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Re: “Facial nerve atrophy in patients with amyotrophic lateral sclerosis: Evaluation with fast imaging employing steady‐state acquisition (FIESTA)”

The article submitted to the Journal of Magnetic Resonance Imaging by Miyata et al entitled "Facial nerve atrophy in patients with amyotrophic lateral sclerosis: Evaluation with fast imaging employing steady-state acquisition (FIESTA)" is an important one in that it is the first to study how the facial nerve (FN) is affected based on lower motor neuron (LMN) depression in amyotrophic lateral sclerosis (ALS) patients and has a novel perspective on the point. In this retrospective study dealing with 15 ALS patients, 29 FNs and cochlear nerves (CNs) were evaluated quantitatively using sectional areas at the midpoint of the internal auditory canal and qualitatively with four different scores using a FIESTA 3T magnetic resonance imaging (MRI) machine. Conventional MR findings (motor cortex hypointensity and corticospinal tract hyperintensity) were also evaluated. As a control group, 20 ageand gender-matched subjects were also included. In the study, the bilateral sectional FN area and FN/CN ratio (FCR) were found significantly lower in ALS patients compared with the control group. Sensitivity and specificity of FN were 93.3 and 90.0%, respectively, for ALS patients in qualitative FN atrophy scoring, which were 40% and 75% with conventional MR findings, respectively. The finding that FN atrophy could be detected with the FIESTA sequence as an early finding could constitute a method to allow early diagnosis of the disease. The low number of cases is one of the limitations of the study. Therefore, the study findings need to be correlated with the findings from studies with larger patient series and different populations. Another limitation of the study was that nerve atrophy was evaluated with sectional area measurements at a point rather than FN and CN volumes. Thus, for a more objective evaluation, studies using volumetric measurements of pontocerebellar angle cistern and internal auditory canal segments are needed. In view of this study, in ALS and other neurodegenerative disorders involving LMNs, evaluation of FN and other cranial nerves such as trigeminal nerves that have motor neurons with both volumetric and advanced MR procedures such as diffusion tensor imaging could give more information, allowing the radiological diagnosis of these conditions in much earlier stages before conventional MRI (T2-weighted and FLAIR sequence) findings are manifested. New studies along these lines await neuroradiologists.