X L Saint-Val

X T Courtin

X P Charles

X C Verny

X M Catala

X R Schiffmann

X O Boespflug-Tanguy

X F Mochel

MD Fanny Mochel
email: fanny.mochel@upmc.fr

GJA1 Variants Cause Spastic Paraplegia Associated with Cerebral Hypomyelination

Keywords: Cx43 ϭ connexin 43, Cx47 ϭ connexin 47, ODDD ϭ oculodentodigital dysplasia

Oculodentodigital dysplasia is an autosomal dominant disorder due to GJA1 variants characterized by dysmorphic features. Neurologic symptoms have been described in some patients but without a clear neuroimaging pattern. To understand the pathophysiology underlying neurologic deficits in oculodentodigital dysplasia, we studied 8 consecutive patients presenting with hereditary spastic paraplegia due to GJA1 variants. Clinical disease severity was highly variable. Cerebral MR imaging revealed variable white matter abnormalities, consistent with a hypomyelination pattern, and bilateral hypointense signal of the basal ganglia on T2-weighted images and/or magnetic susceptibility sequences, as seen in neurodegeneration with brain iron accumulation diseases. Patients with the more prominent basal ganglia abnormalities were the most disabled ones. This study suggests that GJA1-related hereditary spastic paraplegia is a complex neurodegenerative disease affecting both the myelin and the basal ganglia. GJA1 variants should be considered in patients with hereditary spastic paraplegia presenting with brain hypomyelination, especially if associated with neurodegeneration and a brain iron accumulation pattern.

O culodentodigital dysplasia (ODDD, Online Mendelian In- heritance in Man, No. 164200) is an autosomal dominant disorder due to GJA1 variants [START_REF] Paznekas | Connexin 43 (GJA1) mutations cause the pleiotropic phenotype of oculodentodigital dysplasia[END_REF] and characterized by dysmorphic features involving the eyes (microphthalmia and microcornea), the nose (narrow, pinched nose with hypoplastic alae nasi), the teeth (small and carious), and limb extremities (syndactyly, camptodactyly). Some patients may present with neurosensory deficits such as spastic paraplegia, ataxia, decreased visual acuity, and hearing loss, possibly associated with white matter and/or basal ganglia signal abnormalities on brain MR imaging. [START_REF] Gutmann | Oculodentodigital dysplasia syndrome associated with abnormal cerebral white matter[END_REF][START_REF] Loddenkemper | Neurological manifestations of the oculodentodigital dysplasia syndrome[END_REF] However, there is no comprehensive overview of the neuroimaging features of ODDD besides isolated case reports. Therefore, to improve the accuracy of clinical diagnosis and better understand the pathophysiology underlying neurologic symptoms in ODDD, we wished to define key brain imaging findings in 8 consecutive patients presenting with spastic paraplegia due to GJA1 variants.

MATERIALS AND METHODS

We retrospectively studied 8 patients from 5 families presenting with hereditary spastic paraplegia. Patients were referred to reference centers for neurogenetic and neurometabolic diseases. Patients were informed and gave their consent to this study.

GJA1 variants were suspected on the basis of the co-occurrence of hereditary spastic paraplegia with dysmorphic features in all patients. These dysmorphic features included ocular abnormalities (short palpebral fissures, microphthalmia), nasal abnormalities (long and narrow nose, hypoplastic alae nasi), dental abnormalities (microdontia, abnormal coloration of the enamel, multiple caries), and bone extremity abnormalities (syndactyly of the fourth and fifth fingers, clinodactyly, camptodactyly, and aphalangia). Clinical examination was performed by experts in rare neurologic diseases (P.C., C.V., M.C., and F.M.). Disease severity was estimated by a disability stage index: 0, no functional handicap; 1, no functional handicap but signs at examination; 2, mild, able to run, walking unlimited; 3, moderate, unable to run, limited walking without aid; 4, severe, walking with 1 cane; 5, walking with 2 canes; 6, unable to walk, requiring a wheelchair; 7, confined to bed.

MR imaging was performed with a 1.5T (patients 1, 3, 5, 7, 8) or 3T (patients 2, 4, and 6) magnetic field and included at least 1 axial T1-and T2-weighted sequence and 1 sagittal sequence. CT scans were obtained in all patients except patients 1 and 3. Cerebral MR imaging and CT scans were qualitatively reviewed by 3 leukodystrophy experts (R.S., O.B.-T., and F.M.). Visual, brain stem auditory, and somatosensory and motor-evoked potentials were available for 4 patients.

RESULTS

Clinical findings are presented in Table 1. Most patients were women (6/8) and had a family history of the disease (5/8). The age at onset was variable, from 14 to 50 years of age, and symptoms at onset were gait difficulties (4/8) and urinary dysfunction (4/8). Disease severity was highly variable with a disability stage index ranging from 1 to 6. All patients presented with spastic paraplegia associated with reduced muscle strength in 4 patients and decreased vibration sense, more pronounced in the lower limbs, in 6 patients. Six patients presented with signs of neurogenic bladder with variable severity: mild (1/8), moderate (3/8), and severe (2/ 8). One patient required self-catheterization several times a day (patient 3), and 1 had a cystectomy with enterocystoplasty (patient 4). Five patients had mild cerebellar signs.

Cerebral MR imaging revealed white matter abnormalities in all patients, consisting mainly of mild-to-moderate symmetric and diffuse hyperintensities of the corticospinal tracts on T2-and FLAIR-weighted sequences associated with hyper-or isointense T1-weighted signal (Table 2 andFig 1), consistent with a hypomyelination pattern. [START_REF] Vanderver | Case definition and classification of leukodystrophies and leukoencephalopathies[END_REF] Most patients also presented with variable degrees of cerebral and cerebellar atrophy (Table 2 andFig 1). Furthermore, all patients presented with basal ganglia abnormalities-that is, bilateral T2-hypointense signal of the pallidum and, in some instances, substantia nigra, red nucleus, and dentate nu-cleus, associated with bilateral hypointense signal of the pallidum on T2*-or magnetic susceptibility-weighted images ( ) as seen in neurodegeneration with brain iron accumulation diseases. One patient presented with a central region of hyperintensity within the T2-weighted hypointense signal in the globus pallidus, the so-called eye of the tiger sign (Table 2 andFig 2). CT showed bilateral or unilateral calcifications of the basal ganglia in 2 of 5 patients (Table 2 andFig 2). Patients with the more prominent basal ganglia abnormalities were the most disabled ones. When performed, visual, brain stem auditory, and somatosensory and motor-evoked potentials showed diffuse and pronounced central conduction anomalies (4/4), compatible with a hypomyelinating process.

Molecular analyses revealed 4 previously reported GJA1 variants (c.93TϾG, c.412GϾA, c.428GϾA, and c.443GϾA) [START_REF] Paznekas | GJA1 mutations, variants, and connexin 43 dysfunction as it relates to the oculodentodigital dysplasia phenotype[END_REF] and one novel heterozygous GJA1 variant (c.634TϾA). Of note, the mother of patient 4 carried the heterozygous c.428 GϾA variant but without any ODDD symptoms, including normal bone extremities.

DISCUSSION

This series of 8 patients with ODDD presenting with hereditary spastic paraplegia shows that the neurologic symptoms associated with GJA1 variants are related to a complex neurodegenerative process affecting both the white matter and the basal ganglia. Therefore, GJA1 variants should be considered in all patients with hereditary spastic paraplegia presenting with brain hypomyelination, especially when associated with neurodegeneration with a brain iron accumulation pattern. The early occurrence of urinary symptoms in more than half of the patients suggests an ascending process affecting the corticospinal tracts. Of note, most patients were female, while men presented with a later onset of disease.

Indeed, the GJA1 gene encodes connexin 43 (Cx43), a transmembrane protein acting in intercellular communication. [START_REF] Paznekas | Connexin 43 (GJA1) mutations cause the pleiotropic phenotype of oculodentodigital dysplasia[END_REF] Cx43 is expressed in astrocytes and plays a role in astrocyte-oligodendrocyte communication by heterotypic Cx43/connexin 47 (Cx47) channels. Some studies have suggested that Cx43/Cx47 channels participate in myelin maintenance. [START_REF] Orthmann-Murphy | Hereditary spastic paraplegia is a novel phenotype for GJA12/GJC2 mutations[END_REF][START_REF] May | Connexin47 protein phosphorylation and stability in oligodendrocytes depend on expression of connexin43 protein in astrocytes[END_REF] Cx47, encoded by GJA12, is deficient in Pelizaeus-Merzbacher-like disease, 8 a hypomyelinating disorder characterized by nystagmus, delayed psychomotor development, and cerebellospastic signs. Some data suggest that the total loss of function of Cx47/Cx43 is implicated in the pathophysiology of part of GJA12 variants. [START_REF] Orthmann-Murphy | Hereditary spastic paraplegia is a novel phenotype for GJA12/GJC2 mutations[END_REF][START_REF] May | Connexin47 protein phosphorylation and stability in oligodendrocytes depend on expression of connexin43 protein in astrocytes[END_REF] Similarities among neurologic and imaging characteristics between Pelizaeus-Merzbacher-like disease and ODDD could underlie common molecular mechanisms involving the Cx43/Cx47 channels. However, unlike most hypomyelinating disorders such as Pelizaeus-Merzbacher-like disease, the perception of neurologic symptoms by patients with GJA1 variants usually occurs in adulthood, which may be related to the haploinsufficiency (instead of a loss of function) of Cx43 in ODDD.

In our series, all patients had abnormal MR imaging signal of the basal ganglia, as seen in neurodegeneration with brain iron accumulation disorders. We also observed calcifications of the basal ganglia as previously reported. 9,10 One patient even had an eye of the tiger sign described as a hallmark of pantothenate kinase-associated neurodegeneration. [START_REF] Hayflick | Unraveling the Hallervorden-Spatz syndrome: pantothenate kinase-associated neurodegeneration is the name[END_REF] Basal ganglia involvement is observed in other hypomyelinating leukodystrophies, including patients with POLR3A/B and TUBB4 variants. [START_REF] Piana | Brain magnetic resonance imaging (MRI) pattern recognition in Pol III-related leukodystrophies[END_REF][START_REF] Curiel | TUBB4A mutations result in specific neuronal and oligodendrocytic defects that closely match clinically distinct phenotypes[END_REF] In our series, the extent of basal ganglia abnormalities was associated with the degree of the patient's disability. Given our limited number of patients, this observation requires further validation in a larger group of patients.

Disease severity was extremely variable with symptom onset from adolescence to adulthood and pyramidal symptoms ranging from very mild to very disabling. In addition, the mother of pa-tient 4 -bearing the c.428 GϾA variant -had a complete normal phenotype despite the penetrance of ODDD is classically qualified as high. [START_REF] Paznekas | Connexin 43 (GJA1) mutations cause the pleiotropic phenotype of oculodentodigital dysplasia[END_REF] These findings emphasize that intra-and interfamilial expression of the disease is highly variable, without genotypephenotype correlation. Therefore, it appears difficult to predict the risk of developing neurologic symptoms in patients with GJA1 variants, a major pitfall for genetic counseling.

FIG 1 .

 1 FIG 1. Axial scans of patients 8 (A-C) and 7 (E and F) show isointense-to-mild hyperintense T1-weighted signal (A and E) associated with mild-to-moderate hyperintense T2-(B and F) and FLAIR-weighted (C) signal of the white matter, especially the internal capsules (arrows) and optic radiations (arrowheads). Sagittal T1-weighted image of patient 8 (D) shows atrophy of the corpus callosum and the vermis. T2-weighted images of patients 2 (G) and 4 (H) show mild hyperintense signal of the corticospinal tract in the ventral pons (arrows) and cerebellar peduncles (arrowheads).

Table 2 ,

 2 Fig 2, and On-line Figure

Table 1 : Clinical and molecular characteristics of 8 patients with GJA1 variants a

 1 and # indicate patients belonging to the same family; UL, upper limbs; LL, lower limbs; Prox., proximal; dist., distal; 1, increased; 2, decreased; Dysexec., dysexecutive

		Patient 1#	Patient 2#	Patient 3	Patient 4*	Patient 5*	Patient 6*	Patient 7	Patient 8
	Sex/age at examination (yr) Male/64	Female/34 Female/25 Female/49 Female/22	Female/19 Female/49 Male/56
	Family history	Dominant	Dominant None	Dominant Dominant	Dominant None	Dominant
	ODDD dysmorphia	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
	Age (yr)/symptom at onset 50/Gait	28/Gait	18/Urinary 14/Urinary 14/Urinary	16/Urinary 15/Gait	50/Gait
	Current disability stage	1	3	3	3	1	1	6	1
	LL reduced strength	None	Prox.	Prox.	Prox.	None	None	Prox./dist. None
	LL spasticity	Yes	Yes	Yes	Yes	No	No	Yes	Yes
	UL/LL reflexes	1/1	1 /1	1 /1	1 /1	1 /1	1 /1	1 /1	1 /1
	Plantar reflexes	Indifferent	Extensor	Extensor	Extensor	Extensor	Extensor	Extensor	Extensor
	UL/LL vibration sense	N/2	N/2	N/2	2 /2	N/N	N/N	N/2	N/2
	Romberg sign	No	Yes	Yes	No	No	No	Yes	No
	Oculomotor signs	Hypermetric	Saccadic	None	Saccadic	Hypermetric	None	None	Saccadic
		saccades	pursuit		pursuit	saccades			pursuit
	Dysmetria/dysarthria	Yes/No	Yes/No	No/No	Yes/No	Yes/No	No/No	No/No	No/No
	Urinary symptoms	No	ϩ	ϩϩϩ	ϩϩϩ	ϩϩ	ϩϩ	ϩϩ	No
	Cognition	Dysexec.	Normal	Normal	Normal	Normal	Normal	Normal	Normal
	GJA1 variant	c.93TϾG	c.93TϾG	c.443GϾA c.428GϾA c.428GϾA	c.428GϾA c.412GϾA c.634TϾA
	Amino acid change	p.I31M	p.I31M	p.R148Q	p.G143D	p.G143D	p.G143D	p.G138S	p.F212I

Note:-* syndrome; N, normal; ϩ, mild; ϩϩ, moderate; ϩϩϩ, severe. a Disability stage index: 1, no functional handicap but signs at examination; 3, moderate, unable to run, limited walking without aid; 6, unable to walk, requiring wheelchair.

Table 2 : Brain imaging characteristics of 8 patients with GJA1 variants a Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8

 2 Note:-Iso indicates isointense; Hyper, hyperintense; ND, not done; Unilat., unilateral; Bilat., bilateral; Ϫ, absence of abnormalities; ϩ/Ϫ, very mild; ϩ, mild; ϩϩ, moderate; ϩϩϩ, severe.

	Age (yr)/disability stage	64/1	34/3	25/3	49/3	22/1	19/1	49/6	56/1
	WM T1 signal (relative to the cortex	Iso	Hyper	Hyper	Iso	Iso	Hyper	Iso	Hyper
	gray matter)
	WM T2-hyperintense signal
	Periventricular	Ϫ	ϩϩ	ϩ	ϩϩ	ϩ	ϩ	ϩϩ	ϩ
	Internal capsule (posterior limb)	ϩ	ϩ	ϩ	ϩ	ϩ	ϩ /Ϫ	ϩ	ϩ
	Corpus callosum	Ϫ	Ϫ	Ϫ	ϩ	Ϫ	ϩ	Ϫ	Ϫ
	Cerebellar peduncles	Ϫ	ϩ	ϩ	ϩ	ϩ	ϩ	Ϫ	ϩ
	Ventral pons	Ϫ	ϩ	Ϫ	ϩ	Ϫ	Ϫ	Ϫ	ϩ
	Globus pallidus
	Hypointensity on T2*-/susceptibility-	ND	ϩϩ	ϩ	ϩϩ	ϩ/Ϫ	ϩ	ϩϩ	ϩ
	weighted imaging
	Eye of the tiger	Ϫ	Ϫ	Ϫ	ϩ	Ϫ	Ϫ	Ϫ	Ϫ
	Calcifications	ND	Ϫ	ND	ϩ (Unilat.) Ϫ	Ϫ	ϩ ϩ(Bilat.) Ϫ
	Atrophy
	Ventricle/subarachnoid space	ϩϩϩ/ϩϩϩ ϩϩ/ϩ	ϩϩ/ϩ	Ϫ/Ϫ	ϩ /Ϫ	Ϫ/Ϫ	ϩϩϩ/ϩϩ ϩϩϩ/ϩ
	Corpus callosum	ϩϩ	ϩϩ	ϩ/Ϫ	Ϫ	Ϫ	ϩ/Ϫ	ϩϩϩ	ϩ
	Cerebellar vermis/hemisphere	ϩ/Ϫ	ϩ ϩ /ϩ	Ϫ/Ϫ	ϩ/Ϫ	ϩ /Ϫ	ϩ/Ϫ	ϩϩ/ϩ	ϩϩ/ϩ

a Disability stage index: 1, no functional handicap but signs at examination; 3, moderate, unable to run, limited walking without aid; 6, unable to walk, requiring wheelchair.

ACKNOWLEDGMENTS

We thank all our colleagues who provided the radiologic data used in this study. We thank Dr Pascal Hilbert (Institut de Pathologie et Ge ´ne ´tique, Gosselies, Belgique) for performing the genetic analyses of patients 1, 2, 4, 5, and 6, as well as Dr Corinne Magdelaine (Centre Hospitalier Universitaire, Limoges, France) for performing the genetic analyses of patients 3 and 7.

Disclosures: Martin Catala-UNRELATED: Expert Testimony: Agence Nationale de Se ´curite ´du Me ´dicament.


Linda Lasbeur

Emmanuelle Julien Briere

Emmanuelle Amoros

Bertrand Thelot

Keywords: unintentional injuries, mortality, death rate, home and leisure injuries, road traffic injuries, occupational injuries Mortalité, taux de décès, accidents de la route, accidents du travail, accidents de la vie courante