Brain digital twins reveal network changes in congenital and slowly progressive cerebellar ataxias
Cerebellar ataxias are a rare group of disorders manifesting with motor incoordination and cognitive-affective deficits of variable severity. Although neurogenetic has revealed multiple mutations, the study of ataxias still relies on clinical evaluation, while the underlying neural network changes remain unclear. It has been argued that the less severe symptoms in congenital (like Joubert syndrome, JS) than in slowly progressive (SP) ataxias reflect a different interplay of alteration and compensation but direct evidence is still lacking. Moreover, it is unclear why, in front of a wide heterogeneity of molecular alterations, SPs show common clinical symptoms. To address these questions, we created brain digital twins for each participant by combining volumetry, graph theory analysis of structural and functional connectivity, and dynamical simulations using the virtual brain. We studied 8 JS (3 females, 21{+/-}6years), 8 SP (3 females, 20{+/-}5years) and 11 healthy controls (HC; 5 females, 21{+/-}2years).Volumetry quantified atrophy, graph metrics (centrality, segregation and integration) characterized topology, and neural dynamical simulations estimated excitation/inhibition balance, providing anatomo-physiological parameters within the somatomotor (SMN) and ventral attention (VAN) networks. Anatomo-physiological parameters were correlated with clinical/neuropsychological scores, and unsupervised clustering was applied to assess whether network features can discriminate between JS and SP beyond clinical classification. MRI morphometry confirmed selective vermis reduction in JS and a widespread cerebellar atrophy in SP compared to HC. In both ataxia groups, SMN and VAN showed reduced volume and structural connectivity but with different patterns of topological and dynamical alterations. In the SMN of SP, reduced centrality and excitation/inhibition balance depressed information transfer through the network. In the VAN of JS, reduced centrality, segregation, and integration, were detrimental but coexisted with a higher number of functional core nodes and an increased large-scale excitatory coupling, supporting compensatory reorganisation in extracerebellar nodes. Clustering confirmed that SMN better differentiates SP, whereas VAN better clusters JS. Importantly, anatomo-physiological parameters of network volume, topology, and dynamics correlated with patients motor and cognitive performance. In conclusion, primary cerebellar damage secondarily impacts large-scale brain networks, altered in both ataxia groups but compensated only in JS. Similar clinical symptoms in SP reflects the similarity of network changes, while differential involvement of SMN and VAN in JS and SP reflects the connectivity pattern of the lesioned areas inside these large-scale brain circuits. Importantly, anatomo-physiological parameters are sufficient to explain individual motor and cognitive performance, offering a basis for improved patient profiling and personalized therapies.