• Sign Up

Dentatorubral Pallidoluysian Atrophy


Dentatorubral Pallidoluysian Atrophy

Article Author:
Franklyn Rocha Cabrero
Article Editor:
Orlando De Jesus
Updated:
11/14/2020 10:50:06 AM
For CME on this topic:
Dentatorubral Pallidoluysian Atrophy CME
PubMed Link:
Dentatorubral Pallidoluysian Atrophy

Introduction

Dentatorubral-pallidoluysian atrophy (DRPLA) is a progressive autosomal dominant disorder characterized by myoclonic epilepsy, ataxia, choreoathetosis/dystonia, cognitive impairment/dementia, and psychiatric disturbances.[1][2][3][4][5][4][3][1] Rarely, corneal endothelial degeneration, head tremor, or optic atrophy may be present.[6][7][8][7][6] The presentation varies with the age of onset. The disorder was first described in 1946, and the name was given in1958.[9][10][9]

Etiology

Dentatorubral-pallidoluysian atrophy is a cytosine, adenine, and guanine (CAG) trinucleotide repeat expansion in the atrophin-1 (ATN1) gene, in exon 5.[3][11] This gene on chromosome 12p13.31, encodes a transcriptional co-repressor expressed in the central nervous system (CNS) and other organs in the body.[12] Normal CAG repeats range between 6-35. Pathogenic CAG repeat length can range from 48 to 93, with higher repeat length correlated with worse disease severity, in most cases.[13][14]

Some exceptions are reported in rare cases of asymptomatic patients with high CAG repeats. Complete penetrance of the condition is more than 48 tandem copies, which have a typical clinical presentation. Incomplete penetrance phenotypes are found in patients with alleles of 35 to 47 repeat length, associated with a milder clinical phenotype. Japanese patients have a higher number of baseline CAG repeats, 20 to 35, compared to people of European descent.[15][16] The clinical-genetic phenomenology of non-Asian DRPLA is similar to the Asian DRPLA.[17]

Epidemiology

Dentatorubral-pallidoluysian atrophy has a median age of onset of 31 years of age. It mainly affects Asian populations, in particular, the Japanese population. The incidence is approximately 2 to 7 per million people in the Japanese population.[12][18] The prevalence of DRPLA in Japanese people has been estimated to be 0.2 to 0.4 per 100,000.[19] Although DRPLA was initially recognized in Asian populations, wider genetic testing has increased diagnosis in other ethnic groups/families.[17][20][21][22][23][24] 

When worldwide DRPLA cases are counted for among the spinocerebellar ataxia (SCA), the rate in the Japanese population is 7 to 20%, with lower rates in other Asian populations (Singapore, 6%; Korea, 3%), Portuguese families 2 to 4%, other European descent 0.25 to 1%, and Latin-American families 0.14 to 3.1%.[15] It equally affects men and women. Juveline-onset disease or progressive myoclonic epilepsy (PME) phenotype patients (less than 20 years of age), typically present with seizures and some form of neurodevelopment disorder. Genotypically, they have longer CAG repeat lengths ( more than 65), and they have generalized seizures and myoclonus with progressive intellectual disability.[15] Adult-onset or without PME phenotype (more than 20 years of age), on the other hand, has symptoms that include ataxia, choreoathetosis, cognitive impairment, dementia, and psychiatric features. Additionally, they have shorter CAG repeat lengths (less than 65), with seizures being a rare symptom.

Pathophysiology

Dentatorubral-pallidoluysian atrophy is one of the CAG repeat disorders that show atrophin-1 protein deposition in the nucleus of affected neurons, known as neuronal intranuclear inclusion (NII). Polyglutamine (poly-Q) expansion characterizes autosomal-dominant neurodegenerative disorders such as Huntington disease (HD), and six of the spinocerebellar ataxia (SCA) disorders, which could be an important pathogenic feature in common with DRPLA and may explain the genetic anticipation and de novo expansion.[25][26][27][28] 

Lysine-specific demethylase 1 (LSD1) and its target ATN1 may be responsible for neuronal pluripotent development of cells in the cortex.[29] Animal models suggest that NII occurs without completed apoptosis, leading to poor clearance of aggregated polyQ inclusions.[30] It is still unclear whether the inclusion is a pathogenic feature, or a failed neuroprotective process, such as seen in HD.[26][31][32]

Antibody mediated-immunohistochemistry, in DRPLA post-mortem brains, shows polyglutamine protein structures or stretches that co-deposit with a mutant and insoluble ATN1 protein as part of a diffuse intraneuronal accumulation in densely packed areas within the NII. The dominant hypothesis is that the number of NII correlates with clinical features such as dementia and epilepsy, with neuropathological studies showing reduced number and size of spines and diameter of dendrites. All these findings could explain the brain atrophy seen in neuroimaging.[15]

Histopathology

Post-mortem studies of the patients suffering from dentatorubral-pallidoluysian atrophy show interesting features including atrophy in the entire spinal cord neuraxis, neuronal apoptosis, and astrocytosis in the dentatorubral and pallidoluysian systems (globus pallidus, red nucleus, and to a lesser degree, the dentate nucleus and subthalamic nucleus). It can cause severe diffuse cortical white matter disease. Frontal lobe and pontine atrophy are present in the juvenile-onset cases, characterized by a severe clinical phenotype with cognitive deterioration and seizures. Interestingly, hippocampal regions are relatively spared. 

Chemical staining for protein structures encoded by a mutant ATN1 protein shows poly-Q deposition of diffuse intraneuronal accumulation within the nucleus of affected neurons. The latter are spherical, eosinophilic non-membrane bound structures that contain a mixture of granular and filamentous ubiquitinated structures, containing inclusions of the mutant ATN1 protein.[15][33][34]

History and Physical

Clinical diagnosis of dentatorubral-pallidoluysian atrophy is challenging, given heterogeneous phenotypes and similarities to spinocerebellar ataxias. Symptoms and neuroimaging vary according to the age of onset. Late-onset DRPLA can sometimes present as isolated cerebellar ataxia, or dementia.[15]

When it begins before the age of 20 it typically exhibits:

  • Myoclonus
  • Seizures of different types
  • Behavioral changes
  • Progressive intellectual disability and deterioration
  • Ataxia

When it begins after the age of 20 years it presents with: 

  • Ataxia
  • Choreoathetosis or dystonia
  • Psychiatric symptoms (delusions)
  • Dementia
  • Rarely, head tremors and visual problems

Exam findings include neurocognitive impairment on executive function, language, memory, dysmetria, cerebellar ataxia, motor weakness, upper motor neuron signs, and difficulties with gait.

Evaluation

There are no clinical diagnostic criteria for dentatorubral-pallidoluysian atrophy. Clinical symptoms, family history, and ancestry can increase the yield of the targeted molecular genetic testing.[35][36] Genetic testing consists of a polymerase chain reaction (PCR) amplification across the ATN1 CAG repeat region. To increase the sensitivity of the test in higher CAG repeats, a capillary electrophoresis-Southern Blot is used to confirm the diagnosis.

Although whole-genome sequencing technologies are promising, they lack internal and external validation for CAG expansion specific for DRPLA. An electroencephalogram (EEG) is used to guide management in the context of suspicion of seizures. Focal motor seizures with impaired awareness progressing to generalized tonic-clonic seizures are the typical semiology.[37][38] Brain magnetic resonance imaging (MRI) can show diffuse cerebellar and brainstem atrophy, diffuse periventricular white matter disease, but these are mostly non-specific.[39][40][41][42][43][44] 

Hypoalbuminemia has also been studied as a possible biological marker, given that some studies show it is inversely correlated with CAG length.[15][45] Although next-generation sequencing technologies are promising, they have not been widely used or validated for the ATN1 repeat expansion.

Treatment / Management

Unfortunately, there is no cure for dentatorubral-pallidoluysian atrophy. Treatment is predominantly supportive. Genetic counseling of patients and their family members is essential given that the condition is autosomal dominant, with important ethical considerations before diagnosis disclosure.

When there is clinical suspicion of seizures; selecting an anti-epileptic drug (AED) could be individualized to the predominant clinical scenario of the seizures. No AED is found superior to others in randomized controlled studies. However, levetiracetam and perampanel show promise in juvenile-onset DRPLA.[38][46][47] Choreoathetoid and dystonic movements are treated with tetrabenazine, risperidone, and gabapentin.[42][48] Consensus European guidelines show that riluzole (Class B evidence) or amantadine (Class C evidence) can potentially improve ataxic symptoms.[49][50][51][52] Given unknown teratogenicity, however, they are avoided in childbearing patients or currently pregnant patients.

A neuropsychological and psychiatric assessment is instrumental for evaluating major neurocognitive deficits and associated mood disorders, for enhanced quality of life. Physical and occupational therapy is important to maintain functional activities of daily living. Structured and individualized educational programs for children with the disease is another important consideration. Involving an interprofessional team of providers can help address all the co-morbidities associated with the disorder and enhance the number of quality life years. Avoiding general anesthesia during surgical procedures can decrease the rate of breakthrough seizures.[15]

CAG repeat expansion disorder and developments in transcription silencing is a promising venue for curative treatment. This is currently used for SCA and HD with some success in animal models. Ribonucleic acid (RNA) interference of multiple alleles is possible within the CNS, although it is costly and time-consuming, and still in an experimental phase. Another promising strategy is to use targeted RNA small molecules that affect the translation of mutant ATN-1 and has the advantage of crossing the blood-brain barrier. Challenges include poor absorption and allergic reactions.[15][53][54][55][56]

Differential Diagnosis

The diagnosis of dentatorubral-pallidoluysian atrophy is challenging without a known family history of the disease. Clinical symptoms can mimic other familial degenerative or acquired ataxic disorders. An extensive metabolic and genetic workup can be helpful if the diagnosis is unclear. Advanced imaging, along with cerebrospinal fluid and serum studies, may also help rule out other disorders.[15][40][57]

Differential diagnoses for adult-onset DRPLA include:

  • Huntington disease
  • Spinocerebellar ataxia
  • Atypical parkinsonism with cerebellar ataxia
  • Alcohol
  • Toxic/metabolic induced ataxias
  • Ataxic paraneoplastic syndromes

Differentials for juvenile-onset DRPLA are broad and include:

  • Familial essential myoclonus and epilepsy
  • Progressive myoclonic epilepsy
  • Lafora disease
  • Unverricht-Lundborg disease
  • Infantile neuroaxonal dystrophy
  • Neuroferritinopathy
  • Myoclonus epilepsy associated with ragged red fibers
  • Heoxosaminidase A deficiency
  • Neuronal ceroid-lipofuscinosis
  • Gaucher disease
  • Sialidosis
  • Galactosialidosis

Prognosis

As there is no cure for dentatorubral-pallidoluysian atrophy, the mean age at death is 49 years (range 18–80 years); the median time from disease onset to death is 15 years.[13] The length of the CAG repeat expansion in ATN1 is positively correlated with age of onset, clinical symptoms, and longevity, with more than 48 repeats being linked to early-onset, severe disease phenotype, and a shorter lifespan. Functional impairment is also inversely correlated with CAG repeat length and lead to a poorer quality of life years and higher disability burden.[13] Unfortunately, DRPLA is classified as a microsatellite repeat disorder, which shows genetic anticipation with earlier onset and worse disease severity as it passes to the next generation of offsprings.[15]

Complications

Many complications can arise from the comorbidity that comes with dentatorubral-pallidoluysian atrophy. Following are some of the complications such patients can have:

  • Progressive repetitive seizures
  • Status epilepticus
  • Solid/liquid dysphagia with potential aspiration pneumonia[13]

Consultations

As dentatorubral-pallidoluysian atrophy is a disorder involving the neuromuscular system of the patient it requires input from an interprofessional team. This team may comprise of the following:

  • Adult or pediatric neurologists
  • Epilepsy neurologists
  • Geriatrics
  • Pediatrics
  • Geneticists
  • Physical and occupational therapists
  • Social workers
  • Psychiatrists/psychologists
  • Palliative medicine

Deterrence and Patient Education

Dentatorubral-pallidoluysian atrophy is a significant and severe disease affecting parents and children of affected parents. Exhaustive counseling is needed for both generations. It is a hereditary disorder whose symptoms vary depending on whether they begin in childhood or adulthood. A parent with the disease has a 50% chance of passing it to their children, regardless of sex or gender; therefore, genetic counseling is important. It involves excessive protein deposition in the cells of the CNS, causing dysfunction and leading to the death of brain cells. There is no cure for this disorder. Prognosis is poor, mean disease duration is about 15 years, and life expectancy 8 to 16 years from symptom onset. Early recognition of the disorder may improve patient understanding, and access to services and treatments.

Support Resources for Affected Patients and Families 

  • Seek a healthcare specialist for medical advice, you can find them through advocacy organizations, academic medical centers, clinical trials, or medical peer-reviewed articles published in medical journals.
  • If unable to find a specialist in your local area, contact national or international specialists.
  • Global organizations supporting this disease include the National Ataxia Foundation, Ataxia UK, European Federation of Hereditary Ataxias, Epilepsy Foundation, and RareConnect.

Pearls and Other Issues

  • Dentatorubral-pallidoluysian atrophy is a progressive, autosomal dominant CAG repeat disorder typically characterized by ataxia, myoclonus, epilepsy, choreoathetosis, dementia, psychiatric disturbance, and progressive intellectual deterioration.
  • Juvenile onset (less than 20 years) disease presents with progressive myoclonus epilepsy disorder with ataxia and abnormal intellectual development, with recurrent severe seizures. The sudden unexpected death of someone with epilepsy (SUDEP) is the most deadly complication.
  • Adult-onset (more than 20 years) disease presents with dystonias, neurocognitive and neuropsychiatric decline with ataxia, with aspiration pneumonia as the most common cause of mortality.
  • DRPLA is a microsatellite CAG repeat disorder with genetic anticipation affecting the atrophin-1 (ATN1) gene, leading to the intranuclear accumulation of protein deposits in affected neurons, ultimately leading to progressive neuronal dysfunction, atrophy, and death.
  • Pathogenic CAG repeat length can range from 48 to 93. Complete penetrance has 48 tandem copies, incomplete penetrance clinical phenotype has 35–47, and normal is less than 35.
  • Japanese patients have a higher baseline of CAG repeats (20-35) compared to individuals from European descent, which could explain their increased susceptibility to the disease.
  • Prognosis is poor, mean disease duration is about 15 years, and life expectancy is 8–16 years from symptom onset. The length of the ATN1 CAG repeat expansion is directly correlated with the age of onset, clinical phenotype, and life expectancy.
  • Highly suspicious cases for DRPLA are further evaluated by targeted molecular genetic testing: PCR amplification across the ATN1 CAG repeat region; for higher CAG repeats, ancillary Southern Blot electrophoresis, is used to confirm the diagnosis.

  • EEG and MRI are helpful for certain clinical scenarios, but they are mostly non-specific for the disorder.

  • Treatment is predominantly supportive: symptomatic treatment of seizures, ataxias, choreoathetosis, as well as nonpharmacological interventions such as special education programs for children, neurorehabilitation, neuropsychological and neuropsychiatric, and most importantly, genetic counseling.  
  • Avoiding general anesthesia during surgical procedures can decrease the rate of breakthrough seizures.

Enhancing Healthcare Team Outcomes

An interprofessional team that provides a holistic and integrated approach is important in patients with DRPLA, to reach diagnosis sooner, provide symptomatic control of co-morbidities, maximize life expectancy and the quality of life for patients with this devastating disorder.[58] Collaborative patient-centered decision-making and coordination of care between primary providers and subspecialists are essential to avoid gaps in care and improve health outcomes. Education, physiotherapy, occupational therapy, genetic counseling, and environmental adaptation may also be needed at different disease stages. Serious complications may need to be addressed in an intensive care unit. Palliative care can be considered during the late stages of the disease.[59][60][61][62][63] [Level 1]


References

[1] Malek N,Stewart W,Greene J, The progressive myoclonic epilepsies. Practical neurology. 2015 Jun;     [PubMed PMID: 25720773]
[2] Hatano T,Okuma Y,Iijima M,Fujishima K,Goto K,Mizuno Y, Cervical dystonia in dentatorubral-pallidoluysian atrophy. Acta neurologica Scandinavica. 2003 Oct;     [PubMed PMID: 12956864]
[3] Tsuji S, Dentatorubral-pallidoluysian atrophy. Handbook of clinical neurology. 2012;     [PubMed PMID: 21827919]
[4] Lindsay E,Storey E, Cognitive Changes in the Spinocerebellar Ataxias Due to Expanded Polyglutamine Tracts: A Survey of the Literature. Brain sciences. 2017 Jul 14;     [PubMed PMID: 28708110]
[5] Adachi N,Arima K,Asada T,Kato M,Minami N,Goto Yi,Onuma T,Ikeuchi T,Tsuji S,Hayashi M,Fukutani Y, Dentatorubral-pallidoluysian atrophy (DRPLA) presenting with psychosis. The Journal of neuropsychiatry and clinical neurosciences. 2001 Spring;     [PubMed PMID: 11449034]
[6] Ito D,Yamada M,Kawai M,Usui T,Hamada J,Fukuuchi Y, Corneal endothelial degeneration in dentatorubral-pallidoluysian atrophy. Archives of neurology. 2002 Feb;     [PubMed PMID: 11843701]
[7] Ohizumi H,Okuma Y,Fukae J,Fujishima K,Goto K,Mizuno Y, Head tremor in dentatorubral-pallidoluysian atrophy. Acta neurologica Scandinavica. 2002 Nov;     [PubMed PMID: 12371928]
[8] Silver MR,Sethi KD,Mehta SH,Nichols FT,Morgan JC, Case report of optic atrophy in Dentatorubropallidoluysian Atrophy (DRPLA). BMC neurology. 2015 Dec 18;     [PubMed PMID: 26679169]
[9] TITICA J,VAN BOGAERT L, Heredo-degenerative hemiballismus; a contribution to the question of primary atrophy of the corpus luysii. Brain : a journal of neurology. 1946 Dec     [PubMed PMID: 20287644]
[10] SMITH JK,GONDA VE,MALAMUD N, Unusual form of cerebellar ataxia; combined dentato-rubral and pallido-Luysian degeneration. Neurology. 1958 Mar     [PubMed PMID: 13517487]
[11] Nagafuchi S,Yanagisawa H,Sato K,Shirayama T,Ohsaki E,Bundo M,Takeda T,Tadokoro K,Kondo I,Murayama N, Dentatorubral and pallidoluysian atrophy expansion of an unstable CAG trinucleotide on chromosome 12p. Nature genetics. 1994 Jan;     [PubMed PMID: 8136826]
[12] Bidollari E,Rotundo G,Altieri F,Amicucci M,Wiquel D,Ferrari D,Goldoni M,Bernardini L,Consoli F,De Luca A,Fanelli S,Lamorte G,D'Agruma L,Vescovi AL,Squitieri F,Rosati J, Generation of induced pluripotent stem cell line CSSi008-A (4698) from a patient affected by advanced stage of Dentato-Rubral-Pallidoluysian atrophy (DRPLA). Stem cell research. 2019 Oct     [PubMed PMID: 31493762]
[13] Hasegawa A,Ikeuchi T,Koike R,Matsubara N,Tsuchiya M,Nozaki H,Homma A,Idezuka J,Nishizawa M,Onodera O, Long-term disability and prognosis in dentatorubral-pallidoluysian atrophy: a correlation with CAG repeat length. Movement disorders : official journal of the Movement Disorder Society. 2010 Aug 15;     [PubMed PMID: 20589872]
[14] Maruyama S,Saito Y,Nakagawa E,Saito T,Komaki H,Sugai K,Sasaki M,Kumada S,Saito Y,Tanaka H,Minami N,Goto Y, Importance of CAG repeat length in childhood-onset dentatorubral-pallidoluysian atrophy. Journal of neurology. 2012 Nov;     [PubMed PMID: 22527233]
[15] Carroll LS,Massey TH,Wardle M,Peall KJ, Dentatorubral-pallidoluysian Atrophy: An Update. Tremor and other hyperkinetic movements (New York, N.Y.). 2018;     [PubMed PMID: 30410817]
[16] Yamada M, Dentatorubral-pallidoluysian atrophy (DRPLA): The 50th Anniversary of Japanese Society of Neuropathology. Neuropathology : official journal of the Japanese Society of Neuropathology. 2010 Oct;     [PubMed PMID: 20500452]
[17] Wardle M,Morris HR,Robertson NP, Clinical and genetic characteristics of non-Asian dentatorubral-pallidoluysian atrophy: A systematic review. Movement disorders : official journal of the Movement Disorder Society. 2009 Aug 15;     [PubMed PMID: 19514013]
[18] Tsuji S,Onodera O,Goto J,Nishizawa M, Sporadic ataxias in Japan--a population-based epidemiological study. Cerebellum (London, England). 2008;     [PubMed PMID: 18418674]
[19]     [PubMed PMID: 11709002]
[20] Coutinho P,Ruano L,Loureiro JL,Cruz VT,Barros J,Tuna A,Barbot C,Guimarães J,Alonso I,Silveira I,Sequeiros J,Marques Neves J,Serrano P,Silva MC, Hereditary ataxia and spastic paraplegia in Portugal: a population-based prevalence study. JAMA neurology. 2013 Jun;     [PubMed PMID: 23609960]
[21] Erichsen AK,Koht J,Stray-Pedersen A,Abdelnoor M,Tallaksen CM, Prevalence of hereditary ataxia and spastic paraplegia in southeast Norway: a population-based study. Brain : a journal of neurology. 2009 Jun;     [PubMed PMID: 19339254]
[22] Yiş U,Dirik E,Gündoğdu-Eken A,Başak AN, Dentatorubral pallidoluysian atrophy in a Turkish family. The Turkish journal of pediatrics. 2009 Nov-Dec;     [PubMed PMID: 20196398]
[23] Destée A,Delalande I,Vuillaume I,Schraen-Maschke S,Defebvre L,Sablonnière B, The first identified French family with dentatorubral-pallidoluysian atrophy. Movement disorders : official journal of the Movement Disorder Society. 2000 Sep;     [PubMed PMID: 11009212]
[24] Martins S,Matamá T,Guimarães L,Vale J,Guimarães J,Ramos L,Coutinho P,Sequeiros J,Silveira I, Portuguese families with dentatorubropallidoluysian atrophy (DRPLA) share a common haplotype of Asian origin. European journal of human genetics : EJHG. 2003 Oct     [PubMed PMID: 14512972]
[25] Tunc S,Tadic V,Zühlke C,Hellenbroich Y,Brüggemann N, Pearls     [PubMed PMID: 29335306]
[26] Charroux B,Fanto M, The fine line between waste disposal and recycling: DRPLA fly models illustrate the importance of completing the autophagy cycle for rescuing neurodegeneration. Autophagy. 2010 Jul;     [PubMed PMID: 20543566]
[27] Stevanin G,Giunti P,Belal GD,Dürr A,Ruberg M,Wood N,Brice A, De novo expansion of intermediate alleles in spinocerebellar ataxia 7. Human molecular genetics. 1998 Oct;     [PubMed PMID: 9736784]
[28] Keo A,Aziz NA,Dzyubachyk O,van der Grond J,van Roon-Mom WMC,Lelieveldt BPF,Reinders MJT,Mahfouz A, Co-expression Patterns between {i}ATN1{/i} and {i}ATXN2{/i} Coincide with Brain Regions Affected in Huntington's Disease. Frontiers in molecular neuroscience. 2017;     [PubMed PMID: 29249939]
[29] Zhang F,Xu D,Yuan L,Sun Y,Xu Z, Epigenetic regulation of Atrophin1 by lysine-specific demethylase 1 is required for cortical progenitor maintenance. Nature communications. 2014 Dec 18;     [PubMed PMID: 25519973]
[30] Suzuki Y,Nakayama K,Hashimoto N,Yazawa I, Proteolytic processing regulates pathological accumulation in dentatorubral-pallidoluysian atrophy. The FEBS journal. 2010 Dec;     [PubMed PMID: 20977674]
[31] Arrasate M,Mitra S,Schweitzer ES,Segal MR,Finkbeiner S, Inclusion body formation reduces levels of mutant huntingtin and the risk of neuronal death. Nature. 2004 Oct 14;     [PubMed PMID: 15483602]
[32] Miller J,Arrasate M,Shaby BA,Mitra S,Masliah E,Finkbeiner S, Quantitative relationships between huntingtin levels, polyglutamine length, inclusion body formation, and neuronal death provide novel insight into huntington's disease molecular pathogenesis. The Journal of neuroscience : the official journal of the Society for Neuroscience. 2010 Aug 4;     [PubMed PMID: 20685997]
[33] Suzuki K,Sato T,Yamada M,Takahashi H,Tsuji S, DRPLA: recent advances in research using transgenic mouse models. Methods in molecular biology (Clifton, N.J.). 2013;     [PubMed PMID: 23754232]
[34] Yamada M,Shimohata M,Sato T,Tsuji S,Takahashi H, Polyglutamine disease: recent advances in the neuropathology of dentatorubral-pallidoluysian atrophy. Neuropathology : official journal of the Japanese Society of Neuropathology. 2006 Aug;     [PubMed PMID: 16961072]
[35] Dunn P,Albury CL,Maksemous N,Benton MC,Sutherland HG,Smith RA,Haupt LM,Griffiths LR, Next Generation Sequencing Methods for Diagnosis of Epilepsy Syndromes. Frontiers in genetics. 2018;     [PubMed PMID: 29467791]
[36] Jiang T,Tan MS,Tan L,Yu JT, Application of next-generation sequencing technologies in Neurology. Annals of translational medicine. 2014 Dec;     [PubMed PMID: 25568878]
[37] Egawa K,Takahashi Y,Kubota Y,Kubota H,Inoue Y,Fujiwara T,Onodera O, Electroclinical features of epilepsy in patients with juvenile type dentatorubral-pallidoluysian atrophy. Epilepsia. 2008 Dec;     [PubMed PMID: 18616556]
[38] Kobayashi K,Takeuchi A,Oka M,Akiyama M,Ohtsuka Y, Amelioration of disabling myoclonus in a case of DRPLA by levetiracetam. Brain     [PubMed PMID: 21889282]
[39] Sugiyama A,Sato N,Nakata Y,Kimura Y,Enokizono M,Maekawa T,Kondo M,Takahashi Y,Kuwabara S,Matsuda H, Clinical and magnetic resonance imaging features of elderly onset dentatorubral-pallidoluysian atrophy. Journal of neurology. 2018 Feb;     [PubMed PMID: 29236168]
[40] Yoon WT,Youn J,Cho JW, Is cerebral white matter involvement helpful in the diagnosis of dentatorubral-pallidoluysian atrophy? Journal of neurology. 2012 Aug;     [PubMed PMID: 22286658]
[41] Sunami Y,Koide R,Arai N,Yamada M,Mizutani T,Oyanagi K, Radiologic and neuropathologic findings in patients in a family with dentatorubral-pallidoluysian atrophy. AJNR. American journal of neuroradiology. 2011 Jan;     [PubMed PMID: 20966051]
[42] Muñoz E,Campdelacreu J,Ferrer I,Rey MJ,Cardozo A,Gómez B,Tolosa E, Severe cerebral white matter involvement in a case of dentatorubropallidoluysian atrophy studied at autopsy. Archives of neurology. 2004 Jun;     [PubMed PMID: 15210537]
[43] Simpson M,Smith A,Kent H,Roxburgh R, Neurological picture. Distinctive MRI abnormalities in a man with dentatorubral-pallidoluysian atrophy. Journal of neurology, neurosurgery, and psychiatry. 2012 May;     [PubMed PMID: 22362920]
[44] de Souza PV,Batistella GN,Pinto WB,Oliveira AS, Teaching NeuroImages: Leukodystrophy and progressive myoclonic epilepsy disclosing DRPLA. Neurology. 2016 Feb 9;     [PubMed PMID: 26857957]
[45] Nagai S,Saito Y,Endo Y,Saito T,Sugai K,Ishiyama A,Komaki H,Nakagawa E,Sasaki M,Ito K,Saito Y,Sukigara S,Ito M,Goto Y,Ito S,Matsuoka K, Hypoalbuminemia in early onset dentatorubral-pallidoluysian atrophy due to leakage of albumin in multiple organs. Journal of neurology. 2013 May;     [PubMed PMID: 23263592]
[46] Shiraishi H,Egawa K,Ito T,Kawano O,Asahina N,Kohsaka S, Efficacy of perampanel for controlling seizures and improving neurological dysfunction in a patient with dentatorubral-pallidoluysian atrophy (DRPLA). Epilepsy     [PubMed PMID: 28856097]
[47] Hamada S,Shimakawa S,Satomura S,Naito E,Hashimoto T, [Successful treatment of epilepsy and circadian rhythm disturbance with levetiracetam in a patient with dentatorubral-pallidoluysian atrophy (DRPLA)]. No to hattatsu = Brain and development. 2014 Nov;     [PubMed PMID: 25558587]
[48] Gazulla J,Errea JM,Benavente I,Tordesillas CJ, Treatment of ataxia in cortical cerebellar atrophy with the GABAergic drug gabapentin. A preliminary study. European neurology. 2004;     [PubMed PMID: 15218338]
[49] van de Warrenburg BP,van Gaalen J,Boesch S,Burgunder JM,Dürr A,Giunti P,Klockgether T,Mariotti C,Pandolfo M,Riess O, EFNS/ENS Consensus on the diagnosis and management of chronic ataxias in adulthood. European journal of neurology. 2014 Apr;     [PubMed PMID: 24418350]
[50] Ristori G,Romano S,Visconti A,Cannoni S,Spadaro M,Frontali M,Pontieri FE,Vanacore N,Salvetti M, Riluzole in cerebellar ataxia: a randomized, double-blind, placebo-controlled pilot trial. Neurology. 2010 Mar 9;     [PubMed PMID: 20211908]
[51] Romano S,Coarelli G,Marcotulli C,Leonardi L,Piccolo F,Spadaro M,Frontali M,Ferraldeschi M,Vulpiani MC,Ponzelli F,Salvetti M,Orzi F,Petrucci A,Vanacore N,Casali C,Ristori G, Riluzole in patients with hereditary cerebellar ataxia: a randomised, double-blind, placebo-controlled trial. The Lancet. Neurology. 2015 Oct;     [PubMed PMID: 26321318]
[52] Botez MI,Botez-Marquard T,Elie R,Pedraza OL,Goyette K,Lalonde R, Amantadine hydrochloride treatment in heredodegenerative ataxias: a double blind study. Journal of neurology, neurosurgery, and psychiatry. 1996 Sep;     [PubMed PMID: 8795596]
[53] Kotowska-Zimmer A,Ostrovska Y,Olejniczak M, Universal RNAi Triggers for the Specific Inhibition of Mutant Huntingtin, Atrophin-1, Ataxin-3, and Ataxin-7 Expression. Molecular therapy. Nucleic acids. 2020 Mar 6;     [PubMed PMID: 31927329]
[54] Yang S,Chang R,Yang H,Zhao T,Hong Y,Kong HE,Sun X,Qin Z,Jin P,Li S,Li XJ, CRISPR/Cas9-mediated gene editing ameliorates neurotoxicity in mouse model of Huntington's disease. The Journal of clinical investigation. 2017 Jun 30;     [PubMed PMID: 28628038]
[55] Drouet V,Ruiz M,Zala D,Feyeux M,Auregan G,Cambon K,Troquier L,Carpentier J,Aubert S,Merienne N,Bourgois-Rocha F,Hassig R,Rey M,Dufour N,Saudou F,Perrier AL,Hantraye P,Déglon N, Allele-specific silencing of mutant huntingtin in rodent brain and human stem cells. PloS one. 2014;     [PubMed PMID: 24926995]
[56] Verma AK,Khan E,Bhagwat SR,Kumar A, Exploring the Potential of Small Molecule-Based Therapeutic Approaches for Targeting Trinucleotide Repeat Disorders. Molecular neurobiology. 2020 Jan;     [PubMed PMID: 31399954]
[57] Kobayashi J,Nagao M,Kawata A,Matsubara S, A case of late adult-onset dentatorubral-pallidoluysian atrophy mimicking central pontine myelinolysis. Journal of neurology. 2009 Aug;     [PubMed PMID: 19390768]
[58] Ilg W,Synofzik M,Brötz D,Burkard S,Giese MA,Schöls L, Intensive coordinative training improves motor performance in degenerative cerebellar disease. Neurology. 2009 Dec 1;     [PubMed PMID: 19864636]
[59] Fonteyn EM,Keus SH,Verstappen CC,van de Warrenburg BP, Physiotherapy in degenerative cerebellar ataxias: utilisation, patient satisfaction, and professional expertise. Cerebellum (London, England). 2013 Dec;     [PubMed PMID: 23733611]
[60] Fonteyn EM,Keus SH,Verstappen CC,Schöls L,de Groot IJ,van de Warrenburg BP, The effectiveness of allied health care in patients with ataxia: a systematic review. Journal of neurology. 2014 Feb;     [PubMed PMID: 23589192]
[61] Hartley H,Cassidy E,Bunn L,Kumar R,Pizer B,Lane S,Carter B, Exercise and Physical Therapy Interventions for Children with Ataxia: A Systematic Review. Cerebellum (London, England). 2019 Oct;     [PubMed PMID: 31392562]
[62] Miyai I,Ito M,Hattori N,Mihara M,Hatakenaka M,Yagura H,Sobue G,Nishizawa M, Cerebellar ataxia rehabilitation trial in degenerative cerebellar diseases. Neurorehabilitation and neural repair. 2012 Jun;     [PubMed PMID: 22140200]
[63] Ilg W,Bastian AJ,Boesch S,Burciu RG,Celnik P,Claaßen J,Feil K,Kalla R,Miyai I,Nachbauer W,Schöls L,Strupp M,Synofzik M,Teufel J,Timmann D, Consensus paper: management of degenerative cerebellar disorders. Cerebellum (London, England). 2014 Apr;     [PubMed PMID: 24222635]