The dementia familial encephalopathy with neuroserpin inclusion bodies (FENIB) is caused by the accumulation of mutant neuroserpin within neurons (Davis, R. L., Shrimpton, A. E., Holohan, P. D., Bradshaw, C., Feiglin, D., Sonderegger, P., Kinter, J., Becker, L. M., Lacbawan, F., Krasnewich, D., Muenke, M., Lawrence, D. A., Yerby, M. S., Shaw, C.-M., Gooptu, B., Elliott, P. R., Finch, J. T., Carrell, R. W., and Lomas, D. A. (1999) Nature 401, 376 -379), but little is known about the trafficking of wild type and mutant neuroserpins. We have established a cell model to study the processing of wild type neuroserpin and the Syracuse (S49P) and Portland (S52R) mutants that cause FENIB. Here we show that Syracuse and Portland neuroserpin are retained soon after their synthesis in the endoplasmic reticulum and that the limiting step in their processing is the transport to the Golgi complex. This is in contrast to the wild type protein, which is secreted into the culture medium. Mutant neuroserpin is retained within the endoplasmic reticulum as polymers, similar to those isolated from the intraneuronal inclusions in the brains of individuals with FENIB. Remarkably, the Portland mutant showed faster accumulation and slower secretion compared with the Syracuse mutant, in keeping with the more severe clinical phenotype found in patients with the Portland variant of neuroserpin. Both mutant and wild type neuroserpin were partially degraded by proteasomes. Taken together, our results provide further understanding of how cells handle defective but ordered mutant proteins and provide strong support for a common mechanism of disease caused by mutants of the serine protease inhibitor superfamily.Neuroserpin is a member of the serpin superfamily and is predominantly expressed by neurons of the developing and adult brain. This serpin is secreted from the axonal growth cones of the central and peripheral nervous system, where it inhibits the enzyme tissue plasminogen activator (1-5). The expression pattern of neuroserpin and its in vitro inhibitory activity implicate this serpin in regulating axonal growth, reducing seizure activity, controlling damage in cerebral infarction, and regulating emotional behavior and memory (6 -10).We have recently described an autosomal dominant dementia, familial encephalopathy with neuroserpin inclusion bodies (FENIB), 1 that is characterized by inclusions of mutant neuroserpin within cortical and subcortical neurons (11-13). This dementia is unusual in that the inclusions result from the retention of ordered polymers of neuroserpin, most likely within the endoplasmic reticulum (ER) of neurons (11). Moreover, the number of inclusions is directly related to the molecular instability caused by the mutation and inversely proportional to the age of onset of dementia (13). For example, the Syracuse mutation (S49P) causes dementia in middle age, whereas the more severe Portland mutant (S52R) causes more inclusions and an onset of dementia in the early 20s. Polymers of the serpins result from the sequential...