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Barros CDS, Coutinho A, Tengan CH. Arginine Supplementation in MELAS Syndrome: What Do We Know about the Mechanisms? Int J Mol Sci 2024; 25:3629. [PMID: 38612442 PMCID: PMC11011289 DOI: 10.3390/ijms25073629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
MELAS syndrome, characterized by mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes, represents a devastating mitochondrial disease, with the stroke-like episodes being its primary manifestation. Arginine supplementation has been used and recommended as a treatment for these acute attacks; however, insufficient evidence exists to support this treatment for MELAS. The mechanisms underlying the effect of arginine on MELAS pathophysiology remain unclear, although it is hypothesized that arginine could increase nitric oxide availability and, consequently, enhance blood supply to the brain. A more comprehensive understanding of these mechanisms is necessary to improve treatment strategies, such as dose and regimen adjustments; identify which patients could benefit the most; and establish potential markers for follow-up. This review aims to analyze the existing evidence concerning the mechanisms through which arginine supplementation impacts MELAS pathophysiology and provide the current scenario and perspectives for future investigations.
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Affiliation(s)
| | | | - Celia H. Tengan
- Division of Neurology, Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo 04039-032, Brazil; (C.D.S.B.); (A.C.)
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Lluch-Requerey C, Montilla-Garrido MA, Morgado-García-Polavieja JI, Gragera-Martínez Á, Gómez-Menchero A. Left ventricular hypertrophy. Is there only hypertrophic cardiomyopathy? ARCHIVOS DE CARDIOLOGIA DE MEXICO 2024; 94:123-126. [PMID: 38507316 PMCID: PMC11160531 DOI: 10.24875/acm.22000266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 06/07/2023] [Indexed: 03/22/2024] Open
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Dobrynina LA, Shabalina AA, Shamtieva KV, Kremneva EI, Zabitova MR, Krotenkova MV, Burmak AG, Gnedovskaya EV. L-Arginine-eNOS-NO Functional System in Brain Damage and Cognitive Impairments in Cerebral Small Vessel Disease. Int J Mol Sci 2023; 24:14537. [PMID: 37833984 PMCID: PMC10572456 DOI: 10.3390/ijms241914537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/15/2023] Open
Abstract
Cerebral small vessel disease (CSVD) is a significant cause of cognitive impairment (CI), disability, and mortality. The insufficient effectiveness of antihypertensive therapy in curbing the disease justifies the search for potential targets for modifying therapy and indicators supporting its use. Using a laser-assisted optical rotational cell analyzer (LORRCA, Mechatronics, The Netherlands), the rheological properties and deformability of erythrocytes before and after incubation with 10 μmol/L of L-arginine, the nitric oxide (NO) donor, blood-brain barrier (BBB) permeability assessed by dynamic contrast-enhanced MRI, clinical, and MRI signs were studied in 73 patients with CSVD (48 women, mean age 60.1 ± 6.5 years). The control group consisted of 19 volunteers (14 women (73.7%), mean age 56.9 ± 6.4 years). The erythrocyte disaggregation rate (y-dis) after incubation with L-arginine showed better performance than other rheological characteristics in differentiating patients with reduced NO bioavailability/NO deficiency by its threshold values. Patients with y-dis > 113 s-1 had more severe CI, arterial hypertension, white matter lesions, and increased BBB permeability in grey matter and normal-appearing white matter (NAWM). A test to assess changes in the erythrocyte disaggregation rate after incubation with L-arginine can be used to identify patients with impaired NO bioavailability. L-arginine may be part of a therapeutic strategy for CSVD with CI.
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Affiliation(s)
| | | | | | | | - Maryam R. Zabitova
- Research Center of Neurology, 80 Volokolamskoe Shosse, 125367 Moscow, Russia; (L.A.D.); (A.A.S.); (K.V.S.); (E.I.K.); (M.V.K.); (A.G.B.); (E.V.G.)
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Liufu T, Yu H, Yu J, Yu M, Tian Y, Ou Y, Deng J, Xing G, Wang Z. Complex I deficiency in m.3243A>G fibroblasts is alleviated by reducing NADH accumulation. Front Physiol 2023; 14:1164287. [PMID: 37650111 PMCID: PMC10464909 DOI: 10.3389/fphys.2023.1164287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023] Open
Abstract
Introduction: Mitochondrial disease is a spectrum of debilitating disorders caused by mutations in the mitochondrial DNA (mtDNA) or nuclear DNA that compromises the respiratory chain. Mitochondrial 3243A>G (m.3243 A>G) is the most common mutation showing great heterogeneity in phenotype. Previous studies have indicated that NADH: ubiquinone oxidoreductase (complex I) deficiency accompanied by a decreased nicotinamide adenine dinucleotide (NAD+)/reduced NAD+ (NADH) ratio may play a pivotal role in the pathogenesis of m.3243A>G mutation. Methods: To evaluate the potential effects of strategies targeting the imbalanced NAD+/NADH ratio in m.3243A>G mutation, we treated fibroblasts derived from patients with the m.3243 A>G mutation using nicotinamide riboside (NR) or mitochondria-targeted H2O-forming NADH oxidase (mitoLbNOX). Results: M.3243 A>G fibroblasts showed a significant reduction in complex I core subunit 6, complex I enzymatic activity, complex I-dependent oxygen consumption rate (OCR), and adenosine triphosphate (ATP) production compared to the controls. The NAD+/NADH ratio was also significantly reduced in m.3243 A>G fibroblasts, and, using fluorescence lifetime imaging microscopy, we also found that the NADH level was elevated in m.3243 A>G fibroblasts. After NR treatment, the NAD+/NADH ratio, complex I-dependent OCR, and ATP levels increased, whereas NADH levels remained unchanged. More excitingly, after treatment with mitoLbNOX, the NAD+/NADH ratio, complex I-independent OCR, and ATP levels increased more pronouncedly compared with the NR treatment group, accompanied by significantly reduced NADH levels. Discussion: The present study suggests that compared with repletion of NAD+ alone, the combination of this therapeutic modality with alleviation of NADH overload may amplify the treatment effect of restoring NAD+/NADH balance in m.3243A>G fibroblasts.
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Affiliation(s)
- Tongling Liufu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Haiyan Yu
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Jiaxi Yu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Meng Yu
- Department of Neurology, Peking University First Hospital, Beijing, China
| | - Yue Tian
- Neuroscience Research Institute, Peking University, Beijing, China
| | - Yichun Ou
- Neuroscience Research Institute, Peking University, Beijing, China
| | - Jianwen Deng
- Department of Neurology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Neurovascular Disease Discovery, Beijing, China
| | - Guogang Xing
- Neuroscience Research Institute, Peking University, Beijing, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Neurovascular Disease Discovery, Beijing, China
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Hustinx M, Shorrocks AM, Servais L. Novel Therapeutic Approaches in Inherited Neuropathies: A Systematic Review. Pharmaceutics 2023; 15:1626. [PMID: 37376074 DOI: 10.3390/pharmaceutics15061626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/17/2023] [Accepted: 05/27/2023] [Indexed: 06/29/2023] Open
Abstract
The management of inherited neuropathies relies mostly on the treatment of symptoms. In recent years, a better understanding of the pathogenic mechanisms that underlie neuropathies has allowed for the development of disease-modifying therapies. Here, we systematically review the therapies that have emerged in this field over the last five years. An updated list of diseases with peripheral neuropathy as a clinical feature was created based on panels of genes used clinically to diagnose inherited neuropathy. This list was extended by an analysis of published data by the authors and verified by two experts. A comprehensive search for studies of human patients suffering from one of the diseases in our list yielded 28 studies that assessed neuropathy as a primary or secondary outcome. Although the use of various scales and scoring systems made comparisons difficult, this analysis identified diseases associated with neuropathy for which approved therapies exist. An important finding is that the symptoms and/or biomarkers of neuropathies were assessed only in a minority of cases. Therefore, further investigation of treatment efficacy on neuropathies in future trials must employ objective, consistent methods such as wearable technologies, motor unit indexes, MRI or sonography imaging, or the use of blood biomarkers associated with consistent nerve conduction studies.
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Affiliation(s)
- Manon Hustinx
- Department of Paediatrics, MDUK Oxford Neuromuscular Centre and, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX1 3DW, UK
- Centre de Référence des Maladies Neuromusculaires, Department of Neurology, University Hospital Liège, and University of Liège, 4000 Liège, Belgium
| | - Ann-Marie Shorrocks
- Department of Paediatrics, MDUK Oxford Neuromuscular Centre and, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX1 3DW, UK
| | - Laurent Servais
- Department of Paediatrics, MDUK Oxford Neuromuscular Centre and, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford OX1 3DW, UK
- Centre de Référence des Maladies Neuromusculaires, Department of Paediatrics, University Hospital Liège, and University of Liège, 4000 Liège, Belgium
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Kurhaluk N. The Effectiveness of L-arginine in Clinical Conditions Associated with Hypoxia. Int J Mol Sci 2023; 24:ijms24098205. [PMID: 37175912 PMCID: PMC10179183 DOI: 10.3390/ijms24098205] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
The review summarises the data of the last 50 years on the effectiveness of the amino acid L-arginine in therapeutic practice in conditions accompanied by different-origin hypoxia. The aim of this review was to analyse the literature and our research data on the role of nitric oxide in the modulation of individual physiological reactivity to hypoxia. The review considers the possibility of eliminating methodological conflicts in the case of L-arginine, which can be solved by taking into account individual physiological reactivity (or the hypoxia resistance factor). Considerable attention is paid to genetic and epigenetic mechanisms of adaptation to hypoxia and conditions of adaptation in different models. The article presents data on the clinical effectiveness of L-arginine in cardiovascular system diseases (hypertension, atherosclerosis, coronary heart disease, etc.) and stress disorders associated with these diseases. The review presents a generalised analysis of techniques, data on L-arginine use by athletes, and the ambiguous role of NO in the physiology and pathology of hypoxic states shown via nitric oxide synthesis. Data on the protective effects of adaptation in the formation of individual high reactivity in sportsmen are demonstrated. The review demonstrates a favourable effect of supplementation with L-arginine and its application depending on mitochondrial oxidative phosphorylation processes and biochemical indices in groups of individuals with low and high capacity of adaptation to hypoxia. In individuals with high initial anti-hypoxic reserves, these favourable effects are achieved by the blockade of NO-dependent biosynthesis pathways. Therefore, the methodological tasks of physiological experiments and the therapeutic consequences of treatment should include a component depending on the basic level of physiological reactivity.
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Affiliation(s)
- Natalia Kurhaluk
- Department of Biology, Institute of Biology and Earth Sciences, Pomeranian University in Słupsk, Arciszewski St. 22 B, 76-200 Słupsk, Poland
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Tomita K, Indo HP, Sato T, Tangpong J, Majima HJ. Development of a sensitive double TaqMan Probe-based qPCR Angle-Degree method to detect mutation frequencies. Mitochondrion 2023; 70:1-7. [PMID: 36841519 DOI: 10.1016/j.mito.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/10/2023] [Accepted: 02/18/2023] [Indexed: 02/26/2023]
Abstract
We designed a method to examine the mutation frequencies of the A3243G mutation of mitochondrial DNA (mtDNA) in patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome. We performed a qPCR assay using the FAM and VIC TaqMan probes, which detect the 3243G (mutated) and 3243A (wild-type) sequences of mtDNA, respectively. The results obtained by "degree" in a series of differential mutation frequencies were used to plot a standard curve of the mutation frequency. The standard curve was then applied for qPCR assays of the desired samples. The standard deviation (%) of the samples calculated using the standard curve for the TaqMan probe was 2.4 ± 1.5%. This method could be used to examine mutation frequencies in the context of diabetes, aging, cancer, and neurodegenerative diseases.
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Affiliation(s)
- Kazuo Tomita
- Department of Maxillofacial Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; Department of Applied Pharmacology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
| | - Hiroko P Indo
- Department of Maxillofacial Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; Amanogawa Galactic Astronomy Research Center (AGARC), Kagoshima University Graduate School of Sciences and Engineering, 1-21-35 Korimoto, Kagoshima 890-0065, Japan.
| | - Tomoaki Sato
- Department of Applied Pharmacology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan
| | - Jitbanjong Tangpong
- School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand; Research Excellence Center for Innovation and Health Products (RECIHP), School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Hideyuki J Majima
- Department of Maxillofacial Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; Amanogawa Galactic Astronomy Research Center (AGARC), Kagoshima University Graduate School of Sciences and Engineering, 1-21-35 Korimoto, Kagoshima 890-0065, Japan; School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand; Research Excellence Center for Innovation and Health Products (RECIHP), School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand; Center of Excellence Research for Melioidosis and Microorganisms, Walailak University, Thasala, Nakhon Si Thammarat 80161, Thailand.
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Distelmaier F, Klopstock T. Neuroimaging in mitochondrial disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 194:173-185. [PMID: 36813312 DOI: 10.1016/b978-0-12-821751-1.00016-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The anatomic complexity of the brain in combination with its high energy demands makes this organ specifically vulnerable to defects of mitochondrial oxidative phosphorylation. Therefore, neurodegeneration is a hallmark of mitochondrial diseases. The nervous system of affected individuals typically shows selective regional vulnerability leading to distinct patterns of tissue damage. A classic example is Leigh syndrome, which causes symmetric alterations of basal ganglia and brain stem. Leigh syndrome can be caused by different genetic defects (>75 known disease genes) with variable disease onset ranging from infancy to adulthood. Other mitochondrial diseases are characterized by focal brain lesions, which is a core feature of MELAS syndrome (mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes). Apart from gray matter, also white matter can be affected by mitochondrial dysfunction. White matter lesions vary depending on the underlying genetic defect and may progress into cystic cavities. In view of the recognizable patterns of brain damage in mitochondrial diseases, neuroimaging techniques play a key role in diagnostic work-up. In the clinical setting, magnetic resonance imaging (MRI) and MR spectroscopy (MRS) are the mainstay of diagnostic work-up. Apart from visualization of brain anatomy, MRS allows the detection of metabolites such as lactate, which is of specific interest in the context of mitochondrial dysfunction. However, it is important to note that findings like symmetric basal ganglia lesions on MRI or a lactate peak on MRS are not specific, and that there is a broad range of disorders that can mimic mitochondrial diseases on neuroimaging. In this chapter, we will review the spectrum of neuroimaging findings in mitochondrial diseases and discuss important differential diagnoses. Moreover, we will give an outlook on novel biomedical imaging tools that may provide interesting insights into mitochondrial disease pathophysiology.
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Affiliation(s)
- Felix Distelmaier
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Düsseldorf, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University Hospital, Ludwig-Maximilians-Universität (LMU) München, Munich, Germany; German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany; German Network for mitochondrial disorders (mitoNET), Munich, Germany
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Naftali J, Mermelstein M, Landau YE, Barnea R, Shelly S, Auriel E, Peretz S. Clinical score for early diagnosis and treatment of stroke-like episodes in MELAS syndrome. Acta Neurol Belg 2023:10.1007/s13760-023-02196-z. [PMID: 36792807 DOI: 10.1007/s13760-023-02196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Stroke-like episodes (SLEs) in patients with MELAS syndrome are often initially misdiagnosed as acute ischemic stroke (AIS), resulting in treatment delay. We aimed to determine clinical features that may distinguish SLEs from AISs and explore the benefit of early L-arginine treatment on patient outcomes. METHODS We looked retrospectively for MELAS patients admitted between January 2005 and January 2022 and compared them to an AIS cohort with similar lesion topography. MELAS patients who received L-arginine within 40 days of their first SLE were defined as the early treatment group and the remaining as late or no treatment group. RESULTS Twenty-three SLEs in 10 MELAS patients and 21 AISs were included. SLE patients had significantly different features: they were younger, more commonly reported hearing loss, lower body mass index, had more commonly a combination of headache and/or seizures at presentation, serum lactate was higher, and hemiparesis was less common. An SLE Early Clinical Score (SLEECS) was constructed by designating one point to each above features. SLEECS ≥ 4 had 80% sensitivity and 100% specificity for SLE diagnosis. Compared to late or no treatment, early treatment group patients (n = 5) had less recurrent SLEs (total 2 vs. 11), less seizures (14% vs. 25%, p = 0.048), lower degree of disability at first and last follow-up (modified ranking scale, mRS 2 ± 0.7 vs. 4.2 ± 1, p = 0.005; 2 ± 0.7 vs. 5.8 ± 0.5, p < 0.001, respectively), and a lower mortality (0% vs. 80% p = 0.048). CONCLUSIONS The SLEECS model may aid in the early diagnosis and treatment of SLEs and lead to improved clinical outcomes.
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Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel
| | - Maor Mermelstein
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel
| | - Yuval E Landau
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Metabolic Diseases Clinic, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Shelly
- Department of Neurology, Sheba Medical Center, Tel Aviv, Israel.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Peretz
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Guerrero-Molina MP, Morales-Conejo M, Delmiro A, Morán M, Domínguez-González C, Arranz-Canales E, Ramos-González A, Arenas J, Martín MA, de la Aleja JG. High-dose oral glutamine supplementation reduces elevated glutamate levels in cerebrospinal fluid in patients with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes syndrome. Eur J Neurol 2023; 30:538-547. [PMID: 36334048 DOI: 10.1111/ene.15626] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome is a genetically heterogeneous disorder caused by mitochondrial DNA mutations. There are no disease-modifying therapies, and treatment remains mainly supportive. It has been shown previously that patients with MELAS syndrome have significantly increased cerebrospinal fluid (CSF) glutamate and significantly decreased CSF glutamine levels compared to controls. Glutamine has many metabolic fates in neurons and astrocytes, and the glutamate-glutamine cycle couples with many metabolic pathways depending on cellular requirements. The aim was to compare CSF glutamate and glutamine levels before and after dietary glutamine supplementation. It is postulated that high-dose oral glutamine supplementation could reduce the increase in glutamate levels. METHOD This open-label, single-cohort study determined the safety and changes in glutamate and glutamine levels in CSF after 12 weeks of oral glutamine supplementation. RESULTS Nine adult patients with MELAS syndrome (66.7% females, mean age 35.8 ± 3.2 years) were included. After glutamine supplementation, CSF glutamate levels were significantly reduced (9.77 ± 1.21 vs. 18.48 ± 1.34 μmol/l, p < 0.001) and CSF glutamine levels were significantly increased (433.66 ± 15.31 vs. 336.31 ± 12.92 μmol/l, p = 0.002). A side effect observed in four of nine patients was a mild sensation of satiety. One patient developed mild and transient elevation of transaminases, and another patient was admitted for an epileptic status without stroke-like episode. DISCUSSION This study demonstrates that high-dose oral glutamine supplementation significantly reduces CSF glutamate and increases CSF glutamine levels in patients with MELAS syndrome. These findings may have potential therapeutic implications in these patients. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT04948138. Initial release 24 June 2021, first patient enrolled 1 July 2021. https://clinicaltrials.gov/ct2/show/NCT04948138.
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Affiliation(s)
| | - Montserrat Morales-Conejo
- Department of Internal Medicine, University Hospital, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
| | - Aitor Delmiro
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - María Morán
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Cristina Domínguez-González
- Neurology Department, Neuromuscular Disorders Unit, University Hospital, Madrid, Spain
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Elena Arranz-Canales
- Department of Internal Medicine, University Hospital, Madrid, Spain
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
| | | | - Joaquín Arenas
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Miguel A Martín
- Spanish Network for Biomedical Research in Rare Diseases (CIBERER), Madrid, Spain
- Mitochondrial and Neuromuscular Diseases Laboratory, Instituto de Investigación Sanitaria Hospital '12 de Octubre' ('imas12'), Madrid, Spain
- Research Institute ('imas12'), University Hospital, Madrid, Spain
| | - Jesús González de la Aleja
- National Reference Center for Congenital Errors of Metabolism (CSUR) and European Reference Center for Inherited Metabolic Disease (MetabERN), University Hospital, Madrid, Spain
- Neurology Department, Epilepsy Unit, University Hospital, Madrid, Spain
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11
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Dobrynina LA, Shabalina AA, Shamtieva KV, Kremneva EI, Zabitova MR, Burmak AG, Byrochkina AA, Akhmetshina YI, Gnedovskaya EV, Krotenkova MV. [Nitric oxide availability in cerebral microangiopathy]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:47-54. [PMID: 37682095 DOI: 10.17116/jnevro202312308247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To develop a test of individual nitric oxide (NO) availability based on changes in erythrocyte rheological properties after incubation with a NO donor and to evaluate the role of these disorders in brain damage and development of cognitive impairment (CI) in cerebral small vessel disease (cSVD). MATERIAL AND METHODS In 73 cSVD patients (48 (65.8%) women, mean age 60.1±6.5), the rheological properties of erythrocytes before and after incubation with 10 μmol/L L-arginine-NO donor were evaluated using a laser-optical rotating cell analyzer, and the blood-brain barrier (BBB) permeability by MRI-T1 dynamic contrast. RESULTS Among the studied parameters of erythrocyte rheological properties, the best characteristic by ROC analysis was the rate of erythrocyte disaggregation (y-dis) after incubation with L-arginine (area under the curve 0.733 (0.609-0.856), sensitivity 67%, specificity 79%). Patients with a y-dis threshold >113 sec-1 had more severe CI, arterial hypertension, white matter lesions, and increased BBB permeability in gray matter and normal-appearing white matter. CONCLUSION The prolonged rate of erythrocyte disaggregation in cSVD patients after incubation with L-arginine indicates the risk for disease progression due to decreased NO bioavailability/disruption of the functional L-arginine-eNOS-NO system. This test can be used to assess individual NO bioavailability and potentially identify indications for modifying therapy with NO donors such as L-arginine. Clinical trials are needed to standardize and evaluate the efficacy of NO donor therapy in patients with cSVD and CI.
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Affiliation(s)
| | | | | | | | | | - A G Burmak
- Research Center of Neurology, Moscow, Russia
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12
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Muacevic A, Adler JR, Insuasti W, Garofalo G, Aguirre AS, Encalada S, Villamarin J, Oña S, Tenemaza MG, Eissa-Garcés A, Matcheswalla S, Ortiz JF. Arginine for the Treatment of Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-Like Episodes: A Systematic Review. Cureus 2022; 14:e32709. [PMID: 36686069 PMCID: PMC9848692 DOI: 10.7759/cureus.32709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/23/2022] Open
Abstract
Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is a mitochondrial disease that lacks a definitive treatment. Lately, there has been an increased interest in the scientific community about the role of arginine in the short and long-term settings of the disease. We aim to conduct a systematic review of the clinical use of arginine in the management of MELAS and explore the role of arginine in the pathophysiology of the disease. We used PubMed advanced-strategy searches and only included full-text clinical trials on humans written in the English language. After applying the inclusion/exclusion criteria, four clinical trials were reviewed. We used the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol for this systematic review. We used the Cochrane Collaboration risk-of-bias tool to assess the bias encountered in each study. Overall, IV arginine seems to be effective in improving symptoms during acute attacks of MELAS, while oral arginine supplementation increases endothelial function, preventing further stroke-like episodes.
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Long H, Wen C, Zhao J, Wang J, Li Y, Fu X, Huang L. ENT characteristics and therapeutic results in multisystemic disorders of mitochondrial encephalomyopathy. Eur J Med Res 2022; 27:221. [DOI: 10.1186/s40001-022-00832-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractHere we report the evaluation of the frequency of subjective and objective otolaryngologic findings and therapeutic results in 32 patients with mitochondrial encephalomyopathy (MEM) from September 2001 to June 2021. Our analysis included studying the patients’ family histories, the clinical manifestations of MEM, and the therapeutic effects of treatments. The patients’ ages ranged from 2 to 77 years, with a median age of 12.3 years. We found that MEM ENT symptoms were characterized by hearing loss, dysphagia, and facial weakness. Most cases of sensorineural hearing loss were bilateral symmetrical progressive or sudden deafness since adolescence, which were often underestimated. Associated neuromuscular symptoms required mtDNA testing. Dysphagia and facial weakness occurred preferentially in middle-aged patients, and muscle biopsies were advised. Distortion product otoacoustic emissions and auditory brainstem responsetesting were more sensitive and reliable than pure tone averages for objective monitoring of pathogenesis. Administration of the mitochondrial synthase complex benefited patients with acute episodes. If patients did not fully recover and exhibitedresidual language deficits, hearing aids or cochlear implants were recommended. Counsel was given regarding synthetical treatments for facial weakness, endoscopic circopharyngealmyotomy for dysphagia, and surgical correction of ptosis. This study demonstrates that increased awareness of these symptoms is important to address appropriate interventions and avoid complications such as ablepsia, aphasia, social isolation, malnutrition, aspiration pneumonia, and heart failure in the setting of MEM.
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Prabhu SM, Banerjee B, Acharya U, Hegde PP, Shetty M. MELAS (Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-Like Episodes)—Usual and Unusual MRI Finding. Indian J Radiol Imaging 2022; 32:625-626. [DOI: 10.1055/s-0042-1755241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Sameeta M. Prabhu
- Department of Paediatric Neurology, Manipal Hospital, Bangalore, Karnataka, India
| | - Bidisha Banerjee
- Department of Paediatric Neurology, Manipal Hospital, Bangalore, Karnataka, India
| | - Ullas Acharya
- Department of Neuroradiology, Manipal Hospital, Bangalore, Karnataka, India
| | - Poonam P Hegde
- Department of Radiology, Manipal Hospital, Bangalore, Karnataka, India
| | - Mitesh Shetty
- Department of Medical Genetics, Manipal Hospital, Bangalore, Karnataka, India
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15
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Zhao Y, Yu X, Ji K, Lin Y, Xu X, Wang W, Yan C. Reversible cerebral artery constriction accompanied with stroke-like episode in MELAS: A case series. J Neurol Sci 2022; 441:120345. [DOI: 10.1016/j.jns.2022.120345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/18/2022] [Accepted: 07/16/2022] [Indexed: 10/17/2022]
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16
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Stefanetti R, Ng Y, Errington L, Blain A, McFarland R, Gorman GS. L-arginine in Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like Episodes: A Systematic Review. Neurology 2022; 98:e2318-e2328. [PMID: 35428733 PMCID: PMC9202525 DOI: 10.1212/wnl.0000000000200299] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 02/15/2022] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives Stroke management in the context of primary mitochondrial disease is clinically challenging, and the best treatment options for patients with stroke-like episodes remain uncertain. We sought to perform a systematic review of the safety and efficacy of l-arginine use in the acute and prophylactic management of stroke-like episodes in patients with mitochondrial disease. Methods The systematic review was registered in PROSPERO (CRD42020181230). We searched 6 databases from inception to January 15, 2021: MEDLINE, Embase, Scopus, Web of Science, CINAHL, and ClinicalTrials.gov. Original articles and registered trials available, in English, reporting l-arginine use in the acute or prophylactic management of stroke-like episodes in patients with genetically confirmed mitochondrial disease were eligible for inclusion. Data on safety and treatment response were extracted and summarized by multiple observers. Risk of bias was assessed by the methodologic quality of case reports, case series, and a risk-of-bias checklist for nonrandomized studies. Quality of evidence was synthesized with the Oxford Centre for Evidence-Based Medicine Levels of Evidence and Grade of Recommendations. The predetermined main outcome measures were clinical response to l-arginine treatment, adverse events, withdrawals, and deaths (on treatment and/or during follow-up), as defined by the author. Results Thirty-seven articles met inclusion criteria (0 randomized controlled trials; 3 open-label; 1 retrospective cohort; 33 case reports/case series) (N = 91 patients; 86% m.3243A>G). In the case reports, 54% of patients reported a positive clinical response to acute l-arginine, of which 40% were concomitantly treated with antiepileptic drugs. Improved headache at 24 hours was the greatest reported benefit in response to IV l-arginine in the open-label trials (31 of 39, 79%). In 15 of 48 patients (31%) who positively responded to prophylactic l-arginine, antiepileptic drugs were either used (7 of 15) or unreported (8 of 15). Moderate adverse events were reported in the follow-up of both IV and oral l-arginine treatment, and 11 patients (12%) died during follow-up or while on prophylactic treatment. Discussion The available evidence is of poor methodologic quality and classified as Level 5. IV and oral l-arginine confers no demonstrable clinical benefit in either the acute or prophylactic treatment of mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes, with more robust controlled trials required to assess its efficacy and safety profile.
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17
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Mitochondrial stroke-like episodes: the search for new therapies. Pharmacol Res 2022; 180:106228. [DOI: 10.1016/j.phrs.2022.106228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/21/2022]
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18
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Pérez-Cruz E, González-Rivera C, Valencia-Olvera LDCG. Immunonutrition for the acute treatment of MELAS syndrome. ENDOCRINOL DIAB NUTR 2022; 69:144-148. [PMID: 35256057 DOI: 10.1016/j.endien.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/25/2021] [Indexed: 06/14/2023]
Abstract
MELAS syndrome (Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-like episodes) is one of the most frequent mitochondrial pathologies. Its diagnosis is based on the classic triad of symptoms its acronym stands for and the presence of ragged red fibres. There is currently no curative therapy for MELAS, and treatment focuses on managing complications that affect specific organs and functions. However, some immunonutrients can be used as a therapeutic alternative in patients with MELAS. We present a scientific literature review accompanied by the clinical case of a patient with dementia and seizures admitted to the intensive care unit.
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Affiliation(s)
- Elizabeth Pérez-Cruz
- Metabolic Unit and Nutritional Support, Hospital Juárez de México, Mexico City, Mexico.
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Mastrangelo M, Ricciardi G, Giordo L, Michele MD, Toni D, Leuzzi V. Stroke and stroke-like episodes in inborn errors of metabolism: Pathophysiological and clinical implications. Mol Genet Metab 2022; 135:3-14. [PMID: 34996714 DOI: 10.1016/j.ymgme.2021.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/19/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022]
Abstract
Inborn errors of metabolism causing stroke (ischemic or haemorrhagic) or stroke-like episodes (e.g., that are also called "metabolic strokes" and include acute brain lesions not related with alterations of blood flow) cover a wide range of diseases in which acute metabolic decompensations after trigger events (e.g., fever, dehydration, sepsis etc.) may have a variable frequency. The early diagnosis of these conditions is essential because, despite their rarity, effective symptomatic treatments may be available for acute settings (e.g., arginine for Mitochondrial myopathy, Encephalopathy, Lactic Acidosis, and Stroke-like episodes- MELAS) while in other cases disease modifying therapies may be useful to prevent stroke occurrence, recurrence, or relapse (e.g., Fabry disease). The detection of a non-vascular distribution of lesions and the diffuse use of 1HMRS are often diriment in the differential of ischemic and metabolic strokes. This review summarized the main clinical features and the pathophysiological mechanisms of stroke and stroke-like episodes in inborn errors of metabolism presenting with stroke as part of natural history of the disease. These conditions belong to different etiological groups, such as organic acidurias, mitochondrial encephalopathies, homocystinuria and remethylation disorders, urea cycle disorders, lysosomal diseases (e.g. Fabry disease, glycogen storage disease), congenital disorders of glycosylation, neurotransmitter disorders, adenosine deaminase 2 deficiency and few other neurometabolic disorders.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Giacomina Ricciardi
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Laura Giordo
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Manuela De Michele
- Emergency Department Stroke Unit, Department of Human Neuroscience, Sapienza, Università di Roma, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neuroscience, Sapienza, Università di Roma, Italy
| | - Vincenzo Leuzzi
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy.
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20
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Evangelisti S, Gramegna LL, La Morgia C, Di Vito L, Maresca A, Talozzi L, Bianchini C, Mitolo M, Manners DN, Caporali L, Valentino ML, Liguori R, Carelli V, Lodi R, Testa C, Tonon C. Molecular biomarkers correlate with brain grey and white matter changes in patients with mitochondrial m.3243A > G mutation. Mol Genet Metab 2022; 135:72-81. [PMID: 34916127 DOI: 10.1016/j.ymgme.2021.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/18/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The mitochondrial DNA (mtDNA) m.3243A > G mutation in the MT-TL1 gene results in a multi-systemic disease, that is commonly associated with neurodegenerative changes in the brain. METHODS Seventeen patients harboring the m3243A > G mutation were enrolled (age 43.1 ± 11.4 years, 10 M/7F). A panel of plasma biomarkers including lactate acid, alanine, L-arginine, fibroblast growth factor 21 (FGF-21), growth/differentiation factor 15 (GDF-15) and circulating cell free -mtDNA (ccf-mtDNA), as well as blood, urine and muscle mtDNA heteroplasmy were evaluated. Patients also underwent a brain standardized MR protocol that included volumetric T1-weighted images and diffusion-weighted MRI. Twenty sex- and age-matched healthy controls were included. Voxel-wise analysis was performed on T1-weighted and diffusion imaging, respectively with VBM (voxel-based morphometry) and TBSS (Tract-based Spatial Statistics). Ventricular lactate was also evaluated by 1H-MR spectroscopy. RESULTS A widespread cortical gray matter (GM) loss was observed, more severe (p < 0.001) in the bilateral calcarine, insular, frontal and parietal cortex, along with infratentorial cerebellar cortex. High urine mtDNA mutation load, high levels of plasma lactate and alanine, low levels of plasma arginine, high levels of serum FGF-21 and ventricular lactate accumulation significantly (p < 0.05) correlated with the reduced brain GM density. Widespread microstructural alterations were highlighted in the white matter, significantly (p < 0.05) correlated with plasma alanine and arginine levels, with mtDNA mutation load in urine, with high level of serum GDF-15 and with high content of plasma ccf-mtDNA. CONCLUSIONS Our results suggest that the synergy of two pathogenic mechanisms, mtDNA-related mitochondrial respiratory deficiency and defective nitric oxide metabolism, contributes to the brain neurodegeneration in m.3243A > G patients.
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Affiliation(s)
- Stefania Evangelisti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Laura Ludovica Gramegna
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Chiara La Morgia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Bologna, Italy
| | - Lidia Di Vito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Alessandra Maresca
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Bologna, Italy
| | - Lia Talozzi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Claudio Bianchini
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Micaela Mitolo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - David Neil Manners
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Leonardo Caporali
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Maria Lucia Valentino
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Rocco Liguori
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Valerio Carelli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Programma di Neurogenetica, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
| | - Claudia Testa
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy; Department of Physics and Astronomy, University of Bologna, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy.
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Tetsuka S, Ogawa T, Hashimoto R, Kato H. Clinical features, pathogenesis, and management of stroke-like episodes due to MELAS. Metab Brain Dis 2021; 36:2181-2193. [PMID: 34118021 DOI: 10.1007/s11011-021-00772-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 06/06/2021] [Indexed: 02/07/2023]
Abstract
Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) is a disease that should be considered as a differential diagnosis to acute ischemic stroke taking into account its onset pattern and neurological symptoms, which are similar to those of an ischemic stroke. Technological advancements in neuroimaging modalities have greatly facilitated differential diagnosis between stroke and MELAS on diagnostic imaging. Stroke-like episodes in MELAS have the following features: (1) symptoms are neurolocalized according to lesion site; (2) epileptic seizures are often present; (3) lesion distribution is inconsistent with vascular territory; (4) lesions are common in the posterior brain regions; (5) lesions continuously develop in adjacent sites over several weeks or months; (6) neurological symptoms and stroke-like lesions tend to be reversible, as presented on magnetic resonance imaging; (7) the rate of recurrence is high; and; (8) brain dysfunction and atrophy are slowly progressive. The m.3243ANG mutation in the MT-TL1 gene encoding the mitochondrial tRNALeu(UUR) is most commonly associated with MELAS. Although the precise pathophysiology is still unclear, one possible hypothesis for these episodes is a neuronal hyperexcitability theory, including neuron-astrocyte uncoupling. Supplementation, such as with L-arginine or taurine, has been proposed as preventive treatments for stroke-like episodes. As this disease is still untreatable and devastating, numerous drugs are being tested, and new gene therapies hold great promise for the future. This article contributes to the understanding of MELAS and its implications for clinical practice, by deepening their insight into the latest pathophysiological hypotheses and therapeutic developments.
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Affiliation(s)
- Syuichi Tetsuka
- Department of Neurology, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan.
| | - Tomoko Ogawa
- Department of Neurology, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Ritsuo Hashimoto
- Department of Neurology, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
| | - Hiroyuki Kato
- Department of Neurology, International University of Health and Welfare Hospital, 537-3, Iguchi, Nasushiobara, Tochigi, 329-2763, Japan
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Pagano G, Pallardó FV, Lyakhovich A, Tiano L, Trifuoggi M. Mitigating the pro-oxidant state and melanogenesis of Retinitis pigmentosa: by counteracting mitochondrial dysfunction. Cell Mol Life Sci 2021; 78:7491-7503. [PMID: 34718826 PMCID: PMC11072988 DOI: 10.1007/s00018-021-04007-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/08/2021] [Accepted: 10/13/2021] [Indexed: 12/12/2022]
Abstract
Retinitis pigmentosa (RP) is a group of mitochondrial diseases characterized by progressive degeneration of rods and cones leading to retinal loss of light sensitivity and, consequently, to blindness. To date, no cure is available according to the clinical literature. As a disease associated with pigmentation-related, pro-oxidant state, and mitochondrial dysfunction, RP may be viewed at the crossroads of different pathogenetic pathways involved in adverse health outcomes, where mitochondria play a preeminent role. RP has been investigated in a number of experimental and clinical studies aimed at delaying retinal hyperpigmentation by means of a number of natural and synthetic antioxidants, as well as mitochondrial cofactors, also termed mitochondrial nutrients (MNs), such as alpha-lipoic acid, coenzyme Q10 and carnitine. One should consider that each MN plays distinct-and indispensable-roles in mitochondrial function. Thus, a logical choice would imply the administration of MN combinations, instead of individual MNs, as performed in previous studies, and with limited, if any, positive outcomes. A rational study design aimed at comparing the protective effects of MNs, separately or in combinations, and in association with other antioxidants, might foresee the utilization of animal RP models. The results should verify a comparative optimization in preventing or effectively contrasting retinal oxidative stress in mouse RP models and, in prospect, in human RP cases.
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Affiliation(s)
- Giovanni Pagano
- Department of Chemical Sciences, Federico II Naples University, via Cintia, 80126, Naples, Italy.
| | - Federico V Pallardó
- Department of Physiology, Faculty of Medicine and Dentistry, University of Valencia-INCLIVA, CIBERER, 46010, Valencia, Spain
| | - Alex Lyakhovich
- Faculty of Engineering and Natural Sciences, Sabanci University, Tuzla, 34956, Istanbul, Turkey
- Institute of Molecular Biology and Biophysics of the "Federal Research Center of Fundamental and Translational Medicine", 630117, Novosibirsk, Russia
| | - Luca Tiano
- Department of Life and Environmental Sciences, Polytechnical University of Marche, 60121, Ancona, Italy
| | - Marco Trifuoggi
- Department of Chemical Sciences, Federico II Naples University, via Cintia, 80126, Naples, Italy
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Blood biomarkers for assessment of mitochondrial dysfunction: An expert review. Mitochondrion 2021; 62:187-204. [PMID: 34740866 DOI: 10.1016/j.mito.2021.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 12/20/2022]
Abstract
Although mitochondrial dysfunction is the known cause of primary mitochondrial disease, mitochondrial dysfunction is often difficult to measure and prove, especially when biopsies of affected tissue are not available. In order to identify blood biomarkers of mitochondrial dysfunction, we reviewed studies that measured blood biomarkers in genetically, clinically or biochemically confirmed primary mitochondrial disease patients. In this way, we were certain that there was an underlying mitochondrial dysfunction which could validate the biomarker. We found biomarkers of three classes: 1) functional markers measured in blood cells, 2) biochemical markers of serum/plasma and 3) DNA markers. While none of the reviewed single biomarkers may perfectly reveal all underlying mitochondrial dysfunction, combining biomarkers that cover different aspects of mitochondrial impairment probably is a good strategy. This biomarker panel may assist in the diagnosis of primary mitochondrial disease patients. As mitochondrial dysfunction may also play a significant role in the pathophysiology of multifactorial disorders such as Alzheimer's disease and glaucoma, the panel may serve to assess mitochondrial dysfunction in complex multifactorial diseases as well and enable selection of patients who could benefit from therapies targeting mitochondria.
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Fan HC, Lee HF, Yue CT, Chi CS. Clinical Characteristics of Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes. Life (Basel) 2021; 11:life11111111. [PMID: 34832987 PMCID: PMC8617702 DOI: 10.3390/life11111111] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/11/2021] [Accepted: 10/16/2021] [Indexed: 12/12/2022] Open
Abstract
Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome, a maternally inherited mitochondrial disorder, is characterized by its genetic, biochemical and clinical complexity. The most common mutation associated with MELAS syndrome is the mtDNA A3243G mutation in the MT-TL1 gene encoding the mitochondrial tRNA-leu(UUR), which results in impaired mitochondrial translation and protein synthesis involving the mitochondrial electron transport chain complex subunits, leading to impaired mitochondrial energy production. Angiopathy, either alone or in combination with nitric oxide (NO) deficiency, further contributes to multi-organ involvement in MELAS syndrome. Management for MELAS syndrome is amostly symptomatic multidisciplinary approach. In this article, we review the clinical presentations, pathogenic mechanisms and options for management of MELAS syndrome.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (H.-C.F.); (C.-T.Y.)
- Department of Medical Research, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 356, Taiwan
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
| | - Hsiu-Fen Lee
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung 407, Taiwan;
| | - Chen-Tang Yue
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (H.-C.F.); (C.-T.Y.)
| | - Ching-Shiang Chi
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan; (H.-C.F.); (C.-T.Y.)
- Correspondence: ; Tel.: +886-4-26581919-4301
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25
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Dorsey S, Ahmed F. Developments in distinguishing secondary vascular headache from primary headache disorders in clinical practice. Expert Rev Neurother 2021; 21:1357-1369. [PMID: 34553658 DOI: 10.1080/14737175.2021.1984882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Vascular headaches are secondary headache disorders with potentially devastating consequences if missed. Clinicians often struggle to distinguish these from primary headache disorders whereby there is no underlying structural pathology. Here, the authors describe the advancement in our understanding of vascular headache disorders, their clinical presentation and the developments in neuroimaging that facilitate diagnosis. AREAS COVERED Here the authors discuss the definition of primary and secondary headache disorders. They review the literature on the presentation, choice of neuroimaging and diagnostic tools that can be used to diagnose specific vascular headaches including Carotid or Vertebral artery dissection, Stroke, Temporal Arteritis, subarachnoid hemorrhage, cerebral venous thrombosis, Reversible Cerebral Vasoconstriction syndrome, Primary angiitis, AV malformation and Genetic vasculopathy. The authors discuss the influence of Covid-19 on the management of patients with headache. EXPERT OPINION Whilst developments in neuroimaging have been of paramount importance in the diagnosis of vascular headache disorders, there is no substitute for meticulous history taking and examination. Research has aided our understanding of clinical presentation, however further studies are needed as well as increased education of neurologists and acute physicians.
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Affiliation(s)
- Sophie Dorsey
- Department of Neurology, Hull University Teaching Hospitals, Hull, UK
| | - Fayyaz Ahmed
- Department of Neurology, Hull University Teaching Hospitals, Hull, UK.,Department of Neurosciences, Hull York Medical School, Hull, UK
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26
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Almannai M, El-Hattab AW. Nitric Oxide Deficiency in Mitochondrial Disorders: The Utility of Arginine and Citrulline. Front Mol Neurosci 2021; 14:682780. [PMID: 34421535 PMCID: PMC8374159 DOI: 10.3389/fnmol.2021.682780] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/21/2021] [Indexed: 11/21/2022] Open
Abstract
Mitochondrial diseases represent a growing list of clinically heterogeneous disorders that are associated with dysfunctional mitochondria and multisystemic manifestations. In spite of a better understanding of the underlying pathophysiological basis of mitochondrial disorders, treatment options remain limited. Over the past two decades, there is growing evidence that patients with mitochondrial disorders have nitric oxide (NO) deficiency due to the limited availability of NO substrates, arginine and citrulline; decreased activity of nitric oxide synthase (NOS); and NO sequestration. Studies evaluating the use of arginine in patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) presenting with stroke-like episodes showed symptomatic improvement after acute administration as well as a reduction in the frequency and severity of stroke-like episodes following chronic use. Citrulline, another NO precursor, was shown through stable isotope studies to result in a greater increase in NO synthesis. Recent studies showed a positive response of arginine and citrulline in other mitochondrial disorders besides MELAS. Randomized-controlled studies with a larger number of patients are warranted to better understand the role of NO deficiency in mitochondrial disorders and the efficacy of NO precursors as treatment modalities in these disorders.
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Affiliation(s)
- Mohammed Almannai
- Section of Medical Genetics, Children's Hospital, King Fahad Medical City, Riyadh, Saudi Arabia.,College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman W El-Hattab
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates.,Clinical Genetics, University Hospital Sharjah, Sharjah, United Arab Emirates
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27
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Ng YS, Bindoff LA, Gorman GS, Klopstock T, Kornblum C, Mancuso M, McFarland R, Sue CM, Suomalainen A, Taylor RW, Thorburn DR, Turnbull DM. Mitochondrial disease in adults: recent advances and future promise. Lancet Neurol 2021; 20:573-584. [PMID: 34146515 DOI: 10.1016/s1474-4422(21)00098-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 02/17/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023]
Abstract
Mitochondrial diseases are some of the most common inherited neurometabolic disorders, and major progress has been made in our understanding, diagnosis, and treatment of these conditions in the past 5 years. Development of national mitochondrial disease cohorts and international collaborations has changed our knowledge of the spectrum of clinical phenotypes and natural history of mitochondrial diseases. Advances in high-throughput sequencing technologies have altered the diagnostic algorithm for mitochondrial diseases by increasingly using a genetics-first approach, with more than 350 disease-causing genes identified to date. While the current management strategy for mitochondrial disease focuses on surveillance for multisystem involvement and effective symptomatic treatment, new endeavours are underway to find better treatments, including repurposing current drugs, use of novel small molecules, and gene therapies. Developments made in reproductive technology offer women the opportunity to prevent transmission of DNA-related mitochondrial disease to their children.
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Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Directorate of Neurosciences, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Laurence A Bindoff
- Department of Clinical Medicine, University of Bergen, Bergen, Norway; Neuro-SysMed, Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Gráinne S Gorman
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Directorate of Neurosciences, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, LMU Hospital, Ludwig Maximilians University, Munich, Germany; German Center for Neurodegenerative Diseases, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany
| | - Cornelia Kornblum
- Department of Neurology, Neuromuscular Disease Section, University Hospital Bonn, Bonn, Germany; Centre for Rare Diseases, University Hospital Bonn, Bonn, Germany
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy
| | - Robert McFarland
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Carolyn M Sue
- Department of Neurogenetics, Kolling Institute, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Neurology, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Anu Suomalainen
- Research Program in Stem Cells and Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Neuroscience Centre, HiLife, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, HUSlab, Helsinki, Finland
| | - Robert W Taylor
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David R Thorburn
- Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia; Victorian Clinical Genetics Services, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Doug M Turnbull
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
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28
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1057] [Impact Index Per Article: 352.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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29
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Pérez-Cruz E, González-Rivera C, Valencia-Olvera LDCG. Immunonutrition for the acute treatment of MELAS syndrome. ENDOCRINOL DIAB NUTR 2021; 69:S2530-0164(21)00151-8. [PMID: 34210633 DOI: 10.1016/j.endinu.2021.03.004] [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: 12/23/2020] [Revised: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
MELAS syndrome (Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-like episodes) is one of the most frequent mitochondrial pathologies. Its diagnosis is based on the classic triad of symptoms its acronym stands for and the presence of ragged red fibres. There is currently no curative therapy for MELAS, and treatment focuses on managing complications that affect specific organs and functions. However, some immunonutrients can be used as a therapeutic alternative in patients with MELAS. We present a scientific literature review accompanied by the clinical case of a patient with dementia and seizures admitted to the intensive care unit.
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Affiliation(s)
- Elizabeth Pérez-Cruz
- Metabolic Unit and Nutritional Support, Hospital Juárez de México, Mexico City, Mexico.
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30
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Gramegna LL, Evangelisti S, Di Vito L, La Morgia C, Maresca A, Caporali L, Amore G, Talozzi L, Bianchini C, Testa C, Manners DN, Cortesi I, Valentino ML, Liguori R, Carelli V, Tonon C, Lodi R. Brain MRS correlates with mitochondrial dysfunction biomarkers in MELAS-associated mtDNA mutations. Ann Clin Transl Neurol 2021; 8:1200-1211. [PMID: 33951347 PMCID: PMC8164862 DOI: 10.1002/acn3.51329] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/12/2021] [Accepted: 02/11/2021] [Indexed: 12/24/2022] Open
Abstract
Objective The purpose of this study was to investigate correlations between brain proton magnetic resonance spectroscopy (1H‐MRS) findings with serum biomarkers and heteroplasmy of mitochondrial DNA (mtDNA) mutations. This study enrolled patients carrying mtDNA mutations associated with Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke‐like episodes (MELAS), and MELAS‐Spectrum Syndrome (MSS). Methods Consecutive patients carrying mtDNA mutations associated with MELAS and MSS were recruited and their serum concentrations of lactate, alanine, and heteroplasmic mtDNA mutant load were evaluated. The brain protocol included single‐voxel 1H‐MRS (1.5T) in the medial parieto‐occipital cortex (MPOC), left cerebellar hemisphere, parieto‐occipital white matter (POWM), and lateral ventricles. Relative metabolite concentrations of N‐acetyl‐aspartate (NAA), choline (Cho), and myo‐inositol (mI) were estimated relative to creatine (Cr), using LCModel 6.3. Results Six patients with MELAS (age 28 ± 13 years, 3 [50%] female) and 17 with MSS (age 45 ± 11 years, 7 [41%] female) and 39 sex‐ and age‐matched healthy controls (HC) were enrolled. These patients demonstrated a lower NAA/Cr ratio in MPOC compared to HC (p = 0.006), which inversely correlated with serum lactate (p = 0.021, rho = −0.68) and muscle mtDNA heteroplasmy (p < 0.001, rho = −0.80). Similarly, in the cerebellum patients had lower NAA/Cr (p < 0.001), Cho/Cr (p = 0.002), and NAA/mI (p = 0.001) ratios, which negatively correlated with mtDNA blood heteroplasmy (p = 0.001, rho = −0.81) and with alanine (p = 0.050, rho = −0.67). Ventricular lactate was present in 78.3% (18/23) of patients, correlating with serum lactate (p = 0.024, rho = 0.58). Conclusion Correlations were found between the peripheral and biochemical markers of mitochondrial dysfunction and brain in vivo markers of neurodegeneration, supporting the use of both biomarkers as signatures of MELAS and MSS disease, to evaluate the efficacy of potential treatments.
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Affiliation(s)
- Laura L Gramegna
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Stefania Evangelisti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lidia Di Vito
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Chiara La Morgia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Alessandra Maresca
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Leonardo Caporali
- IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Giulia Amore
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Lia Talozzi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Claudio Bianchini
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Claudia Testa
- Department of Physics and Astronomy, University of Bologna, Bologna, Italy
| | - David N Manners
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Irene Cortesi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Maria L Valentino
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Rocco Liguori
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Valerio Carelli
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Clinica Neurologica, Bologna, Italy
| | - Caterina Tonon
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy.,Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
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31
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Tabarki B, Hakami W, Alkhuraish N, Graies-Tlili K, Nashabat M, Alfadhel M. Inherited Metabolic Causes of Stroke in Children: Mechanisms, Types, and Management. Front Neurol 2021; 12:633119. [PMID: 33746889 PMCID: PMC7969979 DOI: 10.3389/fneur.2021.633119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
A stroke should be considered in cases of neurologic decompensation associated with inherited metabolic disorders. A resultant stroke could be a classical ischemic stroke (vascular stroke) or more commonly a "metabolic stroke." A metabolic stroke begins with metabolic dysfunctions, usually caused by a stressor, and leads to the rapid onset of prolonged central neurological deficits in the absence of vessel occlusion or rupture. The cardinal features of a metabolic stroke are stroke-like episodes without the confirmation of ischemia in the typical vascular territories, such as that seen in classic thrombotic or embolic strokes. Identifying the underlying cause of a metabolic stroke is essential for prompt and appropriate treatment. This study reviews the major inherited metabolic disorders that predispose patients to pediatric stroke, with an emphasis on the underlying mechanisms, types, and management.
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Affiliation(s)
- Brahim Tabarki
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Wejdan Hakami
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Nader Alkhuraish
- Division of Neuroradiology, Department of Radiology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Kalthoum Graies-Tlili
- Division of Neuroradiology, Department of Radiology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Marwan Nashabat
- Department of Genetics and Precision Medicine (GPM), King Abdullah Specialized Children's Hospital, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Majid Alfadhel
- Department of Genetics and Precision Medicine (GPM), King Abdullah Specialized Children's Hospital, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,Medical Genomics Research Department, King Abdullah International Medical Research Center (KAIMRC), King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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32
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Gramegna LL, Cortesi I, Mitolo M, Evangelisti S, Lia T, Cirillo L, Tonon C, Lodi R. Major cerebral vessels involvement in patients with MELAS syndrome: Worth a scan? A systematic review. J Neuroradiol 2021; 48:359-366. [PMID: 33596430 DOI: 10.1016/j.neurad.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
Major cerebral vessels have been proposed as a target of defective mitochondrial metabolism in patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes syndrome (MELAS). Cerebral angiographic techniques are not routinely performed in MELAS patients. A systematic literature review was performed to identify studies describing major vessel caliber alterations in MELAS. Twenty-three studies reporting on 46 MELAS patients were included. Alterations in major caliber vessels were present in 59% (27/46) of patients. Dilation occurred in 37% (17/46) of patients, and in 88% (15/17) of them during a stroke-like episode (SLE). Stenosis was reported in 24% (11/46) of patients: 36% (4/11) related to an SLE and 64% (7/11) to dissections or degenerative changes. During an SLE, identification of intracranial vessels dilation or stenosis could be a selection tool for new treatment protocols. Outside SLE, identification of major cerebral vessels dissections and degenerative changes may help to prevent subsequent complications.
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Affiliation(s)
- Laura Ludovica Gramegna
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy; Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy.
| | - Irene Cortesi
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Micaela Mitolo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy; Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Stefania Evangelisti
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Talozzi Lia
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy; Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Caterina Tonon
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy; Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Raffaele Lodi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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33
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Minakawa EN, Nagai Y. Protein Aggregation Inhibitors as Disease-Modifying Therapies for Polyglutamine Diseases. Front Neurosci 2021; 15:621996. [PMID: 33642983 PMCID: PMC7907447 DOI: 10.3389/fnins.2021.621996] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/18/2021] [Indexed: 12/11/2022] Open
Abstract
The polyglutamine (polyQ) diseases are a group of inherited neurodegenerative diseases caused by the abnormal expansion of a CAG trinucleotide repeat that are translated into an expanded polyQ stretch in the disease-causative proteins. The expanded polyQ stretch itself plays a critical disease-causative role in the pathomechanisms underlying polyQ diseases. Notably, the expanded polyQ stretch undergoes a conformational transition from the native monomer into the β-sheet-rich monomer, followed by the formation of soluble oligomers and then insoluble aggregates with amyloid fibrillar structures. The intermediate soluble species including the β-sheet-rich monomer and oligomers exhibit substantial neurotoxicity. Therefore, protein conformation stabilization and aggregation inhibition that target the upstream of the insoluble aggregate formation would be a promising approach toward the development of disease-modifying therapies for polyQ diseases. PolyQ aggregation inhibitors of different chemical categories, such as intrabodies, peptides, and small chemical compounds, have been identified through intensive screening methods. Among them, recent advances in the brain delivery methods of several peptides and the screening of small chemical compounds have brought them closer to clinical utility. Notably, the recent discovery of arginine as a potent conformation stabilizer and aggregation inhibitor of polyQ proteins both in vitro and in vivo have paved way to the clinical trial for the patients with polyQ diseases. Meanwhile, expression reduction of expanded polyQ proteins per se would be another promising approach toward disease modification of polyQ diseases. Gene silencing, especially by antisense oligonucleotides (ASOs), have succeeded in reducing the expression of polyQ proteins in the animal models of various polyQ diseases by targeting the aberrant mRNA with expanded CAG repeats. Of note, some of these ASOs have recently been translated into clinical trials. Here we overview and discuss these recent advances toward the development of disease modifying therapies for polyQ diseases. We envision that combination therapies using aggregation inhibitors and gene silencing would meet the needs of the patients with polyQ diseases and their caregivers in the near future to delay or prevent the onset and progression of these currently intractable diseases.
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Affiliation(s)
- Eiko N Minakawa
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Yoshitaka Nagai
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan.,Department of Neurotherapeutics, Osaka University Graduate School of Medicine, Suita, Japan
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34
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Serrano M. Stroke-Like Episodes in PMM2-CDG: When the Lack of Other Evidence Is the Only Evidence. Front Pediatr 2021; 9:717864. [PMID: 34708008 PMCID: PMC8542667 DOI: 10.3389/fped.2021.717864] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/17/2021] [Indexed: 12/20/2022] Open
Abstract
Phosphomannomutase 2 deficiency (PMM2-CDG) is the most frequent congenital disorder of glycosylation. PMM2-CDG patients develop chronic cerebellar atrophy as a neurological hallmark. However, other acute neurological phenomena such as stroke-like episodes (SLE), epilepsy, migraine, and cerebrovascular events, may also occur, and they are frequently the cause of disability and impaired quality of life. Among these, SLE are among the most stressful situations for families and doctors, as their risk factors are not known, their underlying pathomechanisms remain undiscovered, and clinical guidelines for diagnosis, prevention, and treatment are lacking. In this paper, the recent SLE experiences of two PMM2-CDG patients are examined to provide clinical clues to help improve diagnosis through a clinical constellation of symptoms and a clinical definition, but also to support a neuroelectrical hypothesis as an underlying mechanism. An up-to-date literature review will help to identify evidence-based and non-evidence-based management recommendations. Presently neuropediatricians and neurologists are not capable of diagnosing stroke-like episodes in an unequivocal way, so there is still a need to perform invasive studies (to rule out other acute diseases) that may, in the end, prove unnecessary or even harmful. However, reaching a correct and early diagnosis would lead not only to avoidance of invasive tests but also to better recognition, management, and understanding of the disease itself. There is a great need for understanding of SLE that may ultimately be very informative for the detection of patients at risk, and the future development of preventive and management measures.
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Affiliation(s)
- Mercedes Serrano
- Department of Neuropediatric, Institut de Recerca Hospital Sant Joan de Déu, Barcelona, Spain.,U-703 Center for Biomedical Research on Rare Diseases (CIBER-ER), Hospital Sant Joan de Déu, Instituto de Salud Carlos III, Barcelona, Spain
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35
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Hayashi Y, Iwasaki Y, Yoshikura N, Yamada M, Kimura A, Inuzuka T, Miyahara H, Goto Y, Nishino I, Yoshida M, Shimohata T. Clinicopathological findings of a mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes/Leigh syndrome overlap patient with a novel m.3482A>G mutation in MT-ND1. Neuropathology 2020; 41:84-90. [PMID: 33300189 DOI: 10.1111/neup.12709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 12/24/2022]
Abstract
We report clinicopathological findings of a patient with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes/Leigh syndrome (MELAS/LS) associated with a novel m.3482A>G mutation in MT-ND1. A 41-year-old woman had experienced multiple stroke-like episodes since age 16. She developed akinetic mutism two months before admission to our hospital. Neurological examination revealed akinetic mutism, bilateral deafness, and muscular atrophy. Cerebrospinal fluid tests revealed elevated pyruvate and lactate levels. Fluid-attenuated inversion recovery images on magnetic resonance imaging showed hyperintense areas in the right frontal and both sides of temporal and occipital lobes, both sides of the striatum, and the midbrain. Muscle biopsy revealed strongly succinate dehydrogenase-reactive blood vessels. L-arginine therapy improved her consciousness and prevented further stroke-like episodes. However, she died from aspiration pneumonia. Postmortem autopsy revealed scattered infarct-like lesions with cavitation in the cerebral cortex and necrotic lesions in the striatum and midbrain. The patient was pathologically confirmed as having MELAS/LS based on two characteristic clinicopathological findings: presenting MELAS/LS overlap phenotype and effectiveness of L-arginine treatment.
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Affiliation(s)
- Yuichi Hayashi
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yasushi Iwasaki
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Nobuaki Yoshikura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Megumi Yamada
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takashi Inuzuka
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan.,Department of Neurology, Gifu Municipal Hospital, Gifu, Japan
| | - Hiroaki Miyahara
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Yuichi Goto
- Department of Mental Retardation and Birth Defect Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
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36
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Barcelos I, Shadiack E, Ganetzky RD, Falk MJ. Mitochondrial medicine therapies: rationale, evidence, and dosing guidelines. Curr Opin Pediatr 2020; 32:707-718. [PMID: 33105273 PMCID: PMC7774245 DOI: 10.1097/mop.0000000000000954] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Primary mitochondrial disease is a highly heterogeneous but collectively common inherited metabolic disorder, affecting at least one in 4300 individuals. Therapeutic management of mitochondrial disease typically involves empiric prescription of enzymatic cofactors, antioxidants, and amino acid and other nutrient supplements, based on biochemical reasoning, historical experience, and consensus expert opinion. As the field continues to rapidly advance, we review here the preclinical and clinical evidence, and specific dosing guidelines, for common mitochondrial medicine therapies to guide practitioners in their prescribing practices. RECENT FINDINGS Since publication of Mitochondrial Medicine Society guidelines for mitochondrial medicine therapies management in 2009, data has emerged to support consideration for using additional therapeutic agents and discontinuation of several previously used agents. Preclinical animal modeling data have indicated a lack of efficacy for vitamin C as an antioxidant for primary mitochondrial disease, but provided strong evidence for vitamin E and N-acetylcysteine. Clinical data have suggested L-carnitine may accelerate atherosclerotic disease. Long-term follow up on L-arginine use as prophylaxis against or acute treatment for metabolic strokes has provided more data supporting its clinical use in individuals with mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome and Leigh syndrome. Further, several precision therapies have been developed for specific molecular causes and/or shared clinical phenotypes of primary mitochondrial disease. SUMMARY We provide a comprehensive update on mitochondrial medicine therapies based on current evidence and our single-center clinical experience to support or refute their use, and provide detailed dosing guidelines, for the clinical management of mitochondrial disease. The overarching goal of empiric mitochondrial medicines is to utilize therapies with favorable benefit-to-risk profiles that may stabilize and enhance residual metabolic function to improve cellular resiliency and slow clinical disease progression and/or prevent acute decompensation.
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Affiliation(s)
- Isabella Barcelos
- Center for Applied Genomics, Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Edward Shadiack
- Mitochondrial Medicine Frontier Program, Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rebecca D. Ganetzky
- Mitochondrial Medicine Frontier Program, Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Marni J. Falk
- Mitochondrial Medicine Frontier Program, Division of Human Genetics, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
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Montano V, Gruosso F, Simoncini C, Siciliano G, Mancuso M. Clinical features of mtDNA-related syndromes in adulthood. Arch Biochem Biophys 2020; 697:108689. [PMID: 33227288 DOI: 10.1016/j.abb.2020.108689] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/06/2020] [Accepted: 11/15/2020] [Indexed: 01/26/2023]
Abstract
Mitochondrial diseases are the most common inheritable metabolic diseases, due to defects in oxidative phosphorylation. They are caused by mutations of nuclear or mitochondrial DNA in genes involved in mitochondrial function. The peculiarity of "mitochondrial DNA genetics rules" in part explains the marked phenotypic variability, the complexity of genotype-phenotype correlations and the challenge of genetic counseling. The new massive genetic sequencing technologies have changed the diagnostic approach, enhancing mitochondrial DNA-related syndromes diagnosis and often avoiding the need of a tissue biopsy. Here we present the most common phenotypes associated with a mitochondrial DNA mutation with the recent advances in diagnosis and in therapeutic perspectives.
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Affiliation(s)
- V Montano
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Italy
| | - F Gruosso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Italy
| | - C Simoncini
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Italy
| | - G Siciliano
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Italy
| | - M Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Italy.
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Liufu T, Wang Z. Treatment for mitochondrial diseases. Rev Neurosci 2020; 32:/j/revneuro.ahead-of-print/revneuro-2020-0034/revneuro-2020-0034.xml. [PMID: 32903211 DOI: 10.1515/revneuro-2020-0034] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/22/2020] [Indexed: 11/15/2022]
Abstract
Mitochondrial diseases are predominantly caused by mutations of mitochondrial or nuclear DNA, resulting in multisystem defects. Current treatments are largely supportive, and the disorders progress relentlessly. Nutritional supplements, pharmacological agents and physical therapies have been used in different clinical trials, but the efficacy of these interventions need to be further evaluated. Several recent reviews discussed some of the interventions but ignored bias in those trials. This review was conducted to discover new studies and grade the original studies for potential bias with revised Cochrane Collaboration guidelines. We focused on seven published studies and three unpublished studies; eight of these studies showed improvement in outcome measurements. In particular, two of the interventions have been tested in studies with strict design, which we believe deserve further clinical trials with a large sample. Additionally, allotopic expression of the ND4 subunit seemed to be an effective new treatment for patients with Leber hereditary optic neuropathy.
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Affiliation(s)
- Tongling Liufu
- Department of Neurology, Peking University First Hospital, Beijing, 100034, China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, 100034, China
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Finsterer J, Aliyev R. Metabolic stroke or stroke-like lesion: Peculiarities of a phenomenon. J Neurol Sci 2020; 412:116726. [PMID: 32088469 DOI: 10.1016/j.jns.2020.116726] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES One of the most frequent cerebral lesions in mitochondrial disorders(MIDs) on imaging is the stroke-like lesion(SLL) clinically manifesting as stroke-like episode (SLE, metabolic stroke). This review aims at discussing recent advances concerning the presentation, diagnosis, and treatment of SLLs. METHODS Systematic literature review using appropriate search terms. RESULTS SLLs are the hallmark of MELAS but occasionally occur in other MIDs. SLLs are best identified on multimodal, cerebral MRI. SLLs may present as uni-/multilocular, symmetric/asymmetric, cortical/subcortical, supra-/infratentorial condition, initially resembling a cytotoxic edema and later a vasogenic edema, or a variable mix between them. SLLs run through an acute and a chronic stage. The acute stage is characterised by a progressively expanding lesion over days, weeks, or months, showing up as increasing hyperintensity on T2/FLAIR, DWI, and PWI and by hyperperfusion, that does not conform to a vascular territory. ADC maps are initially hypointens to become hyperintens during the course. More rarely, a variable mixture of hyper- and hypointensities may be found. The chronic stage is characterised by hypoperfusion, gadolinium enhancement, and regression of hyperintensities to various endpoints. SLLs originate from an initial cortical lesion due to focal metabolic breakdown, which either remains stable or expands within the cortex or to subcortical areas. Some SLLs show spontaneous reversibility (fleeing cortical lesions) suggesting that neuronal/glial damage does not reach the threshold of irreversible cell death. CONCLUSIONS SLLs are a unique feature of various MIDs in particular MELAS. SLLs are dynamic and change their appearance over time. SLLs are accessible to treatment.
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Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria.
| | - Rahim Aliyev
- Department of Neurology and Clinical Neurophysiology, Azerbaijan State Advanced Training Institute for Doctors named after A. Aliyev, Baku, Azerbaijan
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Zhang L, Zhang Z, Khan A, Zheng H, Yuan C, Jiang H. Advances in drug therapy for mitochondrial diseases. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:17. [PMID: 32055608 DOI: 10.21037/atm.2019.10.113] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mitochondrial diseases are a group of clinically and genetically heterogeneous disorders driven by oxidative phosphorylation dysfunction of the mitochondrial respiratory chain which due to pathogenic mutations of mitochondrial DNA (mtDNA) or nuclear DNA (nDNA). Recent progress in molecular genetics and biochemical methodologies has provided a better understanding of the etiology and pathogenesis of mitochondrial diseases, and this has expanded the clinical spectrum of this conditions. But the treatment of mitochondrial diseases is largely symptomatic and thus does not significantly change the course of the disease. Few clinical trials have led to the design of drugs aiming at enhancing mitochondrial function or reversing the consequences of mitochondrial dysfunction which are now used in the clinical treatment of mitochondrial diseases. Several other drugs are currently being evaluated for clinical management of patients with mitochondrial diseases. In this review, the current status of treatments for mitochondrial diseases is described systematically, and newer potential treatment strategies for mitochondrial diseases are also discussed.
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Affiliation(s)
- Lufei Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Zhaoyong Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Aisha Khan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hui Zheng
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Chao Yuan
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Haishan Jiang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Ikawa M, Povalko N, Koga Y. Arginine therapy in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes. Curr Opin Clin Nutr Metab Care 2020; 23:17-22. [PMID: 31693521 PMCID: PMC6903379 DOI: 10.1097/mco.0000000000000610] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW We would like to inform clinicians that the systematic administration of oral and intravenous L-arginine is therapeutically beneficial and clinically useful for patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS), when they maintain plasma arginine concentration at least 168 μmol/l. RECENT FINDINGS MELAS is associated with endothelial dysfunction by decreased plasma L-arginine, nitric oxide (NO), and cyclic guanosine monophosphate. Endothelial dysfunction is also evident using flow-mediated vasodilation measurement by high-resolution Doppler echocardiography in the forearm artery in patients with MELAS. L-arginine is known to be an important precursor of NO to normalize the endothelial function in MELAS. In our clinical trial followed by 7 years follow-up study, the systematic administration of L-arginine to patients with MELAS significantly improved the survival curve of patients compared with natural history. Maintaining plasma arginine concentration at least 168 μmol/l may prevent the ictuses through the putative pathophysiologic mechanism and optimal normalization of endothelial dysfunction. SUMMARY Neither death nor bedriddenness occurred during the 2-year clinical trials, and the latter did not develop during the 7-year follow-up despite the progressively neurodegenerative and eventually life-threatening nature of MELAS. Therapeutic regimen of L-arginine on MELAS may be beneficial and clinically useful for patient care with MELAS.
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Affiliation(s)
- Masamichi Ikawa
- Department of Advanced Medicine for Community Healthcare, Faculty of Medical Sciences
- Biomedical Imaging Research Center, University of Fukui, Fukui
| | - Nataliya Povalko
- Department of Pediatrics and Child Health, Kurume University Graduate School of Medicine, Kurume, Japan
- Institute of Fundamental Medicine and Biology, OpenLab Gene and Cell Technology, Kazan Federal University, Kazan Respublika Tatarstan, Russia
| | - Yasutoshi Koga
- Department of Pediatrics and Child Health, Kurume University Graduate School of Medicine, Kurume, Japan
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Abstract
Epilepsy is frequently a severe and sinister symptom in primary mitochondrial diseases, a group of more than 350 different genetic disorders characterized by mitochondrial dysfunction and extreme clinical and biochemical heterogeneity. Mitochondrial epilepsy is notoriously difficult to manage, principally because the vast majority of primary mitochondrial diseases currently lack effective therapies. Treating the underlying mitochondrial disorder is likely to be a more effective strategy than using traditional antiepileptic drugs. This review, initially presented at the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures at the Francis Crick Institute in London, summarizes the currently available and emerging therapies for mitochondrial epilepsy. Potentially treatable mitochondrial diseases include disorders of coenzyme Q10 biosynthesis and a group of mitochondrial respiratory chain complex I subunit and assembly factor defects that respond to riboflavin (vitamin B2). Approaches that have been adopted in actively recruiting clinical trials include redox modulation, harnessing mitochondrial biogenesis, using rapamycin to target mitophagy, nucleoside supplementation, and gene and cell therapies. Most of the clinical trials are at an early stage (Phase 1 or 2) and none of the currently active trials is specifically targeting mitochondrial epilepsy. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Fukuda M, Nagao Y. Dynamic derangement in amino acid profile during and after a stroke-like episode in adult-onset mitochondrial disease: a case report. J Med Case Rep 2019; 13:313. [PMID: 31630688 PMCID: PMC6802332 DOI: 10.1186/s13256-019-2255-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/03/2019] [Indexed: 12/23/2022] Open
Abstract
Background Maternally inherited diabetes and deafness, and mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes are examples of mitochondrial diseases that are relatively common in the adult population. Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes are assumed to be associated with decreases in arginine and citrulline. Biomarkers, such as growth differentiation factor-15, were developed to assist in the diagnosis of mitochondrial diseases. Case presentation A 55-year-old Japanese man, an insulin user, presented after a loss of consciousness. A laboratory test showed diabetic ketoacidosis. He and his mother had severe hearing difficulty. Bilateral lesions on magnetic resonance imaging, the presence of seizure, and an elevated ratio of lactate to pyruvate, altogether suggested a diagnosis of mitochondrial disease. Mitochondrial DNA in our patient’s peripheral blood was positive with a 3243A>G mutation, which is the most frequent cause of maternally inherited diabetes and deafness, and mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes. As a result, maternally inherited diabetes and deafness/mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes was diagnosed. We measured growth differentiation factor-15 and multiple amino acids in his blood, longitudinally during and after the stroke-like episode. Growth differentiation factor-15 was increased to an immeasurably high level on the day of the stroke-like episode. Although his diabetes improved with an increased dose of insulin, the growth differentiation factor-15 level gradually increased, suggesting that his mitochondrial insufficiency did not improve. Multiple amino acid species, including arginine, citrulline, and taurine, showed a decreased level on the day of the episode and a sharp increase the next day. In contrast, the level of aspartic acid increased to an extremely high level on the day of the episode, and decreased gradually thereafter. Conclusions Growth differentiation factor-15 can be used not only for the diagnosis of mitochondrial disease, but as an indicator of its acute exacerbation. A stroke-like episode of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes reflects a drastic derangement of multiple amino acids. The involvement of aspartic acid in the episodes should be explored in future studies.
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Affiliation(s)
- Mai Fukuda
- Hidaka Tokushukai Hospital, 1-10-27 Shizunai Kose-cho, Shin-Hidaka-cho, Hokkaido, 056-0005, Japan
| | - Yoshiro Nagao
- Hidaka Tokushukai Hospital, 1-10-27 Shizunai Kose-cho, Shin-Hidaka-cho, Hokkaido, 056-0005, Japan. .,Present Address: Fukuoka Tokushukai Hospital, 4-5 Sugukita, Kasuga city, Fukuoka, 816-0864, Japan.
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Orsucci D, Ienco EC, Siciliano G, Mancuso M. Mitochondrial disorders and drugs: what every physician should know. Drugs Context 2019; 8:212588. [PMID: 31391854 PMCID: PMC6668504 DOI: 10.7573/dic.212588] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023] Open
Abstract
Mitochondrial disorders are a group of metabolic conditions caused by impairment of the oxidative phosphorylation system. There is currently no clear evidence supporting any pharmacological interventions for most mitochondrial disorders, except for coenzyme Q10 deficiencies, Leber hereditary optic neuropathy, and mitochondrial neurogastrointestinal encephalomyopathy. Furthermore, some drugs may potentially have detrimental effects on mitochondrial dysfunction. Drugs known to be toxic for mitochondrial functions should be avoided whenever possible. Mitochondrial patients needing one of these treatments should be carefully monitored, clinically and by laboratory exams, including creatine kinase and lactate. In the era of molecular and ‘personalized’ medicine, many different physicians (not only neurologists) should be aware of the basic principles of mitochondrial medicine and its therapeutic implications. Multicenter collaboration is essential for the advancement of therapy for mitochondrial disorders. Whenever possible, randomized clinical trials are necessary to establish efficacy and safety of drugs. In this review we discuss in an accessible way the therapeutic approaches and perspectives in mitochondrial disorders. We will also provide an overview of the drugs that should be used with caution in these patients.
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A cluster of disseminated small cortical lesions in MELAS: its distinctive clinical and neuroimaging features. J Neurol 2019; 266:1459-1472. [PMID: 30888501 DOI: 10.1007/s00415-019-09283-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To investigate a diversity of stroke-like episodes (SLEs) in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS), and report a disseminated form of SLEs (D-SLEs) attributed to a cluster of disseminated small cortical lesions. METHODS We retrospectively reviewed the clinical information of 27 MELAS patients seen at Kitasato University Hospital between January 1990 and April 2018. Among those, we selected 13 patients with m.3243A>G mutation [median age at onset, 35 years (11-68 years), two pediatric onset < 17 years] who had at least one SLE. SLEs were classified into classic or non-classic based on characteristic features of stroke-like lesions. RESULTS 44 SLEs were identified during a median observational period of 119 months (3-240 months). Among those, 29 (65.9%) were classic SLEs (C-SLEs) mainly attributed to a single continuous lobular lesion incongruent to vascular territory and occasionally accompanied by a gradual spread associated with hyperperfusion and persistent seizure activity. The remaining 15 were non-classic attributed to sparsely distributed (n = 10), disseminated (n = 4) or cerebellar lesions (n = 1). C-SLEs developed in all patients but non-classic SLEs in 5; D-SLEs developed in 4 patients accounting for 4 of 44 SLEs (9.1%). Non-classic SLEs developed more frequently in pediatric-onset than in adult-onset patients (12/15 vs. 3/29, p < 0.0001). SLEs began with acute onset of symptoms in 42 SLEs (95.5%), but D-SLEs of 2 adult-onset patients began with ill-defined subacute-onset fluctuating encephalopathy. CONCLUSIONS This study showed a diversity of SLEs in patients with m.3243A>G mutation. Further studies are required to elucidate the pathophysiological mechanisms of non-classic SLEs including D-SLEs.
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Whether NO-precursors are truly beneficial for stroke-like episodes remains unsolved. J Neurol 2019; 266:245-246. [DOI: 10.1007/s00415-018-9090-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/08/2018] [Indexed: 10/28/2022]
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