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Manini A, Pantoni L. Genetic Causes of Cerebral Small Vessel Diseases: A Practical Guide for Neurologists. Neurology 2023; 100:766-783. [PMID: 36535782 PMCID: PMC10115494 DOI: 10.1212/wnl.0000000000201720] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Cerebral small vessel disease (CSVD) includes various entities affecting the brain and, often, systemic small arteries, arterioles, venules, and capillaries. The underlying causes of CSVD are different, and some of them are genetic. Monogenic CSVDs are responsible for 1%-5% of all strokes and for several other disturbances. Despite many genes being involved, the phenotypes of monogenic CSVD partly overlap. Given that the genetic testing for different diseases can be challenging and time-consuming, the practicing neurologist should be adequately informed of the genetic background of CSVD and should be able to select patients to undergo genetic assessment and the genes to be analyzed. The purpose of this review was to summarize clinical, neurologic and non-neurologic, and neuroimaging features of monogenic CSVD and to provide a flowchart to be used in clinical practice to guide neurologists in this field. The proposed flowchart and the relative tables can be applied to 3 different settings, depending on the presentation: (1) ischemic stroke and/or transient ischemic attack, (2) cerebral hemorrhage, and (3) other neurologic, non-neurologic, and/or neuroimaging features of monogenic CSVD, in the absence of stroke syndromes because of infarction or hemorrhage.
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Affiliation(s)
- Arianna Manini
- From the Stroke and Dementia Lab (A.M., L.P.), Department of Biomedical and Clinical Sciences, University of Milan, Italy; Department of Neurology and Laboratory of Neuroscience (A.M.), IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Leonardo Pantoni
- From the Stroke and Dementia Lab (A.M., L.P.), Department of Biomedical and Clinical Sciences, University of Milan, Italy; Department of Neurology and Laboratory of Neuroscience (A.M.), IRCCS Istituto Auxologico Italiano, Milan, Italy.
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Park HK, Lee KJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Han MK, Kang J, Kim BJ, Park TH, Park MS, Lee KB, Lee J, Hong KS, Cho YJ, Lee BC, Yu KH, Oh MS, Kim JT, Choi KH, Kim DE, Ryu WS, Choi JC, Kwon JH, Kim WJ, Shin DI, Sohn SI, Hong JH, Lee J, Lee K, Song J, Bae JS, Cheong HS, Debette S, Bae HJ. Prevalence of Mutations in Mendelian Stroke Genes in Early Onset Stroke Patients. Ann Neurol 2023; 93:768-782. [PMID: 36541592 DOI: 10.1002/ana.26575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Heritability of stroke is assumed not to be low, especially in the young stroke population. However, most genetic studies have been performed in highly selected patients with typical clinical or neuroimaging characteristics. We investigated the prevalence of 15 Mendelian stroke genes and explored the relationships between variants and the clinical and neuroimaging characteristics in a large, unselected, young stroke population. METHODS We enrolled patients aged ≤55 years with stroke or transient ischemic attack from a prospective, nationwide, multicenter stroke registry. We identified clinically relevant genetic variants (CRGVs) in 15 Mendelian stroke genes (GLA, NOTCH3, HTRA1, RNF213, ACVRL1, ENG, CBS, TREX1, ABCC6, COL4A1, FBN1, NF1, COL3A1, MT-TL1, and APP) using a customized, targeted next generation sequencing panel. RESULTS Among 1,033 patients, 131 (12.7%) had 28 CRGVs, most frequently in RNF213 (n = 59), followed by ABCC6 (n = 53) and NOTCH3 (n = 15). The frequency of CRGVs differed by ischemic stroke subtypes (p < 0.01): the highest in other determined etiology (20.1%), followed by large artery atherosclerosis (13.6%). It also differed between patients aged ≤35 years and those aged 51 to 55 years (17.1% vs 9.3%, p = 0.02). Only 27.1% and 26.7% of patients with RNF213 and NOTCH3 variants had typical neuroimaging features of the corresponding disorders, respectively. Variants of uncertain significance (VUSs) were found in 15.4% patients. INTERPRETATION CRGVs in 15 Mendelian stroke genes may not be uncommon in the young stroke population. The majority of patients with CRGVs did not have typical features of the corresponding monogenic disorders. Clinical implications of having CRGVs or VUSs should be explored. ANN NEUROL 2023;93:768-782.
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Affiliation(s)
- Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Keon-Joo Lee
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, South Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Moon-Ku Han
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Jihoon Kang
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Moo-Seok Park
- Department of Neurology, Seoul Hospital, Ewha Woman's University College of Medicine, Seoul, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, South Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, South Korea
- Research Center for Artificial Intelligence, JLK Corporation, Seoul, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, South Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University College of Medicine, Ulsan, South Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University College of Medicine, Ulsan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk University Hospital, Cheongju, South Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, South Korea
| | - Kyunghoon Lee
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Joon Seol Bae
- Research Institute of Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Hyun Sub Cheong
- Research Institute for Life Science, GW Vitek, Seoul, South Korea
| | - Stéphanie Debette
- University of Bordeaux, Bordeaux Population Health Research Center, Bordeaux, France
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
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Chang LH, Chi NF, Chen CY, Lin YS, Hsu SL, Tsai JY, Huang HC, Lin CJ, Chung CP, Tung CY, Jeng CJ, Lee YC, Liu YT, Lee IH. Monogenic Causes in Familial Stroke Across Intracerebral Hemorrhage and Ischemic Stroke Subtypes Identified by Whole-Exome Sequencing. Cell Mol Neurobiol 2022:10.1007/s10571-022-01315-3. [PMID: 36580209 DOI: 10.1007/s10571-022-01315-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/20/2022] [Indexed: 12/30/2022]
Abstract
Whole exome sequencing (WES) has been used to detect rare causative variants in neurological diseases. However, the efficacy of WES in genetic diagnosis of clinically heterogeneous familial stroke remains inconclusive. We prospectively searched for disease-causing variants in unrelated probands with defined familial stroke by candidate gene/hotspot screening and/or WES, depending on stroke subtypes and neuroimaging features at a referral center. The clinical significance of each variant was determined according to the American College of Medical Genetics guidelines. Among 161 probands (mean age at onset 53.2 ± 13.7 years; male 63.4%), 33 participants (20.5%) had been identified with 19 pathogenic/likely pathogenic variants (PVs; WES applied 152/161 = 94.4%). Across subtypes, the highest hit rate (HR) was intracerebral hemorrhage (ICH, 7/18 = 38.9%), particularly with the etiological subtype of structural vasculopathy (4/4 = 100%, PVs in ENG, KRIT1, PKD1, RNF213); followed by ischemic small vessel disease (SVD, 15/48 = 31.3%; PVs in NOTCH3, HTRA1, HBB). In contrast, large artery atherosclerosis (LAA, 4/44 = 9.1%) and cardioembolism (0/11 = 0%) had the lowest HR. NOTCH3 was the most common causative gene (16/161 = 9.9%), presenting with multiple subtypes of SVD (n = 13), ICH (n = 2), or LAA (n = 1). Importantly, we disclosed two previously unreported PVs, KRIT1 p.E379* in a familial cerebral cavernous malformation, and F2 p.F382L in a familial cerebral venous sinus thrombosis. The contribution of monogenic etiologies was particularly high in familial ICH and SVD subtypes in our Taiwanese cohort. Utilizing subtype-guided hotspot screening and/or subsequent WES, we unraveled monogenic causes in 20.5% familial stroke probands, including 1.2% novel PVs. Genetic diagnosis may enable early diagnosis, management and lifestyle modification. Among 161 familial stroke probands, 33 (20.5%) had been identified pathogenic or likely pathogenic monogenic variants related to stroke. The positive hit rate among all subtypes was high in intracerebral hemorrhage (ICH) and ischemic small vessel disease (SVD). Notably, two previously unreported variants, KRIT1 p.E379* in a familial cerebral cavernous malformation and F2 p.F382L in familial cerebral venous sinus thrombosis, were disclosed. CVT cerebral venous thrombosis; HTN Hypertensive subtype; LAA large artery atherosclerosis; SV structural vasculopathy; U Undetermined.
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Affiliation(s)
- Li-Hsin Chang
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Yu Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Yung-Shuan Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Shao-Lun Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Jui-Yao Tsai
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Hui-Chi Huang
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Yi Tung
- Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jiuan Jeng
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Institute of Anatomy and Cell Biology, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chung Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yo-Tsen Liu
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - I-Hui Lee
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Meneri M, Bonato S, Gagliardi D, Comi GP, Corti S. New Insights into Cerebral Vessel Disease Landscapes at Single-Cell Resolution: Pathogenetic and Therapeutic Perspectives. Biomedicines 2022; 10:biomedicines10071693. [PMID: 35884997 PMCID: PMC9313091 DOI: 10.3390/biomedicines10071693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
Cerebrovascular diseases are a leading cause of death and disability globally. The development of new therapeutic targets for cerebrovascular diseases (e.g., ischemic, and hemorrhagic stroke, vascular dementia) is limited by a lack of knowledge of the cellular and molecular biology of health and disease conditions and the factors that cause injury to cerebrovascular structures. Here, we describe the role of advances in omics technology, particularly RNA sequencing, in studying high-dimensional, multifaceted profiles of thousands of individual blood and vessel cells at single-cell resolution. This analysis enables the dissection of the heterogeneity of diseased cerebral vessels and their atherosclerotic plaques, including the microenvironment, cell evolutionary trajectory, and immune response pathway. In animal models, RNA sequencing permits the tracking of individual cells (including immunological, endothelial, and vascular smooth muscle cells) that compose atherosclerotic plaques and their alteration under experimental settings such as phenotypic transition. We describe how single-cell RNA transcriptomics in humans allows mapping to the molecular and cellular levels of atherosclerotic plaques in cerebral arteries, tracking individual lymphocytes and macrophages, and how these data can aid in identifying novel immune mechanisms that could be exploited as therapeutic targets for cerebrovascular diseases. Single-cell multi-omics approaches will likely provide the unprecedented resolution and depth of data needed to generate clinically relevant cellular and molecular signatures for the precise treatment of cerebrovascular diseases.
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Affiliation(s)
- Megi Meneri
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, 20122 Milan, Italy; (M.M.); (D.G.); (G.P.C.)
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Sara Bonato
- Stroke Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Delia Gagliardi
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, 20122 Milan, Italy; (M.M.); (D.G.); (G.P.C.)
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giacomo P. Comi
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, 20122 Milan, Italy; (M.M.); (D.G.); (G.P.C.)
- Neuromuscular and Rare Diseases Unit, Department of Neuroscience, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Stefania Corti
- Dino Ferrari Centre, Department of Pathophysiology and Transplantation (DEPT), University of Milan, 20122 Milan, Italy; (M.M.); (D.G.); (G.P.C.)
- Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
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Stroke and Etiopathogenesis: What Is Known? Genes (Basel) 2022; 13:genes13060978. [PMID: 35741740 PMCID: PMC9222702 DOI: 10.3390/genes13060978] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 02/05/2023] Open
Abstract
Background: A substantial portion of stroke risk remains unexplained, and a contribution from genetic factors is supported by recent findings. In most cases, genetic risk factors contribute to stroke risk as part of a multifactorial predisposition. A major challenge in identifying the genetic determinants of stroke is fully understanding the complexity of the phenotype. Aims: Our narrative review is needed to improve our understanding of the biological pathways underlying the disease and, through this understanding, to accelerate the identification of new drug targets. Methods: We report, the research in the literature until February 2022 in this narrative review. The keywords are stroke, causes, etiopathogenesis, genetic, epigenetic, ischemic stroke. Results: While better risk prediction also remains a long-term goal, its implementation is still complex given the small effect-size of genetic risk variants. Some authors encourage the use of stroke genetic panels for stroke risk assessment and further stroke research. In addition, new biomarkers for the genetic causes of stroke and new targets for gene therapy are on the horizon. Conclusion: We summarize the latest evidence and perspectives of ischemic stroke genetics that may be of interest to the physician and useful for day-to-day clinical work in terms of both prevention and treatment of ischemic stroke.
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Giugliani R, Marques S, Andrade LGMD, Pessoa A, Vaisbich MH, Blum A, Tenório F, Rosa Neto NS. Clinical and diagnostic aspects of Fabry disease management: a narrative review with a particular focus on Brazilian experts’ perspectives. JOURNAL OF INBORN ERRORS OF METABOLISM AND SCREENING 2022. [DOI: 10.1590/2326-4594-jiems-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Roberto Giugliani
- Universidade Federal do Rio Grande do Sul, Brazil; Hospital de Clínicas de Porto Alegre, Brazil
| | | | | | - André Pessoa
- Hospital Infantil Albert Sabin, Brazil; Universidade Estadual do Ceará, Brazil
| | - Maria H. Vaisbich
- Universidade Federal de São Paulo, Brazil; Universidade de São Paulo (HCFMUSP), Brazil
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Ekkert A, Šliachtenko A, Grigaitė J, Burnytė B, Utkus A, Jatužis D. Ischemic Stroke Genetics: What Is New and How to Apply It in Clinical Practice? Genes (Basel) 2021; 13:genes13010048. [PMID: 35052389 PMCID: PMC8775228 DOI: 10.3390/genes13010048] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/14/2022] Open
Abstract
The etiology of ischemic stroke is multifactorial. Although receiving less emphasis, genetic causes make a significant contribution to ischemic stroke genesis, especially in early-onset stroke. Several stroke classification systems based on genetic information corresponding to various stroke phenotypes were proposed. Twin and family history studies, as well as candidate gene approach, are common methods to discover genetic causes of stroke, however, both have their own limitations. Genome-wide association studies and next generation sequencing are more efficient, promising and increasingly used for daily diagnostics. Some monogenic disorders, despite covering only about 7% of stroke etiology, may cause well-known clinical manifestations that include stroke. Polygenic disorders are more frequent, causing about 38% of all ischemic strokes, and their identification is a rapidly developing field of modern stroke genetics. Current advances in human genetics provide opportunity for personalized prevention of stroke and novel treatment possibilities. Genetic risk scores (GRS) and extended polygenic risk scores (PRS) estimate cumulative contribution of known genetic factors to a specific outcome of stroke. Combining those scores with clinical information and risk factor profiles might result in better primary stroke prevention. Some authors encourage the use of stroke gene panels for stroke risk evaluation and further stroke research. Moreover, new biomarkers for stroke genetic causes and novel targets for gene therapy are on the horizon. In this article, we summarize the latest evidence and perspectives of ischemic stroke genetics that could be of interest to the practitioner and useful for day-to-day clinical work.
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Affiliation(s)
- Aleksandra Ekkert
- Center of Neurology, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (J.G.); (D.J.)
- Correspondence:
| | | | - Julija Grigaitė
- Center of Neurology, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (J.G.); (D.J.)
| | - Birutė Burnytė
- Center for Medical Genetics, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (B.B.); (A.U.)
| | - Algirdas Utkus
- Center for Medical Genetics, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (B.B.); (A.U.)
| | - Dalius Jatužis
- Center of Neurology, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania; (J.G.); (D.J.)
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Romani I, Nencini P, Sarti C, Pracucci G, Zedde M, Nucera A, Cianci V, Moller J, Toni D, Orsucci D, Casella C, Pinto V, Palumbo P, Barbarini L, Bella R, Ragno M, Scoditti U, Mezzapesa DM, Tassi R, Diomedi M, Cavallini A, Volpi G, Chiti A, Bigliardi G, Sacco S, Linoli G, Ricci S, Giordano A, Bonetti B, Rasura M, Cecconi E, Princiotta Cariddi L, Currò Dossi R, Melis M, Consoli D, Guidetti D, Biagini S, Accavone D, Inzitari D. Fabry-Stroke Italian Registry (FSIR): a nationwide, prospective, observational study about incidence and characteristics of Fabry-related stroke in young-adults. Presentation of the study protocol. Neurol Sci 2021; 43:2433-2439. [PMID: 34609660 PMCID: PMC8918192 DOI: 10.1007/s10072-021-05615-2] [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: 06/06/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Abstract
Background TIA and stroke, both ischemic and hemorrhagic, may complicate Fabry disease at young-adult age and be the first manifestation that comes to the clinician’s attention. No definite indications have yet been elaborated to guide neurologists in Fabry disease diagnostics. In current practice, it is usually sought in case of cryptogenic strokes (while Fabry-related strokes can also occur by classical pathogenic mechanisms) or through screening programs in young cerebrovascular populations. Data on recurrence and secondary prevention of Fabry’s stroke are scanty. Methods The study had a prospective observational design involving 33 Italian neurological Stroke Units. Considering the incidence of TIA/stroke in the European population aged < 60 years and the frequency of Fabry disease in this category (as foreseen by a pilot study held at the Careggi University-Hospital, Florence), we planned to screen for Fabry disease a total of 1740 < 60-year-old individuals hospitalized for TIA, ischemic, or hemorrhagic stroke. We investigated TIA and stroke pathogenesis through internationally validated scales and we gathered information on possible early signs of Fabry disease among all cerebrovascular patients. Every patient was tested for Fabry disease through dried blood spot analysis. Patients who received Fabry disease diagnosis underwent a 12-month follow-up to monitor stroke recurrence and multi-system progression after the cerebrovascular event. Discussion The potential implications of this study are as follows: (i) to add information about the yield of systematic screening for Fabry disease in a prospective large cohort of acute cerebrovascular patients; (ii) to deepen knowledge of clinical, pathophysiological, and prognostic characteristics of Fabry-related stroke.
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Affiliation(s)
- Ilaria Romani
- Department of Neurosciences, Psychology, Pharmacology, and Child Health (NEUROFARBA), University of Florence, Florence, Italy.
| | | | - Cristina Sarti
- Department of Neurosciences, Psychology, Pharmacology, and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Giovanni Pracucci
- Department of Neurosciences, Psychology, Pharmacology, and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | - Antonia Nucera
- Neurovascular Treatment Unit, Spaziani Hospital, Frosinone, Italy
| | - Vittoria Cianci
- Neurology, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | | | - Danilo Toni
- Emergency Department Stroke Unit, Umberto I Polyclinic Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Carmela Casella
- Stroke Unit, Department of Clinical and Experimental Medicine, AOU Policlinico G. Martino, University of Messina, Messina, Italy
| | - Vincenza Pinto
- Neurology and Stroke Unit, Di Summa - Perrino Hospital, Brindisi, Italy
| | - Pasquale Palumbo
- Neurology, Neurophysiopathology, and Stroke Unit, Santo Stefano Hospital, Prato, Italy
| | | | - Rita Bella
- Acute Cerebrovascular Diseases Unit, Vittorio Emanuele University Hospital, Catania, Italy
| | - Michele Ragno
- Division of Neurology, C. e G. Mazzoni Hospital and Madonna del Soccorso Hospital, Ascoli Piceno, Italy
| | - Umberto Scoditti
- Neurology - Stroke Care Program, Parma University Hospital, Parma, Italy
| | | | - Rossana Tassi
- Neurosonology and Stroke Unit, Siena University Hospital, Siena, Italy
| | - Marina Diomedi
- Neurovascular Treatment Unit, Tor Vergata Polyclinic Hospital, Rome, Italy
| | | | - Gino Volpi
- Neurology, San Iacopo Hospital, Pistoia, Italy
| | | | - Guido Bigliardi
- Stroke Unit, Sant'Agostino Estense New Hospital, Modena, Italy
| | - Simona Sacco
- Neurology and Stroke Unit, SS Filippo e Nicola Hospital , Avezzano, Italy
| | | | - Stefano Ricci
- Stroke Center - Neurology, Città Di Castello Hospital and Gubbio-Gualdo Tadino Hospital, Città di Castello, Italy
| | | | - Bruno Bonetti
- Stroke Unit, Verona University Hospital, Verona, Italy
| | | | | | | | | | - Marta Melis
- Neurology, Monserrato University Hospital, Cagliari, Italy
| | | | | | - Silvia Biagini
- Department of Neurosciences, Psychology, Pharmacology, and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Donatella Accavone
- Department of Neurosciences, Psychology, Pharmacology, and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Domenico Inzitari
- Department of Neurosciences, Psychology, Pharmacology, and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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9
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Guey S, Lesnik Oberstein SAJ, Tournier-Lasserve E, Chabriat H. Hereditary Cerebral Small Vessel Diseases and Stroke: A Guide for Diagnosis and Management. Stroke 2021; 52:3025-3032. [PMID: 34399586 DOI: 10.1161/strokeaha.121.032620] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cerebral small vessel diseases represent a frequent cause of stroke and cognitive or motor disability in adults. A small proportion of cerebral small vessel diseases is attributable to monogenic conditions. Since the characterization in the late 1990s of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, several other monogenic conditions leading to adult-onset ischemic or hemorrhagic stroke have been described. In this practical guide, we summarize the key features that should elicit the differential diagnosis of a hereditary cerebral small vessel diseases in adult stroke patients, describe the main clinical and imaging characteristics of the major hereditary cerebral small vessel diseases that can manifest as stroke, and provide general recommendations for the clinical management of affected patients and their relatives.
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Affiliation(s)
- Stéphanie Guey
- CERVCO, FHU NeuroVasc, Assistance Publique des Hôpitaux de Paris and Paris University, France (S.G., E.T.-L., H.C.).,INSERM UMR 1141, NeuroDiderot, Université de Paris, France (S.G., E.T.-L., H.C.)
| | | | - Elisabeth Tournier-Lasserve
- CERVCO, FHU NeuroVasc, Assistance Publique des Hôpitaux de Paris and Paris University, France (S.G., E.T.-L., H.C.).,INSERM UMR 1141, NeuroDiderot, Université de Paris, France (S.G., E.T.-L., H.C.)
| | - Hugues Chabriat
- CERVCO, FHU NeuroVasc, Assistance Publique des Hôpitaux de Paris and Paris University, France (S.G., E.T.-L., H.C.).,INSERM UMR 1141, NeuroDiderot, Université de Paris, France (S.G., E.T.-L., H.C.)
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10
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1004] [Impact Index Per Article: 334.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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11
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12
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Abstract
PURPOSE OF REVIEW This article reviews current knowledge on epidemiology, risk factors and causes, diagnostic considerations, management, and prognosis of ischemic stroke in young adults (those 55 years old and younger). RECENT FINDINGS The incidence of ischemic stroke in young adults has been increasing since the 1980s, which has occurred in parallel with increasing prevalence of vascular risk factors and substance abuse among the younger population. Young adults have a considerably wider range of risk factors than older patients, including age-specific factors such as pregnancy/puerperium and oral contraceptive use. Behavioral risk factors such as low physical activity, excess alcohol consumption, and smoking are factors as well. More than 150 identified causes of early-onset ischemic stroke exist, including rare monogenic disorders. Several recent advances have been made in diagnosis and management of stroke in young adults, including molecular characterization of monogenic vasculitis due to deficiency of adenosine deaminase 2 and transcatheter closure of patent foramen ovale for secondary prevention. Compared with the background population of the same age and sex, long-term mortality in patients remains fourfold higher with cardiovascular causes underlying most of the deaths. The cumulative rate of recurrent stroke extends up to 15% at 10 years. Patients with atherosclerosis, high-risk sources of cardioembolism, and small vessel disease underlying their stroke seem to have the worst prognosis regarding survival and recurrent vascular events. Young stroke survivors also often have other adverse outcomes in the long term, including epilepsy, pain, cognitive problems, and depression. SUMMARY Systematic identification of risk factors and causes and the motivation of patients for long-term prevention and lifestyle changes are of utmost importance to improve the prognosis of early-onset ischemic stroke.
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13
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Cheng S, Xu Z, Liu Y, Lin J, Jiang Y, Wang Y, Meng X, Wang A, Huang X, Wang Z, Chen G, Wu S, Jia Z, Chen Y, Qiu X, Wu J, Song B, Ji W, An Z, Xue W, Zhao L, Geng Y, Li H, Li H, Wang Y. Whole genome sequencing of 10K patients with acute ischaemic stroke or transient ischaemic attack: design, methods and baseline patient characteristics. Stroke Vasc Neurol 2020; 6:291-297. [PMID: 33443231 PMCID: PMC8258062 DOI: 10.1136/svn-2020-000664] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/16/2022] Open
Abstract
Background and purpose Stroke is the second leading cause of death worldwide and the leading cause of mortality and long-term disability in China, but its underlying risk genes and pathways are far from being comprehensively understood. We here describe the design and methods of whole genome sequencing (WGS) for 10 914 patients with acute ischaemic stroke or transient ischaemic attack from the Third China National Stroke Registry (CNSR-III). Methods Baseline clinical characteristics of the included patients in this study were reported. DNA was extracted from white blood cells of participants. Libraries are constructed using qualified DNA, and WGS is conducted on BGISEQ-500 platform. The average depth is intended to be greater than 30× for each subject. Afterwards, Sentieon software is applied to process the sequencing data under the Genome Analysis Toolkit best practice guidance to call genotypes of single nucleotide variants (SNVs) and insertion-deletions. For each included subject, 21 fingerprint SNVs are genotyped by MassARRAY assays to verify that DNA sample and sequencing data originate from the same individual. The copy number variations and structural variations are also called for each patient. All of the genetic variants are annotated and predicted by bioinformatics software or by reviewing public databases. Results The average age of the included 10 914 patients was 62.2±11.3 years, and 31.4% patients were women. Most of the baseline clinical characteristics of the 10 914 and the excluded patients were balanced. Conclusions The WGS data together with abundant clinical and imaging data of CNSR-III could provide opportunity to elucidate the molecular mechanisms and discover novel therapeutic targets for stroke.
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Affiliation(s)
- Si Cheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Zhe Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xinying Huang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhimin Wang
- Department of Neurology, The First people's Hospital of Taizhou, Taizhou, China
| | - Guohua Chen
- Department of Neurology, Wuhan First Hospital, Wuhan, China
| | - Songdi Wu
- Department of Neurology, The First People's Hospital of Xi'an, Xi'an, China
| | - Zhengchang Jia
- Department of Neurology, The Second People's Hospital of Jinzhong, Jinzhong, China
| | - Yongming Chen
- Department of Neurology, WuYuan County People's Hospital, Bayannur, China
| | - Xuerong Qiu
- Department of Neurology, Qiqihar City Rongjian Stroke Prevention and Treatment Institute, Qiqihar, China
| | - Jun Wu
- Department of Neurology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Binbin Song
- Department of Neurology, Luoyang Central Hospital, Luoyang, China
| | - Weizhong Ji
- Department of Neurology, Qinghai Provincial People's Hospital, Xining, China
| | - Zhongping An
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Wenjun Xue
- Department of Neurology, Pingdingshan First People's Hospital, Pingdingshan, China
| | - Lili Zhao
- Department of Neurology, Changzhi People's Hospital, Changzhi, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Hongyan Li
- Department of Neurology, Xinjiang Uygur Autonomous Region People's Hospital, Urumqi, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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14
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Ospina C, Arboleda-Velasquez JF, Aguirre-Acevedo DC, Zuluaga-Castaño Y, Velilla L, Garcia GP, Quiroz YT, Lopera F. Genetic and nongenetic factors associated with CADASIL: A retrospective cohort study. J Neurol Sci 2020; 419:117178. [PMID: 33091750 DOI: 10.1016/j.jns.2020.117178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 10/02/2020] [Accepted: 10/09/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To explore the role of cardiovascular risk factors and the different NOTCH-3 mutations to explain the variability observed in the clinical presentation of CADASIL. METHODS This was a retrospective cohort study of 331 individuals, 90 were carriers of four mutations in the NOTCH3 gene. These four mutations are the ones identified in our region from the genetic evaluation of probands. Cox proportional hazards models were fitted to estimate the effect of genetic and cardiovascular factors on the onset of migraine, first stroke, and dementia. Competing risk regression models considered death as risk. RESULTS Noncarriers (healthy controls from the same families without NOTCH3 mutations) and NOTCH3 mutation carriers had similar frequencies for all cardiovascular risk factors. Diabetes (SHR 2.74, 95% CI 1.52-4.94) was associated with a younger age at onset of strokes among carriers. Additionally, a genotype-phenotype relationship was observed among C455R mutation carriers, with higher frequency of migraines (100%), younger age at onset of migraine (median age 7 years, IQR 8) and strokes (median age 30.5 years, IQR 26). Moreover, fewer carriers of the R141C mutation exhibited migraines (20%), and it was even lower than the frequency observed in the noncarrier group (44.8%). CONCLUSIONS This study characterizes extended family groups, allowing us a comparison in the genotype-phenotype. The results suggest a complex interplay of genetic and cardiovascular risk factors that may help explain the variability in the clinical presentation and severity of CADASIL.
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Affiliation(s)
- Carolina Ospina
- Neuroscience Group of Antioquia, University of Antioquia, Medellín, Colombia.
| | - Joseph F Arboleda-Velasquez
- Schepens Eye Research Institute/Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
| | | | | | - Lina Velilla
- Neuroscience Group of Antioquia, University of Antioquia, Medellín, Colombia
| | - Gloria P Garcia
- Neuroscience Group of Antioquia, University of Antioquia, Medellín, Colombia.
| | - Yakeel T Quiroz
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
| | - Francisco Lopera
- Neuroscience Group of Antioquia, University of Antioquia, Medellín, Colombia
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15
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Cheng YW, Chen CH, Hu CJ, Chiou HY, Tang SC, Jeng JS. Imaging-based pregenetic screening for NOTCH3 p.R544C mutation in ischemic stroke in Taiwan. Ann Clin Transl Neurol 2020; 7:1951-1961. [PMID: 32929895 PMCID: PMC7545606 DOI: 10.1002/acn3.51191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/08/2020] [Accepted: 08/24/2020] [Indexed: 01/05/2023] Open
Abstract
Objective To develop an easily applicable screening score to guide NOTCH3 p.R544C genetic testing for patients who presented with acute ischemic cerebrovascular events in Taiwan. Methods 1734 patients who presented with ischemic cerebrovascular events were enrolled from the Formosa Stroke Genetic Consortium stroke registry and were screened for the NOTCH3 p.R544C mutation. Clinical and MRI characteristics of NOTCH3 p.R544C mutation carriers (n = 36) and a subset of noncarriers (n = 673) were tested in a logistic regression model to identify key features associated with the NOTCH3 p.R544C carrier status. Variables and their odds ratios in the regression model were used to develop the R544C screening score to predict positive NOTCH3 p.R544C test results. Results We constructed the R544C screening score using five clinical and imaging characteristics, including stroke onset before 50 years of age, the small vessel occlusion subtype, a family history of stroke/TIA in siblings, external capsule involvement, and advanced deep white matter hyperintensity. The area under the ROC curve of the screening score was 0.867 (95% CI = 0.810‐0.924). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 0.75, 0.88, 0.13, 0.99, and 0.88, respectively, for a cutoff score of 5 points. In addition, the R544C screening score was validated in another cohort composed of 235 stroke patients with comparable performance (area under the ROC curve = 0.957, 95% CI = 0.916‐0.997). Interpretations For Taiwanese patients presenting with acute ischemic cerebrovascular events, the R544C screening score is easily applicable and can efficiently select high‐risk patients for NOTCH3 p.R544C mutation test.
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Affiliation(s)
- Yu-Wen Cheng
- Department of Neurology, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, Taipei Medical University Hospital and Shuang Ho Hospital, Taipei, Taiwan
| | - Hung-Yi Chiou
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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16
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Fang F, Xu Z, Suo Y, Wang H, Cheng S, Li H, Li W, Wang Y. Gene panel for Mendelian strokes. Stroke Vasc Neurol 2020; 5:416-421. [PMID: 32341005 PMCID: PMC7804056 DOI: 10.1136/svn-2020-000352] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mendelian stroke causes nearly 7% of ischaemic strokes and is also an important aetiology of cryptogenic stroke. Identifying the genetic abnormalities in Mendelian strokes is important as it would facilitate therapeutic management and genetic counselling. Next-generation sequencing makes large-scale sequencing and genetic testing possible. METHODS A systematic literature search was conducted to identify causal genes of Mendelian strokes, which were used to construct a hybridization-based gene capture panel. Genetic variants for target genes were detected using Illumina HiSeq X10 and the Novaseq platform. The sensitivity and specificity were evaluated by comparing the results with Sanger sequencing. RESULTS 53 suspected patients of Mendelian strokes were analysed using the panel of 181 causal genes. According to the American College of Medical Genetics and Genomics standard, 16 likely pathogenic/variants of uncertain significance genetic variants were identified. Diagnostic testing was conducted by comparing the consistency between the results of panel and Sanger sequencing. Both the sensitivity and specificity were 100% for the panel. CONCLUSION This panel provides an economical, time-saving and labour-saving method to detect causal mutations of Mendelian strokes.
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Affiliation(s)
- Fang Fang
- Monogenic Disease Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhe Xu
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yue Suo
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hui Wang
- Monogenic Disease Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Si Cheng
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Li
- Monogenic Disease Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China .,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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17
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Traenka C, Kloss M, Strom T, Lyrer P, Brandt T, Bonati LH, Grond-Ginsbach C, Engelter S. Rare genetic variants in patients with cervical artery dissection. Eur Stroke J 2019; 4:355-362. [PMID: 31903434 DOI: 10.1177/2396987319861869] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/15/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction The potential role of genetic alterations in cervical artery dissection (CeAD) pathogenesis is poorly understood. We aimed to identify pathogenic genetic variants associated with cervical artery dissection by using whole exome sequencing. Patients and methods CeAD-patients with either a family history of cervical artery dissection (f-CeAD) or recurrent cervical artery dissection (r-CeAD) from the CeAD-databases of two experienced stroke centres were analysed by whole exome sequencing.Variants with allele frequency <0.05 and classified as pathogenic by predicting algorithms (SIFT or Polyphen-2) or the ClinVar database were explored. First, we analysed a panel of 30 candidate genes associated with arterial dissection (any site) or aneurysm according to the OMIM (online Mendelian Inheritance of Men) database. Second, we performed a genome-wide search for pathogenic variants causing other vascular phenotypes possibly related to cervical artery dissection.Findings were classified as CeAD-causing (pathogenic variants in genes from the arterial dissection or aneurysm panel) or suggestive (pathogenic variants in genes associated with other vascular phenotypes and variants of unknown significance in genes from the arterial dissection or aneurysm panel). All other variants were classified as benign/uncertain. Results Among 43 CeAD-patients, 28 patients (17 pedigrees) had f-CeAD and 15 had r-CeAD. No CeAD-causing variants were identified in r-CeAD patients. Among f-CeAD-patients, 5/17 pedigrees carried CeAD-causing variants in COL3A1, COL4A1, COL4A3, COL4A4, COL5A1, COL5A2 and FBN1. Suggestive variants in ABCC6, COL3A1, COL5A2, MEF2A, and RNF213 were detected in three pedigrees with f-CeAD and six patients with r-CeAD.Discussion and conclusion: CeAD-causing variants were rare and exclusively found in f-CeAD-patients, suggesting differences between the genetic architectures of f-CeAD and r-CeAD. The identified variants indicate a high genetic heterogeneity of the study sample.
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Affiliation(s)
- Christopher Traenka
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Manja Kloss
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tim Strom
- Institute of Human Genetics, Technische Universität München, Munich, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | - Philippe Lyrer
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland
| | - Tobias Brandt
- Suva/Swiss National Accident Insurance Fund, Lucerne, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland
| | - Caspar Grond-Ginsbach
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany.,Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Engelter
- Department of Neurology and Stroke Center, University Hospital and University of Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
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18
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Marques P, Beato-Coelho J, Durães J, Geraldo A. Ischaemic stroke as the initial manifestation of systemic amyloidosis. BMJ Case Rep 2019; 12:12/6/e228979. [PMID: 31256048 DOI: 10.1136/bcr-2018-228979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A previously healthy 54-year-old woman was admitted to the stroke unit with an acute ischaemic stroke attributed to atrial fibrillation newly diagnosed at the emergency room. Nevertheless, preliminary investigation on stroke aetiology revealed incidental hypoalbuminaemia in the context of nephrotic syndrome, while clinically, the patient developed progressive signs of cardiac failure raising the suspicion of an underlying disorder. Systemic amyloidosis was histologically confirmed a few weeks after hospital admission. The rare presentation and non-specific symptom constellation contributed to delayed institution of the appropriated treatment regimen at a point where multiorganic involvement was irreversible leading to death only 2 months after the first manifestation. The presented case reminds us of the importance of always keeping in mind this rarer cause of ischaemic stroke since an early diagnosis remains the key to a more hopeful prognosis.
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Affiliation(s)
- Patrícia Marques
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - José Beato-Coelho
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - João Durães
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Argemiro Geraldo
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
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19
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Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol 2019; 17:790-801. [PMID: 30129475 DOI: 10.1016/s1474-4422(18)30233-3] [Citation(s) in RCA: 188] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/01/2018] [Accepted: 06/05/2018] [Indexed: 01/15/2023]
Abstract
Epidemiological evidence suggests that the incidence of ischaemic stroke in young adults (18-50 years) has increased substantially. These patients have a long life expectancy after stroke, and the costs of long-term care pose huge challenges to health-care systems. Although the current recommendations for treatment of young and old (>50 years) patients with stroke are similar, the optimal management of young adult patients with stroke is unknown. They are usually not included in trials, and specific subanalyses limited to young adult patients with stroke are usually not done, owing to lower incidence of stroke and lower prevalence of vascular risk factors in young adults. Progress has been made in identifying patients with a considerable risk of stroke occurrence, such as those with patent foramen ovale. Future prevention studies might result in a decrease in the incidence of stroke and its sequelae in young adults. The development of guidelines specifically devoted to the management of stroke in young adults will be an important step in achieving this aim.
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20
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Chen W, Sinha B, Li Y, Benowitz L, Chen Q, Zhang Z, Patel NJ, Aziz-Sultan AM, Chiocca AE, Wang X. Monogenic, Polygenic, and MicroRNA Markers for Ischemic Stroke. Mol Neurobiol 2019; 56:1330-1343. [PMID: 29948938 PMCID: PMC7358039 DOI: 10.1007/s12035-018-1055-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 03/29/2018] [Indexed: 02/08/2023]
Abstract
Ischemic stroke (IS) is a leading disease with high mortality and disability, as well as with limited therapeutic window. Biomarkers for earlier diagnosis of IS have long been pursued. Family and twin studies confirm that genetic variations play an important role in IS pathogenesis. Besides DNA mutations found previously by genetic linkage analysis for monogenic IS (Mendelian inheritance), recent studies using genome-wide associated study (GWAS) and microRNA expression profiling have resulted in a large number of DNA and microRNA biomarkers in polygenic IS (sporadic IS), especially in different IS subtypes and imaging phenotypes. The present review summarizes genetic markers discovered by clinical studies and discusses their pathogenic molecular mechanisms involved in developmental or regenerative anomalies of blood vessel walls, neuronal apoptosis, excitotoxic death, inflammation, neurogenesis, and angiogenesis. The possible impact of environment on genetics is addressed as well. We also include a perspective on further studies and clinical application of these IS biomarkers.
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Affiliation(s)
- Wu Chen
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
- Department of Clinical Laboratory, Dongfeng Hospital, Hubei University of Medicine, Shiyan, 442008, Hubei, China.
| | - Bharati Sinha
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Newborn Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Yi Li
- Department of Clinical Laboratory, Dongfeng Hospital, Hubei University of Medicine, Shiyan, 442008, Hubei, China
| | - Larry Benowitz
- Department of Neurosurgery, Boston Children's Hospital, F.M. Kirby Neurobiology Center for Life Science, Harvard Medical School, Boston, MA, 02115, USA
| | - Qinhua Chen
- Experimental Center, Dongfeng Hospital, Hubei University of Medicine, Shiyan, 442008, Hubei, China
| | - Zhenghong Zhang
- Department of Neurology, Dongfeng Hospital, Hubei University of Medicine, Shiyan, 442008, Hubei, China
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Ali M Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Antonio E Chiocca
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Xin Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
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Bhatt N, Malik AM, Chaturvedi S. Stroke in young adults: Five new things. Neurol Clin Pract 2018; 8:501-506. [PMID: 30588380 PMCID: PMC6294527 DOI: 10.1212/cpj.0000000000000522] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/17/2018] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The incidence of stroke in young adults is increasing, mainly driven by an increasing incidence of ischemic stroke in this population. We provide new information that has been recently presented regarding the risk factor prevalence, some specific etiologic causes, and management strategies in ischemic stroke in this population. RECENT FINDINGS Recent studies indicate a rapid increase in traditional risk factors in young adults. New information regarding the management of patent foramen ovale in cryptogenic stroke and cervical artery dissection is available. SUMMARY Stroke in young adults is a rapidly growing problem with deep public health implications. There are many areas in this field, which require further research.
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Affiliation(s)
- Nirav Bhatt
- Division of Vascular Neurology (NB, AMM, SC), Department of Neurology, University of Miami Miller School of Medicine, and Miami VA Hospital (SC), FL
| | - Amer M Malik
- Division of Vascular Neurology (NB, AMM, SC), Department of Neurology, University of Miami Miller School of Medicine, and Miami VA Hospital (SC), FL
| | - Seemant Chaturvedi
- Division of Vascular Neurology (NB, AMM, SC), Department of Neurology, University of Miami Miller School of Medicine, and Miami VA Hospital (SC), FL
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Ilinca A, Samuelsson S, Piccinelli P, Soller M, Kristoffersson U, Lindgren AG. A stroke gene panel for whole-exome sequencing. Eur J Hum Genet 2018; 27:317-324. [PMID: 30356112 DOI: 10.1038/s41431-018-0274-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/19/2018] [Accepted: 08/28/2018] [Indexed: 12/21/2022] Open
Abstract
Extensive analyses of known monogenic causes of stroke by whole-exome/genome sequencing are technically possible today. We here aimed to compile a comprehensive panel of genes associated with monogenic causes of stroke for use in clinical and research situations. We systematically searched the publically available database Online Mendelian Inheritance in Man, and validated the entries against original peer-reviewed publications in PubMed. First, we selected known pathogenic or putatively pathogenic stroke genes reported in at least one person with stroke, and classified the stroke phenotype for each gene into eight subgroups: (1) large artery atherosclerotic, (2) large artery non-atherosclerotic (tortuosity, dolichoectasia, aneurysm, non-atherosclerotic dissection, occlusion), (3) cerebral small-vessel diseases, (4) cardioembolic (arrhythmia, heart defect, cardiomyopathy), (5) coagulation dysfunctions (venous thrombosis, arterial thrombosis, bleeding tendency), (6) intracerebral hemorrhage, (7) vascular malformations (cavernoma, arteriovenous malformations), and (8) metabolism disorders. Second, we selected other genes that may plausibly cause stroke through diseases related to stroke, but without any documented stroke patient description. A third section comprised SNPs associated with stroke in genome-wide association studies (GWAS). We identified in total 214 genes: 120 associated with stroke, 62 associated with diseases that may cause stroke, and 32 stroke-related genes from recent GWAS. We describe these 214 genes and the clinical stroke subtype(s) associated with each of them. The resulting gene panel can be used to interpret exome sequencing results regarding monogenic stroke. Based on the panel's clinical phenotype description, the pathogenicity of novel variants in these genes may be evaluated in specific situations.
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Affiliation(s)
- Andreea Ilinca
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden. .,Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Malmö, Sweden.
| | - Sofie Samuelsson
- Department of Clinical Genetics and Pathology, Laboratory Medicine, Region Skåne and Lund University, Lund, Sweden
| | - Paul Piccinelli
- Department of Clinical Genetics and Pathology, Laboratory Medicine, Region Skåne and Lund University, Lund, Sweden
| | - Maria Soller
- Department of Clinical Genetics and Pathology, Laboratory Medicine, Region Skåne and Lund University, Lund, Sweden.,Department of Clinical Genetics, Karolinska University Hospital, Solna, Sweden
| | - Ulf Kristoffersson
- Department of Clinical Genetics and Pathology, Laboratory Medicine, Region Skåne and Lund University, Lund, Sweden
| | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
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The role of clinical and neuroimaging features in the diagnosis of CADASIL. J Neurol 2018; 265:2934-2943. [PMID: 30311053 DOI: 10.1007/s00415-018-9072-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common familial cerebral small vessel disease, caused by NOTCH3 gene mutations. The aim of our study was to identify clinical and neuroradiological features which would be useful in identifying which patients presenting with lacunar stroke and TIA are likely to have CADASIL. METHODS Patients with lacunar stroke or TIA were included in the present study. For each patient, demographic and clinical data were collected. MRI images were centrally analysed for the presence of lacunar infarcts, microbleeds, temporal lobe involvement, global atrophy and white matter hyperintensities. RESULTS 128 patients (mean age 56.3 ± 12.4 years) were included. A NOTCH3 mutation was found in 12.5% of them. A family history of stroke, the presence of dementia and external capsule lesions on MRI were the only features significantly associated with the diagnosis of CADASIL. Although thalamic, temporal pole gliosis and severe white matter hyperintensities were less specific for CADASIL diagnosis, the combination of a number of these factors together with familial history for stroke result in a higher positive predictive value and specificity. CONCLUSIONS A careful familial history collection and neuroradiological assessment can identify patients in whom NOTCH3 genetic testing has a higher yield.
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Reversible Dilation of Cerebral Macrovascular Changes in MELAS Episodes. Clin Neuroradiol 2018; 29:321-329. [DOI: 10.1007/s00062-018-0662-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/02/2018] [Indexed: 01/12/2023]
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Doheny D, Srinivasan R, Pagant S, Chen B, Yasuda M, Desnick RJ. Fabry Disease: prevalence of affected males and heterozygotes with pathogenic GLA mutations identified by screening renal, cardiac and stroke clinics, 1995-2017. J Med Genet 2018; 55:261-268. [PMID: 29330335 DOI: 10.1136/jmedgenet-2017-105080] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/29/2017] [Accepted: 12/11/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Fabry Disease (FD), an X linked lysosomal storage disease due to pathogenic α-galactosidase A (GLA) mutations, results in two major subtypes, the early-onset Type 1 'Classic' and the Type 2 'Later-Onset' phenotypes. To identify previously unrecognised patients, investigators screened cardiac, renal and stroke clinics by enzyme assays. However, some screening studies did not perform confirmatory GLA mutation analyses, and many included recently recognised 'benign/likely-benign' variants, thereby inflating prevalence estimates. METHODS Online databases were searched for all FD screening studies in high-risk clinics (1995-2017). Studies reporting GLA mutations were re-analysed for pathogenic mutations, sex and phenotype. Phenotype-specific and sex-specific prevalence rates were determined. RESULTS Of 67 studies, 63 that screened 51363patients (33943M and 17420F) and provided GLA mutations were reanalysed for disease-causing mutations. Of reported GLA mutations, benign variants occurred in 47.9% of males and 74.1% of females. The following were the revised prevalence estimates: among 36820 (23954M and 12866F) haemodialysis screenees, 0.21% males and 0.15% females; among 3074 (2031M and 1043F) renal transplant screenees, 0.25% males and no females; among 5491 (4054M and 1437F) cardiac screenees, 0.94% males and 0.90% females; and among 5978 (3904M and 2074F) stroke screenees, 0.13% males and 0.14% females. Among male and female screenees with pathogenic mutations, the type 1 Classic phenotype was predominant (~60%), except more male cardiac patients (75%) had type 2 Later-Onset phenotype. CONCLUSIONS Compared with previous findings, reanalysis of 63 studies increased the screenee numbers (~3.4-fold), eliminated 20 benign/likely benign variants, and provided more accurate sex-specific and phenotype-specific prevalence estimates, ranging from ~0.13% of stroke to ~0.9% of cardiac male or female screenees.
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Affiliation(s)
- Dana Doheny
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ram Srinivasan
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Silvere Pagant
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brenden Chen
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lambe J, Noone I, Lonergan R, Tubridy N. Auditing the frequency and the clinical and economic impact of testing for Fabry disease in patients under the age of 70 with a stroke admitted to Saint Vincent’s University Hospital over a 6-month period. Ir J Med Sci 2017; 187:189-192. [DOI: 10.1007/s11845-017-1625-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 04/26/2017] [Indexed: 10/19/2022]
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Abstract
PURPOSE OF REVIEW This article is a practical guide to identifying uncommon causes of stroke and offers guidance for evaluation and management, even when large controlled trials are lacking in these rarer forms of stroke. RECENT FINDINGS Fabry disease causes early-onset stroke, particularly of the vertebrobasilar system; enzyme replacement therapy should be considered in affected patients. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), often misdiagnosed as multiple sclerosis, causes migraines, early-onset lacunar strokes, and dementia. Moyamoya disease can cause either ischemic or hemorrhagic stroke; revascularization is recommended in some patients. Cerebral amyloid angiopathy causes both microhemorrhages and macrohemorrhages, resulting in typical stroke symptoms and progressive dementia. Pregnancy raises the risk of both ischemic and hemorrhagic stroke, particularly in women with preeclampsia/eclampsia. Pregnant women are also at risk for posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis. Experts recommend that pregnant women with acute ischemic stroke not be systematically denied the potential benefits of IV recombinant tissue plasminogen activator. SUMMARY Neurologists should become familiar with these uncommon causes of stroke to provide future risk assessment and family counseling and to implement appropriate treatment plans to prevent recurrence.
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