The neurobiology of cell transplantation in Parkinson's disease

Over the past decade, neural grafting has emerged as a new treatment option for Parkinson's disease. When performed successfully, grafts of human embryonic neural tissue can give rise to major symptomatic relief in patients. However, a recent report on a double-blind placebo control study, which received worldwide attention, described less pronounced beneficial effects of the grafts, and found them to be significant only in patients younger than 60 years of age. Moreover, a subgroup of patients developed disabling dyskinesias as a result of the surgery. These findings, and great logistical problems in coordinating the harvesting of sufficient amounts of suitable human embryonic donor tissue with the transplantation surgery, have led the scientific community to question whether cell transplantation really has a future as a therapy for Parkinson's disease. In this review, we argue that the future of neural transplantation for Parkinson's disease is still bright. We relate clinical findings to observations made in experimental animals grafted with embryonic neural tissue and seek explanations for the variability in outcome seen in the clinical trials. We also briefly discuss alternative sources of donor tissue that may be applied in future clinical trials, and mention what features of cells may be crucial for them to be suitable as donor tissue for transplantation in Parkinson's disease.     

Transgenic neural plate contributes neuronal cells that survive greater than one year when transplanted into the adylt mouse central nervous system

Neural plate cells from the early embryo may have a number of important advantages as donor material for the delivery of foreign genes into the diseased adult central nervous system (CNS). Mesencephalic neural plate from transgenic GT4-2 mice was used as a source of marked donor cells to determine whether transgene-expressing embryonic CNS progenitor cells can be used as donor material for implantation into the adult mouse brain. Transgenic mouse embryos from this line express the Escherichia coli β-galactosidase (β-gal) gene throughout early CNS development. At the early somite stage (Embryonic Day 8.5), mesencephalic neural plate tissue from heterozygous embryos was dissected out and either transferred into culture for characterization or immediately implanted into the striatum or lateral ventricle of adult wild-type CD-1 mice. Explants of neural plate tissue possessed intense β-gal activity and produced extensive outgrowth of neurofilament-positive processes after 6 days in vitro. Many β-gal-positive cells migrated away from the explanted tissue mass. Grafts of transgenic neural plate tissue in the normal adult mouse striatum, sampled 2 weeks to 1 year after implantation, possessed healthy β-gal-positive cells. More detailed analysis of grafts 3 months after implantation indicated that most β-gal-positive cells were also immunoreactive for neurofilament and microtubule-associated proteins, two neuron-specific markers. In addition, extensive neurofilament-positive axonal tangles were evident within the grafts among the β-gal-positive cells. Electron microscopic (EM) findings of implanted tissue stained with Bluo-Gal revealed many β-gal-positive neurons received synaptic contacts from other cells. A few donor-derived astrocytes were also found in the grafts by EM analysis. No obvious signs of immunological rejection, or of significant decrease in graft volume, were observed at any age. Some β-gal-positive cells were observed to he up to 230 μm away from the main graft mass in both striatal and intraventricular implantations. These data suggest that the neural plate can contribute a long-surviving population of neuronal and astrocytic cells when transplanted into the adult CNS.     

Neural transplantation: Autoradiographic analysis of histogenesis in neocortical transplants

Neurohistogenesis in neocortical transplants obtained from 15-, 16-, 17-, 18-, 19-, 20- and 21-day-old embryos, was studied employing [3H]thymidine autoradiography. The neural tissues were transplanted in the midvermis of cerebellum of the host animals. Following transplantation the host animals in different groups were injected with the radiochemical at 6 hr, 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 day intervals, to label the neurons forming on different days in the developing transplants. Analysis of autoradiograms showed that all the neocortical transplants did undergo histogenesis in the host cerebellum, and that it was similar to that seen in a normally developing neocortex. Transplants from the 15-day embryos showed histogenesis lasting for 9 days, and at the other extreme transplants from the 21-day embryos showed histogenesis lasting only for 1 day. Histogenesis in other transplants fell between these two extremes in a graded fashion in relation to the age of the donor embryos. The magnitude of histogenesis in transplants from different donor embryos was closely related to the final size of the transplants. Transplants from 15-day embryos were the largest in size, and they were followed by those from 16-, 17-, 18-, 19-, 20- and 21-day donor embryos in a graded fashion. All transplants were intraparenchymal, and histologically appeared normal. They contained fully differentiated neurons, and were anatomically integrated with the host cerebellum without any glial scar tissue or necrotic tissue intervening between them.     

Cell survival and clinical outcome following intrastriatal transplantation in Parkinson disease

Intrastriatal transplantation of embryonic dopaminergic neurons is currently explored as a restorative cell therapy for Parkinson disease (PD). Clinical results have varied, probably due to differences in transplantation methodology and patient selection. In this review, we assess clinical trials and autopsy findings in grafted PD patients and suggest that a minimum number of surviving dopaminergic neurons is required for a favorable outcome. Restoration of [18F]-fluorodopa uptake in the putamen to about 50% of the normal mean seems necessary for moderate to marked clinical benefit to occur. Some studies indicate that this may require mesencephalic tissue from 3-5 human embryos implanted into each hemisphere. The volume, density and pattern of fiber outgrowth and reinnervation, as well as functional integration and dopamine release. are postulated as additional important factors for an optimal clinical outcome. For neural transplantation to become a feasible therapeutic alternative in PD, graft survival must be increased and the need for multiple donors of human embryonic tissue substantially decreased or alternate sources of donor tissue developed. Donor cells derived from alternative sources should demonstrate features comparable to those associated with successful implantation of human embryonic tissue before clinical trials are considered.     

Repair

Transplantation of fetal neural cells represents an attractive replacement strategy for the treatment of certain neurodegenerative diseases. This is the case with Parkinson's disease, which results from a selective loss of dopaminergic neurons of the substantia nigra. Experimentation with animal models has demonstrated the feasibility of this approach. Grafting studies in patients have shown that intrastriatal implantation of solid grafts or cells obtained from human fetal mesencephalon usually results in a clinical benefit in patients. Despite continuous methodological progress, transplantation requires both conceptual and technical improvements. Current research aims at preventing the extensive death of donor dopaminergic neurons during the grafting procedure. However, the possibility of new sources of cells is currently being investigated. These include xenogeneic porcine neurons, or human cells programmed to produce dopamine or neurotrophic factors. A promising approach is based on the use of pluripotent stem cells derived from the brain, the bone marrow or early embryos. It is hoped that it will be possible to tightly control their proliferation and differentiation into dopaminergic neurons. Hence, it seems possible that transplantation will be widely used in the clinic in the future.     

Treatment of neural injury with marrow stromal cells

We describe our preclinical studies on the use of bone-marrow stromal cells (MSC; an uncharacterised mixed population of plastic-adherent cells) in the treatment of neural injury. These cells obtained from donor rats or human beings have been directly transplanted into brain or administered intra-arterially or intravenously. MSC selectively target injured tissue and promote functional recovery. Signals that target inflammatory cells to injured tissue probably direct MSC to injury sites. Although some MSC express proteins typical of neural cells, the possibility that benefit is derived by replacement of infarcted tissue with differentiated MSC is highly unlikely. MSC activate endogenous restorative responses in injured brain, which include angiogenesis, neurogenesis, and synaptogenesis. Given the robust therapeutic benefit of these cells in the treatment of experimental neural injury, and the fact that MSC have been used in the treatment of other human disease, there is justification for further preclinical studies leading to clinical trials for the treatment of neural injury such as stroke.     

Brain networks and their relevance for stroke rehabilitation

Stroke has long been regarded as focal disease with circumscribed damage leading to neurological deficits. However, advances in methods for assessing the human brain and in statistics have enabled new tools for the examination of the consequences of stroke on brain structure and function. Thereby, it has become evident that stroke has impact on the entire brain and its network properties and can therefore be considered as a network disease. The present review first gives an overview of current methodological opportunities and pitfalls for assessing stroke-induced changes and reorganization in the human brain. We then summarize principles of plasticity after stroke that have emerged from the assessment of networks. Thereby, it is shown that neurological deficits do not only arise from focal tissue damage but also from local and remote changes in white-matter tracts and in neural interactions among wide-spread networks. Similarly, plasticity and clinical improvements are associated with specific compensatory structural and functional patterns of neural network interactions. Innovative treatment approaches have started to target such network patterns to enhance recovery. Network assessments to predict treatment response and to individualize rehabilitation is a promising way to enhance specific treatment effects and overall outcome after stroke.     

Long-term survival of neural transplants to senescence in rats

A critical issue for clinical and research applications of transplant techniques is the long-term survival of transplanted tissue and its effect on the host brain. In this study, entorhinal cortices from donor embryos were transplanted into the lesioned angular bundle of juvenile male Sprague-Dawley rats. Animals were maintained for 2 years and then sacrificed for histological and histochemical examinations. The results indicate that entorhinal transplants survive to old age and that both the host and transplant tissues maintain morphological features consistent with those of short-term neural grafts. An unexpected finding of this experiment was the persistence in the transplanted tissue and adjacent host cortex of a pattern of AChE staining which is typical of early postnatal development.     

A multiple target neural transplantation strategy for Parkinson's disease

Intracerebral transplantation of embryonic ventral mesencephalic tissue is a potential treatment for patients with Parkinson's disease for whom medical management is unsatisfactory. Neural transplantation for parkinsonism has been studied experimentally in animal models of Parkinson's disease for more than two decades. These animal studies have shown significant graft survival, synapse formation, graft induced-dopamine release, and behavioural recovery in transplanted animals. Encouraged by these results, clinical programs have been initiated over the past 15 years; more than 250 patients worldwide have undergone neural transplantation. Both animal and clinical studies indicate that neural transplantation has the potential to become a valuable treatment option for Parkinson's disease. However, while many transplant recipients obtain clinically useful symptom relief, in all cases functional recovery is incomplete. Certain symptoms do not respond well to transplant therapy, and those symptoms that do typically do not resolve completely. This has spurred efforts to optimize the transplant procedure. One important approach is exploring novel methods such as multiple site transplantation. This transplantation strategy results in a more complete reinnervation of the dopaminergic circuitry that is affected in Parkinson's disease. In principle, multiple site transplantation should provide a more satisfactory resolution of symptoms. Here we review the progress made in multiple site neural transplantation for Parkinson's disease. The effects of intrastriatal, intranigral, intrasubthalamic nucleus, and intrapallidal grafts in animal models of Parkinson's disease are analysed. The current data suggest that intrastriatal grafts alone are inadequate to promote complete functional recovery. A multiple target strategy may restore dopaminergic input to affected basal ganglia nuclei and improve outcomes of neural transplantation in Parkinson's disease.     

斑马鱼在神经遗传疾病研究中的应用

斑马鱼是最常用的神经遗传学模式生物之一,拥有体积小、性成熟周期短、体外受精、胚胎通体透明等优点。斑马鱼的基因组测序已经完成,研究相关的细胞标记技术、组织移植技术、转基因技术、基因活性抑制技术等均已成熟,在神经发育和神经功能的研究、构建人类遗传性疾病模型等多方面均展现了广阔前景。对斑马鱼在神经遗传性疾病研究中的应用进行综述。     

Birth dating of midbrain dopamine neurons identifies A9 enriched tissue for transplantation into parkinsonian mice

Clinical trials have provided proof of principle that new dopamine neurons isolated from the developing ventral midbrain and transplanted into the denervated striatum can functionally integrate and alleviate symptoms in Parkinson's disease patients. However, extensive variability across patients has been observed, ranging from long-term motor improvement to the absence of symptomatic relief and development of dyskinesias. Heterogeneity of the donor tissue is likely to be a contributing factor in the variable outcomes. Dissections of ventral midbrain used for transplantation will variously contain progenitors for different dopamine neuron subtypes as well as different neurotransmitter phenotypes. The overall impact of the resulting graft will be determined by the functional contribution from these different cell types. The A9 substantia nigra pars compacta dopamine neurons, for example, are known to be particularly important for motor recovery in animal models. Serotonergic neurons, on the other hand, have been implicated in unwanted dyskinesias. Currently little knowledge exists on how variables such as donor age, which have not been controlled for in clinical trials, will impact on the final neuronal composition of fetal grafts. Here we performed a birth dating study to identify the time-course of neurogenesis within the various ventral midbrain dopamine subpopulations in an effort to identify A9-enriched donor tissue for transplantation. The results show that A9 neurons precede the birth of A10 ventral tegmental area dopamine neurons. Subsequent grafting of younger ventral midbrain donor tissue revealed significantly larger grafts containing more mitotic dopamine neuroblasts compared to older donor grafts. These grafts were enriched with A9 neurons and showed significantly greater innervation of the target dorso-lateral striatum and DA release. Younger donor grafts also contained significantly less serotonergic neurons. These findings demonstrate the importance of standardized methods to improve cell therapy for Parkinson's disease and have significant implications for the generation and selectivity of dopamine neurons from stem cell based sources.     

Hematogenous cells in the central nervous system of developing human embryos and fetuses

Examination of large blocks of Epon-embedded, 1.0-μm sections of human embryos and fetuses reveal the presence of hematogenous cells in various stages of differentiation in neural tissue. In every embryo and fetus of 10 weeks ovulation age and younger, hematogenous cells are found randomly scattered in the cerebrum, cerebellum, and spinal cord. Many of these cells appear to undergo spontaneous degeneration in neural tissue and become rarer in older fetuses. Also identified in the neuropil of normal embryos and fetuses are cells with the typical morphological appearance of macrophage containing numerous inclusions of various kinds, both inside and outside the blood vessels. In addition, scattered in the subpial, perivascular, and perineuronal regions of the neural parenchyma are small cells with fusiform nuclei and a small amount of cytoplasm as well as cells with a moderate amount of elongated cytoplasm containing various inclusions and oblong nuclei. All of these cells have clumped heterochromatin along the nuclear membrane which differs from other neuroectodermal cells of the developing human CNS. Although there is no direct evidence to indicate transformation of macrophages to “microglia” or vice versa, the presence of cells having similar nuclear morphology and chromatin pattern while appearing to tbe transitional forms of macrophage, varying from undifferentiated to fully developed, suggest a common lineage of these latter types. It is concluded that migration of hematogenous cells into neural tissue is a ubiquitous developmental phenomenon in young human embryos and fetuses.     

BN rats do not reject F344 brain allografts even after systemic sensitization

Embryonic brain tissue allografts under many circumstances survive transplantation into the brain. It is generally believed that such grafts will not survive if the host animal is systemically sensitized, by skin grafting or other means, to major histocompatibility complex (MHC) antigens of the donor animal. We have found that F344 brain grafts survive in BN hosts even when the host is systemically sensitized to F344 tissue. Embryonic cerebral neocortex from F344 donors was transplanted into BN host rats (n = 95). Subsequently, the host rats were systemically sensitized with donor skin (n = 25), brain tissue (n = 41), or spleen cells (n = 6) and compared with a control group of rats consisting of allografts with no sensitization or sham procedures (n = 23). Rejection of the transplants in BN rat hosts was not provoked by any of the sensitization methods tested. Minor immunological responses that did not result in rejection were, however, present in many host animals. We did not observe infiltration of W3/13+ T cells and OX8+ cytotoxic lymphocytes in any of the groups. Nevertheless, substantial infiltrations of OX6+ antigen-presenting cells and W3/25+ helper T cells were present. There was also an extensive enhancement of MHC class I immunoreactivity in parts of the grafted tissue developing within the third ventricle, but not for the same type of graft in the lateral ventricle. This increase of MHC class I expression was not accompanied by infiltration of cytotoxic T cells. Our findings thus suggest that neural graft rejection depends on general genetic susceptibility to immune reactions, particularly experimental allergic encephalomyelitis and not only on disparity between donor and host antigens encoded by the MHC. Moreover, enhancement of MHC class I and class II expression within transplanted tissue does not predict graft rejection.     

Spatiotemporal expression of leukemia inhibitory factor receptor protein during neural tube development in embryos with neural tube defects

Leukemia inhibitory factor receptor(LIFR),as a neuroregulatory cytokine receptor,generally shows a neuroprotective effect in central nervous system injuries.In this study,to understand the effect of LIFR on pathogenesis of neural tube defects,we explored spatiotemporal expression of LIFR at different stages of fetal development in normal and neural tube defect embryos.Spina bifida aperta was induced with all-trans retinoic acid on embryonic day 10 in rats,and the spatiotemporal expression of LIFR was investigated in spina bifida aperta rats and healthy rats from embryonic day 11 to 17.Real time-polymerase chain reaction and western blot assay were used to examine mRNA and protein expression of LIFR in healthy control and neural tube defect embryos.Results of the animal experiment demonstrated that expression of LIFR protein and mRNA in the spinal cords of normal rat embryos increased with embryonic development.LIFR was significantly downregulated in the spinal cords of spina bifida aperta rats compared with healthy rats from embryonic days 11 to 17.Immunohistochemical staining showed that the expression of LIFR in placenta and spinal cord in spina bifida aperta rat embryos was decreased compared with that in control embryos at embryonic day 15.Results from human embryo specimens showed that LIFR mRNA expression was significantly down-regulated in spinal cords of human fetuses with neural tube defects compared with normal controls at a gestational age of 24 to 33 weeks.The results were consistent with the down-regulation of LIFR in the animal experiments.Our study revealed spatiotemporal changes in expression of LIFR during embryonic neurulation.Thus,LIFR might play a specific role in neural tube development.All animal and human experimental procedures were approved by the Medical Ethics Committee of Shengjing Hospital of China Medical University,China(approval No.2016PS106K)on February 25,2016.     

A new approach to the molecular basis of neoplastic transformation in the brain

Gene transfer into living organisms has evolved as a powerful approach to study in vivo effects of specific genes and to devise animal models of hereditary disorders. We have been particularly interested in an approach to introducing transforming genes into the nervous system. Since specific promoter sequences for targeting the expression of a transgene to many cell types of the brain are not yet isolated, a suitable transgenic mouse model was not available for these experiments. This has prompted us to develop an alternative strategy for gene transfer into the brain. The rationale is to introduce foreign genes into fetal brain transplants using embryonic CNS as donor tissue and replication-defective retroviral vectors as genetic vehicles. This technique relies on the extraordinary organotypic differentiation capacity of neural grafts and the expression of retrovirally transmitted genes in different cell types of CNS transplants. In contrast to transgenic animals but analogous to sporadic tumour formation, target cells for the retroviral vector will develop in an environment of unmodified neural tissue. We have introduced a number of neurotropic oncogenes into fetal brain transplants to study potential effects of such genes on the brain. This review will summarize some of the findings which have emerged from this experimental study including the tropism of several genes for endothelial cells, attempts to identify cooperating combinations of transforming genes and an experimental model for primitive neuroectodermal tumours in neural grafts.     

Multipotency of human neural stem cells from fetal striatum

We had reported that neural stem cells from human fetal striatum (hsNSCs) expressed neural stem cell markers, and were capable of differentiation into neurons, astrocytes, and oligodendrocytes in vitro. To examine multipotency of hsNSCs, some experiments of transgerm layer differentiation in vitro were carried out. Our data indicated that hsNSCs could also generate osteocytes, adipocytes, and hepatocyte-like cells in vitro. Meanwhile, we injected hsNSCs into murine blastocysts at embryonic day 3.5 of gestation. Microinjection of hsNSCs led to the generation of chimeric embryos. Embryos at embryonic day 3.5 of gestation were shown to contribute to the hsNSC-derived cells by PCR-southern blot of 17alphamod, a special method to discover human cells from animals. Analysis of the donor distribution in different tissues showed that donor-derived cells seeded to various tissues. The cellular nature of the human donor cells in chimeric tissues is, however, currently unknown, and further work will be done to identify what differentiated phenotypes have developed from the human cells.     

Immunohistochemical localization of gamma-enolase in early human embryos

gamma-Enolase has been believed to be distributed only in the neurons and it was frequently labelled as neuron-specific enolase. However, recent precise studies have suggested a wider distribution of the protein. It can also be found in neuroendocrine cells, some mesodermal tissues, and some malignant tumors originating from tissues without the antigen in a normal condition. In early rat embryos, before the formation of neural tissues, a sensitive immunoassay system revealed a substantial amount of gamma-enolase, though it is not yet clear where the antigen is located. In the present study, tissue distribution of gamma-enolase in early human embryos was studied using an immunohistochemical method and it was suggested that the protein is present not only in neural tissue primordium but also in most tissues in the youngest embryo of 6.3 mm crown-rump length. Many of the immunoreactive non-neural tissues, however, lost immunoreactivity with the advancement of the embryonic stage while neural tissues became more intensely stained. In the embryo of 24 mm length, the staining pattern was almost the same as that of reported adult men. In embryonic tissues such as notochord and mesonephros, which disappear in the due course of growth, the antigen was also found. These findings will suggest that the antigen is rather common in undifferentiated tissues but then localizes in neural elements with advancing age. Our findings may be useful in explaining why early rat embryos, before the formation of neural tissues, showed a considerable amount of gamma-enolase and why many undifferentiated tumors, originating from tissues which did not have the antigen in normal condition, revealed the antigen.     

Human neural transplantation

Great advances in neurobiology have resulted from 100 years of neural transplantation research. In the last 20 years, there has been a focus on using neural transplantation to repair the damaged central nervous system (CNS) utilising experimental animal models of various human neurodegenerative disease and CNS injury. Since 1985, there has been a rapid proliferation of adrenal medullary autograft transplantation to the caudate nucleus of humans with Parkinson's disease. However, this operation proved to be unsuccessful and was associated with unacceptable morbidity. Implantation of human fetal mesencephalon into patients with severe parkinsonism has supplanted the adrenal operation and has produced promising results, with some patients reported to improve markedly and some evidence of graft survival noted on positron emission tomography (PET). Host tissue recovery appears to be an important mechanism for this clinical improvement. The optimal technique is to use three to four fetuses from induced abortions of 6.5 to 8 weeks gestation, with multiple stereotactic implants into the putamen and caudate nucleus. Many biological questions still remain and the community remains troubled by the ethical problems of using fetal tissue obtained from abortions. This procedure is still experimental and should be restricted to a few centres with excellence in cell and molecular biology. A multicentre study is needed to more carefully evaluate CNS transplantation. Cloned neural precursor cells or immortalized embryonic cell lines genetically modified to manufacture selected growth factors or neurotransmitters may offer an alternative to the use of human fetal tissue. Much more experimental animal research is necessary before transplantation can be used to treat other CNS maladies.     

Porcine neural xenografts in rats and mice: donor tissue development and characteristics of rejection.

Embryonic ventral mesencephalic tissue from the pig is a potential alternative donor tissue for neural transplantation to Parkinson's disease patients. For stable graft survival, the host immune response has to be prevented. This study was performed in order to analyze the mechanisms and dynamics of neural xenograft rejection, as well as neurobiological properties of the donor tissue. Adult normal mice and rats, and cyclosporin A-treated rats, received intrastriatal transplants of dissociated embryonic ventral mesencephalic pig tissue that was 27 or 29 embryonic days of age (E27 and E29). The animals were perfused at 2, 4, 6, and 12 weeks after grafting and the brains were processed for immunohistochemistry of dopaminergic (tyrosine hydroxylase positive) neurons, CD4(+) and CD8(+) lymphocytes, natural killer cells, macrophages, microglia, and astrocytes. Thirty-five rats received daily injections of BrdU for 5 consecutive days at different time points after transplantation and were perfused at 6 weeks. These animals were analyzed for proliferation of cells in the donor tissue, both in healthy and in rejecting grafts. No tyrosine hydroxylase-positive cells proliferated after grafting. Our results demonstrated that E27 was superior to E29 donor tissue for neurobiological reasons. Cyclosporin A immunosuppression was protective only during the first weeks and failed to protect the grafts in a long-term perspective. Grafts in mice were invariably rejected between 2 and 4 weeks after transplantation, while occasional grafts in untreated rats survived up to 12 weeks without signs of an ongoing rejection process. CD8(+) lymphocytes and microglia cells are most likely important effector cells in the late, cyclosporin A-resistant rejection process.     

Cells of the sympathoadrenal lineage: Biological properties as donor tissue for cell-replacement therapies for Parkinson's disease

Sympathoadrenal (SA) cell lineage encompasses neural crest derivatives such as sympathetic neurons, small intensely fluorescent (SIF) cells of sympathetic ganglia and adrenal medulla, and chromaffin cells of adrenal medulla and extra-adrenal paraganglia. SA autografts have been used for transplantation in Parkinson's disease (PD) for three reasons: (i) as autologous donor tissue avoids graft rejection and the need for immunosuppressant therapy, (ii) SA cells express dopaminotrophic factors such as GNDF and TGFβs, and (iii) although most of SA cells release noradrenaline, some of them are able to produce and release dopamine. Adrenal chromaffin cells were the first SA transplanted cells in both animal models of PD and PD patients. However, these autografts have met limited success because long-term cell survival is very poor, and this approach is no longer pursued clinically. Sympathetic neurons from the superior cervical ganglion have been also grafted in PD animal models and PD patients. Poor survival into brain parenchyma of grafted tissue is a serious disadvantage for its clinical application. However, cultured sympathetic cell grafts present a better survival rate, and they reduce the need for levodopa medication in PD patients by facilitating the conversion of exogenous levodopa. SA extra-adrenal chromaffin cells are located on paraganglia (i.e., the Zuckerkandl's organ), and have been used for grafting in a rodent model of PD. Preliminary results indicate that long-term survival of these cells is better than for other SA cells, exerting a more prolonged restorative neurotrophic action on denervated host striatum. The ability of SA extra-adrenal cells to respond to hypoxia, differently to SA sympathetic neurons or adrenal medulla cells, could explain their good survival rate after brain transplantation.