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Mertin R, Diesta C, Brüggemann N, Rosales RL, Hanssen H, Westenberger A, Steinhardt J, Heldmann M, Manalo HTS, Oropilla JQ, Klein C, Helmchen C, Sprenger A. Oculomotor abnormalities indicate early executive dysfunction in prodromal X-linked dystonia-parkinsonism (XDP). J Neurol 2023; 270:4262-4275. [PMID: 37191726 PMCID: PMC10421788 DOI: 10.1007/s00415-023-11761-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND X-Linked dystonia-parkinsonism (XDP) is a movement disorder characterized by the presence of both dystonia and parkinsonism with one or the other more prominent in the initial stages and later on manifesting with more parkinsonian features towards the latter part of the disease. XDP patients show oculomotor abnormalities indicating prefrontal and striatal impairment. This study investigated oculomotor behavior in non-manifesting mutation carriers (NMC). We hypothesized that oculomotor disorders occur before the appearance of dystonic or parkinsonian signs. This could help to functionally identify brain regions already affected in the prodromal stage of the disease. METHODS Twenty XDP patients, 13 NMC, and 28 healthy controls (HC) performed different oculomotor tasks typically affected in patients with parkinsonian signs. RESULTS The error rate for two types of volitional saccades, i.e., anti-saccades and memory-guided saccades, was increased not only in XDP patients but also in NMC compared to HC. However, the increase in error rates of both saccade types were highly correlated in XDP patients only. Hypometria of reflexive saccades was only found in XDP patients. Initial acceleration and maintenance velocity of smooth pursuit eye movements were only impaired in XDP patients. CONCLUSIONS Despite being asymptomatic, NMC already showed some oculomotor deficits reflecting fronto-striatal impairments, typically found in XDP patients. However, NMC did not show saccade hypometria and impaired smooth pursuit as seen in advanced Parkinson's disease and XDP, suggesting oculomotor state rather than trait signs in these mutation carriers. Neurodegeneration may commence in the striatum and prefrontal cortex, specifically the dorsolateral prefrontal cortex.
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Affiliation(s)
- Renana Mertin
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Cid Diesta
- Makati Medical Center, Makati City, Philippines
- Asian Hospital and Medical Center, Manila, Philippines
| | - Norbert Brüggemann
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Raymond L Rosales
- Department of Neurology and Psychiatry, University of Santo Thomas, Manila, Philippines
| | - Henrike Hanssen
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Ana Westenberger
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Julia Steinhardt
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Marcus Heldmann
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
- Institute of Psychology II, University Lübeck, Lübeck, Germany
| | | | - Jean Q Oropilla
- Makati Medical Center, Makati City, Philippines
- Asian Hospital and Medical Center, Manila, Philippines
| | - Christine Klein
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Christoph Helmchen
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany
| | - Andreas Sprenger
- Department of Neurology, University Hospital Schleswig-Holstein, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Lübeck, Germany.
- Institute of Psychology II, University Lübeck, Lübeck, Germany.
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2
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Pozojevic J, von Holt BH, Westenberger A. Factors influencing reduced penetrance and variable expressivity in X-linked dystonia-parkinsonism. MED GENET-BERLIN 2022; 34:97-102. [PMID: 38835911 PMCID: PMC11007627 DOI: 10.1515/medgen-2022-2135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
X-linked dystonia-parkinsonism (XDP) is a neurodegenerative movement disorder that primarily affects adult Filipino men. It is caused by a founder retrotransposon insertion in TAF1 that contains a hexanucleotide repeat, the number of which differs among the patients and correlates with the age at disease onset (AAO) and other clinical parameters. A recent work has identified additional genetic modifiers of age-associated penetrance in XDP, bringing to light the DNA mismatch repair genes MSH3 and PMS2. Despite X-linked recessive inheritance, a minor subset of patients are female, manifesting the disease via various mechanisms such as homozygosity, imbalanced X-chromosome inactivation, or aneuploidy. Here, we summarize and discuss clinical and genetic aspects of XDP, with a focus on variable disease expressivity as a consequence of subtle genetic differences within a seemingly homogenous population of patients.
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Affiliation(s)
- Jelena Pozojevic
- Institute of Neurogenetics, University of Lübeck and University Hospital Schleswig-Holstein, BMF, Building 67; Ratzeburger Allee 160, 23538 Lübeck, Germany
- Institute of Human Genetics, University of Lübeck and University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Björn-Hergen von Holt
- Institute of Medical Biometry and Statistics, University of Lübeck and University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Ana Westenberger
- Institute of Neurogenetics, University of Lübeck and University Hospital Schleswig-Holstein, BMF, Building 67; Ratzeburger Allee 160, 23538 Lübeck, Germany
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3
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GP2
: The Global Parkinson's Genetics Program. Mov Disord 2021; 36:842-851. [PMID: 33513272 PMCID: PMC9290711 DOI: 10.1002/mds.28494] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022] Open
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4
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Weissbach A, Saranza G, Domingo A. Combined dystonias: clinical and genetic updates. J Neural Transm (Vienna) 2020; 128:417-429. [PMID: 33099685 DOI: 10.1007/s00702-020-02269-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/09/2020] [Indexed: 12/28/2022]
Abstract
The genetic combined dystonias are a clinically and genetically heterogeneous group of neurologic disorders defined by the overlap of dystonia and other movement disorders such as parkinsonism or myoclonus. The number of genes associated with combined dystonia syndromes has been increasing due to the wider recognition of clinical features and broader use of genetic testing. Nevertheless, these diseases are still rare and represent only a small subgroup among all dystonias. Dopa-responsive dystonia (DYT/PARK-GCH1), rapid-onset dystonia-parkinsonism (DYT/PARK-ATP1A3), X-linked dystonia-parkinsonism (XDP, DYT/PARK-TAF1), and young-onset dystonia-parkinsonism (DYT/PARK-PRKRA) are monogenic combined dystonias accompanied by parkinsonian features. Meanwhile, MYC/DYT-SGCE and MYC/DYT-KCTD17 are characterized by dystonia in combination with myoclonus. In the past, common molecular pathways between these syndromes were the center of interest. Although the encoded proteins rather affect diverse cellular functions, recent neurophysiological evidence suggests similarities in the underlying mechanism in a subset. This review summarizes recent developments in the combined dystonias, focusing on clinico-genetic features and neurophysiologic findings. Disease-modifying therapies remain unavailable to date; an overview of symptomatic therapies for these disorders is also presented.
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Affiliation(s)
- Anne Weissbach
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany.,Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Gerard Saranza
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, ON, Canada
| | - Aloysius Domingo
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Collaborative Center for X-Linked Dystonia-Parkinsonism, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
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Beste C, Mückschel M, Rosales R, Domingo A, Lee L, Ng A, Klein C, Münchau A. The Basal Ganglia Striosomes Affect the Modulation of Conflicts by Subliminal Information-Evidence from X-Linked Dystonia Parkinsonism. Cereb Cortex 2019; 28:2243-2252. [PMID: 28505262 DOI: 10.1093/cercor/bhx125] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 05/02/2017] [Indexed: 11/12/2022] Open
Abstract
Cognitive control is relevant when distracting information induces behavioral conflicts. Such conflicts can be produced consciously and by subliminally processed information. Interestingly, both sources of conflict interact suggesting that they share neural mechanisms. Here, we ask whether conjoint effects between different sources of conflict are modulated by microstructural basal ganglia dysfunction. To this end, we carried out an electroencephalography study and examined event-related potentials (ERPs) including source localization using a combined flanker-subliminal priming task in patients with X-linked dystonia Parkinsonism (XDP) and a group of healthy controls. XDP in its early stages is known to predominantly affect the basal ganglia striosomes. The results suggest that conjoint effects between subliminal and conscious sources of conflicts are modulated by the striosomes and were stronger in XDP patients. The neurophysiological data indicate that this effect is related to modulations in conflict monitoring and response selection (N2 ERP) mechanisms engaging the anterior cingulate cortex. Bottom-up perceptual gating, attentional selection, and motor response activation processes in response to the stimuli (P1, N1, and lateralized readiness potential ERPs) were unaffected. Taken together, these data indicate that striosomes modulate the processing of conscious and subliminal sources of conflict suggesting that microstructural basal ganglia properties are relevant for cognitive control.
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Affiliation(s)
- Christian Beste
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Fetscherstrasse 74, Dresden, Germany.,Experimental Neurobiology, National Institute of Mental Health, Topolova 748, Klecany, Czech Republic
| | - Moritz Mückschel
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Fetscherstrasse 74, Dresden, Germany
| | - Raymond Rosales
- XDP Study Group, Philippine Children's Medical Center, Quezon Avenue Corner Agham Road, Quezon City, Manila, Philippines
| | - Aloysius Domingo
- Institute of Neurogenetics, University of Lübeck, Maria-Goeppert-Straße 1, Lübeck, Germany
| | - Lillian Lee
- Faculty of Neurology and Psychiatry, University of Santo Tomas, España Boulevard, Manila, Philippines
| | - Arlene Ng
- XDP Study Group, Philippine Children's Medical Center, Quezon Avenue Corner Agham Road, Quezon City, Manila, Philippines
| | - Christine Klein
- Institute of Neurogenetics, University of Lübeck, Maria-Goeppert-Straße 1, Lübeck, Germany
| | - Alexander Münchau
- Institute of Neurogenetics, University of Lübeck, Maria-Goeppert-Straße 1, Lübeck, Germany
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Hanssen H, Prasuhn J, Heldmann M, Diesta CC, Domingo A, Göttlich M, Blood AJ, Rosales RL, Jamora RDG, Münte TF, Klein C, Brüggemann N. Imaging gradual neurodegeneration in a basal ganglia model disease. Ann Neurol 2019; 86:517-526. [DOI: 10.1002/ana.25566] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Henrike Hanssen
- Department of NeurologyUniversity Medical Center Schleswig‐Holstein, Campus Lübeck Lübeck Germany
- Institute of NeurogeneticsUniversity of Lübeck Lübeck Germany
| | - Jannik Prasuhn
- Department of NeurologyUniversity Medical Center Schleswig‐Holstein, Campus Lübeck Lübeck Germany
- Institute of NeurogeneticsUniversity of Lübeck Lübeck Germany
| | - Marcus Heldmann
- Department of NeurologyUniversity Medical Center Schleswig‐Holstein, Campus Lübeck Lübeck Germany
| | - Cid C. Diesta
- Asian Hospital and Medical Center, Filinvest Corporate City, Alabang Muntinlupa City the Philippines
| | - Aloysius Domingo
- Institute of NeurogeneticsUniversity of Lübeck Lübeck Germany
- Department of NeurologyMassachusetts General Hospital Boston MA
| | - Martin Göttlich
- Department of NeurologyUniversity Medical Center Schleswig‐Holstein, Campus Lübeck Lübeck Germany
| | - Anne J. Blood
- Mood and Motor Control LaboratoryMassachusetts General Hospital Charlestown MA
- Laboratory of Neuroimaging and GeneticsMassachusetts General Hospital Charlestown MA
- Department of Neurology and PsychiatryMassachusetts General Hospital Boston MA
- Martinos Center for Biomedical Imaging, Department of RadiologyMassachusetts General Hospital Charlestown MA
- Division of Child NeurologyBoston Children's Hospital Boston MA
| | - Raymond L. Rosales
- Department of Neurology and Psychiatry, Faculty of Medicine and SurgeryUniversity of Santo Tomas Manila the Philippines
| | - Roland D. G. Jamora
- Department of Neurosciences, College of Medicine–Philippine General HospitalUniversity of the Philippines Manila Manila the Philippines
| | - Thomas F. Münte
- Department of NeurologyUniversity Medical Center Schleswig‐Holstein, Campus Lübeck Lübeck Germany
| | - Christine Klein
- Institute of NeurogeneticsUniversity of Lübeck Lübeck Germany
| | - Norbert Brüggemann
- Department of NeurologyUniversity Medical Center Schleswig‐Holstein, Campus Lübeck Lübeck Germany
- Institute of NeurogeneticsUniversity of Lübeck Lübeck Germany
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7
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Sprenger A, Hanssen H, Hagedorn I, Prasuhn J, Rosales RL, Jamora RDG, Diesta CC, Domingo A, Klein C, Brüggemann N, Helmchen C. Eye movement deficits in X-linked dystonia-parkinsonism are related to striatal degeneration. Parkinsonism Relat Disord 2019; 61:170-178. [DOI: 10.1016/j.parkreldis.2018.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/14/2018] [Accepted: 10/14/2018] [Indexed: 11/16/2022]
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8
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Hanssen H, Heldmann M, Prasuhn J, Tronnier V, Rasche D, Diesta CC, Domingo A, Rosales RL, Jamora RD, Klein C, Münte TF, Brüggemann N. Basal ganglia and cerebellar pathology in X-linked dystonia-parkinsonism. Brain 2018; 141:2995-3008. [DOI: 10.1093/brain/awy222] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 07/06/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Henrike Hanssen
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Marcus Heldmann
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Jannik Prasuhn
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Volker Tronnier
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Dirk Rasche
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Cid C Diesta
- Asian Hospital and Medical Center, Filinvest Corporate City, Alabang, Muntinlupa City, Philippines
| | - Aloysius Domingo
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Raymond L Rosales
- Department of Neurology and Psychiatry, University of Santo Tomas Hospital, Manila, Philippines
| | - Roland D Jamora
- Department of Neurosciences, College of Medicine-Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Christine Klein
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Norbert Brüggemann
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
- Department of Neurology, University of Lübeck, Lübeck, Germany
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Beste C, Mückschel M, Rosales R, Domingo A, Lee L, Ng A, Klein C, Münchau A. Dysfunctions in striatal microstructure can enhance perceptual decision making through deficits in predictive coding. Brain Struct Funct 2017; 222:3807-3817. [PMID: 28466359 DOI: 10.1007/s00429-017-1435-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/27/2017] [Indexed: 12/14/2022]
Abstract
An important brain function is to predict upcoming events on the basis of extracted regularities of previous inputs. These predictive coding processes can disturb performance in concurrent perceptual decision-making and are known to depend on fronto-striatal circuits. However, it is unknown whether, and if so, to what extent striatal microstructural properties modulate these processes. We addressed this question in a human disease model of striosomal dysfunction, i.e. X-linked dystonia-parkinsonism (XDP), using high-density EEG recordings and source localization. The results show faster and more accurate perceptual decision-making performance during distraction in XDP patients compared to healthy controls. The electrophysiological data show that sensory memory and predictive coding processes reflected by the mismatch negativity related to lateral prefrontal brain regions were weakened in XDP patients and thus induced less cognitive conflict than in controls as reflected by the N2 event-related potential (ERP). Consequently, attentional shifting (P3a ERP) and reorientation processes (RON ERP) were less pronounced in the XDP group. Taken together, these results suggests that striosomal dysfunction is related to predictive coding deficits leading to a better performance in concomitant perceptual decision-making, probably because predictive coding does not interfere with perceptual decision-making processes. These effects may reflect striatal imbalances between the striosomes and the matrix compartment.
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Affiliation(s)
- Christian Beste
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany. .,Experimental Neurobiology, National Institute of Mental Health, Klecany, Czech Republic.
| | - Moritz Mückschel
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine, TU Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Raymond Rosales
- XDP Study Group, Philippine Children's Medical Center, Quezon City, Philippines
| | - Aloysius Domingo
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Lillian Lee
- Faculty of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
| | - Arlene Ng
- XDP Study Group, Philippine Children's Medical Center, Quezon City, Philippines
| | - Christine Klein
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
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10
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Beste C, Mückschel M, Rosales R, Domingo A, Lee L, Ng A, Klein C, Münchau A. Striosomal dysfunction affects behavioral adaptation but not impulsivity-Evidence from X-linked dystonia-parkinsonism. Mov Disord 2017; 32:576-584. [PMID: 28059473 DOI: 10.1002/mds.26895] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Revised: 11/08/2016] [Accepted: 11/20/2016] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Executive functions including behavioral adaptation and impulse control are commonly impaired in movement disorders caused by striatal pathology. However, as yet it is unclear what aspects of behavioral abnormalities are related to pathology in which striatal subcomponent, that is, the matrix and the striosomes. We therefore studied cognitive control in X-linked dystonia-parkinsonism, a model disease of striosomal degeneration, using behavioral paradigms and EEG. METHODS We studied genetically confirmed X-linked dystonia-parkinsonism patients (N = 21) in their early disease stages and healthy matched controls. Error-related behavioral adaptation was tested in a flanker task and response inhibition in a Go/Nogo paradigm during EEG. We focused on error-related negativity during error processing and the Nogo-N2 and Nogo-P3 in the response inhibition task. Source localization analyses were calculated. In addition, total wavelet power and phase-locking factor reflecting neural synchronization processes in time and frequency across trials were calculated. RESULTS Error processing and behavioral adaptation predominantly engaging the anterior cingulate cortex was markedly impaired in X-linked dystonia-parkinsonism. This was reflected in abnormal reaction times correlating with error-related negativity amplitudes, error related theta band activity, and the phase-locking factor. Also, abnormal error processing correlated with dystonia severity but not with parkinsonism. Response inhibition and corresponding EEG activity were normal. CONCLUSIONS This dissociable pattern of cognitive deficits most likely reflects predominant dysfunction of the striosomal compartment and its connections to the anterior cingulate cortex in X-linked dystonia-parkinsonism. The results underscore the importance of striosomes for cognitive function in humans and suggest that striosomes are relays of error-related behavioral adaptation but not inhibitory control. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Christian Beste
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine of the Technische Universität (TU) Dresden, Dresden, Germany.,Experimental Neurobiology, National Institute of Mental Health, Klecany, Czech Republic
| | - Moritz Mückschel
- Cognitive Neurophysiology, Department of Child and Adolescent Psychiatry, Faculty of Medicine of the Technische Universität (TU) Dresden, Dresden, Germany
| | - Raymond Rosales
- XDP Study Group, Philippine Children's Medical Center, Quezon City, Philippines
| | - Aloysius Domingo
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Lillian Lee
- Faculty of Neurology and Psychiatry, University of Santo Tomas, Manila, Philippines
| | - Arlene Ng
- XDP Study Group, Philippine Children's Medical Center, Quezon City, Philippines
| | - Christine Klein
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
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