Pre-movement gating of somatosensory evoked potentials in Segawa disease.

INTRODUCTION: Segawa disease (SD), an autosomal dominant dopa-responsive dystonia with marked diurnal fluctuation, can be clinically classified into the postural dystonia type (SD-P) and action dystonia type (SD-A). Compared to SD-A, SD-P has an earlier onset and is characterized by postural dystonia. In SD-A, along with postural dystonia, dystonic movements appear in late childhood. To evaluate the differences between these two types of SD, we studied the gating of SEPs, which is useful to investigate sensory-motor integration and might be one of the methods to detect the thalamo-cortical involvement. METHODS: Fourteen patients with SD (11-63 years) and 18 age-matched normal subjects (11-51 years) were studied. Among the 14 patients with SD, 8 patients had SD-P and 6 had SD-A. Using median nerve stimulation at the wrist, the amplitude of the frontal N30 (FrN30) was compared between pre-movement and rest conditions. RESULTS: We found that the amplitude of the contralateral FrN30 was attenuated before movement in normal controls and in the majority of both SD types. On the other hand, the pre-movement-rest amplitude ratio in patients with SD-A was significantly larger than in patients with SD-P (P=0.0025). No significant differences were observed in the pre-movement-rest ratio between SD-P and normal subjects. CONCLUSION: The preservation or impairment of pre-movement gating shown here suggests a physiological difference between the two types of SD. More specifically, sensorimotor integration of the basal ganglia-thalamo-cortical circuits may be intact in SD-P, but are affected in SD-A. We discuss the different pathophysiology seen in the different phenotype of SD based on the different developmental involvement in the basal ganglia.

Genetics and pathophysiology of primary dystonia with special emphasis on DYT1 and DYT5.

DYT1 and DYT5 are early-onset dominant inherited dystonias. DYT1 is caused by mutations of the TOR1A gene, located on 9q34, which causes dysfunction of the D1 direct pathway or the indirect pathway. Dysfunction of the former causes postural-type and segmental dystonia; the latter causes action-type dystonia. In families with action-type dystonia, there are cases with focal and segmental dystonia. Ages of onset of postural-type dystonia are around 6 years, and 8 to 10 years in cases of action-type dystonia. Focal and segmental dystonia develops in the teens. Mental and psychological functions are preserved. DYT5 is caused by heterozygous mutations of the GCH1 gene, located on 14q22.1-q22.2. Again, mental and psychological functions are preserved. Clinically, there are two types: postural and action. Postural-type dystonia occurs around 6 years of age, with postural dystonia of one leg, and all extremities and trunk muscles are involved by the late teens. Action-type dystonia shows dystonic movements from around 8 to 10 years of age. In both types, all symptoms show diurnal fluctuations that diminish with age and are no longer apparent in the late teens. L-dopa produces dramatic effects, which continue throughout the course of the illness. In both postural and action types, each family or sporadic case has a particular mutation. It remains unclear why specific mutations cause certain age- and gender-specific symptoms.

Dopa-responsive dystonia is caused by particular impairment of nigrostriatal dopamine neurons different from those involved in Parkinson disease: evidence observed in studies on Segawa disease.

From the characteristics of its clinical features, Segawa disease is considered to be caused by deficiency of the tyrosine hydroxylase (TH) of the nigrostriatal dopamine neurons, which have high TH activities in the terminal but not in the perikaryon. This hypothesis was confirmed by two autopsied cases. However, these cases were younger than 40 years and left a question as to whether these abnormalities turned to those of Parkinson disease in older ages. An autopsy of a 90-year-old woman with Segawa disease confirmed the hypothesis that Segawa disease has a completely different pathophysiology and pathology than Parkinson disease.

Deterioration of horizontal saccades in progressive supranuclear palsy.

OBJECTIVE: To investigate horizontal saccade changes according to disease stage in patients with progressive supranuclear palsy (PSP). METHODS: We studied visually and memory guided saccades (VGS and MGS) in 36 PSP patients at various disease stages, and compared results with those in 66 Parkinson's disease (PD) patients and 58 age-matched normal controls. RESULTS: Both vertical and horizontal saccades were affected in PSP patients, usually manifesting as "slow saccades" but sometimes as a sequence of small amplitude saccades with relatively well preserved velocities. Disease progression caused saccade amplitude reduction in PSP but not PD patients. In contrast, VGS and MGS latencies were comparable between PSP and PD patients, as were the frequencies of saccades to cue, suggesting that voluntary initiation and inhibitory control of saccades are similar in both disorders. Hypermetria was rarely observed in PSP patients with cerebellar ataxia (PSPc patients). CONCLUSIONS: The progressively reduced accuracy of horizontal saccades in PSP suggests a brainstem oculomotor pathology that includes the superior colliculus and/or paramedian pontine reticular formation. In contrast, the functioning of the oculomotor system above the brainstem was similar between PSP and PD patients. SIGNIFICANCE: These findings may reflect a brainstem oculomotor pathology.

Diffuse central hypomyelination presenting as 4H syndrome caused by compound heterozygous mutations in POLR3A encoding the catalytic subunit of polymerase III.

We describe a 33-year-old male patient with mental retardation and cerebellar ataxia whose brain magnetic resonance imaging (MRI) showed diffuse central hypomyelination. The associated hypogonadotropic hypogonadism and hypodontia were consistent with the clinical diagnosis of 4H syndrome. Two compound heterozygous mutations in POLR3A were found: p.Met852Val and p.Asn1249His. MRI of the brain showed cerebellar atrophy, atrophy of the corpus callosum, and diffuse hypomyelination extending as far as the U-fibers, with preservation of the basal ganglia. T2 hyperintensity was observed in the bilateral middle cerebellar peduncles. The patient showed almost normal development until 4-5years of age. After 25years of age, the patient showed a gradual but consistent motor and cognitive deterioration. We demonstrated the involvement of the corticospinal tract electrophysiologically, but peripheral nerve conduction was normal. Although this disease may start very early in life, the clinical course in the present case suggests that brains that initially appear to have developed normally may show dysfunction later in life, although the pathophysiological bases for this dysfunction may not be evident on MRIs.

[Neurotransmitter disorders in children--special reference to Segawa disease].

Aminergic neurotransmitter disorders occurring in childhood include metabolic disorders of pteridine and tyrosine hydroxylase (TH). Pteridine metabolic disorders cause a deficiency of serotonin (5-HT) and dopamine (DA) and TH disorder causes a deficiency of noradrenaline (NA) and DA in the terminals of each aminergic neuron. The activities of TH or DA in the terminals are marked in early childhood, and then they show an exponential age-dependent decrement and achieve stationary or minimal levels in the twenties. As observed in Segawa disease, TH or DA activities in these disorders follow this age-related decrease with levels around 20% of normal, and patients develop symptoms age-dependently, with onset in childhood, progression by the late teens, and a stationary period after the twenties, but this does not cause morphological changes. These phenomena may occur with other neurotransmitters. So replacement therapies are effective irrespective of the clinical course. However, early-onset cases in infancy or early childhood showing a marked decrement of 5-HT or NA activities show postural hypotonia and failed locomotion. These cause failure in atonia restriction in the REM stage and induce dysfunction of the pedunculopontine nucleus, and, consequently induce dysfunction or failure in the development of DA neurons in the sutbstantia nigra and ventrotegmental area. These relate to failure in the development of higher cortical functions. Thus, assessing of ages at onset and activities of antigravity muscles and locomotion in infancy is cardinal for the treatment the neurotransmitter disorders occurring in infancy and early childhood. PARK2 with deficiency of DA in the substantia nigra leads to dystonia in the teens and Parkinson disease after 20 years, although these respond to 1-Dopa favorably but induce D2 receptor upregulation and intractable dyskinesia. A decrease of DA in the perikaryon leads to symptoms after 10 years and causes dysfunction of the target structures.

Dopa-responsive dystonia.

Clinical characteristics and pahophysiologies of dopa-responsive dystonia are discussed by reviewing autosomal-dominant GTP cyclohydrolase-I deficiency (AD GCHI D), recessive deficiencies of enzymes of pteridine metabolism, and recessive tyrosine hydroxylase (TH). Pteridine and TH metabolism involve TH activities in the terminals of the nigrostriatal dopamine neuron which show high in early childhood and decrease exponentially with age, attaining stational low levels by the early 20s. In these disorders, TH in the terminals follows this course with low levels and develops particular symptoms with functional maturation of the downstream structures of the basal ganglia; postural dystonia through the direct pathway and descending output matured earlier in early childhood and parkinsonism in TH deficiency in teens through the D2 indirect pathway ascending output matured later. In action-type AD GCHI D, deficiency of TH in the terminal on the subthalamic nucleus develops action dystonia through the descending output in childhood, focal and segmental dystonia and parkinsonism in adolescence and adulthood through the ascending pathway maturing later. Dysfunction of dopamine in the terminals does not cause degenerative changes or higher cortical dysfunction. In recessive disorders, hypofunction of serotonin and noradrenaline induces hypofunction of the dopamine in the perikaryon and shows cortical dysfunction.

Initiation and inhibitory control of saccades with the progression of Parkinson's disease - changes in three major drives converging on the superior colliculus.

The cardinal pathophysiology of Parkinson's disease (PD) is considered to be the increase in the activities of basal ganglia (BG) output nuclei, which excessively inhibits the thalamus and superior colliculus (SC) and causes preferential impairment of internal over external movements. Here we recorded saccade performance in 66 patients with PD and 87 age-matched controls, and studied how the abnormality changed with disease progression. PD patients were impaired not only in memory guided saccades, but also in visually guided saccades, beginning in the relatively early stages of the disease. On the other hand, they were impaired in suppressing reflexive saccades (saccades to cue). All these changes deteriorated with disease progression. The frequency of reflexive saccades showed a negative correlation with the latency of visually guided saccades and Unified Parkinson's Disease Rating Scale motor subscores reflecting dopaminergic function. We suggest that three major drives converging on SC determine the saccade abnormalities in PD. The impairment in visually and memory guided saccades may be caused by the excessive inhibition of the SC due to the increased BG output and the decreased activity of the frontal cortex-BG circuit. The impaired suppression of reflexive saccades may be explained if the excessive inhibition of SC is "leaky." Changes in saccade parameters suggest that frontal cortex-BG circuit activity decreases with disease progression, whereas SC inhibition stays relatively mild in comparison throughout the course of the disease. Finally, SC disinhibition due to leaky suppression may represent functional compensation from neural structures outside BG, leading to hyper-reflexivity of saccades and milder clinical symptoms.

Hereditary progressive dystonia with marked diurnal fluctuation.

Hereditary progressive dystonia with marked diurnal fluctuation (HPD) is a dopa-responsive dystonia, now called autosomal dominant GTP cyclohydrolase 1 deficiency or Segawa disease, caused by mutation of the GCH-1 gene located on 14q22.1 to q22.2. Because of heterozygous mutation, partial deficiency of tetrahydrobiopterin affects tyrosine hydroxylase (TH) rather selectively and causes decrease of TH in the terminals of the nigrostriatal dopamine (NS DA) neurons, projecting to the D1 receptors on the striosome, the striatal direct pathways and the subthalamic nucleus (STN) and the D4 receptors of the tuberoinfundibular tract. The activities of TH in the terminal are high in early childhood decrease exponentially to the stational level around early twenties, and show circadian oscillatron. TH in HPD follows these variations with around 20% of normal levels and with development of the downstream structures show appears characteristic clinical symptoms age dependently. In late fetus period to early infancy, through the striosome-substantia nigra pars compacta pathway failure in morphogenesis of the DA neurons in substantia nigra, in childhood around 6 years postural dystonia through the D1 direct pathways and the descending output of the basal ganglia. Diurnal fluctuation is apparent in childhood but decrease its grade with age. TH deficiency at the terminal on the STN causes action dystonia from around 8 years and postural tremor from around 10 years, focal dystonia in adulthood. Adult onset cases in the family with action dystonia start with writer's cramp, torticollis or generalized rigid hypertonus with tremor but do not show postural dystonia. TH deficiency on the D4 receptors causes stagnation of the body length in childhood. With or without action dystonia depends on the locus of mutation. Postural dystonia is inhibitory disorder, while action dystonia is excitatory disorder. The TH deficiency at the terminal does not cause morphological changes or degenerative process. Thus, levodopa shows favorable effects without any relation to the duration of illness.

[Walking abnormalities in children].

Walking is a spontaneous movement termed locomotion that is promoted by activation of antigravity muscles by serotonergic (5HT) neurons. Development of antigravity activity follows 3 developmental epochs of the sleep-wake (S-W) cycle and is modulated by particular 5HT neurons in each epoch. Activation of antigravity activities occurs in the first epoch (around the age of 3 to 4 months) as restriction of atonia in rapid eye movement (REM) stage and development of circadian S-W cycle. These activities strengthen in the second epoch, with modulation of day-time sleep and induction of crawling around the age of 8 months and induction of walking by 1 year. Around the age of 1 year 6 months, absence of guarded walking and interlimb cordination is observed along with modulation of day-time sleep to once in the afternoon. Bipedal walking in upright position occurs in the third epoch, with development of a biphasic S-W cycle by the age of 4-5 years. Patients with infantile autism (IA), Rett syndrome (RTT), or Tourette syndrome (TS) show failure in the development of the first, second, or third epoch, respectively. Patients with IA fail to develop interlimb coordination; those with RTT, crawling and walking; and those with TS, walking in upright posture. Basic pathophysiology underlying these condition is failure in restricting atonia in REM stage; this induces dysfunction of the pedunculopontine nucleus and consequently dys- or hypofunction of the dopamine (DA) neurons. DA hypofunction in the developing brain, associated with compensatory upward regulation of the DA receptors causes psychobehavioral disorders in infancy (IA), failure in synaptogenesis in the frontal cortex and functional development of the motor and associate cortexes in late infancy through the basal ganglia (RTT), and failure in functional development of the prefrontal cortex through the basal ganglia (TS). Further, locomotion failure in early childhood causes failure in development of functional specialization of the cortex through the spinal stepping generator-fastigial nucleus-thalamus-cortex pathway. Early detection of locomotion failure and early adjustment of this condition through environmental factors can prevent the development of higher cortical dysfunction.

Epilepsy in autism: A pathophysiological consideration.

Eighty cases of idiopathic autism with epilepsy and 97 cases without epilepsy were studied to evaluate the pathophysiology of epilepsy in autism. The initial visit to this clinic ranged 8months-30years 3months of age, and the current ages are 5years 8months-42years 3months, 60% reaching to over 30years of age. The average follow up duration is 22.2years±9.4years. The ages of onset of epilepsy were from 7months to 30years of age, with the two peaks at 3.2years and 16.7years. EEG central focus appeared earlier than frontal focus. Abnormality of locomotion and atonic NREM were observed more frequently in epileptic group. These suggest the neuronal system related to abnormality of locomotion and atonic NREM, which are the hypofunction of the brainstem monoaminergic system, is the pathomechanism underling the epilepsy in autism. By showing the abnormal sleep-wake rhythm and locomotion being the very initial symptoms in autism, we had shown the hypofunction of the brainstem monoaminergic system is the initial pathomechanism of autism. Thus, epilepsy in autism is not the secondary manifestation, but one of the pathognomonic symptoms of autism. The brainstem monoaminergic system project to the wider cortical area, and the initial monoaminergic hypofunction may lead to the central focus which appears earlier. The failure of the monoaminergic (serotonergic) system causes dysfunction of the pedunculo-pontine nucleus (PPN) and induces dysfunction of the dopamine (DA) system, and with development of the DA receptor supersensitivity consequently disinhibits the thalamo-frontal pathway, which after maturation of this pathway in teens cause the epileptogenesis in the frontal cortex.

[Carry-over of neurological disorders of infancy and childhood].

Carry-over implies following a patient from the age of childhood to the adulthood. In the developing brain, specific symptoms appear only after development of the neurons of the lesion site and those consisting of the downstream structures. Thus, in the basal ganglia disorders, those involving the striatal direct pathways and the descending output of the basal ganglia develop symptoms in childhood before 10 years old. However, those involving the indirect pathway and the ascending output appear later mostly in adulthood. The development of the brainstem aminergic neuron and the midbrain dopamine neuron are reflected in the sleep-wake rhythm and the pattern of the locomotion. Thus, the order and disorder of those aminergic neurons are evaluated by following the developmental maturation of these biological markers. Thus, carry-over is necessary for child neurology.

Cases of dopa-responsive dystonia (Segawa disease) in Estonia.

The aim of this report is to present the first four cases from three families of dopa-responsive dystonia diagnosed in Estonia. Diagnosis was performed by clinical evaluation and response to levodopa and was confirmed by gene analyses. The prevalence of dopa-responsive dystonia in Estonia was 1.4 per 100,000 (95%CI=0.39-3.65) children less than 18 years of age. In all children with dystonia it is important to think about possible dopa-responsive dystonia as this is treatable condition and improving the quality of life of children.

Autosomal dominant GTP cyclohydrolase I (AD GCH 1) deficiency (Segawa disease, dystonia 5; DYT 5).

Autosomal dominant GTP cyclohydrolase I (AD GCH 1) deficiency (Segawa disease) is an autosomal dominant dopa responsive dystonia caused by heterozygous mutation of the GCH 1 gene located on 14q22.1-q22.2. Although a number of mutations have been reported, the change remains highly stable within families, and causes a decrease in the tyrosine hydroxylase protein at the nigrostriatal (NS)-dopamine (DA) neuron terminal. In addition, decreased tetrahydrobiopterin levels early in the development affect DA receptors age-dependently, and produce a spectrum of specific symptoms attributed to neuronal changes traced to processes in the development of the NS-DA neuron, related striatal projection neurons, and the output projection of the basal ganglia.

[Case of DYT1 dystonia (early-onset torsion dystonia) showing long-term focal dystonia in the arm].

DYTI dystonia (DYT1-D, early-onset torsion dystonia) is caused by a GAG deletion in the DYTI gene. Here we report a girl with child-onset familial DYT1-D showing localized arm involvement. The patient developed postural and action dystonia in the right and left arms at 7 and 9 years, respectively. She was misdiagnosed as hysteria due to lack of abnormalities on laboratory tests. At 11 years of age she was introduced to our clinic. Increased muscle tonus and dystonic discharges seen on surface electromyogram in the right arm and the sternocleidomastoid muscle led to the diagnosis of dystonia. A GAG deletion in the DYTI gene was confirmed in the patient, her healthy father and paternal grandfather with torsion dystonia. Titration of levodopa resulted in the fluctuation of her arm dystonia. Combined therapy by levodopa and trihexyphenidyl relieved postural dystonia in the right arm but not action dystonia in the left. Both types of dystonia in the right and left arms were well ameliorated by the additional increase of levodopa. Somatosensory evoked potentials demonstrated abnormal premovement gating. The latency and accuracy of the amplitude were disturbed in visually guided saccadic eye movement. Now at more than 11 years after onset, the patient has not shown torsion or involvement of the lower extremities. Most DYT1-D patients are refractory to medication and early surgical intervention is recommended. However, the presence of DYT1-D patients showing a milder disease course should also be considered.

[Development of intellect, emotion, and intentions, and their neuronal systems].

Intellect, emotion and intentions, the major components of the human mentality, are neurologically correlated to memory and sensorimotor integration, the neuronal system consisting of the amygdale and hypothalamus, and motivation and learning, respectively. Development of these neuronal processes was evaluated by correlating the pathophysiologies of idiopathic developmental neuropsychiatric disorders and developmental courses of sleep parameters, sleep-wake rhythm (SWR), and locomotion. The memory system and sensory pathways develop by the 9th gestational months. Habituation or dorsal bundle extinction (DBE) develop after the 34th gestational week. In the first 4 months after birth, DBE is consolidated and fine tuning of the primary sensory cortex and its neuronal connection to the unimodal sensory association area along with functional lateralization of the cortex are accomplished. After 4 months, restriction of atonia in the REM stage enables the integrative function of the brain and induces synaptogenesis of the cortex around 6 months and locomotion in late infancy by activating the dopaminergic (DA) neurons induces synaptogenesis of the frontal cortex. Locomotion in early infancy involves functional specialization of the cortex and in childhood with development of biphasic SWR activation of the areas of the prefrontal cortex. Development of emotions reflects in the development of personal communication and the arousal function of the hypothalamus. The former is shown in the mother-child relationship in the first 4 months, in communication with adults and playmates in late infancy to early childhood, and in development of social relationships with sympathy by the early school age with functional maturation of the orbitofrontal cortex. The latter is demonstrated in the secretion of melatonin during night time by 4 months, in the circadian rhythm of body temperature by 8 months, and in the secretion of the growth hormone by 4-5 years with synchronization to the SWR modulated by the brainstem aminergic neurons. For this purpose, nursing according to the day-night light-dark cycle is essential right from early infancy. The deep cerebellar nuclei involved in learning develop by the 9th gestational month. The DA neurons activated in late infancy modulate the nuclei of the basal ganglia and the association cortex for learning. Motivation starts with activation of the PPN in infancy by crawling which makes DA neurons as the lead. In late childhood, DA neurons along with 5HT neurons activate the anterior cingulate area and establish the neuronal process for learning with motivation.

[Segawa disease].

The first report of Segawa disease was a report of two girls, cousin each other, with dystonic posture, under the title of "Hereditary progressive basal ganglia disorder" in 1971. After accumulation of cases with an adult case, I confirmed this disease does not transform to Parkinson's disease in adulthood and published with a nomenclature of "Hereditary progressive dystonia with marked diurnal fluctuation" in 1976. Polysomnographical examination for evaluating the sleep effects and correlation of the natural course to the age variation of the tyrosine hydroxylase activities in the striatum, these speculated this is a particular disorder caused by non-progressive decrement of the tyrosine hydroxylase at the terminal of the nigrostriatal dopamine neuron. This was supported by PET studies in early 1990's. Evaluation of pteridine metabolites in cerebrospinal fluid revealed partial decrement of the GTP cyclohydrolase I as the cause of this disease and induced the discovery of the causative gene. After the discovery of the gene, an autopsied case with dopa-responsive dystonia was confirmed as Segawa disease and the neuropathological and histochemical findings confirmed the hypothesis. Furthermore, these showed rather selective involvement the D1-direct pathways in the disease. However, it was also clarified existence of two types, one, classic type, postural dystonia and the other action dystonia with vigorous dystonic movements besides dystonic posture, which, is postulated to be caused by the dopamine neuron innervating to the subthalamic nucleus with D1 neuron. Existence of these two phenotypes also provides phenotypical variation of Segawa disease.

A study of the factors inducing the development of childhood-onset myasthenia gravis using CDR3 spectratyping analysis of the TCR repertoire.

Myasthenia gravis (MG) is an autoimmune disease. AChR-specific autologous helper T (Th) cells are essential to the pathogenesis of MG. Factors correlated with the development of childhood-onset MG are unknown. In longitudinal studies, we found TCR Vbeta 2/5.1/6/7 usage in the development or relapse phases, but not in the remission phase. We also found that TCR Vbeta 8/9/13.1/15/18/20 usage persisted. The polyclonally expanded TCR Vbeta 2/5.1/6/7 by CDR3 spectratyping was found to be associated with the development of disease. These data suggest that in patients with childhood-onset MG, stimuli such as superantigens induced by a preceding infection, which cause development of the polyclonal pattern in TCR Vbeta families, play an important role in the development of the disease.