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Annu Rev Neurosci. Author manuscript; available in PMC 2015 July 01.
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Annu Rev Neurosci. 2014 ; 37: 221–242. doi:10.1146/annurev-neuro-062012-170354.
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Neural Tube Defects

Nicholas D.E. Greene and Andrew J. Copp
Newlife Birth Defects Research Center, Institute of Child Health, University College London,
WC1N 1EH, United Kingdom
Abstract
Neural tube defects (NTDs), including spina bifida and anencephaly, are severe birth defects of the
central nervous system that originate during embryonic development when the neural tube fails to
close completely. Human NTDs are multifactorial, with contributions from both genetic and
environmental factors. The genetic basis is not yet well understood, but several nongenetic risk
factors have been identified as have possibilities for prevention by maternal folic acid
supplementation. Mechanisms underlying neural tube closure and NTDs may be informed by
experimental models, which have revealed numerous genes whose abnormal function causes
NTDs and have provided details of critical cellular and morphological events whose regulation is
essential for closure. Such models also provide an opportunity to investigate potential risk factors
and to develop novel preventive therapies.
Keywords
anencephaly; spina bifida; folic acid; genetics
INTRODUCTION
Neural tube defects (NTDs) are severe birth defects of the central nervous system that
originate during embryogenesis and result from failure of the morphogenetic process of
neural tube closure (see sidebar). In higher vertebrates, the neural tube is generated by the
processes that shape, bend, and fuse the neural plate, and fusion in the dorsal midline
progressively seals the neural tube as it forms. If closure is not completed, the
neuroepithelium remains exposed to the environment and consequently subject to
degeneration and neuronal deficit. The type and severity of these open NTDs vary with the
level of the body axis affected. Thus, failure of closure in the prospective brain and spinal
cord results in anencephaly and open spina bifida (myelomeningocele), respectively.
Although the unifying feature of open NTDs is incomplete neural tube closure, evidence
points to many different possible causes, both genetic and environmental. In humans, it
appears that most NTDs are multifactorial, resulting from an additive contribution of several
n.greene@ucl.ac.uk
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the
objectivity of this review.
Greene and Copp Page 2
risk factors, which are each individually insufficient to disrupt neural tube closure (the
multifactorial threshold model) (Harris & Juriloff 2007). The challenge of identifying the
primary cause of NTDs in individual patients is highlighted by the numerous candidate
genes and environmental factors indicated by epidemiologic studies and experimental
models. Moreover, the potential for gene-gene and gene-environment interactions introduces
further potential complexity.
UNDERSTANDING THE EMBRYONIC BASIS OF NTDs: NEURAL TUBE

CLOSURE
Determining the specific causes of NTDs is best achieved in the context of an understanding
of the mechanisms underlying neural tube closure (reviewed by Copp & Greene 2013,
Greene & Copp 2009). Given the inaccessibility of the neurulation-stage human embryo, our
knowledge of the key principles of neural tube closure comes mainly from analysis of
experimental models, particularly other mammals, amphibians, and birds, in which primary
neural tube closure is achieved through folding and fusion of the neuroepithelium.
Primary Neurulation: Subtypes of NTDs Relate to Stages of Closure

In the prospective brain and most of the spinal cord, neural tube formation essentially
involves the bending of the neuroepithelium at the midline to generate neural folds that
elevate, meet, and fuse in the dorsal midline (primary neurulation). Rather than
simultaneously rolling up along the extent of the rostrocaudal axis, neural tube closure is
discontinuous with distinct sites of initiation located at characteristic axial levels. Moreover,
the morphological and molecular requirements for closure vary along the body axis, such
that an individual NTD usually affects only a portion of the neural tube. NTDs can thus be
attributed to failure of particular initiation events or disruption of the progression of closure
between these sites (Figure 1).
In mice, closure is first achieved on embryonic day 8.5 at the level of the hindbrain/cervical
boundary (closure 1) (Figure 1a), and failure of this event leads to craniorachischisis (Copp
et al. 2003). Closure initiates at a second site on embryonic day 9, closure 2, in the caudal
forebrain or forebrain/midbrain boundary. Once initial contact and fusion have been
established between the tips of the neural folds, closure spreads bidirectionally from the sites
of closures 1 and 2 and in a caudal direction from the rostral end of the neural tube (closure
3). The open regions of neural folds, termed neuropores, gradually shorten, leading to
complete closure of the anterior neuropore (between closures 2 and 3) on embryonic day 9
and the hindbrain neuropore (between closures 1 and 2) a few hours later. Cranial NTDs
(anencephaly) result from failure of closure 2, or incomplete “zippering” between closures 1
and 2, which closes the midbrain and hindbrain. If fusion does not progress from the anterior
end of the neural plate (closure 3), the resultant phenotype is a split face usually
accompanied by forebrain anencephaly.
Unlike the cranial region where closure proceeds bidirectionally, spinal neurulation is
entirely caudally directed as the embryo continues to grow. Primary neurulation completes
with final closure of the posterior neuropore on embryonic day 10. Impaired progression of
closure, and consequently the presence of a persistently open posterior neuropore, results in
spina bifida, and the size of the ensuing lesion relates directly to the axial level at which
closure stops.
Primary Neurulation in Humans

Examination of human embryos suggests that initiation of closure is discontinuous, as in the
mouse (Nakatsu et al. 2000, O’Rahilly & Müller 2002). Bending of the neural plate begins
at approximately 18 days after fertilization, with an event equivalent to closure 1 at
approximately 21 days and completion of closure at the posterior neuropore by 26--28 days
postfertilization (Figure 1a,b). It appears that closure of the forebrain and midbrain in human
embryos may be achieved by progression between the site of closure 1 and the rostral end of
the neural plate without an intervening initiation site analogous to closure 2 (O’Rahilly &
Müller 2002, Sulik et al. 1998).
Secondary Neurulation
In mice and humans, the neural tube caudal to the midsacral region is continuous with the
caudal end of the primary neural tube but forms by a distinct process, termed secondary
neurulation (Copp & Brook 1989, Schoenwolf 1984). This process involves condensation of
a population of tail bud--derived cells to form an epithelial rod that undergoes canalization
to form the lumen of the tube in the lower sacral and coccygeal regions. Malformations
resulting from disturbance of secondary neurulation are closed (skin covered) and often
involve tethering of the spinal cord, with associated ectopic lipomatous material (Figure 1c)
(Lew & Kothbauer 2007).
MECHANISMS UNDERLYING NEURAL TUBE CLOSURE

Studies of neurulation-stage embryos, both normal and developing NTDs, provide insights
into key molecular and cellular pathways underlying the morphological tissue movements of
neural tube closure (Copp & Greene 2010). The occurrence of isolated NTDs at cranial or
caudal levels in humans and different mouse models suggests the likely involvement of
region-specific mechanisms, dependent on different gene products, in addition to ubiquitous
requirements that are essential at all levels.
Shaping of the Neural Plate: Convergent Extension Is Required to Initiate Closure

Concomitant with the onset of neural tube closure, the neural plate undergoes narrowing in
the mediolateral axis (convergence) and elongation in the rostrocaudal axis (extension),
owing to intercalation of cells at the midline (Keller 2002). Convergent extension depends
on activity of a noncanonical Wnt signaling pathway, homologous to the planar cell polarity
(PCP) pathway first described in Drosophila as regulating cell polarity in the plane of
epithelia (Goodrich & Strutt 2011). Signaling occurs via Frizzled (Fzd) membrane receptors
and cytoplasmic Dishevelled (Dvl) but without stabilization of β-catenin.
PCP: planar cell polarity

Functional disruption of PCP mediators prevents convergent extension, and the neural plate
remains broad in Xenopus (Wallingford & Harland 2001, 2002) and mouse embryos (Greene
et al. 1998, Ybot-Gonzalez et al. 2007b). Hence, closure 1 fails, leading to craniorachischisis
in mice homozygous for mutations in core PCP genes including Vangl2 and Celsr1, or
double mutants for Dvl-1 and -2, or Fzd-3 and -6 (Juriloff & Harris 2012a).
Craniorachischisis also results from mutation of the PCP-related genes Scrb1 (Murdoch et
al. 2001) and Ptk7 (Lu et al. 2004) or genes encoding accessory proteins, such as Sec24b,
which affects Vangl2 transport (Merte et al. 2010). Ultimately, failure of closure initiation in
PCP-mutant embryos is thought to result from insufficient proximity of the neural folds,
owing to the broadened midline.
Failure of closure 1 in most of the core PCP mutant embryos precludes analysis of a
requirement for convergent extension at later stages of neurulation. However, spina bifida
occurs in some loop-tail heterozygotes (Vangl2Lp/+) (Copp et al. 1994) and in compound
heterozygotes of Vangl2Lp/+ with mutations of Ptk7, Sec24b, or Sdc4 (Escobedo et al. 2013,
Lu et al. 2004, Merte et al. 2010). Moreover, non-canonical Wnt signaling is compromised
in Lrp6 null embryos that develop spina bifida (Gray et al. 2013). These observations
suggest that PCP signaling maycontinue to be required as spinal neurulation proceeds.
Despite the entirely open spinal neural tube in Vangl2Lp/Lp embryos with craniorachischisis,
closure does occur in the forebrain and much of the midbrain, implying that PCP-dependent
convergent extension is not required throughout the cranial region. Nonetheless,
exencephaly is observed in digenic combinations of Vangl2Lp/+ with some Wnt pathway
genes (e.g., Dvl3+/−, Fzd1+/−, and Fzd2+/−) (Etheridge et al. 2008, Yu et al. 2010).
Exencephaly also develops in mutants for the PCP effector genes Fuz or Intu, but the role of
these genes in cilium-dependent hedgehog signaling seems more likely to explain their loss-
of-function effect on cranial neural tube closure than does a role in regulating convergent
extension (Gray et al. 2009, Heydeck & Liu 2011, Zeng et al. 2010) (see Bending of the
Neural Folds: Regulation by Shh and BMP Signaling, below). Thus, components of PCP
signaling potentially affect neural tube closure via multiple cellular mechanisms.
Bending of the Neural Folds: Regulation by Shh and BMP Signaling

To achieve closure, the neuroepithelium must bend to bring the tips of the neural folds into
apposition. Bending occurs in a stereotypical manner at hinge points: a median hinge point
(MHP) in the midline and paired dorsolateral hinge points (DLHPs) that arise laterally
(Shum & Copp 1996). The morphology varies along the body axis with differing modes in
the upper (MHP only), mid-spine (MHP and DLHPs), and caudal (DLHPs only) regions of
the primary spinal neural tube.
The mechanisms underlying neuroepithelial bending are not fully understood, but one
notable feature of the MHP is the predominance of wedge-shaped cells (wider basally than
apically) compared with nonbending regions (Schoenwolf & Smith 1990). At neural plate
stages, the neuroepithelium is a pseudostratified epithelium in which nuclei move to the
basal pole during S-phase, owing to interkinetic nuclear migration. Prolongation of S-
phase at the MHP provides a possible means by which regulation of the cell cycle may
contribute to cell wedging and hence MHP formation (Schoenwolf & Smith 1990).
Bending is regulated by signals emanating from nonneural tissues dorsal and ventral to the
neural folds (reviewed by Greene & Copp 2009). The MHP is induced by signals from the
notochord, located immediately ventral to the midline of the neuroepithelium (Smith &
Schoenwolf 1989, Ybot-Gonzalez et al. 2002). At the molecular level, notochord-derived
Shh induces the floor plate of the neural tube at the MHP (Chiang et al. 1996, Placzek &
Briscoe 2005). However, this action is not essential for spinal neural tube closure, which
completes in the absence of a floor plate in mouse embryos lacking Shh or Fox A2 (Ang &
Rossant 1994, Chiang et al. 1996). Thus, the MHP may be functionally important in floor
plate development but is not essential for neural tube closure.
In contrast to the MHP, DLHPs appear essential for the neural tube to close in the low spinal
region. For example, Zic2 mutant embryos, in which DLHPs are absent, develop severe
spina bifida (Ybot-Gonzalez et al. 2007a). The formation of DLHPs is actively regulated;
the interplay of inhibitory and inductive signals determines their appearance at different
axial levels (Copp & Greene 2013). These signals include inhibitory effects of Shh from the
notochord and BMP signaling from the surface ectoderm at the dorsal tips of the neural
folds. These signals are opposed by the BMP antagonist noggin, whose expression in the
dorsal neural folds is sufficient to induce DLHPs (Ybot-Gonzalez et al. 2002, 2007a).
In contrast to the effects of an absence of Shh signaling, NTDs do result from mutations that
enhance Shh signaling, for example, through deficient function of inhibitory or cilia-related
genes such as Gli3, Rab23, Fkbp8, Tulp3, and Ift40 (Miller et al. 2013, Murdoch & Copp
2010). Mutants involving increased Shh signaling display NTDs at cranial and/or spinal
levels. Although spina bifida in some of these models appears to be associated with
suppression of dorsolateral bending of the neural folds (Murdoch & Copp 2010), the
mechanism underlying cranial NTDs is not clear.
Cranial Neurulation: Additional Complexity and Sensitivity to Disruption

The neural folds in the cranial region bend in the midline and dorsolaterally as in the mid-
spinal region, but the closure process appears morphologically more complex. The folds are
initially biconvex, with the tips facing away from the midline, and then switch to a
biconcave shape allowing the tips to approach in the midline. The additional complexity of
cranial compared with spinal neurulation appears to be reflected in a more extensive genetic
underpinning and a greater sensitivity to disruption, at least in rodents. Exencephaly occurs
in approximately three times as many knockout mouse models as does spina bifida and is the
NTD type most commonly induced by teratogens (Copp et al. 1990, Harris & Juriloff 2010).
Cranial neurulation may rely on specific contributory factors that are not involved in the
spinal region such as expansion of the mesenchyme underlying the neural folds (Greene &
Copp 2009, Zohn & Sarkar 2012). Moreover, disruption of the actin cytoskeleton prevents
closure in the cranial but not the spinal region (Morriss-Kay & Tuckett 1985, Ybot-
Gonzalez & Copp 1999). Similarly, exencephaly is observed, but spinal neurulation
completes successfully in null mutants for several cytoskeletal components (e.g., n-cofilin,
vinculin) (Gurniak et al. 2005, Xu et al. 1998). Nevertheless, apically located actin
microfilaments are present throughout the neuroepithelium (Sadler et al. 1982) and
functional disruption of the cytoskeleton-associated proteins MARCKS-related protein or
Shroom3 causes both spinal and cranial NTDs (Hildebrand & Soriano 1999, Xu et al. 1998)
suggesting that regulation of the actomyosin cytoskeleton plays a role in closure in both
regions. Shroom proteins appear to play a key role: Expression of Shroom in Xenopus is
sufficient to induce apical constriction of epithelial cells, whereas functional disruption
inhibits neural fold bending and suppresses closure (Haigo et al. 2003).
Adhesion and Fusion of the Neural Folds

Once the neural folds meet at the dorsal midline, processes of adhesion, fusion, and
remodeling give rise to two discrete epithelial layers, with the nascent neural tube overlain
by an intact surface ectoderm (Pai et al. 2012). At the closure site, the neural fold tips are
composed of neuroepithelium continuous with the nonneural surface ectoderm. The cell type
that adheres first may differ at varying axial levels (Geelen & Langman 1979, Ray &
Niswander 2012). Nevertheless, at all levels initial contact appears to involve subcellular
protrusions, resembling lamellipodia and filopodia, observed by electron microscopy
(Geelen & Langman 1979) and in live embryos (Pyrgaki et al. 2010). The molecular basis of
adhesion is not well characterized, perhaps owing to functional redundancy among the
proteins involved. However, a role for the interaction of cell surface ephrin receptors with
Eph ligands is suggested by the occurrence of cranial NTDs in mice lacking ephrin-A5 or
EphA7 (Holmberg et al. 2000) and by delayed spinal closure in embryos exposed to peptides
that block ephrin-A/EphA interactions (Abdul-Aziz et al. 2009).
Knockout of protease-activated receptors (PAR1 and PAR2) in the surface ectoderm also
causes cranial NTDs, implicating a role for signaling via these G protein--coupled receptors
in closure (Camerer et al. 2010). Further evidence for the function of the nonneural
ectoderm is provided by Grhl2 null mutants, which fail in closure throughout the cranial
region and exhibit spina bifida (Brouns et al. 2011, Rifat et al. 2010, Werth et al. 2010).
Grhl2 is expressed in the surface ectoderm overlying the neural folds and regulates
expression of several components of the apical adhesion junction complex, including E-

cadherin (Pyrgaki et al. 2011, Werth et al. 2010).
Regulation of Cell Proliferation and Cell Death

During neurulation the embryo grows rapidly. Cell cycle exit and neuronal differentiation
begin in the neuroepithelium shortly after closure, and maintenance of adequate proliferation
in the neuroepithelium appears crucial for closure, particularly in the cranial region. Thus, in
mice, NTDs can be caused by exposure to antimitotic agents (Copp et al. 1990) or mutation
of genes encoding proteins associated with cell-cycle progression (e.g., neurofibromin 1,
nucleoporin) or prevention of neuronal differentiation (e.g., Notch pathway genes Hes1,
Hes3, RBP-Jκ) (Harris & Juriloff 2007, 2010). Conversely, excessive cell proliferation is
also associated with NTDs in several mouse models, such as Phactr4 mutants (Kim et al.
2007).
Characteristic patterns of apoptotic cell death occur in the neural folds and the midline of the
closed neural tube (Geelen & Langman 1979, Massa et al. 2009, Yamaguchi et al. 2011).
Increased cell death could inhibit closure by compromising the functional and/or mechanical
integrity of the neuroepithelium. It is associated with NTDs in several teratogen-induced and
genetic models, although only rarely has a direct causal link been definitively established
(Copp & Greene 2013, Fukuda et al. 2011). The occurrence of exencephaly in mice lacking
apoptosis-related genes such as caspase3 or Apaf1 suggests a requirement for apoptosis in
closure (Harris & Juriloff 2010). However, forebrain and spinal closure occurs normally in
these models and pharmacological suppression of apoptosis does not cause NTDs,
suggesting that it is dispensable to complete closure (Massa et al. 2009).
CLINICAL FEATURES OF NEURAL TUBE DEFECTS

Owing to their multifactorial causation NTDs represent a group of disorders. However, after
failure of neural fold closure has occurred defects, originating from various primary causes,
may share similar pathogenic features.
Open NTDs and Associated Conditions

Open NTDs can result from failure of closure at a de novo initiation site or incomplete
progression of closure following successful initiation (Figure 1). Where embryos are
available for examination, as in experimental models, NTDs can be recognized during or
immediately after neurulation stages owing to the persistently open neural folds. However,
at later embryonic and fetal stages, the morphological appearance changes considerably
owing to secondary changes and degeneration.
In cranial NTDs, the open neural folds undergo growth and differentiation and typically
appear to bulge from the developing brain, termed exencephaly. Inability to form the skull
vault over the open region causes the exposed neural tissue to degenerate, leading to the
characteristic appearance of anencephaly, observed later in human or rodent pregnancy
(Wood & Smith 1984, Seller 1995). Both anencephaly and craniorachischisis (~10% of
NTDs) are lethal conditions at or shortly after birth.
Open neural folds in the spinal region prevent the sclerotome-derived vertebral arches from
covering the neuroepithelium, the consequent opening in the vertebral column giving rise to
the term spina bifida (Copp et al. 2013). The neural tissues may be contained within a
meninges-covered sac that protrudes through the open vertebrae (myelomeningocele; spina
bifida cystica) or exposed directly to the amniotic fluid (myelocele). Babies born with open
spina bifida usually survive with appropriate medical care but suffer neurological
impairment, the severity of which depends on the level of the lesion. Associated conditions
include hydrocephalus, Chiari malformation type II, and vertebral abnormalities as well as
genitourinary and gastrointestinal disorders.
Diagnosis, Treatment, and Maternal-Fetal Surgery

NTDs can be diagnosed prenatally by ultrasound (Cameron & Moran 2009). However,
where prenatal diagnosis is not routinely available and/or therapeutic abortion is not an
option, many babies with NTDs are born. Postnatal medical care for babies born with open
spina bifida usually involves surgery to close and cover the lesion. Multiple subsequent
surgeries are commonly required to alleviate tethering of the spinal cord, treat
hydrocephalus, and/or address orthopedic and urological problems.
As open NTDs arise early during pregnancy, there is a prolonged period during which
secondary neurological damage may occur owing to exposure of nervous tissue to the
amniotic fluid environment. These considerations provided impetus for the development of
in utero fetal surgery for spina bifida, which may improve neurological outcomes compared
with postnatal repair, although with fetal and maternal risks (Adzick et al. 1998, 2011).
Experimental models of spina bifida are being used to investigate the possible combination
of surgical intervention with additional therapy, intended to remediate neural damage.

Examples include the implantation of biodegradable scaffolds to promote neural
regeneration and/or neural stem cells to populate the damaged spinal cord (Saadai et al.
2011, 2013).
Disorders of the Closed Neural Tube

This review focuses on open NTDs, characterized by failure of neural tube closure. Various
other conditions are also associated with abnormalities of the closed brain or spinal cord and
are often categorized as NTDs under a broader definition (Figure 1). There is also a less
well-defined group of closed spinal NTDs in which the vertebral arches are malformed but
covered by skin. These conditions, including spina bifida occulta and spinal dysraphisms,
vary widely in clinical presentation. The more severe subtypes are associated with various
abnormalities of the spinal cord, lipoma (Figure 1c), and/or anorectal abnormalities. The
embryonic origin of closed spina bifida is not well defined but is hypothesized to involve
abnormalities of secondary neurulation (Copp et al. 2013). Abnormal development of the
skull or vertebrae may also allow herniation of the closed neural tube through the affected
bony region, as in encephalocele (Figure 1d) or meningocele, respectively.
CAUSES OF NTDs
NTDs are among the most common birth defects worldwide with a prevalence that varies
from 0.5 to more than 10 per 1,000 pregnancies. This variance likely reflects differing
contributions from risk factors such as nutritional status, prevalence of obesity and diabetes,
usage of folic acid supplementation and/or fortification, the presence of environmental
toxicants, and differing genetic predisposition among ethnic groups. In most populations,
there is also a striking gender bias: Anencephaly is more prevalent among females than
males. Many NTD mouse strains also show a female preponderance among cranial NTDs,
apparently reflecting a fundamental higher sensitivity of cranial neural tube closure to
disturbance in female embryos (Juriloff & Harris 2012b). Overall, although studies have
identified numerous risk factors, these may account for less than half of NTDs, suggesting
that additional genetic and nongenetic factors remain to be identified (Agopian et al. 2013).
ENVIRONMENT FACTORS
Various teratogenic agents induce NTDs in rodent models (Copp et al. 1990, Copp &
Greene 2010). In humans, teratogens that have been associated with NTDs include the
anticonvulsant drug valproic acid (Wlodarczyk et al. 2012) and the fungal product fumonisin
(Missmer et al. 2006). Other nongenetic risk factors include maternal fever and excessive
use of hot tubs (Moretti et al. 2005), consistent with the induction of NTDs by hypothermia
in rodent models.
Maternal obesity and diabetes are well-recognized risk factors for NTDs (Correa et al.
2003). Determining the cause of diabetes-related NTDs is hampered by the complexity of
the diabetic milieu, although hyperglycemia alone is sufficient to cause NTDs in cultured
rodent embryos. NTDs may result from increased oxidative stress, altered expression of
genes such as Pax3, and neuroepithelial cell apoptosis (Fine et al. 1999, Reece 2012).
Recent findings suggest that activation of apoptosis signal-regulating kinase 1 (ASK1) in
hyperglycemic conditions leads to activation of the apoptosis mediator caspase 8 by

stimulating the FoxO3a transcription factor (Yang et al. 2013).
Nutritional factors and folate

The historical link between lower socioeconomic status and higher risk of birth defects led
investigators to examine the possible involvement of nutritional factors in NTDs. Lower
blood levels of the B-vitamin folate were observed in mothers of NTD fetuses (Smithells et
al. 1976), prompting an intervention trial of a folic acid--containing multivitamin
supplement to prevent NTD recurrence (Schorah 2008, Smithells et al. 1981). A multicenter
randomized controlled trial confirmed that maternal folic acid supplementation (at 4 mg per
day) significantly reduces the recurrence risk (Wald et al. 1991). Additional clinical trials
provided evidence for reduction of occurrence risk (Berry et al. 1999, Czeizel et al. 2011,
Czeizel & Dudás 1992).
Questions remain concerning the mechanism by which folic acid prevents NTDs (Blom et
al. 2006, Copp et al. 2013). Although maternal folate status is a risk factor, in most cases,
maternal folate levels are within the normal range and rarely clinically deficient.
Nonetheless, data have shown an inverse relationship between blood folate concentration
and risk of an affected pregnancy (Daly et al. 1995). Suboptimal folate levels may contribute
to NTD development in individuals who are genetically susceptible. Such a gene-
environment interaction has been demonstrated in mice, where folate deficiency does not
cause NTDs unless deficiency is present in combination with a mutation of a predisposing

gene, such as Pax3 (Burren et al. 2008).
Folate one-carbon metabolism (Figure 2) comprises a complex network of interlinked

reactions that mediate transfer of one-carbon groups for several biosynthetic processes
(Stover 2009). Among these, attention has focused particularly on the requirement for
nucleotide biosynthesis and methylation reactions in neural tube closure. Abnormal
thymidylate and purine biosynthesis have been identified in mouse NTD models (Beaudin et
al. 2011, Fleming & Copp 1998) and in a proportion of NTD cases (Dunlevy et al. 2007),
whereas deficient methylation may also be implicated in NTDs (see Gene-Regulatory
Mechanisms and NTDs, below).
GENETICS OF NTDS
Most NTDs occur sporadically, with a relative scarcity ofmultigenerational families.
Nevertheless, strong evidence demonstrates a genetic component in the etiology of NTDs,
and the pattern of inheritance favors a multifactorial polygenic or oligogenic model, as
opposed to an effect of single genes with partial penetrance (Harris & Juriloff 2007). Most
studies of NTD genetics have focused on one or more candidate genes (reviewed by Boyles
et al. 2005, Greene et al. 2009, Harris & Juriloff 2010). In general, candidates have been (a)
human orthologs of genes whose mutation causes NTDs in mice, of which there are more
than 200 examples; or (b) genes related to environmental risk factors, particularly folate
metabolism.
Case-control association studies have implicated several genes, whereas mutation screening
by sequencing has identified putative pathogenic mutations. However, the definitive

assignment of a gene variant as causative is complicated by the apparent multigenic nature
of NTDs and by the large number of possible candidate genes, modifier genes, epigenetic
factors, and environmental influences. Moreover, where putative mutations have been
identified in specific genes, each has been involved in only a small proportion of NTD
patients, suggesting that there is considerable heterogeneity underlying the genetic basis of
NTDs. Thus, although the morphological and cellular bases of neural tube closure have
become increasingly well understood, the genetic basis of NTDs in individual cases remains
largely unclear.
Gene-gene interactions and effect of modifier genes

Mouse studies suggest three broad mechanisms by which genetic interactions may result in
NTDs. First, in some instances functional redundancy makes it necessary for two
orthologous genes to be mutated [e.g., Dvl1-Dvl2 (Hamblet et al. 2002), Cdx1-Cdx2 double
knockouts (Savory et al. 2011)], in order to reveal a requirement in neural tube closure.
Second, additive effects of heterozygous mutations may result in NTDs that resemble those
of individual homozygotes [e.g., Dvl3 with Vangl2Lp (Etheridge et al. 2008)]. Third,
variation in the penetrance and expressivity of NTD phenotypes between inbred mouse
strains is widely reported to reflect variants in modifier genes. For example, the rate of
exencephaly resulting from Cecr1 mutation is strongly affected by strain background
(Davidson et al. 2007). Whereas the identity of modifier genes for NTDs has rarely been
determined, a variant in Lmnb1 is present in some mouse strains and significantly increases
the frequency of NTDs in curly tail (Grhl3ct) embryos (de Castro et al. 2012).
Genes implicated through experimental models

In mice, mutation of genes encoding components of the PCP pathway causes NTDs (see
Shaping of the Neural Plate, above). Sequencing of PCP genes in humans has identified
putative mutations in CELSR1, VANGL1, VANGL2, FZD6, SCRIB1, and DVL2 in some
patients with craniorachischisis, spina bifida, anencephaly, or closed forms of spina bifida
(Chandler et al. 2012; De Marco et al. 2013; Kibar et al. 2007; Lei et al. 2010, 2013;
Robinson et al. 2012; and reviewed by Juriloff & Harris 2012a). As in mice, heterozygous
human PCP mutations may interact with other genetic NTD risk factors in a digenic or
polygenic fashion to cause a range of NTD types. This interaction could involve summation
of multiple variants in PCP genes. For example, a putative mutation in DVL2 was identified
in a spina bifida patient in combination with a second, previously identified missense variant
in VANGL2 (De Marco et al. 2013).
Among other genes implicated in NTDs from mouse models, association studies have not
provided evidence for a major contribution to risk, and few positive results have emerged
from sequencing-based mutation screens. As data begin to emerge from large-scale exome
sequencing studies of NTD patients, it will become possible to evaluate the contribution of
multiple genes in the same patient cohorts and the mutational load associated with individual
risk.
Analysis of genes related to environmental risk factors

The identification of environmental factors such as maternal diabetes and folate status as
risk factors for NTDs provides impetus for researchers to analyze related genes in affected
families. Risk could be associated with maternal genotype if genetic variation alters
maternal metabolism and secondarily affects the developing embryo. However, the
inheritance of maternal alleles by the embryo complicates interpretation of such effects.
Alternatively, a genetically determined abnormality in the embryo itself could influence risk
of NTDs, potentially through interaction with a predisposing environmental factor. For
example, it may be informative to analyze genetic data on folate-related genes in the context
of maternal folate status (Etheredge et al. 2012).
Association with risk of spina bifida has been reported for several genes implicated in
diabetes, obesity, glucose metabolism, and oxidative stress. These potential ‘risk’ genes
include GLUT1, SOD1, and SOD2 (Davidson et al. 2008, Kase et al. 2012). Maternal
variants in the obesity-related genes FTO, LEP, and TCF7L2 are also associated with NTDs,
consistent with maternal obesity as a risk factor (Lupo et al. 2012).
Genes related to folate one-carbon metabolism have been perhaps the most intensively
studied group of candidates for NTDs (reviewed by Blom et al. 2006, Greene et al. 2009,
Shaw et al. 2009). The C677T polymorphism of MTHFR, which encodes an alanine-to-
valine substitution, has been associated with NTDs. The TT genotype is found at higher
frequency among NTD cases than in controls in some populations (e.g., Irish) but not others
(e.g., Hispanics) (Botto & Yang 2000). Several studies indicate positive associations with
other folate-related genes, including MTRR, although these have generally not been
observed in all study populations.
In mice, mutations in folate-metabolizing enzymes (e.g., Mthfd1) are sometimes lethal

before the stage of neural tube closure (e.g., Christensen et al. 2013, MacFarlane et al.
2009), whereas others do not disrupt closure (e.g., Chen et al. 2001, Di Pietro et al. 2002).
Null embryos for the folate receptor, Folr1, die preneurulation but develop NTDs when
supplemented with sufficient folic acid to prevent early lethality (Piedrahita et al. 1999).
NTDs are also observed in Shmt1 knockouts, under folate-deficient conditions (Beaudin et
al. 2011). In contrast, NTDs occur spontaneously in mice carrying loss-of-function alleles of
Amt (Narisawa et al. 2012) or Mthfd1L (Momb et al. 2013), both of which encode enzymes
of mitochondrial folate metabolism (see sidebar and Figure 2) (Tibbetts & Appling 2010).
The homologous genes in humans have also been linked to NTDs. Missense mutations have
been identified in NTD patients in AMT as well as in GLDC, which encodes its partner
enzyme in the glycine cleavage system (Narisawa et al. 2012). Genetic associations with
NTDs have been reported for MTHFD1L (Parle-McDermott et al. 2009) and SLC23A32
(MFTC), encoding a mitochondrial folate transporter (Pangilinan et al. 2012). Altogether,
these findings suggest that NTD risk is influenced by the function of mitochondrial folate
metabolism, a major source of one-carbon units to the cytoplasm.
Gene-Regulatory Mechanisms and NTDs

Identification of causative genes may be complicated, in addition to the potential multigenic
nature of NTDs, by the potential involvement of aberrant gene expression, perhaps resulting
from mutations in regulatory elements. For example, mutations resulting in insufficient

expression of Grhl3 or excess expression of Grhl2 cause NTDs in mice in the absence of
coding mutations (Brouns et al. 2011, Gustavsson et al. 2007). Further complexity may be
added by the potential for regulation by epigenetic modifications such as DNA methylation,
histone modification, or chromatin remodeling, each of which has been associated with
NTDs in mice and in some cases in humans (reviewed by Greene et al. 2011, Harris &
Juriloff 2010). For example, methylation of LINE-1 genomic elements was lower than
normal in DNA of anencephalic but not spina bifida fetuses (Wang et al. 2010).
A simple model predicts a positive correlation between folate status and methylation.
However, data from human pregnancy suggest that the relationship is not straightforward
(Crider et al. 2012). A recent study found an inverse correlation of LINE-1 methylation with
maternal and cord blood folate, whereas different imprinted genes showed positive or
negative associations (Haggarty et al. 2013). Somewhat counterintuitively, use of folic acid
supplements was associated with reduced LINE-1 methylation.
A requirement for DNA methylation in mouse neural tube closure is suggested by the
occurrence of NTDs in knockouts of Dnmt3b, encoding a DNA methyltransferase, and in
embryos cultured with 5-azacytidine (Matsuda & Yasutomi 1992, Okano et al. 1999).
Similarly, inhibition of the methylation cycle reduces DNA methylation and causes NTDs in
cultured mouse embryos (Burren et al. 2008, Dunlevy et al. 2006). However, Mthfr null
embryos do not develop NTDs despite a significant reduction in global DNA methylation
(Chen et al. 2001), nor is there an exacerbating effect of Mthfr loss-of-function on Pax3 or
curly tail mutants, although both show increased rates of NTDs under folate-deficient
conditions (Burren et al. 2008, de Castro et al. 2010, Pickell et al. 2009). Thus, questions
remain about the relationships among folate status, DNA methylation, and risk of NTDs.
Other epigenetic mechanisms include various modifications of histone proteins, which

potentially misregulate genes that influence neurulation. NTDs occur in mice carrying
mutations in the histone demethylases Jarid2 (Takeuchi et al. 1999) and Fbxl10 (Fukuda et
al. 2011). Similarly, histone acetylases and deacetylases, which regulate the equilibrium of
histone acetylation, are implicated in NTDs. An acetylase-specific knockin mutation of
Gcn5 causes cranial NTDs (Bu et al. 2007), as does loss-of-function of another histone
acetylase, p300 (Yao et al. 1998). Increased acetylation is also associated with NTDs. For
example, cranial NTDs occur in mice carrying mutations in histone deacetylases Sirt1 or
Hdac4 (Cheng et al. 2003, Vega et al. 2004). The teratogenic effects of valproic acid and
trichostin A may also be mediated through their inhibition of histone deacetylases (Finnell et
al. 2002).
PRIMARY PREVENTION OF NTDs

Once the neural tube has failed to close, ensuing damage to the exposed neural tissue is
irreversible, despite possible palliative benefit of in utero surgery (see Diagnosis,
Treatment, and Maternal-Fetal Surgery). Therefore, primary prevention is the optimal
approach for reducing the burden of NTDs.
Folic Acid Supplementation and Fortification

The reduction in risk of NTDs following maternal folic acid supplementation led to public
health recommendations that women who may become pregnant should consume 0.4 mg of
folic acid daily or 4 mg daily following a previous affected pregnancy (Czeizel et al. 2011).
To ensure that additional folate was received, food fortification programs were introduced in
many countries. This approach has raised blood folate levels and has been associated with
lower NTD frequency (Crider et al. 2011). The magnitude of effect varies, with greatest
reduction found where preexisting rates were highest (Blencowe et al. 2010, Rosenthal et al.
2013). Some countries have delayed a decision on fortification owing to safety concerns
(e.g., possible enhancement of bowel cancer), but a recent meta-analysis found no evidence
for increased cancer rates following folic acid supplementation (Vollset et al. 2013).
Folate-Resistant NTDs
Folic acid supplementation in clinical trials has not approached 100% NTD prevention, and
an estimated one-third of NTDs may be folic acid resistant (Blencowe et al. 2010). A study
in the United States, where folate fortification of food is mandatory, found no apparent
protective effect of folic acid supplements (Mosley et al. 2009), suggesting that increased
dosage would not necessarily provide additional preventive effects.
Given the multifactorial causation of NTDs it seems reasonable to suppose that optimal
prevention will require a combination of multiple interventions. Possible approaches may

relate to folate one-carbon metabolism. For example, as with folate, evidence shows a
graded relationship between lower levels of circulating vitamin B12 and increased risk of an
NTD-affected pregnancy (Molloy et al. 2009). Perhaps use of B12 supplements would
further reduce NTD frequency, although this approach remains to be tested.
Another possibility is that folic acid cannot ameliorate some defects that result from
abnormal folate metabolism, owing to defects in the intervening enzymes required to
transfer one-carbon units to key downstream metabolites. In this case, supplementation with
alternative folates, such as 5-methyl THF (Czeizel et al. 2011), or key downstream
molecules may be advantageous. For example, supplementation with formate prevented
NTDs in Mthfd1L null mice (Momb et al. 2013), whereas combinations of thymidine and
purine precursors prevented NTDs in curly tail mice, in which folic acid is not protective
(Leung et al. 2013).
In addition to low levels of folate and vitamin B12, lower maternal levels of other vitamins,
including vitamin C, have been reported in NTDs (Smithells et al. 1976). Conversely, intake
of several vitamins and maternal diet are associated with lower risk of NTDs, which
suggests that nutrients other than folic acid may be beneficial (Chandler et al. 2012, Sotres-
Alvarez et al. 2013). Experimental analysis of individual vitamins found that myo-inositol
deficiency caused NTDs in cultured rodent embryos (Cockroft 1988). Inositol
supplementation significantly reduced NTD frequency in curly tail mice (Greene & Copp
1997) and in rodent models of diabetes (Reece et al. 1997) and inositol is in clinical testing
for prevention of NTD recurrence.
SUMMARY
Experimental models provide systems for analysis of the developmental events of neural
tube closure, and fundamental cellular and morphological processes continue to be defined
in more detail. In principle, NTDs may result from insufficiency of one or more of the key
driving forces (e.g., cellular properties and/or morphogenetic movements) that are necessary
to achieve closure, for example, through mutation of a PCP gene. Alternatively, a genetic
lesion or environmental insult may disrupt the closure process even where the underlying
machinery is intact, for example through induction of aberrant cellular behaviors such as
excess apoptosis. Experimental models require careful analysis to disentangle these
possibilities. A key challenge will be to understand how the molecular and cellular
determinants of neurulation relate to the biomechanical forces required to fold the
neuroepithelium to achieve closure.
Advances in exome and whole-genome sequencing may help researchers begin to

understand the genetic basis of NTDs in humans. The multifactorial complexity of NTDs
means that analysis of data from such studies will present a major challenge. Moreover,
investigators will need to integrate genetic data with information on epigenetic and
environmental factors to obtain a more complete understanding of the cause of individual
NTDs.
Folic acid supplementation provides a means to reduce NTD risk and represents a major
public health advance. Nevertheless, the heterogeneity of NTDs suggests that primary
prevention may be achieved best by multiple interventions, and use of additional
micronutrients alongside folic acid may provide additional opportunities to further reduce
risk.
ACKNOWLEDGMENTS
Work in the authors’ laboratory is funded by the Medical Research Council (J003794), the Newlife Foundation
(11-1206), and the Wellcome Trust (087525).
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Figure 1.
Diagrammatic representation of the developmental origin of malformations broadly
classified as neural tube defects in humans. (a,b) Disorders of primary neurulation include
craniorachischisis (a) in which the neural tube fails to initiate closure, leaving most of the
brain and the entire spine open. If closure initiates successfully, then the cranial and/or
spinal neural folds may fail to close (b) generating exencephaly/anencephaly and open spina
bifida (myelomeningocele), respectively. (c) Disorders of secondary neurulation comprise
failure of the neural tube to separate completely from adjacent tissues, resulting in tethering
and diminished mobility. The spinal cord is covered by skin and often associated with fatty
tissue accumulation (lipoma) through as-yet-unknown mechanisms. (d) Postneurulation
defects can arise when the bony structure of the skeleton fails to develop fully. Herniation of
the meninges, with or without brain tissue, through a skull defect (shown here as occipital
but sometimes parietal or fronto-ethmodial) generates encephalocele, while an analogous
defect in the spinal region produces meningocele.
Figure 2. Overview of folate one-carbon metabolism

Folates provide a backbone for the transfer of one-carbon units. Key outputs (in green)
include nucleotide biosynthesis and methylation. Among methylation cycle intermediates,
homocysteine may also be converted to cystathionine in the transulfuration pathway and S-
adenosylmethionine is involved in polyamine biosynthesis. FOCM is compartmentalised:
one-carbon units from the mitochondria enter cytoplasmic FOCM as formate while reactions
of thymidylate biosynthesis also operate in the nucleus (catalysed by SHMT1, TYMS and
DHFR). In loss-of-function mouse models, NTDs arise in mutants for Mthfd1l and genes
encoding the glycine cleavage system (GCS). Shmt1 and Mthfr null mice are viable to birth
but may develop NTDs under folate-deficient conditions.

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Europe PMC Funders Group

Neural Tube Defects

UNDERSTANDING THE EMBRYONIC BASIS OF NTDs: NEURAL TUBE

Primary Neurulation: Subtypes of NTDs Relate to Stages of Closure

Primary Neurulation in Humans

MECHANISMS UNDERLYING NEURAL TUBE CLOSURE

Shaping of the Neural Plate: Convergent Extension Is Required to Initiate Closure

PCP: planar cell polarity

Bending of the Neural Folds: Regulation by Shh and BMP Signaling

Cranial Neurulation: Additional Complexity and Sensitivity to Disruption

Adhesion and Fusion of the Neural Folds

expression of several components of the apical adhesion junction complex, including E-

Regulation of Cell Proliferation and Cell Death

CLINICAL FEATURES OF NEURAL TUBE DEFECTS

Open NTDs and Associated Conditions

Diagnosis, Treatment, and Maternal-Fetal Surgery

of surgical intervention with additional therapy, intended to remediate neural damage.

Disorders of the Closed Neural Tube

hyperglycemic conditions leads to activation of the apoptosis mediator caspase 8 by

Nutritional factors and folate

cause NTDs unless deficiency is present in combination with a mutation of a predisposing

Folate one-carbon metabolism (Figure 2) comprises a complex network of interlinked

by sequencing has identified putative pathogenic mutations. However, the definitive

Gene-gene interactions and effect of modifier genes

Genes implicated through experimental models

Analysis of genes related to environmental risk factors

In mice, mutations in folate-metabolizing enzymes (e.g., Mthfd1) are sometimes lethal

Gene-Regulatory Mechanisms and NTDs

from mutations in regulatory elements. For example, mutations resulting in insufficient

Other epigenetic mechanisms include various modifications of histone proteins, which

PRIMARY PREVENTION OF NTDs

Folic Acid Supplementation and Fortification

prevention will require a combination of multiple interventions. Possible approaches may

Advances in exome and whole-genome sequencing may help researchers begin to

93:789–98. [PubMed: 21346092]

defects. Annu. Rev. Pharmacol. Toxicol. 2002; 42:181–208. [PubMed: 11807170]

neural tube morphogenesis in mice. Cell. 1999; 99(5):485–97. [PubMed: 10589677]

de novo methylation and mammalian development. Cell. 1999; 99(3):247–57. [PubMed:

Control of Morphogenesis. Vol. 1. Saunders; London: 1990. p. 325-34.

Stover PJ. One-carbon metabolism-genome interactions in folate-associated pathologies. J. Nutr. 2009;

Tibbetts AS, Appling DR. Compartmentalization of mammalian folate-mediated one-carbon

Figure 2. Overview of folate one-carbon metabolism

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