X-linked adrenoleukodystrophy is an inherited metabolic peroxisomal disorder and one of the more common leukodystrophies in both children and adults. It is characterized by a lack of oxidation of very long chain fatty acids (VLCFAs) that results in severe inflammatory demyelination typically of the periventricular deep white matter with posterior-predominant pattern and early involvement of the splenium of the corpus callosum and parietal white matter changes. Most patients will demonstrate characteristic MRI findings.
The estimated incidence of adrenoleukodystrophy is 1:20,000-50,000. Due to its X-linked inheritance, it classically affects young males, although carrier females can be affected. Although most cases are diagnosed in childhood, a significant proportion of cases manifest in young adults (typically late 20s) 3,11,12 and thus adrenoleukodystrophy is one of the most common adult-onset leukodystrophies 15.
The presentation will depend on the phenotype which in turn depends upon the age (see below). Some individuals can be asymptomatic.
As a general rule, most children will have prominent supratentorial involvement, whereas adults will have more pronounced spinal cord involvement (adrenomyeloneuropathy)15.
Up to eight phenotypes have been described but the three main types in males are 3,8,11,12,15:
- cerebral adrenoleukodystrophy (40%)
- presents after 2.5 years of age (typically at 4-8 years)
- progressive impairment motor and cognitive function, vision and hearing
- when adults present with cerebral involvement presentation is often neuropsychiatric prior to other manifestations (ataxia, seizures, dementia) 15
- most common adult presentation
- progressive paraparesis, sphincter dysfunction, sexual dysfunction, and adrenocortical deficiency
- spinal cord involvement with few if any brain abnormalities
Addison disease only (~10%), i.e. primary adrenocortical deficiency
- no symptomatic leukodystrophy
Approximately 20% of female carriers will be affected, although onset is late (>35 years) with milder paraparesis 11.
The conditions result from the accumulation of very long-chain fatty acids (VLCFAs) due to genetic deficiency in the peroxisomal oxidation of fatty acids. This is thought to result from a mutation in the ABCD1 gene located on Xq28 that encodes the protein adenosine triphosphate–binding cassette transporter embedded within the peroxisomal membrane 5,11,15.
The affected cerebral white matter is typically split into three different zones (also referred to as Schaumberg zones 3, 2, and 1, respectively):
- central (inner) zone: irreversible gliosis and scarring
- intermediate zone: active inflammation and breakdown of the blood-brain barrier
- peripheral (outer) zone: leading edge of active demyelination
- markedly elevated VLCFA concentrations in plasma and cultured skin fibroblasts 11,13
Abnormal MRI findings precede clinical findings in all forms of adrenoleukodystrophy 13. Distribution of involvement results in different clinical forms of the disease.
Loes et al. 10 described five different MRI patterns of adrenoleukodystrophy based on the involved anatomic locations and MR patterns of progression:
- deep white matter in the parieto-occipital lobes and splenium of the corpus callosum (66% of cases, chiefly in children); may include lesions of the visual and auditory pathways
- frontal lobe or genu of the corpus callosum (15.5%, mostly in adolescents)
- frontopontine or corticospinal projection fibers (12%, mostly in adults)
- cerebellar white matter (1%, mostly in adolescents)
- combined parieto-occipital and frontal white matter (2.5%, mostly children)
There tends to be cortical and subcortical U-fiber sparing.
Spinal cord involvement is pronounced in the adrenomyeloneuropathy form of the disease, particularly affecting the thoracic segment 15.
Signal changes can vary according to the zonal distribution within the affected white matter.
- central zone: hypointense
- intermediate zone
- peripheral zone
T1 C+ (Gd)
- enhancement is seen in around 50% of cases according to one study and is thought to be associated with disease progression 6
- with contrast infusion, serpiginous, garland-shaped enhancement may be visible in the anteriormost periphery of the lesions 7
- central zone: markedly hyperintense
- intermediate zone: isointense to hypointense
- peripheral zone: moderately hypointense
Treatment and prognosis
Bone marrow transplantation is thought to be favourable in the early stages of the disease. Restriction of VLCFAs has also been trialled. Steroid replacement can be used in patients with adrenocortical insufficiency.
The pattern of involvement also determines prognosis, with combined frontal and parieto-occipital usually heralding rapid disease progression, whereas isolated cerebellar or corticospinal tract involvement generally having slower progression 15.
The degree of contrast enhancement at the edge or white matter involvement is also predictive of disease progression 15.
Differential consideration of the classic pattern include:
History and etymology
It is thought to have originally been described by Siemerling and Creutzfeldt in 1923 1.
- 1. Victor M, Ropper AH, Adams RD. Adams and Victor's principles of neurology. McGraw-Hill Professional. (2001) ISBN:0070674973. Read it at Google Books - Find it at Amazon
- 2. Bizzi A, Castelli G, Bugiani M et-al. Classification of childhood white matter disorders using proton MR spectroscopic imaging. AJNR Am J Neuroradiol. 2008;29 (7): 1270-5. doi:10.3174/ajnr.A1106 - Pubmed citation
- 3. Moser HW. Adrenoleukodystrophy: phenotype, genetics, pathogenesis and therapy. Brain. 1997;120 ( Pt 8) (8): 1485-508. doi:10.1093/brain/120.8.1485 - Pubmed citation
- 4. Inoue Y, Fukuda T, Takashima S et-al. Adrenoleukodystrophy: new CT findings. AJNR Am J Neuroradiol. 4 (4): 951-4. AJNR Am J Neuroradiol (abstract) - Pubmed citation
- 5. Cheon JE, Kim IO, Hwang YS et-al. Leukodystrophy in children: a pictorial review of MR imaging features. Radiographics. 22 (3): 461-76. Radiographics (full text) - Pubmed citation
- 6. Melhem ER, Loes DJ, Georgiades CS et-al. X-linked adrenoleukodystrophy: the role of contrast-enhanced MR imaging in predicting disease progression. AJNR Am J Neuroradiol. 2000;21 (5): 839-44. AJNR Am J Neuroradiol (full text) - Pubmed citation
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- 8. Engelen M, Kemp S, de Visser M et-al. X-linked adrenoleukodystrophy (X-ALD): clinical presentation and guidelines for diagnosis, follow-up and management. Orphanet J Rare Dis. 2012;7 (1): 51. doi:10.1186/1750-1172-7-51 - Free text at pubmed - Pubmed citation
- 9. Patel PJ, Kolawole TM, Malabarey TM et-al. Adrenoleukodystrophy: CT and MRI findings. Pediatr Radiol. 1995;25 (4): 256-8. Pubmed citation
- 10. Loes DJ, Fatemi A, Melhem ER, Gupte N, Bezman L, Moser HW, Raymond GV. Analysis of MRI patterns aids prediction of progression in X-linked adrenoleukodystrophy. Neurology. 61 (3): 369-74. Pubmed
- 11. Steinberg SJ, Moser AB, Raymond GV. X-Linked Adrenoleukodystrophy. 1999 Mar 26 [Updated 2015 Apr 9]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2015. Available from: http://www.ncbi.nlm.nih.gov/books/NBK1315/
- 12. Laureti S, Casucci G, Santeusanio F, Angeletti G, Aubourg P, Brunetti P. X-linked adrenoleukodystrophy is a frequent cause of idiopathic Addison's disease in young adult male patients. The Journal of clinical endocrinology and metabolism. 81 (2): 470-4. doi:10.1210/jcem.81.2.8636252 - Pubmed
- 13. Elan Louis, Stephan A. Mayer. Merritt's Neurology. ISBN: 9781451193367
- 14. Eichler FS, Itoh R, Barker PB, Mori S, Garrett ES, van Zijl PC, Moser HW, Raymond GV, Melhem ER. Proton MR spectroscopic and diffusion tensor brain MR imaging in X-linked adrenoleukodystrophy: initial experience. Radiology. 225 (1): 245-52. doi:10.1148/radiol.2251011040 - Pubmed
- 15. Resende LL, de Paiva ARB, Kok F, da Costa Leite C, Lucato LT. Adult Leukodystrophies: A Step-by-Step Diagnostic Approach. (2019) Radiographics : a review publication of the Radiological Society of North America, Inc. 39 (1): 153-168. doi:10.1148/rg.2019180081 - Pubmed
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