Cerebral transplantation for Parkinson's disease: current progress and future prospects

A Comparative Study of Preparation Techniques for Improving the Viability of Nigral Grafts using Vital Stains, in Vitro Cultures, and in Vivo Grafts

The intracerebral transplantation of embryonic dopaminergic nigral neurons, although relatively successful, leads to a fairly low yield of surviving cells. Many factors may influence the viability of dopaminergic grafts and one of these is the preparation of the tissue prior to transplantation. We have investigated the effects of different steps during the preparation and storage of embryonic rat nigral cell suspensions on their subsequent survival at a variety of different time points using a combination of techniques and studies. For studies concerned with the first 24 h we employed vital stains, in the period covering the next 7 days we used in vitro cultures, and in the long term experiment we used in vivo grafts. The results suggest that nigral cell suspensions may remain sufficiently viable for grafting for much longer periods than previously reported. In addition a number of parameters which affect cell survival have been characterised, including the age of the embryonic donor tissue, the use of proteolytic enzymes and the trituration procedure used during the preparation of the suspension. The optimal preparation technique, therefore, uses E13-E14 embryos with the dissected ventral mesencephalon being incubated in purified 0.1% trypsin solutions for 60 min and triturated using a flame polished Pasteur pipette. This may have important implications in improving intracerebral transplantation for Parkinson's disease.

Intrastriatal Grafts from Multiple Donors do not Result in a Proportional Increase in Survival of Dopamine Neurons in Nonhuman Primates

We examined the potential for “double grafts,” i.e., grafts from two donors in each recipient, to enhance the total number of ventral mesencephalic dopamine neurons that survive grafting in adult African green monkeys. Because dopamine cell survival in grafts represents a small percentage of the total number of neurons grafted, several human clinical trials recently have employed grafts of tissue from multiple donors (e.g., from two to eight embryos per host recipient) in attempts to increase the total number of dopamine neurons that survive in grafts. Presumably, this is intended to elevate dopamine levels by providing more dopamine neurons to the damaged brain to alleviate the symptoms of parkinsonism. While well-developed grafts with several thousand dopamine neurons were found in most recipient animals, we observed a reduced total number of tyrosine hydroxylase positive neurons in the grafts in spite of the presence of some double grafts that were larger than normal. The overall growth of the grafts was impressive; some grafts were so large that they spanned the full dorsoventral extent of the caudate nucleus, probably reflecting the fact that twice as much tissue was implanted in each drop site in comparison to our standard protocol. However, some animals revealed atypical patterns of neurite outgrowth that appeared limited to the grafted tissue, and at least one monkey revealed “amorphous” grafts generally lacking in cellular structure, which suggests a possible rejection phenomenon. These findings raise questions about the use of multiple donors and suggest that the likelihood of rejection and/or cell death may be enhanced, which is of potential importance in the design of grafting strategies for clinical applications.

Review : Glial Boundaries and Scars: Programs for Normal Development and Wound Healing in the Brain

Early studies of glial boundaries, which are composed of immature astrocytes and extracellular matrix mol ecules (which they express), initially offered insight into the partitioning that occurs in the developing nervous system. More recently, however, it has been suggested that similar "boundaries" may have important roles in other processes occurring in the brain, including repair after traumatic brain injury. As more is understood about the expression and function of boundary molecules and glia, their potential importance is becoming apparent in numerous neuropathological conditions, including neurodegeneration and neuroregeneration in Alzheimer's and Huntington's diseases as well as in brain neoplasms. Furthermore, before we can hope to fully understand and facilitate regeneration in the compromised brain, our knowledge of the glial boundary, both during development and in the adult, must be more complete. The Neuroscientist 1:142-154, 1995

Parkinson's Disease and the Basal Ganglia: Lessons from the Laboratory and from Neurosurgery

During the last decade, a clearer understanding of the circuitry of the basal ganglia and their mode of operation has emerged. The basal ganglia are now viewed as parts of larger, segregated circuits that involve the thalamus and cerebral cortex. A pathophysiological model has been elaborated and tested in which Parkinsonian signs are viewed as resulting from increased activity of neurons in the "motor" portion of the internal pallidum, the major output nucleus of the basal ganglia, leading to increased inhibition of thalamocortical projection neurons and decreased activation of the precentral motor fields. Increased internal pallidal activity is thought to result from striatal dopamine loss, leading to decreased inhibition of the internal pallidum via a monosynaptic ("direct") striatopallidal pathway and to excessive excitatory glutamatergic drive via a polysynaptic ("indirect") striatopallidal pathway. Because current medical therapies for Parkinson's disease, aimed at systemically replacing dopamine, often lose their effectiveness after several years, with patients suffering from motor fluctuations and drug-induced dyski nesias, several new therapeutic strategies have been developed. In addition to the transplantation of dopaminergic tissue, other strategies attempt to reduce increased basal ganglia outflow directly by the placement of stereotactic lesions into the sensorimotor portion of the internal pallidum (pallidotomy) or by the chronic electric stimulation of the subthalamic nucleus. Preliminary results suggest that these new techniques may lead to significant improvement in Parkinsonian signs, motor fluctuations, and drug- induced dyskinesias. The Neuroscientist 1:236-244, 1995

Neural tissue transplantation, repair, and rehabilitation

Transplants of cells and tissues to the central nervous system of adult mammals can, under appropriate conditions, survive, integrate, and function. In particular, the grafted cells can sustain functional recovery in animal models of a range of neurodegenerative conditions including genetic and idiopathic neurodegenerative diseases of adulthood and aging, ischemic stroke, and brain and spinal cord trauma. In a restricted subset of such conditions, cell transplantation has progressed to application in humans in early-stage clinical trials. At the present stage of play, there is clear evidence of clinical efficacy of fetal cell transplants in Parkinson disease (notwithstanding a range of technical difficulties still to be fully resolved), and preliminary claims of promising outcomes in several other severe neurodegenerative conditions, including Huntington disease and stroke. Moreover, the experimental literature is increasingly suggesting that the experience and training of the graft recipient materially affects the functional outcome. For example, environmental enrichment, behavioral activity, and specific training can enhance the recovery process to maximize functional recovery. There are even circumstances where the grafted cells have been demonstrated to restore the neural substrate for new learning. Consequently, it is not sufficient to replace lost cells anatomically; rather, for the grafts to be effective, they need to be integrated functionally into the host circuitry, and the host animal requires training and rehabilitation to maximize function of the reconstructed graft-host circuitry. Such observations require reconsideration of the design of the next generation of clinical trials and subsequent service delivery, to include physiotherapists, cognitive therapists, and rehabilitation experts as core members of the transplant team, along with the neurologists and neurosurgeons that have conventionally led the field.

Nano neurology and the four P's of central nervous system regeneration: preserve, permit, promote, plasticity

True nanomaterials are delivered as a specific structure, or combination of structures, designed to deliver the therapeutic intact, directly to the site, requiring a much lower dose. These materials use very specific and deliberate molecular structures that can interact with neurons or protein structures inside the cells. Until recently, functional recovery of the central nervous system (CNS) was an unattainable goal and nanotechnology was an invisible science. A well-planned treatment spaced over time will produce functional return in the CNS. The four P's of CNS regeneration is a new framework for approaching CNS injury and evidence shows that nanotechnology is currently being used for stroke rehabilitation and, in several clinical trials, the treatment of scar formation blockade in the spinal cord. The four components are preserve, permit, promote, and plasticity.

Factors involved in the determination of the neurotransmitter phenotype of developing neurons of the CNS: Applications in cell replacement treatment for Parkinson's disease

The developmental stages involved in the conversion of stem cells to fully functional neurons of specific neurotransmitter phenotype are complex and not fully understood. Over the past decade many studies have been published that demonstrate that in vitro manipulation of the epigenetic environment of the stem cells allows experimental control of final neuronal phenotypic choice. This review presents the evidence for the involvement of a number of endogenous neurobiochemicals, which have been reported to potently influence DAergic (and other neurotransmitter) phenotype expression in vitro. They act at different stages on the pathway to neurotransmitter phenotype determination, and in different ways. Many are better known for their involvement in other aspects of development, and in other biochemical roles. Their proper place, and precise roles, in neurotransmitter phenotype determination in vivo will no doubt be determined in the future. Meanwhile, considerable medical benefits are offered from producing large, long-term, viable cryostores of self-regenerating multipotential neural precursor cells (i.e., brain stem cells), which can be used for cell replacement therapies in the treatment of degenerative brain diseases, such as Parkinson's disease.

Parkinson's disease: medical and surgical treatment

It has been over three decades since the introduction of L-dihydroxyphenylalanine or levodopa therapy for Parkinson's disease (PD). The early levodopa trials were driven by recognition of a profound cerebral dopamine deficiency state in this disorder. Whereas dopamine fails to cross the blood brain barrier and hence is ineffective as therapy, the amino acid precursor, dopa, is transported across this barrier and provides a substrate for dopamine synthesis. Levodopa is converted to dopamine within the brain by dopa decarboxylase, replenishing central dopamine stores and potentially reversing the motor symptoms of PD.

Restorative neurosurgery: opportunities for restoration of function in acquired, degenerative, and idiopathic neurological diseases

Historically, neurosurgery has improved the environment of the nervous system to promote maximal spontaneous recovery of function. The population of patients whom we treat at present is a small portion of those who suffer from disabling neurological illnesses. Based on a combination of new technology, and advances in neuroscience, restorative neurosurgery is advancing the frontiers of our specialty, and providing the potential to restore lost function. Significant advancements in gene therapy, the discovery and delivery of neurotrophic factors, and cell transplantation now require neurosurgeons to broaden the scope of our practice so that it includes the restoration of function in an enormous number of patients with acquired, degenerative and idiopathic neurological diseases. In order to meet the present challenge, neurosurgeons must broaden our vision, our role, and our future educational goals. In this review, we summarize the landmark advances in the basic and clinical neurosciences and the results of clinical trials that are driving our evolution from passive reaction to disease to active attempts to restore lost central nervous system function.

Induction of immunologic tolerance for transplantation

In the second half of the 20th century, the transplantation of replacement organs and tissues to cure disease has become a clinical reality. Success has been achieved as a direct result of progress in understanding the cellular and molecular biology of the immune system. This understanding has led to the development of immunosuppressive pharmaceuticals that are part of nearly every transplantation procedure. All such drugs are toxic to some degree, however, and their chronic use, mandatory in transplantation, predisposes the patient to the development of infection and cancer. In addition, many of them may have deleterious long-term effects on the function of grafts. New immunosuppressive agents are constantly under development, but organ transplantation remains a therapy that requires patients to choose between the risks of their primary illness and its treatment on the one hand, and the risks of life-long systemic immunosuppression on the other. Alternatives to immunosuppression include modulation of donor grafts to reduce immunogenicity, removal of passenger leukocytes, transplantation into immunologically privileged sites like the testis or thymus, encapsulation of tissue, and the induction of a state of immunologic tolerance. It is the last of these alternatives that has, perhaps, the most promise and most generic applicability as a future therapy. Recent reports documenting long-term graft survival in the absence of immunosuppression suggest that tolerance-based therapies may soon become a clinical reality. Of particular interest to our laboratory are transplantation strategies that focus on the induction of donor-specific T-cell unresponsiveness. The basic biology, protocols, experimental outcomes, and clinical implications of tolerance-based transplantation are the focus of this review.

Co-grafted embryonic striatum increases the survival of grafted embryonic dopamine neurons

To enhance the current therapeutic benefit of dopamine (DA) neuron grafts in Parkinson's disease, strategies must be developed that increase both DA neuron survival and fiber outgrowth into the denervated striatum. Previous work in our laboratory has demonstrated that dopaminergic neurons grow to greater size when co-grafted with striatal cell suspensions and display extensive tyrosine hydroxylase-positive (TH+) projections, but no conclusion could be reached concerning enhancement of survival of grafted DA neurons. The aim of the present study was to characterize further the potential trophic effects of striatal co-grafts on grafted mesencephalic DA neuron survival. Unilaterally lesioned male Fischer 344 rats were grafted with either a suspension of mesencephalic cells or with both mesencephalic and striatal cell suspensions. Co-grafts were either mixed together or placed separately into the striatum. Lesioned rats receiving no graft served as controls. Rotational behavior was assessed following amphetamine challenge at 2 weeks prior to grafting and at 4 and 8 weeks following grafting. Only rats receiving co-grafts of nigral and striatal suspensions separated by a distance of 1 mm showed significant behavioral recovery from baseline rotational asymmetry. Both mixed and separate striatal co-grafts were associated with a doubling of DA neuron survival compared with solo mesencephalic grafts. In the mixed co-graft experiment, DA neurite branching appeared enhanced and TH-rich patches were observed, whereas with co-grafts that were separated, TH+ innervation of the intervening host striatum was increased significantly. These results provide the first evidence suggesting that nigral-striatal co-grafts, particularly those placed separately and in proximity to each other, increase both DA neuron survival and neurite extension from the mesencephalic component of the grafts.

Induction of tyrosine hydroxylase gene expression in human foetal cerebral cortex

Human foetal cerebral cortex (9-14 weeks gestational age) was dissected out and cultured in microwell plates. It was then treated with brain-derived neurotrophic factor (BDNF, 50 ng/ml), dopamine (10 mM) or their combination. After 5 weeks of this treatment tyrosine hydroxylase (TH)-immunopositive neurones were detected at a level of 0.73% of total neurones present. This represented 300-500 TH + neurones per microwell. None were seen in untreated cultures. This correlates with induction of the entire dopaminergic phenotype in foetal rat cerebral cortex (E1214) by the same co-treatment applied for a much shorter time period (7 days), which implies that the complete dopaminergic phenotype is also induced in cultured human foetal tissue over a longer period, reflecting the 5-fold longer neuronal gestational period.

Long-term improvement in patients with severe Parkinson's disease after implantation of fetal ventral mesencephalic tissue in a cavity of the caudate nucleus: 5-year follow up in 10 patients. Clinica Puerta de Hierro Neural Transplantation Group

Different groups worldwide have observed in recent years that stereotactic implantation of fetal tissue can ameliorate the clinical symptoms of Parkinson's disease. The authors therefore investigated whether implantation of fetal ventral mesencephalic (FVM) tissue via open surgery is also capable of producing an improvement and whether this improvement is transient or long lasting. The authors report their findings in a 5-year follow-up study in 10 patients with Hoehn and Yahr Grade IV or V Parkinson's disease in whom a single FVM graft was implanted in a cavity created in the right caudate nucleus. The results indicate that the implants improved motor function and that clinical recovery persisted in seven of the 10 patients 5 years after implantation. Amelioration was observed in both the on and off phases and was accompanied by a 64% reduction in the levodopa dose and withdrawal of the dopamine agonist. The on phase was prolonged from 39% of the waking day to 72%, with reduced intensity and duration of dyskinesias. All symptoms that were analyzed showed improvement, although they differed in intensity and time of onset. The course of improvement seemed to be stepwise, with significant improvement between 5 and 7 months postimplantation followed by two waves of progress peaking in Months 15 and 36. Withdrawal of cyclosporine in three patients after more than 2 years of administration produced a decline in the patients' clinical conditions. In conclusion, the results indicate that open surgery implantation of FVM tissue in the caudate nucleus improves the clinical condition of parkinsonian patients and that this improvement can persist for at least 5 years. In comparison with two earlier series reported by the authors, which involved implants of perfused adrenal medulla and coimplantation of adrenal medulla and peripheral nerve, the course and pattern of improvement in these implant recipients suggests that their recovery can be attributed to more than one factor.

Influence of BDNF on the expression of the dopaminergic phenotype of tissue used for brain transplants

Brain-derived neurotrophic factor (BDNF) has previously been shown by this laboratory among others to promote survival and differentiation of central dopaminergic neurons and to stimulate expression of the dopaminergic phenotype in fetal cerebrocortex in vitro. We have examined the effect of BDNF antibody on nigral dopaminergic neurons in vivo and in vitro. It reduced the survival of rat fetal dopaminergic neurons in culture (up to 40% died). The BDNF antibody also caused ipsilateral rotation after a single in vivo intranigral injection in the adult rats. Pre-treatment of fetal nigral neurons with BDNF improved the performance of dopaminergic cells in fetal nigral transplants based on surviving TH+ cells numbers. Thus, parkinsonian rats receiving fetal nigral cells treated with BDNF showed a significantly greater reduction of turning over the 3 weeks following transplantation, compared with the rats receiving untreated nigral transplants. However, the average number of tyrosine hydroxylase (TH)-positive neurons in the grafts of rats receiving fetal nigral cells treated with BDNF was 211 +/- 35 which was only about 20% of the cell number (1012 +/- 223, mean +/- S.E.M.) found in those receiving untreated nigral transplants. These results suggest that pretreatment of nigral dopaminergic neurons with BDNF may improve their functional performance, but not their survival in transplants. The ability of artificially induced cerebrocortical 'dopaminergic' cells to ameliorate behavioral asymmetry of Parkinsonian rats was assessed. A proportion (1.0% maximum) of the TH+ neurons in these transplants survived in the host brain and were likely to be responsible for the prominent reduction in rotation scores observed to occur 6 weeks after implantation. Thus, the combined treatment of fetal cerebral cortex with BDNF and dopamine created long-lived TH-expressing neuronal populations which were very effective in alleviating the rat parkinsonian model, and thus may be suitable for use in transplantation in treating human Parkinson's disease.

Axonal regeneration

Axons damaged in a peripheral nerve are often able to regenerate from the site of injury along the degenerate distal segment of the nerve to reform functional synapses. Schwann cells play a central role in this process. However, in the adult mammalian central nervous system, from which Schwann cells are absent, axonal regeneration does not progress to allow functional recovery. This is due to inhibitors of axonal growth produced by both oligodendrocytes and astrocytes and also to the decreased ability of adult neurons to extend axons during regeneration compared to embryonic neurons during development. However once provided with a substrate conducive to axonal growth, such as a peripheral nerve graft, many central neurons are able to regenerate axons over long distances. Over the past year this response has been utilised in experimental models to produce a degree of behavioural recovery.

The Richard C. Schneider Lecture. New dimensions of neurosurgery in the realm of high technology: possibilities, practicalities, realities

Fueled by a buoyant economy, popular attitudes and demands, and parallel progress in transferable technical and biological areas, neurosurgery has enjoyed a remarkable quarter of a century of progress. Developmental trends in the discipline have included the following: 1) a refinement of preoperative definition of the structural substrate, 2) miniaturization of operative corridors, 3) reduction of operative trauma, 4) increased effectiveness at the target site, and 5) incorporation of improved technical adjuvants and physical operative tools into treatment protocols. In particular, the computer has become a formidable ally in diagnostic and surgical events. Trends in technical development indicate that we are entering an exciting era of advanced surgery of the human cerebrum, which is heralded by the following: 1) current developments in areas of imaging, sensors, and visualization; 2) new devices for localization and navigation; 3) new capabilities for action at the target point; and 4) innovative concepts related to advanced operative venues. Imaging has provided structurally based surgical maps, which now are being given the new dimension of function in complex and integrated formats for preoperative planning and intraoperative tactical direction. Cerebral localization and navigation based on these advances promise to provide further refinement to the field of stereotactic neurosurgery, as linked systems are superseded by more flexible nonlinked methodologies in functionally defined volume-oriented navigational databases. Target point action now includes not only ablative capabilities through micro-operative methods and the use of stereotactically directed high-energy forms but also the emergence of restorative capabilities through applications of principles of genetic engineering in the areas of molecular and cellular neurosurgery. Complex, dedicated, and self-contained operative venues will be required to optimize the emergence and development of these computer-oriented micro/stereotactic capabilities, which appear to be unavoidably required as locales for the practice and development of virtual reality-based stations for operative rehearsal, simulation, training, and, ultimately, enhancement of operative events through robotic interfaces. Primary impetus for progress has relied upon new combinations of technologies, disciplines, and industries. Philosophical and practical problems include the spectrum of availability of these methods to the population at large, the training of individuals to properly administer these methods, defining the acceptable envelope of expertise, and maintaining suitable delivery and progress while containing spiraling costs. Advanced neurological surgery and the use and development of high-technology adjuvants require a robust economy that has a populace willing to invest in the luxury of such developments. The current socioeconomic situation is fragile from the standpoint of both economics and attitudes of the patients and health care providers, with diversion of economic resources, redistribution of funding bases, modification of patient referrals, practice styles, and service attitudes undermining progress. Economic pressures have brought high-technology methods under great scrutiny regarding their effectiveness and cost-effectiveness. Reform proposals have specifically targeted technology-oriented services, and the Office of Technology Assessment has recommended increasing the use of managed care providers who look to information on cost-effectiveness and clinical practice guidelines to establish efficient management strategies and issue "report cards." Although the premise is laudable and "gimmickry" needs to be identified, it might be argued that such scrutiny and control might be overbearing and overused, impeding appropriate delivery and progress.

Basic fibroblast growth factor increases dopaminergic graft survival and function in a rat model of Parkinson's disease

The clinical use of fetal neural grafts as an intracerebral source of dopamine for patients with Parkinson's disease has met with limited success. Since basic fibroblast growth factor (bFGF) enhances the survival and growth of dopaminergic neurons in vitro, we explored whether cells genetically modified to produce bFGF would improve the functional efficacy of dopaminergic neurons implanted into rats with experimental Parkinson's disease. Results show that bFGF-producing cells grafted together with fetal dopamine neurons have potent growth-promoting effects on the implanted neurons in vivo. Moreover, rats implanted with such co-grafts display the most pronounced behavioural improvements post-grafting. These findings not only provide insight into the function of bFGF in situ, but also suggest an approach for enhancing the survival and function of dopamine neurons grafted into the damaged brain.