1
|
Gupta N, Miller E, Bhatia A, Richer J, Aviv RI, Wilson N. Imaging Review of Pediatric Monogenic CNS Vasculopathy with Genetic Correlation. Radiographics 2024; 44:e230087. [PMID: 38573816 DOI: 10.1148/rg.230087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Monogenic cerebral vasculopathy is a rare but progressively recognizable cause of pediatric cerebral vasculopathy manifesting as early as fetal life. These monogenic cerebral vasculopathies can be silent or manifest variably as fetal or neonatal distress, neurologic deficit, developmental delay, cerebral palsy, seizures, or stroke. The radiologic findings can be nonspecific, but the presence of disease-specific cerebral and extracerebral imaging features can point to a diagnosis and guide genetic testing, allowing targeted treatment. The authors review the existing literature describing the frequently encountered and rare monogenic cerebral vascular disorders affecting young patients and describe the relevant pathogenesis, with an attempt to categorize them based on the defective step in vascular homeostasis and/or signaling pathways and characteristic cerebrovascular imaging findings. The authors also highlight the role of imaging and a dedicated imaging protocol in identification of distinct cerebral and extracerebral findings crucial in the diagnostic algorithm and selection of genetic testing. Early and precise recognition of these entities allows timely intervention, preventing or delaying complications and thereby improving quality of life. It is also imperative to identify the specific pathogenic variant and pattern of inheritance for satisfactory genetic counseling and care of at-risk family members. Last, the authors present an image-based approach to these young-onset monogenic cerebral vasculopathies that is guided by the size and predominant radiologic characteristics of the affected vessel with reasonable overlap. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
Collapse
Affiliation(s)
- Neetika Gupta
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Elka Miller
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Aashim Bhatia
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Julie Richer
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Richard I Aviv
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| | - Nagwa Wilson
- From the Department of Diagnostic and Interventional Radiology, Divisions of ER (N.G.) and Neuroradiology (E.M.), The Hospital for Sick Children, University of Toronto, 170 Elizabeth St, Toronto, ON, Canada M5G 1E8; Departments of Medical Imaging (N.G., N.W.) and Genetics (J.R.), Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada; Department of Radiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa (A.B.); and Department of Radiology, Radiation Oncology, and Medical Physics, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Canada (R.I.A.)
| |
Collapse
|
2
|
Zijun L, Xu Y, Yujia Y, Zhiqiang X. Elderly onset of MELAS carried an M.3243A >G mutation in a female with deafness and visual deficits: A case report. Clin Case Rep 2024; 12:e8438. [PMID: 38487642 PMCID: PMC10937291 DOI: 10.1002/ccr3.8438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/27/2023] [Accepted: 11/11/2023] [Indexed: 03/17/2024] Open
Abstract
Key Clinical Message MELAS is a disorder with clinical variability that also responsible for a significant portion of unexplained hereditary or childhood-onset hearing loss. Although patients typically present in childhood, the first stroke-like episode can occur later in life in some patients, potentially related to a lower heteroplasmy level. It is crucial to consider MELAS as a potential cause of stroke-like events if age at presentation and symptoms are atypical, especially among middle-aged patients without vascular risk factors. Abstract MELAS syndrome (mitochondrial encephalopathy with lactic acidosis and stroke-like episodes) is a rare genetic condition that most patients develop stroke-like episodes before the age of 40. We report a 52-year-old female with a documented 40-year history of progressive sensorineural hearing loss, developed a visual field deficit and stroke-like events in her middle age who finally diagnosed was MELAS. The patient was started on vitamin E, l-carnitine, l-arginine, and coenzyme Q10 that gradually improved before dismissal from the hospital. This case highlights the importance of considering MELAS as a potential cause of stroke-like events if imaging findings are atypical for cerebral infarction, especially among middle-aged patients without vascular risk factors and an unusual cause of progressive sensorineural hearing loss.
Collapse
Affiliation(s)
- Lin Zijun
- Department of NeurologyArmy Medical Center of People's Liberation Army of ChinaChongqingChina
| | - Yi Xu
- Department of NeurologyArmy Medical Center of People's Liberation Army of ChinaChongqingChina
| | - Yang Yujia
- Department of NeurologyArmy Medical Center of People's Liberation Army of ChinaChongqingChina
| | - Xu Zhiqiang
- Department of NeurologyArmy Medical Center of People's Liberation Army of ChinaChongqingChina
| |
Collapse
|
3
|
Enokizono M, Kurokawa R, Yagishita A, Nakata Y, Koyasu S, Nihira H, Kuwashima S, Aida N, Kono T, Mori H. Clinical and neuroimaging review of monogenic cerebral small vessel disease from the prenatal to adolescent developmental stage. Jpn J Radiol 2024; 42:109-125. [PMID: 37847489 PMCID: PMC10810974 DOI: 10.1007/s11604-023-01493-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 10/18/2023]
Abstract
Cerebral small vessel disease (cSVD) refers to a group of pathological processes with various etiologies affecting the small vessels of the brain. Most cases are sporadic, with age-related and hypertension-related sSVD and cerebral amyloid angiopathy being the most prevalent forms. Monogenic cSVD accounts for up to 5% of causes of stroke. Several causative genes have been identified. Sporadic cSVD has been widely studied whereas monogenic cSVD is still poorly characterized and understood. The majority of cases of both the sporadic and monogenic types, including cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), typically have their onset in adulthood. Types of cSVD with infantile and childhood onset are rare, and their diagnosis is often challenging. The present review discusses the clinical and neuroimaging findings of monogenic cSVD from the prenatal to adolescent period of development. Early diagnosis is crucial to enabling timely interventions and family counseling.
Collapse
Affiliation(s)
- Mikako Enokizono
- Department of Radiology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Ryo Kurokawa
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Akira Yagishita
- Department of Neuroradiology, Tokyo Metropolitan Neurological Hospital, Fuchu, Tokyo, Japan
| | - Yasuhiro Nakata
- Department of Neuroradiology, Tokyo Metropolitan Neurological Hospital, Fuchu, Tokyo, Japan
| | - Sho Koyasu
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Hiroshi Nihira
- Department of Pediatrics, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - Shigeko Kuwashima
- Department of Radiology, Dokkyo Medical University, Shimotsuga-gun, Tochigi, Japan
| | - Noriko Aida
- Department of Radiology, Kanagawa Children's Medical Center, Yokohama, Kanagawa, Japan
| | - Tatsuo Kono
- Department of Radiology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Harushi Mori
- Department of Radiology, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| |
Collapse
|
4
|
Khasminsky V, Auriel E, Luckman J, Eliahou R, Inbar E, Pardo K, Landau Y, Barnea R, Mermelstein M, Shelly S, Naftali J, Peretz S. Clinicoradiologic Criteria for the Diagnosis of Stroke-like Episodes in MELAS. Neurol Genet 2023; 9:e200082. [PMID: 37426458 PMCID: PMC10323819 DOI: 10.1212/nxg.0000000000200082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/16/2023] [Indexed: 07/11/2023]
Abstract
Background and Objectives Stroke-like episodes (SLEs) in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome are often misdiagnosed as acute ischemic stroke (AIS). We aimed to determine unique clinical and neuroimaging features for SLEs and formulate diagnostic criteria. Methods We retrospectively identified patients with MELAS admitted for SLEs between January 2012 and December 2021. Clinical features and imaging findings were compared with a cohort of patients who presented with AIS and similar lesion topography. A set of criteria was formulated and then tested by a blinded rater to evaluate diagnostic performance. Results Eleven MELAS patients with 17 SLE and 21 AISs were included. Patients with SLEs were younger (median 45 [37-60] vs 77 [68-82] years, p < 0.01) and had a lower body mass index (18 ± 2.6 vs 29 ± 4, p < 0.01), more commonly reported hearing loss (91% vs 5%, p < 0.01), and more commonly presented with headache and/or seizures (41% vs 0%, p < 0.01). The earliest neuroimaging test performed at presentation was uniformly a noncontrast CT. Two main patterns of lesion topography with a stereotypical spatiotemporal evolution were identified-an anterior pattern (7/21, 41%) starting at the temporal operculum and spreading to the peripheral frontal cortex and a posterior pattern (10/21, 59%) starting at the cuneus/precuneus and spreading to the lateral occipital and parietal cortex. Other distinguishing features for SLEs vs AIS were cerebellar atrophy (91% vs 19%, p < 0.01), previous cortical lesions with typical SLE distribution (46% vs 9%, p = 0.03), acute lesion tissue hyperemia and venous engorgement on CT angiography (CTA) (45% vs 0%, p < 0.01), and no large vessel occlusion on CTA (0% vs 100%, p < 0.01). Based on these clinicoradiologic features, a set of diagnostic criteria were constructed for possible SLE (sensitivity 100%, specificity 81%, AUC 0.905) and probable SLE (sensitivity 88%, specificity 95%, AUC 0.917). Discussion Clinicoradiologic criteria based on simple anamnesis and a CT scan at presentation can accurately diagnose SLE and lead to early administration of appropriate therapy. Classification of Evidence This study provides Class III evidence that an algorithm using clinical and imaging features can differentiate stroke-like episodes due to MELAS from acute ischemic strokes.
Collapse
Affiliation(s)
- Vadim Khasminsky
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Eitan Auriel
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Judith Luckman
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Ruth Eliahou
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Edna Inbar
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Keshet Pardo
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Yuval Landau
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Rani Barnea
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Maor Mermelstein
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Shahar Shelly
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Jonathan Naftali
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| | - Shlomi Peretz
- From the Departments of Imaging (V.K., J.L., R.E., E.I.) and Neurology (E.A., K.P., R.B., M.M., J.N., S.P.), Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine (V.K., E.A., J.L., R.E., E.I., Y.L., R.B., S.P.), Tel Aviv University; Metabolic Diseases Clinic (Y.L.), Schneider Children's Medical Center, Petach Tikva; Department of Neurology (S.S.), Rambam Health Care Campus, Haifa, Israel; and Department of Neurology (S.S.), Mayo Clinic, Rochester, MN
| |
Collapse
|
5
|
Ota Y, Liao E, Shah G, Srinivasan A, Capizzano AA. Comprehensive Update and Review of Clinical and Imaging Features of SMART Syndrome. AJNR Am J Neuroradiol 2023; 44:626-633. [PMID: 37142432 PMCID: PMC10249687 DOI: 10.3174/ajnr.a7859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023]
Abstract
Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a delayed complication of cranial irradiation, with subacute onset of stroke-like symptoms including seizures, visual disturbance, speech impairment, unilateral hemianopsia, facial droop, and aphasia, often associated with migraine-type headache. The diagnostic criteria were initially proposed in 2006. However, the diagnosis of SMART syndrome is challenging because clinical symptoms and imaging features of SMART syndrome are indeterminate and overlap with tumor recurrence and other neurologic diseases, which may result in inappropriate clinical management and unnecessary invasive diagnostic procedures. Recently, various imaging features and treatment recommendations for SMART syndrome have been reported. Radiologists and clinicians should be familiar with updates on clinical and imaging features of this delayed radiation complication because recognition of this entity can facilitate proper clinical work-up and management. This review provides current updates and a comprehensive overview of the clinical and imaging features of SMART syndrome.
Collapse
Affiliation(s)
- Y Ota
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - E Liao
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - G Shah
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A Srinivasan
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - A A Capizzano
- From The Division of Neuroradiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
6
|
Wang JW, Yuan XB, Chen HF. Late-onset mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes syndrome with mitochondrial DNA 3243A>G mutation masquerading as autoimmune encephalitis: A case report. World J Clin Cases 2023; 11:3275-3281. [PMID: 37274040 PMCID: PMC10237123 DOI: 10.12998/wjcc.v11.i14.3275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/27/2023] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Here, we present a unique case of mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome, which initially appeared to be autoimmune encephalitis and was ultimately confirmed as MELAS with the mitochondrial DNA 3243A>G mutation.
CASE SUMMARY A 58-year-old female presented with acute-onset speech impediment and auditory hallucinations, symmetrical bitemporal lobe abnormalities, clinical and laboratory findings, and a lack of relevant prodromal history, which suggested diagnosis of autoimmune encephalitis. Further work-up, in conjunction with the patient’s medical history, family history, and lactate peak on brain lesions on magnetic resonance imaging, suggested a mitochondrial disorder. Mitochondrial genome analysis revealed the m.3243A>G variant in the MT-TL1 gene, which led to a diagnosis of MELAS syndrome.
CONCLUSION This case underscores the importance of considering MELAS as a potential cause of autoimmune encephalitis even if patients are over 40 years of age, as the symptoms and signs are atypical for MELAS syndrome.
Collapse
Affiliation(s)
- Jian-Wei Wang
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| | - Xiao-Bo Yuan
- Department of Neurology, The First People's Hospital of Yongkang, Jinhua 321300, Zhejiang Province, China
| | - Hong-Fang Chen
- Department of Neurology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua 321000, Zhejiang Province, China
| |
Collapse
|
7
|
Alves CAPF, Zandifar A, Peterson JT, Tara SZ, Ganetzky R, Viaene AN, Andronikou S, Falk MJ, Vossough A, Goldstein AC. MELAS: Phenotype Classification into Classic-versus-Atypical Presentations. AJNR Am J Neuroradiol 2023; 44:602-610. [PMID: 37024306 PMCID: PMC10171385 DOI: 10.3174/ajnr.a7837] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/24/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND AND PURPOSE An increased number of pathogenic variants have been described in mitochondrial encephalomyopathy lactic acidosis and strokelike episodes (MELAS). Different imaging presentations have emerged in parallel with a growing recognition of clinical and outcome variability, which pose a diagnostic challenge to neurologists and radiologists and may impact an individual patient's response to therapeutic interventions. By evaluating clinical, neuroimaging, laboratory, and genetic findings, we sought to improve our understanding of the sources of potential phenotype variability in patients with MELAS. MATERIALS AND METHODS This retrospective single-center study included individuals who had confirmed mitochondrial DNA pathogenic variants and a diagnosis of MELAS and whose data were reviewed from January 2000 through November 2021. The approach included a review of clinical, neuroimaging, laboratory, and genetic data, followed by an unsupervised hierarchical cluster analysis looking for sources of phenotype variability in MELAS. Subsequently, experts identified "victory-variables" that best differentiated MELAS cohort clusters. RESULTS Thirty-five patients with a diagnosis of mitochondrial DNA-based MELAS (median age, 12 years; interquartile range, 7-24 years; 24 female) were eligible for this study. Fifty-three discrete variables were evaluated by an unsupervised cluster analysis, which revealed that two distinct phenotypes exist among patients with MELAS. After experts reviewed the variables, they selected 8 victory-variables with the greatest impact in determining the MELAS subgroups: developmental delay, sensorineural hearing loss, vision loss in the first strokelike episode, Leigh syndrome overlap, age at the first strokelike episode, cortical lesion size, regional brain distribution of lesions, and genetic groups. Ultimately, 2-step differentiating criteria were defined to classify atypical MELAS. CONCLUSIONS We identified 2 distinct patterns of MELAS: classic MELAS and atypical MELAS. Recognizing different patterns in MELAS presentations will enable clinical and research care teams to better understand the natural history and prognosis of MELAS and identify the best candidates for specific therapeutic interventions.
Collapse
Affiliation(s)
- C A P F Alves
- From the Division of Neuroradiology (C.A.P.F.A., A.Z., S.A., A.V.), Department of Radiology
| | - A Zandifar
- From the Division of Neuroradiology (C.A.P.F.A., A.Z., S.A., A.V.), Department of Radiology
| | - J T Peterson
- Mitochondrial Medicine Frontier Program (J.T.P., S.Z.T., R.G., M.J.F., A.C.G.), Division of Human Genetics, Department of Pediatrics
| | - S Z Tara
- Mitochondrial Medicine Frontier Program (J.T.P., S.Z.T., R.G., M.J.F., A.C.G.), Division of Human Genetics, Department of Pediatrics
| | - R Ganetzky
- Mitochondrial Medicine Frontier Program (J.T.P., S.Z.T., R.G., M.J.F., A.C.G.), Division of Human Genetics, Department of Pediatrics
- Departments of Pediatrics (R.G., M.J.F., A.C.G.)
| | - A N Viaene
- Department of Pathology and Laboratory Medicine (A.N.V.), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Pathology and Laboratory Medicine (A.N.V.)
| | - S Andronikou
- From the Division of Neuroradiology (C.A.P.F.A., A.Z., S.A., A.V.), Department of Radiology
- Radiology (S.A., A.V.), Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - M J Falk
- Mitochondrial Medicine Frontier Program (J.T.P., S.Z.T., R.G., M.J.F., A.C.G.), Division of Human Genetics, Department of Pediatrics
- Departments of Pediatrics (R.G., M.J.F., A.C.G.)
| | - A Vossough
- From the Division of Neuroradiology (C.A.P.F.A., A.Z., S.A., A.V.), Department of Radiology
- Radiology (S.A., A.V.), Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - A C Goldstein
- Mitochondrial Medicine Frontier Program (J.T.P., S.Z.T., R.G., M.J.F., A.C.G.), Division of Human Genetics, Department of Pediatrics
- Departments of Pediatrics (R.G., M.J.F., A.C.G.)
| |
Collapse
|
8
|
Ng YS, Gorman GS. Stroke-like episodes in adult mitochondrial disease. HANDBOOK OF CLINICAL NEUROLOGY 2023; 194:65-78. [PMID: 36813321 DOI: 10.1016/b978-0-12-821751-1.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Stroke-like episode is a paroxysmal neurological manifestation which affects a specific group of patients with mitochondrial disease. Focal-onset seizures, encephalopathy, and visual disturbances are prominent findings associated with stroke-like episodes, with a predilection for the posterior cerebral cortex. The most common cause of stroke-like episodes is the m.3243A>G variant in MT-TL1 gene followed by recessive POLG variants. This chapter aims to review the definition of stroke-like episode and delineate the clinical phenomenology, neuroimaging and EEG findings typically seen in patients. In addition, several lines of evidence supporting neuronal hyper-excitability as the key mechanism of stroke-like episodes are discussed. The management of stroke-like episodes should focus on aggressive seizure management and treatment for concomitant complications such as intestinal pseudo-obstruction. There is no robust evidence to prove the efficacy of l-arginine for both acute and prophylactic settings. Progressive brain atrophy and dementia are the sequalae of recurrent stroke-like episode, and the underlying genotype in part predicts prognosis.
Collapse
Affiliation(s)
- Yi Shiau Ng
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gráinne S Gorman
- Wellcome Centre for Mitochondrial Research, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
| |
Collapse
|
9
|
Naftali J, Mermelstein M, Landau YE, Barnea R, Shelly S, Auriel E, Peretz S. Clinical score for early diagnosis and treatment of stroke-like episodes in MELAS syndrome. Acta Neurol Belg 2023:10.1007/s13760-023-02196-z. [PMID: 36792807 DOI: 10.1007/s13760-023-02196-z] [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: 08/24/2022] [Accepted: 01/18/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Stroke-like episodes (SLEs) in patients with MELAS syndrome are often initially misdiagnosed as acute ischemic stroke (AIS), resulting in treatment delay. We aimed to determine clinical features that may distinguish SLEs from AISs and explore the benefit of early L-arginine treatment on patient outcomes. METHODS We looked retrospectively for MELAS patients admitted between January 2005 and January 2022 and compared them to an AIS cohort with similar lesion topography. MELAS patients who received L-arginine within 40 days of their first SLE were defined as the early treatment group and the remaining as late or no treatment group. RESULTS Twenty-three SLEs in 10 MELAS patients and 21 AISs were included. SLE patients had significantly different features: they were younger, more commonly reported hearing loss, lower body mass index, had more commonly a combination of headache and/or seizures at presentation, serum lactate was higher, and hemiparesis was less common. An SLE Early Clinical Score (SLEECS) was constructed by designating one point to each above features. SLEECS ≥ 4 had 80% sensitivity and 100% specificity for SLE diagnosis. Compared to late or no treatment, early treatment group patients (n = 5) had less recurrent SLEs (total 2 vs. 11), less seizures (14% vs. 25%, p = 0.048), lower degree of disability at first and last follow-up (modified ranking scale, mRS 2 ± 0.7 vs. 4.2 ± 1, p = 0.005; 2 ± 0.7 vs. 5.8 ± 0.5, p < 0.001, respectively), and a lower mortality (0% vs. 80% p = 0.048). CONCLUSIONS The SLEECS model may aid in the early diagnosis and treatment of SLEs and lead to improved clinical outcomes.
Collapse
Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel
| | - Maor Mermelstein
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel
| | - Yuval E Landau
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Metabolic Diseases Clinic, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Shelly
- Department of Neurology, Sheba Medical Center, Tel Aviv, Israel.,Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Peretz
- Department of Neurology, Rabin Medical Center, Zeev Jabotinsky St 39, 49100, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
10
|
Zheng H, Zhang X, Tian L, Liu B, He X, Wang L, Ding S, Guo Y, Cai J. Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes with an MT-TL1 m.3243A>G point mutation: Neuroradiological features and their implications for underlying pathogenesis. Front Neurosci 2023; 16:1028762. [PMID: 36685235 PMCID: PMC9853426 DOI: 10.3389/fnins.2022.1028762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) is one of the most common inherited mitochondrial disorders. Due to the high clinical and genetic heterogeneity of MELAS, it is still a major challenge for clinicians to accurately diagnose the disease at an early stage. Herein, we evaluated the neuroimaging findings of MELAS with an m.3243A>G mutation in MT-TL1 and analyzed the possible underlying pathogenesis of stroke-like episodes. Materials and methods Fifty-nine imaging studies in 24 patients who had a confirmed genetic diagnosis of m.3243A>G (MT-TL1; tRNA Leu) associated with MELAS were reviewed in our case series. The anatomic location, morphological features, signal/intensity characteristics and temporal evolution of lesions were analyzed on magnetic resonance imaging (MRI), and computed tomography (CT) images. The supplying vessels and metabolite content of the lesions were also evaluated by using MR angiography (MRA)/CT angiography (CTA), and MR spectroscopy (MRS), respectively. Results The lesions were most commonly located in the posterior brain, with 37 (37/59, 63%) in the occipital lobe, 32 (32/59, 54%) in the parietal lobe, and 30 (30/59, 51%) in the temporal lobe. The signal characteristics of the lesions varied and evolved over time. Bilateral basal ganglia calcifications were found in 6 of 9 (67%) patients who underwent CT. Cerebral and cerebellar atrophy were found in 38/59 (64%) and 40/59 (68%) patients, respectively. Lesion polymorphism was found in 37/59 (63%) studies. MRS showed elevated lactate doublet peaks in 9/10 (90%) cases. MRA or CTA revealed that the lesion-related arteries were slightly dilated compared with those of the contralateral side in 4 of 6 (67%) cases. Conclusion The imaging features of MELAS vary depending on the disease stage. Polymorphic lesions in a single imaging examination should be considered a diagnostic clue for MELAS. Stroke-like episodes may be involved in a complex pathogenetic process, including mitochondrial angiopathy, mitochondrial cytopathy, and neuronal excitotoxicity.
Collapse
Affiliation(s)
- Helin Zheng
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xuemei Zhang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Medical Affairs, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Lu Tian
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Liu
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoya He
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Longlun Wang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Ding
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Guo
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Pediatric Neurology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China,*Correspondence: Yi Guo,
| | - Jinhua Cai
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Department of Radiology, National Clinical Research Center for Child Health and Disorders, Children’s Hospital of Chongqing Medical University, Chongqing, China,Jinhua Cai,
| |
Collapse
|
11
|
Camacho-Caballero K, Malaga M, Peixoto de Barcelos I, Prentice AF, Berkowitz AL. A 47-Year-Old Man Presenting With Seizures and Prior Stroke. Neurohospitalist 2023; 13:74-77. [PMID: 36531844 PMCID: PMC9755623 DOI: 10.1177/19418744221122877] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
A 47-year-old man presented to his local hospital in Peru after a generalized tonic-clonic seizure. His family reported a history of prior stroke of unclear etiology. This case report discusses the approach to a first seizure (including in tropical regions like Peru), the relationship between stroke and seizures, the approach to stroke in the young, and how to diagnose rare diseases in resource-limited settings.
Collapse
Affiliation(s)
- Kiara Camacho-Caballero
- Facultad de Ciencias de la Salud, CHANGE Research Working Group Lima, Universidad Científica del Sur, Lima, Perú
- Grupo Estudiantil de Investigación en Neurociencias, SOCIEM-USMP, Lima, Perú
| | - Marco Malaga
- Grupo Estudiantil de Investigación en Neurociencias, SOCIEM-USMP, Lima, Perú
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Perú
| | - Isabella Peixoto de Barcelos
- Center for Applied Genomics, Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | | | | |
Collapse
|
12
|
Flomin Y, Hetman T, Guliaieva M, Havryliv I, Tsurkalenko O. Determining the etiology of cerebral stroke: from the most prevalent to rare causes. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2022-2(40)-14-40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cerebral stroke remains the leading cause of death and disability worldwide as well as in Ukraine. After a cerebral stroke, there is an increased risk of a new cerebral stroke (9‒15 % within 1 year), and about a quarter of all cerebral stroke are recurrent. Up to 80 % of recurrent cerebral stroke can be avoided through lifestyle modifications (healthy diet, sufficient amount of physical activity, normalization of body weight, cessation of smoking and alcohol abuse) and control of chronic diseases such as hypertension, diabetes, hyperlipidemia and atrial fibrillation. The key to effective secondary prevention is determining the etiology of cerebral stroke, which requires a primary examination in all cases and a number of additional tests as needed. The most common causes of ischemic cerebral stroke are cardiogenic embolism, atherosclerosis of the large cerebral arteries (macroangiopathy), and brain small vessels disease (microangiopathy), but approximately 1/3 of cerebral stroke have other, rear, determined cause or the cause remains unknown despite the appropriate workup (cryptogenic cerebral stroke). In the review, we discuss modern approaches to ischemic cerebral stroke classification and determination of their etiology, from the most prevalent to the rarest causes. A careful search for the cause of cerebral stroke is particularly important in young patients (aged 18 to 50 years) with a high life expectancy. We have reviewed in detail the possibilities of screening for subclinical atrial fibrillation by long-term cardiac monitoring with implantable devices and the diagnosis of monogenetic causes of cerebral stroke, with a particular focus on Fabry disease, for which there is an effective treatment.
Collapse
|
13
|
Hawken J, Tobin P, Hu M, Edwards M, Abburu S, Pickrell WO. Radiological clues to a mitochondrial problem. Pract Neurol 2022; 22:239-240. [PMID: 35450961 DOI: 10.1136/practneurol-2022-003356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Jonathan Hawken
- Neurology Department, Swansea Bay University Health Board, Swansea, UK
| | - Paul Tobin
- Neurology Department, Swansea Bay University Health Board, Swansea, UK
| | - Mo Hu
- Neurology Department, Swansea Bay University Health Board, Swansea, UK
| | - Marc Edwards
- Neurology Department, Swansea Bay University Health Board, Swansea, UK
| | - Srinivasa Abburu
- Radiology Department, Swansea Bay University Health Board, Swansea, UK
| | - William Owen Pickrell
- Neurology Department, Swansea Bay University Health Board, Swansea, UK
- Swansea University Medical School, Swansea, UK
| |
Collapse
|
14
|
Seed LM, Dean A, Krishnakumar D, Phyu P, Horvath R, Harijan PD. Molecular and neurological features of MELAS syndrome in paediatric patients: A case series and review of the literature. Mol Genet Genomic Med 2022; 10:e1955. [PMID: 35474314 PMCID: PMC9266612 DOI: 10.1002/mgg3.1955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/21/2022] [Accepted: 04/04/2022] [Indexed: 12/15/2022] Open
Abstract
Background Mitochondrial encephalomyopathy, lactic acidosis and stroke‐like episodes (MELAS) syndrome is one of the most well‐known mitochondrial diseases, with most cases attributed to m.3243A>G. MELAS syndrome patients typically present in the first two decades of life with a broad, multi‐systemic phenotype that predominantly features neurological manifestations––stroke‐like episodes. However, marked phenotypic variability has been observed among paediatric patients, creating a clinical challenge and delaying diagnoses. Methods A literature review of paediatric MELAS syndrome patients and a retrospective analysis in a UK tertiary paediatric neurology centre were performed. Results Three children were included in this case series. All patients presented with seizures and had MRI changes not confined to a single vascular territory. Blood heteroplasmy varied considerably, and one patient required a muscle biopsy. Based on a literature review of 114 patients, the mean age of presentation is 8.1 years and seizures are the most prevalent manifestation of stroke‐like episodes. Heteroplasmy is higher in a tissue other than blood in most cases. Conclusion The threshold for investigating MELAS syndrome in children with suspicious neurological symptoms should be low. If blood m.3243A>G analysis is negative, yet clinical suspicion remains high, invasive testing or further interrogation of the mitochondrial genome should be considered.
Collapse
Affiliation(s)
- Lydia M Seed
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Dean
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK.,Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Deepa Krishnakumar
- Department of Paediatric Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Poe Phyu
- Department of Clinical Neuroradiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rita Horvath
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - Pooja Devi Harijan
- Department of Paediatric Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
15
|
Abkur T, Cleaver J, Sharma K. A cause of encephalopathy not to be missed. Pract Neurol 2022; 22:524-527. [PMID: 35383120 DOI: 10.1136/practneurol-2022-003389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Tarig Abkur
- Department of Neurology, North Bristol NHS Trust, Bristol, UK
| | - Jonathan Cleaver
- Department of Neurology, North Bristol NHS Trust, Bristol, UK.,Department of Neurology, Gloucestershire Royal Hospital, Gloucester, UK
| | - Kanchan Sharma
- Department of Neurology, North Bristol NHS Trust, Bristol, UK.,School of Medicine, University of Bristol, Bristol, UK.,Faculty of Medicine, University of Amoud, Borama, Somaliland
| |
Collapse
|
16
|
Lopriore P, Ricciarini V, Siciliano G, Mancuso M, Montano V. Mitochondrial Ataxias: Molecular Classification and Clinical Heterogeneity. Neurol Int 2022; 14:337-356. [PMID: 35466209 PMCID: PMC9036286 DOI: 10.3390/neurolint14020028] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 01/25/2023] Open
Abstract
Ataxia is increasingly being recognized as a cardinal manifestation in primary mitochondrial diseases (PMDs) in both paediatric and adult patients. It can be caused by disruption of cerebellar nuclei or fibres, its connection with the brainstem, or spinal and peripheral lesions leading to proprioceptive loss. Despite mitochondrial ataxias having no specific defining features, they should be included in hereditary ataxias differential diagnosis, given the high prevalence of PMDs. This review focuses on the clinical and neuropathological features and genetic background of PMDs in which ataxia is a prominent manifestation.
Collapse
|
17
|
Abstract
Higd1a is a conserved gene in evolution which is widely expressed in many tissues in mammals. Accumulating evidence has revealed multiple functions of Higd1a, as a mitochondrial inner membrane protein, in the regulation of metabolic homeostasis. It plays an important role in anti-apoptosis and promotes cellular survival in several cell types under hypoxic condition. And the survival of porcine Sertoli cells facilitated by Higd1a helps to support reproduction. In some cases, Higd1a can serve as a sign of metabolic stress. Over the past several years, a considerable amount of studies about how tumor fate is determined and how cancerous proliferation is regulated by Higd1a have been performed. In this review, we summarize the physiological functions of Higd1a in metabolic homeostasis and its pathophysiological roles in distinct diseases including cancer, nonalcoholic fatty liver disease (NAFLD), type II diabetes and mitochondrial diseases. The prospect of Higd1a with potential to preserve mammal health is also discussed. This review might pave the way for Higd1a-based research and application in clinical practice.
Collapse
|
18
|
Cheng W, Zhang Y, He L. MRI Features of Stroke-Like Episodes in Mitochondrial Encephalomyopathy With Lactic Acidosis and Stroke-Like Episodes. Front Neurol 2022; 13:843386. [PMID: 35222261 PMCID: PMC8863858 DOI: 10.3389/fneur.2022.843386] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022] Open
Abstract
Mitochondrial myopathy encephalopathy lactic acidosis and stroke-like episodes (MELAS) is an important cause of stroke-mimicking diseases that predominantly affect patients before 40 years of age. MELAS results from gene mutations in either mitochondrial DNA (mtDNA) or nuclear DNA (nDNA) responsible for the wide spectrum of clinical symptoms and imaging findings. Neurological manifestations can present with stroke-like episodes (the cardinal features of MELAS), epilepsy, cognitive and mental disorders, or recurrent headaches. Magnetic resonance imaging (MRI) is an important tool for detecting stroke-like lesions, accurate recognition of imaging findings is important in guiding clinical decision making in MELAS patients. With the development of neuroimaging technologies, MRI plays an increasingly important role in course monitoring and efficacy assessment of the disease. In this article, we provide an overview of the neuroimaging features and the application of novel MRI techniques in MELAS syndrome.
Collapse
|
19
|
Haast RAM, De Coo IFM, Ivanov D, Khan AR, Jansen JFA, Smeets HJM, Uludağ K. OUP accepted manuscript. Brain Commun 2022; 4:fcac024. [PMID: 35187487 PMCID: PMC8853728 DOI: 10.1093/braincomms/fcac024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 11/26/2021] [Accepted: 02/01/2022] [Indexed: 11/14/2022] Open
Abstract
Mutations of the mitochondrial DNA are an important cause of inherited diseases that can severely affect the tissue’s homeostasis and integrity. The m.3243A > G mutation is the most commonly observed across mitochondrial disorders and is linked to multisystemic complications, including cognitive deficits. In line with in vitro experiments demonstrating the m.3243A > G’s negative impact on neuronal energy production and integrity, m.3243A > G patients show cerebral grey matter tissue changes. However, its impact on the most neuron dense, and therefore energy-consuming brain structure—the cerebellum—remains elusive. In this work, we used high-resolution structural and functional data acquired using 7 T MRI to characterize the neurodegenerative and functional signatures of the cerebellar cortex in m.3243A > G patients. Our results reveal altered tissue integrity within distinct clusters across the cerebellar cortex, apparent by their significantly reduced volume and longitudinal relaxation rate compared with healthy controls, indicating macroscopic atrophy and microstructural pathology. Spatial characterization reveals that these changes occur especially in regions related to the frontoparietal brain network that is involved in information processing and selective attention. In addition, based on resting-state functional MRI data, these clusters exhibit reduced functional connectivity to frontal and parietal cortical regions, especially in patients characterized by (i) a severe disease phenotype and (ii) reduced information-processing speed and attention control. Combined with our previous work, these results provide insight into the neuropathological changes and a solid base to guide longitudinal studies aimed to track disease progression.
Collapse
Affiliation(s)
- Roy A. M. Haast
- Correspondence to: Roy A. M. Haast Centre for Functional and Metabolic Mapping Robarts Research Institute Western University 1151 Richmond St N., London ON, Canada N6A 5B7 E-mail:
| | - Irenaeus F. M. De Coo
- Department of Toxicogenomics, Unit Clinical Genomics, Maastricht University, MHeNs School for Mental Health and Neuroscience, Maastricht, the Netherlands
| | - Dimo Ivanov
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
| | - Ali R. Khan
- Centre for Functional and Metabolic Mapping, Robarts Research Institute, Western University, London, ON, Canada, N6A 5B7
- Brain and Mind Institute, Western University, London, ON, Canada, N6A 3K7
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, N6A 5B7
| | - Jacobus F. A. Jansen
- Department of Radiology & Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- School for Mental Health & Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Hubert J. M. Smeets
- Department of Toxicogenomics, Unit Clinical Genomics, Maastricht University, MHeNs School for Mental Health and Neuroscience, Maastricht, the Netherlands
- School for Mental Health & Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Kâmil Uludağ
- IBS Center for Neuroscience Imaging Research, Sungkyunkwan University, Seobu-ro, 2066, Jangan-gu, Suwon, South Korea
- Department of Biomedical Engineering, N Center, Sungkyunkwan University, Seobu-ro, 2066, Jangan-gu, Suwon, South Korea
- Techna Institute and Koerner Scientist in MR Imaging, University Health Network, Toronto, ON, Canada, M5G 1L5
| |
Collapse
|
20
|
Chojdak-Łukasiewicz J, Dziadkowiak E, Budrewicz S. Monogenic Causes of Strokes. Genes (Basel) 2021; 12:1855. [PMID: 34946804 PMCID: PMC8700771 DOI: 10.3390/genes12121855] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023] Open
Abstract
Strokes are the main cause of death and long-term disability worldwide. A stroke is a heterogeneous multi-factorial condition, caused by a combination of environmental and genetic factors. Monogenic disorders account for about 1% to 5% of all stroke cases. The most common single-gene diseases connected with strokes are cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) Fabry disease, mitochondrial myopathy, encephalopathy, lactacidosis, and stroke (MELAS) and a lot of single-gene diseases associated particularly with cerebral small-vessel disease, such as COL4A1 syndrome, cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), and Hereditary endotheliopathy with retinopathy, nephropathy, and stroke (HERNS). In this article the clinical phenotype for the most important single-gene disorders associated with strokes are presented. The monogenic causes of a stroke are rare, but early diagnosis is important in order to provide appropriate therapy when available.
Collapse
|
21
|
Lim J, Shayota BJ, Lay E, Elsea SH, Bekheirnia MR, Tessier MEM, Kralik SF, Rice GM, Soler-Alfonso C, Scaglia F. Acute Strokelike Presentation and Long-term Evolution of Diffusion Restriction Pattern in Ethylmalonic Encephalopathy. J Child Neurol 2021; 36:841-852. [PMID: 33900143 DOI: 10.1177/08830738211006507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ethylmalonic encephalopathy is a rare autosomal recessive mitochondrial disorder caused by pathogenic biallelic variants in the ETHE1 gene. The phenotype of this disease has been attributed to deficiency in the mitochondrial sulfur dioxygenase leading to many downstream effects. Ethylmalonic encephalopathy classically presents with developmental regression, petechiae, acrocyanosis, and chronic diarrhea. The neurologic phenotype includes hypotonia, spastic diplegia, ataxia, and developmental delay. As more patients with this condition are described, the neurologic phenotype continues to expand. Although strokelike episodes or metabolic strokes have been studied in other mitochondrial disorders, they have not been thoroughly reported in this disorder. Herein, we describe 3 patients with ethylmalonic encephalopathy who presented clinically with strokelike episodes and strokelike abnormalities on brain magnetic resonance imaging in the setting of acute illness, and the long-term sequelae with evolution into cystic changes in one of these subjects.
Collapse
Affiliation(s)
- Jaehyung Lim
- Division of Pediatric Neurology and Developmental Neurosciences, 3989Baylor College of Medicine, Houston, TX, USA
| | - Brian J Shayota
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA
| | - Erica Lay
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA
| | - Sarah H Elsea
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Mir Reza Bekheirnia
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA.,Renal Section, Department of Pediatrics, 3989Baylor College of Medicine, Houston, TX, USA
| | - Mary Elizabeth M Tessier
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology and Nutrition 3989Baylor College of Medicine Houston TX, USA
| | - Stephen F Kralik
- Department of Radiology, 3984Texas Children's Hospital, Houston, TX, USA
| | - Gregory M Rice
- Department of Pediatrics and the Waisman Center, 5232University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Claudia Soler-Alfonso
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA
| | - Fernando Scaglia
- Department of Molecular and Human Genetics, 3989Baylor College of Medicine, Houston, TX, USA.,3984Texas Children's Hospital, Houston, TX, USA.,Joint 3989BCM-CUHK Center of Medical Genetics, Prince of Wales Hospital, Shatin, Hong Kong SAR
| |
Collapse
|
22
|
Vassar R, Mehta N. Pearls & Oy-sters: Symmetric Numbness and Paresthesia Due to Stroke-like Episode in an Adolescent Male With MELAS. Neurology 2021; 97:1006-1008. [PMID: 34376513 DOI: 10.1212/wnl.0000000000012611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Mitochondrial Encephalopathy, Lactic Acidosis, and Stroke-like episodes (MELAS) syndrome is a mitochondrial condition with a wide range of neurologic complications including migraines, seizures, and stroke-like episodes. This case report highlights a rare presentation of bilateral sensory changes related to MELAS and offers an opportunity to consider how a differential diagnosis may need to be modified in patients with underlying mitochondrial disorders. Neurologic symptoms in MELAS may defy classic localization patterns, and early neuroimaging is warranted.
Collapse
Affiliation(s)
- Rachel Vassar
- Child Neurology Residency Program, Department of Neurology, University of California San Francisco, San Francisco, CA
| | - Nehali Mehta
- Child Neurology Residency Program, Department of Neurology, University of California San Francisco, San Francisco, CA
| |
Collapse
|
23
|
Lang AE, Desai D, Desai S, Sethi KD. Commentary: A Boy with Spells of Unusual Movements after Failure in Exam. Mov Disord Clin Pract 2021; 8:S63-S64. [PMID: 34514057 PMCID: PMC8414505 DOI: 10.1002/mdc3.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Anthony E. Lang
- Edmond J. Safra Program in Parkinson's DiseaseUniversity Health NetworkTorontoOntarioCanada
| | - Devangi Desai
- Department of Medicine, Shree Krishna Hospital and Pramukhswami Medical CollegeBhaikaka UniversityKaramsad, AnandIndia
| | - Soaham Desai
- Department of Neurology, Shree Krishna Hospital and Pramukhswami Medical CollegeBhaikaka UniversityKaramsad, AnandIndia
| | - Kapil D. Sethi
- Professor Emeritus of Neurology, Medical College of GeorgiaAugusta UniversityAugustaGeorgia
| |
Collapse
|
24
|
Lee H, Shin JH, Na JH, Lee YM. Clinical Value of Magnetic Resonance Spectroscopy in the Initial Evaluation of Patients with Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes. ANNALS OF CHILD NEUROLOGY 2021. [DOI: 10.26815/acn.2021.00381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
25
|
Wang R, Hu B, Sun C, Geng D, Lin J, Li Y. Metabolic abnormality in acute stroke-like lesion and its relationship with focal cerebral blood flow in patients with MELAS: Evidence from proton MR spectroscopy and arterial spin labeling. Mitochondrion 2021; 59:276-282. [PMID: 34186261 DOI: 10.1016/j.mito.2021.06.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/24/2021] [Accepted: 06/23/2021] [Indexed: 11/29/2022]
Abstract
Our purpose is to detect the metabolic alterations in acute stroke-like lesions (SLLs) and further investigate the correlations between metabolic concentrations and focal cerebral blood flow in patients with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS) using proton MR spectroscopy (1H-MRS) and arterial spin labeling (ASL). A total of 23 patients with MELAS at acute stage of stroke-like episodes (SLEs) and 20 normal controls (NC) were recruited in this study, respectively. All subjects underwent conventional MRI and1H-MRS. In addition, ASL was performed in each patient. The measurements of creatine (Cr), choline (Cho), N-acetyl aspartate (NAA), lactate (Lac), glutamine/glutamate (Glx) levels and the ratios of Cho/Cr, NAA/Cr, Lac/Cr and Glx/Cr in acute SLLs for MELAS patients and left parietal and occipital lobes for NC were measured using LC-model software. Furthermore, in MELAS group, the associations between relative cerebral blood flow (rCBF) and metabolite concentrations in acute SLLs were also assessed. In MELAS group, acute SLLs were identified with metabolic abnormalities and increased rCBF. Specifically, compared with controls, MELAS patients exhibited significantly higher Lac, Cho levels and Lac/Cr, Cho/Cr ratios, and lower NAA, Glx levels and NAA/Cr and Glx/Cr ratios. Moreover, for MELAS patients, Lac concentration in acute SLLs was positively correlated with focal rCBF. This study exhibited the neural injury with increasing lactate and cerebral blood flow in the acute SLEs. It might shed light on the underlying biochemical mechanism of mitochondrial cytopathy and angiopathy in MELAS.
Collapse
Affiliation(s)
- Rong Wang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Bin Hu
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Daoying Geng
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China.
| | - Yuxin Li
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China.
| |
Collapse
|
26
|
Pichon L, Ivanoiu A, Duprez T, Lacomblez D, Wilms G. NEURO-IMAGE: MELAS (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes syndrome). Acta Neurol Belg 2021; 122:1597-1598. [PMID: 33948900 DOI: 10.1007/s13760-021-01694-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/23/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Louise Pichon
- Radiology Department, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Bruxelles, Belgium.
| | - Adrian Ivanoiu
- Neurology Department, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Bruxelles, Belgium
| | - Thierry Duprez
- Radiology Department, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Bruxelles, Belgium
| | - Douglas Lacomblez
- Radiology Department, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Bruxelles, Belgium
| | - Guido Wilms
- Radiology Department, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Bruxelles, Belgium
| |
Collapse
|
27
|
Meyers SP. Intracranial Abnormalities with Diffusion Restriction. Magn Reson Imaging Clin N Am 2021; 29:137-161. [PMID: 33902900 DOI: 10.1016/j.mric.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Multiple pathologic conditions can cause changes in the random movement of water, which can be detected with diffusion-weighted imaging (DWI). DWI plays a powerful clinical role in detecting restricted diffusion associated with acute brain infarction. Other disorders can also result in restricted diffusion. This article focuses on showing examples of common and uncommon disorders that have restricted diffusion secondary to cytotoxic and/or intramyelinic edema. These disorders include ischemia, infection, noninfectious demyelinating diseases, genetic mutations affecting metabolism, acquired metabolic disorders, toxic or drug exposures, neoplasms and tumorlike lesions, radiation treatment, trauma, and denervation.
Collapse
Affiliation(s)
- Steven P Meyers
- Department of Radiology/Imaging Sciences, University of Rochester Medical Center, University Medical Imaging, 4901 Lac de Ville Boulevard, Building D - Suite 140, Rochester, NY 14618, USA.
| |
Collapse
|
28
|
Biswas A, Malhotra M, Mankad K, Carney O, D'Arco F, Muthusamy K, Sudhakar SV. Clinico-radiological phenotyping and diagnostic pathways in childhood neurometabolic disorders-a practical introductory guide. Transl Pediatr 2021; 10:1201-1230. [PMID: 34012862 PMCID: PMC8107844 DOI: 10.21037/tp-20-335] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Inborn errors of metabolism (IEM) although individually rare, together constitute a significant proportion of childhood neurological disorders. Majority of these disorders occur due to deficiency of an enzyme in a specific metabolic pathway, leading to damage by accumulation of a toxic substrate or deficiency of an essential metabolite. Early diagnosis is crucial in many of these conditions to prevent or minimise brain damage. Whilst many of the neuroimaging features are nonspecific, certain disorders demonstrate specific patterns due to selective vulnerability of different structures to different insults. Along with clinical and biochemical profile, neuroimaging thus plays a pivotal role in differentiating metabolic disorders from other causes, in providing a differential diagnosis or suggesting a metabolic pathway derangement, and on occasion also helps make a specific diagnosis. This allows initiation of targeted metabolic and genetic work up and treatment. Familiarity with the clinical features, relevant biochemical features and neuroimaging findings of common metabolic disorders to facilitate a prompt diagnosis cannot thus be overemphasized. In this article, we describe the latest classification scheme, the clinical and biochemical clues and common radiological patterns. The diagnostic algorithm followed in daily practice after clinico-radiological phenotyping is alluded to and illustrated by clinical vignettes. Focused sections on neonatal metabolic disorders and mitochondrial disorders are also provided. The purpose of this article is to provide a brief overview and serve as a practical primer to clinical and radiological phenotypes and diagnostic aspects of IEM.
Collapse
Affiliation(s)
- Asthik Biswas
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Mukul Malhotra
- Department of Neurology, Christian Medical College, Vellore, India
| | - Kshitij Mankad
- Neuroradiology Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Olivia Carney
- Neuroradiology Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Felice D'Arco
- Neuroradiology Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Sniya Valsa Sudhakar
- Neuroradiology Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
29
|
Wang R, Lin J, Sun C, Hu B, Liu X, Geng D, Li Y, Yang L. Topological reorganization of brain functional networks in patients with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes. NEUROIMAGE-CLINICAL 2020; 28:102480. [PMID: 33395972 PMCID: PMC7645289 DOI: 10.1016/j.nicl.2020.102480] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022]
Abstract
MELAS patients showed topological reorganization of brain functional network. Network abnormalities in MELAS patients may be affected by stroke-like lesions. Graph theory based on rs-fMRI may be used for monitoring the status of MELAS.
Mitochondrial encephalomyopathy with lactic acidosis and stroke‐like episodes (MELAS) is a rare maternally inherited genetic disease; however, little is known about its underlying brain basis. Furthermore, the topological organization of brain functional network in MELAS has not been explored. Here, 45 patients with MELAS (22 at acute stage, 23 at chronic stage) and 22 normal controls were studied using resting- state functional magnetic resonance imaging and graph theory analysis approaches. Topological properties of brain functional networks including global and nodal metrics, rich club organization and modularity were analyzed. At the global level, MELAS patients exhibited reduced clustering coefficient, normalized clustering coefficient, normalized characteristic path length and local network efficiency compared with the controls. At the nodal level, several nodes with abnormal degree centrality and nodal efficiency were detected in MELAS patients, and the distribution of these nodes was partly consistent with the stroke-like lesions. For rich club organization, rich club nodes were reorganized and the connections among them were decreased in MELAS patients. Modularity analysis revealed that MELAS patents had altered intra- or inter-modular connections in default mode network, fronto-parietal network, sensorimotor network, occipital network and cerebellum network. Notably, the patients at acute stage showed more obvious changes in these topological properties than the patients at chronic stage. These findings indicated that MELAS patients, particularly those at acute stage, exhibited topological reorganization of the whole-brain functional network. This study may help us to understand the neuropathological mechanisms of MELAS.
Collapse
Affiliation(s)
- Rong Wang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Bin Hu
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Xueling Liu
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Daoying Geng
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Shanghai Institution of Medical Imaging, Shanghai 200032, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China
| | - Yuxin Li
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China.
| | - Liqin Yang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai 200040, China; Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai 200040, China.
| |
Collapse
|
30
|
Wang R, Sun C, Lin J, Chen N, Hu B, Liu X, Geng D, Yang L, Li Y. Altered Dynamic Functional Connectivity in Patients With Mitochondrial Encephalomyopathy With Lactic Acidosis and Stroke-Like Episodes (MELAS) at Acute and Chronic Stages: Shared and Specific Brain Connectivity Abnormalities. J Magn Reson Imaging 2020; 53:427-436. [PMID: 32869426 DOI: 10.1002/jmri.27353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) is a rare maternally inherited genetic disease; however, little is known about its underlying brain basis. Furthermore, the dynamic functional connectivity (dFC) of brain networks in MELAS has not been explored. PURPOSE To investigate the abnormalities of dFC in patients with MELAS at the acute and chronic stages, and to determine the possible relations between dynamic connectivity alterations and volumes of stroke-like lesions (SLLs). STUDY TYPE Prospective. SUBJECTS Twenty-two MELAS patients at the acute stage, 23 MELAS patients at the chronic stage, and 22 healthy controls. FIELD STRENGTH/SEQUENCE Single-shot gradient-recalled echo planar imaging (EPI) sequence at 3T. ASSESSMENT Dynamic FC states were estimated using the sliding window approach and k-means clustering analyses. Combined with graph theory, the topological properties of the dFC network were also accessed. STATISTICAL TESTS Permutation test, Pearson correlation coefficient, and false discovery rate correction. RESULTS We identified four dFC states and found that MELAS patients (especially at the acute stage) spent more time in a state with weaker connectivity (state 1) and less time in states with stronger connectivity. In addition, volumes of acute SLLs were positively correlated with mean dwell time in state 1 (r = 0.539, P < 0.05) and negatively correlated with the number of transitions (r = -0.520, P < 0.05). Furthermore, MELAS patients at the acute stage exhibited significantly increased global efficiency (P < 0.01) and decreased local efficiency (P < 0.001) compared to the controls and the patients at the chronic stage. Patients at the chronic stage only showed significantly (P < 0.001) decreased local efficiency compared to the controls. DATA CONCLUSION Our findings suggest similar and distinct dFC alterations in MELAS patents at the acute and chronic stages, providing novel insights for understanding the neuropathological mechanisms of MELAS. Level of Evidence 2 Technical Efficacy Stage Stage 2 J. MAGN. RESON. IMAGING 2021;53:427-436.
Collapse
Affiliation(s)
- Rong Wang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai, China.,Shanghai Institution of Medical Imaging, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Ne Chen
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Bin Hu
- Shanghai Institution of Medical Imaging, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Xueling Liu
- Shanghai Institution of Medical Imaging, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Daoying Geng
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai, China.,Shanghai Institution of Medical Imaging, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Liqin Yang
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| | - Yuxin Li
- Department of Radiology, HuaShan Hospital, Fudan University, Shanghai, China.,Institute of Functional and Molecular Medical Imaging, Fudan University, Shanghai, China
| |
Collapse
|
31
|
Sharma H, Singh D, Mahant A, Sohal SK, Kesavan AK, Samiksha. Development of mitochondrial replacement therapy: A review. Heliyon 2020; 6:e04643. [PMID: 32984570 PMCID: PMC7492815 DOI: 10.1016/j.heliyon.2020.e04643] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/10/2020] [Accepted: 08/03/2020] [Indexed: 12/19/2022] Open
Abstract
Mitochondrial replacement therapy (MRT) is a new form of reproductive invitro fertilization (IVF) which works on the principle of replacing a women's abnormal mitochondrial DNA (mt-DNA) with the donor's healthy one. MRT include different techniques like spindles transfer (ST), pronuclear transfer (PNT) or polar body transfer (PBT). Transmission of defective mitochondrial DNA to the next generation can also be prevented by using these approaches. The development of healthy baby free from genetic disorders and to terminate the lethal mitochondrial disorders are the chief motive of this technique. In aged individuals, through in vitro fertilization, MRT provides the substitution of defective cytoplasm with cured one to enhance the expectation of pregnancy rates. However, moral, social, and cultural objections have restricted its exploration. Therefore, this review summarizes the various methods involved in MRT, its global status, its exaggerated censure over the years which depicts a strong emphasis for social acceptance and clinical application in the world of medical science.
Collapse
Affiliation(s)
- Hitika Sharma
- Department of Zoology, Khalsa College Amritsar, Punjab, 143005, India
| | - Drishtant Singh
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | | | - Satwinder Kaur Sohal
- Department of Zoology, Guru Nanak Dev University Amritsar, Punjab, 143005, India
| | - Anup Kumar Kesavan
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, Punjab, 143005, India
| | - Samiksha
- Department of Zoology, Guru Nanak Dev University Amritsar, Punjab, 143005, India
| |
Collapse
|
32
|
Finsterer J. The metabolic hypothesis is more likely than the epileptogenic hypothesis to explain stroke-like lesions. Wellcome Open Res 2020; 5:51. [PMID: 32647751 PMCID: PMC7324943 DOI: 10.12688/wellcomeopenres.15758.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 11/20/2022] Open
Abstract
Stroke-like episodes (SLEs) are a hallmark of mitochondrial encephalopathy, lactic acidosis, and stroke-like episode (MELAS) syndrome but occur in other mitochondrial disorders (MIDs) as well. The morphological equivalent of the SLE is the stroke-like lesion (SLL) on magnetic resonance imaging (MRI). The pathophysiology of SLLs is under debate, but several hypotheses have been raised to explain the phenomenon. Of these, the metabolic, epileptogenic, and vascular hypotheses are the most frequently discussed. There are several arguments for and against these hypotheses, but a consensus has not been reached which of them provides the correct explanation. A recent consensus statement generated by a panel of experts applying the Delphi method, favoured the epileptogenic hypothesis and recommended treatment of SLEs with antiepileptic drugs, irrespective if the patient presented with a seizure or epileptiform discharges on electroencephalography (EEG) or not. We disagree with this general procedure and provide the following arguments against the epileptogenic hypothesis: 1. not each SLE is associated with seizures. 2. epileptiform discharges may be absent on EEG during a SLE. 3. SLLs are not restricted to the cortex. 4. antiseizure-drugs (ASDs) may not prevent the progression or recurrence of a SLL. 5. ASDs may terminate seizures but no other phenotypic feature of a SLE. 6. patients already under ASDs are not immune from developing a SLL. 7. SLLs usually last longer than seizures. 8. no animal model supports the epileptogenic hypothesis. The strongest arguments for the metabolic hypothesis are that SLLs are not confined to a vascular territory, that the oxygen-extraction fraction within a SLL is reduced, and that there is hypometabolism within a SLL on FDG-PET. SLLs may respond to antioxidants, NO-precursors, steroids, or the ketogenic diet. ASDs should be applied only if there is clinical or electrophysiological evidence of seizure-activity.
Collapse
Affiliation(s)
- Josef Finsterer
- Krankenanstalt Rudolfstiftung, Messerli Institute, Vienna, 1180, Austria
| |
Collapse
|
33
|
Finsterer J. The metabolic hypothesis is more likely than the epileptogenic hypothesis to explain stroke-like lesions. Wellcome Open Res 2020; 5:51. [DOI: 10.12688/wellcomeopenres.15758.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2020] [Indexed: 11/20/2022] Open
Abstract
Stroke-like episodes (SLEs) are a hallmark of mitochondrial encephalopathy, lactic acidosis, and stroke-like episode (MELAS) syndrome but occur in other mitochondrial disorders (MIDs) as well. The morphological equivalent of the SLE is the stroke-like lesion (SLL) on magnetic resonance imaging (MRI). The pathophysiology of SLLs is under debate, but several hypotheses have been raised to explain the phenomenon. Of these, the metabolic, epileptogenic, and vascular hypotheses are the most frequently discussed. There are several arguments for and against these hypotheses, but a consensus has not been reached which of them provides the correct explanation. A recent consensus statement generated by a panel of experts applying the Delphi method, favoured the epileptogenic hypothesis and recommended treatment of SLEs with antiepileptic drugs, irrespective if the patient presented with a seizure or epileptiform discharges on electroencephalography (EEG) or not. We disagree with this general procedure and provide the following arguments against the epileptogenic hypothesis: 1. not each SLE is associated with seizures. 2. epileptiform discharges may be absent on EEG during a SLE. 3. SLLs are not restricted to the cortex. 4. antiseizure-drugs (ASDs) may not prevent the progression or recurrence of a SLL. 5. ASDs may terminate seizures but no other phenotypic feature of a SLE. 6. patients already under ASDs are not immune from developing a SLL. 7. SLLs usually last longer than seizures. 8. no animal model supports the epileptogenic hypothesis. The strongest arguments for the metabolic hypothesis are that SLLs are not confined to a vascular territory, that the oxygen-extraction fraction within a SLL is reduced, and that there is hypometabolism within a SLL on FDG-PET. SLLs may respond to antioxidants, NO-precursors, steroids, or the ketogenic diet. ASDs should be applied only if there is clinical or electrophysiological evidence of seizure-activity.
Collapse
|
34
|
Finsterer J. Stroke-like Episodes in m.3243A≥G Carriers Need to Be Monitored by MRI Starting with the Onset of Clinical Manifestations. AJNR Am J Neuroradiol 2020; 41:E17-E18. [PMID: 32029472 DOI: 10.3174/ajnr.a6418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- J Finsterer
- Krankenanstalt RudolfstiftungMesserli InstituteVienna, Austria
| |
Collapse
|