[Factors affecting phenotypes in the patients with MMACHC gene c.609G>A homozygous variant cblC type methylmalonic acidemia combined with homocysteinuria].

OBJECTIVE: To investigate the factors affecting phenotypes in the patients of methylmalonic acidemia combined with homocysteinemia cblC type with MMACHC c.609G>A homologous variant. METHODS: A retrospective study on the clinical manifestations, complications, treatment, and outcome in 164 patients of cblC type with MMACHC c.609G>A homologous variant was conducted. The patients were diagnosed by biochemical and genetic analysis from January 1998 to December 2020. RESULTS: Among the 164 patients, 2 cases were prenatally diagnosed and began treatment after birth. They are 3 and 12 years old with normal physical and mental development. Twenty-one cases were diagnosed by newborn screening. Among them, 15 cases had with normal development. They were treated from the age of two weeks at the asymptomatic period. Six cases began treatment aged 1 to 3 months after onset. Their development was delayed. One hundred and forty-one cases were clinically diagnosed. Their onset age ranges from a few minutes after birth to 6 years old. 110 cases had early-onset (78.0%). 31 cases had late-onset (22.0%). Five of them died. 24 patients lost to follow-up. Of the 141 clinically diagnosed patients, 130 (92.2%) with psychomotor retardation, 69 (48.9%) with epilepsy, 39 (27.7%) with anemia, 30 (21.3%) had visual impairment, 27 (19.1%) had hydrocephalus, 26 (18.4%) had feeding difficulties, 7 (5.0%) with liver damage, and 5 (3.5%) with metabolic syndrome. The frequency of hydrocephalus and seizures was significantly higher in the early-onset group. The urinary methylmalonic acid increased significantly in the patients with epilepsy. During the long-term follow-up, the level of plasma total homocysteine in the seizure-uncontrolled group was significantly higher than that in the seizure-controlled group, the difference had a statistical significance (P<0.05). CONCLUSION: Most of the patients with MMACHC c.609G>A homozygous variant had early-onset disease, with a high mortality and disability rate. If not treated in time, it will lead to neurological damage, resulting in epilepsy, mental retardation, hydrocephalus, and multiple organ damage. Pre-symptomatic diagnosis and treatment are crucial to prevent irreversible neurological damage. Neonatal screening and prenatal diagnosis are important to improve the outcome of the patients.

Outcomes of Isolated Fetal Ventriculomegaly That Resolve In Utero.

OBJECTIVE: Isolated fetal ventriculomegaly is often an incidental finding on antenatal ultrasound. It is benign in up to 90% of cases, although it can be associated with genetic, structural, and neurocognitive disorders. The literature suggests that over 40% of isolated mild ventriculomegaly will resolve in utero, but it is unclear if resolution decreases the associated risks.The aim of this study is to compare the fetal and neonatal genetic outcomes of ventriculomegaly that persists or resolves on subsequent ultrasound. STUDY DESIGN: This is a retrospective cohort study of women diagnosed with isolated ventriculomegaly via fetal ultrasound at a tertiary referral center between 2011 and 2019. Patients were excluded if other structural anomalies were identified on ultrasound. RESULTS: A total of 49 patients were included in the study, 19 in the resolved ventriculomegaly group and 30 in the persistent ventriculomegaly group. Women in the resolved ventriculomegaly group were more likely to be diagnosed earlier (24 vs. 28 weeks, p = 0.007). Additionally, they were more likely to have mild ventriculomegaly (63 vs. 84%, p = 0.15), and less likely to have structural neurological abnormalities diagnosed on postnatal imaging (5 vs. 17%, p = 0.384), although these were not statistically significant. Aneuploidy risk for resolved compared with persistent ventriculomegaly was similar (5 vs. 7%, p = 0.999). CONCLUSION: This study suggests that resolution of isolated ventriculomegaly in utero may not eliminate the risk of genetic or chromosomal abnormalities in this population and may warrant inclusion as part of the counselling of these at-risk patients. Larger prospective studies are needed to confirm these findings. KEY POINTS: · Ventriculomegaly is known to be associated with genetic and chromosomal abnormalities.. · Resolution of the ventriculomegaly in utero may not eliminate those risks.. · Patients with resolved ventriculomegaly should be offered aneuploidy screening or testing..

Prognostic value of intrathecal heme oxygenase-1 concentration in patients with Fisher Grade III aneurysmal subarachnoid hemorrhage.

OBJECT: Experimental studies have demonstrated the crucial role of posthemorrhagic erythrocyte catabolism in the pathogenesis of subarachnoid hemorrhage (SAH). The authors of this study aimed to investigate the prognostic value of a series of CSF biomarkers linked to heme metabolism in SAH patients. METHODS: Patients with Fisher Grade III aneurysmal SAH undergoing early aneurysm obliteration were enrolled. The levels of heme oxygenase-1 (HO-1), oxyhemoglobin, ferritin, and bilirubin in intrathecal CSF were measured on the 7th day posthemorrhage. The associations of functional outcome with clinical and CSF parameters were analyzed. RESULTS: The study included 41 patients (mean age 59 ± 14 years; 16 male, 25 female), 17 (41.5%) of whom had an unfavorable outcome (Glasgow Outcome Scale score ≤ 3) 3 months after SAH. In terms of the clinical data, age > 60 years, admission World Federation of Neurosurgical Societies Grade ≥ III, and the presence of acute hydrocephalus were independent factors associated with an unfavorable outcome. After adjusting for clinical parameters, a higher level of HO-1 appeared to be the most significant CSF parameter related to an unfavorable outcome among all tested CSF molecules (OR 0.934, 95% CI 0.883-0.989, p = 0.018). Further analysis using a generalized additive model identified a cutoff HO-1 value of 81.2 µM, with higher values predicting unfavorable outcome (82.4% accuracy). CONCLUSIONS: The authors propose that the level of intrathecal CSF HO-1 at Day 7 post-SAH can be an effective outcome indicator in patients with Fisher Grade III aneurysmal SAH.

Nuclear factor κB activation impairs ependymal ciliogenesis and links neuroinflammation to hydrocephalus formation.

Hydrocephalus formation is a frequent complication of neuropathological insults associated with neuroinflammation. However, the mechanistic role of neuroinflammation in hydrocephalus development is unclear. We have investigated the function of the proinflammatory acting inhibitor of κB kinase (IKK)/nuclear factor κB (NF-κB) signaling system in neuroinflammatory processes and generated a novel mouse model that allows conditional activation of the IKK/NF-κB system in astrocytes. Remarkably, NF-κB activation in astrocytes during early postnatal life results in hydrocephalus formation and additional defects in brain development. NF-κB activation causes global neuroinflammation characterized by a strong, astrocyte-specific expression of proinflammatory NF-κB target genes as well as a massive infiltration and activation of macrophages. In this animal model, hydrocephalus formation is specifically induced during a critical time period of early postnatal development, in which IKK/NF-κB-induced neuroinflammation interferes with ependymal ciliogenesis. Our findings demonstrate for the first time that IKK/NF-κB activation is sufficient to induce hydrocephalus formation and provides a potential mechanistic explanation for the frequent association of neuroinflammation and hydrocephalus formation during brain development, namely impairment of ependymal cilia formation. Therefore, our study might open up new perspectives for the treatment of certain types of neonatal and childhood hydrocephalus associated with hemorrhages and infections.

De novo germline and postzygotic mutations in AKT3, PIK3R2 and PIK3CA cause a spectrum of related megalencephaly syndromes.

Megalencephaly-capillary malformation (MCAP) and megalencephaly-polymicrogyria-polydactyly-hydrocephalus (MPPH) syndromes are sporadic overgrowth disorders associated with markedly enlarged brain size and other recognizable features. We performed exome sequencing in 3 families with MCAP or MPPH, and our initial observations were confirmed in exomes from 7 individuals with MCAP and 174 control individuals, as well as in 40 additional subjects with megalencephaly, using a combination of Sanger sequencing, restriction enzyme assays and targeted deep sequencing. We identified de novo germline or postzygotic mutations in three core components of the phosphatidylinositol 3-kinase (PI3K)-AKT pathway. These include 2 mutations in AKT3, 1 recurrent mutation in PIK3R2 in 11 unrelated families with MPPH and 15 mostly postzygotic mutations in PIK3CA in 23 individuals with MCAP and 1 with MPPH. Our data highlight the central role of PI3K-AKT signaling in vascular, limb and brain development and emphasize the power of massively parallel sequencing in a challenging context of phenotypic and genetic heterogeneity combined with postzygotic mosaicism.

The behavioral change of locomotor activity in a kaolin-induced hydrocephalus rat model: evaluation of the effect on the dopaminergic system with progressive ventricle dilatation.

Hydrocephalus is a pathological enlargement of the cerebral ventricle that results from an obstruction of the space containing cerebrospinal fluid (CSF) in the brain. Motor abnormalities, such as abnormal gait and posture, are frequently seen in patients with hydrocephalus. The present study was designed to investigate locomotor activity in the elevated plus maze behaviorally. Hydrocephalus was induced in Sprague-Dawley rats by injection of 0.1 ml of 20% kaolin solution into the cisterna magna (n=14). Control rats received the same volume of saline (n=12). The rats were sacrificed at 3 days and 4 weeks after the elevated plus maze test. Tyrosine hydroxlyase (TH) immunoreactivity in the substantia nigra was evaluated by immunohistological staining. Hydrocephalic rats showed decreased motor activity for entries of arms when compared to control rats (p<0.05). Compared to control rats, the number of TH immunoreactive neurons was significantly decreased in hydrocephalic rats. These results suggest that decreased motor responses due to ventricle enlargement in hydrocephalic rats are associated with the functional impairment of the central dopamine system.

Differential involvement of the extracellular 6-O-endosulfatases Sulf1 and Sulf2 in brain development and neuronal and behavioural plasticity.

The extracellular sulfatases Sulf1 and Sulf2 remove specific 6-O-sulfate groups from heparan sulfate, thereby modulating numerous signalling pathways underlying development and homeostasis. In vitro data have suggested that the two enzymes show functional redundancy. To elucidate their in vivo functions and to further address the question of a putative redundancy, we have generated Sulf1- and Sulf2-deficient mice. Phenotypic analysis of these animals revealed higher embryonic lethality of Sulf2 knockout mice, which can be associated with neuroanatomical malformations during embryogenesis. Sulf1 seems not to be essential for developmental or postnatal viability, as mice deficient in this sulfatase show no overt phenotype. However, neurite outgrowth deficits were observed in hippocampal and cerebellar neurons of both mutant mouse lines, suggesting that not only Sulf2 but also Sulf1 function plays a role in the developing nervous system. Behavioural analysis revealed differential deficits with regard to cage activity and spatial learning for Sulf1- and Sulf2-deficient mouse lines. In addition, Sulf1-specific deficits were shown for synaptic plasticity in the CA1 region of the hippocampus, associated with a reduced spine density. These results reveal that Sulf1 and Sulf2 fulfil non-redundant functions in vivo in the development and maintenance of the murine nervous system.

Matrix metalloproteinases in infants with posthemorrhagic hydrocephalus.

The cerebrospinal fluid matrix metalloproteinase (MMP) activities were measured in infants with posthemorrhagic hydrocephalus to elucidate the intrinsic mechanism for the resolution of ventricular dilation. Increased MMP-9 activities were observed in the patients who escaped a shunt operation, suggesting its potential contribution to the resolution of ventricular dilation.

High levels of Cre expression in neuronal progenitors cause defects in brain development leading to microencephaly and hydrocephaly.

Hydrocephalus is a common and variegated pathology often emerging in newborn children after genotoxic insults during pregnancy (Hicks and D'Amato, 1980). Cre recombinase is known to have possible toxic effects that can compromise normal cell cycle and survival. Here we show, by using three independent nestin Cre transgenic lines, that high levels of Cre recombinase expression into the nucleus of neuronal progenitors can compromise normal brain development. The transgenics analyzed are the nestin Cre Balancer (Bal1) line, expressing the Cre recombinase with a nuclear localization signal, and two nestin CreER(T2) (Cre recombinase fused with a truncated estrogen receptor) mice lines with different levels of expression of a hybrid CreER(T2) recombinase that translocates into the nucleus after tamoxifen treatment. All homozygous Bal1 nestin Cre embryos displayed reduced neuronal proliferation, increased aneuploidy and cell death, as well as defects in ependymal lining and lamination of the cortex, leading to microencephaly and to a form of communicating hydrocephalus. An essentially overlapping phenotype was observed in the two nestin CreER(T2) transgenic lines after tamoxifen mediated-CreER(T2) translocation into the nucleus. Neither tamoxifen-treated wild-type nor nestin CreER(T2) oil-treated control mice displayed these defects. These results indicate that some forms of hydrocephalus may derive from a defect in neuronal precursors proliferation. Furthermore, they underscore the potential risks for developmental studies of high levels of nuclear Cre in neurogenic cells.

Hydrocephalus, situs inversus, chronic sinusitis, and male infertility in DNA polymerase lambda-deficient mice: possible implication for the pathogenesis of immotile cilia syndrome.

A growing number of DNA polymerases have been identified, although their physiological function and relation to human disease remain mostly unknown. DNA polymerase lambda (Pol lambda; also known as Pol beta2) has recently been identified as a member of the X family of DNA polymerases and shares 32% amino acid sequence identity with DNA Pol beta within the polymerase domain. With the use of homologous recombination, we generated Pol lambda(-/-) mice. Pol lambda(-/-) mice develop hydrocephalus with marked dilation of the lateral ventricles and exhibit a high rate of mortality after birth, although embryonic development appears normal. Pol lambda(-/-) mice also show situs inversus totalis and chronic suppurative sinusitis. The surviving male, but not female, Pol lambda(-/-) mice are sterile as a result of spermatozoal immobility. Microinjection of sperm from male Pol lambda(-/-) mice into oocytes gives rise to normal offspring, suggesting that the meiotic process is not impaired. Ultrastructural analysis reveals that inner dynein arms of cilia from both the ependymal cell layer and respiratory epithelium are defective, which may underlie the pathogenesis of hydrocephalus, situs inversus totalis, chronic sinusitis, and male infertility. Sensitivity of Pol lambda(-/-) cells to various kinds of DNA damage is indistinguishable from that of Pol lambda(+/+) cells. Collectively, Pol lambda(-/-) mice may provide a useful model for clarifying the pathogenesis of immotile cilia syndrome.

Lactic dehydrogenase isoenzymes in cerebrospinal fluid associated with hydrocephalus.

UNLABELLED: Various neurological disorders are associated with specific changes in the level of total lactic dehydrogenase and concentrations of its isoenzymes in the cerebrospinal fluid. We describe the lactic dehydrogenase isoenzyme values in children with hydrocephalus. Cerebrospinal fluid samples collected from 10 patients (2 to 16 mo) with hydrocephalus were analysed for total lactic dehydrogenase activity and lactic dehydrogenase isoenzymes. Findings were compared with those in samples from 15 paediatric patients, with normal results. Mean total lactic dehydrogenase activity in the cerebrospinal fluid was significantly higher in the patients with hydrocephalus (101 +/- 23.11 U/L) than in the controls (33.53 +/- 5.75 U/L) (p <0.001). In the control samples, lactic dehydrogenase-1 was the main fraction, followed by lactic dehydrogenase-2 and 3; only small concentrations of lactic dehydrogenase-4 and lactic dehydrogenase-5 were detected. By contrast, patients with hydrocephalus had lower concentrations of the lactic dehydrogenase-1 fraction and higher lactic dehydrogenase-2 and lactic dehydrogenase-3 concentrations, the differences between these results and those in the control group being statistically significant (p < 0.001). The values for lactic dehydrogenase-4 and lactic dehydrogenase-5 were similar in both groups. CONCLUSION: Findings should be considered together with computed tomography/magnetic resonance imaging and ultrasound scans. The cerebrospinal fluid lactic dehydrogenase profile may prove to be an important predictor of cerebral injury, obstructive hydrocephalus and long-term neurodevelopmental problems.

Comparative values of CSF-LDH isoenzymes in neurological disorders.

The present study was carried out to evaluate the usefulness of Cerebrospinal fluid (CSF) Lactate dehydrogenase (LDH) isoenzymes in the diagnosis in tuberculous meningitis (TBM), pyogenic meningitis (PM), viral encephalitis (VE) and hydrocephalus (HC). A characteristic dominance of isoenzymes in cerebrospinal fluid was observed: LDH4 in TBM while LDH3 in PM. However, in VE and HC, LDH2 and LDH1 were dominant respectively. The control subjects revealed the presence of isoenzymes LDH1 and LDH2 in very low concentrations. Pattern of LDH isoenzymes in CSF may serve as a diagnostic tool to differentiate these neurological disorders.

Changes in brain glutamine synthetase activity in congenital hydrocephalic rats (LEW-HYR) after ventriculoperitoneal shunt.

Significantly reduced activities of glutamine synthetase (GS), which is predominantly present in glial cells, occur in the early stage of congenital hydrocephalic rat (LEW-HYR) brain development. GS activity is reported to be related to brain dysfunction. The effect of ventriculoperitoneal (VP) shunt on the suppression of GS activity was studied in the LEW-HYR. VP shunting improved the attenuation of GS activity in the LEW-HYR and the response of GS activity to methionine sulfoximine (a competitive GS inhibitor) treatment was similar to that seen in normal siblings. However, no enhancement of GS activity by hydrocortisone could be detected, although this enhancement occurs in the normal siblings. These results suggest that VP shunting is not completely effective in improving the suppression of brain GS activity in the LEW-HYR, since the suppression of GS activity in the LEW-HYR might be programmed genetically.

An enzyme immunoassay for neuron-specific enolase in cerebrospinal fluid.

A direct (as opposed to competitive) enzyme immunoassay (EIA) was developed to detect neuron-specific enolase (NSE) in cerebrospinal fluid (CSF). Most common methods of evaluating NSE levels have utilized radioimmunoassay. These are highly sensitive, but cannot be employed in laboratories not equipped or licensed for the use of radioisotopes. The EIA developed here shows sensitivity within the physiological range of values for CSF-NSE (> I ng/ml) and can be used in laboratories with appropriate densitometric scanning capabilities. The assay was applied to CSF samples obtained from patients with a variety of diagnoses at the time of surgical intervention for their respective disorders. While there were no diagnostically significant differences between the level of NSE in CSF from patients with different neurological disorders utilized in the development of this procedure, we were able to differentiate between marginally different levels of NSE. We conclude that we have developed a safe, fast, reliable, and sensitive assay for NSE in the CSF that can be used to study NSE levels in a variety of neurological cases.

Ornithine decarboxylase in developing brain of normal and hydrocephalic rats. Biochemical and immunohistochemical studies.

Polyamines have various roles in cortical development. We examined the ontogenic changes in ornithine decarboxylase (ODC), the rate-limiting enzyme of polyamine biosynthesis, in cerebral cortices of normal and hydrocephalic rats. Both biochemical and immunohistochemical examinations revealed increased ODC protein and enzyme activity during the perinatal period. Apical dendrites of developing neuroblasts migrating from the superficial layer of cortical plate showed intense ODC immunoreactivity. Once they had settled at their final destination, ODC immunoreactivity weakened. Both ODC immunoreactivity and enzyme activity reached very low levels after completion of layer formation of cortex. The enzyme activity of ODC in hydrocephalic cortices exceeded that in normal cortex during the perinatal periods. ODC was rather overexpressed, but no characteristic distribution was observed in the hydrocephalic cortex. These findings indicate the participation of polyamines in the cortical development, especially in the layer formation. The overexpression of ODC in hydrocephalus appears to promote development despite increased hydrostatic pressure.

A competitive dual-label time-resolved immunofluorometric assay for simultaneous detection of carbonic anhydrase I and II in cerebrospinal fluid.

Carbonic anhydrase (CA) is functionally an important enzyme in the central nervous system (CNS) where it is involved in the control of acid-base balance and regulation of the production of cerebrospinal fluid (CSF). Isoenzyme II (CAII) is the most widely distributed CA in the CNS being specifically present in CNS glial tissue and therefore it is expected to be leaked to CSF in degenerative CNS diseases. A competitive dual-labeled time-resolved immunofluorometric assay was developed for simultaneous quantification of human CAI (HCA I) and II (HCA II) in CSF. HCA I was measured to determine the blood contamination in the samples. This solid-phase immunoassay is based on competition between europium (Eu3+)- or samarium (Sm3+)-labeled antigen and the sample antigens for polyclonal rabbit antibodies which are attached to microtiter-plate wells precoated with sheep anti-rabbit IgG. The subsequent immunoassay, including the separation of free and bound HCA I and II, requires only one incubation step, after which an enhancement solution dissociates Sm3+ and Eu3+ ions from the labeled HCA I and II, respectively, into a solution where they form highly fluorescent chelates. Spectra of the fluorescent chelates in the microtitration strip wells were run on time-resolved fluorometers equipped with filters for Eu3+ (613 nm) and Sm3+ (643 nm), the fluorescence from each sample being inversely proportional to the concentration of antigens. The detection limit of the HCA II assay was 0.3 micrograms/l and that of the HCA I assay was 5.2 micrograms/l. The intra- and inter-assay imprecisions (C.V.s) were 8.0% and 8.8% for HCA I and 6.3% and 4.8% for HCA II, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dopamine beta-hydroxylase activity in cerebrospinal fluid of hydrocephalic patients].

Dopamine beta-hydroxylase (DBH) activity in cerebrospinal fluid (CSF) was determined to evaluate the noradrenergic activity in the central nervous system of hydrocephalic patients in the acute phase. Seven patients with hydrocephalus resulting from various causes and 7 control children without neurological diseases were subjected to this study. DBH activity was measured by high-performance liquid chromatography with electrochemical detection. DBH activity of control children, more than 5 years of age in our series, showed the similar activity of adult controls which was previously reported. Hydrocephalic patients revealed the higher DBH activity than controls (statistically significant, p less than 0.05). Sequential measurements of DBH activity in a case of herpes encephalitis revealed that its activity increased with the development of hydrocephalus and decreased after the treatment with repeated lumbar punctures. The present study suggests that the central noradrenergic activity is enhanced in the hydrocephalic patients in the acute phase.

[Macrocephaly as the initial manifestation of glutaryl-CoA-dehydrogenase deficiency (glutaric aciduria type I)]. / Makrozephalie als Initialmanifestation des Glutaryl-CoA-Dehydrogenase-Mangels (Glutarazidurie Typ I).

Glutaric aciduria type I is due to an impaired glutaryl-CoA-dehydrogenase with an increased urinary excretion of glutaric and 3-OH glutaric acid. Typically, the clinical course until the sixth month or even 3rd year of life is symptom free, and only later an encephalopathic crisis develops. The only symptom of our 4 patients was macrocephaly (head circumference greater than 97. percentile) in early infancy. 3 of them suffered from an encephalopathic crisis at 8 months to 3 years of age; during that time they lost already established abilities as sitting, walking and speaking, and developed choereoathetotic movements. One child aged 15 months was normal beside it's macrocephalus. All children were treated with a diet low in lysine (80 mg/kg BW/day), tryptophane (21 mg/kg BW/day), and by supplementation of L-carnitine (200 mg/kg BW/day) and riboflavine (200 mg/day) and the motorically disturbed children received Lioresal 1 mg/kg BW/day. The effect of this treatment cannot be evaluated so far, but there is evidence that the dietetic therapy together with carnitine supplementation may prevent further deterioration in affected, or an encephalopathic crisis in unaffected patients. Therefore we suggest to investigate organic acids in urine in every child or infant with macrocephalus to exclude glutaric aciduria type I.

Enzymatic changes in the cerebrospinal fluid as indices of pathological change.

Enzymatic determinations in cerebrospinal fluid (CSF) of lactic dehydrogenase (LDH), creatine phosphokinase (CPK) and creatine kinase BB (CK-BB) were performed on 94 patients presenting with a range of disorders of the central nervous system. Enzyme results from 37 patients undergoing myelography were used as controls. The highest concentration of these enzymes appeared in patients with the most severe brain injury. In head-injured patients with a Glasgow Coma Score (GCS) of 3 to 7, only the CK-BB correlated with the degree of injury and with the ultimate outcome. Within the subgroup of spinal cord injuries none of the enzymes correlated with the severity of neurological injury. However, patients with acute spinal cord trauma who demonstrated CSF CK-BB values greater than 10 U/litre had never recovered. The present study confirms that CSF CK-BB seems to be a sensitive index of acute brain damage, but it reflects best the extent of CNS tissue disruption rather than the severity of neurological deficits.