Prenatal ultrasound diagnosis of Down syndrome. After major malformations, soft markers, nuchal translucency and skeletal signs, a new vascular sign?

Vascular defects of DYRK1A knockouts are ameliorated by modulating calcium signaling in zebrafish

DYRK1A is a major causative gene in Down syndrome (DS). Reduced incidence of solid tumors such as neuroblastoma in DS patients and increased vascular anomalies in DS fetuses suggest a potential role of DYRK1A in angiogenic processes, but in vivo evidence is still scarce. Here, we used zebrafish dyrk1aa mutant embryos to understand DYRK1A function in cerebral vasculature formation. Zebrafish dyrk1aa mutants exhibited cerebral hemorrhage and defects in angiogenesis of central arteries in the developing hindbrain. Such phenotypes were rescued by wild-type dyrk1aa mRNA, but not by a kinase-dead form, indicating the importance of DYRK1A kinase activity. Chemical screening using a bioactive small molecule library identified a calcium chelator, EGTA, as one of the hits that most robustly rescued the hemorrhage. Vascular defects of mutants were also rescued by independent modulation of calcium signaling by FK506. Furthermore, the transcriptomic analyses supported the alterations of calcium signaling networks in dyrk1aa mutants. Together, our results suggest that DYRK1A plays an essential role in angiogenesis and in maintenance of the developing cerebral vasculature via regulation of calcium signaling, which may have therapeutic potential for DYRK1A-related vascular diseases.

Summary: The roles of DYRK1A in angiogenesis and maintenance of the developing cerebral vasculature mediated by calcium signaling were revealed using zebrafish dyrk1aa knockout mutants.

Adult-onset seizures in a patient with Down syndrome and portosystemic shunt

OBJECTIVE

The prevalence of epilepsy in patients with Down syndrome (DS) is 5-13%, which is higher than the prevalence in the general population. Transient hyperammonemia is often observed following seizure, but it typically resolves within a day. Here, we describe the case a 37-year-old woman who had DS and a history of adult-onset epilepsy and was admitted to our hospital with recurrent seizures. After admission, her ammonia levels fluctuated without any apparent cause, and dynamic computed tomography revealed a portosystemic shunt. The findings suggest that her seizures possibly precipitated from hyperammonemia secondary to a portosystemic shunt, and we reviewed the relevant literature.

METHODS

We conducted PubMed, Web of Science, and EMBASE searches without language restrictions for articles published between 1970 and February 2013.

RESULTS

In addition to the present case, 7 cases were ultimately included in this review. Four patients were newborns, 2 patients were 1 month old, and 1 patient was 3 years old. No adult cases were described until now.

CONCLUSION

Adult patients with DS diagnosed with epilepsy are not routinely assessed for portosystemic venous shunts. Measuring ammonia levels in patients with DS the day after admission would help detect portosystemic shunts, even if the patients have been previously diagnosed with epilepsy.

PRACTICE IMPLICATIONS

If ammonia levels fluctuate without any apparent cause after seizure, dynamic computed tomography should be performed, especially for patients with DS, whether or not they have been previously diagnosed with epilepsy.

Alzheimer's disease and vascular deficiency: lessons from imaging studies and down syndrome

Down syndrome (DS) individuals are at high risk for developing Alzheimer's disease (AD) and consequently provide a unique opportunity to examine the factors leading to the onset of AD. This paper focuses on the neglected vascular parallels between AD and DS that can readily be examined in DS. Several recent AD studies provide evidence that internal jugular vein (IJV) reflux may result in white matter lesions and a 30% decrease in cerebrospinal fluid (CSF) clearance of amyloid-β. At the same time, studies analyzing the synthesis of amyloid-β in DS showed greater than expected amounts of Aβ than would be predicted by the increase in gene dosage, perhaps due to slower clearance. These studies are discussed along with the possibility that the venous and CSF dysfunction found in AD patients may be present early in life in persons with DS, leaving them particularly vulnerable to early onset AD. Studying IJV function in DS provides an opportunity to understand the role of vascular function in the initiation of AD.

Portal vascular anomalies in Down syndrome: spectrum of clinical presentation and management approach

PURPOSE

The occurrence of portal vascular anomalies in Down syndrome has been sporadically reported in the literature. These rare disorders have a wide spectrum of anatomical and clinical presentations. The aim of this communication was to describe the clinical course, imaging features, and management approaches in patients with this association.

METHODS

We conducted a comprehensive search of the databases of the Vascular Anomalies Center and the Department of Radiology at Children's Hospital Boston for patients with Down syndrome and portal vascular anomalies. Medical records and imaging studies of varying modalities were reviewed.

RESULTS

Three children with Down syndrome and portal anomalies (portosystemic shunt, simple arterioportal shunt, complex arterioportal shunt) were managed at our institution. The portosystemic shunt was clinically insignificant and resolved without any intervention. The simple arterioportal shunt was successfully treated with embolization. The complex arterioportal shunt was associated with major congenital cardiac defects and the child ultimately expired despite a decrease in the arterioportal shunting after embolization.

CONCLUSIONS

Three is a wide spectrum of clinical and anatomical features of portal vascular shunts in Down syndrome. The management approach should be tailored based on the severity of symptoms. Percutaneous embolization can offer a safe, effective, and minimally invasive alternative to the surgical approach in selective cases.

Fetal echocardiography at the time of the nuchal translucency scan

OBJECTIVE

The fetal heart is not studied routinely in the first trimester because of technical and time limitations. Our aim was to assess the feasibility of performing a fetal cardiac study in pregnancies referred for nuchal translucency (NT) screening, using high-frequency linear transabdominal transducers with a specific ultrasound preset.

METHODS

A single trained operator assessed the fetal heart in pregnancies with a fetal crown-rump length (CRL) of 60-84 mm that had been referred for NT screening. A 15- or 6-MHz transabdominal linear transducer with a specific preset suitable mainly for color-flow mapping was used to confirm or refute normal cardiac anatomy rather than to establish a specific diagnosis. Fetuses having an increased risk for congenital heart disease were referred to a tertiary center for a further examination within 1 week. This group consisted of all fetuses with NT > 95(th) centile and those in which a family history or the initial heart scan increased the risk.

RESULTS

A total of 608 fetuses with a median CRL of 65 mm was examined between 2003 and 2005. A cardiac scan was performed successfully in 456 (75%) using a 15-MHz linear transducer alone, and the additional use of a 6-MHz transducer allowed diagnostic images to be obtained in a further 152. Normal cardiac anatomy was assessed confidently within 10 min in 517/608 (85%) pregnancies; in 85 (14%) a longer time was needed and six patients were rescheduled within 2 weeks because of non-diagnostic images at the initial scan. In 571/608 (94%) the risk for congenital heart disease (CHD) was not increased and the heart was considered normal at initial echocardiography; this was confirmed by later scans and at postnatal follow-up. In 37/608 (6%) fetuses the risk for CHD was increased (35 for NT > 95(th) centile and two for family history). In this group normal heart anatomy was described in 34 fetuses and confirmed by subsequent specialist echocardiography. Cardiac defects were suspected in three fetuses (all with increased NT) and confirmed by a fetal cardiologist in each case.

CONCLUSIONS

A trained operator can perform a fetal heart study during the NT screening test using transabdominal high-resolution transducers in an acceptable length of time.