Friedreich ataxia is the most frequent
hereditary ataxia, with an estimated prevalence of 3-4 cases per 100,000 individuals. This autosomal-recessive
neurodegenerative disease is characterized by progressive gait and
limb ataxia,
dysarthria, lower-limb areflexia, decreased vibration sense,
muscular weakness in the legs, and a positive extensor plantar response. Non-neurological signs include
hypertrophic cardiomyopathy and
diabetes mellitus. Symptom onset typically occurs around puberty, and life expectancy is 40-50 years.
Friedreich ataxia is usually caused by a large GAA-triplet-repeat expansion within the first intron of the
frataxin (FXN) gene. FXN mutations cause deficiencies of the
iron-
sulfur cluster-containing subunits of the mitochondrial electron transport complexes I, II, and III, and of the
iron-sulfur protein aconitase.
Mitochondrial dysfunction has been addressed in several open-label, non-placebo-controlled trials, which indicated that treatment with
idebenone might ameliorate
hypertrophic cardiomyopathy; a well-designed phase II trial suggested concentration-dependent functional improvements in non-wheelchair-bound children and adolescents. Other current experimental approaches address
iron-mediated toxicity, or aim to increase FXN expression through the use of
erythropoietin and
histone deacetylase inhibitors. This Review provides guidelines, from a European perspective, for the diagnosis of
Friedreich ataxia, differential diagnosis of
ataxias and genetic counseling, and treatment of neurological and non-neurological symptoms.