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Letter to the Editor
Charcot-Marie-Tooth 4C and bilateral spinal dissection: causal or coincidental relationship?
Charcot-Marie-Tooth 4C y disección vertebral bilateral: ¿relación causal o coincidente?
S. López Anguitaa,
Corresponding author
sergio.lopezanguita@gmail.com

Corresponding author.
, A.M. Iglesias Mohedanob, M.A. Palacios Mendozac, J.L. Muñoz Blancod
a Servicio de Neurología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain
b Sección Neurología Vascular, Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
c Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
d Unidad de ELA/Neuromuscular, Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Charcot-Marie-Tooth disease &#40;CMT&#41; is one of the most complex neurological syndromes&#44; and presents a prevalence of 28&#46;2 cases&#47;100&#160;000 population in Spain&#46; CMT type 4C&#44; which accounts for 18&#37; of cases&#44; is characterised by clinical symptoms of demyelinating neuropathy following an autosomal recessive inheritance pattern&#44; and is more prevalent among people of Roma descent&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;6&#44;8</span></a> It is caused by a biallelic mutation of the <span class="elsevierStyleItalic">SH3TC2</span> gene&#44; located on chromosome 5q32&#44; which participates in encoding a membrane protein of Schwann cells&#44; involved in endocytic recycling through the Rab11 GTPase system&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4&#44;7&#44;8</span></a> PCR and ELISA studies have detected the SH3TC2 protein in the tissues of the brain&#44; spinal cord&#44; cardiac muscle&#44; testes&#44; lungs&#44; liver&#44; skeletal muscle&#44; kidneys&#44; pancreas&#44; ovaries&#44; and spleen&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7</span></a> We describe the case of a patient with CMT type 4C and vertebral artery dissection&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 37-year-old woman of Roma descent&#44; born to consanguineous parents&#44; who was under follow-up due to diagnosis of CMT type 4C &#40;<span class="elsevierStyleItalic">SH3TC2</span> mutation p&#46;R1109X in homozygosis&#41;&#46; She visited the emergency department due to neck pain and sudden worsening of gait instability&#44; a week after undergoing a cervical traction manoeuvre due to moderate cervical pain&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Neurological examination revealed severe dysarthria&#59; persistent horizontal nystagmus in all gaze positions&#59; right-sided trigeminal hypoaesthesia and facial palsy&#59; deviation of the tongue to the right side&#59; paresis and dysmetria of the right arm&#59; and unstable&#44; wide-based gait with a tendency to veer to the right&#46; The patient scored 6 on the National Institutes of Health Stroke Scale&#46; We initially suspected vertebrobasilar stroke presenting as right bulbo-pontine syndrome&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">An emergency blood analysis &#40;complete blood count&#44; coagulation profile&#44; electrolyte study&#44; glycaemia&#44; and kidney and liver function&#41;&#44; ECG&#44; and head CT identified no alterations&#46; A CT angiography of the supra-aortic arteries &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; identified reduced calibre of the right V2 and left V3 segments of the vertebral artery&#44; without filling of the posterior inferior cerebellar artery &#40;PICA&#41;&#44; and a filling defect in the proximal third of the basilar artery&#44; with distal filling&#59; these findings are compatible with bilateral vertebral artery dissection and non-occlusive thrombosis of the proximal basilar artery&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We requested further testing&#44; including a lipid profile&#44; vitamins&#44; thyroid function&#44; total protein test&#44; autoimmunity&#44; and serology studies&#44; as well as a transoesophageal echocardiography study and 24-hour Holter ECG monitoring&#59; all studies yielded normal results&#46; A follow-up head CT study performed at 24&#160;hours identified subacute infarction in the territory of the right anterior-inferior cerebellar artery &#40;AICA&#41; and PICA&#44; with no haemorrhagic transformation or mass effect&#46; The brain MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and angiography studies detected infarction at different times of the AICA and PICA territories&#44; affecting the fifth&#44; seventh&#44; and eighth cranial nerve nuclei&#44; and mural thrombosis of the right proximal basilar artery and vertebral artery segments V3 and V4 &#40;stenosis of 50&#37; and 75&#37;&#44; respectively&#41;&#44; and confirmed vertebral artery dissection&#44; with arterial wall irregularities compatible with dysplasia in the left V2 segment&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient progressed favourably&#44; with persistence of the right hypoaesthesia and facial palsy&#44; and scored 1 on the modified Rankin Scale at discharge&#46; We prescribed 100&#160;mg acetylsalicylic acid and 80&#160;mg atorvastatin for secondary prevention of ischaemic stroke&#46; A thrombophilia study performed at 3 months of follow-up detected no alterations&#44; and an MRI angiography study performed at 6 months identified no new lesions and no signs of dissection&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Little evidence is available on the relationship between CMT variants and arterial wall abnormalities&#46; The only association reported to date is the involvement of mutations of <span class="elsevierStyleItalic">SMAD3</span> &#40;15q22&#41;&#44; <span class="elsevierStyleItalic">COL3A1</span> &#40;2q32&#41;&#44; and <span class="elsevierStyleItalic">TNXB</span> &#40;6p21&#41;&#44; participating in TGF-beta signalling pathways and the synthesis of type III collagen and tenascin X&#44; which are related to Ehler-Danlos syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These mutations are associated with dissections&#44; dilation&#44; and tortuosity of the cervical arteries in up to 78&#37; of cases&#44; and of the thoracic aorta in up to 75&#37;&#44; with only 68&#37; of patients presenting neurological symptoms&#46; Studies of related patients describe CMT2-like sensory-motor axonal neuropathy in fewer than 50&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> None of these present the typical mutations associated with CMT2 &#40;<span class="elsevierStyleItalic">GJB1</span>&#44; <span class="elsevierStyleItalic">MPZ</span>&#44; and <span class="elsevierStyleItalic">GDAP 1</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">A systematic literature review identified no reports of CMT type 4 associated with arterial wall abnormalities or detection of the SH2TC2 protein in the peripheral nerves with the tests used&#46; However&#44; given the evidence of other CMT-like variants and the importance of differential diagnosis in young patients with stroke due to the special management required&#44; we deem it important to report this case within such a heterogeneous disease as CMT&#44; which suggests the possibility that structural alterations to the walls of the cervical arteries may play a causal role&#46;</p></span></span>"
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