MRI-based multivariate gray matter volumetric distance for predicting motor symptom progression in Parkinson's disease

While Parkinson's disease (PD)-related neurodegeneration is associated with structural changes in the brain, conventional magnetic resonance imaging (MRI) has proven less effective for clinical diagnosis due to its inability to reliably identify subtle changes early in the disease course. In this study, we aimed to develop a structural MRI-based biomarker to predict the rate of progression of motor symptoms in the early stages of PD. The study included 88 patients with PD and 120 healthy controls from the Parkinson's Progression Markers Initiative database; MRI at baseline and motor symptom scores assessed using the MDS-UPDRS-III at two time points (baseline and 48 months) were selected. Group-level volumetric analyses revealed that the volumetric reductions in the left striatum were associated with the decline in motor functioning. Then, we developed a patient-specific multivariate gray matter volumetric distance and demonstrated that it could significantly predict changes in motor symptom scores (P < 0.05). Further, we classified patients as relatively slower and faster progressors with 89% accuracy using a support vector machine classifier. Thus, we identified a promising structural MRI-based biomarker for predicting the rate of progression of motor symptoms and classifying patients based on motor symptom severity.

Dopaminergic Dysfunction in Parkinsonism: New Lessons from Imaging

In recent decades, identification of the dopaminergic deficit in Parkinson's disease has spawned an explo sion of research in the molecular neurobiology of the basal ganglia. In vivo imaging has provided a tool to bridge developments in basic neuroscience and clinicial neurology. Imaging studies have opened a unique window on the neurochemical pathophysiology of Parkinson's disease and more specifically on the onset, progression and physiology of the degenerative process. As we are poised on the brink of new protective and restorative therapies for Parkinson's disease, the potential of imaging to teach us about in vivo brain neurochemistry offers both promise and challenge. NEUROSCIENTIST 5:333-340, 1999

Is deep brain stimulation a form of psychosurgery?

OBJECTIVE

To examine the potential for the experimental treatment of deep brain stimulation for neuropsychiatric disorders, and to debate the argument that it should be considered another form of psychosurgery.

CONCLUSIONS

Psychosurgery is an old term with considerable pejorative connotations. It should be replaced with the more descriptive and accurate 'neurosurgery for psychiatric disorders'. Moreover, neurosurgery should reflect ablative neurosurgery, and surgery for brain stimulation should be categorised as brain stimulation rather than neurosurgery, or indeed psychosurgery. This will prevent legislative restrictions on the development of brain stimulation techniques and not tar them with the lobotomy brush.

Basal-corticofrontal circuits in schizophrenia and obsessive-compulsive disorder: a controlled, double dissociation study

BACKGROUND

Several lines of research suggest that prefrontal cortex dysfunctions observed in obsessive compulsive disorder (OCD) and schizophrenia (SKZ) are linked to two partially independent neuroanatomic systems: the ventromedial prefrontal cortex and the dorsolateral prefrontal cortex, with different neuroanatomic connections, including the striatum. The primary aim of this study was to test this hypothesis using a double dissociation study of neuropsychological tasks performance of the dorsolateral prefrontal cortex and ventromedial prefrontal cortex.

METHODS

We administered the Wisconsin Card Sorting Test, the Gambling Task, and the four-disk version of the Tower of Hanoi to 110 SKZ and 67 OCD patients and 56 control subjects.

RESULTS

A clear double dissociation of Wisconsin Card Sorting Test and Gambling Task performances was found, with SKZ patients performing the Wisconsin Card Sorting test significantly worse than OCD patients and control subjects and OCD patients performing the Gambling Task significantly worse than SKZ and control subjects. Both SKZ and OCD patients performed the Tower of Hanoi significantly worse than control subjects.

CONCLUSIONS

Results from our double dissociation study confirm the hypothesis of involvement of different frontal lobe subsystems within basal-corticofrontal circuits function in SKZ and OCD.

Neuropsychological outcome of GPi pallidotomy and GPi or STN deep brain stimulation in Parkinson's disease

This paper highlights the neuropsychological sequelae of posteroventral pallidotomy (PVP) and deep brain stimulation (DBS) of the subthalamic nucleus (STN) and the internal segment of the globus pallidus (GPi) at 3/6 months postoperatively. Results are based on our extensive experience with PVP and our preliminary observations with DBS. Patients with borderline cognitive or psychiatric functioning risk postoperative decompensation. Nonlateralizing attentional and hemisphere-specific impairments of frontostriatal cognitive functions followed unilateral PVP. "Frontal" behavioral dyscontrol was observed in approximately 25% of patients. Three cases of staged bilateral PVP suggest that premorbid factors may predict outcome, although lesion size and location are also critical. Older patients are at risk for significant cognitive and behavioral decline after bilateral STN DBS, while GPi DBS may be safer.

Impaired reaching and grasping after focal inactivation of globus pallidus pars interna in the monkey

The purpose of this study was to test the hypothesis that the basal ganglia output from globus pallidus pars interna (GPi) contributes to inhibition of competing motor patterns to prevent them from interfering with a volitional movement. To test this hypothesis, the kinematics of a natural reach, grasp, and retrieval task were measured in the monkey before and after focal inactivation in GPi with the GABA(A) agonist muscimol. Two rhesus monkeys were trained to reach in a parasagittal plane to grasp a 1-cm cube of apple and retrieve it. Reflective markers were applied to the shoulder, elbow, wrist, and index finger. Movements were videotaped at 60 fields/s, digitized, and analyzed off-line. In each session the monkey performed 12-15 reaches before and 12-15 reaches after injection of 0.5 microl of 8.8 mM muscimol. Muscimol was injected into 22 separate locations in the "arm" area of GPi. Inactivation of the GPi with muscimol produced movement deficits in a reach-grasp-retrieve task that can be summarized as follows: 1) decreased peak wrist velocity during the reach to target; 2) decreased elbow and shoulder angular velocities, with elbow angular velocity relatively more impaired than shoulder angular velocity; resulting in 3) higher maximum vertical wrist and index finger positions at the apex of the reach; 4) prolonged latency from the end of the reach to the completion of grasp; and 5) less impairment of retrieval than reach, with inactivation at the majority of sites causing no impairment and some actually speeding up retrieval despite slow reaching. The results of this study show that reaching movements are impaired in a specific way after focal inactivation of GPi in previously normal monkeys. The slowing of the reach with normal (or fast) retrieval suggests that there is difficulty inhibiting the posture holding mechanisms that were active before the reach, but that assist the retrieval. The nature of the impairment supports the hypothesis that GPi lesions disrupt the ability to inhibit competing motor mechanisms to prevent them from interfering with desired voluntary movement.

Visuo-motor adaptation in smokeless tobacco users

Ten smokeless tobacco (ST) users and 11 non-smokers participated in a visuo-motor adaptation experiment in which the visual feedback of point-to-point horizontal arm movements, displayed in real-time on a computer screen, was rotated by 45 degrees counterclockwise for some trials. Visuo-motor performance between smokers and non-smokers was compared on three occasions, once after at least 8 h of tobacco abstinence (Session 1), a second time following ST intake (Session 2), and a third time 45 min after the original ST intake (Session 3). Non-smokers were tested at the same relative times as the smokers in the absence of any tobacco. Both groups performed the three conditions during each session: baseline (normal visual feedback), rotated visual feedback (45 degrees visual feedback rotation), and post-adaptation (normal visual feedback immediately following feedback rotation). Compared with non-smokers, ST users had significantly larger normalized jerk scores (a measure of movement smoothness) after ST intake during the adaptation and post-adaptation conditions in Sessions 2 and 3, but not during the baseline conditions, implying a differential effect of ST use specific to rotated visual feedback. Movement duration was also longer for smokers than for non-smokers after ST intake, but only in the post-adaptation condition. Overall the results suggest that ST use, and hence nicotine, has a detrimental effect on visuo-motor performance, particularly on movement smoothness.

Striatal mechanisms in Parkinson's disease: new insights from computer modeling

We review data and hypotheses concerning the functional anatomy of the striatum and the role of its corticostriatal and nigrostriatal afferents in Parkinson's disease (PD). Starting from molecular mechanisms of glutamatergic and dopaminergic actions in the striatum we have developed a compartmental model of striatal principal neurons that displays a significant degree of biological realism. Simulations of a network of striatal projection neurons under conditions likely to be found in healthy subjects as well as untreated and therapeutic situations of advanced PD provide clues concerning the dynamics of neuronal interactions and their possible effects on downstream motor structures in the generation of positive and negative motor symptoms. We present tentative biological explanations of the symptoms of rigidity and akinesia in PD leading to predictions concerning the origin of abnormal movements and the beneficial effects of dopaminergic treatment. Although these attempts are not yet sufficient to account for the complexity of clinical symptoms found in PD they can guide further empirical research and foster fruitful interactions between experimentalists, theoreticians, and clinicians in unraveling the functional anatomy of the basal ganglia.

Operant conditioning and the orbitofrontal cortex in schizophrenic patients: unexpected evidence for intact functioning

Neuroimaging and neuropsychological studies have consistently implicated dorsolateral prefrontal cortex as abnormal in schizophrenia. However, other areas of frontal cortex have received far less attention. In particular, few studies have examined orbital frontal regions with other than olfactory tests. In the present study we wished to assess the functional capability of orbital frontal cortex using a test developed by Bechara et al. (1994) that assesses a subject's capacity to acquire a preference through reward and punishment, using a gambling task that involved gains and losses of play money. Thirty normal subjects and 12 patients with schizophrenia (three undifferentiated, eight paranoid, one schizoaffective) comprised the sample in the present study. We found that patients with schizophrenia exhibited a pattern of findings similar to that of normals and dissimilar to that of patients with known orbital frontal damage. In our study, both normal subjects and schizophrenic patients chose most frequently from decks of cards in which there were frequent rewards and infrequent penalties, as might be expected on the basis of operant conditioning literature. We also found that performance on this task was not correlated with tests of working memory or long-term memory, suggesting that the development of a preference may occur implicitly. Our findings also argue against a general deficit in schizophrenia, as performance on the gambling task appeared relatively uncompromised.

Opposite motor effects of pallidal stimulation in Parkinson's disease

We studied the effects--on parkinsonian signs, on levodopa-induced dyskinesias, and on levodopa response--of acute experimental high-frequency stimulation of the internal pallidum (GPi) during off-drug and on-drug phases. Thirteen quadripolar electrodes were evaluated in 8 patients with Parkinson's disease (PD). Stimulation of the most ventral contacts, lying at the ventral margin of or just below the GPi, led to pronounced improvement in rigidity and a complete arrest of levodopa-induced dyskinesias. The antiakinetic effect of levodopa was also blocked and the patients became severely akinetic. Stimulation of the most dorsal contacts, lying at the dorsal border of the GPi or inside the external pallidum, usually led to moderate improvement of off-drug akinesia and could also induce dyskinesias in some patients. When using an intermediate contact for chronic stimulation, a good compromise between these opposite effects was usually obtained, mimicking the effect of pallidotomy. We conclude that there are at least two different functional zones within the globus pallidus, at the basis of a different pathophysiology of the cardinal symptoms of PD. The opposite effects may explain the variable results of pallidal surgery reported in the literature and may also largely explain the paradox of PD surgery. A possible anatomical basis for these differential functional effects could be a functional somatotopy within the GPi, with the segregation of the pallidofugal fibers from the outer portion of the GPi, on one hand, forming the ventral ansa lenticularis and from the inner portion of the GPi, on the other hand, forming the dorsal lenticular fasciculus.

A brief history of pallidotomy

A large number of surgical procedures involving the globus pallidus and ansa lenticularis were performed from 1939 to the late 1950s for alleviation of rigidity and tremor, two of the main symptoms of Parkinson's disease. Several groups reported beneficial effects using a wide array of techniques and targets within the pallidum and its projections. Over time, pallidal targets lying in the ventral and posterior portions of the internal pallidum were considered to be the most effective. Based on anatomic studies, surgical misadventures, and empirical observations, there was an abrupt shift regarding the favored target to treat parkinsonian tremor to the thalamus, and most neurosurgeons abandoned pallidotomy in the 1960s. With the advent of L-dopa and the realization of its striking clinical benefits in the mid 1960s, within 5 to 10 years, virtually all surgery for Parkinson's disease ceased. We are now witnessing a rediscovery of pallidotomy as patients with Parkinson's disease are experiencing the shortcomings of medical therapy. In this article, we examine the evolution of pallidotomy and discuss the reasons for the renewed interest in this procedure.

Sixty years of psychosurgery: its present status and its future

After its introduction 60 years ago, psychosurgery witnessed a remarkable rise followed by a decline. In the 1990s, it is a marginal treatment practised by a few psychiatrists in some specialised centres around the world. The psychiatric profession, however, continues to support it, and there is some evidence for a recent renewal of interest in the procedure. In this paper, the reasons for this reluctant acceptance of psychosurgery are examined, and the factors that are likely to determine its future are identified. The profession is urged to keep the interest in psychosurgery alive until further theoretical and empirical developments can either announce its death or lead to a resurgence of psychiatric neurosurgery in its present or modified form.

Neuropsychological functioning before and after unilateral thalamic stimulating electrode implantation in Parkinson's disease

One theoretical advantage of chronic thalamic stimulation compared with thalamotomy for the treatment of refractory Parkinson's disease (PD) entails the avoidance and reversibility of potential cognitive morbidity. Support for the cognitive safety of thalamic stimulation remains largely anecdotal; empirical data are limited to the neuropsychological findings published for one small series of patients. The purpose of this study was to supplement those published findings that pertain to the mean changes in neuropsychological test scores and to extend previous findings by evaluating cognitive changes in individual cases from preoperative baseline to 4 months after electrode implantation. Nine patients with tremor-dominant, refractory PD underwent unilateral implantation of a deep brain stimulating electrode in the ventralis intermedius thalamic nucleus (five patients on their left and four patients on their right sides). A neuropsychological test battery was administered to each patient to evaluate attention, language, memory, and visuoperceptual and executive functions during their best “on” state before surgery, while on a medication regimen, and with the stimulator turned on after surgery. As a group, the patients attained significantly higher scores on word list recognition (discriminability) and delayed recall of prose passages after surgery than before surgery. In addition, there was a trend toward higher scores on a visual confrontation naming test after surgery. Examination of individual patient data indicated gains and losses in test scores exceeding two standard deviations to be very rare. Changes of one standard deviation were also relatively rare, but gains were more likely to occur than losses. These observations provide preliminary support for the cognitive safety of thalamic stimulation for PD.

Therapeutic potentials for glial cell line-derived neurotrophic factor (GDNF) based upon pharmacological activities in the CNS

Since the discovery of the novel neurotrophic factor GDNF in 1993 [25], the molecule has received a great deal of attention from neuroscientists studying all aspects of neurotrophic factor physiology and pharmacology. GDNF instantly became a focus of basic research when it was discovered that GDNF was a potent neurotrophic factor for at least two diverse neuronal populations including dopaminergic neurons and motor neurons [25,47] magnitude. A comprehensive review of the pharmacology of GDNF and hypotheses concerning its possible clinical uses is presented. Based upon our current knowledge of GDNF's pharmacology, it appears that the molecule may be useful in the treatment of neurodegenerative diseases, such as Parkinson's disease (PD), amyotrophic lateral sclerosis (ALS), other motor neuron diseases (MND) and cholinergic deficit-related dementia.