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Cerebellar Dysfunction and Ataxia in Patients with Epilepsy: Coincidence, Consequence, or Cause? Cover

Cerebellar Dysfunction and Ataxia in Patients with Epilepsy: Coincidence, Consequence, or Cause?

Open Access
|Jun 2016

Figures & Tables

Table 1

Ataxia in Conditions Associated with Epilepsy

Group of DiseasesSpecific Description and Clinical Notes
ChannelopathiesSodium channel gene mutationSCN1A gene mutation: severe myoclonic epilepsy of infants (Dravet syndrome), infants with febrile seizures presenting around 6 months of age with hemiclonic seizures18
SCN2A gene mutation: benign familial neonatal infantile seizures, febrile seizures plus, and intractable epilepsy of infancy, late-onset episodic ataxia, myoclonus19
SCN8A gene mutation: infant seizures not triggered by fever, multiple seizure types including focal, tonic, clonic, myoclonic and absence seizures and epileptic spasms; seizures refractory to antiepileptic therapy, motor manifestations: hypotonia, dystonia, hyperreflexia, and ataxia86
Potassium channel gene mutationKCTD7 gene mutation: progressive myoclonus epilepsy, infant seizures, myoclonus, ataxia17
KCNJ10 gene mutation: epilepsy, ataxia, sensorineural deafness, and tubulopathy (EAST syndrome), tonic-clonic seizures in infancy, later cerebellar ataxia, and hearing loss16
Sodium/hydrogen channel gene mutationSLC9A6 gene mutation: mental retardation, microcephaly, epilepsy, ataxia, Angelman-like syndrome87
Calcium channel gene mutationCACNA1A gene mutation: loss-of-function mutations classically present as episodic ataxia type 2 or progressive spinocerebellar ataxia (SCA6), minority of patients carrying CACNA1A mutations develop epilepsy, cognitive impairment, autism, and epileptic encephalopathy with mild cerebellar symptoms88
Deficiency disorders and metabolically conditioned diseasesMutation of FOLR1 gene (folic acid transport disorder)Case study: ataxic syndrome in the second year of life, later a febrile tonic-clonic status, daily tonic and myoclonic seizures.28
Autosomal recessive ataxia with vitamin E deficiencyCase study, caused by mutations of the α-tocopherol transport protein gene located on chromosome 8q1329
GLUT-1 deficiency syndromePersistently low glucose in the cerebrospinal fluid, intellectual disability, epilepsy, movement disorders onset from infancy to adulthood: spasticity, ataxia, dystonia, caused by SLC2A1 gene mutation30
Inherited glycosylation disordersSystemic symptoms during infancy – susceptibility to infection, episodes of hepatic impairment, hemocoagulation impairment, childhood seizures and stroke-like episodes and later progressive limb atrophy with severe ataxia and intellectual deficiency, this group represents nearly 70 genetic disorders known to be caused by impaired synthesis of glycoconjugates89
Wernicke’s encephalopathyB1 deficiency, ataxia, ophthalmoplegia and confusion, additional symptoms: seizures, peripheral neuropathy, impaired vision and hearing to varying degrees90
Lysosomal storage diseaseNiemann-Pick CNPC1 gene mutations, deficiency of sphingomyelinase, onset from infancy to adulthood, supranuclear gaze palsy followed by epilepsy development and later progressive gait ataxia91
Lafora diseaseLafora bodies within the cytoplasm of cells, progressive myoclonus epilepsy, intractable tonic-clonic seizures, myoclonus, ataxia, visual hallucinations, and progressive dementia, onset in 2nd decade, fatal within 10 years92 Caused by mutations in either the EPM2A or EPM2B/NHLRC1 gene.93
Neuronal ceroid lipofuscinosesAccumulation of autofluorescent lipopigments resembling ceroid and lipofuscin, seizures, dementia, motor function impairment (myoclonus, ataxia, spasticity), vision loss, forms: infantile, late-infantile, juvenile, adult, most common infantile form (from 2 to 4 years of age), starting with epilepsy, later ataxia24 There are more than a dozen genes containing over 430 mutations underlying human NCLs have been identified, CLN1-14.94
SialoidosesNeuraminidase deficiency caused by a mutation in the neuraminidase gene (NEU), located on 6p21.33, cerebellar ataxia, myoclonic epilepsy, myoclonus, macular cherry-red spots, onset from childhood to young adulthood95
Gaucher diseaseGBA gene mutation, hereditary glucocerebrosidase deficiency, type I (non-neuropathic) – hepatosplenomegaly, type II (acute infantile neuropathic) – hepatosplenomegaly and neurological symptoms: eye movement disorders, spasticity, seizures, limb rigidity, typically begins within 6 months of birth, type III (chronic neuropathic) – onset in childhood or even in adulthood, similar to type II but milder symptoms96
Progressive myoclonus epilepsiesLeigh syndromeDifferent inheritance patterns, genes contained in nuclear DNA or genes contained in mitochondrial DNA, mitochondrial syndrome, optic atrophy, ataxia, and dystonia, later epilepsy27
MERRFMutation in the MT-TK gene of mitochondrial DNA, progressive course with worsening of the epilepsy and onset of additional symptoms including ataxia, deafness, muscle weakness (myopathy), and dementia97
Unverricht-Lundborg diseaseCSTB gene mutation, progressive myoclonus epilepsy, ataxia is an additional symptom98
Action myoclonus-renal failure syndromeSCARB2 gene mutation,99 progressive myoclonus epilepsy associated with renal dysfunction, severe progressive action myoclonus, dysarthria, ataxia, and later infrequent generalized seizures in 2nd or 3rd decade26
May and White syndromeMitochondrial disorder, ataxia, severe action myoclonus, dysarthria, generalized seizures.100
Immune-mediated conditionsCerebellar ataxia and epilepsy with anti-GAD antibodiesAdult-onset cerebellar syndrome, ataxia and stiffness, incontinence, retinal pathologies, seizures, and immunological co-morbidities40
Celiac diseaseNeurological symptoms in up to 10% of cases, gastrointestinal symptoms preceding years of neurological symptoms, ataxia, myoclonus, tremor, seizures, abnormalities of eye movement31
Hashimoto encephalopathyAntibodies to thyroperoxidase, cerebellar ataxia occurs in more than half of patients, diffuse encephalopathy with cognitive abnormalities, tremor, myoclonus, seizures and sleep disturbances acute to subacute with a rapid progression onset in all age groups more common in females than in males90,101
Hereditary ataxiasDRPLAHighest frequency in the Japanese population, age of onset 1–60 years (mean age 28,8), early onset: myoclonus, epilepsy and mental retardation, late onset: cerebellar ataxia, choreoathetosis and dementia, caused by a mutation in the ATN1 gene – increased CAG trinucleotide repeat.102,103
SCA2ATXN2 gene mutation, onset in the 3rd or 4th decade, truncal ataxia, dysarthria, slowed saccades and less commonly ophthalmoparesis and chorea or parkinsonism104,105
SCA10ATXN10 (E46L) gene mutation, onset from 18 to 45, slowly progressive cerebellar syndrome and epilepsy, sometimes mild pyramidal signs, peripheral neuropathy and neuropsychological disturbances104,106,107,108
SCA13KCNC3 gene mutation, onset in childhood, delayed motor and cognitive development followed by mild progression of cerebellar ataxia41,104,108
SCA17TBP gene mutation, dementia, psychiatric disorders, parkinsonism, dystonia, chorea, spasticity, and epilepsy42,104,107,109
Friedreich ataxiaFXN gene mutation, ataxia followed by epilepsy, case report, ataxia, weakness and spasticity, sensory impairment, skeletal abnormalities, cardiac difficulties, diabetes43,110
Ataxia teleangiectasiaATM gene mutation, progressive cerebellar ataxia beginning between ages 1 and 4 years, oculomotor apraxia, choreoathetosis, telangiectasia of the conjunctivae, immunodeficiency, frequent infections, and an increased risk for malignancy, particularly leukemia and lymphoma111

[i] Abbreviations: DRPLA, Dentatorubral-pallidoluysian Atrophy; GAD  =  Glutamic Acid Decarboxylase; GLUT-1, Glucose Transporter-1; MERRF, Myoclonus Epilepsy with Ragged-red Fibers; SCA  =  Spinocerebellar Ataxia.

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Figure 1

Difficulties in Assessing the Extent of Cerebellar Atrophy. Magnetic resonance imaging in the medial sagittal plane. Left, 40-year-old patient with temporal lobe epilepsy due to focal cortical dysplasia type II and a 17-year history of predominantly generalized tonic-clonic seizures; right, the average-sized cerebellum of healthy control. Cerebellar size always should be evaluated with respect to intracranial volume.

Table 2

Antiepileptic Drugs that Induce Cerebellar Ataxia1

1a – Overview of all of the case and cohort studies found in the literature and included in the present review, percentage of affected patients
1b – Data on ataxia described as an adverse reaction in randomized placebo-controlled studies, percentage of affected patients
1a1b
Clobazam6.3%
Clonazepam50%
Eslicarbazepine7.5%
Gabapentin8.7%10.1%
Lacosamide9.3%
Lamotrigine5.5%18.5%
Levetiracetam1.5%
Oxcarbazepine29.9%
Phenytoin37.9%
Pregabalin9.7%
Retigabine15%10.4%
Tiagabine7.2%6.1%
Topiramate1.3%6.6%
Valproate3.6%3%
Vigabatrin6.8%3.6%
Zonisamide10.6%12.7%

1 Data from (60).

DOI: https://doi.org/10.5334/tohm.331 | Journal eISSN: 2160-8288
Language: English
Submitted on: Mar 6, 2016
Accepted on: May 5, 2016
Published on: Jun 23, 2016
Published by: Columbia University Libraries/Information Services
In partnership with: Paradigm Publishing Services
Publication frequency: 1 issue per year

© 2016 Václav Marcián, Pavel Filip, Martin Bareš, Milan Brázdil, published by Columbia University Libraries/Information Services
This work is licensed under the Creative Commons License.