AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Huntington disease (HD) is an incurable, adult-onset, autosomal dominant inherited disorder associated with cell loss within a specific subset of neurons in the basal ganglia and cortex. HD is named after George Huntington, the physician who described it as hereditary chorea in 1872.¹ Characteristic features of HD include involuntary movements, dementia, and behavioral changes.²

Pathophysiology

The most striking neuropathology in HD occurs within the neostriatum, in which gross atrophy of the caudate nucleus and putamen is accompanied by selective neuronal loss and astrogliosis. Marked neuronal loss also is seen in deep layers of the cerebral cortex. Other regions, including the globus pallidus, thalamus, subthalamic nucleus, substantia nigra, and cerebellum, show varying degrees of atrophy depending on the pathologic grade.

The extent of gross striatal pathology, neuronal loss, and gliosis provides a basis for grading the severity of HD pathology (grades 0-4).³

No gross striatal atrophy is observed in grades 0 and 1. Grade 0 cases have no detectable histologic neuropathology in the presence of a typical clinical picture and positive family history suggesting HD. Grade 1 cases have neuropathologic changes that can be detected microscopically but without gross atrophy. In grade 2, striatal atrophy is present, but the caudate nucleus remains convex. In grade 3, striatal atrophy is more severe, and the caudate nucleus is flat. In grade 4, striatal atrophy is most severe, and the medial surface of the caudate nucleus is concave.⁴

The genetic basis of HD is the expansion of a cysteine-adenosine-guanine (CAG) repeat encoding a polyglutamine tract in the N-terminus of the protein product called huntingtin.⁵ 

The function of huntingtin is not known. Normally, it is located in the cytoplasm. The association of huntingtin with the cytoplasmic surface of a variety of organelles, including transport vesicles, synaptic vesicles, microtubules, and mitochondria, raises the possibility of the occurrence of normal cellular interactions that might be relevant to neurodegeneration.

N-terminal fragments of mutant huntingtin accumulate and form inclusions in the cell nucleus in the brains of patients with HD, as well as in various animal and cell models of HD.⁶ 

The presence of neuronal intranuclear inclusions (NIIs) initially led to the view that they are toxic and, hence, pathogenic.⁷ More recent data from striatal neuronal cultures transfected with mutant huntingtin and transgenic mice carrying the spinocerebellar ataxia-1 (SCA-1) gene (another CAG repeat disorder) suggest that NIIs may not be necessary or sufficient to cause neuronal cell death, but translocation into the nucleus is sufficient to cause neuronal cell death.⁸ Caspase inhibition in clonal striatal cells showed no correlation between the reduction of aggregates in the cells and increased survival.⁹

Furthermore, postmortem studies reveal that NIIs are quite rare in the striata of patients with HD as compared to the cortex, and most of the aggregates within the striatum are observed in populations of interneurons that typically are spared in individuals with HD.

Frequency

United States

Estimates of the prevalence of HD in the United States range from 4.1-8.4 per 100,000 people. Accurate estimates of the incidence of HD are not available.

International

The frequency of HD in different countries varies greatly. A few isolated populations of western European origin have an unusually high prevalence of HD that appears to have resulted from a founder effect. These include the Lake Maracaibo region in Venezuela (700 per 100,000 people), the island of Mauritius off the South African coast (46 per 100,000 people), and Tasmania (17.4 per 100,000 people). The prevalence in most European countries ranges from 1.63-9.95 per 100,000 people. The prevalence of HD in Finland and Japan is less than 1 per 100,000 people.

Mortality/Morbidity

HD is a relentlessly progressive disorder, leading to disability and death, usually from an intercurrent illness.

• The mean age at death in all major series ranges from 51-57 years, but the range may be broader. Duration of illness varies considerably, with a mean of approximately 19 years. Most patients survive for 10-25 years after the onset of illness. In a large study, pneumonia and cardiovascular disease were the most common primary causes of death.
• Juvenile HD (ie, onset of HD in patients younger than 20 years) accounts for approximately 5-10% of all affected patients. Most patients with juvenile HD inherit the disease from their father, whereas patients with onset of the disease after age 20 years are more likely to have inherited the gene from their mother. Inheritance through the father can lead to earlier onset through succeeding generations, a phenomenon termed anticipation. This is caused by greater instability of the HD allele during spermatogenesis. CAG repeat length correlates inversely with age of onset, and the correlation is stronger when the onset of symptoms occurs earlier.
• The length of the CAG repeat is the most important factor in determining age of onset of HD, although substantial variability remains after controlling for repeat length. Both genetic and environmental components account for this variability. The US-Venezuela Collaborative Research Project studied Venezuelan HD kindreds, the world's largest genetically related HD community (18,149 individuals spanning 10 generations) since 1979, collecting genetic and clinical data.¹⁰
• A small number of homozygotes for the HD mutation have been identified, and they seem to be phenotypically indistinguishable from heterozygotes, making HD a truly autosomal dominant disorder.¹¹

Sex

No sex predilection has been reported.

Age

Most studies show a mean age at onset ranging from 35-44 years. However, the range is large and varies from 2 years to older than 80 years. Onset in patients younger than 10 years and in patients older than 70 years is rare. The Venezuelan kindreds manifest an earlier mean age of onset (34.35 y) when compared with Americans (37.47 y) and Canadians (40.36 y). Modifying genes and environmental factors are thought to influence the age of onset in these different populations.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The clinical features of Huntington disease (HD) include a movement disorder, a cognitive disorder, and a behavioral disorder. Patients may present with one or all disorders in varying degrees.

• Chorea (derived from the Greek word meaning to dance) is the most common movement disorder seen in HD.
• • Initially, mild chorea may pass for fidgetiness. Severe chorea may appear as uncontrollable flailing of the extremities (ie, ballism), which interferes with function.
  • As the disease progresses, chorea coexists with and gradually is replaced by dystonia and parkinsonian features, such as bradykinesia, rigidity, and postural instability, which are usually more disabling than the choreic syndrome per se.
  • In advanced disease, patients develop an akinetic-rigid syndrome, with minimal or no chorea. Other late features are spasticity, clonus, and extensor plantar responses.
  • Dysarthria and dysphagia are common. Abnormal eye movements may be seen early in the disease. Other movement disorders, such as tics and myoclonus, may be seen in patients with HD.
  • Juvenile HD (Westphal variant), defined as having an age of onset of younger than 20 years, is characterized by parkinsonian features, dystonia, long-tract signs, dementia, epilepsy, and mild or even absent chorea.
• Cognitive decline is characteristic of HD, but the rate of progression among individual patients can vary considerably. Dementia and the psychiatric features of HD are perhaps the earliest and most important indicators of functional impairment.
• • The dementia syndrome associated with HD includes early onset behavioral changes, such as irritability, untidiness, and loss of interest. Slowing of cognition, impairment of intellectual function, and memory disturbances are seen later. This pattern corresponds well to the syndrome of subcortical dementia, and it has been suggested to reflect dysfunction of frontal-subcortical neuronal circuitry. (The so-called cortical dementias primarily involve the cerebral cortex and are associated with aphasia, agnosia, apraxia, and severe amnesia.)
  • Early stages of HD are characterized by deficits in short-term memory, followed by motor dysfunction and a variety of cognitive changes in the intermediate stages of dementia. These deficits include diminished verbal fluency, problems with attention, executive function, visuospatial processing, and abstract reasoning. Language skills become affected in the final stages of the illness, resulting in a marked word-retrieval deficit.
• The behavioral disorder of HD is represented most commonly by affective illness.
• • Depression is more prevalent, with a small percentage of patients experiencing episodic bouts of mania characteristic of bipolar disorder.
  • Patients with HD and persons at risk for HD may have an increased rate of suicide.
  • Patients with HD also can develop psychosis, obsessive-compulsive symptoms, sexual and sleep disorders, and changes in personality.

Physical

Most patients with HD have a mixed pattern of neurological and psychiatric abnormalities. Understanding of the clinical signs must take into account the fact that signs change during the course of the illness and that different patterns may be observed, depending on the age of onset.

• Chorea is a characteristic feature of HD and, until recently, the disorder commonly was called Huntington chorea. Chorea, as defined by the World Federation of Neurology, is a state of excessive, spontaneous movements, irregularly timed, randomly distributed, and abrupt. Severity of chorea may vary from restlessness with mild intermittent exaggeration of gesture and expression, fidgeting movements of the hands, and unstable dancelike gait to a continuous flow of disabling violent movements. Chorea in cases of HD usually is generalized.
• • Patients may incorporate involuntary choreiform movements into apparently purposeful gestures, a phenomenon referred to as parakinesia.
  • Ballism is characterized by large amplitude, usually proximal, flinging movements of a limb or body part. Ballism is considered to be a severe form of chorea by most authors.
  • Chorea may coexist with slower, distal, writhing, sinuous movements called athetosis; it then is described as choreoathetosis.
  • Chorea is less prominent in juvenile HD and in advanced stages of the illness.
• Bradykinesia and akinesia are frequent features of HD and may explain some of the abnormalities of voluntary movement observed clinically.
• • Bradykinesia may be a major source of disability of voluntary movement, though it commonly is overshadowed by the hyperkinetic movement disorder.
  • Other parkinsonian signs, such as rigidity and postural instability, may be seen. Patients may become akinetic and rigid in the terminal stages of the illness.
• Dystonia is defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures.
• • Mild dystonia, in combination with chorea, may give the writhing appearance of choreoathetosis.
  • Sustained dystonic posturing may result in contractures, immobility, and breakdown of skin.
  • Dystonia may be prominent in juvenile HD.
• Eye movement abnormalities can be seen early in the disease.
• • Initiation of saccadic movements is slow and uncoordinated. Patients have difficulty suppressing head movements or blinking in order to break fixation and generate saccadic movements.
  • Smooth pursuit is interrupted by saccadic intrusions.
  • Patients are unable to inhibit saccades toward a peripheral stimulus when instructed to look in the opposite direction.
• Tendon reflexes are variable in HD, ranging from reduced in some patients to pathologically brisk with clonus in other patients. The plantar response usually is flexor, but it may be extensor in advanced stages of the illness.
• Other hyperkinesias, such as tics and myoclonus, may be seen in HD.
• Dementia, depression, and other psychiatric manifestations may be seen at the time of examination as well.

Causes

The selective neuronal dysfunction and subsequent loss of neurons in the striatum, cerebral cortex, and other parts of the brain can explain the clinical picture seen in cases of HD. Several mechanisms of neuronal cell death have been proposed for HD, including excitotoxicity, oxidative stress, impaired energy metabolism, and apoptosis.

• Excitotoxicity
• • Excitotoxicity refers to the neurotoxic effect of excitatory amino acids in the presence of excessive activation of postsynaptic receptors.
  • Intrastriatal injections of kainic acid, an agonist of a subtype of glutamate receptor, produce lesions similar to those seen in HD.
  • Intrastriatal injections of quinolinic acid, an N-methyl-D-aspartate (NMDA) receptor agonist, selectively affect medium-sized GABA-ergic spiny projection neurons, sparing the striatal interneurons and closely mimicking the neuropathology seen in HD.
  • NMDA receptors are depleted in the striata of patients with HD, suggesting a role of NMDA receptor-mediated excitotoxicity, but no correlation exists between the distribution of neuronal loss and the density of such receptors.
  • The theory that reduced uptake of glutamate by glial cells may play a role in the pathogenesis of HD also has been proposed.
• Oxidative stress
• • Oxidative stress is caused by the presence of free radicals (ie, highly reactive oxygen derivatives) in large amounts. This may occur as a consequence of mitochondrial malfunction or excitotoxicity and can trigger apoptosis.
  • Striatal damage induced by quinolinic acid can be ameliorated by the administration of spin-trap agents, which reduce oxidative stress, providing indirect evidence for the involvement of free radicals in excitotoxic cell death.
• Impaired energy metabolism
• • Impaired energy metabolism reduces the threshold for glutamate toxicity and can lead to activation of excitotoxic mechanisms as well as increased production of reactive oxygen species.
  • Nuclear magnetic resonance spectroscopy studies have shown elevated lactate levels in the basal ganglia and occipital cortex of patients with HD.
  • Patients with HD have an elevated lactate-pyruvate ratio in the cerebrospinal fluid.
  • A reduction in the activity of the respiratory chain complex II and III (and less in complex IV) of mitochondria of caudate neurons in patients with HD has been reported.
  • In rats, intrastriatal injections of 3-nitroproprionic acid (3-NP), an inhibitor of succinate dehydrogenase or complex II of the respiratory chain, cause dose-dependent ATP depletion, increased lactate concentration, and neuronal loss in the striatum. Systemic injections of 3-NP into rats produce a selective loss of medium spiny neurons in the striatum.
• Apoptosis
• • Apoptosis is the programmed cell death that is activated normally in the nervous system during embryogenesis to remove supernumerary neurons as part of natural development.
  • Morphological features of apoptosis have been well characterized. Oxidative stress, excitotoxicity, and partial energy failure can lead to apoptosis.
  • A subset of neurons and glia in the neostriata of patients with HD appears to undergo apoptosis, as shown by in situ DNA nick end labeling (TUNEL) staining, but clear morphological evidence for an apoptotic process in HD is still missing.
• One theory is that expanded polyglutamine repeats cause neuronal degeneration through abnormal interactions with other proteins containing short polyglutamine tracts. Recent work suggests that polyglutamine interference with transcription of CREB binding protein (CBP), a major mediator of survival signals in mature neurons, may constitute a genetic gain of function underlying polyglutamine disorders including HD.¹²
• The role of caspases (a class of highly specific proteases) in apoptosis involves cleavage of target proteins at different sites. In humans with HD and in animal models of HD, the intracellular accumulation of N-terminal huntingtin fragments is one of the neuropathological features. Caspases, among other proteins, cleave huntingtin within the N-terminal region. To address the question of a potential in vivo neuroprotective effect of inhibition of caspases, a YAC mouse model expressing mutant huntingtin, along with selective mutations of the caspase-3 and caspase-6 cleavage sites, was studied. Selective elimination of the caspase-6, but not caspase-3, cleavage site in mutant huntingtin resulted in protection from neuronal dysfunction and neurodegeneration in vivo. These results suggest that preventing caspase-6 cleavage of huntingtin may be of therapeutic interest.¹³

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Sydenham chorea
Antiphospholipid antibody syndrome
Benign hereditary chorea
Dentatorubropallidoluysian atrophy (DRPLA)
Senile chorea
Vascular chorea, hemichorea, and hemiballismus
Hyperthyroidism
Polycythemia vera
Paroxysmal dyskinesias
Drug effects

See Medscape CME activity The Huntington's Disease-Like Syndromes: What to Consider in Patients With a Negative Huntington's Disease Gene Test.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• No single imaging technique is necessary or sufficient for diagnosis of Huntington disease (HD). Measurement of the bicaudate diameter (ie, the distance between the heads of the 2 caudate nuclei) by CT scan or MRI is a reliable marker of HD.¹⁴
• Abnormalities in positron emission tomography (PET) scanning and proton MR spectroscopy have been reported; however, their use in clinical practice is limited.

Other Tests

• Genetic testing (reported as the CAG repeat number for each allele) is now commercially available.
• • Genetic testing may not be necessary in a patient with a typical clinical picture and a genetically proven family history of HD.
  • In the absence of a family history of HD, patients with a suggestive clinical presentation should undergo genetic testing to exclude or confirm HD.
  • Persons at risk for HD who request presymptomatic testing should undergo extensive genetic counseling and neurologic and psychiatric evaluation, given the implications of receiving a positive (or negative) result for an untreatable, familial, progressive, neurodegenerative disease. Most testing centers follow strict protocols, such as the one put forth by the Huntington's Disease Society of America (HDSA).¹⁵
• If the genetic test is negative for HD, then testing for systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome, thyroid disease, neuroacanthocytosis, DRPLA, Wilson disease, and other less common causes of chorea may be reasonable, depending on the individual case.

Staging

The extent of gross striatal pathology, neuronal loss, and gliosis provides a basis for grading the severity of HD pathology (grades 0-4). See Pathophysiology.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Consider general safety measures and nonpharmacologic interventions first in the management of Huntington disease (HD).

• If chorea is severe enough to interfere with function, consider treatment with benzodiazepines, such as clonazepam or diazepam; valproic acid; dopamine-depleting agents, such as reserpine or tetrabenazine (approved by the US Food and Drug Administration [FDA] in August 2008); and finally, neuroleptics.
• • The drug tetrabenazine has shown some positive effects in the treatment of chorea, for patients with HD. It selectively depletes central monoamines by reversibly binding to the type-2 vesicular monoamine transporter.
  • Results from a phase III clinical study showed that this investigational drug is an effective treatment for chorea associated with HD. The dosing range that proved effective was 12.5-100 mg/d.¹⁶ Its manufacturer has been granted fast track and orphan drug status by the FDA. It is the first treatment for chorea in patients with HD in the United States. Always weigh potential adverse effects against the benefits of each drug.
• Patients who have HD and predominant features of bradykinesia and rigidity may benefit from treatment with levodopa or dopamine agonists.¹⁷
• Depression in patients with HD is treatable and should be recognized promptly. Selective serotonin reuptake inhibitors (SSRIs) should be considered as first-line therapy. Other antidepressants, including bupropion, venlafaxine, nefazodone, and tricyclic antidepressants, also can be used. Electroconvulsive therapy (ECT) can be used in patients with refractory depression.
• Antipsychotic medications may be necessary in patients with hallucinations, delusions, or schizophrenia-like syndromes. Newer agents, such as quetiapine, clozapine, olanzapine, and risperidone, are preferred to older agents because of the lower incidence of extrapyramidal side effects and the decreased risk for tardive syndromes.
• Irritability may be treated with antidepressants, particularly the SSRIs; mood stabilizers, such as valproic acid or carbamazepine; and, if needed, atypical neuroleptics.
• Other less frequent aspects of HD that may require pharmacologic treatment are mania, obsessive-compulsive disorder, anxiety, sexual disorders, myoclonus, tics, dystonia, and epilepsy.

Surgical Care

Ablative surgical procedures and fetal cell transplantation have been attempted in patients with HD. Currently, enough data to support this type of treatment are not available. It is still experimental.

Consultations

• Physical therapist
• Occupational therapist
• Speech therapist
• Psychiatrist
• Genetic counselor

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Although no therapy is currently available to delay the onset of symptoms or prevent the progression of the disease, symptomatic treatment of patients with Huntington disease (HD) may improve the quality of life and prevent complications. As is the case with other neurological diseases, HD makes individuals more vulnerable to side effects from medications, particularly cognitive adverse effects. Avoid polypharmacy if possible. Symptomatic treatment for HD can be divided into drugs to treat the movement disorder and drugs to treat psychiatric or behavioral problems.

Experimental therapies for HD currently are being tested in animal models and human trials. Awareness of ongoing research to find an effective cure for HD must be a part of the care plan of an individual patient and the patient's family.

Therapeutic options include dopamine-depleting agents (eg, reserpine, tetrabenazine) and dopamine-receptor antagonists (eg, neuroleptics). Long-term use of these drugs may carry a high risk of adverse effects. Choreic movements in patients with HD should be treated pharmacologically only if they become disabling to the patient. Neuroleptics may worsen other features of the disease, such as bradykinesia and rigidity, leading to further functional decline.

Results of some studies have suggested that valproic acid and clonazepam may be effective in the treatment of chorea, while results of other studies have been less conclusive. In the authors' experience, using valproic acid and clonazepam first may be worthwhile because of their safer adverse-effect profiles.

Tetrabenazine is a dopamine-depleting agent was approved by the FDA in August 2008. It may be more effective than reserpine in the treatment of chorea and less likely to cause hypotension. The dose is titrated slowly and may be increased over several weeks to a maximum 75-100 mg/d in divided doses.

Drug Category: Monoamine inhibitor

Tetrabenazine is the first drug approved specifically to treat chorea associated with Huntington disease.

Drug Category: Anticonvulsant

These agents are used to manage muscle spasms in chorea.

Drug Category: Antipsychotic agents

These agents may improve choreic movements in patients.

Drug Category: Rauwolfia alkaloids

These agents may improve choreic movements in patients.

Drug Category: Antidepressants

Depression is relatively common in patients with HD and should be treated pharmacologically as soon as diagnosis of depression is made. Depression in patients with HD can be treated with the same agents used for treatment of depression of any other cause. SSRIs may be used as first-line therapy because of their low adverse-effect profile, convenient dosing, and safety in the event of overdose. Other antidepressants can be used, including bupropion, venlafaxine, nefazodone, and the tricyclic antidepressants. Electroconvulsive therapy can be effective if an immediate intervention is required and in patients who do not respond to several good trials of medication.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Patient Education

For excellent patient education resources, visit eMedicine's Dementia Center. Also, see eMedicine's patient education article Huntington Disease Dementia.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The usual medicolegal pitfalls of missed diagnosis, delayed diagnosis, and complications of medication therapy are pertinent in those with HD.
• With the increasing amount of genetic/hereditary information available in HD, the question of whether patients and/or family members should be made aware of the genetic risks is becoming an increasingly important issue.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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33. PEARSON JS, PETERSEN MC, LAZARTE JA, BLODGETT HE, KLEY IB. An educational approach to the social problem of Huntington's chorea. Proc Staff Meet Mayo Clin. Aug 10 1955;30(16):349-57. [Medline].
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Article Last Updated: Sep 4, 2008