Innovative Treatments for Mucopolysaccharidoses

Florian B. Lagler

doi:10.1055/s-0038-1667350

Journal of Child Science, Table of Contents

CC BY-NC-ND 4.0 · Journal of Child Science 2018; 08(01): e163-e171
DOI: 10.1055/s-0038-1667350

Review Article

Georg Thieme Verlag KG Stuttgart · New York

Innovative Treatments for Mucopolysaccharidoses

Authors

Florian B. Lagler

¹Institute for Inborn Errors of Metabolism and Department of Paediatrics, Paracelsus Medical University Salzburg, Salzburg, Austria

Abstract

Mucopolysaccharidoses (MPSs) are caused by deficiency of specific lysosomal enzymes that affect the degradation of mucopolysaccharides or glycosaminoglycans. Since more than 15 years enzyme replacement therapies are available for an increasing number of MPSs. These therapies together with hematopoietic stem cell transplantation today are the gold standard of causal treatment in MPS. Despite confirmed efficacy, both do not cure these severe conditions. In this article, we discuss the limitations of established and promises of emerging therapies. The limitations of intravenous enzyme replacement and cell therapy can be summarized as immune reactions against the therapeutic molecules/cells and the failure to restore enduring and sufficient enzyme concentration in all relevant tissues. Accordingly, innovative approaches comprise small molecules and encapsulated cells that do not activate antitherapeutic immune reactions, several gene therapy approaches that aim for sustained enzyme expression, and new enzymes that penetrate blood–brain and other barriers for drug distribution. This article provides an update on the state of development of these new therapies and highlights enduring challenges.

Keywords

mucopolysaccharidoses - gene therapy - innovative therapies - cell therapy - pharmacology

Full Text

References

References
1 Neufeld EMJ. The mucopolysaccharidosis. In: Scriver CR, Beaudet AL, Sly WS, Valle D. , eds. The Metabolic and Molecular Basis of Inherited Disease. 8th ed. New York, NY: McGraw-Hill; 2001: 3421-3452
2 Hurler G. Über einen Typ multipler Abartungen, vorwiegend am Skelettsystem. Z Kinderheilkd 1920; 24: 220-234
3 Hunter C. A rare disease in two brothers. Proc R Soc Med 1917; 10 (Sect Study Dis Child): 104-116
4 Morquio L. Sur une forme de dystrophie osseuse familiale. Archives de medecine des infants. 1929;32:129–135
5 Scheie HG, Hambrick Jr GW, Barness LA. A newly recognized forme fruste of Hurler's disease (gargoylism). Am J Ophthalmol 1962; 53: 753-769
6 Sanfilippo S, Podosin R, Langer LJ. , et al. Mental retardation associated with acid mucpolysacchariduria (heparin sulfate type). J Pediatr 1963; 63: 837-838
7 Maroteaux P, Leveque B, Marie J, Lamy M. A new dysostosis with urinary elimination of chondroitin sulfate B [Article in French]. Presse Med 1963; 71: 1849-1852
8 Sly WS, Quinton BA, McAlister WH, Rimoin DL. Beta glucuronidase deficiency: report of clinical, radiologic, and biochemical features of a new mucopolysaccharidosis. J Pediatr 1973; 82 (02) 249-257
9 De Duve C. From cytases to lysosomes. Fed Proc 1964; 1045-1049
10 Brady RO. The sphingolipidoses. N Engl J Med 1966; 275: 312-318
11 Fratantoni JC, Hall CW, Neufeld EF. Hurler and Hunter syndromes: mutual correction of the defect in cultured fibroblasts. Science 1968; 162 (3853): 570-572
12 Heartlein MWKA. Discovery and clinical development of idursulfase (Elaprase®) for the treatment of mucopolysaccharidosis II (Hunter syndrome). In: David CPM. , ed. Orphan Drugs and Rare Diseases. London: Royal Society of Chemistry; 2014: 164-182
13 Lenders M, Schmitz B, Brand SM, Foell D, Brand E. Characterization of drug-neutralizing antibodies in patients with Fabry disease during infusion. J Allergy Clin Immunol 2018; 141 (06) 2289-2292.e7
14 Kim S, Whitley CB, Jarnes Utz JR. Correlation between urinary GAG and anti-idursulfase ERT neutralizing antibodies during treatment with NICIT immune tolerance regimen: a case report. Mol Genet Metab 2017; 122 (1–2): 92-99
15 Lin HY, Lin SP, Chuang CK, Chen MR, Chen BF, Wraith JE. Mucopolysaccharidosis I under enzyme replacement therapy with laronidase--a mortality case with autopsy report. J Inherit Metab Dis 2005; 28 (06) 1146-1148
16 Yano S, Moseley K, Pavlova Z. Postmortem studies on a patient with mucopolysaccharidosis type I: histopathological findings after one year of enzyme replacement therapy. J Inherit Metab Dis 2009; 32 (Suppl. 01) S53-S57
17 Hendriksz CJ. Elosulfase alfa (BMN 110) for the treatment of mucopolysaccharidosis IVA (Morquio A syndrome). Expert Rev Clin Pharmacol 2016; 9 (12) 1521-1532
18 Ruane T, Haskins M, Cheng A. , et al. Pharmacodynamics, pharmacokinetics and biodistribution of recombinant human N-acetylgalactosamine 4-sulfatase after 6months of therapy in cats using different IV infusion durations. Mol Genet Metab 2016; 117 (02) 157-163
19 Qi Y, Musson DG, Schweighardt B. , et al. Pharmacokinetic and pharmacodynamic evaluation of elosulfase alfa, an enzyme replacement therapy in patients with Morquio A syndrome. Clin Pharmacokinet 2014; 53 (12) 1137-1147
20 Xie H, Chung JK, Mascelli MA, McCauley TG. Pharmacokinetics and bioavailability of a therapeutic enzyme (idursulfase) in cynomolgus monkeys after intrathecal and intravenous administration. PLoS One 2015; 10 (04) e0122453
21 Burton BK, Berger KI, Lewis GD. , et al. Safety and physiological effects of two different doses of elosulfase alfa in patients with Morquio A syndrome: a randomized, double-blind, pilot study. Am J Med Genet A 2015; 167A (10) 2272-2281
22 King B, Hassiotis S, Rozaklis T. , et al. Low-dose, continuous enzyme replacement therapy ameliorates brain pathology in the neurodegenerative lysosomal disorder mucopolysaccharidosis type IIIA. J Neurochem 2016; 137 (03) 409-422
23 King B, Marshall NR, Hassiotis S. , et al. Slow, continuous enzyme replacement via spinal CSF in dogs with the paediatric-onset neurodegenerative disease, MPS IIIA. J Inherit Metab Dis 2017; 40 (03) 443-453
24 Martin JJ, Ceuterick C. Prenatal pathology in mucopolysaccharidoses: a comparison with postnatal cases. Clin Neuropathol 1983; 2 (03) 122-127
25 Wiesmann UN, Spycher MA, Meier C, Liebaers I, Herschkowitz N. Prenatal mucopolysaccharidosis II (Hunter): a pathogenetic study. Pediatr Res 1980; 14 (05) 749-756
26 Dierenfeld AD, McEntee MF, Vogler CA. , et al. Replacing the enzyme alpha-L-iduronidase at birth ameliorates symptoms in the brain and periphery of dogs with mucopolysaccharidosis type I. Sci Transl Med 2010; 2 (60) 60ra89
27 Scott CR, Elliott S, Buroker N. , et al. Identification of infants at risk for developing Fabry, Pompe, or mucopolysaccharidosis-I from newborn blood spots by tandem mass spectrometry. J Pediatr 2013; 163 (02) 498-503
28 Hopkins PV, Campbell C, Klug T, Rogers S, Raburn-Miller J, Kiesling J. Lysosomal storage disorder screening implementation: findings from the first six months of full population pilot testing in Missouri. J Pediatr 2015; 166 (01) 172-177
29 Mechtler TP, Stary S, Metz TF. , et al. Neonatal screening for lysosomal storage disorders: feasibility and incidence from a nationwide study in Austria. Lancet 2012; 379 (9813): 335-341
30 Munoz-Rojas MV, Vieira T, Costa R. , et al. Intrathecal enzyme replacement therapy in a patient with mucopolysaccharidosis type I and symptomatic spinal cord compression. Am J Med Genet A 2008; 146A (19) 2538-2544
31 Dickson P, McEntee M, Vogler C. , et al. Intrathecal enzyme replacement therapy: successful treatment of brain disease via the cerebrospinal fluid. Mol Genet Metab 2007; 91 (01) 61-68
32 Kakkis E, McEntee M, Vogler C. , et al. Intrathecal enzyme replacement therapy reduces lysosomal storage in the brain and meninges of the canine model of MPS I. Mol Genet Metab 2004; 83 (1–2): 163-174
33 Kan SH, Aoyagi-Scharber M, Le SQ. , et al. Delivery of an enzyme-IGFII fusion protein to the mouse brain is therapeutic for mucopolysaccharidosis type IIIB. Proc Natl Acad Sci U S A 2014; 111 (41) 14870-14875
34 Dickson PI, Kaitila I, Harmatz P. , et al; Mucopolysaccharidosis I Intrathecal Research Collaborative. Safety of laronidase delivered into the spinal canal for treatment of cervical stenosis in mucopolysaccharidosis I. Mol Genet Metab 2015; 116 (1-2): 69-74
35 Jones SA, Breen C, Heap F. , et al. A phase 1/2 study of intrathecal heparan-N-sulfatase in patients with mucopolysaccharidosis IIIA. Mol Genet Metab 2016; 118 (03) 198-205
36 Muenzer J, Hendriksz CJ, Fan Z. , et al. A phase I/II study of intrathecal idursulfase-IT in children with severe mucopolysaccharidosis II. Genet Med 2016; 18 (01) 73-81
37 Muenzer J, Burton BK, Harmatz P. , et al. Efficacy and safety of intrathecal idursulfase in pediatric patients with mucopolysaccharidosis type II and early cognitive impairment: design and methods of a controlled, randomized, phase II/III multicenter study. Mol Genet Metab 2018; 123: S99-S100
38 Muschol N, Cleary M, Couce ML. , et al. ICV-administered BMN 250 (NAGLU-IGF2) is well tolerated and reduces heparan sulfate accumulation in the CNS of subjects with Sanfilippo syndrome type B (MPS IIIB). Mol Genet Metab 2018; 123: S102
39 Muenzer J, Hendriksz CJ, Stein MB, Fan Z, Kearney S, Horton J, Vijayaraghavan S, Santra S, Solanki GA, Pan L. et al. A long-term extension study evaluating intrathecal idursulfase-IT in children with Hunter syndrome and cognitive impairment. Mol Genet Metab 2017; 120: S99-S100
40 Study of intrathecal idursulfase-IT administered in conjunction with elaprase in pediatric patients with Hunter syndrome and early cognitive impairment available at: https://clinicaltrials.gov/ct2/show/study/NCT02055118 . Accessed March 5, 2018
41 Shire announces top-line results for phase II/III clinical trial in children with Hunter syndrome and cognitive impairment. Available at; https://www.shire.com/en/newsroom/2017/december/wvdwq3 . Accessed March 5, 2018
42 Boado RJ, Pardridge WM. Brain and organ uptake in the Rhesus monkey in vivo of recombinant iduronidase compared to an insulin receptor antibody-iduronidase fusion protein. Mol Pharm 2017; 14 (04) 1271-1277
43 Boado RJ, Hui EK, Lu JZ, Pardridge WM. Glycemic control and chronic dosing of rhesus monkeys with a fusion protein of iduronidase and a monoclonal antibody against the human insulin receptor. Drug Metab Dispos 2012; 40 (10) 2021-2025
44 Boado RJ, Ka-Wai Hui E, Zhiqiang Lu J, Pardridge WM. Insulin receptor antibody-iduronate 2-sulfatase fusion protein: pharmacokinetics, anti-drug antibody, and safety pharmacology in Rhesus monkeys. Biotechnol Bioeng 2014; 111 (11) 2317-2325
45 Boado RJ, Lu JZ, Hui EK, Pardridge WM. Insulin receptor antibody-sulfamidase fusion protein penetrates the primate blood-brain barrier and reduces glycosaminoglycans in Sanfilippo type A cells. Mol Pharm 2014; 11 (08) 2928-2934
46 Boado RJ, Lu JZ, Hui EK, Pardridge WM. Reduction in brain heparan sulfate with systemic administration of an IgG Trojan Horse-sulfamidase fusion protein in the mucopolysaccharidosis type IIIA mouse. Mol Pharm 2018; 15 (02) 602-608
47 Boado RJ, Lu JZ, Hui EK, Lin H, Pardridge WM. Insulin receptor antibody-α-N-acetylglucosaminidase fusion protein penetrates the primate blood-brain barrier and reduces glycosaminoglycans in Sanfilippo type B fibroblasts. Mol Pharm 2016; 13 (04) 1385-1392
48 Giugliani L, Carvalho Doni K, Poswar F, Giugliani R, Boado R. Somatic effects of AGT-181 in patients with mucopolysaccharidosisI enrolled in a phase I/II clinical trial in Brazil. Mol Genet Metab 2018; 123 (02) S53
49 Giugliani R, Giugliani L, Dalle Corte A. , et al. Safety and clinical efficacy of AGT-181, a brain penetrating human insulin receptor antibody-iduronidase fusion protein, in a 26-week study with pediatric patients with mucopolysaccharidosis type I. Mol Genet Metab 2018; 123 (02) S54
50 Mühlstein A, Gelperina S, Kreuter J. Development of nanoparticle-bound arylsulfatase B for enzyme replacement therapy of mucopolysaccharidosis VI. Pharmazie 2013; 68 (07) 549-554
51 Mayer FQ, Adorne MD, Bender EA. , et al. Laronidase-functionalized multiple-wall lipid-core nanocapsules: promising formulation for a more effective treatment of mucopolysaccharidosis type I. Pharm Res 2015; 32 (03) 941-954
52 Baldo G, Giugliani R, Matte U. Gene delivery strategies for the treatment of mucopolysaccharidoses. Expert Opin Drug Deliv 2014; 11 (03) 449-459
53 Ellinwood NM, Vite CH, Haskins ME. Gene therapy for lysosomal storage diseases: the lessons and promise of animal models. J Gene Med 2004; 6 (05) 481-506
54 Wakabayashi T, Shimada Y, Akiyama K. , et al. Hematopoietic stem cell gene therapy corrects neuropathic phenotype in Murine model of mucopolysaccharidosis type II. Hum Gene Ther 2015; 26 (06) 357-366
55 Sergijenko A, Langford-Smith A, Liao AY. , et al. Myeloid/microglial driven autologous hematopoietic stem cell gene therapy corrects a neuronopathic lysosomal disease. Mol Ther 2013; 21 (10) 1938-1949
56 Sessa M, Lorioli L, Fumagalli F. , et al. Lentiviral haemopoietic stem-cell gene therapy in early-onset metachromatic leukodystrophy: an ad-hoc analysis of a non-randomised, open-label, phase 1/2 trial. Lancet 2016; 388 (10043): 476-487
57 Biffi A, Montini E, Lorioli L. , et al. Lentiviral hematopoietic stem cell gene therapy benefits metachromatic leukodystrophy. Science 2013; 341 (6148): 1233158
58 Tardieu M, Zérah M, Husson B. , et al. Intracerebral administration of adeno-associated viral vector serotype rh.10 carrying human SGSH and SUMF1 cDNAs in children with mucopolysaccharidosis type IIIA disease: results of a phase I/II trial. Hum Gene Ther 2014; 25 (06) 506-516
59 Tardieu M, Zérah M, Gougeon ML. , et al. Intracerebral gene therapy in children with mucopolysaccharidosis type IIIB syndrome: an uncontrolled phase 1/2 clinical trial. Lancet Neurol 2017; 16 (09) 712-720
60 Flanigan KM, Truxal KV, McBride KL. , et al. A phase 1/2 clinical trial of systemic gene transfer of scAAV9.U1a.HSGSH for MPS IIIA: Safety, tolerability, and preliminary evidence of biopotency. Mol Genet Metab 2018; 123: S46
61 Ross CJ, Bastedo L, Maier SA, Sands MS, Chang PL. Treatment of a lysosomal storage disease, mucopolysaccharidosis VII, with microencapsulated recombinant cells. Hum Gene Ther 2000; 11 (15) 2117-2127
62 Friso A, Tomanin R, Alba S. , et al. Reduction of GAG storage in MPS II mouse model following implantation of encapsulated recombinant myoblasts. J Gene Med 2005; 7 (11) 1482-1491
63 Baldo G, Mayer FQ, Martinelli B. , et al. Intraperitoneal implant of recombinant encapsulated cells overexpressing alpha-L-iduronidase partially corrects visceral pathology in mucopolysaccharidosis type I mice. Cytotherapy 2012; 14 (07) 860-867
64 Lagranha VL, de Carvalho TG, Giugliani R, Matte U. Treatment of MPS I mice with microencapsulated cells overexpressing IDUA: effect of the prednisolone administration. J Microencapsul 2013; 30 (04) 383-389
65 Lizzi Lagranha V, Zambiasi Martinelli B, Baldo G. , et al. Subcutaneous implantation of microencapsulated cells overexpressing α-L-iduronidase for mucopolysaccharidosis type I treatment. J Mater Sci Mater Med 2017; 28 (03) 43
66 Mayer FQ, Artigalás OA, Lagranha VL. , et al. Chloramphenicol enhances IDUA activity on fibroblasts from mucopolysaccharidosis I patients. Curr Pharm Biotechnol 2013; 14 (02) 194-198
67 Kamei M, Kasperski K, Fuller M. , et al. Aminoglycoside-induced premature stop codon read-through of mucopolysaccharidosis type I patient Q70X and W402X mutations in cultured cells. JIMD Rep 2014; 13: 139-147
68 Hein LK, Bawden M, Muller VJ, Sillence D, Hopwood JJ, Brooks DA. α-L-iduronidase premature stop codons and potential read-through in mucopolysaccharidosis type I patients. J Mol Biol 2004; 338 (03) 453-462
69 Keeling KM, Wang D, Dai Y. , et al. Attenuation of nonsense-mediated mRNA decay enhances in vivo nonsense suppression. PLoS One 2013; 8 (04) e60478
70 Bartolomeo R, Polishchuk EV, Volpi N, Polishchuk RS, Auricchio A. Pharmacological read-through of nonsense ARSB mutations as a potential therapeutic approach for mucopolysaccharidosis VI. J Inherit Metab Dis 2013; 36 (02) 363-371
71 Takai T, Higaki K, Aguilar-Moncayo M. , et al. A bicyclic 1-deoxygalactonojirimycin derivative as a novel pharmacological chaperone for GM1 gangliosidosis. Mol Ther 2013; 21 (03) 526-532
72 Hoshina H, Shimada Y, Higuchi T, Kobayashi H, Ida H, Ohashi T. Chaperone effect of sulfated disaccharide from heparin on mutant iduronate-2-sulfatase in mucopolysaccharidosis type II. Mol Genet Metab 2018; 123 (02) 118-122
73 Fantur K, Hofer D, Schitter G. , et al. DLHex-DGJ, a novel derivative of 1-deoxygalactonojirimycin with pharmacological chaperone activity in human G(M1)-gangliosidosis fibroblasts. Mol Genet Metab 2010; 100 (03) 262-268
74 Suzuki H, Ohto U, Higaki K. , et al. Structural basis of pharmacological chaperoning for human β-galactosidase. J Biol Chem 2014; 289 (21) 14560-14568
75 Thonhofer M, Weber P, Gonzalez Santana A. , et al. Synthesis of C-5a-substituted derivatives of 4-epi-isofagomine: notable β-galactosidase inhibitors and activity promotors of GM1-gangliosidosis related human lysosomal β-galactosidase mutant R201C. Carbohydr Res 2016; 429: 71-80
76 Matos L, Canals I, Dridi L. , et al. Therapeutic strategies based on modified U1 snRNAs and chaperones for Sanfilippo C splicing mutations. Orphanet J Rare Dis 2014; 9: 180
77 Pshezhetsky AV, Pan X, Héon-Roberts R. , et al. Chaperone therapy for mucopolysaccharidosis type IIIC. Mol Genet Metab 2018; 123: S121-S122
78 Malinowska M, Wilkinson FL, Langford-Smith KJ. , et al. Genistein improves neuropathology and corrects behaviour in a mouse model of neurodegenerative metabolic disease. PLoS One 2010; 5 (12) e14192
79 Piotrowska E, Jakobkiewicz-Banecka J, Maryniak A. , et al. Two-year follow-up of Sanfilippo Disease patients treated with a genistein-rich isoflavone extract: assessment of effects on cognitive functions and general status of patients. Med Sci Monit 2011; 17 (04) CR196-CR202
80 Delgadillo V, O'Callaghan MM, Artuch R, Montero R, Pineda M. Genistein supplementation in patients affected by Sanfilippo disease. J Inherit Metab Dis 2011; 34 (05) 1039-1044
81 de Ruijter J, Valstar MJ, Narajczyk M. , et al. Genistein in Sanfilippo disease: a randomized controlled crossover trial. Ann Neurol 2012; 71 (01) 110-120
82 Kim KH, Dodsworth C, Paras A, Burton BK. High dose genistein aglycone therapy is safe in patients with mucopolysaccharidoses involving the central nervous system. Mol Genet Metab 2013; 109 (04) 382-385
83 Frohbergh M, Ge Y, Meng F. , et al. Dose responsive effects of subcutaneous pentosan polysulfate injection in mucopolysaccharidosis type VI rats and comparison to oral treatment. PLoS One 2014; 9 (06) e100882
84 Simonaro CM, Ge Y, Eliyahu E, He X, Jepsen KJ, Schuchman EH. Involvement of the Toll-like receptor 4 pathway and use of TNF-α antagonists for treatment of the mucopolysaccharidoses. Proc Natl Acad Sci U S A 2010; 107 (01) 222-227
85 Schuchman EH, Ge Y, Lai A. , et al. Pentosan polysulfate: a novel therapy for the mucopolysaccharidoses. PLoS One 2013; 8 (01) e54459
86 Simonaro CM, Tomatsu S, Sikora T. , et al. Pentosan polysulfate: oral versus subcutaneous injection in mucopolysaccharidosis type I dogs. PLoS One 2016; 11 (04) e0153136
87 Hennermann JB, Gökce S, Solyom A, Mengel E, Schuchman EH, Simonaro CM. Treatment with pentosan polysulphate in patients with MPS I: results from an open label, randomized, monocentric phase II study. J Inherit Metab Dis 2016; 39 (06) 831-837
88 Banecka-Majkutewicz Z, Jakóbkiewicz-Banecka J, Gabig-Cimińska M, Węgrzyn A, Węgrzyn G. Putative biological mechanisms of efficiency of substrate reduction therapies for mucopolysaccharidoses. Arch Immunol Ther Exp (Warsz) 2012; 60 (06) 461-468
89 Noh H, Lee JI. Current and potential therapeutic strategies for mucopolysaccharidoses. J Clin Pharm Ther 2014; 39 (03) 215-224
90 Roberts AL, Rees MH, Klebe S, Fletcher JM, Byers S. Improvement in behaviour after substrate deprivation therapy with rhodamine B in a mouse model of MPS IIIA. Mol Genet Metab 2007; 92 (1–2): 115-121
91 Roberts AL, Thomas BJ, Wilkinson AS, Fletcher JM, Byers S. Inhibition of glycosaminoglycan synthesis using rhodamine B in a mouse model of mucopolysaccharidosis type IIIA. Pediatr Res 2006; 60 (03) 309-314
92 Derrick-Roberts ALK, Jackson MR, Pyragius CE, Byers S. Substrate deprivation therapy to reduce glycosaminoglycan synthesis improves aspects of neurological and skeletal pathology in MPS I mice. Diseases 2017; 5 (01) 5
93 Giugliani R, Federhen A, Silva A. , et al. Emerging treatment options for the mucopolysaccharidoses. Res and Rep in Endocrine Disorders 2012; 2: 53-64
94 Hinderer C, Bell P, Louboutin JP. , et al. Neonatal tolerance induction enables accurate evaluation of gene therapy for MPS I in a canine model. Mol Genet Metab 2016; 119 (1–2): 124-130
95 Ellinwood NM, Ausseil J, Desmaris N. , et al. Safe, efficient, and reproducible gene therapy of the brain in the dog models of Sanfilippo and Hurler syndromes. Mol Ther 2011; 19 (02) 251-259
96 Whitley CB, McIvor RS, Aronovich EL. , et al. Retroviral-mediated transfer of the iduronate-2-sulfatase gene into lymphocytes for treatment of mild Hunter syndrome (mucopolysaccharidosis type II). Hum Gene Ther 1996; 7 (04) 537-549
97 Holley RJ, Ellison SM, Fil D. , et al. Macrophage enzyme and reduced inflammation drive brain correction of mucopolysaccharidosis IIIB by stem cell gene therapy. Brain 2018; 141 (01) 99-116