Cette thèse propose des techniques pour le traitement d'images IRM de diffusion. Les méthodes proposées concernent l'estimation et la régularisation, le groupement et la segmentation ainsi que le recalage. Le cadre variationnel proposé dans cette thèse pour l'estimation d'un champ de tenseurs de diffusion à partir d'observations bruitées exploite le fait que les données de diffusion représentent des populations de fibres et que chaque tenseur peut être reconstruit à partir d'une combinaison pondérée de tenseurs dans son voisinage. La méthode de segmentation traite aussi bien les voxels que les fibres. Elle est basée sur l'utilisation de noyaux défini-positifs sur des probabilités gaussiennes de diffusion afin de modéliser la similarité entre tenseurs et les interactions spatiales. Ceci permet de définir des métriques entre fibres qui combinent les informations de localisation spatiale et de tenseurs de diffusion. Plusieurs approches de groupement peuvent être appliquées par la suite pour segmenter des champs de tenseurs et des trajectoires de fibres. Un cadre de groupement supervisé est proposé pour étendre cette technique. L'algorithme de recalage utilise les noyaux sur probabilités pour recaler une image source et une image cible. La régularité de la déformation est évaluée en utilisant la distortion induite sur les distances entre probabilités spatialement voisines. La minimisation de la fonctionnelle de recalage est faite dans un cadre discret. La validation expérimentale est faite sur des images du muscle du mollet pour des sujets sains et pour des patients atteints de myopathies. Les résultats des techniques développées dans cette thèse sont encourageants.

Cette thèse propose des techniques pour le traitement d'images IRM de diffusion. Les méthodes proposées concernent l'estimation et la régularisation, le groupement et la segmentation ainsi que le recalage. Le cadre variationnel proposé dans cette thèse pour l'estimation d'un champ de tenseurs de diffusion à partir d'observations bruitées exploite le fait que les données de diffusion représentent des populations de fibres et que chaque tenseur peut être reconstruit à partir d'une combinaison pondérée de tenseurs dans son voisinage. La méthode de segmentation traite aussi bien les voxels que les fibres. Elle est basée sur l'utilisation de noyaux défini-positifs sur des probabilités gaussiennes de diffusion afin de modéliser la similarité entre tenseurs et les interactions spatiales. Ceci permet de définir des métriques entre fibres qui combinent les informations de localisation spatiale et de tenseurs de diffusion. Plusieurs approches de groupement peuvent être appliquées par la suite pour segmenter des champs de tenseurs et des trajectoires de fibres. Un cadre de groupement supervisé est proposé pour étendre cette technique. L'algorithme de recalage utilise les noyaux sur probabilités pour recaler une image source et une image cible. La régularité de la déformation est évaluée en utilisant la distortion induite sur les distances entre probabilités spatialement voisines. La minimisation de la fonctionnelle de recalage est faite dans un cadre discret. La validation expérimentale est faite sur des images du muscle du mollet pour des sujets sains et pour des patients atteints de myopathies. Les résultats des techniques développées dans cette thèse sont encourageants. / In this thesis, we present several techniques for the processing of diffusion tensor images. They span a wide range of tasks such as estimation and regularization, clustering and segmentation, as well as registration. The variational framework proposed for recovering a tensor field from noisy diffusion weighted images exploits the fact that diffusion data represent populations of fibers and therefore each tensor can be reconstructed using a weighted combination of tensors lying in its neighborhood. The segmentation approach operates both at the voxel and the fiber tract levels. It is based on the use of Mercer kernels over Gaussian diffusion probabilities to model tensor similarity and spatial interactions, allowing the definition of fiber metrics that combine information from spatial localization and diffusion tensors. Several clustering techniques can be subsequently used to segment tensor fields and fiber tractographies. Moreover, we show how to develop supervised extensions of these algorithms. The registration algorithm uses probability kernels in order to match moving and target images. The deformation consistency is assessed using the distortion induced in the distances between neighboring probabilities. Discrete optimization is used to seek an optimum of the defined objective function. The experimental validation is done over a dataset of manually segmented diffusion images of the lower leg muscle for healthy and diseased subjects. The results of the techniques developed throughout this thesis are promising.

Bien que l’innocuité de la pratique de l’activité physique (AP) ait été acceptée dans les myopathies y compris dans les dystrophies, il existe très peu de preuve de pertinence dans la littérature. Ce travail de thèse a permis d’apporter pour la première fois les preuves confirmées de l’innocuité et des effets bénéfiques de la thérapie par l’exercice dans le cadre de la dystrophie facio scapulo humérale. Ceci à travers une vision intégrée de ces bénéfices potentiels émanant d’évaluations conjointes fonctionnelles, tissulaires et de qualité de vie. Deux groupes ont été formés par randomisation : groupe contrôle (CG : 44 ± 10ans) et groupe entraîné (TG : 40 ± 13ans). Au terme de 24 semaines d’un entraînement mixte adapté, supervisé et coaché à domicile, les bénéfices fonctionnels importants ont été rapportés notamment en terme de capacité aérobie (VO2pic, PMA), de force (MVC) suivi d’une augmentation de la surface de section (CSA) des fibres musculaires, de fonction musculaire (endurance musculaire, TM6) et de fatigue ressentie par les patients. L’absence de dommages musculaires et la forte tendance à l’amélioration de la qualité de vie confortent l’idée de l’innocuité de notre programme d’AP. La biologie du muscle révèle aussi des améliorations de l’activité de certains enzymes du métabolisme oxydatif (CS et CK). En somme, ce programme d’entraînement mixte, supervisé et coaché à domicile a permis d’aboutir à des améliorations fonctionnelles, tissulaires et de qualité de vie, ce qui ouvre des perspectives d’application à d’autres types de myopathies / Although it is now accepted that physical activity (PA) is not deleterious in myopathies, including muscular dystrophies, there is very little evidence of relevance in the literature. This thesis has allowed to provide for the first time, confirmed evidence of safety and beneficial effects of exercise therapy in FSHD, through an integrative view of the potential benefits of such programs on functional, biological and quality of life. Two groups were randomly formed: control group (CG: 44 ± 10 years) and trained group (TG: 40 ± 13 years). After 6-month of adapted and home-based training, benefits have been reported particularly in terms of aerobic capacity (VO2pic, PMA), strength (MVC) followed by an increase in cross-sectional area (CSA) of muscle fibers, muscle function (muscle endurance, 6MWT) and fatigue experienced by patients. The lack of muscle damage (HES analysis & plasma CK values) and the strong tendency to improving the quality of life, support the idea that our training program is safe. Muscle biology also shows improvements in the activity of some oxidative enzymes (CS and CK). In short, this home-based mixed training program has allowed to achieve functional, tissue and quality of life improvements, which opens perspectives for application to other types of myopathies

Les muscles sont des structures très organisées qui nous permettent d’effectuer un grand nombre de fonctions. Ils sont constitués de cellules musculaires mais aussi de tissus conjonctifs qui comprennent à la fois des cellules et la matrice extracellulaire. Les interactions entre les cellules musculaires et le tissu conjonctif sont cruciales pour la physiologie du muscle. Le collagène VI (COLVI) est une molécule hétérotrimérique ubiquitaire située dans les tissus conjonctifs, qui est impliquée dans un grand nombre de processus biologiques. Les trimères de COLVI sont composés de 2 chaines dites “courtes” et d’une chaine “longue”. Chez les mammifères, il existe à ce jour, 6 chaines COLVI (deux courtes (α1-2(VI) et 4 chaines longues (α3-6(VI)). Peu de choses sont encore connues à propos de l’assemblage des chaines les plus récemment décrites α4-6(VI) avec les chaines courtes ainsi qu’une la potentielle compensation entre les différentes chaines longues. De plus, chez l’homme, un déficit en α1-3(VI) du fait de mutations dans les gènes correspondants COL6A1-3 conduit à un spectre de maladies neuromusculaires appelées myopathies liées au COLVI. Pendant ma thèse, je me suis intéressée au COLVI durant le développement du poisson-zèbre, un modèle pertinent pour l’étude de maladies neuromusculaires. Dans la première partie de mon travail, j’ai identifié 2 orthologues des chaines α4-6(VI) chez le poisson-zèbre grâce à des études bio-informatiques. Du fait de leur plus grande homologie avec la chaine α4(VI) murine, nous les avons nommés col6a4a et col6a4b. Pour mieux comprendre les rôles des protéines correspondantes, j’ai créé des embryons de poissons-zèbres déficients en COLVI en utilisant l’approche transitoire par oligo morpholino antisens (MOs). Nous avons dessiné des MOs ciblant des sites d’épissage des pré-messagers col6a2, col6a4a et col6a4b, provoquant un saut d’exon et conduisant à un stop prématuré (PTC). J’ai observé une forte diminution des transcrits ciblés. Tous les embryons injectés (morphants) ont présenté des phénotypes morphologiques macroscopiques qui ont conduit à des défauts fonctionnels. Ces phénotypes ont été confirmés au niveau ultra-structural par microscopie électronique. Toutefois, l’analyse de la croissance des motoneurones a permis de mettre en évidence des différences entre ces morphants. Par la suite, j’ai voulu créer deux types de lignées transgéniques, pour pouvoir à la fois étudier le déficit en COLVI à plus long terme (grâce à l’utilisation de Zinc Finger Nucleases) et tester des approches de cribles pharmacologiques (lignée transgénique col6a2 contenant un PTC, fusionné à la GFP). J’ai effectué les clonages nécessaires à l’obtention des différentes constructions, et ces dernières ont été testées in vitro pour validation, lorsque cela était possible. Malheureusement, du fait des forts taux de mortalité in vivo dans les deux cas, nous avons dû nous résoudre à arrêter ces projets. En parallèle, ma connaissance du modèle poisson-zèbre m’a donné l’opportunité, dans le cadre d’une collaboration avec l’équipe de Denis Furling, d’aborder une autre problématique. Ce groupe, qui travaille sur la Dystrophie Myotonique de type 1 (DM1), s’est intéressé à la réexpression d’une isoforme fœtale de la dystrophine retrouvée chez les patients DM1 et à sa possible implication dans la pathologie. L’isoforme fœtale diffère de la forme adulte notamment par l’exclusion de l’exon 78, conduisant à un changement de cadre de lecture et un changement dans la partie 3’ de l’ARN de la dystrophine. Nous avons montré que le maintien de l’isoforme fœtale de la dystrophine était délétère pendant le développement du poisson-zèbre, puisque ces embryons ont présenté un phénotype macroscopique dépendant de la dose de MO injectée ainsi que des troubles de la mobilité. / Muscles are highly organized structures that allow us to perform many functions. They are made from muscular cells but also surrounding tissues that comprise both cells and extracellular matrix. The interactions between them are crucial for the muscle physiology. Collagen VI (COLVI) is a heterotrimeric protein, ubiquitously expressed in connective tissues. It plays multiple biological roles in the maintenance of structural integrity, cellular adhesion, migration and survival. COLVI trimers are formed by the assembly of 2 “short” chains and 1 “long” chain. To date, six COLVI chains are recognized in mammalians with 2 short (α1-2(VI)) and 3 long (α3-6(VI)) chains. Little is known regarding the possible assembly of the newly characterized α4-6(VI) polypeptides with the short chains, and a putative functional compensation between the different long chains. Furthermore, in humans, deficiency in α1-3(VI) due to mutations in the COL6A1-3 genes causes a heterogeneous group of neuromuscular disorders collectively termed COLVI-myopathies. During my Ph.D, I got interested in COLVI during the development of zebrafish, a relevant model of neuromuscular disorders. In the first part of my work, I identified 2 orthologs of the α4-6(VI) chains in zebrafish thanks to bio-informatics studies. In light of their stronger homology with the mammalian α4(VI) chain, we named the genes encoding the novel chains col6a4a and col6a4b. To further unveil the roles of the corresponding proteins, we created COLVI deficient zebrafish embryos using a morpholino antisense oligonucleotides approach (MO) . We chose to design MOs that block splicing of col6a2, col6a4a and col6a4b, thereby creating premature termination codons. As expected, the targeted transcripts levels were drastically reduced, likely due to degradation by the nonsense mediated RNA decay. All morphant embryos presented macroscopic and morphologic phenotypes that overall resulted in functional muscle defects: altered muscle structure detected by birefringence analysis and impaired motility upon touch-evoked escape test. These alterations were confirmed at the ultra-structural level by electron microscopy. Nevertheless, some phenotypical specificities were uncovered between the different col6a2, col6a4a and col6a4b morphants, with the discovery of axon outgrowth defects. In a second part, we wanted to create stable zebrafish lines to study COLVI deficiency at later stages using Zinc Finger Nucleases (ZFN) and to be able to carry out pharmacological screenings with a transgenic line containing col6a2 with a premature codon (PTC) fused to the GFP. I performed clonings to obtain the different constructs. When possible, constructs were tested in vitro. Unfortunately, due to high mortality in vivo in both cases, we had to interrupt these projects. In parallel, my knowledge of the zebrafish model gave me the opportunity to be part of another project, in collaboration with the team of Denis Furling...

Title: Body composition in patients with idiopatic inflammatory myopathies Objectives: The aim of this study was to compare selected parameters of body composition in patients with idiopathic inflammatory myopathies (IIM) with age- and sex-matched healthy controls (HC). Another objective was to evaluate the effect of selected clinical parameters in patients with IIM on the detectedvariability of the parameters of body composition and on physical activity of patients. Methods: The research sample consisted of 84 individuals (54 IIM, 30 HC). In anthropometry, we measured: body height (cm), weight (kg) and BMI (kg/m2 ). Using bioelectrical impedance analysis BIA 2000-M we obtained values: total body water (TBW in%), muscle mass (LBM in kg), body fat (BF in%) cell mass of lean body mass (BCM of FFM in%), and the proportion of extracellular/intracellular matrix (ECM/BCM). Using Lunar series iDXA we obtained values: muscle mass (LBM in kg), body fat (BF in %), bone mineral density (BMD in g/cm3 ), and visceral fat (Visceral in kg). To these measured values we added a questionnaire on physical activity Human Acitvity Profile (HAP). Statistics: T-test, Mann Whitney U test, Cohen's d, and Partialeta-squared. Results: Selected values (mean ± SD): body height: IIM 164.7 ± 9.1 cm, HC 170.3 ± 7 cm; body weight:...

Introduction: This work focused on two rare rheumatic diseases systemic sclerosis (SSc) and idiopathic inflammatory myopathies (IIM). Skin and musculoskeletal involvement in patients with SSc leads to disability and loss of functional abilities of an individual. Chronic inflammation of the muscles, subsequent muscle atrophy and permanent muscle damage in patients with IIM are the cause of a decrease in muscle strength and endurance. Moreover, both diseases also affect internal organs and manifest often with impaired lung and heart function. All of these involvements in both diseases lead to a decrease in the quality of life of patients. The data on efficacy of non-pharmacological care in SSc and IIM are very limited due to the heterogeneity of the studied interventions and/or outcomes. However, due to limitations in pharmacological therapy, non-pharmacological interventions could help bring patients back into their everyday life and improve their quality of life. Objectives: The main objective of this project was to evaluate the impact of physical intervention on disease course and activity in a substantial number of SSc and IIM patients, with the aim of minimizing the limitations of available studies, thereby improving the quality and reliability of the obtained results. Methods: This is a...

The eukaryotic nuclear envelope (NE), separates the nucleoplasm from cytoplasm and is made up of two concentric lipid membranes, the outer and the inner nuclear membranes (ONM and INM), the nuclear pore complexes (NPCs) and an underlying filamentous nuclear lamina. The INM contains hundreds of unique transmembrane proteins of which only a handful have been characterized. In this thesis, I aimed to understand the functional organization of proteins in the nuclear envelope and I focused on investigating the functions of a recently identified INM transmembrane protein, Samp1. We have developed a novel and robust approach, MCLIP, to identify specific protein-protein interactions taking place in live cells. Using MCLIP, we have shown that Samp1 interacts with proteins of the LINC complex, the nuclear lamina and components of the mitotic spindle. Samp1's specific interactions with a variety of binding partners, suggest that Samp1 plays important roles both in interphase and in mitosis.  We have also shown that Samp1 can provide a binding site at the INM for the GTPase Ran, a master regulator of protein interactions in interphase and in mitosis. Furthermore, we have also investigated the role of Samp1 in cell differentiation using two independent model systems. In human iPSCs, ectopic expression of Samp1 promoted differentiation despite pluripotent culture conditions. In C2C12 myoblast, depletion of Samp1 completely blocked differentiation into myotubes. The two studies complement each other and suggest that Samp1 has a strong differentiation promoting activity. Taken together, the findings in this thesis, give insights on the unexpected and unforeseen roles played by a transmembrane protein in different fundamental cellular process. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 3: Manuscript. Paper 4: Manuscript. Paper 5: Manuscript.</p>

INTRODUÇÃO: A forma clássica de encefalomiopatia mitocondrial associada à mutação do DNA mitocondrial m.3243A>G é a Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like episodes (síndrome de MELAS). Entretanto, o espectro de manifestações clínicas dos indivíduos que apresentam essa mutação é bastante amplo. OBJETIVO: Descrever o espectro clínico, laboratorial e de imagem de pacientes com doença mitocondrial decorrente da mutação m.3243A>G. MÉTODOS: Estudo descritivo retrospectivo de uma série de casos de pacientes com a mutação m.3243A>G em seguimento no ANEM/HCFMRP-USP. Os dados clínicos e informações sobre exames complementares foram coletados através de revisão sistemática dos prontuários médicos dos pacientes selecionados. Os exames de neuroimagem foram revisados juntamente com neurorradiologista experiente para descrição das lesões encontradas. RESULTADOS: No período compreendido entre maio de 2000 e maio de 2015, a mutação m.3243A>G foi pesquisada em um total de 817 pacientes, em DNA extraído de células do sangue periférico (n= 441), de fragmentos de biópsia de músculo esquelético (n= 293), de ambos (n= 82) e mais raramente de células do sedimento urinário (n=1). Dentre esses, 16 indivíduos de 12 famílias apresentaram a referida mutação, resultando em uma taxa de detecção da mutação de 1,96% nessa população. Foram incluídos no estudo 12 indivíduos de 9 famílias que estavam em seguimento no nosso serviço. Os achados mais comuns nesta série foram em ordem de frequência: sinais de miopatia, transtornos neurocomportamentais, epilepsia, endocrinopatias, ataxia cerebelar, migrânea, episódios semelhantes a AVC, vômitos recorrentes, distúrbios de condução cardíaca, neuropatia periférica e sinais de disautonomia, mioclonias, surdez neurossensorial, cegueira cortical, comprometimento ocular, e proteinúria. Em nossa série, identificamos que cinco pacientes foram classificados com a forma clássica de MELAS, dois apresentaram CPEO associada a outros sintomas como transtornos psiquiátricos e diabetes mellitus. Os demais pacientes apresentavam características clínicas que não configuravam uma síndrome clinica definida. Além das lesões semelhantes a AVC, as lesões reveladas por neuroimagem mais frequentes nessa população foram alteração de sinal dos núcleos da base, atrofia encefálica e alteração de sinal da substância branca, sendo igualmente prevalentes entre os pacientes com a síndrome clássica de MELAS e os pacientes que não apresentaram lesões semelhantes a AVC. Dos pacientes com MELAS, 100% apresentaram pico anômalo de lactado e 60% redução do NAA à espectroscopia de prótons; enquanto que entre os pacientes sem lesões semelhantes a AVC essas alterações foram encontradas em dois e em um paciente Caracterização clínica, laboratorial e de neuroimagem de pacientes com doença mitocondrial associada à mutação m.3243A>G 8 respectivamente. Nós identificamos o achado inédito de azoospermia associada à mutação m.3243A>G. Essa é a maior série de casos de pacientes brasileiros com a mutação m.3243A>G até o momento. CONCLUSÃO: O amplo espectro de apresentação clínica e de neuroimagem é uma característica notável entre os pacientes com a mutação m.3243A>G do DNAmt. Essa desordem deve ser considerada em pacientes com evidência de sinais e sintomas que sugiram acometimento multissistêmico. / INTRODUCTION: The classic form of mitochondrial encephalomyopathy associated with m.3243A>G mutation is the Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like episodes (MELAS syndrome). However, the spectrum of clinical manifestations of patients with this mutation is quite wide. OBJECTIVE: To describe the clinical, laboratory and imaging spectrum of patients with mitochondrial disease due to m.3243A>G mutation METHODS: A retrospective descriptive study of a series of cases of patients with the m.3243A>G mutation in follow-up in ANEM/HCFMRP-USP. Clinical data and information about additional tests were collected through systematic review of medical records of selected patients. Neuroimaging studies were reviewed with supervision of experienced neuroradiologist and the lesions were described. RESULTS: Between May 2000 and May 2015, the mutation m.3243A>G was evaluated in a total of 817 patients, on DNA extracted from peripheral blood (n = 441), skeletal muscle biopsy samples (n = 293), both (n = 82) and more rarely urinary sediment cells (n = 1). We founded 16 individuals 12 families with the mutation, resulting in a mutation detection rate of 1.96 % that population. 12 individuals from nine families, who were following at our service, were included in this study. The most common findings in this series were in order of frequency: myopathy signs, neurobehavioral disorders, epilepsy, endocrine disorders, cerebellar ataxia, migraine, stroke-like episodes, recurrent vomiting, cardiac conduction disorders, peripheral neuropathy and signs of dysautonomia, myoclonus, sensorineural deafness, cortical blindness, uveitis, and proteinuria. In our series, we found that five of the patients were classified with the classical MELAS syndrome, two patients had CPEO associated with other symptoms such as psychiatric disorders and diabetes mellitus. The remaining patients had other features of mitochondrial disease not consistent with another recognised syndrome. In addition to stroke-like lesions, the more frequent lesions revealed in neuroimaging studies were deep gray matter changes, brain atrophy and white matter changes. These changes had similar prevalences between the patients with the classic syndrome of MELAS and patients who did not have stroke-like lesions. All patients with classical MELAS have lactate peak and 60% of them have reduction of NAA at spectroscpopy; while these changes were found in two and one patient respectively, in the group of patients without stroke-like lesions. We identified azoospermia in one paciente with classic MELAS, a finding not previously associated with m.3243A>G. At moment, this is the largest Brazilian case series of patients with the m.3243A>G mutation. Clinical, laboratory and neuroimaging features of patients with mitochondrial disease associated with mutation m.3243A > G 10 CONCLUSION: The wide spectrum of clinical presentation and neuroimaging is a notable feature among patients with the mutation m.3243A> G mtDNA. This disorder should be considered in patients with evidence of signs and symptoms suggestive of multisystem involvement.

INTRODUÇÃO: A forma clássica de encefalomiopatia mitocondrial associada à mutação do DNA mitocondrial m.3243A>G é a Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like episodes (síndrome de MELAS). Entretanto, o espectro de manifestações clínicas dos indivíduos que apresentam essa mutação é bastante amplo. OBJETIVO: Descrever o espectro clínico, laboratorial e de imagem de pacientes com doença mitocondrial decorrente da mutação m.3243A>G. MÉTODOS: Estudo descritivo retrospectivo de uma série de casos de pacientes com a mutação m.3243A>G em seguimento no ANEM/HCFMRP-USP. Os dados clínicos e informações sobre exames complementares foram coletados através de revisão sistemática dos prontuários médicos dos pacientes selecionados. Os exames de neuroimagem foram revisados juntamente com neurorradiologista experiente para descrição das lesões encontradas. RESULTADOS: No período compreendido entre maio de 2000 e maio de 2015, a mutação m.3243A>G foi pesquisada em um total de 817 pacientes, em DNA extraído de células do sangue periférico (n= 441), de fragmentos de biópsia de músculo esquelético (n= 293), de ambos (n= 82) e mais raramente de células do sedimento urinário (n=1). Dentre esses, 16 indivíduos de 12 famílias apresentaram a referida mutação, resultando em uma taxa de detecção da mutação de 1,96% nessa população. Foram incluídos no estudo 12 indivíduos de 9 famílias que estavam em seguimento no nosso serviço. Os achados mais comuns nesta série foram em ordem de frequência: sinais de miopatia, transtornos neurocomportamentais, epilepsia, endocrinopatias, ataxia cerebelar, migrânea, episódios semelhantes a AVC, vômitos recorrentes, distúrbios de condução cardíaca, neuropatia periférica e sinais de disautonomia, mioclonias, surdez neurossensorial, cegueira cortical, comprometimento ocular, e proteinúria. Em nossa série, identificamos que cinco pacientes foram classificados com a forma clássica de MELAS, dois apresentaram CPEO associada a outros sintomas como transtornos psiquiátricos e diabetes mellitus. Os demais pacientes apresentavam características clínicas que não configuravam uma síndrome clinica definida. Além das lesões semelhantes a AVC, as lesões reveladas por neuroimagem mais frequentes nessa população foram alteração de sinal dos núcleos da base, atrofia encefálica e alteração de sinal da substância branca, sendo igualmente prevalentes entre os pacientes com a síndrome clássica de MELAS e os pacientes que não apresentaram lesões semelhantes a AVC. Dos pacientes com MELAS, 100% apresentaram pico anômalo de lactado e 60% redução do NAA à espectroscopia de prótons; enquanto que entre os pacientes sem lesões semelhantes a AVC essas alterações foram encontradas em dois e em um paciente Caracterização clínica, laboratorial e de neuroimagem de pacientes com doença mitocondrial associada à mutação m.3243A>G 8 respectivamente. Nós identificamos o achado inédito de azoospermia associada à mutação m.3243A>G. Essa é a maior série de casos de pacientes brasileiros com a mutação m.3243A>G até o momento. CONCLUSÃO: O amplo espectro de apresentação clínica e de neuroimagem é uma característica notável entre os pacientes com a mutação m.3243A>G do DNAmt. Essa desordem deve ser considerada em pacientes com evidência de sinais e sintomas que sugiram acometimento multissistêmico. / INTRODUCTION: The classic form of mitochondrial encephalomyopathy associated with m.3243A>G mutation is the Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like episodes (MELAS syndrome). However, the spectrum of clinical manifestations of patients with this mutation is quite wide. OBJECTIVE: To describe the clinical, laboratory and imaging spectrum of patients with mitochondrial disease due to m.3243A>G mutation METHODS: A retrospective descriptive study of a series of cases of patients with the m.3243A>G mutation in follow-up in ANEM/HCFMRP-USP. Clinical data and information about additional tests were collected through systematic review of medical records of selected patients. Neuroimaging studies were reviewed with supervision of experienced neuroradiologist and the lesions were described. RESULTS: Between May 2000 and May 2015, the mutation m.3243A>G was evaluated in a total of 817 patients, on DNA extracted from peripheral blood (n = 441), skeletal muscle biopsy samples (n = 293), both (n = 82) and more rarely urinary sediment cells (n = 1). We founded 16 individuals 12 families with the mutation, resulting in a mutation detection rate of 1.96 % that population. 12 individuals from nine families, who were following at our service, were included in this study. The most common findings in this series were in order of frequency: myopathy signs, neurobehavioral disorders, epilepsy, endocrine disorders, cerebellar ataxia, migraine, stroke-like episodes, recurrent vomiting, cardiac conduction disorders, peripheral neuropathy and signs of dysautonomia, myoclonus, sensorineural deafness, cortical blindness, uveitis, and proteinuria. In our series, we found that five of the patients were classified with the classical MELAS syndrome, two patients had CPEO associated with other symptoms such as psychiatric disorders and diabetes mellitus. The remaining patients had other features of mitochondrial disease not consistent with another recognised syndrome. In addition to stroke-like lesions, the more frequent lesions revealed in neuroimaging studies were deep gray matter changes, brain atrophy and white matter changes. These changes had similar prevalences between the patients with the classic syndrome of MELAS and patients who did not have stroke-like lesions. All patients with classical MELAS have lactate peak and 60% of them have reduction of NAA at spectroscpopy; while these changes were found in two and one patient respectively, in the group of patients without stroke-like lesions. We identified azoospermia in one paciente with classic MELAS, a finding not previously associated with m.3243A>G. At moment, this is the largest Brazilian case series of patients with the m.3243A>G mutation. Clinical, laboratory and neuroimaging features of patients with mitochondrial disease associated with mutation m.3243A > G 10 CONCLUSION: The wide spectrum of clinical presentation and neuroimaging is a notable feature among patients with the mutation m.3243A> G mtDNA. This disorder should be considered in patients with evidence of signs and symptoms suggestive of multisystem involvement.

Cette thèse propose des techniques pour le traitement d'images IRM de diffusion. Les méthodes proposées concernent l'estimation et la régularisation, le groupement et la segmentation ainsi que le recalage. Le cadre variationnel proposé dans cette thèse pour l'estimation d'un champ de tenseurs de diffusion `a partir d'observations bruitées exploite le fait que les données de diffusion représentent des populations de fibres et que chaque tenseur peut être reconstruit à partir d'une combinaison pondérée de tenseurs dans son voisinage. La méthode de segmentation traite aussi bien les voxels que les fibres. Elle est basée sur l'utilisation de noyaux défini-positifs sur des probabilités gaussiennes de diffusion afin de modéliser la similarité entre tenseurs et les interactions spatiales. Ceci permet de définir des métriques entre fibres qui combinent les informations de localisation spatiale et de tenseurs de diffusion. Plusieurs approches de groupement peuvent être appliquees par la suite pour segmenter des champs de tenseurs et des trajectoires de fibres. Un cadre de groupement supervisé est proposé pour étendre cette technique. L'algorithme de recalage utilise les noyaux sur probabilités pour recaler une image source et une image cible. La régularité de la déformation est évaluée en utilisant la distortion induite sur les distances entre probabilités spatialement voisines. La minimisation de la fonctionnelle de recalage est faite dans un cadre discret. La validation expérimentale est faite sur des images du muscle du mollet pour des sujets sains et pour des patients atteints de myopathies. Les résultats des techniques d´eveloppées dans cette thèse sont encourageants.