BACKGROUND: Defects of mitochondrial ATP synthase (ATPase) represent an emerging, yet incompletely understood group of neurodevelopmental diseases with abnormal movements. OBJECTIVE: The aim of this study was to redefine the phenotypic and mutational spectrum of movement disorders linked to the ATPase subunit-encoding genes ATP5F1A and ATP5F1B. METHODS: We recruited regionally distant patients who had been genome or exome sequenced. Fibroblast cultures from two patients were established to perform RNA sequencing, immunoblotting, mass spectrometry-based high-throughput quantitative proteomics, and ATPase activity assays. In silico three-dimensional missense variant modeling was performed. RESULTS: We identified a patient with developmental delay, myoclonic dystonia, and spasticity who carried a heterozygous frameshift c.1404del (p.Glu469Serfs*3) variant in ATP5F1A. The patient's cells exhibited significant reductions in ATP5F1A mRNA, underexpression of the α-subunit of ATPase in association with other aberrantly expressed ATPase components, and compromised ATPase activity. In addition, a novel deleterious heterozygous ATP5F1A missense c.1252G>A (p.Gly418Arg) variant was discovered, shared by three patients from two families with hereditary spastic paraplegia (HSP). This variant mapped to a functionally important intersubunit communication site. A third heterozygous variant, c.1074+1G>T, affected a canonical donor splice site of ATP5F1B and resulted in exon skipping with significantly diminished ATP5F1B mRNA levels, as well as impaired ATPase activity. The associated phenotype consisted of cerebral palsy (CP) with prominent generalized dystonia. CONCLUSIONS: Our data confirm and expand the role of dominant ATP5F1A and ATP5F1B variants in neurodevelopmental movement disorders. ATP5F1A/ATP5F1B-related ATPase diseases should be considered as a cause of dystonia, HSP, and CP. © 2025 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Comprehensive Center for Clinical Neurosciences and Mental Health Medical University of Vienna Vienna Austria

CRMR Neurogenetique Service de Neurologie Centre Hospitalier Universitaire d'Angers Angers France

CRMRs Anomalies du Développement et syndromes malformatifs et Déficiences Intellectuelles de causes rares FHU TRANSLAD CHU Dijon Bourgogne Dijon France

Department of Developmental Neurology Medical University of Gdansk Gdansk Poland

Department of Medical Genetics Sorbonne Université AP HP Sorbonne Université Paris France

Department of Neurology and Center of Clinical Neuroscience 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czech Republic

Department of Neurology Medical University of Vienna Vienna Austria

Department of Neurology P J Safarik University Kosice Slovakia

Department of Neurology University Hospital of L Pasteur Kosice Slovakia

Department of Neurology Zvolen Hospital Zvolen Slovakia

DZPG Munich Germany

Institute for Advanced Study Technical University of Munich Garching Germany

Institute of Human Genetics School of Medicine and Health Technical University of Munich Munich Germany

Institute of Neurogenomics Helmholtz Zentrum München Munich Germany

Laboratoire de Biologie Médicale Multi Site SeqOIA Sorbonne Université Paris France

Laboratoire de Génomique Médicale UF Innovation en diagnostic génomique des maladies rares CHU Dijon Bourgogne Dijon France

Munich Cluster for Systems Neurology SyNergy Munich Germany

Neurological Clinic of Faculty Hospital Trnava and Slovak Health University Bratislava Bratislava Slovakia

Parkinsonism and Movement Disorders Treatment Center Zvolen Hospital Zvolen Slovakia

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