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Gupta N, Hiremath SB, Aviv RI, Wilson N. Childhood Cerebral Vasculitis : A Multidisciplinary Approach. Clin Neuroradiol 2023; 33:5-20. [PMID: 35750917 PMCID: PMC9244086 DOI: 10.1007/s00062-022-01185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022]
Abstract
Cerebral vasculitis is increasingly recognized as a common cause of pediatric arterial stroke. It can present with focal neurological deficits, psychiatric manifestations, seizures, and encephalopathy. The etiopathogenesis of childhood cerebral vasculitis (CCV) is multifactorial, making an inclusive classification challenging. In this review, we describe the common and uncommon CCV with a comprehensive discussion of etiopathogenesis, the role of various imaging modalities, and advanced techniques in diagnosing CCV. We also highlight the implications of relevant clinical, laboratory, and genetic findings to reach the final diagnosis. Based on the clinicoradiological findings, a stepwise diagnostic approach is proposed to facilitate CCV diagnosis and rule out potential mimics. Identification of key clinical manifestations, pertinent blood and cerebrospinal fluid results, and evaluation of central nervous system vessels for common and disease-specific findings will be emphasized. We discuss the role of magnetic resonance imaging, MR angiography, and vessel wall imaging as the imaging investigation of choice, and reservation of catheter angiography as a problem-solving tool. We emphasize the utility of brain and leptomeningeal biopsy for diagnosis and exclusion of imitators and masqueraders.
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Affiliation(s)
- Neetika Gupta
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
- Clinical Fellow—Pediatric Radiology, Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
| | - Shivaprakash B. Hiremath
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, Ontario Canada
| | - Richard I. Aviv
- Department of Medical Imaging, Division of Neuroradiology, Civic and General Campus, University of Ottawa, The Ottawa Hospital, Ottawa, Ontario Canada
| | - Nagwa Wilson
- Department of Medical Imaging, Children’s Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, Ontario Canada
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Haskell GT, Mori M, Powell C, Amrhein TJ, Rice GI, Bailey L, Strande N, Weck KE, Evans JP, Berg JS, Kishnani P. Combination of exome sequencing and immune testing confirms Aicardi-Goutières syndrome type 5 in a challenging pediatric neurology case. Cold Spring Harb Mol Case Stud 2018; 4:a002758. [PMID: 30275001 PMCID: PMC6169830 DOI: 10.1101/mcs.a002758] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/10/2018] [Indexed: 11/28/2022] Open
Abstract
Exome sequencing is increasingly being used to help diagnose pediatric neurology cases when clinical presentations are not specific. However, interpretation of equivocal results that include variants of uncertain significance remains a challenge. In those cases, follow-up testing and clinical correlation can help clarify the clinical relevance of the molecular findings. In this report, we describe the diagnostic odyssey of a 4-year-old girl who presented with global developmental delay and seizures, with leukodystrophy seen on MRI. Clinical evaluation, MRI, and comprehensive metabolic testing were performed, followed by whole-exome sequencing (WES), parental testing, follow-up testing, and retrospective detailed clinical evaluation. WES identified two candidate causative pathogenic variants in SAMHD1, a gene associated with the recessive condition Aicardi-Goutières syndrome (AGS) type 5 (OMIM 612952): a previously reported pathogenic variant NM_015474 c.602T>A (p.I201N), maternally inherited, and a rare missense variant of uncertain significance, c.1293A>T(p.L431F). Analysis of type I interferon-related biomarkers demonstrated that the patient has an interferon signature characteristic of AGS. Retrospective detailed clinical evaluation showed that the girl has a phenotype consistent with AGS5, a rare neurological condition. These results further define the phenotypic spectrum associated with specific SAMHD1 variants, including heterozygous variants in AGS carriers, and support the idea that autoinflammatory dysregulation is part of the disease pathophysiology. More broadly, this work highlights the issues and methodology involved in ascribing clinical relevance to interpretation of variants detected by WES.
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Affiliation(s)
- Gloria T Haskell
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina 27705, USA
| | - Mari Mori
- Brown University, Alpert Medical School, Providence, Rhode Island 02903, USA
| | - Cynthia Powell
- Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
| | - Timothy J Amrhein
- Department of Radiology, Duke University School of Medicine, Durham, North Carolina 27705, USA
| | - Gillian I Rice
- University of Manchester School of Biological Sciences, Manchester M13 9WL, United Kingdom
| | - Lauren Bailey
- Departments of Pediatrics and of Medical Genetics, Duke University, Durham, North Carolina 27705, USA
| | - Natasha Strande
- Department of Genetics, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
- Department of Pathology and Laboratory Medicine, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
| | - Karen E Weck
- Department of Genetics, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
- Department of Pathology and Laboratory Medicine, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
| | - James P Evans
- Department of Genetics, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
| | - Jonathan S Berg
- Department of Genetics, UNC School of Medicine, Chapel Hill, North Carolina 27599, USA
| | - Priya Kishnani
- Departments of Pediatrics and of Medical Genetics, Duke University, Durham, North Carolina 27705, USA
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The Pediatric Cerebellum in Inherited Neurodegenerative Disorders: A Pattern-recognition Approach. Neuroimaging Clin N Am 2017; 26:373-416. [PMID: 27423800 DOI: 10.1016/j.nic.2016.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Evaluation of imaging studies of the cerebellum in inherited neurodegenerative disorders is aided by attention to neuroimaging patterns based on anatomic determinants, including biometric analysis, hyperintense signal of structures, including the cerebellar cortex, white matter, dentate nuclei, brainstem tracts, and nuclei, the presence of cysts, brain iron, or calcifications, change over time, the use of diffusion-weighted/diffusion tensor imaging and T2*-weighted sequences, magnetic resonance spectroscopy; and, in rare occurrences, the administration of contrast material.
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Karikkineth AC, Scheibye-Knudsen M, Fivenson E, Croteau DL, Bohr VA. Cockayne syndrome: Clinical features, model systems and pathways. Ageing Res Rev 2017; 33:3-17. [PMID: 27507608 PMCID: PMC5195851 DOI: 10.1016/j.arr.2016.08.002] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/29/2016] [Accepted: 08/04/2016] [Indexed: 12/12/2022]
Abstract
Cockayne syndrome (CS) is a disorder characterized by a variety of clinical features including cachectic dwarfism, severe neurological manifestations including microcephaly and cognitive deficits, pigmentary retinopathy, cataracts, sensorineural deafness, and ambulatory and feeding difficulties, leading to death by 12 years of age on average. It is an autosomal recessive disorder, with a prevalence of approximately 2.5 per million. There are several phenotypes (1-3) and two complementation groups (CSA and CSB), and CS overlaps with xeroderma pigmentosum (XP). It has been considered a progeria, and many of the clinical features resemble accelerated aging. As such, the study of CS affords an opportunity to better understand the underlying mechanisms of aging. The molecular basis of CS has traditionally been ascribed to defects in transcription and transcription-coupled nucleotide excision repair (TC-NER). However, recent work suggests that defects in base excision DNA repair and mitochondrial functions may also play key roles. This opens up the possibility for molecular interventions in CS, and by extrapolation, possibly in aging.
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Affiliation(s)
- Ajoy C Karikkineth
- Clinical Research Branch, National Institute on Aging, Baltimore, MD, USA
| | - Morten Scheibye-Knudsen
- Laboratory of Molecular Gerontology, National Institute on Aging, Baltimore, MD, USA; Department of Cellular and Molecular Medicine, University of Copenhagen, Denmark
| | - Elayne Fivenson
- Laboratory of Molecular Gerontology, National Institute on Aging, Baltimore, MD, USA
| | - Deborah L Croteau
- Laboratory of Molecular Gerontology, National Institute on Aging, Baltimore, MD, USA
| | - Vilhelm A Bohr
- Laboratory of Molecular Gerontology, National Institute on Aging, Baltimore, MD, USA.
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Ramantani G, Maillard LG, Bast T, Husain RA, Niggemann P, Kohlhase J, Hertzberg C, Ungerath K, Innes MA, Walkenhorst H, Bevot A, von Stülpnagel C, Thomas K, Niemann F, Ergun MA, Tacke U, Häusler M, Ikonomidou C, Korinthenberg R, Lee-Kirsch MA. Epilepsy in Aicardi-Goutières syndrome. Eur J Paediatr Neurol 2014; 18:30-7. [PMID: 24011626 DOI: 10.1016/j.ejpn.2013.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 07/18/2013] [Accepted: 07/27/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Aicardi-Goutières syndrome (AGS) is a genetically determined early-onset encephalopathy with variable phenotype, including neurologic manifestations such as dystonia, spasticity, epileptic seizures, progressive microcephaly, and severe developmental delay. The aim of our study was the characterization of epilepsy, one of the most frequent and severe AGS manifestations, in molecularly confirmed patients. METHODS We reviewed the medical records, EEG, and CT/MRI findings in 16 patients aged 1-22 years that carried AGS1-5 mutations. RESULTS Epilepsy manifested in 12 (75%) patients and took a refractory course in 9 (56%). 4 (25%) patients presented with seizures in the first four weeks and 11 (69%) altogether in the first year of life. Spasms were reported in 3 (19%) patients, focal seizures in 4 (25%), myoclonic in 5 (31%), symmetric or asymmetric tonic in 11 (69%), generalized tonic-clonic in 3 (19%) and status epilepticus in 4 (25%). EEG recordings initially showed a slow and disorganized background, followed by a regional intermittent theta/delta slow, while obvious multifocal or generalized epileptic discharges were only observed at follow-up. None of these EEG features were specific of AGS. There was no discernible correlation between the genotype and epilepsy onset, seizure types and epilepsy evolution. Epilepsy severity did not correspond to neuroimaging pathology. DISCUSSION Epilepsy constitutes a cardinal feature of AGS, characterized by early onset, predominantly tonic semiology and a refractory course. The early discrimination of epileptic seizures from paroxysmal dystonia poses a challenge for neuropaediatricians, considering the initially inconspicuous or non-specific EEG findings. This study underlines the necessity of a more systematic serial evaluation of AGS patients using long-term video-EEG recordings.
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Affiliation(s)
- Georgia Ramantani
- Epilepsy Center, University Hospital Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany.
| | - Louis G Maillard
- Department of Neurology, University Hospital Nancy, Lorraine University, Nancy, France
| | | | - Ralf A Husain
- Department of Neuropediatrics, University Children's Hospital, Jena, Germany
| | | | | | - Christoph Hertzberg
- Diagnose und Behandlungszentrum für Kinder und Jugendliche, Vivantes Klinikum Neukölln, Berlin, Germany
| | | | - Micheil A Innes
- Department of Medical Genetics, Alberta Health Services, University of Calgary, Calgary, Alberta, Canada
| | | | - Andrea Bevot
- Universitätsklinik für Kinder- und Jugendmedizin, Tübingen, Germany
| | - Celina von Stülpnagel
- Schön Klinik Vogtareuth, Hospital for Neuropediatrics and Neurological Rehabilitation, Epilepsy Center for Children and Adolescents, Vogtareuth, Germany
| | - Kara Thomas
- Children's Hospital of The King's Daughters and Eastern Virginia Medical School, Norfolk, VA, USA
| | - Frank Niemann
- Kinder- und Jugendklinik Gelsenkirchen, Gelsenkirchen, Germany
| | - Mehmet Ali Ergun
- Gazi University, Faculty of Medicine, Department of Medical Genetics, Besevler-Ankara, Turkey
| | - Uta Tacke
- Division of Neuropediatrics and Muscular Disorders, Department of Pediatrics and Adolescent Medicine, University Hospital Freiburg, Germany
| | - Martin Häusler
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Aachen, Aachen, Germany
| | | | - Rudolf Korinthenberg
- Division of Neuropediatrics and Muscular Disorders, Department of Pediatrics and Adolescent Medicine, University Hospital Freiburg, Germany
| | - Min Ae Lee-Kirsch
- Klinik für Kinder- und Jugendmedizin, Technische Universität Dresden, Dresden, Germany
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Rossler L, Ludwig-Seibold C, Thiels C, Schaper J. Aicardi-Goutières syndrome with emphasis on sonographic features in infancy. Pediatr Radiol 2012; 42:932-40. [PMID: 22639057 DOI: 10.1007/s00247-012-2384-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 02/02/2012] [Accepted: 02/12/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Aicardi-Goutières syndrome (AGS) is a severe familial, mostly autosomal recessive encephalopathy, first described in 1984. The clinical picture and genetic abnormalities are heterogeneous. US findings in AGS have thus far not been systematically described. OBJECTIVE The purpose of this study was to analyse sonographic features in AGS and to compare them to CT/MRI. MATERIALS AND METHODS Four male infants with AGS, two brothers, underwent imaging between the ages of 4 weeks and 6 months. RESULTS Sonographically isolated mineralization of lenticulostriate vessels, dilatation of the lateral ventricles, subependymal cysts, and diffuse and focal hyperechogenicity of the periventricular white matter and basal ganglia, respectively, were the abnormal findings, that may be present even before the development of major neurological symptoms. CONCLUSION Early cranial US is able to visualize the whole spectrum of cerebral anomalies in AGS: calcifying microangiopathy, white matter disease and unusual subependymal cysts. The imaging pattern is similar to that of congenital viral infection of the central nervous system, which may mislead the genetic counseling.
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Affiliation(s)
- L Rossler
- Klinik für Kinder- und Jugendmedizin der Ruhr-Universität Bochum, Alexandrinenstr 5, 44791 Bochum, Germany.
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Activation of type I interferon pathway in systemic lupus erythematosus: association with distinct clinical phenotypes. J Biomed Biotechnol 2011; 2011:273907. [PMID: 22162633 PMCID: PMC3227532 DOI: 10.1155/2011/273907] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 08/14/2011] [Indexed: 12/16/2022] Open
Abstract
Growing evidence over the last few years suggests a central role of type I IFN pathway in the pathogenesis of systemic autoimmune disorders. Data from clinical and genetic studies in patients with systemic lupus erythematosus (SLE) and lupus-prone mouse models, indicates that the type I interferon system may play a pivotal role in the pathogenesis of several lupus and associated clinical features, such as nephritis, neuropsychiatric and cutaneous lupus, premature atherosclerosis as well as lupus-specific autoantibodies particularly against ribonucleoproteins. In the current paper, our aim is to summarize the latest findings supporting the association of type I IFN pathway with specific clinical manifestations in the setting of SLE providing insights on the potential use of type I IFN as a therapeutic target.
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Ramantani G, Häusler M, Niggemann P, Wessling B, Guttmann H, Mull M, Tenbrock K, Lee-Kirsch MA. Aicardi-Goutières syndrome and systemic lupus erythematosus (SLE) in a 12-year-old boy with SAMHD1 mutations. J Child Neurol 2011; 26:1425-8. [PMID: 21670392 DOI: 10.1177/0883073811408310] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Aicardi-Goutières syndrome is an early-onset encephalopathy with a presumed immune pathogenesis caused by inherited defects in nucleic acid metabolism. The clinical picture resembles a congenital viral infection despite negative investigations for common viruses. In addition to leukoencephalopathy with calcifications of basal ganglia, patients show increased levels of the antiviral cytokine interferon-α in cerebrospinal fluid. We report on a 12-year-old boy with Aicardi-Goutières syndrome and systemic lupus erythematosus (SLE) due to mutations in the SAMHD1 (sterile alpha motif domain and HD domain-containing protein 1) gene, illustrating an emerging pattern of the natural history of Aicardi-Goutières syndrome characterized by neurological disease followed by symptoms of systemic autoimmunity. Thus, Aicardi-Goutières syndrome constitutes a model disease for systemic autoimmunity triggered by the activation of the innate immune system. Recognition of the etiologic link between Aicardi-Goutières syndrome and systemic lupus erythematosus has direct implications on therapeutic management and suggests that early immune modulatory intervention can improve neurological outcome.
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