Auditory interhemispheric transfer deficits, hearing difficulties, and brain magnetic resonance imaging abnormalities in children with congenital aniridia due to PAX6 mutations.

OBJECTIVE: To assess auditory processing, hearing difficulties, and brain magnetic resonance (MR) imaging abnormalities in children with panocular developmental aniridia due to PAX6 mutations. DESIGN: Case-control study. SETTING: Great Ormond Street Hospital and Institute of Child Health. PARTICIPANTS: Eleven case subjects with PAX6 mutations and 11 age-matched and sex-matched healthy control subjects. INTERVENTIONS: All subjects completed a structured hearing questionnaire, baseline audiometry, and central auditory tests (dichotic speech tests, frequency and duration pattern tests, and gaps-in-noise test). Case subjects underwent brain MR imaging with volumetry, and the results were compared with those of age-matched and sex-matched healthy control subjects randomly selected from the Radiology and Physics Unit database. MAIN OUTCOME MEASURES: Brain MR imaging, central auditory test results, and questionnaire scores. RESULTS: The corpus callosum area was significantly smaller on brain volumetry in the cases compared with the controls. The anterior commissure was small in 7 cases and was normal in 3 cases on visual inspection of brain MR images (conducted in 10 of 11 cases). Audiograms showed no abnormalities in any of the children. Central auditory test results were normal in all the controls and were abnormal in all the cases except for 1 case with a pattern of abnormalities consistent with reduced auditory interhemispheric transfer. The cases had greater difficulty localizing sound and understanding speech in noise than the controls. CONCLUSIONS: Despite normal audiograms, children with PAX6 mutations may experience auditory interhemispheric transfer deficits and have difficulty localizing sound and understanding speech in noise. In view of their additional visual difficulties, thorough audiological evaluation of these children is indicated to initiate appropriate management.

Evaluation of quantitative magnetic resonance imaging contrasts in MRI-negative refractory focal epilepsy.

PURPOSE: Conventional optimal MRI is unremarkable in 20%-30% of patients with intractable focal epilepsy. These MRI-negative patients are the most challenging in surgical programs. Our aim was to evaluate the yield and utility of quantitative MRI with novel contrasts in MRI-negative patients with refractory focal epilepsy, who were potential surgical candidates. METHODS: Ninety-three consecutive potential surgical candidates with refractory focal epilepsy, 44 with temporal lobe epilepsy, and 49 with frontal lobe epilepsy as determined with ictal scalp video-EEG; and normal optimal conventional MRI, including hippocampal volumes and T2 measures were investigated with quantitative MRI contrasts. The contrasts comprised fast fluid attenuated inversion recovery based T2 measurement (FFT2), double inversion recovery (DIR), magnetization transfer ratio (MTR), and voxel-based morphometry of gray matter (VBM). Voxel-based analyses of whole brain data were used to compare each patient with a control group. RESULTS: In patients with a putative single focus on scalp video-EEG telemetry, 16% had concordant FFT2 abnormalities, as did 16% with DIR, 5% with MTR and 9% with VBM. The greatest agreement in the localization of abnormalities was between FFT2 and DIR. Altogether, 31% patients had a focal abnormality with at least one contrast in the lobe of seizure onset. Signal changes outside the lobe of the putative focus were found with FFT2 in 36% patients, with DIR in 42%, with MTR in 6% and with VBM in 7%. DISCUSSION: Quantitative analysis of MRI contrasts had a low yield of identifying focal abnormalities concordant with putative epileptic foci in patients with unremarkable conventional MRI. Specificity was low for FFT2 and DIR. With the low specificity, data must be interpreted with caution, but in some patients may assist in creating a hypothesis for testing with intracranial electrodes.

Genetic enhancement of cognition in a kindred with cone-rod dystrophy due to RIMS1 mutation.

BACKGROUND: The genetic basis of variation in human cognitive abilities is poorly understood. RIMS1 encodes a synapse active-zone protein with important roles in the maintenance of normal synaptic function: mice lacking this protein have greatly reduced learning ability and memory function. OBJECTIVE: An established paradigm examining the structural and functional effects of mutations in genes expressed in the eye and the brain was used to study a kindred with an inherited retinal dystrophy due to RIMS1 mutation. MATERIALS AND METHODS: Neuropsychological tests and high-resolution MRI brain scanning were undertaken in the kindred. In a population cohort, neuropsychological scores were associated with common variation in RIMS1. Additionally, RIMS1 was sequenced in top-scoring individuals. Evolution of RIMS1 was assessed, and its expression in developing human brain was studied. RESULTS: Affected individuals showed significantly enhanced cognitive abilities across a range of domains. Analysis suggests that factors other than RIMS1 mutation were unlikely to explain enhanced cognition. No association with common variation and verbal IQ was found in the population cohort, and no other mutations in RIMS1 were detected in the highest scoring individuals from this cohort. RIMS1 protein is expressed in developing human brain, but RIMS1 does not seem to have been subjected to accelerated evolution in man. CONCLUSIONS: A possible role for RIMS1 in the enhancement of cognitive function at least in this kindred is suggested. Although further work is clearly required to explore these findings before a role for RIMS1 in human cognition can be formally accepted, the findings suggest that genetic mutation may enhance human cognition in some cases.

Statistical neuroanatomy of the human inferior frontal gyrus and probabilistic atlas in a standard stereotaxic space.

We manually defined the inferior frontal gyrus (IFG) on high-resolution MRIs in native space in 30 healthy subjects (15 female, median age 31 years; 15 male, median age 30 years), resulting in 30 individual atlases. Using standard software (SPM99), these were spatially transformed to a widely used stereotaxic space (MNI/ICBM 152) to create probabilistic maps. In native space, the total IFG volume was on average 5%, and the gray matter (GM) portion 12% larger in women (not significant). Expressed as a percentage of ipsilateral frontal lobe volume (i.e., correcting for brain size), the IFG was an average of 20%, and the GM portion of the IFG 27%, larger in women (P < 0.005). Correcting for total lobar volume yielded the same result. No asymmetry was found in IFG volumes. There were significant positional differences between the right and left IFGs, with the right IFG being further lateral in both native and stereotaxic space. Variability was similar on the left and right, but more pronounced anteriorly and superiorly. We show differences in IFG volume, composition, and position between sexes and between hemispheres. Applications include probabilistic determination of location in group studies, automatic labeling of new scans, and detection of anatomical abnormalities in patients.

High-resolution diffusion tensor imaging of the hippocampus in temporal lobe epilepsy.

PURPOSE: To assess the quantitative diffusion characteristics of the hippocampus with high-resolution diffusion tensor imaging (DTI) in temporal lobe epilepsy (TLE). METHODS: Thirteen controls and seven unilateral TLE patients (six with hippocampal sclerosis, one with normal magnetic resonance imaging (MRI)) were scanned with DTI using a zonally magnified oblique multislice echo planar imaging (ZOOM-EPI) acquisition. Fractional anisotropy (FA) and mean diffusivity (MD) were measured in the hippocampi. RESULTS: The mean hippocampal MD ipsilateral to the seizure focus was higher than the contralateral MD in patients (p<0.05) and the mean MD in controls (p<0.001). Hippocampal FA ipsilateral to the seizure focus was lower than the mean FA in controls (p<0.05). MD asymmetry indexes were significantly different between the patient and control groups (p<0.01). All six individual HS patients had ipsilateral hippocampal MD >or=2 standard deviations (S.D.) above the control mean. The patient with normal structural MRI had bilaterally low hippocampal FA and high MD. DISCUSSION: High-resolution DTI identifies lateralizing abnormalities of MD and FA in TLE patients. This quantitative data on hippocampal integrity may assist in evaluating TLE patients with normal MRI, and in longitudinal studies.

Role of SOX2 mutations in human hippocampal malformations and epilepsy.

PURPOSE: Seizures are noted in a significant proportion of cases of de novo, heterozygous, loss-of-function mutations in SOX2, ascertained because of severe bilateral eye malformations. We wished to determine the underlying cerebral phenotype in SOX2 mutation and to test the candidacy of SOX2 as a gene contributing to human epilepsies. METHODS: We examined high-resolution MRI scans in four patients with SOX2 mutations, two of whom had seizures. We determined the Sox2 expression pattern in developing murine brain. We searched for SOX2 mutation in 24 patients with typical hippocampal sclerosis and for common variations in SOX2 in 655 patients without eye disease but with epilepsy, including 91 patients with febrile seizures, 93 with hippocampal sclerosis, and 258 with temporal lobe epilepsy. RESULTS: Striking hippocampal and parahippocampal malformations were seen in all cases, with a history of febrile seizures or epilepsy in two of four cases. The Sox2 expression pattern in developing mouse brain supports the pattern of malformations observed. Mutation screening in patients with epilepsy did not reveal any abnormalities in SOX2. No associations were found between any clinical epilepsy phenotype and common variation in SOX2. CONCLUSIONS: SOX2 haploinsufficiency causes mesial temporal malformation in humans, making SOX2 dysfunction a candidate mechanism for mesial temporal abnormalities associated with chronic epilepsy. However, although mutation of SOX2 in humans causes hippocampal malformation, SOX2 mutation or variation is unlikely to contribute commonly to mesial temporal lobe epilepsy or its structural (hippocampal sclerosis) or historic (febrile seizures) associations in humans.

A novel homeobox mutation in the PITX2 gene in a family with Axenfeld-Rieger syndrome associated with brain, ocular, and dental phenotypes.

Axenfeld-Rieger Syndrome (ARS) is a genetically heterogeneous birth defect characterized by malformation of the anterior segment of the eye associated with glaucoma. Mutation of the PITX2 homeobox gene has been identified as a cause of ARS. We report a novel Arg5Trp missense mutation in the PITX2 homeodomain, which is associated with brain abnormalities. One patient had a small sella turcica likely to reflect hypoplasia of the pituitary gland and consistent with the critical role identified for Pitx2 in pituitary development in mice. Two patients had an enlarged cisterna magna, one with a malformed cerebellum, and two had executive skills deficits one in isolation and one in association with a below average intellectual capacity. The mutation caused a typical ARS ocular phenotype. All affected had iris hypoplasia, anterior iris to corneal adhesions, and corectopia. The ocular phenotype varied significantly in severity and showed some asymmetry. All affected also had redundant peri-umbilical skin, a hypoplastic maxilla, microdontia, and hypodontia missing between 20 and 27 teeth with an unusual pattern of tooth loss. Dental phenotypes were documented as they are often poorly characterized in ARS patients. All affected individuals showed an absence of first permanent molars with variable absence of other rarely absent teeth: the permanent upper central incisors, maxillary and mandibular first and second molars, and the mandibular canines. Based on the distinctive dental anomalies, we suggest that the dental phenotype can assist in predicting the presence of a PITX2 mutation and the possibility of brain abnormalities.

Reliable registration of preoperative MRI with histopathology after temporal lobe resections.

PURPOSE: Conventional and novel magnetic resonance imaging (MRI) techniques can detect cerebral abnormalities in patients with refractory focal epilepsies. Correlation of preoperative MRI and histopathology is important to validate MRI findings, but in practice is far from straightforward. Peroperative neuronavigation and placement of markers on tissue is of limited use in temporal lobe resections. MRI scanning of the resected specimen for registration with in vivo MRI is complicated by anisotropic tissue deformation. We have developed a method to facilitate registration of preoperative MRI with the resected specimen and to enable correlation of MRI findings with histopathology. METHODS: Sixteen en bloc temporal lobe resections undertaken for refractory temporal lobe epilepsy were studied. The specimens were fixed in formalin and then cut coronally by using a cradle with parallel blades at 5-mm intervals to ensure evenly thick tissue slices in the same orientation. Volumetric T1-weighted preoperative MRIs were reformatted, and consecutive slices (0.94 mm) cut in the same orientation as the resected lobe were visually compared with photographs of tissue slices by two independent observers. RESULTS: In 15 (94%) of 16 cases, a <2-mm difference was found between the two observers' matches of MRI slices with tissue slices. In the last case, a 4-mm difference was noted. In all cases, a consensus was reached by the two observers. The suggested MRI-histology matches were within the resections seen on postoperative scans. CONCLUSIONS: Careful labelling and postoperative handling and slicing ensured histopathologic tissue slices of uniform thickness and slicing angle. This technique can be applied to a range of MRI datasets, enabling exploration of the pathologic basis of abnormalities on conventional and novel MRI acquisitions.

SOX2 anophthalmia syndrome.

Heterozygous, de novo, loss-of-function mutations in SOX2 have been shown to cause bilateral anophthalmia. Here we provide a detailed description of the clinical features associated with SOX2 mutations in the five individuals with reported mutations and four newly identified cases (including the first reported SOX2 missense mutation). The SOX2-associated ocular malformations are variable in type, but most often bilateral and severe. Of the nine patients, six had bilateral anophthalmia and two had anophthalmia with contralateral microphthalmia with sclerocornea. The remaining case had anophthalmia with contralateral microphthalmia, posterior cortical cataract and a dysplastic optic disc, and was the only patient to have measurable visual acuity. The relatively consistent extraocular phenotype observed includes: learning disability, seizures, brain malformation, specific motor abnormalities, male genital tract malformations, mild facial dysmorphism, and postnatal growth failure. Identifying SOX2 mutations from large cohorts of patients with structural eye defects has delineated a new, clinically-recognizable, multisystem disorder and has provided important insight into the developmental pathways critical for morphogenesis of the eye, brain, and male genital tract.

Deficient auditory interhemispheric transfer in patients with PAX6 mutations.

PAX6 mutations are associated with absence/hypoplasia of the anterior commissure and reduction in the callosal area in humans. Both of these structures contain auditory interhemispheric fibers. The aim of this study was to characterize central auditory function in patients with a PAX6 mutation. We conducted central auditory tests (dichotic speech, pattern, and gaps in noise tests) on eight subjects with a PAX6 mutation and eight age- and sex-matched controls. Brain magnetic resonance imaging showed absent/hypoplastic anterior commissure in six and a hypoplastic corpus callosum in three PAX6 subjects. The control group gave normal central auditory tests results. All the PAX6 subjects gave abnormal results in at least two tests that require interhemispheric transfer, and all but one gave normal results in a test not requiring interhemispheric transfer. The left ear scores in the dichotic speech tests was significantly lower in the PAX6 than in the control group. These results are consistent with deficient auditory interhemispheric transfer in patients with a PAX6 mutation, which may be attributable to structural and/or functional abnormalities of the anterior commisure and corpus callosum, although the exact contribution of these two formations to our findings remains unclear. Our unique findings broaden the possible functions of PAX6 to include neurodevelopmental roles in higher order auditory processing.

Quantitative MR image analysis in subjects with defects in the PAX6 gene.

Cerebral development is governed by genetic and environmental factors. Animal models provide much of our knowledge about genetic influences in the brain but it is not clear how similar or relevant these are to the human brain. The investigation of human subjects with mutations in genes known to be expressed in the developing brain is an alternative approach to improving our understanding of the role of genetic factors in brain development. We investigated 24 subjects with known mutations in the PAX6 gene (including representatives of all the known mutations of the gene) which are associated with characteristic ocular abnormalities in humans and animals. We have quantified MRI data using several techniques to assess qualities of cerebral structure which are difficult to interpret visually. Abnormalities were identified using voxel-based morphometry, statistical morphometrics, and measurement of corpus callosum cross-sectional area when comparing data from subjects with PAX6 abnormality and 72 age-and sex-matched control subjects. These abnormalities include grey matter changes in the cerebellum and occipital poles and white matter loss in the corpus callosum, alteration of sulcal orientation in the occipital lobe, and alteration to overall neuronal connectivity. These abnormalities complement and exceed the changes seen in the mouse models, and those seen on visual inspection alone of the human MRI data. Structural differences were also identified between the two largest genotype mutation subgroups.

Evaluation of nerve cell distribution in cerebral cortex--a proposal for a new method applied to patients with epilepsy.

Microdysgenesis is a microscopic malformation of cortical development (MCD) associated with epilepsy, but its significance in epileptogenesis is debated. This is partly since the histopathological aberrations associated with microdysgenesis can also be found in normal brains. We here report a method for objective analysis of one criterion for microdysgenesis, irregular cortical nerve cell distribution. Tissue from the lateral temporal lobe from two epilepsy patients was compared with tissue from two post-mortem controls. An expansion/shrinkage factor was calculated to determine the change in tissue size during cutting and mounting. Neurons were identified and the positions of their nucleoli were marked and stored. The spatial distribution of neurons was analysed using distance to nearest neighbouring neuron and Voronoi tessellation. Specimens from the epilepsy patients expanded markedly during mounting compared with controls. Epilepsy specimens had shorter mean distances to nearest neighbour than controls and smaller Voronoi tessellation areas than controls. Both measurements suggest more densely packed neurons in epilepsy specimens. This pilot study describes a new objective method for identification of cortical neurons and their spatial distribution. Voronoi tessellation and distance to nearest neighbouring neuron might provide robust methods for objective analysis of cortical nerve cell distribution. The yield of such comparisons might be improved if each cortical layer is analysed separately.

Three-dimensional maximum probability atlas of the human brain, with particular reference to the temporal lobe.

Probabilistic atlases of neuroanatomy are more representative of population anatomy than single brain atlases. They allow anatomical labeling of the results of group studies in stereotaxic space, automated anatomical labeling of individual brain imaging datasets, and the statistical assessment of normal ranges for structure volumes and extents. No such manually constructed atlas is currently available for the frequently studied group of young adults. We studied 20 normal subjects (10 women, median age 31 years) with high-resolution magnetic resonance imaging (MRI) scanning. Images were nonuniformity corrected and reoriented along both the anterior-posterior commissure (AC-PC) line horizontally and the midsagittal plane sagittally. Building on our previous work, we have expanded and refined existing algorithms for the subdivision of MRI datasets into anatomical structures. The resulting algorithm is presented in the Appendix. Forty-nine structures were interactively defined as three-dimensional volumes-of-interest (VOIs). The resulting 20 individual atlases were spatially transformed (normalized) into standard stereotaxic space, using SPM99 software and the MNI/ICBM 152 template. We evaluated volume data for all structures both in native space and after spatial normalization, and used the normalized superimposed atlases to create a maximum probability map in stereotaxic space, which retains quantitative information regarding inter-subject variability. Its potential applications range from the automatic labeling of new scans to the detection of anatomical abnormalities in patients. Further data can be extracted from the atlas for the detailed analysis of individual structures.

Polymicrogyria and absence of pineal gland due to PAX6 mutation.

Identification of genes involved in human cerebral development is important for our understanding of disorders with potential neurodevelopmental causes such as epilepsy and learning disability. Murine models suggest that PAX6 plays a key role in human brain development. With magnetic resonance imaging in 24 humans heterozygous for defined PAX6 mutations, we demonstrated widespread structural abnormalities including absence of the pineal gland and unilateral polymicrogyria.

Reliable callosal measurement: population normative data confirm sex-related differences.

BACKGROUND AND PURPOSE: Corpus callosal cross-sectional area (CCA) may be a clinical indicator of disease progression, but factors influencing callosal morphology in healthy subjects must be determined before comparisons can be made in patients. We sought to define a reliable and easily repeatable method for CCA measurement and to examine the effects of sex, age, handedness, and cerebral volume. METHODS: Neurologically healthy volunteers (age range, 14-68 years; mean age, 32.6 years +/- 12.3 [SD]; 44 men, 56 women; 87 right handed) underwent conventional MR imaging. Data were reoriented in the image space to account for intersubject variations in head position before the midsagittal plane was defined by using midpoints of the anterior commissure (AC), posterior commissure (PC), and interhemispheric fissure (IF). Midsagittal CCA and total cerebral volume were measured and correlated with sex, age, and handedness. RESULTS: The mean CCA was 6.27 cm(2) +/- 0.90. Women had a larger CCA proportional to cerebral volume (6.16 x 10(-3) cm(-1) vs 5.78 x 10(-3) cm(-1) in men; P =.02). The percentage difference for the CCA-cerebral volume from the group mean was +2.6% in women and -3.6% in men. Only a small linear relationship of CCA with cerebral volume was noted (r(2) = 0.15), and CCA was not significantly correlated with age or handedness. CONCLUSION: To our knowledge, this is the largest study of callosal area in a community-based sample of control subjects; such subjects provide controls for future studies. Our findings provide anatomic evidence of sex differences in interhemispheric connectivity. Much CCA variability is independent of cerebral volume.

Implementation and application of a brain template for multiple volumes of interest.

We present a region template and a protocol for transforming that template to define anatomical volumes of interest (VOIs) in the human brain without operator intervention, based on software contained in the SPM99 package (Statistical Parametric Mapping, Wellcome Department of Cognitive Neurology, London, UK). We used an MRI of a reference brain to create an anatomical template of 41 VOIs, covering the entire brain, that can be spatially transformed to fit individual brain scans. Modified software allows for the reslicing and adaptation of the transformed template to any type of coregistered functional data. Individually defined VOIs can be added. We present an assessment of the necessary spatial transformations and compare results obtained for scans acquired in two different orientations. To evaluate the spatial transformations, 11 landmarks distributed throughout the brain were chosen. Euclidean distances between repeat samples at each landmark were averaged across all landmarks to give a mean difference of 1.3 plus minus 1.0 mm. Average Euclidean distances between landmarks (MRI:transformed template) were 8.1 plus minus 3.7 mm in anterior-posterior commissure (ACPC) and 7.6 plus minus 3.7 mm in temporal lobe (TL) orientation. In this study, we use [(11)C]-flumazenil-(FMZ-)PET as an example for the application of the region template. Thirty-four healthy volunteers were scanned, 21 in standard ACPC orientation, 13 in TL orientation. All had high resolution MRI and FMZ-PET. The average coefficient of variation (CV) of FMZ binding for cortical regions was 0.15, comparable with CVs from manually defined VOIs. FMZ binding was significantly different in 6/19 anatomical areas in the control groups obtained in the different orientations, probably due to anisotropic voxel dimensions. This new template allows for the reliable and fast definition of multiple VOIs. It can be used for different imaging modalities and in different orientations. It is necessary that imaging data for groups compared are acquired in the same orientation.