1
|
Srivastava S, Yang F, Prohl AK, Davis PE, Capal JK, Filip-Dhima R, Bebin EM, Krueger DA, Northrup H, Wu JY, Warfield SK, Sahin M, Zhang B. Abnormality of Early White Matter Development in Tuberous Sclerosis Complex and Autism Spectrum Disorder: Longitudinal Analysis of Diffusion Tensor Imaging Measures. J Child Neurol 2024; 39:178-189. [PMID: 38751192 DOI: 10.1177/08830738241248685] [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] [Indexed: 06/13/2024]
Abstract
Background: Abnormalities in white matter development may influence development of autism spectrum disorder in tuberous sclerosis complex (TSC). Our goals for this study were as follows: (1) use data from a longitudinal neuroimaging study of tuberous sclerosis complex (TACERN) to develop optimized linear mixed effects models for analyzing longitudinal, repeated diffusion tensor imaging metrics (fractional anisotropy, mean diffusivity) pertaining to select white matter tracts, in relation to positive Autism Diagnostic Observation Schedule-Second Edition classification at 36 months, and (2) perform an exploratory analysis using optimized models applied to all white matter tracts from these data. Methods: Eligible participants (3-12 months) underwent brain magnetic resonance imaging (MRI) at repeated time points from ages 3 to 36 months. Positive Autism Diagnostic Observation Schedule-Second Edition classification at 36 months was used. Linear mixed effects models were fine-tuned separately for fractional anisotropy values (using fractional anisotropy corpus callosum as test outcome) and mean diffusivity values (using mean diffusivity right posterior limb internal capsule as test outcome). Fixed effects included participant age, within-participant longitudinal age, and autism spectrum disorder diagnosis. Results: Analysis included data from n = 78. After selecting separate optimal models for fractional anisotropy and mean diffusivity values, we applied these models to fractional anisotropy and mean diffusivity of all 27 white matter tracts. Fractional anisotropy corpus callosum was related to positive Autism Diagnostic Observation Schedule-Second Edition classification (coefficient = 0.0093, P = .0612), and mean diffusivity right inferior cerebellar peduncle was related to positive Autism Diagnostic Observation Schedule-Second Edition classification (coefficient = -0.00002071, P = .0445), though these findings were not statistically significant after multiple comparisons correction. Conclusion: These optimized linear mixed effects models possibly implicate corpus callosum and cerebellar pathology in development of autism spectrum disorder in tuberous sclerosis complex, but future studies are needed to replicate these findings and explore contributors of heterogeneity in these models.
Collapse
Affiliation(s)
- Siddharth Srivastava
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Fanghan Yang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anna K Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Peter E Davis
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Jamie K Capal
- Carolina Institute for Developmental Disabilities, Carrboro, NC, USA
| | - Rajna Filip-Dhima
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - E Martina Bebin
- Department of Neurology, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Darcy A Krueger
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Hope Northrup
- Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth) and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Joyce Y Wu
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - Mustafa Sahin
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Bo Zhang
- Department of Neurology and ICCTR Biostatistics and Research Design Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
2
|
Ahtam B, Yun HJ, Vyas R, Pienaar R, Wilson JH, Goswami CP, Berto LF, Warfield SK, Sahin M, Grant PE, Peters JM, Im K. Morphological Features of Language Regions in Individuals with Tuberous Sclerosis Complex. J Autism Dev Disord 2023:10.1007/s10803-023-06004-8. [PMID: 37222965 DOI: 10.1007/s10803-023-06004-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/25/2023]
Abstract
A significant number of individuals with tuberous sclerosis complex (TSC) exhibit language difficulties. Here, we examined the language-related brain morphometry in 59 participants (7 participants with TSC and comorbid autism spectrum disorder (ASD) (TSC + ASD), 13 with TSC but no ASD (TSC-ASD), 10 with ASD-only (ASD), and 29 typically developing (TD) controls). A hemispheric asymmetry was noted in surface area and gray matter volume of several cortical language areas in TD, ASD, and TSC-ASD groups, but not in TSC + ASD group. TSC + ASD group demonstrated increased cortical thickness and curvature values in multiple language regions for both hemispheres, compared to other groups. After controlling for tuber load in the TSC groups, within-group differences stayed the same but the differences between TSC-ASD and TSC + ASD were no longer statistically significant. These preliminary findings suggest that comorbid ASD in TSC as well as tuber load in TSC is associated with changes in the morphometry of language regions. Future studies with larger sample sizes will be needed to confirm these findings.
Collapse
Affiliation(s)
- Banu Ahtam
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
| | - Hyuk Jin Yun
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Rutvi Vyas
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Rudolph Pienaar
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Josephine H Wilson
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Caroline P Goswami
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Laura F Berto
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Mustafa Sahin
- Rosamund Stone Zander Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, MA, 02115, USA
| | - P Ellen Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Neuroradiology, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Kiho Im
- Fetal-Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| |
Collapse
|
3
|
Sforza G, Monte G, Voci A, Figà Talamanca L, Papetti L, Ferilli MAN, Proietti Checchi M, Valeriani M, Moavero R. A Case Report of Pediatric Patient with Tuberous Sclerosis and Radiologically Isolated Syndrome. J Clin Med 2023; 12:jcm12093284. [PMID: 37176724 PMCID: PMC10179347 DOI: 10.3390/jcm12093284] [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: 03/18/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disease with central nervous system (CNS) involvement. Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the CNS characterized by symptomatic episodes that occur months or years apart and affect different anatomic locations. In the absence of symptomatic episodes, radiologically isolated syndrome (RIS) could be diagnosed. Here, we report the case of a 10-year-old boy followed-up for TSC and diagnosed with RIS after a routine neuroimaging assessment. CASE DESCRIPTION The patient was diagnosed with TSC after seizure onset at the age of 4 years. The follow-up magnetic resonance imaging (MRI) showed multiple asymptomatic demyelinating lesions. Brain and spinal cord MRI was performed after 2 months and showed additional lesions in the right frontal white matter and left cerebral peduncle, the latter with contrast enhancement. Therefore, he received a diagnosis of RIS. Visual evoked potentials were normal. Cerebrospinal fluid examination showed oligoclonal bands. The search for AQP4-IgG and MOG-IgG antibodies was negative. He was treated with interferon beta-1a. Six months later, follow-up MRI revealed no new demyelinating lesions and resolution of contrast enhancement. CONCLUSION To the best of our knowledge, this is the third reported patient presenting a co-occurrence of TSC and demyelinating disease. Although we cannot state if the described comorbidity is casual or not, some clinical and preclinical data suggest that the mTOR complex might be the link between TSC and demyelinating disease.
Collapse
Affiliation(s)
- Giorgia Sforza
- Developmental Neurology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
| | - Gabriele Monte
- Developmental Neurology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
| | - Alessandra Voci
- Developmental Neurology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
| | | | - Laura Papetti
- Developmental Neurology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
| | | | | | - Massimiliano Valeriani
- Developmental Neurology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
- Center for Sensory-Motor Interaction, Denmark Neurology Unit, Aalborg University, 922 Aalborg, Denmark
| | - Romina Moavero
- Developmental Neurology Unit, Bambino Gesù Children's Hospital IRCCS, 00165 Rome, Italy
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, 00133 Rome, Italy
| |
Collapse
|
4
|
Mitchell RA, Mitchell M, Williams K. The autism spectrum disorder phenotype in children with tuberous sclerosis complex: A systematic review and meta-analysis. Dev Med Child Neurol 2022; 64:1214-1229. [PMID: 35724267 DOI: 10.1111/dmcn.15307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 12/18/2022]
Abstract
AIM To investigate the phenotype in autistic children with tuberous sclerosis complex (TSC), specifically autism spectrum disorder (ASD) severity and characteristics, intellectual ability, adaptive and executive function, language skills, attention-deficit/hyperactivity disorder features, and internalizing and externalizing behaviours. METHOD MEDLINE, Embase, and the Cochrane Library were searched up to March 2021. Studies that investigated predefined phenotypic factors in children with TSC-ASD were included according to the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. Two authors independently reviewed titles, abstracts, full texts, and extracted the data. Risk of bias and GRADE assessments were completed. RESULTS Thirty-four studies with 3160 children with TSC, 30% with ASD, were included. Meta-analysis found that 90% (95% confidence interval 86%-94%) of children with TSC-ASD have an intellectual disability. There was some evidence to suggest that young children with TSC-ASD and idiopathic ASD have a similar pattern of severity and behaviour. Overall, data about phenotypic characteristics were limited. INTERPRETATION A greater proportion of children with TSC-ASD are reported to have an intellectual disability than children with idiopathic ASD. Early intervention should consider the needs of children with a high likelihood of intellectual disability. Research is needed to better understand the impacts of intellectual disability and other co-occurring difficulties on adaptive function, participation, and quality of life in TSC-ASD. WHAT THIS PAPER ADDS Most children with tuberous sclerosis complex (TSC) and autism spectrum disorder (ASD) have an intellectual disability. TSC-ASD early intervention planning should consider the high likelihood of intellectual disability. Quality of life and the functional impact of intellectual disability in TSC-ASD are not understood. Little is known about co-occurring difficulties in TSC-ASD.
Collapse
Affiliation(s)
- Rebecca A Mitchell
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Australia
- Murdoch Children's Research Institute, Parkville, Australia
| | - Marijke Mitchell
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Australia
- Department of Paediatrics, Monash University, Clayton, Australia
| | - Katrina Williams
- The Royal Children's Hospital, Parkville, Australia
- Department of Paediatrics, Monash University, Clayton, Australia
- Monash Health, Monash Children's Hospital, Clayton, Australia
| |
Collapse
|
5
|
Sato A, Tominaga K, Iwatani Y, Kato Y, Wataya-Kaneda M, Makita K, Nemoto K, Taniike M, Kagitani-Shimono K. Abnormal White Matter Microstructure in the Limbic System Is Associated With Tuberous Sclerosis Complex-Associated Neuropsychiatric Disorders. Front Neurol 2022; 13:782479. [PMID: 35359647 PMCID: PMC8963953 DOI: 10.3389/fneur.2022.782479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTuberous sclerosis complex (TSC) is a genetic disease that arises from TSC1 or TSC2 abnormalities and induces the overactivation of the mammalian/mechanistic target of rapamycin pathways. The neurological symptoms of TSC include epilepsy and tuberous sclerosis complex-associated neuropsychiatric disorders (TAND). Although TAND affects TSC patients' quality of life, the specific region in the brain associated with TAND remains unknown. We examined the association between white matter microstructural abnormalities and TAND, using diffusion tensor imaging (DTI).MethodsA total of 19 subjects with TSC and 24 age-matched control subjects were enrolled. Tract-based spatial statistics (TBSS) were performed to assess group differences in fractional anisotropy (FA) between the TSC and control groups. Atlas-based association analysis was performed to reveal TAND-related white matter in subjects with TSC. Multiple linear regression was performed to evaluate the association between TAND and the DTI parameters; FA and mean diffusivity in seven target regions and projection fibers.ResultsThe TBSS showed significantly reduced FA in the right hemisphere and particularly in the inferior frontal occipital fasciculus (IFOF), inferior longitudinal fasciculus (ILF), superior longitudinal fasciculus (SLF), uncinate fasciculus (UF), and genu of corpus callosum (CC) in the TSC group relative to the control group. In the association analysis, intellectual disability was widely associated with all target regions. In contrast, behavioral problems and autistic features were associated with the limbic system white matter and anterior limb of the internal capsule (ALIC) and CC.ConclusionThe disruption of white matter integrity may induce underconnectivity between cortical and subcortical regions. These findings suggest that TANDs are not the result of an abnormality in a specific brain region, but rather caused by connectivity dysfunction as a network disorder. This study indicates that abnormal white matter connectivity including the limbic system is relevant to TAND. The analysis of brain and behavior relationship is a feasible approach to reveal TAND related white matter and neural networks. TAND should be carefully assessed and treated at an early stage.
Collapse
Affiliation(s)
- Akemi Sato
- United Graduate School of Child Development, Osaka University, Osaka, Japan
| | - Koji Tominaga
- United Graduate School of Child Development, Osaka University, Osaka, Japan
- Molecular Research Center for Children's Mental Development, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiko Iwatani
- United Graduate School of Child Development, Osaka University, Osaka, Japan
- Molecular Research Center for Children's Mental Development, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoko Kato
- Molecular Research Center for Children's Mental Development, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Mari Wataya-Kaneda
- Division of Health Science, Department of Neurocutaneous Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Dermatology, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kai Makita
- Research Center for Child Mental Development, University of Fukui, Fukui, Japan
| | - Kiyotaka Nemoto
- Division of Clinical Medicine, Department of Psychiatry, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masako Taniike
- United Graduate School of Child Development, Osaka University, Osaka, Japan
- Molecular Research Center for Children's Mental Development, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kuriko Kagitani-Shimono
- United Graduate School of Child Development, Osaka University, Osaka, Japan
- Molecular Research Center for Children's Mental Development, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
- *Correspondence: Kuriko Kagitani-Shimono
| |
Collapse
|
6
|
Anaby D, Shrot S, Belenky E, Ben-Zeev B, Tzadok M. Neurite density of white matter significantly correlates with tuberous sclerosis complex disease severity. NEUROIMAGE: CLINICAL 2022; 35:103085. [PMID: 35780663 PMCID: PMC9421460 DOI: 10.1016/j.nicl.2022.103085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/11/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022] Open
Abstract
Whole-brain white matter neurite density significantly reduces with TSC severity. A white matter quantification may be important for the evaluation of TSC patients. Low neurite density clusters are larger in severe TSC patients. Neurite density is an accurate MRI metric for the evaluation of TSC white-matter.
Objective To assess whether white matter (WM) diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) derived measures correlate with tuberous sclerosis complex (TSC) disease severity. Cohort and methods A multi-shell diffusion protocol was added to the clinical MRI brain scans of thirteen patients including 6 males and 7 females with a mean ± std age of 17.2 ± 5.8 years. Fractional anisotropy (FA) and mean diffusivity (MD) were generated from DTI and neurite density index (NDI), orientation dispersion index (ODI) and free water index (fiso) were generated from NODDI. A clinical score was determined for each patient according to the existence of epilepsy, developmental delay, autism or psychiatric disorders. Whole-brain segmented WM was averaged for each parametric map and 3 group k-means clustering was performed on the NDI and FA maps. MRI quantitative parameters were correlated with the clinical scores. Results Segmented whole brain WM averages of MD and NDI values showed significant negative (p = 0.0058) and positive (p = 0.0092) correlations with the clinical scores, respectively. Additionally, the contribution of the low and high NDI-based clusters to the whole brain WM significantly correlated with the clinical scores (p = 0.03 and p = 0.00047, respectively). No correlation was found when the clusters were based on the FA maps. Conclusion Advanced diffusion MRI of TSC patients revealed widespread WM alterations. Neurite density showed significant correlations with disease severity and is therefore suggested to reflect an underlying biological process in TSC WM. The quantification of WM alterations by advanced diffusion MRI may be an additional biomarker for TSC and may be advantageous as a complementary MR protocol for the evaluation of TSC patients.
Collapse
|
7
|
Shephard E, McEwen FS, Earnest T, Friedrich N, Mörtl I, Liang H, Woodhouse E, Tye C, Bolton PF. Oscillatory neural network alterations in young people with tuberous sclerosis complex and associations with co-occurring symptoms of autism spectrum disorder and attention-deficit/hyperactivity disorder. Cortex 2021; 146:50-65. [PMID: 34839218 DOI: 10.1016/j.cortex.2021.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/25/2021] [Accepted: 10/20/2021] [Indexed: 12/20/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic disorder caused by mutations on the TSC1/TSC2 genes, which result in alterations in molecular signalling pathways involved in neurogenesis and hamartomas in the brain and other organs. TSC carries a high risk for autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD), although the reasons for this are unclear. One proposal is that TSC-related alterations in molecular signalling during neurogenesis lead to atypical development of neural networks, which are involved in the occurrence of ASD and ADHD in TSC. We investigated this proposal in young people with TSC who have been studied longitudinally since their diagnosis in childhood. Electroencephalography (EEG) was used to examine oscillatory connectivity in functional neural networks and local and global network organisation during three tasks (resting-state, attentional and inhibitory control Go/Nogo task, upright and inverted face processing task) in participants with TSC (n = 48) compared to an age- and sex-matched group of typically developing Controls (n = 20). Compared to Controls, the TSC group showed hypoconnected neural networks in the alpha frequency during the resting-state and in the theta and alpha frequencies during the Go/Nogo task (P ≤ .008), as well as reduced local network organisation in the theta and alpha frequencies during the Go/Nogo task (F = 3.95, P = .010). There were no significant group differences in network metrics during the face processing task. Increased connectivity in the hypoconnected alpha-range resting-state network was associated with greater ASD and inattentive ADHD symptoms (rho≥.40, P ≤ .036). Reduced local network organisation in the theta-range during the Go/Nogo task was significantly associated with higher hyperactive/impulsive ADHD symptoms (rho = -.43, P = .041). These findings suggest that TSC is associated with widespread hypoconnectivity in neural networks and support the proposal that altered network function may be involved in the co-occurrence of ASD and ADHD in TSC.
Collapse
Affiliation(s)
- Elizabeth Shephard
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK; Department of Psychiatry, University of São Paulo, Brazil.
| | - Fiona S McEwen
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK; Department of Psychology, Queen Mary University of London, UK
| | - Thomas Earnest
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | - Nina Friedrich
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | - Isabelle Mörtl
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | - Holan Liang
- Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Emma Woodhouse
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | | | - Charlotte Tye
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK; Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK
| | - Patrick F Bolton
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, UK; The Maudsley NIHR Biomedical Research Centre in Mental Health, King's College London and South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
8
|
Capal JK, Williams ME, Pearson DA, Kissinger R, Horn PS, Murray D, Currans K, Kent B, Bebin M, Northrup H, Wu JY, Sahin M, Krueger DA. Profile of Autism Spectrum Disorder in Tuberous Sclerosis Complex: Results from a Longitudinal, Prospective, Multisite Study. Ann Neurol 2021; 90:874-886. [PMID: 34668231 DOI: 10.1002/ana.26249] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Tuberous sclerosis complex (TSC) is highly associated with autism spectrum disorder (ASD). Objectives of the study were to characterize autistic features in young children with TSC. METHODS Participants included 138 children followed from ages 3 to 36 months with TSC from the Tuberous Sclerosis Complex Autism Center of Excellence Research Network (TACERN), a multicenter, prospective observational study aimed at understanding the underlying mechanisms of ASD in TSC. Developmental and autism-specific assessments were administered, and a clinical diagnosis of ASD was determined for all participants at 36 months. Further analyses were performed on 117 participants with valid autism assessments based on nonverbal mental age greater than 15 months. RESULTS Prevalence of clinical diagnosis of ASD at 36 months was 25%. Nearly all autistic behaviors on the Autism Diagnostic Observation Schedule-2 (ADOS-2) and Autism Diagnostic Interview-Revised (ADI-R) were more prevalent in children diagnosed with ASD; however, autism-specific behaviors were also observed in children without ASD. Overall quality of social overtures, facial expressions, and abnormal repetitive interests and behaviors were characteristics most likely to distinguish children with ASD from those without an ASD diagnosis. Participants meeting ADOS-2 criteria but not a clinical ASD diagnosis exhibited intermediate developmental and ADOS-2 scores compared to individuals with and without ASD. INTERPRETATION ASD is highly prevalent in TSC, and many additional individuals with TSC exhibit a broad range of subthreshold autistic behaviors. Our findings reveal a broader autism phenotype that can be identified in young children with TSC, which provides opportunity for early targeted treatments. ANN NEUROL 2021.
Collapse
Affiliation(s)
- Jamie K Capal
- University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Marian E Williams
- Keck School of Medicine of USC, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA
| | - Deborah A Pearson
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Robin Kissinger
- Keck School of Medicine of USC, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA
| | - Paul S Horn
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Donna Murray
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Autism Speaks Inc, Boston, MA
| | - Kristn Currans
- Department of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bridget Kent
- Department of Developmental and Behavioral Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Hope Northrup
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Joyce Y Wu
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mustafa Sahin
- Department of Neurology, Rosamund Stone Zander Translational Neuroscience Center, Boston Children's Hospital, Boston, MA
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
9
|
Scherrer B, Prohl AK, Taquet M, Kapur K, Peters JM, Tomas-Fernandez X, Davis PE, M Bebin E, Krueger DA, Northrup H, Y Wu J, Sahin M, Warfield SK. The Connectivity Fingerprint of the Fusiform Gyrus Captures the Risk of Developing Autism in Infants with Tuberous Sclerosis Complex. Cereb Cortex 2021; 30:2199-2214. [PMID: 31812987 DOI: 10.1093/cercor/bhz233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/05/2019] [Accepted: 09/12/2019] [Indexed: 12/13/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disorder characterized by benign tumors throughout the body; it is generally diagnosed early in life and has a high prevalence of autism spectrum disorder (ASD), making it uniquely valuable in studying the early development of autism, before neuropsychiatric symptoms become apparent. One well-documented deficit in ASD is an impairment in face processing. In this work, we assessed whether anatomical connectivity patterns of the fusiform gyrus, a central structure in face processing, capture the risk of developing autism early in life. We longitudinally imaged TSC patients at 1, 2, and 3 years of age with diffusion compartment imaging. We evaluated whether the anatomical connectivity fingerprint of the fusiform gyrus was associated with the risk of developing autism measured by the Autism Observation Scale for Infants (AOSI). Our findings suggest that the fusiform gyrus connectivity captures the risk of developing autism as early as 1 year of age and provides evidence that abnormal fusiform gyrus connectivity increases with age. Moreover, the identified connections that best capture the risk of developing autism involved the fusiform gyrus and limbic and paralimbic regions that were consistent with the ASD phenotype, involving an increased number of left-lateralized structures with increasing age.
Collapse
Affiliation(s)
- Benoit Scherrer
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Anna K Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Maxime Taquet
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Kush Kapur
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Jurriaan M Peters
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Xavier Tomas-Fernandez
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Peter E Davis
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Elizabeth M Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, 35233 USA
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229 USA
| | - Hope Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 77030 USA
| | - Joyce Y Wu
- Department of Pediatrics, UCLA Mattel Children's Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, 90095 USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115 USA
| |
Collapse
|
10
|
Mitchell RA, Barton SM, Harvey AS, Ure AM, Williams K. Factors associated with autism spectrum disorder in children with tuberous sclerosis complex: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:791-801. [PMID: 33432576 DOI: 10.1111/dmcn.14787] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 12/21/2022]
Abstract
AIM To investigate associations between clinical factors and the development of autism spectrum disorder (ASD) in children with tuberous sclerosis complex (TSC), specifically seizures, electroencephalogram abnormalities, tubers and other neurostructural abnormalities, and genetic factors. METHOD MEDLINE, Embase, PubMed, the Cochrane Library, and Web of Science were searched until January 2019. Studies that considered the predefined factors for development of ASD in children with TSC were included, following PRISMA-P guidelines. Two authors independently reviewed titles, abstracts, and full texts, extracted data, and assessed risk of bias. RESULTS Forty-two studies with 3542 children with TSC were included. ASD was associated with a history of seizures (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.77-8.14), infantile spasms compared with other seizure types (OR 3.04, 95% CI 2.17-4.27), onset of any seizure type during infancy (OR 2.65, 95% CI 1.08-6.54), and male sex (OR 1.62, 95% CI 1.23-2.14). There was no association with tuber number, tuber location, or genotype. INTERPRETATION While a causal link between seizures and ASD in children with TSC cannot be inferred, a strong association between seizures and ASD in children with TSC, particularly with seizure onset during infancy and specifically infantile spasms, is present. Children with TSC and infant-onset seizures should be monitored for emerging features of ASD. What this paper adds Seizures and autism spectrum disorder (ASD) strongly associate in children with tuberous sclerosis complex (TSC). Infant-onset seizures and infantile spasms are particularly strongly associated with ASD in TSC.
Collapse
Affiliation(s)
- Rebecca A Mitchell
- Department of Neurodevelopment and Disability, The Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Sarah M Barton
- Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - A Simon Harvey
- Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Neurology, The Royal Children's Hospital, Parkville, VIC, Australia
| | - Alexandra M Ure
- Department of Paediatrics, The University of Melbourne, Parkville, VIC, Australia.,Murdoch Children's Research Institute, Parkville, VIC, Australia.,Mental Health, The Royal Children's Hospital, Parkville, VIC, Australia.,Paediatrics and Education Research, Monash University, Clayton, VIC, Australia
| | - Katrina Williams
- Department of Neurodevelopment and Disability, The Royal Children's Hospital, Parkville, VIC, Australia.,Paediatrics and Education Research, Monash University, Clayton, VIC, Australia.,Monash Health, Monash Children's Hospital, Clayton, VIC, Australia
| |
Collapse
|
11
|
Mühlebner A, van Scheppingen J, de Neef A, Bongaarts A, Zimmer TS, Mills JD, Jansen FE, Spliet WGM, Krsek P, Zamecnik J, Coras R, Blumcke I, Feucht M, Scholl T, Gruber VE, Hainfellner JA, Söylemezoğlu F, Kotulska K, Lagae L, Jansen AC, Kwiatkowski DJ, Jozwiak S, Curatolo P, Aronica E. Myelin Pathology Beyond White Matter in Tuberous Sclerosis Complex (TSC) Cortical Tubers. J Neuropathol Exp Neurol 2021; 79:1054-1064. [PMID: 32954437 PMCID: PMC7559237 DOI: 10.1093/jnen/nlaa090] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tuberous sclerosis complex (TSC) is a monogenetic disease that arises due to mutations in either the TSC1 or TSC2 gene and affects multiple organ systems. One of the hallmark manifestations of TSC are cortical malformations referred to as cortical tubers. These tubers are frequently associated with treatment-resistant epilepsy. Some of these patients are candidates for epilepsy surgery. White matter abnormalities, such as loss of myelin and oligodendroglia, have been described in a small subset of resected tubers but mechanisms underlying this phenomenon are unclear. Herein, we analyzed a variety of neuropathologic and immunohistochemical features in gray and white matter areas of resected cortical tubers from 46 TSC patients using semi-automated quantitative image analysis. We observed divergent amounts of myelin basic protein as well as numbers of oligodendroglia in both gray and white matter when compared with matched controls. Analyses of clinical data indicated that reduced numbers of oligodendroglia were associated with lower numbers on the intelligence quotient scale and that lower amounts of myelin-associated oligodendrocyte basic protein were associated with the presence of autism-spectrum disorder. In conclusion, myelin pathology in cortical tubers extends beyond the white matter and may be linked to cognitive dysfunction in TSC patients.
Collapse
Affiliation(s)
- Angelika Mühlebner
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jackelien van Scheppingen
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Andrew de Neef
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anika Bongaarts
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Till S Zimmer
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - James D Mills
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Floor E Jansen
- Department of Pediatric Neurology, Brain Center University Medical Center
| | - Wim G M Spliet
- Department of Pathology, University Medical Center Utrecht (WGMS) Utrecht, The Netherlands
| | | | | | - Roland Coras
- Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic; Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | - Ingmar Blumcke
- Second Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic; Department of Neuropathology, University Hospital Erlangen, Erlangen, Germany
| | | | | | | | | | - Figen Söylemezoğlu
- Medical University of Vienna, Vienna, Austria; Department of Pathology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Katarzyna Kotulska
- Department of Neurology and Epileptology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Lieven Lagae
- Department of Development and Regeneration-Section Pediatric Neurology, University Hospitals KU Leuven, Leuven
| | - Anna C Jansen
- Pediatric Neurology Unit-UZ Brussel, Brussels Belgium
| | | | - Sergiusz Jozwiak
- Department of Neurology and Epileptology, The Children's Memorial Health Institute.,Department of Child Neurology, Medical University of Warsaw Warsaw, Poland
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| | - Eleonora Aronica
- Department of (Neuro)Pathology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| |
Collapse
|
12
|
Russo C, Nastro A, Cicala D, De Liso M, Covelli EM, Cinalli G. Neuroimaging in tuberous sclerosis complex. Childs Nerv Syst 2020; 36:2497-2509. [PMID: 32519125 DOI: 10.1007/s00381-020-04705-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Tuberous sclerosis complex (TSC) is a rare autosomal dominant disorder affecting multiple systems, due to inactivating mutations of TSC1 or TSC2 mTOR pathway genes. Neurological manifestations are observed in about 95% cases, representing the most frequent cause of morbidity and one of the most common causes of mortality. BACKGROUND Neuroimaging is crucial for early diagnosis, monitoring, and management of these patients. While computed tomography is generally used as first-line investigation at emergency department, magnetic resonance imaging is the reference method to define central nervous system involvement and investigate subtle pathophysiological alterations in TSC patients. PURPOSE Here, we review the state-of-the-art knowledge in TSC brain imaging, describing conventional findings and depicting the role of advanced techniques in providing new insights on the disease, also offering an overview on future perspectives of neuroimaging applications for a better understanding of disease pathophysiology.
Collapse
Affiliation(s)
- Camilla Russo
- Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy.,Department of Electrical Engineering and Information Technology (DIETI), University of Naples "Federico II", Naples, Italy
| | - Anna Nastro
- Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Domenico Cicala
- Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Maria De Liso
- Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Eugenio Maria Covelli
- Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuseppe Cinalli
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Via Mario Fiore n. 6, 80129, Naples, Italy.
| |
Collapse
|
13
|
Specchio N, Pietrafusa N, Trivisano M, Moavero R, De Palma L, Ferretti A, Vigevano F, Curatolo P. Autism and Epilepsy in Patients With Tuberous Sclerosis Complex. Front Neurol 2020; 11:639. [PMID: 32849171 PMCID: PMC7431762 DOI: 10.3389/fneur.2020.00639] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/29/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction: Individuals with Tuberous Sclerosis Complex (TSC) are at increased risk of developing both epilepsy and autism spectrum disorder (ASD), but the relationship between these conditions is little understood. We reviewed published reports to elucidate the relationship between ASD, epilepsy, and TSC, and to define the genetic and neurological risk factors. Methods: Articles (January 2004-May 2019) were identified via PubMed, EMBASE, and CENTRAL databases. Article inclusion required report on individuals with TSC-associated ASD and epilepsy with prevalence, odds ratio, or rate report on the comorbidity of ASD in epileptic patients due to TSC. Results: A total of 841 abstracts were identified in the original search. Thirty-six articles were included, which identified study populations, ASD measures used, and study confounders as bias factors. This review included 2,666 TSC patients, with a mean age of 15.9 years (range 1.94-30.3 years). The percentage of TSC patients with epilepsy and autism was 33.7%. Patients with TSC and autism showed more frequent seizures and earlier epilepsy onset than TSC patients without autism. ASD and intractable epilepsy were both predicted by a higher number of areas with dysplastic features revealed in brain MR scans. ASD, the onset of seizures in children <2 years of age, and >3 tubers have all been associated with an increased risk of refractory epilepsy in TSC patients. However, the direction of the relationship is not clear because a history of epilepsy, or infantile spasms in patients with TSC is also associated with an increased likelihood of ASD. Overall, 73.2% of patients carried TSC2 genetic variant and, among patients with TSC and autism, the percentage of TSC2 individuals was 85.6%. Conclusions: The complex interrelationship between TSC, autism, and epilepsy, coupled with limited knowledge on the neurobiological basis for the interrelationship, limits overall understanding and opportunities for management. The results of this review highlight the need for early identification and management to optimize favorable outcomes in the most vulnerable individuals with TSC. Regardless of whether studies are considered individually or collectively, interpretation is made difficult due to the differences between the studies, most notably between methods and diagnostic criteria used to assess intellectual ability.
Collapse
Affiliation(s)
- Nicola Specchio
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- Member of European Reference Network EpiCARE
| | - Nicola Pietrafusa
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marina Trivisano
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca De Palma
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro Ferretti
- Rare and Complex Epilepsy Unit, Division of Neurology, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federico Vigevano
- Member of European Reference Network EpiCARE
- Department of Neuroscience, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University, Rome, Italy
| |
Collapse
|
14
|
Grayson LE, Peters JM, McPherson T, Krueger DA, Sahin M, Wu JY, Northrup HA, Porter B, Cutter GR, O’Kelley SE, Krefting J, Stone SS, Madsen JR, Fallah A, Blount JP, Weiner HL, Bebin EM. Pilot Study of Neurodevelopmental Impact of Early Epilepsy Surgery in Tuberous Sclerosis Complex. Pediatr Neurol 2020; 109:39-46. [PMID: 32418847 PMCID: PMC7387194 DOI: 10.1016/j.pediatrneurol.2020.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND To determine if early epilepsy surgery mitigates detrimental effects of refractory epilepsy on development, we investigated surgical and neurodevelopmental outcomes in children with tuberous sclerosis complex who underwent surgery before age two years. METHODS Prospective multicenter observational study of 160 children with tuberous sclerosis complex. Surgical outcome was determined for the seizure type targeted by surgery. We obtained Vineland Adaptive Behavior Scales, Second Edition (Vineland-II); Mullen Scales of Early Learning; and Preschool Language Scales, Fifth Edition, at age three, six, nine, 12, 18, 24, and 36 months. Surgical cases were compared with children without seizures, with controlled seizures, and with medically refractory seizures. RESULTS Nineteen children underwent surgery (median age 17 months, range 3.7 to 21.3), and mean follow-up was 22.8 months (range 12 to 48). Surgical outcomes were favorable in 12 (63%, Engel I-II) and poor in seven (37%, Engel III-IV). Nine (47%) had new or ongoing seizures distinct from those surgically targeted. All children with seizures demonstrated longitudinal decline or attenuated gains in neurodevelopment, the surgical group scoring the lowest. Favorable surgical outcome was associated with increased Mullen Scales of Early Learning receptive and expressive language subscores compared with the medically refractory seizure group. A nonsignificant but consistent pattern of improvement with surgery was seen in all tested domains. CONCLUSIONS These pilot data show neurodevelopmental gains in some domains following epilepsy surgery. A properly powered, prospective multicenter observational study of early epilepsy surgery is needed, using both surgical and developmental outcome metrics.
Collapse
Affiliation(s)
- Leslie E Grayson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Jurriaan M Peters
- Localization Laboratory, Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Tarrant McPherson
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children’s Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Mustafa Sahin
- Department of Neurology and the F.M. Kirby Neurobiology Center, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Joyce Y Wu
- Division of Pediatric Neurology, UCLA Mattel Children’s Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Hope A Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Brenda Porter
- Department of Neurology, The Stanford University Medical Center, Stanford, CA
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Sarah E O’Kelley
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Jessica Krefting
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Scellig S Stone
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Joseph R Madsen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA
| | - Aria Fallah
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of California Los Angeles Mattel Children’s Hospital, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Children’s Hospital of Alabama and University of Alabama at Birmingham, Birmingham, AL
| | - Howard L. Weiner
- Division of Pediatric Neurosurgery, Department of Surgery, Texas Children’s Hospital and Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - E. Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.,Corresponding author. Department of Neurology; CIRC 312; 1530 3rd Ave S; Birmingham, AL 35294-3280. Tel (256) 533-0833 Fax (256) 533-0855
| | | |
Collapse
|
15
|
Tsai JD, Ho MC, Lee HY, Shen CY, Li JY, Weng JC. Disrupted white matter connectivity and organization of brain structural connectomes in tuberous sclerosis complex patients with neuropsychiatric disorders using diffusion tensor imaging. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2020; 34:189-200. [PMID: 32715372 DOI: 10.1007/s10334-020-00870-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/02/2020] [Accepted: 07/20/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tuberous sclerosis complex (TSC) is a genetic neurocutaneous syndrome with variable and unpredictable neurological comorbidity that includes epilepsy, intellectual disability (ID), autism spectrum disorder, and neurobehavioral abnormalities. The degree of white matter involvement is believed to be associated with the severity of neurological impairment. The goal of the present study was to evaluate diffusion characteristics of tubers, white matter lesions, and brain structural network alterations in TSC patients using diffusion tensor imaging (DTI), graph theoretical analysis (GTA), and network-based statistical (NBS) analysis. MATERIALS AND METHODS Forty-two patients with a definitive diagnosis of TSC were recruited for this study. All patients underwent brain DTI examination using a 3 T magnetic resonance imaging system. Mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD) values, and fractional anisotropy (FA) mapping in 52 tubers and white matter lesions were measured and compared with those of contralateral normal regions. GTA was performed on the inter-regional connectivity matrix, and NBS analysis was used to identify the significance of any connected subnetworks evident in the set of altered connections. For neurological severity subgrouping, a neurological severity score was assigned to TSC patients including those with ID, seizure, autism, and other neuropsychiatric disorders (NPDs). RESULTS Significantly higher MD, AD, and RD, and lower FA values, were found in TSC lesions compared with those measured in contralateral normal regions for tubers (P < 0.05). GTA and NBS analysis provided better local segregation but worse global integration of the structural network (regular-like network) in TSC patients with ID, seizure, and higher Neurological Severity Score. Disrupted subnetworks in TSC patients with severe status included connections from the frontal lobe to the parietal lobe, temporal lobe to the caudate, and temporal lobe to the insula. DISCUSSION DTI has the potential to provide valuable information about cytoarchitectural changes in TSC lesions beyond morphological MRI findings alone. Using GTA and NBS, current results provide the information of disrupted white matter connectivity and organization in TSC patients with different neuropsychological impairments.
Collapse
Affiliation(s)
- Jeng-Dau Tsai
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ming-Chou Ho
- Department of Psychology, Chung Shan Medical University, Taichung, Taiwan
- Clinical Psychological Room, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Hom-Yi Lee
- Department of Psychology, Chung Shan Medical University, Taichung, Taiwan
- Department of Speech Language Pathology and Audiology, Chung Shan Medical University, Taichung, Taiwan
| | - Chao-Yu Shen
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Jheng-Yan Li
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan
| | - Jun-Cheng Weng
- Department of Medical Imaging and Radiological Sciences, Chang Gung University, No. 259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan.
- Medical Imaging Research Center, Institute for Radiological Research, Chang Gung University and Chang Gung Memorial Hospital At Linkou, Taoyuan, Taiwan.
- Department of Psychiatry, Chang Gung Memorial Hospital, Chiayi, Taiwan.
| |
Collapse
|
16
|
Hsieh CCJ, Lo YC, Li SJ, Lin TC, Chang CW, Chen TC, Yang SH, Lee YC, Chen YY. Detection of endophenotypes associated with neuropsychiatric deficiencies in a mouse model of tuberous sclerosis complex using diffusion tensor imaging. Brain Pathol 2020; 31:4-19. [PMID: 32530070 PMCID: PMC8018051 DOI: 10.1111/bpa.12870] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/09/2020] [Accepted: 06/02/2020] [Indexed: 12/13/2022] Open
Abstract
Tuberous sclerosis complex (TSC) is a rare hereditary disease, which results from the mutation of either TSC1 or TSC2, and its clinical features include benign tumors and dysfunctions in numerous organs, including the brain. Many individuals with TSC manifest neuropsychiatric symptoms, such as learning impairments, cognitive deficits and anxiety. Current pharmacological treatment for TSC is the use of mTOR inhibitors. However, they are not effective in treating neuropsychiatric symptoms. We previously used curcumin, a diet-derived mTOR inhibitor, which possesses both anti-inflammatory and antiproliferative properties, to improve learning and memory deficits in Tsc2+/- mice. Diffusion tensor imaging (DTI) provides microstructural information in brain tissue and has been used to study the neuropathological changes in TSC. In this study, we confirmed that the impaired recognition memory and increased anxiety-like behavior in Tsc2+/- mice can be reversed by curcumin treatment. Second, we found altered fractional anisotropy and mean diffusivity in the anterior cingulate cortex and the hippocampus of the Tsc2+/- mice, which may indicate altered circuitry. Finally, the mTOR complex 1 hyperactivity was found in the cortex and hippocampus, coinciding with abnormal cortical myelination and increased glial fibrillary acidic protein expression in the hippocampal CA1 of Tsc2+/- mice, both of which can be rescued with curcumin treatment. Overall, DTI is sensitive to the subtle alterations that cannot be detected by conventional imaging, suggesting that noninvasive DTI may be suitable for longitudinally monitoring the in vivo neuropathology associated with the neuropsychiatric symptoms in TSC, thereby facilitating future clinical trials of pharmacological treatments.
Collapse
Affiliation(s)
- Christine Chin-Jung Hsieh
- Taiwan International Graduate Program in Interdisciplinary Neuroscience, National Yang-Ming University and Academia Sinica, Taipei, 11574, Taiwan.,Department of Biomedical Engineering, National Yang-Ming University, Taipei, 11221, Taiwan
| | - Yu-Chun Lo
- PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan
| | - Ssu-Ju Li
- Department of Biomedical Engineering, National Yang-Ming University, Taipei, 11221, Taiwan
| | - Ting-Chun Lin
- Department of Biomedical Engineering, National Yang-Ming University, Taipei, 11221, Taiwan
| | - Ching-Wen Chang
- Department of Biomedical Engineering, National Yang-Ming University, Taipei, 11221, Taiwan
| | - Ting-Chieh Chen
- Department of Biomedical Engineering, National Yang-Ming University, Taipei, 11221, Taiwan
| | - Shih-Hung Yang
- Department of Mechanical Engineering, National Cheng Kung University, Tainan, 70101, Taiwan
| | - Yi-Chao Lee
- PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan
| | - You-Yin Chen
- Taiwan International Graduate Program in Interdisciplinary Neuroscience, National Yang-Ming University and Academia Sinica, Taipei, 11574, Taiwan.,Department of Biomedical Engineering, National Yang-Ming University, Taipei, 11221, Taiwan.,PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, 11031, Taiwan
| |
Collapse
|
17
|
van der Poest Clement E, Jansen FE, Braun KPJ, Peters JM. Update on Drug Management of Refractory Epilepsy in Tuberous Sclerosis Complex. Paediatr Drugs 2020; 22:73-84. [PMID: 31912454 DOI: 10.1007/s40272-019-00376-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tuberous sclerosis complex (TSC) is a genetic neurocutaneous disorder with epilepsy as a common and early presenting symptom. The neurological phenotype, however, is variable and unpredictable. Early and refractory seizures, infantile spasms in particular, are associated with a poor neurological outcome. Preliminary data suggests early and aggressive seizure control may mitigate the detrimental neurodevelopmental effects of epilepsy. For infantile spasms, vigabatrin is the first line of treatment, and steroids and classic antiepileptic drugs (AEDs) are suitable for second line. Based on retrospective data, vigabatrin should be considered for other indications, especially in infants with focal seizures, as this may prevent infantile spasms, but also in children and adults with epileptic spasms and tonic seizures. Otherwise, for most seizure types, treatment is similar to that for patients without TSC, including the use of novel AEDs, although limited data are available. Three major developments are changing the field of epilepsy management in TSC. First, final recommendations on preventive treatment with vigabatrin will result from two multicenter trials in the US (PREVeNT, clinicaltrials.gov #NCT02849457) and Europe (EPISTOP, clinicaltrials.gov #NCT02098759). Second, treatment with everolimus, an inhibitor of the mechanistic target of rapamycin (mTOR), reduced seizures when compared to placebo. Further, mTOR inhibitors may have an overall disease-modifying effect. Third, the role of cannabidiol in the treatment of refractory seizures in TSC is yet to be established. With treatment recommendations in TSC, we keep an eye on the prize for the broader field of pediatric epilepsy: the lessons learned from TSC are likely applicable to other epileptic encephalopathies.
Collapse
Affiliation(s)
| | - Floor E Jansen
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Kees P J Braun
- Department of Child Neurology, University Medical Center Utrecht Brain Center, Utrecht, The Netherlands
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, FE9, Boston, 02115, USA.
| |
Collapse
|
18
|
Jones JE, Asato MR, Brown MG, Doss JL, Felton EA, Kearney JA, Talos D, Dacks PA, Whittemore V, Poduri A. Epilepsy Benchmarks Area IV: Limit or Prevent Adverse Consequence of Seizures and Their Treatment Across the Life Span. Epilepsy Curr 2020; 20:31S-39S. [PMID: 31973592 PMCID: PMC7031803 DOI: 10.1177/1535759719895277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Epilepsy represents a complex spectrum disorder, with patients sharing seizures as a common symptom and manifesting a broad array of additional clinical phenotypes. To understand this disorder and treat individuals who live with epilepsy, it is important not only to identify pathogenic mechanisms underlying epilepsy but also to understand their relationships with other health-related factors. Benchmarks Area IV focuses on the impact of seizures and their treatment on quality of life, development, cognitive function, and other aspects and comorbidities that often affect individuals with epilepsy. Included in this review is a discussion on sudden unexpected death in epilepsy and other causes of mortality, a major area of research focus with still many unanswered questions. We also draw attention to special populations, such as individuals with nonepileptic seizures and pregnant women and their offspring. In this study, we review the progress made in these areas since the 2016 review of the Benchmarks Area IV and discuss challenges and opportunities for future study.
Collapse
Affiliation(s)
- Jana E Jones
- University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
| | - Miya R Asato
- Division of Child Neurology, UPMC Children's Hospital of Pittsburgh, PA, USA
| | - Mesha-Gay Brown
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Elizabeth A Felton
- University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
| | | | - Delia Talos
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Vicky Whittemore
- Division of Neuroscience, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MA, USA.,Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Annapurna Poduri
- Epilepsy Genetics Program, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
19
|
TrkB hyperactivity contributes to brain dysconnectivity, epileptogenesis, and anxiety in zebrafish model of Tuberous Sclerosis Complex. Proc Natl Acad Sci U S A 2020; 117:2170-2179. [PMID: 31932427 PMCID: PMC6995026 DOI: 10.1073/pnas.1910834117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Tuberous Sclerosis Complex (TSC) is a rare genetic disease that manifests with early symptoms, including cortical malformations, childhood epilepsy, and TSC-associated neuropsychiatric disorders (TANDs). Cortical malformations arise during embryonic development and have been linked to childhood epilepsy before, but the underlying mechanisms of this relationship remain insufficiently understood. Zebrafish have emerged as a convenient model to study elementary neurodevelopment; however, without in-depth functional analysis, the Tsc2-deficient zebrafish line cannot be used for studies of TANDs or new drug screening. In this study, we found that the lack of Tsc2 in zebrafish resulted in heterotopias and hyperactivation of the mTorC1 pathway in pallial regions, which are homologous to the mammalian cortex. We observed commissural thinning that was responsible for brain dysconnectivity, recapitulating TSC pathology in human patients. The lack of Tsc2 also delayed axonal development and caused aberrant tract fasciculation, corresponding to the abnormal expression of genes involved in axon navigation. The mutants underwent epileptogenesis that resulted in nonmotor seizures and exhibited increased anxiety-like behavior. We further mapped discrete parameters of locomotor activity to epilepsy-like and anxiety-like behaviors, which were rescued by reducing tyrosine receptor kinase B (TrkB) signaling. Moreover, in contrast to treatment with vigabatrin and rapamycin, TrkB inhibition rescued brain dysconnectivity and anxiety-like behavior. These data reveal that commissural thinning results in the aberrant regulation of anxiety, providing a mechanistic link between brain anatomy and human TANDs. Our findings also implicate TrkB signaling in the complex pathology of TSC and reveal a therapeutic target.
Collapse
|
20
|
Wong M. The role of glia in epilepsy, intellectual disability, and other neurodevelopmental disorders in tuberous sclerosis complex. J Neurodev Disord 2019; 11:30. [PMID: 31838997 PMCID: PMC6913020 DOI: 10.1186/s11689-019-9289-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 11/11/2019] [Indexed: 01/12/2023] Open
Abstract
Background Tuberous sclerosis complex (TSC) is a genetic disorder characterized by severe neurological manifestations, including epilepsy, intellectual disability, autism, and a range of other behavioral and psychiatric symptoms, collectively referred to as TSC-associated neuropsychiatric disorders (TAND). Various tumors and hamartomas affecting different organs are the pathological hallmarks of the disease, especially cortical tubers of the brain, but specific cellular and molecular abnormalities, such as involving the mechanistic target of rapamycin (mTOR) pathway, have been identified that also cause or contribute to neurological manifestations of TSC independent of gross structural lesions. In particular, while neurons are immediate mediators of neurological symptoms, different types of glial cells have been increasingly recognized to play important roles in the phenotypes of TSC. Main body This review summarizes the literature supporting glial dysfunction from both mouse models and clinical studies of TSC. In particular, evidence for the role of astrocytes, microglia, and oligodendrocytes in the pathophysiology of epilepsy and TAND in TSC is analyzed. Therapeutic implications of targeting glia cells in developing novel treatments for the neurological manifestations of TSC are also considered. Conclusions Different types of glial cells have both cell autonomous effects and interactions with neurons and other cells that are involved in the pathophysiology of the neurological phenotype of TSC. Targeting glial-mediated mechanisms may represent a novel therapeutic approach for epilepsy and TAND in TSC patients.
Collapse
Affiliation(s)
- Michael Wong
- Department of Neurology and the Hope Center for Neurological Disorders, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA.
| |
Collapse
|
21
|
Prohl AK, Scherrer B, Tomas-Fernandez X, Davis PE, Filip-Dhima R, Prabhu SP, Peters JM, Bebin EM, Krueger DA, Northrup H, Wu JY, Sahin M, Warfield SK. Early white matter development is abnormal in tuberous sclerosis complex patients who develop autism spectrum disorder. J Neurodev Disord 2019; 11:36. [PMID: 31838998 PMCID: PMC6912944 DOI: 10.1186/s11689-019-9293-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 11/11/2019] [Indexed: 11/23/2022] Open
Abstract
Background Autism spectrum disorder (ASD) is prevalent in tuberous sclerosis complex (TSC), occurring in approximately 50% of patients, and is hypothesized to be caused by disruption of neural circuits early in life. Tubers, or benign hamartomas distributed stochastically throughout the brain, are the most conspicuous of TSC neuropathology, but have not been consistently associated with ASD. Widespread neuropathology of the white matter, including deficits in myelination, neuronal migration, and axon formation, exist and may underlie ASD in TSC. We sought to identify the neural circuits associated with ASD in TSC by identifying white matter microstructural deficits in a prospectively recruited, longitudinally studied cohort of TSC infants. Methods TSC infants were recruited within their first year of life and longitudinally imaged at time of recruitment, 12 months of age, and at 24 months of age. Autism was diagnosed at 24 months of age with the ADOS-2. There were 108 subjects (62 TSC-ASD, 55% male; 46 TSC+ASD, 52% male) with at least one MRI and a 24-month ADOS, for a total of 187 MRI scans analyzed (109 TSC-ASD; 78 TSC+ASD). Diffusion tensor imaging properties of multiple white matter fiber bundles were sampled using a region of interest approach. Linear mixed effects modeling was performed to test the hypothesis that infants who develop ASD exhibit poor white matter microstructural integrity over the first 2 years of life compared to those who do not develop ASD. Results Subjects with TSC and ASD exhibited reduced fractional anisotropy in 9 of 17 white matter regions, sampled from the arcuate fasciculus, cingulum, corpus callosum, anterior limbs of the internal capsule, and the sagittal stratum, over the first 2 years of life compared to TSC subjects without ASD. Mean diffusivity trajectories did not differ between groups. Conclusions Underconnectivity across multiple white matter fiber bundles develops over the first 2 years of life in subjects with TSC and ASD. Future studies examining brain-behavior relationships are needed to determine how variation in the brain structure is associated with ASD symptoms.
Collapse
Affiliation(s)
- Anna K Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Benoit Scherrer
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Xavier Tomas-Fernandez
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Peter E Davis
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Rajna Filip-Dhima
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Sanjay P Prabhu
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Jurriaan M Peters
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA.,Department of Neurology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - E Martina Bebin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Darcy A Krueger
- Department of Neurology and Rehabilitation Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Hope Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Joyce Y Wu
- Division of Pediatric Neurology, University of California at Los Angeles Mattel Children's Hospital, David Geffen School of Medicine, University of California, California, Los Angeles, USA
| | - Mustafa Sahin
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA.,F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts, USA.
| | | |
Collapse
|
22
|
Dickinson A, Varcin KJ, Sahin M, Nelson CA, Jeste SS. Early patterns of functional brain development associated with autism spectrum disorder in tuberous sclerosis complex. Autism Res 2019; 12:1758-1773. [PMID: 31419043 PMCID: PMC6898751 DOI: 10.1002/aur.2193] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 01/12/2023]
Abstract
Tuberous sclerosis complex (TSC) is a rare genetic disorder that confers a high risk for autism spectrum disorders (ASD), with behavioral predictors of ASD emerging early in life. Deviations in structural and functional neural connectivity are highly implicated in both TSC and ASD. For the first time, we explore whether electroencephalographic (EEG) measures of neural network function precede or predict the emergence of ASD in TSC. We determine whether altered brain function (a) is present in infancy in TSC, (b) differentiates infants with TSC based on ASD diagnostic status, and (c) is associated with later cognitive function. We studied 35 infants with TSC (N = 35), and a group of typically developing infants (N = 20) at 12 and 24 months of age. Infants with TSC were later subdivided into ASD and non-ASD groups based on clinical evaluation. We measured features of spontaneous alpha oscillations (6-12 Hz) that are closely associated with neural network development: alpha power, alpha phase coherence (APC), and peak alpha frequency (PAF). Infants with TSC demonstrated reduced interhemispheric APC compared to controls at 12 months of age, and these differences were found to be most pronounced at 24 months in the infants who later developed ASD. Across all infants, PAF at 24 months was associated with verbal and nonverbal cognition at 36 months. Associations between early network function and later neurodevelopmental and cognitive outcomes highlight the potential utility of early scalable EEG markers to identify infants with TSC requiring additional targeted intervention initiated very early in life. Autism Res 2019, 12: 1758-1773. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Approximately half of infants with tuberous sclerosis complex (TSC) develop autism. Here, using EEG, we find that there is a reduction in communication between brain regions during infancy in TSC, and that the infants who show the largest reductions are those who later develop autism. Being able to identify infants who show early signs of disrupted brain development may improve the timing of early prediction and interventions in TSC, and also help us to understand how early brain changes lead to autism.
Collapse
Affiliation(s)
- Abigail Dickinson
- UCLA Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, Los Angeles, California
| | - Kandice J Varcin
- Telethon Kids Institute, University of Western Australia, Subiaco, Western Australia, Australia
| | - Mustafa Sahin
- Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Charles A Nelson
- Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Graduate School of Education, Cambridge, Massachusetts
| | - Shafali S Jeste
- UCLA Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, Los Angeles, California
| |
Collapse
|
23
|
Ahtam B, Dehaes M, Sliva DD, Peters JM, Krueger DA, Bebin EM, Northrup H, Wu JY, Warfield SK, Sahin M, Grant PE. Resting-State fMRI Networks in Children with Tuberous Sclerosis Complex. J Neuroimaging 2019; 29:750-759. [PMID: 31304656 DOI: 10.1111/jon.12653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/16/2019] [Accepted: 06/20/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE There are no published studies examining resting state networks (RSNs) and their relationship with neurodevelopmental metrics in tuberous sclerosis complex (TSC). We aimed to identify major resting-state functional magnetic resonance imaging (rs-fMRI) networks in infants with TSC and correlate network analyses with neurodevelopmental assessments, autism diagnosis, and seizure history. METHODS Rs-fMRI data from 34 infants with TSC, sedated with propofol during the scan, were analyzed to identify auditory, motor, and visual RSNs. We examined the correlations between auditory, motor, and visual RSNs at approximately 11.5 months, neurodevelopmental outcome at approximately 18.5 months, and diagnosis of autism spectrum disorders at approximately 36 months of age. RESULTS RSNs were obtained in 76.5% (26/34) of infants. We observed significant negative correlations between auditory RSN and auditory comprehension test scores (p = .038; r = -.435), as well as significant positive correlations between motor RSN and gross motor skills test scores (p = .023; r = .564). Significant positive correlations between motor RSNs and gross motor skills (p = .012; r = .754) were observed in TSC infants without autism, but not in TSC infants with autism, which could suggest altered motor processing. There were no significant differences in RSNs according to seizure history. CONCLUSIONS Negative correlation between auditory RSN, as well as positive correlation between motor RSN and developmental outcome measures might reflect different brain mechanisms and, when identified, may be helpful in predicting later function. A larger study of TSC patients with a healthy control group is needed before auditory and motor RSNs could be considered as neurodevelopmental outcome biomarkers.
Collapse
Affiliation(s)
- Banu Ahtam
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mathieu Dehaes
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Department of Radiology, Radio-oncology and Nuclear Medicine, University of Montreal and CHU Sainte-Justine, Montreal, QC, Canada
| | - Danielle D Sliva
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Department of Neuroscience, Brown University, Providence, RI
| | - Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Darcy A Krueger
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Hope Northrup
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Joyce Y Wu
- Division of Pediatric Neurology, University of California at Los Angeles Mattel Children's Hospital, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Mustafa Sahin
- Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA.,F.M. Kirby Neurobiology Center, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, MA
| | - Patricia Ellen Grant
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.,Division of Neuroradiology, Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | -
- Fetal-Neonatal Neuroimaging & Developmental Science Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
24
|
Peters JM, Struyven RR, Prohl AK, Vasung L, Stajduhar A, Taquet M, Bushman JJ, Lidov H, Singh JM, Scherrer B, Madsen JR, Prabhu SP, Sahin M, Afacan O, Warfield SK. White matter mean diffusivity correlates with myelination in tuberous sclerosis complex. Ann Clin Transl Neurol 2019; 6:1178-1190. [PMID: 31353853 PMCID: PMC6649396 DOI: 10.1002/acn3.793] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 11/26/2022] Open
Abstract
Objective Diffusion tensor imaging (DTI) of the white matter is a biomarker for neurological disease burden in tuberous sclerosis complex (TSC). To clarify the basis of abnormal diffusion in TSC, we correlated ex vivo high‐resolution diffusion imaging with histopathology in four tissue types: cortex, tuber, perituber, and white matter. Methods Surgical specimens of three children with TSC were scanned in a 3T or 7T MRI with a structural image isotropic resolution of 137–300 micron, and diffusion image isotropic resolution of 270‐1,000 micron. We stained for myelin (luxol fast blue, LFB), gliosis (glial fibrillary acidic protein, GFAP), and neurons (NeuN) and registered the digitized histopathology slides (0.686 micron resolution) to MRI for visual comparison. We then performed colocalization analysis in four tissue types in each specimen. Finally, we applied a linear mixed model (LMM) for pooled analysis across the three specimens. Results In white matter and perituber regions, LFB optical density measures correlated with fractional anisotropy (FA) and inversely with mean diffusivity (MD). In white matter only, GFAP correlated with MD, and inversely with FA. In tubers and in the cortex, there was little variation in mean LFB and GFAP signal intensity, and no correlation with MRI metrics. Neuronal density correlated with MD. In the analysis of the combined specimens, the most robust correlation was between white matter MD and LFB metrics. Interpretation In TSC, diffusion imaging abnormalities in microscopic tissue types correspond to specific histopathological markers. Across all specimens, white matter diffusivity correlates with myelination.
Collapse
Affiliation(s)
- Jurriaan M Peters
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robbert R Struyven
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anna K Prohl
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lana Vasung
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrija Stajduhar
- Croatian Institute for Brain Research and Center of Research Excellence for Basic, Clinical and Translational Neuroscience, University of Zagreb, Zagreb, Croatia
| | - Maxime Taquet
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John J Bushman
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hart Lidov
- Division of Neuropathology, Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jolene M Singh
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Benoit Scherrer
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph R Madsen
- Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sanjay P Prabhu
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mustafa Sahin
- Translational Neuroscience Center, Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Onur Afacan
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Simon K Warfield
- Computational Radiology Laboratory, Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
25
|
Longitudinal Effects of Everolimus on White Matter Diffusion in Tuberous Sclerosis Complex. Pediatr Neurol 2019; 90:24-30. [PMID: 30424962 PMCID: PMC6314307 DOI: 10.1016/j.pediatrneurol.2018.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/10/2018] [Accepted: 10/14/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We studied the longitudinal effects of everolimus, an inhibitor of the mammalian target of rapamycin (mTOR), on callosal white matter diffusion tensor imaging (DTI) in patients with tuberous sclerosis complex (TSC). METHODS Serial imaging data spanning nine years were used from the open label, Phase I/II trial (NCT00411619) and open-ended extension phase of everolimus for the treatment of subependymal giant cell astrocytoma associated with TSC. From 28 patients treated with everolimus and 25 untreated control patients, 481 MRI scans were available. Rigorous quality control resulted in omission of all scans with diffusion weighted imaging data in less than 15 directions or more than eight artifacted volumes, and all postsurgical scans. We applied a linear mixed-effects model to the remaining 125 scans (17 treated, 24 controls) for longitudinal analysis of each DTI metric of manually drawn callosal regions of interest. RESULTS On a population level, mTOR inhibition was associated with a decrease in mean diffusivity. In addition, in treated patients only, a decrease of radial diffusivity was observed; in untreated patients only, an increase of axial diffusivity was seen. In patients below age 10, effect-sizes were consistently greater, and longer treatment was associated with greater rate of diffusion change. There was no correlation between DTI metrics and reduction of subependymal giant cell astrocytoma volume, or everolimus serum levels. CONCLUSIONS Effects from mTOR overactivity on white matter microstructural integrity in TSC were modified through pharmacologic inhibition of mTOR. These changes sustained over time, were greater with longer treatment and in younger patients during a time of rapid white matter maturation.
Collapse
|
26
|
Franz DN, Krueger DA. mTOR inhibitor therapy as a disease modifying therapy for tuberous sclerosis complex. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2018; 178:365-373. [PMID: 30307123 DOI: 10.1002/ajmg.c.31655] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 11/07/2022]
Abstract
Between 1993 and 2003, through experiments involving Drosophila sp., cancer biologists identified the protein kinase known as the mammalian target of rapamycin, its pathway, and its relationship to the genes responsible for tuberous sclerosis. Thereafter, clinical research has resulted in regulatory approval of mTOR inhibitors for four distinct manifestations of the disease: giant cell astrocytoma, angiomyolipoma, lymphangioleiomyomatosis, and epilepsy. These developments are summarized and the practical use of mTOR inhibitors to improve the lives of patients with tuberous sclerosis reviewed.
Collapse
Affiliation(s)
- David Neal Franz
- Department of Pediatrics, Division of Child Neurology, Cincinnati Childrens Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Darcy Andrew Krueger
- Department of Pediatrics, Division of Child Neurology, Cincinnati Childrens Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|