortex. 2015;bhu317.
PubMed
33.
Lacomblez  L, Bensimon  G, Leigh  PN, Guillet  P, Meininger  V; Amyotrophic Lateral Sclerosis/Riluzole Study Group II.  Dose-ranging study of riluzole in amyotrophic lateral sclerosis. Lancet. 1996;347(9013):1425-1431.
PubMedArticle
34.
Bensimon  G, Lacomblez  L, Meininger  V; ALS/Riluzole Study Group.  A controlled trial of riluzole in amyotrophic lateral sclerosis. N Engl J Med. 1994;330(9):585-591.
PubMedArticle
35.
Haidet-Phillips  AM, Hester  ME, Miranda  CJ,  et al.  Astrocytes from familial and sporadic ALS patients are toxic to motor neurons. Nat Biotechnol. 2011;29(9):824-828.
PubMedArticle
36.
Vucic  S, Cheah  BC, Yiannikas  C, Vincent  A, Kiernan  MC.  Corticomotoneuronal function and hyperexcitability in acquired neuromyotonia. Brain. 2010;133(9):2727-2733.
PubMedArticle
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