1
|
Cox BC, Pearson JY, Mandrekar J, Gavrilova RH. The clinical spectrum of MELAS and associated disorders across ages: a retrospective cohort study. Front Neurol 2023; 14:1298569. [PMID: 38156086 PMCID: PMC10753009 DOI: 10.3389/fneur.2023.1298569] [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] [Received: 09/21/2023] [Accepted: 11/20/2023] [Indexed: 12/30/2023] Open
Abstract
Objective Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a severe multisystemic disease, although some have a milder phenotype. We aimed to evaluate the clinical spectrum of this disease from MELAS patients to asymptomatic carriers and identify predictors of severity. Methods We reviewed 81 patients, who had MELAS or had positive genetics without meeting clinical criteria. Patients who met criteria including lactic acidosis, encephalomyopathy, and stroke-like episodes (SLE) were categorized as MELAS, symptomatic non-MELAS, and asymptomatic. MELAS was further categorized as "standard-onset" if the first stroke-like episode (SLE) occurred before age 40 or "late-onset." Results Eighty-one patients were included: 42 MELAS (13 late-onset), 30 symptomatic non-MELAS, and 9 asymptomatic. MELAS patients had lower BMI at onset (mean 18.6 vs. 25.1 asymptomatic and 22.0 symptomatic non-MELAS, p < 0.05). There was a trend toward higher serum heteroplasmy in MELAS compared to symptomatic non-MELAS and asymptomatic (means 39.3, 29.3, and 21.8% p = 0.09). Symptomatic non-MELAS had more sensorineural hearing loss as first presenting symptom (51.6% vs. 24.4%, p < 0.05). MELAS had higher prevalence of seizures (88.1% vs. 16.7%, p < 0.05) and shorter survival from onset to death (50% mortality at 25 years vs. 10%, p < 0.05). Late-onset MELAS had longer disease duration from first symptom to first SLE (mean 16.6 vs. 9.3 yrs) and also lived longer (mean age at death 62 vs. 30). Standard-onset MELAS had more neurologic involvement at onset than late-onset (51.7% vs. 15.4%). Late-onset patients had more prevalent diabetes (69.2% vs. 13.8%) and nephropathy (53.8% vs. 10.3%). Patients with late-onset MELAS also had more organ systems involved (mean 4.1 vs. 2.7, p < 0.05). There was a trend toward higher heteroplasmy levels in standard-onset (mean 44.8% vs. 25.3%, p = 0.18). Discussion Our study highlights the spectrum of MELAS. The lower BMI in MELAS at presentation as well as higher rates of sensorineural hearing loss as initial symptom in symptomatic non-MELAS may be useful clinical markers. While many patients present before age 40 with SLE, some can present with SLE later in life. Standard onset MELAS is more likely to present with neurologic symptoms. Late-onset is more likely to suffer diabetes or nephropathy and have more organ systems involved.
Collapse
Affiliation(s)
- Benjamin C. Cox
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jennifer Y. Pearson
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jay Mandrekar
- Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ralitza H. Gavrilova
- Department of Neurology, College of Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
2
|
Liao NY, Lai KL, Liao YC, Hsiao CT, Lee YC. Identification of m.3243A>G mitochondrial DNA mutation in patients with cerebellar ataxia. J Formos Med Assoc 2023; 122:1028-1034. [PMID: 37311680 DOI: 10.1016/j.jfma.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The mitochondrial DNA m.3243A>G mutation can affect mitochondrial function and lead to a wide phenotypic spectrum, including mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome, diabetes mellitus, hearing impairment, cardiac involvement, epilepsy, migraine, myopathy, and cerebellar ataxia. However, m.3243A>G has been rarely reported in patients with cerebellar ataxia as their predominant manifestation. The aim of this study is to investigate the prevalence and clinical features of m.3243A>G in a Taiwanese cohort of cerebellar ataxia with unknown genetic diagnosis. METHODS This retrospective cohort study conducted the mutation analysis of m.3243A>G by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) in 232 unrelated Han Chinese patients with genetically-undetermined cerebellar ataxia. The clinical presentation and neuroimaging features of patients with m.3243A>G mutation-related cerebellar ataxia were characterized. RESULTS We identified two patients harboring m.3243A>G mutation. These patients have suffered from apparently sporadic and slowly progressive cerebellar ataxia since age 52 and 35 years, respectively. Both patients had diabetes mellitus and/or hearing impairment. The neuroimaging studies revealed generalized brain atrophy with predominantly cerebellar involvement in both individuals and bilateral basal ganglia calcifications in one of the patients. CONCLUSION Mitochondrial m.3243A>G mutation accounted for 0.9% (2/232) of genetically-undetermined cerebellar ataxia in the Han Chinese cohort in Taiwan. These findings highlight the importance of investigating m.3243A>G in patients with genetically-undetermined cerebellar ataxia.
Collapse
Affiliation(s)
- Nai-Yi Liao
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuan-Lin Lai
- Department of Neurology, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Yi-Chu Liao
- Department of Neurology, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan
| | - Cheng-Tsung Hsiao
- Department of Neurology, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.
| | - Yi-Chung Lee
- Department of Neurology, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan.
| |
Collapse
|
3
|
Khasminsky V, Auriel E, Luckman J, Eliahou R, Inbar E, Pardo K, Landau Y, Barnea R, Mermelstein M, Shelly S, Naftali J, Peretz S. Clinicoradiologic Criteria for the Diagnosis of Stroke-like Episodes in MELAS. Neurol Genet 2023; 9:e200082. [PMID: 37426458 PMCID: PMC10323819 DOI: 10.1212/nxg.0000000000200082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/16/2023] [Indexed: 07/11/2023]
Abstract
Background and Objectives Stroke-like episodes (SLEs) in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome are often misdiagnosed as acute ischemic stroke (AIS). We aimed to determine unique clinical and neuroimaging features for SLEs and formulate diagnostic criteria. Methods We retrospectively identified patients with MELAS admitted for SLEs between January 2012 and December 2021. Clinical features and imaging findings were compared with a cohort of patients who presented with AIS and similar lesion topography. A set of criteria was formulated and then tested by a blinded rater to evaluate diagnostic performance. Results Eleven MELAS patients with 17 SLE and 21 AISs were included. Patients with SLEs were younger (median 45 [37-60] vs 77 [68-82] years, p < 0.01) and had a lower body mass index (18 ± 2.6 vs 29 ± 4, p < 0.01), more commonly reported hearing loss (91% vs 5%, p < 0.01), and more commonly presented with headache and/or seizures (41% vs 0%, p < 0.01). The earliest neuroimaging test performed at presentation was uniformly a noncontrast CT. Two main patterns of lesion topography with a stereotypical spatiotemporal evolution were identified-an anterior pattern (7/21, 41%) starting at the temporal operculum and spreading to the peripheral frontal cortex and a posterior pattern (10/21, 59%) starting at the cuneus/precuneus and spreading to the lateral occipital and parietal cortex. Other distinguishing features for SLEs vs AIS were cerebellar atrophy (91% vs 19%, p < 0.01), previous cortical lesions with typical SLE distribution (46% vs 9%, p = 0.03), acute lesion tissue hyperemia and venous engorgement on CT angiography (CTA) (45% vs 0%, p < 0.01), and no large vessel occlusion on CTA (0% vs 100%, p < 0.01). Based on these clinicoradiologic features, a set of diagnostic criteria were constructed for possible SLE (sensitivity 100%, specificity 81%, AUC 0.905) and probable SLE (sensitivity 88%, specificity 95%, AUC 0.917). Discussion Clinicoradiologic criteria based on simple anamnesis and a CT scan at presentation can accurately diagnose SLE and lead to early administration of appropriate therapy. Classification of Evidence This study provides Class III evidence that an algorithm using clinical and imaging features can differentiate stroke-like episodes due to MELAS from acute ischemic strokes.
Collapse
Affiliation(s)
- Vadim Khasminsky
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Eitan Auriel
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Judith Luckman
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Ruth Eliahou
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Edna Inbar
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Keshet Pardo
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Yuval Landau
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Rani Barnea
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Maor Mermelstein
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Shahar Shelly
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Jonathan Naftali
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Shlomi Peretz
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| |
Collapse
|
4
|
Salari M, Etemadifar M, Rashedi R, Rashedi R. Patent foramen ovale leading to mismanagement in a mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes patient. Clin Case Rep 2023; 11:e7723. [PMID: 37484747 PMCID: PMC10359446 DOI: 10.1002/ccr3.7723] [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] [Received: 05/11/2022] [Revised: 03/14/2023] [Accepted: 07/08/2023] [Indexed: 07/25/2023] Open
Abstract
Key Clinical Message The stroke-like episodes and brain MRI lesions in MELAS usually have a nonischemic pattern, are resolved over time, and have a migrating pattern that helps us distinguish them from ischemic cerebral infarcts. Nevertheless, conditions such as intracardiac thromboses, PFO, and hypercoagulable state may be present concomitantly, leading to mismanagement. Therefore, further investigation and echocardiography are suggested in MELAS patients. Abstract Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is the most common maternally-inherited mitochondrial disorder presenting by stroke-like episodes, seizures, encephalopathy and muscle weakness. We report the clinical, imaging, echocardiography and muscle biopsy findings of a patient presenting by unique characteristics which have not been reported in previous cases of MELAS. The reported case is a 34 year old man with the history of three times hospitalization due to muscle weakness, encephalopathy, progressive cognitive decline, and gradual visual loss. Muscle biopsy revealed Ragged Red Fibers concomitant with mitochondrial disorders. PFO was found in echocardiography leading to mismanagement of this patient and MR imaging showed ischemic lesions with a progressive pattern. This is the first reported case of MELAS accompanying with PFO. All previous reported cases of MELAS have mentioned a fluctuating characteristic for the ischemic lesions; hence this is the first case of MELAS with the progressive pattern of ischemic lesions.
Collapse
Affiliation(s)
- Mehri Salari
- Clinical Reasearch Development Unit of Shohada‐e Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of ExcellenceShahid Beheshti University of medical SciencesTehranIran
| | - Masoud Etemadifar
- Department of Functional NeurosurgeryMedical School, Isfahan University of Medical SciencesIsfahanIran
| | - Ronak Rashedi
- Clinical Reasearch Development Unit of Shohada‐e Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of ExcellenceShahid Beheshti University of medical SciencesTehranIran
| | - Romina Rashedi
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of ExcellenceShahid Beheshti University of medical SciencesTehranIran
| |
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
Al Yazidi G, Mulder J, Licht C, Harvey E, Tein I. Response to the Letter to the Editor "The apparent beneficial effect of L-arginine for stroke-like lesions can be accidental" by Josef Finsterer and Sinda Zarrouk. Neurohospitalist 2022; 12:715-720. [PMID: 36147768 PMCID: PMC9485703 DOI: 10.1177/19418744221090276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Affiliation(s)
- Ghalia Al Yazidi
- Division of Neurology, Dept. of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jaap Mulder
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Harvey
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid Tein
- Division of Neurology, Dept. of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Genetics and Genome Biology Program, The Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Będkowska N, Zontek A, Paprocka J. Stroke-like Episodes in Inherited Neurometabolic Disorders. Metabolites 2022; 12:metabo12100929. [PMID: 36295831 PMCID: PMC9611026 DOI: 10.3390/metabo12100929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022] Open
Abstract
Stroke-like episodes (SLEs) are significant clinical manifestations of metabolic disorders affecting the central nervous system. Morphological equivalents presented in neuroimaging procedures are described as stroke-like lesions (SLLs). It is crucial to distinguish SLEs from cerebral infarction or intracerebral hemorrhage, mainly due to the variety in management. Another significant issue to underline is the meaning of the main pathogenetic hypotheses in the development of SLEs. The diagnostic process is based on the patient’s medical history, physical and neurological examination, neuroimaging techniques and laboratory and genetic testing. Implementation of treatment is generally symptomatic and includes L-arginine supplementation and adequate antiepileptic management. The main aim of the current review was to summarize the basic and actual knowledge about the occurrence of SLEs in various inherited neurometabolic disorders, discuss the possible pathomechanism of their development, underline the role of neuroimaging in the detection of SLLs and identification of the electroencephalographic patterns as well as histological abnormalities in inherited disorders of metabolism.
Collapse
Affiliation(s)
- Natalia Będkowska
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Aneta Zontek
- Students’ Scientific Society, Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Justyna Paprocka
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
- Correspondence:
| |
Collapse
|
8
|
Serrallach BL, Orman G, Boltshauser E, Hackenberg A, Desai NK, Kralik SF, Huisman TAGM. Neuroimaging in cerebellar ataxia in childhood: A review. J Neuroimaging 2022; 32:825-851. [PMID: 35749078 DOI: 10.1111/jon.13017] [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: 04/14/2022] [Revised: 05/27/2022] [Accepted: 06/05/2022] [Indexed: 11/28/2022] Open
Abstract
Ataxia is one of the most common pediatric movement disorders and can be caused by a large number of congenital and acquired diseases affecting the cerebellum or the vestibular or sensory system. It is mainly characterized by gait abnormalities, dysmetria, intention tremor, dysdiadochokinesia, dysarthria, and nystagmus. In young children, ataxia may manifest as the inability or refusal to walk. The diagnostic approach begins with a careful clinical history including the temporal evolution of ataxia and the inquiry of additional symptoms, is followed by a meticulous physical examination, and, depending on the results, is complemented by laboratory assays, electroencephalography, nerve conduction velocity, lumbar puncture, toxicology screening, genetic testing, and neuroimaging. Neuroimaging plays a pivotal role in either providing the final diagnosis, narrowing the differential diagnosis, or planning targeted further workup. In this review, we will focus on the most common form of ataxia in childhood, cerebellar ataxia (CA). We will discuss and summarize the neuroimaging findings of either the most common or the most important causes of CA in childhood or present causes of pediatric CA with pathognomonic findings on MRI. The various pediatric CAs will be categorized and presented according to (a) the cause of ataxia (acquired/disruptive vs. inherited/genetic) and (b) the temporal evolution of symptoms (acute/subacute, chronic, progressive, nonprogressive, and recurrent). In addition, several illustrative cases with their key imaging findings will be presented.
Collapse
Affiliation(s)
- Bettina L Serrallach
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Gunes Orman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Eugen Boltshauser
- Department of Pediatric Neurology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Annette Hackenberg
- Department of Pediatric Neurology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nilesh K Desai
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Stephen F Kralik
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| | - Thierry A G M Huisman
- Edward B. Singleton Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
9
|
Yang F, Peng S, Peng Q. Diagnosis of adult‑onset MELAS with suspected recurrent strokes: A case report. Exp Ther Med 2022; 24:466. [PMID: 35747150 PMCID: PMC9204559 DOI: 10.3892/etm.2022.11393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/13/2022] [Indexed: 11/05/2022] Open
Abstract
Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) is caused by mutations in mitochondrial DNA and is one of the most common syndromes among the mitochondrial diseases. Clinical manifestations typically occur before the age of 40 years. The present study reports a case of MELAS with a mutation in the adenine to guanine conversion at mitochondrial genome 3243 in a 48-year-old woman who was suspected of suffering from recurrent strokes. Finally, the genomic analysis confirmed the diagnosis of MELAS. This case highlights the importance of considering MELAS as a potential cause of recurrent stroke-like events if imaging findings are atypical for cerebral infarction, even among middle-aged patients with vascular risk factors.
Collapse
Affiliation(s)
- Fei Yang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Shan Peng
- Department of Medical Rehabilitation, The Second Clinical College of North Sichuan Medical College, Nanchong Central Hospital, Nanchong, Sichuan 637000, P.R. China
| | - Qiaojun Peng
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| |
Collapse
|
10
|
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.
Collapse
|
11
|
Alessi I, Caroleo AM, de Palma L, Mastronuzzi A, Pro S, Colafati GS, Boni A, Della Vecchia N, Velardi M, Evangelisti M, Carboni A, Carai A, Vinti L, Valeriani M, Reale A, Parisi P, Raucci U. Short and Long-Term Toxicity in Pediatric Cancer Treatment: Central Nervous System Damage. Cancers (Basel) 2022; 14:cancers14061540. [PMID: 35326692 PMCID: PMC8946171 DOI: 10.3390/cancers14061540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary The purpose of this review is to describe central nervous system side effects in the treatment of pediatric cancer patients. Unfortunately, we must consider that the scarce data in the literature does not allow us to expand on some issues, especially those related to innovative immunotherapy. We have described the major neurotoxicities arising with the various types of treatment to help specialists who approach these treatments recognize them early, prevent them, and treat them promptly. Abstract Neurotoxicity caused by traditional chemotherapy and radiotherapy is well known and widely described. New therapies, such as biologic therapy and immunotherapy, are associated with better outcomes in pediatric patients but are also associated with central and peripheral nervous system side effects. Nevertheless, central nervous system (CNS) toxicity is a significant source of morbidity in the treatment of cancer patients. Some CNS complications appear during treatment while others present months or even years later. Radiation, traditional cytotoxic chemotherapy, and novel biologic and targeted therapies have all been recognized to cause CNS side effects; additionally, the risks of neurotoxicity can increase with combination therapy. Symptoms and complications can be varied such as edema, seizures, fatigue, psychiatric disorders, and venous thromboembolism, all of which can seriously influence the quality of life. Neurologic complications were seen in 33% of children with non-CNS solid malign tumors. The effects on the CNS are disabling and often permanent with limited treatments, thus it is important that clinicians recognize the effects of cancer therapy on the CNS. Knowledge of these conditions can help the practitioner be more vigilant for signs and symptoms of potential neurological complications during the management of pediatric cancers. As early detection and more effective anticancer therapies extend the survival of cancer patients, treatment-related CNS toxicity becomes increasingly vital. This review highlights major neurotoxicities due to pediatric cancer treatments and new therapeutic strategies; CNS primary tumors, the most frequent solid tumors in childhood, are excluded because of their intrinsic neurological morbidity.
Collapse
Affiliation(s)
- Iside Alessi
- Department of Hematology/Oncology, Gene Therapy and Hematopoietic Transplantation, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Anna Maria Caroleo
- Department of Hematology/Oncology, Gene Therapy and Hematopoietic Transplantation, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Luca de Palma
- Child Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Angela Mastronuzzi
- Department of Hematology/Oncology, Gene Therapy and Hematopoietic Transplantation, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Stefano Pro
- Child Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | | | - Alessandra Boni
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicoletta Della Vecchia
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Margherita Velardi
- Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
| | - Melania Evangelisti
- Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
| | - Alessia Carboni
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Luciana Vinti
- Department of Hematology/Oncology, Gene Therapy and Hematopoietic Transplantation, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Massimiliano Valeriani
- Child Neurology Unit, Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Antonino Reale
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Pasquale Parisi
- Child Neurology, NESMOS Department, Faculty of Medicine and Psychology, Sant'Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
| | - Umberto Raucci
- Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| |
Collapse
|
12
|
Guo H, Guo L, Yuan Y, Liang XY, Bi R. Co-occurrence of m.15992A>G and m.15077G>A Is Associated With a High Penetrance of Maternally Inherited Hypertension in a Chinese Pedigree. Am J Hypertens 2022; 35:96-102. [PMID: 34346491 DOI: 10.1093/ajh/hpab123] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/25/2021] [Accepted: 08/03/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mitochondrial DNA (mtDNA) pathogenic variants have been identified to be associated with maternally inherited essential hypertension (MIEH). However, the distinctive clinical features and molecular pathogenesis of MIEH are not fully understood. METHODS In this study, we collected a Chinese MIEH family with extraordinary higher penetrance of essential hypertension (88.89%) and early ages of onset (31-40 years old), and performed clinical and genetic characterization for this family. The complete mitochondrial genome of the proband was sequenced and analyzed. RESULTS The maternally related members in this family were presented with severe increased blood pressure, left ventricular remodeling, and metabolic abnormalities. Through sequencing the entire mtDNA of the proband and performing systematic analysis of the mtDNA variants with a phylogenic approach, we identified a potentially pathogenic tRNA variant (m.15992A>G in the MT-TP gene) that may account for the MIEH in this family. One nonsynonymous variant (m.15077G>A in the MT-CYB gene) was identified to play a synergistic role with m.15992A>G to cause a high penetrance of MIEH. CONCLUSIONS Our results, together with previous findings, have indicated that tRNA pathogenic variants in the mtDNA could act important roles in the pathogenesis of MIEH through reducing mitochondrial translation and disturbing mitochondrial function.
Collapse
Affiliation(s)
- Hao Guo
- Department of Cardiology, 1st Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Cardiology, Yunnan Key Laboratory of Laboratory Medicine, Kunming, Yunnan, China
| | - Li Guo
- Department of Radiology, 2nd Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yong Yuan
- Department of emergency, 2nd Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xin-yue Liang
- Department of Cardiology, 1st Affiliated Hospital of Kunming Medical University, Kunming, China
- Department of Cardiology, Graduate School of the Kunming Medical University, Kunming, China
| | - Rui Bi
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences & Yunnan Province, and KIZ/CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, China
- Kunming College of Life Science, University of Chinese Academy of Sciences, Kunming, Yunnan, China
| |
Collapse
|
13
|
Chojdak-Łukasiewicz J, Dziadkowiak E, Budrewicz S. Monogenic Causes of Strokes. Genes (Basel) 2021; 12:1855. [PMID: 34946804 PMCID: PMC8700771 DOI: 10.3390/genes12121855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
Strokes are the main cause of death and long-term disability worldwide. A stroke is a heterogeneous multi-factorial condition, caused by a combination of environmental and genetic factors. Monogenic disorders account for about 1% to 5% of all stroke cases. The most common single-gene diseases connected with strokes are cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) Fabry disease, mitochondrial myopathy, encephalopathy, lactacidosis, and stroke (MELAS) and a lot of single-gene diseases associated particularly with cerebral small-vessel disease, such as COL4A1 syndrome, cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), and Hereditary endotheliopathy with retinopathy, nephropathy, and stroke (HERNS). In this article the clinical phenotype for the most important single-gene disorders associated with strokes are presented. The monogenic causes of a stroke are rare, but early diagnosis is important in order to provide appropriate therapy when available.
Collapse
|
14
|
Lang AE, Desai D, Desai S, Sethi KD. Commentary: A Boy with Spells of Unusual Movements after Failure in Exam. Mov Disord Clin Pract 2021; 8:S63-S64. [PMID: 34514057 PMCID: PMC8414505 DOI: 10.1002/mdc3.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Anthony E. Lang
- Edmond J. Safra Program in Parkinson's DiseaseUniversity Health NetworkTorontoOntarioCanada
| | - Devangi Desai
- Department of Medicine, Shree Krishna Hospital and Pramukhswami Medical CollegeBhaikaka UniversityKaramsad, AnandIndia
| | - Soaham Desai
- Department of Neurology, Shree Krishna Hospital and Pramukhswami Medical CollegeBhaikaka UniversityKaramsad, AnandIndia
| | - Kapil D. Sethi
- Professor Emeritus of Neurology, Medical College of GeorgiaAugusta UniversityAugustaGeorgia
| |
Collapse
|
15
|
Wang R, Hu B, Sun C, Geng D, Lin J, Li Y. Metabolic abnormality in acute stroke-like lesion and its relationship with focal cerebral blood flow in patients with MELAS: Evidence from proton MR spectroscopy and arterial spin labeling. Mitochondrion 2021; 59:276-282. [PMID: 34186261 DOI: 10.1016/j.mito.2021.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/24/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
Our purpose is to detect the metabolic alterations in acute stroke-like lesions (SLLs) and further investigate the correlations between metabolic concentrations and focal cerebral blood flow in patients with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) using proton MR spectroscopy (1H-MRS) and arterial spin labeling (ASL). A total of 23 patients with MELAS at acute stage of stroke-like episodes (SLEs) and 20 normal controls (NC) were recruited in this study, respectively. All subjects underwent conventional MRI and1H-MRS. In addition, ASL was performed in each patient. The measurements of creatine (Cr), choline (Cho), N-acetyl aspartate (NAA), lactate (Lac), glutamine/glutamate (Glx) levels and the ratios of Cho/Cr, NAA/Cr, Lac/Cr and Glx/Cr in acute SLLs for MELAS patients and left parietal and occipital lobes for NC were measured using LC-model software. Furthermore, in MELAS group, the associations between relative cerebral blood flow (rCBF) and metabolite concentrations in acute SLLs were also assessed. In MELAS group, acute SLLs were identified with metabolic abnormalities and increased rCBF. Specifically, compared with controls, MELAS patients exhibited significantly higher Lac, Cho levels and Lac/Cr, Cho/Cr ratios, and lower NAA, Glx levels and NAA/Cr and Glx/Cr ratios. Moreover, for MELAS patients, Lac concentration in acute SLLs was positively correlated with focal rCBF. This study exhibited the neural injury with increasing lactate and cerebral blood flow in the acute SLEs. It might shed light on the underlying biochemical mechanism of mitochondrial cytopathy and angiopathy in MELAS.
Collapse
Affiliation(s)
- Rong Wang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Bin Hu
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Daoying Geng
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China.
| | - Yuxin Li
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China.
| |
Collapse
|
16
|
Abstract
We herein report a patient with neuronal intranuclear inclusion disease (NIID) who presented with encephalitis-like episodes. A neurological examination revealed a disturbance of consciousness without any evidence of encephalitis or epilepsy on laboratory tests. Brain perfusion single-photon emission computed tomography revealed an elevated cerebral blood flow during the encephalitis-like episode and reduced cerebral blood flow in the chronic phase with clinical recovery. This report suggests that the cerebral blood flow of patients with NIID can change over the clinical course. Encephalitis-like episodes of NIID should thus be considered in the differential diagnosis of acute disturbance of consciousness.
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Wang R, Lin J, Sun C, Hu B, Liu X, Geng D, Li Y, Yang L. Topological reorganization of brain functional networks in patients with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes. NEUROIMAGE-CLINICAL 2020; 28:102480. [PMID: 33395972 PMCID: PMC7645289 DOI: 10.1016/j.nicl.2020.102480] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022]
Abstract
MELAS patients showed topological reorganization of brain functional network. Network abnormalities in MELAS patients may be affected by stroke-like lesions. Graph theory based on rs-fMRI may be used for monitoring the status of MELAS.
Mitochondrial encephalomyopathy with lactic acidosis and stroke‐like episodes (MELAS) is a rare maternally inherited genetic disease; however, little is known about its underlying brain basis. Furthermore, the topological organization of brain functional network in MELAS has not been explored. Here, 45 patients with MELAS (22 at acute stage, 23 at chronic stage) and 22 normal controls were studied using resting- state functional magnetic resonance imaging and graph theory analysis approaches. Topological properties of brain functional networks including global and nodal metrics, rich club organization and modularity were analyzed. At the global level, MELAS patients exhibited reduced clustering coefficient, normalized clustering coefficient, normalized characteristic path length and local network efficiency compared with the controls. At the nodal level, several nodes with abnormal degree centrality and nodal efficiency were detected in MELAS patients, and the distribution of these nodes was partly consistent with the stroke-like lesions. For rich club organization, rich club nodes were reorganized and the connections among them were decreased in MELAS patients. Modularity analysis revealed that MELAS patents had altered intra- or inter-modular connections in default mode network, fronto-parietal network, sensorimotor network, occipital network and cerebellum network. Notably, the patients at acute stage showed more obvious changes in these topological properties than the patients at chronic stage. These findings indicated that MELAS patients, particularly those at acute stage, exhibited topological reorganization of the whole-brain functional network. This study may help us to understand the neuropathological mechanisms of MELAS.
Collapse
Affiliation(s)
- Rong Wang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bin Hu
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Xueling Liu
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Daoying Geng
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Yuxin Li
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China.
| | - Liqin Yang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China.
| |
Collapse
|
19
|
Rodan LH, Poublanc J, Fisher JA, Sobczyk O, Mikulis DJ, Tein I. L-arginine effects on cerebrovascular reactivity, perfusion and neurovascular coupling in MELAS (mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes) syndrome. PLoS One 2020; 15:e0238224. [PMID: 32881886 PMCID: PMC7470264 DOI: 10.1371/journal.pone.0238224] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 08/11/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE We previously showed that MELAS patients have decreased cerebrovascular reactivity (CVR) (p≤ 0.002) and increased cerebral blood flow (CBF) (p<0.0026); changes correlated with disease severity and % mutant mtDNA (inversely for CVR; directly for CBF). We ran a prospective pilot in 3 MELAS sibs (m.3243A>G tRNALeu(UUR)) with variable % mutant blood mtDNA to assess effects of L-Arginine (L-Arg) (single dose and 6-wk steady-state trial) on regional CBF, arterial CVR and neurovascular coupling. METHODS Patients were studied with 3T MRI using arterial spin labeling (ASL) to measure CBF and changes in % Blood Oxygen Level Dependent (BOLD) signal to changes in arterial partial pressure of CO2 to measure CVR. Task fMRI consisted of an alternating black and white checkerboard to evaluate visual cortex response in MELAS and controls. RESULTS Following L-Arg, there was restoration of serum Arg (76-230 μM) in MELAS sibs and a trend towards increasing CVR in frontal and corresponding decrease in occipital cortex; CVR was unchanged globally. There was a 29-37% reduction in baseline CBF in one patient following 6 wks of L-Arg. Pre-treatment fMRI activation in response to visual cortex stimulus was markedly decreased in the same patient compared to controls in primary visual striate cortex V1 and extrastriate regions V2 to V5 with a marked increase toward control values following a single dose and 6 wks of L-Arg. CONCLUSION Proposed "healing" effect may be due to more efficient utilization of energy substrates with increased cellular energy balances and ensuing reduction in signalling pathways that augment flow in the untreated state. CLASSIFICATION OF EVIDENCE This prospective pilot study provides Class III evidence that oral L-Arginine (100 mg/kg single dose or 100 mg/kg three times daily po X 6 weeks) normalizes resting blood flow from elevated pre-treatment levels in patients with MELAS syndrome, selectively increases their CVR from reduced pre-treatment levels in regions most impaired at the expense of less abnormal regions, and normalizes reduced BOLD fMRI activation in response to visual cortex stimulus. CLINICAL TRIALS.GOV (NIH) NCT01603446.
Collapse
Affiliation(s)
- Lance H. Rodan
- Division of Neurology, Dept. of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julien Poublanc
- Dept. of Medical Imaging, The Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joseph A. Fisher
- Dept. of Anesthesiology, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Dept. of Physiology and Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- The Toronto General Hospital Medical Research Institute, Toronto, Ontario, Canada
| | - Olivia Sobczyk
- Dept. of Medical Imaging, The Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David J. Mikulis
- Dept. of Medical Imaging, The Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid Tein
- Division of Neurology, Dept. of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Genetics and Genome Biology Program, The Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Dept. of Laboratory Medicine and Pathobiology, The University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
20
|
Liao NY, Liao KK, Liao YC, Lee YC. Mitochondrial DNA m.3243A>G mutation rarely causes CADASIL-like phenotype. Neurobiol Aging 2020; 97:145.e5-145.e6. [PMID: 32950272 DOI: 10.1016/j.neurobiolaging.2020.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/03/2020] [Accepted: 08/22/2020] [Indexed: 11/17/2022]
Abstract
Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) are 2 monogenic cerebral small vessel diseases sharing several common clinical features including young stroke, migraine, and cognitive dysfunction. The aim of this study was to understand the role of MELAS in patients with CADASIL-like manifestations. We screened 429 unrelated patients with genetically unassigned CADASIL-like syndrome for mitochondrial DNA m.3243A>G mutation. None of them were found to have the mutation. Our finding suggests that m.3243A>G rarely causes CADASIL-like phenotype. It may be not necessary to consider MELAS as a differential diagnosis of CADASIL. Screening m.3243A>G in patients with CADASIL-like phenotype is of limited value.
Collapse
Affiliation(s)
- Nai-Yi Liao
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kwong-Kum Liao
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Neurology, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yi-Chu Liao
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Neurology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Chung Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Neurology, National Yang-Ming University School of Medicine, Taipei, Taiwan; Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
| |
Collapse
|
21
|
Pai V, Sitoh YY, Purohit B. Gyriform restricted diffusion in adults: looking beyond thrombo-occlusions. Insights Imaging 2020; 11:20. [PMID: 32040645 PMCID: PMC7010902 DOI: 10.1186/s13244-019-0829-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/11/2019] [Indexed: 12/31/2022] Open
Abstract
Gyriform restricted diffusion (GRD) refers to hyperintense signal involving the cerebral cortex on diffusion-weighted images (DWI) with corresponding hypointensity on apparent diffusion coefficient (ADC) images. These changes are commonly seen following a vascular occlusion, reflecting the limitation of water molecule movement across cell membranes (restricted diffusion) due to the failure of Na+/K+-ATPase pumps (cytotoxic oedema). However, GRD can occur in several other neurological conditions as well. A thorough understanding of these conditions and their anatomic predilection plays a critical role in identifying and differentiating them from vascular thrombo-occlusion, with impact towards appropriate clinical management. This review highlights the less commonly encountered, non-stroke causes of GRD in adults with case-based examples. A tabulated chart of the patterns of cortical and subcortical involvement associated with these aetiologies is provided for a quick, pattern-based reference for daily radiological reporting.
Collapse
Affiliation(s)
- Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| |
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Multisystem mitochondrial diseases due to mutations in mtDNA-encoded subunits of complex I. BMC Pediatr 2020; 20:41. [PMID: 31996177 PMCID: PMC6988306 DOI: 10.1186/s12887-020-1912-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/07/2020] [Indexed: 12/18/2022] Open
Abstract
Background Maternally inherited complex I deficiencies due to mutations in MT-ND genes represent a heterogeneous group of multisystem mitochondrial disorders (MD) with a unfavourable prognosis. The aim of the study was to characterize the impact of the mutations in MT-ND genes, including the novel m.13091 T > C variant, on the course of the disease, and to analyse the activities of respiratory chain complexes, the amount of protein subunits, and the mitochondrial energy-generating system (MEGS) in available muscle biopsies and cultivated fibroblasts. Methods The respiratory chain complex activities were measured by spectrophotometry, MEGS were analysed using radiolabelled substrates, and protein amount by SDS-PAGE or BN-PAGE in muscle or fibroblasts. Results In our cohort of 106 unrelated families carrying different mtDNA mutations, we found heteroplasmic mutations in the genes MT-ND1, MT-ND3, and MT-ND5, including the novel variant m.13091 T > C, in 13 patients with MD from 12 families. First symptoms developed between early childhood and adolescence and progressed to multisystem disease with a phenotype of Leigh or MELAS syndromes. MRI revealed bilateral symmetrical involvement of deep grey matter typical of Leigh syndrome in 6 children, cortical/white matter stroke-like lesions suggesting MELAS syndrome in 3 patients, and a combination of cortico-subcortical lesions and grey matter involvement in 4 patients. MEGS indicated mitochondrial disturbances in all available muscle samples, as well as a significantly decreased oxidation of [1-14C] pyruvate in fibroblasts. Spectrophotometric analyses revealed a low activity of complex I and/or complex I + III in all muscle samples except one, but the activities in fibroblasts were mostly normal. No correlation was found between complex I activities and mtDNA mutation load, but higher levels of heteroplasmy were generally found in more severely affected patients. Conclusions Maternally inherited complex I deficiencies were found in 11% of families with mitochondrial diseases in our region. Six patients manifested with Leigh, three with MELAS. The remaining four patients presented with an overlap between these two syndromes. MEGS, especially the oxidation of [1-14C] pyruvate in fibroblasts might serve as a sensitive indicator of functional impairment due to MT-ND mutations. Early onset of the disease and higher level of mtDNA heteroplasmy were associated with a worse prognosis.
Collapse
|
24
|
Ng YS, Bindoff LA, Gorman GS, Horvath R, Klopstock T, Mancuso M, Martikainen MH, Mcfarland R, Nesbitt V, Pitceathly RDS, Schaefer AM, Turnbull DM. Consensus-based statements for the management of mitochondrial stroke-like episodes. Wellcome Open Res 2019; 4:201. [PMID: 32090171 PMCID: PMC7014928 DOI: 10.12688/wellcomeopenres.15599.1] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/15/2022] Open
Abstract
Background: Focal-onset seizures and encephalopathy are prominent features of a stroke-like episode, which is a severe neurological manifestation associated with subtypes of mitochondrial disease. Despite more than 30 years of research, the acute treatment of stroke-like episodes remains controversial. Methods: We used the modified Delphi process to harness the clinical expertise of a group of mitochondrial disease specialists from five European countries to produce consensus guidance for the acute management of stroke-like episodes and commonly associated complications. Results: Consensus on a new definition of mitochondrial stroke-like episodes was achieved and enabled the group to develop diagnostic criteria based on clinical features, neuroimaging and/or electroencephalogram findings. Guidelines for the management of strokelike episodes were agreed with aggressive seizure management strongly recommended at the outset of stroke-like episodes. Conclusions: Our consensus statement defines stroke-like episodes in terms of an epileptic encephalopathy and we have used this to revise both diagnostic criteria and guidelines for management. A prospective, multi-centre, randomised controlled trial is required for evaluating the efficacy of any compound on modifying the trajectory of stroke-like episodes.
Collapse
Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laurence A. Bindoff
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Gráinne S. Gorman
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Rita Horvath
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy
| | - Mika H. Martikainen
- Division of Clinical Neurosciences, University of Turku and Turku University Hospital, Turku, Finland
| | - Robert Mcfarland
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Great North Children Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Victoria Nesbitt
- Department of Paediatrics, The Children's Hospital, Oxford, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders,, Nuffield Dept Women’s & Reproductive Health, The Churchill Hospital, Oxford, UK
| | - Robert D. S. Pitceathly
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Centre for Neuromuscular Diseases, The National Hospital of Neurology and Neurosurgery, London, UK
| | - Andrew M. Schaefer
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Doug M. Turnbull
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| |
Collapse
|
25
|
Bhatia KD, Krishnan P, Kortman H, Klostranec J, Krings T. Acute Cortical Lesions in MELAS Syndrome: Anatomic Distribution, Symmetry, and Evolution. AJNR Am J Neuroradiol 2019; 41:167-173. [PMID: 31806591 DOI: 10.3174/ajnr.a6325] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/02/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome is a rare mitochondrial disorder affecting children and young adults. Stroke-like episodes are often associated with acute cortical lesions in the posterior cerebral cortex and are classically described as asymmetric and transient. In this study we assessed the anatomic distribution of acute cortical lesions, the incidence of symmetry, and the temporal evolution of lesions. MATERIALS AND METHODS This was a retrospective cohort study of patients who had a confirmed genetic diagnosis of a pathogenic variant associated with MELAS and MR imaging performed at our center (2006-2018). Each MR imaging study was assessed for new lesions using T1, T2, FLAIR, DWI, ADC, and SWI. The anatomic location, symmetry, and temporal evolution of lesions were analyzed. RESULTS Eight patients with the same pathogenic variant of MELAS (MT-TL1 m.3243A>G) with 31 MR imaging studies were included. Forty-one new lesions were identified in 17 of the studies (5 deep, 36 cortical). Cortical lesions most commonly affected the primary visual cortex, the middle-third of the primary somatosensory cortex, and the primary auditory cortex. Thirty of 36 cortical lesions had acute cortical diffusion restriction, of which 21 developed cortical laminar necrosis on subacute imaging. Six of 11 studies with multiple lesions showed symmetric cortical involvement. CONCLUSIONS Acute cortical lesions in MELAS most commonly affect the primary visual, somatosensory, and auditory cortices, all regions of high neuronal density and metabolic demand. The most common pattern of temporal evolution is acute cortical diffusion restriction with subacute cortical laminar necrosis and chronic volume loss. Symmetric involvement is more common than previously described.
Collapse
Affiliation(s)
- K D Bhatia
- From the Division of Neuroradiology (K.D.B., H.K., J.K., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - P Krishnan
- Department of Diagnostic Imaging (P.K.), Hospital for Sick Children, Toronto, Ontario, Canada
| | - H Kortman
- From the Division of Neuroradiology (K.D.B., H.K., J.K., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - J Klostranec
- From the Division of Neuroradiology (K.D.B., H.K., J.K., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - T Krings
- From the Division of Neuroradiology (K.D.B., H.K., J.K., T.K.), Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| |
Collapse
|
26
|
Zuflacht JP, Pusso AN. Teaching NeuroImages: A 48-year-old woman with MELAS. Neurology 2019; 93:e624-e625. [DOI: 10.1212/wnl.0000000000007910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
27
|
Galardi MM, Gaudioso C, Ahmadi S, Evans E, Gilbert L, Mar S. Differential Diagnosis of Pediatric Multiple Sclerosis. CHILDREN-BASEL 2019; 6:children6060075. [PMID: 31163654 PMCID: PMC6617098 DOI: 10.3390/children6060075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 01/28/2023]
Abstract
The differential diagnosis of pediatric multiple sclerosis (MS) can be broad and pose diagnostic challenges, particularly at initial presentation. Among demyelinating entities, neuromyelitis optica spectrum disorders (NMOSD), myelin oligodendrocyte glycoprotein antibodies (MOG-ab) associated disorders, and acute disseminated encephalomyelitis (ADEM) are now well-known as unique disease processes and yet continue to overlap with MS in regards to clinical presentation and imaging. In non-inflammatory entities, such as metabolic disorders and leukodystrophies, an erroneous diagnosis of MS can be made even while applying appropriate diagnostic criteria. Knowing the epidemiology, typical clinical presentation, diagnostic criteria, and ancillary test results in each disease, can aid in making the correct diagnosis by contrasting these features with those of pediatric MS. Determining the correct diagnosis early, allows for efficient and effective treatment as well as appropriate prognostication.
Collapse
Affiliation(s)
| | - Cristina Gaudioso
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Saumel Ahmadi
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Emily Evans
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Laura Gilbert
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| | - Soe Mar
- Department of Neurology, Washington University in St. Louis, St. Louis, MO 63110, USA.
| |
Collapse
|
28
|
Ko A, Lee YM. Magnetic resonance spectroscopy in Leigh-MELAS overlap syndrome. World J Pediatr 2019; 15:306-308. [PMID: 30968306 DOI: 10.1007/s12519-019-00250-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 03/20/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Ara Ko
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, 2011 Eonju-ro, Gangnam-gu, Seoul, 06273, South Korea.
| |
Collapse
|
29
|
Sinnecker T, Andelova M, Mayr M, Rüegg S, Sinnreich M, Hench J, Frank S, Schaller A, Stippich C, Wuerfel J, Bonati LH. Diagnosis of adult-onset MELAS syndrome in a 63-year-old patient with suspected recurrent strokes - a case report. BMC Neurol 2019; 19:91. [PMID: 31068171 PMCID: PMC6505262 DOI: 10.1186/s12883-019-1306-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/15/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) is a mitochondrial cytopathy caused by mutations in mitochondrial DNA. Clinical manifestation is typically before the age of 40. CASE PRESENTATION We present the case of a 63-year-old female in whom the symptoms of MELAS were initially misdiagnosed as episodes of recurrent ischemic strokes. Brain imaging including MRI, clinical and laboratory findings that lent cues to the diagnosis of MELAS are discussed. In addition, MRI findings in MELAS in comparison to imaging mimics of MELAS are presented. CONCLUSIONS This case underscores the importance of considering MELAS as a potential cause of recurrent stroke-like events if imaging findings are untypical for cerebral infarction, even among middle-aged patients with vascular risk factors.
Collapse
Affiliation(s)
- Tim Sinnecker
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland.,Medical Imaging Analysis Center AG, Basel, Switzerland
| | - Michaela Andelova
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Michael Mayr
- Department of Internal Medicine, University Hospital and University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Michael Sinnreich
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Juergen Hench
- Division of Neuropathology, Institute of Pathology, University Hospital and University of Basel, Basel, Switzerland
| | - Stephan Frank
- Division of Neuropathology, Institute of Pathology, University Hospital and University of Basel, Basel, Switzerland
| | - André Schaller
- Division of Human Genetics, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Stippich
- Department of Radiology, University Hospital and University of Basel, Basel, Switzerland
| | - Jens Wuerfel
- Medical Imaging Analysis Center AG, Basel, Switzerland
| | - Leo H Bonati
- Neurologic Clinic and Policlinic, Departments of Medicine, Clinical Research and Biomedical Engineering, University Hospital and University of Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
| |
Collapse
|
30
|
Ko A, Lee SJ, Lee YM. Focal cerebellar infarction as an initial sign of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes. J Inherit Metab Dis 2019; 42:575-576. [PMID: 30693531 DOI: 10.1002/jimd.12020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/10/2018] [Accepted: 11/20/2018] [Indexed: 01/06/2023]
Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a type of mitochondrial disorder and stroke-like lesions are observed prominently in the brain magnetic resonance imaging. Those stroke-like lesions of MELAS patients are usually located in the posterior quadrants and do not correspond to typical vascular territories. This case illustrates that focal cerebellar infarction can be the sole initial sign of MELAS.
Collapse
Affiliation(s)
- Ara Ko
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Sang-Jun Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
31
|
Severino M, Nesti C, Rubegni A, Tolomeo D, Santorelli FM. The features of the m.10197G>A mtDNA mutation. J Neurol Sci 2019; 400:184-185. [DOI: 10.1016/j.jns.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 04/01/2019] [Indexed: 11/25/2022]
|
32
|
Abstract
OBJECTIVES Because the central nervous system (CNS) is the second most frequently affected organ in mitochondrial disorders (MIDs) and since paediatric MIDs are increasingly recognised, it is important to know about the morphological CNS abnormalities on imaging in these patients. This review aims at summarising and discussing current knowledge and recent advances concerning CNS imaging abnormalities in paediatric MIDs. METHODS A systematic literature review was conducted. RESULTS The most relevant CNS abnormalities in paediatric MIDs on imaging include white and grey matter lesions, stroke-like lesions as the morphological equivalent of stroke-like episodes, cerebral atrophy, calcifications, optic atrophy, and lactacidosis. Because these CNS lesions may be seen with or without clinical manifestations, it is important to screen all MID patients for cerebral involvement. Some of these lesions may remain unchanged for years whereas others may be dynamic, either in the sense of progression or regression. Typical dynamic lesions are stroke-like lesions and grey matter lesions. Clinically relevant imaging techniques for visualisation of CNS abnormalities in paediatric MIDs are computed tomography, magnetic resonance (MR) imaging, MR spectroscopy, single-photon emission computed tomography, positron-emission tomography, and angiography. CONCLUSIONS CNS imaging in paediatric MIDs is important for diagnosing and monitoring CNS involvement. It also contributes to the understanding of the underlying pathomechanisms that lead to CNS involvement in MIDs.
Collapse
Affiliation(s)
| | - Sinda Zarrouk-Mahjoub
- University of Tunis, El Manar and Genomics Platform, Pasteur Institute of Tunis, Tunisia
| |
Collapse
|
33
|
Inoue Y, Hara T, Ikari T, Takahashi K, Miyatake H, Abe Y. Super-early images of brain perfusion SPECT using 123I-IMP for the assessment of hyperperfusion in stroke patients. Ann Nucl Med 2018; 32:695-701. [DOI: 10.1007/s12149-018-1293-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/29/2018] [Indexed: 01/01/2023]
|
34
|
Lee HN, Yoon CS, Lee YM. Correlation of Serum Biomarkers and Magnetic Resonance Spectroscopy in Monitoring Disease Progression in Patients With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes Due to mtDNA A3243G Mutation. Front Neurol 2018; 9:621. [PMID: 30140253 PMCID: PMC6094978 DOI: 10.3389/fneur.2018.00621] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 07/10/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Analysis of serum biomarkers and magnetic resonance spectroscopy (MRS) are useful for monitoring disease progression in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS). We evaluated the correlation of serum biomarkers and MRS parameters during changes associated with stroke-like episodes. Methods: In 13 symptomatic MELAS patients carrying the A3243G mutation, we retrospectively obtained 207 voxels from 41 MRS studies, which were divided into three groups according to the temporal association with stroke-like episodes. The MRS NAA/Cr, Cho/Cr, NAA/Cho ratios, the presence of a lactate peak, serum biomarkers, serum lactate level and the pyruvate (Lac/Pyr) ratio were determined. Results: In regions with acute infarcts, the severity of serum Lac/Pyr and that of the MRS lactate peak (P = 0.0007) correlated; serum lactate (P = 0.02), severity of elevated serum lactate (P = 0.04), and serum Lac/Pyr (P = 0.02) correlated weakly. In previously infarcted regions, the severity of the MRS lactate peak and serum Lac/Pyr (P = 0.03), as well as the severity of serum Lac/Pyr (P = 0.02) were weakly correlated. In structurally normal regions, we found a weak to moderate negative correlation between serum lactate and MRS NAA/Cr (P = 0.008), and between the severity of elevated serum lactate and MRS NAA/Cr (P = 0.002) as well as MRS NAA/Cho (P = 0.02). Conclusions: MRS parameters correlate with specific serum biomarkers, and are useful for monitoring changes in brain metabolites, particularly as related to stroke-like episodes.
Collapse
Affiliation(s)
- Ha Neul Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
| | - Choon-Sik Yoon
- Department of Diagnostic Radiology, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Mock Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
35
|
Neuroimaging in mitochondrial disorders. Essays Biochem 2018; 62:409-421. [DOI: 10.1042/ebc20170109] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/02/2018] [Accepted: 06/05/2018] [Indexed: 12/13/2022]
Abstract
MRI and 1H magnetic resonance spectroscopy (1HMRS) are the main neuroimaging methods to study mitochondrial diseases. MRI can demonstrate seven ‘elementary’ central nervous system (CNS) abnormalities in these disorders, including diffuse cerebellar atrophy, cerebral atrophy, symmetric signal changes in subcortical structures (basal ganglia, brainstem, cerebellum), asymmetric signal changes in the cerebral cortex and subcortical white matter, leukoencephalopathy, and symmetric signal changes in the optic nerve and the spinal cord. These elementary MRI abnormalities can be variably combined in the single patient, often beyond what can be expected based on the classically known clinical-pathological patterns. However, a normal brain MRI is also possible. 1HMRS has a diagnostic role in patients with suspected mitochondrial encephalopathy, especially in the acute phase, as it can detect within the lesions, but also in normal appearing nervous tissue or in the ventricular cerebrospinal fluid (CSF), an abnormally prominent lactate peak, reflecting failure of the respiratory chain with a shift from the Krebs cycle to anaerobic glycolysis. So far, studies correlating MRI findings with genotype in mitochondrial disease have been possible only in small samples and would greatly benefit from data pooling. MRI and 1HMRS have provided important information on the pathophysiology of CNS damage in mitochondrial diseases by enabling in vivo non-invasive assessment of tissue abnormalities, the associated changes of blood perfusion and cellular metabolic derangement. MRI and 1HMRS are expected to serve as surrogate biomarkers in trials investigating therapeutic options in mitochondrial disease.
Collapse
|
36
|
Clinical syndromes associated with mtDNA mutations: where we stand after 30 years. Essays Biochem 2018; 62:235-254. [DOI: 10.1042/ebc20170097] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 01/16/2023]
Abstract
The landmark year 1988 can be considered as the birthdate of mitochondrial medicine, when the first pathogenic mutations affecting mtDNA were associated with human diseases. Three decades later, the field still expands and we are not ‘scraping the bottom of the barrel’ yet. Despite the tremendous progress in terms of molecular characterization and genotype/phenotype correlations, for the vast majority of cases we still lack a deep understanding of the pathogenesis, good models to study, and effective therapeutic options. However, recent technological advances including somatic cell reprogramming to induced pluripotent stem cells (iPSCs), organoid technology, and tailored endonucleases provide unprecedented opportunities to fill these gaps, casting hope to soon cure the major primary mitochondrial phenotypes reviewed here. This group of rare diseases represents a key model for tackling the pathogenic mechanisms involving mitochondrial biology relevant to much more common disorders that affect our currently ageing population, such as diabetes and metabolic syndrome, neurodegenerative and inflammatory disorders, and cancer.
Collapse
|
37
|
Conventional and Diffusional Magnetic Resonance Imaging Features of Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes in Chinese Patients. J Comput Assist Tomogr 2018; 42:510-516. [DOI: 10.1097/rct.0000000000000712] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
38
|
Vilela P. Acute stroke differential diagnosis: Stroke mimics. Eur J Radiol 2017; 96:133-144. [DOI: 10.1016/j.ejrad.2017.05.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 01/09/2023]
|
39
|
Whitehead MT, Wien M, Lee B, Bass N, Gropman A. Black Toenail Sign in MELAS Syndrome. Pediatr Neurol 2017; 75:61-65. [PMID: 28818358 DOI: 10.1016/j.pediatrneurol.2017.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 06/26/2017] [Accepted: 06/29/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome is a mitochondrial disorder often causing progressive brain injury that is not confined to large arterial territories. Severe insults ultimately lead to gyral necrosis affecting the cortex and juxtacortical white matter; the neuroimaging correlate is partial gyral signal suppression on T2/FLAIR sequences that resemble black toenails. We aimed to characterize the imaging features and the natural history of MELAS-related gyral necrosis. MATERIALS AND METHODS Databases at two children's hospitals were searched for brain magnetic resonance imaging studies of individuals with MELAS. Examinations with motion artifact and those lacking T2/FLAIR sequences were excluded. The location, the cumulative number, and the maximum transverse diameter of necrotic gyral lesions were assessed using T2-weighted images and T2/FLAIR sequences. Wilcoxon signed-rank test was employed to evaluate the relationship between disease duration and the number of necrotic lesions. RESULTS One hundred twenty-four examinations from patients with 14 unique MELAS patients (16 ± 3 years) were evaluated. Six of the eight patients who developed brain lesions also developed gyral necroses (mean 13, range 0 to 44). Necrotic lesions varied in maximal diameter from 4 to 25 mm. Cumulative necrotic lesions correlated with disease duration (P < 0.001). CONCLUSIONS The black toenail sign signifying gyral necrosis is a common imaging feature in individuals with MELAS syndrome. The extent of gyral necrosis correlates with disease duration.
Collapse
Affiliation(s)
- Matthew T Whitehead
- Department of Neuroradiology, Children's National Medical Center, Washington, District of Columbia; Department of Radiology, George Washington University School of Medicine, Washington, District of Columbia.
| | - Michael Wien
- Rainbow Babies and Children's Hospital, University Hospital Cleveland Medical Center, Cleveland, Ohio; Department of Radiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Bonmyong Lee
- Department of Radiology, Johns Hopkins Medical Institute, Baltimore, Maryland
| | - Nancy Bass
- Rainbow Babies and Children's Hospital, University Hospital Cleveland Medical Center, Cleveland, Ohio; Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Andrea Gropman
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia
| |
Collapse
|
40
|
Tetsuka S, Tagawa A, Ogawa T, Otsuka M, Hashimoto R, Kato H. Importance of Distinguishing Between Mitochondrial Encephalomyopathy With Elderly Onset of Stroke-Like Episodes and Cerebral Infarction. J Clin Med Res 2017; 9:812-819. [PMID: 28811861 PMCID: PMC5544489 DOI: 10.14740/jocmr3122w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/21/2017] [Indexed: 11/11/2022] Open
Abstract
The most common disease-causing mitochondrial DNA (mtDNA) mutation in mitochondrial encephalomyopathy (ME) with lactic acidosis and stroke-like episodes (MELAS) is m.3243A>G. In the future, the incidence of patients with cerebral infarction and diabetes mellitus is expected to increase tremendously. Additionally, the A3243G mutation typical of diabetes is estimated to be present in approximately 2% of all diabetes patients, which suggests that the potential disease population with a mitochondrial disorder is greater than previously thought, and there may have been many cases among the elderly that were misdiagnosed. Considering this background, MELAS with the onset of stroke-like episodes should be considered an important differential diagnosis for elderly patients with cerebral infarction, although it might have been overlooked until now. A 68-year-old Japanese female developed convulsive seizures and was admitted to Hospital of International University of Health and Welfare for epilepsy. She had been hospitalized twice in the previous year for cerebral infarction and seizures. She experienced sensorineural hearing loss at a young age. Thus, although she was elderly, we suspected MELAS and detected elevations of pyruvic and lactic acid. A genetic test revealed a point mutation in the mtDNA (m.3243A>G) that led to a definitive diagnosis of MELAS. To date, MELAS has been regarded as a disease of the relatively young. The incidence of patients with cerebral infarction and diabetes mellitus is expected to greatly increase. Thus, we should evaluate cerebral infarction in the elderly with caution to prevent missed diagnoses of MELAS.
Collapse
Affiliation(s)
- Syuichi Tetsuka
- Department of Neurology, Hospital of Yuki, 9629-1, Yuki, Yuki-City, Ibaraki 307-0001, Japan
| | - Asako Tagawa
- Department of Neurology, Hospital of International University of Health and Welfare, 537-3, Iguchi, Nasushiobara, Tochigi 329-2763, Japan
| | - Tomoko Ogawa
- Department of Neurology, Hospital of International University of Health and Welfare, 537-3, Iguchi, Nasushiobara, Tochigi 329-2763, Japan
| | - Mieko Otsuka
- Department of Neurology, Hospital of International University of Health and Welfare, 537-3, Iguchi, Nasushiobara, Tochigi 329-2763, Japan
| | - Ritsuo Hashimoto
- Department of Neurology, Hospital of International University of Health and Welfare, 537-3, Iguchi, Nasushiobara, Tochigi 329-2763, Japan
| | - Hiroyuki Kato
- Department of Neurology, Hospital of International University of Health and Welfare, 537-3, Iguchi, Nasushiobara, Tochigi 329-2763, Japan
| |
Collapse
|
41
|
Gaudino S, Gangemi E, Colantonio R, Botto A, Ruberto E, Calandrelli R, Martucci M, Vita MG, Masullo C, Cerase A, Colosimo C. Neuroradiology of human prion diseases, diagnosis and differential diagnosis. Radiol Med 2017; 122:369-385. [PMID: 28110369 DOI: 10.1007/s11547-017-0725-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/03/2017] [Indexed: 01/14/2023]
Abstract
Human transmissible spongiform encephalopathies (TSEs), or prion diseases, are invariably fatal conditions associated with a range of clinical presentations. TSEs are classified as sporadic [e.g. sporadic Creutzfeldt-Jakob disease (sCJD), which is the most frequent form], genetic (e.g. Gerstmann-Straussler-Scheinker disease, fatal familial insomnia, and inherited CJD), and acquired or infectious (e.g. Kuru, iatrogenic CJD, and variant CJD). In the past, brain imaging played a supporting role in the diagnosis of TSEs, whereas nowadays magnetic resonance imaging (MRI) plays such a prominent role that MRI findings have been included in the diagnostic criteria for sCJD. Currently, MRI is required for all patients with a clinical suspicion of TSEs. Thus, MRI semeiotics of TSEs should become part of the cultural baggage of any radiologist. The purposes of this update on the neuroradiology of CJD are to (i) review the pathophysiology and clinical presentation of TSEs, (ii) describe both typical and atypical MRI findings of CJD, and (iii) illustrate diseases mimicking CJD, underlining the MRI key findings useful in the differential diagnosis.
Collapse
Affiliation(s)
- Simona Gaudino
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Emma Gangemi
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Raffaella Colantonio
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Annibale Botto
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Emanuela Ruberto
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Rosalinda Calandrelli
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Matia Martucci
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Maria Gabriella Vita
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Carlo Masullo
- Institute of Neurology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Alfonso Cerase
- Unit of Neuroimaging and Neurointervention, Department of Neurological and Sensorineural Sciences, Azienda Ospedaliera Università Senese, "Santa Maria alle Scotte" University and NHS Hospital, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Cesare Colosimo
- Department of Radiological Sciences, Institute of Radiology, Fondazione Policlinico Universitario A. Gemelli, School of Medicine, Catholic University, Largo A. Gemelli, 8, 00168, Rome, Italy
| |
Collapse
|
42
|
Henry C, Patel N, Shaffer W, Murphy L, Park J, Spieler B. Mitochondrial Encephalomyopathy With Lactic Acidosis and Stroke-Like Episodes-MELAS Syndrome. Ochsner J 2017; 17:296-301. [PMID: 29026367 PMCID: PMC5625994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome is a rare inherited disorder that results in waxing and waning nervous system and muscle dysfunction. MELAS syndrome may overlap with other neurologic disorders but shows distinctive imaging features. CASE REPORT We present the case of a 28-year-old female with atypical stroke-like symptoms, a strong family history of stroke-like symptoms, and a relapsing-remitting course for several years. We discuss the imaging features distinctive to the case, the mechanism of the disease, typical presentation, imaging diagnosis, and disease management. CONCLUSION This case is a classic example of the relapse-remitting MELAS syndrome progression with episodic clinical flares and fluctuating patterns of stroke-like lesions on imaging. MELAS is an important diagnostic consideration when neuroimaging reveals a pattern of disappearing and relapsing cortical brain lesions that may occur in different areas of the brain and are not necessarily limited to discrete vascular territories. Future studies should investigate disease mechanisms at the cellular level and the value of advanced magnetic resonance imaging techniques for a targeted approach to therapy.
Collapse
Affiliation(s)
- Caitlin Henry
- Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA
| | - Neema Patel
- Department of Radiology, Mayo Clinic Hospital, Jacksonville, FL
| | - William Shaffer
- Department of Radiology, Slidell Memorial Hospital, Slidell, LA
| | - Lillian Murphy
- Department of Radiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Joe Park
- Department of Radiology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Bradley Spieler
- Department of Radiology, Louisiana State University Health Sciences Center, New Orleans, LA
| |
Collapse
|
43
|
Affiliation(s)
| | - Daniele Masarone
- Second University of Naples-AORN Colli, Ospedale Monaldi, Naples, Italy
| | - Giuseppe Pacileo
- Second University of Naples-AORN Colli, Ospedale Monaldi, Naples, Italy
| |
Collapse
|
44
|
Baertling F, Klee D, Haack TB, Prokisch H, Meitinger T, Mayatepek E, Schaper J, Distelmaier F. The many faces of paediatric mitochondrial disease on neuroimaging. Childs Nerv Syst 2016; 32:2077-2083. [PMID: 27449766 DOI: 10.1007/s00381-016-3190-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/08/2016] [Indexed: 01/11/2023]
Abstract
The knowledge about the genetic spectrum underlying paediatric mitochondrial diseases is rapidly growing. As a consequence, the range of neuroimaging findings associated with mitochondrial diseases became extremely broad. This has important implications for radiologists and clinicians involved in the care of these patients. Here, we provide a condensed overview of brain magnetic resonance imaging (MRI) findings in children with genetically confirmed mitochondrial diseases. The neuroimaging spectrum ranges from classical Leigh syndrome with symmetrical lesions in basal ganglia and/or brain stem to structural abnormalities including cerebellar hypoplasia and corpus callosum dysgenesis. We highlight that, although some imaging patterns can be suggestive of a genetically defined mitochondrial syndrome, brain MRI-based candidate gene prioritization is only successful in a subset of patients.
Collapse
Affiliation(s)
- Fabian Baertling
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Dirk Klee
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Tobias B Haack
- Institute of Human Genetics, Technische Universität München, Trogerstr. 32, 81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Holger Prokisch
- Institute of Human Genetics, Technische Universität München, Trogerstr. 32, 81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Thomas Meitinger
- Institute of Human Genetics, Technische Universität München, Trogerstr. 32, 81675, Munich, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jörg Schaper
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Felix Distelmaier
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| |
Collapse
|
45
|
Cai SS, von Coelln R, Kouo TJ. Migratory stroke-like lesions in a case of adult-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome and a review of imaging findings. Radiol Case Rep 2016; 11:425-429. [PMID: 27920873 PMCID: PMC5128397 DOI: 10.1016/j.radcr.2016.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/29/2016] [Accepted: 09/04/2016] [Indexed: 11/26/2022] Open
Abstract
Imaging findings of adult-onset mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is poorly documented. The authors present a 48-year-old woman with subacute onset of word-finding difficulties and right arm stiffness. Magnetic resonance imaging performed 2 weeks prior revealed left temporal lobe diffusion and fluid-attenuated inversion recovery hyperintensity predominantly involving the cortex. The apparent diffusion coefficient map showed preserved signal in the temporal cortex. Subsequent magnetic resonance imagings demonstrated a new diffusion signal abnormality extending to the left parietal cortex and occipital cortex with resolving diffusion hyperintensity in the temporal lobe. MR spectroscopy showed scattered areas of lactate deposition. Diagnosis of MELAS syndrome was confirmed by genetic analysis. Fluctuating, migratory stroke-like lesions with a predilection for the parietal, temporal, and occipital cortex that do not conform to a vascular territory and a lactate spike at 1.3 ppm on MR spectroscopy are characteristic of MELAS syndrome. Preserved signal intensity on apparent diffusion coefficient is useful to distinguish MELAS syndrome from ischemic infarction where the signal is typically reduced.
Collapse
Affiliation(s)
- Stephen S Cai
- Department of Radiology, University of Maryland School of Medicine, 22S. Green Street, Baltimore, MD 21201, USA
| | - Rainer von Coelln
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theresa J Kouo
- Department of Radiology, University of Maryland School of Medicine, 22S. Green Street, Baltimore, MD 21201, USA
| |
Collapse
|
46
|
|
47
|
Dahmoush HM, Melhem ER, Vossough A. Metabolic, endocrine, and other genetic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:1221-1259. [PMID: 27430466 DOI: 10.1016/b978-0-444-53486-6.00063-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Metabolic, endocrine, and genetic diseases of the brain include a very large array of disorders caused by a wide range of underlying abnormalities and involving a variety of brain structures. Often these disorders manifest as recognizable, though sometimes overlapping, patterns on neuroimaging studies that may enable a diagnosis based on imaging or may alternatively provide enough clues to direct further diagnostic evaluation. The diagnostic workup can include various biochemical laboratory or genetic studies. In this chapter, after a brief review of normal white-matter development, we will describe a variety of leukodystrophies resulting from metabolic disorders involving the brain, including mitochondrial and respiratory chain diseases. We will then describe various acidurias, urea cycle disorders, disorders related to copper and iron metabolism, and disorders of ganglioside and mucopolysaccharide metabolism. Lastly, various other hypomyelinating and dysmyelinating leukodystrophies, including vanishing white-matter disease, megalencephalic leukoencephalopathy with subcortical cysts, and oculocerebrorenal syndrome will be presented. In the following section on endocrine disorders, we will examine various disorders of the hypothalamic-pituitary axis, including developmental, inflammatory, and neoplastic diseases. Neonatal hypoglycemia will also be briefly reviewed. In the final section, we will review a few of the common genetic phakomatoses. Throughout the text, both imaging and brief clinical features of the various disorders will be discussed.
Collapse
Affiliation(s)
- Hisham M Dahmoush
- Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Elias R Melhem
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD, USA
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
48
|
Bindu PS, Arvinda H, Taly AB, Govindaraju C, Sonam K, Chiplunkar S, Kumar R, Gayathri N, Bharath Mm S, Nagappa M, Sinha S, Khan NA, Govindaraj P, Nunia V, Paramasivam A, Thangaraj K. Magnetic resonance imaging correlates of genetically characterized patients with mitochondrial disorders: A study from south India. Mitochondrion 2015; 25:6-16. [PMID: 26341968 DOI: 10.1016/j.mito.2015.08.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/16/2015] [Accepted: 08/21/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Large studies analyzing magnetic resonance imaging correlates in different genotypes of mitochondrial disorders are far and few. This study sought to analyze the pattern of magnetic resonance imaging findings in a cohort of genetically characterized patients with mitochondrial disorders. METHODS The study cohort included 33 patients (age range 18 months-50 years, M:F - 0.9:1) with definite mitochondrial disorders seen over a period of 8 yrs. (2006-2013). Their MR imaging findings were analyzed retrospectively. RESULTS The patients were classified into three groups according to the genotype, Mitochondrial point mutations and deletions (n=21), SURF1 mutations (n=7) and POLG1 (n=5). The major findings included cerebellar atrophy (51.4%), cerebral atrophy (24.2%), signal changes in basal ganglia (45.7%), brainstem (34.2%) & white matter (18.1%) and stroke like lesions (25.7%). Spinal cord imaging showed signal changes in 4/6 patients. Analysis of the special sequences revealed, basal ganglia mineralization (7/22), lactate peak on magnetic resonance spectrometry (10/15), and diffusion restriction (6/22). Follow-up images in six patients showed that the findings are dynamic. Comparison of the magnetic resonance imaging findings in the three groups showed that cerebral atrophy and cerebellar atrophy, cortical signal changes and basal ganglia mineralization were seen mostly in patients with mitochondrial mutation. Brainstem signal changes with or without striatal lesions were characteristically noted in SURF1 group. There was no consistent imaging pattern in POLG1 group. CONCLUSION Magnetic resonance imaging findings in mitochondrial disorders are heterogeneous. Definite differences were noted in the frequency of anatomical involvement in the three groups. Familiarity with the imaging findings in different genotypes of mitochondrial disorders along with careful analysis of the family history, clinical presentation, biochemical findings, histochemical and structural analysis will help the physician for targeted metabolic and genetic testing.
Collapse
Affiliation(s)
- Parayil Sankaran Bindu
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Hanumanthapura Arvinda
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
| | - Chikanna Govindaraju
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Kothari Sonam
- Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Shwetha Chiplunkar
- Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Rakesh Kumar
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Narayanappa Gayathri
- Department of Neuropathology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Srinivas Bharath Mm
- Department of Neurochemistry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Nahid Akthar Khan
- Centre for Scientific and Industrial Research-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad, India
| | - Periyasamy Govindaraj
- Centre for Scientific and Industrial Research-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad, India
| | - Vandana Nunia
- Centre for Scientific and Industrial Research-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad, India
| | - Arumugam Paramasivam
- Centre for Scientific and Industrial Research-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad, India
| | - Kumarasamy Thangaraj
- Centre for Scientific and Industrial Research-Centre for Cellular and Molecular Biology (CSIR-CCMB), Hyderabad, India
| |
Collapse
|
49
|
Siddiq I, Widjaja E, Tein I. Clinical and radiologic reversal of stroke-like episodes in MELAS with high-dose L-arginine. Neurology 2015; 85:197-8. [PMID: 26070336 DOI: 10.1212/wnl.0000000000001726] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 03/16/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ishita Siddiq
- From the Division of Neurology, Department of Pediatrics (I.S., I.T.), Department of Radiology, The Hospital for Sick Children (E.W.), and Department of Laboratory Medicine and Pathobiology (I.T.), University of Toronto, Canada
| | - Elysa Widjaja
- From the Division of Neurology, Department of Pediatrics (I.S., I.T.), Department of Radiology, The Hospital for Sick Children (E.W.), and Department of Laboratory Medicine and Pathobiology (I.T.), University of Toronto, Canada
| | - Ingrid Tein
- From the Division of Neurology, Department of Pediatrics (I.S., I.T.), Department of Radiology, The Hospital for Sick Children (E.W.), and Department of Laboratory Medicine and Pathobiology (I.T.), University of Toronto, Canada.
| |
Collapse
|
50
|
Cerebral hyperperfusion and decreased cerebrovascular reactivity correlate with neurologic disease severity in MELAS. Mitochondrion 2015; 22:66-74. [DOI: 10.1016/j.mito.2015.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 02/17/2015] [Accepted: 03/06/2015] [Indexed: 12/19/2022]
|