Advances in the understanding of early Huntington's disease using the functional imaging techniques of PET and SPET

The Role of Neurovascular System in Neurodegenerative Diseases

The neurovascular system (NVS), which consisted of neurons, glia, and vascular cells, is a functional and structural unit of the brain. The NVS regulates blood-brain barrier (BBB) permeability and cerebral blood flow (CBF), thereby maintaining the brain's microenvironment for normal functioning, neuronal survival, and information processing. Recent studies have highlighted the role of vascular dysfunction in several neurodegenerative diseases. This is not unexpected since both nervous and vascular systems are functionally interdependent and show close anatomical apposition, as well as similar molecular pathways. However, despite extensive research, the precise mechanism by which neurovascular dysfunction contributes to neurodegeneration remains incomplete. Therefore, understanding the mechanisms of neurovascular dysfunction in disease conditions may allow us to develop potent and effective therapies for prevention and treatment of neurodegenerative diseases. This review article summarizes the current research in the context of neurovascular signaling associated with neurodegenerative diseases, such as Alzheimer's disease (AD), Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), and Huntington's disease (HD). We also discuss the potential implication of neurovascular factor as a novel therapeutic target and prognostic marker in patients with neurodegenerative conditions. Graphical Abstract.

Cognition, function and awareness of disease impact in early Parkinson's and Huntington's disease

Purpose: Patients with Parkinson's and Huntington's Disease (PD and HD) present impairments in cognitively challenging everyday activities. This study contrasts these two basal ganglia disorders on the ability to perform daily life- like tasks and their level of awareness regarding the disease impact on function.Methods: 19 controls, 10 early-onset PD, 20 early stage PD, and 15 early manifest HD patients were compared in the "EcoKitchen," a virtual reality task with increasing executive load, the "Behavioural Assessment of Dysexecutive Syndrome battery - BADS," and "The Adults and Older Adults Functional Assessment Inventory - IAFAI," a self-report functional questionnaire. The EcoKitchen clinical correlates were investigated.Results: All clinical groups presented slower EcoKitchen performance than controls, however, only HD patients showed decreased accuracy. HD and PD patients exhibited reduced BADS scores compared to the other study participants. Importantly, on the IAFAI, PD patients signalled more physically related incapacities and HD patients indicated more cognitively related incapacities. Accordingly, the EcoKitchen performance was significantly associated with PD motor symptom severity.Conclusions: Our findings suggest differential disease impact on cognition and function across PD and HD patients, with preserved awareness regarding disease- related functional sequelae. These observations have important implications for clinical management, research and rehabilitation.Implications for rehabilitationPatients with early stage Parkinson's and Huntington's disease have diagnosis-specific impairments in the performance of executively demanding everyday activities and, yet, show preserved awareness about the disease impact on their daily life.An active involvement of patients in the rehabilitation process should be encouraged, as their appraisal of the disease effects can help on practical decisions about meaningful targets for intervention, vocational choices, quality-of-life issues and/or specific everyday skills to boost.The EcoKitchen, a non-immersive virtual reality task, can detect and quantify early deficits in everyday-like tasks and is therefore a valuable tool for assessing the effects of rehabilitation strategies on the functional cognition of these patients.Rehabilitation efforts in the mild stages of Parkinson's and Huntington's disease should be aware of greater time needs from the patients in the performance of daily life tasks, target executive skills, and give a more prominent role to patients in symptoms report and management.

Deficits in selective attention in symptomatic Huntington disease: assessment using an attentional blink paradigm

BACKGROUND

Impaired selective attention in Huntington disease (HD) may manifest as difficulty in identifying a single target embedded among a series of distractors in rapid serial visual presentation tasks.

METHOD

We used an attentional blink (AB) paradigm to examine whether attentional control is impaired in symptomatic HD. Fourteen HD patients and 13 age-matched healthy controls performed a rapid serial visual presentation task in which 2 targets (T1 and T2) and numerous distractors were presented in rapid succession. We assessed the accuracy of T1 identification and the AB (impaired T2 detection after the correct identification of T1).

RESULTS

Among the HD patients, identification of T1 was significantly impaired and AB was significantly larger but not longer. The HD patients also made significantly more random errors.

CONCLUSIONS

Frontostriatal or frontoparietal dysfunction is likely to compromise attentional control in HD, such that well-masked and rapidly presented target stimuli are difficult to detect and identify, especially as the difficulty level increases. Although we previously reported no AB deficits in presymptomatic HD, with manifest disease we found that the progressive frontoparietal cortical changes compromise attentional control mechanisms.

Radiosynthesis and in vivo evaluation of [11C]MP-10 as a PET probe for imaging PDE10A in rodent and non-human primate brain

2-((4-(1-[(11)C]Methyl-4-(pyridin-4-yl)-1H-pyrazol-3-yl)phenoxy)methyl)-quinoline (MP-10), a specific PDE10A inhibitor (IC(50)=0.18 nM with 100-fold selectivity over other PDEs), was radiosynthesized by alkylation of the desmethyl precursor with [(11)C]CH(3)I, ∼45% yield, >92% radiochemical purity, >370 GBq/μmol specific activity at end of bombardment (EOB). Evaluation in Sprague-Dawley rats revealed that [(11)C]MP-10 had highest brain accumulation in the PDE10A enriched-striatum, the 30 min striatum: cerebellum ratio reached 6.55. MicroPET studies of [(11)C]MP-10 in monkeys displayed selective uptake in striatum. However, a radiolabeled metabolite capable of penetrating the blood-brain-barrier may limit the clinical utility of [(11)C]MP-10 as a PDE10A PET tracer.

Mitochondrial dysfunction in neurodegenerative diseases and cancer

Mitochondria are important integrators of cellular function and therefore affect the homeostatic balance of the cell. Besides their important role in producing adenosine triphosphate through oxidative phosphorylation, mitochondria are involved in the control of cytosolic calcium concentration, metabolism of key cellular intermediates, and Fe/S cluster biogenesis and contributed to programmed cell death. Mitochondria are also one of the major cellular producers of reactive oxygen species (ROS). Several human pathologies, including neurodegenerative diseases and cancer, are associated with mitochondrial dysfunction and increased ROS damage. This article reviews how dysfunctional mitochondria contribute to Alzheimer's disease, Parkinson's disease, Huntington's disease, and several human cancers.

Biomarkers in Huntington's and Parkinson's Disease

Parkinson's (PD) and Huntington's disease (HD) are chronic neurodegenerative conditions of the brain with a variety of clinical presentations including a disorder of movement and a range of nonmotor deficits. HD is genetic in origin and the causative gene and protein known, namely mutant Huntingtin, which leads to widespread early neuronal dysfunction and death throughout the brain. In contrast, the etiology of sporadic PD is unknown, and the pathology targets the nigrostriatal dopaminergic neurons with the formation of alpha-synuclein positive Lewy bodies. In both diseases, the ability to accurately diagnose the disease in the early stages and monitor progression over time remains a major challenge given the majority of the pathology is sited deep within the CNS. This challenge has gained extra significance as the development of disease-modifying drugs starts to emerge into the clinic. To this end, there is a need to find biomarkers that will help in the accurate diagnosis of the disease and/or prediction of its clinical onset as well as biomarkers that are able to faithfully track disease progression independent of any symptomatic effects of any therapies. In addition, these same markers may also help stratify each of these heterogeneous disorders into specific subtypes that share particular clinical and pathological characteristics.

MS vs. HD: can white matter and subcortical gray matter pathology be distinguished neuropsychologically?

This study was conducted to examine the neuropsychological effects of white matter and subcortical gray matter pathology. Nineteen patients with multiple sclerosis (MS), 16 with Huntington's disease (HD), and 17 normal controls (NC) participated. Participants completed the California Verbal Learning Test (CVLT), Rotary Pursuit (RP) and Mirror Tracing (MT) tasks, and the Symbol Digit Modalities Test (SDMT). The principal findings pertain to a dissociation in procedural memory: on RP, the HD group demonstrated impaired sequence learning compared to the MS group, which performed similarly to the NC group, yet on MT, the MS and HD groups demonstrated normal perceptual-motor integration learning. On the CVLT, both patient groups performed better on recognition than on recall. On the SDMT, both patient groups performed worse than the NC group, with the HD group performing more poorly than the MS and NC groups. These results suggest that involvement of white and subcortical gray matter may produce different neuropsychological effects.

Abnormal cortical synaptic plasticity in a mouse model of Huntington's disease

Huntington's disease is a fatal neurodegenerative disorder characterised by a progressive motor, psychiatric and cognitive decline and associated with a marked loss of neurons in the cortex and striatum of affected individuals. The disease is inherited in an autosomal dominant fashion and is caused by a trinucleotide (CAG) repeat expansion in the gene encoding the protein huntingtin. Predictive genetic testing has revealed early cognitive deficits in asymptomatic gene carriers such as altered working memory, executive function and recognition memory. The perirhinal cortex is believed to process aspects of recognition memory. Evidence from primate studies suggests that decrements in neuronal firing within this cortical region encode recognition memory and that the underlying mechanism is an activity-dependent long-term depression (LTD) of excitatory neurotransmission, the converse of long-term potentiation (LTP). We have used the R6/1 mouse model of HD to assess synaptic plasticity in the perirhinal cortex. This mouse model provides an ideal tool for investigating early and progressive changes in synaptic function in HD. We report here that LTD at perirhinal synapses is markedly reduced in R6/1 mice. We also provide evidence to suggest that a reduction in dopamine D2 receptor signalling may be implicated.

The capacity of attention and simultaneous perception of objects: A group study of Huntington's disease patients

Using a whole report-paradigm based on [Bundesen, C. (1990). A theory of visual attention. Psychological Review, 97, 523-547; Bundesen, C. (1998). A computational theory of visual attention. Philosophical Transactions of the Royal Society of London B, Biological Sciences, 353, 1271-1281] theory of visual attention (TVA), [Finke, K., Bublak, P., Dose, M., Müller, H. J., & Schneider, W. X. (2006). Parameter-based assessment of spatial and non-spatial attentional deficits in Huntington's disease. Brain, 129, 1137-1151] demonstrated profound reductions in perceptual processing speed and visual working memory (WM) storage capacity in Huntington's disease (HD) patients. A comparably severe impairment of visual processing capacity has previously been reported for two simultanagnosia patients [Duncan, J., Bundesen, C., Olson, A., Humphreys, G., Ward, R., Kyllingsbaek, S., van Raamsdonk, M., Rorden, C., & Chavda, S. (2003). Attentional functions in dorsal and ventral simultanagnosia. Cognitive Neuropsychology, 20, 675-702]. To investigate whether such a deficit does also prevail in HD, the simultaneous perception of visual objects was tested in 10 HD patients under free viewing conditions and without time constraints. Objects were presented under four different conditions: (i) single, (ii) multiple adjacent, (iii) multiple embedded, and (iv) multiple overlapping. The dependent measure was the percentage of identification failures. Performance was compared to that of 15 healthy subjects matched for age, education, gender and general mental ability. For HD patients, the percentage of errors in the various testing conditions was examined for correlations with the TVA parameters of visuo-perceptual processing speed and WM storage capacity. These parameters were estimated using verbal whole report of briefly presented letters. TVA permits the two parameters to be estimated mathematically independently and relatively unaffected by any motor deficits present in HD. The identification error rate was substantially increased in HD patients, compared to control subjects, in the overlapping-figures subtest. This deficit was significantly and negatively correlated with processing speed, whereas there was no correlation with WM storage capacity. These results demonstrate the presence of deficits in simultaneous perception in HD, related to a severe reduction in perceptual processing speed. The results are discussed with respect to a dopamine mediated decline of cortical cholinergic activation, diminishing the number of visual objects that can be simultaneously represented within the visual processing system.

Aberrant cortical synaptic plasticity and dopaminergic dysfunction in a mouse model of huntington's disease

Predictive genetic testing for Huntington's disease (HD) has revealed early cognitive deficits in asymptomatic gene carriers, such as altered working memory, executive function and impaired recognition memory. The perirhinal cortex processes aspects of recognition memory and the underlying mechanism is believed to be long-term depression (LTD) of excitatory neurotransmission, the converse of long-term potentiation (LTP). We have used the R6/1 mouse model of HD to assess synaptic plasticity in the perirhinal cortex. We report here a progressive derailment of both LTD and short-term plasticity at perirhinal synapses. Layer II/III neurones gradually lose their ability to support LTD, show early nuclear localization of mutant huntingtin and display a progressive loss of membrane integrity (depolarization and loss of cell capacitance) accompanied by a reduction in the expression of D1 and D2 dopamine receptors visualized in layer I of the perirhinal cortex. Importantly, abnormalities in both short-term and long-term plasticity can be reversed by the introduction of a D2 dopamine receptor agonist (Quinpirole), suggesting that alterations in dopaminergic signalling may underlie early cognitive dysfunction in HD.

Parameter-based assessment of spatial and non-spatial attentional deficits in Huntington's disease

A major challenge for neuropsychological research on Huntington's disease is the identification of biomarkers for the disease at the level of cognitive functions. Given that cortical-striatal-thalamic circuits are particularly vulnerable, possible markers loading functionally on these brain regions should be particularly significant. We investigated whether parametric values derived from a 'theory of visual attention' (TVA) can serve that purpose. They are derived as mathematically independent, quantitative measures of attentional components, and the tasks require only non-speeded vocal responses. As such, the methodology seems well suited for testing patients with motor problems and general cognitive decline. Accumulating neuroanatomical evidence suggests that striatal atrophy in Huntington's disease is asymmetrical with a more pronounced left-sided degeneration. We applied a partial-report paradigm to analyse whether this results in a pathological (leftward) bias of the spatial distribution of attention. In partial report, red target letters are presented either alone or accompanied by either a second target or a green distractor letter presented in the same or in the opposite hemi-field. Since basal ganglia lesions have also been shown to cause spatially non-lateralized impairments, that is, reduced perceptual processing speed and visual working memory (WM) storage capacity within both hemi-fields, we tested possible reductions in these parameters with a whole-report paradigm. Here, columns of five red or green letters are briefly presented and the subject has to report as many as possible. Eighteen patients and 18 matched control subjects performed a partial- and a whole-report task with briefly presented letter displays. In partial report, Huntington's disease patients demonstrated a pathological bias, indicating increased attentional weighting to the left hemi-field. The extent of lateralization was strongly related to age at onset and to the number of cytosine-adenine-guanine (CAG) triplet repeats on gene IT15. In contrast, the extent of lateralization was not related to disease progression as reflected by the duration of the disease since onset of the first symptoms. In whole report, the non-lateralized attentional parameters processing speed and visual WM storage capacity were reduced bilaterally in both hemi-fields. The extent of the reduction was related to the disease duration since onset, whereas no significant correlation with CAG repeats or age at onset was found. Laterality of attentional weighting may, therefore, represent a possible trait marker reflecting the intensity of the pathogenic mechanisms, while the reduction of visual processing speed and storage capacity may be state markers for the stage of disease progression.

Alterations in dopamine and benzodiazepine receptor binding precede overt neuronal pathology in mice modelling early Huntington disease pathogenesis

Huntington disease (HD) is an inherited, late onset, progressive neurodegenerative disorder. Primary degeneration appears to selectively occur in striatal medium spiny neurones but this is most likely preceded by a period of neuronal dysfunction. Altered levels of neurotransmitter receptors may disrupt neuronal function and contribute to a toxic environment within the brain. In the present study, a knock-in HD mouse modelling early stages of the disease was used to determine whether alterations in neurotransmitter receptor densities occurred before overt neuronal loss. Receptor autoradiography demonstrated reduced dopamine D2 and increased benzodiazepine receptor binding in the striatum of HD animals compared to wild-type littermates. The density of benzodiazepine receptor binding was also increased in the cerebral cortex of the HD mice. Changes in opioid and dopamine D1 receptor densities were more subtle and influenced by the genetic background of the mice. Our findings are consistent with the hypothesis that alterations in neurotransmitter receptor density precede cell loss and may be an active cellular response to the initial stages of HD pathogenesis.

Future directions in research with presymptomatic individuals carrying the gene for Huntington's disease

Presymptomatic individuals carrying the gene for Huntington's disease (HD) provide researchers with a unique opportunity of learning more about the neuropathophysiology, symptom onset, behavioural functioning, and mediating factors of this fatal disease. In this review, we attempt to demonstrate that research over the last 8 years, since the isolation of the gene, has remained at large controversial. Although we are aware of some of the factors that can influence age at onset and disease progression, we are still unable to determine exactly when an individual will develop HD symptoms, and how fast these symptoms will progress. In an era rapidly advancing with respect to therapeutic intervention that could forestall the onset and progression of HD, systematic research with improved inclusion criteria is paramount. A greater understanding of the time course of the disease would be beneficial not only in monitoring the effectiveness of future treatments, but also in determining the most appropriate time to administer them. Finally, we present various ethical considerations, as well as put forward various recommendations that could assist in better diagnosing preclinical deficits in presymptomatic individuals.

Protection of malonate-induced GABA but not dopamine loss by GABA transporter blockade in rat striatum

Previous work has shown that overstimulation of GABA(A) receptors can potentiate neuronal cell damage during excitotoxic or metabolic stress in vitro and that GABA(A) antagonists or GABA transport blockers are neuroprotective under these situations. Malonate, a reversible succinate dehydrogenase/mitochondrial complex II inhibitor, is frequently used in animals to model cell loss in neurodegenerative diseases such as Parkinson's and Huntington's diseases. To determine if GABA transporter blockade during mitochondrial impairment can protect neurons in vivo as compared with in vitro studies, rats received a stereotaxic infusion of malonate (2 micromol) into the left striatum to induce a metabolic stress. The nonsubstrate GABA transport blocker, NO711 (20 nmol) was infused in some rats 30 min before and 3 h following malonate infusion. After 1 week, dopamine and GABA levels in the striata were measured. Malonate caused a significant loss of striatal dopamine and GABA. Blockade of the GABA transporter significantly attenuated GABA, but not dopamine loss. In contrast with several in vitro reports, GABA(A) receptors were not a downstream mediator of protection by NO711. Intrastriatal infusion of malonate (2 micromol) plus or minus the GABA(A) receptor agonist muscimol (1 micromol), the GABA(A) Cl- binding site antagonist picrotoxin (50 nmol) or the GABA(B) receptor antagonist saclofen (33 nmol) did not modify loss of striatal dopamine or GABA when examined 1 week following infusion. These data show that GABA transporter blockade during mitochondrial impairment in the striatum provides protection to GABAergic neurons. GABA transporter blockade, which is currently a pharmacological strategy for the treatment of epilepsy, may thus also be beneficial in the treatment of acute and chronic conditions involving energy inhibition such as stroke/ischemia or Huntington's disease. These findings also point to fundamental differences between immature and adult neurons in the downstream involvement of GABA receptors during metabolic insult.

Neuropsychiatric assessment of Gilles de la Tourette patients: comparative study with other hyperkinetic and hypokinetic movement disorders

The role of the basal ganglia in conditions with co-occurring movement disorders and neuropsychiatric symptoms is not well known. It has been hypothesized that hyperkinesia -disinhibited behaviors and hypokinesia-inhibited behaviors result from an imbalance between the direct and indirect striatal output pathways, and that differential involvement of these pathways could account for the concurrent abnormalities in movement and behavior observed in these disorders. This study aimed to evaluate whether the pattern and the extent of the neuropsychiatric manifestations of patients with GTS, a hyperkinetic movement disorder of basal ganglia origin, differs from that of patients with other basal ganglia hyperkinetic (e.g., HD) or hypokinetic (e.g., PSP) movement disorders, and to determine whether patients with GTS show a greater frequency of hyperactive behaviors (e.g., agitation, irritability, euphoria, or anxiety) than PSP patients, and are comparable to patients with HD. The Neuropsychiatric Inventory (NPI), a scale with established validity and reliability, was administered to 26 patients with GTS (mean age, 30.2 +/- 2.2 years), and the results were compared with that of 29 patients with HD (mean age, 43.8 +/- 2 years) and 34 with PSP (mean +/- S.D. age, 66.6 +/- 1.2 years). There was no difference between the groups in the total NPI scores. However, there was a double dissociation in behaviors: patients with hyperkinetic disorders (HD and GTS) exhibited significantly more agitation, irritability, anxiety, euphoria, and hyperkinesia, whereas hypokinetic patients (PSP) exhibited more apathy. Patients with GTS showed greater scores than HD patients in all those scores differentiating HD and GTS from PSP patients (e.g., agitation, irritability, anxiety and euphoria), and were differentiated in a logistic regression analysis from both HD and PSP patients in having significantly more anxiety. We found that patients with GTS manifested predominantly hyperactive behaviors similar but more pronounced than those presented by patients with HD, while those with PSP manifested hypoactive behaviors. Based on our findings and the proposed models of basal ganglia dysfunction in these disorders, we suggest that the hyperactive behaviors in GTS are comparable to those observed in HD, being both secondary to an excitatory subcortical output through the medial and orbitofrontal cortical circuits, while in PSP the hypoactive behaviors are secondary to hypostimulation of these circuits. Abnormalities of other brain structures (e.g., amygdala, brainstem nuclei) may account for the significantly higher anxiety scores differentiating GTS from HD patients.

Of mice and men: solving the molecular mysteries of Huntington's disease

Recent advances in the manipulation of mouse embryos provide opportunities for the disciplines of neuroscience and molecular genetics to join forces and tackle some previously intractable questions in this area of research. Even Huntington's disease has started to yield clues to its complex pathophysiology as a result of the recent application of transgenic technologies. This short review, while necessarily providing some background clinical information on Huntington's disease, will focus on how modifications of the mouse genome have contributed, and are continuing to contribute, to our understanding of the complex disease process. Such new insights may well turn the hope of developing the first effective treatment for this devastating disease into reality.

Bioenergetics in Huntington's disease

Huntington's disease (HD) is an autosomal dominant inherited neurodegenerative disorder with relentless course and prototypical clinical symptoms. In 1993 HD was associated with an expanded CAG triplet repeat stretch on chromosome 4 in the coding region of its target protein, huntington. The length of the resulting polyglutamine++ extensions correlates with lower age of onset and a higher density of ubiquitin-positive neuronal intranuclear inclusions. Recently it has been proposed that mutant huntington induces progressive neuronal cell death by an apoptotic mechanism. There is strong evidence that disturbances in cellular energy homeostasis and oxidative damage contribute to neurodegeneration. This review will summarize and discuss the current concepts that point towards an involvement of free radical-induced oxidative stress, glutamate excitotoxicity and mitochondrial respiratory chain defects in pathogenesis of HD.

Gene therapy in the CNS

Gene therapy for neurological disorder is currently an experimental concept. The goals for clinical utilization are the relief of symptoms, slowing of disease progression, and correction of genetic abnormalities. Experimental studies are realizing these goals in the development of gene therapies in animal models. Discoveries of the molecular basis of neurological disease and advances in gene transfer systems have allowed focal and global delivery of therapeutic genes for a wide variety of CNS disorders. Limitations are still apparent, such as stability and regulation of transgene expression, and safety of both vector and expressed transgene. In addition, the brain adds several challenges not seen in peripheral gene therapy paradigms, such as post-mitotic cells, heterogeneity of cell types and circuits, and limited access. Moreover, it is likely that several modes of gene delivery will be necessary for successful gene therapies of the CNS. Collaborative efforts between clinicians and basic researchers will likely yield effective gene therapy in the CNS.