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Okkels N, Grothe MJ, Taylor JP, Hasselbalch SG, Fedorova TD, Knudsen K, van der Zee S, van Laar T, Bohnen NI, Borghammer P, Horsager J. Cholinergic changes in Lewy body disease: implications for presentation, progression and subtypes. Brain 2024; 147:2308-2324. [PMID: 38437860 DOI: 10.1093/brain/awae069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024] Open
Abstract
Cholinergic degeneration is significant in Lewy body disease, including Parkinson's disease, dementia with Lewy bodies, and isolated REM sleep behaviour disorder. Extensive research has demonstrated cholinergic alterations in the CNS of these disorders. More recently, studies have revealed cholinergic denervation in organs that receive parasympathetic denervation. This enables a comprehensive review of cholinergic changes in Lewy body disease, encompassing both central and peripheral regions, various disease stages and diagnostic categories. Across studies, brain regions affected in Lewy body dementia show equal or greater levels of cholinergic impairment compared to the brain regions affected in Lewy body disease without dementia. This observation suggests a continuum of cholinergic alterations between these disorders. Patients without dementia exhibit relative sparing of limbic regions, whereas occipital and superior temporal regions appear to be affected to a similar extent in patients with and without dementia. This implies that posterior cholinergic cell groups in the basal forebrain are affected in the early stages of Lewy body disorders, while more anterior regions are typically affected later in the disease progression. The topographical changes observed in patients affected by comorbid Alzheimer pathology may reflect a combination of changes seen in pure forms of Lewy body disease and those seen in Alzheimer's disease. This suggests that Alzheimer co-pathology is important to understand cholinergic degeneration in Lewy body disease. Thalamic cholinergic innervation is more affected in Lewy body patients with dementia compared to those without dementia, and this may contribute to the distinct clinical presentations observed in these groups. In patients with Alzheimer's disease, the thalamus is variably affected, suggesting a different sequential involvement of cholinergic cell groups in Alzheimer's disease compared to Lewy body disease. Patients with isolated REM sleep behaviour disorder demonstrate cholinergic denervation in abdominal organs that receive parasympathetic innervation from the dorsal motor nucleus of the vagus, similar to patients who experienced this sleep disorder in their prodrome. This implies that REM sleep behaviour disorder is important for understanding peripheral cholinergic changes in both prodromal and manifest phases of Lewy body disease. In conclusion, cholinergic changes in Lewy body disease carry implications for understanding phenotypes and the influence of Alzheimer co-pathology, delineating subtypes and pathological spreading routes, and for developing tailored treatments targeting the cholinergic system.
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Affiliation(s)
- Niels Okkels
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Michel J Grothe
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Reina Sofia Alzheimer's Centre, CIEN Foundation-ISCIII, 28031 Madrid, Spain
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Steen Gregers Hasselbalch
- Danish Dementia Research Center, Department of Neurology, Copenhagen University Hospital, 2100 Copenhagen Ø, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen Ø, Denmark
| | - Tatyana D Fedorova
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Karoline Knudsen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Sygrid van der Zee
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Teus van Laar
- Department of Neurology, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Nicolaas I Bohnen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
| | - Per Borghammer
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark
| | - Jacob Horsager
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
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Lench DH, Turner TH, Wetmore E, Rodriguez-Porcel FJ, Revuelta GJ. Integrity of the nucleus basalis of meynert and self-reported cognitive dysfunction during wearing-off periods in parkinson's disease. Brain Imaging Behav 2024; 18:256-261. [PMID: 37889445 PMCID: PMC10872236 DOI: 10.1007/s11682-023-00817-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Cognition in Parkinson's Disease can be impacted by the wearing-off phenomenon which results from changes in dopaminergic tone throughout the day. Given the well-established role of the cholinergic basal forebrain in cognition, we hypothesized that the Nucleus Basalis of Meynert may support cognitive processes during wearing-off periods. Specifically, we evaluated whether worsening of cognitive symptoms during wearing-off is more likely to occur with structural degeneration of the Nucleus Basalis of Meynert. METHODS Cognitive wearing-off was evaluated via the Movement Disorders Society Non-Motor Fluctuation Assessment Questionnaire in 33 Parkinson's Disease participants undergoing evaluation for deep brain stimulation. Pre-operative diffusion MRIs were used to measure brain diffusion metrics of the Nucleus Basalis of Meynert and control regions (caudate and putamen). RESULTS The number of cognitive symptoms which worsened during OFF periods positively correlated with mean diffusivity (ρ = 0.561, p = 0.0007) and generalized fractional anisotropy (ρ=-0.447, p = 0.009) within the Nucleus Basalis of Meynert but not in the caudate or putamen. Meanwhile, stable cognitive symptoms, and ON-state cognitive performance as measured by the DRS-2 did not correlate with Nucleus Basalis of Meynert metrics. Correlations were corrected for age, sex, scanner type, disease duration, education and LEDD. CONCLUSIONS Our study suggests that reduced structural integrity of the Nucleus Basalis of Meynert is associated with worsening of participant-reported cognitive deficits during OFF periods, but not overall cognitive functioning in the ON-state. These findings support the hypothesis that structural integrity of the cholinergic Nucleus Basalis of Meynert may provide resilience to cognitive worsening during dopamine-related wearing-off.
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Affiliation(s)
- Daniel H Lench
- Department of Neurology, Medical University of South Carolina, 208-B Rutledge Ave, Charleston, SC, 29403, USA.
| | - Travis H Turner
- Department of Neurology, Medical University of South Carolina, 208-B Rutledge Ave, Charleston, SC, 29403, USA
| | - Emma Wetmore
- Department of Neurology, Medical University of South Carolina, 208-B Rutledge Ave, Charleston, SC, 29403, USA
| | - Federico J Rodriguez-Porcel
- Department of Neurology, Medical University of South Carolina, 208-B Rutledge Ave, Charleston, SC, 29403, USA
| | - Gonzalo J Revuelta
- Department of Neurology, Medical University of South Carolina, 208-B Rutledge Ave, Charleston, SC, 29403, USA
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Okkels N, Horsager J, Fedorova TD, Knudsen K, Skjærbæk C, Andersen KB, Labrador-Espinosa M, Vestergaard K, Mortensen JK, Klit H, Møller M, Danielsen EH, Johnsen EL, Bekan G, Hansen KV, Munk OL, Damholdt MF, Kjeldsen PL, Hansen AK, Gottrup H, Grothe MJ, Borghammer P. Impaired cholinergic integrity of the colon and pancreas in dementia with Lewy bodies. Brain 2024; 147:255-266. [PMID: 37975822 DOI: 10.1093/brain/awad391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/20/2023] [Accepted: 10/28/2023] [Indexed: 11/19/2023] Open
Abstract
Dementia with Lewy bodies is characterized by a high burden of autonomic dysfunction and Lewy pathology in peripheral organs and components of the sympathetic and parasympathetic nervous system. Parasympathetic terminals may be quantified with 18F-fluoroetoxybenzovesamicol, a PET tracer that binds to the vesicular acetylcholine transporter in cholinergic presynaptic terminals. Parasympathetic imaging may be useful for diagnostics, improving our understanding of autonomic dysfunction and for clarifying the spatiotemporal relationship of neuronal degeneration in prodromal disease. Therefore, we aimed to investigate the cholinergic parasympathetic integrity in peripheral organs and central autonomic regions of subjects with dementia with Lewy bodies and its association with subjective and objective measures of autonomic dysfunction. We hypothesized that organs with known parasympathetic innervation, especially the pancreas and colon, would have impaired cholinergic integrity. To achieve these aims, we conducted a cross-sectional comparison study including 23 newly diagnosed non-diabetic subjects with dementia with Lewy bodies (74 ± 6 years, 83% male) and 21 elderly control subjects (74 ± 6 years, 67% male). We obtained whole-body images to quantify PET uptake in peripheral organs and brain images to quantify PET uptake in regions of the brainstem and hypothalamus. Autonomic dysfunction was assessed with questionnaires and measurements of orthostatic blood pressure. Subjects with dementia with Lewy bodies displayed reduced cholinergic tracer uptake in the pancreas (32% reduction, P = 0.0003) and colon (19% reduction, P = 0.0048), but not in organs with little or no parasympathetic innervation. Tracer uptake in a region of the medulla oblongata overlapping the dorsal motor nucleus of the vagus correlated with autonomic symptoms (rs = -0.54, P = 0.0077) and changes in orthostatic blood pressure (rs = 0.76, P < 0.0001). Tracer uptake in the pedunculopontine region correlated with autonomic symptoms (rs = -0.52, P = 0.0104) and a measure of non-motor symptoms (rs = -0.47, P = 0.0230). In conclusion, our findings provide the first imaging-based evidence of impaired cholinergic integrity of the pancreas and colon in dementia with Lewy bodies. The observed changes may reflect parasympathetic denervation, implying that this process is initiated well before the point of diagnosis. The findings also support that cholinergic denervation in the brainstem contributes to dysautonomia.
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Affiliation(s)
- Niels Okkels
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Jacob Horsager
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Tatyana D Fedorova
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Karoline Knudsen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Casper Skjærbæk
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Katrine B Andersen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Miguel Labrador-Espinosa
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | | | - Janne K Mortensen
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Henriette Klit
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mette Møller
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Erik H Danielsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Erik L Johnsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Goran Bekan
- Department of Neurology, Regionshospitalet Gødstrup, 7400 Herning, Denmark
| | - Kim V Hansen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Ole L Munk
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Malene F Damholdt
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
| | - Pernille L Kjeldsen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
- Department of Neurology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Allan K Hansen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Nuclear Medicine, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Hanne Gottrup
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Michel J Grothe
- Unidad de Trastornos del Movimiento, Servicio de Neurología y Neurofisiología Clínica, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Per Borghammer
- Department of Nuclear Medicine and PET, Aarhus University Hospital, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, 8000 Aarhus C, Denmark
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Citro S, Lazzaro GD, Cimmino AT, Giuffrè GM, Marra C, Calabresi P. A multiple hits hypothesis for memory dysfunction in Parkinson disease. Nat Rev Neurol 2024; 20:50-61. [PMID: 38052985 DOI: 10.1038/s41582-023-00905-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2023] [Indexed: 12/07/2023]
Abstract
Cognitive disorders are increasingly recognized in Parkinson disease (PD), even in early disease stages, and memory is one of the most affected cognitive domains. Classically, hippocampal cholinergic system dysfunction was associated with memory disorders, whereas nigrostriatal dopaminergic system impairment was considered responsible for executive deficits. Evidence from PD studies now supports involvement of the amygdala, which modulates emotional attribution to experiences. Here, we propose a tripartite model including the hippocampus, striatum and amygdala as key structures for cognitive disorders in PD. First, the anatomo-functional relationships of these structures are explored and experimental evidence supporting their role in cognitive dysfunction in PD is summarized. We then discuss the potential role of α-synuclein, a pathological hallmark of PD, in the tripartite memory system as a key mechanism in the pathogenesis of memory disorders in the disease.
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Affiliation(s)
- Salvatore Citro
- Neurology Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Di Lazzaro
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Angelo Tiziano Cimmino
- Neurology Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Maria Giuffrè
- Neurology Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Camillo Marra
- Neurology Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Calabresi
- Neurology Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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5
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Yarnall AJ, Morris R. A cholinergic contribution to postural control and freezing of gait in Parkinson's disease. Brain 2023; 146:3110-3111. [PMID: 37403729 PMCID: PMC10393389 DOI: 10.1093/brain/awad223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023] Open
Abstract
This scientific commentary refers to ‘Cholinergic system correlates of postural control changes in Parkinson's disease freezers’ by Roytman et al. (https://doi.org/10.1093/brain/awad134).
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Affiliation(s)
- Alison J Yarnall
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, UK
- Newcastle upon Tyne NHS Foundation Trust, Newcastle, UK
| | - Rosie Morris
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
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6
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Ray NJ, Kanel P, Bohnen NI. Atrophy of the Cholinergic Basal Forebrain can Detect Presynaptic Cholinergic Loss in Parkinson's Disease. Ann Neurol 2023; 93:991-998. [PMID: 36597786 PMCID: PMC10192078 DOI: 10.1002/ana.26596] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/19/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Structural imaging of the cholinergic basal forebrain may provide a biomarker for cholinergic system integrity that can be used in motor and non-motor outcome studies in Parkinson's disease. However, no prior studies have validated these structural metrics with cholinergic nerve terminal in vivo imaging in Parkinson's disease. Here, we correlate cholinergic basal forebrain morphometry with the topography of vesicular acetylcholine transporter in a large Parkinson's sample. METHODS [18 F]-Fluoroethoxybenzovesamicol vesicular acetylcholine transporter positron emission tomography was carried out in 101 non-demented people with Parkinson's (76.24% male, mean age 67.6 ± 7.72 years, disease duration 5.7 ± 4.4 years). Subregional cholinergic basal forebrain volumes were measured using magnetic resonance imaging morphometry. Relationships were assessed via volume-of-interest based correlation analysis. RESULTS Subregional volumes of the cholinergic basal forebrain predicted cholinergic nerve terminal loss, with most robust correlations occurring between the posterior cholinergic basal forebrain and temporofrontal, insula, cingulum, and hippocampal regions, and with modest correlations in parieto-occipital regions. Hippocampal correlations were not limited to the cholinergic basal forebrain subregion Ch1-2. Correlations were also observed in the striatum, thalamus, and brainstem. INTERPRETATION Cholinergic basal forebrain morphometry is a robust predictor of regional cerebral vesicular acetylcholine transporter bindings, especially in the anterior brain. The relative lack of correlation between parieto-occipital binding and basal forebrain volumes may reflect the presence of more diffuse synaptopathy in the posterior cortex due to etiologies that extend well beyond the cholinergic system. ANN NEUROL 2023;93:991-998.
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Affiliation(s)
- Nicola J Ray
- Health, Psychology and Communities Research Centre, Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Prabesh Kanel
- Radiology, University of Michigan, Ann Arbor, Michigan, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, Michigan, USA
- Parkinson's Foundation Center of Excellence, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicolaas I Bohnen
- Radiology, University of Michigan, Ann Arbor, Michigan, USA
- Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, Michigan, USA
- Parkinson's Foundation Center of Excellence, University of Michigan, Ann Arbor, Michigan, USA
- Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Neurology Service and GRECC, Veterans Administration Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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7
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Bohnen NI, Yarnall AJ. Emerging non-invasive therapeutic approaches targeting hypocholinergic neural systems in Parkinson's disease. Neural Regen Res 2023; 18:809-810. [PMID: 36204846 PMCID: PMC9700120 DOI: 10.4103/1673-5374.353490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/28/2022] [Accepted: 07/20/2022] [Indexed: 12/02/2022] Open
Affiliation(s)
- Nicolaas I. Bohnen
- Department of Radiology and Neurology, University of Michigan, Ann Arbor VAMC, Ann Arbor, MI, USA
| | - Alison J. Yarnall
- Department of Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK (Yarnall AJ)
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8
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Maiti B, Perlmutter JS. Imaging in Movement Disorders. Continuum (Minneap Minn) 2023; 29:194-218. [PMID: 36795878 DOI: 10.1212/con.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article reviews commonly used imaging modalities in movement disorders, particularly parkinsonism. The review includes the diagnostic utility, role in differential diagnosis, reflection of pathophysiology, and limitations of neuroimaging in the setting of movement disorders. It also introduces promising new imaging modalities and describes the current status of research. LATEST DEVELOPMENTS Iron-sensitive MRI sequences and neuromelanin-sensitive MRI can be used to directly assess the integrity of nigral dopaminergic neurons and thus may reflect disease pathology and progression throughout the full range of severity in Parkinson disease (PD). The striatal uptake of presynaptic radiotracers in their terminal axons as currently assessed using clinically approved positron emission tomography (PET) or single-photon emission computed tomography (SPECT) imaging correlates with nigral pathology and disease severity only in early PD. Cholinergic PET, using radiotracers that target the presynaptic vesicular acetylcholine transporter, constitutes a substantial advance and may provide crucial insights into the pathophysiology of clinical symptoms such as dementia, freezing, and falls. ESSENTIAL POINTS In the absence of valid, direct, objective biomarkers of intracellular misfolded α-synuclein, PD remains a clinical diagnosis. The clinical utility of PET- or SPECT-based striatal measures is currently limited given their lack of specificity and inability to reflect nigral pathology in moderate to severe PD. These scans may be more sensitive than clinical examination to detect nigrostriatal deficiency that occurs in multiple parkinsonian syndromes and may still be recommended for clinical use in the future to identify prodromal PD if and when disease-modifying treatments become available. Multimodal imaging to evaluate underlying nigral pathology and its functional consequences may hold the key to future advances.
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Horsager J, Okkels N, Hansen AK, Damholdt MF, Andersen KH, Fedorova TD, Munk OL, Danielsen EH, Pavese N, Brooks DJ, Borghammer P. Mapping Cholinergic Synaptic Loss in Parkinson's Disease: An [18F]FEOBV PET Case-Control Study. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2493-2506. [PMID: 36336941 DOI: 10.3233/jpd-223489] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cholinergic degeneration is strongly associated with cognitive decline in patients with Parkinson's disease (PD) but may also cause motor symptoms and olfactory dysfunction. Regional differences are striking and may reflect different PD related symptoms and disease progression patterns. OBJECTIVE To map and quantify the regional cerebral cholinergic alterations in non-demented PD patients. METHODS We included 15 non-demented PD patients in early-moderate disease stage and 15 age- and sex-matched healthy controls for [18F]FEOBV positron emission tomography imaging. We quantitated regional variations using VOI-based analyses which were supported by a vertex-wise cluster analysis. Correlations between imaging data and clinical and neuropsychological data were explored. RESULTS We found significantly decreased [18F]FEOBV uptake in global neocortex (38%, p = 0.0002). The most severe reductions were seen in occipital and posterior temporo-parietal regions (p < 0.0001). The vertex-wise cluster analysis corroborated these findings. All subcortical structures showed modest non-significant reductions. Motor symptoms (postural instability and gait difficulty) and cognition (executive function and composite z-score) correlated with regional [18F]FEOBV uptake (thalamus and cingulate cortex/insula/hippocampus, respectively), but the correlations were not statistically significant after multiple comparison correction. A strong correlation was found between interhemispheric [18F]FEOBV asymmetry, and motor symptom asymmetry of the extremities (r = 0.84, p = 0.0001). CONCLUSION Cortical cholinergic degeneration is prominent in non-demented PD patients, but more subtle in subcortical structures. Regional differences suggest uneven involvement of cholinergic nuclei in the brain and may represent a window to follow disease progression. The correlation between asymmetric motor symptoms and neocortical [18F]FEOBV asymmetry indicates that unilateral cholinergic degeneration parallels ipsilateral dopaminergic degeneration.
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Affiliation(s)
- Jacob Horsager
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Niels Okkels
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Allan K Hansen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Katrine H Andersen
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tatyana D Fedorova
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ole Lajord Munk
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark
| | - Erik H Danielsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Nicola Pavese
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Institute of Translational and Clinical Research, University of Newcastle upon Tyne, UK
| | - David J Brooks
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Institute of Translational and Clinical Research, University of Newcastle upon Tyne, UK
| | - Per Borghammer
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Vercouillie J, Buron F, Sérrière S, Rodrigues N, Gulhan Z, Chartier A, Chicheri G, Marzag H, Oury A, Percina N, Bodard S, Ben Othman R, Busson J, Suzenet F, Guilloteau D, Marchivie M, Emond P, Routier S, Chalon S. Development and preclinical evaluation of [18F]FBVM as a new potent PET tracer for vesicular acetylcholine transporter. Eur J Med Chem 2022; 244:114794. [DOI: 10.1016/j.ejmech.2022.114794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/13/2022] [Accepted: 09/23/2022] [Indexed: 11/30/2022]
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11
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Tiepolt S, Meyer PM, Patt M, Deuther-Conrad W, Hesse S, Barthel H, Sabri O. PET Imaging of Cholinergic Neurotransmission in Neurodegenerative Disorders. J Nucl Med 2022; 63:33S-44S. [PMID: 35649648 DOI: 10.2967/jnumed.121.263198] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/06/2022] [Indexed: 12/13/2022] Open
Abstract
As a neuromodulator, the neurotransmitter acetylcholine plays an important role in cognitive, mood, locomotor, sleep/wake, and olfactory functions. In the pathophysiology of most neurodegenerative diseases, such as Alzheimer disease (AD) or Lewy body disorder (LBD), cholinergic receptors, transporters, or enzymes are involved and relevant as imaging targets. The aim of this review is to summarize current knowledge on PET imaging of cholinergic neurotransmission in neurodegenerative diseases. For PET imaging of presynaptic vesicular acetylcholine transporters (VAChT), (-)-18F-fluoroethoxybenzovesamicol (18F-FEOBV) was the first PET ligand that could be successfully translated to clinical application. Since then, the number of 18F-FEOBV PET investigations on patients with AD or LBD has grown rapidly and provided novel, important findings concerning the pathophysiology of AD and LBD. Regarding the α4β2 nicotinic acetylcholine receptors (nAChRs), various second-generation PET ligands, such as 18F-nifene, 18F-AZAN, 18F-XTRA, (-)-18F-flubatine, and (+)-18F-flubatine, were developed and successfully translated to human application. In neurodegenerative diseases such as AD and LBD, PET imaging of α4β2 nAChRs is of special value for monitoring disease progression and drugs directed to α4β2 nAChRs. For PET of α7 nAChR, 18F-ASEM and 11C-MeQAA were successfully applied in mild cognitive impairment and AD, respectively. The highest potential for α7 nAChR PET is seen in staging, in evaluating disease progression, and in therapy monitoring. PET of selective muscarinic acetylcholine receptors (mAChRs) is still in an early stage, as the development of subtype-selective radioligands is complicated. Promising radioligands to image mAChR subtypes M1 (11C-LSN3172176), M2 (18F-FP-TZTP), and M4 (11C-MK-6884) were developed and successfully translated to humans. PET imaging of mAChRs is relevant for the assessment and monitoring of therapies in AD and LBD. PET of acetylcholine esterase activity has been investigated since the 1990s. Many PET studies with 11C-PMP and 11C-MP4A demonstrated cortical cholinergic dysfunction in dementia associated with AD and LBD. Recent studies indicated a solid relationship between subcortical and cortical cholinergic dysfunction and noncognitive dysfunctions such as balance and gait in LBD. Taken together, PET of distinct components of cholinergic neurotransmission is of great interest for diagnosis, disease monitoring, and therapy monitoring and to gain insight into the pathophysiology of different neurodegenerative disorders.
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Affiliation(s)
- Solveig Tiepolt
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany; and
| | - Philipp M Meyer
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany; and
| | - Marianne Patt
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany; and
| | | | - Swen Hesse
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany; and
| | - Henryk Barthel
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany; and
| | - Osama Sabri
- Department of Nuclear Medicine, University of Leipzig, Leipzig, Germany; and
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12
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Albin RL, Kanel P, van Laar T, van der Zee S, Roytman S, Koeppe RA, Scott PJH, Bohnen NI. No Dopamine Agonist Modulation of Brain [ 18F]FEOBV Binding in Parkinson's Disease. Mol Pharm 2022; 19:1176-1182. [PMID: 35289620 PMCID: PMC8983523 DOI: 10.1021/acs.molpharmaceut.1c00961] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The [18F]fluoroethoxybenzovesamicol ([18F]FEOBV) positron emission tomography (PET) ligand targets the vesicular acetylcholine transporter. Recent [18F]FEOBV PET rodent studies suggest that regional brain [18F]FEOBV binding may be modulated by dopamine D2-like receptor agents. We examined associations of regional brain [18F]FEOBV PET binding in Parkinson's disease (PD) subjects without versus with dopamine D2-like receptor agonist drug treatment. PD subjects (n = 108; 84 males, 24 females; mean age 68.0 ± 7.6 [SD] years), mean disease duration of 6.0 ± 4.0 years, and mean Movement Disorder Society-revised Unified PD Rating Scale III 35.5 ± 14.2 completed [18F]FEOBV brain PET imaging. Thirty-eight subjects were taking dopamine D2-like agonists. Vesicular monoamine transporter type 2 [11C]dihydrotetrabenazine (DTBZ) PET was available in a subset of 54 patients. Subjects on dopamine D2-like agonists were younger, had a longer duration of disease, and were taking a higher levodopa equivalent dose (LED) compared to subjects not taking dopamine agonists. A group comparison between subjects with versus without dopamine D2-like agonist use did not yield significant differences in cortical, striatal, thalamic, or cerebellar gray matter [18F]FEOBV binding. Confounder analysis using age, duration of disease, LED, and striatal [11C]DTBZ binding also failed to show significant regional [18F]FEOBV binding differences between these two groups. Chronic D2-like dopamine agonist use in PD subjects is not associated with significant alterations of regional brain [18F]FEOBV binding.
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Affiliation(s)
- Roger L Albin
- Department of Neurology, University of Michigan, Ann Arbor, Michigan 48109, United States.,GRECC & Neurology Service, VAAAHS, Ann Arbor, Michigan 48105, United States.,University of Michigan Udall Center, Ann Arbor, Michigan 48109, United States.,University of Michigan Parkinson's Foundation Research Center of Excellence, Ann Arbor, Michigan 48109, United States
| | - Prabesh Kanel
- University of Michigan Udall Center, Ann Arbor, Michigan 48109, United States.,Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Teus van Laar
- University of Michigan Udall Center, Ann Arbor, Michigan 48109, United States.,Department of Neurology, University Medical Center Groningen, University of Groningen, 9713 AV Groningen, The Netherlands
| | - Sygrid van der Zee
- University of Michigan Udall Center, Ann Arbor, Michigan 48109, United States.,Department of Neurology, University Medical Center Groningen, University of Groningen, 9713 AV Groningen, The Netherlands
| | - Stiven Roytman
- Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Robert A Koeppe
- University of Michigan Udall Center, Ann Arbor, Michigan 48109, United States.,Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Peter J H Scott
- Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Nicolaas I Bohnen
- Department of Neurology, University of Michigan, Ann Arbor, Michigan 48109, United States.,GRECC & Neurology Service, VAAAHS, Ann Arbor, Michigan 48105, United States.,University of Michigan Udall Center, Ann Arbor, Michigan 48109, United States.,University of Michigan Parkinson's Foundation Research Center of Excellence, Ann Arbor, Michigan 48109, United States.,Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109, United States
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13
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Bohnen NI, Yarnall AJ, Weil RS, Moro E, Moehle MS, Borghammer P, Bedard MA, Albin RL. Cholinergic system changes in Parkinson's disease: emerging therapeutic approaches. Lancet Neurol 2022; 21:381-392. [PMID: 35131038 PMCID: PMC8985079 DOI: 10.1016/s1474-4422(21)00377-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/30/2021] [Accepted: 10/20/2021] [Indexed: 01/16/2023]
Abstract
In patients with Parkinson's disease, heterogeneous cholinergic system changes can occur in different brain regions. These changes correlate with a range of clinical features, both motor and non-motor, that are refractory to dopaminergic therapy, and can be conceptualised within a systems-level framework in which nodal deficits can produce circuit dysfunctions. The topographies of cholinergic changes overlap with neural circuitries involved in sleep and cognitive, motor, visuo-auditory perceptual, and autonomic functions. Cholinergic deficits within cognition network hubs predict cognitive deficits better than do total brain cholinergic changes. Postural instability and gait difficulties are associated with cholinergic system changes in thalamic, caudate, limbic, neocortical, and cerebellar nodes. Cholinergic system deficits can involve also peripheral organs. Hypercholinergic activity of mesopontine cholinergic neurons in people with isolated rapid eye movement (REM) sleep behaviour disorder, as well as in the hippocampi of cognitively normal patients with Parkinson's disease, suggests early compensation during the prodromal and early stages of Parkinson's disease. Novel pharmacological and neurostimulation approaches could target the cholinergic system to treat motor and non-motor features of Parkinson's disease.
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Affiliation(s)
- Nicolaas I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Neurology Service, Ann Arbor, MI, USA; VA Geriatric Research Education and Clinical Center, Ann Arbor, MI, USA; Ann Arbor VAMC, Ann Arbor, MI, USA.
| | - Alison J Yarnall
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rimona S Weil
- Dementia Research Centre, University College London, London, UK
| | - Elena Moro
- Division of Neurology, CHU of Grenoble, Grenoble, France; Grenoble Alpes University, and INSERM u1216, Grenoble, France
| | - Mark S Moehle
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, FL, USA
| | - Per Borghammer
- Department of Nuclear Medicine and PET, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Marc-André Bedard
- Cognitive Pharmacology Research Unit, UQAM, Montreal, QC, Canada; McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, QC, Canada; Research Centre for Studies in Aging, McGill University, Montreal, QC, Canada; Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
| | - Roger L Albin
- VA Geriatric Research Education and Clinical Center, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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Cholinergic systems, attentional-motor integration, and cognitive control in Parkinson's disease. PROGRESS IN BRAIN RESEARCH 2022; 269:345-371. [PMID: 35248201 PMCID: PMC8957710 DOI: 10.1016/bs.pbr.2022.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Dysfunction and degeneration of CNS cholinergic systems is a significant component of multi-system pathology in Parkinson's disease (PD). We review the basic architecture of human CNS cholinergic systems and the tools available for studying changes in human cholinergic systems. Earlier post-mortem studies implicated abnormalities of basal forebrain corticopetal cholinergic (BFCC) and pedunculopontine-laterodorsal tegmental (PPN-LDT) cholinergic projections in cognitive deficits and gait-balance deficits, respectively. Recent application of imaging methods, particularly molecular imaging, allowed more sophisticated correlation of clinical features with regional cholinergic deficits. BFCC projection deficits correlate with general and domain specific cognitive deficits, particularly for attentional and executive functions. Detailed analyses suggest that cholinergic deficits within the salience and cingulo-opercular task control networks, including both neocortical, thalamic, and striatal nodes, are a significant component of cognitive deficits in non-demented PD subjects. Both BFCC and PPN-LDT cholinergic projection systems, and striatal cholinergic interneuron (SChI), abnormalities are implicated in PD gait-balance disorders. In the context of experimental studies, these results indicate that disrupted attentional functions of BFCC and PPN-LDT cholinergic systems underlie impaired gait-balance functions. SChI dysfunction likely impairs intra-striatal integration of attentional and motor information. Thalamic and entorhinal cortex cholinergic deficits may impair multi-sensory integration. Overt degeneration of CNS systems may be preceded by increased activity of cholinergic neurons compensating for nigrostriatal dopaminergic deficits. Subsequent dysfunction and degeneration of cholinergic systems unmasks and exacerbates functional deficits secondary to dopaminergic denervation. Research on CNS cholinergic systems dysfunctions in PD requires a systems-level approach to understanding PD pathophysiology.
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