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Neuroimage Clin. 2013 Aug 30;3:539-47. doi: 10.1016/j.nicl.2013.08.012. eCollection 2013.

The effects of tetrahydrobiopterin (BH4) treatment on brain function in individuals with phenylketonuria.

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Department of Psychological Sciences, University of Missouri, Columbia, MO, United States.
Department of Child Health, University of Missouri School of Medicine, Columbia, MO, United States.
Department of Psychology, Washington University, St. Louis, MO, United States.


Phenylketonuria (PKU) is a rare genetic condition characterized by an absence or mutation of the PAH enzyme, which is necessary for the metabolism of the amino acid phenylalanine into tyrosine. Recently, sapropterin dihydrochloride, a synthetic form of tetrahydrobiopterin (BH4), has been introduced as a supplemental treatment to dietary phe control for PKU. Very little is known regarding BH4 treatment and its effect on brain and cognition. The present study represents the first examination of potential changes in neural activation in patients with PKU during BH4 treatment. To this end, we utilized an n-back working memory task in conjunction with functional magnetic resonance imaging (fMRI) to evaluate functional brain integrity in a sample of individuals with PKU at three timepoints: Just prior to BH4 treatment, after 4 weeks of treatment, and after 6 months of treatment. Neural activation patterns observed for the PKU treatment group were compared with those of a demographically-matched sample of healthy non-PKU individuals who were assessed at identical time intervals. Consistent with past research, baseline evaluation revealed impaired working memory and atypical brain activation in the PKU group as compared to the non-PKU group. Most importantly, BH4 treatment was associated with improvements in both working memory and brain activation, with neural changes evident earlier (4-week timepoint) than changes in working memory performance (6-month timepoint).


Executive function; Phenylketonuria; Prefrontal cortex; Sapropterin; Working memory; fMRI

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