Scientific Program

Day 1 :

Biography:

Muhammad Akbar Malik was trained in General Pediatrics in Pakistan and then was trained in Pediatric Neurology in Frenchay Hospital Bristol, UK. He established Pediatric Neurology department and worked for five years in Lahore Children Hospital. Now he heading a charity project: Top-Down-Bottom-Up project, aiming to provide pediatric neurology services at door-steps of out-reached poor communities in Pakistan.

Abstract:

Statement of the Problem: Systemic pediatric cancer patients are prone to become critically ill and may develop seizures and encephalopathy, which can result in permanent neurologic disability. There are few techniques for monitoring brain functions in these patients, especially in resource-poor settings. The emergent bed-side electroencephalogram (EEG) can be useful. Purpose: to determine, usefulness of emergent bedside EEG features among these patients with unexplained coma (GCS≤8) of ≤6 hrs duration. Methodology & Theoretical Orientation: Prospective EEG assessment of 40 systemic cancer patients consecutively diagnosed and admitted in neurointensive care units. Patients with brain tumor, brain metastasis, seizures or those with known cause of coma were excluded. Findings: Over a period of 2 year, 40 children; boys 65% and girls 35%, with systemic cancer patients with a median age of 9.8 years were studied. This cohort underwent bed-side EEG of ≥ 30 minutes, which was abnormal in 100% of the records. The most common EEG abnormalities were invariant mixed theta-delta slowing (27.5%), followed by low-amplitude delta pattern plus epileptiform discharges (20%) and there was electrographic evidence of EEG seizures in 17(42.5%) of the cohort. These electrographic seizures were present in 55.5% of 18 patients with subtle convulsions, whereas were documented only in 20% of the 22 patients without such movements. Electrographic seizures among patients with subtle convulsions responded to anticonvulsant drugs in 75% cases as compared 50% such response among patients without such convulsions. Conclusion& Significance: seizures are common among critically ill children with systemic cancer. Bed-side EEG record of ≥30 minutes is useful in such patients. Recommendations are made for emergent ≥ 30min EEG among systemic cancer patients with unexplained acute coma.

 

Biography:

Ying Peng, M.D. & Ph.D. From 1997 to 2001, he got his post-doctor training in National Institutes of Health, USA. Now He is working in Sun Yaat-Sen Memorial Hospital, Sun Yat-Sen University as a full-professor.  His current research fields include: 1. Addiction & Toxic Encephalopathy; 2. Gene therapy of Neurological Disease; 3. Cerebral ischemic stroke; 4.Brain injure and neural regeneration. He got 7 funds during the period of working in the University of Hong Kong and 16 grants after working in the Sun Yat-Sen Memorial Hospital. He published 105 papers in SCI journals. Additionally, he got the “Fellows Award for Research Excellence 2001”, sponsored by National Institutes of  Health of  USA., and the “Second Prize for Scientific Technique Progress Award of Guangdong Province” in China.

Abstract:

Chronic alcoholism encephalopathy is a common disease existing all over the world, which is an important symptom of alcohol abuse and alcoholism. In order to promote neurologists’ understanding, popularize the standardized diagnosis and treatment of chronic alcoholism encephalopathy, we have made extensive discussion to reach the following consensus on the principles related to the clinical diagnosis and treatment on chronic alcoholism encephalopathy. I. Definition of chronic alcoholic encephalopathy : Chronic alcoholism encephalopathy is a chronic and recrudescent brain disease caused by alcohol acting on the brain tissue due to long-term drinking, that is to say, a seriously poisoning condition on the central nervous system caused by excessive drinking for a long time, and almost all patients have dependently chronic pathogenesis of alcohol syndrome. II. Clinical manifestations and characteristics of chronically alcoholic encephalopathy: We divide chronic alcoholism encephalopathy into 6 kinds of syndrome according to the patient's clinical manifestation and the condition of onset and the duration of the disease, including Wernicke encephalopathy, Coxsackoff syndrome, chronic alcoholism dementia, alcoholic tremor-delirium, alcoholic epilepsy, alcoholically mental and behavioral disorders. III. Clinical diagnosis of chronic alcoholic encephalopathy : The coring symptoms/diagnostic criteria for alcohol dependence are described in DSM-4/ICD-10 as followings (3 Or more of the following within 12 months): (1)Alcoholic tolerance;(2)interrupting symptoms/reactions after stopping drinking; (3)Excessive intake; (4)Beyond control and abstinence; (5)Spending a lot of time seeking, acquiring and ingesting alcohol; (6)The intention of social communication is decreased; (7)Regardless of any adverse consequences. The clinicians should be based on the above-mentioned diagnostic criteria, combined with the clinical manifestations and imaging characteristicsfor comprehensive judgment. IV. Treatment of chronically alcoholic encephalopathy: Abstinence from alcohol: Currently first-line medicine: Nalmefen, naloxone, dithiolam, aconic acid; The second-line medicine: Baclofen, topiramate, benzodiazepines, tricyclic antidepressants, high-dose antioxidants. Others include etiological treatment, correction on nutritional disorders, brain-protecting therapy, rehabilitation therapy and others.

  • Neurology

Session Introduction

Fadia El Bitar

King Faisal Specialist Hospital and Research Centre Saudi Arabia

Title: Dual Activity of PAC Neurotrophicity and Neuroprotection against amyloid peptides causing Alzheimers disease
Speaker
Biography:

Faida El Bitar is the professor in the Department of Genetics at King Faisal Specialist Hospital and Research Centre, Saudi Arabia. She is currently working in the Alzheimers project.

Abstract:

Alzheimer’s disease (AD) is the most common cause of dementia in the elderly. The toxicity of b-amyloid (Ab) peptides is thought to be involved in neuronal damage in this pathology. Multiple studies focused on role of neuroprotective molecules to attenuate the toxic consequences of Ab peptides in the development of AD.

In the present work, our objective is to investigate in vitro if PAC which is the synthetic analogue of curcumin displays neuroprotective activity against Ab peptide-induced neurotoxicity, using rat neuroblastoma B104 as cell culture model. Our results showed that PAC is not neurotoxic per se. In addition, PAC showed a striking neurotrophic activity in cells cultured at low density. This neuronal outgrowth increases importantly with increasing days of culture starting from 2 folds increase at day 2 to 3 folds increase at day 5. The number of neurites per cell rises also in presence of PAC.

Most importantly, we demonstrate the capacity of PAC to correct sAb25-35 neurotoxicity. The percentage of cell viability increases significantly by PAC at 0.5µM in presence of sAb 25-35 compared to that in presence of the peptide alone .Interestingly, our neurotrophic and neuroprotection studies showed the PAC was 20 times more efficient than curcumin. Both PAC and curcumin displayed an effect on cell-cell interaction.

Thus, our results revealed neuroprotective properties of PAC against Ab peptide. The continuity in examining the mechanism(s) underlying PAC activity is promising towards identifying efficient therapy for AD.

  • Neuroscience
Speaker
Biography:

Dr. Lihuan Lan earned an undergraduate degree in Clinical Medicine from Wu Han University, he is currently a postgraduate student majoring in Neuroscience at Sun Yat-Sen University and a resident at Department of Neurology, Sun Yat-Sen Memorial Hospital. He has his expertise in clinical and mechanism studies of transcranial magnetic stimulation, migraine and stroke.  Currently, he focus on recanalization and stroke with white matter lesion.

Abstract:

Background : Intravenous recombinant tissue plasminogen activator is a preferred therapy for patients with acute ischemic stroke within 4.5 hours. But patients with unknown stroke onset usually excluded from the standard thrombolytic therapy. Although some existing studies which evaluated conducted the thrombolytic therapy for patients with unknown stroke onset or wake-up stroke, there have been no comprehensive meta-analyses of the effect of thrombolytic therapy for these patients. We performed the first meta-analysis to evaluate the effect of thrombolytic therapy for patients with wake-up stroke or unknown stroke onset. Methods: Articles were screened from electronic database in September 2017 and all randomized controlled trials and retrospective comparative studies were included.Results: Two randomized controlled trials, three retrospective studies, one prospective, multicenter, single-arm study, one case-controlled study and one open-label pilot study including 964 patients. The control group had lower National Institutes of Health stroke scale score (95% CI 0.62 – 4.26; p = 0.009). For excellent clinical outcome (mRS, 0–1), no significant difference was found between experiment group and control group (OR1.76; 95% CI 0.71 – 4.35; p = 0.22). There was not statistically significant when we compared the favorable clinical outcome (mRS, 0–2)between both groups (OR1.42; 95% CI 0.85 – 2.36; p = 0.18). Intracranial hemorrhage of control group were lower than experiment group (OR1.81; 95% CI 1.00 – 3.37; p = 0.05). But the mortality between both group was not statistically significant (OR1.29; 95% CI 0.64 – 2.59; p = 0.47). Conclusion: Intravenous rt-PA in patients with WUS based on neuroimaging didn't improve clinical prognosis. However the ICH rate was statistically significant higher for experiment group than control group. More well-designed RCTs are needed to evaluate the effect of intravenous rt-PA for WUS.

Speaker
Biography:

Soheil Kazemi Roodsari is a Research Assistant in Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.

Abstract:

Abstract: Methadone is widely used in preventation of opiate withdrawal and also treatment opiate addiction. In addition to its clinical uses some studies demonstrated that methadone is associated with some alterations in seizure susceptibility. In this study, we tried to clarify the modulatory effect of methadone in clonic seizure threshold (CST) induced by pentylenetetrazole (PTZ) in mice, and we also further determined the probability role of N-Methyl-D- Aspartate (NMDA) receptor or Nitric oxide (NO) signaling in tolerance, dependence and seizure threshold of methadone. Our data showed that methadone (0.1,0.3,1, and 3 mg/kg) in acute administration has pro convulsive effect whereas chronic injection ( 3mg/kg, 3times/day for 5 days) enhanced seizure threshold. The non-effective (i.e., did not significantly alter the PTZ-induced seizure threshold by itself) doses of NMDA receptor antagonists [Ketamine (0.5 mg/kg) and MK-801(0.05 mg/kg)] were able to inhibit the pro-convulsive effect of methadone, while the non-effective doses of a nonspecific NOS inhibitor [L-NAME (10 mg/kg)] and a specific nNOS inhibitor [7-NI(15mg/kg)] could reversed the anti-convulsive effect of methadone in chronic administration. Additionally, the withdrawal syndrome signs, precipitated by naloxone and also anti-nociception effects of methadone were reduced by administration of NMDA receptor antagonists and NOS inhibitors accompanying methadone. These results suggest the involvement of NMDA receptors in pro and NO pathway in anti-convulsive effects of acute and chronic administration of methadone respectively and also both of them in dependence and tolerance.

 

  • Child Neurology

Session Introduction

Xiaoni Zhang

Sun Yat-Sen University China

Title: Substance Dependence Alters Serum Lipid Levels in Addicted Male Patients
Speaker
Biography:

Dr. Xiaoni Zhang has her expertise in clinical and mechanism studies of substance dependence. Dr. Zhang has completed her M.D. and M.S. at Sun Yat-Sen University. She is currently a resident at Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University. Her research field is focused on substance dependence and morphine-induced immunosuppressive effects.

Abstract:

Objectives: Studies have shown that opiate and heroin dependence causes alterations in serum lipids. In this study, we investigated the relationship between different types of substance dependence and serum lipid levels.

Methods: Serum lipid levels were measured in 97 patients with different types of substance dependence (heroin, methamphetamine, ketamine, and codeine phosphate dependence), and in 99 healthy subjects. The clinical characteristics of substance-dependent patients were also investigated.

Results: Serum total cholesterol (TC; 3.74±1.02 mmol/L, P=0.017) and high-density lipoprotein cholesterol (HDL-C; 1.12±0.19, P=0.007) levels were lower, and triglyceride levels (TG; 1.73±0.89 mmol/L, P=0.008) were higher in the heroin dependence group compared to the control group. Serum TG (1.74±1.11 mmol/L, P=0.000), HDL-C (1.44±0.30 mmol/L, P=0.011), apolipoprotein A-1 (ApoA-1; 1.55±0.28 g/L, P=0.000), and apolipoprotein B (ApoB; 1.55±0.28 g/L, P=0.000) levels were higher in the methamphetamine dependence group, while serum TG (2.49±1.56 mmol/L, P=0.000) and ApoB (0.93±0.25 g/L, P=0.000) levels were higher in the ketamine dependence group compared to the control group. Additionally, the codeine dependence group exhibited higher serum TG (1.94±1.34 mmol/L, P=0.000) and ApoB (0.82±0.28 g/L, P=0.003) levels. We also found that patients with psychotic symptoms had significantly higher TG levels in the heroin, methamphetamine, and ketamine dependence groups, and lower TC and HDL-C levels in the heroin dependence group.

Conclusions: Our data suggested that different types of substance dependence caused varying degrees of change in serum lipid levels, and that hypertriglyceridemia was consistent with psychotic symptoms in substance abuse patients.

Speaker
Biography:

Farzad Ahmadabadi is a child neurologist from Iran. He is graduated from Shahid beheshti medical sciences university in2012.He is working in Ardabil medical sciences university in north of Iran. His favorite field is Neurometabolic and majority of his studies are in this field. He is the admin of Iranian Neurometabolic registry site(Neurometabolic.ir).

Abstract:

Introduction: Five million people worldwide have epilepsy and 3 million of them are children. Phenobarbital is one of the oldest, safest and most available anti-epileptic drugs. The drug approved by WHO as first-line therapy for partial and generalized tonic-clonic seizures. Behavioral problems including hyperactivity, aggression, inattention and restlessness are seen due to phenobarbital. Therefore, we evaluate the effectiveness of vitamin B6 on behavioral disorders due to phenobarbital in epileptic patients. Methods: In this study, 77 patients with seizures between 2 and 15 years were enrolled in two groups .One group received Phenobarbital plus vitamin B6 and the other group Phenobarbital plus placebo .After 3 month we change two groups and crossed them (after 10 days washed out period)and study continued for 3 month  again. Behavioral  parameter are evaluated in starting of study ,3 month later  and at the  end of study(6month later) using the Modified " Conner’s" questionnaire and the data were collected and analyzed by statistical software. Results: There was no difference in hyperactivity, attention and aggression between two groups at the end of 3 month study but after crossing two groups we found statistical difference between two groups in hyperactivity (P value<0.01).This study showed that behavioral disorders due to Phenobarbital use in epileptic children reduced overtime and if we prescribe Vitamin B6 with phenobarbital this improvement will be more significant. Conclusion: This study showed that behavioral disorders due to Phenobarbital use in epileptic children reduced overtime and if we prescribe Vitamin B6 with phenobarbital this improvement will be more significant.

  • Demyelinating Disease & Diagnosis

Session Introduction

Jes Paul

Research Scientist Albany medical centre USA

Title: Decreasing Grey Matter in Multiple Sclerosis; A serious disorder in the brain
Speaker
Biography:

Jes Paul  have done Ph.D. in Neurology & Molecular Cell Biology, stem cells with 3 years’ post-doctoral training, Master’s degree with 7 years’ post-graduate training and Good Laboratory Practice (GLP).Currently he is working as a Research Scientist in Albany medical centre in the department of cardiovascular sciences.

Abstract:

Multiple sclerosis (MS) is a chronic  degenerative disease of the central nervous system that is frequently accompanied by  decline in grey matter composition .

Specific patterns of brain atrophy in MS is associated with reduced gray matter . Even earlier studies also showed the abnormalities in gray matter networks several neurological and psychiatric disorders, such as Alzheimer disease and schizophrenia. The link between gray matter lessening and disability is more pronounced as the MS progresses .

The study,  aimed to investigate decreasing gray matter content in MS by hypothesing that the more pronounced network disorganization and disability there is more worse decrease in grey matter  in MS.A very random topology in MS patients was related to reduced grey matter, explaining variance beyond conventional MRI and volumetric measures. This suggests that during the progression of MS the gray matter networks will diminish contributing to  worsened disability,neuropathophysiological  and cognitive impairment. Advancements in to the grey matter morphology  showcases an improved relationship with clinical and cognitive observed profiles in MS.

In future research grey matter network-based pathology in MS which  lead to cognitive and physical disability, should be addressed  so that a serious neurological disorder like ms can be tackled to an extent.

  • Neurotrauma

Session Introduction

Elham Ataei

Assistant University of Medical Sciences, Iran

Title: Relation between Changing ECG and Location of Aneurysm in Subarachnoid Hemorrhage
Speaker
Biography:

Elham Ataei is the Assistant of Neurology at  Rasool Akram Hospital, University of Medical Sciences Tehran, Iran.

Abstract:

ECG changes are presented in about 90% of patients with cerebral aneurysm that results subarachnoid hemorrhage (SAH). The most common site of these lesions among the cerebral arteries is anterior cerebral artery which supplies Autonomic cardiovascular centers. However it seems that the location of aneurysm influences critically on changes of ECG, which has not been studied grossly in literatures and there is no definite data to mention that. Materials and Methods: Here, a cross sectional, retrospective study was done on 500 patients presenting SAH due to cerebral aneurysm which patient´s angiography detected the location of pathology. ECG of these patients was taken two times, one on admission and other on discharge after 3rd week of admission. Results: The mean age of patients was 57.3 years old and this group included 271 male and 229 females. 388 cases had ECG changes; some of them had more than one changed factor. QRS changes were seen in 18 cases on the day of admission, QTc changes were observed in 258 cases, and changes of ST distance were observed in 126 cases. Among all of them, the location of the aneurysm was in Anterior cerebral artery in 142 cases, in communicating arteries in 84 cases, in Middle cerebral artery 64 in cases, in ICA in 36 cases and in Posterior cerebral artery in 52 cases. Conclusion: In cases which their brain angiography showed cerebral aneurysm, the frequency of ECG changes was more seen. Patients with the anterior cerebral artery aneurysms had more ECG changes. According to the obtained results, ECG of patients with SAH could be a recognized as a factor to understand better the situation of brain after SAH and be useful for managing and treating patients with SAH.

  • Seizure

Session Introduction

Elham Ataei

Assistant University of Medical Sciences Iran

Title: Evaluation of Short-term Mortality of Status Epilepticus and Its Risk Factors
Speaker
Biography:

Elham Ataei is the Assistant of Neurology at  Rasool Akram Hospital, University of Medical Sciences Tehran, Iran.

Abstract:

Background and Purpose: Status epilepticus (SE) is defined as epileptic seizures of greater than five minutes or more than one seizure within a five minute period without returning to normal consciousness between them. It is a life-threatening condition particularly if treatment is delayed. Previous studies reported age, duration and etiology of SE as primary determinants of mortality. Methods: This prospective cross-sectional study performed on the patients with status epilepticus admitted in Rasoul-e-Akram hospital in Tehran. Patients followed at 30th day after SE to assess their living status. Results: Sixty-five patients, (56.9% was male) with 15 to 88 years of age entered the study. Mean duration of SE was 40 minutes and for hospital stay was 7 days. 84.6% of patients responded to treatment and 11 patients (16.9%) died within 30 days after SE. Mortality rate in patients with refractory SE was 70%. Mean interval between SE and death was 11.9 ± 11.7 days. Age, duration of SE and hospital stay, history of head trauma and neurosurgery were not predictors of mortality. Negative history for epilepsy had significantly higher mortality rate. Anoxic encephalopathy increased the mortality rate and response to treatment decreased it. Conclusions: Short-term mortality rate of SE was comparable with most of the previous reports Since our hospital has equipped emergency department, resuscitation and primary treatment of SE is usually start soon, percentage of anoxic encephalopathy is decreased and lower mortality rate is expected. We conclude that early treatment by decrease chance of anoxic encephalopathy, has significant role in outcome of SE. Keywords: Status epilepticus, Mortality rate, Refractory seizure.

  • Cerebrovascular Diseases and Cure

Session Introduction

Noor-ul-huda Maria

College of Physician and Surgeons Pakistan

Title: Relation of Lipid Profile with ischemic Stroke
Speaker
Biography:

Abstract:

Objective: to evaluate correlation of blood total cholesterol (TC), high-density lipoprotein (HDL), triglycerides, and the TC:HDL ratio as risk factors for ischemic stroke. Methodology: After ethical approval from hospital ethical board this case control study was conducted in the department of neurosurgery and neurology Lahore General Hospital Lahore/Punjab Institute of Neurosciences/Postgraduate Medical Institute/Ameerudin Medical College Lahore. Duration of study was two years from October 2015 to October 2017. A total of 600 patients were included in the study after obtaining written consent from patients. After completion of data collection, data was entered in computer software SPSS version 23 and analyzed for continuous and categorical variables. Continuous/numerical variables were presented as mean and SD and categorical variables were presented in form of numbers and percentages. Independent t-test and chi-square test were applied to see significance of data. P value less than or equal to 0.05 was considered as significant. Results: Overall, 100% (n=600) patients were included in this study. The study comprised of two equal groups, 50% (n=300) in each, i.e. cases and controls. The  controls had mean TC, HDL and triglycerides 220.76±4.29 mg/dL, 54.02±4.45 mg/dL and 153.99±2.68 mg/dL respectively. The TC:HDL ratio was 5.48±1.41 and 4.09±1.22 for cases and controls respectively. The mean differences between TC, HDL, triglycerides and TC: HCL ratios were statistically significant among both groups. Conclusion: Results of our study revealed that significant difference was observed between cases and controls regarding the levels of Total cholesterol , HDL, triglycerides and TC:HDL ratio. Cases of ischemic stroke were found with high levels of TC, Tridlycerides, And TC:HDL ratio and low HDL , this difference was found statistically significant with P value 0.001. so it was concluded that hyperlipidemia has significant relation with ischemic stroke.

Day 2 :

Biography:

Bingsheng Huang is the Professor at Shenzhen University.

Abstract:

Background:Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents antisocial behaviors, and is associated with structural alterations in brain. However, whether these structural alterations can distinguish CD from healthy controls (HCs) remains unknown. Here, we quantified these structural differences and explored the classification ability of these quantitative features based on machine learning (ML). Materials and Methods: High-resolution 3D structural magnetic resonance imaging (sMRI) was acquired from 60 CD subjects and 60 age-matched HCs. Voxel-based morphometry (VBM) was used to assess the regional gray matter (GM) volume difference. The significantly different regional GM volumes were then extracted as features, and input into three ML classifiers: logistic regression, random forest and support vector machine (SVM). We trained and tested these ML models for classifying CD from HCs by using 5-fold cross-validation (CV). Results: Eight brain regions with abnormal GM volumes were detected, which mainly distributed in the frontal lobe, parietal lobe, anterior cingulate, cerebellum posterior lobe, lingual gyrus, and insula areas. We found that these ML models achieved comparable classification performance, with accuracy of 77.9%~80.4%, specificity of 73.3%~80.4%, sensitivity of 75.4%~87.5%, and area under the receiver operating characteristic curve (AUC) of 0.76~0.80. Conclusion: Based on sMRI and ML, the regional GM volumes may be used as potential imaging biomarkers for stable and accurate classification of CD. Keywords: Conduct disorder, structural MRI, voxel-based morphometry, support vector machine, classification.

Biography:

Ailian Du is the professor in Shanghai Jiotong University School of Medicine, China.

Abstract:

To study the heteroplasmy and phenotype correlations of mtDNA 3243A>G mutation in 7 Han Chinese families using restrict fragment length polymorphism (RFLP) and pyrosequencing (Pyro). Methods Seven probands were pathologically and genetically diagnosed as mitochondrial diseases with 3243A>G mutation. The clinical phenotypes were studied in 39 maternal family members. 5 were diagnosed as mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS), 2 with pure mitochondrial myopathy (MM), 1 with early neuropathy, ataxia, and retinitis pigmentosa (NARP) syndrome. Six with diabetes, 3 with hearing loss, and 20 family members are normal. Blood DNA from 37 members were detected with RFLP and pyrosequencing. mtDNA 3243A>G heterogeneity were analyzed. Results Mutation load in blood of 5 MELAS patients were 15.7% by RFLP (29% by Pyro), 12.8% (19% by Pyro), 40.1% (53% by Pyro), 25.8% (30% by Pyro), 28.3% (59% by Pyro). Mutation load in 2 MM patients were 13.7% (29% by Pyro) and 76.8% (79% by Pyro), and that in the NARP patient was 20.0% (57% by Pyro). Six family members with diabetes were range from 3.7%-7.6% (0%-14% by Pyro). Three family members with hearing loss were range from 4%-18.2% (6%-18%). The mutation load of 14 normal family members range from 2% to 12.5% (0%-5% by Pyro). Detection by Pyro is more accurate than RFLP when mutation load is lower than 10%. The mutation load is higher in those earlier age of onset. Conclusion Pyrosequencing is more reliable when mutation load is lower than 10%. The mutation load is negatively correlate to the age of onset in this research.