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Haque S, Crawley K, Davis R, Schofield D, Shrestha R, Sue CM. Clinical drivers of hospitalisation in patients with mitochondrial diseases. BMJ Neurol Open 2024; 6:e000717. [PMID: 38868460 PMCID: PMC11168164 DOI: 10.1136/bmjno-2024-000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/13/2024] [Indexed: 06/14/2024] Open
Abstract
Background Mitochondrial diseases in adults are generally chronic conditions with a wide spectrum of severity contributing to disease burden and healthcare resource utilisation. Data on healthcare resource utilisation in mitochondrial diseases are limited. Objectives We performed a retrospective longitudinal study to investigate the clinical drivers of hospitalisation in adult patients with mitochondrial diseases to better understand healthcare resource utilisation. Methods We recruited participants from our specialised Mitochondrial Disease Clinic in Sydney, Australia between September 2018 and December 2021. We performed a retrospective chart review for the period 2013-2022 considering emergency department (ED) and/or hospital admission notes, as well as discharge summaries. We used multiple linear regression models to examine the association between the type of presenting symptom(s) and duration of hospital stay and frequency of admissions, while adjusting for relevant covariates. Results Of the 99 patients considered, the duration of hospitalisation ranged from 0 to 116 days per participant and the number of admissions ranged from 0 to 21 per participant. Participants with one or more mitochondrial disease-associated admissions constituted 52% of the study cohort. 13% of the participants presented to the ED without requiring an admission and 35% never attended the ED or required a hospital admission during this period. Neurological (p<0.0001), gastroenterological (p=0.01) and symptoms categorised as 'other' (p<0.0001) were the main presentations driving the total number of days admitted to hospital. A statistically significant association was evident for the number of admissions and all types of presenting symptoms (p<0.0001). Conclusion There are variable reasons for hospitalisation in adults with mitochondrial diseases, with neurological and gastroenterological presentations being associated with prolonged and complex hospitalisation. A better understanding of clinical drivers such as these allows for better informed and well-coordinated management aimed at optimising healthcare resource utilisation.
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Affiliation(s)
- Sameen Haque
- Neurology, Nepean Hospital, Kingswood, New South Wales, Australia
- Neurogenetics, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Karen Crawley
- Neurogenetics, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Ryan Davis
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Neurogenetics Research Group, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Deborah Schofield
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie University, Sydney, New South Wales, Australia
| | - Rupendra Shrestha
- Centre for Economic Impacts of Genomic Medicine (GenIMPACT), Macquarie University, Sydney, New South Wales, Australia
| | - Carolyn M Sue
- Kinghorn Chair, Neurodegeneration, Neuroscience Research Australia, Randwick, New South Wales, Australia
- Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
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Bai P, Feng Y, Chen J, Chang H. Diffuse posterior leukoencephalopathy in MELAS without stroke-like episodes: A case report. Medicine (Baltimore) 2023; 102:e33725. [PMID: 37144988 PMCID: PMC10158904 DOI: 10.1097/md.0000000000033725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 04/19/2023] [Indexed: 05/06/2023] Open
Abstract
RATIONALE Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is the most common subtype of mitochondrial encephalopathy. In the past, it was believed that most hereditary white matter lesions were lysosome storage disorders or peroxisome diseases. However, in recent years, white matter lesions have been increasingly regarded as a common feature of patients with mitochondrial diseases. In addition to stroke-like lesions, about half of the patients with MELAS reported white matter lesions in the brain. PATIENT CONCERNS Herein, we provide a case of A 48-year-old female who presented with episodic loss of consciousness with twitching of extremities. Previous medical history revealed 10 years of history of epilepsy, 10 years of history of diabetes, a history of hearing loss, and unknown etiology. Ancillary findings included brain magnetic fluid-attenuated inversion recovery showed symmetrical lesions in the bilateral parietal lobe with high signal intensity at the edge, and high signal intensity in the bilateral occipital lobe, paraventricular white matter, corona radiata, and the center of semiovale. DIAGNOSES Mitochondrial deoxyribonucleic acid gene sequencing returned A3243G point mutation and it supports the diagnosis of intracranial hypertension. INTERVENTIONS Considered the diagnosis of symptomatic epilepsy, the patient was treated with mechanical ventilation, midazolam, and levetiracetam, and the limb twitching symptoms were controlled. The patient was comatose, chronically bedridden, with gastrointestinal dysfunction, and was treated prophylactically with antibiotics against infection, parenteral nutrition, and other supportive measures. B vitamins, vitamin C, vitamin E, coenzyme Q10, and idebenone were given, and mechanical ventilation and midazolam were stopped after 8 days. He was discharged from the hospital on 30 days and continued symptomatic treatment with B-vitamins, vitamin C, vitamin E, coenzyme Q10, and idebenone, and antiepileptic treatment with levetiracetam, with outpatient follow-up. OUTCOMES No further seizures were recorded and the patient recovered well. LESSONS MELAS syndrome without stroke-like episodes of diffuse posterior cerebral white matter lesions is rare in clinical practice, and the possibility of MELAS syndrome should be considered in symmetric posterior cerebral white matter lesions.
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Affiliation(s)
- Peng Bai
- Department of Neurology, Inner Mongolia People’s Hospital, Hohhot, People’s Republic of China
- Inner Mongolia Medical University, Jinshan Development Zone, Hohhot, People’s Republic of China
| | - Yinling Feng
- Department of Neurology, Inner Mongolia People’s Hospital, Hohhot, People’s Republic of China
| | - Jin Chen
- Department of Neurology, Inner Mongolia People’s Hospital, Hohhot, People’s Republic of China
| | - Hong Chang
- Department of Neurology, Inner Mongolia People’s Hospital, Hohhot, People’s Republic of China
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3
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Ng YS, Gorman GS. Stroke-like episodes in adult mitochondrial disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 194:65-78. [PMID: 36813321 DOI: 10.1016/b978-0-12-821751-1.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Stroke-like episode is a paroxysmal neurological manifestation which affects a specific group of patients with mitochondrial disease. Focal-onset seizures, encephalopathy, and visual disturbances are prominent findings associated with stroke-like episodes, with a predilection for the posterior cerebral cortex. The most common cause of stroke-like episodes is the m.3243A>G variant in MT-TL1 gene followed by recessive POLG variants. This chapter aims to review the definition of stroke-like episode and delineate the clinical phenomenology, neuroimaging and EEG findings typically seen in patients. In addition, several lines of evidence supporting neuronal hyper-excitability as the key mechanism of stroke-like episodes are discussed. The management of stroke-like episodes should focus on aggressive seizure management and treatment for concomitant complications such as intestinal pseudo-obstruction. There is no robust evidence to prove the efficacy of l-arginine for both acute and prophylactic settings. Progressive brain atrophy and dementia are the sequalae of recurrent stroke-like episode, and the underlying genotype in part predicts prognosis.
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Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gráinne S Gorman
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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4
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Abstract
Mitochondrial dysfunction, especially perturbation of oxidative phosphorylation and adenosine triphosphate (ATP) generation, disrupts cellular homeostasis and is a surprisingly frequent cause of central and peripheral nervous system pathology. Mitochondrial disease is an umbrella term that encompasses a host of clinical syndromes and features caused by in excess of 300 different genetic defects affecting the mitochondrial and nuclear genomes. Patients with mitochondrial disease can present at any age, ranging from neonatal onset to late adult life, with variable organ involvement and neurological manifestations including neurodevelopmental delay, seizures, stroke-like episodes, movement disorders, optic neuropathy, myopathy, and neuropathy. Until relatively recently, analysis of skeletal muscle biopsy was the focus of diagnostic algorithms, but step-changes in the scope and availability of next-generation sequencing technology and multiomics analysis have revolutionized mitochondrial disease diagnosis. Currently, there is no specific therapy for most types of mitochondrial disease, although clinical trials research in the field is gathering momentum. In that context, active management of epilepsy, stroke-like episodes, dystonia, brainstem dysfunction, and Parkinsonism are all the more important in improving patient quality of life and reducing mortality.
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Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Robert McFarland
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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5
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Wijdicks EFM. Identifying encephalopathies from acute metabolic derangements. J Intern Med 2022; 292:846-857. [PMID: 35809045 DOI: 10.1111/joim.13538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Metabolic derangements, when acute and severe, affect brain function. This presents mostly with a marked decline in the level of consciousness, resulting in impaired responsiveness, abnormal receptivity, impaired content, and loss of memory retention. The term metabolic encephalopathy has been used but is conjecture that can be challenged in the age of modern neuroimaging. We now recognize that many metabolic encephalopathies may involve structural lesions and at an early stage. Common clinical conundrums are the evaluation of the degree of brain injury and its recoverability. This review discusses the appropriate terminology for these conditions, the diagnostic approach, therapy recommendations, and prediction of recovery potential. In evaluating a presumed metabolic cause for encephalopathy, we must (1) search for and rule out structural injury to the brain despite an obvious explanatory metabolic derangement, (2) recognize that several confounding conditions often co-exist, and (3) acknowledge that resolution of brain dysfunction may be protracted despite normalization of laboratory values.
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Affiliation(s)
- Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, Rochester, Minnesota, USA
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6
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Lopriore P, Gomes F, Montano V, Siciliano G, Mancuso M. Mitochondrial Epilepsy, a Challenge for Neurologists. Int J Mol Sci 2022; 23:ijms232113216. [PMID: 36362003 PMCID: PMC9656379 DOI: 10.3390/ijms232113216] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 01/29/2023] Open
Abstract
Primary mitochondrial diseases are relatively common inborn errors of energy metabolism, with a combined prevalence of 1 in 4300. These disorders typically affect tissues with high energy requirements, including the brain. Epilepsy affects >1% of the worldwide population, making it one of the most common neurological illnesses; it may be the presenting feature of a mitochondrial disease, but is often part of a multisystem clinical presentation. The major genetic causes of mitochondrial epilepsy are mutations in mitochondrial DNA and in the nuclear-encoded gene POLG. Treatment of mitochondrial epilepsy may be challenging, often representing a poor prognostic feature. This narrative review will cover the most recent advances in the field of mitochondrial epilepsy, from pathophysiology and genetic etiologies to phenotype and treatment options.
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Affiliation(s)
- Piervito Lopriore
- Neurological Institute, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Fábio Gomes
- Neurology Department, Coimbra University Hospital Centre, 3004-561 Coimbra, Portugal
| | - Vincenzo Montano
- Neurological Institute, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Gabriele Siciliano
- Neurological Institute, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Michelangelo Mancuso
- Neurological Institute, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Correspondence:
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7
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Klein IL, van de Loo KFE, Smeitink JAM, Janssen MCH, Kessels RPC, van Karnebeek CD, van der Veer E, Custers JAE, Verhaak CM. Cognitive functioning and mental health in mitochondrial disease: A systematic scoping review. Neurosci Biobehav Rev 2021; 125:57-77. [PMID: 33582231 DOI: 10.1016/j.neubiorev.2021.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/06/2021] [Accepted: 02/01/2021] [Indexed: 11/29/2022]
Abstract
Mitochondrial diseases (MDs) are rare, heterogeneous, hereditary and progressive in nature. In addition to the serious somatic symptoms, patients with MD also experience problems regarding their cognitive functioning and mental health. We provide an overview of all published studies reporting on any aspect of cognitive functioning and/or mental health in patients with MD and their relatives. A total of 58 research articles and 45 case studies were included and critically reviewed. Cognitive impairments in multiple domains were reported. Mental disorders were frequently reported, especially depression and anxiety. Furthermore, most studies showed impairments in self-reported psychological functioning and high prevalence of mental health problems in (matrilineal) relatives. The included studies showed heterogeneity regarding patient samples, measurement instruments and reference groups, making comparisons cautious. Results highlight a high prevalence of cognitive impairments and mental disorders in patients with MD. Recommendations for further research as well as tailored patientcare with standardized follow-up are provided. Key gaps in the literature are identified, of which studies on natural history are of highest importance.
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Affiliation(s)
- Inge-Lot Klein
- Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud Center for Mitochondrial Medicine, Department of Medical Psychology, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Kim F E van de Loo
- Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud Center for Mitochondrial Medicine, Department of Medical Psychology, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Jan A M Smeitink
- Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud Center for Mitochondrial Medicine, Department of Pediatrics, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands; Khondrion BV, Philips van Leydenlaan 15, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Mirian C H Janssen
- Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Radboud Center for Mitochondrial Medicine, Department of Internal Medicine, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Roy P C Kessels
- Radboud University Medical Center, Department of Medical Psychology, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Thomas van Aquinostraat 4, Postbus 9104, 6500 HE, Nijmegen, the Netherlands; Vincent van Gogh Institute for Psychiatry, d'n Herk 90, 5803 DN, Venray, the Netherlands
| | - Clara D van Karnebeek
- Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Molecular Life Sciences, Radboud Center for Mitochondrial Medicine, Department of Pediatrics, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Elja van der Veer
- International Mito Patients Association, 2861 AD, Bergambacht, the Netherlands
| | - José A E Custers
- Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud Center for Mitochondrial Medicine, Department of Medical Psychology, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
| | - Christianne M Verhaak
- Radboud University Medical Center, Amalia Children's Hospital, Radboud Institute for Health Sciences, Radboud Center for Mitochondrial Medicine, Department of Medical Psychology, Geert Grooteplein Zuid 10, PO Box 9101, 6500 HB, Nijmegen, the Netherlands
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8
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Ewida A, Ahmed R, Luo A, Ghonim HT, Anilkumar AC. Mitochondrial Myopathy, Encephalopathy, Lactic acidosis and Stroke-Like Episodes Syndrome Presenting With Anton-Babinski Syndrome and Concurrent Occipital Lobe Seizures. Cureus 2021; 13:e12908. [PMID: 33654593 PMCID: PMC7904536 DOI: 10.7759/cureus.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a complex group of disorders with multisystem involvement that have a wide range of biochemical and genetic defects. The earliest symptoms of MELAS typically include easy fatigability, muscle weakness, encephalopathy with stroke-like episodes, recurrent headaches and seizures. The pathogenesis of stroke-like episodes manifesting as focal deficits like acute cortical blindness is not fully understood. We present an eight-year-old, right-handed boy with MELAS confirmed by the presence of pathogenic missense variant mutation (mt.3243A>G) presenting with acute intermittent reversible episodes of cortical blindness and Anton-Babinski Syndrome secondary to concurrent occipital lobe seizures captured during video electroencephalography (V-EEG) monitoring, in addition to the neuro-imaging which was not consistent with acute ischemic stroke. This case highlights the importance of the V-EEG monitoring besides clinical testing and radiographic correlation during acute cortical blindness episodes in MELAS as occipital lobe seizures could be a part of the symptomatology.
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Affiliation(s)
- Amr Ewida
- Neurology, Upstate University Hospital, Syracuse, USA
| | - Rashid Ahmed
- Neurology, Upstate University Hospital, Syracuse, USA
| | - Anqi Luo
- Neurology, University of Texas (UT) Health Science Center at San Antonio, San Antonio, USA
| | - Hesham T Ghonim
- Neurology, University of Pittsburgh Medical Center, Pittsburgh, USA
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9
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Azman F, Tezer FI, Saygi S. Aphasic status epilepticus in a tertiary referral center in Turkey: Clinical features, etiology, and outcome. Epilepsy Res 2020; 167:106479. [DOI: 10.1016/j.eplepsyres.2020.106479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 10/23/2022]
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10
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Moukaddam N, Choi R, Tucci V. Managing Acute Agitation and Psychotic Symptoms in the Emergency Department. ADOLESCENT PSYCHIATRY 2020. [DOI: 10.2174/2210676609666191015123943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background and goals:
It is fairly common for adolescents with a presenting
problem of acute agitation to present to the Emergency Department. These patients present
challenges with respect to both differential diagnosis and management. Furthermore, with
many adolescents having extended stays in emergency departments, it is important for ED
physicians to have a basic familiarity with diagnosis and treatment.
Method:
In this paper, we present a primer on the conditions underlying acute agitation and
review approaches to management in the emergency department.
Discussion:
Psychotic disorders, such as schizophrenia, are distinct from other
conditions presenting with psychotic symptoms, which can range from depression to substance
use to non-psychiatric medical conditions. Agitation, a state of excessive verbal and
physical activity, can accompany any of these conditions. Unlike the case for adults, practice
guidelines do not exist, and there is no fully agreed upon expert consensus yet. Emergency
physicians should have a working knowledge of antipsychotic medications and need to consider
pharmacological as well as non-pharmacological treatments for optimal management.
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Affiliation(s)
| | - Raymond Choi
- Baylor College of Medicine, Texas, United States
| | - Veronica Tucci
- University of South Florida College of Medicine Tampa, FL, United States
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11
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Khacho M, Harris R, Slack RS. Mitochondria as central regulators of neural stem cell fate and cognitive function. Nat Rev Neurosci 2019; 20:34-48. [PMID: 30464208 DOI: 10.1038/s41583-018-0091-3] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Emerging evidence now indicates that mitochondria are central regulators of neural stem cell (NSC) fate decisions and are crucial for both neurodevelopment and adult neurogenesis, which in turn contribute to cognitive processes in the mature brain. Inherited mutations and accumulated damage to mitochondria over the course of ageing serve as key factors underlying cognitive defects in neurodevelopmental disorders and neurodegenerative diseases, respectively. In this Review, we explore the recent findings that implicate mitochondria as crucial regulators of NSC function and cognition. In this respect, mitochondria may serve as targets for stem-cell-based therapies and interventions for cognitive defects.
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Affiliation(s)
- Mireille Khacho
- Department of Biochemistry, Microbiology and Immunology, Ottawa Institute of Systems Biology (OISB), University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Harris
- Department of Cellular and Molecular Medicine, University of Ottawa Brain and Mind Research Institute, Ottawa, Ontario, Canada
| | - Ruth S Slack
- Department of Cellular and Molecular Medicine, University of Ottawa Brain and Mind Research Institute, Ottawa, Ontario, Canada.
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12
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Ng YS, Bindoff LA, Gorman GS, Horvath R, Klopstock T, Mancuso M, Martikainen MH, Mcfarland R, Nesbitt V, Pitceathly RDS, Schaefer AM, Turnbull DM. Consensus-based statements for the management of mitochondrial stroke-like episodes. Wellcome Open Res 2019; 4:201. [PMID: 32090171 PMCID: PMC7014928 DOI: 10.12688/wellcomeopenres.15599.1] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2019] [Indexed: 12/15/2022] Open
Abstract
Background: Focal-onset seizures and encephalopathy are prominent features of a stroke-like episode, which is a severe neurological manifestation associated with subtypes of mitochondrial disease. Despite more than 30 years of research, the acute treatment of stroke-like episodes remains controversial. Methods: We used the modified Delphi process to harness the clinical expertise of a group of mitochondrial disease specialists from five European countries to produce consensus guidance for the acute management of stroke-like episodes and commonly associated complications. Results: Consensus on a new definition of mitochondrial stroke-like episodes was achieved and enabled the group to develop diagnostic criteria based on clinical features, neuroimaging and/or electroencephalogram findings. Guidelines for the management of strokelike episodes were agreed with aggressive seizure management strongly recommended at the outset of stroke-like episodes. Conclusions: Our consensus statement defines stroke-like episodes in terms of an epileptic encephalopathy and we have used this to revise both diagnostic criteria and guidelines for management. A prospective, multi-centre, randomised controlled trial is required for evaluating the efficacy of any compound on modifying the trajectory of stroke-like episodes.
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Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laurence A. Bindoff
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Gráinne S. Gorman
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Rita Horvath
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Thomas Klopstock
- Department of Neurology, Friedrich-Baur-Institute, University Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy
| | - Mika H. Martikainen
- Division of Clinical Neurosciences, University of Turku and Turku University Hospital, Turku, Finland
| | - Robert Mcfarland
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Great North Children Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Victoria Nesbitt
- Department of Paediatrics, The Children's Hospital, Oxford, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders,, Nuffield Dept Women’s & Reproductive Health, The Churchill Hospital, Oxford, UK
| | - Robert D. S. Pitceathly
- MRC Centre for Neuromuscular Diseases, UCL Queen Square Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
- NHS Highly Specialised Service for Rare Mitochondrial Disorders, Centre for Neuromuscular Diseases, The National Hospital of Neurology and Neurosurgery, London, UK
| | - Andrew M. Schaefer
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Doug M. Turnbull
- Wellcome Centre for Mitochondrial Research, Newcastle University, UK, Newcastle upon Tyne, Tyne and Wear, NE2 4HH, UK
- Directorate of Neurosciences, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, UK
- NHS Highly Specialised Service for Rare Mitohcondrial Disorders, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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13
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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: 40] [Impact Index Per Article: 8.0] [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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14
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Abstract
This narrative review focuses on the pathophysiology, diagnosis, and management of status epilepticus in the context of primary mitochondrial disease. Epilepsy is common in mitochondrial disease, reported in >20% of adult cases and 40%-60% of pediatric cohorts. Status epilepticus is less frequently reported and appears to be associated with particular subgroups of mitochondrial disorders, namely defects of the mitochondrial DNA and its maintenance, and disorders of mitochondrial translation and dynamics. Mechanisms underlying mitochondrial status epilepticus are incompletely understood, and may include bioenergetic failure, oxidative stress, immune dysfunction, and impaired mitochondrial dynamics. Treatments tried in mitochondrial status epilepticus include antiepileptic drugs, anesthetic agents, magnesium, high-dose steroids, immune globulins, vagus nerve stimulation, and surgical procedures, all with variable success. The outcome of mitochondrial status epilepticus is extremely poor, and effective therapeutic options have not been reported. Improved understanding of the mechanisms underpinning mitochondrial status epilepticus is needed in order to develop more effective treatments.
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Affiliation(s)
- Shamima Rahman
- Mitochondrial Research Group, UCL Great Ormond Street Institute of Child Health, London, UK.,Metabolic Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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15
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Finsterer J, Zarrouk-Mahjoub S. Phenotypic manifestations of the m.8969G>A variant. Neurogenetics 2018; 19:131-132. [DOI: 10.1007/s10048-018-0543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 02/17/2018] [Indexed: 10/17/2022]
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16
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Rare Dementias. NEURODEGENER DIS 2018. [DOI: 10.1007/978-3-319-72938-1_15] [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] Open
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17
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Rosebush PI, Anglin RE, Rasmussen S, Mazurek MF. Mental illness in patients with inherited mitochondrial disorders. Schizophr Res 2017; 187:33-37. [PMID: 28545943 DOI: 10.1016/j.schres.2017.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/04/2017] [Accepted: 05/07/2017] [Indexed: 12/30/2022]
Affiliation(s)
- P I Rosebush
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, Canada; MiNDS Graduate Programme, McMaster University, Canada; Biomedical Sciences Graduate Programme, McMaster University, Canada.
| | - R E Anglin
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, Canada; Department of Medicine, Division of Neurology, McMaster University, Canada; MiNDS Graduate Programme, McMaster University, Canada; Biomedical Sciences Graduate Programme, McMaster University, Canada
| | - S Rasmussen
- MiNDS Graduate Programme, McMaster University, Canada
| | - M F Mazurek
- Department of Psychiatry and Behavioural Neuroscience, McMaster University, Canada; Department of Medicine, Division of Neurology, McMaster University, Canada; MiNDS Graduate Programme, McMaster University, Canada; Biomedical Sciences Graduate Programme, McMaster University, Canada
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18
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Lee HN, Eom S, Kim SH, Kang HC, Lee JS, Kim HD, Lee YM. Epilepsy Characteristics and Clinical Outcome in Patients With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes (MELAS). Pediatr Neurol 2016; 64:59-65. [PMID: 27671241 DOI: 10.1016/j.pediatrneurol.2016.08.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 07/31/2016] [Accepted: 08/18/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Epileptic seizures in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) are heterogeneous with no pathognomonic features. We reviewed epilepsy characteristics and clinical outcome exclusively in a pediatric population. METHODS Twenty-two children and adolescents (13 males) with confirmed mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes due to mitochondrial DNA A3243G mutation and epilepsy were recruited. Clinical data including seizure semiology, treatment response, neuroimaging findings, and electroencephalography were analyzed. We also examined the effect of the age at seizure onset and initial symptoms on the clinical variables. RESULTS Seizure semiology and electroencephalography abnormalities showed no syndrome-specific findings. Focal seizures occurred in 21 of 22 subjects (95.5%), whereas generalized seizures developed in seven of 22 subjects (31.8%). Twenty of 22 subjects (90.9%) achieved partial to complete reduction of clinical seizures for more than one year with a combination of more than two antiepileptic drugs. The subgroup with earlier seizure onset presented significantly earlier and showed significantly higher rates of drug-resistant epilepsy compared with the late onset group, although there were no significant differences in the initial symptoms. The subjects with severe epileptic conditions tended to have more severe clinical dysfunction and more severe organ involvement. CONCLUSIONS Both focal and generalized seizures occurred in patients with MELAS. Epilepsy in this population is drug resistant, but a certain degree of clinical seizure reduction was achievable with antiepileptic drugs, with more favorable outcomes than historically expected. Close observation and active epilepsy treatment of individuals with MELAS episodes and earlier seizure onset might improve the prognosis.
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Affiliation(s)
- Ha Neul Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Soyong Eom
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Se Hoon Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Hoon-Chul Kang
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea; Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Soo Lee
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea; Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Heung Dong Kim
- Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea; Division of Pediatric Neurology, Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Mock Lee
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; Epilepsy Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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19
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Finsterer J, Wakil SM. Stroke-like episodes, peri-episodic seizures, and MELAS mutations. Eur J Paediatr Neurol 2016; 20:824-829. [PMID: 27562097 DOI: 10.1016/j.ejpn.2016.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE Stroke-like episodes (SLEs) are a hallmark of various mitochondrial disorders, in particular MELAS syndrome. SLEs manifest with vasogenic oedema (DWI and ADC hyperintensity) or partial cytotoxic oedema (DWI hyperintensity, ADC hypointensity) in the acute and subacute stage, and with gyriform T1-hyperintensity (cortical necrosis) in the chronic stage. PRINCIPAL RESULTS SLEs must be clearly distinguished from ischaemic stroke, since management of these two entities is different. SLEs may go along with or without seizures or epileptiform discharges on EEG. However, in MELAS syndrome seizures may also occur in the absence of SLEs. Focal and generalised seizures have been reported but it is currently unknown if the one or the other prevail. SLEs with and without seizures may respond to NO-precursors l-arginine, succinate, or citrulline. As a supportive measure a ketogenic diet should be initiated. Seizures prior to or during a SLE or paroxysmal EEG-activity during a SLE should be initially treated with antiepileptic drugs (AEDs) with low mitochondrion-toxicity. Only in case these AEDs are ineffective, AEDs with higher mitochondrion-toxicity should be added. MAJOR CONCLUSIONS All patients with SLEs need to have an EEG recorded irrespective if they have manifesting seizures or not. There are no mtDNA or nDNA mutations which predispose for SLEs with seizures.
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Affiliation(s)
| | - Salma Majid Wakil
- Department of Genetics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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20
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Fernández-Torre JL, Kaplan PW, Hernández-Hernández MA. New understanding of nonconvulsive status epilepticus in adults: treatments and challenges. Expert Rev Neurother 2015; 15:1455-73. [DOI: 10.1586/14737175.2015.1115719] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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21
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Kaufman KR. Epilepsy & behavior: a professional and a personal home. Epilepsy Behav 2014; 40:2-3. [PMID: 25258052 DOI: 10.1016/j.yebeh.2014.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Kenneth R Kaufman
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA; Department of Neurology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA; Department of Anesthesiology, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, Suite #2200, New Brunswick, NJ 08901, USA.
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22
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Nannucci S, Donnini I, Pantoni L. Inherited leukoencephalopathies with clinical onset in middle and old age. J Neurol Sci 2014; 347:1-13. [PMID: 25307983 DOI: 10.1016/j.jns.2014.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/20/2014] [Accepted: 09/15/2014] [Indexed: 01/30/2023]
Abstract
The currently widespread use of neuroimaging has led neurologists to often face the problem of the differential diagnosis of white matter diseases. There are various forms of leukoencephalopathies (vascular, inflammatory and immunomediated, infectious, metabolic, neoplastic) and sometimes white matter lesions are expression of a genetic disease. While many inherited leukoencephalopathies fall in the child neurologist's interest, others may have a delayed or even a typical onset in the middle or old age. This field is rapidly growing and, in the last few years, many new inherited white matter diseases have been described and genetically defined. A non-delayed recognition of middle and old age inherited leukoencephalopathies appears important to avoid unnecessary tests and therapies in the patient and to possibly anticipate the diagnosis in relatives. The aim of this review is to provide a guide to direct the diagnostic process when facing a patient with a suspicion of an inherited form of leukoencephalopathy and with clinical onset in middle or old age. Based on a MEDLINE search from 1990 to 2013, we identified 24 middle and old age onset inherited leukoencephalopathies and reviewed in this relation the most recent findings focusing on their differential diagnosis. We provide summary tables to use as a check list of clinical and neuroimaging findings that are most commonly associated with these forms of leukoencephalopathies. When present, we reported specific characteristics of single diseases. Several genetic diseases may be suspected in patients with middle or old age and white matter abnormalities. In only few instances, pathognomonic clinical or associated neuroimaging features help identifying a specific disease. Therefore, a comprehensive knowledge of the characteristics of these inherited white matter diseases appears important to improve the diagnostic work-up, optimize the choice of genetic tests, increase the number of diagnosed patients, and stimulate the research interest in this field.
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Affiliation(s)
- Serena Nannucci
- NEUROFARBA Department, Neuroscience section, University of Florence, Florence, Italy
| | - Ida Donnini
- NEUROFARBA Department, Neuroscience section, University of Florence, Florence, Italy
| | - Leonardo Pantoni
- Stroke Unit and Neurology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
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23
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Demarest ST, Whitehead MT, Turnacioglu S, Pearl PL, Gropman AL. Phenotypic analysis of epilepsy in the mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes-associated mitochondrial DNA A3243G mutation. J Child Neurol 2014; 29:1249-56. [PMID: 25038129 DOI: 10.1177/0883073814538511] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The A to G mitochondrial DNA point mutation at position 3243 (A3243G) is the most common cause of mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS), a systemic multiorgan disease. Epilepsy is a common finding but there is wide phenotypic variation that has not been thoroughly explored. We report the epilepsy phenotypes of 7 patients with the A3243G mutation. Most presented with typical MELAS and epilepsy characterized by infrequent prolonged focal seizures, including epilepsia partialis continua, hemiclonic status epilepticus, nonconvulsive status, and occipital status epilepticus. Seizures usually occurred during the acute phase of a strokelike episode. Periodic lateralized epileptiform discharges may be seen electrographically. Some patients with this mutation are completely asymptomatic or have mild symptoms typical for mitochondrial diseases. Slow spike-wave activity consistent with Lennox-Gastaut syndrome and electrographic status epilepticus was seen in 1 patient who responded to ethosuximide.
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Affiliation(s)
- Scott T Demarest
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Matthew T Whitehead
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Sinan Turnacioglu
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
| | - Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea L Gropman
- Children's National Medical Center, The George Washington University School of Medicine, Washington, DC, USA
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24
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Avula S, Parikh S, Demarest S, Kurz J, Gropman A. Treatment of mitochondrial disorders. Curr Treat Options Neurol 2014; 16:292. [PMID: 24700433 DOI: 10.1007/s11940-014-0292-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT While numerous treatments for mitochondrial disorders have been suggested, relatively few have undergone controlled clinical trials. Treatment of these disorders is challenging, as only symptomatic therapy is available. In this review we will focus on newer drugs and treatment trials in mitochondrial diseases, with a special focus on medications to avoid in treating epilepsy and ICU patient with mitochondrial disease, which has not been included in such a review. Readers are also referred to the opinion statement in A Modern Approach to the Treatment of Mitochondrial Disease published in Current Treatment Options in Neurology 2009. Many of the supplements used for treatment were reviewed in the previous abstract, and dosing guidelines were provided. The focus of this review is on items not previously covered in depth, and our discussion includes more recently studied compounds as well as any relevant updates on older compounds . We review a variety of vitamins and xenobiotics, including dichloroacetate (DCA), arginine, coenzyme Q10, idebenone, EPI-743, and exercise training. Treatment of epilepsy, which is a common feature in many mitochondrial phenotypes, warrants special consideration due to the added toxicity of certain medications, and we provide a discussion of these unique treatment challenges. Interesting, however, with only a few exceptions, the treatment strategies for epilepsy in mitochondrial cytopathies are the same as for epilepsy without mitochondrial dysfunction. We also discuss intensive care management, building upon similar reviews, adding new dimensions, and demonstrating the complexity of overall care of these patients.
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Affiliation(s)
- Sreenivas Avula
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA,
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25
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Gibson LM, Hanby MF, Al-Bachari SM, Parkes LM, Allan SM, Emsley HCA. Late-onset epilepsy and occult cerebrovascular disease. J Cereb Blood Flow Metab 2014; 34:564-70. [PMID: 24517978 PMCID: PMC3982095 DOI: 10.1038/jcbfm.2014.25] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 01/13/2014] [Indexed: 11/09/2022]
Abstract
The interface between cerebrovascular disease (CVD) and epilepsy is complex and multifaceted. Late-onset epilepsy (LOE) is increasingly common and is often attributed to CVD, and is indeed associated with an increased risk of stroke. This relationship is easily recognizable where there is a history of stroke, particularly involving the cerebral cortex. However, the relationship with otherwise occult, subcortical CVD is currently less well established yet causality is often invoked. In this review, we consider the diagnosis of LOE in clinical practice--including its behaviour as a potential mimic of acute ischemic stroke and transient ischemic attack; evidence for an association between occult CVD and LOE; and potential mechanisms of epileptogenesis in occult CVD, including potential interrelationships between disordered cerebral metabolism and perfusion, disrupted neurovascular unit integrity, blood-brain barrier dysfunction, and inflammation. We also discuss recently recognized issues concerning antiepileptic drug treatment and vascular risk and consider a variety of less common CVD entities associated with seizures.
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Affiliation(s)
- Lorna M Gibson
- Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | | | - Sarah M Al-Bachari
- 1] Department of Neurology, Royal Preston Hospital, Preston, UK [2] University of Manchester, Manchester, UK
| | - Laura M Parkes
- Biomedical Imaging Institute, University of Manchester, Manchester, UK
| | - Stuart M Allan
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Hedley C A Emsley
- 1] Department of Neurology, Royal Preston Hospital, Preston, UK [2] School of Medicine, University of Manchester, Manchester, UK
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26
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Chevallier JA, Von Allmen GK, Koenig MK. Seizure semiology and EEG findings in mitochondrial diseases. Epilepsia 2014; 55:707-712. [DOI: 10.1111/epi.12570] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Justyna A. Chevallier
- Department of Pediatrics; Division of Child and Adolescent Neurology; University of Texas Health Science Center; Houston Texas U.S.A
| | - Gretchen K. Von Allmen
- Department of Pediatrics; Division of Child and Adolescent Neurology; University of Texas Health Science Center; Houston Texas U.S.A
| | - Mary Kay Koenig
- Department of Pediatrics; Division of Child and Adolescent Neurology; University of Texas Health Science Center; Houston Texas U.S.A
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27
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Uncommon Dementias. NEURODEGENER DIS 2014. [DOI: 10.1007/978-1-4471-6380-0_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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28
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Finsterer J, Zarrouk Mahjoub S. Mitochondrial epilepsy in pediatric and adult patients. Acta Neurol Scand 2013; 128:141-52. [PMID: 23480231 DOI: 10.1111/ane.12122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2013] [Indexed: 01/04/2023]
Abstract
Few data are available about the difference between epilepsy in pediatric mitochondrial disorders (MIDs) and adult MIDs. This review focuses on the differences between pediatric and adult mitochondrial epilepsy with regard to seizure type, seizure frequency, and underlying MID. A literature search via Pubmed using the keywords 'mitochondrial', 'epilepsy', 'seizures', 'adult', 'pediatric', and all MID acronyms, was carried out. Frequency of mitochondrial epilepsy strongly depends on the type of MID included and is higher in pediatric compared to adult patients. In pediatric patients, mitochondrial epilepsy is more frequent due to mutations in nDNA-located than mtDNA-located genes and vice versa in adults. In pediatric patients, mitochondrial epilepsy is associated with a syndromic phenotype in half of the patients and in adults more frequently with a non-syndromic phenotype. In pediatric patients, focal seizures are more frequent than generalized seizures and vice versa in adults. Electro-clinical syndromes are more frequent in pediatric MIDs compared to adult MIDs. Differences between pediatric and adult mitochondrial epilepsy concern the onset of epilepsy, frequency of epilepsy, seizure type, type of electro-clinical syndrome, frequency of syndromic versus non-syndromic MIDs, and the outcome. To optimize management of mitochondrial epilepsy, it is essential to differentiate between early and late-onset forms.
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Affiliation(s)
| | - S. Zarrouk Mahjoub
- Laboratory of Biochemistry; UR ‘Human Nutrition and Metabolic Disorders’ Faculty of Medicine Monastir; Tunisia
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29
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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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30
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Abstract
Among the various central nervous system (CNS) manifestations of mitochondrial disorders (MIDs), cognitive impairment is increasingly recognized and diagnosed (mitochondrial cognitive dysfunction). Aim of the review was to summarize recent findings concerning the aetiology, pathogenesis, diagnosis and treatment of cognitive decline in MIDs. Among syndromic MIDs due to mitochondrial DNA (mtDNA) mutations, cognitive impairment occurs in patients with mitochondrial encephalopathy, lactic acidosis and stroke-like episodes syndrome, myoclonus epilepsy with ragged-red fibres syndrome, mitochondrial chronic progressive external ophthalmoplegia, Kearns-Sayre syndrome, neuropathy, ataxia and retinitis pigmentosa syndrome and maternally inherited diabetes and deafness. Among syndromic MIDs due to nuclear DNA (nDNA) mutations, cognitive decline has been reported in myo-neuro-gastro-intestinal encephalopathy, mitochondrial recessive ataxia syndrome, spinocerebellar ataxia with encephalopathy, Mohr-Tranebjaerg syndrome, leuko-encephalopathy; brain and spinal cord involvement and lactic acidosis, CMT2, Wolfram syndrome, Wolf-Hirschhorn syndrome and Leigh syndrome. In addition to syndromic MIDs, a large number of non-syndromic MIDs due to mtDNA as well as nDNA mutations have been reported, which present with cognitive impairment as the sole or one among several other CNS manifestations of a MID. Delineation of mitochondrial cognitive impairment from other types of cognitive impairment is essential to guide the optimal management of these patients. Treatment of mitochondrial cognitive impairment is largely limited to symptomatic and supportive measures. Cognitive impairment may be a CNS manifestation of syndromic as well as non-syndromic MIDs. Correct diagnosis of mitochondrial cognitive impairment is a prerequisite for the optimal management of these patients.
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Affiliation(s)
- J. Finsterer
- Danube University Krems; Krems and Krankenanstalt Rudolfstiftung; Vienna; Austria
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31
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Finsterer J, Zarrouk Mahjoub S. Epilepsy in mitochondrial disorders. Seizure 2012; 21:316-21. [DOI: 10.1016/j.seizure.2012.03.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/04/2012] [Accepted: 03/05/2012] [Indexed: 10/28/2022] Open
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32
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Piccoli GB, Bonino LD, Campisi P, Vigotti FN, Ferraresi M, Fassio F, Brocheriou I, Porpiglia F, Restagno G. Chronic kidney disease, severe arterial and arteriolar sclerosis and kidney neoplasia: on the spectrum of kidney involvement in MELAS syndrome. BMC Nephrol 2012; 13:9. [PMID: 22353239 PMCID: PMC3306738 DOI: 10.1186/1471-2369-13-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 02/21/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND MELAS syndrome (MIM ID#540000), an acronym for Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-like episodes, is a genetically heterogeneous mitochondrial disorder with protean manifestations and occasional kidney involvement. Interest in the latter is rising due to the identification of cases with predominant kidney involvement and to the hypothesis of a link between mitochondrial DNA and kidney neoplasia. CASE PRESENTATION We report the case of a 41-year-old male with full blown MELAS syndrome, with lactic acidosis and neurological impairment, affected by the "classic" 3243A > G mutation of mitochondrial DNA, with kidney cancer. After unilateral nephrectomy, he rapidly developed severe kidney functional impairment, with nephrotic proteinuria. Analysis of the kidney tissue at a distance from the two tumor lesions, sampled at the time of nephrectomy was performed in the context of normal blood pressure, recent onset of diabetes and before the appearance of proteinuria. The morphological examination revealed a widespread interstitial fibrosis with dense inflammatory infiltrate and tubular atrophy, mostly with thyroidization pattern. Vascular lesions were prominent: large vessels displayed marked intimal fibrosis and arterioles had hyaline deposits typical of hyaline arteriolosclerosis. These severe vascular lesions explained the different glomerular alterations including ischemic and obsolescent glomeruli, as is commonly observed in the so-called "benign" arteriolonephrosclerosis. Some rare glomeruli showed focal segmental glomerulosclerosis; as the patient subsequently developed nephrotic syndrome, these lesions suggest that silent ischemic changes may result in the development of focal segmental glomerulosclerosis secondary to nephron loss. CONCLUSIONS Nephron loss may trigger glomerular sclerosis, at least in some cases of MELAS-related nephropathy. Thus the incidence of kidney disease in the "survivors" of MELAS syndrome may increase as the support therapy of these patients improves.
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Finsterer J, Zarrouk Mahjoub S. Leukoencephalopathies in Mitochondrial Disorders: Clinical and MRI Findings. J Neuroimaging 2012; 22:e1-11. [DOI: 10.1111/j.1552-6569.2011.00693.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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34
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Epilepsy, mental health disorder, or both? EPILEPSY RESEARCH AND TREATMENT 2011; 2012:163731. [PMID: 22934158 PMCID: PMC3420407 DOI: 10.1155/2012/163731] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Accepted: 11/02/2011] [Indexed: 01/28/2023]
Abstract
Temporal lobe epilepsy (TLE), a subset of the seizure disorder family, represents a complex neuropsychiatric illness, where the neurological presentation may be complemented by varying severity of affective, behavioral, psychotic, or personality abnormalities, which, in turn, may not only lead to misdiagnosis, but also affect the management. This paper outlines a spectrum of mental health presentations, including psychosis, mood, anxiety, panic, and dissociative states, associated with epilepsy that make the correct diagnosis a challenge.
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Kaufman KR, Struck PJ, Wu B, Wong S. Off-label gabapentin masking ictal triphasic waves: case analysis of neuropsychiatric and electrographic correlates. Epilepsy Behav 2011; 22:606-9. [PMID: 21945412 DOI: 10.1016/j.yebeh.2011.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 08/18/2011] [Accepted: 08/19/2011] [Indexed: 10/17/2022]
Abstract
Antiepileptic drugs (AEDs) are frequently used off-label for the treatment of psychiatric, pain, and other neurological disorders. Off-label AED use may confound the diagnosis for acute neuropsychiatric changes associated with delirium by fortuitously treating, or partially treating, underlying seizure disorders while masking ictal electrographic patterns on EEGs. Standard video/EEG monitoring includes weaning from AEDs to maximize ictal activity and better determine seizure focus. We report a case of off-label gabapentin use masking ictal electrographic activity, the neuropsychiatric and electrographic consequences of discontinuing gabapentin, and the therapeutic response when gabapentin was re-initiated and titrated to a total daily dose greater than that at time of admission. Weaning from AEDs with concurrent video/EEG monitoring is an important diagnostic tool in these complex cases.
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Affiliation(s)
- Kenneth R Kaufman
- Department of Psychiatry, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
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Pong AW, Pal DK, Chung WK. Developments in molecular genetic diagnostics: an update for the pediatric epilepsy specialist. Pediatr Neurol 2011; 44:317-27. [PMID: 21481738 DOI: 10.1016/j.pediatrneurol.2011.01.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 08/31/2010] [Accepted: 01/31/2011] [Indexed: 02/02/2023]
Abstract
The contributions of genetic influences in both rare and common epilepsies are rapidly being elucidated, and neurologists routinely consider genetic testing in the workup of numerous epilepsy syndromes. Trends in patient attitudes and developments in clinical molecular diagnostics will increase interest in, and the availability of genetic tests for, genetic evaluations of epilepsies. We review recent and planned developments in clinical genetic testing platforms, including their indications, strengths, and limitations. We discuss genome-wide microarray methods (i.e., methods to detect copy number variations), karyotypes, and sequence-based testing. We outline the general approach to genetic evaluations of epilepsy, emphasizing the importance of clinical evaluations, and provide online clinical resources. Finally, we present potential social, legal, and financial barriers to genetic evaluations, and discuss concerns regarding clinical utility and recurrence risk. This review provides a practical overview of molecular diagnostics for the neurologist in the genetic evaluation of epilepsies in 2011.
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Affiliation(s)
- Amanda W Pong
- Department of Neurology, Neurological Institute, Columbia University Medical Center, Columbia University, New York, New York 10032, USA.
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