e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 4 ( 2 0 1 0 ) 1 8 2 – 1 8 7

Official Journal of the European Paediatric Neurology Society

Case study

A dominantly inherited mutation in collagen IV A1 (COL4A1)causing childhood onset stroke without porencephaly

Siddharth Shaha, Yadlapalli Kumarb, Brendan McLeanh, Amanda Churchillc,Neil Stoodleyd, Julia Rankine, Patrizia Rizzuf, Marjo van der Knaapg, Philip Jardinea,*aDepartment of Paediatric Neurology, Bristol Royal Hospital for Children, United KingdombDepartment of Paediatrics, Royal Cornwall Hospital NHS Trust, United KingdomcDepartment of Ophthalmology, Bristol Eye Hospital, United KingdomdDepartment of Neuroradiology, North Bristol NHS Trust, United KingdomeDepartment of Clinical Genetics, Royal Devon and Exeter NHS Foundation Trust, United KingdomfDepartment of Human and Clinical Genetics, VU University Medical Centre, The NetherlandsgDepartment of Child Neurology, VU University Medical Centre, The NetherlandshDepartment of Neurology, Royal Cornwall Hospital NHS Trust, United Kingdom

a r t i c l e i n f o

Article history:

Received 12 December 2008

Received in revised form

13 April 2009

Accepted 15 April 2009

Keywords:

Leukoencephalopathy

Collagen 4A1

Mutation

Cataracts

* Corresponding author. Tel.: þ44 0117 34201E-mail address: philip.jardine@bristol.ac.

1090-3798/$ – see front matter ª 2009 Europdoi:10.1016/j.ejpn.2009.04.010

a b s t r a c t

We describe a three generation family with recurrent strokes and cataracts. The index

case, a 14 year old boy presented with stroke at the age of 14 years and again 6 months

later. His mother had long standing episodic headaches diagnosed as migraine. Grand-

mother was initially diagnosed with multiple sclerosis and had recurrent strokes at age 18

years and 49 years. MRI scanning showed a diffuse leukoencephalopathy with micro-

haemorrhages in all three individuals. All of the family members had cataracts but did not

have retinal arterial changes. Sequence analysis of COL4A1 revealed the heterozygous

missense mutation c.2263G/A in exon 30, responsible for a glycine-to-arginine substitu-

tion (p.Gly755Arg) in both the index case and mother. Grandmother died at the age of 73

years and DNA analysis was not possible. Mutation in COL4A1 should be considered in

families with a history of autosomal dominant cerebral vasculopathy, even in the absence

of porencephaly.

ª 2009 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights

reserved.

1. Introduction porencephaly have been reexamined and confirmed to have

Mutation in the collagen gene COL4A1 is a recently described

cause of autosomal dominant cerebral small vessel disease.

Studies on mutant mice have shown a mutation in this gene to

be pathogenic in causing porencephaly secondary to vascular

basement membrane abnormalities.1,2 Since then some

families previously identified to have dominantly inherited

66; fax: þ44 0117 3420186uk (P. Jardine).ean Paediatric Neurology

mutations in the COL4A1 gene.3–7 Further observations in

these families showed that apart from the porencephaly,

affected persons developed haemorrhagic strokes or ‘silent’

microhaemorrhages. Mutations in COL4A1 gene lead to alter-

ations and resultant weakness in the vascular basement

membrane in humans.4,8–10 MRI brain imaging in this condi-

tion is striking with leucoencephalopathy, dilated perivascular

.

Society. Published by Elsevier Ltd. All rights reserved.

Fig. 1 – CT scan (index case) – periventricular and deep

white matter changes and a focal area of hyperdensity in

the left periventricular white matter suggestive of an acute

haemorrhage in the left centrum semiovale.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 4 ( 2 0 1 0 ) 1 8 2 – 1 8 7 183

spaces and microhaemorrhages.4–7,11 The eye and kidney may

also be affected in this disorder leading to retinal vascular

tortuosity, renal cysts and microalbuminuria.1,4,6,11,12

We describe the first English family reported with this

disorder, and broaden the phenotype to include childhood

onset stroke and cataract, in the absence of porencephaly.

2. Case report

A 14 year old boy presented with sudden onset of weakness on

the right side. He was born by full term normal delivery after

an uneventful pregnancy. He was making good academic

progress at school and had not suffered from any previous

illnesses. There was no history of associated illness or trauma.

He did not have a history of previous headaches. On exami-

nation he had a right side hemiparesis with upper motor

neuron signs. He did not fulfill the Ghent criteria for Marfan

but had features to suggest involvement of the skeletal

system. These included a height of 191.3 cm (above 99th

centile for his age), arm span of 198 cm, a reduced upper to

lower ratio, high arched palate, malar hyoplasia and striae.

There were bilateral dot-like cataracts, which were first

identified at 9 years of age, with normal visual acuity.

CT brain scan was suggestive of an acute haemorrhage

(Fig. 1). MRI brain scan (Fig. 2a–c) was performed at this stage.

MRAngiography and carotid/vertebral Doppler did not show

any abnormalities in the carotids or cerebral arteries. Electro-

cardiogram and echocardiography were normal. Full blood

count, liver function tests and renal function were normal. A

clotting screen showed borderline reduction in multiple

clotting factors. Further tests looking for an underlying

etiology including leukocyte lysosomal enzyme analysis,

plasma amino acid analysis and urine organic acid screen, very

long chain fatty acids and plasma homocysteine levels were all

normal. Mutation analysis for NOTCH3 was negative.

Six months later he had a further episode of transient loss

of speech, which recovered within a period of 48 h. Repeat MRI

brain at this stage (Fig. 3a and b) showed a new area of hae-

morrhage. Closer questioning revealed an episode of transient

weakness at age 7 years that could have been a first episode of

stroke.

The mother has a history of headaches with vomiting that

occur every 2–3 months and last for about 3 days. She occa-

sionally has tingling down the left leg or visual obscurations at

the onset of headaches leading to a diagnosis of migraine with

aura. Mother was diagnosed with cataracts in her mid thirties.

She also had varicose veins, which were stripped. At 8 years of

age she had an episode where she was unable to walk and

lasted several weeks, this in retrospect could have been

a stroke. MRI brain (Fig. 4a–c) showed a similar leukoence-

phalopathy. A gradient echo sequence showed extensive

areas of low signal due to blood breakdown products,

including the basal ganglia bilaterally. MRAngiography

(Fig. 4d) showed a dysplastic change involving the left peri and

supra clinoid internal carotid arteries with a combination of

aneurysmal dilatation and stenosis. The stenosis extended to

involve the carotid bifurcation and left middle cerebral artery.

There were also small aneurysms involving the right carotid.

Maternal grandmother was diagnosed with bilateral

cataracts at age 9 years. She had a stroke-like episode at age

18 years, which was diagnosed as multiple sclerosis based on

white matter changes on a CT scan. She suffered from

a further episode of stroke at age 49 years, 2 days after

undergoing a cataract operation. There was no history of

headaches. She died at age 73 years from renal failure and

sepsis. MRI brain (Fig. 5a and b) showed white matter changes

in the areas identical to the index case. In addition there were

small focal areas of signal change in the white matter

suggestive of microhaemorrhages or calcification.

Sequence analysis of COL4A1 revealed the heterozygous

missense mutation c.2263G/A in exon 30, responsible for

a glycine-to-arginine substitution (p.Gly755Arg) in the mother

and her son. DNA from grandmother was not available. The

substitution was not observed in 192 Caucasian control

individuals.

3. Discussion

We describe a three generation family affected with a muta-

tion in COL4A1 (p.Gly755Arg) transmitted in an autosomal

dominant pattern. There is a wide variability in phenotype

between the affected members of the same family. The

phenotype is different in some respects when compared to

previous reports, especially the absence of porencephaly in all

members and childhood onset of leukoencephalopathy and

stroke. Other features, which have been described in some

previous reports, are presence of cataracts and aneurysms

involving the carotid arteries. Whilst there was a history of

migraine in the mother it is difficult to establish whether there

is a true association with this condition.

Fig. 2 – MRI brain (index case). a axial view, T2 – shows signal abnormalities in the periventricular deep white bilaterally

symmetrical and in both frontal and parietal regions with sparing of subcortical white matter. b axial view, FLAIR image –

diffuse periventricular and deep white matter high signal are seen with scattered focal areas of low signal seen in both

cerebral hemispheres. c axial view, T2 – the area of signal change in the left hemisphere has a low signal intensity (also low

signal in Fig. 2b) suggestive of haemorrhage whilst the area on the right is one of cystic change.

Fig. 3 – MRI brain (index case). a axial view, FLAIR – new areas of haemorrhage (low signal) involving the right parietal white

matter. There is no progression of the diffuse white matter high signal. b axial view, FLAIR – there is no progression of the

white matter abnormalities.

Fig. 4 – MRI brain (mother). a axial view, T2 – signal abnormalities in the periventricular deep white bilaterally symmetrical

and in both frontal and parietal regions with sparing of subcortical white matter, in a similar distribution to the index case.

b axial view, Gradient ECHO – extensive areas of low signal within the basal ganglia bilaterally suggestive of

microhaemorrhage. c axial view, Gradient ECHO – areas of low signal within the white matter change bilaterally, suggestive

of microhaemorrhages. d MRAngiogarphy – aneurysmal dilatation and stenosis involving the left internal carotid,

extending to the left middle cerebral artery, also small aneurysms of the right internal carotid.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 4 ( 2 0 1 0 ) 1 8 2 – 1 8 7 185

The p.Gly755Arg occurs in a highly conserved Gly residue

within Gly-Xaa-Yaa repeats (where Xaa and Yaa are amino

acids) in the triple helix domain of the COL4A1 gene. Muta-

tions in Gly-X-Y domains have been shown in several collagen

proteins, leading to a dominant negative effect. Glycine has

a single hydrogen-atom side chain, and there is little tolerance

for amino acids with larger side chains that may disrupt the

triple helix during collagen assembly. Mutations in codons

encoding glycine have been shown to be pathogenic in

multiple species.1,11,13,14

The studies by Gould et al. using mutant mice demon-

strated reduced viability, cerebral haemorrhage and

porencephaly.1,2 The causative gene was mapped to a single

locus encoding collagen IV A1. Electron microscopy of the

vascular basement membrane of cerebral vessels showed

changes leading to compromise of the structural integrity.

Similarly a skin biopsy in a Dutch family with the mutation

and neuroimaging findings showed focal disruptions and

a major increase in thickness of the vascular basement

membrane of skin capillaries.4 The clinical and brain MRI

Fig. 5 – MRI brain (Grandmother). a axial view, T2 – signal abnormalities within the deep white matter in an identical

distribution to the index case and his mother. b axial view, T2 – small focal areas of low signal within the white matter,

again in a similar distribution to the index case’s mother, suggestive of microhaemorrhages or calcification.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 4 ( 2 0 1 0 ) 1 8 2 – 1 8 7186

findings have been described in a French family with six

family members affected.6 Further case reports have

increased our knowledge of the clinical and brain MRI findings

of this condition.5,11 A recent publication looked at three

families with a mutation in COL4A1 leading to a phenotype

including haematuria and renal cysts, muscle cramps and

elevated creatine kinase levels, aneurysms of the carotid

arteries along with the retinal changes and brain MRI findings

described before.11 This leads to a probability that mutations

in COL4A1 might be responsible for a systemic basement

membrane disease with a variable phenotype.

In this family the index case presented to us at age 14 years

with a sudden onset stroke. On CT scan this was confirmed to

be an acute haemorrhagic stroke. There was also an episode of

transient weakness at age 7 years, which in retrospect is likely

to have been a stroke. He had a further stroke 6 months after

initial presentation. Hence in this case this child had 2 or 3

separate strokes, which on neuroimaging are haemorrhagic in

nature. It is worth noting the absence of porencephaly in any

of the family members.

Mice studies have shown that birth trauma through

natural delivery as compared to surgical delivery leads to

a significantly higher incidence of cerebral haemorrhage in

affected mice.2 Contact sports are also considered a risk factor

for recurrent bleeds.5 In this report the grandmother suffered

from a stroke following cataract surgery. This raises the

possibility that anaesthesia and surgery may be provoking

factors in affected cases.

Another interesting finding is one of dot-like opacities or

cataracts, which might be congenital. Because the cataract

phenotype is generally mild, they may be relatively asymp-

tomatic and unless specifically looked for remain undetected

until later life. The mother had cataracts diagnosed in her mid

thirties and grandmother had them diagnosed at age 9 years.

This is similar to a Dutch family where the mother was

diagnosed with cataracts at age 52 years, also the son and

daughter when examined were found to have cataracts at age

33 and 30 years respectively.4 Retinal arterial changes were

not detected in any of the members in the family we have

described, but have been described in other reports.6

The white matter change seen on neuroimaging is

diffuse, involving both the periventricular and deep white

matter but with sparing of subcortical white matter. The

changes are most striking in frontal and parietal regions.

This pattern of leukoencephalopathy, along with micro-

haemorrhages within the abnormal white matter change

and the basal ganglia lesions are recognizable features of

this condition and suggestive of small vessel disease. Arte-

riosclerosis and cerebral amyloid angiopathy can occlude

small vessels, both of these highly unlikely in children.

Cerebral autosomal dominant arteriopathy with subcortical

infarcts and leucoencephalopathy (CADASIL) is a small

vessel disease which occurs due to mutations in the NOTCH3

gene in an autosomal dominant pattern and presents with

relapsing strokes in young adults (OMIM#125310). The MRI

changes include hyperintense signal on T2 weighted images

in the white matter of frontal and anterior temporal lobes

and progressively later on in the occipital periventricular

area. Subcortical lacunar infarcts are also seen in one fifth of

patients. Microhaemorrhages may also occur. Hereditary

endotheliopathy with retinopathy, nephropathy and stroke

(HERNS) is a multi-infarct syndrome with systemic involve-

ment of unknown cause, providing a similar clinical and MRI

picture.

We have described the phenotype in a 3 generation family

with a COL4A1 mutation without porencephaly. This is the

first case to be described in the literature with childhood onset

stroke as the presentation. When should testing for a muta-

tion in COL4A1 be requested? Porencephaly and childhood

onset stroke are both on their own good indications for

COL4A1 testing if the family history is positive for por-

encephaly and/or stroke, especially if the eye findings are

present in either the patient or in family members. Kidney

disease is also positive evidence, but is rare among patients, so

absence of kidney involvement is no evidence against the

diagnosis.

e u r o p e a n j o u r n a l o f p a e d i a t r i c n e u r o l o g y 1 4 ( 2 0 1 0 ) 1 8 2 – 1 8 7 187

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2. Gould DB, Phalan FC, van Mil SE, Sundberg JP, Vahedi K,Massin P, et al. Role of COL4A1 in small-vessel disease andhemorrhagic stroke. N Engl J Med 2006;354(14):1489–96.

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