Axonal injury or loss in the internal capsule and motor impairment in multiple sclerosis

Objective: To test the hypothesis that axonal damage extending into primari ly normal-appearing white matter is clinically important by comparing the c oncentrations of N-acetylaspartate (NAA) bilaterally within the internal ca psule with lateralization of motor impairment in patients with multiple scl erosis (MS) and persistent asymmetrical motor deficit. Design: We performed magnetic resonance spectroscopy and T2-weighted imagin g of the internal capsule, calculated central motor conduction times, and r elated these results to measures of motor function asymmetry in 12 patients with MS. Results: Levels of NAA from normal-appearing white matter of the internal c apsule in patients with MS were significantly lower than those in control s ubjects (P = .05). Side-to-side differences in NAA levels were also signifi cantly greater in patients with MS than in controls (P = .01). There was a correlation between asymmetry in motor function for the left and right limb s and asymmetry of internal capsule NAA concentrations (r = 0.60; P = .04). This correlation seemed slightly stronger when tests specifically of arm a nd hand motor asymmetry were considered alone. Central motor conduction tim es were abnormal in most patients with MS and showed a side-to-side differe nce that also correlated with asymmetry in motor function. Conclusion: Our demonstration of a graded association between NAA concentra tions within primarily normal-appearing white matter of a specific tract an d functional impairments referable to that tract suggests that axonal patho logy distant from macroscopic lesions might be an important determinant of disability in MS.