Functional brain imaging of movement disorders

Metabolic Imaging of Deep Brain Stimulation in Meige Syndrome

Objectives

The subthalamic nucleus (STN) has been shown to be a safe and effective deep brain stimulation (DBS) surgical target for the treatment of Meige syndrome. The aim of this study was to compare changes in brain metabolism before and 6 months after STN-DBS surgery.

Methods

Twenty-five patients with primary Meige syndrome underwent motor function assessment, including the Burke–Fahn–Marsden Dystonia Rating Scale movement (BFMDRS-M) and disability subscale (BFMDRS-D) and positron emission tomography with an 18[F]-fluorodeoxyglucose scan before and 6 months after STN-DBS surgery. For the voxelwise metabolic change assessment, the p-value was controlled for multiple comparisons using the familywise error rate.

Results

There was a significant decrease in BFMDRS-M scores 6 months after STN-DBS, from 10.02 ± 3.99 to 4.00 ± 2.69 (p < 0.001). The BFMDRS-D scores also decreased significantly from 4.52 ± 2.90 to 0.64 ± 1.29 (p < 0.001). In the left hemisphere, hypermetabolism was found in the occipital lobe, superior parietal gyrus, postcentral gyrus and thalamus. In the right hemisphere, hypermetabolism was found in the lentiform nucleus, precuneus and precentral gyrus in patients with Meige syndrome receiving DBS. In addition, the bilateral inferior temporal gyrus and middle frontal gyrus exhibited glucose hypermetabolism.

Conclusion

Our findings indicate that STN-DBS has a significant effect on metabolic level in the brain, which may be an important mechanism for the treatment of Meige syndrome using STN-DBS.

Cortical hemodynamic mapping of subthalamic nucleus deep brain stimulation in Parkinsonian patients, using high-density functional near-infrared spectroscopy

Subthalamic nucleus deep brain stimulation (STN-DBS) is an effective treatment for idiopathic Parkinson's disease. Despite recent progress, the mechanisms responsible for the technique's effectiveness have yet to be fully elucidated. The purpose of the present study was to gain new insights into the interactions between STN-DBS and cortical network activity. We therefore combined high-resolution functional near-infrared spectroscopy with low-resolution electroencephalography in seven Parkinsonian patients on STN-DBS, and measured cortical haemodynamic changes at rest and during hand movement in the presence and absence of stimulation (the ON-stim and OFF-stim conditions, respectively) in the off-drug condition. The relative changes in oxyhaemoglobin [HbO], deoxyhaemoglobin [HbR], and total haemoglobin [HbT] levels were analyzed continuously. At rest, the [HbO], [HbR], and [HbT] over the bilateral sensorimotor (SM), premotor (PM) and dorsolateral prefrontal (DLPF) cortices decreased steadily throughout the duration of stimulation, relative to the OFF-stim condition. During hand movement in the OFF-stim condition, [HbO] increased and [HbR] decreased concomitantly over the contralateral SM cortex (as a result of neurovascular coupling), and [HbO], [HbR], and [HbT] increased concomitantly in the dorsolateral prefrontal cortex (DLPFC)-suggesting an increase in blood volume in this brain area. During hand movement with STN-DBS, the increase in [HbO] was over the contralateral SM and PM cortices was significantly lower than in the OFF-stim condition, as was the decrease in [HbO] and [HbT] in the DLPFC. Our results indicate that STN-DBS is associated with a reduction in blood volume over the SM, PM and DLPF cortices, regardless of whether or not the patient is performing a task. This particular effect on cortical networks might explain not only STN-DBS's clinical effectiveness but also some of the associated adverse effects.

Carbon-11 radiolabeling of iron-oxide nanoparticles for dual-modality PET/MR imaging

Dual-modality imaging, using Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET) simultaneously, is a powerful tool to gain valuable information correlating structure with function in biomedicine. The advantage of this dual approach is that the strengths of one modality can balance the weaknesses of the other. However, success of this technique requires developing imaging probes suitable for both. Here, we report on the development of a nanoparticle labeling procedure via covalent bonding with carbon-11 PET isotope. Carbon-11 in the form of [(11)C]methyl iodide was used as a methylation agent to react with carboxylic acid (-COOH) and amine (-NH2) functional groups of ligands bound to the nanoparticles (NPs). The surface coating ligands present on superparamagnetic iron-oxide nanoparticles (SPIO NPs) were radiolabeled to achieve dual-modality PET/MR imaging capabilities. The proof-of-concept dual-modality PET/MR imaging using the radiolabeled SPIO NPs was demonstrated in an in vivo experiment.

Changes in brain glucose metabolism in subthalamic nucleus deep brain stimulation for advanced Parkinson's disease

BACKGROUND

Despite its large clinical application, our understanding about the mechanisms of action of deep brain stimulation of the subthalamic nucleus is still limited. Aim of the present study was to explore cortical and subcortical metabolic modulations measured by Positron Emission Tomography associated with improved motor manifestations after deep brain stimulation in Parkinson disease, comparing the ON and OFF conditions.

PATIENTS AND METHODS

Investigations were performed in the stimulator off- and on-conditions in 14 parkinsonian patients and results were compared with a group of matched healthy controls. The results were also used to correlate metabolic changes with the clinical effectiveness of the procedure.

RESULTS

The comparisons using Statistical parametric mapping revealed a brain metabolic pattern typical of advanced Parkinson disease. The direct comparison in ON vs OFF condition showed mainly an increased metabolism in subthalamic regions, corresponding to the deep brain stimulation site. A positive correlation exists between neurostimulation clinical effectiveness and metabolic differences in ON and OFF state, including the primary sensorimotor, premotor and parietal cortices, anterior cingulate cortex.

CONCLUSION

Deep brain stimulation seems to operate modulating the neuronal network rather than merely exciting or inhibiting basal ganglia nuclei. Correlations with Parkinson Disease cardinal features suggest that the improvement of specific motor signs associated with deep brain stimulation might be explained by the functional modulation, not only in the target region, but also in surrounding and remote connecting areas, resulting in clinically beneficial effects.

Combining functional imaging with brain stimulation in Parkinson's disease

Brain stimulation techniques such as deep brain stimulation (DBS) and transcranial magnetic stimulation (TMS) constitute promising clinical and research tools to investigate neural mechanisms underlying neurological and psychiatric diseases. They have enormous potential in modifying brain activity and subsequent function. However, it is still a matter of debate how either of these stimulation approaches operates to produce the clinical outcomes observed in patients. The combination of these techniques with functional neuroimaging is contributing significantly to disentangle the mechanisms through which brain stimulation affects neuronal activity and related networks. In the present review we outline the research done to date on the effects of DBS and TMS on motor, cognition and behaviour in Parkinson's disease (PD) with particular emphasis on neuroimaging.

Deep brain stimulation: technology at the cutting edge

Deep brain stimulation (DBS) surgery has been performed in over 75,000 people worldwide, and has been shown to be an effective treatment for Parkinson's disease, tremor, dystonia, epilepsy, depression, Tourette's syndrome, and obsessive compulsive disorder. We review current and emerging evidence for the role of DBS in the management of a range of neurological and psychiatric conditions, and discuss the technical and practical aspects of performing DBS surgery. In the future, evolution of DBS technology may depend on several key areas, including better scientific understanding of its underlying mechanism of action, advances in high-spatial resolution imaging and development of novel electrophysiological and neurotransmitter microsensor systems. Such developments could form the basis of an intelligent closed-loop DBS system with feedback-guided neuromodulation to optimize both electrode placement and therapeutic efficacy.

Basal Ganglia circuits underlying the pathophysiology of levodopa-induced dyskinesia

Involuntary movements or dyskinesia, represent a debilitating complication of levodopa therapy for Parkinson's disease. Dyskinesia is, ultimately, experienced by the vast majority of the patients. Despite the importance of this problem, little was known about the cause of dyskinesia, a situation that has dramatically evolved in the last few years with a focus upon the molecular and signaling changes induced by chronic levodopa treatment. Departing from this, we here review the progress made in functional anatomy and neuroimaging that have had a tremendous impact on our understanding of the anatomo-functional organization of the basal ganglia in Parkinsonism and dyskinetic states, notably the demonstration that dyskinesia are linked to a pathological processing of limbic and cognitive information.

Metabolic changes detected in vivo by 1H MRS in the MPTP-intoxicated mouse

We used in vivo proton ((1)H) Magnetic Resonance Spectroscopy (MRS) to measure the levels of the main excitatory amino acid, glutamate (Glu) and also glutamine (Gln) and GABA in the striatum and cerebral cortex in the MPTP-intoxicated mouse, a model of dopaminergic denervation, before and after dopamine (DA) replacement. The study was performed at 9.4T on control mice (n = 8) and MPTP-intoxicated mice (n = 8). In vivo spectra were acquired in a voxel (8 microL) centered in the striatum, and in the cortex (4.6 microL). Three days after basal MRS acquisitions new spectra were acquired in the striatum and cortex, after levodopa (200 mg.kg(-1)). Glu, Gln and GABA concentrations obtained in the basal state were significantly increased in the striatum of MPTP-lesioned mice (Glu: 20.2 +/- 0.8 vs 11.4 +/- 0.9 mM, p < 0.001; Gln: 5.4 +/- 1.6 vs 2.0 +/- 0.6 mM, p < 0.05; GABA: 3.6 +/- 0.8 vs 1.6 +/- 0.2 mM, p < 0.05). Levodopa lowered metabolites concentrations in the striatum of MPTP-lesioned mice (Glu: 20.2 +/- 0.8 vs 11.2 +/- 0.4 mM (+ Ldopa), p < 0.001; Gln: 5.4 +/- 1.6 vs 1.6 +/- 0.4 mM (+ Ldopa), p < 0.05; GABA: 3.6 +/- 0.8 vs 1.7 +/- 0.4 mM (+ Ldopa), p < 0.01). Metabolite levels in the striatum of MPTP-intoxicated mice + levodopa were not significantly different from those in the striatum of controls. No change was found in the cortex after DA denervation and after DA replacement between the two animals groups. These results strongly support a predominant change in striatal Glu synaptic activity in the cortico-striatal pathway. Acute levodopa administration reverses the increase of metabolites in the striatum.

Effects of bilateral deep brain stimulation of the subthalamic nucleus on olfactory function in Parkinson's disease patients

OBJECTIVE

The goal of the present study was to evaluate the effects of bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) on olfaction in patients with Parkinson's disease (PD).

METHODS

15 patients suffering from sporadic PD-related dysosmia were implanted with bilateral electrodes aimed at the STN. One week before the surgery, odor detection threshold (DT) and identification threshold (IT) were evaluated in all patients using the 'five odor olfactory detection arrays' in both medication-off and medication-on conditions. 15 healthy age-matched controls also received the same olfactory evaluation. Patient evaluations were repeated at 6 and 12 months postoperatively in a medication-off/stimulator-on or medication-off/stimulator-off condition. Odor DT and IT scores were compared pre- and postoperatively, as well as between the medication-off/stimulator-on or -off conditions.

RESULTS

The motor symptoms of all 15 PD patients, including rigidity, tremor, bradykinesia, postural instability, and gait were significantly improved after stimulator implantation. The UPDRS motor (UPDRS III) scores decreased significantly in the medication-off/stimulator-on condition (p < 0.01). The odor DT and IT scores of PD patients were higher than those of healthy controls (p < 0.01). In the medication-off/stimulator-off condition, there was no significant difference in the odor DT and IT scores in PD patients pre- vs. postoperatively (p > 0.05). Notably, there were no significant alterations to DT scores in the stimulator-on and -off conditions at the 6- and 12-month follow-up (p > 0.05), whereas IT scores were significantly improved in the stimulation-on relative to the stimulation-off condition at the 6- and 12-month follow-up.

CONCLUSIONS

STN DBS can significantly improve olfactory cognitive function in PD patients. The possible mechanisms include an improvement in striatal metabolism and neuronal activity in the orbitofrontal cortex mediated by STN DBS, as well as increased glucose metabolism in the striatum, midbrain, cingulate gyrus, and motor and higher-order somatosensory association cortices.

Metabolic changes detected by proton magnetic resonance spectroscopy in vivo and in vitro in a murin model of Parkinson's disease, the MPTP-intoxicated mouse

Parkinson's disease is a neurodegenerative disorder characterized by the progressive loss of the dopaminergic neurons in the substantia nigra pars compacta, which project to the striatum. The aim of this study was to analyze in vivo and in vitro consequences of dopamine depletion on amount of metabolites in a mouse model of Parkinson's disease using proton (1)H magnetic resonance spectroscopy (MRS). The study was performed on control mice (n = 7) and MPTP-intoxicated mice (n = 7). All the experiments were performed at 9.4 T. For in vivo MRS acquisitions, mice were anesthetized and carefully placed on an animal handling system with the head centered in birdcage coil used for both excitation and signal reception. Spectra were acquired in a voxel (8 microL) centered in the striatum, applying a point-resolved spectroscopy sequence (TR = 4000 ms, TE = 8.8 ms). After in vivo MRS acquisitions, mice were killed; successful lesion verified by tyrosine hydroxylase immunolabeling on the substantia nigra pars compacta and in vitro MRS acquisitions performed on perchloric extracts of anterior part of mice brains. In vitro spectra were acquired using a standard one-pulse experiment. The absolute concentrations of metabolites were determined using jmrui (Lyon, France) from (1)H spectra obtained in vivo on striatum and in vitro on perchloric extracts. Glutamate (Glu), glutamine (Gln), and GABA concentrations obtained in vivo were significantly increased in striatum of MPTP-lesioned mice (Glu: 15.5 +/- 2.5 vs. 12.9 +/- 1.0 mmol/L, p < 0.05; Gln: 2.3 +/- 0.9 vs. 1.8 +/- 0.6 mmol/L, p < 0.05; GABA: 2.3 +/- 0.9 vs. 1.3 +/- 0.6 mmol/L, p < 0.05). The in vitro results confirmed these results, Glu (10.9 +/- 2.5 vs. 7.9 +/- 1.7 micromol/g, p < 0.05), Gln (6.8 +/- 2.9 vs. 4.3 +/- 1.0 micromol/g, p < 0.05), and GABA (2.9 +/- 0.9 vs. 1.5 +/- 0.4 micromol/g, p < 0.01). The present study strongly supports a hyperactivity of the glutamatergic cortico-striatal pathway hypothesis after dopaminergic denervation in association with an increase of striatal GABA levels. It further shows an increased of striatal Gln concentrations, perhaps as a strategy to protect neurons from Glu excitotoxic injury after striatal dopamine depletion.

Phase contrast radiography of Lewy bodies in Parkinson disease

Parkinson's disease (PD), defined as a neurodegenerative disorder, is characterized by the loss of dopaminergic neurons and the presence of Lewy bodies in neurons. Morphological study of Lewy bodies is important to identify the causes and the processes of PD. Here, we investigate a possibility of phase contrast radiography using coherent synchrotron X-rays to explore the microscopic details of Lewy bodies in thick (approximately 3 mm) midbrain tissues. Autopsied midbrain tissues of a PD patient were sliced in 3 mm thickness and then examined using synchrotron X-rays from the 7B2 beamline of the Pohang Light Source. Refraction-enhanced phase contrast radiography and microtomography were adopted to identify dark core and dim edge of Lewy bodies in neurons. The morphology of Lewy bodies was clearly revealed by the phase contrast radiography in very thick (3 mm) midbrain tissues without any staining treatment. Three-dimensional volume rendered microtomography of the autopsied midbrain tissues demonstrates striking evidence that several Lewy bodies are agglomerated by dim edges in a neuron. We suggest that the phase contrast radiography could be a useful tool to morphologically investigate the causes or the processes in PD.

Anatomy and physiology of the basal ganglia: Implications for deep brain stimulation for Parkinson's disease

Central to surgical management of movement disorders is an understanding of the anatomy and physiology of the basal ganglia. The basal ganglia have been a target for neuromodulation surgery since Russell Meyers' pioneering works in the late 1930s. With the development of deep brain stimulation as the gold standard of surgical intervention for movement disorders, there has been a concomitant evolution in the understanding of the role the basal ganglia plays in the genesis of normal and abnormal motor behaviors. The fundamental concept of the cortico-striato-pallido-thalamocortical loop will be explored in the context of deep brain stimulation. The current targets for deep brain stimulation for Parkinson's disease, the subthalamic nucleus, the globus pallidus internus, and the ventral intermediate nucleus, will be discussed in the framework of the current physiological and anatomical models of Parkinson's disease (PD). Finally, the current understandings of the mechanisms underpinning the beneficial effects of deep brain stimulation for PD will be discussed.

Distributed neural actions of anti-parkinsonian therapies as revealed by PET

There is a limited understanding of how different anti-parkinsonian treatments act at the neuronal systems level. Using positron emission tomography we examined the effects of levodopa and deep brain stimulation of the subthalamic nucleus on patterns of regional cerebral blood flow in patients with Parkinson's disease during a homogenous cognitive-behavioural state rather than during an unspecified resting state. We found that when medicated precuneus, frontal, parietal, cerebellar and midbrain areas were relatively more activated than when stimulated, whereas when stimulated the precentral gyrus, caudate and thalamus were relatively more activated than when medicated. Areas that were activated by both treatments included the temporal gyri, anterior thalamus, and midbrain. Regions of prefrontal cortex showed relatively greater activation in the "off treatment" conditions of both the medicated and stimulated groups. Our findings suggest that the two treatment methods may lead to symptomatic relief via both common and different sites of action.

Brain perfusion differences between Parkinson's disease and multiple system atrophy with predominant parkinsonian features

BACKGROUND

The patterns of regional cerebral blood flow in Parkinson's disease and multiple system atrophy remain inconsistent.

OBJECTIVES

To compare brain perfusion images of 123I-IMP SPECT between Parkinson's disease, multiple system atrophy with predominant parkinsonian features (MSA-P) and controls.

METHODS

Eighty-two patients with Parkinson's disease, 10 patients with MSA-P and 14 controls were studied. We performed 3D-SSP and volume of interest analysis using 123I-IMP scintigraphy.

RESULTS

Occipital perfusion of MSA-P increased compared to that of Parkinson's disease and perfusion in the cerebellum and primary sensorimotor cortex of Parkinson's disease increased compared to that of MSA-P. Perfusion in the putamen of MSA-P decreased compared to that of Parkinson's disease.

CONCLUSION

Our study demonstrated perfusion differences in 123I-IMP SPECT between the two diseases.

Organization of midbrain dopamine systems and the pathophysiology of Parkinson's disease

Understanding of the pathophysiology of Parkinson disease (PD) has advanced rapidly over the last two decades through basic and clinical studies using modern neuroanatomical, clinical assessment, neuropathological and functional brain imaging methods. Two interacting processes determine the development of functional impairment, neuronal degeneration with selective denervation of specific regions and compensatory responses, which oppose the effects of denervation. The clinical manifestations of PD, at least in early stages, reflect selective degeneration of dopamine neurons in the substantia nigra projecting through the nigrostriatal pathway to the caudal putamen with compensatory changes in this and related systems. Positron emission tomography with specific ligands for the dopamine system is a powerful tool for analysis of both degenerative and compensatory processes in the pathophysiology of Parkinson disease in vivo and can be used to confirm the diagnosis of dopamine deficient Parkinson disease.

Pathophysiology of Parkinson's disease: the MPTP primate model of the human disorder

The striatum is viewed as the principal input structure of the basal ganglia, while the internal pallidal segment (GPi) and the substantia nigra pars reticulata (SNr) are output structures. Input and output structures are linked via a monosynaptic "direct" pathway and a polysynaptic "indirect" pathway involving the external pallidal segment (GPe) and the subthalamic nucleus (STN). According to current schemes, striatal dopamine (DA) enhances transmission along the direct pathway (via D1 receptors), and reduces transmission over the indirect pathway (via D2 receptors). DA also acts on receptors in GPe, GPi, SNr, and STN. Electrophysiologic and other studies in primates rendered parkinsonian by treatment with the dopaminergic neurotoxin MPTP have demonstrated a reduction of neuronal activity of GPe and an increase of neuronal discharge in STN, GPi. and SNr. These findings are compatible with the view that striatal DA loss results in increased activity over the indirect pathway. Prominent bursting, oscillatory discharge patterns, and increased synchronization of neighboring neurons are found throughout the basal ganglia. These may result from changes in the activity of local circuits (e.g., the GPe-STN "pacemaker") or from more global abnormalities of the basal ganglia-thalamocortical network. These findings have been replicated in human patients undergoing microelectrode-guided stereotactic procedures targeted at GPi or STN. PET studies in patients with Parkinson's disease have lent further support to the proposed circuit abnormalities. The current models of basal ganglia function have recently been criticized. For instance, the strict separation of direct and indirect pathways and the segregation of D1 and D2 receptors have been questioned, and the almost complete absence of motor side effects of pallidal or thalamic lesions in human patients and animals is inconsistent. These results suggest that changes in discharge patterns and synchronization between basal ganglia neurons, abnormal network interactions, and compensatory mechanisms are at least as important in the pathophysiology of parkinsonism as changes in discharge rates in individual basal ganglia nuclei. Lesions of GPi or STN are effective in treating parkinsonism, because they reduce or abolish abnormal basal ganglia output, enabling remaining circuits to function more normally.

Functional magnetic resonance imaging during deep brain stimulation: a pilot study in four patients with Parkinson's disease

Functional magnetic resonance imaging (fMRI) was performed in patients with Parkinson's disease during deep brain stimulation of the subthalamic nucleus (three patients) and during deep brain stimulation of the ventral intermedius nucleus of the thalamus (one patient). All showed an increase in blood oxygenation level-dependent signal in the subcortical regions ipsilateral to the stimulated nucleus. This effect cannot be simply explained by a mechanism of depolarization blockade; rather, it is caused by overstimulation of the target nucleus, resulting in the suppression of its spontaneous activity. We confirm that fMRI during deep brain stimulation is a safe method with considerable potential for elucidating the functional connectivity of the stimulated nuclei.