Breakdown in the synaptic vesicle cycle defines early and reversible cortical pathogenesis in ALS

Synaptic failure is considered an early driver of Amyotrophic Lateral Sclerosis (ALS), yet identifying the molecular events initiating synaptic decline remains challenging in end-stage human tissue. Here, we exploit the late involvement of the primary visual cortex (Brodmann Area 17 (BA17)) to investigate early disease-associated changes in human ALS. Structural analyses revealed neuropil compaction, presynaptic terminal shrinkage, and synaptic degeneration despite preservation of local neuronal populations. Deep synaptoneurosome proteomics identified a regional signature characterised by disruption of presynaptic vesicle cycling, which closely resembles early pathological changes observed in the inducible human TDP-43 rNLS8 mouse model. Importantly, suppression of TDP-43 expression in vivo restored these proteomic alterations, highlighting recovery of presynaptic vesicle machinery within preserved synaptic structures. Together, these findings reveal early synaptic pathology as a distinct and potentially reversible stage of ALS neurodegeneration.