Conversion of individuals at risk for spinocerebellar ataxia types 1, 2, 3, and 6 to manifest ataxia (RISCA): a longitudinal cohort study

BACKGROUND

Spinocerebellar ataxias (SCAs) are autosomal dominant neurodegenerative diseases. Our aim was to study the conversion to manifest ataxia among apparently healthy carriers of mutations associated with the most common SCAs (SCA1, SCA2, SCA3, and SCA6), and the sensitivity of clinical and functional measures to detect change in these individuals.

METHODS

In this prospective, longitudinal, observational cohort study, based at 14 referral centres in seven European countries, we enrolled children or siblings of patients with SCA1, SCA2, SCA3, or SCA6. Eligible individuals were those without ataxia, defined by a score on the Scale for the Assessment and Rating of Ataxia (SARA) of less than 3; participants had to be aged 18-50 years for children or siblings of patients with SCA1, SCA2, or SCA3, and 35-70 years for children or siblings of patients with SCA6. Study visits took place at recruitment and after 2, 4, and 6 years (plus or minus 3 months). We did genetic testing to identify mutation carriers, with results concealed to the participant and clinical investigator. We assessed patients with clinical scales, questionnaires of patient-reported outcome measures, a rating of the examiner's confidence of presence of ataxia, and performance-based coordination tests. Conversion to ataxia was defined by an SARA score of 3 or higher. We analysed the association of factors at baseline with conversion to ataxia and the evolution of outcome parameters on temporal scales (time from inclusion and time to predicted age at ataxia onset) in the context of mutation status and conversion status. This study is registered with ClinicalTrials.gov, NCT01037777.

FINDINGS

Between Sept 13, 2008, and Oct 28, 2015, 302 participants were enrolled. We analysed data for 252 participants with at least one follow-up visit. 83 (33%) participants were from families affected by SCA1, 99 (39%) by SCA2, 46 (18%) by SCA3, and 24 (10%) by SCA6. In participants who carried SCA mutations, 26 (52%) of 50 SCA1 carriers, 22 (59%) of 37 SCA2 carriers, 11 (42%) of 26 SCA3 carriers, and two (13%) of 15 SCA6 carriers converted to ataxia. One (3%) of 33 SCA1 non-carriers and one (2%) of 62 SCA2 non-carriers converted to ataxia. Owing to the small number of people who met our criteria for ataxia, subsequent analyses could not be done in carriers of the SCA6 mutation. Baseline factors associated with conversion were age (hazard ratio 1·13 [95% CI 1·03-1·24]; p=0·011), CAG repeat length (1·25 [1·11-1·41]; p=0·0002), and ataxia confidence rating (1·72 [1·23-2·41]; p=0·0015) for SCA1; age (1·08 [1·02-1·14]; p=0·0077) and CAG repeat length (1·65 [1·27-2·13]; p=0·0001) for SCA2; and age (1·27 [1·09-1·50]; p=0·0031), confidence rating (2·60 [1·23-5·47]; p=0·012), and double vision (14·83 [2·15-102·44]; p=0·0063) for SCA3. From the time of inclusion, the SARA scores of SCA1, SCA2, and SCA3 mutation carriers increased, whereas they remained stable in non-carriers. On a timescale defined by the predicted time of ataxia onset, SARA progression in SCA1, SCA2, and SCA3 mutation carriers was non-linear, with marginal progression before ataxia and increasing progression after ataxia onset.

INTERPRETATION

Our study provides quantitative data on the conversion of non-ataxic SCA1, SCA2, and SCA3 mutation carriers to manifest ataxia. Our data could prove useful for the design of preventive trials aimed at delaying the onset of ataxia by aiding sample size calculations and stratification of study participants.

FUNDING

European Research Area Network for Research Programmes on Rare Diseases, Polish Ministry of Science and Higher Education, Italian Ministry of Health, European Community's Seventh Framework Programme.

P1326 Recurrent isolated pulmonary valve endocarditis complicated by heart failure, septic pulmonary embolism and multiple lung abscesses in an intravenous drug abuser

Background

Right-sided infective endocarditis (IE) ( 5-10% of all IE cases)is the most frequently observed in intravenous drug abusers (IVDA) with tricuspid valve as the most predominant site. Isolated pulmonary valve IE is an extremely rare entity in adults.

Case report

27-year-old women, IVDA for 15 years, was admitted to the hospital due to fever and severe shortness of breath. Her past history was significant for isolated pulmonary valve IE of methicillin-susceptible Staphylococcus aureus 9 months before with mild pulmonary regurgitation and normal right ventricular (RV) function at discharge after medical treatment. At admission on physical examination, the patient showed tachycardia 140/’, tachypnoea, hypotension and crackles. Initial chest X-ray documented massive bilateral infiltrates. Laboratory tests showed highly elevated inflammatory markers and anaemia. Transthoracic echocardiography (TTE) revealed large (36 x 20 mm) very mobile vegetations on the pulmonary valve (Fig A), pulmonary trunk dilatation, mild pulmonary regurgitation and moderate pericardial effusion. No sign of IE was found on the tricuspid valve (Fig C), which presented anterior leaflet prolapse with mild regurgitation. Computed tomography (CT) revealed numerous cavitary infiltrates in both lungs surrounded by ground-glass opacification. Blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was started on vancomycin. On day seven the patient status worsened with symptoms of heart failure and elevated pro-BNP up to 2833pg/ml. TTE revealed severe pulmonary regurgitation (Fig B) with pulmonary hypertension and RV dysfunction (Fig D). Repeated CT showed pulmonary embolism (PE), RV enlargement and multiple abscesses in both lungs. The patient was consulted with cardio surgeon but the intervention was denied and medical treatment was continued with vancomycin, gentamicin, rifampin, glicocorticoids, enoxaparin, betablockers, digoxin and diuretics. Under serial TTE and CT control antibiotics were continued up to 10 weeks. Ultimately patient was discharged in relatively good condition without any symptoms of heart or respiratory failure with smaller vegetation (15-16mm) on the pulmonary valve but with severe pulmonary regurgitation and mild RV enlargement and dysfunction in TTE and significant regression of pulmonary lesions and PE in CT.

Discussion

With respect to the high recurrence rate of right-sided IE in IVADs surgery should generally be avoided. A prolonged course of parental antibiotics is recommended in cases with lung abscesses.

Conclusions

We report a case of recurrent isolated pulmonary valve IE and extensive complications but with a positive outcome. Pulmonary valve IE is very rare in IVADs but requires early as well as serial multimodality imaging in the diagnostic workup.

Abstract P1326 Figure. TTE of complicated pulmonary valve IE

Sphenopalatine Ganglion Stimulation to Augment Cerebral Blood Flow

Background and Purpose—

Many patients with acute ischemic stroke are not eligible for thrombolysis or mechanical reperfusion therapies due to contraindications, inaccessible vascular occlusions, late presentation, or large infarct core. Sphenopalatine ganglion (SPG) stimulation to enhance collateral flow and stabilize the blood-brain barrier offers an alternative, potentially more widely deliverable, therapy.

Methods—

In a randomized, sham-controlled, double-masked trial at 41 centers in 7 countries, patients with anterior circulation ischemic stroke not treated with reperfusion therapies within 24 hours of onset were randomly allocated to active SPG stimulation or sham control. The primary efficacy outcome was improvement beyond expectations on the modified Rankin Scale of global disability at 90 days (sliding dichotomy), assessed in the modified intention-to-treat population. The initial planned sample size was 660 patients, but the trial was stopped early when technical improvements in device placement occurred, so that analysis of accumulated experience could be conducted to inform a successor trial.

Results—

Among 303 enrolled patients, 253 received at least one active SPG or sham stimulation, constituting the modified intention-to-treat population (153 SPG stimulation and 100 sham control). Age was median 73 years (interquartile range, 64–79), 52.6% were female, deficit severity on the National Institutes of Health Stroke Scale was median 11 (interquartile range, 9–15), and time from last known well median 18.6 hours (interquartile range, 14.5–22.5). For the primary outcome, improved 3-month disability beyond expectations, rates in the SPG versus sham treatment groups were 49.7% versus 40.0%; odds ratio, 1.48 (95% CI, 0.89–2.47); P =0.13. A significant treatment interaction with stroke location (cortical versus noncortical) was noted, P =0.04. In the 87 patients with confirmed cortical involvement, rates of improvement beyond expectations were 50.0% versus 27.0%; odds ratio, 2.70 (95% CI, 1.08–6.73); P =0.03. Similar response patterns were observed for all prespecified secondary efficacy outcomes. No differences in mortality or serious adverse event safety end points were observed.

Conclusions—

SPG stimulation within 24 hours of onset is safe in acute ischemic stroke. SPG stimulation was not shown to statistically significantly improve 3-month disability above expectations, though favorable outcomes were nominally higher with SPG stimulation. Beneficial effects may distinctively be conferred in patients with confirmed cortical involvement. The results of this study need to be confirmed in a larger pivotal study.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT03767192.

Autoimmune meningitis and encephalitis in adult-onset still disease - Case report

INTRODUCTION

Adult-onset Still disease (AOSD) is a rare systemic inflammatory disease of unknown cause. Its symptoms usually include persistent fever, fugitive salmon-colored rash, arthritis, sore throat (not specific), but it may also lead to internal organs' involvement, which presents with enlargement of the liver and spleen, swollen lymph nodes, carditis or pleuritis - potentially life-threatening complications. In rare cases, AOSD can cause aseptic meningitis or/and encephalitis.

CASE PRESENTATION

We report a case of 31-year-old male patient, who was referred to neurological department for extending diagnostics of frontal lobes lesions with involvement of adjacent meninges. Abnormalities have been revealed in brain MRI, which was performed due to persistent headaches, visual disturbances, fever, fatigue and cognitive decline. Wide differential diagnosis was performed including laboratory findings, contrast enhanced MRI, MR spectroscopy, flow cytometry and finally brain biopsy to exclude neoplastic or infectious origin. Final diagnosis of autoimmune meningoencephalitis in adult-onset Still disease has been made.

CONCLUSION

Adult-onset Still disease is a rare cause of inflammatory changes in central nervous system, which if diagnosed, may be treated successfully with steroids (commonly available agent), intravenous immunoglobulins or more specific immunomodulating regiments.

Variants of cerebral arteries - anterior circulation

Advances in imaging techniques allow for in vivo identification of abnormalities and normal variants of cerebral arteries. These arterial variations can be asymptomatic and uncomplicated although, some of them increase the risk of aneurysm formation, acute intracranial hemorrhage, play a vital role in neurosurgical planning or can be misidentified as serious pathology and medical errors. The goal of this publication is to discuss arterial anomalies of anterior cerebral circulation, their prevalence and demonstrate radiological images of some of those variants. In this article we will discuss variants of internal carotid artery, anterior cerebral artery, anterior communicating artery, middle cerebral artery, persistent stapedial artery and fenestration.

MRI brain findings in ephedrone encephalopathy associated with manganese abuse: Single-center perspective

BACKGROUND

Manganese (Mn) is a well-known toxic agent causing symptoms of parkinsonism in employees of certain branches of industry. Home production of a psychostimulant ephedrone (methcathinone), involving the use of potassium permanganate, became a new cause of intoxications in Poland.

CASE REPORT

This article presents clinical symptoms, initial brain MRI findings and characteristics of changes observed in follow-up examinations in 4 patients with manganese intoxication associated with intravenous administration of ephedrone. All patients in our case series presented symptoms of parkinsonism. T1-WI MRI revealed high intensity signal in globi pallidi in all patients; hyperintense lesions in midbrain were observed in three patients, while lesions located in cerebellar hemispheres and pituitary gland in just one patient. The reduction of signal intensity in the affected brain structures was observed in follow-up studies, with no significant improvement in clinical symptoms.

CONCLUSIONS

Brain MRI is helpful in the assessment of distribution as well as dynamics of changes in ephedrone encephalopathy. Regression of signal intensity changes visible in brain MRI is not associated with clinical condition improvement. Although brain MRI findings are not characteristic for ephedrone encephalopathy, they may contribute to diagnosing this condition.