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Cerebrospinal Fluid Analysis in the Workup of GLUT1 Deficiency Syndrome A Systematic Review

Wilhelmina G. Leen, MD1; Ron A. Wevers, PhD3; Erik-Jan Kamsteeg, PhD4; Hans Scheffer, PhD4; Marcel M. Verbeek, PhD1,3; Michèl A. Willemsen, MD, PhD2
[+] Author Affiliations
1Department of Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
2Department of Pediatric Neurology, Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
3Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
4Department of Genetics, Radboud University Medical Centre, Nijmegen, the Netherlands
JAMA Neurol. 2013;70(11):1440-1444. doi:10.1001/jamaneurol.2013.3090.
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Importance  GLUT1 deficiency syndrome is a treatable neurometabolic disorder, characterized by a low concentration of glucose in cerebrospinal fluid (CSF) and a decreased CSF to blood glucose ratio. Reports of patients with apparently normal CSF glucose levels, however, have raised the question whether CSF analysis is a reliable screening tool for GLUT1 deficiency syndrome.

Objective  To determine the value of CSF analysis in the workup of GLUT1 deficiency syndrome.

Evidence Review  PubMed was searched until July 2012 by using the terms glucose transporter 1 (GLUT-1) deficiency syndrome, glucose transporter defect, and SLC2A1-gene. Relevant references mentioned in the articles were also included. The CSF results of all patients with genetically proven GLUT1 deficiency syndrome described in literature were reevaluated.

Findings  The levels of glucose in CSF, the CSF to blood glucose ratios, and the levels of lactate in CSF were reported for 147 (94%), 152 (97%), and 73 (46%) of 157 patients, respectively. The CSF glucose levels ranged from 16.2 to 50.5 mg/dL and were at or below the 10th percentile for all 147 patients. The CSF to blood glucose ratios ranged from 0.19 to 0.59 and were at or below the 10th percentile for 139 of 152 patients (91%), but they could be within the normal range as well. The CSF lactate levels ranged from 5.4 to 13.5 mg/dL and were at or below the 10th percentile for 59 of 73 patients (81%). A typical CSF profile for GLUT1 deficiency syndrome, which is defined as a CSF glucose level at or below the 10th percentile, a CSF to blood glucose ratio at or below the 25th percentile, and a CSF lactate level at or below the 10th percentile, was found in only 35 of 4099 CSF samples (0.9%) present in our CSF database of patients who received a diagnosis other than GLUT1 deficiency syndrome.

Conclusions and Relevance  We conclude that if age-specific reference values are applied, CSF glucose and lactate levels are adequate biomarkers in the diagnostic workup of GLUT1 deficiency syndrome. Future availability of whole-exome sequencing in clinical practice will make the existence of a reliable biomarker for GLUT1 deficiency syndrome even more important, in order to interpret genetic results and, even more importantly, not to miss SLC2A1-negative patients with GLUT1 deficiency syndrome.

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Figure 1.
Cerebrospinal Fluid (CSF) Values of 157 Patients With GLUT1 Deficiency Syndrome Compared With Age-Specific Reference Ranges

The CSF glucose levels of 147 patients with GLUT1 deficiency syndrome are compared with those of 8871 controls (A); the CSF to blood glucose ratios of 152 patients with GLUT1 deficiency syndrome are compared with those of 4516 controls (B); and the CSF lactate levels of 73 patients with GLUT1 deficiency syndrome are compared with those of 7614 controls. The upper and lower lines indicate the 10th and 90th percentiles, respectively. The circles indicate patients with the classical phenotype of GLUT1 deficiency syndrome, the triangles indicate patients with nonclassical phenotype B, the squares indicate patients with nonclassical phenotype C, and the gray dots indicate controls.13

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Figure 2.
Flowchart of Diagnostic Workup of GLUT1 Deficiency Syndrome

aSee Table. CNS indicates central nervous system.

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