Diagnostic clues and pitfalls in pontocerebellar hypoplasia type 2A

IntroductionPontocerebellar hypoplasia type 2A (PCH2A) is a rare autosomal recessive neurodegenerative disease caused by a specific pathogenic variant in the TSEN54 gene (p.A307S). Affected children show early but initially unspecific symptoms, diagnosed primarily through postnatal MRI, with confirmation by genetic testing. This study examines the diagnostic process and key considerations for accurate diagnosis. Patients and MethodsWe retrospectively collected data from 65 children (33 female, 32 male) with genetically confirmed PCH2A as part of a Natural History Study. Data were gathered via parental questionnaires, interviews, and medical reports. The cohort was divided into two groups based on year of birth: children born before (n=30) and after (n=35) the identification of the pathogenic variant in 2008. ResultsPrenatally, in 4 of 21 cases with specialized ultrasound (gestational weeks 12-32), only unspecific cerebebellar abnormalities were reported. One fetal MRI (week 31) revealed clear cerebellar hypoplasia, in two others (week 21 and 31), slight cerebellar abnormalities were reported. Postnatal neurosonography often indicated disease features (26/54), later confirmed by MRI (62/63). Clinical symptoms appeared at a median age of 0 months (range 0-6 months), often initially suggesting acute rather than congenital issues. In the group born after 2008, median time from first symptoms to genetic confirmation was 5 months. ConclusionPCH2A presents early with nonspecific symptoms. Prenatal and postnatal ultrasound imaging can fail to detect the condition, with MRI being the gold standard for diagnosis. Over time, the diagnostic process, including genetic confirmation, has become faster. Highlights- Diagnostic Challenges: Prenatal imaging fails to detect PCH2A - Postnatal Imaging: MRI 92% diagnostic sensitive, ultrasound misinterpretations - Genetic testing impact: Earlier PCH2A diagnosis in children born after 2008