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Wilms AE, de Boer I, Pelzer N, In't Veld SGJG, Middelkoop HAM, Teunissen CE, Terwindt GM. NFL and GFAP in (pre)symptomatic RVCL-S carriers: a monogenic cerebral small vessel disease. J Neurol 2024:10.1007/s00415-024-12292-6. [PMID: 38581544 DOI: 10.1007/s00415-024-12292-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) have emerged as biomarkers for cerebral small vessel disease (SVD). We investigated their role in a hereditary SVD model, retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations (RVCL-S). METHODS NfL and GFAP levels of 17 pre-symptomatic, 22 symptomatic RVCL-S mutation carriers and 69 controls were measured using a Simoa assay. We assessed the association of serum and cerebrospinal fluid (CSF) levels of NfL and GFAP with RVCL-S symptomatology and neuropsychological functioning. RESULTS Serum and CSF NfL levels were higher in symptomatic RVCL-S compared to controls ≥ 45 years (33.5 pg/mL vs. 9.2 pg/mL, p < 0.01; 8.5*102 pg/mL vs. 3.9*102 pg/mL, p < 0.01, respectively). Serum NfL levels were higher in symptomatic RVCL-S than pre-symptomatic carriers (33.5 pg/mL vs. 5.9 pg/mL, p = 0.02). Pre-symptomatic RVCL-S carriers had increased CSF NfL levels compared to controls < 45 years (5.2*102 pg/mL vs. 1.9*102 pg/mL, p < 0.01). No differences were found in GFAP levels across groups, but in RVCL-S carriers higher serum levels of both NfL and GFAP were linked to poorer global cognitive functioning (β[95%CI] = - 2.86 [- 5.58 to - 0.13], p = 0.04 and β[95%CI] = - 6.85 [- 11.54 to - 2.15], p = 0.01, respectively) and prolonged psychomotor test times (β[95%CI] = 6.71 [0.78-12.65], p = 0.03 and β[95%CI] = 13.84 [3.09-24.60], p = 0.01). DISCUSSION Higher levels of serum NfL and GFAP are associated with worse cognitive functioning in RVCL-S carriers and may serve as marker for disease progression. CSF NfL levels may serve as early marker as pre-symptomatic RVCL-S patients already show differences compared to young controls.
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Affiliation(s)
- Annelise E Wilms
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - I de Boer
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - N Pelzer
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - S G J G In't Veld
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H A M Middelkoop
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
- Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
| | - C E Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G M Terwindt
- Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands.
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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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Al-Nofal M, de Boer I, Agirman S, Wilms AE, Zamanipoor Najafabadi AH, Terwindt GM, Notting IC. Optical coherence tomography angiography biomarkers of microvascular alterations in RVCL-S. Front Neurol 2022; 13:989536. [PMID: 36090874 PMCID: PMC9459015 DOI: 10.3389/fneur.2022.989536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/12/2022] [Indexed: 11/15/2022] Open
Abstract
Background The brain and retina share many neuronal and vasculature characteristics. We investigated the retinal microvasculature in patients with a monogenic vasculopathy using optical coherence tomography angiography (OCTA). OCT-A is a novel precise non-invasive imaging method that may provide biomarkers suitable for diagnosis and follow-up of small vessel diseases. Methods In this exploratory cross-sectional study, eleven RVCL-S patients and eleven age-matched healthy control participants were included. The size of the foveal avascular zone (FAZ) and the vascular density of the superficial capillary networks in the retina were measured by OCT-A. Results The symptomatic and presymptomatic patients showed significantly lower vascular density values than controls in the foveal region [median (IQR) 18.2% (15.8–18.6) vs. 24.4% (21.5–26.8) (p < 0.001), 29.8% (29.6–30.8) vs. 33.2% (32.0–33.6) (p = 0.002), respectively]. The FAZ was significantly larger in the symptomatic RVCL-S patients than in the control group [13,416 square pixels [7,529–22,860] vs. 1,405 square pixels [1,344–2,470] (p < 0.001)]. No significant difference was identified in measurements of FAZ comparing presymptomatic and controls. Conclusion Our findings with OCT-A demonstrated that RVCL-S causes an increase in the size of the FAZ in symptomatic RVCL-S patients compared to healthy participants. Moreover, there is a decrease in vessel density in the superficial capillary networks in both symptomatic and presymptomatic patients. In the future, newly developed precise objective instruments such as OCT (-A) may provide important tools in determining disease activity for follow up of common small vessel diseases.
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Affiliation(s)
- Mays Al-Nofal
- Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | - Irene de Boer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Seda Agirman
- Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | - Anne E. Wilms
- Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Gisela M. Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Gisela M. Terwindt
| | - Irene C. Notting
- Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
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Ayrignac X, Carra-Dallière C, Marelli C, Taïeb G, Labauge P. Adult-Onset Genetic Central Nervous System Disorders Masquerading as Acquired Neuroinflammatory Disorders: A Review. JAMA Neurol 2022; 79:1069-1078. [PMID: 35969413 DOI: 10.1001/jamaneurol.2022.2141] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Adult-onset genetic disorders may present with clinical and magnetic resonance imaging (MRI) features suggestive of acquired inflammatory diseases. An ever-growing number of potentially treatable adult-onset genetic neuroinflammatory disorders have been described in the past few years that need to be rapidly identified. Observations Adult-onset acquired neuroinflammatory disorders encompass a large group of central nervous system (CNS) diseases with varying presentation, MRI characteristics, and course, among which the most common is multiple sclerosis. Despite recent progress, including the discovery of specific autoantibodies, a significant number of adult-onset neuroinflammatory disorders with progressive or relapsing course still remain without a definite diagnosis. In addition, some patients with genetic disorders such as leukodystrophies, hemophagocytic lymphohistiocytosis, or genetic vasculopathies can mimic acquired neuroinflammatory disorders. These genetic disorders, initially described in pediatric populations, are increasingly detected in adulthood thanks to recent progress in molecular genetics and the larger availability of high-throughput sequencing technologies. Conclusions and Relevance Genetic adult-onset neuroinflammatory diseases are at the border between primary CNS inflammatory diseases and systemic disorders with multiorgan involvement and predominantly neurologic manifestations. Neurologists must be aware of the main clues and red flags so they can confirm a diagnosis early, when some of these genetic disorders can be successfully treated.
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Affiliation(s)
- Xavier Ayrignac
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France.,Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
| | - Clarisse Carra-Dallière
- Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
| | - Cecilia Marelli
- Department of Neurology, Montpellier University Hospital, Montpellier, France.,Molecular Mechanisms in Neurodegenerative Dementias, University of Montpellier, École Pratique des Hautes Études, INSERM, Montpellier, France.,Expert Centre for Neurogenetic Diseases and Adult Mitochondrial and Metabolic Diseases, Montpellier University Hospital, Montpellier, France
| | - Guillaume Taïeb
- Department of Neurology, Montpellier University Hospital, Montpellier, France
| | - Pierre Labauge
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France.,Department of Neurology, Montpellier University Hospital, Montpellier, France.,Reference Centre for Adult-Onset Leukoencephalopathy and Leukodystrophies, Montpellier University Hospital, Montpellier, France.,Reference Centre for Multiple Sclerosis, Montpellier University Hospital, Montpellier, France
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Santellán-Hernández JO, Romero-Luna G, Ramírez-Cruz J, Aguilar-Hidalgo KM, Mejía-Pérez SI. Tumor-Like Brain Lesions Associated With Variants of Uncertain Significance Compared to Previous Studies: A Case Report. Cureus 2022; 14:e26844. [PMID: 35974842 PMCID: PMC9375516 DOI: 10.7759/cureus.26844] [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] [Accepted: 07/13/2022] [Indexed: 11/18/2022] Open
Abstract
TREX1 is a gene that encodes an exonuclease on the C-terminal strand at the 3 ́ end for DNA repair. Multiple syndromes associated with the alteration of this gene have been described, focusing in this case on retinal vasculopathy with cerebral leukodystrophy (RVCL). We present the case of a 44-year-old female patient with a familial history of cerebral pseudotumors. At the time of diagnosis, the patient presented weakness in the lower limbs and dysesthesias of the right body at the beginning of the clinical picture, without visual alterations or retinal changes at fundus examination. A cranial magnetic resonance imaging (MRI) study showed a pseudotumoral lesion at the inferior frontal gyrus with a report of a choline peak in spectroscopy, ring enhancement in contrasted T1 sequence, and apparent central necrosis. A molecular study shows a mutation in c2136G>A, c.799dup, and c.5312A>G related to genes expressing PDE6A, TREX1, and VCAN proteins, respectively, mutations that have not been previously reported.
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Wilms A, de Boer I, Terwindt G. Retinal Vasculopathy with Cerebral Leukoencephalopathy and Systemic manifestations (RVCL-S): An update on basic science and clinical perspectives. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2022; 3:100046. [PMID: 36324396 PMCID: PMC9616387 DOI: 10.1016/j.cccb.2022.100046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/07/2022] [Accepted: 02/13/2022] [Indexed: 04/29/2023]
Abstract
Retinal vasculopathy with cerebral leukoencephalopathy and systemic manifestations (RVCL-S) is a rare, underrecognized, systemic small vessel disease caused by heterozygous C-terminal truncating TREX1 mutations. The disease is characterized by vascular retinopathy, focal neurological complaints, cognitive decline and a wide range of systemic manifestations, including Raynaud's phenomenon, anemia and liver and kidney disease. Eventually, RVCL-S leads to premature death. The underlying pathological finding in RVCL-S is a nonatherosclerotic, amyloid-negative angiopathy involving small arteries and capillaries. However, the exact mechanisms by which the truncated TREX1 protein causes angiopathy remains unknown. Timely recognition of this disease is important to slow down and treat complications of the disorder, but also to prevent unnecessary (invasive) diagnostic or therapeutic procedures. As we move forward, translational research combining basic science advances and clinical findings as well as studies focusing on natural history following RVCL-S patients at different disease stages, will be critical to help elucidate RVCL-S pathophysiology. These studies will also provide the tools to identify appropriate biomarkers and therapeutic agent options for RVCL-S patients.
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