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Irilouzadian R, Goudarzi A, Hesami H, Sarmadian R, Biglari HN, Gilani A. An unusual case of a toddler with Canavan disease with frequent
intractable seizures: A case report and review of the literature. SAGE Open Med Case Rep 2023; 11:2050313X231160885. [PMID: 36968992 PMCID: PMC10034305 DOI: 10.1177/2050313x231160885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/10/2023] [Indexed: 03/24/2023] Open
Abstract
Canavan disease is a rare fetal inherited leukodystrophy, caused by accumulation
of N-acetyl-aspartate in the brain. Here, we report a child presented with
frequent intractable seizures and visual impairment. A 14-month-old female
infant with a complaint of the absence of neck holding and generalized
tonic-clonic seizures was referred to our hospital. Macrocephaly, setting sun
eyes, tremor, and hypotonia were observed. Funduscopy showed optic atrophy. Our
patient’s flash visual evoked potential showed blindness. Her brain magnetic
resonance imaging showed diffuse white matter in subcortical, basal ganglia, and
dorsal pons. Electroencephalography showed diffuse slow and sharp waves. The
genetic study detected a hemizygous mutation in the aspartoacylase gene. Our
patient was diagnosed with Canavan disease and began anticonvulsant treatment.
However, seizures were not under control. Then, her medications were
discontinued, and clobazam and primidone were administered. In conclusion,
starting clobazam and primidone may help prevent frequently intractable seizures
in Canavan disease patients.
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Affiliation(s)
- Rana Irilouzadian
- Burn Research Center, Iran University
of Medical Sciences, Tehran, Iran
| | - Ali Goudarzi
- Iranian Center of Neurological
Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran,
Iran
| | - Hamed Hesami
- School of Medicine, Shahid Beheshti
University of Medical Sciences, Tehran, Iran
| | - Roham Sarmadian
- Infectious Diseases Research Center,
Arak University of Medical Sciences, Arak, Iran
| | - Habibe Nejad Biglari
- Neurosciences Research Center, Kerman
University of Medical Sciences, Kerman, Iran
| | - Abolfazl Gilani
- Sina Trauma and Surgery Research
Center, Tehran University of Medical Sciences, Tehran, Iran
- Abolfazl Gilani, Sina Trauma and Surgery
Research Center, Building 7, Sina Hospital, Hassan-Abad Sq, Tehran 11365-3876,
Iran.
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2
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Kotambail A, Selvam P, Muthusamy K, Thomas M, Sudhakar SV, Ghati C, Danda S, Arunachal G. Clustering of Juvenile Canavan disease in an Indian community due to population bottleneck and isolation: genomic signatures of a founder event. Eur J Hum Genet 2023; 31:73-80. [PMID: 36202930 PMCID: PMC9823096 DOI: 10.1038/s41431-022-01198-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/10/2022] [Accepted: 09/15/2022] [Indexed: 02/08/2023] Open
Abstract
Mild/juvenile Canavan disease (M/JCD) is less frequently reported in the literature and little is known about its pathogenetic mechanisms. We report a comprehensive investigation into the pathogenetic mechanism of a novel NM_000049.4(ASPA):c.526G>A variant in two families. The families belong to Telugu Devanga Chettiar community (TDC) from southern India. TDC has a complex history of migration from their historical origin centuries ago with high endogamy. TDC probably has the highest clustering M/JCD recorded historically (around 24 cases). The pathogenic variant was shown to cause non-classical splicing defect resulting in two different transcripts. The splicing aberration, a loss of function mechanism coupled with a milder missense effect can explain the milder phenotype compared to the infantile-onset CD. The high clustering of an extremely rare form of neurodegenerative disorder with reduced fitness, led us to speculate the possibility of a founder event. Genotyping array of TDC and multiple distinct populations of Indian origin for several population genetic parameters was performed. It yielded robust signatures of a founder event in TDC, such as a high fixation index, increased runs of homozygosity and identity-by-descent in the absence of consanguinity; a large haplotype with high linkage disequilibrium among markers comprising the pathogenic variant; a robust population structure; mutation dating, estimating the age of the potential founder of TDC at around 375 years; possibly a high carrier rate in TDC. This study has not only focused its attention on natural history and pathogenetics but also paves way for carrier screening programs in TDC and future therapeutic studies.
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Affiliation(s)
- Ananthapadmanabha Kotambail
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Pavalan Selvam
- Department of Clinical Genetics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Karthik Muthusamy
- Paediatric Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Maya Thomas
- Paediatric Neurology Unit, Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sniya Valsa Sudhakar
- Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Chetan Ghati
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sumita Danda
- Department of Clinical Genetics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Gautham Arunachal
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India.
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3
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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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4
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Tabarki B, Hakami W, Alkhuraish N, Graies-Tlili K, Nashabat M, Alfadhel M. Inherited Metabolic Causes of Stroke in Children: Mechanisms, Types, and Management. Front Neurol 2021; 12:633119. [PMID: 33746889 PMCID: PMC7969979 DOI: 10.3389/fneur.2021.633119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
A stroke should be considered in cases of neurologic decompensation associated with inherited metabolic disorders. A resultant stroke could be a classical ischemic stroke (vascular stroke) or more commonly a "metabolic stroke." A metabolic stroke begins with metabolic dysfunctions, usually caused by a stressor, and leads to the rapid onset of prolonged central neurological deficits in the absence of vessel occlusion or rupture. The cardinal features of a metabolic stroke are stroke-like episodes without the confirmation of ischemia in the typical vascular territories, such as that seen in classic thrombotic or embolic strokes. Identifying the underlying cause of a metabolic stroke is essential for prompt and appropriate treatment. This study reviews the major inherited metabolic disorders that predispose patients to pediatric stroke, with an emphasis on the underlying mechanisms, types, and management.
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Affiliation(s)
- Brahim Tabarki
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Wejdan Hakami
- Division of Pediatric Neurology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Nader Alkhuraish
- Division of Neuroradiology, Department of Radiology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Kalthoum Graies-Tlili
- Division of Neuroradiology, Department of Radiology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Marwan Nashabat
- Department of Genetics and Precision Medicine (GPM), King Abdullah Specialized Children's Hospital, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Majid Alfadhel
- Department of Genetics and Precision Medicine (GPM), King Abdullah Specialized Children's Hospital, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia.,Medical Genomics Research Department, King Abdullah International Medical Research Center (KAIMRC), King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
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5
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Aksoy DÖ, Alkan A. Neurometabolic Diseases in Children: Magnetic Resonance Imaging and Magnetic Resonance Spectroscopy Features. Curr Med Imaging 2020; 15:255-268. [PMID: 31989877 DOI: 10.2174/1573405613666171123152451] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/30/2017] [Accepted: 11/14/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Neurometabolic diseases are a group of diseases secondary to disorders in different metabolic pathways, which lead to white and/or gray matter of the brain involvement. DISCUSSION Neurometabolic disorders are divided in two groups as dysmyelinating and demyelinating diseases. Because of wide spectrum of these disorders, there are many different classifications of neurometabolic diseases. We used the classification according to brain involvement areas. In radiological evaluation, MRI provides useful information for these disseases. CONCLUSION Magnetic Resonance Spectroscopy (MRS) provides additional metabolic information for diagnosis and follow ups in childhood with neurometabolic diseases.
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Affiliation(s)
| | - Alpay Alkan
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
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6
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Finsterer J. Mitochondrial metabolic stroke: Phenotype and genetics of stroke-like episodes. J Neurol Sci 2019; 400:135-141. [PMID: 30946993 DOI: 10.1016/j.jns.2019.03.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 02/07/2023]
Abstract
Stroke-like episodes (SLEs) are the hallmark of mitochondrial encephalopathy with lactic acidosis and stroke-like episode (MELAS) syndrome but rarely occur also in other specific or nonspecific mitochondrial disorders. Pathophysiologically, SLLs are most likely due to a regional disruption of the blood-brain barrier triggered by the underlying metabolic defect, epileptic activity, drugs, or other factors. SLEs manifest clinically with a plethora of cerebral manifestations, which not only include features typically seen in ischemic stroke, but also headache, epilepsy, ataxia, visual impairment, vomiting, and psychiatric abnormalities. The morphological correlate of a SLE is the stroke-like lesion (SLL), best visualised on multimodal MRI. In the acute stages, a SLL presents as vasogenic edema but may be mixed up with cytotoxic components. Additionally, SLLs are characterized by hyperperfusion on perfusion studies. In the chronic stage, SLLs present with a colorful picture before they completely disappear, or end up as white matter lesion, cyst, laminar cortical necrosis, focal atrophy, or as toenail sign. Treatment of SLLs is symptomatic and relies on recommendations by experts. Beneficial effects have been reported with nitric-oxide precursors, antiepileptic drugs, antioxidants, the ketogenic diet, and steroids. Lot of research is still needed to uncover the enigma SLE/SLL.
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Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, Austria.
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7
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Kimiskidis VK, Papaliagkas V, Papagiannopoulos S, Zafeiriou D, Kazis D, Tsatsali-Foroglou E, Kouvatsou Z, Kapina V, Koutsonikolas D, Anogianakis G, Geroukis T, Bostantjopoulou S. Investigation of the motor system in two siblings with Canavan's disease: a combined transcranial magnetic stimulation (TMS) - diffusion tensor imaging (DTI) study. Metab Brain Dis 2017; 32:307-310. [PMID: 28130616 DOI: 10.1007/s11011-017-9955-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 01/18/2017] [Indexed: 12/11/2022]
Abstract
Canavan's disease (CD) is a hereditary leukodystrophy caused by mutations in the aspartoacylase gene (ASPA), leading to spongiform degeneration of the white matter and severe impairment of psychomotor development. We present the cases of two non-Jewish sisters with CD that have a milder and protracted clinical course compared to typical CD. MRI imaging revealed bilateral high-signal-intensity areas in the thalami and the internal capsule and MR spectroscopy showed typical findings for CD (a marked increase in N-acetylaspartate (NAA) levels). FA values of the right and left corticospinal tracts at the level of the posterior limb of the internal capsule, and the centrum semiovale were found to be significantly reduced compared to healthy controls. From a neurophysiological point of view, the peripheral motor system was normal. In contrast, cortical stimulation at maximal intensity failed to elicit facilitated or resting MEPs and silent periods (SPs) in upper and lower limbs, providing evidence for significant upper motor pathway dysfunction.
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Affiliation(s)
- V K Kimiskidis
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Vasileios Papaliagkas
- Laboratory of Clinical Neurophysiology, AHEPA University Hospital, Thessaloniki, Greece.
| | - S Papagiannopoulos
- Third Department of Neurology, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - D Zafeiriou
- First Department of Pediatrics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D Kazis
- Third Department of Neurology, G. Papanikolaou Hospital, Thessaloniki, Greece
| | | | - Z Kouvatsou
- Third Department of Neurology, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - V Kapina
- Third Department of Neurology, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - D Koutsonikolas
- Department of Experimental Physiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - G Anogianakis
- Department of Experimental Physiology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - T Geroukis
- Department of Radiology, G. Papanikolaou Hospital, Thessaloniki, Greece
| | - S Bostantjopoulou
- Third Department of Neurology, G. Papanikolaou Hospital, Thessaloniki, Greece
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Mendes MI, Smith DE, Pop A, Lennertz P, Fernandez Ojeda MR, Kanhai WA, van Dooren SJ, Anikster Y, Barić I, Boelen C, Campistol J, de Boer L, Kariminejad A, Kayserili H, Roubertie A, Verbruggen KT, Vianey-Saban C, Williams M, Salomons GS. Clinically Distinct Phenotypes of Canavan Disease Correlate with Residual Aspartoacylase Enzyme Activity. Hum Mutat 2017; 38:524-531. [PMID: 28101991 PMCID: PMC5412892 DOI: 10.1002/humu.23181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/16/2017] [Indexed: 11/29/2022]
Abstract
We describe 14 patients with 12 novel missense mutations in ASPA, the gene causing Canavan disease (CD). We developed a method to study the effect of these 12 variants on the function of aspartoacylase—the hydrolysis of N‐acetyl‐l‐aspartic acid (NAA) to aspartate and acetate. The wild‐type ASPA open reading frame (ORF) and the ORFs containing each of the variants were transfected into HEK293 cells. Enzyme activity was determined by incubating cell lysates with NAA and measuring the released aspartic acid by LC–MS/MS. Clinical data were obtained for 11 patients by means of questionnaires. Four patients presented with a non‐typical clinical picture or with the milder form of CD, whereas seven presented with severe CD. The mutations found in the mild patients corresponded to the variants with the highest residual enzyme activities, suggesting that this assay can help evaluate unknown variants found in patients with atypical presentation. We have detected a correlation between clinical presentation, enzyme activity, and genotype for CD.
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Affiliation(s)
- Marisa I Mendes
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Desirée Ec Smith
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Ana Pop
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Pascal Lennertz
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Matilde R Fernandez Ojeda
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Warsha A Kanhai
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Silvy Jm van Dooren
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Yair Anikster
- Edmond and Lily Safra Children's Hospital, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Israel
| | - Ivo Barić
- Department of Pediatrics, University Hospital Center Zagreb & University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Caroline Boelen
- Department of Pediatrics, Admiraal De Ruyter Ziekenhuis, Goes, Zeeland, The Netherlands
| | - Jaime Campistol
- Neurology Department, CIBERER ISCIII, Hospital Sant Joan de Deu, University of Barcelona, Barcelona, Spain
| | - Lonneke de Boer
- Department of pediatrics, metabolic diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Hulya Kayserili
- Medical Genetics Department, Koç University School of Medicine (KUSOM), Istanbul, Turkey
| | - Agathe Roubertie
- Département de Neuropédiatrie, Hopital Gui de Chauliac, Montpellier, Languedoc-Roussillon, France.,INSERM U1051, Institut des Neurosciences de Montpellier, Montpellier, France
| | - Krijn T Verbruggen
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christine Vianey-Saban
- Centre de Biologie et de Pathologie Est CHU de Lyon, Service Maladies Héréditaires du Métabolisme et Dépistage Néonatal, Lyon, France
| | - Monique Williams
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
| | - Gajja S Salomons
- Department of Clinical Chemistry, Metabolic Unit, VU University Medical Center, Amsterdam Neuroscience, Amsterdam, The Netherlands
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Merrill ST, Nelson GR, Longo N, Bonkowsky JL. Cytotoxic edema and diffusion restriction as an early pathoradiologic marker in canavan disease: case report and review of the literature. Orphanet J Rare Dis 2016; 11:169. [PMID: 27927234 PMCID: PMC5142413 DOI: 10.1186/s13023-016-0549-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/29/2016] [Indexed: 12/27/2022] Open
Abstract
Background Canavan disease is a devastating autosomal recessive leukodystrophy leading to spongiform degeneration of the white matter. There is no cure or treatment for Canavan disease, and disease progression is poorly understood. Results We report a new presentation of a patient found to have Canavan disease; brain magnetic resonance imaging (MRI) revealed white matter cytotoxic edema, indicative of an acute active destructive process. We performed a comprehensive review of published cases of Canavan disease reporting brain MRI findings, and found that cytotoxic brain edema is frequently reported in early Canavan disease. Conclusions Our results and the literature review support the notion of an acute phase in Canavan disease progression. These findings suggest that there is a window available for therapeutic intervention and support the need for early identification of patients with Canavan disease.
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Affiliation(s)
- Steven T Merrill
- College of Osteopathic Medicine, Touro University Nevada, Henderson, NV, USA
| | - Gary R Nelson
- Division of Pediatric Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nicola Longo
- Division of Medical Genetics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.,Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way/Williams Building, 84108, Salt Lake City, UT, USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA. .,Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way/Williams Building, 84108, Salt Lake City, UT, USA.
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