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Srour MK, Bidzimou MTK, Muralidharan P, Mitchell SM, Moya-Mendez ME, Parker LE, Reyes Valenzuela G, Caraballo R, Garone G, Vigevano F, Weckhuysen S, Millevert C, Troncoso M, Matamala M, Balestrini S, Sisodiya SM, Poole J, Zucca C, Panagiotakaki E, Papadopoulou MT, Tchaicha S, Papathanasiou Terzi MA, Zawadzka M, Mazurkiewicz-Bełdzińska M, Fons C, Anticona J, De Grandis E, Cordani R, Pisciotta L, Groppa S, Paryjas S, Ragona F, Mangia E, Granata T, Megvinov A, Vavassori R, Mikati MA, Landstrom AP. Children and Adolescent Patients with Variants in the ATP1A3 -encoded Sodium-Potassium ATPase Alpha-3 Subunit Demonstrate an Impaired QT Response to Bradycardia and Predisposition to Sinus Node Dysfunction. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.31.24312446. [PMID: 39252916 PMCID: PMC11383464 DOI: 10.1101/2024.08.31.24312446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Background Alternating hemiplegia of childhood (AHC) is a rare disorder with both neurologic and cardiac manifestations. The ATP1A3-D801N variant is associated with a pathologically short QT interval and risk of ventricular arrhythmia following bradycardia; however, the mechanism of this remains unknown. We investigated the relationship between heart rate (HR), QT, and QTc, hypothesizing that individuals with ATP1A3-D801N have abnormal, impaired shortening of QT and QTc at lower HR leading to arrhythmia predisposition. Methods We performed a retrospective observational study of individuals who underwent clinical evaluation, Holter monitoring, and genetic testing for AHC at Duke University Hospitals. We also compiled a group of healthy individuals as a control cohort. A larger, worldwide cohort of individuals with ATP1A3 - related phenotypes was compiled to investigate sinus node dysfunction. Linear regression analysis was then performed. Results The cohort consisted of 44 individuals with ATP1A3 -related phenotypes with 81 Holter recordings (52.27% female; mean age at first Holter 8.04 years, range 0.58 - 33 years), compared to 36 healthy individuals with 57 Holter recordings (52.78% female; mean age at first Holter 9.84 years, range 0.08 - 38 years). Individuals with ATP1A3-D801N had reduced prolongation of QT at lower HR, manifest as a significantly lower slope for HR vs QT compared to healthy (P<0.0001). This resulted in a significantly higher slope of the relationship for HR vs QTc compared to healthy (P<0.0001). Individuals with ATP1A3 - related phenotypes and baseline QTc <350 milliseconds (ms) had increased shortening of QT and QTc at lower HR compared to those with normal QTc (P=0.003; P=0.001). Among worldwide cases, 3 out of 131 individuals with ATP1A3 -related phenotypes required device implantation and/or had sinus pauses >4 seconds. Conclusions Individuals with the ATP1A3-D801N variant exhibit paradoxical shortening of QT and QTc at lower HR, which contribute to an increased risk of arrhythmias during bradycardia. This is exacerbated by an underlying risk of sinus node dysfunction. Clinical Perspective What is Known: Individuals with ATP1A3-D801N have a short baseline QTc.Two individuals with AHC experienced ventricular fibrillation following bradycardia. What the Study Adds: The QT and QTc shorten to a greater extent at lower heart rate in individuals with ATP1A3-D801N than in healthy individuals. Individuals with ATP1A3 -related phenotypes and QTc <350ms show greater impairment of QT and QTc dynamics than those with normal QTc. There is low prevalence of device implantation and significant sinus pauses in individuals with ATP1A3 -related phenotypes, with a relatively greater prevalence in those with ATP1A3-D801N.
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Liu YB, Arystarkhova E, Sacino AN, Szabari MV, Lutz CM, Terrey M, Morsci NS, Jakobs TC, Lykke-Hartmann K, Brashear A, Napoli E, Sweadner KJ. Phenotype Distinctions in Mice Deficient in the Neuron-Specific α3 Subunit of Na,K-ATPase: Atp1a3 tm1Ling/+ and Atp1a3 +/D801Y. eNeuro 2024; 11:ENEURO.0101-24.2024. [PMID: 39111836 PMCID: PMC11360364 DOI: 10.1523/eneuro.0101-24.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 08/30/2024] Open
Abstract
ATP1A3 is a Na,K-ATPase gene expressed specifically in neurons in the brain. Human mutations are dominant and produce an unusually wide spectrum of neurological phenotypes, most notably rapid-onset dystonia parkinsonism (RDP) and alternating hemiplegia of childhood (AHC). Here we compared heterozygotes of two mouse lines, a line with little or no expression (Atp1a3tm1Ling/+) and a knock-in expressing p.Asp801Tyr (D801Y, Atp1a3 +/D801Y). Both mouse lines had normal lifespans, but Atp1a3 +/D801Y had mild perinatal mortality contrasting with D801N mice (Atp1a3 +/D801N), which had high mortality. The phenotypes of Atp1a3tm1Ling/+ and Atp1a3 +/D801Y were different, and testing of each strain was tailored to its symptom range. Atp1a3tm1Ling/+ mice displayed little at baseline, but repeated ethanol intoxication produced hyperkinetic motor abnormalities not seen in littermate controls. Atp1a3 +/D801Y mice displayed robust phenotypes: hyperactivity, diminished posture consistent with hypotonia, and deficiencies in beam walk and wire hang tests. Symptoms also included qualitative motor abnormalities that are not well quantified by conventional tests. Paradoxically, Atp1a3 +/D801Y showed sustained better performance than wild type on the accelerating rotarod. Atp1a3 +/D801Y mice were overactive in forced swimming and afterward had intense shivering, transient dystonic postures, and delayed recovery. Remarkably, Atp1a3 +/D801Y mice were refractory to ketamine anesthesia, which elicited hyperactivity and dyskinesia even at higher dose. Neither mouse line exhibited fixed dystonia (typical of RDP patients), spontaneous paroxysmal weakness (typical of AHC patients), or seizures but had consistent, measurable neurological abnormalities. A gradient of variation supports the importance of studying multiple Atp1a3 mutations in animal models to understand the roles of this gene in human disease.
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Affiliation(s)
- Yi Bessie Liu
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts 02114
| | - Elena Arystarkhova
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts 02115
| | - Amanda N Sacino
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts 02114
| | - Margit V Szabari
- Department Anesthesia, Massachusetts General Hospital, Boston, Massachusetts 02114
| | | | | | | | - Tatjana C Jakobs
- Harvard Medical School, Boston, Massachusetts 02115
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary/Schepens Eye Research Institute, Harvard Medical School, Boston, Massachusetts 02114
| | | | - Allison Brashear
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York 14203
| | - Elenora Napoli
- Department of Neurology, University of California Davis School of Medicine, Sacramento, California 95817
| | - Kathleen J Sweadner
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts 02114
- Harvard Medical School, Boston, Massachusetts 02115
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Patel S, Maney K, Morris L, Papadopoulou MT, Prange L, Boggs A, Hunanyan A, Megvinov A, Vavassori R, Panagiotakaki E, Mikati MA. Real life retrospective study of cannabidiol therapy in alternating hemiplegia of childhood. Eur J Paediatr Neurol 2024; 49:55-59. [PMID: 38367370 DOI: 10.1016/j.ejpn.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/15/2024] [Accepted: 02/06/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Many alternating hemiplegia of childhood (AHC) patients have received Cannabidiol (CBD) but, to our knowledge, there are no published data available. GOALS Test the hypothesis that CBD has favorable effects on AHC spells. METHODS Retrospective review of available data of AHC patients who received CBD. Primary analysis: Clinical Global Impression Scale of Improvement (CGI-I) score for response of AHC spells to CBD with calculation of 95% confidence interval (CI) for rejection of the null hypothesis. Secondary analyses, performed to achieve an understanding of the effect of CBD as compared to flunarizine, were CGI-I scores of 1) epileptic seizures to CBD, 2) AHC spells to flunarizine, 3) epileptic seizures to flunarizine. Also, Mann-Whitney test was done for comparison of CGI-I scores of CBD and flunarizine to both AHC spells and seizures. RESULTS We studied 16 AHC patients seen at Duke University and University of Lyon. CI of CGI-I scores for AHC spells in response to CBD and to flunarizine, each separately, indicated a positive response to each of these two medications: neither overlapped with the null hypothesis score, 4, indicating significant positive responses with p < 0.05 for both. These two scores also did not differ (p = 0.84) suggesting similar efficacy of both: CBD score was 2 ± 1.1 with a 95% CI of 1.5-2.6 and flunarizine score was 2.3 ± 1.3 with a 95% CI of 1.7-3.1. In patients who had seizures, CI calculations indicated a positive effect of CBD on seizure CGI scores but not of flunarizine on seizure scores. CBD was well tolerated with no patients discontinuing it due to side effects and with some reporting positive behavioral changes. CONCLUSION Our study indicates a real-life positive effect of CBD on AHC type spells.
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Affiliation(s)
- Shital Patel
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Kayli Maney
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Lauren Morris
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Maria T Papadopoulou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Lyndsey Prange
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - April Boggs
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Arsen Hunanyan
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Andrey Megvinov
- Euro Mediterranean Institute of Science and Technology I.E.ME.S.T., Palermo, Italy
| | - Rosaria Vavassori
- Euro Mediterranean Institute of Science and Technology I.E.ME.S.T., Palermo, Italy; Association AHC18+ e.V., Member of the EPAG of ERN EpiCARE, Germany
| | - Eleni Panagiotakaki
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Mohamad A Mikati
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA.
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Thamby J, Prange L, Boggs A, Subei MO, Myers C, Uchitel J, ElMallah M, Bartlett-Lee B, Riviello JJ, Mikati MA. Characteristics of non-sleep related apneas in children with alternating hemiplegia of childhood. Eur J Paediatr Neurol 2024; 48:101-108. [PMID: 38096596 DOI: 10.1016/j.ejpn.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/17/2023] [Accepted: 12/03/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND Non-sleep related apnea (NSA) has been observed in alternating hemiplegia of childhood (AHC) but has yet to be characterized. GOALS Investigate the following hypotheses: 1) AHC patients manifest NSA that is often severe. 2) NSA is usually triggered by precipitating events. 3) NSA is more likely in patients with ATP1A3 mutations. METHODS Retrospective review of 51 consecutive AHC patients (ages 2-45 years) enrolled in our AHC registry. NSAs were classified as mild (not needing intervention), moderate (needing intervention but not perceived as life threatening), or severe (needing intervention and perceived as life threatening). RESULTS 19/51 patients (37 %) had 52 NSA events (6 mild, 11 moderate, 35 severe). Mean age of onset of NSA (± Standard Error of the Mean (SEM)): 3.8 ± 1.5 (range 0-24) years, frequency during follow up was higher at younger ages as compared to adulthood (year 1: 2.2/year, adulthood: 0.060/year). NSAs were associated with triggering factors, bradycardia and with younger age (p < 0.008 in all) but not with mutation status (p = 0.360). Triggers, observed in 17 patients, most commonly included epileptic seizures in 9 (47 %), anesthesia, AHC spells and intercurrent, stressful, conditions. Management included use of pulse oximeter at home in nine patients, home oxygen in seven, intubation/ventilatory support in seven, and basic CPR in six. An additional patient required tracheostomy. There were no deaths or permanent sequalae. CONCLUSIONS AHC patients experience NSAs that are often severe. These events are usually triggered by seizures or other stressful events and can be successfully managed with interventions tailored to the severity of the NSA.
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Affiliation(s)
- Julie Thamby
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Lyndsey Prange
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - April Boggs
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - M Omar Subei
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Duke University School of Medicine, Durham, NC, United States
| | - Cory Myers
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Duke University School of Medicine, Durham, NC, United States
| | - Julie Uchitel
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States; Stanford University Medical School, Palo Alto, CA, United States
| | - Mai ElMallah
- Department of Pediatrics, Division of Pulmonary Medicine, Duke University School of Medicine, United States
| | | | - James J Riviello
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Mohamad A Mikati
- Department of Pediatrics, Division of Neurology and Developmental Pediatrics, Duke University School of Medicine, Durham, NC, United States.
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Patel SH, Panagiotakaki E, Papadopoulou MT, Fons C, De Grandis E, Vezyroglou A, Balestrini S, Hong H, Liu B, Prange L, Arzimanoglou A, Vavassori R, Mikati MA. Methodology of a Natural History Study of a Rare Neurodevelopmental Disorder: Alternating Hemiplegia of Childhood as a Prototype Disease. J Child Neurol 2023; 38:597-610. [PMID: 37728088 DOI: 10.1177/08830738231197861] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Here, we describe the process of development of the methodology for an international multicenter natural history study of alternating hemiplegia of childhood as a prototype disease for rare neurodevelopmental disorders. We describe a systematic multistep approach in which we first identified the relevant questions about alternating hemiplegia of childhood natural history and expected challenges. Then, based on our experience with alternating hemiplegia of childhood and on pragmatic literature searches, we identified solutions to determine appropriate methods to address these questions. Specifically, these solutions included development and standardization of alternating hemiplegia of childhood-specific spell video-library, spell calendars, adoption of tailored methodologies for prospective measurement of nonparoxysmal and paroxysmal manifestations, unified data collection protocols, centralized data platform, adoption of specialized analysis methods including, among others, Cohen kappa, interclass correlation coefficient, linear mixed effects models, principal component, propensity score, and ambidirectional analyses. Similar approaches can, potentially, benefit in the study of other rare pediatric neurodevelopmental disorders.
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Affiliation(s)
- Shital H Patel
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, USA
| | - Eleni Panagiotakaki
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Maria T Papadopoulou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Carmen Fons
- Department of Child Neurology, Sant Joan de Déu Children's Hospital, Member of the ERN EpiCARE, Barcelona, Spain
| | - Elisa De Grandis
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Aikaterini Vezyroglou
- Department of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - Simona Balestrini
- Department of Clinical and Experimental Epilepsy, University College of London (UCL), Queen Square Institute of Neurology, London, UK
| | - Hwanhee Hong
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - Beiyu Liu
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - Lyndsey Prange
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, USA
| | - Alexis Arzimanoglou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon, France
| | - Rosaria Vavassori
- Euro Mediterranean Institute of Science and Technology IEMEST, Palermo, Italy
- Association AHC18+ e.V., member of the ERN EpiCARE Patient Advocacy Group (ePAG), Germany
| | - Mohamad A Mikati
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, USA
- Department of Neurobiology, Duke University, Durham, NC, USA
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Sentmanat MK, Papadopoulou MT, Prange L, Fons C, De Grandis E, Vezyroglou A, Boggs A, Su S, Comajuan M, Wuchich J, Jóhannesson S, Huaynate JA, Stagnaro M, Megvinov A, Patel S, Arzimanoglou A, Vavassori R, Panagiotakaki E, Mikati MA. Development and testing of methods to record and follow up spells in patients with alternating hemiplegia of childhood. Eur J Paediatr Neurol 2023; 46:98-107. [PMID: 37562161 DOI: 10.1016/j.ejpn.2023.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Developing methods to record Alternating Hemiplegia of Childhood (AHC) spells is essential for clinical trials and patient care. OBJECTIVES Test the following hypotheses: 1) Video-library training improves participants' ability to correctly identify AHC spells. 2) A custom-designed event-calendar with weekly reviews results in consistent documentation of such events over time. 3) Use of an electronic diary (e-Diary) to register events is a useful tool. METHODS 1) A video-library of AHC type spells was developed along with specific training; the effect of the training was tested in 36 caregivers. 2) An event-calendar was similarly developed and provided to 5 caregivers with weekly videoconference meetings for 8 weeks. 3) An e-Diary was developed and offered to 33 patients; time of usage and caregivers' feedback (telephone interview) were analyzed. RESULTS 1) Video-library training: Wilcoxon test showed improvement in caregiver identification of spells (p = 0.047), Cohen's Kappa demonstrated high degree of agreement between caregivers'-experts' classifications (>0.9). 2) Event-calendar: 96.42% of entries had complete information; this did not change during follow up (p = 0.804). 3) e-Diary: whereas 52% of respondents used the e-Diary when offered (duration: 10.5 ± 8.1 months), 96.3% indicated they would use it in future studies. Those who used it for 13 months, were very likely to use it during the rest of that year. CONCLUSIONS Video-library training improved spell identification. Calendar with weekly reviews resulted in a sustained and consistent record keeping. Caregivers' e-Diary feedback was encouraging with long-term usage in many. These approaches could be helpful for AHC and, potentially, in similar disorders.
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Affiliation(s)
- Maria K Sentmanat
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Maria T Papadopoulou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, University Hospitals of Lyon (HCL), Lyon, France; EpiCARE-ERN Full Member, Italy
| | - Lyndsey Prange
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Carmen Fons
- EpiCARE-ERN Full Member, Italy; Department of Child Neurology, Sant Joan de Déu Children's Hospital, Barcelona, Spain
| | - Elisa De Grandis
- EpiCARE-ERN Full Member, Italy; Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Aikaterini Vezyroglou
- Department of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London, UK
| | - April Boggs
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Samantha Su
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Marion Comajuan
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, University Hospitals of Lyon (HCL), Lyon, France; EpiCARE-ERN Full Member, Italy
| | | | | | | | - Michela Stagnaro
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Andrey Megvinov
- Euro Mediterranean Institute of Science and Technology I.E.ME.S.T., Palermo, Italy
| | - Shital Patel
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA
| | - Alexis Arzimanoglou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, University Hospitals of Lyon (HCL), Lyon, France; EpiCARE-ERN Full Member, Italy
| | - Rosaria Vavassori
- EpiCARE-ERN Full Member, Italy; Euro Mediterranean Institute of Science and Technology I.E.ME.S.T., Palermo, Italy; Association AHC18+ e.V., Germany
| | - Eleni Panagiotakaki
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, University Hospitals of Lyon (HCL), Lyon, France; EpiCARE-ERN Full Member, Italy
| | - Mohamad A Mikati
- Duke University Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Durham, NC, USA; Department of Neurobiology, Duke University, Durham, NC, USA.
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7
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Pearl PL. Autonomic risks in Alternating Hemiplegia of Childhood. Eur J Paediatr Neurol 2022; 38:A3. [PMID: 35487825 DOI: 10.1016/j.ejpn.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Phillip L Pearl
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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