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Distinctive Pattern of Metal Deposition in Neurologic Wilson Disease: Insights From 7T Susceptibility-Weighted
Dongning Su1, Zhijin Zhang1, Zhe Zhang1
1From the Department of Neurology (D.S., Zhijin Zhang, H.Z., Z.W., H.M., W.L., T.W., J.J., T.F.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (D.S., Zhijin Zhang, Zhe Zhang, W.Z., N.W., Y.S., X.L., H.Z., Z.W., H.M., W.L., T.W., J.J., T.F.); Tiantan Neuroimaging Center of Excellence (Zhe Zhang, W.Z., N.W., Y.S., X.L., J.J.), and Department of Hepatology (S.Z.), Beijing Youan Hospital, Capital Medical University; Department of Neurology (T.Y.), Xuanwu Hospital, Capital Medical University, National Clinical Research Center for Geriatric Disorders; Senior Department of Hepatology (Y.D.), the Fifth Medical Center of PLA General Hospital, Beijing, China; Hinda and Arthur Marcus Institute for Aging Research (J.Z.), Hebrew SeniorLife, Roslindale; Harvard Medical School (J.Z.), Boston, MA; Pacific Parkinson's Research Centre (J.S.T.L., A.J.S.), Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, Canada; Department of Neurology and Centre of Clinical Neuroscience (P.D.), First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic; Division of Neurology (A.J.S.), Department of Medicine, University of British Columbia, Vancouver, Canada; and Department of Neurology (X.W.), Jiading Branch of Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, China.
Background And Objectives:
Noninvasive and accurate biomarkers of neurologic Wilson disease (NWD), a rare inherited disorder, could reduce diagnostic error or delay. Excessive subcortical metal deposition seen on susceptibility imaging has suggested a characteristic pattern in NWD. With submillimeter spatial resolution and increased contrast, 7T susceptibility-weighted imaging (SWI) may enable better visualization of metal deposition in NWD. In this study, we sought to identify a distinctive metal deposition pattern in NWD using 7T SWI and investigate its diagnostic value and underlying pathophysiologic mechanism.
Methods:
Patients with WD, healthy participants with monoallelic ATP7B variant(s) on a single chromosome, and health controls (HCs) were recruited. NWD and non-NWD (nNWD) were defined according to the presence or absence of neurologic symptoms during investigation. Patients with other diseases with comparable clinical or imaging manifestations, including early-onset Parkinson disease (EOPD), multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and neurodegeneration with brain iron accumulation (NBIA), were additionally recruited and assessed for exploratory comparative analysis. All participants underwent 7T T1, T2, and high-resolution SWI scanning. Quantitative susceptibility mapping and principal component analysis were performed to illustrate metal distribution.
Results:
We identified a linear signal intensity change consisting of a hyperintense strip at the lateral border of the globus pallidus in patients with NWD. We termed this feature "hyperintense globus pallidus rim sign." This feature was detected in 38 of 41 patients with NWD and was negative in all 31 nNWD patients, 15 patients with EOPD, 30 patients with MSA, 15 patients with PSP, and 12 patients with NBIA; 22 monoallelic ATP7B variant carriers; and 41 HC. Its sensitivity to differentiate between NWD and HC was 92.7%, and specificity was 100%. Severity of the hyperintense globus pallidus rim sign measured by a semiquantitative scale was positively correlated with neurologic severity (ρ = 0.682, 95% CI 0.467-0.821, p < 0.001). Patients with NWD showed increased susceptibility in the lenticular nucleus with high regional weights in the lateral globus pallidus and medial putamen.
Discussion:
The hyperintense globus pallidus rim sign showed high sensitivity and excellent specificity for diagnosis and differential diagnosis of NWD. It is related to a special metal deposition pattern in the lenticular nucleus in NWD and can be considered as a novel neuroimaging biomarker of NWD.
Classification Of Evidence:
The study provides Class II evidence that the hyperintense globus pallidus rim sign on 7T SWI MRI can accurately diagnose neurologic WD.
