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Manto M, Hadjivassiliou M, Baizabal-Carvallo JF, Hampe CS, Honnorat J, Joubert B, Mitoma H, Muñiz-Castrillo S, Shaikh AG, Vogrig A. Consensus Paper: Latent Autoimmune Cerebellar Ataxia (LACA). CEREBELLUM (LONDON, ENGLAND) 2024; 23:838-855. [PMID: 36991252 PMCID: PMC10060034 DOI: 10.1007/s12311-023-01550-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 06/01/2023]
Abstract
Immune-mediated cerebellar ataxias (IMCAs) have diverse etiologies. Patients with IMCAs develop cerebellar symptoms, characterized mainly by gait ataxia, showing an acute or subacute clinical course. We present a novel concept of latent autoimmune cerebellar ataxia (LACA), analogous to latent autoimmune diabetes in adults (LADA). LADA is a slowly progressive form of autoimmune diabetes where patients are often initially diagnosed with type 2 diabetes. The sole biomarker (serum anti-GAD antibody) is not always present or can fluctuate. However, the disease progresses to pancreatic beta-cell failure and insulin dependency within about 5 years. Due to the unclear autoimmune profile, clinicians often struggle to reach an early diagnosis during the period when insulin production is not severely compromised. LACA is also characterized by a slowly progressive course, lack of obvious autoimmune background, and difficulties in reaching a diagnosis in the absence of clear markers for IMCAs. The authors discuss two aspects of LACA: (1) the not manifestly evident autoimmunity and (2) the prodromal stage of IMCA's characterized by a period of partial neuronal dysfunction where non-specific symptoms may occur. In order to achieve an early intervention and prevent cell death in the cerebellum, identification of the time-window before irreversible neuronal loss is critical. LACA occurs during this time-window when possible preservation of neural plasticity exists. Efforts should be devoted to the early identification of biological, neurophysiological, neuropsychological, morphological (brain morphometry), and multimodal biomarkers allowing early diagnosis and therapeutic intervention and to avoid irreversible neuronal loss.
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Affiliation(s)
- Mario Manto
- Service de Neurologie, Médiathèque Jean Jacquy, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
| | | | | | | | - Jerome Honnorat
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Bastien Joubert
- French Reference Center on Paraneoplastic Neurological Syndromes, Hospices Civils de Lyon, Hôpital Neurologique, Bron, France
- Institut NeuroMyoGene MELIS INSERM U1314/CNRS UMR 5284, Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan.
| | | | - Aasef G Shaikh
- Louis Stokes Cleveland VA Medical Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Alberto Vogrig
- Clinical Neurology, Udine University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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Theeranaew W, Wang F, Ghasia FF, Wilmot G, Shaikh AG. Gaze-holding and anti-GAD antibody: prototypic heterogeneous motor dysfunction in immune disease. CEREBELLUM (LONDON, ENGLAND) 2022; 21:55-63. [PMID: 33977497 DOI: 10.1007/s12311-021-01272-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 06/12/2023]
Abstract
The variability in motor dysfunction is not uncommon in autoimmune disorders. Antibody-mediated system-wide malfunction or effects on the neural network shared by two independent pathophysiological processes can cause such heterogeneity. We tested this prediction for motor dysfunction during gaze holding in 11 patients with increased titers of glutamic acid decarboxylase (anti-GAD) antibody. High-resolution oculography measured horizontal and vertical eye positions. The analysis was performed with customized signal processing algorithms. Downbeat and gaze-evoked nystagmus commonly coexisted; one patient had a combination of upbeat and gaze-evoked nystagmus. The nystagmus was associated with saccadic intrusions in 10 patients; all had squarewaves, but five also had saccadic oscillations. The nystagmus and saccadic intrusions, both in the same axis of eye rotations, were not uncommon. Tandem appearance of the episodes of nystagmus and saccadic intrusions suggested a coupling between the two abnormalities. We speculated a unifying framework where the anti-GAD antibody inhibited (GAD mediated) conversion of glutamate to gamma-aminobutyric acid (GABA). Paucity GABA and excess of glutamate cause nystagmus (less GABA) and high-frequency saccadic oscillations (excessive glutamate).
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Affiliation(s)
- Wanchat Theeranaew
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44110, USA
| | - Fajun Wang
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44110, USA
| | | | - George Wilmot
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Aasef G Shaikh
- Department of Neurology, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, 44110, USA.
- Neurology Service and Daroff-Dell' Osso Ocular Motility Laboratory, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
- Departments of Neurology and Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA.
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Kaspranskaya G, Chernenkaya V, Fominykh V, Brylev L. Peripheral vertigo as onset of an immune-mediated disorder. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:97-100. [DOI: 10.17116/jnevro202212202197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Mahale RR, Dutta D, Kovoor J, Mailankody P, Padmanabha H, Mathuranath PS. Upbeat Nystagmus in Late Onset Cerebellar Ataxia: Think of Anti-Glutamate Decarboxylase 65 Antibody-Associated Cerebellar Ataxia. Ann Indian Acad Neurol 2021; 24:441-443. [PMID: 34447019 PMCID: PMC8370166 DOI: 10.4103/aian.aian_470_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 05/28/2020] [Accepted: 05/31/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rohan R Mahale
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Debayan Dutta
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Jennifer Kovoor
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Pooja Mailankody
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Hansashree Padmanabha
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - P S Mathuranath
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Stiff-Eye Syndrome-Anti-GAD Ataxia Presenting with Isolated Ophthalmoplegia: A Case Report. Brain Sci 2021; 11:brainsci11070932. [PMID: 34356166 PMCID: PMC8304346 DOI: 10.3390/brainsci11070932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/18/2022] Open
Abstract
Anti-GAD ataxia is one of the most common forms of immune-mediated cerebellar ataxias. Many neurological syndromes have been reported in association with anti-GAD. Ophthalmoparesis has been described in stiff person syndrome. We report a case of anti-GAD ataxia presenting initially with isolated ophthalmoplegia and showing complete resolution after immunotherapy. A 26-year-old male patient presented with ophthalmoparesis characterized by tonic upwards deviation of the right eye. In the following month, he developed progressive ataxia with anti-GAD titers of 1972 UI/mL. After treatment with methylprednisolone and immunoglobulin, there was complete resolution of symptoms and anti-GAD titers decreased. This is the first report of isolated ophthalmoparesis due to tonic eye deviation associated with anti-GAD antibodies without stiff-person syndrome. Tonic eye deviation has been reported in SPS, possibly secondary to continuous discharge in gaze holding neurons in the brainstem (similar to what occurs in spinal motor neurons). With growing evidence for ocular abnormalitites in SPS, anti-GAD associated neurological syndromes should be included in the differential diagnosis of isolated ophthalmoplegia.
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