Involvement of the Spinal Cord in Parkinson's Disease

FASB: an integrated processing pipeline for Functional Analysis of simultaneous Spinal cord-Brain fMRI

Simultaneous functional magnetic resonance imaging (fMRI) of the spinal cord and brain represents a powerful method for examining both ascending sensory and descending motor pathways in humans in vivo . However, its image acquisition protocols, and processing pipeline are less well established. This limitation is mainly due to technical difficulties related to spinal cord fMRI, and problems with the logistics stemming from a large field of view covering both brain and cervical cord. Here, we propose an acquisition protocol optimized for both anatomical and functional images, as well as an optimized integrated image processing pipeline, which consists of a novel approach for automatic modeling and mitigating the negative impact of spinal voxels with low temporal signal to noise ratio (tSNR). We validate our integrated pipeline, named FASB, using simultaneous fMRI data acquired during the performance of a motor task, as well as during resting-state conditions. We demonstrate that FASB outperforms the current spinal fMRI processing methods in three domains, including motion correction, registration to the spinal cord template, and improved detection power of the group-level analysis by removing the effects of participant-specific low tSNR voxels, typically observed at the disk level. Using FASB, we identify significant task-based activations in the expected sensorimotor network associated with a unilateral handgrip force production task across the entire central nervous system, including the contralateral sensorimotor cortex, thalamus, striatum, cerebellum, brainstem, as well as ipsilateral ventral horn at C5-C8 cervical levels. Additionally, our results show significant task-based functional connectivity between the key sensory and motor brain areas and the dorsal and ventral horns of the cervical cord. Overall, our proposed acquisition protocol and processing pipeline provide a robust method for characterizing the activation and functional connectivity of distinct cortical, subcortical, brainstem and spinal cord regions in humans.

Temporal Investigations of the Changes in Presynaptic Inhibition Associated With Subthalamic Nucleus-Deep-Brain Stimulation

BACKGROUND AND PURPOSE

There are controversies regarding the role of presynaptic inhibition (PSI) in the mechanisms underlying the efficacy of deep-brain stimulation (DBS) in Parkinson's disease (PD). We sought to determine the involvement of PSI in DBS-related mechanisms and clinical correlates.

METHODS

We enrolled PD subjects who had received subthalamic nucleus DBS (STN-DBS) therapy and had been admitted to our clinic between January 2022 and March 2022. The tibial H-reflex was studied bilaterally during the medication-off state, and all tests were repeated 10 and 20 minutes after the simulation was turned off. Simultaneous evaluations based on the Movement-Disorder-Society-sponsored revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III) were performed in all of the patients.

RESULTS

Ultimately we enrolled 18 patients aged 58.7±9.3 years (mean±standard deviation, 10 females). Fifty percent of the patients showed a decrease in the MDS-UPDRS-III score of more than 60% during the stimulation-on period. Comparative analyses of the repeated measurements made according to the stimulation status revealed significant differences only in the left H-reflex/M-response amplitude ratio (H/M ratio). However, no difference in the left H/M ratio was found in the subgroup of patients with a prominent clinical response to stimulation (n=9). Analyses of the less-affected side revealed differences in the H-reflex amplitude and H/M ratio.

CONCLUSIONS

We found evidence of PSI recovery on the less-affected side of our PD subjects associated with STN-DBS. We hypothesize that the involvement of this spinal pathway and its contribution to the mechanisms of DBS differ between individuals based on the severity of the disease and which brainstem regions and descending tracts are involved.

Altered Spinal Cord Functional Connectivity Associated with Parkinson's Disease Progression

BACKGROUND

Parkinson's disease (PD) has traditionally been viewed as an α-synucleinopathy brain pathology. Yet evidence based on postmortem human and animal experimental models indicates that the spinal cord may also be affected.

OBJECTIVE

Functional magnetic resonance imaging (fMRI) seems to be a promising candidate to better characterize spinal cord functional organization in PD patients.

METHODS

Resting-state spinal fMRI was performed in 70 PD patients and 24 age-matched healthy controls, the patients being divided into three groups based on their motor symptom severity: PD_low (n = 24), PD_med (n = 22), and PD_adv (n = 24) groups. A combination of independent component analysis (ICA) and a seed-based approach was applied.

RESULTS

When pooling all participants, the ICA revealed distinct ventral and dorsal components distributed along the rostro-caudal axis. This organization was highly reproducible within subgroups of patients and controls. PD severity, assessed by Unified Parkinson's Disease Rating Scale (UPDRS) scores, was associated with a decrease in spinal functional connectivity (FC). Notably, we observed a reduced intersegmental correlation in PD as compared to controls, the latter being negatively associated with patients' upper-limb UPDRS scores (P = 0.0085). This negative association between FC and upper-limb UPDRS scores was significant between adjacent C4-C5 (P = 0.015) and C5-C6 (P = 0.20) cervical segments, levels associated with upper-limb functions.

CONCLUSIONS

The present study provides the first evidence of spinal cord FC changes in PD and opens new avenues for the effective diagnosis and therapeutic strategies in PD. This underscores how spinal cord fMRI can serve as a powerful tool to characterize, in vivo, spinal circuits for a variety of neurological diseases. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Systemic Rotenone Administration Causes Extra-Nigral Alterations in C57BL/6 Mice

Systemic administration of rotenone replicates several pathogenic and behavioural features of Parkinson's disease (PD), some of which cannot be explained by deficits of the nigrostriatal pathway. In this study, we provide a comprehensive analysis of several neurochemical alterations triggered by systemic rotenone administration in the CNS of C57BL/6 mice. Mice injected with either 1, 3 or 10 mg/kg rotenone daily via intraperitoneal route for 21 days were assessed weekly for changes in locomotor and exploratory behaviour. Rotenone treatment caused significant locomotor and exploratory impairment at dosages of 3 or 10 mg/kg. Molecular analyses showed reductions of both TH and DAT expression in the midbrain, striatum and spinal cord, accompanied by altered expression of dopamine receptors and brain-derived neurotrophic factor (BDNF). Rotenone also triggered midbrain-restricted inflammatory responses with heightened expression of glial markers, which was not seen in extra-nigral regions. However, widespread alterations of mitochondrial function and increased signatures of oxidative stress were identified in both nigral and extra-nigral regions, along with disruptions of neuroprotective peptides, such as pituitary adenylate cyclase-activating polypeptide (PACAP), vasoactive intestinal peptide (VIP) and activity-dependent neuroprotective protein (ADNP). Altogether, this study shows that systemic rotenone intoxication, similarly to PD, causes a series of neurochemical alterations that extend at multiple CNS levels, reinforcing the suitability of this pre-clinical model for the study extra-nigral defects of PD.

Investigation of the changes in the presynaptic inhibition in association with the subthalamic nucleus stimulation in Parkinson's disease

BACKGROUND AND PURPOSE

Presynaptic inhibition (PSI) is a critical spinal inhibitory mechanism for modulating muscle coordination by adjusting both supraspinal motor commands and sensory feedback at the spinal level. The literature data regarding the role of PSI in the efficiency of STN-DBS therapy in Parkinson's disease (PD) are limited. We aimed to investigate the possible alteration in this pathway in association with the STN stimulation (STIM) within the very early period after the STIM is off.

METHODS

We performed the H-reflex investigation on 8 PD subjects with STN-DBS who applied to our polyclinic for routine clinical evaluations. The investigations were initially performed at the STIM-on period and repeated after the STIM set is off for 5 min. A within-subjects ANOVA was used to test for a significant difference between the STIM-on and -off states for the variables of (repeated measures) H-latency, H amplitude, M amplitude, H/M amplitude, H threshold, and M threshold.

RESULTS

The results of the analyses did not reveal marked changes in the variables of the H-reflex between the STIM-on and -off states.

CONCLUSION

PSI do not alter in the very early period after the STIM is off. Taken together with the related literature data and our study results, it can be hypothesized that the PSI might involve in the DBS efficiency in the later phase of the STIM as a compensatory mechanism. Further prospective studies including a larger number of patients with serial electrophysiological recordings to investigate the temporal course of the underlying dynamics are required to clarify these discussions.

Parkinsonism and motor neuron disorders: Lessons from Western Pacific ALS/PDC

Recognized worldwide as an unusual "overlap" syndrome, Parkinsonism and motor neuron disease, with or without dementia, is best exemplified by the former high-incidence clusters of Amyotrophic Lateral Sclerosis and Parkinsonism-Dementia Complex (ALS/PDC) in Guam, USA, in the Kii Peninsula of Honshu Island, Japan, and in Papua, Indonesia, on the western side of New Guinea. Western Pacific ALS/PDC is a disappearing neurodegenerative disorder with multiple and sometime overlapping phenotypes (ALS, atypical parkinsonism, dementia) that appear to constitute a single disease of environmental origin, in particular from exposure to genotoxins/neurotoxins in seed of cycad plants (Cycas spp.) formerly used as a traditional source of food (Guam) and/or medicine (Guam, Kii-Japan, Papua-Indonesia). Seed compounds include the principal cycad toxin cycasin, its active metabolite methylazoxymethanol (MAM) and a non-protein amino acid β-N-methylamino-L-alanine (L-BMAA); each reproduces components of ALS/PDC neuropathology when individually administered to laboratory species in single doses perinatally (MAM, L-BMAA) or repeatedly for prolonged periods to young adult animals (L-BMAA). Human exposure to MAM, a potent DNA-alkylating mutagen, also has potential relevance to the high incidence of diverse mutations found among Guamanians with/without ALS/PDC. In sum, seven decades of intensive study of ALS/PDC has revealed field and laboratory approaches leading to discovery of disease etiology that are now being applied to sporadic neurodegenerative disorders such as ALS beyond the Western Pacific region. This article is part of the Special Issue "Parkinsonism across the spectrum of movement disorders and beyond" edited by Joseph Jankovic, Daniel D. Truong and Matteo Bologna.

New developments for spinal cord stimulation

Spinal cord stimulation (SCS) is a well-established therapy for the treatment of chronic neuropathic pain. Newer SCS waveforms have improved patient outcomes, leading to its increased utilization among many pain conditions. More recently, SCS has been used to treat some symptoms in several movement disorders because of its good profile tolerability and capacity to stimulate local and distant areas of the central nervous system. After the original experimental findings in animal models of Parkinson's disease (PD) in the late 2000s, several studies have reported the beneficial clinical effects of SCS stimulation on gait in PD patients. Additionally, the spinal cord has emerged as a potential therapeutic target to treat essential and orthostatic tremor, some forms of ataxia, and atypical parkinsonisms. In this chapter, we describe the most recent advances in SCS for pain and the rationale and potential mechanism of action of stimulating the spinal cord for treating movement disorders, focusing on its network modulation. We also summarize the main clinical studies performed to date as well as their limitations and future perspectives.

Abnormal Spinal Cord Myelination due to Oligodendrocyte Dysfunction in a Model of Huntington's Disease

BACKGROUND

The relative contribution of grey matter (GM) and white matter (WM) degeneration to the progressive brain atrophy in Huntington's disease (HD) has been well studied. The pathology of the spinal cord in HD is comparatively less well documented.

OBJECTIVE

We aim to characterize spinal cord WM abnormalities in a mouse model of HD and evaluate whether selective removal of mutant huntingtin (mHTT) from oligodendroglia rescues these deficits.

METHODS

Histological assessments were used to determine the area of GM and WM in the spinal cord of 12-month-old BACHD mice, while electron microscopy was used to analyze myelin fibers in the cervical area of the spinal cord. To investigate the impact of inactivation of mHTT in oligodendroglia on these measures, we used the previously described BACHDxNG2Cre mouse line where mHTT is specifically reduced in oligodendrocyte progenitor cells.

RESULTS

We show that spinal GM and WM areas are significantly atrophied in HD mice compared to wild-type controls. We further demonstrate that specific reduction of mHTT in oligodendroglial cells rescues the atrophy of spinal cord WM, but not GM, observed in HD mice. Inactivation of mHTT in oligodendroglia had no effect on the density of oligodendroglial cells but enhanced the expression of myelin-related proteins in the spinal cord.

CONCLUSION

Our findings demonstrate that the myelination abnormalities observed in brain WM structures in HD extend to the spinal cord and suggest that specific expression of mHTT in oligodendrocytes contributes to such abnormalities.

Physical exercise increases the production of tyrosine hydroxylase and CDNF in the spinal cord of a Parkinson's disease mouse model

Previous research advocates that exercise is a non-pharmacological therapy for Parkinson's disease (PD). However, few studies have investigated the effects of exercise on central nervous system structures other than the nigrostriatal pathway by using PD animal models. This study investigated the effects of exercise on tyrosine hydroxylase (TH)- and cerebral dopamine neurotrophic factor (CDNF)-containing spinal-cord neurons. Male Swiss mice were divided into 4 groups: sedentary control (SEDCONT), exercise control (EXERCONT), sedentary Parkinson (SEDPD), and exercise Parkinson (EXERPD). The PD groups were submitted to a surgical procedure for stereotaxic bilateral injection of 6-hydroxydopamine into the striatum. TH- and CDNF-containing spinal-cord neurons were evaluated in all groups, using immunohistochemistry and western-blotting. TH content in the ventral horn differed notably between the SEDPD and EXERPD groups. CDNF content was highest in the EXERPD group. SEDPD and EXERPD groups differed the most, as shown by immunohistochemistry and western-blotting. The EXERPD group showed the most intense labeling in immunohistochemistry compared to the SEDCONT and EXERCONT groups. Therefore, we showed here that exercise increased the content of both TH and CDNF in the spinal-cord neurons of a bilateral PD mouse model. We may assume that the spinal cord is affected in a PD model, and therefore this central nervous system region deserves more attention from researchers dealing with PD.

Genetically modified macrophages accomplish targeted gene delivery to the inflamed brain in transgenic Parkin Q311X(A) mice: importance of administration routes

Cell-based drug delivery systems have generated an increasing interest in recent years. We previously demonstrated that systemically administered macrophages deliver therapeutics to CNS, including glial cell line-derived neurotrophic factor (GDNF), and produce potent effects in Parkinson’s disease (PD) mouse models. Herein, we report fundamental changes in biodistribution and brain bioavailability of macrophage-based formulations upon different routes of administration: intravenous, intraperitoneal, or intrathecal injections. The brain accumulation of adoptively transferred macrophages was evaluated by various imaging methods in transgenic Parkin Q311(X)A mice and compared with those in healthy wild type littermates. Neuroinflammation manifested in PD mice warranted targeting macrophages to the brain for each route of administration. The maximum amount of cell-carriers in the brain, up to 8.1% ID/g, was recorded followed a single intrathecal injection. GDNF-transfected macrophages administered through intrathecal route provided significant increases of GDNF levels in different brain sub-regions, including midbrain, cerebellum, frontal cortex, and pons. No significant offsite toxicity of the cell-based formulations in mouse brain and peripheral organs was observed. Overall, intrathecal injection appeared to be the optimal administration route for genetically modified macrophages, which accomplished targeted gene delivery, and significant expression of reporter and therapeutic genes in the brain.

New players in basal ganglia dysfunction in Parkinson's disease

The classical model of the basal ganglia (BG) circuit has been recently revised with the identification of other structures that play an increasing relevant role especially in the pathophysiology of Parkinson's disease (PD). Numerous studies have supported the spreading of the alpha-synuclein pathology to several areas beyond the BG and likely even before their involvement. With the aim of better understanding PD pathophysiology and finding new targets for treatment, the spinal cord, the pedunculopontine nucleus, the substantia nigra pars reticulata, the retina, the superior colliculus, the cerebellum, the nucleus parabrachialis and the Meynert's nucleus have been investigated both in animal and human studies. In this chapter, we describe the main anatomical and functional connections between the above structures and the BG, the relationship between their pathology and PD features, and the rational of applying neuromodulation treatment to improve motor and non-motor symptoms in PD. Some of these new players in the BG circuits might also have a potential intriguing role as early biomarkers of PD.

Motor Neurons Pathology After Chronic Exposure to MPTP in Mice

The neurotoxin 1-methyl,4-phenyl-1,2,3,6-tetrahydropiridine (MPTP) is widely used to produce experimental parkinsonism in rodents and primates. Among different administration protocols, continuous or chronic exposure to small amounts of MPTP is reported to better mimic cell pathology reminiscent of Parkinson's disease (PD). Catecholamine neurons are the most sensitive to MPTP neurotoxicity; however, recent studies have found that MPTP alters the fine anatomy of the spinal cord including motor neurons, thus overlapping again with the spinal cord involvement documented in PD. In the present study, we demonstrate that chronic exposure to low amounts of MPTP (10 mg/kg daily, × 21 days) significantly reduces motor neurons in the ventral lumbar spinal cord while increasing α-synuclein immune-staining within the ventral horn. Spinal cord involvement in MPTP-treated mice extends to Calbindin D28 KDa immune-reactive neurons other than motor neurons within lamina VII. These results were obtained in the absence of significant reduction of dopaminergic cell bodies in the Substantia Nigra pars compacta, while a slight decrease was documented in striatal tyrosine hydroxylase immune-staining. Thus, the present study highlights neuropathological similarities between dopaminergic neurons and spinal motor neurons and supports the pathological involvement of spinal cord in PD and experimental MPTP-induced parkinsonism. Remarkably, the toxic threshold for motor neurons appears to be lower compared with nigral dopaminergic neurons following a chronic pattern of MPTP intoxication. This sharply contrasts with previous studies showing that MPTP intoxication produces comparable neuronal loss within spinal cord and Substantia Nigra.

Optimizing Parkinson's disease diagnosis: the role of a dual nuclear imaging algorithm

The diagnosis of Parkinson's disease (PD) currently relies almost exclusively on the clinical judgment of an experienced neurologist, ideally a specialist in movement disorders. However, such clinical diagnosis is often incorrect in a large percentage of patients, particularly in the early stages of the disease. A commercially available, objective and quantitative marker of nigrostriatal neurodegeneration was recently provided by 123-iodine ¹²³I-ioflupane SPECT imaging, which is however unable to differentiate PD from a variety of other parkinsonian syndromes associated with striatal dopamine deficiency. There is evidence to support an algorithm utilizing a dual neuroimaging strategy combining ¹²³I-ioflupane SPECT and the noradrenergic receptor ligand ¹²³I-metaiodobenzylguanidine (MIBG), which assesses the post-ganglion peripheral autonomic nervous system. Evolving concepts regarding the synucleinopathy affecting the central and peripheral autonomic nervous systems as part of a multisystem disease are reviewed to sustain such strategy. Data are presented to show how MIBG deficits are a common feature of multisystem Lewy body disease and can be used as a unique feature to distinguish PD from atypical parkinsonisms. We propose that the combination of cardiac (MIBG) and cerebral ¹²³I-ioflupane SPECT could satisfy one of the most significant unmet needs of current PD diagnosis and management, namely the early and accurate diagnosis of patients with typical Lewy body PD. Exemplary case scenarios will be described, highlighting how dual neuroimaging strategy can maximize diagnostic accuracy for patient care, clinical trials, pre-symptomatic PD screening, and special cases provided by specific genetic mutations associated with PD.

Critical appraisal of pathology transmission in the α-synuclein fibril model of Lewy body disorders

Lewy body disorders are characterized by the emergence of α-synucleinopathy in many parts of the central and peripheral nervous systems, including in the telencephalon. Dense α-synuclein+ pathology appears in regio inferior of the hippocampus in both Parkinson's disease and dementia with Lewy bodies and may disturb cognitive function. The preformed α-synuclein fibril model of Parkinson's disease is growing in use, given its potential for seeding the self-propagating spread of α-synucleinopathy throughout the mammalian brain. Although it is often assumed that the spread occurs through neuroanatomical connections, this is generally not examined vis-à-vis the uptake and transport of tract-tracers infused at precisely the same stereotaxic coordinates. As the neuronal connections of the hippocampus are historically well defined, we examined the first-order spread of α-synucleinopathy three months following fibril infusions centered in the mouse regio inferior (CA2+CA3), and contrasted this to retrograde and anterograde transport of the established tract-tracers FluoroGold and biotinylated dextran amines (BDA). Massive hippocampal α-synucleinopathy was insufficient to elicit memory deficits or loss of cells and synaptic markers in this model of early disease processes. However, dense α-synuclein+ inclusions in the fascia dentata were negatively correlated with memory capacity. A modest compensatory increase in synaptophysin was evident in the stratum radiatum of cornu Ammonis in fibril-infused animals, and synaptophysin expression correlated inversely with memory function in fibril but not PBS-infused mice. No changes in synapsin I/II expression were observed. The spread of α-synucleinopathy was somewhat, but not entirely consistent with FluoroGold and BDA axonal transport, suggesting that variables other than innervation density also contribute to the materialization of α-synucleinopathy. For example, layer II entorhinal neurons of the perforant pathway exhibited somal α-synuclein+ inclusions as well as retrogradely labeled FluoroGold+ somata. However, some afferent brain regions displayed dense retrograde FluoroGold label and no α-synuclein+ inclusions (e.g. medial septum/diagonal band), supporting the selective vulnerability hypothesis. The pattern of inclusions on the contralateral side was consistent with specific spread through commissural connections (e.g. stratum pyramidale of CA3), but again, not all commissural projections exhibited α-synucleinopathy (e.g. hilar mossy cells). The topographical extent of inclusions is displayed here in high-resolution images that afford viewers a rich opportunity to dissect the potential spread of pathology through neural circuitry. Finally, the results of this expository study were leveraged to highlight the challenges and limitations of working with preformed α-synuclein fibrils.

Immunotherapy targeting α-synuclein protofibrils reduced pathology in (Thy-1)-h[A30P] α-synuclein mice

Several lines of evidence suggest that accumulation of aggregated alpha-synuclein (α-synuclein) in the central nervous system (CNS) is an early pathogenic event in Parkinson's disease and other Lewy body disorders. In recent years, animal studies have indicated immunotherapy with antibodies directed against α-synuclein as a promising novel treatment strategy. Since large α-synuclein oligomers, or protofibrils, have been demonstrated to possess pronounced cytotoxic properties, such species should be particularly attractive as therapeutic targets. In support of this, (Thy-1)-h[A30P] α-synuclein transgenic mice with motor dysfunction symptoms were found to display increased levels of α-synuclein protofibrils in the CNS. An α-synuclein protofibril-selective monoclonal antibody (mAb47) was evaluated in this α-synuclein transgenic mouse model. As measured by ELISA, 14month old mice treated for 14weeks with weekly intraperitoneal injections of mAb47 displayed significantly lower levels of both soluble and membrane-associated protofibrils in the spinal cord. Besides the lower levels of pathogenic α-synuclein demonstrated, a reduction of motor dysfunction in transgenic mice upon peripheral administration of mAb47 was indicated. Thus, immunotherapy with antibodies targeting toxic α-synuclein species holds promise as a future disease-modifying treatment in Parkinson's disease and related disorders.

Lack of non-voluntary stepping responses in Parkinson's disease

The majority of research and therapeutic actions in Parkinson's disease (PD) focus on the encephalic areas, however, the potential involvement of the spinal cord in its genesis has received little attention. Here we examined spinal locomotor circuitry activation in patients with PD using various types of central and peripheral tonic stimulation and compared results to those of age-matched controls. Subjects lay on their sides with both legs suspended, allowing low-friction horizontal rotation of the limb joints. Air-stepping can be used as a unique and important model for investigating human rhythmogenesis since its manifestation is largely facilitated by the absence of external resistance. In contrast to the frequent occurrence of non-voluntary stepping responses in healthy subjects, both peripheral (muscle vibration) and central (Jendrassik maneuver, mental task, Kohnstamm phenomenon) tonic influences had little if any effect on rhythmic leg responses in PD. On the other hand, a remarkable feature of voluntary air-stepping movements in patients was a significantly higher frequency of leg oscillations than in age-matched controls. A lack of non-voluntary stepping responses was also observed after dopaminergic treatment despite the presence of prominent shortening reactions (SRs) to passive movements. We argue that the state and the rhythmogenesis capacity of the spinal circuitry are impaired in patients with PD. In particular, the results suggest impaired central pattern generator (CPG) access by sensory and central activations.