Annals of Neurology最新文献

Objective: To evaluate whether white matter hyperintensities (WMH) and apolipoprotein E (APOE) ε4 status have an additive or multiplicative effect on the risk of incident all-cause dementia.

Methods: We conducted a prospective cohort study in the Atherosclerosis Risk in Communities (ARIC) study and confirmed findings in the UK Biobank (UKB). The exposures were APOE ε4 status (0 vs. ≥1 allele) and WMH on magnetic resonance imaging (MRI). The primary outcome was incident all-cause dementia. After confirming an additive interaction, we created combined exposure groups: WMH-/ε4-, WMH+/ε4-, WMH-/ε4+, and WMH+/ε4+. Cox proportional hazards models were adjusted for age, sex, race, education, cognition (ARIC only), hypertension, diabetes, and prior stroke.

Results: In ARIC (n = 1,736, mean age 63, 58.8% female, 48.7% non-Hispanic White individuals, median follow-up 18.6 years), the dementia incidence rate was 10.4 (95% CI, 9.2-11.6) per 1,000 person-years. Compared to WMH-/ε4-, adjusted hazard ratios (HRs) for dementia were: WMH-/ε4+, 1.5 (95% CI, 1.1-2.1); WMH+/ε4-, 2.0 (95% CI, 1.4-2.7); and WMH+/ε4+, 3.2 (95% CI, 2.2-4.6). In UKB (n = 40,307, mean age 55, 52.7% female, 97.1% non-Hispanic White individuals, median follow-up 3.2 years), the dementia incidence rate was 0.42 (95% CI, 0.32-0.55) per 1,000 person-years. Adjusted HRs were: WMH-/ε4+, 2.3 (95% CI, 1.2-4.5); WMH+/ε4-, 2.1 (95% CI, 1.0-4.6); and WMH+/ε4+, 6.7 (95% CI, 3.2-13.9).

Interpretation: WMH burden and APOE ε4 status additively increase dementia risk. These findings support the potential benefit of vascular risk management to reduce WMH and delay dementia onset, even among genetically at-risk individuals. ANN NEUROL 2025.

Objective: Amyotrophic lateral sclerosis (ALS) has a very specific neuroimaging signature, but the molecular underpinnings of the strikingly selective anatomic involvement have not elucidated to date. Accordingly, a large neuroimaging study was conducted with 258 participants to evaluate associations between patterns of neurodegeneration and focal metabolic metrics.

Methods: Structural and diffusivity alterations were systematically evaluated in a genetically stratified cohort. Voxelwise associations between neurodegeneration and physiological mitochondrial indices were systematically evaluated over the entire brain and also examined in specific regions.

Results: Significant topological associations were identified between physiological mitochondria tissue density, nicotinamide adenine dinucleotide (NADH)-ubiquinone oxidoreductase, succinate dehydrogenase, cytochrome c oxidase (COX), mitochondrial respiratory capacity (MRC), tissue respiratory capacity (TRC), and propensity to focal atrophy in ALS. Anatomic correlations between mitochondrial metrics and morphometric change were particularly strong in GGGGCC hexanucleotide repeat carriers in C9orf72. Diffusivity analyses also confirmed associations between brain metabolism and microstructural degeneration. Higher focal mitochondria tissue density was associated with higher likelihood of frontal, temporal, cerebellar, opercular, thalamic, cingulum, putamen, corpus callosum, and corona radiata degeneration. Uncinate fasciculus degeneration was associated with higher Complex I, II, COX, and TRC activity. Topological associations were readily replicated in an external validation cohort.

Interpretation: Our data indicate that brain regions with high metabolic activity are particularly vulnerable to neurodegeneration in ALS. Anatomic associations between physiological cerebral metabolism and patterns of neurodegeneration implicate mitochondrial dysfunction in the pathophysiology of ALS. Although mitochondrial dysfunction may not be the primary etiological factor, it may represent a shared bottleneck of multiple converging molecular and genetic pathways, offering a potential opportunity for meaningful pharmacological intervention. ANN NEUROL 2025.

Frailty is increasingly recognized as a critical factor in neurology, influencing disease susceptibility, progression, and outcomes. Emerging evidence highlights the pivotal role of sex and gender in shaping frailty trajectories across major neurological disorders, including stroke, Parkinson's disease (PD), dementia, and multiple sclerosis. This systematic review synthesizes current knowledge on the interplay between frailty and neurological disease, with a focus on sex-specific patterns. Recognizing sex- and gender-related differences in frailty expression is critical to advancing a more personalized and equitable model of neurological care, and reducing disparities in a growing population affected by age-related neurological conditions. ANN NEUROL 2025.

Objective: The effects of deep brain stimulation (DBS) manifest across multiple timescales, spanning seconds to months, and involve direct electrical effects, neuroplasticity, and network reorganization. In epilepsy, the delayed impact of DBS on seizures presents challenges for optimization. Single-pulse stimulation and resulting brain stimulation evoked potentials (BSEPs) provide a means to assess effective connectivity and network excitability. This study integrates BSEPs and short trials of DBS during stereoelectroencephalography (sEEG) to map seizure network engagement, modulate network dynamics, and monitor excitability and interictal abnormalities for biomarker informed neuromodulation.

Methods: Ten individuals with drug resistant epilepsy undergoing clinical sEEG were enrolled in this retrospective cohort study of epilepsy neuromodulation biomarkers. Each patient underwent a trial of high frequency (145Hz) thalamic DBS. BSEPs were acquired before and after DBS trials. Baseline BSEP amplitude assessed seizure network engagement, and modulation of amplitude (pre vs post DBS) assessed change in network excitability. Interictal epileptiform discharges were tracked by an automated classifier.

Results: Baseline BSEPs delineated distinct patterns of network engagement between thalamic subfields with maximal frontotemporal engagement achieved with stimulation of the anterior nucleus of the thalamus-ventral anterior nucleus junction. DBS delivered for >1.5 hours reduced BSEP amplitudes compared to baseline, and the degree of modulation correlated with baseline connectivity strength. Shorter DBS trials did not induce reliable BSEP amplitude suppression, but did immediately suppress interictal epileptiform discharge rates in well-connected seizure networks.

Interpretation: BSEPs and trials of DBS during sEEG provide novel network biomarkers to evaluate the modulation of large-scale networks across multiple timescales, advancing biomarker informed neuromodulation. ANN NEUROL 2025.

Pathogenic DMD variants usually follow the reading-frame rule: out-of-frame changes cause Duchenne muscular dystrophy, whereas in-frame ones produce Becker muscular dystrophy (BMD). We report a 23-year-old man with BMD-like weakness, calf hypertrophy, elevated creatine kinase, and dilated cardiomyopathy. A novel hemizygous c.2281delG variant converted an A₄GA₅ motif to A₉, predicting a frameshift; however, Western blot showed ~15% full-length dystrophin. cDNA and polymerse chain reaction (PCR)-free direct RNA sequencing demonstrated transcriptional slippage, adding 1 adenine (A₁₀) that restores the reading frame and dystrophin. This RNA-level rescue of an out-of-frame DMD variant explains the mild phenotype and highlights the importance of transcript-level analysis in dystrophinopathies. ANN NEUROL 2025.

RNU2-2 is a non-coding small nuclear RNA (snRNA) that forms part of the spliceosome. We identified recurrent pathogenic RNU2-2 variants in 4 of 672 (0.6%) patients with developmental and epileptic encephalopathies (DEEs) of unknown cause. An additional patient was subsequently included. Patients with RNU2-2 DEE had median seizure onset age of 24 months, focal and generalized seizures, status epilepticus (n = 5), severe to profound impairment, hyperventilation (n = 3), and obstructive sleep apnea (n = 3). Electroencephalography showed sleep-activated multifocal epileptiform discharges (n = 4) and hippocampal sclerosis on magnetic resonance imaging (n = 3). Pathogenic variants in RNU2-2 cause a distinctive severe DEE.SnRNAs are emerging as an important cause of genetic DEEs. ANN NEUROL 2025.

Objective: Growing evidence underscores the importance of host-response/secondary-injury-likely influenced by genetics-in outcome variability post-traumatic brain injury (TBI). Intracranial hypertension and hemorrhage progression are critical secondary injuries in severe TBI; these are mediated by the SUR1-TRPM4 channel (a target in clinical trials). We aimed to deconstruct the complex network surrounding SUR1-TRPM4 and define the cumulative impact of key genetic variants on mechanistically connected secondary injuries/outcomes after severe TBI.

Methods: This exploratory study analyzed 492 prospectively enrolled patients with severe TBI. A network of regulators, mediators, and effectors upstream/downstream of SUR1-TRPM4 was bioinformatically constructed. Single nucleotide variants (SNVs) were evaluated for multivariable model association with intracranial pressure, intraparenchymal hemorrhage progression, and Glasgow Outcome Scale (GOS) score. Weighted/unweighted polygenic-risk scores (PRS) were constructed and interrogated. Spatial modeling and functional predictions were determined. Single-cell cortical transcriptomic differences were assessed in a parallel murine TBI model.

Results: Ninety-seven genes (625 SNVs) were analyzed. Nineteen genes contained variants associated with all outcomes (intracranial pressure, hemorrhage progression, and GOS score; p < 0.05). Twenty-two genes (42 SNVs) retained significance for ≥ 1 outcome, with overlap across outcomes. Functions included Ca²⁺-transport/signaling, glutamate-clearance, neuroinflammation, and cell death. Single-cell analyses revealed cell-specific gene-expression differences. SNVs were brain-specific cis-expression quantitative trait locus (eQTLs)/missense/frameshift mutations suggesting high likelihood of biological impact. PRSs were associated with all outcomes with large effects, and markedly improved model explanatory power/performance (R², receiver operating characteristic [ROC]).

Interpretation: Polygenic variability in key nodes linked to SUR1-TRPM4 were associated with mechanistically related secondary injuries and outcome after severe TBI; findings suggest a major role of heritability. Functional implications indicate biological plausibility and identify novel targets. The data, whereas requiring validation, support a shift toward incorporating biologically relevant genetics in advancing precision medicine. ANN NEUROL 2025.

Objective: Lewy body disease (LBD) is a complex neurodegenerative disorder characterized by the accumulation of misfolded α-synuclein in the brain. Neuroinflammation has long been implicated in LBD pathogenesis, and recent genetic studies in Parkinson's disease (a clinical manifestation of LBD) have shown consistent association with the human leukocyte antigen (HLA) gene complex. Here, we assessed whether variation in HLA alleles influences neuropathological burden in a neuropathologically-defined series of LBD cases.

Methods: We conducted a comprehensive analysis of HLA allelic variants in a cohort of 539 LBD cases of European descent from the Mayo Clinic brain bank. High-resolution whole-genome sequencing was used, and the HLA alleles of each sample were called using the HLA*LA tool and assessed for association with neuropathological outcomes.

Results: Our analysis identified 1 significant (P < 3.43 × 10^-5) and 4 suggestive (P < 0.001) associations between certain HLA alleles and specific neuropathological outcomes in LBD, suggesting a potential role for HLA-mediated immune mechanisms in disease progression and subtype differentiation. Specifically, HLA-DPB1*06:01 was significantly associated with lower Lewy body counts in the parahippocampal gyrus (P = 3.30 × 10^-5), with weaker and suggestive associations observed in the middle frontal (P = 1.80 × 10^-4) and inferior parietal gyrus (P = 6.33 × 10^-4). Additionally, although only suggestive, HLA-DRB1*11:01 correlated with a lower Thal amyloid phase (P = 1.56 x 10^-4), and HLA-B*15:01 correlated with an increased risk of diffuse LBD (P = 7.58 x 10^-4).

Interpretation: This study provides a detailed evaluation of the relationship between HLA alleles and LBD pathology, highlighting the importance of immune-related genetic factors in the etiology of LBD. ANN NEUROL 2025.