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Original Investigation |

Clinical, Genetic, and Radiological Features of Extrapyramidal Movement Disorders in Mitochondrial Disease

Mika H. Martikainen, MD, PhD1,2; Yi Shiau Ng, MRCP2; Gráinne S. Gorman, PhD, FRCP2; Charlotte L. Alston, BSc (Hons)2; Emma L. Blakely, PhD, FRCPath2; Andrew M. Schaefer, MRCP2; Patrick F. Chinnery, PhD, FRCP2,3,4; David J. Burn, PhD, FRCP2; Robert W. Taylor, PhD, FRCPath2; Robert McFarland, PhD, MRCP, MRCPCH2; Doug M. Turnbull, PhD, FRCP2
[+] Author Affiliations
1Division of Clinical Neurosciences, University of Turku and Turku University Hospital, Turku, Finland
2Wellcome Trust Centre for Mitochondrial Research and Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, England
3Department of Clinical Neuroscience, School of Clinical Medicine, University of Cambridge, Cambridge, England
4Medical Research Council Mitochondrial Biology Unit, Cambridge Biomedical Campus, Cambridge, England
JAMA Neurol. 2016;73(6):668-674. doi:10.1001/jamaneurol.2016.0355.
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Importance  Extrapyramidal movement disorders associated with mitochondrial disease are difficult to treat and can lead to considerable disability. Moreover, potential new treatment trials on the horizon highlight the importance of genotype-phenotype associations and deep phenotyping of the movement disorders related to mitochondrial disease.

Objective  To describe the phenotype, genetic etiology, and investigation of extrapyramidal movement disorders in a large and well-defined mitochondrial disease cohort.

Design, Setting, and Participants  An observational cohort study at a single national referral center. Among 678 patients (87% adults) followed up at the Newcastle mitochondrial disease specialized referral center between January 1, 2000, and January 31, 2015, 42 patients (12 pediatric, 30 adult) with genetic or biochemical evidence of mitochondrial disease and with 1 or more predefined extrapyramidal movement disorders (parkinsonism, dystonia, tremor, chorea, and restless legs syndrome) were included.

Main Outcomes and Measures  We investigated the prevalence and genetic causes of dystonia and parkinsonism as well as radiological findings in the context of movement disorders in mitochondrial disease. All patients were interviewed and examined. All available medical notes and clinical, radiological, and genetic investigations were reviewed.

Results  Forty-two patients (mean [SD] age, 37 [25] years; 38% female) with mitochondrial disease (12 pediatric [age range, 4-14 years], 30 adult [age range, 20-81 years]) with extrapyramidal movement disorders were identified. Dystonia manifested in 11 pediatric patients (92%), often in the context of Leigh syndrome; parkinsonism predominated in 13 adult patients (43%), among whom 5 (38%) harbored either dominant (n = 1) or recessive (n = 4) mutations in POLG. Eleven adult patients (37%) manifested with either generalized or multifocal dystonia related to mutations in mitochondrial DNA, among which the most common were the m.11778G>A mutation and mutations in MT-ATP6 (3 of 11 patients [27%] each). Bilateral basal ganglia lesions were the most common finding in brain magnetic resonance imaging, usually associated with generalized dystonia or Leigh syndrome.

Conclusions and Relevance  Dystonia, often associated with Leigh syndrome, was the most common extrapyramidal movement disorder among pediatric patients with mitochondrial disease. Parkinsonism was the most prevalent extrapyramidal movement disorder in adults and was commonly associated with POLG mutations; dystonia was predominantly associated with mitochondrial DNA mutations. These findings may help direct genetic screening in a busy neurology outpatient setting.

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Figure.
Brain Magnetic Resonance Imaging (MRI) and Dopamine Transporter Single-Photon Emission Computed Tomography (DAT-SPECT) Imaging Findings in Patients With Mitochondrial Disease

A and D, Bilateral putaminal lesions in brain MRI (A) and bilaterally reduced striatal uptake in DAT-SPECT imaging (D) in patient P30. B and E, Normal brain MRI findings (B) but bilaterally reduced striatal uptake in DAT-SPECT imaging (E) in patient P29. C and F, Cerebral and cerebellar atrophy but normal basal ganglia in brain MRI (C) and bilaterally reduced striatal uptake in DAT-SPECT imaging (F) in patient P33.

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