1
|
Hadjinicolaou A, Quinlan A, Liu S, Zhang B, Takeoka M, Sahin M, Prabhu SP, Pinto AL. Variation in neuroimaging and outcomes in patients with Sturge Weber syndrome Type III. Brain Dev 2024; 46:244-249. [PMID: 38740533 DOI: 10.1016/j.braindev.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 04/19/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Sturge Weber syndrome (SWS) is a neurovascular condition with an estimated incidence of 1 in 20,000 to 50,000 live births. SWS Types I and II involve cutaneous and ophthalmological findings, with neurological involvement in Type I. SWS Type III is exclusive to brain stigmata. Our study aims to describe the characteristics of brain MRI findings and report neuroradiological features with seizure and cognitive outcomes in patients with SWS Type III. METHODS This is a retrospective case series examining the clinical, radiological, and cognitive characteristics of patients with SWS Type III referred to the SWS Clinic at Boston Children's Hospital. We analyzed brain MRI findings based on vascular and parenchymal features. Clinical and cognitive outcomes were based on a validated assessment tool in this population (Neuroscore). RESULTS This dedicated case series of patients with Type III SWS from a single center identified ten patients. All patients had classic stigmata indicative of SWS. Two distinct radiological phenotypes were found, one characterized by more pronounced deep venous enlargement, and the other, with more pronounced parenchymal abnormalities. There was heterogeneity in seizure presentation and outcome. Earlier age of onset and seizures predict more severe outcomes, as seen in classic SWS. CONCLUSION We could not find significant divergence in outcomes between patients with differing neuroimaging phenotypes. These results raise the question of whether the two distinct radiological phenotypes found in SWS Type III are reflective of different disease entities, with underlying genetic heterogeneity. These results suggest the need for larger, multi-center natural history studies.
Collapse
Affiliation(s)
- Aristides Hadjinicolaou
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Neurology Service, Department of Pediatrics, Sainte-Justine University Health Center, Université de Montréal, Montreal, QC, Canada
| | - Aisling Quinlan
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shanshan Liu
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bo Zhang
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Masanori Takeoka
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sanjay P Prabhu
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Lecticia Pinto
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
2
|
Mankel FL, Papandreou A, Mankad K, Richardson H, Aylett SE. Diagnostic pathway and management of first seizures in infants with Sturge-Weber syndrome. Dev Med Child Neurol 2024. [PMID: 38867438 DOI: 10.1111/dmcn.15983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 06/14/2024]
Abstract
AIM Sturge-Weber syndrome (SWS) is a rare neurocutaneous syndrome, frequently associated with pharmaco-resistant, early-onset epilepsy. Optimal seizure control is paramount to maximize neurodevelopment. METHOD A single-centre case series of 49 infants explored early SWS care. Ninety-two per cent of children developed seizures aged 0 to 3 years; 55% of cases were before diagnostic magnetic resonance imaging (MRI) or tertiary referral. Delay in SWS diagnosis affected 31% of infants because of a lack of gadolinium enhancement for initial MRI. First seizures were frequently prolonged, with phenytoin administration necessary in 46%. Presymptomatic antiseizure medication prophylaxis (n = 8/49) decreased seizure burden. No patients on antiseizure medication prophylaxis suffered status epilepticus for longer than 30 minutes, and half of them (n = 4) had not developed seizures at last follow-up (aged 2-10 years). RESULTS A parental survey enabled further service evaluation. Eighty-three per cent of parents considered local clinicians' understanding of SWS inadequate: 61% felt insufficiently informed about SWS and 81% received no epilepsy education before seizures. INTERPRETATION To overcome the identified shortfalls, guidelines towards improving and standardizing SWS management are proposed.
Collapse
Affiliation(s)
- Finola Lauren Mankel
- Neurosciences Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Medical School, London, UK
| | - Apostolos Papandreou
- Neurosciences Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Developmental Neurosciences, University College London, Great Ormond Street Institute of Child Health, London, UK
| | - Kshitij Mankad
- Neuroradiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Hanna Richardson
- Neurosciences Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sarah E Aylett
- Neurosciences Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| |
Collapse
|
3
|
Zecchin D, Knöpfel N, Gluck AK, Stevenson M, Sauvadet A, Polubothu S, Barberan-Martin S, Michailidis F, Bryant D, Inoue A, Lines KE, Hannan FM, Semple RK, Thakker RV, Kinsler VA. GNAQ/GNA11 Mosaicism Causes Aberrant Calcium Signaling Susceptible to Targeted Therapeutics. J Invest Dermatol 2024; 144:811-819.e4. [PMID: 37802293 PMCID: PMC10957341 DOI: 10.1016/j.jid.2023.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/12/2023] [Accepted: 08/26/2023] [Indexed: 10/08/2023]
Abstract
Mosaic variants in genes GNAQ or GNA11 lead to a spectrum of vascular and pigmentary diseases including Sturge-Weber syndrome, in which progressive postnatal neurological deterioration led us to seek biologically targeted therapeutics. Using two cellular models, we find that disease-causing GNAQ/11 variants hyperactivate constitutive and G-protein coupled receptor ligand-induced intracellular calcium signaling in endothelial cells. We go on to show that the aberrant ligand-activated intracellular calcium signal is fueled by extracellular calcium influx through calcium-release-activated channels. Treatment with targeted small interfering RNAs designed to silence the variant allele preferentially corrects both the constitutive and ligand-activated calcium signaling, whereas treatment with a calcium-release-activated channel inhibitor rescues the ligand-activated signal. This work identifies hyperactivated calcium signaling as the primary biological abnormality in GNAQ/11 mosaicism and paves the way for clinical trials with genetic or small molecule therapies.
Collapse
Affiliation(s)
- Davide Zecchin
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Nicole Knöpfel
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom; Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Anna K Gluck
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mark Stevenson
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Aimie Sauvadet
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Satyamaanasa Polubothu
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom; Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Sara Barberan-Martin
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Fanourios Michailidis
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Dale Bryant
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Asuka Inoue
- Graduate School of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Kate E Lines
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Fadil M Hannan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Robert K Semple
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Veronica A Kinsler
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom; Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom.
| |
Collapse
|
4
|
Knöpfel N, Zecchin D, Richardson H, Polubothu S, Barberan-Martin S, Cullup T, Gholam K, Heales S, Krywawych S, López-Balboa P, Muwanga-Nanyonjo N, Ogunbiyi O, Puvirajasinghe C, Solman L, Swarbrick K, Syed SB, Tahir Z, Tisdall MM, Allgrove J, Chesover AD, Aylett SE, Jacques TS, Hannan FM, Löbel U, Semple RK, Thakker RV, Kinsler VA. GNAQ/GNA11 Mosaicism Is Associated with Abnormal Serum Calcium Indices and Microvascular Neurocalcification. J Invest Dermatol 2024; 144:820-832.e9. [PMID: 37802294 PMCID: PMC11139655 DOI: 10.1016/j.jid.2023.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/31/2023] [Accepted: 09/02/2023] [Indexed: 10/08/2023]
Abstract
Mosaic mutations in genes GNAQ or GNA11 lead to a spectrum of diseases including Sturge-Weber syndrome and phakomatosis pigmentovascularis with dermal melanocytosis. The pathognomonic finding of localized "tramlining" on plain skull radiography, representing medium-sized neurovascular calcification and associated with postnatal neurological deterioration, led us to study calcium metabolism in a cohort of 42 children. In this study, we find that 74% of patients had at least one abnormal measurement of calcium metabolism, the commonest being moderately low serum ionized calcium (41%) or high parathyroid hormone (17%). Lower levels of ionized calcium even within the normal range were significantly associated with seizures, and with specific antiepileptics despite normal vitamin D levels. Successive measurements documented substantial intrapersonal fluctuation in indices over time, and DEXA scans were normal in patients with hypocalcemia. Neurohistology from epilepsy surgery in five patients revealed not only intravascular, but perivascular and intraparenchymal mineral deposition and intraparenchymal microvascular disease in addition to previously reported findings. Neuroradiology review clearly demonstrated progressive calcium deposition in individuals over time. These findings and those of the adjoining paper suggest that calcium deposition in the brain of patients with GNAQ/GNA11 mosaicism may not be a nonspecific sign of damage as was previously thought, but may instead reflect the central postnatal pathological process in this disease spectrum.
Collapse
Affiliation(s)
- Nicole Knöpfel
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom; Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Davide Zecchin
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Hanna Richardson
- Neurodisability, Great Ormond St Hospital for Children, London, United Kingdom
| | - Satyamaanasa Polubothu
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom; Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Sara Barberan-Martin
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Thomas Cullup
- North Thames Genomic Laboratory Hub, Levels 4-6, Barclay House, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Karolina Gholam
- Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Simon Heales
- Department of Chemical Pathology NIHR BRC, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Steve Krywawych
- Department of Chemical Pathology NIHR BRC, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Pablo López-Balboa
- Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Noreen Muwanga-Nanyonjo
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom
| | - Olumide Ogunbiyi
- Department of Histopathology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Clinda Puvirajasinghe
- North Thames Genomic Laboratory Hub, Levels 4-6, Barclay House, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Lea Solman
- Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Katherine Swarbrick
- Department of Histopathology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Samira B Syed
- Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Zubair Tahir
- Paediatric Neurosurgery, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Martin M Tisdall
- Paediatric Neurosurgery, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jeremy Allgrove
- Endocrinology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Alexander D Chesover
- Endocrinology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sarah E Aylett
- Neurodisability, Great Ormond St Hospital for Children, London, United Kingdom
| | - Thomas S Jacques
- Department of Histopathology, Great Ormond St Hospital for Children NHS Foundation Trust, London, United Kingdom; Developmental Biology and Cancer Programme, UCL GOS Institute of Child Health, London, United Kingdom
| | - Fadil M Hannan
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Ulrike Löbel
- Radiology, Great Ormond St Hospital for Children, London, United Kingdom
| | - Robert K Semple
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; National Institute for Health Research Oxford Biomedical Research Centre; Oxford, United Kingdom
| | - Veronica A Kinsler
- Mosaicism and Precision Medicine Laboratory, Francis Crick Institute, London, United Kingdom; Genetics and Genomic Medicine, UCL GOS Institute of Child Health, London, United Kingdom; Department of Paediatric Dermatology, Great Ormond St Hospital for Children, London, United Kingdom.
| |
Collapse
|
5
|
Valery CB, Iannotti I, Kossoff EH, Zabel A, Cohen B, Ou Y, Pinto A, Comi AM. Retrospective Analysis of Presymptomatic Treatment In Sturge-Weber Syndrome. ANNALS OF THE CHILD NEUROLOGY SOCIETY 2024; 2:60-72. [PMID: 38745912 PMCID: PMC11090403 DOI: 10.1002/cns3.20058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/11/2023] [Indexed: 05/16/2024]
Abstract
Background Ninety percent of infants with Sturge-Weber syndrome (SWS) brain involvement have seizure onset before 2 years of age; this is associated with worse neurologic outcome. Presymptomatic treatment before seizure onset may delay seizure onset and improve outcome, as has been shown in other conditions with a high-risk of developing epilepsy such as tuberous sclerosis complex. Electroencephalogram (EEG) may be a biomarker to predict seizure onset. This retrospective clinical data analysis aims to assess impact of presymptomatic treatment in SWS. Methods This two-centered, IRB-approved, retrospective study analyzed records from patients with SWS brain involvement. Clinical data recorded included demographics, age of seizure onset (if present), brain involvement extent (unilateral versus bilateral), port-wine birthmark (PWB) extent, family history of seizure, presymptomatic treatment if received, neuroscore, and anti-seizure medication. EEG reports prior to seizure onset were analyzed. Results Ninety-two patients were included (48 females), and 32 received presymptomatic treatment outside of a formal protocol (5 aspirin, 16 aspirin and levetiracetam; 9 aspirin and oxcarbazepine, 2 valproic acid). Presymptomatically-treated patients were more likely to be seizure-free at 2 years (15 of 32; 47% versus 7 of 60; 12%; p<.001). A greater percentage of presymptomatically-treated patients had bilateral brain involvement (38% treated versus 17% untreated; p=.026). Median hemiparesis neuroscore at 2 years was better in presymptomatically-treated patients. In EEG reports prior to seizure onset, the presence of slowing, epileptiform discharges, or EEG-identified seizures was associated with seizure onset by 2 (p=.001). Conclusion Presymptomatic treatment is a promising approach to children diagnosed with SWS prior to seizure onset. Further study is needed, including prospective drug trials, long-term neuropsychological outcome, and prospective EEG analysis to assess this approach and determine biomarkers for presymptomatic treatment.
Collapse
Affiliation(s)
| | | | - Eric H. Kossoff
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine
| | - Andrew Zabel
- Department of Neuropsychology, Kennedy Krieger Institute
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Bernard Cohen
- Department if Dermatology and Pediatrics, Johns Hopkins School of Medicine
| | - Yangming Ou
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School
| | - Anna Pinto
- Department of Neurology, Boston Children’s Hospital
| | - Anne M. Comi
- Department of Neurology, Kennedy Krieger Institute
- Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine
| |
Collapse
|
6
|
Clifford SM, Ghosh A, Zandifar A, Tierradentro-García LO, Kim JDU, Andronikou S. Arterial spin-labeled (ASL) perfusion in children with Sturge-Weber syndrome: a retrospective cross-sectional study. Neuroradiology 2023; 65:1825-1834. [PMID: 37794141 DOI: 10.1007/s00234-023-03224-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Sturge-Weber syndrome (SWS) is a developmental disorder with venous hypertension and associated tissue responses including pial angiomatosis, cortical calcifications, and cerebral atrophy. Arterial spin-labeled (ASL) perfusion is an advanced MR sequence which can assess perfusion, without the need for contrast. We systematically evaluated the potential benefits of using ASL in Sturge-Weber syndrome, to determine the extent of intracranial perfusion abnormality and stage of disease, relevant for prognostication and surgical planning. METHODS Two pediatric neuroradiologists retrospectively evaluated ASL perfusion imaging of 31 children with confirmed SWS and recorded the presence of hyper-perfusion, hypo-perfusion, or normal perfusion. The presence and distribution of ASL abnormality were compared against the presence and side of atrophy/calcification and pial angiomatosis on standard MR sequences. RESULTS Thirty-one children (52% female, median age 16.7 months) with SWS had ASL imaging. Seven (23%) had hyper-perfusion, 15 (48%) had hypo-perfusion, and 9 (29%) had no perfusion abnormalities. ASL perfusion abnormality matched the location of SWS findings on conventional imaging in 86% (19/22). ASL demonstrated statistically significant increased perfusion in the early stage of the disease and decreased perfusion when there was atrophy. The parietal lobe was involved in 86% of cases. CONCLUSION ASL perfusion imaging is an advanced technique which may contribute to earlier diagnosis and more accurate prognostication of Sturge-Weber syndrome, helping guide management and potential surgical planning.
Collapse
Affiliation(s)
- Simon M Clifford
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Adarsh Ghosh
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Jorge D U Kim
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Savvas Andronikou
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| |
Collapse
|
7
|
Smegal LF, Vedmurthy P, Ryan M, Eagen M, Andrejow NW, Sweeney K, Reidy TG, Yeom S, Lin DD, Suskauer SJ, Kalb LG, Salpekar JA, Zabel TA, Comi AM. Cannabidiol Treatment for Neurological, Cognitive, and Psychiatric Symptoms in Sturge-Weber Syndrome. Pediatr Neurol 2023; 139:24-34. [PMID: 36508880 DOI: 10.1016/j.pediatrneurol.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 10/20/2022] [Accepted: 10/29/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND A prior drug trial of cannabidiol for treatment-resistant epilepsy in patients with Sturge-Weber syndrome (SWS), a rare neurovascular condition, implicated improvements in neurological, quality of life (QOL), neuropsychologic, psychiatric, and motor outcomes. METHODS Ten subjects with SWS brain involvement, controlled seizures, and cognitive impairments received study drug in this Johns Hopkins institutional review board-approved, open-label, prospective drug trial. Oral cannabidiol was taken for six months (dose ranged from 5 to 20 mg/kg/day). SWS neuroscore, port-wine birthmark score, QOL, and adverse events were recorded every four to 12 weeks. Neuropsychologic, psychiatric, and motor assessments were administered at baseline and six months' follow-up. Most evaluations were conducted virtually due to the coronavirus disease 2019 pandemic. RESULTS Cannabidiol was generally well tolerated. Six subjects reported mild to moderate side effects related to study drug and continued on drug; one subject withdrew early due to moderate side effects. No seizures were reported. Significant improvements in SWS neuroscore, patient-reported QOL, anxiety and emotional regulation, and report of bimanual ability use were noted. Migraine QOL scores were high at baseline in these subjects, and remained high. Neuropsychologic and other QOL and motor outcomes remained stable, with some within-subject improvements noted. CONCLUSIONS Further studies are needed to determine whether Epidiolex can improve quality of life and be beneficial for neurological, anxiety, and motor impairments in SWS independent of seizure control. Large multicentered studies are needed to extend these preliminary findings.
Collapse
Affiliation(s)
- Lindsay F Smegal
- Department of Neurology and Developmental Medicine, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Pooja Vedmurthy
- Department of Neurology and Developmental Medicine, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Matthew Ryan
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Melissa Eagen
- Fairmount Rehabilitation Programs, Kennedy Krieger Institute, Baltimore, Maryland
| | | | - Kristie Sweeney
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Teressa Garcia Reidy
- Fairmount Rehabilitation Programs, Kennedy Krieger Institute, Baltimore, Maryland
| | - SangEun Yeom
- Department of Neurology and Developmental Medicine, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Doris D Lin
- Division of Neuroradiology, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stacy J Suskauer
- Pediatric Rehabilitation Medicine, Kennedy Krieger Institute, Baltimore, Maryland; Departments of Physical Medicine & Rehabilitation and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Luther G Kalb
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Kennedy Krieger Institute, Baltimore, Maryland
| | - Jay A Salpekar
- Departments of Psychiatry and Neurology, Johns Hopkins University School of Medicine, Kennedy Krieger Institute, Baltimore, Maryland
| | - T Andrew Zabel
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anne M Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland; Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
| |
Collapse
|
8
|
Pouliquen G, Fillon L, Dangouloff-Ros V, Kuchenbuch M, Bar C, Chemaly N, Levy R, Roux CJ, Saitovitch A, Boisgontier J, Nabbout R, Boddaert N. Arterial Spin-Labeling Perfusion Imaging in the Early Stage of Sturge-Weber Syndrome. AJNR Am J Neuroradiol 2022; 43:1516-1522. [PMID: 36137664 PMCID: PMC9575527 DOI: 10.3174/ajnr.a7643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/27/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Sturge-Weber syndrome is a rare congenital neuro-oculo-cutaneous disorder. Although the principal mechanism of Sturge-Weber syndrome is characterized by a leptomeningeal vascular malformation, few data regarding perfusion abnormalities of the brain parenchyma are available. Therefore, the aim of this study was to assess the diagnostic performance of arterial spin-labeling perfusion imaging in the early stage of Sturge-Weber syndrome before 1 year of age until 3.5 years of age. We hypothesized that a leptomeningeal vascular malformation has very early hypoperfusion compared with controls with healthy brains. MATERIALS AND METHODS We compared the CBF using arterial spin-labeling perfusion imaging performed at 3T MR imaging in the brain parenchymal regions juxtaposing the leptomeningeal vascular malformation in patients with Sturge-Weber syndrome (n = 16; 3.5 years of age or younger) with the corresponding areas in age-matched controls with healthy brains (n = 58). The analysis was performed following two complementary methods: a whole-brain voxel-based analysis and a visual ROI analysis focused on brain territory of the leptomeningeal vascular malformation. RESULTS Whole-brain voxel-based comparison revealed a significant unilateral decrease in CBF localized in the affected cortices of patients with Sturge-Weber syndrome (P < .001). CBF values within the ROIs in patients with Sturge-Weber syndrome were lower than those in controls (in the whole cohort: median, 25 mL/100g/min, versus 44 mL/100g/min; P < .001). This finding was also observed in the group younger than 1 year of age, emphasizing the high sensitivity of arterial spin-labeling in this age window in which the diagnosis is difficult. CONCLUSIONS Arterial spin-labeling perfusion imaging in the early stage of Sturge-Weber syndrome can help to diagnose the disease by depicting a cortical hypoperfusion juxtaposing the leptomeningeal vascular malformation.
Collapse
Affiliation(s)
- G Pouliquen
- From the Department of Pediatric Radiology (G.P., V.D.-R., R.L., C.-J.R., N.B.)
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - L Fillon
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - V Dangouloff-Ros
- From the Department of Pediatric Radiology (G.P., V.D.-R., R.L., C.-J.R., N.B.)
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - M Kuchenbuch
- Centre de Reference Epilepsies Rares (M.K., C.B., N.C., R.N.), Department of Pediatric Neurology, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - C Bar
- Centre de Reference Epilepsies Rares (M.K., C.B., N.C., R.N.), Department of Pediatric Neurology, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - N Chemaly
- Centre de Reference Epilepsies Rares (M.K., C.B., N.C., R.N.), Department of Pediatric Neurology, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - R Levy
- From the Department of Pediatric Radiology (G.P., V.D.-R., R.L., C.-J.R., N.B.)
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - C-J Roux
- From the Department of Pediatric Radiology (G.P., V.D.-R., R.L., C.-J.R., N.B.)
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - A Saitovitch
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - J Boisgontier
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| | - R Nabbout
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
- Centre de Reference Epilepsies Rares (M.K., C.B., N.C., R.N.), Department of Pediatric Neurology, Necker Children's Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - N Boddaert
- From the Department of Pediatric Radiology (G.P., V.D.-R., R.L., C.-J.R., N.B.)
- Imagine Institute for Genetic Diseases (G.P., L.F., V.D.-R., R.L., C.-J.R., A.S., J.B., R.N., N.B.), L'Institut National de la Santé et de la Recherche Médicale U1163, Paris, France
| |
Collapse
|
9
|
Vedmurthy P, Pinto ALR, Lin DDM, Comi AM, Ou Y. Study protocol: retrospectively mining multisite clinical data to presymptomatically predict seizure onset for individual patients with Sturge-Weber. BMJ Open 2022; 12:e053103. [PMID: 35121603 PMCID: PMC8819809 DOI: 10.1136/bmjopen-2021-053103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 01/13/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Secondary analysis of hospital-hosted clinical data can save time and cost compared with prospective clinical trials for neuroimaging biomarker development. We present such a study for Sturge-Weber syndrome (SWS), a rare neurovascular disorder that affects 1 in 20 000-50 000 newborns. Children with SWS are at risk for developing neurocognitive deficit by school age. A critical period for early intervention is before 2 years of age, but early diagnostic and prognostic biomarkers are lacking. We aim to retrospectively mine clinical data for SWS at two national centres to develop presymptomatic biomarkers. METHODS AND ANALYSIS We will retrospectively collect clinical, MRI and neurocognitive outcome data for patients with SWS who underwent brain MRI before 2 years of age at two national SWS care centres. Expert review of clinical records and MRI quality control will be used to refine the cohort. The merged multisite data will be used to develop algorithms for abnormality detection, lesion-symptom mapping to identify neural substrate and machine learning to predict individual outcomes (presence or absence of seizures) by 2 years of age. Presymptomatic treatment in 0-2 years and before seizure onset may delay or prevent the onset of seizures by 2 years of age, and thereby improve neurocognitive outcomes. The proposed work, if successful, will be one of the largest and most comprehensive multisite databases for the presymptomatic phase of this rare disease. ETHICS AND DISSEMINATION This study involves human participants and was approved by Boston Children's Hospital Institutional Review Board: IRB-P00014482 and IRB-P00025916 Johns Hopkins School of Medicine Institutional Review Board: NA_00043846. Participants gave informed consent to participate in the study before taking part. The Institutional Review Boards at Kennedy Krieger Institute and Boston Children's Hospital approval have been obtained at each site to retrospectively study this data. Results will be disseminated by presentations, publication and sharing of algorithms generated.
Collapse
Affiliation(s)
- Pooja Vedmurthy
- Department of Neurology and Developmental Medicine, Hugo Moser Research Institute, Baltimore, Maryland, USA
- Department of Neurology and Pediatrics, Kennedy Krieger Institute, Baltimore, MD, USA
| | - Anna L R Pinto
- Department of Neurology, Division of Epilepsy, Harvard Medical School, Boston, Massachusetts, USA
| | - Doris D M Lin
- Neuroradiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Anne M Comi
- Department of Neurology and Developmental Medicine, Hugo Moser Research Institute, Baltimore, Maryland, USA
- Department of Neurology and Pediatrics, Kennedy Krieger Institute, Baltimore, MD, USA
- Department of Neurology and Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Yangming Ou
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, Massachusetts, USA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Radiology, Boston Children's Hospital; Harvard Medical School, Boston, MA, USA
| |
Collapse
|
10
|
Iyer RR, Strahle JM, Groves ML. Neurosurgical Considerations of Neurocutaneous Syndromes. Neurosurg Clin N Am 2021; 33:81-89. [PMID: 34801145 DOI: 10.1016/j.nec.2021.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The phakomatoses are a group of genetic and acquired disorders characterized by neurologic, cutaneous, and often ocular manifestations, thus commonly referred to as neurocutaneous syndromes. In several of these conditions the underlying genetic pathophysiology has been elucidated, which will continue to play an important role in advancing therapeutic techniques. This article focuses on several examples of such neurocutaneous syndromes, with special attention to the relevant neurosurgical considerations of these patients.
Collapse
Affiliation(s)
- Rajiv R Iyer
- Department of Neurosurgery/Division of Pediatric Neurosurgery, University of Utah/Primary Children's Hospital, 100 N. Mario Capecchi Drive Suite 3850, Salt Lake City, UT 84113, USA.
| | - Jennifer M Strahle
- Pediatric Neuro Spine Program, Pediatric Cerebrovascular Surgery, Division of Pediatric Neurosurgery, Department of Neurosurgery, Washington University School of Medicine, 1 Childrens Pl Suite 4S20, St. Louis, MO 63110, USA
| | - Mari L Groves
- Department of Neurosurgery, Johns Hopkins School of Medicine, 600 N. Wolfe Street Phipps 554, Baltimore, MD 21287, USA
| |
Collapse
|
11
|
Powell S, Fosi T, Sloneem J, Hawkins C, Richardson H, Aylett S. Neurological presentations and cognitive outcome in Sturge-Weber syndrome. Eur J Paediatr Neurol 2021; 34:21-32. [PMID: 34293629 DOI: 10.1016/j.ejpn.2021.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/03/2021] [Accepted: 07/07/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION This study of children with Sturge-Weber syndrome (SWS) profiled neurological presentations; compared patients with (+) and without (-) port-wine stain (PWS); and determined risk factors for intellectual and language impairments. METHODS A retrospective case note review was conducted at a national centre. RESULTS This cohort (n = 140, male 72, median follow up 114 months) showed sex parity. Intellectual disability ("ID": IQ ≤ 70) affected half (66), being severe (IQ ≤ 40) in two-fifths (27) with ID. Language disorder (core score≤70) affected half (57). Neurological presentations were: status epilepticus 57% (80), hemiplegia 58% (81), headaches 36% (50) and acutely acquired neurological deficits lasting over 24 h 40% (56). One-seventh (20) were PWS(-). This group had: fewer lobes with angioma (p < 0.0001); and less frequent ID (p = 0.002) or language disorder (p = 0.013). Seizure frequency and status epilepticus prevalence did not differ from PWS(+). ID and language disorder were associated with: more lobes with angioma; earlier seizure onset; more frequent status epilepticus and seizure clusters. On multivariable analysis recurrent status epilepticus (p = 0.037) and multi-lobe involvement (p = 0.002) increased the risk of severe intellectual disability. Active epilepsy was associated with language disorder (p = 0.030). CONCLUSIONS This is the largest reported series documenting detailed developmental profiles of children with SWS, including ID and ASD. PWS(+) shows high rates of ID and language disorder. PWS(-) SWS has a more favourable outcome. Cognitive outcome is contingent on number of affected lobes and bilateral involvement. Epilepsy exerts an additional deleterious effect on language and cognition. A high percentage of children have a history of status epilepticus, with evidence that this impacts language and cognitive outcomes. Acutely acquired neurological deficits did not penalise either. Regular structured clinical and developmental assessment permit greater identification of neurological and neurodevelopmental impairments in SWS, and appropriate support.
Collapse
Affiliation(s)
- Sebastian Powell
- University College London Medical School, London, Gower Street, WC1E 6BT, United Kingdom.
| | - Tangunu Fosi
- Great Ormond Street Hospital for Children Neurodisability Department, Great Ormond Street, UCL Great Ormond Street Institute of Child Health Clinical Neurosciences, London, United Kingdom
| | - Jenny Sloneem
- Great Ormond Street Hospital for Children Neurodisability Department, Great Ormond Street, London, United Kingdom
| | - Christina Hawkins
- Great Ormond Street Hospital for Children Neurodisability Department, Great Ormond Street, London, United Kingdom
| | - Hanna Richardson
- Great Ormond Street Hospital for Children Neurodisability Department, Great Ormond Street, London, United Kingdom
| | - Sarah Aylett
- Great Ormond Street Hospital for Children Neurodisability Department, Great Ormond Street, UCL Great Ormond Street Institute of Child Health Clinical Neurosciences, London, United Kingdom
| |
Collapse
|
12
|
Quantitative EEG improves prediction of Sturge-Weber syndrome in infants with port-wine birthmark. Clin Neurophysiol 2021; 132:2440-2446. [PMID: 34454271 DOI: 10.1016/j.clinph.2021.06.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/05/2021] [Accepted: 06/19/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Port-wine birthmark (PWB) is a common occurrence in the newborn, and general pediatricians, dermatologists, and ophthalmologists are often called on to make an assessment of risk for Sturge-Weber syndrome (SWS) due to workforce shortages in pediatric neurologists and MRI's low sensitivity for SWS brain involvement in infants. We therefore aimed to develop a quantitative EEG (qEEG) approach to safely screen young infants with PWB for SWS risk and optimal timing of diagnostic MRI. METHODS Forty-eight infants (prior to first birthday) underwent EEG recording. Signal processing methods compared voltage between left and right sides using a previously defined pipeline and diagnostic threshold. In this test sample, we compared sensitivity/specificity of the qEEG metric against MRI performed after the first birthday. We also used likelihood ratio testing to determine whether qEEG adds incremental information beyond topographical extent of PWB, another risk marker of brain involvement. RESULTS qEEG helped predict SWS risk in the first year of life (p = 0.031), with a sensitivity of 50% and a specificity of 81%. It added about 40% incremental information beyond PWB extent alone (p = 0.042). CONCLUSION qEEG adds information to risk prediction in infants with facial PWB. SIGNIFICANCE qEEG can be used to help determine whether to obtain an MRI in the first year of life. The data collected can assist in developing a predictive model risk calculator that incorporates both PWB extent and qEEG results, which can be validated and then employed in the community.
Collapse
|
13
|
Smegal LF, Sebold AJ, Hammill AM, Juhász C, Lo WD, Miles DK, Wilfong AA, Levin AV, Fisher B, Ball KL, Pinto AL, Comi AM. Multicenter Research Data of Epilepsy Management in Patients With Sturge-Weber Syndrome. Pediatr Neurol 2021; 119:3-10. [PMID: 33813331 PMCID: PMC8162684 DOI: 10.1016/j.pediatrneurol.2021.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Epilepsy in typical Sturge-Weber syndrome (SWS) is common, and many questions remain regarding the treatment outcomes. We analyzed a large multicenter database with focus on neurological drug treatment in different demographic and SWS characteristic groups. METHODS A total of 268 patients with brain involvement and a history of seizures were selected from a research data registry generated from a multicenter cross-sectional questionnaire. We examined associations between medication use and binary variables such as sex, ethnicity, and brain, skin, and eye involvement laterality. We analyzed group differences in mean number of antiseizure medications and age at diagnosis, enrollment, and seizure onset and examined differences in median SWS neurological scores in groups of interest. RESULTS The most frequently used medications were levetiracetam (48.1%), low-dose aspirin (44.8%), oxcarbazepine (39.9%), and phenobarbital (14.9%). Lamotrigine was more frequently used in adults than in children (P = 0.001). History of neurosurgery was associated with no current antiseizure medication use (P = 0.001), whereas bilateral brain involvement and family history of seizures were associated with using a higher number of antiseizure medications (P = 0.002, P = 0.027, respectively). Subjects with bilateral brain involvement and early seizure onset were associated with using a higher number of antiseizure medications (P = 0.002) and phenobarbital use (0.003). CONCLUSIONS Levetiracetam, low-dose aspirin, and oxcarbazepine were the most frequently used medications. More severely affected patients were frequently on a greater number of antiseizure medications. Surgery for epilepsy was associated with the ability to discontinue antiseizure medication. Longitudinal studies are needed to further investigate medication use in patients with SWS.
Collapse
Affiliation(s)
- Lindsay F. Smegal
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Alison J. Sebold
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland
| | - Adrienne M. Hammill
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Csaba Juhász
- Departments of Pediatrics, Neurology, and Neurosurgery, Wayne State University School of Medicine, Children’s Hospital of Michigan, Detroit, Michigan
| | - Warren D. Lo
- Neurology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Daniel K. Miles
- Department of Neurology, Pediatric Epilepsy, New York University Langone Health, New York, New York
| | - Angus A. Wilfong
- Neurology, Barrow Neurological Institute, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Alex V. Levin
- Pediatric Ophthalmology and Ocular Genetics, Flaum Eye Institute, Golisano Children’s Hospital, University of Rochester, Rochester, New York
| | | | | | - Anna L. Pinto
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anne M. Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland,Communications should be addressed to: Dr. Comi; Department of Neurology; Hugo Moser Kennedy Krieger Research Institute; Rm 553, Kennedy Krieger Outpatient Bldg, 801 North Broadway; Baltimore, MD 21205. (A.M. Comi)
| | | |
Collapse
|
14
|
Sah J, Balucani C, Abrams A, Hisamoto Y, Chari G, Velayudhan V, Pavlakis SG. Pearls & Oy-sters: Sturge-Weber Syndrome Unmasked by Traumatic Brain Injury. Neurology 2021; 96:e1262-e1265. [PMID: 33067405 DOI: 10.1212/wnl.0000000000011075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jeetendra Sah
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD.
| | - Clotilde Balucani
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD
| | - Aaron Abrams
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD
| | - Yoshimi Hisamoto
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD
| | - Geetha Chari
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD
| | - Vinodkumar Velayudhan
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD
| | - Steven G Pavlakis
- From the Departments of Pediatric Neurology (J.S., A.A., Y.H., G.C., S.G.P.) and Radiology (V.V.), SUNY Downstate Health Sciences University, Kings County Hospital Center, Brooklyn, NY; and Johns Hopkins Medicine (C.B.), Department of Neurology, Baltimore, MD
| |
Collapse
|
15
|
Sebold AJ, Day AM, Ewen J, Adamek J, Byars A, Cohen B, Kossoff EH, Mizuno T, Ryan M, Sievers J, Smegal L, Suskauer SJ, Thomas C, Vinks A, Zabel TA, Hammill AM, Comi AM. Sirolimus Treatment in Sturge-Weber Syndrome. Pediatr Neurol 2021; 115:29-40. [PMID: 33316689 PMCID: PMC8209677 DOI: 10.1016/j.pediatrneurol.2020.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Sturge-Weber syndrome is a rare neurovascular disorder associated with capillary malformation, seizures, cognitive impairments, and stroke-like episodes (SLEs), arising from a somatic activating mutation in GNAQ. Studies suggest this mutation may cause hyperactivation of the mammalian target of rapamycin pathway. Sirolimus is an mammalian target of rapamycin inhibitor studied in other vascular anomalies and a potentially promising therapy in Sturge-Weber syndrome. METHODS Ten patients with Sturge-Weber syndrome brain involvement and cognitive impairments were enrolled. Oral sirolimus was taken for six months (maximum dose: 2 mg/day, target trough level: 4-6 ng/mL). Neuropsychological testing, electroencephalography, and port-wine score were performed at baseline and after six months on sirolimus. Neuroquality of life, adverse events, and Sturge-Weber Syndrome Neurological Score (neuroscore) were recorded at each visit. RESULTS Sirolimus was generally well tolerated; one subject withdrew early. Adverse events considered related to sirolimus were mostly (15/16) grade 1. A significant increase in processing speed was seen in the overall group (P = 0.031); five of nine patients with available data demonstrated statistically rare improvement in processing speed. Improvements were seen in the neuroquality of life subscales measuring anger (P = 0.011), cognitive function (P = 0.015), and depression (P = 0.046). Three subjects experiencing SLEs before and during the study reported shortened recovery times while on sirolimus. CONCLUSIONS Sirolimus was well tolerated in individuals with Sturge-Weber syndrome and may be beneficial for cognitive impairments, especially in patients with impaired processing speed or a history of SLE. A future, randomized, placebo-controlled trial of sirolimus in patients with Sturge-Weber syndrome is needed to further understand these potentially beneficial effects.
Collapse
Affiliation(s)
- Alison J. Sebold
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Alyssa M. Day
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Joshua Ewen
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Psychological and Brain Sciences, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jack Adamek
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Anna Byars
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bernard Cohen
- Division of Pediatric Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Eric H. Kossoff
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Hospital, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tomoyuki Mizuno
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew Ryan
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Jacqueline Sievers
- Clinical Trials Compliance and Quality Assurance, Kennedy Krieger Institute, Baltimore, Maryland, USA
| | - Lindsay Smegal
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA
| | - Stacy J. Suskauer
- Johns Hopkins Hospital, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Department of Pediatric Rehabilitation Medicine, Krieger Institute, Baltimore, Maryland, USA,Johns Hopkins University School of Medicine, Departments of Physical Medicine and Rehabilitation, Baltimore, Maryland, USA
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - T. Andrew Zabel
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland, USA.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adrienne M. Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Division of Hematology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Anne M. Comi
- Department of Neurology, Hugo Moser Kennedy Krieger Research Institute, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Johns Hopkins Hospital, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.,Communications should be addressed to: Dr. Anne M. Comi; Department of Neurology, Hugo Moser Kennedy Krieger Research Institute,801 N. Broadway; Baltimore, MD, 21205. (A.M. Comi)
| |
Collapse
|
16
|
Sturge-Weber syndrome: an update on the relevant issues for neurosurgeons. Childs Nerv Syst 2020; 36:2553-2570. [PMID: 32564157 DOI: 10.1007/s00381-020-04695-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/21/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Sturge-Weber syndrome (SWS) is a neurocutaneous facomatosis characterized by facial and leptomeningeal angioma, glaucoma, seizures, and neurological disability. Therefore, a challenging multidisciplinary interaction is required for its management. The goal of this paper is to review the main aspects of SWS and to present an illustrative pediatric series. METHODS The pertinent literature has been analyzed, focused mainly on etiopathogenesis, pathology, clinical features, diagnostic tools, management, and outcome of the disease. Moreover, a series of 11 children operated on for refractory epilepsy between 2005 and 2015 (minimum follow-up 5 years, mean follow-up 9.6 years) is reported. The series consists of six boys and five girls with 6.5-month and 16.2-month mean age at seizure onset and at surgery, respectively. Seizures affected all children, followed by hemiparesis and psychomotor delay (81%), glaucoma (54%), and other neurological deficits (45%). RESULTS All children underwent hemispherectomy (anatomical in three cases, functional in two cases, hemispherotomy in six cases); one patient needed a redo hemispherotomy. Mortality was nil; disseminated intravascular coagulation and interstitial pneumonia occurred in one patient each; three children had subdural fluid collection. Eight patients (72%) are in the ILAE Class 1 (completely seizure and aura free), two in Class 2 (only auras, no seizure), and one in Class 3 (1-3 seizure days per year). AEDs discontinuation was possible in 73% of cases. The most important news from the literature concerned the pathogenesis (role of the mutation of the GNAQ gene in the abnormal SWS vasculogenesis), the clinical findings (the features and pathogenesis of the stroke-like episodes are being understood), the diagnostic tools (quantitative MRI and EEG), and both the medical (migraine, seizures) and surgical management (epilepsy). The epileptic outcome of SWS patients is very good (80% are seizure-free), if compared with other hemispheric syndromes. The quality of life is affected by the neurological and cognitive deficits. CONCLUSIONS SWS still is an etiological and clinical challenge. However, the improvements over the time are consistent. In particular, the neurosurgical treatment of refractory epilepsy provides very good results as long as the indication to treatment is correct.
Collapse
|
17
|
Doumiri M, Labied M, Salam S, Laoudiyi D, Chbani K, Ouzidane L. [Sturge-Weber syndrome: about a case]. Pan Afr Med J 2020; 36:273. [PMID: 33088402 PMCID: PMC7546018 DOI: 10.11604/pamj.2020.36.273.24346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 11/26/2022] Open
Abstract
Le syndrome de Sturge-Weber (SWS) ou angiomatose encéphalo-faciale, est un syndrome neuro-cutané et oculaire congénital rare. Il comporte deux types de malformations: capillaire faciale congénitale à type d’angiome plan et capillaro-veineux lepto-méningé de localisation le plus souvent pariéto-occipitale homolatérale. La Neuroimagerie, essentiellement l’imagerie par résonnance magnétique (IRM), joue un rôle important dans l'établissement du diagnostic, idéalement avant l'apparition de complications neuro-oculaires. Nous rapportons le cas d’un enfant chez qui le SWS est suspecté devant la présence d’un angiome facial et d’une épilepsie pharmaco-résistante.
Collapse
Affiliation(s)
- Meriem Doumiri
- Service de la Radiologie Pédiatrique, Hôpital Harouchi, Casablanca, Morocco
| | - Mohamed Labied
- Service de la Radiologie Pédiatrique, Hôpital Harouchi, Casablanca, Morocco
| | - Siham Salam
- Service de la Radiologie Pédiatrique, Hôpital Harouchi, Casablanca, Morocco
| | - Dalal Laoudiyi
- Service de la Radiologie Pédiatrique, Hôpital Harouchi, Casablanca, Morocco
| | - Kamilia Chbani
- Service de la Radiologie Pédiatrique, Hôpital Harouchi, Casablanca, Morocco
| | - Lahcen Ouzidane
- Service de la Radiologie Pédiatrique, Hôpital Harouchi, Casablanca, Morocco
| |
Collapse
|
18
|
Abstract
INTRODUCTION Cerebral hemiatrophy is an uncommon neuroimaging finding of diverse etiologies, conventionally classified into two broad categories: congenital and acquired. The authors propose an alternative pragmatic clinical approach to cerebral hemiatrophy, classifying its diverse etiologies into a single event insult such as an in utero stroke, or a progressive disorder from an inflammatory or neoplastic process, the latter of which needs urgent intervention and will be the focus of our review paper. Illustrative cases will also be presented to facilitate the understanding of the discussed disorders. CONCLUSION A systematic approach, linking both clinical and neuroimaging features, is important to facilitate the diagnostic workup of cerebral hemiatrophy. This may potentially help avoid large-scale investigations. Determining the underlying aetiology of cerebral hemiatrophy may impact treatment and prognostication as some conditions such as Rasmussen encephalitis and Parry-Romberg syndrome may benefit from timely implementation of immunomodulatory therapy.
Collapse
|
19
|
De la Torre AJ, Luat AF, Juhász C, Ho ML, Argersinger DP, Cavuoto KM, Enriquez-Algeciras M, Tikkanen S, North P, Burkhart CN, Chugani HT, Ball KL, Pinto AL, Loeb JA. A Multidisciplinary Consensus for Clinical Care and Research Needs for Sturge-Weber Syndrome. Pediatr Neurol 2018; 84:11-20. [PMID: 29803545 PMCID: PMC6317878 DOI: 10.1016/j.pediatrneurol.2018.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/11/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Sturge-Weber syndrome is a neurocutaneous disorder associated with port-wine birthmark, leptomeningeal capillary malformations, and glaucoma. It is associated with an unpredictable clinical course. Because of its rarity and complexity, many physicians are unaware of the disease and its complications. A major focus moving ahead will be to turn knowledge gaps and unmet needs into new research directions. METHODS On October 1-3, 2017, the Sturge-Weber Foundation assembled clinicians from the Clinical Care Network with patients from the Patient Engagement Network of the Sturge-Weber Foundation to identify our current state of knowledge, knowledge gaps, and unmet needs. RESULTS One clear unmet need is a need for consensus guidelines on care and surveillance. It was strongly recommended that patients be followed by multidisciplinary clinical teams with life-long follow-up for children and adults to monitor disease progression in the skin, eye, and brain. Standardized neuroimaging modalities at specified time points are needed together with a stronger clinicopathologic understanding. Uniform tissue banking and clinical data acquisition strategies are needed with cross-center, longitudinal studies that will set the stage for new clinical trials. A better understanding of the pathogenic roles of cerebral calcifications and stroke-like symptoms is a clear unmet need with potentially devastating consequences. CONCLUSIONS Biomarkers capable of predicting disease progression will be needed to advance new therapeutic strategies. Importantly, how to deal with the emotional and psychological effects of Sturge-Weber syndrome and its impact on quality of life is a clear unmet need.
Collapse
Affiliation(s)
- Alejandro J De la Torre
- Department of Neurology, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Aimee F Luat
- Department of Pediatrics and Neurology, Wayne State University, Children's Hospital of Michigan, Detroit, Michigan
| | - Csaba Juhász
- Department of Pediatrics and Neurology, Wayne State University, Children's Hospital of Michigan, Detroit, Michigan
| | - Mai Lan Ho
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Davis P Argersinger
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Kara M Cavuoto
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | - Paula North
- Department of Pediatric Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Craig N Burkhart
- Department of Dermatology, University of North Carolina, Chapel Hill, North Carolina
| | - Harry T Chugani
- Department of Neurology, Nemours DuPont Hospital for Children, Wilmington, Delaware
| | | | - Anna Lecticia Pinto
- Department of Neurology, Harvard Medical School, Children's Hospital Boston, Boston, Massachusetts
| | - Jeffrey A Loeb
- Department of Neurology and Rehabilitation, University of Illinois, Chicago, Illinois.
| |
Collapse
|
20
|
Luat AF, Behen ME, Chugani HT, Juhász C. Cognitive and motor outcomes in children with unilateral Sturge-Weber syndrome: Effect of age at seizure onset and side of brain involvement. Epilepsy Behav 2018; 80:202-207. [PMID: 29414553 PMCID: PMC5845773 DOI: 10.1016/j.yebeh.2018.01.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 01/06/2023]
Abstract
PURPOSE Most children with Sturge-Weber syndrome (SWS) develop seizures that may contribute to neurocognitive status. In this study, we tested the hypothesis that very early seizure onset has a particularly detrimental effect on the cognitive and/or motor outcomes of children with unilateral SWS. We also tested whether side of SWS brain involvement modulates the effect of seizure variables on the pattern of cognitive abnormalities. METHODS Thirty-four children (22 girls; mean age 6.1years) with unilateral SWS and history of epilepsy in a longitudinal cohort underwent neurological and cognitive evaluations. Global intelligent quotient (GIQ), verbal intelligent quotient (VIQ), nonverbal intelligent quotient (IQ), and motor function were correlated with epilepsy variables, side and extent of brain involvement on magnetic resonance imaging (MRI). RESULTS Mean age at seizure onset was 1.3years (0.1-6years) and mean IQ at follow-up was 86 (45-118). Age at seizure onset showed a logarithmic association with IQ, with maximum impact of seizures starting before age 1year, both in uni- and multivariate regression analyses. In the left SWS group (N=20), age at seizure onset was a strong predictor of nonverbal IQ (p=0.001); while early seizure onset in the right-hemispheric group had a more global effect on cognitive functions (p=0.02). High seizure frequency and long epilepsy duration also contributed to poor outcome IQ independently in multivariate correlations. Children with motor involvement started to have seizures at/before 7months of age, while frontal lobe involvement was the strongest predictor of motor deficit in a multivariate analysis (p=0.017). CONCLUSION These findings suggest that seizure onset prior to age 1year has a profound effect on severity of cognitive and motor dysfunction in children with SWS; however, the effect of seizures on the type of cognitive deficit is influenced by laterality of brain involvement.
Collapse
Affiliation(s)
- Aimee F Luat
- Departments of Pediatrics and Neurology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit Medical Center, 3901 Beaubien St., Detroit, MI 48201, USA.
| | - Michael E Behen
- Departments of Pediatrics and Neurology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit Medical Center, 3901 Beaubien St., Detroit, MI 48201, USA
| | - Harry T Chugani
- Departments of Pediatrics and Neurology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit Medical Center, 3901 Beaubien St., Detroit, MI 48201, USA; Department of Neurology, School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA; Division of Pediatric Neurology, Nemours A.I. DuPont Hospital for Children, 1600 Rockland Rd., Wilmington, Delaware, 19803, USA
| | - Csaba Juhász
- Departments of Pediatrics and Neurology, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit Medical Center, 3901 Beaubien St., Detroit, MI 48201, USA
| |
Collapse
|
21
|
Offermann EA, Sreenivasan A, DeJong MR, Lin DD, McCulloch CE, Chung MG, Comi AM. Reliability and Clinical Correlation of Transcranial Doppler Ultrasound in Sturge-Weber Syndrome. Pediatr Neurol 2017; 74:15-23.e5. [PMID: 28757309 PMCID: PMC5977390 DOI: 10.1016/j.pediatrneurol.2017.04.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/28/2017] [Accepted: 04/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The reproducibility of transcranial Doppler (TCD) ultrasound measurements in Sturge-Weber syndrome (SWS) and TCD's ability to predict neurological progression is unknown. METHODS In 14 individuals with SWS, TCD measured mean flow velocity, pulsatility index, peak systolic velocity, and end-diastolic velocity in the middle, posterior, and anterior cerebral arteries of the affected and unaffected hemisphere. TCD was performed either once (n = 5) or twice in one day (n = 9). We assessed the reproducibility of the measurements performed twice on the same day on subjects and compared the TCD measurements to previously published age-matched controls. Clinically obtained neuroimaging was scored for extent and severity of SWS brain involvement. Patients were prospectively assigned SWS neuroscores. RESULTS Middle cerebral artery velocity (r = 0.79, P = 0.04, n = 7), posterior cerebral artery velocity (r = 0.90, P = 0.04, n = 5), and anterior cerebral artery pulsatility index (r = 0.82, P = 0.02, n = 7) were reproducible TCD measurements comparing same-day percent side-to-side differences. In subjects with SWS, affected and unaffected mean peak systolic velocity and end-diastolic velocity in the middle, posterior, and anterior cerebral arteries were globally lower compared with age-matched control subjects. Subjects with the lowest affected middle cerebral artery velocity had the greatest worsening in the total neurological score between time 1 and 2 (r = -0.73, P = 0.04, n = 8) and the most severe magnetic resonance imaging involvement of the affected frontal lobe (r = -0.82, P = 0.007, n = 9). CONCLUSIONS TCD may be a reliable measure with potential clinical value, indicating that blood flow may be globally decreased in SWS patients with unilateral brain involvement.
Collapse
Affiliation(s)
- Elizabeth A. Offermann
- Department of Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, U.S.A
| | - Aditya Sreenivasan
- Department of Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, U.S.A
| | - M. Robert DeJong
- Department of Radiology and Radiological Science, Johns School of Medicine, Baltimore, MD, U.S.A
| | - Doris D.M. Lin
- Department of Radiology and Radiological Science, Johns School of Medicine, Baltimore, MD, U.S.A
| | - Charles E. McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, U.S.A
| | - Melissa G. Chung
- Divisions of Neurology and Critical Care Medicine, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, OH, U.S.A
| | - Anne M. Comi
- Department of Neurodevelopmental Medicine, Kennedy Krieger Institute, Baltimore, MD, U.S.A,Department of Neurology, Johns School of Medicine, Baltimore, MD, U.S.A,Department of Pediatrics, Johns School of Medicine, Baltimore, MD, U.S.A
| | | | | | | | | |
Collapse
|
22
|
Abstract
Sturge-Weber syndrome is the third most common neurocutaneous disorder, after neurofibromatosis and tuberous sclerosis, and impacts approximately 1 in 20000 live births. Sturge-Weber syndrome is not inherited, but rather occurs exclusively sporadically, in both males and females and in all races and ethnic backgrounds. Sturge-Weber syndrome presents at birth with a capillary malformation on the face (port-wine birthmark) with later diagnosis of abnormal vasculature in the eye and the brain which result in a range of complications. The underlying somatic mosaic mutation causing both Sturge-Weber syndrome and isolated port-wine birthmarks was recently discovered and is an activating mutation in GNAQ. When a newborn presents with a facial port-wine birthmark on the upper face, that child has a 15-50% risk of developing Sturge-Weber syndrome brain and/or eye involvement, depending on the extent of the birthmark, and close monitoring and appropriate screening is essential for early diagnosis and optimal treatment. Treatment options include laser therapy for lightening of the birthmark, eye drops and surgery for glaucoma management, and aggressive anticonvulsant treatment, low dose aspirin, and neurosurgery where necessary. Future possible treatments based upon new knowledge of the somatic mutation and downstream pathways are currently being considered and studied.
Collapse
|
23
|
Kaplan EH, Kossoff EH, Bachur CD, Gholston M, Hahn J, Widlus M, Comi AM. Anticonvulsant Efficacy in Sturge-Weber Syndrome. Pediatr Neurol 2016; 58:31-6. [PMID: 26997037 PMCID: PMC4943018 DOI: 10.1016/j.pediatrneurol.2015.10.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 10/31/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We analyzed individuals with epilepsy due to Sturge-Weber syndrome to determine which anticonvulsants provided optimal seizure control and which resulted in the fewest side effects. METHODS One-hundred-eight records from a single center were retrospectively analyzed for Sturge-Weber syndrome brain involvement, epilepsy, Sturge-Weber syndrome neuroscores, and currently used anticonvulsants. RESULTS Of the fourteen anticonvulsants that had been employed, the most often used agents were oxcarbazepine or carbamazepine, and levetiracetam. Individuals whose seizures at the most recent visit were fully controlled (seizure-free) for 6 months or longer were more likely to have ever tried, or currently used, oxcarbazepine or carbamazepine than those with uncontrolled seizures. Thirty-nine of 69 individuals (56.5%) were seizure-free with oxcarbazepine or carbamazepine history versus 11 of 35 individuals (31.4%) who had not taken these agents (P < 0.05); 38 of 62 patients (61.3%) were seizure-free while currently taking these anticonvulsants versus 12 of 42 (28.6%) not taking them (P < 0.01). Patients with seizure control for 6 months or longer were less likely to have ever tried, or to currently be taking, levetiracetam than those without control. Sixteen of 56 individuals (28.6%) were seizure-free with levetiracetam history versus 34 of 48 (70.8%) without it (P < 0.001); 14 of 43 individuals (32.6%) were seizure-free and currently taking levetiracetam versus 36 of 61 (59.0%) not taking it (P < 0.01). When topiramate was added as second-line medication, five of nine patients (55.6%) experienced decreased seizure severity, and worsening of glaucoma was not reported. CONCLUSIONS Carbamazepine and oxcarbazepine were associated with better seizure control than levetiracetam in this Sturge-Weber syndrome cohort and so may be preferred as the initial therapy. When used as adjunctive therapy, topiramate was effective in this limited analysis without a clear increased incidence of glaucoma.
Collapse
Affiliation(s)
- Emma H. Kaplan
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Eric H. Kossoff
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland,Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Milton Gholston
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Jihoon Hahn
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Matthew Widlus
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland
| | - Anne M. Comi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland,Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland,Communications should be addressed to: Dr. Comi; Department of Neurology; Kennedy Krieger Institute; 801 North Broadway; Baltimore, MD 21205.
| |
Collapse
|
24
|
Abstract
Epilepsy is a major morbidity in Sturge Weber syndrome, a segmental vascular neurocutaneous disorder classically associated with facial angiomas, glaucoma, and leptomeningeal capillary-venous type vascular malformations. The extent of the latter correlates with neurological outcome. Post-zygotic mosaicism for the activating mutation p.R183Q of the
GNAQ gene has been identified as the major cause.
GNAQ encodes for an alpha subunit of a heterotrimeric G protein critical to blood vessel development. The earlier the timing of the mutation in development, the more severe the involvement, e.g. from isolated port-wine stains to the full syndrome. The strongest predictors of adverse outcomes are MRI and the presence of angiomas involving any part of the forehead, delineated inferiorly from the outer canthus of the eye to the top of the ear, and including the upper eyelid. The neurological course may be progressive and the typical constellation of symptoms is focal onset seizures, hemiparesis, headache, stroke-like episodes, behavior problems, intellectual disability, and visual field deficits. Antiseizure medications are effective in about half of patients. The presence of localized seizures, focal neurological deficits, and drug resistant epilepsy indicate epilepsy surgical evaluation. Earlier seizure onset, i.e. before six months of age, is associated with a more severe course with significant residual deficits. Factors contributing to epileptogenesis include decreased brain tissue perfusion due to abnormal venous drainage, anoxic injury contributing to cerebral calcification, breakdown of the blood-brain barrier, and the presence of developmental cortical malformations. Pre-symptomatic prophylactic treatment may be a future option to modify the course of the disease including the associated epileptogenesis.
Collapse
Affiliation(s)
- Anna Pinto
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Neurology, Dartmouth Hitchcock, Manchester, New Hampshire, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Epilepsy, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Abstract
Neurocutaneous syndromes (or phakomatoses) are a diverse group of congenital disorders that encompass abnormalities of neuroectodermal and, sometimes, mesodermal development, hence commonly involving the skin, eye, and central nervous system. These are often inherited conditions and typically present in early childhood or adolescence. Some of the abnormalities and clinical symptoms may, however, be progressive, and there is an increased risk of neoplastic formation in many of the syndromes. As a group, neurocutaneous syndromes are characterized by distinctive cutaneous stigmata and neurologic symptomology, the latter often representing the most devastating and debilitating features of these diseases. Many of these syndromes are markedly heterogeneous in nature as they affect many organ systems. Given the incurable nature of these conditions and the broad spectrum of pathologies they comprise, treatments vary on a case-by-case basis and tend to be palliative rather than curative. With the advances in molecular genetics, however, greater understanding of biologic functions of the gene products and the correlative phenotypic expression is being attained, and this knowledge may guide future therapeutic developments. This chapter focuses on the cutaneous and neurologic pathology with emphasis on neuroimaging of selective neurocutaneous syndromes, including tuberous sclerosis, Sturge-Weber syndrome, Klippel-Trenaunay syndrome, ataxia-telangiectasia, and incontinentia pigmenti.
Collapse
Affiliation(s)
- Nitasha Klar
- Division of Neuroradiology, Russell H. Morgan Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bernard Cohen
- Departments of Dermatology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Doris D M Lin
- Division of Neuroradiology, Russell H. Morgan Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
26
|
Reidy TG, Suskauer SJ, Bachur CD, McCulloch CE, Comi AM. Preliminary reliability and validity of a battery for assessing functional skills in children with Sturge-Weber syndrome. Childs Nerv Syst 2014; 30:2027-36. [PMID: 25344741 PMCID: PMC4276129 DOI: 10.1007/s00381-014-2573-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/10/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate inter-rater reliability and validity of a proposed functional outcome battery for clinical trials in children with Sturge-Weber syndrome (SWS). METHODS Ten children were evaluated twice on the same day using a series of functional outcome measures selected for sensitivity to the range of age and function of children with SWS: Modified Rankin Scale, Pediatric Evaluation of Disability Index, Modified House Functional Classification, and a modified version of the Erhardt Developmental Prehension Assessment. Inter-rater reliability was calculated, and criterion validity was explored through correlations with the Sturge-Weber Syndrome-Neurological Rating Score (SWS-NRS). RESULTS Inter-rater reliability was high across all measures. Correlations were identified between the SWS-NRS and the study measures. CONCLUSIONS The proposed battery of functional outcome measures captures child's functioning at the levels of impairment, activity and participation and is robust to evaluation by different raters and across sessions on the same day. This battery is expected to be sensitive to treatment-related changes in qualitative patterns of hand use, functional skills, and/or change in independence in daily living.
Collapse
Affiliation(s)
| | - Stacy J. Suskauer
- Kennedy Krieger Institute; 707 North Broadway, Baltimore, MD 21205, USA,Johns Hopkins University School of Medicine, Departments of Physical Medicine and Rehabilitation and Pediatrics
| | - Cathy D. Bachur
- Kennedy Krieger Institute; 707 North Broadway, Baltimore, MD 21205, USA
| | - Charles E. McCulloch
- University of California San Francisco School of Medicine, Division of Biostatistics; UCSF Box 0560, San Francisco, CA 94107-1762, USA
| | - Anne M. Comi
- Kennedy Krieger Institute; 707 North Broadway, Baltimore, MD 21205, USA,Johns Hopkins University School of Medicine, Departments of Neurology and Pediatrics
| |
Collapse
|
27
|
Kossoff EH, Bachur CD, Quain AM, Ewen JB, Comi AM. EEG evolution in Sturge-Weber syndrome. Epilepsy Res 2014; 108:816-9. [PMID: 24560844 DOI: 10.1016/j.eplepsyres.2014.01.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 01/17/2014] [Accepted: 01/25/2014] [Indexed: 11/28/2022]
Abstract
The EEG in Sturge-Weber syndrome (SWS) was theorized over 50 years ago as changing over time from normality to focal asymmetry to lastly epileptiform. We sought to validate these findings in a larger cohort today. Children with confirmed SWS and routine EEG at our center were evaluated retrospectively. An EEG score (0-3) was created and linked to patient current age, overall neurologic function, and seizure frequency. Eighty-one EEGs from 44 patients with SWS (mean age 2.0 years (range: 0.2-37.9 years)) were evaluated and assigned an EEG score. The mean age for patients with an EEG score of 0-1 (normal or focal slowing) was 3.2 years (SEM 0.6), whereas those with an EEG score of 2-3 (focal sharp waves or frequent spike-wave bursts) was 8.7 years (SEM 1.7) (p=0.006). There was no correlation between the EEG score and either the SWS overall neuroscore or seizure subscore (measuring frequency). The EEG in patients with SWS does appear to evolve over time, becoming more abnormal with more frequent epileptiform activity, as suspected in smaller studies decades ago. This progressive change, however, did not correlate with the child's neurologic function or seizure frequency.
Collapse
|
28
|
Comi AM. Sturge–Weber syndrome and epilepsy: an argument for aggressive seizure management in these patients. Expert Rev Neurother 2014; 7:951-6. [PMID: 17678489 DOI: 10.1586/14737175.7.8.951] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sturge-Weber syndrome (SWS) involves vascular malformations of the skin (facial port-wine stain), eye (glaucoma) and the brain (leptomeningeal angioma). Children born with a port-wine stain on the upper part of the face are also at risk for brain involvement. These infants and young children often develop seizures and other neurologic impairments. Progression in neurologic deficits does occur in some patients, but this is quite variable. A diagnosis of brain involvement is made with head computed tomography and contrast-enhanced MRI, but the sensitivity of standard imaging in young asymptomatic infants is low. Seizures occur in more than 75% of affected individuals. Clinical course and functional imaging suggest a role for both cerebral perfusion impairments and seizures in the development of neurologic deficits. Several controversies exist in the management of seizures and other neurologic impairments in SWS. Continued efforts are needed to develop a multicentered network for SWS clinical trials. Future research should be focused on this goal and on studies to improve our understanding of the cause(s) and molecular neuropathology of SWS.
Collapse
Affiliation(s)
- Anne M Comi
- Department of Neurology, Kennedy Krieger Institute & Johns Hopkins Medicine, Baltimore, MD, USA.
| |
Collapse
|
29
|
Sharma A, Zipfel GJ, Hildebolt C, Derdeyn CP. Hemodynamic effects of developmental venous anomalies with and without cavernous malformations. AJNR Am J Neuroradiol 2013; 34:1746-51. [PMID: 23598827 DOI: 10.3174/ajnr.a3516] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Association between developmental venous anomalies is well known, but remains unexplained. Our aim was to study possible hemodynamic differences around developmental venous anomalies with and without cavernous malformations. MATERIALS AND METHODS In this prospective study approved by the institutional review board, PWI was performed in 24 patients with 25 DVAs (10 with and 15 without CMs) who consented to participate. We calculated relative cerebral blood volume, relative cerebral blood flow, and relative mean transit time for the brain surrounding the DVA tributaries in reference to contralateral mirror image locations. Corresponding control values (cCBV, cCBF, and cMTT) were generated in a similar fashion for remote ipsilateral regions with normal venous drainage, also in reference to contralateral mirror image locations. Perfusion parameters for DVAs and control regions were tested for differences between groups with the t test for independent or paired samples (or the nonparametric equivalents). Similar testing was done for perfusion parameters for DVAs with and without CMs. RESULTS Normal-appearing brain surrounding DVAs showed increased rCBV (median = 2.98; range = 1.39-6.61), increased rCBF (median = 2.00, range = 0.79-4.43), and increased rMTT (mean = 1.46; 95% confidence interval, 1.32-1.59). These were significantly higher than median cCBV (0.99; 95% confidence interval, 0.89-1.06; P < .01), median cCBF (1.00; 95% confidence interval, 0.94-1.27; P < .01), and mean cMTT (1.00; 95% confidence interval, 0.98-1.02; P < .01), respectively. Mean rMTT (1.70; 95% confidence interval, 1.46-1.93) for DVAs with CMs was higher than mean rMTT (1.29; 95% confidence interval, 1.19-1.40; P < .01) for DVAs without CMs. CONCLUSIONS DVAs are strongly associated with altered hemodynamics. Significant differences in these hemodynamic alterations for DVAs with and without CMs suggest their possible role in the formation of CMs.
Collapse
Affiliation(s)
- A Sharma
- Mallinckrodt Institute of Radiology
| | | | | | | |
Collapse
|
30
|
Uduma FU, Emejulu JKC, Motah M, Okere PCN, Ongolo PC, Muna W. Differential diagnoses of cerebral hemiatrophy in childhood: a review of literature with illustrative report of two cases. Glob J Health Sci 2013; 5:195-207. [PMID: 23618490 PMCID: PMC4776813 DOI: 10.5539/gjhs.v5n3p195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 12/20/2012] [Indexed: 12/28/2022] Open
Abstract
Childhood cerebral hemiatrophy is an uncommon clinical entity. Its aetiologies are diverse but can generally be grouped into congenital and acquired. The congenital type is intrauterine in origin while the acquired type occurs early in life, usually before two year of life. When childhood cerebral hemiatrophy occurs, it evokes a spectrum of compensatory calvarial sequlae. These include ipsilateral calvarial thickening, diploe widening, hyper-pneumatization of paranasal sinues/ mastoids, elevation of petrous bone and small middle cranial fossa. MRI is very effective in high lightening brain atrophy, associated parenchymal changes and even the above enumerated skull changes. Our two case reports of left hemi-cerebral atrophy in male Cameroonian children seen in our MRI practice aptly demonstrated some of the aforementioned radiological features of childhood cerebral hemiatrophy noted in literature review.
Collapse
Affiliation(s)
- Felix Uduma Uduma
- Department of Radiology, Faaculty of Clinical Sciences, University of Uyo, Nigeria.
| | | | | | | | | | | |
Collapse
|
31
|
Abstract
Sturge-Weber syndrome (SWS) is a rare sporadic neurocutaneous syndrome defined by the association of a facial capillary malformation in the ophthalmic distribution of the trigeminal nerve, with ipsilateral vascular glaucoma and vascular malformation of the eye, and a leptomeningeal angioma. SWS is suspected at birth in the presence of facial angioma in the trigeminal nerve area. MRI with gadolinium enhancement and pondered T1, T2, FLAIR and diffusion sequences is today the technique of choice to visualize the leptomeningeal angioma or to suspect it by indirect signs, even before the development of neurological signs, from the first months of life. The prognosis of SWS with leptomeningeal angioma is related to the severity of neurological signs that are absent at birth and develop later in life (epilepsy, hemiparesis, and mental delay). Seizures are usually the presenting neurological symptom. Status epilepticus might inaugurate the epilepsy and remains frequent in infancy. Repetitive seizures are thought to increase the atrophy of brain tissue in regard to the leptomeningeal angioma. Preventive presymptomatic treatment with antiepileptic drugs is often recommended, and parents are trained to use rescue benzodiazepines in case of seizures. After epilepsy onset, in patients intractable to antiepileptic drugs, surgery should be considered.
Collapse
Affiliation(s)
- R Nabbout
- Department of Pediatric Neurology, Hôpital Necker-Enfants Malades; Centre de référence épilepsies rares; INSERM U663, Paris, France
| | | |
Collapse
|
32
|
A perfusion-metabolic mismatch in Sturge-Weber syndrome: a multimodality imaging study. Brain Dev 2012; 34:553-62. [PMID: 22075184 PMCID: PMC3288211 DOI: 10.1016/j.braindev.2011.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 09/29/2011] [Accepted: 10/13/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We combined perfusion weighted imaging (PWI) with 2-deoxy-2[(18)F]fluoro-D-glucose (FDG) positron emission tomography (PET) to study the relationship between regional metabolic and perfusion abnormalities and their clinical correlates in children with Sturge-Weber syndrome (SWS). METHODS Fifteen children (age: 0.9-10 years) with unilateral SWS underwent high-resolution PWI and FDG PET prospectively. Regional (lobar) asymmetry indices (AIs) of subcortical white matter (WM) cerebral blood flow (CBF) were correlated with corresponding cortical FDG uptake asymmetries, extent of leptomeningeal vascular malformation and clinical seizure variables. RESULTS Abnormal cortical glucose metabolism and/or subcortical WM CBF were seen in all lobes affected by vascular malformation and extended to lobes not affected by abnormal pial vessels in 6 patients. Lower CBF was associated with lower cortical glucose metabolism in the temporal, parietal and occipital lobes (p≤0.02). While decreased perfusion was associated with hypometabolism in most cases, increased regional CBF (found in 6 patients) was commonly associated with relatively mild or no hypometabolism. Ten of 24 cerebral lobes with normal glucose metabolism in the affected hemisphere showed abnormal perfusion. High seizure frequency was associated with severe parieto-occipital hypoperfusion (p≤0.03), while long duration of epilepsy was related to frontal lobe hypometabolism (p=0.015). CONCLUSIONS Regional perfusion and cortical metabolic abnormalities can extend beyond lobes affected by leptomeningeal vascular malformations and are related to epilepsy in SWS. Despite a general correlation between perfusion and metabolism, increased WM perfusion with preserved cortical metabolism in overlying cortex is a common pattern of a perfusion/metabolic mismatch. This may represent a disease stage where cortical function is preserved while increased WM perfusion provides collateral drainage of cortex via the deep vein system.
Collapse
|
33
|
Lo W, Marchuk DA, Ball KL, Juhász C, Jordan LC, Ewen JB, Comi A. Updates and future horizons on the understanding, diagnosis, and treatment of Sturge-Weber syndrome brain involvement. Dev Med Child Neurol 2012; 54:214-23. [PMID: 22191476 PMCID: PMC3805257 DOI: 10.1111/j.1469-8749.2011.04169.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To review recent developments in the understanding, diagnosis, and treatment of Sturge-Weber syndrome (SWS). METHOD Members of the Brain Vascular Malformation Consortium Sturge-Weber Syndrome National Workgroup contributed their expertise to review the literature and present promising directions for research. RESULTS The increasing number of reports dealing with SWS over the last decade reflects progress in the diagnosis and understanding of the neurological involvement. The proliferation of centers and advocacy groups to care for patients with SWS and to stimulate research has aided the development of new insights into the clinical manifestations and the pathophysiology of neurological progression, and the development of novel hypotheses to direct future research. Many key questions remain, but the tools and networks to answer them are being developed. INTERPRETATION This review summarizes important new knowledge and presents new research directions that are likely to provide further insights, earlier diagnosis, improved treatments, and possibly, prevention of this syndrome.
Collapse
Affiliation(s)
- Warren Lo
- Departments of Pediatrics and Neurology, Nationwide Children’s Hospital, Columbus, OH
| | - Douglas A. Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham NC
| | | | - Csaba Juhász
- Departments of Pediatrics and Neurology Wayne State University of Medicine, Detroit, MI
| | - Lori C. Jordan
- Department of Neurology and Pediatrics, Vanderbilt University, Nashville, TN
| | - Joshua B. Ewen
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute Hugo Moser Research Institute, Baltimore MD, USA
| | - Anne Comi
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute Hugo Moser Research Institute, Baltimore MD, USA
| | | |
Collapse
|
34
|
Abstract
With a major role in revealing epileptogenic lesions, magnetic resonance imaging (MRI) has also been very helpful in surgical planning and postoperative follow-up of drug-resistant focal epilepsies. In this article, in addition to discussing the most common epileptogenic lesions, advanced quantitative and functional MRI techniques in detecting abnormalities and revealing hemodynamic and microstructural changes are emphasized.
Collapse
|
35
|
Affiliation(s)
- Gerhard Kurlemann
- Neuropediatric Department, University Hospital Munster, Munster, Germany.
| |
Collapse
|
36
|
Wu J, Tarabishy B, Hu J, Miao Y, Cai Z, Xuan Y, Behen M, Li M, Ye Y, Shoskey R, Haacke EM, Juhász C. Cortical calcification in Sturge-Weber Syndrome on MRI-SWI: relation to brain perfusion status and seizure severity. J Magn Reson Imaging 2011; 34:791-8. [PMID: 21769978 DOI: 10.1002/jmri.22687] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 05/23/2011] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To determine the relationship between calcified cortex and perfusion status of white matter and seizure severity in patients with Sturge-Weber Syndrome (SWS), a sporadic neurocutaneous disorder characterized by a leptomeningeal angioma, progressive brain ischemia, and a high incidence of seizures using susceptibility weighted imaging (SWI) and dynamic susceptibility contrast-enhanced perfusion weighted imaging (DSC-PWI). MATERIALS AND METHODS Fifteen children (ages: 0.9-10 years) with unilateral SWS prospectively underwent magnetic resonance imaging (MRI). The degree of cortical calcification was assessed using SWI while perfusion status was quantified using DSC-PWI images (asymmetries of various perfusion parameters). Comparisons between calcification, perfusion status, and seizure variables were performed. RESULTS Patients with severely calcified cortex demonstrated significantly lower perfusion in the ipsilateral white matter (mean asymmetry: -0.52 ± 0.22) as compared to patients with only mildly calcified cortex or no calcification (mean asymmetry: 0.08 ± 0.25). Patients with severely calcified cortex also suffered from a higher seizure burden (a composite measure of seizure frequency and epilepsy duration; P = 0.01) and a trend for earlier seizure onset and longer epilepsy duration. CONCLUSION Severe calcification in the affected hemisphere is related to severely decreased perfusion in underlying white matter and is associated with more severe epilepsy in SWS patients.
Collapse
Affiliation(s)
- Jianlin Wu
- Affiliated Zhongshan Hospital of Dalian University, Department of Radiology, Dalian, Liaoning, China
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Miao Y, Juhász C, Wu J, Tarabishy B, Lang Z, Behen ME, Kou Z, Ye Y, Chugani HT, Hu J. Clinical correlates of white matter blood flow perfusion changes in Sturge-Weber syndrome: a dynamic MR perfusion-weighted imaging study. AJNR Am J Neuroradiol 2011; 32:1280-5. [PMID: 21724573 DOI: 10.3174/ajnr.a2540] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND PURPOSE Low brain tissue perfusion due to abnormal venous drainage is thought to be a central mechanism of brain damage in SWS. Here, HR-PWI was used to quantify WM perfusion abnormalities and to correlate these with brain atrophy and clinical variables. MATERIALS AND METHODS Fourteen children (age range, 0.8-10.0 years) with unilateral SWS underwent MR imaging examinations, including HR-PWI. rCBV, rCBF, and MTT in the affected WM and in contralateral homotopic WM were measured. AI for each perfusion parameter was correlated with age, brain atrophy, and motor and seizure variables as well as IQ. RESULTS Increased perfusion was seen in the affected hemisphere in 5 children and decreased perfusion in 9 children. Brain atrophy was more severe in the low-perfusion group (P = .01) and was related to both CBF-AI and CBV-AI (r = -0.69, P = .007; r = -0.64, P = .014, respectively). Older children had lower CBV values on the affected side (r = -0.62, P = .02). Longer duration of epilepsy was related to lower CBF (more negative CBF-AI, r = -0.58, P = .03) and low CBV (r = -0.55, P = .04) on the affected side. Lower perfusion was associated with more frequent seizures (rCBF-AI: r = -0.56, P = .04; rCBV-AI: r = -0.63, P = .02). CONCLUSIONS Increased perfusion in the affected cerebral WM may indicate an early stage of SWS without severe brain atrophy. Decreased perfusion is associated with frequent seizures, long duration of epilepsy, and brain atrophy.
Collapse
Affiliation(s)
- Y Miao
- Department of Radiology, First Affiliated Hospital, Dalian Medical University, Dalian, Liaoning, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Alkonyi B, Chugani HT, Muzik O, Chugani DC, Sundaram SK, Kupsky WJ, Batista CE, Juhász C. Increased L-[1-11 C] leucine uptake in the leptomeningeal angioma of sturge-weber syndrome: a PET study. J Neuroimaging 2011; 22:177-83. [PMID: 21223431 DOI: 10.1111/j.1552-6569.2010.00565.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE We used L-[1-(11) C]leucine (LEU) positron emission tomography (PET) to measure amino acid uptake in children with Sturge-Weber syndrome (SWS), and to relate amino acid uptake measures with glucose metabolism. METHODS LEU and 2-deoxy-2[(18) F]fluoro-D-glucose (FDG) PET were performed in 7 children (age: 5 months-13 years) with unilateral SWS. Asymmetries of LEU uptake in the posterior brain region, underlying the angioma and in frontal cortex, were measured and correlated with glucose hypometabolism. Kinetic analysis of LEU uptake was performed in 4 patients. RESULTS Increased LEU standard uptake value (SUV, mean: 15.1%) was found in the angioma region in 6 patients, and smaller increases in LEU SUV (11.5%) were seen in frontal cortex in 4 of the 6 patients, despite normal glucose metabolism in frontal regions. High LEU SUV was due to both increased tracer transport (3/4 patients) and high protein synthesis rates (2/4). FDG SUV asymmetries in the angioma region were inversely related to LEU SUV asymmetries (r=-.83, P= .042). CONCLUSIONS Increased amino acid uptake in the angioma region and also in less affected frontal regions may provide a marker of pathological mechanisms contributing to chronic brain damage in children with SWS.
Collapse
Affiliation(s)
- Bálint Alkonyi
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
Sturge-Weber syndrome (SWS) is characterized by seizures, port-wine birthmarks, vascular malformations, and rarely studied psychobehavioral features. This study describes a small group of outpatients (N = 16, age, 3-34 years) with Sturge-Weber syndrome seeking medical services (due to seizures, ophthalmological, and dermatological problems among others). The patients were screened for psychiatric diagnoses. The most frequent diagnoses were mood disorder (31%), disruptive behavior disorder (25%), and adjustment disorder (25%). A substance-related disorder was the most frequent in adults (67%). A significant association was found between disruptive behavior disorder not otherwise specified and more left frontal and left parietal involvement. A trend toward significant association of having a seizure in the past 3 months with disruptive behavior disorder not otherwise specified was observed. Problems with mood, attention, sleep, learning, and substance use were common. Disruptive behavior disorders and their association with medical conditions should be further investigated.
Collapse
|
40
|
Hellwig S, Keuler A, Mader I, Amtage F. Hemispheral brain atrophy without leptomeningeal malformation in an adult with neurocutaneous overlap syndrome. J Neuroradiol 2010; 38:195-6. [PMID: 20952065 DOI: 10.1016/j.neurad.2010.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Revised: 07/08/2010] [Accepted: 07/12/2010] [Indexed: 11/28/2022]
|
41
|
Abstract
Sturge-Weber syndrome is a rare neurocutaneous disorder that often results in functional impairment caused by motor (typically hemiparesis) and cognitive deficits. A retrospective chart review of physiatric evaluation of 30 individuals, aged 4 mos to 55 yrs (median age, 2.4 yrs), with Sturge-Weber syndrome with brain involvement was conducted for the purpose of summarizing physiatric findings and recommendations in this cohort. Presence or absence of motor, cognitive, and behavioral concerns and need for orthoses, spasticity management, and therapy services were noted. Hemiparesis was common, but the need for intervention for spasticity was rare. Cognitive and behavioral concerns were noted frequently, meriting additional evaluation. Case vignettes are presented to highlight (1) a child with repeated functional setbacks in association with increased seizure frequency who, with seizure control, demonstrated return to functional baseline and subsequent further skill development and (2) a child with Sturge-Weber syndrome who made functional gains with constraint-induced movement therapy.
Collapse
|
42
|
Freilinger T, Peters N, Rémi J, Linn J, Hacker M, Straube A, Pfefferkorn T. A case of Sturge-Weber syndrome with symptomatic hemiplegic migraine: clinical and multimodality imaging data during a prolonged attack. J Neurol Sci 2009; 287:271-4. [PMID: 19733861 DOI: 10.1016/j.jns.2009.08.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 08/11/2009] [Accepted: 08/17/2009] [Indexed: 10/20/2022]
Abstract
Hemiplegic migraine (HM) in the setting of Sturge-Weber syndrome (SWS) has been previously described. Here, we report clinical and multimodal imaging data on a 21-year-old man with SWS and HM, who presented during an acute HM attack with a dense left-hemispheric syndrome (expressive aphasia and right sensorimotor hemiplegia), lasting for more than 10 days. Repeated EEGs were without evidence of status epilepticus. Consistent with previous findings in prolonged migraine aura, perfusion computed tomography demonstrated left-hemispheric hyperperfusion on day 7. 18F-FDG positron emission tomography (day 7) revealed left-hemispheric hypermetabolism. After 14 days, the patient was symptom-free and discharged home. Follow-up after 30 days showed normal neurological status. Our observation confirms and reinforces the comorbidity of SWS and HM and shows that prolonged HM attacks are associated with complex changes of both cerebral perfusion and glucose metabolism. A pathophysiological model explaining both the association between SWS/HM and the observed imaging changes is presented.
Collapse
Affiliation(s)
- Tobias Freilinger
- Department of Neurology, Ludwig-Maximilians-University, Munich, Germany.
| | | | | | | | | | | | | |
Collapse
|
43
|
Batista CEA, Chugani HT, Hu J, Haacke EM, Behen ME, Helder EJ, Juhász C. Magnetic resonance spectroscopic imaging detects abnormalities in normal-appearing frontal lobe of patients with Sturge-Weber syndrome. J Neuroimaging 2009; 18:306-13. [PMID: 18808656 DOI: 10.1111/j.1552-6569.2007.00207.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In Sturge-Weber syndrome (SWS), structural MRI abnormalities are most common in the posterior brain regions. Frontal lobe involvement increases the risk of motor impairment. The goal of this study was to determine whether Magnetic Resonance Spectroscopic Imaging (MRSI) can improve detection of frontal lobe involvement in children with SWS. METHODS Sixteen children (age: .9-10.4 years) with unilateral SWS underwent MRI with MRSI prospectively. N-acetyl-aspartate (NAA) and choline asymmetries in the posterior and frontal regions were measured. RESULTS Eight children presented normal-appearing frontal lobes on conventional MRI, but 7 of them showed abnormal NAA and/or choline content in the frontal lobe of the affected hemisphere. Lower frontal lobe gray matter NAA was associated with earlier onset of seizures (r= .76; P= .04) and impaired motor function (r=-.89, P < .001). Frontal NAA asymmetry was an independent predictor of motor function in a regression analysis (P= .01) CONCLUSION MRSI is more sensitive than conventional structural MRI for detection of frontal lobe involvement in SWS. Decreased frontal lobe NAA is an excellent predictor of motor functions. Thus, MRSI can provide complementary information for the assessment of normal-appearing brain regions, and may assist prognosis evaluation in children with SWS.
Collapse
Affiliation(s)
- Carlos E A Batista
- Department of Pediatrics, Radiology, Wayne State University, Detroit, Michigan, USA
| | | | | | | | | | | | | |
Collapse
|
44
|
Hu J, Yu Y, Juhasz C, Kou Z, Xuan Y, Latif Z, Kudo K, Chugani HT, Haacke EM. MR susceptibility weighted imaging (SWI) complements conventional contrast enhanced T1 weighted MRI in characterizing brain abnormalities of Sturge-Weber Syndrome. J Magn Reson Imaging 2008; 28:300-7. [PMID: 18666142 DOI: 10.1002/jmri.21435] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the efficacy of susceptibility weighted imaging (SWI) in comparison to standard T1 weighted postgadolinium contrast (T1-Gd) MRI in patients with Sturge-Weber Syndrome (SWS). MATERIALS AND METHODS Twelve children (mean age, 5.6 years) with the diagnosis of SWS and unilateral hemispheric involvement were recruited prospectively and examined with high resolution three dimensional SWI and conventional T1-Gd. Both SWI and T1-Gd images were evaluated using a four-grade scoring system according to six types of imaging findings (enlargement of transmedullary veins, periventricular veins, and choroid plexus, as well as leptomeningeal abnormality, cortical gyriform abnormality, and gray matter/white matter junctional abnormality). The scores of SWI versus T1-Gd images were then compared for each type of abnormality. RESULTS SWI was superior to T1-Gd in identifying the enlarged transmedullary veins (P = 0.0020), abnormal periventricular veins (P = 0.0078), cortical gyriform abnormalities (P = 0.0020), and gray matter/white matter junction abnormalities (P = 0.0078). Conversely, T1-Gd was better than SWI in identifying enlarged choroid plexus (P = 0.0050) and leptomeningeal abnormalities (P = 0.0050). CONCLUSION SWI can provide useful and unique information complementary to conventional contrast enhanced T1 weighted MRI for characterizing SWS. Therefore, SWI should be integrated into routine clinical MRI protocols for suspected SWS.
Collapse
Affiliation(s)
- Jiani Hu
- Department of Radiology, Wayne State University, Detroit, Michigan 48201, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Comi AM. Update on Sturge-Weber syndrome: diagnosis, treatment, quantitative measures, and controversies. Lymphat Res Biol 2008; 5:257-64. [PMID: 18370916 DOI: 10.1089/lrb.2007.1016] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Sturge-Weber syndrome (SWS) is defined by the association of a facial capillary malformation (port-wine stain), with a vascular malformation of the eye, and/or vascular malformation of the brain (leptomeningeal angioma). Variants exist where only one of these three structures is involved with the vascular malformation. SWS occurs sporadically and is congenital. Port-wine stains occur in 3 per 1000 live births. No good population-based data exist for how many people have Sturge-Weber syndrome, however, estimates range between one in 20-50,000 live births. This review summarizes literature regarding the main features and pathophysiology of Sturge-Weber syndrome, however the cause of this syndrome remains obscure. Recent advances in neuroimaging have provided important insights into the progression of neurologic injury that occurs as a result of impaired blood flow. Important limitations exist, however, as currently the early diagnosis and exclusion of Sturge-Weber syndrome is impaired by the poor sensitivity of imaging in the newborn period and early infancy. Several important controversies complicate our ability to care for these patients and include the questions of ideal timing of surgery, whether seizures themselves contribute to the neurologic injury, and what the role of low-dose aspirin should be. This review will summarize several recent advances in our understanding of the mechanisms of brain injury in SWS, new measures for quantifying the neurologic involvement and new approaches and controversies in the management of the neurologic complications.
Collapse
Affiliation(s)
- Anne M Comi
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Department of Neurology and Pediatrics, Johns Hopkins School of Medicine; Baltimore, MD 21205, USA.
| |
Collapse
|
46
|
Jordan LC, Wityk RJ, Dowling MM, DeJong MR, Comi AM. Transcranial Doppler ultrasound in children with Sturge-Weber syndrome. J Child Neurol 2008; 23:137-43. [PMID: 18056693 DOI: 10.1177/0883073807307079] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transcranial Doppler ultrasound is a noninvasive vascular assessment technique proved useful in the management of pediatric disorders predisposed to stroke and may have similar utility for Sturge-Weber syndrome. Eight children with Sturge-Weber syndrome had velocities measured in the major cerebral arteries via the Stroke Prevention Trial in Sickle Cell Anemia methodology. Velocities and pulsatility indexes were compared between the unaffected and affected sides. All subjects had reduced velocity on the affected side; the mean middle cerebral artery percentage difference was 20% (95% CI, 15%-25%). Pulsatility index was increased on the affected side; mean middle cerebral artery pulsatility index percentage difference, 34% (95% CI, 15%-53%). Six subjects also had reduced posterior cerebral artery velocity on the affected side. Side-to-side differences in middle cerebral artery and posterior cerebral artery velocities correlated with severity of MRI asymmetry (Spearman rho = 0.88, P = .02). Decreased arterial flow velocity and increased pulsatility index in the middle cerebral artery and posterior cerebral artery suggests a high resistance pattern that may reflect venous stasis and may contribute to chronic hypoperfusion of brain tissue. Further study of Transcranial Doppler in children with Sturge-Weber syndrome is indicated.
Collapse
Affiliation(s)
- Lori C Jordan
- Department of Neurology, The Johns Hopkins University School of Medicine, USA
| | | | | | | | | |
Collapse
|
47
|
Moritani T, Kim J, Sato Y, Bonthius D, Smoker WR. Abnormal hypermyelination in a neonate with Sturge-Weber syndrome demonstrated on diffusion-tensor imaging. J Magn Reson Imaging 2008; 27:617-20. [DOI: 10.1002/jmri.21248] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
48
|
Yu TW, Liu HM, Lee WT. The correlation between motor impairment and cerebral blood flow in Sturge-Weber syndrome. Eur J Paediatr Neurol 2007; 11:96-103. [PMID: 17317246 DOI: 10.1016/j.ejpn.2006.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2006] [Revised: 10/03/2006] [Accepted: 11/20/2006] [Indexed: 11/24/2022]
Abstract
Recent studies of regional cerebral blood flow (rCBF) and cerebral metabolism in patients with Sturge-Weber syndrome (SWS) have demonstrated a regional decrease of CBF and metabolism in the affected hemisphere, which may reflect the neurological status of the patients. Therefore, in the present study, we use stable xenon computed tomography (xenon-CT) and/or (99m)technetium hexamethylprophylene amine oxime ((99mTc)HMPAO) single photon emission computed tomography (SPECT) to determine whether the degree of cerebral hemodynamic disturbance correlates with the severity of motor impairment in 5 children with Sturge-Weber syndrome. We found that 5 patients had great variation in clinical progression and outcome, but MR imaging investigations all revealed extensive but stable abnormalities. rCBF, assessed by stable xenon-CT and/or (99mTc)HMPAO-SPECT, showed perfusion defect in all subjects. However, the xenon-CT disclosed reduction of rCBF and cerebrovascular reactivity in patients with severe motor paralysis. The total CBF and rCBF detected by xenon-CT were improved after clinical status was stabilized. We conclude that the motor function impairment in patients with SWS appeared to better correlate with the degree of rCBF impairment than with the abnormalities in conventional neuroimaging. Therefore, the quantitative CBF study is one of the diagnostic modality of choice in evaluating the neurological status in patients with SWS.
Collapse
Affiliation(s)
- Tsui-Wen Yu
- Department of Pediatrics, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | | | | |
Collapse
|