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Parker LE, Wallace K, Thevathasan A, Funk E, Pratt M, Thamby J, Tran L, Prange L, Uchitel J, Boggs A, Minton M, Jasien J, Nagao KJ, Richards A, Cruse B, De-Lisle Dear G, Landstrom AP, Mikati MA. Characterization of sedation and anesthesia complications in patients with alternating hemiplegia of childhood. Eur J Paediatr Neurol 2022; 38:47-52. [PMID: 35390560 DOI: 10.1016/j.ejpn.2022.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/05/2022] [Accepted: 03/17/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Alternating hemiplegia of childhood (AHC) pathophysiology suggests predisposition to sedation and anesthesia complications. GOALS Hypotheses: 1) AHC patients experience high rates of sedation-anesthesia complications. 2) ATP1A3 mutation genotype positivity, age, and AHC severity correlate with more severe complications. 3) Prior short QTc correlates with cardiac rhythm complications. METHODS Analysis of 34 consecutive AHC patients who underwent sedation or anesthesia. Classification of complications: mild (not requiring intervention), moderate (intervention), severe (intervention, risk for permanent injury or potential life-threatening emergency). STATISTICS Fisher Exact test, Spearman correlations. RESULTS These patients underwent 129 procedures (3.79 ± 2.75 procedures/patient). Twelve (35%) experienced complications during at least one procedure. Fourteen/129 procedures (11%) manifested one or more complications (2.3% mild, 7% moderate, 1.6% severe). Of the total 20 observed complications, six (33.3%) were severe: apneas (2), seizures (2), bradycardia (1), ventricular fibrillation that responded to resuscitation (1). Moderate complications: non-life-threatening bradycardias, apneas, AHC spells or seizures. Complications occurred during sedation or anesthesia and during procedures or recovery periods. Patients with disease-associated ATP1A3 variants were more likely to have moderate or severe complications. There was no correlation between complications and age or AHC severity. Presence of prior short QTc correlated with cardiac rhythm complications. After this series was analyzed, another patient had severe recurrent laryngeal dystonia requiring tracheostomy following anesthesia with intubation. CONCLUSIONS During sedation or anesthesia, AHC patients, particularly those with ATP1A3 variants and prior short QTc, are at risk for complications consistent with AHC pathophysiology. Increased awareness is warranted during planning, performance, and recovery from such procedures.
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Affiliation(s)
- Lauren E Parker
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States; Department of Pediatrics, Division of Cardiology, and Department of Cell Biology, Duke University School of Medicine, Durham, NC, United States
| | - Keri Wallace
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Arthur Thevathasan
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily Funk
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Milton Pratt
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Thamby
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Linh Tran
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Lyndsey Prange
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Uchitel
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - April Boggs
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Melissa Minton
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Joan Jasien
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States
| | - Kanae Jennifer Nagao
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amanda Richards
- Department of Otolaryngology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Belinda Cruse
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine (Royal Melbourne Hospital), Faculty of Medicine, Health and Dentistry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Guy De-Lisle Dear
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Andrew P Landstrom
- Department of Pediatrics, Division of Cardiology, and Department of Cell Biology, Duke University School of Medicine, Durham, NC, United States
| | - Mohamad A Mikati
- Department of Pediatrics, Division of Neurology, Duke University School of Medicine, Durham, NC, United States.
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Jasien JM, Bonner M, D'alli R, Prange L, Mclean M, Sachdev M, Uchitel J, Ricano J, Smith B, Mikati MA. Cognitive, adaptive, and behavioral profiles and management of alternating hemiplegia of childhood. Dev Med Child Neurol 2019; 61:547-554. [PMID: 30362107 DOI: 10.1111/dmcn.14077] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2018] [Indexed: 11/28/2022]
Abstract
AIM To determine the neuropsychological abnormalities that occur in alternating hemiplegia of childhood (AHC) and report on our experience in managing them. METHOD Patients underwent evaluations according to our standardized AHC pathway. Data were entered into our prospective AHC database and then analyzed. RESULTS Of the cohort of 25 consecutive patients (ages 15mo-42y), eight had initial chief complaints about cognition, 14 language, five attention, and 11 behavior. As compared to population norms means, neuropsychological and behavioral assessment tools (including Child Behavior Checklist, Vineland Adaptive Behavior Scales, Peabody Picture Vocabulary, and Wechsler Intelligence Quotient tests) showed significant impairments in multiple domains: cognition, expressive and receptive language, executive function/attention, and behavior (p<0.05 in all comparisons). Evaluations generated management recommendations in all patients. Twenty had neuropsychiatric diagnoses: 10 attention-deficit/hyperactivity disorder (ADHD), seven disruptive behavior, and three anxiety disorder. Eight out of nine patients with ADHD who were prescribed medications responded to pharmacotherapy. INTERPRETATION Patients with AHC have developmental difficulties related to impairments in multiple neuropsychological domains. This supports the hypothesis that the underlying AHC pathophysiology involves diffuse neuronal dysfunction. Testing generated recommendations to help manage these difficulties. Patients with AHC also have a range of neuropsychiatric diagnoses, the most common being ADHD which responds to pharmacotherapy. WHAT THIS PAPER ADDS Patients with alternating hemiplegia of childhood (AHC) have developmental difficulties with underlying neuropsychological impairments. The findings in this study are consistent with an underlying AHC pathophysiology which involves diffuse neuronal, probably largely GABAergic, dysfunction. Patients with AHC have a range of neuropsychiatric diagnoses, the most common being attention-deficit/hyperactivity disorder.
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Affiliation(s)
- Joan M Jasien
- Division of Pediatric Neurology, Duke University Health System, Durham, NC, USA
| | - Melanie Bonner
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Richard D'alli
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Lyndsey Prange
- Division of Pediatric Neurology, Duke University Health System, Durham, NC, USA
| | - Melissa Mclean
- Division of Pediatric Neurology, Duke University Health System, Durham, NC, USA
| | | | - Julie Uchitel
- Division of Pediatric Neurology, Duke University Health System, Durham, NC, USA
| | - Jennifer Ricano
- Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| | - Brian Smith
- Department of Pediatrics, Division of Quantitative Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Health System, Durham, NC, USA.,Duke Institute for Brain Sciences and Duke Department of Neurobiology, Durham, NC, USA
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Novel Homozygous Variant in TTC19 Causing Mitochondrial Complex III Deficiency with Recurrent Stroke-Like Episodes: Expanding the Phenotype. Semin Pediatr Neurol 2018; 26:16-20. [PMID: 29961508 DOI: 10.1016/j.spen.2018.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 7-year-old boy with family history of consanguinity presented with developmental delay and recurrent hemiplegia involving both sides of the body, with variable facial and ocular involvement. Brain MRI showed bilateral striatal necrosis with cystic degeneration and lactate peaks on spectroscopy. Biochemical testing demonstrated mildly elevated lactate and pyruvate. Whole-exome sequencing revealed a novel homozygous pathogenic frameshift mutation in gene TTC19, diagnostic of mitochondrial complex III deficiency.
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Masoud M, Prange L, Wuchich J, Hunanyan A, Mikati MA. Diagnosis and Treatment of Alternating Hemiplegia of Childhood. Curr Treat Options Neurol 2017; 19:8. [PMID: 28337648 DOI: 10.1007/s11940-017-0444-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OPINION STATEMENT The diagnosis and treatment of patients with Alternating Hemiplegia of Childhood (AHC) and related disorders should be provided by a multidisciplinary team experienced with the spectrum of presentations of this disease, with its related disorders, with its complex and fluctuating manifestations, and with cutting edge advances occurring in the field. Involvement in research to advance the understanding of this disease and partnership with international collaborators and family organizations are also important. An example of such an approach is that of The Duke AHC and Related Disorders Multi-Disciplinary Clinic and Program, which, in partnership with the Cure AHC Foundation, has developed and applied this approach to patients seen since early 2013. The program provides comprehensive care and education directly to AHC patients and their families and collaborates with referring physicians on the care of patients with AHC whether evaluated at Duke clinics or not. It also is involved in clinical and basic research and in collaborations with other International AHC Research Consortium (IAHCRC) partners. The clinic is staffed with physicians and experts from Neurology, Cardiology, Child Behavioral Health, Medical Genetics, Neurodevelopment, Neuropsychology, Nursing, Physical and Occupational Therapies, Psychiatry, Sleep Medicine, and Speech/Language Pathology. Patients are seen either for full comprehensive evaluations that last several days or for targeted evaluations with one or few appointments.
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Affiliation(s)
- Melanie Masoud
- Duke University Children Health Center, 2301 Erwin Rd., Durham, NC, 27710, USA
| | - Lyndsey Prange
- Duke University Children Health Center, 2301 Erwin Rd., Durham, NC, 27710, USA
| | | | - Arsen Hunanyan
- Duke University Children Health Center, 2301 Erwin Rd., Durham, NC, 27710, USA
| | - Mohamad A Mikati
- Duke University Children Health Center, 2301 Erwin Rd., Durham, NC, 27710, USA.
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Heinzen EL, Arzimanoglou A, Brashear A, Clapcote SJ, Gurrieri F, Goldstein DB, Jóhannesson SH, Mikati MA, Neville B, Nicole S, Ozelius LJ, Poulsen H, Schyns T, Sweadner KJ, van den Maagdenberg A, Vilsen B. Distinct neurological disorders with ATP1A3 mutations. Lancet Neurol 2014; 13:503-14. [PMID: 24739246 DOI: 10.1016/s1474-4422(14)70011-0] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Genetic research has shown that mutations that modify the protein-coding sequence of ATP1A3, the gene encoding the α3 subunit of Na(+)/K(+)-ATPase, cause both rapid-onset dystonia parkinsonism and alternating hemiplegia of childhood. These discoveries link two clinically distinct neurological diseases to the same gene, however, ATP1A3 mutations are, with one exception, disease-specific. Although the exact mechanism of how these mutations lead to disease is still unknown, much knowledge has been gained about functional consequences of ATP1A3 mutations using a range of in-vitro and animal model systems, and the role of Na(+)/K(+)-ATPases in the brain. Researchers and clinicians are attempting to further characterise neurological manifestations associated with mutations in ATP1A3, and to build on the existing molecular knowledge to understand how specific mutations can lead to different diseases.
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Affiliation(s)
- Erin L Heinzen
- Center for Human Genome Variation, Duke University, School of Medicine, Durham, NC, USA; Department of Medicine, Section of Medical Genetics, Duke University, School of Medicine, Durham, NC, USA.
| | - Alexis Arzimanoglou
- Epilepsy, Sleep and Pediatric Neurophysiology Department, HFME, University Hospitals of Lyon, France; Centre de Recherche en Neurosciences de Lyon, Centre National de la Recherche Scientifique, UMR 5292, INSERM U1028, Lyon, France
| | - Allison Brashear
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | | | - Fiorella Gurrieri
- Istituto di Genetica Medica, Università Cattolica S Cuore, Rome, Italy
| | - David B Goldstein
- Center for Human Genome Variation, Duke University, School of Medicine, Durham, NC, USA; Department of Molecular Genetics and Microbiology, Duke University, School of Medicine, Durham, NC, USA
| | | | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University, School of Medicine, Durham, NC, USA; Department of Neurobiology, Duke University, School of Medicine, Durham, NC, USA
| | - Brian Neville
- Institute of Child Health, University College London, London, UK
| | - Sophie Nicole
- Institut National de la Santé et de la Recherche Médicale, U975, Centre de Recherche de l'Institut du Cerveau et de la Moelle, Paris, France; Centre National de la Recherche Scientifique, UMR7225, Paris, France; Université Pierre et Marie Curie Paris VI, UMRS975, Paris, France
| | - Laurie J Ozelius
- Department of Genetics and Genomic Sciences and Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hanne Poulsen
- Danish Research Institute for Translational Neuroscience, Nordic-EMBL Partnership of Molecular Medicine, Department of Molecular Biology and Genetics, Aarhus University, Aarhus, Denmark; Centre for Membrane Pumps in Cells and Disease-PUMPKIN, Danish National Research Foundation, Aarhus, Denmark
| | - Tsveta Schyns
- European Network for Research on Alternating Hemiplegia (ENRAH), Brussels, Belgium
| | | | - Arn van den Maagdenberg
- Department of Human Genetics and Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Bente Vilsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
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Kansagra S, Mikati MA, Vigevano F. Alternating hemiplegia of childhood. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:821-826. [PMID: 23622289 DOI: 10.1016/b978-0-444-52910-7.00001-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Alternating hemiplegia of childhood (AHC) is a very rare disease characterized by recurrent attacks of loss of muscular tone resulting in hypomobility of one side of the body. The etiology of the disease due to ATP1A3 gene mutations in the majority of patients. Few familial cases have been described. AHC has an onset in the first few months of life. Hemiplegic episodes are often accompanied by other paroxysmal manifestations, such as lateral eyes and head deviation toward the hemiplegic side and a very peculiar monocular nystagmus. As the attack progresses, hemiplegia can shift to the other side of the body. Sometimes the attack can provoke bilateral paralysis, and these patients may have severe clinical impairment, with difficulty in swallowing and breathing. Hemiplegic attacks may be triggered by different stimuli, like bath in warm water, motor activity, or emotion. The frequency of attacks is high, usually several in a month or in a week. The duration is variable from a few minutes to several hours or even days. Sleep can stop the attack. Movement disorders such as dystonia and abnormal movements are frequent. Cognitive delay of variable degree is a common feature. Epilepsy has been reported in 50% of the cases, but seizure onset is usually during the third or fourth year of life. Many drugs have been used in AHC with very few results. Flunarizine has the most supportive anecdotal evidence regarding efficacy.
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Affiliation(s)
- Sujay Kansagra
- Division of Pediatric Neurology, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Mikati MA, Kramer U, Zupanc ML, Shanahan RJ. Alternating hemiplegia of childhood: clinical manifestations and long-term outcome. Pediatr Neurol 2000; 23:134-41. [PMID: 11020638 DOI: 10.1016/s0887-8994(00)00157-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We present our analysis of 44 patients with alternating hemiplegia of childhood. The clinical course usually consisted of three phases. The first was dominated by abnormal eye movements and dystonic episodes, the second by hemiplegic spells and psychomotor regression, and the third by persistent developmental delay and fixed neurologic deficits. The age of onset was 0-54 months (mean = 7.9 +/- 13 months). The presenting signs included abnormal ocular movements in 65%, dystonia in 60%, and hemiplegia in 32%. Patients with an early onset of the disorder and an early appearance of hemiplegic spells faired the poorest developmentally. Developmental delay was present in 91%, ataxia in 68%, choreoathetosis in 50%, and seizures in 18%. Laboratory investigations suggested mitochondrial abnormalities and cerebrovascular dysfunction in several patients. Numerous therapies were largely ineffective. Flunarizine reduced the duration, severity, and frequency of the hemiplegic attacks in 78%. Patients who received flunarizine did not differ developmentally from those who did not. Our data suggest that flunarizine does not adversely affect and may favorably influence the outcome in patients with alternating hemiplegia of childhood. Additionally, the occurrence of autosomal-dominant cases of the syndrome, although rare, suggests that, in addition to mitochondrial dysfunction, genetic factors may be important.
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Affiliation(s)
- M A Mikati
- Department of Neurology, Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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