Ataxia telangiectasia is a rare multisystem disorder which carries an autosomal recessive inheritance, sometimes classified as a phakomatosis. It is characterised by multiple telangiectasias, cerebellar ataxia, pulmonary infections and immunodeficiency.
On brain imaging, it usually demonstrates vermian atrophy, compensatory enlargement of the fourth ventricle, cerebral infarcts and cerebral haemorrhage secondary to ruptured telangiectatic vessels.
The estimated incidence is at around 1:40,000-300,000 live births.
The main clinical characteristics include:
- cerebellar ataxia: progressive and present in all cases
- oculomucocutaneous telangiectasias
- greater susceptibility to types of infection (partial combined immunodeficiency 3) and neoplasms
The condition is thought to result from a defective gene located on chromosome 11q22–23.
In less severe cases, termed "ataxia telangiectasia variants", there is retention of some ATM kinase activity due to either expression of very low levels of normal ATM protein (from splice site mutations) or expression of mutant ATM (from missense mutations)4.
AT variants are a phenotypically heterogeneous group, characterised by slower progression of clinical signs, an extended lifespan compared to most patients with the classical form of the disease with less cellular sensitivity to radiation, susceptibility to malignancies and recurrent sinopulmonary infection.
MRI typically demonstrates cerebellar volume loss and compensatory enlargement of the 4th ventricle.
Additionally, scattered small white matter T2 hypointensities are often identified in patients with ataxia telangiectasia, most likely representing tiny hemosiderin deposits related to thrombosis and vascular leaks from telangiectatic vessels 5,11. This imaging appearance can also be seen in amyloid angiopathy, disseminated intravascular coagulopathy and multiple cavernomas 6. “Gliovascular nodules” within the white matter have previously been described and consist of dilated capillary loops with perivascular haemorrhages and hemosiderosis, surrounded by reactive fibrosis and demyelinated white matter7.
Diffuse T2/FLAIR hyperintense signal within the cerebral white matter consistent with demyelination and gliosis has previously been described in ataxia telangiectasia and may reflect ischaemia and white matter degeneration due to vascular abnormalities 11, severe oligodendrocyte and myelin loss 8, coagulation necrosis9 and leukodystrophy10. A recent study using MR spectroscopy of adult patients with ataxia telangiectasia suggests that the white matter T2/FLAIR hyperintense signal abnormality is secondary to reduced cellularity rather than active demyelination or ischaemia 11.
MR spectroscopy: increased choline signal in the cerebellum has been described as a valuable differentiator from other forms of ataxia 2.
Treatment and prognosis
As there is no cure (currently), treatment is generally around supportive measures.
- recurrent bronchopulmonary infection is a frequent complication that can result in permanent lung damage
- there is an increased incidence of malignancy (e.g. bowel and breast cancer)
See differential for diffuse cerebellar atrophy.
- neurofibromatosis type 1 (NF1) (von Recklinghausen disease)
- neurofibromatosis type 2 (NF2) (mnemonic)
- tuberous sclerosis (Bourneville-Pringle disease)
- ataxia telangiectasia
- Sturge-Weber syndrome (encephalotrigeminal angiomatosis)
- von Hippel-Lindau disease (retinocerebellar angiomatosis)
- incontinentia pigmenti (Bloch-Sulzberger syndrome)
- basal cell naevus syndrome (Gorlin-Goltz syndrome)
- Wyburn-Mason syndrome (Bonnet-Dechaume-Blanc syndrome)
- encephalocraniocutaneous lipomatosis
- hypomelanosis of Ito
- Nijmegen breakage syndrome
- epidermal naevus syndrome
- neurocutaneous melanosis
- progressive facial hemiatrophy (Parry-Romberg syndrome)
- PHACE syndrome
- Cowden disease/COLD syndrome
- Gomez-Lopez-Hernandez syndrome
- 1. Ciemins JJ, Horowitz AL. Abnormal white matter signal in ataxia telangiectasia. AJNR Am J Neuroradiol. 2000;21 (8): 1483-5. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 2. Wallis LI, Griffiths PD, Ritchie SJ et-al. Proton spectroscopy and imaging at 3T in ataxia-telangiectasia. AJNR Am J Neuroradiol. 2007;28 (1): 79-83. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 3. Yin EZ, Frush DP, Donnelly LF et-al. Primary immunodeficiency disorders in pediatric patients: clinical features and imaging findings. AJR Am J Roentgenol. 2001;176 (6): 1541-52. AJR Am J Roentgenol (full text) - Pubmed citation
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- 5. Ciemins JJ, Horowitz AL. Abnormal white matter signal in ataxia telangiectasia. AJNR. American journal of neuroradiology. 2000;21:1483-1485
- 6. Atlas SW. Magnetic resonance imaging of the brain and spine. New York: Raven Press; 1991 521-523.
- 7. Amromin GD, Boder E, Teplitz R. Ataxia-telangiectasia with a 32 year survival. A clinicopathological report. Journal of neuropathology and experimental neurology. 1979;38:621-643.
- 8. Habek M, Brinar VV, Rados M, Zadro I, Zarkovic K. Brain mri abnormalities in ataxia-telangiectasia. The neurologist. 2008;14:192-195.
- 9. Kamiya M, Yamanouchi H, Yoshida T, Arai H, Yokoo H, Sasaki A, et al. Ataxia telangiectasia with vascular abnormalities in the brain parenchyma: Report of an autopsy case and literature review. Pathology international. 2001;51:271-276
- 10. Chung EO, Bodensteiner JB, Noorani PA, Schochet SS, Jr. Cerebral white-matter changes suggesting leukodystrophy in ataxia telangiectasia. Journal of child neurology. 1994;9:31-35
- 11. Lin DD, Barker PB, Lederman HM, Crawford TO. Cerebral abnormalities in adults with ataxia-telangiectasia. AJNR. American journal of neuroradiology. 2014;35:119-123.