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Cani I, Sambati L, Bartiromo F, Asioli GM, Baiardi S, Belotti LMB, Giannini G, Guaraldi P, Quadalti C, Romano L, Lodi R, Parchi P, Cortelli P, Tonon C, Calandra-Buonaura G. Cognitive profile in idiopathic autonomic failure: relation with white matter hyperintensities and neurofilament levels. Ann Clin Transl Neurol 2022; 9:864-876. [PMID: 35582924 PMCID: PMC9186146 DOI: 10.1002/acn3.51567] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/27/2022] [Accepted: 04/17/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To disclose the nature of cognitive deficits in a cohort of patients with idiopathic autonomic failure (IAF) by exploring the relation among cognitive functions, cardiovascular autonomic failure (AF) and clinical progression to another α-synucleinopathy (phenoconversion). METHODS We retrospectively identified all patients with a clinical diagnosis of IAF who underwent a comprehensive neuropsychological evaluation, clinical examination and cardiovascular autonomic tests from the IAF-BO cohort. Brain magnetic resonance imaging (MRI) studies and cerebrospinal fluid (CSF) analysis, including neurofilament light chain (NfL), Alzheimer disease core biomarkers, and α-synuclein seeding activity were further evaluated when available. Correlations among cognitive functions, clinical features, cardiovascular AF, cerebral white matter hyperintensities (WMH) load, and CSF biomarkers were estimated using Spearman correlation coefficient. RESULTS Thirteen out of 30 (43%) patients with IAF displayed cognitive deficits (CI) mainly concerning executive functioning. Seven out of 30 (23%) met the criteria for mild cognitive impairment (MCI). The diagnosis of CI and MCI was not associated with phenoconversion or autonomic function parameters, including duration and severity of neurogenic orthostatic hypotension, presence and severity of supine hypertension, and nocturnal dipper profile. Twenty patients underwent a brain MRI and CSF analysis. MCI was related to WMH load (r = 0.549) and NfL levels (r = 0.656), while autonomic function parameters were not associated with either WMH or NfL levels. INTERPRETATION Cardiovascular AF and phenoconversion, underlying the spreading of neurodegeneration to the central nervous system, were not independent drivers of cognitive dysfunction in IAF. We identified WMH load and NfL levels as potential biomarkers of the neural network disruption associated with cognitive impairment in patients with IAF.
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Affiliation(s)
- Ilaria Cani
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Luisa Sambati
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Fiorina Bartiromo
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Gian Maria Asioli
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Simone Baiardi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy.,Department of Experimental Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Laura M B Belotti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Pietro Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Corinne Quadalti
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Luciano Romano
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Piero Parchi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy.,Department of Experimental Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Pietro Cortelli
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
| | - Giovanna Calandra-Buonaura
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), Alma Mater Studiorum - University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Via Altura, 3, 40139, Bologna, Italy
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Abstract
Multiple system atrophy (MSA) is a progressive neurodegenerative disease variably associated with motor, nonmotor, and autonomic symptoms, resulting from putaminal and cerebellar degeneration and associated with glial cytoplasmic inclusions enriched with α-synuclein in oligodendrocytes and neurons. Although symptomatic treatment of MSA can provide significant improvements in quality of life, the benefit is often partial, limited by adverse effects, and fails to treat the underlying cause. Consistent with the multisystem nature of the disease and evidence that motor symptoms, autonomic failure, and depression drive patient assessments of quality of life, treatment is best achieved through a coordinated multidisciplinary approach driven by the patient's priorities and goals of care. Research into disease-modifying therapies is ongoing with a particular focus on synuclein-targeted therapies among others. This review focuses on both current management and emerging therapies for this devastating disease.
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Affiliation(s)
- Matthew R. Burns
- Norman Fixel Institute for Neurological Diseases at UFHealth, Movement Disorders Division, Department of Neurology, University of Florida, 3009 SW Williston Rd, Gainesville, FL 32608 USA
| | - Nikolaus R. McFarland
- Norman Fixel Institute for Neurological Diseases at UFHealth, Movement Disorders Division, Department of Neurology, University of Florida, 3009 SW Williston Rd, Gainesville, FL 32608 USA
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Palma JA, Norcliffe-Kaufmann L, Kaufmann H. Diagnosis of multiple system atrophy. Auton Neurosci 2018; 211:15-25. [PMID: 29111419 PMCID: PMC5869112 DOI: 10.1016/j.autneu.2017.10.007] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 02/08/2023]
Abstract
Multiple system atrophy (MSA) may be difficult to distinguish clinically from other disorders, particularly in the early stages of the disease. An autonomic-only presentation can be indistinguishable from pure autonomic failure. Patients presenting with parkinsonism may be misdiagnosed as having Parkinson disease. Patients presenting with the cerebellar phenotype of MSA can mimic other adult-onset ataxias due to alcohol, chemotherapeutic agents, lead, lithium, and toluene, or vitamin E deficiency, as well as paraneoplastic, autoimmune, or genetic ataxias. A careful medical history and meticulous neurological examination remain the cornerstone for the accurate diagnosis of MSA. Ancillary investigations are helpful to support the diagnosis, rule out potential mimics, and define therapeutic strategies. This review summarizes diagnostic investigations useful in the differential diagnosis of patients with suspected MSA. Currently used techniques include structural and functional brain imaging, cardiac sympathetic imaging, cardiovascular autonomic testing, olfactory testing, sleep study, urological evaluation, and dysphagia and cognitive assessments. Despite advances in the diagnostic tools for MSA in recent years and the availability of consensus criteria for clinical diagnosis, the diagnostic accuracy of MSA remains sub-optimal. As other diagnostic tools emerge, including skin biopsy, retinal biomarkers, blood and cerebrospinal fluid biomarkers, and advanced genetic testing, a more accurate and earlier recognition of MSA should be possible, even in the prodromal stages. This has important implications as misdiagnosis can result in inappropriate treatment, patient and family distress, and erroneous eligibility for clinical trials of disease-modifying drugs.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, NY, USA.
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Norcliffe-Kaufmann L, Kaufmann H, Palma JA, Shibao CA, Biaggioni I, Peltier AC, Singer W, Low PA, Goldstein DS, Gibbons CH, Freeman R, Robertson D. Orthostatic heart rate changes in patients with autonomic failure caused by neurodegenerative synucleinopathies. Ann Neurol 2018; 83:522-531. [PMID: 29405350 PMCID: PMC5867255 DOI: 10.1002/ana.25170] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Blunted tachycardia during hypotension is a characteristic feature of patients with autonomic failure, but the range has not been defined. This study reports the range of orthostatic heart rate (HR) changes in patients with autonomic failure caused by neurodegenerative synucleinopathies. METHODS Patients evaluated at sites of the U.S. Autonomic Consortium (NCT01799915) underwent standardized autonomic function tests and full neurological evaluation. RESULTS We identified 402 patients with orthostatic hypotension (OH) who had normal sinus rhythm. Of these, 378 had impaired sympathetic activation (ie, neurogenic OH) and based on their neurological examination were diagnosed with Parkinson disease, dementia with Lewy bodies, pure autonomic failure, or multiple system atrophy. The remaining 24 patients had preserved sympathetic activation and their OH was classified as nonneurogenic, due to volume depletion, anemia, or polypharmacy. Patients with neurogenic OH had twice the fall in systolic blood pressure (SBP; -44 ± 25 vs -21 ± 14 mmHg [mean ± standard deviation], p < 0.0001) but only one-third of the increase in HR of those with nonneurogenic OH (8 ± 8 vs 25 ± 11 beats per minute [bpm], p < 0.0001). A ΔHR/ΔSBP ratio of 0.492 bpm/mmHg had excellent sensitivity (91.3%) and specificity (88.4%) to distinguish between patients with neurogenic from nonneurogenic OH (area under the curve = 0.96, p < 0.0001). Within patients with neurogenic OH, HR increased more in those with multiple system atrophy (p = 0.0003), but there was considerable overlap with patients with Lewy body disorders. INTERPRETATION A blunted HR increase during hypotension suggests a neurogenic cause. A ΔHR/ΔSBP ratio < 0.5 bpm/mmHg is diagnostic of neurogenic OH. Ann Neurol 2018;83:522-531.
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Affiliation(s)
- Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Cyndya A. Shibao
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Italo Biaggioni
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | - Amanda C. Peltier
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - David S. Goldstein
- Clinical Neurocardiology Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD
| | - Christopher H. Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Robertson
- Departments of Medicine and Pharmacology, Vanderbilt University Medical Center, Nashville, TN
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