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Armangue T, Whitehead MT, Tonduti D, Farina L, Tavasoli AR, Vossough A, Bennett ML, Vaia Y, Bernard G, Salsano E, Mercimek-Andrews S, Waldman A, Vanderver A. Brainstem Chipmunk Sign: A Diagnostic Imaging Clue across All Subtypes of Alexander Disease. AJNR Am J Neuroradiol 2024; 45:769-772. [PMID: 38697787 PMCID: PMC11288593 DOI: 10.3174/ajnr.a8220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/01/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND AND PURPOSE While classic brain MR imaging features of Alexander disease have been well-documented, lesional patterns can overlap with other leukodystrophies, especially in the early stages of the disease or in milder phenotypes. We aimed to assess the utility of a new neuroimaging sign to help increase the diagnostic specificity of Alexander disease. MATERIALS AND METHODS A peculiar bilateral symmetric hyperintense signal on T2-weighted images affecting the medulla oblongata was identified in an index patient with type I Alexander disease. Subsequently, 5 observers performed a systematic MR imaging review for this pattern by examining 55 subjects with Alexander disease and 74 subjects with other leukodystrophies. Interobserver agreement was assessed by the κ index. Sensitivity, specificity, and receiver operating characteristic curves were determined. RESULTS The identified pattern was present in 87% of subjects with Alexander disease and 14% of those without Alexander disease leukodystrophy (P < .001), 3 with vanishing white matter, 4 with adult polyglucosan body disease, and 3 others. It was found equally in both type I and type II Alexander disease (28/32, 88% versus 18/21, 86%; P = .851) and in subjects with unusual disease features (2/2). Sensitivity (87.3%; 95% CI, 76.0%-93.7%), specificity (86.5%; 95% CI, 76.9%-92.5%), and interobserver agreement (κ index = 0.82) were high. CONCLUSIONS The identified pattern in the medulla oblongata, called the chipmunk sign due to its resemblance to the face of this rodent, is extremely common in subjects with Alexander disease and represents a diagnostic tool that can aid in early diagnosis, especially in subjects with otherwise atypical MR imaging findings and/or clinical features.
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Affiliation(s)
- Thaís Armangue
- From the Neuroimmunology Program (T.A.), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-Hospital Clinic, University of Barcelona, Barcelona, Spain
- Neurology Department (T.A.), Neuroimmunology Unit, Sant Joan de Deu Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Matthew T Whitehead
- Department of Radiology (M.T.W., A.Vossough), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (M.T.W., A.Vossough, A.W., A.Vanderver), University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Tonduti
- Unit of Pediatric Neurology (D.T., Y.V.), Center for Diagnosis and Treatment of Leukodystrophies, V. Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Laura Farina
- Neuroimaging Laboratory (L.F.), IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Ali Reza Tavasoli
- Department of Neurology (A.R.T.), Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurology (A.R.T.), Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona
| | - Arastoo Vossough
- Department of Radiology (M.T.W., A.Vossough), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine (M.T.W., A.Vossough, A.W., A.Vanderver), University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mariko L Bennett
- Division of Neurology (M.L.B., Y.V., A.W., A.Vanderver), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ylenia Vaia
- Unit of Pediatric Neurology (D.T., Y.V.), Center for Diagnosis and Treatment of Leukodystrophies, V. Buzzi Children's Hospital, University of Milan, Milan, Italy
- Division of Neurology (M.L.B., Y.V., A.W., A.Vanderver), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Geneviève Bernard
- Departments of Neurology and Neurosurgery, Pediatrics, and Human Genetics (G.B.), McGill University, Montreal, Quebec, Canada
- Department of Specialized Medicine (G.B.), Division of Medical Genetics, McGill University Health Centre, Montreal, Quebec, Canada
- Child Health and Human Development Program (G.B.), Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Ettore Salsano
- Unit of Rare Neurological Diseases (E.S.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Saadet Mercimek-Andrews
- Department of Medical Genetics (S.M.-A.), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- The Hospital for Sick Children (S.M.-A.), Toronto, Ontario, Canada
| | - Amy Waldman
- Perelman School of Medicine (M.T.W., A.Vossough, A.W., A.Vanderver), University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Neurology (M.L.B., Y.V., A.W., A.Vanderver), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adeline Vanderver
- Perelman School of Medicine (M.T.W., A.Vossough, A.W., A.Vanderver), University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Neurology (M.L.B., Y.V., A.W., A.Vanderver), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Kang YR, Nam TS, Kim JM, Kang KW, Lee SH, Choi SM, Kim MK. Older adult-onset Alexander disease with atypical clinicoradiological features: a case report. Front Neurol 2023; 14:1139047. [PMID: 37396762 PMCID: PMC10310951 DOI: 10.3389/fneur.2023.1139047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/22/2023] [Indexed: 07/04/2023] Open
Abstract
Alexander disease (AxD) is a rare autosomal dominant astrogliopathy caused by mutations in the gene encoding for glial fibrillary acidic protein. AxD is divided into two clinical subtypes: type I and type II AxD. Type II AxD usually manifests bulbospinal symptoms and occurs in the second decade of life or later, and its radiologic features include tadpole-like appearance of the brainstem, ventricular garlands, and pial signal changes along the brainstem. Recently, eye-spot signs in the anterior medulla oblongata (MO) have been reported in patients with elderly-onset AxD. In this case, an 82-year-old woman presented with mild gait disturbance and urinary incontinence without bulbar symptoms. The patient died 3 years after symptom onset as a result of rapid neurological deterioration after a minor head injury. MRI showed signal abnormalities resembling angel wings in the middle portion of the MO along with hydromyelia of the cervicomedullary junction. Herein, we report the case of this patient with older adult-onset AxD with an atypical clinical course and distinctive MRI findings.
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Affiliation(s)
- You-Ri Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Jae-Myung Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seung-Han Lee
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seong-Min Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Myeong-Kyu Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Republic of Korea
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Heshmatzad K, Naderi N, Masoumi T, Pouraliakbar H, Kalayinia S. Identification of a novel de novo pathogenic variant in GFAP in an Iranian family with Alexander disease by whole-exome sequencing. Eur J Med Res 2022; 27:174. [PMID: 36088400 PMCID: PMC9464415 DOI: 10.1186/s40001-022-00799-5] [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: 05/21/2022] [Accepted: 08/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Alexander disease (AxD) is a rare leukodystrophy with an autosomal dominant inheritance mode. Variants in GFAP lead to this disorder and it is classified into three distinguishable subgroups: infantile, juvenile, and adult-onset types. Objective The aim of this study is to report a novel variant causing AxD and collect all the associated variants with juvenile and adult-onset as well. Methods We report a 2-year-old female with infantile AxD. All relevant clinical and genetic data were evaluated. Search strategy for all AxD types was performed on PubMed. The extracted data include total recruited patients, number of patients carrying a GFAP variant, nucleotide and protein change, zygosity and all the clinical symptoms. Results A novel de novo variant c.217A > G: p. Met73Val was found in our case by whole-exome sequencing. In silico analysis categorized this variant as pathogenic. Totally 377 patients clinically diagnosed with juvenile or adult-onset forms were recruited in these articles, among them 212 patients were affected with juvenile or adult-onset form carrier of an alteration in GFAP. A total of 98 variants were collected. Among these variants c.262C > T 11/212 (5.18%), c.1246C > T 9/212 (4.24%), c.827G > T 8/212 (3.77%), c.232G > A 6/212 (2.83%) account for the majority of reported variants. Conclusion This study highlighted the role of genetic in AxD diagnosing. It also helps to provide more information in order to expand the genetic spectrum of Iranian patients with AxD. Our literature review is beneficial in defining a better genotype–phenotype correlation of AxD disorder.
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Abstract
Alexander disease (ALXDRD) is a primary astrocyte disease caused by GFAP gene mutation. The clinical features of ALXDRD vary from infantile-onset cerebral white matter involvement to adult-onset brainstem involvement. Several studies revealed that the level of GFAP overexpression is correlated with disease severity, and basic research on therapies to reduce abnormal GFAP accumulation has recently been published. Therefore, the accumulation of clinical data to advance understanding of the natural history is essential for clinical trials expected in the future. This review focuses on the clinical characteristics of ALXDRD including the clinical symptoms, imaging findings and genetics to provide diagnostic information useful in daily clinical practice.
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Affiliation(s)
- Tomokatsu Yoshida
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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Yoshida T. [Clinical characteristics and diagnostic criteria on Alexander disease]. Rinsho Shinkeigaku 2020; 60:581-588. [PMID: 32779598 DOI: 10.5692/clinicalneurol.cn-001442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Alexander disease (ALXDRD) is a primary astrocyte disease caused by glial fibrillary acidic protein (GFAP) gene mutation. ALXDRD had been clinically regarded as a cerebral white matter disease that affects only children for about 50 years since the initial report in 1949; however, in the early part of the 21st century, case reports of adult-onset ALXDRD with medulla and spinal cord lesions increased. Basic research on therapies to reduce abnormal GFAP accumulation, such as drug-repositioning and antisense oligonucleotide suppression, has recently been published. The accumulation of clinical data to advance understanding of natural history is essential for clinical trials expected in the future. In this review, I classified ALXDRD into two subtypes: early-onset and late-onset, and detail the clinical symptoms, imaging findings, and genetic characteristics as well as the epidemiology and historical changes in the clinical classification described in the literature. The diagnostic criteria based on Japanese ALXDRD patients that are useful in daily clinical practice are also mentioned.
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Affiliation(s)
- Tomokatsu Yoshida
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
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Yasuda R, Nakano M, Yoshida T, Sato R, Adachi H, Tokuda Y, Mizuta I, Saito K, Matsuura J, Nakagawa M, Tashiro K, Mizuno T. Towards genomic database of Alexander disease to identify variations modifying disease phenotype. Sci Rep 2019; 9:14763. [PMID: 31611638 PMCID: PMC6791890 DOI: 10.1038/s41598-019-51390-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/01/2019] [Indexed: 01/13/2023] Open
Abstract
Alexander disease (AxD) is an extremely rare neurodegenerative disorder caused by glial fibrillary acidic protein (GFAP) gene mutations. Compared with the cerebral type, which is characterized by infantile onset, the bulbospinal type and intermediate form are associated with a late onset, spanning from juveniles to the elderly, and more diverse clinical spectrum, suggesting the existence of factors contributing to phenotypic diversity. To build a foundation for future genetic studies of this rare disease, we obtained genomic data by whole exome-sequencing (WES) and DNA microarray derived from thirty-one AxD patients with the bulbospinal type and intermediate form. Using this data, we aimed to identify genetic variations determining the age at onset (AAO) of AxD. As a result, WES- or microarray-based association studies between younger (<45 years; n = 13)- and older (≥45 years; n = 18)-onset patients considering the predicted GFAP-mutation pathogenicity identified no genome-wide significant variant. The candidate gene approach identified several variants likely correlated with AAO (p < 0.05): GAN, SLC1A2, CASP3, HDACs, and PI3K. Although we need to replicate the results using an independent population, this is the first step towards constructing a database, which may serve as an important tool to advance our understanding of AxD.
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Affiliation(s)
- Rei Yasuda
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masakazu Nakano
- Department of Genomic Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomokatsu Yoshida
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Ryuichi Sato
- Department of Genomic Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroko Adachi
- Department of Genomic Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuichi Tokuda
- Department of Genomic Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ikuko Mizuta
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kozo Saito
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Jun Matsuura
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masanori Nakagawa
- Department of Neurology, North Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kei Tashiro
- Department of Genomic Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Maeda K, Iwai K, Ando T, Kobayashi Y, Yoshida M. Degenerative inferior olivary nucleus and medullary tegmentum produced the characteristic magnetic resonance imaging signs in Alexander disease: A case report. J Neurol Sci 2019; 403:159-161. [PMID: 31299543 DOI: 10.1016/j.jns.2019.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/18/2019] [Accepted: 06/27/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Kentaro Maeda
- Department of Neurology, Okazaki city hospital, Aichi, Japan 3-1 Koryuji-cho goshoai, Okazaki, Aichi, 4448553, Japan
| | - Katsushige Iwai
- Department of Neurology, Okazaki city hospital, Aichi, Japan 3-1 Koryuji-cho goshoai, Okazaki, Aichi, 4448553, Japan
| | - Takashi Ando
- Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan 1-1 Yazakokarimata, Nagakute, Aichi 4801195, Japan; Department of Neurology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 4668550, Japan
| | - Yasushi Kobayashi
- Department of Neurology, Okazaki city hospital, Aichi, Japan 3-1 Koryuji-cho goshoai, Okazaki, Aichi, 4448553, Japan
| | - Mari Yoshida
- Institute for Medical Science of Aging, Aichi Medical University, Aichi, Japan 1-1 Yazakokarimata, Nagakute, Aichi 4801195, Japan.
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Maeda K, Iwai K, Kobayashi Y, Tsuji H, Yoshida T, Kobayashi Y. [A case of Alexander disease with dropped head syndrome]. Rinsho Shinkeigaku 2018; 58:198-201. [PMID: 29491332 DOI: 10.5692/clinicalneurol.cn-001116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 51-year-old woman presented with progressive weakness of the neck extensor muscles and gait disturbances since the past 6 years. In addition, she presented with symptoms such as dysarthria, dysphagia, bladder, and rectal disturbances. Bilateral plantar reflex was positive. Her gait was short-stepped-spastic. Brain and cervical MRI showed atrophy of the medulla and spinal cord. As these imaging features were suggestive of Alexander disease (AxD), we sequenced the GFAP gene. We identified a heterozygous c.368T>C missense mutation of the GFAP gene in the patient. This was the first case of the mutation in Japanese patients, and subsequently, she was diagnosed with AxD type 2. There are a few studies which reported that patients with AxD complained of dropped head syndrome. Dropped head syndrome can be the initial manifestation of AxD.
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Affiliation(s)
| | - Katsushige Iwai
- Department of Neurology, Okazaki City Hospital.,Present Address: Department of Neurology, Toyohashi City Hospital
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A novel three-base duplication, E243dup, of GFAP identified in a patient with Alexander disease. Hum Genome Var 2017; 4:17028. [PMID: 28690862 PMCID: PMC5498426 DOI: 10.1038/hgv.2017.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/28/2017] [Accepted: 05/09/2017] [Indexed: 11/08/2022] Open
Abstract
Alexander disease (AxD) is a rare hereditary neurodegenerative disorder caused by glial fibrillary acidic protein (GFAP) gene mutations, most of which are missense mutations. We present an AxD case with a novel de novo three-base duplication mutation in GFAP resulting in E243dup.
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Yoshida T, Yasuda R, Mizuta I, Nakagawa M, Mizuno T. Quantitative Evaluation of Brain Stem Atrophy Using Magnetic Resonance Imaging in Adult Patients with Alexander Disease. Eur Neurol 2017; 77:296-302. [DOI: 10.1159/000475661] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/07/2017] [Indexed: 11/19/2022]
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