Unfavorable outcome of adrenal medullary transplant for Parkinson's disease

Summary A 45-year-old woman with moderately severe parkinsonism underwent adrenal medullary autograft to the brain. The operation was performed in Mexico City. There were multiple post-Operative complications, including worsening of the parkinsonism with almost complete loss of ability to communicate. Death from bronchopneumonia occurred 13 months after surgery. At autopsythe surgical tract was found to extend through the corpus callosum and into the thalamus on the oppsiite side. Residual necrotic adrenal tissue was found as a small round well-defined mass in the ventricle loosely attached to the left fornix. This case emphasizes the obvious risks of this still experimental procedure and the difficulties in obtaining a surviving and functional adrenal medullary graft.Supported by the Veterans Affairs medical Research Program and the California Parkinson's Foundation     

Long-term follow-up of adrenal medullary transplantation for Parkinson's disease.

Long-term follow-up of eight patients who underwent stereotactic grafting of adrenal medullary tissue into unilateral or bilateral caudate nuclei is presented. We demonstrate that this procedure can be performed with minimal risk. Our results show little benefit when the group as a whole is analyzed. A subgroup of four patients was identified who responded to the procedure, as evidenced by a reduction in motor scores, reduction in medication requirements, and greater "on" time. Three of these patients continue to accrue benefit after 2 years. No characterization of a responder profile was evident. We conclude that a modest benefit is derived from this procedure that may persist for as long as 2 years. Future clinical studies to evaluate grafting procedures are encouraged.     

Catecholamine content of intracerebral adrenal medulla grafts

The rotational behavior which is produced by substantia nigra lesions can be decreased by adrenal medulla grafts adjacent to the denervated striatum. Perhaps these grafts secrete dopamine that diffuses into the striatum. In the present study, we measured concentrations of catecholamines in adrenal medulla grafts as compared with the normal adrenal medulla. The grafts were found to have high but extremely variable concentrations of dopamine. In hosts with substantia nigra lesions, concentrations of dopamine in the adrenal medulla grafts were decreased. Substantia nigra lesions, however, tended to increase concentrations of epinephrine in the grafts, while norepinephrine and total catecholamine concentrations were not significantly affected. It is concluded that at least some adrenal medulla grafts contain concentrations of dopamine sufficient to account for their behavioral effects.     

Nicotinic stimulation of catecholamine synthesis and tyrosine hydroxylase phosphorylation in cervine adrenal medullary chromaffin cells

The synthesis and secretion of catecholamines by the adrenal medulla is of major importance in the stress response. Tyrosine hydroxylase, the rate-limiting enzyme for catecholamine biosynthesis, has been extensively studied in adrenal medullary chromaffin cells from a number of species. Cervine chromaffin cells are of interest because the deer is known to be a relatively stress-prone reactive species. We report the first characterisation of tyrosine hydroxylase regulation in cervine chromaffin cells. Nicotinic receptor activation resulted in a time- and concentration-dependent increase in catecholamine synthesis, which was significantly reduced by the extracellular signal-regulated kinase (ERK)1/2 signalling pathway inhibitor PD98059 and the calcium/calmodulin protein kinase II inhibitor KN-93, but not by H89 or bisindolylmaleimide I, inhibitors of protein kinase A and C, respectively. Nicotinic stimulation also increased the phosphorylation of ERK1/2 and tyrosine hydroxylase. This latter response occurred on serine residues 19, 31 and 40 of the enzyme. The nicotinic-induced phosphorylation of ERK1/2 and serine 31 of tyrosine hydroxylase was suppressed by PD98059 but not bisindolylmaleimide I. These data indicate that nicotinic stimulation of tyrosine hydroxylase involves the phosphorylation of serine 31 via an ERK1/2-dependent, protein kinase C-independent pathway. Protein kinase C activation by phorbol 12-myristate 13-acetate also caused an ERK1/2-dependent increase in the serine 31 phosphorylation of tyrosine hydroxylase but, in contrast to the nicotinic response, was not accompanied by an increase in enzyme activity. Thus, ERK1/2-mediated serine 31 phosphorylation of tyrosine hydroxylase appears necessary but not sufficient for nicotinic activation of catecholamine synthesis in cervine chromaffin cells. These data present potentially important similarities and differences between the regulation of catecholamine synthesis in cervine and the more widely studied bovine adrenal medulla.     

Autologous adrenal medullary, fetal mesencephalic, and fetal adrenal brain transplantation in Parkinson's disease: a long-term postoperative follow-up.

We report on the clinical status of 5 patients with Parkinson's disease (PD) 3 years after autologous adrenal medullary (AM)-to-caudate nucleus (CN) implantation, and of 2 PD patients, 2 years after fetal ventral mesencephalon (VM)- and fetal adrenal (A)-to-CN homotransplantation. Current clinical evaluation of 4 of the AM grafted patients revealed sustained bilateral amelioration of their PD signs, most notably of rigidity, postural imbalance and gait disturbances, resulting in a substantial improvement in their quality of life. The disease-related dystonia of one of them disappeared only 2 years after surgery. The levodopa requirements of 2 of these patients and the anticholinergic therapy of another have been reduced. In agreement with the satisfactory clinical evaluation of these 4 patients, their neuropsychological and electrophysiological improvements, initially registered 3 months after surgery, have been maintained for 3 years. After 1 year of significant recovery, the 5th patient of this group has almost returned to her preoperative state. The 2 homotransplanted patients also showed sustained bilateral improvement of their PD signs. Two years after surgery, the most improved signs of the fetal VM case were rigidity, bradykinesia, postural imbalance, gait disturbances and facial expression. The fetal A case has only shown amelioration of rigidity and bradykinesia. Neither of them has shown significant neuropsychological changes. Their current levodopa requirements are less than before surgery. The improvements shown here by PD patients after brain tissue grafts go beyond those obtained using any other therapeutic approach, when levodopa fails. Although more studies and the development of these procedures are obviously required, these initial human trials appear to be resisting the test of time.     

Neuropathological findings in PINK1-associated Parkinson's disease

IntroductionBiallelic mutations in PTEN-induced putative kinase 1 (PINK1) is a relatively common cause of autosomal recessive early-onset Parkinson's disease (PD). However, only three PINK1 patients with brain autopsy have been reported in the literature.MethodsWe describe the clinical and pathological characteristics of a patient with early-onset PD. We screened for copy number variants SNCA, PRKN, PINK1, DJ-1, ATP13A2, LPA and TNFRSF9 by multiplex ligation-dependent probe amplification (MLPA), and subsequently we performed whole-exome sequencing.ResultsClinically the patient presented with typical parkinsonism that responded well to levodopa. After 23 years of disease she had a bilateral GPi deep brain stimulation (DBS) surgery. Genetic analyses revealed a heterozygous exon 4–5 deletion and a homozygous exon 1 [c. 230T > C (p.Leu77Pro)] mutation in PINK1. Post-mortem neuropathological examination after more than 30 years of disease revealed gliosis and a large loss of melanin-containing neurons in the substantia nigra. Lewy body pathology was evident in substantia nigra, temporal cortex, locus coeruleus and the parahippocampal region.ConclusionWe describe the first clinical and pathological characterization of a PINK1 patient with a typical disease presentation and long disease duration. Previous reports describe two patients with Lewy-related pathologies, albeit with differential distribution, and one patient with no Lewy-related pathology. Hence, it seems that only two patients with parkinsonism due to mutations in PINK1 are consistent with α-synucleinopathy distribution like that seen in the majority of cases with sporadic PD. Our data further extend the clinicopathological characterization of PINK1-associated PD.     

Transplants of adrenal medullary chromaffin cells reduce forelimb and hindlimb allodynia in a rodent model of chronic central pain after spinal cord hemisection injury

In the majority of patients, spinal cord injury (SCI) results in abnormal pain syndromes in which non-noxious stimuli become noxious (allodynia). To reduce allodynia, it would be desirable to implant a permanent biological pump such as adrenal medullary chromaffin cells (AM), which secrete catecholamines and opioid peptides, both antinociceptive substances, near the spinal cord. We tested this approach using a recently developed a mammalian SCI model of chronic central pain, which results in development of mechanical and thermal allodynia. Thirty day-old male Sprague-Dawley rats were spinally hemisected at T13 and allowed 4 weeks for recovery of locomotor function and development of allodynia. Nonimmunosuppressed injured animals received either control-striated muscle (n = 7) or AM (n = 10) transplants. Nociceptive behavior was tested for 4 weeks posttransplant as measured by paw withdrawals to von Frey filaments, radiant heat, and pin prick stimuli. Hemisected animals receiving AM demonstrated statistically significant reductions in both fore- and hindlimb mechanical and thermal allodynia, but not analgesia, when compared to hemisected animals receiving striated muscle transplants (P < 0.05). Tyrosine hydroxylase immunoreactivity indicated prolonged transplant survival and production of catecholamines. HPLC analysis of cerebrospinal fluid samples from animals receiving AM transplants demonstrated statistically significant increases in levels of dopamine (sevenfold), norepinephrine (twofold), and epinephrine (threefold), compared to control values several weeks following transplant (P < 0.05). By 28 days posttransplant, however, antinociceptive effects were diminished. These results support the therapeutic potential of transplanted AM in reducing chronic central pain following spinal cord injury.     

Imaging in Parkinson's disease: the role of monoamines in behavior.

Positron emission tomography (PET) and single photon emission computed tomography (SPECT) can measure striatal dopamine (DA) terminal function in vivo as reflected by DA storage capacity and transporter binding. In Parkinson's disease (PD) posterior dorsal putamen DA terminals are initially targeted, the anterior putamen and head of caudate subsequently becoming affected. In contrast, dopaminergic function in pallidal, amygdala, and cingulate regions is upregulated in early PD and only later becomes reduced. Rigidity and bradykinesia in PD have been shown to correlate with loss of putamen dopaminergic function, whereas performance on executive and working memory tasks correlates with integrity of caudate dopaminergic terminals. 11C-RTI32 PET, a marker of noradrenergic and dopaminergic transporter binding, can be used to assess noradrenergic along with dopaminergic terminal function. Serotonergic transporter binding can be assessed with 11C-DASB PET and 123I-beta CIT SPECT, whereas HT1A binding can be measured with 11C-WAY100635 PET. With these modalities, the relationship between mood, noradrenergic and serotonergic function can be examined in PD. The functional effects of focal DA replacement on DA storage capacity and patterns of brain activation via implantation of fetal midbrain cells or glial derived neurotrophic factor (GDNF) infusion into putamen of PD patients has been examined with PET. Both approaches lead to consistently increased levels of putamen 18F-dopa uptake, and cell implantation can restore levels of frontal activation. Clinical outcome, however, has proved to be variable and off-medication dyskinesias are an unwanted side effect in transplanted cases. Dopamine release after pharmacological challenges or during behavioral tasks can be assessed indirectly by studying changes in receptor availability to PET radioligands. Stereotyped sequential movements are associated with striatal DA release, and this increases with more complex behaviors and the presence of financial incentives, which also increase frontal DA levels. Parkinson patients release less putamen DA than healthy control subjects during stereotyped finger movements. Interestingly, those PD patients who develop a dopa dependency syndrome, craving their medication, generate significantly greater levels of ventral striatal DA compared with similarly disabled patients without such a psychological dependency. In the future, functional imaging is likely to throw light on the roles of peptide transmission in regulating mood and behavior as non-peptide analogue ligands become available. Novel markers of amyloid plaque load will also help clarify the etiology of dementia in PD.     

Sleepiness in Parkinson's disease: a controlled study.

Sudden-onset sleep episodes while driving have been reported in Parkinson's disease (PD) patients, and termed sleep attacks because they were reported to be irresistible and to occur without warning. We postulate that these episodes are due to excessive daytime sleepiness secondary to the high frequency of sleep disorders in PD patients and the sedative effects of dopaminergic medications. We assessed the frequency and relationship between excess daytime sleepiness and sleep episodes while driving (SE) in patients with PD. We evaluated 101 consecutive PD patients presenting to the Movement Disorder Center at the Mount Sinai School of Medicine using a questionnaire that incorporated a subjective estimate of sleepiness, the Epworth Sleepiness Scale (ESS) and information on disease severity and dopaminergic medications. One hundred age-matched respondents without PD served as a control population. Excess daytime sleepiness was reported in 76% of PD patients compared to 47% of controls (P < 0.05). The mean ESS scores for PD patients was 9.1 +/- 6.1 versus 5.7 +/- 4.4 in controls (P < 0.001). ESS scores > or =10 were observed in 40.6% of PD patients compared to 19% of controls (P < 0.01) and 24% of PD patients had scores > or =15, compared to 5% of controls (P < 0.001). Sleep episodes while driving were experienced by 20.8% of PD drivers compared to 6% of control drivers (P < 0.05). The mean daily levodopa (L-dopa) dose equivalent was 1,142 +/- 858 mg in PD drivers who experienced a SE while driving compared to 626 +/- 667 mg in those who had not (P < 0.05). Similarly, ESS was significantly greater in drivers with a SE than in those without (11.6 +/- 6.4 vs. 8.4 +/- 4.1; P < 0.05). Logistic regression analysis demonstrated that ESS and mean daily L-dopa dose equivalents were predictors of sleep episodes while driving, whereas age, gender, disease severity, and individual dopaminergic agents were not. These findings support the notion that sleep episodes while driving in PD patients are related to excess daytime sleepiness and dopaminergic load. Physicians should advise and treat patients accordingly.     

Long-term survival of autologous adrenal medulla grafts in the great omentum of the rat

Abstract

The omentum, a rich source for trophic and angiogenic factors, was explored as a potential intermediate transplant site to facilitate long-term survival of chromaffin tissue. Autologous rat adrenal medullas were grafted into omental pockets. All grafts became densely vascularized. The grafted chromaffin tissue exhibited strong immunoreactivities for tyrosine hydroxylase, synaptophysin and chromogranin A throughout the observation period of 16 weeks. The expression of these markers implies that grafted chromaffin cells retained the key enzyme for catecholamine biosynthesis and the organelles required for catecholamine secretion. Moreover, intermediate transplant of chromaffin tissue to the omentum could provide a favourable conditioning microenvironment thus augmenting the potential for survival of functional chromaffin tissue. [Neurol Res 1993; 15: 269-272]     

Striatal dopaminergic activity (FDOPA-PET) associated with cognitive items of a depression scale (MADRS) in Parkinson's disease

Motor symptoms form the hallmark of Parkinson's disease (PD), although other features such as depression are often present. Currently-used depression rating scales measure affective and somatic symptoms. These somatic symptoms of depression can also be core PD symptoms, suggesting an overlap of symptoms between depression and PD. Using in vivo radiotracer methods, striatal dopaminergic dysfunction is found in both PD and depression. This study investigates to what extent the overlapping symptoms of depression and PD are associated with the striatal dopaminergic dysfunction typical of PD. Symptoms of depression were assessed in 23 PD patients who did not have major depression according to the Montgomery-Asberg depression rating scale (MADRS; cut-off < 18) and according to a trained psychologist who interviewed all patients. The striatal dopaminergic activity of patients was assessed with FDOPA-PET. Dopaminergic activity of the putamen and caudate nucleus was associated with MADRS total score and specifically with the symptom 'Concentration difficulties'. These results suggest that the typical striatal dopaminergic dysfunction of PD can cause symptoms that can also be categorized as symptoms of depression. In particular, cognitive symptoms measured with a depression rating scale may be based on the dopaminergic dysfunction of the striatum in PD patients.     

Transplantation in Parkinson's disease: PET changes correlate with the amount of grafted tissue.

We compared the striatal uptake of [(18)F]fluorodopa with [(76)Br]-FE-CBT, a positron emission tomography (PET) ligand of the dopamine transporter (DAT), which estimates the density of dopamine nerve terminals, in 6 patients with Parkinson's disease grafted with fetal mesencephalic cells. There was no change in DAT ligand binding in the grafted putamen, despite a significant increase of [(18)F]fluorodopa uptake. This finding suggests that the clinical benefit induced by the graft is more related to increased dopaminergic activity than improved dopaminergic innervation in the host striatum and, therefore, that [(18)F]fluorodopa remains the optimal tracer to evaluate grafted PD patients. Further analysis showed that the clinical and [(18)F]fluorodopa uptake changes after the grafts were correlated with the number of ventral mesencephalae used for implantation.     

Human brain phenolsulfotransferase. Regional distribution in Parkinson's disease

Summary Brain phenolsulfotransferase (PST) in 105.000×g supernatant fractions prepared from post mortem human brain catalyzes the sulfate conjugation of dopamine (DA). Using 50 M DA, the PST activity was linear up to one hour. The KM value for DA was 3.1 M. Higher concentrations of DA from 25 bM up caused inhibition of PST activity. Assessment of regional distribution in normal brain using 20 M DA concentration revealed the highest PST activites in temporal and frontal cortex. About ten times lower activities were measured in parietal and occipital lobe, amygdala, hypothalamus, and hippocampus, whereas the nucleus accumbens, nucleus basalis of Meynert, caudate nucleus, and substantia nigra showed the lowest activities (about 1% of those in frontal and parietal cortex). In the brains of subjects with Parkinson's disease (PD) treated with levodopa, a significant reduction of PST activities was observed in hypothalamus, frontal and temporal cortex, amygdaloid nucleus, occipital and parietal cortex (between 20 and 38.8% of controls). Depletion of PST activity was less severe in hippocampus (46% of controls), nucleus accumbens, putamen, and substantia nigra (67 and 72% of controls, respectively). No changes were observed in the nucleus basalis of Meynert, while PST activity was increased in the caudate nucleus (174 to 203% of controls). The presented data indicate that on PD brain the PST activity is reduced in areas of the cerebral isocortex and limbic system, while in the basal ganglia it is either mildly reduced (putamen) or increased (caudate nucleus). Selective changes of PST activity in PD brain may indicate an important function of this enzyme in the metabolism and/or storage of DA under pathological conditions.     

A 100% increase of dopaminergic cells in the olfactory bulb may explain hyposmia in Parkinson's disease.

Hyposmia is one of the most prevalent symptoms of Parkinson's disease. It may occur even before the motor symptoms start. To determine whether the olfactory dysfunctions, like the motor symptoms, are associated with a loss of dopamine, the number of dopaminergic cells in the olfactory bulb of Parkinson's disease patients was studied using tyrosine hydroxylase immunohistochemistry. The quantitative analysis reveals that the total number of tyrosine hydroxylase-immunoreactive neurons in the olfactory bulb is twice as high in Parkinson patients compared to age and gender-matched controls. Because dopamine is known to inhibit olfactory transmission in the olfactory glomeruli, we suggest that the increase of dopaminergic neurons in the olfactory bulb is responsible for the hyposmia in Parkinson patients. The increase of dopamine in the olfactory bulb explains why olfaction does not improve with levodopa therapy.     

胚胎多巴胺神经元移植治疗帕金森病的实验研究

目的探讨胚胎多巴胺神经元移植对帕金森病大鼠的治疗作用。方法立体定向注射6-羟多巴胺建立帕金森病大鼠模型,随机分为对照组(n=12)和细胞移植组(n=12)。细胞移植组将荧光染料CM-DiI标记的大鼠胚胎多巴胺神经元立体定向注入帕金森病大鼠纹状体区,对照组于相同部位注入生理盐水。用阿扑吗啡诱导帕金森病大鼠旋转行为评估细胞移植的治疗作用。细胞移植8周后取大脑标本行冷冻切片,荧光显微镜下观察移植细胞在脑内存活情况。结果与对照组比较,移植多巴胺神经元能显著改善阿扑吗啡诱导帕金森病大鼠的异常旋转行为(P0.01)。移植8周后,仅少量多巴胺神经元存活。结论多巴胺神经元移植可短期内改善帕金森病大鼠的运动障碍,但长期疗效不佳,可能与移植多巴胺神经元长期存活率较低有关。     

High-performance liquid chromatography with electrochemical detection as a highly efficient tool for studying catecholaminergic systems. I. Quantification of noradrenaline,adrenaline and dopamine in cultured adrenal medullary cells

A method for simultaneous determinations of noradrenaline (NA), adrenaline (A) and dopamine (DA) in tissue is described. After extraction from crude deproteinized homogenates by the batch mode aluminium oxide method individual catecholamines (CA) were separated in a high-performance liquid chromatography (HPLC) system by isocratic elution with pure aqueous buffers from an octadecyl column. These eluates were directly monitored with a new amperometric detector device (Metrohm VA E 641) in a wall-jet flow cell. Sensitivity, specificity, precision and performance of this relatively simple procedure are characterized. Different applications of this assay with relevance to neurobiological research are presented.     

Adrenal medullary implants in the dopamine-denervated rat striatum. I. Acute catecholamine levels in grafts and host caudate as determined by HPLC-electrochemistry and fluorescence histochemical image analysis

Rats with unilateral 6-hydroxydopamine-induced degeneration of the left nigrostriatal dopamine system were given intrastriatal implants of one cortex-free adrenal medulla divided into 4 pieces. Two pieces were placed in the center of the anterior part of the denervated caudate and two pieces in a more posterior position in lateral caudate. The distribution of catecholamines (CA) in grafts and host brain was studied 2, 100 and 400 min after grafting by HPLC-electrochemistry and Falck-Hillarp fluorescence histochemistry combined with computer-aided image analysis. Two minutes after implantation the chromaffin tissue grafts contained large amounts of adrenaline (A) and noradrenaline (NA) and small amounts of dopamine (DA). The chromaffin cells had a relatively normal fluorescence histochemical appearance. From the grafts, CA had spread into the surrounding host brain tissue where high levels of A and NA and low levels of DA were now found in the denervated host striatum. Fluorescence histochemistry and image analysis showed the CA to have spread 1-1.5 mm in all directions from the grafts. The CA concentrations decreased almost linearly with increasing distance from the grafts. At 100 min after implantation approximately a third of the chromaffin cells were still strongly fluorescent while the rest of the cells were very weakly fluorescent or non-fluorescent. The amounts of A, NA and DA in the host brain had decreased considerably, while the size of the fluorescent halo around the grafts had not diminished. At 400 min after grafting, only scattered cells in the chromaffin implants were strongly fluorescent and the surrounding host striatum contained low amounts of CA. It is concluded that intrastriatal adrenal medullary implants acutely release or leak large amounts of CA into surrounding host brain tissue. Taken together with results from the accompanying paper these data show that the grafts can maintain CA levels in host striatum high enough to elicit strong rotational responses during approximately 200 min.