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Wang Y, Zhang E, Ye C, Wu B. Refractory Hypotension in a Late-Onset Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like Episodes (MELAS) Male with m.3243 A>G Mutation: A Case Report. Brain Sci 2023; 13:1080. [PMID: 37509011 PMCID: PMC10377322 DOI: 10.3390/brainsci13071080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Introduction: Symptom spectrum can be of great diversity and heterogeneity in mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) patients in clinical practice. Here, we report a case of MELAS presenting asymptomatic refractory hypotension with m.3243 A>G mutation. (2) Case representation: A 51-year-old male patient presented with a headache, vertigo, and difficulty in expression and understanding. The magnetic resonance imaging of the brain revealed an acute stroke-like lesion involving the left temporoparietal lobe. A definitive diagnosis of MELAS was given after the genetic test identified the chrM-3243 A>G mutation. The patient suffered recurrent stroke-like episodes in the 1-year follow-up. Notably, refractory hypotension was observed during hospitalizations, and no significant improvement in blood pressure was found after continuous use of vasopressor drugs and fluid infusion therapy. (3) Conclusions: We report a case of refractory hypotension which was unresponsive to fluid infusion therapy found in a patient with MELAS. Our case suggests that comprehensive management should be paid attention to during treatment. A further study on the pathological mechanism of the multisystem symptoms in MELAS would be beneficial to the treatment of patients.
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Affiliation(s)
- Youjie Wang
- West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Enhui Zhang
- Department of Neurology, West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu 610041, China
| | - Chen Ye
- Department of Neurology, West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Guo Xue Xiang 37, Chengdu 610041, China
- Center of Cerebrovascular Diseases, West China Hospital, Sichuan University, Chengdu 610041, China
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2
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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
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Mastrangelo M, Ricciardi G, Giordo L, Michele MD, Toni D, Leuzzi V. Stroke and stroke-like episodes in inborn errors of metabolism: Pathophysiological and clinical implications. Mol Genet Metab 2022; 135:3-14. [PMID: 34996714 DOI: 10.1016/j.ymgme.2021.12.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/19/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022]
Abstract
Inborn errors of metabolism causing stroke (ischemic or haemorrhagic) or stroke-like episodes (e.g., that are also called "metabolic strokes" and include acute brain lesions not related with alterations of blood flow) cover a wide range of diseases in which acute metabolic decompensations after trigger events (e.g., fever, dehydration, sepsis etc.) may have a variable frequency. The early diagnosis of these conditions is essential because, despite their rarity, effective symptomatic treatments may be available for acute settings (e.g., arginine for Mitochondrial myopathy, Encephalopathy, Lactic Acidosis, and Stroke-like episodes- MELAS) while in other cases disease modifying therapies may be useful to prevent stroke occurrence, recurrence, or relapse (e.g., Fabry disease). The detection of a non-vascular distribution of lesions and the diffuse use of 1HMRS are often diriment in the differential of ischemic and metabolic strokes. This review summarized the main clinical features and the pathophysiological mechanisms of stroke and stroke-like episodes in inborn errors of metabolism presenting with stroke as part of natural history of the disease. These conditions belong to different etiological groups, such as organic acidurias, mitochondrial encephalopathies, homocystinuria and remethylation disorders, urea cycle disorders, lysosomal diseases (e.g. Fabry disease, glycogen storage disease), congenital disorders of glycosylation, neurotransmitter disorders, adenosine deaminase 2 deficiency and few other neurometabolic disorders.
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Affiliation(s)
- Mario Mastrangelo
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Giacomina Ricciardi
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Laura Giordo
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy
| | - Manuela De Michele
- Emergency Department Stroke Unit, Department of Human Neuroscience, Sapienza, Università di Roma, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neuroscience, Sapienza, Università di Roma, Italy
| | - Vincenzo Leuzzi
- Child Neurology and Psychiatry Unit - Department of Human Neuroscience-Sapienza, Università di Roma, Italy.
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Ishigaki H, Sato N, Kimura Y, Takeshita E, Komaki H, Chiba E, Shigemoto Y, Goto YI, Mori-Yoshimura M, Sasaki M. Linear cortical cystic lesions: Characteristic MR findings in MELAS patients. Brain Dev 2021; 43:931-938. [PMID: 34049744 DOI: 10.1016/j.braindev.2021.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a progressive neurodegenerative disorder with stroke-like lesions. The common MRI findings are gyral swelling and high signal intensity on T2WI/FLAIR images crossing the vascular territories. We have observed a linear cystic lesion and a laminar necrosis in the affected cortices of MELAS patients. Herein, we evaluated these cortical MRI findings in each subtype of mitochondrial disease. PATIENTS AND METHODS We retrospectively reviewed the MRI findings of 71 consecutive patients with clinically and genetically confirmed mitochondrial diseases. The cortical cystic lesions and laminar necrotic lesions were evaluated on T1, T2, and FLAIR images in each subtype of mitochondrial disease, as were their clinical and other imaging characteristics. RESULTS The cortical cystic lesion was observed in 21 of the 71 patients (29.6%) with mitochondrial diseases. Laminar necrosis was detected in only three patients (4.2%). MELAS was the most frequent subtype with cortical cystic lesions, accounting for 81.0%, and all showed the linear pattern except for one patient whose pattern was beaded-like. CONCLUSION A cortical linear cystic lesion was a common MRI finding in our series of patients with mitochondrial disease, especially in those with MELAS, but laminar necrosis was not. These findings can help differentiate MELAS from infarction.
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Affiliation(s)
- Hidetoshi Ishigaki
- Department of Child Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Noriko Sato
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan.
| | - Yukio Kimura
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Eri Takeshita
- Department of Child Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Emiko Chiba
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoko Shigemoto
- Department of Radiology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yu-Ichi Goto
- Department of Child Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Mental Retardation and Birth Defect Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan; Medical Genome Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | | | - Masayuki Sasaki
- Department of Child Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan
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Sugiyama A, Suzuki M, Suichi T, Uchida T, Iizuka T, Tanaka K, Yoneda M, Kuwabara S. Gerstmann's Syndrome in a Patient Double-positive for Antibodies against the N-methyl-D-aspartate Receptor and NH 2-terminal of α-enolase. Intern Med 2021; 60:1463-1468. [PMID: 33229813 PMCID: PMC8170245 DOI: 10.2169/internalmedicine.6344-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/06/2020] [Indexed: 11/24/2022] Open
Abstract
We herein report a case of anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis concurrent with NH2-terminal of α-enolase (NAE) antibodies. A 36-year-old Japanese woman presented with Gerstmann's syndrome followed by jerky involuntary movements, seizure, autonomic instability, and consciousness disturbance. NAE antibodies were detected in the serum; however, NMDAR antibodies were identified in the cerebrospinal fluid with a cell-based assay, confirming the diagnosis of anti-NMDAR encephalitis. This case highlights the fact that Gerstmann's syndrome can be a manifestation of anti-NMDAR encephalitis and that NAE may be identified concurrently with NMDAR antibodies, suggesting that the diagnosis of Hashimoto encephalopathy requires the reasonable exclusion of alternative diagnoses, including anti-NMDAR encephalitis.
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Affiliation(s)
- Atsuhiko Sugiyama
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
| | - Masahide Suzuki
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
| | - Tomoki Suichi
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
| | - Tomohiko Uchida
- Department of Neurology, Eastern Chiba Medical Center, Japan
| | - Takahiro Iizuka
- Department of Neurology, Kitasato University School of Medicine, Japan
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Japan
| | - Makoto Yoneda
- Faculty of Nursing and Social Welfare Science, Department of Nursing Sciences, Fukui Prefectural University, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Japan
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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.
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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
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Kalashnikova LA, Dobrynina LA, Dreval MV, Gubanova MV, Krotenkova MV, Konovalov RN, Legenko MS. [Intracerebral hemorrhage in the late period of internal carotid artery dissection]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:28-34. [PMID: 31825359 DOI: 10.17116/jnevro201911908228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cervical artery dissection is the common cause of ischemic stroke in young and middle-age patients. According to our previous studies, dissection is related to arterial wall dysplastic changes, which in their turn are due to mitochondrial cytopathy. The authors describe three male patients who at the age of 53, 25 and 35 years underwent internal artery (ICA) dissection with occlusion of its lumen and subsequent recanalization in one of them. In 3.5 months, 13.5 years and 3 years respectively, patients developed intracerebral hemorrhage (IСH), which was not related to arterial hypertension, cerebral arterial aneurysms and anticoagulants. IСH were located on the side of ICA occluded after dissection (2 patients) or bilaterally in the territory of patent ICA (1 patient). Multivoxel 1H-MR spectroscopy performed in one patient on 40 and 48 days after ICH revealed a high lactate peak in the externally unchanged hemispheric white matter. It is assumed that mitochondrial cytopathy in patients with dissection may involve large as well as small intracerebral arteries (mitochondrial microangiopathy), which could be the cause of ICH.
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Affiliation(s)
| | | | - M V Dreval
- Research Center of Nevrology, Moscow, Russia
| | | | | | | | - M S Legenko
- Research Center of Nevrology, Moscow, Russia
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Yamadera M, Fujimura H, Shimizu Y, Matsui M, Nakamichi I, Yokoe M, Sakoda S. Increased number of mitochondria in capillaries distributed in stroke‐like lesions of two patients with MELAS. Neuropathology 2019; 39:404-410. [DOI: 10.1111/neup.12593] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 06/14/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Misaki Yamadera
- Department of PathologyOsaka Police Hospital Osaka Japan
- Department of NeurologyNational Hospital Organization Toneyama National Hospital Toyonaka Japan
| | - Harutoshi Fujimura
- Department of NeurologyNational Hospital Organization Toneyama National Hospital Toyonaka Japan
| | - Yuri Shimizu
- Department of Diabetes, Metabolism and EndocrinologyMinoh City Hospital Minoh Japan
| | - Misa Matsui
- Department of NeurologyNational Hospital Organization Toneyama National Hospital Toyonaka Japan
| | | | - Masaru Yokoe
- Department of NeurologyMinoh City Hospital Minoh Japan
| | - Saburo Sakoda
- Department of NeurologyNational Hospital Organization Toneyama National Hospital Toyonaka Japan
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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.
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Affiliation(s)
| | - Sinda Zarrouk-Mahjoub
- University of Tunis, El Manar and Genomics Platform, Pasteur Institute of Tunis, Tunisia
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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.
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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
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Yokoyama J, Yamaguchi H, Shigeto H, Uchiumi T, Murai H, Kira JI. [A case of rhabdomyolysis after status epilepticus without stroke-like episodes in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes]. Rinsho Shinkeigaku 2016; 56:204-7. [PMID: 26960270 DOI: 10.5692/clinicalneurol.cn-000834] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 24-year-old man was referred to our hospital emergency department due to a sudden onset of convulsions after drinking. On arrival he presented status epilepticus and was managed by artificial ventilation. He had no brainstem signs or meningeal irritation. Head MRI showed an old infarction-like lesion in the left occipital lobe, but no abnormal signals on diffusion-weighted images. The patient showed acute rhabdomyolysis (CK 18,000 IU/l) and renal failure, and hemodialysis was started. On 18 day after admission, he was transferred to our department with mild proximal limb muscle weakness and bilateral sensorineural hearing impairment. Electroencephalography demonstrated diffuse intermittent slow wave activities. We suspected a mitochondrial disease because of a significant increase in the lactate/pyruvate ratio (24.1) in the spinal fluid, and identified A3243G mutations in mitochondrial DNA (heteroplasmy 20%) in peripheral white blood cells. We diagnosed his illness as mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). This is a rare case presenting an acute onset of rhabdomyolysis following alcohol intake related to A3243G mitochondrial mutation without preceding stroke-like episodes.
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Affiliation(s)
- Jun Yokoyama
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University
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12
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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]
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Abstract
Because of their high-energy metabolism, neurons are strictly dependent on mitochondria, which generate cellular ATP through oxidative phosphorylation. The mitochondrial genome encodes for critical components of the oxidative phosphorylation pathway machinery, and therefore, mutations in mitochondrial DNA (mtDNA) cause energy production defects that frequently have severe neurological manifestations. Here, we review the principles of mitochondrial genetics and focus on prototypical mitochondrial diseases to illustrate how primary defects in mtDNA or secondary defects in mtDNA due to nuclear genome mutations can cause prominent neurological and multisystem features. In addition, we discuss the pathophysiological mechanisms underlying mitochondrial diseases, the cellular mechanisms that protect mitochondrial integrity, and the prospects for therapy.
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Affiliation(s)
- Valerio Carelli
- IRCCS Institute of Neurological Sciences of Bologna, Bellaria Hospital, Bologna, Italy; Neurology Unit, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - David C Chan
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA 91125, USA.
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14
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Abstract
Imaging of central-nervous-system (CNS) abnormalities is important in patients with mitochondrial disorders (MCDs) since the CNS is the organ second most frequently affected in MCDs and some of them are potentially treatable. Clinically relevant imaging techniques for visualization of CNS abnormalities in MCDs are computed tomography, magnetic resonance imaging, and MR-spectroscopy. The CNS abnormalities in MCDs visualized by imaging techniques include stroke-like lesions with cytotoxic or vasogenic edema, laminar cortical necrosis, basal ganglia necrosis, focal or diffuse white matter lesions, focal or diffuse atrophy, intra-cerebral calcifications, cysts, lacunas, hypometabolisation, lactacidosis, hemorrhages, cerebral hypo- or hyperperfusion, intra-cerebral artery stenoses, or moyamoya syndrome. The CNS lesions may proceed with or without clinical manifestations, why neuroimaging should be routinely carried out in all MCDs to assess the degree of CNS involvement. Some of these lesions may remain unchanged for years, some may show contiguous spread and progression, but some may even disappear, spontaneously or in response to medication. Dynamics of Stroke-like lesions may be positively influenced by L-arginine, dichloracetate, steroids, edavarone, or antiepileptics. Symptomatic treatment of CNS abnormalities in MCD patients may positively influence their outcome.
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Abstract
BACKGROUND Migraine, particularly with aura, increases the risk for ischemic stroke, at least in a subset of patients. The underlying mechanisms are poorly understood and probably multifactorial. METHODS We carried out an extended literature review of experimental and clinical evidence supporting the association between migraine and ischemic stroke to identify potential mechanisms that can explain the association. RESULTS Observational, imaging and genetic evidence support a link between migraine and ischemic stroke. Based on clinical and experimental data, we propose mechanistic hypotheses to explain the link, such as microembolic triggers of migraine and enhanced sensitivity to ischemic injury in migraineurs. DISCUSSION We discuss the possible practical implications of clinical and experimental data, such as aggressive risk factor screening and management, stroke prophylaxis and specific acute stroke management in migraineurs. However, evidence from prospective clinical trials is required before modifying the practice in this patient population.
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Affiliation(s)
- Jerome Mawet
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA Emergency Headache Center, Lariboisiere Hospital, Assistance Publique-Hopitaux de Paris, France DHU NeuroVasc, France
| | - Tobias Kurth
- Inserm Research Center for Epidemiology and Biostatistics (U897), Team Neuroepidemiology, France University of Bordeaux, College of Health Sciences, France Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, MA, USA Stroke Service and Neuroscience Intensive Care Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, MA, USA
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Uehara R, Yamashita K, Hiwatashi A, Togao O, Kikuchi K, Yokoyama J, Matsuse D, Yoshiura T, Honda H. Intravoxel incoherent motion magnetic resonance imaging findings in the acute phase of MELAS: a case report. Brain Behav 2014; 4:798-800. [PMID: 25365795 PMCID: PMC4178247 DOI: 10.1002/brb3.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/14/2014] [Accepted: 08/19/2014] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE We report the clinical application of intravoxel incoherent motion (IVIM) magnetic resonance (MR) imaging to diagnose a case of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) in the acute phase. RESULTS On IVIM MR Images of this patient, higher perfusion (f) and diffusion (D) values in the left occipital and temporal lobes were found compared to the contralateral areas. CONCLUSION These findings imply a breakdown of autoregulation with hyperperfusion and vasogenic edema during the acute phase of MELAS, as described in previous reports. IVIM imaging is a valuable, noninvasive tool that simultaneously quantifies perfusion and diffusion parameters.
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Affiliation(s)
- Ryuji Uehara
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Yamashita
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Akio Hiwatashi
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Osamu Togao
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazufumi Kikuchi
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Jun Yokoyama
- Department of Neurology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Dai Matsuse
- Department of Neurology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takashi Yoshiura
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hiroshi Honda
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Yu L, Xie S, Xiao J, Wang Z, Zhang X. Quantitative measurement of cerebral oxygen extraction fraction using MRI in patients with MELAS. PLoS One 2013; 8:e79859. [PMID: 24260310 PMCID: PMC3832652 DOI: 10.1371/journal.pone.0079859] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 09/25/2013] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To quantify the cerebral OEF at different phases of stroke-like episodes in patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) by using MRI. METHODS We recruited 32 patients with MELAS confirmed by gene analysis. Conventional MRI scanning, as well as functional MRI including arterial spin labeling and oxygen extraction fraction imaging, was undertaken to obtain the pathological and metabolic information of the brains at different stages of stroke-like episodes in patients. A total of 16 MRI examinations at the acute and subacute phase and 19 examinations at the interictal phase were performed. In addition, 24 healthy volunteers were recruited for control subjects. Six regions of interest were placed in the anterior, middle, and posterior parts of the bilateral hemispheres to measure the OEF of the brain or the lesions. RESULTS OEF was reduced significantly in brains of patients at both the acute and subacute phase (0.266 ± 0.026) and at the interictal phase (0.295 ± 0.009), compared with normal controls (0.316 ± 0.025). In the brains at the acute and subacute phase of the episode, 13 ROIs were prescribed on the stroke-like lesions, which showed decreased OEF compared with the contralateral spared brain regions. Increased blood flow was revealed in the stroke-like lesions at the acute and subacute phase, which was confined to the lesions. CONCLUSION MRI can quantitatively show changes in OEF at different phases of stroke-like episodes. The utilization of oxygen in the brain seems to be reduced more severely after the onset of episodes in MELAS, especially for those brain tissues involved in the episodes.
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Affiliation(s)
- Lei Yu
- Department of Radiology, Peking University First Hospital, BeiJing, China
| | - Sheng Xie
- Department of Radiology, China-Japan Friendship Hospital, BeiJing, China
- * E-mail: (SX); (JX)
| | - Jiangxi Xiao
- Department of Radiology, Peking University First Hospital, BeiJing, China
- * E-mail: (SX); (JX)
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, BeiJing, China
| | - Xiaodong Zhang
- Department of Radiology, Peking University First Hospital, BeiJing, China
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Early-onset cataracts, spastic paraparesis, and ataxia caused by a novel mitochondrial tRNAGlu (MT-TE) gene mutation causing severe complex I deficiency: a clinical, molecular, and neuropathologic study. J Neuropathol Exp Neurol 2013; 72:164-75. [PMID: 23334599 DOI: 10.1097/nen.0b013e31828129c5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mitochondrial respiratory chain disease is associated with a spectrum of clinical presentations and considerable genetic heterogeneity. Here we report molecular genetic and neuropathologic findings from an adult with an unusual manifestation of mitochondrial DNA disease. Clinical features included early-onset cataracts, ataxia, and progressive paraparesis, with sequencing revealing the presence of a novel de novo m.14685G>A mitochondrial tRNA(Glu) (MT-TE) gene mutation. Muscle biopsy showed that 13% and 34% of muscle fibers lacked cytochrome c oxidase activity and complex I subunit expression, respectively. Biochemical studies confirmed a marked decrease in complex I activity. Neuropathologic investigation revealed a large cystic lesion affecting the left putamen, caudate nucleus, and internal capsule, with evidence of marked microvacuolation, neuron loss, perivascular lacunae, and blood vessel mineralization. The internal capsule showed focal axonal loss, whereas brainstem and spinal cord showed descending anterograde degeneration in medullary pyramids and corticospinal tracts. In agreement with muscle biopsy findings, reduced complex I immunoreactivity was detected in the remaining neuronal populations, particularly in the basal ganglia and cerebellum, correlating with the neurologic dysfunction exhibited by the patient. This study emphasizes the importance of molecular genetic and postmortem neuropathologic analyses for furthering our understanding of underlying mechanisms of mitochondrial disorders.
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19
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Yeh HL, Chen YK, Chen WH, Wang HC, Chiu HC, Lien LM, Wei YH. Perfusion status of the stroke-like lesion at the hyperacute stage in MELAS. Brain Dev 2013; 35:158-64. [PMID: 22516515 DOI: 10.1016/j.braindev.2012.03.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 11/28/2022]
Abstract
Hypoperfusion on single-photon emission computed tomography (SPECT) of the stroke-like lesion (SLL) at the hyperacute stage of mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS) is considered to be a supportive evidence of the mitochondrial angiopathy theory. Our objectives were to examine whether other neuroimages, especially transcranial color-coded sonography (TCCS), done at the hyperacute stage of stroke-like episode (SLE) is consistent with hypoperfusion of the SLL. We reviewed the magnetic resonance imaging (MRI), SPECT, cerebral angiography, and TCCS of a patient with MELAS syndrome, all of which were performed at the hyperacute stage of one SLE. MRI on the 1st day post SLE showed right temporoparietal lesion with vasogenic edema. SPECT on the 2nd day showed focal decreased uptake of technetium-99m hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) in the same region, but cerebral angiography and TCCS on the 3rd day showed increased regional cerebral blood flow (rCBF) and distal arteriole dilation in the same region. TCCS can delineate increased rCBF of the SLL at the hyperacute stage of SLE. We propose that the discrepancy between the decreased (99m)Tc-HMPAO uptake and increased rCBF might be caused by mitochondrial dysfunction. The phenomenon of "hypoperfusion" on SPECT might be caused by cell dysfunction but not decreased rCBF. We suggest that SPECT can be complemented by angiography and TCCS in future studies to delineate the perfusion status of SLLs.
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Affiliation(s)
- Hsu-Ling Yeh
- Department of Neurology, Shin-Kong WHS Memorial Hospital, No. 95 Wenchang Road, Taipei, Taiwan
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20
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Neuroimaging characteristics in mitochondrial encephalopathies associated with the m.3243A>G MTTL1 mutation. J Neurol 2012. [DOI: 10.1007/s00415-012-6763-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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Tzoulis C, Bindoff LA. Acute mitochondrial encephalopathy reflects neuronal energy failure irrespective of which genome the genetic defect affects. Brain 2012; 135:3627-34. [PMID: 23065482 DOI: 10.1093/brain/aws223] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mitochondrial dysfunction and disease may arise as a result of mutations in either the mitochondrial genome itself or nuclear encoded genes involved in mitochondrial homeostasis and function. Irrespective of which genome is affected, mitochondrial encephalopathies share clinical and biochemical features suggesting common pathophysiological pathways. Two common paradigms of mitochondrial encephalopathy are mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes caused by maternally transmitted mutations of mitochondrial DNA and mitochondrial spinocerebellar ataxia and epilepsy caused by recessively inherited mutations of the nuclear-encoded DNA polymerase gamma, which replicates and repairs the mitochondrial genome. We studied and compared the disease mechanisms involved in these two syndromes. Despite having different genetic origins, their pathophysiological pathways converge on one critical event, damage to the respiratory chain leading to insufficient energy to maintain cellular homeostasis. In the central nervous system, this appears to cause selective neuronal damage leading to the development of lesions that mimic ischaemic damage, but which lack evidence of decreased tissue perfusion. Although these stroke-like lesions may expand or regress dynamically, the critical factor that dictates prognosis is the presence of epilepsy. Epileptic seizures increase the energy requirements of the metabolically already compromised neurons establishing a vicious cycle resulting in worsening energy failure and neuronal death. We believe that it is this cycle of events that determines outcome and which provides us with a mechanistic structure to understand the pathophysiology of acute mitochondrial encephalopathies and plan future treatments.
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Affiliation(s)
- Charalampos Tzoulis
- Department of Neurology, Haukeland University Hospital, 5021 Bergen, Norway.
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22
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Wang Z, Xiao J, Xie S, Zhao D, Liu X, Zhang J, Yuan Y, Huang Y. MR evaluation of cerebral oxygen metabolism and blood flow in stroke-like episodes of MELAS. J Neurol Sci 2012; 323:173-7. [PMID: 23062409 DOI: 10.1016/j.jns.2012.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 09/05/2012] [Accepted: 09/10/2012] [Indexed: 10/27/2022]
Abstract
Metabolic information is essential in the investigation of the pathophysiology of stroke-like episodes in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS). Here, we used magnetic resonance imaging to evaluate the dynamic metabolic changes before and after a stroke-like episode in two patients with MELAS caused by the mitochondrial DNA mutation A3243G. We performed functional magnetic resonance imaging, including arterial spin labeling and oxygen extraction fraction imaging, and generated cerebral blood flow and oxygen extraction fraction maps. We recruited eight healthy volunteers to define the normal range of the oxygen extraction fraction. We detected a heterogeneous reduction in the oxygen extraction fraction in the brain in the interictal period as well as at the onset of a stroke-like attack. However, the oxygen extraction fraction in the stroke-like lesions normalized in the acute stage. The stroke-like lesions showed consistent hyperperfusion in the acute phase but hypoperfusion in the chronic phase. We have demonstrated the utility of using new magnetic resonance imaging techniques in the evaluation of the pathophysiology of stroke-like lesions. The increased utilization of oxygen in an acute lesion is a novel finding in our study, which might play a role in the oxidative stress.
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Affiliation(s)
- Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, Beijing, 100034, China
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23
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Bhuvaneswar CG, Goetz JL, Stern TA. Multiple neurologic, psychiatric, and endocrine complaints in a young woman: a case discussion and review of the clinical features and management of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 10:237-44. [PMID: 18615168 DOI: 10.4088/pcc.v10n0309] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Finsterer J. Stroke and Stroke-like Episodes in Muscle Disease. Open Neurol J 2012; 6:26-36. [PMID: 22715346 PMCID: PMC3377871 DOI: 10.2174/1874205x01206010026] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 04/02/2012] [Accepted: 04/11/2012] [Indexed: 12/13/2022] Open
Abstract
Background: Though not obvious at a first glance, myopathies may be associated with ischemic stroke. Stroke-like episodes resemble ischemic stroke only to some extent but are a unique feature of certain mitochondrial disorders with a pathogenesis at variance from that of ischemic stroke. Only limited data are available about ischemic stroke in pri-mary myopathies and the management of stroke-like episodes in mitochondrial disorders. This review aims to summarize and discuss current knowledge about stroke in myopathies and to delineate stroke-like episodes from ischemic stroke. Methods: Literature review via PubMED using the search terms “stroke”, “cerebrovascular”, “ischemic event”, “stroke-like episode”, “stroke-mimic”, “mitochondrial disorder”. Results: Stroke in myopathies is most frequently cardioembolic due to atrial fibrillation or atrial flutter, dilated cardio-myopathy, or left-ventricular hypertrabeculation (noncompaction). The second most frequent cause of stroke in myopathies is angiopathy from atherosclerosis or vasculitis, which may be a feature of inflammatory myopathies. Athero-sclerosis may either result from classical risk factors, such as diabetes, arterial hypertension, hyperlpidemia, or smoking, associated with muscle disease, or may be an inherent feature of a mitochondrial disorder. In case of severe heart failure from cardiomyopathy as a manifestation of muscle disease low flow infarcts may occur. Thrombophilic stroke has been described in polymyositis and dermatomyositis in association with anti-phospholipid syndrome. Stroke-like episodes occur particularly in mitochondrial encephalopathy, lactacidosis and stroke-likeepisode syndrome but rarely also in Leigh-syndrome and other mitochondrial disorders. Stroke-like episodes are at variance from ischemic stroke, pathogenically, clinically and on imaging. They may be the manifestation of a vascular, metabolic or epileptic process and present with predominantly vasogenic but also cytotoxic edema on MRI. Differentiation between ischemic stroke and stroke-like episodes is essential in terms of management and prognosis. Management of ischemic stroke in patients with myopathy is not at variance from the treatment of ischemic stroke in non-myopathic patients. There is no standardized treatment of stroke-like episodes but there is increasing evidence that these patients profit from the administration of L-arginine and conse-quent antiepileptic treatment if associated with seizure activity. Conclusions: Ischemic stroke may be a complication of myopathy and needs to be delineated from stroke-like episodes, which are unique to mitochondrial disorders, particularly mitochondrial encephalopathy, lactacidosis and stroke-likeepisode syndrome. Ischemic stroke in myopathies is most frequently cardioembolic and treatment is not at variance from non-myopathic ischemic stroke. Treatment of stroke-like episodes is not standardized but seems to respond to L-arginine and adequate antiepileptic treatment.
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Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Vienna, Danube University Krems, Austria
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25
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Lax NZ, Pienaar IS, Reeve AK, Hepplewhite PD, Jaros E, Taylor RW, Kalaria RN, Turnbull DM. Microangiopathy in the cerebellum of patients with mitochondrial DNA disease. ACTA ACUST UNITED AC 2012; 135:1736-50. [PMID: 22577219 PMCID: PMC3359757 DOI: 10.1093/brain/aws110] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neuropathological findings in mitochondrial DNA disease vary and are often dependent on the type of mitochondrial DNA defect. Many reports document neuronal cell loss, demyelination, gliosis and necrotic lesions in post-mortem material. However, previous studies highlight vascular abnormalities in patients harbouring mitochondrial DNA defects, particularly in those with the m.3243A>G mutation in whom stroke-like events are part of the mitochondrial encephalopathy lactic acidosis and stroke-like episodes syndrome. We investigated microangiopathic changes in the cerebellum of 16 genetically and clinically well-defined patients. Respiratory chain deficiency, high levels of mutated mitochondrial DNA and increased mitochondrial mass were present within the smooth muscle cells and endothelial cells comprising the vessel wall in patients. These changes were not limited to those harbouring the m.3243A>G mutation frequently associated with mitochondrial encephalopathy, lactic acidosis and stroke-like episodes, but were documented in patients harbouring m.8344A>G and autosomal recessive polymerase (DNA directed), gamma (POLG) mutations. In 8 of the 16 patients, multiple ischaemic-like lesions occurred in the cerebellar cortex suggestive of vascular smooth muscle cell dysfunction. Indeed, changes in vascular smooth muscle and endothelium distribution and cell size are indicative of vascular cell loss. We found evidence of blood–brain barrier breakdown characterized by plasma protein extravasation following fibrinogen and IgG immunohistochemistry. Reduced immunofluorescence was also observed using markers for endothelial tight junctions providing further evidence in support of blood–brain barrier breakdown. Understanding the structural and functional changes occurring in central nervous system microvessels in patients harbouring mitochondrial DNA defects will provide an important insight into mechanisms of neurodegeneration in mitochondrial DNA disease. Since therapeutic strategies targeting the central nervous system are limited, modulating vascular function presents an exciting opportunity to lessen the burden of disease in these patients.
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Affiliation(s)
- Nichola Z Lax
- The Wellcome Trust Centre for Mitochondrial Research, Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
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Koga Y, Povalko N, Nishioka J, Katayama K, Yatsuga S, Matsuishi T. Molecular pathology of MELAS and l-arginine effects. Biochim Biophys Acta Gen Subj 2012; 1820:608-14. [DOI: 10.1016/j.bbagen.2011.09.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 07/07/2011] [Accepted: 09/07/2011] [Indexed: 11/30/2022]
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27
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Finsterer J, Mahjoub SZ. Primary mitochondrial arteriopathy. Nutr Metab Cardiovasc Dis 2012; 22:393-399. [PMID: 22520486 DOI: 10.1016/j.numecd.2012.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 12/27/2011] [Accepted: 01/05/2012] [Indexed: 12/28/2022]
Abstract
AIM Whether arteries are affected in mitochondrial disorders (MIDs) was under debate for years but meanwhile there are strong indications that large and small arteries are primarily or secondarily affected in MIDs. DATA SYNTHESIS When reviewing the literature for appropriate studies it turned out that vascular involvement in MIDs includes primary or secondary micro- or macroangiopathy of the cerebral, cervical, and retinal arteries, the aorta, the iliac arteries, the brachial arteries, or the muscular arteries. Arteriopathy in MIDs manifests as atherosclerosis, stenosis, occlusion, dissection, ectasia, aneurysm formation, or arteriovenous malformation. Direct evidence for primary cerebral microangiopathy comes from histological studies and indirect evidence from imaging and perfusion studies of the brain. Microangiopathy of the retina is highly prevalent in Leber's hereditary optic neuropathy. Macroangiopathy of the carotid arteries may be complicated by stroke. Arteriopathy of the aorta may result in ectasia, aneurysm formation, or even rupture. Further evidence for arteriopathy in MIDs comes from the frequent association of migraine with MIDs and the occurrence of premature atherosclerosis in MID patients without classical risk factors. CONCLUSIONS Mitochondrial arteriopathy most frequently concerns the cerebral arteries and may result from the underlying metabolic defect or secondary from associated vascular risk factors. Vascular involvement in MIDs has a strong impact on the prognosis and outcome of these patients.
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Affiliation(s)
- J Finsterer
- Danube University Krems, Krems, Postfach 20, 1180 Vienna, Austria.
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28
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Tsujikawa T, Yamamoto T, Ikawa M, Yoneda M, Kimura H. Crossed cerebellar hyperperfusion after MELAS attack followed up by whole brain continuous arterial spin labeling perfusion imaging. Acta Radiol 2012; 53:220-2. [PMID: 22139718 DOI: 10.1258/ar.2011.110274] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Crossed cerebellar hyperperfusion (CCH) is detected in patients with epilepsy by brain perfusion studies including single photon emission computed tomography and positron emission tomography. In addition, brain perfusion can be studied with arterial spin labeling (ASL), which is a non-invasive MRI perfusion method that quantitatively measures cerebral blood flow per unit tissue mass. We followed up a 47-year-old patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) by continuous arterial spin labeling technique, which showed crossed cerebellar hyperperfusion after acute stroke-like episode. This cerebellar hyperperfusion normalized in the follow-up.
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Affiliation(s)
| | | | - Masamichi Ikawa
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Makoto Yoneda
- Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
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Liu Z, Zheng D, Wang X, Zhang J, Xie S, Xiao J, Jiang X. Apparent diffusion coefficients of metabolites in patients with MELAS using diffusion-weighted MR spectroscopy. AJNR Am J Neuroradiol 2011; 32:898-902. [PMID: 21349966 DOI: 10.3174/ajnr.a2395] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE DW-MR spectroscopy can detect the diffusion coefficients of NAA, Cr, PCr, and Cho and can, therefore, provide some useful information. The aims of this study were to probe the mechanisms underlying the pathogenesis of MELAS and to see whether DW-MR spectroscopy is a useful technique for other diseases besides cerebral infarction. MATERIALS AND METHODS Fifteen healthy volunteers and 10 patients with MELAS were enrolled in the study. All were scanned on a 3T whole-body MR imaging scanner. Fifteen ADCs of the singlet metabolites in the gray matter of the healthy subjects, 10 ADCs of the singlet metabolites in the lesions, and 8 ADCs of the singlet metabolites in the nonaffected areas were used in the statistical analysis, respectively. RESULTS The metabolite ADCs of the nonaffected areas and the lesions in the patients were higher than those of the frontal gray matter in the healthy controls. There were significant differences between the metabolite ADCs of the nonaffected areas in patients and those in the healthy controls, and it was the same with the metabolite ADCs of the lesions and those of the healthy controls. CONCLUSIONS The increased ADC values of the metabolites reveal that MELAS is a mitochondrial neuronopathy and involves the entire brain. DW-MR spectroscopy is a very useful noninvasive technique, which can show some valuable information that conventional MR imaging cannot display. Thus, it can be applied to brain diseases besides cerebral infarction.
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Affiliation(s)
- Z Liu
- Department of Radiology, Center for Functional Imaging, Peking University First Hospital, Peking University, Beijing, China
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30
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Milh M, Cano A, Halbert C, Chabrol B. Déficit moteur aigu et troubles du métabolisme énergétique. Arch Pediatr 2011. [DOI: 10.1016/s0929-693x(11)71005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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Ito H, Mori K, Kagami S. Neuroimaging of stroke-like episodes in MELAS. Brain Dev 2011; 33:283-8. [PMID: 20609541 DOI: 10.1016/j.braindev.2010.06.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 04/02/2010] [Accepted: 06/11/2010] [Indexed: 11/18/2022]
Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) shows sudden neurological deficits that are called 'stroke-like episodes'. With regard to the pathophysiology of stroke-like episodes, so-called mitochondrial angiopathy and cytopathy theories have been proposed, but the subject is still controversial. To clarify this matter and to contribute to the development of a treatment for MELAS, we review here current neuroimaging research and consider the pathophysiology of stroke-like lesions. With regard to diffusion-weighted imaging findings, early reports often showed an elevated apparent diffusion coefficient (ADC) in stroke-like lesions; this was considered to be mainly vasogenic edema in the acute phase and is a different pattern than that in stroke. However, there has recently been an increase in the number of reports of a decrease in ADC; these cases are considered to be cytotoxic edema in the acute phase, which is compatible with stroke. With regard to (1)H-magnetic resonance spectroscopy findings in stroke-like lesions, a decrease in N-acetylaspartate and an increase in lactate have been reported. With regard to single photon emission computed tomography findings for stroke-like lesions in MELAS, an overall trend is hyperperfusion in the acute stage (within 1 month) of stroke-like episodes and hypoperfusion in the chronic stage (several months later). With regard to positron emission tomography, nearly all of these reports are consistent with the mitochondrial cytopathy theory. With regard to neuropathology in MELAS, the most common findings during the chronic stage of stroke-like episodes include foci of necrosis and peculiar vascular changes (abnormalities of mitochondria in small arteries). Concerning the pathology of the acute stage of stroke-like episodes, extensive petechial hemorrhage along the gyri of the cortex corresponding to acute stroke-like lesions has been reported. To clarify the true pathophysiology of stroke-like episodes, we offer three suggestions. First, we must define the precise onset of stroke-like episodes. Second, current studies are limited by the difficulty of imaging just before and just after (within a few minutes) the onset of stroke-like episodes. Third, we hope to establish an experimental animal model. We should conduct a simultaneous multimodal imaging and histological study just before and just after (within a few minutes) the onset of stroke-like episodes in an experimental animal model.
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Affiliation(s)
- Hiromichi Ito
- Department of Pediatrics, School of Medicine, University of Tokushima, Japan.
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32
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Moustris A, Edwards MJ, Bhatia KP. Movement disorders and mitochondrial disease. HANDBOOK OF CLINICAL NEUROLOGY 2011; 100:173-92. [PMID: 21496577 DOI: 10.1016/b978-0-444-52014-2.00010-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Andreas Moustris
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
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Zhang ZQ, Niu ST, Liang XH, Jian F, Wang Y. Vascular involvement in the pathogenesis of mitochondrial encephalomyopathies. Neurol Res 2010; 32:403-8. [PMID: 20483008 DOI: 10.1179/016164110x12670144526345] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to perform perfusion CT imaging in the acute phase of myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS), to assess whether these patients had cerebral perfusion abnormalities. Furthermore, the pathology of muscle vessel was evaluated, to explore the role of vasculopathy and ischemic events in the pathogenesis of mitochondrial encephalomyopathies. METHODS Computed tomography perfusion (CTP) imaging was applied to the evaluation of brain perfusion during the symptomatic period of mitochondrial encephalomyopathies. Mitochondria structures in the blood vessels wall within muscle fibers were observed by light and electron microscopy analyses. RESULTS Neuroimaging studies demonstrated uni- and bilateral lesions predominantly in the occipital and temporal-parietal lobes. Compared with the healthy control subjects, significant decreases in cerebral blood flow and cerebral blood volume were noted in affected brain areas of individuals with MELAS. In particular, mean transit time and the time to peak were prolonged both in lesion and non-lesion brain areas. Muscle pathology showed large granular deposits on vessel wall as demonstrated by succinic acid dehydrogenase staining. Electron microscopy of blood vessels revealed swelling of cristae and a striking increase in the number of mitochondria in the smooth muscle and endothelial cells. CONCLUSION Insufficient cerebral perfusion or vascular reserve and secondary metabolic dysfunction may represent an important feature of the pathogenesis of the stroke-like episodes in MELAS.
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Affiliation(s)
- Zai-Qiang Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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Koga Y, Povalko N, Nishioka J, Katayama K, Kakimoto N, Matsuishi T. MELAS and l-arginine therapy: pathophysiology of stroke-like episodes. Ann N Y Acad Sci 2010; 1201:104-10. [DOI: 10.1111/j.1749-6632.2010.05624.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Fraser JA, Biousse V, Newman NJ. The neuro-ophthalmology of mitochondrial disease. Surv Ophthalmol 2010; 55:299-334. [PMID: 20471050 PMCID: PMC2989385 DOI: 10.1016/j.survophthal.2009.10.002] [Citation(s) in RCA: 177] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 09/21/2009] [Accepted: 10/01/2009] [Indexed: 01/16/2023]
Abstract
Mitochondrial diseases frequently manifest neuro-ophthalmologic symptoms and signs. Because of the predilection of mitochondrial disorders to involve the optic nerves, extraocular muscles, retina, and even the retrochiasmal visual pathways, the ophthalmologist is often the first physician to be consulted. Disorders caused by mitochondrial dysfunction can result from abnormalities in either the mitochondrial DNA or in nuclear genes which encode mitochondrial proteins. Inheritance of these mutations will follow patterns specific to their somatic or mitochondrial genetics. Genotype-phenotype correlations are inconstant, and considerable overlap may occur among these syndromes. The diagnostic approach to the patient with suspected mitochondrial disease entails a detailed personal and family history, careful ophthalmic, neurologic, and systemic examination, directed investigations, and attention to potentially life-threatening sequelae. Although curative treatments for mitochondrial disorders are currently lacking, exciting research advances are being made, particularly in the area of gene therapy. Leber hereditary optic neuropathy, with its window of opportunity for timely intervention and its accessibility to directed therapy, offers a unique model to study future therapeutic interventions. Most patients and their relatives benefit from informed genetic counseling.
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Affiliation(s)
- J. Alexander Fraser
- Departments of Ophthalmology (J.A.F., V.B., N.J.N.), Neurology (V.B., N.J.N.), and Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, GA
| | - Valérie Biousse
- Departments of Ophthalmology (J.A.F., V.B., N.J.N.), Neurology (V.B., N.J.N.), and Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, GA
| | - Nancy J. Newman
- Departments of Ophthalmology (J.A.F., V.B., N.J.N.), Neurology (V.B., N.J.N.), and Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, GA
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Liu Z, Liu X, Hui L, Zhao D, Wang X, Xie S, Xiao J, Jiang X. The appearance of ADCs in the non-affected areas of the patients with MELAS. Neuroradiology 2010; 53:227-32. [PMID: 20556599 DOI: 10.1007/s00234-010-0729-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2010] [Accepted: 06/04/2010] [Indexed: 01/24/2023]
Abstract
INTRODUCTION The exact mechanism of the mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) remain unclear. Diffusion-weighted imaging (DWI) is a magnetic resonance (MR) imaging technique for studying the pathophysiologic change of the MELAS. The purpose of the study is to see whether the apparent diffusion coefficient (ADC) of MELAS in the non-affected areas is different from the ADC of the normal subjects and to speculate the pathophysiological mechanisms of the MELAS. METHODS Sixteen cases of MELAS were retrospectively analyzed. Thirty healthy subjects were chosen to constitute the control group. All of them were performed on the 3.0T whole-body MR scanner with axial view T2 fluid attenuated inversion recovery (flair), T2-weighted imaging, T1flair, and DWI. An ADC map was reconstructed in the workstation. Two to five regions of interest were put in the non-affected frontal lobe and basal ganglia. All data took statistical analysis. RESULTS There were significant differences between the ADC of the patients with MELAS and the controls in the non-affected areas, including the superior frontal gyrus, precentral gyrus, corpus striatum, thalamus, and white matter of the semi-oval centrum. CONCLUSION ADCs in the non-affected areas of the patients with MELAS are higher than those of the normal subjects. Pathological changes take place in the non-affected areas of the patients with MELAS.
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Affiliation(s)
- Zhenghua Liu
- The Department of Radiology, Peking University First Hospital, Center for Functional Imaging, Peking University, Beijing, People's Republic of China
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Reversible brain atrophy in anti-NMDA receptor encephalitis: a long-term observational study. J Neurol 2010; 257:1686-91. [PMID: 20517615 DOI: 10.1007/s00415-010-5604-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 05/17/2010] [Indexed: 11/27/2022]
Abstract
The long-term neuroimaging correlates of clinical recovery have not been described in anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis. The aim of the study is to evaluate the long-term outcome of brain atrophy in anti-NMDAR encephalitis. Patients were two women (ages 17 and 33 years) with severe anti-NMDAR encephalitis resulting in decreased level of consciousness, autonomic instability, hypoventilation, and dyskinesias requiring continuous infusion of anesthetic agents for 6-7 months. Brain MRI and cerebral blood flow SPECT obtained at the time of maximal neurological disability were compared with similar studies obtained 5-7 years later. Both patients were hospitalized for 9-14 months and developed frontotemporal atrophy and hypoperfusion 7-12 months after symptom presentation. In both patients, cognitive functions gradually improved over the next 4-5 years. Comparative neuroimaging studies obtained 5-7 years after symptom presentation showed dramatic improvement of the atrophy and frontotemporal hypoperfusion. The severe and protracted deficits and the frontotemporal atrophy that occur in some patients with anti-NMDAR encephalitis are potentially reversible. This suggests that a functional rather than a structural neuronal damage underlies the pathogenesis of this disorder.
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Lindroos MM, Borra RJ, Parkkola R, Virtanen SM, Lepomäki V, Bucci M, Virta JR, Rinne JO, Nuutila P, Majamaa K. Cerebral oxygen and glucose metabolism in patients with mitochondrial m.3243A>G mutation. ACTA ACUST UNITED AC 2010; 132:3274-84. [PMID: 19843652 DOI: 10.1093/brain/awp259] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The m.3243A>G mutation is the most common pathogenic mutation in mitochondrial DNA. It leads to defective oxidative phosphorylation, decreased oxygen consumption and increased glucose utilization and lactate production in vitro. However, oxygen and glucose metabolism has not been studied in the brain of patients harbouring the m.3243A>G mutation. Therefore, 14 patients with the m.3243A>G mutation, not experiencing acute stroke-like episodes and 14 age-matched controls underwent positron emission tomography using 2-[(18)F]fluoro-2-deoxyglucose, [(15)O]H(2)O and [(15)O]O(2) as the tracers during normoglycaemia. The metabolic rate of oxygen and glucose were determined using a quantitative region of interest analysis. Metabolites in unaffected periventricular tissue were measured using magnetic resonance spectroscopy. We found that the cerebral metabolic rate of oxygen was decreased by 26% (range 18%-29%) in the grey as well as the white matter of patients with the m.3243A>G mutation. A decrease in the metabolic rate of glucose was found with predilection to the posterior part of the brain. No major changes were detected in cerebral blood flow or the number of white matter lesions. Our results show that the m.3243A>G mutation leads to a global decrease in oxygen consumption in the grey matter including areas where no other signs of disease were present.
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Affiliation(s)
- Markus M Lindroos
- Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland
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Tsujikawa T, Yoneda M, Shimizu Y, Uematsu H, Toyooka M, Ikawa M, Kudo T, Okazawa H, Kuriyama M, Kimura H. Pathophysiologic evaluation of MELAS strokes by serially quantified MRS and CASL perfusion images. Brain Dev 2010; 32:143-9. [PMID: 19171446 DOI: 10.1016/j.braindev.2008.12.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Revised: 11/25/2008] [Accepted: 12/04/2008] [Indexed: 12/21/2022]
Abstract
PURPOSE To clarify the roles of serial MR spectroscopy (MRS) and continuous arterial spin labeling (CASL) perfusion images for evaluating cerebral lesions in patients with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). MATERIALS AND METHODS Two cases of MELAS followed up serially using MRS and CASL images in addition to routine MR imaging were enrolled. RESULTS Newly appeared lesions assessed by MRS revealed increased lactate doublets which correlated well with CSF lactate level, and these showed a decreasing trend after treatment, although conventional T2 weighted images revealed hyper-intensity in both phases. Spectra from normally appearing white matter depicted slight lactate peaks during clinical exacerbation periods with marked elevation of CSF lactate and showed a decreasing NAA concentration during the prolonged course. In CASL images, acute lesions of the disease were clearly visible as hyper-perfusion foci, and chronic lesions were demonstrated as hypo- or iso-perfusion regions. CONCLUSION The detection of lactate peaks in the MR spectrum from normally appearing white matter may be considered as systemic lactic acidosis or an exacerbation of MELAS, and active lesions can be distinguished from chronic inactive lesions by the increase of lactate peaks in MRS or the state of hyper-perfusion in CASL images.
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Iizuka T, Sakai F. Pathophysiology of stroke-like episodes in MELAS: neuron–astrocyte uncoupling in neuronal hyperexcitability. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.09.71] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) is a distinct clinical syndrome characterized by fluctuated encephalopathy, migraineous headache, seizure and stroke-like episodes. The molecular mechanism of MELAS mutations has been elucidated; however, the pathogenesis of stroke-like episodes remains largely unknown. Three main hypotheses include ischemic, metabolic and neuronal hyperexcitability hypotheses. Recently, emerging hypotheses include alterations in nitric oxide homeostasis and over-reduction/oxidative stress mechanisms. Although neuron–astrocyte communication is crucial in various physiological functions, it has not been seriously considered in the pathophysiology of stroke-like episodes. This review summarizes what is known about the molecular mechanisms of gene mutation, clinico-radiological, clinico-physiological and pathological features of stroke-like episodes, as well as its pathogenesis. We finally discuss potential mechanisms involved in the pathogenesis of stroke-like episodes based on currently available clinical data and the current understanding of the mechanisms of neuron–astrocyte communications. We propose that neuron–astrocyte uncoupling is a new target of research in mitochondrial disorders.
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Fumihiko Sakai
- International Headache Center, Shinyurigaoka, Kanagawa, Japan
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Abstract
Treatment of mitochondrial disorders (MIDs) is a challenge since there is only symptomatic therapy available and since only few randomized and controlled studies have been carried out, which demonstrate an effect of some of the symptomatic or supportive measures available. Symptomatic treatment of MIDs is based on mainstay drugs, blood transfusions, hemodialysis, invasive measures, surgery, dietary measures, and physiotherapy. Drug treatment may be classified as specific (treatment of epilepsy, headache, dementia, dystonia, extrapyramidal symptoms, Parkinson syndrome, stroke-like episodes, or non-neurological manifestations), non-specific (antioxidants, electron donors/acceptors, alternative energy sources, cofactors), or restrictive (avoidance of drugs known to be toxic for mitochondrial functions). Drugs which more frequently than in the general population cause side effects in MID patients include steroids, propofol, statins, fibrates, neuroleptics, and anti-retroviral agents. Invasive measures include implantation of a pacemaker, biventricular pacemaker, or implantable cardioverter defibrillator, or stent therapy. Dietary measures can be offered for diabetes, hyperlipidemia, or epilepsy (ketogenic diet, anaplerotic diet). Treatment should be individualized because of the peculiarities of mitochondrial genetics. Despite limited possibilities, symptomatic treatment should be offered to MID patients, since it can have a significant impact on the course and outcome.
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Laminar cortical necrosis in mitochondrial disorders. Clin Neurol Neurosurg 2009; 111:655-8. [DOI: 10.1016/j.clineuro.2009.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 07/01/2009] [Accepted: 07/04/2009] [Indexed: 11/18/2022]
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Finsterer J. CT und MRT des Zerebrums bei mitochondrialen Erkrankungen. DER NERVENARZT 2009; 80:700-7. [DOI: 10.1007/s00115-009-2678-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Katayama Y, Maeda K, Iizuka T, Hayashi M, Hashizume Y, Sanada M, Kawai H, Kashiwagi A. Accumulation of oxidative stress around the stroke-like lesions of MELAS patients. Mitochondrion 2009; 9:306-13. [PMID: 19393775 DOI: 10.1016/j.mito.2009.04.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 04/04/2009] [Accepted: 04/15/2009] [Indexed: 02/05/2023]
Abstract
To investigate the relationship between oxidative stress and progressive spread of the stroke-like lesions in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) with 3243A>G mutation, we retrospectively analyzed the spread frequency in patients with and without treatment with the radical scavenger edaravone. Oxidative damage and defensive enzymes were histologically evaluated. Spread was significantly less frequent in the patients treated with edaravone. Although 8-hydroxy-2'-deoxyguanosine, a marker for oxidative damage of DNA, was obviously accumulated in peri-lesional surviving neurons, manganese superoxide dismutase and 8-oxoguanine glycosylase 1 were not up-regulated in those neurons. Increased oxidative stress and insufficient defense could be involved in the pathogenesis of the spreading lesions in MELAS.
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Affiliation(s)
- Yuri Katayama
- Division of Neurology, Department of Internal Medicine, Shiga University of Medical Science, Seta-Tsukinowa, Otsu, Shiga 520-2192, Japan
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Abstract
Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a distinct clinical syndrome caused by mutations in mitochondrial DNA. Crucial molecular mechanism includes a lack of taurine modification at the wobble uridine of the mutant tRNA(Leu(UUR)), causing UUG condon-specific translational defect and mitochondrial protein synthesis failure. However, the pathogenesis of stroke-like episodes remains unknown. We previously reported that stroke-like episodes were more likely non-ischemic events, characterized by increased capillary permeability, hyperperfusion, neuronal vulnerability and neuronal hyperexcitability, in which neuronal hyperexcitability plays an important role in initiation of the cascades of stroke-like events by increasing energy demand. We also emphasized a role of prolonged epileptic activities in progressive spread of stroke-like lesions, and then proposed a non-ischemic neurovascular cellular mechanism. Once neuronal hyperexcitability developed in a localized region as a result from either mitochondrial dysfunction in capillary endothelial cells, or in neurons or astrocytes, epileptic activities depolarize adjacent neurons, leading to propagation of epileptic activities in surrounding cortex. Increased capillary permeability in the presence of mitochondrial capillary angiopathy may cause unique edematous lesions predominantly involving the cortex. As a consequence, most susceptible layers of the cortex may result in neuronal loss. Therapeutic targets include each ongoing process of the disease.
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Affiliation(s)
- Takahiro Iizuka
- Department of Neurology, School of Medicine, Kitasato University
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Sproule DM, Kaufmann P. Mitochondrial encephalopathy, lactic acidosis, and strokelike episodes: basic concepts, clinical phenotype, and therapeutic management of MELAS syndrome. Ann N Y Acad Sci 2008; 1142:133-58. [PMID: 18990125 DOI: 10.1196/annals.1444.011] [Citation(s) in RCA: 216] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Since the initial description almost 25 years ago, the syndrome of mitochondrial encephalopathy, lactic acidosis, and strokelike episodes (MELAS) has been a useful model to study the complex interplay of factors that define mitochondrial disease. This syndrome, most commonly caused by an A-to-G transition mutation at position 3243 of the mitochondrial genome, is typified by characteristic neurological manifestations including seizures, encephalopathy, and strokelike episodes, as well as other frequent secondary manifestations including short stature, cognitive impairment, migraines, depression, cardiomyopathy, cardiac conduction defects, and diabetes mellitus. In this review, we discuss the history, pathogenesis, clinical features, and diagnostic and management strategies of mitochondrial disease in general and of MELAS in particular. We explore features of mitochondrial genetics, including the concepts of heteroplasmy, mitotic segregation, and threshold effect, as a basis for understanding the variability and complicated inheritance patterns seen with this group of diseases. We also describe systemic manifestations of MELAS-associated mutations, including cardiac, renal, endocrine, gastrointestinal, and endothelial abnormalities and pathology, as well as the hypothetical role of derangements to COX enzymatic function in driving the unique pathology and clinical manifestations of MELAS. Although therapeutic options for MELAS and other mitochondrial diseases remain limited, and recent trials have been disappointing, we also consider current and potential therapeutic modalities.
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Affiliation(s)
- Douglas M Sproule
- Columbia University, Pediatric Neurology, 180 Fort Washington Ave., Harkness Pavilion, 5th floor, New York, NY 10032, USA.
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Current world literature. Curr Opin Rheumatol 2008; 20:729-35. [PMID: 18946335 DOI: 10.1097/bor.0b013e328317a234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Current world literature. Curr Opin Neurol 2008; 21:615-24. [PMID: 18769258 DOI: 10.1097/wco.0b013e32830fb782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hajjar I, Selim M, Novak P, Novak V. The relationship between nighttime dipping in blood pressure and cerebral hemodynamics in nonstroke patients. J Clin Hypertens (Greenwich) 2008; 9:929-36. [PMID: 18046099 DOI: 10.1111/j.1524-6175.2007.07342.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Inadequate dipping in nighttime blood pressure (BP) is associated with cerebrovascular disease. The authors aimed to determine whether inadequate nocturnal dipping was associated with abnormalities in cerebrovascular hemodynamics in individuals without stroke. Participants in this study underwent 24-hour ambulatory BP monitoring followed by morning transcranial Doppler measurements of blood flow velocities (BFVs) in the middle cerebral artery during supine rest, head-up tilt, hypocapnia, and hypercapnia. Nighttime BP decline by <10% was considered nondipping. Of the 102 nonstroke participants (mean age, 53.6 years), 35 (34%) were dippers. Although nondippers had similar BFV and cerebrovascular resistance (CVR) while supine, they had a lower BFV (P=.04) and greater CVR (P=.02) during head-up tilt compared with dippers. Moreover, greater nighttime dipping in both systolic BP (P=.006) and diastolic BP (P=.03) were associated with higher daytime BFV and lower CVR (P=.01 for systolic BP; P=.02 for diastolic BP). Inadequate nocturnal BP dipping is associated with lower daytime cerebral blood flow, especially during head-up tilt.
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Affiliation(s)
- Ihab Hajjar
- Beth Israel Deaconess Medical Center, Institute for Aging Research at Hebrew SeniorLife, Boston, MA 02131, USA.
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