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Cerebral Folate Deficiency, Folate Receptor Alpha Autoantibodies and Leucovorin (Folinic Acid) Treatment in Autism Spectrum Disorders: A Systematic Review and Meta-Analysis. J Pers Med 2021; 11:jpm11111141. [PMID: 34834493 PMCID: PMC8622150 DOI: 10.3390/jpm11111141] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 01/26/2023] Open
Abstract
The cerebral folate receptor alpha (FRα) transports 5-methyltetrahydrofolate (5-MTHF) into the brain; low 5-MTHF in the brain causes cerebral folate deficiency (CFD). CFD has been associated with autism spectrum disorders (ASD) and is treated with d,l-leucovorin (folinic acid). One cause of CFD is an autoantibody that interferes with the function of the FRα. FRα autoantibodies (FRAAs) have been reported in ASD. A systematic review was performed to identify studies reporting FRAAs in association with ASD, or the use of d,l-leucovorin in the treatment of ASD. A meta-analysis examined the prevalence of FRAAs in ASD. The pooled prevalence of ASD in individuals with CFD was 44%, while the pooled prevalence of CFD in ASD was 38% (with a significant variation across studies due to heterogeneity). The etiology of CFD in ASD was attributed to FRAAs in 83% of the cases (with consistency across studies) and mitochondrial dysfunction in 43%. A significant inverse correlation was found between higher FRAA serum titers and lower 5-MTHF CSF concentrations in two studies. The prevalence of FRAA in ASD was 71% without significant variation across studies. Children with ASD were 19.03-fold more likely to be positive for a FRAA compared to typically developing children without an ASD sibling. For individuals with ASD and CFD, meta-analysis also found improvements with d,l-leucovorin in overall ASD symptoms (67%), irritability (58%), ataxia (88%), pyramidal signs (76%), movement disorders (47%), and epilepsy (75%). Twenty-one studies (including four placebo-controlled and three prospective, controlled) treated individuals with ASD using d,l-leucovorin. d,l-Leucovorin was found to significantly improve communication with medium-to-large effect sizes and have a positive effect on core ASD symptoms and associated behaviors (attention and stereotypy) in individual studies with large effect sizes. Significant adverse effects across studies were generally mild but the most common were aggression (9.5%), excitement or agitation (11.7%), headache (4.9%), insomnia (8.5%), and increased tantrums (6.2%). Taken together, d,l-leucovorin is associated with improvements in core and associated symptoms of ASD and appears safe and generally well-tolerated, with the strongest evidence coming from the blinded, placebo-controlled studies. Further studies would be helpful to confirm and expand on these findings.
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Gao Y, Sheng C, Xie RH, Sun W, Asztalos E, Moddemann D, Zwaigenbaum L, Walker M, Wen SW. New Perspective on Impact of Folic Acid Supplementation during Pregnancy on Neurodevelopment/Autism in the Offspring Children - A Systematic Review. PLoS One 2016; 11:e0165626. [PMID: 27875541 PMCID: PMC5119728 DOI: 10.1371/journal.pone.0165626] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 10/14/2016] [Indexed: 11/20/2022] Open
Abstract
It has been conclusively established that folic acid supplementation prior to and during early pregnancy (up to 12 weeks of gestation) can prevent neural tube defects (NTDs). We hypothesized that folate effects may extend from neuro-structural defects to alterations in neuro-behavioural and emotional skills including autism spectrum disorders (ASDs) and other developmental disorders. The objective of this review was to comprehensively evaluate evidence on the impact of folic acid on neurodevelopment other than NTDs. We conducted an online search of relevant literature compiled by the National Library of Medicine from Medline and EMBASE (searched on Dec 31, 2014: http://www.ncbi.nlm.nih.gov/entrez/query/fcgi and http://www.elsevier.com/online-tools/embase). We first created 3 files (search restricted to English literature) using the following key words: 1) folate or folic acid (171322 papers identified by this search); 2) maternal or pregnancy or pregnant or gestation or gestational or prenatal or antenatal or periconception or periconceptional (1349219 papers identified by this search); and 3) autism or autism spectrum disorders or developmental delay or development or neurodevelopment or mental or cognitive or language or personal-social or gross motor or fine motor or behaviour or intellectual or intelligence or Bayley Scale (8268145 papers identified by this search). We then merged the 3 files and reviewed the papers that addressed these three issues simultaneously. A total of 22 original papers that examined the association between folic acid supplementation in human pregnancy and neurodevelopment/autism were identified after the screening, with 15 studies showing a beneficial effect of folic acid supplementation on neurodevelopment/autism, 6 studies showed no statistically significant difference, while one study showed a harmful effect in > 5 mg folic acid supplementation/day during pregnancy. Folic acid supplementation in pregnancy may have beneficial effects on the neurodevelopment of children beyond its proven effect on NTDs.
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Affiliation(s)
- Yunfei Gao
- Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong, China
- OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Chao Sheng
- Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong, China
| | - Ri-hua Xie
- OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Canada
- Hunan University of Medicine Department of Nursing, Huaihua, Hunan, China
- McLaughlin Center for Population Risk Assessment, University of Ottawa Faculty of Medicine, Ottawa, Canada
| | - Wen Sun
- Department of Obstetrics and Gynecology, Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Elizabeth Asztalos
- Centre for Mother, Infant and Child Research, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Departments of Pediatrics and Obstetrics and Gynecology Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Diane Moddemann
- Department of Pediatrics and Child Health and Neonatal Follow-up Program, University of Manitoba, Winnipeg, Canada
| | - Lonnie Zwaigenbaum
- Departments of Pediatrics and of Psychiatry, University of Alberta, Edmonton, Canada
- Autism Research Centre, Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Mark Walker
- OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Shi Wu Wen
- OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Canada
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Bhavsar AS, Verma S, Lamba R, Lall CG, Koenigsknecht V, Rajesh A. Abdominal manifestations of neurologic disorders. Radiographics 2013; 33:135-53. [PMID: 23322834 DOI: 10.1148/rg.331125097] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A variety of disorders-including infectious, inflammatory, hereditary, and metabolic diseases-may affect both the brain and abdominal cavity, and the findings in one region may help establish the diagnosis or limit the differential diagnosis. Establishing an accurate early diagnosis enables clinicians to adequately manage these unusual diseases and potentially avert life-threatening complications. For example, an early diagnosis of Gardner syndrome enables annual sigmoid- or colonoscopy and ultrasonography. In many conditions, abdominal manifestations precede neurologic manifestations and may have prognostic significance. Patients with celiac disease more often present with abdominal manifestations such as duodenitis, slow transit time, reversal of the jejunal-ileal fold pattern, and transient small bowel intussusception than with intracranial manifestations. In other conditions, the neurologic manifestations may be the same as the presenting symptoms. For example, patients with Gardner syndrome may initially present with multiple mandibular or sinonasal osteomas. In addition, sarcoidosis may manifest with multifocal enhancing dural masses. Abdominal and neurologic manifestations may even occur simultaneously, as in several of the phakomatoses such as neurofibromatosis type 1, tuberous sclerosis complex, and von Hippel-Lindau syndrome. Ultimately, familiarity with the appearances of these conditions allows radiologists to pinpoint a diagnosis, even when imaging findings in either location are nonspecific.
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Affiliation(s)
- Anil S Bhavsar
- Department of Radiology, University of Cincinnati Hospitals, 234 Goodman St, ML 0761, PO Box 670761, Cincinnati, OH 45267-0761, USA.
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Ferretti A, Parisi P, Villa MP. The role of hyperhomocysteinemia in neurological features associated with coeliac disease. Med Hypotheses 2013; 81:524-31. [PMID: 23891042 DOI: 10.1016/j.mehy.2013.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 06/15/2013] [Accepted: 06/22/2013] [Indexed: 12/14/2022]
Abstract
Although a range of neurological and psychiatric disorders are widely reported to be associated with coeliac patients, their pathogenesis remains unclear. Some such disorders are believed to be secondary to vitamin deficiency due to malabsorption, others to immune mechanisms. We hypothesise that hyperhomocysteinemia might, by damaging the blood-brain barrier, expose neuronal tissue to all neuro-irritative metabolites, such as homocysteine itself, a neurotoxic excitatory and proconvulsant amino acid. Neurons respond to these stimuli through hyperexcitability, thereby predisposing subjects to neurological disorders such as epilepsy and headache. Furthermore, persisting endothelial damage may cause blood extravasation and subsequent deposition of calcium salts. We suggest that this might be the pathogenesis of the CEC syndrome, which is characterized by the association of coeliac disease, epilepsy and cerebral calcifications. Indeed, homocysteine plays a well-known role in cardiovascular endothelial dysfunction, with high serum and cerebrospinal fluid levels often being reported in coeliac patients. Moreover, data in the literature show a strong, growing association of homocysteine with epilepsy and migraine in non-coeliac subjects. Despite these findings, homocysteine has never been held directly responsible for neuronal functional features (neuronal hyperexcitability underlying epilepsy and migraine) and structural brain damage (expressed as cerebral calcification) in coeliac patients. Damage to the blood-brain barrier might also facilitate immune reactions against neuronal tissue to a considerable extent. This hypothesis combines the two afore-mentioned theories (vitamin deficiency due to malabsorption and immune mechanisms). We also wish to point out that no studies have yet investigated the prevalence of neuronal hyperexcitability and subclinical electroencephalic abnormalities in children and adults with newly-diagnosed coeliac disease before the introduction of a gluten-free diet, and in particular any changes following the introduction of the diet. We believe that the onset of clinical symptoms such as migraine and convulsions is preceded by a period in which damage is expressed exclusively by subclinical electroencephalic abnormalities; persisting damage to neuronal tissue subsequently leads to clinical manifestations. We propose two types of investigations: the first is to determine whether newly-diagnosed coeliac patients with hyperhomocysteinemia are a subgroup at risk for neurological features (clinical and subclinical); the second is to determine whether appropriate treatment of hyperhomocysteinemia and vitamin B status deficiency improves neurological abnormalities and reduces the risk of cerebral calcifications. The aim of these investigations is to develop new therapeutic strategies designed to prevent neuronal damage and increase the quality of life in children affected by such disorders.
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Affiliation(s)
- Alessandro Ferretti
- Pediatric Sleep Disease Centre, Child Neurology, NESMOS Department, School of Medicine and Psychology, Sapienza University of Rome, S. Andrea Hospital, Via di Grottarossa 1035-39, 00189 Rome, Italy
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Abstract
Neurologic complications of celiac disease (CD) include ataxia and peripheral neuropathy, which can be the presenting symptoms and signs. Early diagnosis and intervention could prevent development of further neurologic and systemic complications. Questions remain regarding the prevalence of the neurologic complications, the pathophysiological mechanisms, and the effectiveness of therapy or response to a gluten-free diet.
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Licchetta L, Bisulli F, Di Vito L, La Morgia C, Naldi I, Volta U, Tinuper P. Epilepsy in coeliac disease: not just a matter of calcifications. Neurol Sci 2011; 32:1069-74. [PMID: 21630037 DOI: 10.1007/s10072-011-0629-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 05/11/2011] [Indexed: 10/18/2022]
Abstract
The clinical spectrum of epilepsy related to celiac disease (CD) ranges from benign syndromes to intractable epilepsy with evolution to a severe encephalopathy, including progressive myoclonic epilepsy (PME). A more specific syndrome characterised by the association of CD, epilepsy, and occipital calcifications (CEC) has also been reported. This study describes the clinical, neuroradiological and neurophysiological features of eight consecutive epileptic patients with a diagnosis of CD confirmed by laboratory tests and duodenal biopsy, referring to our Epilepsy Centre. Despite its small size, this series reflects the broad spectrum of the association between the two diseases, since it includes four cases of CEC and a more heterogeneous group of patients without cerebral calcifications comprising one case of limbic encephalitis and a case of PME. Our cohort suggests that more complex pathogenic mechanisms may be involved in the association between epilepsy and CD, and that CD should be included in the screening for PME etiology. Our data also confirm the major involvement of the occipital lobe, and minimise both the importance of calcifications in epileptogenesis and folic acid deficit in the development of calcifications.
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Affiliation(s)
- Laura Licchetta
- Department of Neurological Sciences, University of Bologna, via Ugo Foscolo 7, 40123 Bologna, Italy.
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Abstract
Celiac disease (CD) long has been associated with neurologic and psychiatric disorders including cerebellar ataxia, peripheral neuropathy, epilepsy, dementia, and depression. Earlier reports mainly have documented the involvement of the nervous system as a complication of prediagnosed CD. However, more recent studies have emphasized that a wider spectrum of neurologic syndromes may be the presenting extraintestinal manifestation of gluten sensitivity with or without intestinal pathology. These include migraine, encephalopathy, chorea, brain stem dysfunction, myelopathy, mononeuritis multiplex, Guillain-Barre-like syndrome, and neuropathy with positive antiganglioside antibodies. The association between most neurologic syndromes described and gluten sensitivity remains to be confirmed by larger epidemiologic studies. It further has been suggested that gluten sensitivity (as evidenced by high antigliadin antibodies) is a common cause of neurologic syndromes (notably cerebellar ataxia) of otherwise unknown cause. Additional studies showed high prevalence of gluten sensitivity in genetic neurodegenerative disorders such as hereditary spinocerebellar ataxia and Huntington's disease. It remains unclear whether gluten sensitivity contributes to the pathogenesis of these disorders or whether it represents an epiphenomenon. Studies of gluten-free diet in patients with gluten sensitivity and neurologic syndromes have shown variable results. Diet trials also have been inconclusive in autism and schizophrenia, 2 diseases in which sensitivity to dietary gluten has been implicated. Further studies clearly are needed to assess the efficacy of gluten-free diet and to address the underlying mechanisms of nervous system pathology in gluten sensitivity.
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Affiliation(s)
- Khalafalla O Bushara
- Neurology Department, Minneapolis VA Medical Center, University of Minnesota, Minneapolis, Minnesota, USA.
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Gobbi G. Coeliac disease, epilepsy and cerebral calcifications. Brain Dev 2005; 27:189-200. [PMID: 15737700 DOI: 10.1016/j.braindev.2004.05.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2003] [Revised: 03/10/2004] [Accepted: 05/11/2004] [Indexed: 12/12/2022]
Abstract
Coeliac disease, epilepsy and cerebral calcifications (CEC) syndrome is a rare clinical condition. One hundred and seventy-one patients have been reported in the literature. Patients are mostly from Italy, Spain, and Argentina, suggesting a geographically restricted condition. Epilepsy is more frequently characterized by occipital seizures. It may be benign or drug-resistant, sometime evolving into severe epileptic encephalopathy. Gluten free diet (GFD) efficacy seems to be inversely related to the duration of epilepsy and the young age of the patient. Patients with cerebral calcifications (CC) and coeliac disease (CD) without epilepsy are considered as having an incomplete form of CEC syndrome. Some patients with epilepsy and CC without CD are supposed to have a CEC syndrome with silent or latent CD. Whether CEC syndrome is a genetic condition, or whether epilepsy and/or CC are a consequence of an untreated CD is unknown yet. Since histopathological findings seem to be the expression of vascular calcified malformation, CEC syndrome may be considered a genetically determined entity, such as a type of Sturge-Weber-like phacomatosis. Moreover, CEC, as well as CD, is associated with HLA-DQ2 and HLA-DQ8 phenotype and genotype. The progressive growth and late occurrence of CC before beginning a GFD, the demonstration of anti-gliadin antibodies in the cerebro-spinal fluid and the association with HLA class II genes, suggest that an immune reaction originating from the jejunal mucosa, triggered by gliadin in gluten intolerance predisposed subjects (HLA phenotype) may be responsible for seizures and CC. Moreover, a long-lasting untreated CD folic acid deficiency may cause calcifications. Probably, CEC is considered a genetic, non-inherited, ethnically and geographically restricted syndrome associated with environmental factors.
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Affiliation(s)
- Giuseppe Gobbi
- Ospedale Maggiore Pizzardi, Unita Operative di Neurologia Infan., Largo Nigrisoli 2, 40133 Bologna, Italy.
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Arroyo HA, De Rosa S, Ruggieri V, de Dávila MTG, Fejerman N. Epilepsy, occipital calcifications, and oligosymptomatic celiac disease in childhood. J Child Neurol 2002; 17:800-6. [PMID: 12585717 DOI: 10.1177/08830738020170110801] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The association of epilepsy, occipital calcifications, and celiac disease has been recognized as a distinct syndrome. The objective of this study was to present the clinical, electrophysiologic, and neuroradiologic features in a series of patients with this syndrome. Thirty-two patients with the constellation of epilepsy, occipital calcifications, and celiac disease were identified in our epilepsy clinic. The mean age was 11 years and the mean length of follow-up was 7.4 years. The 1990 criteria of the European Society of Pediatric Gastroenterology and Nutrition were used to diagnose celiac disease. The Kruskal-Wallis statistics test was employed with a signficance of P < .05. Thirty-one patients had partial seizures, 21 of them with symptoms related to the occipital lobe. In most patients, the epilepsy was controlled or the seizures were sporadic. Three developed severe epilepsy. Occipital calcifications were present in all cases. Computed tomography in 7 patients showed hypodense areas in the white matter around calcifications, which decreased or disappeared after a period of gluten-free diet in 3 patients. A favorable outcome of epilepsy was detected in patients with the earliest dietary therapy. This study presents the largest series of children with this syndrome outside Italy. White-matter hypodensities surrounding calcifications are rarely reported. A prompt diagnosis of celiac disease might improve the evolution of the epilepsy and may improve cognitive status.
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Affiliation(s)
- Hugo A Arroyo
- Department of Neurology, Hospital Nacional de Pediatría JP Garrahan, Buenos Aires, Argentina.
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Santos CHS, Almeida ILBD, Gomes MDC, Serafim A, Pereira MM, Muszkat M, Rizzutti S, Patrício FRDS, Miranda MC, Vilanova LCP. Calcificação intracraniana occipital bilateral, epilepsia e doença celíaca: relato de caso. ARQUIVOS DE NEURO-PSIQUIATRIA 2002. [DOI: 10.1590/s0004-282x2002000500028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Relatamos o caso de uma menina com 6 anos de idade que apresentava episódios recorrentes de diarréia desde os 6 meses de vida associada a anemia ferropriva com desenvolvimento neuromotor normal. Aos 3 anos de idade começou a apresentar crises parciais que foram controladas com carbamazepina. Tomografia computadorizada de crânio aos 5 anos demonstrou calcificações girais grosseiras nas regiões occipital e parietal posterior bilateralmente. A ressonância magnética de crânio evidenciou áreas de hipossinal em T2 na região parieto-occipital bilateralmente. Realizou investigação para síndrome de mal absorção incluindo estudo da função digestivo/absortiva (teste D-xilose), avaliação sorológica (anticorpos antigliadina, antiendomísio e antitransglutaminase) e biopsia de intestino delgado que demonstrou intensa atrofia de vilosidades com infiltrado linfoplasmocitário no córion compatível com doença celíaca.
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Kieslich M, Errázuriz G, Posselt HG, Moeller-Hartmann W, Zanella F, Boehles H. Brain white-matter lesions in celiac disease: a prospective study of 75 diet-treated patients. Pediatrics 2001; 108:E21. [PMID: 11483831 DOI: 10.1542/peds.108.2.e21] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Celiac disease (CD), or gluten sensitivity, is considered to be a state of heightened immunologic responsiveness to ingested gluten proteins in genetically predisposed individuals. The gastrointestinal manifestation suggests a severe enteropathy of the small intestine with malabsorption, steatorrhea, and weight loss because of a deranged mucosal immune response. Neurologic complications occur, especially epilepsy, possibly associated with occipital calcifications or folate deficiency and cerebellar ataxia. There have been reports of brain white-matter lesions as an extraintestinal manifestation in Crohn disease and ulcerative colitis but not in CD. METHODS In this study, 75 diet-treated mainly pediatric patients with biopsy-proven CD underwent prospectively clinical neurologic examinations, laboratory investigations, electroencephalography, computed tomography, and magnetic resonance imaging. The age range was 2.8 to 24.2 years with a mean of 11.6 years. The mean period of gluten exposure was 2.4 years. RESULTS Ten patients had neurologic findings such as febrile seizures, single generalized seizures, mild ataxia, and muscular hypotonia with retarded motor development. No folate deficiency was found. The hippocampal regions showed no abnormalities. Computed tomography did not reveal any cerebral calcifications, but magnetic resonance imaging detected unilateral and bilateral T2-hyperintensive white-matter lesions in 15 patients (20%). There was no correlation between these lesions and dietary compliance or neurologic or electroencephalographic abnormalities. The mean gluten exposure time of these patients was slightly increased (not significant). CONCLUSIONS Focal white-matter lesions in the brain may represent an extraintestinal manifestation of CD. They may be ischemic in origin as a result of a vasculitis or caused by inflammatory demyelination. They seem to be more typical of pediatric CD than cerebral calcifications. Their prognostic value is unclear and needs to be elucidated in additional studies. CD should be suggested as a differential diagnosis in children with unclear white-matter lesions even without intestinal symptoms.
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Affiliation(s)
- M Kieslich
- Department of Pediatrics, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
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La Mantia L, Pollo B, Savoiardo M, Costa A, Eoli M, Allegranza A, Boiardi A, Cestari C. Meningo-cortical calcifying angiomatosis and celiac disease. Clin Neurol Neurosurg 1998; 100:209-15. [PMID: 9822844 DOI: 10.1016/s0303-8467(98)00029-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A woman with ophthalmic migraine was found to have bilateral cerebellar and cerebral calcifications. She progressively developed severe intracranial hypertension, with swelling of the brain and downward transtentorial and tonsillar herniation. Because steroid treatment was ineffective, the right occipital pole was resected. Histological study demonstrated meningo-cortical calcifying angiomatosis. Within 2 months, brain swelling and papilledema disappeared. Subtle signs of malabsorption led to the hypothesis of celiac disease, confirmed by jejunal biopsy. Similar cerebral histological findings have been reported in the brain of two young patients affected by epilepsy and celiac disease. The association between cerebral calcifications and celiac disease is peculiar; the pathogenetic relationship is unknown.
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Affiliation(s)
- L La Mantia
- Department of Clinical Neurology, Istituto Nazionale Neurologica C. Besta, Milan, Italy
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Bernasconi A, Bernasconi N, Andermann F, Dubeau F, Guberman A, Gobbi G, Olivier A. Celiac disease, bilateral occipital calcifications and intractable epilepsy: mechanisms of seizure origin. Epilepsia 1998; 39:300-6. [PMID: 9578049 DOI: 10.1111/j.1528-1157.1998.tb01377.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To elucidate the mechanisms of seizure origin in patients with celiac disease and bilateral occipital calcifications (CEBOC). Individuals with CEBOC frequently present with occipital lobe seizures, but additional lesions and additional attack patterns may occur. METHODS We studied two men and one woman who had CEBOC. Villous atrophy was revealed in the two patients who underwent duodenal biopsy. All had a comprehensive presurgical evaluation, including prolonged video-EEG recordings. Two had magnetic resonance imaging (MRI) with volumetric study of mesial temporal structures (MRIV). One patient had undergone stereotactic intracranial depth electrode studies (SEEG). RESULTS All patients presented with intractable complex partial seizures. Two had partial simple seizures with visual aura. Neurologic examination was normal; one was of normal intelligence, and two were mildly retarded. Neuroimaging studies showed that each had bilateral occipital calcifications as well as epileptiform abnormalities over temporal lobes. In one, MRI showed an additional right frontal lesion, but SEEG demonstrated right occipital lobe seizure origin with anterior spread; this male patient later underwent a right occipital lobe resection. Another with a history of prolonged febrile convulsions had bilateral hippocampal and amygdalar atrophy demonstrated by MRIV. CONCLUSIONS In one patient, SEEG confirmed that seizures originated in the occipital lobe. The presence of dual pathology was demonstrated in another, raising the possibility of both occipital and temporal seizure onset. The presence of extraoccipital lesions or of mesial temporal atrophy requires SEEG for clarification of seizure onset. In the absence of confounding factors and when laterality can be demonstrated, surgical treatment may be considered.
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Affiliation(s)
- A Bernasconi
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Quebec, Canada
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Hernández MA, Colina G, Ortigosa L. Epilepsy, cerebral calcifications and clinical or subclinical coeliac disease. Course and follow up with gluten-free diet. Seizure 1998; 7:49-54. [PMID: 9548226 DOI: 10.1016/s1059-1311(98)90008-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We have studied four patients (three male, one female, age range 15-25 years) with epilepsy, bilateral occipital calcifications and latent coeliac disease (CD). The epilepsy started at mean age 7 years, in three cases there were partial seizures and in one case generalized seizure. Three cases had symptoms suggesting malabsorptive syndrome during infancy and one case was diagnosed CD before the onset of seizures. In all cases serologic markers of CD were found, especially antiendomisium antibody, and intestinal biopsy indicated several grades of atrophy. The electroencephalograph (EEG) findings pointed to focal abnormalities in three patients and generalized abnormalities in one patient. In all cases computer tomography (CT) showed bilateral, almost symmetrical occipital calcifications in the cortical subcortical layers. The enhanced CT were unremarkable and magnetic resonance images (MRI) were normal. After diagnosis of CD, all patients followed a gluten-free diet and in three patients a significant reduction in seizure frequency was observed. CD should be ruled out in all cases of epilepsy, cerebral calcifications of unexplained origin and malabsorption syndrome in infancy.
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Affiliation(s)
- M A Hernández
- Neurology Department, Nuestra Señora de la Candelaria Hospital, Santa Cruz de Tenerife, Spain.
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Vignolo M, Taddei L, Garzia P, Naselli A, Veneselli E, Aicardi G. Occipital cerebral calcifications and celiac disease: an additional case. J Pediatr Gastroenterol Nutr 1996; 23:194-6. [PMID: 8856590 DOI: 10.1097/00005176-199608000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- M Vignolo
- Istituto di Puericultura e Medicina Neonatale, Universitá di Genova, Italy
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Holmes GK. Non-malignant complications of coeliac disease. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1996; 412:68-75. [PMID: 8783765 DOI: 10.1111/j.1651-2227.1996.tb14257.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients with coeliac disease are at increased risk of developing complications which increase morbidity and mortality. Emphasis on malignant complications has often overshadowed the non-malignant risks, which have received relatively little attention, although some of these can be very troublesome and even life-threatening. This article points out that a large population of unidentified or neglected coeliac patients is at potential risk. The challenge is to identify this group by case-finding or screening programmes in selected populations, so that they can be offered a gluten-free diet and other treatments which will not only improve general health but may also prevent or reduce the development of health problems. The non-malignant risks are outlined and bone and neuropsychiatric disturbances considered in more detail because of recent developments in these areas.
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Affiliation(s)
- G K Holmes
- Department of Medicine, Derbyshire Royal Infirmary, Derby, UK
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18
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Abstract
1. Folic acid deficiency has been associated with diverse neuropsychiatric symptoms. 2. This paper discusses the impact of folate on brain development, maturation and function and reviews the role of folate in psychiatric disorders, particularly childhood disorders. 3. A brief case report examines the use of folate in the treatment of attentional problems in a child with fragile X syndrome.
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Affiliation(s)
- J M Greenblatt
- Department of Psychiatry, Johns Hopkins University School of Medicine
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19
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Pascotto A, Coppola G, Ecuba P, Liguori G, Guandalini S. Epilepsy and occipital calcifications with or without celiac disease: Report of four cases. ACTA ACUST UNITED AC 1994. [DOI: 10.1016/0896-6974(94)90010-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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20
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Magaudda A, Dalla Bernardina B, De Marco P, Sfaello Z, Longo M, Colamaria V, Daniele O, Tortorella G, Tata MA, Di Perri R. Bilateral occipital calcification, epilepsy and coeliac disease: clinical and neuroimaging features of a new syndrome. J Neurol Neurosurg Psychiatry 1993; 56:885-9. [PMID: 8350105 PMCID: PMC1015143 DOI: 10.1136/jnnp.56.8.885] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Twenty patients affected by bilateral occipital cortical-subcortical calcification (BOC) are described, 19 (95%) had epilepsy. In 8 of 16 cases studied, intestinal biopsy revealed coeliac disease. Fourteen patients had occipital partial epilepsy with a relatively benign outcome, while 4 patients were affected by a severe form of epilepsy, with very frequent, drug-resistant, generalised and partial seizures with mental deterioration. One patient had a single episode of convulsive status epilepticus at four months of age. The neurological examination was normal in all patients. CT showed flocculo-nodular, cortico-subcortical BOC, without enhancement and without lobar or hemispheric atrophy. MRI was normal. The clinical and neuroimaging features of these patients are different therefore from those with the Sturge-Weber Syndrome. The study confirms a high prevalence of coliac disease in patients with BOC, but the relationship between these two pathologies still needs to be clarified.
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Affiliation(s)
- A Magaudda
- Institute of Neurological and Neurosurgical Sciences, University of Messina, Italy
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21
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Tiacci C, D'Alessandro P, Cantisani TA, Piccirilli M, Signorini E, Pelli MA, Cavalletti ML, Castellucci G, Palmeri S, Battisti C. Epilepsy with bilateral occipital calcifications: Sturge-Weber variant or a different encephalopathy? Epilepsia 1993; 34:528-39. [PMID: 8504785 DOI: 10.1111/j.1528-1157.1993.tb02592.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A series of cases of epilepsy with associated bilateral occipital calcifications (EBOC) without signs of phakomatosis and without any disorders known to produce cerebral calcifications have been reported. It is unclear whether EBOC is an incomplete variant of Sturge-Weber disease (SWD) or if it is a different, as yet undefined encephalopathy. We describe four new cases of EBOC that are different clinically by age of onset, type, course, severity of epilepsy, and associated cognitive deficits but that are linked by similar neuroradiologic findings. Similar to cases described in the literature, there is convincing evidence in favor of the hypothesis that these cases belong to an encephalopathy different from SWD and frequently associated with celiac disease.
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Affiliation(s)
- C Tiacci
- Unità Organica di Neurofisiopatologia, Ospedale Policlinico, Perugia, Italy
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22
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Ambrosetto G, Antonini L, Tassinari CA. Occipital lobe seizures related to clinically asymptomatic celiac disease in adulthood. Epilepsia 1992; 33:476-81. [PMID: 1592023 DOI: 10.1111/j.1528-1157.1992.tb01695.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
We report the electroclinical ictal findings of four epileptic patients with clinically asymptomatic celiac disease (CD). Celiac disease diagnosis was suspected by past history and/or computed tomography (CT) findings in all patients and confirmed by laboratory tests and jejunal biopsy. All patients had paroxysmal visual manifestations and ictal EEG discharges arising from the occipital lobe. Epilepsy evolution was favorable in two patients and severe in 2, regardless of CT evidence of occipital corticosubcortical calcifications in 2 patients. Occipital lobe seizures may be characteristic of the epilepsy related to CD, and epileptic patients with these seizures of unknown etiology should be carefully investigated for malabsorption. If past history and/or laboratory tests suggest gastrointestinal (GI) dysfunction they should also undergo small intestinal biopsy even if they do not have GI tract symptoms.
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Affiliation(s)
- G Ambrosetto
- Institute of Neurology, University of Bologna, Italy
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23
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Gobbi G, Ambrosetto P, Zaniboni MG, Lambertini A, Ambrosioni G, Tassinari CA. Celiac disease, posterior cerebral calcifications and epilepsy. Brain Dev 1992; 14:23-9. [PMID: 1590524 DOI: 10.1016/s0387-7604(12)80275-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ten patients (5 males) affected by epilepsy with cerebral calcifications of unknown etiology mainly located in the posterior regions were subjected to a battery of tests including an intestinal biopsy. Our aim was to establish whether or not the patients also suffered from celiac disease. Celiac diseases was found in 6 patients. This result and the individual cases reported in the literature suggest that this triad of diseases (celiac disease, posterior cerebral calcifications and epilepsy) are casually related. The same HLA phenotype was found in all 10 patients, i.e., including the cases without celiac disease, suggesting an underlying disorder of the immune system. Our results emphasize that particular attention should be paid to a search for celiac disease in all patients with epilepsy and posterior cerebral calcifications.
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Affiliation(s)
- G Gobbi
- Neurological Institute, University of Bologna, Italy
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24
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Ventura A, Bouquet F, Sartorelli C, Barbi E, Torre G, Tommasini G. Coeliac disease, folic acid deficiency and epilepsy with cerebral calcifications. ACTA PAEDIATRICA SCANDINAVICA 1991; 80:559-62. [PMID: 1908173 DOI: 10.1111/j.1651-2227.1991.tb11906.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Two cases of focal occipital epilepsy with cerebral calcifications poorly responsive to antiepileptic treatment are described. In both cases coeliac disease was diagnosed and folic acid deficiency documented. A gluten-free diet and a brief supplementation with folic acid lead to a complete EEG and clinical normalization in one case and to a significant improvement of EEG and seizure control in the other.
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Affiliation(s)
- A Ventura
- Department of Paediatrics, University Hospital, Istituto per l'Infanzia Burlo Garofolo, Italy
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25
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Close PJ, Carty HM. Transient gyriform brightness on non-contrast enhanced computed tomography (CT) brain scan of seven infants. Pediatr Radiol 1991; 21:189-92. [PMID: 2047156 DOI: 10.1007/bf02011044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Spontaneous gyriform brightness seen on CT scan is an unusual finding unless associated with arteriovenous malformations (AVM). There are sporadic case reports in the literature of its occurrence in association with herpex simplex virus encephalitis (HSVE), purulent meningitis, following chemotherapy for leukaemia, in a child with chronic renal failure, and in a child with folic acid deficiency. We present a series of seven cases exhibiting this phenomenon, none of whom have AVMs, who have been scanned at this hospital in the first 2 1/2 years following the installation of a CT scanner. Four of the cases had congenital heart disease requiring corrective surgery or cardiac catheterisation. The other three had probable meningo-encephalitis. In all cases the gyriform brightness followed an ischaemic insult to the child's brain. We hypothesise that this phenomenon is an ischaemic response in the immature brain and that its occurrence is not so rare as the literature may suggest.
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Affiliation(s)
- P J Close
- Royal Liverpool Childrens Hospital, UK
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Nalin A, Ruggerini C, Ferrari E, Galli V, Ferrari P, Finelli T. [Clinical aspects, differential diagnosis and evolution of visual epileptic seizures in children]. Neurophysiol Clin 1989; 19:25-36. [PMID: 2716729 DOI: 10.1016/s0987-7053(89)80082-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We studied 13 boys and girls, treated for ictal visual episodes, followed-up in the Center for Epilepsy of the University of Modena. In 10 cases visual symptoms (amaurosis, hallucinations, and illusions) started between 6 and 14 years, associated with occipital EEG anomalies. In 6 cases, EEG abnormalities (sharp-waves, slow waves, spikes, spike-waves) disappeared after eyes opening. In the history of half of our cases, there was no significant antecedent. Normal intelligence and behaviour were present in all cases. Only in one case, CT demonstrated bilateral occipital calcifications. In the other 9, visual ictal symptoms disappeared after antiepileptic treatment. We think that these last cases present the characteristic features of Benign Occipital Epilepsy described by Gastaut (1982-1985). On the basis of our results, we can confirm the existence of this syndrome, even if it is rare. Nevertheless, 3 of our cases with visual symptoms, don't show the typical picture of BOE, and must be diagnostically distinguished from psychiatric disorders, basilar migraine, and other partial epilepsies.
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Affiliation(s)
- A Nalin
- Service de neuropsychiatrie infantile et Service de pédiatrie du Centre hospitalier universitaire de Modena, Italie
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27
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Battistella PA, Mattesi P, Casara GL, Carollo C, Condini A, Allegri F, Rigon F. Bilateral cerebral occipital calcifications and migraine-like headache. Cephalalgia 1987; 7:125-9. [PMID: 3111714 DOI: 10.1046/j.1468-2982.1987.0702125.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Computed tomography scanning in two young patients with recurrent, pulsating, migraine-like headache showed parieto-occipital calcifications. One patient presented with an atypical form of the Sturge-Weber syndrome, and the other with celiac disease and folic acid deficiency. The clinical features were analyzed and compared with those in other cases reported in the recent literature which have shown bioccipital calcifications but no cutaneous angiomas, sometimes associated with visual and/or intelligence deficit and epilepsy. Finally, the possible connection between cerebral calcifications and headache is discussed.
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28
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Russo A, Di Bella D, Lo Bianco M, Rizzari C, Schilirò G. Convulsions and intracranial calcifications in a leukemic infant receiving only intrathecal methotrexate as central nervous system prophylaxis. Pediatr Hematol Oncol 1987; 4:269-72. [PMID: 3152931 DOI: 10.3109/08880018709141277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- A Russo
- Istituto di Clinica Pediatrica I, Università di Catania, Italy
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29
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30
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Yamanouchi Y, Someda K, Tani S, Kawamura Y, Matsumura H. Gyriform calcification after purulent meningitis. Neuroradiology 1980; 20:159-62. [PMID: 7443045 DOI: 10.1007/bf00341781] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A 2-month-old baby developed bilateral frontoparietal gyriform calcification after purulent meningitis. Biopsy revealed severe cerebral cortical degeneration with many calcified foci. Another feature of interest was reabsorption of calcification over a period of 4.5 months.
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31
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32
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Crosley CJ, Binet EF. Sturge-Weber Syndrome: presentation as a focal seizure disorder without nevus flammeus. Clin Pediatr (Phila) 1978; 17:606-9. [PMID: 97040 DOI: 10.1177/000992287801700801] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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33
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Garwicz S, Mortensson W. Cerebral calcifications associated with intrathecal methotrexate therapy in acute lymphocytic leukemia. J Pediatr 1977; 90:496-7. [PMID: 264958 DOI: 10.1016/s0022-3476(77)80733-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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