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Sriram N, Holla VV, Kumari R, Kamble N, Saini J, Mahale R, Netravathi M, Padmanabha H, Gowda VK, Battu R, Pandey A, Yadav R, Muthusamy B, Pal PK. Clinical, imaging and genetic profile of twenty-four patients with pantothenate kinase-associated neurodegeneration (PKAN)- A single centre study from India. Parkinsonism Relat Disord 2023; 111:105409. [PMID: 37121191 DOI: 10.1016/j.parkreldis.2023.105409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/20/2023] [Accepted: 04/19/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Pantothenate kinase-associated neurodegeneration (PKAN) is the most common "Neurodegeneration with Brain Iron Accumulation" disorder. This study aimed to study the clinical, radiological and genetic profiling of a large cohort of patients with PKAN. METHODS This is an ambispective hospital-based single centre study conducted at a tertiary care centre from India. After tabulating the clinical details, appropriate rating scales were applied followed by magnetic resonance imaging brain and exome sequencing. The segregation of the causal variants in the families were analysed using Sanger sequencing. RESULTS Twenty-four patients (14 males) with a median age at initial examination of 13 years (range: 4-54 years) and age at onset of 8 years (range: 0.5-40 years) were identified. Almost two-thirds (62%) had onset before 10 years. Difficulty walking was the most common presenting symptom (41.6%) and dystonia was the most common extrapyramidal phenomenology (100%) followed by parkinsonism (54.2%). Retinitis pigmentosa was present in 37.5% patients. MRI showed hypo intensity on T2 and SWI sequences in globus pallidus (100%), substantia nigra (70.8%) and red nucleus (12.5%). Eye-of-the-tiger sign was present in 95.8%. Biallelic variants in PANK2 gene was identified in all 20 patients who underwent genetic testing. Among the 18 unique variants identified in these 20 patients 10 were novel. Sanger sequencing confirmed the segregation of the mutation in the available family members. CONCLUSIONS Wide range of age at onset was noted. Dystonia at presentation, pathognomonic eye-of-tiger sign, and disease-causing variants in PANK2 gene were identified in nearly all patients. Ten novel variants were identified expanding the genotypic spectrum of PKAN.
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Affiliation(s)
- Neeharika Sriram
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Vikram V Holla
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Riyanka Kumari
- Institute of Bioinformatics, International Technology Park, Bengaluru, 560066, India; Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Nitish Kamble
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Jitender Saini
- Neuroimaging and Intervention Radiology, National Institute of Mental Health and Neurosciences, 560029, India
| | - Rohan Mahale
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Manjunath Netravathi
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Hansashree Padmanabha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Vykuntaraju K Gowda
- Department of Paediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, 560029, India
| | - Rajani Battu
- Centre for Eye Genetics and Research, Bangalore, India
| | - Akhilesh Pandey
- Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA; Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India
| | - Babylakshmi Muthusamy
- Institute of Bioinformatics, International Technology Park, Bengaluru, 560066, India; Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, 560029, India.
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Cavestro C, Diodato D, Tiranti V, Di Meo I. Inherited Disorders of Coenzyme A Biosynthesis: Models, Mechanisms, and Treatments. Int J Mol Sci 2023; 24:ijms24065951. [PMID: 36983025 PMCID: PMC10054636 DOI: 10.3390/ijms24065951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Coenzyme A (CoA) is a vital and ubiquitous cofactor required in a vast number of enzymatic reactions and cellular processes. To date, four rare human inborn errors of CoA biosynthesis have been described. These disorders have distinct symptoms, although all stem from variants in genes that encode enzymes involved in the same metabolic process. The first and last enzymes catalyzing the CoA biosynthetic pathway are associated with two neurological conditions, namely pantothenate kinase-associated neurodegeneration (PKAN) and COASY protein-associated neurodegeneration (CoPAN), which belong to the heterogeneous group of neurodegenerations with brain iron accumulation (NBIA), while the second and third enzymes are linked to a rapidly fatal dilated cardiomyopathy. There is still limited information about the pathogenesis of these diseases, and the knowledge gaps need to be resolved in order to develop potential therapeutic approaches. This review aims to provide a summary of CoA metabolism and functions, and a comprehensive overview of what is currently known about disorders associated with its biosynthesis, including available preclinical models, proposed pathomechanisms, and potential therapeutic approaches.
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Affiliation(s)
- Chiara Cavestro
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20126 Milan, Italy
| | - Daria Diodato
- Unit of Muscular and Neurodegenerative Disorders, Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Valeria Tiranti
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20126 Milan, Italy
| | - Ivano Di Meo
- Unit of Medical Genetics and Neurogenetics, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20126 Milan, Italy
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Neurodegeneration with brain iron accumulation: a case series highlighting phenotypic and genotypic diversity in 20 Indian families. Neurogenetics 2023; 24:113-127. [PMID: 36790591 DOI: 10.1007/s10048-023-00712-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
Neurodegeneration with brain iron accumulation (NBIA) is an umbrella term encompassing various inherited neurological disorders characterised by abnormal iron accumulation in basal ganglia. We aimed to study the clinical, radiological and molecular spectrum of disorders with NBIA. All molecular-proven cases of NBIA presented in the last 5 years at 2 tertiary care genetic centres were compiled. Demographic details and clinical and neuroimaging findings were collated. We describe 27 individuals from 20 unrelated Indian families with causative variants in 5 NBIA-associated genes. PLA2G6-associated neurodegeneration (PLAN) was the most common, observed in 13 individuals from 9 families. They mainly presented in infancy with neuroregression and hypotonia. A recurrent pathogenic variant in COASY was observed in two neonates with prenatal-onset severe neurodegeneration. Pathogenic bi-allelic variants in PANK2, FA2H and C19ORF12 genes were observed in the rest, and these individuals presented in late childhood and adolescence with gait abnormalities and extrapyramidal symptoms. No intrafamilial and interfamilial variability were observed. Iron deposition on neuroimaging was seen in only 6/17 (35.3%) patients. A total of 22 causative variants across 5 genes were detected including a multiexonic duplication in PLA2G6. The variants c.1799G > A and c.2370 T > G in PLA2G6 were observed in three unrelated families. In silico assessments of 8 amongst 9 novel variants were also performed. We present a comprehensive compilation of the phenotypic and genotypic spectrum of various subtypes of NBIA from the Indian subcontinent. Clinical presentation of NBIAs is varied and not restricted to extrapyramidal symptoms or iron accumulation on neuroimaging.
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Álvarez-Córdoba M, Reche-López D, Cilleros-Holgado P, Talaverón-Rey M, Villalón-García I, Povea-Cabello S, Suárez-Rivero JM, Suárez-Carrillo A, Munuera-Cabeza M, Piñero-Pérez R, Sánchez-Alcázar JA. Therapeutic approach with commercial supplements for pantothenate kinase-associated neurodegeneration with residual PANK2 expression levels. Orphanet J Rare Dis 2022; 17:311. [PMID: 35945593 PMCID: PMC9364590 DOI: 10.1186/s13023-022-02465-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/24/2022] [Indexed: 12/24/2022] Open
Abstract
Background Neurodegeneration with brain iron accumulation (NBIA) is a group of rare neurogenetic disorders frequently associated with iron accumulation in the basal nuclei of the brain characterized by progressive spasticity, dystonia, muscle rigidity, neuropsychiatric symptoms, and retinal degeneration or optic nerve atrophy. Pantothenate kinase-associated neurodegeneration (PKAN) is one of the most widespread NBIA subtypes. It is caused by mutations in the gene of pantothenate kinase 2 (PANK2) that result in dysfunction in PANK2 enzyme activity, with consequent deficiency of coenzyme A (CoA) biosynthesis, as well as low levels of essential metabolic intermediates such as 4′-phosphopantetheine, a necessary cofactor for essential cytosolic and mitochondrial proteins. Methods In this manuscript, we examined the therapeutic effectiveness of pantothenate, panthetine, antioxidants (vitamin E and omega 3) and mitochondrial function boosting supplements (L-carnitine and thiamine) in mutant PANK2 cells with residual expression levels. Results Commercial supplements, pantothenate, pantethine, vitamin E, omega 3, carnitine and thiamine were able to eliminate iron accumulation, increase PANK2, mtACP, and NFS1 expression levels and improve pathological alterations in mutant cells with residual PANK2 expression levels. Conclusion Our results suggest that several commercial compounds are indeed able to significantly correct the mutant phenotype in cellular models of PKAN. These compounds alone or in combinations are of common use in clinical practice and may be useful for the treatment of PKAN patients with residual enzyme expression levels. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02465-9.
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Affiliation(s)
- Mónica Álvarez-Córdoba
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Diana Reche-López
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Paula Cilleros-Holgado
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Marta Talaverón-Rey
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Irene Villalón-García
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Suleva Povea-Cabello
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Juan M Suárez-Rivero
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Alejandra Suárez-Carrillo
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Manuel Munuera-Cabeza
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - Rocío Piñero-Pérez
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain
| | - José A Sánchez-Alcázar
- Centro Andaluz de Biología del Desarrollo (CABD-CSIC-Universidad Pablo de Olavide), and Centro de Investigación Biomédica en Red: Enfermedades Raras, Instituto de Salud Carlos III, 41013, Sevilla, Spain.
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Cerebral and cerebellar white matter tract alterations in patients with Pantothenate Kinase-Associated Neurodegeneration (PKAN). Parkinsonism Relat Disord 2022; 98:1-6. [PMID: 35395584 DOI: 10.1016/j.parkreldis.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND To examine structural connectivity of white matter tracts in patients with Pantothenate Kinase-Associated Neurodegeneration (PKAN) dystonia and identify those ones which correlate negatively to severity of symptoms. METHODS In a group of 41 patients suffering from PKAN dystonia and an age- and gender-matched control group, white matter tractography was carried out, based on diffusion tensor imaging magnetic resonance data. Postprocessing included assessment of Quantitative Anisotropy (QA) using q-space diffeomorphic reconstruction in order to reduce influence of iron accumulation in globus pallidus of patients. RESULTS Whole brain tractography presented significantly reduced QA values in patients (0.282 ± 0.056, as compared to controls (0.325 ± 0.046, p < 0.001). 9 fiber clusters of tracts correlated negatively to the dystonia score of patients: the middle cerebellar peduncle and the tracts of both cerebellar hemispheres as well as corpus callosum, forceps minor, the superior cortico-striate tracts and the superior thalamic radiations of both cerebral hemispheres (False Discovery Rate FDR = 0.041). CONCLUSION The finding of a reduced global structural connectivity within the white matter and of negative correlation of motor system-related tracts, mainly those between the basal ganglia, cortical areas and the cerebellum, fits well to the concept of a general functional disturbance of the motor system in PKAN.
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Roa-Sanchez P, Bido P, Oviedo J, Huppertz HJ, Speckter H, Stoeter P. Changes in Cerebral Gray and White Matter in Patients with Pantothenate Kinase-Associated Neurodegeneration: A Long-Term Magnetic Resonance Imaging Follow-Up Study. J Mov Disord 2021; 14:148-152. [PMID: 34062648 PMCID: PMC8175809 DOI: 10.14802/jmd.20102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 03/17/2021] [Indexed: 11/25/2022] Open
Abstract
Objective To determine the volume changes in gray and white matter during a long-term follow-up in patients suffering from pantothenate kinase-associated neurodegeneration (PKAN). Methods Magnetic resonance imaging was repeated in 13 patients and 14 age-matched controls after a mean interval of more than 7 years. T1-weighted sequences were evaluated by fully automated atlas-based volumetry, compared between groups and correlated with disease progression. Results The patients did not show generalized cerebral atrophy but did show a significantly faster volume reduction in the globus pallidus during follow-up (between -0.96% and -1.02% per year, p < 0.05 adjusted for false discovery rate) than controls, which was significantly related to the progression in their dystonia scores (p = 0.032). Conclusion The volume loss in the globus pallidus over time—together with the accumulation of iron known as the “tiger’s eye”—supports the pathophysiologic concept of this nucleus as a center of inhibition and its severe malfunction in PKAN.
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Affiliation(s)
| | - Pamela Bido
- Department of Neurology, CEDIMAT, Santo Domingo, Dominican Republic
| | - Jairo Oviedo
- Department of Radiology, CEDIMAT, Santo Domingo, Dominican Republic
| | | | - Herwin Speckter
- Department of Radiology, CEDIMAT, Santo Domingo, Dominican Republic
| | - Peter Stoeter
- Department of Radiology, CEDIMAT, Santo Domingo, Dominican Republic
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Abstract
PURPOSE OF REVIEW The diagnosis of neurodegeneration with brain iron accumulation (NBIA) typically associates various extrapyramidal and pyramidal features, cognitive and psychiatric symptoms with bilateral hypointensities in the globus pallidus on iron-sensitive magnetic resonance images, reflecting the alteration of iron homeostasis in this area. This article details the contribution of MRI in the diagnosis by summarizing and comparing MRI patterns of the various NBIA subtypes. RECENT FINDINGS MRI almost always shows characteristic changes combining iron accumulation and additional neuroimaging abnormalities. Iron-sensitive MRI shows iron deposition in the basal ganglia, particularly in bilateral globus pallidus and substantia nigra. Other regions may be affected depending on the NBIA subtypes including the cerebellum and dentate nucleus, the midbrain, the striatum, the thalamus, and the cortex. Atrophy of the cerebellum, brainstem, corpus callosum and cortex, and white matter changes may be associated and worsen with disease duration. Iron deposition can be quantified using R2 or quantitative susceptibility mapping. SUMMARY Recent MRI advances allow depicting differences between the various subtypes of NBIA, providing a useful analytical framework for clinicians. Standardization of protocols for image acquisition and analysis may help improving the detection of imaging changes associated with NBIA and the quantification of iron deposition.
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Correlation of dystonia severity and iron accumulation in Rett syndrome. Sci Rep 2021; 11:838. [PMID: 33436916 PMCID: PMC7804965 DOI: 10.1038/s41598-020-80723-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 12/21/2020] [Indexed: 01/29/2023] Open
Abstract
Individuals with Rett syndrome (RTT) commonly demonstrate Parkinsonian features and dystonia at teen age; however, the pathological reason remains unclear. Abnormal iron accumulation in deep gray matter were reported in some Parkinsonian-related disorders. In this study, we investigated the iron accumulation in deep gray matter of RTT and its correlation with dystonia severity. We recruited 18 RTT-diagnosed participants with MECP2 mutations, from age 4 to 28, and 28 age-gender matched controls and investigated the iron accumulation by susceptibility weighted image (SWI) in substantia nigra (SN), globus pallidus (GP), putamen, caudate nucleus, and thalamus. Pearson's correlation was applied for the relation between iron accumulation and dystonia severity. In RTT, the severity of dystonia scales showed significant increase in subjects older than 10 years, and the contrast ratios of SWI also showed significant differences in putamen, caudate nucleus and the average values of SN, putamen, and GP between RTT and controls. The age demonstrated moderate to high negative correlations with contrast ratios. The dystonia scales were correlated with the average contrast ratio of SN, putamen and GP, indicating iron accumulation in dopaminergic system and related grey matter. As the first SWI study for RTT individuals, we found increased iron deposition in dopaminergic system and related grey matter, which may partly explain the gradually increased dystonia.
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Hinarejos I, Machuca C, Sancho P, Espinós C. Mitochondrial Dysfunction, Oxidative Stress and Neuroinflammation in Neurodegeneration with Brain Iron Accumulation (NBIA). Antioxidants (Basel) 2020; 9:antiox9101020. [PMID: 33092153 PMCID: PMC7589120 DOI: 10.3390/antiox9101020] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/16/2020] [Accepted: 10/17/2020] [Indexed: 12/13/2022] Open
Abstract
The syndromes of neurodegeneration with brain iron accumulation (NBIA) encompass a group of invalidating and progressive rare diseases that share the abnormal accumulation of iron in the basal ganglia. The onset of NBIA disorders ranges from infancy to adulthood. Main clinical signs are related to extrapyramidal features (dystonia, parkinsonism and choreoathetosis), and neuropsychiatric abnormalities. Ten NBIA forms are widely accepted to be caused by mutations in the genes PANK2, PLA2G6, WDR45, C19ORF12, FA2H, ATP13A2, COASY, FTL1, CP, and DCAF17. Nonetheless, many patients remain without a conclusive genetic diagnosis, which shows that there must be additional as yet undiscovered NBIA genes. In line with this, isolated cases of known monogenic disorders, and also, new genetic diseases, which present with abnormal brain iron phenotypes compatible with NBIA, have been described. Several pathways are involved in NBIA syndromes: iron and lipid metabolism, mitochondrial dynamics, and autophagy. However, many neurodegenerative conditions share features such as mitochondrial dysfunction and oxidative stress, given the bioenergetics requirements of neurons. This review aims to describe the existing link between the classical ten NBIA forms by examining their connection with mitochondrial impairment as well as oxidative stress and neuroinflammation.
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Affiliation(s)
- Isabel Hinarejos
- Unit of Genetics and Genomics of Neuromuscular and Neurodegenerative Disorders, Centro de Investigación Príncipe Felipe (CIPF), 46012 Valencia, Spain; (I.H.); (C.M.); (P.S.)
- Rare Diseases Joint Units, CIPF-IIS La Fe & INCLIVA, 46012 Valencia, Spain
| | - Candela Machuca
- Unit of Genetics and Genomics of Neuromuscular and Neurodegenerative Disorders, Centro de Investigación Príncipe Felipe (CIPF), 46012 Valencia, Spain; (I.H.); (C.M.); (P.S.)
- Rare Diseases Joint Units, CIPF-IIS La Fe & INCLIVA, 46012 Valencia, Spain
- Unit of Stem Cells Therapies in Neurodegenerative Diseases, Centro de Investigación Príncipe Felipe (CIPF), 46012 Valencia, Spain
| | - Paula Sancho
- Unit of Genetics and Genomics of Neuromuscular and Neurodegenerative Disorders, Centro de Investigación Príncipe Felipe (CIPF), 46012 Valencia, Spain; (I.H.); (C.M.); (P.S.)
- Rare Diseases Joint Units, CIPF-IIS La Fe & INCLIVA, 46012 Valencia, Spain
| | - Carmen Espinós
- Unit of Genetics and Genomics of Neuromuscular and Neurodegenerative Disorders, Centro de Investigación Príncipe Felipe (CIPF), 46012 Valencia, Spain; (I.H.); (C.M.); (P.S.)
- Rare Diseases Joint Units, CIPF-IIS La Fe & INCLIVA, 46012 Valencia, Spain
- Department of Genetics, University of Valencia, 46100 Valencia, Spain
- Correspondence: ; Tel.: +34-963-289-680
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Dusek P, Mekle R, Skowronska M, Acosta-Cabronero J, Huelnhagen T, Robinson SD, Schubert F, Deschauer M, Els A, Ittermann B, Schottmann G, Madai VI, Paul F, Klopstock T, Kmiec T, Niendorf T, Wuerfel J, Schneider SA. Brain iron and metabolic abnormalities in C19orf12 mutation carriers: A 7.0 tesla MRI study in mitochondrial membrane protein-associated neurodegeneration. Mov Disord 2019; 35:142-150. [PMID: 31518459 DOI: 10.1002/mds.27827] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mitochondrial membrane protein-associated neurodegeneration is an autosomal-recessive disorder caused by C19orf12 mutations and characterized by iron deposits in the basal ganglia. OBJECTIVES The aim of this study was to quantify iron concentrations in deep gray matter structures using quantitative susceptibility mapping MRI and to characterize metabolic abnormalities in the pyramidal pathway using 1 H MR spectroscopy in clinically manifesting membrane protein-associated neurodegeneration patients and asymptomatic C19orf12 gene mutation heterozygous carriers. METHODS We present data of 4 clinically affected membrane protein-associated neurodegeneration patients (mean age: 21.0 ± 2.9 years) and 9 heterozygous gene mutation carriers (mean age: 50.4 ± 9.8 years), compared to age-matched healthy controls. MRI assessments were performed on a 7.0 Tesla whole-body system, consisting of whole-brain gradient-echo scans and short echo time, single-volume MR spectroscopy in the white matter of the precentral/postcentral gyrus. Quantitative susceptibility mapping, a surrogate marker for iron concentration, was performed using a state-of-the-art multiscale dipole inversion approach with focus on the globus pallidus, thalamus, putamen, caudate nucleus, and SN. RESULTS AND CONCLUSION In membrane protein-associated neurodegeneration patients, magnetic susceptibilities were 2 to 3 times higher in the globus pallidus (P = 0.02) and SN (P = 0.02) compared to controls. In addition, significantly higher magnetic susceptibility was observed in the caudate nucleus (P = 0.02). Non-manifesting heterozygous mutation carriers exhibited significantly increased magnetic susceptibility (relative to controls) in the putamen (P = 0.003) and caudate nucleus (P = 0.001), which may be an endophenotypic marker of genetic heterozygosity. MR spectroscopy revealed significantly increased levels of glutamate, taurine, and the combined concentration of glutamate and glutamine in membrane protein-associated neurodegeneration, which may be a correlate of corticospinal pathway dysfunction frequently observed in membrane protein-associated neurodegeneration patients. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Petr Dusek
- Department of Neurology and Centre of Clinical Neuroscience, Charles University, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czechia.,Department of Radiology, Charles University, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czechia
| | - Ralf Mekle
- Physikalisch-Technische Bundesanstalt (PTB), Braunschweig and Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marta Skowronska
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Julio Acosta-Cabronero
- Wellcome Centre for Human Neuroimaging, UCL Institute of Neurology, University College London, London, United Kingdom
| | - Till Huelnhagen
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Simon Daniel Robinson
- High Field MR Centre, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Florian Schubert
- Physikalisch-Technische Bundesanstalt (PTB), Braunschweig and Berlin, Germany
| | - Marcus Deschauer
- Department of Neurology, Technical University Munich, Munich, Germany
| | - Antje Els
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Bernd Ittermann
- Physikalisch-Technische Bundesanstalt (PTB), Braunschweig and Berlin, Germany
| | - Gudrun Schottmann
- NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Vince I Madai
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Thomas Klopstock
- Department of Neurology with Friedrich-Baur-Institute, Ludwig-Maximilians-University of Munich, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Tomasz Kmiec
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Jens Wuerfel
- NeuroCure Clinical Research Center and Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité-Universitaetsmedizin Berlin, Berlin, Germany.,Medical Image Analysis Center and Department Biomedical Engineering, University Basel, Basel, Switzerland
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Diagnostic and clinical experience of patients with pantothenate kinase-associated neurodegeneration. Orphanet J Rare Dis 2019; 14:174. [PMID: 31300018 PMCID: PMC6625120 DOI: 10.1186/s13023-019-1142-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pantothenate kinase-associated neurodegeneration (PKAN) is an autosomal recessive neurodegenerative disorder with brain iron accumulation (NBIA). OBJECTIVES To assess PKAN diagnostic pathway, history, and burden across the spectrum of PKAN severity from patient and/or caregiver perspectives. METHODS Caregivers of patients (n = 37) and patients themselves (n = 2) were interviewed in a validation study of the PKAN-Activities of Daily Living (ADL) scale. The current study used quartiles of the PKAN-ADL total score to divide patients by severity of impairment (Lowest, Second Lowest, Third Lowest, Highest). Diagnostic and treatment history, healthcare utilization, disease burden, and caregiver experience were compared between groups. RESULTS The analyses included data from 39 patients. Mean age at PKAN symptom onset (P = 0.0007), initial MRI (P = 0.0150), and genetic testing (P = 0.0016) generally decreased across the PKAN severity spectrum. The mean duration of illness did not differ among PKAN severity groups (range, 9.7-15.2 years; P = 0.3029). First MRI led to diagnosis in 56.4% of patients (range, 30.0-90.0%). A mean (SD) of 13.0 (13.1) medical and 55.2 (78.5) therapy visits (eg, physical, speech) occurred in the past year. More patients in the higher PKAN severity groups experienced multiple current functional losses and/or earlier onset of problems (P-values < 0.0500). Over half (56.8%) of caregivers experienced a change in employment because of caregiving. The percentage of patients requiring full-time caregiving increased across the PKAN severity spectrum (range, 11.1-100%; P = 0.0021). CONCLUSIONS PKAN diagnosis was often delayed, most probably due to low awareness. Considerable burden of functional impairment and high healthcare utilization were found across the PKAN severity spectrum.
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Mohd Fauzi NA, Mohamed Ibrahim N, Mohamed Mukari SA, Jegan T, Abdul Aziz Z. Amelioration of Dystonic Opisthotonus in Pantothenate Kinase-Associated Neurodegeneration Syndrome with Absent "Eye-of-the-Tiger" Sign Following Bilateral Pallidal Deep Brain Stimulation. Mov Disord Clin Pract 2019; 6:332-334. [PMID: 31061845 DOI: 10.1002/mdc3.12748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 11/08/2022] Open
Affiliation(s)
- Nor Amelia Mohd Fauzi
- Department of Medicine, Faculty of Medicine Universiti Teknologi MARA (UiTM) Sungai Buloh Campus Selangor Malaysia
| | - Norlinah Mohamed Ibrahim
- Department of Medicine Universiti Kebangsaan Malaysia Medical Center (UKMMC) Kuala Lumpur Malaysia
| | | | - Thanabalan Jegan
- Department of Neurosurgery Universiti Kebangsaan Malaysia Medical Center (UKMMC) Kuala Lumpur Malaysia
| | - Zariah Abdul Aziz
- Department of Medicine Hospital Sultanah Nur Zahirah Kuala Terengganu Malaysia
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Beh SC. The “eye of the tiger” in a patient with multiple sclerosis. J Neurol Sci 2019; 399:1-2. [DOI: 10.1016/j.jns.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/03/2019] [Accepted: 02/01/2019] [Indexed: 11/25/2022]
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Marshall RD, Collins A, Escolar ML, Jinnah H, Klopstock T, Kruer MC, Videnovic A, Robichaux‐Viehoever A, Swett L, Revicki DA, Bender RH, Lenderking WR. A Scale to Assess Activities of Daily Living in Pantothenate Kinase-Associated Neurodegeneration. Mov Disord Clin Pract 2019; 6:139-149. [PMID: 30838313 PMCID: PMC6384181 DOI: 10.1002/mdc3.12716] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/09/2018] [Accepted: 11/11/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Pantothenate kinase-associated neurodegeneration (PKAN) is an autosomal-recessive, neurodegenerative disorder with a mixed-motor phenotype caused by a defective PanK2 enzyme, for which there are few adequate treatment options. Clinimetrically sound measures of patient-reported outcomes are necessary to facilitate therapeutic development for this debilitating disease. This study's objective was to develop such a scale and assess its clinimetric properties. METHODS A conceptually driven, iterative, content development process incorporating input from experts, caregivers, and patients was used. Scale items were initially adapted from the Unified Parkinson's Disease Rating Scale (UPDRS) Part II resulting in the 12-item Pantothenate Kinase-Associated Neurodegeneration Activities of Daily Living (PKAN-ADL). The PKAN-ADL scale was administered to caregivers (n = 37) and patients (n = 2) twice over 2 weeks, along with selected Quality of Life in Neurological Disorders (Neuro-QoL) measures, selected attributes of the Health Utilities Index (HUI)-2/3, and the Stroke Aphasia Depression Questionnaire (SADQ-10) to assess construct validity. RESULTS Internal consistency was 0.93, with excellent test-retest reliability (intraclass correlation coefficient = 0.99). Of the 12 items, 25% (n = 3) showed a ceiling effect >30% (range, 31-54) and 42% (n = 5) showed a floor effect >30% (range, 31-46), reflecting disease heterogeneity. Convergent validity was shown with Neuro-QoL measures (rs > 0.90) and HUI-2/3 attributes (rs ≥ 0.48); divergent validity was demonstrated with the SADQ-10 (r = 0.11). Participants reported a high level of comprehension (98%), and average item relevance ratings (0-10 scale) ranged from 7.0 to 9.9. CONCLUSION The PKAN-ADL scale demonstrated acceptable content validity, with evidence of construct validity and excellent reliability. Overall results support the use of the PKAN-ADL scale in clinical trials.
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Affiliation(s)
| | - Abigail Collins
- Departments of Pediatrics and NeurologyUniversity of Colorado School of MedicineDenverColoradoUSA
| | - Maria L. Escolar
- Department of PediatricsUniversity of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - H.A. Jinnah
- Departments of Neurology and Human GeneticsEmory University School of MedicineAtlantaGeorgiaUSA
| | - Thomas Klopstock
- Department of Neurology, Friedrich‐Baur‐InstituteUniversity of Munich, Munich, Germany and German Center for Neurodegenerative Diseases (DZNE)MunichGermany
| | - Michael C. Kruer
- Barrow Neurological InstitutePhoenix Children's Hospital, University of Arizona College of MedicinePhoenixArizonaUSA
| | - Aleksandar Videnovic
- Department of NeurologyMassachusetts General Hospital/Harvard Medical SchoolBostonMassachusettsUSA
| | - Amy Robichaux‐Viehoever
- Departments of Neurology and PediatricsUniversity of California‐San FranciscoSan FranciscoCaliforniaUSA
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Zeng J, Xing W, Liao W, Wang X. Magnetic resonance imaging, susceptibility weighted imaging and quantitative susceptibility mapping findings of pantothenate kinase-associated neurodegeneration. J Clin Neurosci 2019; 59:20-28. [DOI: 10.1016/j.jocn.2018.10.090] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/07/2018] [Accepted: 10/24/2018] [Indexed: 11/28/2022]
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Lee JH, Gregory A, Hogarth P, Rogers C, Hayflick SJ. Looking Deep into the Eye-of-the-Tiger in Pantothenate Kinase-Associated Neurodegeneration. AJNR Am J Neuroradiol 2018; 39:583-588. [PMID: 29371252 DOI: 10.3174/ajnr.a5514] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 10/31/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE A detailed delineation of the MR imaging changes in the globus pallidus in pantothenate kinase-associated neurodegeneration will be helpful for diagnosis and monitoring of patients. The aim of this study was to determine the morphologic spectrum of the "eye-of-the-tiger" sign and the topographic pattern of iron deposition in a group of patients with pantothenate kinase-associated neurodegeneration. MATERIALS AND METHODS Seventy-four MR imaging scans from 54 individuals with PANK2 mutations were analyzed for signal patterns in the globus pallidus. Sixteen SWI data from 15 patients who underwent 1.5T (n = 7), 3T (n = 7), and 7T (n = 2) MR imaging were included to visualize the iron topography. RESULTS The linear hyperintensity alongside the medial border of the globus pallidus was the earliest T2 signal change. This finding was evident before SWI changes from iron deposition became visible. T2WI performed in early childhood mostly showed isolated hyperintense signal. In adult patients, marked signal reduction within an earlier hyperintense center resulting from iron accumulation led to the loss of signal difference between the central and surrounding areas. Signal hypointensity on SWI progressed from the medial to the lateral portion of the globus pallidus with increasing age. The fiber connections between the medial globus pallidus and the anteromedial aspect of the substantia nigra and subthalamic nucleus were markedly hypointense on SWI. CONCLUSIONS In pantothenate kinase-associated neurodegeneration, the globus pallidus MR imaging changes using SWI develop as region-specific and age-dependent phenomena. Signal inhomogeneity was observed across the globus pallidus in pantothenate kinase-associated neurodegeneration and should be considered when determining the concentration of iron.
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Affiliation(s)
- J-H Lee
- From the Departments of Molecular and Medical Genetics (J.-H.L., A.G., P.H., C.R., S.J.H.) .,Department of Neurology (J.-H.L.), Pusan National University Yangsan Hospital, Medical Research Institute, Pusan National University School of Medicine, Yangsan, South Korea
| | - A Gregory
- From the Departments of Molecular and Medical Genetics (J.-H.L., A.G., P.H., C.R., S.J.H.)
| | - P Hogarth
- From the Departments of Molecular and Medical Genetics (J.-H.L., A.G., P.H., C.R., S.J.H.).,Neurology (P.H., S.J.H.)
| | - C Rogers
- From the Departments of Molecular and Medical Genetics (J.-H.L., A.G., P.H., C.R., S.J.H.)
| | - S J Hayflick
- From the Departments of Molecular and Medical Genetics (J.-H.L., A.G., P.H., C.R., S.J.H.) .,Neurology (P.H., S.J.H.).,Pediatrics (S.J.H.), Oregon Health & Science University, Portland, Oregon
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Hayflick SJ, Kurian MA, Hogarth P. Neurodegeneration with brain iron accumulation. HANDBOOK OF CLINICAL NEUROLOGY 2018; 147:293-305. [PMID: 29325618 DOI: 10.1016/b978-0-444-63233-3.00019-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Neurodegeneration with brain iron accumulation (NBIA) comprises a clinically and genetically heterogeneous group of disorders affecting children and adults. These rare disorders are often first suspected when increased basal ganglia iron is observed on brain magnetic resonance imaging. For the majority of NBIA disorders the genetic basis has been delineated, and clinical testing is available. The four most common NBIA disorders include pantothenate kinase-associated neurodegeneration (PKAN) due to mutations in PANK2, phospholipase A2-associated neurodegeneration caused by mutation in PLA2G6, mitochondrial membrane protein-associated neurodegeneration from mutations in C19orf12, and beta-propeller protein-associated neurodegeneration due to mutations in WDR45. The ultrarare NBIA disorders are caused by mutations in CoASY, ATP13A2, and FA2H (causing CoA synthase protein-associated neurodegeneration, Kufor-Rakeb disease, and fatty acid hydroxylase-associated neurodegeneration, respectively). Together, these genes account for disease in approximately 85% of patients diagnosed with an NBIA disorder. New NBIA genes are being recognized with increasing frequency as a result of whole-exome sequencing, which is also facilitating early ascertainment of patients whose phenotype is often nonspecific.
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Affiliation(s)
- Susan J Hayflick
- Departments of Molecular and Medical Genetics, Pediatrics and Neurology, Oregon Health and Science University, Portland, OR, United States.
| | - Manju A Kurian
- Molecular Neurosciences, Developmental Neurosciences Programme, Institute of Child Health, University College London and Department of Neurology, Great Ormond Street Hospital, London, United Kingdom
| | - Penelope Hogarth
- Departments of Molecular and Medical Genetics and Neurology, Oregon Health and Science University, Portland, OR, United States
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Hogarth P, Kurian MA, Gregory A, Csányi B, Zagustin T, Kmiec T, Wood P, Klucken A, Scalise N, Sofia F, Klopstock T, Zorzi G, Nardocci N, Hayflick SJ. Consensus clinical management guideline for pantothenate kinase-associated neurodegeneration (PKAN). Mol Genet Metab 2017; 120:278-287. [PMID: 28034613 DOI: 10.1016/j.ymgme.2016.11.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/07/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Penelope Hogarth
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, USA; Department of Neurology, Oregon Health & Science University, Portland, USA
| | - Manju A Kurian
- Molecular Neurosciences, Developmental Neurosciences Programme, UCL Institute of Child Health, London, UK
| | - Allison Gregory
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, USA
| | - Barbara Csányi
- Molecular Neurosciences, Developmental Neurosciences Programme, UCL Institute of Child Health, London, UK
| | - Tamara Zagustin
- Department of Physiatry, Children's Healthcare of Atlanta, GA, USA
| | - Tomasz Kmiec
- Department of Child Neurology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | | | - Natale Scalise
- AISNAF - Associazione Italiana Sindromi Neurodegenerative Da Accumulo Di Ferro, Rossano, Italy
| | | | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, Ludwig-Maximilians-University, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Giovanna Zorzi
- Department of Pediatric Neuroscience, IRCCS Foundation Neurological Institute C. Besta, Milan, Italy
| | - Nardo Nardocci
- Department of Pediatric Neuroscience, IRCCS Foundation Neurological Institute C. Besta, Milan, Italy
| | - Susan J Hayflick
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, USA; Department of Neurology, Oregon Health & Science University, Portland, USA
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Udani V, Das S, Chhabria R. Panthotenate Kinase-Associated Neurodegeneration Has a Founder Mutation (c.215_216insa) in Indian Agrawal Patients. Mov Disord Clin Pract 2017; 4:96-99. [PMID: 30713952 PMCID: PMC6353435 DOI: 10.1002/mdc3.12341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 11/30/2015] [Accepted: 01/09/2016] [Indexed: 11/10/2022] Open
Abstract
The early-onset classic form of panthotenate kinase-associated neurodegeneration (PKAN) is a rare genetic disorder of brain iron deposition associated with mutations in the pantothenate kinase 2 gene. Genetic testing was performed in 17 patients with early-onset classic PKAN and 2 atypical patients identified from a clinic database. Seventeen patients with early-onset classic disease exhibited pathogenic mutations in the panthotenate kinase 2 (PANK2) gene. One atypical patient had an indeterminate result and the other atypical case was later confirmed to have late-onset GM1 gangliosidosis. Of the 17, 13 belonged to the Agrawal community, with a common truncating mutation, c.215_216insA, in the homozygous state in all, which is highly suggestive of a founder effect. Of the remaining 4 patients, 2 had novel mutations. PKAN is the third neurological disease after megelencephalic leukoencephalopathy with subcortical cysts and calpainopathy with founder mutations in the Agrawal community.
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Affiliation(s)
- Vrajesh Udani
- Department of Pediatrics and NeurologyP.D. Hinduja National Hospital & Medical Research CentreMumbaiIndia
| | - Soma Das
- Department of Human GeneticsUniversity of ChicagoChicagoILUSA
| | - Rahul Chhabria
- Department of CardiologyJaslok Hospital & Medical Research CenterMumbaiIndia
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Abstract
Neurodegeneration with brain iron accumulation (NBIA) describes a heterogeneous group of inherited rare clinical and genetic entities. Clinical core symptoms comprise a combination of early-onset dystonia, pyramidal and extrapyramidal signs with ataxia, cognitive decline, behavioral abnormalities, and retinal and axonal neuropathy variably accompanying these core features. Increased nonphysiologic, nonaging-associated brain iron, most pronounced in the basal ganglia, is often termed the unifying characteristic of these clinically variable disorders, though occurrence and extent can be fluctuating or even absent. Neuropathologically, NBIA disorders usually are associated with widespread axonal spheroids and local iron accumulation in the basal ganglia. Postmortem, Lewy body, TDP-43, or tau pathology has been observed. Genetics have fostered ongoing progress in elucidating underlying pathophysiologic mechanisms of NBIA disorders. Ten associated genes have been established, with many more being suggested as new technologies and data emerge. Clinically, certain symptom combinations can suggest a specific genetic defect. Genetic tests, combined with postmortem neuropathology, usually make for the final disease confirmation. Despite these advances, treatment to date remains mainly symptomatic. This chapter reviews the established genetic defects leading to different NBIA subtypes, highlights phenotypic presentations to direct genetic testing, and briefly discusses the scarce available treatment options and upcoming challenges and future hopes of the field.
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Affiliation(s)
- Sarah Wiethoff
- UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom; Center for Neurology and Hertie Institute for Clinical Brain Research, Eberhard-Karls-University, Tübingen, Germany.
| | - Henry Houlden
- UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
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Brain MR Contribution to the Differential Diagnosis of Parkinsonian Syndromes: An Update. PARKINSONS DISEASE 2016; 2016:2983638. [PMID: 27774334 PMCID: PMC5059618 DOI: 10.1155/2016/2983638] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/08/2016] [Accepted: 09/01/2016] [Indexed: 12/26/2022]
Abstract
Brain magnetic resonance (MR) represents a useful and feasible tool for the differential diagnosis of Parkinson's disease. Conventional MR may reveal secondary forms of parkinsonism and may show peculiar brain alterations of atypical parkinsonian syndromes. Furthermore, advanced MR techniques, such as morphometric-volumetric analyses, diffusion-weighted imaging, diffusion tensor imaging, tractography, proton MR spectroscopy, and iron-content sensitive imaging, have been used to obtain quantitative parameters useful to increase the diagnostic accuracy. Currently, many MR studies have provided both qualitative and quantitative findings, reflecting the underlying neuropathological pattern of the different degenerative parkinsonian syndromes. Although the variability in the methods and results across the studies limits the conclusion about which technique is the best, specific radiologic phenotypes may be identified. Qualitative/quantitative MR changes in the substantia nigra do not discriminate between different parkinsonisms. In the absence of extranigral abnormalities, the diagnosis of PD is more probable, whereas basal ganglia changes (mainly in the putamen) suggest the diagnosis of an atypical parkinsonian syndrome. In this context, changes in pons, middle cerebellar peduncles, and cerebellum suggest the diagnosis of MSA, in midbrain and superior cerebellar peduncles the diagnosis of PSP, and in whole cerebral hemispheres (mainly in frontoparietal cortex with asymmetric distribution) the diagnosis of Corticobasal Syndrome.
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Pavese N, Tai YF. Genetic and degenerative disorders primarily causing other movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 135:507-523. [PMID: 27432681 DOI: 10.1016/b978-0-444-53485-9.00025-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In this chapter, we will discuss the contributions of structural and functional imaging to the diagnosis and management of genetic and degenerative diseases that lead to the occurrence of movement disorders. We will mainly focus on Huntington's disease, Wilson's disease, dystonia, and neurodegeneration with brain iron accumulation, as they are the more commonly encountered clinical conditions within this group.
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Affiliation(s)
- Nicola Pavese
- Division of Brain Sciences, Imperial College London, UK; Aarhus University, Denmark.
| | - Yen F Tai
- Division of Brain Sciences, Imperial College London, UK
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Schneider SA. Neurodegenerations with Brain Iron Accumulation. Parkinsonism Relat Disord 2016; 22 Suppl 1:S21-5. [DOI: 10.1016/j.parkreldis.2015.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 10/23/2022]
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Potential of Diffusion Tensor Imaging and Relaxometry for the Detection of Specific Pathological Alterations in Parkinson's Disease (PD). PLoS One 2015; 10:e0145493. [PMID: 26713760 PMCID: PMC4705111 DOI: 10.1371/journal.pone.0145493] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 12/04/2015] [Indexed: 11/19/2022] Open
Abstract
The purpose of the present study was to evaluate the potential of multimodal MR imaging including mean diffusivity (MD), fractional anisotropy (FA), relaxation rates R2 and R2* to detect disease specific alterations in Parkinson's Disease (PD). We enrolled 82 PD patients (PD-all) with varying disease durations (≤5 years: PD≤5, n = 43; >5 years: PD>5, n = 39) and 38 matched healthy controls (HC), receiving diffusion tensor imaging as well as R2 and R2* relaxometry calculated from multi-echo T2*-weighted and dual-echo TSE imaging, respectively. ROIs were drawn to delineate caudate nucleus (CN), putamen (PU), globus pallidus (GP) and substantia nigra (SN) on the co-registered maps. The SN was divided in 3 descending levels (SL 1–3). The most significant parameters were used for a flexible discrimination analysis (FDA) in a training collective consisting of 25 randomized subjects from each group in order to predict the classification of remaining subjects. PD-all showed significant increases in MD, R2 and R2* within SN and its subregions as well as in MD and R2* within different basal ganglia regions. Compared to the HC group, the PD≤5 and the PD>5 group showed significant MD increases within the SN and its lower two subregions, while the PD≤5 group exhibited significant increases in R2 and R2* within SN and its subregions, and tended to elevation within the basal ganglia. The PD>5 group had significantly increased MD in PU and GP, whereas the PD≤5 group presented normal MD within the basal ganglia. FDA achieved right classification in 84% of study participants. Micro-structural damage affects primarily the SN of PD patients and in later disease stages the basal ganglia. Iron contents of PU, GP and SN are increased at early disease stages of PD.
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Schiessl-Weyer J, Roa P, Laccone F, Kluge B, Tichy A, De Almeida Ribeiro E, Prohaska R, Stoeter P, Siegl C, Salzer U. Acanthocytosis and the c.680 A>G Mutation in the PANK2 Gene: A Study Enrolling a Cohort of PKAN Patients from the Dominican Republic. PLoS One 2015; 10:e0125861. [PMID: 25915509 PMCID: PMC4411072 DOI: 10.1371/journal.pone.0125861] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/24/2015] [Indexed: 11/29/2022] Open
Abstract
Pantothenate Kinase-Associated Neurodegeneration (PKAN) is a form of Neurodegeneration with Brain Iron Accumulation (NBIA) associated with mutations in the pantothenate kinase 2 gene (PANK2). Pantothenate kinases catalyze the rate-limiting step of coenzyme A synthesis and Pank2 is the only pantothenate kinase isoform in humans that is localized to mitochondria. Acanthocytosis, the occurrence of spiculated erythrocytes, is observed in about 10% of the PKAN patients. Therefore PKAN is also classified together with other rare neurodegenerative diseases like Chorea Acanthocytosis (ChAc) and McLeod syndrome (MLS) into the Neuroacanthocytosis (NA) syndromes. It has not been investigated yet whether acanthocytosis in PKAN is associated with a specific subset of Pank2 mutations. In this study, we analyzed acanthocytosis of a cohort of 25 PKAN patients from the Dominican Republic that are homozygous for the c.680 A>G mutation in the PANK2 gene as compared to control donors that are heterozygous or wild-type with respect to this mutation. 3D modeling of this mutation indicated that the replacement of a tyrosine by a cysteine at position 227 in Pank2 disrupts a polar interaction within the A domain of the enzyme. Mean acanthocyte count was elevated in the cohort of patients, however, acanthocytosis varied among the patients with nearly half of them showing high (>20%) or elevated acanthocytosis and the rest showing mild (6-10%) or no (<6%) acanthocytosis. Heterozygous control donors revealed a tendency to mild acanthocytosis. Based on the insight that Pank2 is a normal constituent of red blood cells and de novo biosynthesis of coenzyme A is likely to take place in the erythrocyte cytosol we propose a hypothetical model that accounts for the variability in the occurrence of acanthocytic cells in PKAN.
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Affiliation(s)
- Jasmin Schiessl-Weyer
- Department of Medical Biochemistry, Max F. Perutz Laboratories, Medical University of Vienna, Vienna, Austria
| | - Pedro Roa
- Centro de Diagnostico Medicina Avanzada, Laboratorio y Telemedicina, Santo Domingo, República Dominicana
| | - Franco Laccone
- Department of Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Britta Kluge
- Department of Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Alexander Tichy
- Platform Bioinformatics and Biostatistics, University of Veterinary Medicine, Vienna, Austria
| | - Euripedes De Almeida Ribeiro
- Department of Structural and Computational Biology, Max F. Perutz Laboratories, University of Vienna, Vienna, Austria
| | - Rainer Prohaska
- Department of Medical Biochemistry, Max F. Perutz Laboratories, Medical University of Vienna, Vienna, Austria
| | - Peter Stoeter
- Centro de Diagnostico Medicina Avanzada, Laboratorio y Telemedicina, Santo Domingo, República Dominicana
| | - Claudia Siegl
- Department of Medical Biochemistry, Max F. Perutz Laboratories, Medical University of Vienna, Vienna, Austria
| | - Ulrich Salzer
- Department of Medical Biochemistry, Max F. Perutz Laboratories, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Stoeter P, Roa-Sanchez P, Speckter H, Perez-Then E, Foerster B, Vilchez C, Oviedo J, Rodriguez-Raecke R. Changes of cerebral white matter in patients suffering from Pantothenate Kinase-Associated Neurodegeneration (PKAN): A diffusion tensor imaging (DTI) study. Parkinsonism Relat Disord 2015; 21:577-81. [PMID: 25819806 DOI: 10.1016/j.parkreldis.2015.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 02/24/2015] [Accepted: 03/08/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND To look for microstructural white matter alterations in patients with dystonia due to Pantothenate Kinase-Associated Neurodegeneration. MATERIAL AND METHODS We examined 21 genetically confirmed patients and an age-matched group of 21 healthy controls by diffusion tensor imaging. Evaluation of data was performed by tract-based spatial statistics analysis and a voxel-wise comparison of calculated maps of fractional anisotropy. Findings were compared between groups and correlated to the dystonia score of the Burke-Fahn-Marsden Scale (p ≤ 0.05). RESULTS Patients showed reductions of fractional anisotropy mainly in the periventricular substance surrounding the third ventricle, in the medial part of both putamina and in the frontal white matter including the anterior limbs of the internal capsules and the corpus callosum. Infratentorially, the cerebellar white matter and dorsal parts of the pons and medulla were affected. CONCLUSION In addition to cortical grey matter changes, we now have a second structural finding pointing to a more widespread affection of cerebral tissue in PKAN dystonia than just the lesion and iron accumulation in the globus pallidus.
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Affiliation(s)
- P Stoeter
- Dep. of Radiology, Santo Domingo, Dominican Republic.
| | - P Roa-Sanchez
- Dep. of Neurology, Santo Domingo, Dominican Republic
| | - H Speckter
- Dep. of Radiology, Santo Domingo, Dominican Republic
| | - E Perez-Then
- Dep. of Medical Science, CEDIMAT, Santo Domingo, Dominican Republic
| | - B Foerster
- Philips Medical Systems LatAm, Sao Paulo, Brazil
| | - C Vilchez
- Dep. of Radiology, Santo Domingo, Dominican Republic
| | - J Oviedo
- Dep. of Radiology, Santo Domingo, Dominican Republic
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28
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Hogarth P. Neurodegeneration with brain iron accumulation: diagnosis and management. J Mov Disord 2015; 8:1-13. [PMID: 25614780 PMCID: PMC4298713 DOI: 10.14802/jmd.14034] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 10/15/2014] [Accepted: 10/20/2014] [Indexed: 12/14/2022] Open
Abstract
Neurodegeneration with brain iron accumulation (NBIA) encompasses a group of inherited disorders that share the clinical features of an extrapyramidal movement disorder accompanied by varying degrees of intellectual disability and abnormal iron deposition in the basal ganglia. The genetic basis of ten forms of NBIA is now known. The clinical features of NBIA range from rapid global neurodevelopmental regression in infancy to mild parkinsonism with minimal cognitive impairment in adulthood, with wide variation seen between and within the specific NBIA sub-type. This review describes the clinical presentations, imaging findings, pathologic features, and treatment considerations for this heterogeneous group of disorders.
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Affiliation(s)
- Penelope Hogarth
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, OR, USA
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29
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Dusek P, Tovar Martinez EM, Madai VI, Jech R, Sobesky J, Paul F, Niendorf T, Wuerfel J, Schneider SA. 7-Tesla Magnetic Resonance Imaging for Brain Iron Quantification in Homozygous and Heterozygous PANK2 Mutation Carriers. Mov Disord Clin Pract 2014; 1:329-335. [PMID: 30363918 DOI: 10.1002/mdc3.12080] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/06/2014] [Accepted: 06/18/2014] [Indexed: 01/18/2023] Open
Abstract
Pantothenate-kinase-associated neurodegeneration (PKAN) is an autosomal recessive disorder characterized by iron deposits in basal ganglia. The aim of this study was to quantify iron concentrations of deep gray matter structures in heterozygous PANK2 mutation carriers and in PKAN patients using quantitative susceptibility mapping MRI. By determining iron concentration, we intended to find mutation-specific brain parenchymal stigmata in heterozygous PANK2 mutation carriers in comparison to age-matched healthy volunteers. We studied 11 heterozygous PANK2 gene mutation carriers (mean age: 43.4 years; standard deviation [SD]: 10.5), who were found to be clinically asymptomatic by neurological examination. These carriers were compared to 2 clinically affected PKAN patients 21 and 32 years of age and to 13 age-matched, healthy controls (mean age: 39.7; SD, 13.6). Scanning was performed on a 7.0-Tesla whole-body scanner applying three-dimensional susceptibility-weighted gradient echo acquisitions. Susceptibility maps were calculated by threshold-based k-space division with single-orientation acquisition. Magnetic susceptibility values, relative to the occipital white matter, were determined for the following regions of interest (ROI): globus pallidus (GP), thalamus, putamen, internal capsule (IC), caudate nucleus, substantia nigra (SN), and red nucleus. Heterozygous PANK2 mutation carriers did not show increased brain iron concentrations, compared to healthy controls (P > 0.05), in any of the examined ROIs. In PKAN patients, more than 3 times higher concentrations of iron were found in the GP, SN, and IC. Our results suggest that heterozygous mutations in PANK2 gene do not cause brain iron accumulation nor do they cause movement disorders.
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Affiliation(s)
- Petr Dusek
- Department of Neurology and Center of Clinical Neuroscience Charles University in Prague First Faculty of Medicine and General University Hospital in Prague Prague Czech Republic.,Institute of Neuroradiology University Medicine Goettingen Goettingen Germany
| | | | - Vince Istvan Madai
- Department of Neurology and Center for Stroke Research Berlin Charité-Universitaetsmedizin Berlin Germany
| | - Robert Jech
- Department of Neurology and Center of Clinical Neuroscience Charles University in Prague First Faculty of Medicine and General University Hospital in Prague Prague Czech Republic
| | - Jan Sobesky
- Department of Neurology and Center for Stroke Research Berlin Charité-Universitaetsmedizin Berlin Germany.,Experimental and Clinical Research Center Charité-Universitaetsmedizin and Max Delbrueck Center for Molecular Medicine Berlin Germany
| | - Friedemann Paul
- NeuroCure Clinical Research Center Charité University Medicine Berlin Berlin Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility Max-Delbrueck Center for Molecular Medicine Berlin Germany.,Experimental and Clinical Research Center Charité-Universitaetsmedizin and Max Delbrueck Center for Molecular Medicine Berlin Germany
| | - Jens Wuerfel
- Institute of Neuroradiology University Medicine Goettingen Goettingen Germany.,Berlin Ultrahigh Field Facility Max-Delbrueck Center for Molecular Medicine Berlin Germany.,Experimental and Clinical Research Center Charité-Universitaetsmedizin and Max Delbrueck Center for Molecular Medicine Berlin Germany.,NeuroCure Clinical Research Center Charité University Medicine Berlin Berlin Germany
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Abstract
Hallervorden-Spatz disease (HSD) is a rare disorder characterized by progressive extrapyramidal dysfunction and dementia. Hallervorden and Spatz first described the disease, in 1922 as a form of familial brain degeneration characterized by iron deposition in the brain. Here we present four HSD cases with different clinical pictures.
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Affiliation(s)
- Maseumeh Dashti
- Department of Neurology, Shahid Sadooghi Hospital, Isfahan, Iran
| | - Ahmad Chitsaz
- Department of Neurology, Shahid Sadooghi Hospital, Isfahan, Iran
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31
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Rodriguez-Raecke R, Roa-Sanchez P, Speckter H, Fermin-Delgado R, Perez-Then E, Oviedo J, Stoeter P. Grey matter alterations in patients with Pantothenate Kinase-Associated Neurodegeneration (PKAN). Parkinsonism Relat Disord 2014; 20:975-9. [PMID: 24965278 DOI: 10.1016/j.parkreldis.2014.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/05/2014] [Accepted: 06/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pantothenate Kinase-Associated Neurodegeneration (PKAN) is a rare heritable disease marked by dystonia and loss of movement control. In contrast to the well-known "Eye-of-the-Tiger" sign affecting the globus pallidus, little is known about other deviations of brain morphology, especially about grey matter changes. METHODS We investigated 29 patients with PKAN and 29 age-matched healthy controls using Magnet Resonance Imaging and Voxel-Based Morphometry. RESULTS As compared to controls, children with PKAN showed increased grey matter density in the putamen and nucleus caudatus and adults with PKAN showed increased grey matter density in the ventral part of the anterior cingulate cortex. A multiple regression analysis with dystonia score as predictor showed grey matter reduction in the cerebellum, posterior cingulate cortex, superior parietal lobule, pars triangularis and small frontal and temporal areas and an analysis with age as predictor showed grey matter decreases in the putamen, nucleus caudatus, supplementary motor area and anterior cingulate cortex. CONCLUSIONS The grey matter increases may be regarded as a secondary phenomenon compensating the increased activity of the motor system due to a reduced inhibitory output of the globus pallidus. With increasing age, the grey matter reduction of cortical midline structures however might contribute to the progression of dystonic symptoms due to loss of this compensatory control.
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Affiliation(s)
| | - Pedro Roa-Sanchez
- Department of Neurology, CEDIMAT, Santo Domingo, República Dominicana
| | - Herwin Speckter
- Department of Radiology, CEDIMAT, Santo Domingo, República Dominicana
| | | | - Eddy Perez-Then
- Department of Research, CEDIMAT, Santo Domingo, República Dominicana
| | - Jairo Oviedo
- Department of Radiology, CEDIMAT, Santo Domingo, República Dominicana
| | - Peter Stoeter
- Department of Radiology, CEDIMAT, Santo Domingo, República Dominicana.
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32
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Update on neurodegeneration with brain iron accumulation. Neurol Neurochir Pol 2014; 48:206-13. [PMID: 24981186 DOI: 10.1016/j.pjnns.2014.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 05/06/2014] [Indexed: 11/22/2022]
Abstract
Neurodegeneration with brain iron accumulation (NBIA) defines a heterogeneous group of progressive neurodegenerative disorders characterized by excessive iron accumulation in the brain, particularly affecting the basal ganglia. In the recent years considerable development in the field of neurodegenerative disorders has been observed. Novel genetic methods such as autozygosity mapping have recently identified several genetic causes of NBIA. Our knowledge about clinical spectrum has broadened and we are now more aware of an overlap between the different NBIA disorders as well as with other diseases. Neuropathologic point of view has also been changed. It has been postulated that pantothenate kinase-associated neurodegeneration (PKAN) is not synucleinopathy. However, exact pathologic mechanism of NBIA remains unknown. The situation implicates a development of new therapies, which still are symptomatic and often unsatisfactory. In the present review, some of the main clinical presentations, investigational findings and therapeutic results of the different NBIA disorders will be presented.
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33
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Wu YW, Hess CP, Singhal NS, Groden C, Toro C. Idiopathic basal ganglia calcifications: an atypical presentation of PKAN. Pediatr Neurol 2013; 49:351-4. [PMID: 23968566 DOI: 10.1016/j.pediatrneurol.2013.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 06/15/2013] [Accepted: 06/28/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND We report a patient with pantothenate kinase-associated neurodegeneration presenting as idiopathic basal ganglia calcifications, previously known as Fahr's disease. METHODS A teenage girl presented with slowly progressive dystonia. Her brain magnetic resonance imaging scan revealed T1 and T2 hypointensities in both globus pallidi, and no eye-of-the-tiger sign. Computed tomography showed dense globus pallidi calcifications. Metabolic evaluation was negative. The patient was diagnosed with idiopathic basal ganglia calcifications, a poorly understood syndrome of unknown cause. Whole exome sequencing was performed. RESULTS The patient was found to have two mutations in the pantothenate kinase 2 (PANK2) gene that have been previously associated with pantothenate kinase-associated neurodegeneration: a paternally inherited p.G521R and maternally inherited p.T528M. No deleterious changes were identified in genes associated with idiopathic basal ganglia calcifications or dystonia. CONCLUSIONS Pantothenate kinase-associated neurodegeneration should be considered in patients with idiopathic basal ganglia calcifications, especially when findings are confined to the globus pallidus.
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Affiliation(s)
- Yvonne W Wu
- Department of Neurology, University of California, San Francisco, California; Department of Pediatrics, University of California, San Francisco, California.
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34
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Schneider SA, Zorzi G, Nardocci N. Pathophysiology and treatment of neurodegeneration with brain iron accumulation in the pediatric population. Curr Treat Options Neurol 2013; 15:652-67. [PMID: 23888388 DOI: 10.1007/s11940-013-0254-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OPINION STATEMENT Syndromes of neurodegeneration with brain iron accumulation (NBIA) are characterized by increased iron deposition in the basal ganglia leading to complex progressive neurological symptoms. Several genetically distinct subforms have been recognized. In addition to pantothenate kinase-associated neurodegeneration (PKAN, NBIA1) and PLA2G6-associated neurodegeneration (PLAN, NBIA2), further genetic causes continue to be identified. Most of these present in childhood and are inherited following an autosomal recessive trait. However, the clinical and pathological spectrum has broadened and new age-dependent presentations have been described and there is overlap between the different NBIA disorders and with other diseases (such as spastic paraplegias, leukodystrophies and neuronal ceroid lipofuscinosis). Thus, additional clinical information (e.g., radiological findings such as precise patters of deposition of iron or co-occurrence of white matter lesions) may be useful when prioritizing genetic screening. Neuropathological work-up demonstrated variable involvement of iron deposition, but also Lewy bodies, neurofibrillary tangles and spheroid bodies. Treatment remains symptomatic. Here we review characteristic features of NBIA syndromes with a focus on pediatric cases.
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Affiliation(s)
- Susanne A Schneider
- Department of Neurology, University of Kiel, Arnold Heller Str 3, 24105, Kiel, Germany,
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35
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Dezortova M, Herynek V, Krssak M, Kronerwetter C, Trattnig S, Hajek M. Two forms of iron as an intrinsic contrast agent in the basal ganglia of PKAN patients. CONTRAST MEDIA & MOLECULAR IMAGING 2013; 7:509-15. [PMID: 22991317 DOI: 10.1002/cmmi.1482] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Iron deposits in the human brain can be considered as intrinsic contrast agents for magnetic resonance imaging and are used as markers of neurodegeneration accompanied by brain-iron accumulation. We studied one of them - panthotenate-kinase associated neurodegeneration (PKAN) - by using relaxometry at 1.5, 3.0 and 7 T in a group of six patients; we also measured a group of five volunteers for comparison. Based on the magnetic field dependency of antiferromagnetic ferritin and maghemite iron oxide nanoparticle relaxivities, we derived a two-component model for the description of iron deposits in the globus pallidus of PKAN patients. According to this model, we estimated the iron content in PKAN patients as 391 µg/ml of antiferromagnetic iron (ferritin) and 1.1 µg/ml of ferrimagnetic iron, compared with 178 µg/ml of iron in ferritin found in controls. This two-component model explains the nonlinear shape of the relaxometric curves in in vivo measurements of the relaxation rates of PKAN patients and is supported by histological findings in the original reports on PKAN patients.
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Affiliation(s)
- Monika Dezortova
- MR Unit, Department of Diagnostic and Interventional Radiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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36
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Kurian MA, Hayflick SJ. Pantothenate kinase-associated neurodegeneration (PKAN) and PLA2G6-associated neurodegeneration (PLAN): review of two major neurodegeneration with brain iron accumulation (NBIA) phenotypes. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2013; 110:49-71. [PMID: 24209433 PMCID: PMC6059649 DOI: 10.1016/b978-0-12-410502-7.00003-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Neurodegeneration with brain iron accumulation (NBIA) comprises a heterogeneous group of disorders characterized by the presence of radiologically discernible high brain iron, particularly within the basal ganglia. A number of childhood NBIA syndromes are described, of which two of the major subtypes are pantothenate kinase-associated neurodegeneration (PKAN) and PLA2G6-associated neurodegeneration (PLAN). PKAN and PLAN are autosomal recessive NBIA disorders due to mutations in PANK2 and PLA2G6, respectively. Presentation is usually in childhood, with features of neurological regression and motor dysfunction. In both PKAN and PLAN, a number of classical and atypical phenotypes are reported. In this chapter, we describe the clinical, radiological, and genetic features of these two disorders and also discuss the pathophysiological mechanisms postulated to play a role in disease pathogenesis.
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Affiliation(s)
- Manju A Kurian
- Neurosciences Unit, UCL-Institute of Child Health, London, United Kingdom; Department of Neurology, Great Ormond Street Hospital, London, United Kingdom.
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Schneider SA, Dusek P, Hardy J, Westenberger A, Jankovic J, Bhatia KP. Genetics and Pathophysiology of Neurodegeneration with Brain Iron Accumulation (NBIA). Curr Neuropharmacol 2013; 11:59-79. [PMID: 23814539 PMCID: PMC3580793 DOI: 10.2174/157015913804999469] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 01/19/2023] Open
Abstract
Our understanding of the syndromes of Neurodegeneration with Brain Iron Accumulation (NBIA) continues to grow considerably. In addition to the core syndromes of pantothenate kinase-associated neurodegeneration (PKAN, NBIA1) and PLA2G6-associated neurodegeneration (PLAN, NBIA2), several other genetic causes have been identified (including FA2H, C19orf12, ATP13A2, CP and FTL). In parallel, the clinical and pathological spectrum has broadened and new age-dependent presentations are being described. There is also growing recognition of overlap between the different NBIA disorders and other diseases including spastic paraplegias, leukodystrophies and neuronal ceroid lipofuscinosis which makes a diagnosis solely based on clinical findings challenging. Autopsy examination of genetically-confirmed cases demonstrates Lewy bodies, neurofibrillary tangles, and other hallmarks of apparently distinct neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer's disease. Until we disentangle the various NBIA genes and their related pathways and move towards pathogenesis-targeted therapies, the treatment remains symptomatic. Our aim here is to provide an overview of historical developments of research into iron metabolism and its relevance in neurodegenerative disorders. We then focus on clinical features and investigational findings in NBIA and summarize therapeutic results reviewing reports of iron chelation therapy and deep brain stimulation. We also discuss genetic and molecular underpinnings of the NBIA syndromes.
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Affiliation(s)
- Susanne A Schneider
- Department of Neurology; University of Kiel, 24105 Kiel, Germany
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, UK
| | - Petr Dusek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - John Hardy
- Department of Molecular Neuroscience, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, England
| | - Ana Westenberger
- Schilling Section of Clinical and Molecular Neurogenetics at the Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, UK
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Schneider SA, Bhatia KP. Excess iron harms the brain: the syndromes of neurodegeneration with brain iron accumulation (NBIA). J Neural Transm (Vienna) 2012; 120:695-703. [PMID: 23212724 DOI: 10.1007/s00702-012-0922-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 11/11/2012] [Indexed: 12/14/2022]
Abstract
Regulation of iron metabolism is crucial: both iron deficiency and iron overload can cause disease. In recent years, our understanding of the syndromes of Neurodegeneration with Brain Iron Accumulation (NBIA) continues to grow considerably. These are characterized by excessive iron deposition in the brain, mainly the basal ganglia. Pantothenate kinase-associated neurodegeneration (PKAN, NBIA1) and PLA2G6-associated neurodegeneration (PLAN, NBIA2) are the core syndromes, but several other genetic causes have been identified (including FA2H, C19orf12, ATP13A2, CP and FTL). These conditions show a wide clinical and pathological spectrum, with clinical overlap between the different NBIA disorders and other diseases including spastic paraplegias, leukodystrophies, and neuronal ceroid lipofuscinosis. Lewy body pathology was confirmed in some clinical subtypes (C19orf12-associated neurodegeneration and PLAN). Research aims at disentangling the various NBIA genes and their related pathways to move towards pathogenesis-targeted therapies. Until then treatment remains symptomatic. Here we will introduce the group of NBIA syndromes and review the main clinical features and investigational findings.
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Affiliation(s)
- Susanne A Schneider
- Department of Neurology, University Kiel, Arnold Heller Str. 3, 24105, Kiel, Germany.
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Abstract
PURPOSE OF REVIEW Recent years have witnessed the discoveries of several genes causing neurodegeneration with brain iron accumulation (NBIA) and subsequently their novel classification scheme was suggested. The first results of treatments with modern chelating drugs are also being published. RECENT FINDINGS Most recently, mutations in the c19orf12 gene encoding a mitochondrial protein of unknown function were identified in patients suffering from hitherto unknown NBIA presenting with a clinical phenotype similar to pantothenate kinase-associated neurodegeneration (PKAN) but with a slightly later onset. A case study has shown that mutations in the fatty-acid 2-hydroxylase gene may lead to various phenotypes combining the features of leukodystrophy and NBIA, supporting that abnormal metabolism of myelin and iron accumulation may have a common cause. A phase-II pilot study did not find any clinical improvement after chelating treatment in a group of PKAN patients. However, benefits of chelating treatment have been observed in individual patients with PKAN and idiopathic NBIA in another study. SUMMARY This review gives an outline of the clinical presentations of recently discovered NBIA syndromes and summarizes the clues to their differential diagnosis. While chelating treatment still remains experimental, advances have been made regarding the indications of deep brain stimulation in symptomatic treatment of NBIAs manifesting with generalized dystonia.
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40
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Schneider SA, Bhatia KP. Syndromes of neurodegeneration with brain iron accumulation. Semin Pediatr Neurol 2012; 19:57-66. [PMID: 22704258 DOI: 10.1016/j.spen.2012.03.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In parallel to recent developments of genetic techniques, understanding of the syndromes of neurodegeneration with brain iron accumulation has grown considerably. The acknowledged clinical spectrum continues to broaden, with age-dependent presentations being recognized. Postmortem brain examination of genetically confirmed cases has demonstrated Lewy bodies and/or tangles in some forms, bridging the gap to more common neurodegenerative disorders, including Parkinson disease. In this review, the major forms of neurodegeneration with brain iron accumulation (NBIA) are summarized, concentrating on clinical findings and molecular insights. In addition to pantothenate kinase-associated neurodegeneration (PKAN) and phospholipase A2-associated neurodegeneration (PLAN), fatty acid hydroxylase-associated neurodegeneration (FAHN) NBIA, mitochondrial protein-associated neurodegeneration, Kufor-Rakeb disease, aceruloplasminemia, neuroferritinopathy, and SENDA syndrome (static encephalopathy of childhood with neurodegeneration in adulthood) are discussed.
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Affiliation(s)
- Susanne A Schneider
- Schilling Section of Clinical and Molecular Neurogenetics, Department of Neurology, University of Lübeck, Lübeck, Germany.
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41
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Fermin-Delgado R, Roa-Sanchez P, Speckter H, Perez-Then E, Rivera-Mejia D, Foerster B, Stoeter P. Involvement of globus pallidus and midbrain nuclei in pantothenate kinase-associated neurodegeneration: measurement of T2 and T2* time. Clin Neuroradiol 2012; 23:11-5. [PMID: 22258188 DOI: 10.1007/s00062-011-0127-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 12/21/2011] [Indexed: 12/12/2022]
Abstract
PURPOSE To quantify involvement of globus pallidus and two midbrain nuclei (substantia nigra and red nucleus) in Pantothenate Kinase-Associated Neurodegeneration (PKAN). MATERIAL AND METHODS We performed T2 and T2* weighted imaging with calculation of the corresponding relaxation times on a subset of 5 patients from a larger group of 20 patients with PKAN from the southwest part of the Dominican Republic. Examinations were carried out on a 3T scanner and included a multi-echo spin-echo as well as a multi-echo gradient echo sequence. Results were compared to a control group of 19 volunteers. RESULTS T2 and T2* weighted sequences showed abnormal signal reduction in the globus pallidus of all patients. On T2* weighted imaging, abnormal signal in the substantia nigra could reliably be detected in 75% of cases, but differentiation from normal was less reliable in T2 weighted scans. Correspondingly, relaxation times differed from normal with very high significance (p < 0.0001) in the globus pallidus, but with with less significance in the substantia nigra (p ≤ 0.03). The red nucleus was not affected. CONCLUSIONS Signal reduction in the globus pallidus, which probably is due to abnormal accumulation of iron, is severe in PKAN and can be differentiated from normal with high reliability. The substantia nigra is affected to a lesser degree, and the red nucleus is not involved. The reason for this selective susceptibility of normally iron-rich brain structures for pathological accumulation of iron remains speculative. Our quantitative results might be helpful to assess the value of an iron chelation approach to therapy.
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Affiliation(s)
- R Fermin-Delgado
- Dep of Radiology, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
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