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Li YM, Jia W, Xin T, Fang YQ. Case report: Heterozygous mutation in HTRA1 causing typical cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy. Front Genet 2023; 14:1235650. [PMID: 37799144 PMCID: PMC10547585 DOI: 10.3389/fgene.2023.1235650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/30/2023] [Indexed: 10/07/2023] Open
Abstract
Background: Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) is an autosomal recessive disorder characterized by baldness, recurrent ischemic stroke, lumbago, headache, and dementia which is closely related to homozygous mutations of the high-temperature requirement serine peptidase A1 (HTRA1) gene. Heterozygous mutations of HTRA1 are usually considered to be non-pathogenic. Although it has been revealed that only a few patients with heterozygous mutations could present some manifestations, their clinical symptoms were atypical, milder, and always with a lower frequency of extra-neurological features. Here, a rare patient with heterozygous mutation of HTRA1 who had all typical features of CARASIL as well as severe clinical symptoms and rapid progression was initially reported in our study. Case presentation: A 43-year-old female patient presented with a gradual onset of headache and cognitive decline. As time progressed, her headache intensified and symptoms of dementia began to manifest gradually. During her early years, she had thinning hair and subsequently experienced two occurrences of ischemic strokes in her thirties. Furthermore, she also had a history of lumbago and urinary retention before visiting our hospital. The patient's magnetic resonance imaging revealed the presence of widespread white matter lesions, infarctions, and microbleeds, in addition to lumbar disc herniation and degenerative lesions. The observed clinical characteristics had a strong correlation with CARASIL, and the patient was diagnosed with a heterozygous missense mutation of 905G>A (Arg302Gln) in the HTRA1 gene. The patient has been under continuous follow-up for a duration exceeding 3 years subsequent to her release from the hospital. She underwent cystostomy, and symptoms of bulbar paralysis developed in a progressive way. Currently, there has been a notable decrease in motor function and activities of daily living, resulting in the individual being confined to bed for a duration exceeding 1 year. Conclusion: This case suggests that patients carrying a heterozygous mutation in G905A may also have typical clinical features of CARASIL, which allows us to have a more comprehensive understanding of CARASIL.
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Affiliation(s)
- Yu-Ming Li
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Wei Jia
- Department of Gastroenterology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
| | - Tao Xin
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
- Medical Science and Technology Innovation Center, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
- Department of Neurosurgery, Jiangxi Provincial People’s Hospital, Nanchang, Jiangxi, China
- Post-Doctoral Scientific Research Station, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Yu-Qing Fang
- Post-Doctoral Scientific Research Station, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
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2
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Zhou H, Jiao B, Ouyang Z, Wu Q, Shen L, Fang L. Report of two pedigrees with heterozygous HTRA1 variants-related cerebral small vessel disease and literature review. Mol Genet Genomic Med 2022; 10:e2032. [PMID: 35946346 PMCID: PMC9544214 DOI: 10.1002/mgg3.2032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/11/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Biallelic HTRA1 pathogenic variants are associated with autosomal recessive cerebral arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL). Recent studies have indicated that heterozygous HTRA1 variants are related to autosomal dominant hereditary cerebral small vessel disease (CSVD). However, few studies have assessed heterozygous HTRA1 carriers or the genotype-phenotype correlation. METHODS The clinical data of two unrelated Chinese Han families with CSVD were collected. Panel sequencing was used to search for pathogenic genes, Sanger sequencing was used for verification, three-dimensional protein models were constructed, and pathogenicity was analyzed. Published HTRA1-related phenotypes included in PubMed up to September 2021 were extensively reviewed, and the patients' genetic and clinical characteristics were summarized. RESULTS We report a novel heterozygous variant c.920T>C p.L307P in the HTRA1, whose main clinical and neuroimaging phenotypes are stroke and gait disturbance. We report another patient with the previously reported pathogenic variant HTRA1 c.589C>T p.R197X characterized by early cognitive decline. A literature review indicated that compared with CARASIL, HTRA1-related autosomal dominant hereditary CSVD has a later onset age, milder clinical symptoms, fewer extraneurological symptoms, and slower progression, indicating a milder CARASIL phenotype. In addition, HTRA1 heterozygous variants were related to a higher proportion of vascular risk factors (p < .001) and male sex (p = .022). CONCLUSION These findings broaden the known mutational spectrum and possible clinical phenotype of HTRA1. Considering the semidominant characteristics of HTRA1-related phenotypes, we recommend that all members of HTRA1 variant families undergo genetic screening and clinical follow-up if carrying pathogenic variants.
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Affiliation(s)
- Hui Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Bin Jiao
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Central South University, Changsha, China.,Engineering Research Center of Hunan Province in Cognitive Impairment Disorders, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases, Changsha, China.,Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
| | - Ziyu Ouyang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Qihui Wu
- Translational Research Institute of Brain and Brain-Like Intelligence, Shanghai Fourth People's Hospital affiliated to Tongji University School of Medicine, Shanghai, China
| | - Lu Shen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Central South University, Changsha, China.,Engineering Research Center of Hunan Province in Cognitive Impairment Disorders, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases, Changsha, China.,Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China.,Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, China
| | - Liangjuan Fang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Central South University, Changsha, China.,Engineering Research Center of Hunan Province in Cognitive Impairment Disorders, Central South University, Changsha, China.,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic Diseases, Changsha, China.,Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, Changsha, China
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3
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Coste T, Hervé D, Neau JP, Jouvent E, Ba F, Bergametti F, Lamy M, Cogez J, Derache N, Schneckenburger R, Grelet M, Gollion C, Lanotte L, Lauer V, Layet V, Urbanczyk C, Didic M, Raynouard I, Delaval L, Dassa J, Florea A, Badiu C, Nguyen K, Tournier-Lasserve E. Heterozygous HTRA1 nonsense or frameshift mutations are pathogenic. Brain 2021; 144:2616-2624. [PMID: 34270682 DOI: 10.1093/brain/awab271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/12/2022] Open
Abstract
Heterozygous missense HTRA1 mutations have been associated with an autosomal dominant cerebral small vessel disease (CSVD) whereas the pathogenicity of heterozygous HTRA1 stop codon variants is unclear. We performed a targeted high throughput sequencing of all known CSVD genes, including HTRA1, in 3853 unrelated consecutive CSVD patients referred for molecular diagnosis. The frequency of heterozygous HTRA1 mutations leading to a premature stop codon in this patient cohort was compared with their frequency in large control databases. An analysis of HTRA1 mRNA was performed in several stop codon carrier patients. Clinical and neuroimaging features were characterized in all probands. Twenty unrelated patients carrying a heterozygous HTRA1 variant leading to a premature stop codon were identified. A highly significant difference was observed when comparing our patient cohort with control databases: gnomAD v3.1.1 [P = 3.12 × 10-17, odds ratio (OR) = 21.9], TOPMed freeze 5 (P = 7.6 × 10-18, OR = 27.1) and 1000 Genomes (P = 1.5 × 10-5). Messenger RNA analysis performed in eight patients showed a degradation of the mutated allele strongly suggesting a haploinsufficiency. Clinical and neuroimaging features are similar to those previously reported in heterozygous missense mutation carriers, except for penetrance, which seems lower. Altogether, our findings strongly suggest that heterozygous HTRA1 stop codons are pathogenic through a haploinsufficiency mechanism. Future work will help to estimate their penetrance, an important information for genetic counselling.
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Affiliation(s)
- Thibault Coste
- AP-HP, Service de Génétique Moléculaire Neurovasculaire, Hôpital Saint-Louis, France
- Université de Paris, INSERM UMR-1141 Neurodiderot, Paris F-75019, France
| | - Dominique Hervé
- Université de Paris, INSERM UMR-1141 Neurodiderot, Paris F-75019, France
- AP-HP, CERVCO, Service de Neurologie, Hôpital Lariboisière, France
| | - Jean Philippe Neau
- Centre Hospitalier Universitaire de Poitiers, Service de Neurologie, Poitiers, France
| | - Eric Jouvent
- Université de Paris, INSERM UMR-1141 Neurodiderot, Paris F-75019, France
- AP-HP, CERVCO, Service de Neurologie, Hôpital Lariboisière, France
| | - Fatoumata Ba
- AP-HP, Service de Génétique Moléculaire Neurovasculaire, Hôpital Saint-Louis, France
| | | | - Matthias Lamy
- Centre Hospitalier Universitaire de Poitiers, Service de Neurologie, Poitiers, France
| | - Julien Cogez
- Centre Hospitalier Universitaire de Caen, Service de Neurologie, Caen, France
| | - Nathalie Derache
- Centre Hospitalier Universitaire de Caen, Service de Neurologie, Caen, France
| | | | - Maude Grelet
- Centre Hospitalier Intercommunal de Toulon- La Seyne sur mer, Service de Génétique Médicale, Toulon, France
| | - Cédric Gollion
- Centre Hospitalier Universitaire de Toulouse, Service de Neurologie, Toulouse, France
| | - Livia Lanotte
- Hôpital De Hautepierre, Service de Neurologie, Strasbourg, France
| | - Valérie Lauer
- Hôpital De Hautepierre, Unité Neuro-Vasculaire, Strasbourg, France
| | - Valérie Layet
- Groupe Hospitalier Du havre, Service de Génétique Médicale, Le Havre, France
| | - Cédric Urbanczyk
- Centre Hospitalier Départemental La Roche-Sur-Yon, Service de Neurologie, La Roche-Sur-Yon, France
| | - Mira Didic
- APHM, Hôpital Timone Adultes, Service de Neurologie et Neuropsychologie, Marseille, France
- Aix Marseille Université, INSERM, INS, Inst Neurosci Syst, Marseille, France
| | - Igor Raynouard
- Fondation Adolphe de Rothschild, Service de Neurologie, Paris, France
| | - Laure Delaval
- AP-HP, Hôpital Bichat, Service de Médecine Interne, France
| | - Jérémie Dassa
- Centre Hospitalier Emile Roux, Service de Neurologie, Le Puy-en-Velay, France
| | - Alexandru Florea
- Centre Hospitalier Marie Madeleine, Service de Neurologie, Forbach, France
| | - Carmen Badiu
- Centre Hospitalier Metz-Thionville, Service de Neurologie, Metz, France
| | - Karine Nguyen
- APHM, Hôpital Timone Adultes, Département de Génétique, Marseille, France
| | - Elisabeth Tournier-Lasserve
- AP-HP, Service de Génétique Moléculaire Neurovasculaire, Hôpital Saint-Louis, France
- Université de Paris, INSERM UMR-1141 Neurodiderot, Paris F-75019, France
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Yu Z, Cao S, Wu A, Yue H, Zhang C, Wang J, Xia M, Wu J. Genetically Confirmed CARASIL: Case Report with Novel HTRA1 Mutation and Literature Review. World Neurosurg 2020; 143:121-128. [PMID: 32445900 DOI: 10.1016/j.wneu.2020.05.128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) is an extremely rare monogenic autosomal disease associated with the HtrA serine protease 1 (HTRA 1) gene mutation. Recently, a few genetically confirmed CARASIL cases with novel HTRA1 mutations have been reported in countries other than Japan. CASE DESCRIPTION Here, we report a case of a patient presenting with worsening right hemiplegia and hemiparesthesia. Physical examination revealed that the patient had typical clinical features of CARASIL including thinning hair, cognitive impairment, emotional changes, lumbago, and gait disorder. Brain magnetic resonance imaging showed abnormal diffuse symmetric changes in white matter and hypertensive diffusion-weighted imaging signals in the left centrum ovale and right splenium of the corpus callosum, and susceptibility-weighted imaging showed multiple cerebral microbleeds. Lumbar magnetic resonance imaging showed herniated disks with degenerative changes. A genetic test showed a novel homozygous nucleotide variation of c.847G>T in the HTRA1 gene, thereby resulting in p.Gly283Ter. Thus the patient met the diagnostic criteria for CARASIL. We provide a literature review of genetically confirmed CARASIL cases reported to date. CONCLUSIONS CARASIL is a rare autosomal recessive disease with an HTRA1 mutation. Familiarity with the early clinical and imaging features of CARASIL combined with a genetic test is key for its early diagnosis.
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Affiliation(s)
- Zhaoping Yu
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Shugang Cao
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Aimei Wu
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Hong Yue
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Chi Zhang
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Juan Wang
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Mingwu Xia
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China
| | - Juncang Wu
- Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, Hefei, Anhui, P.R. China.
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5
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Liu JY, Zhu YC, Zhou LX, Wei YP, Mao CH, Cui LY, Peng B, Yao M. HTRA1-related autosomal dominant cerebral small vessel disease. Chin Med J (Engl) 2020; 134:178-184. [PMID: 33109952 PMCID: PMC7817319 DOI: 10.1097/cm9.0000000000001176] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Homozygous or compound heterozygous mutations in high temperature requirement serine peptidase A1 (HTRA1) gene are responsible for cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL). Recently, increasing evidence has shown that heterozygous HTRA1 mutations are also associated with cerebral small vessel disease (CSVD) with an autosomal dominant pattern of inheritance. This study was aimed to analyze the genetic and clinical characteristics of HTRA1-related autosomal dominant CSVD. METHODS We presented three new Chinese cases of familial CSVD with heterozygous HTRA1 mutations and reviewed all clinical case reports and articles on HTRA1-related autosomal dominant CSVD included in PUBMED by the end of March 1, 2020. CARASIL probands with genetic diagnosis reported to date were also reviewed. The genetic and clinical characteristics of HTRA1-related autosomal dominant CSVD were summarized and analyzed by comparing with CARASIL. RESULTS Forty-four HTRA1-related autosomal dominant CSVD probands and 22 CARASIL probands were included. Compared with typical CARASIL, HTRA1-related autosomal dominant probands has a higher proportion of vascular risk factors (P < 0.001), a later onset age (P < 0.001), and a relatively slower clinical progression. Alopecia and spondylosis can be observed, but less than those in the typical CARASIL. Thirty-five heterozygous mutations in HTRA1 were reported, most of which were missense mutations. Amino acids located close to amino acids 250-300 were most frequently affected, followed by these located near 150∼200. While amino acids 250∼300 were also the most frequently affected region in CARASIL patients, fewer mutations precede the 200th amino acids were detected, especially in the Kazal-type serine protease domain. CONCLUSIONS HTRA1-related autosomal dominant CSVD is present as a mild phenotype of CARASIL. The trend of regional concentration of mutation sites may be related to the concentration of key sites in these regions which are responsible for pathogenesis of HTRA1-related autosomal dominant CSVD.
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Affiliation(s)
- Jing-Yi Liu
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing 100730, China
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6
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Uemura M, Nozaki H, Kato T, Koyama A, Sakai N, Ando S, Kanazawa M, Hishikawa N, Nishimoto Y, Polavarapu K, Nalini A, Hanazono A, Kuzume D, Shindo A, El-Ghanem M, Abe A, Sato A, Yoshida M, Ikeuchi T, Mizuta I, Mizuno T, Onodera O. HTRA1-Related Cerebral Small Vessel Disease: A Review of the Literature. Front Neurol 2020; 11:545. [PMID: 32719647 PMCID: PMC7351529 DOI: 10.3389/fneur.2020.00545] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/14/2020] [Indexed: 11/13/2022] Open
Abstract
Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL) is clinically characterized by early-onset dementia, stroke, spondylosis deformans, and alopecia. In CARASIL cases, brain magnetic resonance imaging reveals severe white matter hyperintensities (WMHs), lacunar infarctions, and microbleeds. CARASIL is caused by a homozygous mutation in high-temperature requirement A serine peptidase 1 (HTRA1). Recently, it was reported that several heterozygous mutations in HTRA1 also cause cerebral small vessel disease (CSVD). Although patients with heterozygous HTRA1-related CSVD (symptomatic carriers) are reported to have a milder form of CARASIL, little is known about the clinical and genetic differences between the two diseases. Given this gap in the literature, we collected clinical information on HTRA1-related CSVD from a review of the literature to help clarify the differences between symptomatic carriers and CARASIL and the features of both diseases. Forty-six symptomatic carriers and 28 patients with CARASIL were investigated. Twenty-eight mutations in symptomatic carriers and 22 mutations in CARASIL were identified. Missense mutations in symptomatic carriers are more frequently identified in the linker or loop 3 (L3)/loop D (LD) domains, which are critical sites in activating protease activity. The ages at onset of neurological symptoms/signs were significantly higher in symptomatic carriers than in CARASIL, and the frequency of characteristic extraneurological findings and confluent WMHs were significantly higher in CARASIL than in symptomatic carriers. As previously reported, heterozygous HTRA1-related CSVD has a milder clinical presentation of CARASIL. It seems that haploinsufficiency can cause CSVD among symptomatic carriers according to the several patients with heterozygous nonsense/frameshift mutations. However, the differing locations of mutations found in the two diseases indicate that distinct molecular mechanisms influence the development of CSVD in patients with HTRA1-related CSVD. These findings further support continued careful examination of the pathogenicity of mutations located outside the linker or LD/L3 domain in symptomatic carriers.
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Affiliation(s)
- Masahiro Uemura
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Hiroaki Nozaki
- Department of Medical Technology, Graduate School of Health Sciences, Niigata University, Niigata, Japan.,Department of Neurology, Niigata City General Hospital, Niigata, Japan
| | - Taisuke Kato
- Department of System Pathology for Neurological Disorders, Brain Research Institute, Niigata University, Niigata, Japan
| | - Akihide Koyama
- Division of Legal Medicine, Niigata University, Niigata, Japan
| | - Naoko Sakai
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Shoichiro Ando
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masato Kanazawa
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Nozomi Hishikawa
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Kiran Polavarapu
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Atchayaram Nalini
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Akira Hanazono
- Division of Gastroenterology, Hepato-Biliary-Pancreatology and Neurology, Akita University Hospital, Akita, Japan
| | - Daisuke Kuzume
- Department of Neurology, Chikamori Hospital, Kochi, Japan
| | - Akihiro Shindo
- Department of Neurology, Mie University Graduate School of Medicine, Mie, Japan
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona-Banner University Medicine, Tucson, AZ, United States
| | - Arata Abe
- Department of Neurology, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Aki Sato
- Department of Neurology, Niigata City General Hospital, Niigata, Japan
| | - Mari Yoshida
- Department of Neuropathology, Institute for Medical Science of Aging, Aichi Medical University, Nagakute, Japan
| | - Takeshi Ikeuchi
- Department of Molecular Genetics, Brain Research Institute, Niigata University, Niigata, Japan
| | - Ikuko Mizuta
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Onodera
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
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