Neurologische Klinik und Poliklinik
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Sonstige beteiligte Institutionen
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- Wurzburg Fabry Center for Interdisciplinary Therapy (FAZIT), Wurzburg, Germany (1)
- Würzburg Fabry Center for Interdisciplinary Therapy (FAZIT), University of Würzburg, Würzburg, Germany (1)
Introduction:
Evidence from a number of open-label, uncontrolled studies has suggested that rituximab may benefit patients with autoimmune diseases who are refractory to standard-of-care. The objective of this study was to evaluate the safety and clinical outcomes of rituximab in several standard-of-care-refractory autoimmune diseases (within rheumatology, nephrology, dermatology and neurology) other than rheumatoid arthritis or non-Hodgkin’s lymphoma in a real-life clinical setting.
Methods:
Patients who received rituximab having shown an inadequate response to standard-of-care had their safety and clinical outcomes data retrospectively analysed as part of the German Registry of Autoimmune Diseases. The main outcome measures were safety and clinical response, as judged at the discretion of the investigators.
Results:
A total of 370 patients (299 patient-years) with various autoimmune diseases (23.0% with systemic lupus erythematosus, 15.7% antineutrophil cytoplasmic antibody-associated granulomatous vasculitides, 15.1% multiple sclerosis and 10.0% pemphigus) from 42 centres received a mean dose of 2,440 mg of rituximab over a median (range) of 194 (180 to 1,407) days. The overall rate of serious infections was 5.3 per 100 patient-years during rituximab therapy. Opportunistic infections were infrequent across the whole study population, and mostly occurred in patients with systemic lupus erythematosus. There were 11 deaths (3.0% of patients) after rituximab treatment (mean 11.6 months after first infusion, range 0.8 to 31.3 months), with most of the deaths caused by infections. Overall (n = 293), 13.3% of patients showed no response, 45.1% showed a partial response and 41.6% showed a complete response. Responses were also reflected by reduced use of glucocorticoids and various immunosuppressives during rituximab therapy and follow-up compared with before rituximab. Rituximab generally had a positive effect on patient well-being (physician’s visual analogue scale; mean improvement from baseline of 12.1 mm)
Transient receptor potential channels are important mediators of thermal and mechanical stimuli and play an important role in neuropathic pain. The contribution of hereditary variants in the genes of transient receptor potential channels to neuropathic pain is unknown. We investigated the frequency of transient receptor potential ankyrin 1, transient receptor potential melastin 8 and transient receptor potential vanilloid 1 single nucleotide polymorphisms and their impact on somatosensory abnormalities in neuropathic pain patients. Within the German Research Network on Neuropathic Pain (Deutscher Forscbungsverbund Neuropathischer Schmerz) 371 neuropathic pain patients were phenotypically characterized using standardized quantitative sensory testing. Pyrosequencing was employed to determine a total of eleven single nucleotide polymorphisms in transient receptor potential channel genes of the neuropathic pain patients and a cohort of 253 German healthy volunteers. Associations of quantitative sensory testing parameters and single nucleotide polymorphisms between and within groups and subgroups, based on sensory phenotypes, were analyzed. Single nucleotide polymorphisms frequencies did not differ between both the cohorts. However, in neuropathic pain patients transient receptor potential ankyrin 1 710G>A (rs920829, E179K) was associated with the presence of paradoxical heat sensation (p=0.03), and transient receptor potential vanilloid 1 1911A>G (rs8065080, I585V) with cold hypoalgesia (p=0.0035). Two main subgroups characterized by preserved (1) and impaired (2) sensory function were identified. In subgroup 1 transient receptor potential vanilloid 1 1911A>G led to significantly less heat hyperalgesia, pinprick hyperalgesia and mechanical hypaesthesia (p=0.006, p=0.005 and p<0.001) and transient receptor potential vanilloid 1 1103C>G (rs222747, M315I) to cold hypaesthesia (p=0.002), but there was absence of associations in subgroup 2. In this study we found no evidence that genetic variants of transient receptor potential channels are involved in the expression of neuropathic pain, but transient receptor potential channel polymorphisms contributed significantly to the somatosensory abnormalities of neuropathic pain patients.
Charcot-Marie-Tooth Neuropathien sind die häufigsten hereditären Erkrankungen des peripheren Nervensystems und dennoch bis heute nicht therapierbar. Die Lebensqualität der Patienten ist durch motorische und sensorische Defizite der Extremitäten häufig stark eingeschränkt. Ursache können unter anderem Mutationen in Schwann-Zellen sein, die zu dem typischen Bild von Demyelinisierung und axonalem Schaden führen. In den letzten Jahren konnte in Mausmodellen das Immunsystem als wichtiger Mediator in der Pathogenese der CMT 1 Subtypen A, B und X identifiziert werden. Insbesondere Makrophagen spielen eine tragende Rolle bei dem Verlust der axonalen Integrität, bei der Schädigung der Myelinscheiden, sowie bei der Dedifferenzierung von Schwann-Zellen. Entscheidender Faktor für Proliferation und Aktivierung der Makrophagen ist hierbei das Zytokin CSF-1, dessen korrespondierender Rezeptor auf Makrophagen exprimiert wird. Der CSF-1/CSF1R Signalweg bietet somit einen vielversprechenden Angriffspunkt.
In der vorliegenden Arbeit wurden Mausmodelle der CMT 1 Subtypen A, B und X mit einem niedermolekularen CSF-1-Rezeptor Inhibitor behandelt. Anschließend erfolgte eine funktionelle und strukturelle Auswertung der peripheren Nerven.
Das beste Ansprechen auf die Therapie zeigten Cx32def Mutanten. Strukturell fielen ein verringerter axonaler Schaden und eine verbesserte axonale Regenerationsfähigkeit sowie erhaltene neuromuskuläre Synapsen auf. Funktionell äußerte sich dies in verbesserten elektrophysiologischen Parametern und einem Krafterhalt, welcher als klinischer Parameter die größte Relevanz für betroffene Patienten hat und somit besonders hervorzuheben ist.
Auch P0het Mutanten zeigten Verbesserungen nach der CSF1RI Behandlung. Anders als bei Cx32def Tieren zeigte sich hier jedoch vor allem ein Erhalt der Myelinintegrität. Weiterhin wirkte sich die Therapie positiv auf elektrophysiologische Parameter und Krafttests aus. Vor allem besonders stark betroffene Individuen schienen hierbei von der CSF1RI Behandlung zu profitieren.
Bei PMP22tg Mutanten hingegen konnten keine positiven Effekte der CSF1RI Behandlung nachgewiesen werden. Strukturelle und funktionelle Parameter behandelter Tiere unterschieden sich nicht von unbehandelten.
Diese Ergebnisse unterstreichen die Relevanz der sekundären Entzündungsreaktion in CMT 1 Neuropathien als wichtigen Mediator in der Pathogenese. Weiterhin konnte gezeigt werden, dass eine Intervention im CSF-1/CSF1R Signalweg einen vielversprechenden möglichen Ansatz für die Therapie der bisher nicht behandelbaren CMT 1 Subypen X und B darstellt. Unausweichlich ist hierbei ein möglichst früher Therapiestart vor Ausprägung der ersten molekularen und histologischen Veränderungen. Im Hinblick auf die nicht die Lebenserwartung reduzierende Erkrankung muss ferner eine Minimierung der Nebenwirkungen der Therapie gewährleistet sein. Besonders hervorzuheben ist hier die Verwendung eines Inhibitors, welcher nicht in das zentrale Nervensystem vordringen kann und somit die Funktion der Mikroglia nicht beeinträchtigt.
Background:
Inhibition of early platelet adhesion by blockade of glycoprotein-IB (GPIb) protects mice from ischemic stroke. To elucidate underlying mechanisms in-vivo, infarct development was followed by ultra-high field MRI at 17.6 Tesla.
Methods:
Cerebral infarction was induced by transient-middle-cerebral-artery-occlusion (tMCAO) for 1 hour in C57/BL6 control mice (N = 10) and mice treated with 100 mg Fab-fragments of the GPIb blocking antibody p0p/B 1 h after tMCAO (N = 10). To control for the effect of reperfusion, additional mice underwent permanent occlusion and received anti-GPIb treatment (N = 6; pMCAO) or remained without treatment (N = 3; pMCAO). MRI 2 h and 24 h after MCAO measured cerebral-blood-flow (CBF) by continuous arterial-spin labelling, the apparent-diffusion-coefficient (ADC), quantitative-T2 and T2-weighted imaging. All images were registered to a standard mouse brain MRI atlas and statistically analysed voxel-wise, and by cortico-subcortical ROI analysis.
Results:
Anti-GPIb treatment led to a relative increase of postischemic CBF vs. controls in the cortical territory of the MCA (2 h: 44.2 +/- 6.9 ml/100g/min versus 24 h: 60.5 +/- 8.4; p = 0.0012, F((1,18)) = 14.63) after tMCAO. Subcortical CBF 2 h after tMCAO was higher in anti-GPIb treated animals (45.3 +/- 5.9 vs. controls: 33.6 +/- 4.3; p = 0.04). In both regions, CBF findings were clearly related to a lower probability of infarction (Cortex/Subcortex of treated group: 35%/65% vs. controls: 95%/100%) and improved quantitative-T2 and ADC. After pMCAO, anti-GPIb treated mice developed similar infarcts preceded by severe irreversible hypoperfusion as controls after tMCAO indicating dependency of stroke protection on reperfusion.
Conclusion:
Blockade of platelet adhesion by anti-GPIb-Fab-fragments results in substantially improved CBF early during reperfusion. This finding was in exact spatial correspondence with the prevention of cerebral infarction and indicates in-vivo an increased patency of the microcirculation. Thus, progression of infarction during early ischemia and reperfusion can be mitigated by anti-platelet treatment.
Introduction:
Fabry disease (FD) is a lysosomal storage disorder resulting in progressive nervous system, kidney and heart disease. Enzyme replacement therapy (ERT) may halt or attenuate disease progression. Since administration is burdensome and expensive, appropriate use is mandatory. We aimed to define European consensus recommendations for the initiation and cessation of ERT in patients with FD.
Methods:
A Delphi procedure was conducted with an online survey (n = 28) and a meeting (n = 15). Patient organization representatives were present at the meeting to give their views. Recommendations were accepted with ≥75% agreement and no disagreement.
Results:
For classically affected males, consensus was achieved that ERT is recommended as soon as there are early clinical signs of kidney, heart or brain involvement, but may be considered in patients of ≥16 years in the absence of clinical signs or symptoms of organ involvement. Classically affected females and males with non-classical FD should be treated as soon as there are early clinical signs of kidney, heart or brain involvement, while treatment may be considered in females with non-classical FD with early clinical signs that are considered to be due to FD. Consensus was achieved that treatment should not be withheld from patients with severe renal insufficiency (GFR < 45 ml/min/1.73 m\(^{2}\)) and from those on dialysis or with cognitive decline, but carefully considered on an individual basis. Stopping ERT may be considered in patients with end stage FD or other co-morbidities, leading to a life expectancy of <1 year. In those with cognitive decline of any cause, or lack of response for 1 year when the sole indication for ERT is neuropathic pain, stopping ERT may be considered. Also, in patients with end stage renal disease, without an option for renal transplantation, in combination with advanced heart failure (NYHA class IV), cessation of ERT should be considered. ERT in patients who are non-compliant or fail to attend regularly at visits should be stopped.
Conclusion:
The recommendations can be used as a benchmark for initiation and cessation of ERT, although final decisions should be made on an individual basis. Future collaborative efforts are needed for optimization of these recommendations.
Different phosphoinositide 3-kinase isoforms mediate carrageenan nociception and inflammation
(2016)
Phosphoinositide 3-kinases (PI3Ks) participate in signal transduction cascades that can directly activate and sensitize nociceptors and enhance pain transmission. They also play essential roles in chemotaxis and immune cell infiltration leading to inflammation. We wished to determine which PI3K isoforms were involved in each of these processes. Lightly anesthetized rats (isoflurane) were injected subcutaneously with carrageenan in their hind paws. This was preceded by a local injection of 1% DMSO vehicle or an isoform-specific antagonist to PI3K-α (compound 15-e), -β (TGX221), -δ (Cal-101), or -γ (AS252424). We measured changes in the mechanical pain threshold and spinal c-Fos expression (4 hours after injection) as indices of nociception. Paw volume, plasma extravasation (Evans blue, 0.3 hours after injection), and neutrophil (myeloperoxidase; 1 hour after injection) and macrophage (CD11b+; 4 hour after injection) infiltration into paw tissue were the measured inflammation endpoints. Only PI3K-γ antagonist before treatment reduced the carrageenan-induced pain behavior and spinal expression of c-Fos (P ≤ 0.01). In contrast, pretreatment with PI3K-α, -δ, and-γ antagonists reduced early indices of inflammation. Plasma extravasation PI3K-α (P ≤ 0.05), -δ (P ≤ 0.05), and -γ (P ≤ 0.01), early (0-2 hour) edema -α (P ≤ 0.05), -δ (P ≤ 0.001), and -γ (P ≤ 0.05), and neutrophil infiltration (all P ≤ 0.001) were all reduced compared to vehicle pretreatment. Later (2-4 hour), edema and macrophage infiltration (P ≤ 0.05) were reduced by only the PI3K-δ and -γ isoform antagonists, with the PI3K-δ antagonist having a greater effect on edema. PI3K-β antagonism was ineffective in all paradigms. These data indicate that pain and clinical inflammation are pharmacologically separable and may help to explain clinical conditions in which inflammation naturally wanes or goes into remission, but pain continues unabated.
Cortex-basal ganglia circuits participate in motor timing and temporal perception, and are important for the dynamic configuration of sensorimotor networks in response to exogenous demands. In Parkinson's disease (PD) patients, rhythmic auditory stimulation (RAS) induces motor performance benefits. Hitherto, little is known concerning contributions of the basal ganglia to sensory facilitation and cortical responses to RAS in PD. Therefore, we conducted an EEG study in 12 PD patients before and after surgery for subthalamic nucleus deep brain stimulation (STN-DBS) and in 12 age-matched controls. Here we investigated the effects of levodopa and STN-DBS on resting-state EEG and on the cortical-response profile to slow and fast RAS in a passive-listening paradigm focusing on beta-band oscillations, which are important for auditory–motor coupling. The beta-modulation profile to RAS in healthy participants was characterized by local peaks preceding and following auditory stimuli. In PD patients RAS failed to induce pre-stimulus beta increases. The absence of pre-stimulus beta-band modulation may contribute to impaired rhythm perception in PD. Moreover, post-stimulus beta-band responses were highly abnormal during fast RAS in PD patients. Treatment with levodopa and STN-DBS reinstated a post-stimulus beta-modulation profile similar to controls, while STN-DBS reduced beta-band power in the resting-state. The treatment-sensitivity of beta oscillations suggests that STN-DBS may specifically improve timekeeping functions of cortical beta oscillations during fast auditory pacing.
Hintergrund dieser Doktorarbeit ist die ungeklärte Pathophysiologie der idiopathischen Dystonie. Die DYT1 Dystonie ist die häufigste hereditäre Dystonie und weist eine Mutation im Tor1a-Gen auf, welches das Protein TorsinA kodiert. Diese DYT1 Dystonie besitzt interessanterweise lediglich eine Penetranz von 30%. Ein gutes Nagermodell mit einem klinisch dystonen Phänotyp existiert bislang nicht. Diese Dissertation adressiert die Frage, ob sich eine Dystonie bei DYT1 relevanter genetischer Prädisposition durch peripheren Stress („second-hit“) manifestiert.
Bei Tor1a +/- Mäusen (50% TorsinA Expression, Tor1a +/-), die im naiven Zustand keinen dystonen Phänotyp haben, sowie bei Wildtyp (wt) Kontrolltieren im Alter von vier Monaten wurde eine rechtsseitige reversible N. ischiadicus Quetschläsion durchgeführt. Die Tiere wurden daraufhin in einem Beobachtungszeitraum von acht Wochen nach dem Trauma verhaltensanalytisch und morphologisch untersucht.
Folgende Ergebnisse wurden hierbei erzielt: Im „Tail-suspension-Test“ zeigte sich bereits ein Tag nach der Quetschläsion des N. ischiadicus eine passagere Parese des betroffenen rechten Hinterbeins bei wt und Tor1a +/- Mäusen. Die fokale Dystonie entwickelte sich ab der vierten Woche bei Tor1a +/- Mäusen stärker als bei den wt Kontrolltieren. Durch das computergestützte Ganganalysesystem (Catwalk™ XT 10.0) konnte bei wt und Tor1a +/- Tieren eine Woche nach der Quetschläsion eine Veränderung der Schrittfolgemuster mit einer Reduktion des Schrittfolge-Regularitäts-Index festgestellt werden. Die abnormale Schrittfolge beim Laufen führte bei Tor1a +/- Mäusen zu einer progredienten Abnahme des Schrittfolge-Regularitäts-Index, während sich wt Mäuse nach fünf Wochen aber wieder erholten. Bei der Überprüfung der Koordinationsfähigkeit beider Genotypen durch den Rotarod Test konnten keine signifikanten Unterschiede festgestellt werden. Immunhistochemische Färbungen des N. ischiadicus auf den Myelinmarker Myelinprotein Zero MPZ, den axonalen Marker Neurofilament und Makrophagen Marker F4/80+ vor der Nervenläsion und acht Wochen nach der Nervenläsion zeigten ebenso keine signifikanten Unterschiede zwischen wt und Tor1a +/- Tieren. Die Anzahl Nissl+ Neurone im lumbalen Rückenmark (L2-4), Striatum und zerebralen Kortex und zudem die Anzahl CD11b positiver Mikroglia im lumbalen Rückenmark (L2-4) wiesen ebenfalls keine signifikanten Unterschiede im Vergleich der beiden Genotypen nach Nervenläsion auf.
Abschließend wurden noch verschiedene Behandlungsexperimente durchgeführt, um zu klären, ob die gefundenen Unterschiede zwischen Tor1a +/- und Tor1a +/+ Mäusen dopaminerg verursacht sind. Hierfür wurden sowohl genetisch mutierte Tor1a +/- Mäuse als auch wt Mäuse nach der Quetschläsion entweder mit einem Kombinationspräparat aus L-Dopa und Benserazid oder mit AMPT acht Wochen lang behandelt.
Folgende Ergebnisse wurden hierbei ermittelt: Die Schrittfolgeregularität beim Catwalk™ XT 10.0 zeigte bei genetisch mutierten Mäusen eine deutliche Auswirkung der Medikation. Tor1a +/- AMPT Mäuse wiesen nach der Läsion eine progrediente Zunahme der Schrittfolgeregularität auf das Ausgangsniveau auf, Tor1a + /- L-Dopa Mäuse hingegen entwickelten auf die Läsion hin eine kontinuierliche Abnahme der Schrittfolgeregularität und konnten sich nicht auf ihr Ausgangsniveau erholen. Die Ergebnisse beim „Tail-suspension-Test“ zeigten ähnliche Resultate: Tor1a +/- Mäuse wiesen nach der Quetschläsion auf die Verabreichung von AMPT hin eine Reduktion der fokalen Dystonie auf, wohingegen die Behandlung mit L-Dopa bei Mutanten zu einer Verschlechterung der Dystonie führte.
Schlussfolgernd zeigt die vorliegende Dissertation, dass ein peripheres Trauma bei genetisch prädispositionierten Mäusen im Sinne eines „second-hits“ zur klinischen Ausprägung einer DYT1 Dystonie führt. Die verstärkte fokale Dystonie in Tor1a +/- Mäusen ist nicht durch ein unterschiedliches Ausmaß an Nervenschädigung nach N. ischiadicus Quetschläsion oder durch morphologische Veränderungen der Tor1a +/- Mäuse im Bereich des N. ischiadicus, Rückenmarks, Striatums oder des Kortex zu begründen.
Background:
Action myoclonus-renal failure syndrome is a hereditary form of progressive myoclonus epilepsy associated with renal failure. It is considered to be an autosomal-recessive disease related to loss-of-function mutations in SCARB2. We studied a German AMRF family, additionally showing signs of demyelinating polyneuropathy and dilated cardiomyopathy. To test the hypothesis whether isolated appearance of individual AMRF syndrome features could be related to heterozygote SCARB2 mutations, we screened for SCARB2 mutations in unrelated patients showing isolated AMRF features.
Methods:
In the AMRF family all exons of SCARB2 were analyzed by Sanger sequencing. The mutation screening of unrelated patients with isolated AMRF features affected by either epilepsy (n = 103, progressive myoclonus epilepsy or generalized epilepsy), demyelinating polyneuropathy (n = 103), renal failure (n = 192) or dilated cardiomyopathy (n = 85) was performed as high resolution melting curve analysis of the SCARB2 exons.
Results:
A novel homozygous 1 bp deletion (c.111delC) in SCARB2 was found by sequencing three affected homozygous siblings of the affected family. A heterozygous sister showed generalized seizures and reduction of nerve conduction velocity in her legs. No mutations were found in the epilepsy, renal failure or dilated cardiomyopathy samples. In the polyneuropathy sample two individuals with demyelinating disease were found to be carriers of a SCARB2 frameshift mutation (c.666delCCTTA).
Conclusions:
Our findings indicate that demyelinating polyneuropathy and dilated cardiomyopathy are part of the action myoclonus-renal failure syndrome. Moreover, they raise the possibility that in rare cases heterozygous SCARB2 mutations may be associated with PNP features.
This review outlines the most frequently used rodent stroke models and discusses their strengths and shortcomings. Mimicking all aspects of human stroke in one animal model is not feasible because ischemic stroke in humans is a heterogeneous disorder with a complex pathophysiology. The transient or permanent middle cerebral artery occlusion (MCAo) model is one of the models that most closely simulate human ischemic stroke. Furthermore, this model is characterized by reliable and well-reproducible infarcts. Therefore, the MCAo model has been involved in the majority of studies that address pathophysiological processes or neuroprotective agents. Another model uses thromboembolic clots and thus is more convenient for investigating thrombolytic agents and pathophysiological processes after thrombolysis. However, for many reasons, preclinical stroke research has a low translational success rate. One factor might be the choice of stroke model. Whereas the therapeutic responsiveness of permanent focal stroke in humans declines significantly within 3 hours after stroke onset, the therapeutic window in animal models with prompt reperfusion is up to 12 hours, resulting in a much longer action time of the investigated agent. Another major problem of animal stroke models is that studies are mostly conducted in young animals without any comorbidity. These models differ from human stroke, which particularly affects elderly people who have various cerebrovascular risk factors. Choosing the most appropriate stroke model and optimizing the study design of preclinical trials might increase the translational potential of animal stroke models.
Background
Animal models have been instrumental in defining thrombus formation, including the role of platelet surface glycoprotein (GP) receptors, in acute ischemic stroke (AIS). However, the involvement of GP receptors in human ischemic stroke pathophysiology and their utility as biomarkers for ischemic stroke risk and severity requires elucidation.
Aims
To determine whether platelet GPIb and GPIIb/IIIa receptors are differentially expressed in patients with AIS and chronic cerebrovascular disease (CCD) compared with healthy volunteers (HV) and to identify predictors of GPIb and GPIIb/IIIa expression.
Methods
This was a case-control study of 116 patients with AIS or transient ischemic attack (TIA), 117 patients with CCD, and 104 HV who were enrolled at our University hospital from 2010 to 2013. Blood sampling was performed once in the CCD and HV groups, and at several time points in patients with AIS or TIA. Linear regression and analysis of variance were used to analyze correlations between platelet GPIb and GPIIb/IIIa receptor numbers and demographic and clinical parameters.
Results
GPIb and GPIIb/IIIa receptor numbers did not significantly differ between the AIS, CCD, and HV groups. GPIb receptor expression level correlated significantly with the magnitude of GPIIb/IIIa receptor expression and the neutrophil count. In contrast, GPIIb/IIIa receptor numbers were not associated with peripheral immune-cell sub-population counts. Creactive protein was an independent predictor of GPIIb/IIIa (not GPIb) receptor numbers.
Conclusions
Platelet GPIb and GPIIb/IIIa receptor numbers did not distinguish between patient or control groups in this study, negating their potential use as a biomarker for predicting stroke risk.
Bei den Charcot-Marie-Tooth (CMT) Neuropathien handelt es sich um erbliche Erkrankungen des peripheren Nervensystems, die progredient zu motorischen und sensorischen Defiziten führen und für die bislang keine kausalen Therapieoptionen existieren. In verschiedenen Studien konnte gezeigt werden, dass Entzündungsreaktionen, insbesondere durch Lymphozyten und Makrophagen vermittelt, eine bedeutende Rolle bei der Pathogenese dieser Erkrankung spielen. Neben neuronaler und axonaler Schädigung, sowie Demyelinisierung ist in untersuchten Myelin Mutanten auch eine erhöhte Anzahl an denervierten neuromuskulärer Endplatten zu erkennen. Eine genetische Blockade der Makrophagen-Aktivierung konnte in den Studien eine Verbesserung sämtlicher neuropathologischer Merkmale bei gleichzeitig reduzierter Makrophagenanzahl zeigen. Ob und welche Rolle Makrophagen bei der Denervation neuromuskulärer Endplatten spielen, blieb bislang ungeklärt.
In dieser Studie konnte in allen untersuchten Myelin Mutanten im Vergleich zum Wildtyp eine Zunahme an neuromuskulären Synapsen beobachtet werden, die mit Makrophagen räumlich assoziiert waren. Daneben zeigten entsprechende Myelin Mutanten eine Zunahme denervierter und partiell denervierter Endplatten und zwar interessanterweise direkt proportional zur Anzahl an Synapsen in Assoziation mit Makrophagen. Das bedeutet, dass die Anzahl an Endplatten in Assoziation mit Makrophagen verhältnismäßig parallel zur Anzahl an denervierten Endplatten zunahm, während die Anzahl an Makrophagen im gesamten Muskel nahezu unverändert blieb. Dies deutet eine mögliche Rolle der räumlich mit Endplatten assoziierten Makrophagen an deren Denervation an. Dabei waren alle Synapsen in Assoziation mit Makrophagen innerviert und damit morphologisch intakt. Bei doppel-mutanten Mäusen mit genetischer Blockade der Makrophagen-Aktivierung waren die beschriebenen pathologischen Merkmale an der neuromuskulären Synapse deutlich reduziert bei gleichzeitig signifikanter Abnahme an Makrophagen in Assoziation mit Endplatten. Ähnliche pathologische Auffälligkeiten wie bei Myelin Mutanten fanden sich in geringerer Ausprägung auch im Wildtyp im Rahmen des Alterungsprozesses sowie auch bei Mäusen mit Defizienz des neurotrophen Faktors CNTF.
Zusammenfassend deuten die Ergebnisse darauf hin, dass sowohl in der Pathogenese der CMT Neuropathie wie auch im Rahmen altersbedingter Neurodegeneration ein Makrophagen-vermittelter Schaden an der neuromuskulären Endplatte entsteht. Wesentliche Mediatoren scheinen hierbei das von Fibroblasten und vermutlich auch perisynaptischen Fibroblasten exprimierte CSF-1 zu sein, sowie MCP-1, das durch Schwann Zellen und möglicherweise auch von terminalen Schwann Zellen freigesetzt wird. Auch eine Defizienz des neurotrophen Faktors CNTF bewirkt zumindest in geringem Ausmaß eine Zunahme der pathologischen Merkmale Denervation und Makrophagen-Endplatten-Assoziation im Vergleich zum Wildtyp. Diese Ergebnisse erweitern insbesondere das Wissen um Pathomechanismen an der neuromuskulären Endplatte und eröffnen neue Möglichkeiten der Behandlung für CMT und weitere neuromuskuläre Erkrankungen.
The efficacy and safety of first-line disease-modifying therapies (DMT) for relapsing-remitting multiple sclerosis (RRMS) has been demonstrated in pivotal, randomized trials, but these studies do not reflect the routine care setting where treatment gaps or switches are common. The Avonex as Treatment Option for Untreated MS Patients (AXIOM) trial assessed the efficacy of newly-initiated intramuscular interferon beta-1a (IM IFNb-1a) after a treatment-free interval, with particular consideration of the previous course of disease and therapy. The AXIOM trial was an open, 12-month, observational, non-interventional study with a retrospective and a prospective part conducted in Germany. RRMS patients with a treatment-free interval of at least three months were included and treated with IFNb-1a for up to 12 months. Relapse rate, disability progression, injection-related parameters and quality of life observed during the prospective part were compared with retrospectively-collected data. Two hundred and thirty five RRMS patients participated in AXIOM. The mean relapse rate decreased from 1.1 in the three months before baseline to 0.2 per quarter during the twelve-month observational period; the Multiple Sclerosis Functional Composite score improved during twelve months of IM IFNb-1a treatment, while the Expanded Disability Status Scale score did not change over the course of this study. Compared to previous DMTs (IM IFNb-1a, subcutaneous IFNb-1a (SC IFNb-1a), SC IFNb-1b, glatiramer acetate), the patients experienced less injection site reactions and flu-like symptoms, with a stated improved quality of life. IM IFNb-1a was effective and well accepted in RRMS patients with no or discontinued previous therapy. These results from the routine care setting may inform optimization of DMT treatment in RRMS, but need confirmation in further studies.
Dimethyl fumarate (DMF) is approved for disease-modifying treatment of patients with relapsing-remitting multiple sclerosis. Animal experiments suggested that part of its therapeutic effect is due to a reduction of T-cell infiltration of the central nervous system (CNS) by uncertain mechanisms. Here we evaluated whether DMF and its primary metabolite monomethyl fumarate (MMF) modulate pro-inflammatory intracellular signaling and T-cell adhesiveness of nonimmortalized single donor human brain microvascular endothelial cells at low passages. Neither DMF nor MMF at concentrations of 10 or 50 \(\mu\)M blocked the IL-1\(\beta\)-induced nuclear translocation of NF-\(\kappa\)B/p65, whereas the higher concentration of DMF inhibited the nuclear entry of p65 in human umbilical vein endothelium cultured in parallel. DMF and MMF also did not alter the IL-1\(\beta\)-stimulated activation of p38 MAPK in brain endothelium. Furthermore, neither DMF nor MMF reduced the basal or IL-1\(\beta\)-inducible expression of ICAM-1. In accordance, both fumaric acid esters did not reduce the adhesion of activated Jurkat T cells to brain endothelium under basal or inflammatory conditions. Therefore, brain endothelial cells probably do not directly mediate a potential blocking effect of fumaric acid esters on the inflammatory infiltration of the CNS by T cells.
B cells have only recently begun to attract attention in the immunopathology of multiple sclerosis (MS). Suitable markers for the prediction of treatment success with immunomodulatory drugs are still missing. Here we evaluated the B cell response to brain antigens in n = 34 relapsing-remitting MS (RRMS) patients treated with glatiramer acetate (GA) using the enzyme-linked immunospot technique (ELISPOT). Our data demonstrate that patients can be subdivided into responders that show brain-specific B cell reactivity in the blood and patients without this reactivity. Only in patients that classified as B cell responders, there was a significant positive correlation between treatment duration and the time since last relapse in our study. This correlation was GA-specific because it was absent in a control group that consisted of interferon-\(\beta\) (IFN-\(\beta\))-treated RRMS patients (n = 23). These data suggest that GA has an effect on brain-reactive B cells in a subset of patients and that only this subset benefits from treatment. The detection of brain-reactive B cells is likely to be a suitable tool to identify drug responders.
Background:
Anxiety is a heterogeneous behavioral domain playing a role in a variety of neuropsychiatric diseases. While anxiety is the cardinal symptom in disorders such as panic disorder, co-morbid anxious behavior can occur in a variety of diseases. Stiff person syndrome (SPS) is a CNS disorder characterized by increased muscle tone and prominent agoraphobia and anxiety. Most patients have high-titer antibodies against glutamate decarboxylase (GAD) 65. The pathogenic role of these autoantibodies is unclear.
Methodology/Principal Findings:
We re-investigated a 53 year old woman with SPS and profound anxiety for GABA-A receptor binding in the amygdala with (11) C-flumazenil PET scan and studied the potential pathogenic role of purified IgG from her plasma filtrates containing high-titer antibodies against GAD 65. We passively transferred the IgG fraction intrathecally into rats and analyzed the effects using behavioral and in vivo electrophysiological methods. In cell culture, we measured the effect of patient IgG on GABA release from hippocampal neurons. Repetitive intrathecal application of purified patient IgG in rats resulted in an anxious phenotype resembling the core symptoms of the patient. Patient IgG selectively bound to rat amygdala, hippocampus, and frontal cortical areas. In cultured rat hippocampal neurons, patient IgG inhibited GABA release. In line with these experimental results, the GABA-A receptor binding potential was reduced in the patient's amygdala/hippocampus complex. No motor abnormalities were found in recipient rats.
Conclusion/Significance:
The observations in rats after passive transfer lead us to propose that anxiety-like behavior can be induced in rats by passive transfer of IgG from a SPS patient positive for anti-GAD 65 antibodies. Anxiety, in this case, thus may be an antibody-mediated phenomenon with consecutive disturbance of GABAergic signaling in the amygdala region.
Breakdown of the blood-brain barrier (BBB) is an early hallmark of multiple sclerosis (MS), a progressive inflammatory disease of the central nervous system. Cell adhesion in the BBB is modulated by sphingosine-1-phosphate (S1P), a signaling protein, via S1P receptors (S1P\(_1\)). Fingolimod phosphate (FTY720-P) a functional S1P\(_1\) antagonist has been shown to improve the relapse rate in relapsing-remitting MS by preventing the egress of lymphocytes from lymph nodes. However, its role in modulating BBB permeabilityin particular, on the tight junction proteins occludin, claudin 5 and ZO-1has not been well elucidated to date. In the present study, FTY720-P did not change the transendothelial electrical resistance in a rat brain microvascular endothelial cell (RBMEC) culture exposed to inflammatory conditions and thus did not decrease endothelial barrier permeability. In contrast, occludin was reduced in RBMEC culture after adding FTY720-P. Additionally, FTY720-P did not alter the amount of endothelial matrix metalloproteinase (MMP)-9 and MMP-2 in RBMEC cultures. Taken together, our observations support the assumption that S1P\(_1\) plays a dual role in vascular permeability, depending on its ligand. Thus, S1P\(_1\) provides a mechanistic basis for FTY720-P-associated disruption of endothelial barrierssuch as the blood-retinal barrierwhich might result in macular edema.
Tenderness and mechanical allodynia are key symptoms of malignant tumor, inflammation and neuropathy. The proinflammatory cytokine interleukin-6 (IL-6) is causally involved in all three pathologies. IL-6 not only regulates innate immunity and inflammation but also causes nociceptor sensitization and hyperalgesia. In general and in most cell types including immune cells and sensory neurons, IL-6 binds soluble mu receptor subunits which heteromerizes with membrane bound IL-6 signal transducer gp130. In the present study, we used a conditional knock-out strategy to investigate the importance of signal transducer gp130 expressed in C nociceptors for the generation and maintenance of mechanical hypersensitivity. Nociceptors were sensitized to mechanical stimuli by experimental tumor and this nociceptor sensitization was preserved at later stages of the pathology in control mice. However, in mice with a conditional deletion of gp130 in Nav1.8 expressing nociceptors mechanical hypersensitivity by experimental tumor, nerve injury or inflammation recovery was not preserved in the maintenance phase and nociceptors exhibited normal mechanical thresholds comparable to untreated mice. Together, the results argue for IL-6 signal transducer gp130 as an essential prerequisite in nociceptors for long-term mechanical hypersensitivity associated with cancer, inflammation and nerve injury.
Zielsetzung der Studie war es, Ablagerungen des phosphorylierten Alpha-Synucleins in der Haut von Patienten mit Morbus Parkinson und atypischen Parkinson-Syndromen zu untersuchen und deren Auswirkungen auf das periphere Nervensystem zu erforschen.
Dazu wurden Hautbiopsien von 92 Patienten mit Morbus Parkinson, 12 Patienten mit MSA und 13 Patienten mit einer Tauopathie sowie 83 gesunden Kontrollpersonen immunhisto-chemisch gefärbt und unter dem Mikroskop untersucht.
Mit einer Sensitivität von 52 % für den Morbus Parkinson und 67 % für die MSA bei hoher Spezifität stellt der Nachweis von Phospho-Alpha-Synuclein in den kleinen Nervenfasern der Haut einen geeigneten Biomarker dar. Während die Ablagerungen des phosphorylierten Alpha-Synucleins bei Patienten mit Morbus Parkinson eher in autonomen Strukturen nachweisbar waren, fanden sie sich bei Patienten mit MSA eher in sub- und intraepidermal gelegenen Nervenfasern. Phospho-Alpha-Synuclein konnte in allen untersuchten Nervenfasersubtypen nachgewiesen werden, also in CGRP-, SP-, TH- und VIP-positiven Fasern. Bei den in der vorliegenden Studie untersuchten Parkinson-Patienten waren keine Veränderungen in der sensiblen Neurographie des Nervus suralis erkennbar. Die intraepidermale Nervenfaserdichte sowie die Innervation der Schweißdrüsen waren jedoch teilweise vermindert und auch in der QST zeigten sich Auffälligkeiten. Ein Zusammenhang zu dem Vorhandensein von Phospho-Alpha-Synuclein-Ablagerungen konnte jedoch nur für die Innervation der Musculi arrectores pilorum hergestellt werden. Bei der Untersuchung der pathophysiologischen Hintergründe, durch die Phospho-Alpha-Synuclein-Ablagerungen zu Nervenfaserschädigungen führen, konnten die Hinweise auf eine Beteiligung von axonalen Transportproteinen, Mikrotubuli oder Mitochondrien nicht erhärtet werden.
Mechanical thrombectomy is a novel treatment option for patients with acute ischemic stroke (AIS). Only a few studies have previously suggested strategies to categorize retrieved clots according to their histologic composition. However, these reports did not analyze potential biomarkers that are of importance in stroke-related inflammation. We therefore histopathologically investigated 37 intracerebral thrombi mechanically retrieved from patients with AIS, and focused on the composition of immune cells and platelets. We also conducted correlation analyses of distinctive morphologic patterns (erythrocytic, serpentine, layered, red, white, mixed appearance) with clinical parameters. Most T cells and monocytes were detected in erythrocytic and red clots, in which the distribution of these cells was random. In contrast, von Willebrand factor (vWF)-positive areas co-localized with regions of fibrin and collagen. While clots with huge amounts of vWF seem to be associated with a high National Institute of Health Stroke Scale score at admission, histologic findings could not predict the clinical outcome at discharge. In summary, we provide the first histologic description of mechanically retrieved intracerebral thrombi regarding biomarkers relevant for inflammation in ischemic stroke.
Neuromyelitis Optica Spectrum Disorders (NMOSD) are associated with autoantibodies (ABs) targeting the astrocytic aquaporin-4 water channels (AQP4-ABs). These ABs have a direct pathogenic role by initiating a variety of immunological and inflammatory processes in the course of disease. In a recently-established animal model, chronic intrathecal passive-transfer of immunoglobulin G from NMOSD patients (NMO-IgG), or of recombinant human AQP4-ABs (rAB-AQP4), provided evidence for complementary and immune-cell independent effects of AQP4-ABs. Utilizing this animal model, we here tested the effects of systemically and intrathecally applied pooled human immunoglobulins (IVIg) using a preventive and a therapeutic paradigm. In NMO-IgG animals, prophylactic application of systemic IVIg led to a reduced median disease score of 2.4 on a 0–10 scale, in comparison to 4.1 with sham treatment. Therapeutic IVIg, applied systemically after the 10th intrathecal NMO-IgG injection, significantly reduced the disease score by 0.8. Intrathecal IVIg application induced a beneficial effect in animals with NMO-IgG (median score IVIg 1.6 vs. sham 3.7) or with rAB-AQP4 (median score IVIg 2.0 vs. sham 3.7). We here provide evidence that treatment with IVIg ameliorates disease symptoms in this passive-transfer model, in analogy to former studies investigating passive-transfer animal models of other antibody-mediated disorders.
Introduction
CD4+ T cells express K2P5.1 (TWIK-related acid-sensitive potassium channel 2 (TASK2); KCNK5), a member of the two-pore domain potassium channel family, which has been shown to influence T cell effector functions. Recently, it was shown that K2P5.1 is upregulated upon (autoimmune) T cell stimulation. The aim of this study was to correlate expression levels of K2P5.1 on T cells from patients with rheumatoid arthritis (RA) to disease activity in these patients.
Methods
Expression levels of K2P5.1 were measured by RT-PCR in the peripheral blood of 58 patients with RA and correlated with disease activity parameters (C-reactive protein levels, erythrocyte sedimentation rates, disease activity score (DAS28) scores). Twenty patients undergoing therapy change were followed-up for six months. Additionally, synovial fluid and synovial biopsies were investigated for T lymphocytes expressing K2P5.1.
Results
K2P5.1 expression levels in CD4+ T cells show a strong correlation to DAS28 scores in RA patients. Similar correlations were found for serological inflammatory parameters (erythrocyte sedimentation rate, C-reactive protein). In addition, K2P5.1 expression levels of synovial fluid-derived T cells are higher compared to peripheral blood T cells. Prospective data in individual patients show a parallel behaviour of K2P5.1 expression to disease activity parameters during a longitudinal follow-up for six months.
Conclusions
Disease activity in RA patients correlates strongly with K2P5.1 expression levels in CD4+ T lymphocytes in the peripheral blood in cross-sectional as well as in longitudinal observations. Further studies are needed to investigate the exact pathophysiological mechanisms and to evaluate the possible use of K2P5.1 as a potential biomarker for disease activity and differential diagnosis.
Activation of the basal ganglia has been shown during the preparation and execution of movement. However, the functional interaction of cortical and subcortical brain areas during movement and the relative contribution of dopaminergic striatal innervation remains unclear. We recorded local field potential (LFP) activity from the subthalamic nucleus (STN) and high-density electroencephalography (EEG) signals in four patients with Parkinson’s disease (PD) off dopaminergic medication during a multi-joint motor task performed with their dominant and non-dominant hand. Recordings were performed by means of a fully-implantable deep brain stimulation (DBS) device at 4 months after surgery. Three patients also performed a single-photon computed tomography (SPECT) with [123I]N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)nortropane (FP-CIT) to assess striatal dopaminergic innervation. Unilateral movement execution led to event-related desynchronization (ERD) followed by a rebound after movement termination event-related synchronization (ERS) of oscillatory beta activity in the STN and primary sensorimotor cortex of both hemispheres. Dopamine deficiency directly influenced movement-related beta-modulation, with greater beta-suppression in the most dopamine-depleted hemisphere for both ipsi- and contralateral hand movements. Cortical-subcortical, but not interhemispheric subcortical coherencies were modulated by movement and influenced by striatal dopaminergic innervation, being stronger in the most dopamine-depleted hemisphere. The data are consistent with a role of dopamine in shielding subcortical structures from an excessive cortical entrapment and cross-hemispheric coupling, thus allowing fine-tuning of movement.
Die Pathophysiologie der PNP wie auch die Entstehung der oft assoziierten neuropathischen Schmerzen ist unklar. Gleichzeitig gibt es bislang keine geeigneten Biomarker, die die oft komplizierte Differentialdiagnose vereinfachen können. Einige Tiermodelle und klinische Studien lieferten bereits Hinweise auf die entscheidende Rolle pro- und anti-inflammatorischer Zytokine in diesen Prozessen. Ziel unserer Studie war es, die systemische Genexpression pro- und anti-inflammatorischer Zytokine in einer großen Kohorte von Patienten mit PNP verschiedener Ätiologie zu charakterisieren. Insgesamt konnten 111 PNP-Patienten und 38 gesunde Kontrollpersonen prospektiv rekrutiert werden. Nach Isolation von PBMC aus Blutproben von 97 Patienten wurde die Genexpression der pro-inflammatorischen Zytokine TNF, IL1, IL2, IL6, IL8 und der anti-inflammatorischen Zytokine IL4 und IL10 mittels qRT-PCR bestimmt. Bei 47 Patienten und 12 Kontrollen wurde zudem die IL6-, IL-8- und TNF-Zytokinproduktion von PBMC in vitro nach Stimulation durch LPS mittels ELISA untersucht. Hauptbefund war ein pro-inflammatorisches Zytokinprofil der PNP-Patienten mit höherer Genexpression von IL1, IL2, IL8 und TNF im Vergleich zu den gesunden Kontrollen. Im Falle der entzündlichen Neuropathien konnte zudem eine niedrigere Genexpression von IL10 im Vergleich zu Gesunden nachgewiesen werden. Sowohl schmerzhafte als auch schmerzlose Verlaufsformen wiesen ein pro-inflammatorisches Zytokingenexpressionsprofil im Vergleich zu Gesunden auf, das bei schmerzhaften PNP deutlich mehr beteiligte pro-inflammatorische Zytokine umfasste; relevante Unterschiede zwischen den PNP-Patienten mit und ohne Schmerz sowie der diagnostischen Subgruppen fanden sich nicht. Eine niedrigere Stimulationsschwelle der PBMC lag bei PNP-Patienten im Vergleich zu Gesunden nicht vor. Insgesamt erscheint die Rolle einzelner Zytokine als systemische Biomarker für die Differenzierung verschiedener PNP-Formen bzw. bezüglich neuropathischen Schmerzes aufgrund einer niedrigen Spezifität deutlich eingeschränkt. Dennoch sprechen unsere Ergebnisse für eine mögliche Rolle eines pro-inflammatorischen Milieus bei der Entstehung bzw. des Verlaufes verschiedener entzündlicher und nicht-entzündlicher Neuropathien und neuropathischen Schmerzes.
In dieser Studie wurden 108 Patienten mit PNP, 60 Patienten mit M. Fabry und 58 gesunde Kontrollpersonen mittels PREP auf eine small fiber-Pathologie untersucht. Zudem erfolgte eine PREP-Untersuchung bei 5 gesunden Probanden und 3 Patienten nach Anwendung von lokalem Capsaicin. Zur Charakterisierung der small fibers erfolgten zudem Anamnese, klinische Untersuchung, die Fragebögen NPSI, GCPS und ADS, QST und eine Hautbiopsie.
In der Gruppe der Patienten mit PNP waren sowohl Patienten mit LFN, MFN und SFN unterschiedlicher Ätiologie vertreten. Patienten mit einer MFN und Patienten mit einer zu einer Mitbeteiligung der small fibers passenden Anamnese (MFN und SFN) wiesen eine verlängerte N1-Latenz nach Stimulation am Fuß auf. Bei einer reduzierten IENFD in der proximalen Hautbiopsie zeigte sich die PPA nach Stimulation im Gesicht reduziert, beide Werte korrelierten positiv miteinander. Bei Patienten mit einer demyelinisierenden PNP war die N1-Latenz nach Stimulation an der Hand verlängert, zudem war bei Patienten mit CIDP die PPA nach Stimulation an Gesicht und Hand reduziert.
M. Fabry ist eine X-chromosomal vererbte lysosomale Speicherkrankheit, welche mit einer SFN einhergehen kann. Weibliche Patienten mit M. Fabry und einer subjektiven Hypohidrose als klinische Präsentation einer small fiber Pathologie wiesen eine reduzierte PPA nach Stimulation an Gesicht, Hand und Fuß auf.
Über die gesamte Patientengruppe hinweg zeigte sich eine negative Korrelation der PPA nach Stimulation am Fuß mit der klinischen Schmerzpräsentation im NPSI (Summenscore, Subscores evozierte Schmerzen und Schmerzattacken), sowie bei weiblichen Patienten mit der CDT, WDT und TSL in der QST als Marker für die small fiber Funktion. Patienten mit einer längenunabhängigen Reduktion der IENFD wiesen eine niedrigere PPA nach Stimulation am Fuß auf. Ein nicht-auswertbares PREP-Potential spricht nach Ausschluss messtechnischer Artefakte für eine fortgeschrittene Nervenfaserschädigung. Probanden und Patienten zeigten nach Applikation von topischem Capsaicin eine Reduktion der PPA.
PREP ist eine einfache, komplikationslos durchzuführende und objektive Methode zur Untersuchung der small fibers. Sie stellt eine sinnvolle Ergänzung zu den bereits etablierten Methoden QST und Hautbiopsie dar und bietet insbesondere für die Evaluation von Medikamenteneffekten wie z.B. von topischem Capsaicin eine vielversprechende Untersuchungsmöglichkeit.
Parkinson's disease (PD) is a progressive neurodegenerative disorder in which the major pathologic substrate is a loss of dopaminergic neurons from the substantia nigra. Our main objective was to determine the correspondence between changes in the substantia nigra, evident in neuromelanin and iron sensitive magnetic resonance imaging (MRI), and dopaminergic striatal innervation loss in patients with PD. Eighteen patients and 18 healthy control subjects were included in the study. Using neuromelanin-MRI, we measured the volume of the substantia nigra and the contrast-to-noise-ratio between substantia nigra and a background region. The apparent transverse relaxation rate and magnetic susceptibility of the substantia nigra were calculated from dual-echo MRI. Striatal dopaminergic innervation was measured as density of dopamine transporter (DAT) by means of single-photon emission computed tomography and [123I] N-ω-fluoropropyl-2b-carbomethoxy-3b-(4-iodophenyl) tropane. Patients showed a reduced volume of the substantia nigra and contrast-to-noise-ratio and both positively correlated with the corresponding striatal DAT density. The apparent transverse relaxation rate and magnetic susceptibility values of the substantia nigra did not differ between patients and healthy controls. The best predictor of DAT reduction was the volume of the substantia nigra. Clinical and imaging correlations were also investigated for the locus coeruleus. Our results suggest that neuromelanin-MRI can be used for quantifying substantia nigra pathology in PD where it closely correlates with dopaminergic striatal innervation loss. Longitudinal studies should further explore the role of Neuromelanin-MRI as an imaging biomarker of PD, especially for subjects at risk of developing the disease.
Organ manifestations and long-term outcome of Fabry disease in patients with the GLA haplotype D313Y
(2016)
Objectives: The severity of Fabry disease is dependent on the type of mutation in the α-galactosidase A (AgalA) encoding gene (GLA). This study focused on the impact of the GLA haplotype D313Y on long-term organ involvement and function.
Setting and participants: In this monocentric study, all participants presenting with the D313Y haplotype between 2001 and 2015 were comprehensively clinically investigated at baseline and during a 4-year follow-up if available. Five females and one male were included.
Primary and secondary outcome measures: Cardiac, nephrological, neurological, laboratory and quality of life data.
Results: AgalA enzyme activity in leucocytes (0.3±0.9 nmol/min/mg protein (mean±SD)) and serum lyso-Gb3 (0.6±0.3 ng/mL at baseline) were in normal range in all patients. Cardiac morphology and function were normal (left-ventricular (LV) ejection fraction 66±8%; interventricular septum 7.7±1.4 mm; LV posterior wall 7.5±1.4 mm; normalised LV mass in MRI 52±9 g/m2; LV global longitudinal strain −21.6±1.9%) and there were no signs of myocardial fibrosis in cardiac MRI. Cardiospecific biomarkers were also in normal range. Renal function was not impaired (estimated glomerular filtration rate MDRD 103±15 mL/min; serum-creatinine 0.75±0.07 mg/dL; cystatin-c 0.71±0.12 mg/L). One female patient (also carrying a Factor V Leiden mutation) had a transitory ischaemic attack. One patient showed white matter lesions in brain MRI, but none had Fabry-associated pain attacks, pain crises, evoked pain or permanent pain. Health-related quality of life analysis revealed a reduction in individual well-being. At long-term follow-up after 4 years, no significant change was seen in any parameter.
Conclusions: The results of the current study suggest that the D313Y genotype does not lead to severe organ manifestations as seen in genotypes known to be causal for classical FD."
M. Fabry ist eine X-chromosomale, lysosomale Speicherkrankheit, die aufgrund einer Mutation im für das Enzym αGalaktosidase A (αGalA)-kodierenden Gen GLA, zu einer vollständig fehlenden oder verminderten Expression von αGalA führt. Aufgrund ubiquitärer Ablagerungen von Globotriaosylceramid 3 (Gb3) kommt es zu einer progressiven Multiorganerkrankung sowie der Entwicklung einer small-fiber Neuropathie (SFN). Der Pathomechanismus des Fabry-assoziierten Schmerzes blieb trotz Entwicklung eines αGalA-defizienten Mausmodells (Fabry-ko-Maus) durch Ohshima et al. bisher weitgehend ungeklärt. Ziel der vorliegenden Arbeit war die systematische Charakterisierung des Fabry-ko-Mausmodells hinsichtlich Schmerz-assoziierten Verhaltens und Expression Schmerz-assoziierter Ionenkanäle in Spinalganglienneuronen. Hierzu wurden insgesamt 42 drei Monate und 41 12 Monate alte männliche und weibliche Fabry-ko-Mäuse und ihre gleichaltrigen Wurfgeschwister untersucht. Die Verhaltenstestungen beinhalteten einen von Frey-, einen Hargreaves- sowie einen „Cold“-Test zur Evaluation der mechanischen und thermischen Rückzugslatenz. Weiterhin erfolgten die Analyse der intraepidermalen Nervenfaserdichte (IENFD) in Fußsohlen der Mäuse sowie eine H.E.-Färbung von Spinalganglien zur Untersuchung morphologischer Veränderungen der Neurone. Zusätzlich folgten immunhistochemische und molekulargenetische Untersuchungen des Gb3-Rezeptors (CD77), des transient receptor potential vanilloid 1 (TRPV1)-Kanals, des spannungsgesteuerten Natrium-Kanals 1.8 (Nav1.8), des Calcitonin Gene related peptide (CGRP), des Neurofilaments 200 (NF200) sowie von Isolectin B4 (IB4) an kryokonservierten und kultivierten Spinalganglienneuronen.
In Verhaltenstestungen konnten eine Überempfindlichkeit gegenüber mechanischen und Hitze-Stimuli sowie ein vermindertes Kälteempfinden festgestellt werden. Es zeigte sich eine reduzierte IENFD in Fußsohlen sowie eine Vergrößerung der neuronalen Fläche in Spinalganglien von Fabry-ko-Mäusen. Die immunhistochemischen Untersuchungen ergaben eine erhöhte CD77- und TRPV1-Immunreaktivität sowie eine erniedrigte NF200-Immunreaktivität in Fabry-ko-Mäusen; Untersuchungen hinsichtlich der Immunreaktivität von Nav1.8 ergaben keine Unterschiede. Molekulargenetisch konnte neben einer verminderten Nav1.8-Expression in jungen Fabry-ko-Mäusen keine Unterschiede festgestellt werden.
Die Ergebnisse der Verhaltenstestungen sowie die verminderte IENFD bei Fabry-ko-Mäusen entsprechen klinischen Befunden bei Fabry-Patienten. Erstmals konnte in dieser Arbeit eine Vergrößerung der Neuronenfläche in Fabry-ko-Mäusen quantitativ nachgewiesen und eine vermehrte Immunreaktivität von TRPV1 und CD77 festgestellt werden. Bei fehlendem Nachweis eines geschlechtsspezifischen Unterschieds der Ergebnisse, konnte ein Einfluss des weiblichen Geschlechts auf den Phänotyp des M. Fabry ausgeschlossen werden.
Die Ergebnisse der vorliegenden Arbeit zeigen, dass die von Oshima et al. entwickelte Fabry-ko-Maus ein suffizientes Model zur Erforschung des M. Fabry darstellt. Weiterhin rücken sie TRPV1 und spannungsgesteuerte Natriumkanäle weiter in den Fokus der Untersuchung Fabry-assoziierten Schmerzes und können aufgrund der hohen Anzahl an Versuchstieren und dem Vergleich mit Wurfgeschwistern als Grundlage für weitere Studien dienen.
Movement preparation and bilateral modulation of beta activity in aging and Parkinson's disease
(2015)
In previous studies of young subjects performing a reaction-time reaching task, we found that faster reaction times are associated with increased suppression of beta power over primary sensorimotor areas just before target presentation. Here we ascertain whether such beta decrease similarly occurs in normally aging subjects and also in patients with Parkinson's disease (PD), where deficits in movement execution and abnormalities of beta power are usually present. We found that in both groups, beta power decreased during the motor task in the electrodes over the two primary sensorimotor areas. However, before target presentation, beta decreases in PD were significantly smaller over the right than over the left areas, while they were symmetrical in controls. In both groups, functional connectivity between the two regions, measured with imaginary coherence, increased before the target appearance; however, in PD, it decreased immediately after, while in controls, it remained elevated throughout motor planning. As in previous studies with young subjects, the degree of beta power before target appearance correlated with reaction time. The values of coherence during motor planning, instead, correlated with movement time, peak velocity and acceleration. We conclude that planning of prompt and fast movements partially depends on coordinated beta activity of both sensorimotor areas, already at the time of target presentation. The delayed onset of beta decreases over the right region observed in PD is possibly related to a decreased functional connectivity between the two areas, and this might account for deficits in force programming, movement duration and velocity modulation.
Schwerpunktmäßig befasst sich diese Arbeit mit den praktischen Vorgängen zur Zählung von Neuronen mit dem optischen Fraktionator unter dem Mikroskop, wobei zur Veranschaulichung die Neuronen in der Substantia Nigra an C57BL/6-Mäusen gezählt wurden. Es wurde erläutert, wie die Einstellungen der jeweiligen Methode vorzunehmen sind und auf die angestrebten Ziele angepasst werden können, um ein effizientes Zählen von Neuronen unter Berücksichtigung grundlegender Zählregeln zu gewährleisten. Gleichzeitig wurde gezeigt, wie die Methoden des optischen Fraktionators die gewünschten präzisen Ergebnisse anhand des CE-Wertes liefern können.
Die in dieser Arbeit präsentierte Axiophot-2-Methode ist in der Lage, selbst mit einem einfachen, kommerziell erhältlichen Lichtmikroskop und einem Standbildaufnahmeprogramm die Gesamtanzahl von Zellen einer gegebenen Struktur unter Beachtung aller stereologischen Regeln zu zählen – und zwar genauso effizient und mit vergleichbaren Ergebnissen wie mit einem speziell für stereologische Untersuchungen vorgefertigtes Komplettsystem. Vergleiche beider Methoden zueinander ergeben folgende Schlussfolgerungen: bei dem Stereo Investigator, ist die Untersuchung zwar wesentlich schneller, da die Bildaufnahme und Auswertung mittels voreingestellten Programmes automatisch durchgeführt werden. Allerdings ist solch ein Komplettsystem sehr kostspielig (ca. 60.000 Euro Anschaffungskosten) und nicht flexibel auf andere Untersuchungsbereiche einsetzbar.
Die Axiophot-2-Methode weist zwar einige Nachteile aufgrund der manuellen Vorarbeiten auf, ist aber dafür wesentlich günstiger und zugänglicher, da sie nur ein konventionelles Mikroskop mit einem Standardprogramm erfordert.
Die Forschung auf dem Gebiet der Parkinson-Erkrankung erlebt einen großen Wandel. Eindeutig ist mittlerweile, dass es zu kurz gefasst wäre diese Erkrankung auf die motorischen Symptome zu beschränken. In den letzten Jahren wurde durch intensive Forschung bewiesen, dass der idiopathische M. Parkinson eine multisystemische Erkrankung ist, welche verschiedene Teile des Nervensystems betreffen kann. Um die zugrundeliegende Pathophysiologie und die Beteiligung des autonomen Nervensystems bei M. Parkinson näher zu untersuchen, wurden für diese Studie 30 Patienten mit idiopathischem M. Parkinson, 19 Patienten mit atypischem Parkinsonsyndrom und 30 gesunde Probanden am Universitätsklinikum Würzburg und an der Paracelsus-Elena-Klinik Kassel rekrutiert. Um Beeinträchtigungen von groß-und kleinkalibrigen Nervenfasern einschätzen zu können, wurden eine Neurografie des N. suralis sowie eine quantitativ sensorische Testung durchgeführt. Zur Bewertung einer möglichen toxischen Komponente von Levodopa gegenüber einer direkten Schädigung peripherer Nerven durch p-α-Synuclein wurden am Vitamin B12 Stoffwechsel beteiligte Proteine im Blut bestimmt. Alle Patienten und Probanden erhielten Hautbiopsien an Unterschenkel, Oberschenkel, Rücken und Finger, um anschließend eine immunhistochemische Aufarbeitung der Präparate durchführen zu können. Einerseits wurde die Beteiligung somatosensibler Nervenfasern mithilfe der Auszählung intraepidermaler Nervenfasern (PGP 9.5) bewertet. Andererseits wurden die Schweißdrüsen auf Pathologien der sympathischen Nervenfasern (VIP, TH, SP, CGRP) und der sudomotorischen Synapsen (SNCA, Synaptophysin, SNAP 25) untersucht. Weiterhin wurde versucht p-α-Synuclein, als Biomarker der Parkinson-Erkrankung, in der Haut nachzuweisen.
Positive Ergebnisse konnten hinsichtlich pathologischer Prozesse an den Synapsen erzielt werden. Es zeigte sich sowohl eine Reduktion von nativem α-Synuclein (Unterschenkel, p=0,009 und Rücken, p=0,013), Synaptophysin (Unterschenkel, p=0,007) als auch SNAP 25 (Unterschenkel, p=0,023) an den untersuchten Schweißdrüsen der Patientengruppe. Bei der Untersuchung von SNAP 25 zeigte sich des Weiteren eine negative Korrelation zwischen der SNAP 25 Dichte im Unterschenkel und p-α-Synuclein (p=0,007). Bei der Suche nach p-α-Synuclein wurden beinahe 72% der Parkinson-Patienten positiv getestet, wohingegen keiner der gesunden Probanden p-α-Synuclein in der Haut zeigte. Weiterhin konnte bei 75% der positiv getesteten Patienten mit Multisystematrophie p-α-Synuclein an somatosensiblen Nervenfasern des subepidermalen Plexus nachgewiesen werden, wohingegen es bei den M. Parkinson Patienten nur 13% waren. Die Ergebnisse der zugrundeliegenden Arbeit zeigen, dass die Hautbiopsie als frühdiagnostisches Mittel und in der Differentialdiagnose ein hohes Potenzial hat. Die Erforschung von Pathologien an Synapsen wird in der Zukunft an großer Bedeutung gewinnen und scheint ein wichtiger Ansatz, um die Pathophysiologie des M. Parkinson genauer zu verstehen. Die Hautbiopsie könnte dabei von Vorteil sein, da sich Pathologien in vivo untersuchen lassen und man nicht auf Ergebnisse von Autopsien angewiesen ist.
In der vorliegenden Arbeit wurde geprüft, ob Gb3 in Hautstanzbiopsien von Patienten mit M. Fabry nachweisbar ist, die Ablagerungen quantifizierbar sind, mit der Krankheitsschwere korrelieren, und ob eine Unterscheidung von Patienten und gesunden Kontrollen anhand der dermalen Gb3-Ablagerungen möglich ist. Es wurden 84 Patienten mit M. Fabry über das FAZiT sowie 27 gesunde Kontrollen zwischen 2008 und 2013 prospektiv rekrutiert und jeweils eine proximale und eine distale Hautbiopsie entnommen. Zusätzlich erfolgten eine Anamnese, eine klinische Untersuchung, eine QST, das Ausfüllen von Fragebögen mit der Fragestellung nach Schmerz und Depression sowie eine Blutentnahme und kardiale Diagnostik. Die Immunfluoreszenz erfolgte mit Antikörpern gegen CD77, einem Marker für Gb3. Es erfolgte die verblindete, semiautomatische Quantifizierung der Gb3 Ablagerungen. Hierzu wurden pro Biopsie drei ROI ausgewählt und die Fläche der ROIs mit Gb3-Ablagerungen in Relation zu der Gesamtfläche der ROIs gesetzt. Für die Auswertung wurden die Patienten sowohl nach Geschlecht als auch nach Krankheitsschwere und einzelnen Symptomen stratifiziert Die Gb3 Ablagerungen ließen sich bevorzugt in Schweißdrüsen und Endothel nachweisen. Es fanden sich jedoch auch größere Mengen an Gb3-Ablagerungen ohne ersichtliches anatomischer Korrelat. Die Gb3-Ablagerungen wurden semiautomatisch quantifiziert. Es konnte nachgewiesen werden, dass männliche Fabry-Patienten eine deutlich größere Menge an Gb3 in den distalen Hautbiopsien zeigen als gesunde Kontrollen, Patienten mit einer eingeschränkten Nierenfunktion hatten eine größere Menge an Gb3-Ablagerungen in der Haut als Patienten mit einer uneingeschränkten Nierenfunktion. Bei Patienten mit einer SFN waren erhöhte dermale Gb3 Mengen vorhanden im Vergleich zu gesunden Kontrollen, bei Patienten ohne eine SFN fand sich dieser Unterschied nicht. Patienten mit einem niedrigen SNAP zeigten im Vergleich zu gesunden Kontrollen eine größere Menge an Gb3 in ihrer distalen Haut, bei Patienten mit einem höheren SNAP fand sich dies nicht. Aus diesen Ergebnissen ergeben sich ein mögliches weiteres Werkzeug sowohl für die Diagnosestellung als auch für das Monitoring der Erkrankung, sowie weiterführend auch ein möglicher Indikator für den Therapieerfolg der ERT.
Fullerenols, water-soluble C60-fullerene derivatives, have been shown to exert neuroprotective effects in vitro and in vivo, most likely due to their capability to scavenge free radicals. However, little is known about the effects of fullerenols on the blood–brain barrier (BBB), especially on cerebral endothelial cells under inflammatory conditions. Here, we investigated whether the treatment of primary mouse brain microvascular endothelial cells with fullerenols impacts basal and inflammatory blood–brain barrier (BBB) properties in vitro. While fullerenols (1, 10, and 100 µg/mL) did not change transendothelial electrical resistance under basal and inflammatory conditions, 100 µg/mL of fullerenol significantly reduced erk1/2 activation and resulted in an activation of NFκB in an inflammatory milieu. Our findings suggest that fullerenols might counteract oxidative stress via the erk1/2 and NFκB pathways, and thus are able to protect microvascular endothelial cells under inflammatory conditions.
α-Synuclein is a protein implicated in the etiopathogenesis of Parkinson’s disease (PD). AAV1/2-driven overexpression of human mutated A53T-α-synuclein in rat and monkey substantia nigra (SN) induces degeneration of nigral dopaminergic neurons and decreases striatal dopamine and tyrosine hydroxylase (TH). Given certain advantages of the mouse, especially it being amendable to genetic manipulation, translating the AAV1/2-A53T α-synuclein model to mice would be of significant value. AAV1/2-A53T α-synuclein or AAV1/2 empty vector (EV) at a concentration of 5.16 x 10\(^{12}\) gp/ml were unilaterally injected into the right SN of male adult C57BL/6 mice. Post-mortem examinations included immunohistochemistry to analyze nigral α-synuclein, Ser129 phosphorylated α-synuclein and TH expression, striatal dopamine transporter (DAT) levels by autoradiography and dopamine levels by high performance liquid chromatography. At 10 weeks, in AAV1/2-A53T α-synuclein mice there was a 33% reduction in TH+ dopaminergic nigral neurons (P < 0.001), 29% deficit in striatal DAT binding (P < 0.05), 38% and 33% reductions in dopamine (P < 0.001) and DOPAC (P < 0.01) levels and a 60% increase in dopamine turnover (homovanilic acid/dopamine ratio; P < 0.001). Immunofluorescence showed that the AAV1/2-A53T α-synuclein injected mice had widespread nigral and striatal expression of vector-delivered A53T-α-synuclein. Concurrent staining with human PD SN samples using gold standard histological methodology for Lewy pathology detection by proteinase K digestion and application of specific antibody raised against human Lewy body α-synuclein (LB509) and Ser129 phosphorylated α-synuclein (81A) revealed insoluble α-synuclein aggregates in AAV1/2-A53T α-synuclein mice resembling Lewy-like neurites and bodies. In the cylinder test, we observed significant paw use asymmetry in the AAV1/2-A53T α-synuclein group when compared to EV controls at 5 and 9 weeks post injection (P < 0.001; P < 0.05). These data show that unilateral injection of AAV1/2-A53T α-synuclein into the mouse SN leads to persistent motor deficits, neurodegeneration of the nigrostriatal dopaminergic system and development of Lewy-like pathology, thereby reflecting clinical and pathological hallmarks of human PD.
In der vorliegenden Studie wurden 32 Patienten (19 Frauen, 13 Männer, medianes Alter 50 Jahren, Spanne: 26-83 Jahre) mit einem klinisch akralen neuropathischen Schmerzsyndrom unterschiedlicher Genese mittels QST, PREP und Hautbiopsie untersucht. Unser Patientenkollektiv bestand aus drei Subgruppen: sechsen Patienten erfüllten die Kriterien einer SFN, acht Patienten hatten eine Neuropathie der großkalibrigen Nervenfasern mit zusätzlicher Beeinträchtigung der kleinkalibrigen Nervenfasern und weitere acht Patienten hatten ein akrales Schmerzsyndrom mit neuropathischen Charakteristika, ohne vorbekannte Diagnose einer Neuropathie der groß- oder kleinkalibrigen Nervenfasern. Die Patienten wurden mittels klinischer neurologischer Untersuchung, elektrophysiologischer Tests, QST, PREP und Hautbiopsie untersucht. Die Patientendaten wurden jeweils mit Daten großer Kontrollgruppen verglichen, die wir in unserer Klinik unter Angehörigen und Freunden unserer Patienten mit deren Einwilligung rekrutiert hatten.
QST und die Hautbiopsie waren bei Patienten mit SFN und PNP jeweils auffällig, bei akralem Schmerzsyndrom unklarer Ätiologie hingegen unauffällig. Nach elektrischer kutaner Stimulation aller drei Körperregionen zeigte sich eine Amplitudenminderung der PREP-Reizantwort in allen Patientensubgruppen (7,5 µV in der SFN-Gruppe, 3,8 µV in der PNP-Gruppe, und 11,3 µV bei den Patienten mit akralem Schmerzsyndrom). Somit konnten wir zeigen, dass eine Kleinfaserpathologie in der Studienpopulation von Patienten mit neuropathischem Schmerzsyndrom besteht. Nur die Amplitudenminderung der PREP bildet diese Pathologie ab.
Diese Daten erlauben uns die eingangs aufgestellte Hypothese, dass PREP zur Diagnostik bei Frage nach Kleinfaserbeteiligung geeignet ist, positiv zu belegen. PREP ist eine nicht-invasive Methode für die Evaluation der Funktion v.a. der Aδ-Faser mit standardisiertem Ablaufprotokoll zur Erhebung von reproduzierbaren Daten. Sie kann bei Patienten mit der Anamnese eines akralen neuropathischen Schmerzsyndroms einen objektiven Hinweis auf eine Dysfunktion der kleinkalibrigen Nervenfasern, auch wenn bereits etablierte Methoden (QST und Hautbiopsie) unauffällig bleiben, erbringen. Entsprechend können die PREP eine wertvolle Ergänzung der klinischen Untersuchungsbatterie für die Evaluation der Funktion der kleinkalibrigen Nervenfasern sein.
Background:
Standard echocardiography (SE) is an essential part of the routine diagnostic work-up after ischemic stroke (IS) and also serves for research purposes. However, access to SE is often limited. We aimed to assess feasibility and accuracy of point-of-care (POC) echocardiography in a stroke unit (SU) setting.
Methods:
IS patients were recruited on the SU of the University Hospital Würzburg, Germany. Two SU team members were trained in POC echocardiography for a three-month period to assess a set of predefined cardiac parameters including left ventricular ejection fraction (LVEF). Diagnostic agreement was assessed by comparing POC with SE executed by an expert sonographer, and intraclass correlation coefficient (ICC) or kappa (κ) with 95% confidence intervals (95% CI) were calculated.
Results:
In the 78 patients receiving both POC and SE agreement for cardiac parameters was good, with ICC varying from 0.82 (95% CI 0.71–0.89) to 0.93 (95% CI 0.87–0.96), and κ from 0.39 (−95% CI 0.14–0.92) to 0.79 (95% CI 0.67–0.91). Detection of systolic dysfunction with POC echocardiography compared to SE was very good, with an area under the curve of 0.99 (0.96–1.00). Interrater agreement for LVEF measured by POC echocardiography was good with κ 0.63 (95% CI 0.40–0.85).
Conclusions:
POC echocardiography in a SU setting is feasible enabling reliable quantification of LVEF and preliminary assessment of selected cardiac parameters that might be used for research purposes. Its potential clinical utility in triaging stroke patients who should undergo or do not necessarily require SE needs to be investigated in larger prospective diagnostic studies.
Background
Lymphocytes have been shown to play an important role in the pathophysiology of acute ischemic stroke, but the properties of B cells remain controversial. The aim of this study was to unravel the role of B cells during acute cerebral ischemia using pharmacologic B cell depletion, B cell transgenic mice, and adoptive B cell transfer experiments.
Methods
Transient middle cerebral artery occlusion (60 min) was induced in wild-type mice treated with an anti-CD20 antibody 24 h before stroke onset, JHD\(^{−/−}\) mice and Rag1\(^{−/−}\) mice 24 h after adoptive B cell transfer. Stroke outcome was assessed at days 1 and 3. Infarct volumes were calculated from 2,3,5-triphenyltetrazolium chloride (TTC)-stained brain sections, and neurological scores were evaluated. The local inflammatory response was determined by real-time PCR and immunohistochemistry. Apoptosis was analyzed by TUNEL staining, and astrocyte activation was revealed using immunohistochemistry and Western blot.
Results
Pharmacologic depletion of B cells did not influence infarct volumes and functional outcome at day 1 after stroke. Additionally, lack of circulating B cells in JHD\(^{−/−}\) mice also failed to influence stroke outcome at days 1 and 3. Furthermore, reconstitution of Rag1\(^{−/−}\) mice with B cells had no influence on infarct volumes.
Conclusion
Targeting B cells in experimental stroke did not influence lesion volume and functional outcome during the acute phase. Our findings argue against a major pathophysiologic role of B cells during acute ischemic stroke.
Differential effects of FTY720 on the B cell compartment in a mouse model of multiple sclerosis.
(2017)
Background:
MP4-induced experimental autoimmune encephalomyelitis (EAE) is a mouse model of multiple sclerosis (MS), which enables targeted research on B cells, currently much discussed protagonists in MS pathogenesis. Here, we used this model to study the impact of the S1P1 receptor modulator FTY720 (fingolimod) on the autoreactive B cell and antibody response both in the periphery and the central nervous system (CNS).
Methods:
MP4-immunized mice were treated orally with FTY720 for 30 days at the peak of disease or 50 days after EAE onset. The subsequent disease course was monitored and the MP4-specific B cell/antibody response was measured by ELISPOT and ELISA. RNA sequencing was performed to determine any effects on B cell-relevant gene expression. S1P\(_{1}\) receptor expression by peripheral T and B cells, B cell subset distribution in the spleen and B cell infiltration into the CNS were studied by flow cytometry. The formation of B cell aggregates and of tertiary lymphoid organs (TLOs) was evaluated by histology and immunohistochemistry. Potential direct effects of FTY720 on B cell aggregation were studied in vitro.
Results:
FTY720 significantly attenuated clinical EAE when treatment was initiated at the peak of EAE. While there was a significant reduction in the number of T cells in the blood after FTY720 treatment, B cells were only slightly diminished. Yet, there was evidence for the modulation of B cell receptor-mediated signaling upon FTY720 treatment. In addition, we detected a significant increase in the percentage of B220\(^{+}\) B cells in the spleen both in acute and chronic EAE. Whereas acute treatment completely abrogated B cell aggregate formation in the CNS, the numbers of infiltrating B cells and plasma cells were comparable between vehicle- and FTY720-treated mice. In addition, there was no effect on already developed aggregates in chronic EAE. In vitro B cell aggregation assays suggested the absence of a direct effect of FTY720 on B cell aggregation. However, FTY720 impacted the evolution of B cell aggregates into TLOs.
Conclusions:
The data suggest differential effects of FTY720 on the B cell compartment in MP4-induced EAE.
Background:
Ischemic stroke causes a strong inflammatory response that includes T cells, monocytes/macrophages, and neutrophils. Interaction of these immune cells with platelets and endothelial cells facilitates microvascular dysfunction and leads to secondary infarct growth. We recently showed that blocking of platelet glycoprotein (GP) receptor Ib improves stroke outcome without increasing the risk of intracerebral hemorrhage. Until now, it has been unclear whether GPIb only mediates thrombus formation or also contributes to the pathophysiology of local inflammation.
Methods:
Focal cerebral ischemia was induced in C57BL/6 mice by a 60-min transient middle cerebral artery occlusion (tMCAO). Animals were treated with antigen-binding fragments (Fab) against the platelet surface molecules GPIb (p0p/B Fab). Rat immunoglobulin G (IgG) Fab was used as control treatment. Stroke outcome, including infarct size and functional deficits as well as the local inflammatory response, was assessed on day 1 after tMCAO.
Results:
Blocking of GPIb reduced stroke size and improved functional outcome on day 1 after tMCAO without increasing the risk of intracerebral hemorrhage. As expected, disruption of GPIb-mediated pathways in platelets significantly reduced thrombus burden in the cerebral microvasculature. In addition, inhibition of GPIb limited the local inflammatory response in the ischemic brain as indicated by lower numbers of infiltrating T cells and macrophages and lower expression levels of inflammatory cytokines compared with rat IgG Fab-treated controls.
Conclusion:
In acute ischemic stroke, thrombus formation and inflammation are closely intertwined (“thrombo-inflammation”). Blocking of platelet GPIb can ameliorate thrombo-inflammation.
Background:
Clinical reasoning in Neurology is based on general associations which help to deduce the site of the lesion. However, even “golden principles” may occasionally be deceptive. Here, we describe the case of subacute flaccid tetraparesis due to motor cortical lesions. To our knowledge, this is the first report to include an impressive illustration of nearly symmetric motor cortical involvement of encephalitis on brain MRI.
Case presentation:
A 51 year old immunocompromized man developed a high-grade pure motor flaccid tetraparesis over few days. Based on clinical presentation, critical illness polyneuromyopathy was suspected. However, brain MRI revealed symmetrical hyperintensities strictly limited to the subcortical precentral gyrus. An encephalitis, possibly due to CMV infection, turned out to be the most likely cause.
Conclusion:
While recognition of basic clinical patterns is indispensable in neurological reasoning, awareness of central conditions mimicking peripheral nervous disease may be crucial to detect unsuspected, potentially treatable conditions.
Background:
Traumatic brain injury (TBI) is a devastating neurological condition and a frequent cause of permanent disability. Posttraumatic inflammation and brain edema formation, two pathological key events contributing to secondary brain injury, are mediated by the contact-kinin system. Activation of this pathway in the plasma is triggered by activated factor XII. Hence, we set out to study in detail the influence of activated factor XII on the abovementioned pathophysiological features of TBI.
Methods:
Using a cortical cryogenic lesion model in mice, we investigated the impact of genetic deficiency of factor XII and inhibition of activated factor XII with a single bolus injection of recombinant human albumin-fused Infestin-4 on the release of bradykinin, the brain lesion size, and contact-kinin system-dependent pathological events. We determined protein levels of bradykinin, intracellular adhesion molecule-1, CC-chemokine ligand 2, and interleukin-1β by enzyme-linked immunosorbent assays and mRNA levels of genes related to inflammation by quantitative real-time PCR. Brain lesion size was determined by tetrazolium chloride staining. Furthermore, protein levels of the tight junction protein occludin, integrity of the blood-brain barrier, and brain water content were assessed by Western blot analysis, extravasated Evans Blue dye, and the wet weight-dry weight method, respectively. Infiltration of neutrophils and microglia/activated macrophages into the injured brain lesions was quantified by immunohistological stainings.
Results:
We show that both genetic deficiency of factor XII and inhibition of activated factor XII in mice diminish brain injury-induced bradykinin release by the contact-kinin system and minimize brain lesion size, blood-brain barrier leakage, brain edema formation, and inflammation in our brain injury model.
Conclusions:
Stimulation of bradykinin release by activated factor XII probably plays a prominent role in expanding secondary brain damage by promoting brain edema formation and inflammation. Pharmacological blocking of activated factor XII could be a useful therapeutic principle in the treatment of TBI-associated pathologic processes by alleviating posttraumatic inflammation and brain edema formation.
Die autosomal-dominant vererbte facioscapulohumerale Muskeldystrophie (FSHD) ist mit einer Prävalenz von etwa 1:20.000 die dritthäufigste Form der hereditären Myopathien. Erste Beschwerden werden meist in der zweiten Lebensdekade beobachtet. Betroffen sind vor allem die Muskulatur von Gesicht, Schultern, Oberarmen, die Fußhebermuskulatur und die Muskeln des Hüftgürtels.
FSHD wird durch einen Gendefekt ausgelöst, der den langen Arm des Chromosoms vier (4q35) betrifft, wobei es zur teilweisen Deletion des polymorphen Abschnitts D4Z4, der für das Protein DUX4 codiert, kommt. Dabei treten unter anderem Störungen in der DUX4-Expression, Veränderungen der myogenen Genexpression, eine Unterdrückung der Muskelzelldifferenzierung und eine Inhibition der Muskelbildung auf.
FSHD und eine andere Form der Muskeldystrophie, die Emery-Dreifuss-Muskeldystrophie (EDMD), zeigen trotz unterschiedlicher genetischer Ursachen phänotypisch Ähnlichkeiten in der Ausprägung der Erkrankungen. In früheren Studien zeigte die Kernhülle von EDMD-Myoblasten morphologische Auffälligkeiten. In anderen Untersuchungen waren morphologische Veränderungen der Mitochondrien von FSHD-Patienten festzustellen.
Daher wurden elektronenmikroskopische Untersuchungen der Kernhülle und der Mitochondrien von FSHD-Myoblasten durchgeführt und mit der entsprechenden Kontrolle verglichen.
Hierfür wurden drei verschiedene Zelllinien-Paare in unterschiedlichen Passagen, das heißt unterschiedlicher Anzahl an Subkultivierungen, eingesetzt, wobei in den höheren Passagen vermehrt morphologische Atypien beobachtet werden konnten.
Die eingesetzten Zelllinien differenzieren sich durch verschiedene Parameter wie beispielsweise Alter und Geschlecht der Patienten. Dabei zeigten sich sowohl zwischen den Kontrollzellen als auch zwischen den FSHD-Myoblasten Unterschiede.
Im Rahmen der Probenvorbereitung für die Elektronenmikroskopie kamen zwei verschiedene Fixierungsmethoden zum Einsatz: die konventionelle chemische Fixierung, Entwässerung und Flacheinbettung von Kulturzellen und die Hochdruckgefrierung mit anschließender Gefriersubstitution. In Bezug auf die Qualität des Strukturerhalts, die beim Hochdruckgefrieren erreicht wird, wird dieser Art der Fixierung eine Überlegenheit gegenüber allen anderen Verfahren zugeschrieben. Diese allgemeine Aussage kann nicht vollständig auf die Untersuchungen an den Myoblasten übertragen werden.
Für die Untersuchung der Kernmembranen sind beide Methoden geeignet, wobei der Abstand zwischen innerer und äußerer Kernmembran nach der HPF-Fixierung schärfer abgebildet wurde. Bei der Darstellung der Mitochondrien zeigten die elektronenmikroskopischen Aufnahmen nach dem Hochdruckgefrieren bessere und schärfere Ergebnisse. Die Kernporen waren bei beiden Fixierungsmethoden gut erkennbar.
Beim Vergleich der gesunden und erkrankten Myoblasten wiesen die Kontrollzellen deutlich weniger Auffälligkeiten auf als die Myoblasten von FSHD-Patienten.
Innere und äußere Kernmembran verliefen bei den Kontrollzellen meist parallel und die Mitochondrien zeigten in den meisten Fällen eine typische wurmartige, längliche Form mit Cristae. Dies traf sowohl für die konventionelle Fixierung als auch für das Hochdruckgefrieren zu.
Die erkrankten Myoblasten wiesen im Vergleich zur Kontrolle bei beiden Fixierungsmethoden deutliche Auffälligkeiten in der Mitochondrien-Morphologie auf. Neben einer oft großen Variationsbreite hinsichtlich Form und Länge war auch das teilweise Fehlen der Cristae festzustellen.
Bei Betrachtung der Kernhülle fielen jedoch deutliche Unterschiede zwischen konventioneller und HPF-Fixierung auf. Die äußere Kernmembran der konventionell fixierten FSHD-Myoblasten verlief unregelmäßig und gewellt. Im Gegensatz dazu wies die Kernhülle der HPF-fixierten erkrankten Myoblasten einen erstaunlich parallelen Verlauf auf.
Da bei EDMD in vorangegangenen Untersuchungen auch fluoreszenzmikroskopisch Veränderungen der erkrankten Zellen auffällig waren, wurde neben den Methoden der Elektronenmikroskopie das Vorliegen und die Verteilung verschiedener Proteine in FSHD-Myoblasten mittels indirekter Immunfluoreszenz untersucht und mit den Kontrollzellen verglichen.
Zur Beurteilung der Kernhülle wurden Antikörper gegen Lamin A/C und Nukleoporine eingesetzt. Die Mitochondrien wurden mithilfe des Antikörpers ANT1/2, der an den Adenin-Nukleotid-Translokator der inneren Mitochondrienmembran bindet, untersucht.
Im Gegensatz zu den Untersuchungen an EDMD-Myoblasten waren die Lamine A und C sowie die Kernporen sowohl bei den Myoblasten der FSHD-Patienten als auch bei den Kontrollzellen nachweisbar und gleichmäßig verteilt.
Bei der indirekten Immunfluoreszenz mit ANT1/2 zeigten sich Unterschiede zwischen den untersuchten Myoblasten-Paaren.
Durch die vorliegenden Ergebnisse ist darauf zu schließen, dass die Myoblasten von FSHD-Patienten Veränderungen Mitochondrien aufweisen. Die Untersuchungen der Kernhülle liefern abhängig von der Fixierungsmethode unterschiedliche Ergebnisse.
The role of miR-21 in the pathophysiology of neuropathic pain using the model of B7-H1 knockout mice
(2017)
The impact of microRNA (miRNA) as key players in the regulation of immune and neuronal gene expression and their role as master switches in the pathophysiology of neuropathic pain is increasingly recognized. miR-21 is a promising candidate that could be linked to the immune and the nociceptive system. To further investigate the pathophysiological role of miR-21 in neuropathic pain, we assesed mice deficient of B7 homolog 1 (B7-H1 ko), a protein with suppressive effect on inflammatory responses.
B7-H1 ko mice and wildtype littermates (WT) of three different age-groups, young (8 weeks), middle-aged (6 months), and old (12 months) received a spared nerve injury (SNI). Thermal withdrawal latencies and mechanical withdrawal thresholds were determined. Further, we investigated anxiety-, depression-like and cognitive behavior. Quantitative real time PCR was used to determine miR-21 relative expression in peripheral nerves, dorsal root ganglia and white blood cells (WBC) at distinct time points after SNI.
Naïve B7-H1 ko mice showed mechanical hyposensitivity with increasing age. Young and middle-aged B7-H1 ko mice displayed lower mechanical withdrawal thresholds compared to WT mice. From day three after SNI both genotypes developed mechanical and heat hypersensitivity, without intergroup differences. As supported by the results of three behavioral tests, no relevant differences were found for anxiety-like behavior after SNI in B7-H1 ko and WT mice. Also, there was no indication of depression-like behavior after SNI or any effect of SNI on cognition in both genotypes. The injured nerves of B7-H1 ko and WT mice showed higher miR-21 expression and invasion of macrophages and T cells 7 days after SNI without intergroup differences. Perineurial miR-21 inhibitor injection reversed SNI-induced mechanical and heat hypersensitivity in old B7-H1 ko and WT mice.
This study reveals that reduced mechanical thresholds and heat withdrawal latencies are associated with miR-21 induction in the tibial and common peroneal nerve after SNI, which can be reversed by perineurial injection of a miR-21 inhibitor. Contrary to expectations, miR-21 expression levels were not higher in B7-H1 ko compared to WT mice. Thus, the B7-H1 ko mouse may be of minor importance for the study of miR-21 related pain. However, these results spot the contribution of miR-21 in the pathophysiology of neuropathic pain and emphasize the crucial role of miRNA in the regulation of neuronal and immune circuits that contribute to neuropathic pain.
Mice overexpressing proteolipid protein (PLP) develop a leukodystrophy-like disease involving cytotoxic, CD8+ T-lymphocytes. Here we show that these cytotoxic T-lymphocytes perturb retrograde axonal transport. Using fluorogold stereotactically injected into the colliculus superior, we found that PLP overexpression in oligodendrocytes led to significantly reduced retrograde axonal transport in retina ganglion cell axons. We also observed an accumulation of mitochondria in the juxtaparanodal axonal swellings, indicative for a disturbed axonal transport. PLP overexpression in the absence of T-lymphocytes rescued retrograde axonal transport defects and abolished axonal swellings. Bone marrow transfer from wildtype mice, but not from perforin- or granzyme B-deficient mutants, into lymphocyte-deficient PLP mutant mice led again to impaired axonal transport and the formation of axonal swellings, which are predominantly located at the juxtaparanodal region. This demonstrates that the adaptive immune system, including cytotoxic T-lymphocytes which release perforin and granzyme B, are necessary to perturb axonal integrity in the PLP-transgenic disease model. Based on our observations, so far not attended molecular and cellular players belonging to the immune system should be considered to understand pathogenesis in inherited myelin disorders with progressive axonal damage.
Neuroprotection aims to prevent salvageable neurons from dying. Despite showing efficacy in experimental stroke studies, the concept of neuroprotection has failed in clinical trials. Reasons for the translational difficulties include a lack of methodological agreement between preclinical and clinical studies and the heterogeneity of stroke in humans compared to homogeneous strokes in animal models. Even when the international recommendations for preclinical stroke research, the Stroke Academic Industry Roundtable (STAIR) criteria, were followed, we have still seen limited success in the clinic, examples being NXY-059 and haematopoietic growth factors which fulfilled nearly all the STAIR criteria. However, there are a number of neuroprotective treatments under investigation in clinical trials such as hypothermia and ebselen. Moreover, promising neuroprotective treatments based on a deeper understanding of the complex pathophysiology of ischemic stroke such as inhibitors of NADPH oxidases and PSD-95 are currently evaluated in preclinical studies. Further concepts to improve translation include the investigation of neuroprotectants in multicenter preclinical Phase III-type studies, improved animal models, and close alignment between clinical trial and preclinical methodologies. Future successful translation will require both new concepts for preclinical testing and innovative approaches based on mechanistic insights into the ischemic cascade.
Polyneuropathien sind Erkrankungen des peripheren Nervensystems. Die Erkrankung kommt gehäuft als Zweiterkrankungen bei anderen Primärerkrankungen vor, daher ist es schwierig, epidemiologische Angaben zu machen.
Ätiologisch lassen sich Polyneuropathien in fünf große Gruppen einteilen: Hereditäre Polyneuropathien, entzündliche Polyneuropathien, vaskulär bedingte Polyneuropathien, exotoxische Polyneuropathien und endotoxisch-metabolische Polyneuropathien. Die Differentialdiagnose der Polyneuropathie richtet sich nach dem zeitlichen Verlauf der Krankheit, dem betroffenen System und danach, ob primär die Axone oder die Markscheiden betroffen sind.
Für die Diagnosestellung einer Polyneuropathie werden Anamnese und klinischer Befund, elektrophysiologische Untersuchungen, Laboruntersuchungen, genetische Untersuchungen und die histopathologische Untersuchung herangezogen. Entscheidend für die Therapie ist es, die behandelbaren Polyneuropathien zu erkennen, hierunter u.a. die entzündlichen Formen. Die hierfür entnommene Suralisbiopsie ist wegen ihrer invasiven Natur erst dann indiziert, wenn die Differentialdiagnose mit nicht-invasiven Maßnahmen nicht geklärt werden kann, sich aber eine Behandlungskonsequenz erwarten lässt.
Die exakte Diagnose setzt bei einigen Polyneuropathien eine neuropathologische Diagnostik voraus. Die Nervenbiopsie muss optimal aufbereitet und ausgewertet werden. Hierfür stehen verschiedene Färbe- und Aufbereitungsmethoden zur Verfügung.
In dieser Arbeit wurde untersucht, ob anhand eines Schnellschnittes (d.h. Gefrier-Querschnitt des biopsierten Nerven mit Hämatoxylin-Eosin gefärbt) bereits Hinweise auf entzündliche Infiltrate als Zeichen einer Neuritis und damit einer therapiebedürftigen und aber auch therapierbaren Neuropathie gefunden werden können.
Anhand eines vordefinierten Schemas wurden die Biopsate in verblindeter Weise von einem Laien und einem erfahrenem Untersucher histologisch begutachtet und den entzündlichen/nicht entzündlichen Diagnosegruppen zugeordnet. Es wurde untersucht, ob die entzündlichen Veränderungen im Hämatoxylin-Eosin-Gefrierschnitt so deutlich sind, dass auch ein Laienauswerter diese erkennen kann. Ebenso wurden die Untersuchungsergebnisse mittels Hämatoxylin-Eosin- Färbung an Gefrier- und Paraffinschnitten mit den Untersuchungsergebnissen mittels immunhistochemischer Färbemethoden verglichen. Des weiteren wurde untersucht, ob bei histologisch gesicherter Entzündung klinische Einflussfaktoren ermittelt werden können, die auf die neuropathologische Diagnostik Auswirkung haben.
Die Ergebnisse der Studie zeigen, dass sich die Hämatoxylin-Eosin-Färbung für eine erste und schnelle Diagnostik von entzündlichen Polyneuropathien als wertvoll erwies. Dies gilt für den erfahrenen und unerfahrenen Untersucher. Es zeigen sich keine klinischen Einflussfaktoren für die histopathologische Diagnosestellung. Die Ergebnisse der Studie zeigen, dass schon eine einfache Färbemethode wie die Hämatoxylin-Eosin-Färbung an Gefrier-und Paraffinschnitten bei Polyneuropathie unklarer Genese hilfreich bei einer differenzierten Diagnosefindung sein kann.
Der M. Fabry ist eine X-chromosomal vererbte lysosomale Speicherkankheit, die zu einem Multiorganversagen führt. Ein frühes Symptom sind Schmerzen, die meist schon in der frühen Kindheit einsetzen. Das Besondere an diesen Schmerzen ist, dass sie sich sehr unterschiedlich u.a. bezüglich ihres Verlaufs, ihrer Dauer und ihrer Lokalisation präsentieren können. Diese Fabry-assoziierten Schmerzen sind meist brennend und akral betont, können aber auch andere Qualitäten aufweisen und sehr variable Körperpartien erfassen, was ihre diagnostische Einordnung erschwert. Bisher verfügbare validierte Schmerzfragebögen können das Spektrum der Fabry-assoziierten Schmerzen nicht erfassen. In dieser Arbeit wird der erste M. Fabry spezifische Schmerzfragebogen für Erwachsene in zwei Versionen präsentiert. Die erste Version ist eine Interview Version (iFPQ), bei der der Arzt in einem persönlichen Gespräch mit dem Patienten mit Hilfe des Fragbogens alle wesentlichen Aspekte der Fabry-assoziierten Schmerzen erfragen kann. Die zweite Version kann eigenständig vom Patienten ausgefüllt werden (saFPQ). Zur Etablierung der Fragebögen wurde in einer Pilotstudie zunächst mit 20 Patienten eine erste Version des iFPQ entwickelt. Nach Verbesserungen wurde die Interview Version mit Hilfe von 42 Studienteilnehmern validiert, die jeweils an einem Erst- und Zweitgespräch im Abstand von zwei Wochen teilnahmen. Hierbei wurde auch der NPSI als vergleichender Fragebogen ausgefüllt. Bei der ersten statistischen Analyse ergab sich eine gute Reliabilität mit ICC-Werten von 0,896 bis 0,999 aber eine unzureichende Validität zwischen iFPQ und NPSI mit K-Werten von 0,257 bis 0,566. Nach der ersten statistischen Analyse wurde der Fragebogen erneut überarbeitet und mit Hilfe von 20 Studienteilnehmern erneut validiert. Anschließend zeigte sich eine gute Validität mit K-Werten von 0,634 bis 1,0. Der saFPQ wurde im Anschluss an die finale iFPQ Version entwickelt. Bei 40 Patienten erfolgte ein Erstgespräch, bei dem die Patienten die valide Version des iFPQ ausfüllten. Im Abstand von zwei Wochen schickten die Patienten dann die selbständig ausgefüllte Version des saFPQ postalisch zurück. Die postalische Version erweitert die Flexibilität dieses Fragebogens. Sie ist für den klinischen Alltag sehr relevant. Die Resonanz der Patienten hinsichtlich beider Fragebögen war sehr positiv. Perspektivisch ist die Entwicklung einer englischen Version geplant.
Neuro-immune alterations in the peripheral and central nervous system play a role in the pathophysiology of chronic pain, and non-coding RNAs – and microRNAs (miRNAs) in particular – regulate both immune and neuronal processes. Specifically, miRNAs control macromolecular complexes in neurons, glia and immune cells and regulate signals used for neuro-immune communication in the pain pathway. Therefore, miRNAs may be hypothesized as critically important master switches modulating chronic pain. In particular, understanding the concerted function of miRNA in the regulation of nociception and endogenous analgesia and defining the importance of miRNAs in the circuitries and cognitive, emotional and behavioral components involved in pain is expected to shed new light on the enigmatic pathophysiology of neuropathic pain, migraine and complex regional pain syndrome. Specific miRNAs may evolve as new druggable molecular targets for pain prevention and relief. Furthermore, predisposing miRNA expression patterns and inter-individual variations and polymorphisms in miRNAs and/or their binding sites may serve as biomarkers for pain and help to predict individual risks for certain types of pain and responsiveness to analgesic drugs. miRNA-based diagnostics are expected to develop into hands-on tools that allow better patient stratification, improved mechanism-based treatment, and targeted prevention strategies for high risk individuals.
Rationale
While brain serotonin (5-HT) function is implicated in gene-by-environment interaction (GxE) impacting the vulnerability-resilience continuum in neuropsychiatric disorders, it remains elusive how the interplay of altered 5-HT synthesis and environmental stressors is linked to failure in emotion regulation.
Objective
Here, we investigated the effect of constitutively impaired 5-HT synthesis on behavioral and neuroendocrine responses to unpredictable chronic mild stress (CMS) using a mouse model of brain 5-HT deficiency resulting from targeted inactivation of the tryptophan hydroxylase-2 (Tph2) gene.
Results
Locomotor activity and anxiety- and depression-like behavior as well as conditioned fear responses were differentially affected by Tph2 genotype, sex, and CMS. Tph2 null mutants (Tph2\(^{−/−}\)) displayed increased general metabolism, marginally reduced anxiety- and depression-like behavior but strikingly increased conditioned fear responses. Behavioral modifications were associated with sex-specific hypothalamic-pituitary-adrenocortical (HPA) system alterations as indicated by plasma corticosterone and fecal corticosterone metabolite concentrations. Tph2\(^{−/−}\) males displayed increased impulsivity and high aggressiveness. Tph2\(^{−/−}\) females displayed greater emotional reactivity to aversive conditions as reflected by changes in behaviors at baseline including increased freezing and decreased locomotion in novel environments. However, both Tph2\(^{−/−}\) male and female mice were resilient to CMS-induced hyperlocomotion, while CMS intensified conditioned fear responses in a GxE-dependent manner.
Conclusions
Our results indicate that 5-HT mediates behavioral responses to environmental adversity by facilitating the encoding of stress effects leading to increased vulnerability for negative emotionality.
Dysregulated IGFBP5 expression causes axon degeneration and motoneuron loss in diabetic neuropathy
(2015)
Diabetic neuropathy (DNP), afflicting sensory and motor nerve fibers, is a major complication in diabetes.The underlying cellular mechanisms of axon degeneration are poorly understood. IGFBP5, an inhibitory binding protein for insulin-like growth factor 1 (IGF1) is highly up-regulated in nerve biopsies of patients with DNP. We investigated the pathogenic relevance of this finding in transgenic mice overexpressing IGFBP5 in motor axons and sensory nerve fibers. These mice develop motor axonopathy and sensory deficits similar to those seen in DNP. Motor axon degeneration was also observed in mice in which the IGF1 receptor(IGF1R) was conditionally depleted in motoneurons, indicating that reduced activity of IGF1 on IGF1R in motoneurons is responsible for the observed effect. These data provide evidence that elevated expression of IGFBP5 in diabetic nerves reduces the availability of IGF1 for IGF1R on motor axons, thus leading to progressive neurodegeneration. Inhibition of IGFBP5 could thus offer novel treatment strategies for DNP.
Die hereditäre Spinalparalyse SPG17 ist eine autosomal-dominant vererbte Motoneuronerkrankung, welche durch Mutationen im BSCL2 (Seipin) Gen verursacht wird. Klassischerweise äußert sich die Krankheit durch eine spastische Paraparese der Beine und Amyotrophie der Hände (Silver-Syndrom) oder eine vorwiegend periphere (senso-)motorische Neuropathie. Für die vorliegende Arbeit wurden insgesamt sieben Patienten aus vier verschiedenen Familien, bei denen heterozygote Mutationen im BSCL2 Gen nachgewiesen werden konnten, klinisch sowie elektrophysiologisch und molekulargenetisch untersucht. Es gelang hierbei zwei bisher unbekannte phänotypische Ausprägungen zu beschreiben, welche die Symptomatik und den Verlauf einer Multifokalen Motorischen Neuropathie (MMN) bzw. einer Amyotrophen Lateralsklerose (ALS) imitieren und hiervon nur durch den genetischen Befund zu unterscheiden sind. Anhand dieser Ergebnisse erfolgte dann nach extensiver Literaturrecherche eine Zusammenfassung aller bisher publizierten Fälle der SPG17 und eine Einordnung der hier erstbeschriebenen Phänotypen in einen Vorschlag zur Erweiterung des bisher verwendeten Klassifikationssystems von BSCL 2 Mutationen.
Background:
Deep brain stimulation (DBS) is the chronic electrical stimulation of selected target sites in the brain through stereotactically implanted electrodes. More than 150 000 patients around the world have been treated to date with DBS for medically intractable conditions. The indications for DBS include movement disorders, epilepsy, and some types of mental illness.
Methods:
This review is based on relevant publications retrieved by a selective search in PubMed and the Cochrane Library, and on the current guidelines of the German Neurological Society (Deutsche Gesellschaft fur Neurologie, DGN).
Results: DBS is usually performed to treat neurological diseases, most often movement disorders and, in particular, Parkinson's disease. Multiple randomized controlled trials (RCTs) have shown that DBS improves tremor, dyskinesia, and quality of life in patients with Parkinson's disease by 25% to 50%, depending on the rating scales used. DBS for tremor usually involves stimulation in the cerebello-thalamo-cortical regulatory loop. In an RCT of DBS for the treatment of primary generalized dystonia, the patients who underwent DBS experienced a 39.3% improvement of dystonia, compared to only 4.9% in the control group. Two multicenter trials of DBS for depression were terminated early because of a lack of efficacy.
Conclusion:
DBS is an established treatment for various neurological and psychiatric diseases. It has been incorporated in the DGN guidelines and is now considered a standard treatment for advanced Parkinson's disease. The safety and efficacy of DBS can be expected to improve with the application of new technical developments in electrode geometry and new imaging techniques. Controlled trials would be helpful so that DBS could be extended to further indications, particularly psychiatric ones.
Lymphocytes express potassium channels that regulate physiological cell functions, such as activation, proliferation and migration. Expression levels of K\(_{2P}\)5.1(TASK2; KCNK5) channels belonging to the family of two-pore domain potassium channels have previously been correlated to the activity of autoreactive T lymphocytes in patients with multiple sclerosis and rheumatoid arthritis. In humans, K\(_{2P}\)5.1 channels are upregulated upon T cell stimulation and influence T cell effector functions. However, a further clinical translation of targeting K\(_{2P}\)5.1 is currently hampered by a lack of highly selective inhibitors, making it necessary to evaluate the impact of KCNK5 in established preclinical animal disease models. We here demonstrate that K\(_{2P}\)5.1 knockout (K\(_{2P}\)5.1\(^{-/-}\) mice display no significant alterations concerning T cell cytokine production, proliferation rates, surface marker molecules or signaling pathways. In an experimental model of autoimmune neuroinflammation, K\(_{2P}\)5.1\(^{-/-}\) mice show a comparable disease course to wild-type animals and no major changes in the peripheral immune system or CNS compartment. A compensatory upregulation of the potassium channels K\(_{2P}\)3.1 and K\(_{V}\)1.3 seems to counterbalance the deletion of K\(_{2P}\)5.1. As an alternative model mimicking autoimmune neuroinflammation, experimental autoimmune encephalomyelitis in the common marmoset has been proposed, especially for testing the efficacy of new potential drugs. Initial experiments show that K\(_{2P}\)5.1 is functionally expressed on marmoset T lymphocytes, opening up the possibility for assessing future K\(_{2P}\)5.1-targeting drugs.
Biomedical research suffers from a dramatically poor translational success. For example, in ischemic stroke, a condition with a high medical need, over a thousand experimental drug targets were unsuccessful. Here, we adopt methods from clinical research for a late-stage pre-clinical meta-analysis (MA) and randomized confirmatory trial (pRCT) approach. A profound body of literature suggests NOX\(_{2}\) to be a major therapeutic target in stroke. Systematic review and MA of all available NOX\(_{2}\)\(^{-/y}\) studies revealed a positive publication bias and lack of statistical power to detect a relevant reduction in infarct size. A fully powered multi-center pRCT rejects NOX\(_{2}\) as a target to improve neurofunctional outcomes or achieve a translationally relevant infarct size reduction. Thus stringent statistical thresholds, reporting negative data and a MA-pRCT approach can ensure biomedical data validity and overcome risks of bias.
Polyneuropathien sind eine ätiologisch heterogene Erkrankung des peripheren Nervensystems. In bis zu 30% der Fälle ist eine Zuordnung zu einem bestimmten PNP Subtyp auch nach aufwändiger und zum Teil invasiver Diagnostik nicht möglich. Bislang fehlt ein diagnostischer Biomarker bei PNP, der z.B. bei der Unterscheidung zwischen einzelnen diagnostischen Subgruppen oder entzündlichen und nicht-entzündlichen Erkrankungsformen helfen könnte. In einer prospektiven Studie mit insgesamt 97 Patienten mit Neuropathien verschiedenster Ätiologie und 17 gesunden Kontrollpersonen erstellten wir Genexpressionsprofile von inflammatorischen Markern und Markern der Regeneration peripherer Nerven in Haut- und N. suralis-Biopsaten. Es wurden Inflammationsmarker (TAC1, CRMP2, AIF1, IL-6) und Marker, die in die Regeneration peripherer Nerven involviert sind (SCD, Netrin-1, DCC, UNC5H2, NEO1, Netrin-G1, Netrin-G2), mittels qRT-PCR untersucht. Alle Patienten erhielten eine N. suralis-Biopsie und/oder eine Hautbiopsie von Ober- beziehungsweise Unterschenkel. Weder in den Haut- noch in den N. suralis-Biopsaten konnten Unterschiede in der Genexpression dieser Marker zwischen einzelnen diagnostischen Subgruppen gefunden werden. Der Inflammationsmarker AIF1 war jedoch in Patienten-Hautproben sowohl proximal als auch distal höher exprimiert als bei gesunden Kontrollpersonen (p < 0,05 bzw. p < 0,01). Zudem fand sich in den Hautproben von PNP-Patienten eine deutlich reduzierte Genexpression von Regenerationsmarkern aus der Netrin-Familie verglichen mit den Hautproben gesunder Probanden (Netrin-1, DCC, UNC5H2, NEO1 sowie Netrin-G1 und G2; p < 0,05 bis p < 0,001). Ferner wies Netrin-1 in distalen Hautproben bei Patienten mit einer entzündlichen PNP eine niedrigere Genexpression auf, als bei Patienten mit einer nicht-entzündlichen Erkrankungsform (p < 0,05). Die Genexpression von NEO1 in distalen Hautproben war bei schmerzloser PNP und gesunden Kontrollpersonen höher als bei schmerzhafter PNP (p < 0,05). Sowohl eine Erhöhung bestimmter Inflammationsmarker als auch eine Verminderung von Regenerationsmarkern peripherer Nerven können bei der Pathophysiologie von Polyneuropathien involviert sein. Insbesondere Mitglieder der Netrin-Familie scheinen eine komplexe Rolle für das Axonwachstum, jedoch auch für entzündliche Prozesse zu spielen.
Die Charcot-Marie-Tooth Typ 1 Erkrankungen sind eine genetisch heterogene Gruppe, aktuell nicht kurativ therapierbarer, erblicher Neuropathien des Peripheren Nervensystems. Klinische Manifestationen reichen von Sensibilitäts-störungen, verminderten Muskeleigenreflexen, sowie fortschreitenden Lähmungen, bis hin zu Muskelatrophie und bedeuten für die betroffenen Patienten eine starke Einschränkung der Lebensqualität. Anhand früherer Studien wurde Makrophagen, als Teil des angeborenen Immunsystems, eine entscheidende Rolle in der Pathogenese dreier CMT1-Unterformen zugeschrieben. Abgesehen von den morphologischen Manifestationen der demyelinisierenden CMT1-Erkrankungen, wie simultanes Auftreten von Dedifferenzierung, sowie Hypo-, und Demyelinisierung erkrankter Schwann-Zellen, sind pathologische Veränderungen der Domänengliederung der Ranvier’schen Schnürringe betroffener Nervenfasern ebenfalls von der Aktivierung pathogener Makrophagen abhängig.
Auf der Basis verschiedener veröffentlichter Studien, welche sowohl demyelinisierende Erkrankungen des ZNS, aber auch primär durch axonale Schäden gekennzeichnete Erkrankungen des PNS beinhalten, besteht ein möglicher räumlicher Zusammenhang zwischen Architekturstörungen der RS und aktivierten pathogenen Mikrogliazellen bzw. Makrophagen.
In dieser Studie konnte, anhand morphologischer Analysen von peripherem Nervengewebe, in Wt-Mäusen erstmals eine unerwartete präferentielle Lokalisation von Makrophagen im räumlichen Umfeld von RS beobachtet werden. Hierbei scheint, trotz des Fehlens einer direkten Zell-Zell-Interaktion zwischen Makrophagen und RS, vor allem im Hinblick auf die ebenfalls im räumlichen Umfeld von RS nachweisbare EZM und Fibroblasten, eine funktionelle Relevanz der assoziierten Makrophagen für die Aufrechterhaltung der Domänengliederung bzw. elektrophysiologischen Eigenschaften myelinisierter peripherer Nervenfasern denkbar.
Im Gegensatz dazu wurde trotz der signifikanten Zunahme der Makrophagenanzahlen in den drei untersuchten CMT1-Mausmodellen keine erhöhte räumliche Assoziation mit den RS der mutierten Schwann-Zellen beobachtet. Vielmehr konnten anhand des Vergleiches mit wildtypischen Kontrollmäusen signifikant erniedrigte Assoziationsraten beider Strukturen in den CMT1-Modelltieren festgestellt werden. Folglich scheint die von der Einwanderung und Aktivierung pathogener Makrophagen abhängige Störung der Domänengliederung der RS der mutierten Schwann-Zellen, nicht durch eine direkte Interaktion bzw. räumliche Assoziation von Makrophagen mit RS ausgelöst zu werden.
Intrathecal, Polyspecific Antiviral Immune Response in Oligoclonal Band Negative Multiple Sclerosis
(2012)
Background: Oligoclonal bands (OCB) are detected in the cerebrospinal fluid (CSF) in more than 95% of patients with multiple sclerosis (MS) in the Western hemisphere. Here we evaluated the intrathecal, polyspecific antiviral immune response as a potential diagnostic CSF marker for OCB-negative MS patients.
Methodology/Principal Findings: We tested 46 OCB-negative German patients with paraclinically well defined, definite MS. Sixteen OCB-negative patients with a clear diagnosis of other autoimmune CNS disorders and 37 neurological patients without evidence for autoimmune CNS inflammation served as control groups. Antibodies against measles, rubella, varicella zoster and herpes simplex virus in paired serum and CSF samples were determined by ELISA, and virus-specific immunoglobulin G antibody indices were calculated. An intrathecal antibody synthesis against at least one neurotropic virus was detected in 8 of 26 (31%) patients with relapsing-remitting MS, 8 of 12 (67%) with secondary progressive MS and 5 of 8 (63%) with primary progressive MS, in 3 of 16 (19%) CNS autoimmune and 3 of 37 (8%) non-autoimmune control patients. Antibody synthesis against two or more viruses was found in 11 of 46 (24%) MS patients but in neither of the two control groups. On average, MS patients with a positive antiviral immune response were older and had a longer disease duration than those without.
Conclusion: Determination of the intrathecal, polyspecific antiviral immune response may allow to establish a CSF-supported diagnosis of MS in OCB-negative patients when two or more of the four virus antibody indices are elevated.
Das ON-Freezing ist ein seltenes, aber generell extrem schwer zu therapierendes Phänomen. Es betrifft Parkinson-Patienten mit und ohne THS.
Die derzeitige Literaturlage spiegelt wider, dass es unterschiedliche Strategien gibt, diesem Phänomen zu begegnen. Ein allgemeingültiges Therapiekonzept existiert dabei nicht. Für einige Patienten mit STN-THS konnte durch eine Reduktion der Stimulationsfrequenz eine Besserung der Gangstörung erzielt werden. Andere profitierten vom Einsatz sogenannter Interleaving-Protokolle mit gleichzeitiger Stimulation der Substantia nigra (Sn).
Im Vergleich zu anderen Arbeiten, die keine vorhersagbaren Parameter gefunden oder sich auf Symptome, Ausprägung der Subtypen und Erkrankungsdauer oder
den Zeitpunkt der Erkrankung konzentriert haben, verfolgten wir die Absicht, die Effekte der LF-Stim des STN auf Parkinson-Patienten mit Gangstörung und Freezing-Phänomen zu untersuchen und herauszufinden, ob man Gangparameter identifizieren kann, an Hand derer man das Ansprechen auf eine LF-Stim vorhersagen kann.
Unter der Einschränkung, dass die Zahl der Probanden unserer Studie sehr gering ist, haben wir herausgefunden, dass diejenigen Patienten besser auf eine LF-Stim ansprechen, die unter der Standard-HF-Stim eine signifikant höhere Ganggeschwindigkeit und eine größere Schrittlänge aufzeigen und nur ein intermittierendes Freezing haben.
Darüber hinaus zeigte sich ein besseres Ansprechen der LF-Stim bei Parkinson-Patienten mit akinetisch-rigidem Parkinson-Phänotyp.
Unsere Ergebnisse bestätigen die Annahme, dass sich L-Dopa additiv zur Stimulationstherapie bei manchen Parkinson-Patienten zusätzlich positiv auf die motorischen PD-Symptome auswirken kann. In Bezug auf die Verbesserung der Gangparameter zeigte sich in unseren Ergebnissen allerdings, dass L-Dopa eher eine untergeordnete Rolle spielt.
Aufgrund der niedrigen Anzahl von Respondern in unserer Studie lässt sich daher sicherlich noch keine allgemeingültige Regel ableiten. Es bedarf letztlich weiterer Studien mit größeren Untersuchungszahlen, um unsere Thesen zu stützen und abzusichern.
In jedem Fall wird aber das ON-Freezing auch weiterhin eine therapeutische Herausforderung bleiben.
Isolated generalized dystonia is a central motor network disorder characterized by twisted movements or postures. The most frequent genetic cause is a GAG deletion in the Tor1a (DYT1) gene encoding torsinA with a reduced penetrance of 30-40 % suggesting additional genetic or environmental modifiers. Development of dystonia-like movements after a standardized peripheral nerve crush lesion in wild type (wt) and Tor1a+/- mice, that express 50 % torsinA only, was assessed by scoring of hindlimb movements during tail suspension, by rotarod testing and by computer-assisted gait analysis. Western blot analysis was performed for dopamine transporter (DAT), D1 and D2 receptors from striatal and quantitative RT-PCR analysis for DAT from midbrain dissections. Autoradiography was used to assess the functional DAT binding in striatum. Striatal dopamine and its metabolites were analyzed by high performance liquid chromatography. After nerve crush injury, we found abnormal posturing in the lesioned hindlimb of both mutant and wt mice indicating the profound influence of the nerve lesion (15x vs. 12x relative to control) resembling human peripheral pseudodystonia. In mutant mice the phenotypic abnormalities were increased by about 40 % (p < 0.05). This was accompanied by complex alterations of striatal dopamine homeostasis. Pharmacological blockade of dopamine synthesis reduced severity of dystonia-like movements, whereas treatment with L-Dopa aggravated these but only in mutant mice suggesting a DYT1 related central component relevant to the development of abnormal involuntary movements. Our findings suggest that upon peripheral nerve injury reduced torsinA concentration and environmental stressors may act in concert in causing the central motor network dysfunction of DYT1 dystonia.
Fabry disease is an X-linked lysosomal storage disorder due to impaired activity of alpha-galactosidase A with intracellular accumulation of globotriaosylceramide. Associated small fiber pathology leads to characteristic pain in Fabry disease. We systematically assessed sensory system, physical activity, metabolic parameters, and morphology of male and female mice with alpha-galactosidase A deficiency (Fabry ko) from 2 to 27 months of age and compared results with those of age- and gender-matched wild-type littermates of C57Bl/6J background. Results From the age of two months, male and female Fabry mice showed mechanical hypersensitivity (p < 0.001 each) compared to wild-type littermates. Young Fabry ko mice of both genders were hypersensitive to heat stimulation (p < 0.01) and developed heat hyposensitivity with aging (p < 0.05), while cold hyposensitivity was present constantly in young (p < 0.01) and old (p < 0.05) Fabry ko mice compared to wild-type littermates. Stride angle increased only in male Fabry ko mice with aging (p < 0.01) in comparison to wild-type littermates. Except for young female mice, male (p < 0.05) and female (p < 0.01) Fabry ko mice had a higher body weight than wild-type littermates. Old male Fabry ko mice were physically less active than their wild-type littermates (p < 0.05), had lower chow intake (p < 0.001), and lost more weight (p < 0.001) in a one-week treadmill experiment than wild-type littermates. Also, Fabry ko mice showed spontaneous pain protective behavior and developed orofacial dysmorphism resembling patients with Fabry disease.
Conclusions. Mice with alpha-galactosidase A deficiency show age-dependent and distinct deficits of the sensory system. alpha-galactosidase A-deficient mice seem to model human Fabry disease and may be helpful when studying the pathophysiology of Fabry-associated pain.
Background
Traumatic brain injury (TBI) is a major cause of death and disability. Neuroinflammation contributes to acute damage after TBI and modulates long-term evolution of degenerative and regenerative responses to injury. The aim of the present study was to evaluate the relationship of microglia activation to trauma severity, brain energy metabolism, and cellular reactions to injury in a mouse closed head injury model using combined in vivo PET imaging, ex vivo autoradiography, and immunohistochemistry.
Methods
A weight-drop closed head injury model was used to produce a mixed diffuse and focal TBI or a purely diffuse mild TBI (mTBI) in C57BL6 mice. Lesion severity was determined by evaluating histological damage and functional outcome using a standardized neuroscore (NSS), gliosis, and axonal injury by immunohistochemistry. Repeated intra-individual in vivo μPET imaging with the specific 18-kDa translocator protein (TSPO) radioligand [\(^{18}\)F]DPA-714 was performed on day 1, 7, and 16 and [\(^{18}\)F]FDG-μPET imaging for energy metabolism on days 2–5 after trauma using freshly synthesized radiotracers. Immediately after [\(^{18}\)F]DPA-714-μPET imaging on days 7 and 16, cellular identity of the [\(^{18}\)F]DPA-714 uptake was confirmed by exposing freshly cut cryosections to film autoradiography and successive immunostaining with antibodies against the microglia/macrophage marker IBA-1.
Results
Functional outcome correlated with focal brain lesions, gliosis, and axonal injury. [\(^{18}\)F]DPA-714-μPET showed increased radiotracer uptake in focal brain lesions on days 7 and 16 after TBI and correlated with reduced cerebral [\(^{18}\)F]FDG uptake on days 2–5, with functional outcome and number of IBA-1 positive cells on day 7. In autoradiography, [\(^{18}\)F]DPA-714 uptake co-localized with areas of IBA1-positive staining and correlated strongly with both NSS and the number of IBA1-positive cells, gliosis, and axonal injury. After mTBI, numbers of IBA-1 positive cells with microglial morphology increased in both brain hemispheres; however, uptake of [\(^{18}\)F]DPA-714 was not increased in autoradiography or in μPET imaging.
Conclusions
[\(^{18}\)F]DPA-714 uptake in μPET/autoradiography correlates with trauma severity, brain metabolic deficits, and microglia activation after closed head TBI.
From October 30–November 1, 2015, the 7th NEUROWIND e.V. meeting was held in Motzen, Brandenburg, Germany. Seventy doctoral students and postdocs from over 25 different groups working in German and Swiss University Hospitals or Research Institutes attended the meeting to discuss their latest experiments and findings in the fields of neuroimmunology, neurodegeneration and neurovascular research. This meeting report summarizes the many diverse presentations and the new preclinical to clinical neurology research data that were shared by the participants at the meeting.
Background
Serotonin (5-hydroxytryptamin, 5-HT) is an indolamine platelet agonist, biochemically derived from tryptophan. 5-HT is secreted from the enterochromaffin cells into the gastrointestinal tract and blood. Blood 5-HT has been proposed to regulate hemostasis by acting as a vasoconstrictor and by triggering platelet signaling through 5-HT receptor 2A (5HTR2A). Although platelets do not synthetize 5-HT, they take 5-HT up from the blood and store it in their dense granules which are secreted upon platelet activation.
Objective
To identify the molecular composite of the 5-HT uptake system in platelets and elucidate the role of platelet released 5-HT in thrombosis and ischemic stroke. Methods: 5-HT transporter knockout mice (5Htt\(^{-/-}\)) were analyzed in different in vitro and in vivo assays and in a model of ischemic stroke.
Results
In 5Htt\(^{-/-}\) platelets, 5-HT uptake from the blood was completely abolished and agonist-induced Ca2+ influx through store operated Ca\(^{2+}\) entry (SOCE), integrin activation, degranulation and aggregation responses to glycoprotein VI (GPVI) and C-type lectin-like receptor 2 (CLEC-2) were reduced. These observed in vitro defects in 5Htt\(^{-/-}\) platelets could be normalized by the addition of exogenous 5-HT. Moreover, reduced 5-HT levels in the plasma, an increased bleeding time and the formation of unstable thrombi were observed ex vivo under flow and in vivo in the abdominal aorta and carotid artery of 5Htt\(^{-/-}\) mice. Surprisingly, in the transient middle cerebral artery occlusion (tMCAO) model of ischemic stroke 5Htt\(^{-/-}\) mice showed nearly normal infarct volume and the neurological outcome was comparable to control mice.
Conclusion
Although secreted platelet 5-HT does not appear to play a crucial role in the development of reperfusion injury after stroke, it is essential to amplify the second phase of platelet activation through SOCE and plays an important role in thrombus stabilization.
Background
Mobile 3D fluoroscopes have become increasingly available in neurosurgical operating rooms. In this series, the image quality and value of intraoperative 3D fluoroscopy with intravenous contrast agent for the evaluation of aneurysm occlusion and vessel patency after clip placement was assessed in patients who underwent surgery for intracranial aneurysms.
Materials and methods
Twelve patients were included in this retrospective analysis. Prior to surgery, a 360° rotational fluoroscopy scan was performed without contrast agent followed by another scan with 50 ml of intravenous iodine contrast agent. The image files of both scans were transferred to an Apple PowerMac® workstation, subtracted and reconstructed using OsiriX® free software. The procedure was repeated after clip placement. Both image sets were compared for assessment of aneurysm occlusion and vessel patency.
Results
Image acquisition and contrast administration caused no adverse effects. Image quality was sufficient to follow the patency of the vessels distal to the clip. Metal artifacts reduce the assessability of the immediate vicinity of the clip. Precise image subtraction and post-processing can reduce metal artifacts and make the clip-site assessable and depict larger neck-remnants.
Conclusion
This technique quickly supplies images at adequate quality to evaluate distal vessel patency after aneurysm clipping. Significant aneurysm remnants may be depicted as well. As it does not require visual control of all vessels that are supposed to be evaluated intraoperatively, this technique may be complementary to other intraoperative tools like indocyanine green videoangiography and micro-Doppler, especially for the assessment of larger aneurysms. At the momentary state of this technology, it cannot replace postoperative conventional angiography. However, 3D fluoroscopy and image post-processing are young technologies. Further technical developments are likely to result in improved image quality.
microRNAs in chronic pain
(2016)
Chronic pain is a common problem in clinical practice, not well understood clinically, and frequently tough to satisfactorily diagnose. Because the pathophysiology is so complex, finding effective treatments for people with chronic pain has been overall less than successful and typically reduced to an unsatisfactory trial-and-error process, all of which translates into a significant burden to society. Knowledge of the mechanisms underlying the development of chronic pain, and moreover why some patients experience pain and others not, may aid in developing specific treatment regimens. Although nerve injuries are major contributors to pain chronification, they cannot explain the entire phenomenon. Considerable research has underscored the importance of the immune system for the development and maintenance of chronic pain, albeit the exact factors regulating inflammatory reactions remain unclear. Understanding the putative molecular and cellular regulator switches of inflammatory reactions will open novel opportunities for immune modulatory analgesics with putatively higher specificity and less adverse effects. It has become clear that small, non- coding RNA molecules known as microRNAs are in fact potent regulators of many thousands of genes and possibly cross-communicate between cellular pathways in multiple systems acting as so-called “master-switches”. Aberrant expression of miRNAs is now implicated in numerous disorders, including nerve injuries as well as in inflammatory processes. Moreover, compelling evidence supports the idea that miRNAs also regulate pain, and in analogy to the oncology field aid in the differential diagnosis of disease subtypes. In fact, first reports describing characteristic miRNA expression profiles in blood or cerebrospinal fluid of patients with distinct pain conditions are starting to emerge, however evidence linking specific miRNA expression profiles to specific pain disorders is still insufficient. The present thesis aimed at first, identifying specific miRNA signatures in two distinct chronic pain conditions, namely peripheral neuropathies of different etiologies and fibromyalgia syndrome. Second, it aimed at identifying miRNA profiles to better understand potential factors that differentiate painful from painless neuropathies and third, study the mechanistic role of miRNAs in the pathophysiology of pain, to pave the way for new druggable targets.
Three studies were conducted in order to identify miRNA expression signatures that are characteristic for the given chronic pain disorder. The first study measured expression of miR-21, miR-146a and miR-155 in white blood cells, skin and nerve biopsies of patients with peripheral neuropathies. It shows that peripheral neuropathies of different etiologies are associated with increased peripheral miR-21 and miR-146a, but decreased miR-155 expression. More importantly, it was shown that painful neuropathies have increased sural nerve miR-21 and miR-155 expression, but reduced miR-146a and miR-155 expression in distal skin of painful neuropathies. These results point towards the potential use of miRNAs profiles to stratify painful neuropathies. The seconds study extends these findings and first analyzed the role of miR-132-3p in patients and subsequently in an animal model of neuropathic pain. Interestingly, miR-132-3p was upregulated in white blood cells and sural nerve biopsies of patients with painful neuropathies and in animals after spared nerve injury. Pharmacologically modulating the expression of miR-132-3p dose-dependently reversed pain behavior and pain aversion, indicating the pro-nociceptive effect of miR-132-3p in chronic pain. This study thus demonstrates the potential analgesic impact by modulating miRNA expression. Fibromyalgia is associated with chronic widespread pain and, at least in a subgroup, impairment in small nerve fiber morphology and function. Interestingly, the disease probably comprises subgroups with different underlying pathomechanisms. In accordance with this notion, the third study shows that fibromyalgia is associated with both aberrant white blood cell and cutaneous miRNA expression. Being the first of its kind, this study identified miR-let-7d and its downstream target IGF-1R as potential culprit for impaired small nerve fiber homeostasis in a subset of patients with decreased intra-epidermal nerve fiber density. The work presented in this thesis is a substantial contribution towards the goal of better characterizing chronic pain based on miRNA expression signatures and thus pave the way for new druggable targets.
Background
Fabry-associated pain may be the first symptom of Fabry disease (FD) and presents with a unique phenotype including mostly acral burning triggerable pain attacks, evoked pain, pain crises, and permanent pain. We recently developed and validated the first Fabry Pain Questionnaire (FPQ) for adult patients. Here we report on the validation of the self-administered version of the FPQ that no longer requires a face-to-face interview but can be filled in by the patients themselves allowing more flexible data collection.
Methods
At our Würzburg Fabry Center for Interdisciplinary Treatment, Germany, we have developed the self-administered version of the FPQ by adapting the questionnaire to a self-report version. To do this, consecutive Fabry patients with current or past pain history (n = 56) were first interviewed face-to-face. Two weeks later patients’ self-reported questionnaire results were collected by mail (n = 55). We validated the self-administered version of the FPQ by assessing the inter-rater reliability agreement of scores obtained by supervised administration and self-administration of the FPQ.
Results
The FPQ contains 15 questions on the different pain phenotypes, on pain development during life with and without therapy, and on impairment due to pain. Statistical analysis showed that the majority of questions were answered in high agreement in both sessions with a mean AC1-statistic of 0.857 for 55 nominal-scaled items and a mean ICC of 0.587 for 9 scores.
Conclusions
This self-administered version of the first pain questionnaire for adult Fabry patients is a useful tool to assess Fabry-associated pain without a time-consuming face-to-face interview but via a self-reporting survey allowing more flexible usage.
Susac syndrome, a rare but probably underdiagnosed combination of encephalopathy, hearing loss, and visual deficits due to branch retinal artery occlusion of unknown aetiology has to be considered as differential diagnosis in various conditions. Particularly, differentiation from multiple sclerosis is often challenging since both clinical presentation and diagnostic findings may overlap. Optical coherence tomography is a powerful and easy to perform diagnostic tool to analyse the morphological integrity of retinal structures and is increasingly established to depict characteristic patterns of retinal pathology in multiple sclerosis. Against this background we hypothesised that differential patterns of retinal pathology facilitate a reliable differentiation between Susac syndrome and multiple sclerosis. In this multicenter cross-sectional observational study optical coherence tomography was performed in nine patients with a definite diagnosis of Susac syndrome. Data were compared with age-, sex-, and disease duration-matched relapsing remitting multiple sclerosis patients with and without a history of optic neuritis, and with healthy controls. Using generalised estimating equation models, Susac patients showed a significant reduction in either or both retinal nerve fibre layer thickness and total macular volume in comparison to both healthy controls and relapsing remitting multiple sclerosis patients. However, in contrast to the multiple sclerosis patients this reduction was not distributed over the entire scanning area but showed a distinct sectorial loss especially in the macular measurements. We therefore conclude that patients with Susac syndrome show distinct abnormalities in optical coherence tomography in comparison to multiple sclerosis patients. These findings recommend optical coherence tomography as a promising tool for differentiating Susac syndrome from MS.
To determine the role of striatal dopaminergic innervation on upper limb synergies during walking, we measured arm kinematics in 13 subjects with Parkinson disease. Patients were recruited according to several inclusion criteria to represent the best possible in vivo model of dopaminergic denervation. Of relevance, we included only subjects with normal spatio-temporal parameters of the stride and gait speed to avoid an impairment of upper limbs locomotor synergies as a consequence of gait impairment per se. Dopaminergic innervation of the striatum was measured by FP-CIT and SPECT. All patients showed a reduction of gait-associated arms movement. No linear correlation was found between arm ROM reduction and contralateral dopaminergic putaminal innervation loss. Still, a partition analysis revealed a 80% chance of reduced arm ROM when putaminal dopamine content loss was >47%. A significant correlation was described between the asymmetry indices of the swinging of the two arms and dopaminergic striatal innervation. When arm ROM was reduced, we found a positive correlation between upper-lower limb phase shift modulation ( at different gait velocities) and striatal dopaminergic innervation. These findings are preliminary evidence that dopaminergic striatal tone plays a modulatory role in upper-limb locomotor synergies and upper-lower limb coupling while walking at different velocities.
We analyzed rest tremor, one of the etiologically most elusive hallmarks of Parkinson disease(PD), in 12 consecutive PD patients during a specific task activating the locus coeruleus (LC) to investigate a putative role of noradrenaline (NA) in tremor generation and suppression. Clinical diagnosis was confirmed in all subjects by reduced dopamine reuptake transporter (DAT) binding values investigated by single photon computed tomography imaging (SPECT) with [\(^{123}\)I] N-\(\omega\)-fluoropropyl-2 \(\beta\)-carbomethoxy-3 \(\beta\)-(4-iodophenyl) tropane (FP-CIT). The intensity of tremor (i.e., the power of Electromyography [EMG] signals), but not its frequency, significantly increased during the task. In six subjects, tremor appeared selectively during the task. In a second part of the study, we retrospectively reviewed SPECT with FP-CIT data and confirmed the lack of correlation between dopaminergic loss and tremor by comparing DAT binding values of 82 PD subjects with bilateral tremor (n = 27), unilateral tremor (n = 22), and no tremor (n = 33). This study suggests a role of the LC in Parkinson tremor.
Das Schädel-Hirn-Trauma (SHT) entsteht durch äußere Gewalteinwirkung auf den Kopf und verursacht mechanisch eine Schädigung des Hirngewebes. Zusätzlich tragen sekundäre Pathomechanismen, wie Entzündungsprozesse und die Schädigung der Blut-Hirn-Schranke (BHS), dazu bei, dass sich das initial geschädigte Läsionsareal im Laufe der Zeit vergrößert. Vor allem bei jungen Erwachsenen ist das SHT eine der häufigsten Ursachen für bleibende Behinderungen und Todesfälle. Aufgrund der schweren Auswirkungen des SHT und der bislang fehlenden Therapieoptionen ist die Identifizierung neuer Zielstrukturen für eine kausale Therapie von größter Bedeutung. Ausgehend von tierexperimentellen Studien ist das Kallikrein-Kinin-System (KKS) ein besonders erfolgversprechender Angriffspunkt zur Behandlung des SHT. Die Aktivierung des KKS über den Gerinnungsfaktor XII (FXII) und die darauf folgende Bildung von Bradykinin sind mit dem Entstehen von Hirnödemen und Entzündungsreaktionen assoziiert. Vorangegangene Studien haben weiterhin die Frage aufgeworfen, ob und in welchem Maße thrombotische Prozesse einen Einfluss auf die Pathophysiologie und die sekundären Hirnschädigungen nach SHT haben. Da FXII sowohl das KKS als auch die intrinsische plasmatische Gerinnungskaskade initiiert und somit zur Fibrinbildung beiträgt, stand FXII im Mittelpunkt der Untersuchungen dieser Dissertation. Die vorliegende Arbeit beschäftigt sich mit den Fragen, (I) inwiefern FXII eine Rolle bei der sekundären Hirnschädigung nach Trauma spielt und (II) ob thrombotische Prozesse ein pathophysiologisches Merkmal nach Trauma darstellen. In zwei unterschiedlichen Trauma-Modellen wurden FXII-defiziente Tiere und mit einem spezifischen Inhibitor des aktivierten FXII (FXIIa) behandelte Tiere gegen Kontrolltiere nach SHT verglichen. Die Analyse der funktionellen Ausfallerscheinungen und des Ausmaßes an neuronaler Degeneration zeigte, dass FXII-Defizienz und FXIIa-Inhibition vor den Auswirkungen eines SHT schützen. Als zugrundeliegende Mechanismen wurden die Reduktion von thrombotisch verschlossenen Gefäßen in der Mikrovaskulatur des Gehirns sowie der Schutz vor BHS-Störungen und verringerte inflammatorische Prozesse identifiziert. Weiterhin wurde festgestellt, dass eine Blockade der intrinsischen Gerinnungskaskade über FXII keine intrazerebralen Blutungen auslöst. In Gewebeproben von Patienten mit SHT wurde gezeigt, dass Thrombozytenaggregate auch im klinischen Verlauf auftreten und sich somit die tierexperimentellen Befunde auf die humane Situation übertragen lassen. Insgesamt tragen die Ergebnisse dazu bei, die komplexen und vielfältigen Pathomechanismen nach SHT besser zu verstehen und vor allem die Relevanz thrombo-inflammatorischer Prozesse nach SHT aufzuzeigen. Die gezielte Blockade des FXII(a) könnte als therapeutisches Prinzip zur Abschwächung der Sekundärschaden nach SHT geeignet sein.
Background: The diagnostic and pathophysiological relevance of antibodies to aquaporin-4 (AQP4-Ab) in patients with neuromyelitis optica spectrum disorders (NMOSD) has been intensively studied. However, little is known so far about the clinical impact of AQP4-Ab seropositivity.
Objective: To analyse systematically the clinical and paraclinical features associated with NMO spectrum disorders in Caucasians in a stratified fashion according to the patients' AQP4-Ab serostatus.
Methods: Retrospective study of 175 Caucasian patients (AQP4-Ab positive in 78.3%).
Results: Seropositive patients were found to be predominantly female (p < 0.0003), to more often have signs of co-existing autoimmunity (p < 0.00001), and to experience more severe clinical attacks. A visual acuity of <= 0.1 during acute optic neuritis (ON) attacks was more frequent among seropositives (p < 0.002). Similarly, motor symptoms were more common in seropositive patients, the median Medical Research Council scale (MRC) grade worse, and MRC grades <= 2 more frequent, in particular if patients met the 2006 revised criteria (p < 0.005, p < 0.006 and p < 0.01, respectively), the total spinal cord lesion load was higher (p < 0.006), and lesions >= 6 vertebral segments as well as entire spinal cord involvement more frequent (p < 0.003 and p < 0.043). By contrast, bilateral ON at onset was more common in seronegatives (p < 0.007), as was simultaneous ON and myelitis (p < 0.001); accordingly, the time to diagnosis of NMO was shorter in the seronegative group (p < 0.029). The course of disease was more often monophasic in seronegatives (p < 0.008). Seropositives and seronegatives did not differ significantly with regard to age at onset, time to relapse, annualized relapse rates, outcome from relapse (complete, partial, no recovery), annualized EDSS increase, mortality rate, supratentorial brain lesions, brainstem lesions, history of carcinoma, frequency of preceding infections, oligoclonal bands, or CSF pleocytosis. Both the time to relapse and the time to diagnosis was longer if the disease started with ON (p < 0.002 and p < 0.013). Motor symptoms or tetraparesis at first myelitis and > 1 myelitis attacks in the first year were identified as possible predictors of a worse outcome.
Background: Pioglitazone, an oral anti-diabetic that stimulates the PPAR-gamma transcription factor, increased survival of mice with amyotrophic lateral sclerosis (ALS).
Methods/Principal Findings: We performed a phase II, double blind, multicentre, placebo controlled trial of pioglitazone in ALS patients under riluzole. 219 patients were randomly assigned to receive 45 mg/day of pioglitazone or placebo (one: one allocation ratio). The primary endpoint was survival. Secondary endpoints included incidence of non-invasive ventilation and tracheotomy, and slopes of ALS-FRS, slow vital capacity, and quality of life as assessed using EUROQoL EQ-5D. The study was conducted under a two-stage group sequential test, allowing to stop for futility or superiority after interim analysis. Shortly after interim analysis, 30 patients under pioglitazone and 24 patients under placebo had died. The trial was stopped for futility; the hazard ratio for primary endpoint was 1.21 (95% CI: 0.71-2.07, p = 0.48). Secondary endpoints were not modified by pioglitazone treatment. Pioglitazone was well tolerated.
Conclusion/Significance: Pioglitazone has no beneficial effects on the survival of ALS patients as add-on therapy to riluzole.
Interleukin-4 (IL-4) is an anti-inflammatory and analgesic cytokine that induces opioid receptor transcription. We investigated IL-4 knockout (ko) mice to characterize their pain behavior before and after chronic constriction injury (CCI) of the sciatic nerve as a model for neuropathic pain. We investigated opioid responsivity and measured cytokine and opioid receptor gene expression in the peripheral and central nervous system (PNS, CNS) of IL-4 ko mice in comparison with wildtype (wt) mice. Naïve IL-4 ko mice displayed tactile allodynia (wt: 0.45 g; ko: 0.18 g; p<0.001), while responses to heat and cold stimuli and to muscle pressure were not different. No compensatory changes in the gene expression of tumor necrosis factor-alpha (TNF), IL-1β, IL-10, and IL-13 were found in the PNS and CNS of naïve IL-4 ko mice. However, IL-1β gene expression was stronger in the sciatic nerve of IL-4 ko mice (p<0.001) 28 days after CCI and only IL-4 ko mice had elevated IL-10 gene expression (p = 0.014). Remarkably, CCI induced TNF (p<0.01), IL-1β (p<0.05), IL-10 (p<0.05), and IL-13 (p<0.001) gene expression exclusively in the ipsilateral spinal cord of IL-4 ko mice. The compensatory overexpression of the anti-inflammatory and analgesic cytokines IL-10 and IL-13 in the spinal cord of IL-4 ko mice may explain the lack of genotype differences for pain behavior after CCI. Additionally, CCI induced gene expression of μ, κ, and δ opioid receptors in the contralateral cortex and thalamus of IL-4 ko mice, paralleled by fast onset of morphine analgesia, but not in wt mice. We conclude that a lack of IL-4 leads to mechanical sensitivity; the compensatory hyperexpression of analgesic cytokines and opioid receptors after CCI, in turn, protects IL-4 ko mice from enhanced pain behavior after nerve lesion.
In Vivo Imaging of Stepwise Vessel Occlusion in Cerebral Photothrombosis of Mice by \(^{19}\)F MRI
(2011)
Background
\(^{19}\)F magnetic resonance imaging (MRI) was recently introduced as a promising technique for in vivo cell tracking. In the present study we compared \(^{19}\)F MRI with iron-enhanced MRI in mice with photothrombosis (PT) at 7 Tesla. PT represents a model of focal cerebral ischemia exhibiting acute vessel occlusion and delayed neuroinflammation.
Methods/Principal Findings
Perfluorocarbons (PFC) or superparamagnetic iron oxide particles (SPIO) were injected intravenously at different time points after photothrombotic infarction. While administration of PFC directly after PT induction led to a strong \(^{19}\)F signal throughout the entire lesion, two hours delayed application resulted in a rim-like \(^{19}\)F signal at the outer edge of the lesion. These findings closely resembled the distribution of signal loss on T2-weighted MRI seen after SPIO injection reflecting intravascular accumulation of iron particles trapped in vessel thrombi as confirmed histologically. By sequential administration of two chemically shifted PFC compounds 0 and 2 hours after illumination the different spatial distribution of the \(^{19}\)F markers (infarct core/rim) could be visualized in the same animal. When PFC were applied at day 6 the fluorine marker was only detected after long acquisition times ex vivo. SPIO-enhanced MRI showed slight signal loss in vivo which was much more prominent ex vivo indicative for neuroinflammation at this late lesion stage.
Conclusion
Our study shows that vessel occlusion can be followed in vivo by \(^{19}\)F and SPIO-enhanced high-field MRI while in vivo imaging of neuroinflammation remains challenging. The timing of contrast agent application was the major determinant of the underlying processes depicted by both imaging techniques. Importantly, sequential application of different PFC compounds allowed depiction of ongoing vessel occlusion from the core to the margin of the ischemic lesions in a single MRI measurement.
Background
"Negative affect" is one of the major migraine triggers. The aim of the study was to assess attentional biases for negative affective stimuli that might be related to migraine triggers in migraine patients with either few or frequent migraine and healthy controls.
Methods
Thirty-three subjects with frequent migraine (FM) or with less frequent episodic migraine, and 20 healthy controls conducted two emotional Stroop tasks in the interictal period. In task 1, general affective words and in task 2, pictures of affective faces (angry, neutral, happy) were used. For each task we calculated two emotional Stroop indices. Groups were compared using one-way ANOVAs.
Results
The expected attentional bias in migraine patients was not found. However, in task 2 the controls showed a significant attentional bias to negative faces, whereas the FM group showed indices near zero. Thus, the FM group responded faster to negative than to positive stimuli. The difference between the groups was statistically significant.
Conclusions
The findings in the FM group may reflect a learned avoidance mechanism away from affective migraine triggers.
Background: Despite pleiotropic immunomodulatory effects of apolipoprotein E (apoE) in vitro, its effects on the clinical course of experimental autoimmune encephalomyelitis (EAE) and multiple sclerosis (MS) are still controversial. As sex hormones modify immunomodulatory apoE functions, they may explain contentious findings. This study aimed to investigate sex-specific effects of apoE on disease course of EAE and MS.
Methods: MOG\(_{35-55}\) induced EAE in female and male apoE-deficient mice was assessed clinically and histopathologically. apoE expression was investigated by qPCR. The association of the MS severity score (MSSS) and APOE rs429358 and rs7412 was assessed across 3237 MS patients using linear regression analyses.
Results: EAE disease course was slightly attenuated in male apoE-deficient (apoE\(^{-/-}\)) mice compared to wildtype mice (cumulative median score: apoE\(^{-/-}\) = 2 [IQR 0.0-4.5]; wildtype = 4 [IQR 1.0-5.0]; n = 10 each group, p = 0.0002). In contrast, EAE was more severe in female apoE\(^{-/-}\) mice compared to wildtype mice (cumulative median score: apoE\(^{-/-}\) = 3 [IQR 2.0-4.5]; wildtype = 3 [IQR 0.0-4.0]; n = 10, p = 0.003). In wildtype animals, apoE expression during the chronic EAE phase was increased in both females and males (in comparison to naive animals; p < 0.001). However, in MS, we did not observe a significant association between MSSS and rs429358 or rs7412, neither in the overall analyses nor upon stratification for sex.
Conclusions: apoE exerts moderate sex-specific effects on EAE severity. However, the results in the apoE knock-out model are not comparable to effects of polymorphic variants in the human APOE gene, thus pinpointing the challenge of translating findings from the EAE model to the human disease.
The two bradykinin receptors B1R and B2R are central components of the kallikrein–kinin system with different expression kinetics and binding characteristics. Activation of these receptors by kinins triggers inflammatory responses in the target organ and in most situations enhances tissue damage. We could recently show that blocking of B1R, but not B2R, protects from cortical cryolesion by reducing inflammation and edema formation. In the present study, we investigated the role of B1R and B2R in a closed head model of focal traumatic brain injury (TBI; weight drop). Increased expression of B1R in the injured hemispheres of wild-type mice was restricted to the later stages after brain trauma, i.e. day 7 (P<0.05), whereas no significant induction could be observed for the B2R (P>0.05). Mice lacking the B1R, but not the B2R, showed less functional deficits on day 3 (P<0.001) and day 7 (P<0.001) compared with controls. Pharmacological blocking of B1R in wild-type mice had similar effects. Reduced axonal injury and astroglia activation could be identified as underlying mechanisms, while inhibition of B1R had only little influence on the local inflammatory response in this model. Inhibition of B1R may become a novel strategy to counteract trauma-induced neurodegeneration.
The 7th International Symposium on Neuroprotection and Neurorepair was held from May 2nd to May 5th, 2012 in Potsdam, Germany. The symposium, which directly continues the successful Magdeburg meeting series, attracted over 330 colleagues from 29 countries to discuss recent findings and advances in the field. The focus of the 2012 symposium was widened from stroke and traumatic brain injury to neurodegenerative diseases, notably dementia, and more generally the ageing brain. Thereby, emphasis was given on neurovascular aspects of neurodegeneration and stroke including the blood–brain barrier, recent findings regarding the pathomechanism of Alzheimer’s disease, and brain imaging approaches. In addition, neurobiochemical aspects of neuroprotection, the role of astrogliosis, the clinical progress of cell-based approaches as well as translational hurdles and opportunities were discussed in-depth. This review summarizes some of the most stimulating discussions and reports from the meeting.
The present antithrombotic drugs used to treat or prevent ischemic stroke have significant limitations: either they show only moderate efficacy (platelet inhibitors), or they significantly increase the risk for hemorrhages (thrombolytics, anticoagulants). Although most strokes are caused by thrombotic or embolic vessel occlusions, the pathophysiological role of platelets and coagulation is largely unclear. The introduction of novel transgenic mouse models and specific coagulation inhibitors facilitated a detailed analysis of molecular pathways mediating thrombus formation in models of acute ischemic stroke. Prevention of early platelet adhesion to the damaged vessel wall by blocking platelet surface receptors glycoprotein Ib alpha (GPIbα) or glycoprotein VI (GPVI) protects from stroke without provoking bleeding complications. In addition, downstream signaling of GPIbα and GPVI has a key role in platelet calcium homeostasis and activation. Finally, the intrinsic coagulation cascade, activated by coagulation factor XII (FXII), has only recently been identified as another important mediator of thrombosis in cerebrovascular disease, thereby disproving established concepts. This review summarizes the latest insights into the pathophysiology of thrombus formation in the ischemic brain. Potential clinical merits of novel platelet inhibitors and anticoagulants as powerful and safe tools to combat ischemic stroke are discussed.
NKG2D is an activating receptor on T cells, which has been implicated in the pathogenesis of autoimmune diseases. T cells are critically involved in idiopathic inflammatory myopathies (IIM) and have been proposed as specific therapeutic targets. However, the mechanisms underlying T cell-mediated progressive muscle destruction in IIM remain to be elucidated. We here determined the involvement of the NKG2D - IL-15 signaling pathway. Primary human myoblasts expressed NKG2D ligands, which were further upregulated upon inflammatory stimuli. In parallel, shedding of the soluble NKG2D ligand MICA (sMICA) decreased upon inflammation potentially diminishing inhibition of NKG2D signaling. Membrane-related expression of IL-15 by myoblasts induced differentiation of naive CD8\(^+\) T cells into highly activated, cytotoxic \(CD8^+NKG2D^{high}\) T cells demonstrating NKG2D-dependent lysis of myoblasts in vitro. \(CD8^+NKG2D^{high}\) T cell frequencies were increased in the peripheral blood of polymyositis (PM) patients and correlated with serum creatinine kinase concentrations, while serum sMICA levels were not significantly changed. In muscle biopsy specimens from PM patients expression of the NKG2D ligand MICA/B was upregulated, IL-15 was expressed by muscle cells, CD68\(^+\) macrophages as well as CD4\(^+\) T cells, and \(CD8^+NKG2D^+\) cells were frequently detected within inflammatory infiltrates arguing for a local signaling circuit in the inflammatory muscle milieu. In conclusion, the NKG2D - IL-15 signaling pathway contributes to progressive muscle destruction in IIM potentially opening new therapeutic avenues.
Die Rolle thromboinflammatorischer Vorgänge in der Pathogenese des ischämischen Schlaganfalls ist in den letzten Jahren immer mehr in den wissenschaftlichen Fokus gerückt. Plasmakallikrein (PK) spaltet von hochmolekularem Kininogen (KNG) Bradykinin (BK) ab und ist dadurch Ausgangspunkt des proinflammatorischen Kallikrein-Kinin-Systems (KKS). Zum anderen kann es den Gerinnungsfaktor XII (FXII) aktivieren, den Ausgangspunkt der intrinsischen Gerinnungskaskade. Es initiiert also sowohl inflammatorische als auch thrombotische Vorgänge. Daher wurde in dieser Arbeit der Effekt einer Blockade PKs in einem Mausmodell der fokalen zerebralen Ischämie untersucht – und zwar sowohl durch genetische Depletion als auch durch pharmakologische Blockade. Beide Ansätze brachten einen nachhaltigen protektiven Effekt in Bezug auf Infarktgrößen und funktionelles Outcome, ohne die Blutungsgefahr zu erhöhen.
Studying the function and malfunction of genes and proteins associated with inherited forms of peripheral neuropathies has provided multiple clues to our understanding of myelinated nerves in health and disease. Here, we have generated a mouse model for the peripheral neuropathy Charcot–Marie–Tooth disease type 4H by constitutively disrupting the mouse orthologue of the suspected culprit gene FGD4 that encodes the small RhoGTPase Cdc42-guanine nucleotide exchange factor Frabin. Lack of Frabin/Fgd4 causes dysmyelination in mice in early peripheral nerve development, followed by profound myelin abnormalities and demyelination at later stages. At the age of 60 weeks, this was accompanied by electrophysiological deficits. By crossing mice carrying alleles of Frabin/Fgd4 flanked by loxP sequences with animals expressing Cre recombinase in a cell type-specific manner, we show that Schwann cell-autonomous Frabin/Fgd4 function is essential for proper myelination without detectable primary contributions from neurons. Deletion of Frabin/Fgd4 in Schwann cells of fully myelinated nerve fibres revealed that this protein is not only required for correct nerve development but also for accurate myelin maintenance. Moreover, we established that correct activation of Cdc42 is dependent on Frabin/Fgd4 function in healthy peripheral nerves. Genetic disruption of Cdc42 in Schwann cells of adult myelinated nerves resulted in myelin alterations similar to those observed in Frabin/Fgd4-deficient mice, indicating that Cdc42 and the Frabin/Fgd4–Cdc42 axis are critical for myelin homeostasis. In line with known regulatory roles of Cdc42, we found that Frabin/Fgd4 regulates Schwann cell endocytosis, a process that is increasingly recognized as a relevant mechanism in peripheral nerve pathophysiology. Taken together, our results indicate that regulation of Cdc42 by Frabin/Fgd4 in Schwann cells is critical for the structure and function of the peripheral nervous system. In particular, this regulatory link is continuously required in adult fully myelinated nerve fibres. Thus, mechanisms regulated by Frabin/Fgd4–Cdc42 are promising targets that can help to identify additional regulators of myelin development and homeostasis, which may crucially contribute also to malfunctions in different types of peripheral neuropathies.
Introduction: Reversible posterior leukoencephalopathy syndrome – a reversible subacute global encephalopathy clinically presenting with headache, altered mental status, visual symptoms such as hemianopsia or cortical blindness, motor symptoms, and focal or generalized seizures – is characterized by a subcortical vasogenic edema symmetrically affecting posterior brain regions. Complete reversibility of both clinical signs and magnetic resonance imaging lesions is regarded as a defining feature of reversible posterior leukoencephalopathy syndrome. Reversible posterior leukoencephalopathy syndrome is almost exclusively seen in the setting of a predisposing clinical condition, such as pre-eclampsia, systemic infections, sepsis and shock, certain autoimmune diseases, various malignancies and cytotoxic chemotherapy, transplantation and concomitant immunosuppression (especially with calcineurin inhibitors) as well as episodes of abrupt hypertension. We describe for the first time clinical, radiological and histological findings in a case of reversible posterior leukoencephalopathy syndrome with an irreversible and fatal outcome occurring in the absence of any of the known predisposing clinical conditions except for a hypertensive episode.
Case presentation: A 58-year-old Caucasian woman presented with a two-week history of subacute and progressive occipital headache, blurred vision and imbalance of gait and with no evidence for raised arterial blood pressure during the two weeks previous to admission. Her past medical history was unremarkable except for controlled arterial hypertension. Cerebral magnetic resonance imaging demonstrated cortical and subcortical lesions with combined vasogenic and cytotoxic edema atypical for both venous congestion and arterial infarction. Routine laboratory and cerebrospinal fluid parameters were normal. The diagnosis of reversible posterior leukoencephalopathy syndrome was established.
Within hours after admission the patient showed a rapidly decreasing level of consciousness, extension and flexion synergisms, bilaterally extensor plantar responses and rapid cardiopulmonary decompensation requiring ventilatory and cardiocirculatory support. Follow-up cerebral imaging demonstrated widespread and confluent cytotoxic edematous lesions in different arterial territories, global cerebral swelling, and subsequent upper and lower brainstem herniation. Four days after admission, the patient was declared dead because of brain death.
Conclusion: This case demonstrates that fulminant and fatal reversible posterior leukoencephalopathy syndrome may occur spontaneously, that is, in the absence of any of the known predisposing systemic conditions.
Background
Brain ischemia is known to include neuronal cell death and persisting neurological deficits. A lack of oxygen and glucose are considered to be key mediators of ischemic neurodegeneration while the exact mechanisms are yet unclear. In former studies the expression of two different two-pore domain potassium \((K_{2P})\) channels (TASK1, TREK1) were shown to ameliorate neuronal damage due to cerebral ischemia. In neurons, TASK channels carrying hyperpolarizing \(K^+\) leak currents, and the pacemaker channel HCN2, carrying depolarizing \(I_h\), stabilize the membrane potential by a mutual functional interaction. It is assumed that this ionic interplay between TASK and HCN2 channels enhances the resistance of neurons to insults accompanied by extracellular pH shifts.
Methods
In C57Bl/6 (wildtype, WT), \(hcn2^{+/+}\) and \(hcn2^{-/-}\) mice we used an in vivo model of cerebral ischemia (transient middle cerebral artery occlusion (tMCAO)) to depict a functional impact of HCN2 in stroke formation. Subsequent analyses comprise behavioural tests and hcn2 gene expression assays.
Results
After 60 min of tMCAO induction in WT mice, we collected tissue samples at 6, 12, and 24 h after reperfusion. In the infarcted neocortex, hcn2 expression analyses revealed a nominal peak of hcn2 expression 6 h after reperfusion with a tendency towards lower expression levels with longer reperfusion times. Hcn2 gene expression levels in infarcted basal ganglia did not change after 6 h and 12 h. Only at 24 h after reperfusion, hcn2 expression significantly decreases by ~55%. However, 30 min of tMCAO in hcn2-/- as well as hcn2+/+ littermates induced similar infarct volumes. Behavioural tests for global neurological function (Bederson score) and motor function/coordination (grip test) were performed at day 1 after surgery. Again, we found no differences between the groups.
Conclusions
Here, we hypothesized that the absence of HCN2, an important functional counter player of TASK channels, affects neuronal survival during stroke-induced tissue damage. However, together with a former study on TASK3 these results implicate that both TASK3 and HCN2 which were supposed to be neuroprotective due to their pH-dependency, do not influence ischemic neurodegeneration during stroke in the tMCAO model.
From october 25th - 27th 2013, the 5th NEUROWIND e.V. meeting was held in Motzen, Brandenburg, Germany. This year more than 60 doctoral students and postdocs from over 25 different groups working in German university hospitals or research institutes attended the meeting to discuss their latest findings in the fields of neuroimmunology, neurodegeneration and neurovascular research. All participants appreciated the stimulating environment in Motzen, Brandenburg, and people took the opportunity for scientific exchange, discussion about ongoing projects and already started further collaborations. Like in the previous years, the symposium was regarded as a very well organized platform to support research of young investigators in Germany.
According to the major aim of NEUROWIND e.V. to support younger researchers in Germany the 3rd NEUROWIND YOUNG SCIENTIST AWARD for experimental neurology was awarded to Ruth Stassart working in the group of Klaus Armin Nave and Wolfgang Brück (MPI Göttingen and Department of Neuropathology, Göttingen Germany). The successful work was published in Nature Neuroscience entitled “A role for Swann cell-derived neuregulin-1 in remyelination”. This outstanding paper deals with the function of Schwann cell neuregulin as an endogenous factor for myelin repair. The award is endowed with 20.000 Euro sponsored by Merck Serono GmbH, Darmstadt, Germany (unrestricted educational grant). This year’s keynote lecture was given by Albert Ludolph, Head of the Department of Neurology at the University Clinic of Ulm. Dr. Ludolph highlighted the particular role of individual scientists for the development of research concepts in Alzheimer´s disease (AD) and frontotemporal dementia (FTD).
Das Körperselbstgefühl (KSG) bezeichnet das Gefühl, einen bestimmten Kör-perteil als dem eigenen Körper zugehörig zu empfinden. Es erscheint stabil und nicht störbar, lässt sich jedoch bei den meisten Menschen experimentell beein-flussen. Ein Beispiel hierfür ist die Puppenhandillusion (PHI), bei der die nicht sichtbare eigene Hand des Probanden und eine sichtbare Plastikhand in glei-cher Stellung an den gleichen Fingerstellen synchron mit zwei Pinseln bestri-chen wird, wodurch die Wahrnehmung entsteht, die Plastikhand sei die eigene. Veränderungen des KSG können jedoch auch im Rahmen neurodegenerativer Erkrankungen vorkommen. So nimmt beim kortikobasalen Syndrom (CBS) etwa die Hälfte der Patienten im Krankheitsverlauf einen Arm und seine Bewegungen als fremd war ("Alien-limb“-Phänomen). Das CBS beginnt oft einseitig und ist durch eine rasch fortschreitende, akinetisch-rigide Parkinson-Symptomatik, aber auch durch kortikale Funktionsstörungen gekennzeichnet, so dass es ne-ben einer Störung des KSG auch zu einer Störung der räumlichen Aufmerk-samkeit (Hemineglect) kommt. Bislang wurde der Zusammenhang zwischen Raumwahrnehmung, KSG und PHI bei gesunden älteren Menschen noch nicht systematisch untersucht. Ebenso wenig war bisher bekannt, inwieweit das KSG bei CBS-Patienten durch die PHI modulierbar ist. Wir untersuchten 65 gesunde ältere Probanden (60 - 90 Jahre) ohne neurologi-sche Vorerkrankungen sowie zehn Patienten zwischen 59 und 77 Jahren mit wahrscheinlichem oder möglichem CBS. Den kognitiven und orientierend seeli-schen Zustand eruierten wir mit Hilfe des PANDA- und des Uhrentests, die Raumwahrnehmung testeten wir mittels des Milner-Landmark-Tests sowie des Letter-Cancellation-Tests, das spontane Körperselbstgefühl wurde mittels eines Fragebogens erfasst. Der PHI-Versuch wurde mit synchroner sowie asynchro-ner taktiler Stimulation durchgeführt, das Auftreten eines Selbstgefühls für die Plastikhand wurde subjektiv über spontane Äußerungen und einen etablierten Fragebogen, objektiv über den sog. propriozeptiven Drift der stimulierten Hand erfasst. Unter den Kontrollprobanden fanden sich 12% mit einer wahrscheinlichen De-menz, wohingegen dies bei 80% der CBS-Patienten der Fall war. Im Milner-Landmark-Test zeigte sich bei den Kontrollprobanden eine Überschätzung des rechten Segmentes einer mittig geteilten Linie, entsprechend einem milden Hemineglect, bei den CBS-Patienten konnte keine einheitliche Tendenz festge-stellt werden. Das spontane Körperselbstgefühl stellte sich bei nahezu allen Probanden als intakt dar, während sich bei vier Patienten mit CBS Hinweise auf aktuelle oder intermittierende Störungen desselben ergaben. Die Puppenhandil-lusion war in der Gruppe gesunder Älterer bei synchroner Stimulation auslös-bar, nicht jedoch bei asynchroner Stimulation. Eine Lateralisierungstendenz zeigte sich nicht. Darüber hinaus konnte bei den Probanden eine positive Korre-lation zwischen dem propriozeptiven Drift der linken Hand nach synchroner Stimulation und dem Hemineglect nach links gefunden werden. Bei den CBS-Patienten fand sich unabhängig von der Stimulationsart (synchron oder asyn-chron) eine erhöhte Bereitschaft, die linke Puppenhand ins eigene Körperbild zu integrieren. Das Auftreten der PHI bei gesunden älteren Probanden ist vergleichbar mit den Daten jüngerer Probandengruppen. Hinweise auf eine hemisphärische Laterali-sierungstendenz der PHI ergaben sich nicht, jedoch scheint der in dieser Grup-pe festgestellte leichtgradige Hemineglect nach links den multisensorischen Prozess zu beeinflussen, eine künstliche Hand in das eigene Körperschema zu integrieren. Bei den CBS-Patienten war die PHI unabhängig vom Stimulations-modus links besser auslösbar als rechts, was mit vorwiegend rechtshemisphä-rischen krankheitsbedingten Veränderungen des multisensorischen Integrati-onsprozesses vereinbar ist.
Motor complications in Parkinson’s disease (PD) result from the short half-life and irregular plasma fluctuations of oral levodopa. When strategies of providing more continuous dopaminergic stimulation by adjusting oral medication fail, patients may be candidates for one of three device-aided therapies: deep brain stimulation (DBS), continuous subcutaneous apomorphine infusion, or continuous duodenal/jejunal levodopa/carbidopa pump infusion (DLI). These therapies differ in their invasiveness, side-effect profile, and the need for nursing care. So far, very few comparative studies have evaluated the efficacy of the three device-aided therapies for specific motor problems in advanced PD. As a result, neurologists currently lack guidance as to which therapy could be most appropriate for a particular PD patient. A group of experts knowledgeable in all three therapies reviewed the currently available literature for each treatment and identified variables of clinical relevance for choosing one of the three options such as type of motor problems, age, and cognitive and psychiatric status. For each scenario, pragmatic and (if available) evidence-based recommendations are provided as to which patients could be candidates for either DBS, DLI, or subcutaneous apomorphine.
Introduction: Reversible posterior leukoencephalopathy syndrome – a reversible subacute global encephalopathy clinically presenting with headache, altered mental status, visual symptoms such as hemianopsia or cortical blindness, motor symptoms, and focal or generalized seizures – is characterized by a subcortical vasogenic edema symmetrically affecting posterior brain regions. Complete reversibility of both clinical signs and magnetic resonance imaging lesions is regarded as a defining feature of reversible posterior leukoencephalopathy syndrome. Reversible posterior leukoencephalopathy syndrome is almost exclusively seen in the setting of a predisposing clinical condition, such as pre-eclampsia, systemic infections, sepsis and shock, certain autoimmune diseases, various malignancies and cytotoxic chemotherapy, transplantation and concomitant immunosuppression (especially with calcineurin inhibitors) as well as episodes of abrupt hypertension. We describe for the first time clinical, radiological and histological findings in a case of reversible posterior leukoencephalopathy syndrome with an irreversible and fatal outcome occurring in the absence of any of the known predisposing clinical conditions except for a hypertensive episode.
Case presentation: A 58-year-old Caucasian woman presented with a two-week history of subacute and progressive occipital headache, blurred vision and imbalance of gait and with no evidence for raised arterial blood pressure during the two weeks previous to admission. Her past medical history was unremarkable except for controlled arterial hypertension. Cerebral magnetic resonance imaging demonstrated cortical and subcortical lesions with combined vasogenic and cytotoxic edema atypical for both venous congestion and arterial infarction. Routine laboratory and cerebrospinal fluid parameters were normal. The diagnosis of reversible posterior leukoencephalopathy syndrome was established. Within hours after admission the patient showed a rapidly decreasing level of consciousness, extension and flexion synergisms, bilaterally extensor plantar responses and rapid cardiopulmonary decompensation requiring ventilatory and cardiocirculatory support. Follow-up cerebral imaging demonstrated widespread and confluent cytotoxic edematous lesions in different arterial territories, global cerebral swelling, and subsequent upper and lower brainstem herniation. Four days after admission, the patient was declared dead because of brain death.
Conclusion: This case demonstrates that fulminant and fatal reversible posterior leukoencephalopathy syndrome may occur spontaneously, that is, in the absence of any of the known predisposing systemic conditions.
Background
Brain ischemia is known to include neuronal cell death and persisting neurological deficits. A lack of oxygen and glucose are considered to be key mediators of ischemic neurodegeneration while the exact mechanisms are yet unclear. In former studies the expression of two different two-pore domain potassium \((K_{2P})\) channels (TASK1, TREK1) were shown to ameliorate neuronal damage due to cerebral ischemia. In neurons, TASK channels carrying hyperpolarizing \(K^+\) leak currents, and the pacemaker channel HCN2, carrying depolarizing Ih, stabilize the membrane potential by a mutual functional interaction. It is assumed that this ionic interplay between TASK and HCN2 channels enhances the resistance of neurons to insults accompanied by extracellular pH shifts.
Methods
In C57Bl/6 (wildtype, WT), \(hcn2^{+/+}\) and \(hcn2^{-/-}\) mice we used an in vivo model of cerebral ischemia (transient middle cerebral artery occlusion (tMCAO)) to depict a functional impact of HCN2 in stroke formation. Subsequent analyses comprise behavioural tests and hcn2 gene expression assays.
Results
After 60 min of tMCAO induction in WT mice, we collected tissue samples at 6, 12, and 24 h after reperfusion. In the infarcted neocortex, hcn2 expression analyses revealed a nominal peak of hcn2 expression 6 h after reperfusion with a tendency towards lower expression levels with longer reperfusion times. Hcn2 gene expression levels in infarcted basal ganglia did not change after 6 h and 12 h. Only at 24 h after reperfusion, hcn2 expression significantly decreases by ~55%. However, 30 min of tMCAO in hcn2-/- as well as hcn2+/+ littermates induced similar infarct volumes. Behavioural tests for global neurological function (Bederson score) and motor function/coordination (grip test) were performed at day 1 after surgery. Again, we found no differences between the groups.
Conclusions
Here, we hypothesized that the absence of HCN2, an important functional counter player of TASK channels, affects neuronal survival during stroke-induced tissue damage. However, together with a former study on TASK3 these results implicate that both TASK3 and HCN2 which were supposed to be neuroprotective due to their pH-dependency, do not influence ischemic neurodegeneration during stroke in the tMCAO model.
Die vorliegende Arbeit ist die erste, die sich mit der Frage beschäftigt, mit welcher zur Deeskalation eingesetzten Therapie nach Beendigung einer Eskalationstherapie mit Mitoxantron am besten Krankheitsstabilität erreicht werden kann bzw. ob Patienten-/Krankheitscharakteristika existieren, die eine bestimmte Nachfolge-Therapie favorisieren.
Trotz neuer Behandlungsmöglichkeiten der hochaktiven MS mit Fingolimod, Natalizumab und Alemtuzumab hat Mitoxantron im klinischen Alltag nach wie vor einen hohen Stellenwert, so dass die Fragestellung dieser Studie weiter relevant ist.
Es zeigten sich keine Patientencharakteristika, die auf eine erfolgsversprechende Therapie in der Deeskalationsphase nach Mitoxantron schließen ließen.
Bei Patienten, bei denen während der Eskalation mit Mitoxantron die Dosis reduziert werden konnte, wurden während der Deeskalationstherapie ein stabilerer Verlauf und weniger Therapiewechsel beobachtet. Bei Patienten, die wegen einer rein chronischen Krankheitsprogredienz eskaliert wurden, trat eine Verschlechterung nach Deeskalation häufiger auf als bei denjenigen, welche wegen Schubaktivität eskaliert wurden.
Die Aussagekraft der Daten wird durch die nur niedrige Anzahl der in diese Studie eingeschlossenen Patienten limitiert. Rekrutierungsprobleme stellten die Hauptursache für die geringe Anzahl der Studienteilnehmer dar.
Treatment of dysferlinopathy with deflazacort: a double-blind, placebo-controlled clinical trial
(2013)
Background: Dysferlinopathies are autosomal recessive disorders caused by mutations in the dysferlin (DYSF) gene encoding the dysferlin protein. DYSF mutations lead to a wide range of muscular phenotypes, with the most prominent being Miyoshi myopathy (MM) and limb girdle muscular dystrophy type 2B (LGMD2B).
Methods: We assessed the one-year-natural course of dysferlinopathy, and the safety and efficacy of deflazacort treatment in a double-blind, placebo-controlled cross-over trial. After one year of natural course without intervention, 25 patients with genetically defined dysferlinopathy were randomized to receive deflazacort and placebo for six months each (1 mg/kg/day in month one, 1 mg/kg every 2nd day during months two to six) in one of two treatment sequences. Results: During one year of natural course, muscle strength declined about 2% as measured by CIDD (Clinical Investigation of Duchenne Dystrophy) score, and 76 Newton as measured by hand-held dynamometry. Deflazacort did not improve muscle strength. In contrast, there is a trend of worsening muscle strength under deflazacort treatment, which recovers after discontinuation of the study drug. During deflazacort treatment, patients showed a broad spectrum of steroid side effects.
Conclusion: Deflazacort is not an effective therapy for dysferlinopathies, and off-label use is not warranted. This is an important finding, since steroid treatment should not be administered in patients with dysferlinopathy, who may be often misdiagnosed as polymyositis.
Background: Hereditary spastic paraplegias (HSPs) are characterised by lower limb spasticity due to degeneration of the corticospinal tract. We set out for an electrophysiological characterisation of motor and sensory tracts in patients with HSP.
Methods: We clinically and electrophysiologically examined a cohort of 128 patients with genetically confirmed or clinically probable HSP. Motor evoked potentials (MEPs) to arms and legs, somato-sensory evoked potentials of median and tibial nerves, and nerve conduction studies of tibial, ulnar, sural, and radial nerves were assessed.
Results: Whereas all patients showed clinical signs of spastic paraparesis, MEPs were normal in 27% of patients and revealed a broad spectrum with axonal or demyelinating features in the others. This heterogeneity can at least in part be explained by different underlying genotypes, hinting for distinct pathomechanisms in HSP subtypes. In the largest subgroup, SPG4, an axonal type of damage was evident. Comprehensive electrophysiological testing disclosed a more widespread affection of long fibre tracts involving peripheral nerves and the sensory system in 40%, respectively. Electrophysiological abnormalities correlated with the severity of clinical symptoms.
Conclusions: Whereas HSP is primarily considered as an upper motoneuron disorder, our data suggest a more widespread affection of motor and sensory tracts in the central and peripheral nervous system as a common finding in HSP. The distribution patterns of electrophysiological abnormalities were associated with distinct HSP genotypes and could reflect different underlying pathomechanisms. Electrophysiological measures are independent of symptomatic treatment and may therefore serve as a reliable biomarker in upcoming HSP trials.
Objective. Current evidence indicates that there is no single ideal treatment for fibromyalgia syndrome (FMS). First choice treatment options remain debatable, especially concerning the importance of complementary and alternative medicine (CAM) treatments. Methods. Three evidence-based interdisciplinary guidelines on FMS in Canada, Germany, and Israel were compared for their first choice and CAM-recommendations. Results. All three guidelines emphasized a patient-tailored approach according to the key symptoms. Aerobic exercise, cognitive behavioral therapy, and multicomponent therapy were first choice treatments. The guidelines differed in the grade of recommendation for drug treatment. Anticonvulsants (gabapentin, pregabalin) and serotonin noradrenaline reuptake inhibitors (duloxetine, milnacipran) were strongly recommended by the Canadian and the Israeli guidelines. These drugs received only a weak recommendation by the German guideline. In consideration of CAM-treatments, acupuncture, hypnosis/guided imagery, and Tai Chi were recommended by the German and Israeli guidelines. The Canadian guidelines did not recommend any CAM therapy. Discussion. Recent evidence-based interdisciplinary guidelines concur on the importance of treatment tailored to the individual patient and further emphasize the need of self-management strategies (exercise, and psychological techniques).
This review addresses the current status of drug therapy for the management of fibromyalgia syndrome (FMS) and is based on interdisciplinary FMS management guidelines, meta-analyses of drug trial data, and observational studies. In the absence of a single gold-standard medication, patients are treated with a variety of drugs from different categories, often with limited evidence. Drug therapy is not mandatory for the management of FMS. Pregabalin, duloxetine, milnacipran, and amitriptyline are the current first-line prescribed agents but have had a mostly modest effect. With only a minority of patients expected to experience substantial benefit, most will discontinue therapy because of either a lack of efficacy or tolerability problems. Many drug treatments have undergone limited study and have had negative results. It is unlikely that these failed pilot trials will undergo future study. However, medications, though imperfect, will continue to be a component of treatment strategy for these patients. Both the potential for medication therapy to relieve symptoms and the potential to cause harm should be carefully considered in their administration.
GTP cyclohydrolase 1, encoded by the GCH1 gene, is an essential enzyme for dopamine production in nigrostriatal cells. Loss-of-function mutations in GCH1 result in severe reduction of dopamine synthesis in nigrostriatal cells and are the most common cause of DOPA-responsive dystonia, a rare disease that classically presents in childhood with generalized dystonia and a dramatic long-lasting response to levodopa. We describe clinical, genetic and nigrostriatal dopaminergic imaging ([(123)I]N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl) tropane single photon computed tomography) findings of four unrelated pedigrees with DOPA-responsive dystonia in which pathogenic GCH1 variants were identified in family members with adult-onset parkinsonism. Dopamine transporter imaging was abnormal in all parkinsonian patients, indicating Parkinson's disease-like nigrostriatal dopaminergic denervation. We subsequently explored the possibility that pathogenic GCH1 variants could contribute to the risk of developing Parkinson's disease, even in the absence of a family history for DOPA-responsive dystonia. The frequency of GCH1 variants was evaluated in whole-exome sequencing data of 1318 cases with Parkinson's disease and 5935 control subjects. Combining cases and controls, we identified a total of 11 different heterozygous GCH1 variants, all at low frequency. This list includes four pathogenic variants previously associated with DOPA-responsive dystonia (Q110X, V204I, K224R and M230I) and seven of undetermined clinical relevance (Q110E, T112A, A120S, D134G, I154V, R198Q and G217V). The frequency of GCH1 variants was significantly higher (Fisher's exact test P-value 0.0001) in cases (10/1318 = 0.75%) than in controls (6/5935 = 0.1%; odds ratio 7.5; 95% confidence interval 2.4-25.3). Our results show that rare GCH1 variants are associated with an increased risk for Parkinson's disease. These findings expand the clinical and biological relevance of GTP cycloydrolase 1 deficiency, suggesting that it not only leads to biochemical striatal dopamine depletion and DOPA-responsive dystonia, but also predisposes to nigrostriatal cell loss. Further insight into GCH1-associated pathogenetic mechanisms will shed light on the role of dopamine metabolism in nigral degeneration and Parkinson's disease.
The ganglioside-induced differentiation-associated protein 1 (GDAP1) is a mitochondrial fission factor and mutations in GDAP1 cause Charcot–Marie–Tooth disease. We found that Gdap1 knockout mice (\(Gdap1^{−/−}\)), mimicking genetic alterations of patients suffering from severe forms of Charcot–Marie–Tooth disease, develop an age-related, hypomyelinating peripheral neuropathy. Ablation of Gdap1 expression in Schwann cells recapitulates this phenotype. Additionally, intra-axonal mitochondria of peripheral neurons are larger in \(Gdap1^{−/−}\) mice and mitochondrial transport is impaired in cultured sensory neurons of \(Gdap1^{−/−}\) mice compared with controls. These changes in mitochondrial morphology and dynamics also influence mitochondrial biogenesis. We demonstrate that mitochondrial DNA biogenesis and content is increased in the peripheral nervous system but not in the central nervous system of \(Gdap1^{−/−}\) mice compared with control littermates. In search for a molecular mechanism we turned to the paralogue of GDAP1, GDAP1L1, which is mainly expressed in the unaffected central nervous system. GDAP1L1 responds to elevated levels of oxidized glutathione by translocating from the cytosol to mitochondria, where it inserts into the mitochondrial outer membrane. This translocation is necessary to substitute for loss of GDAP1 expression. Accordingly, more GDAP1L1 was associated with mitochondria in the spinal cord of aged \(Gdap1^{−/−}\) mice compared with controls. Our findings demonstrate that Charcot–Marie–Tooth disease caused by mutations in GDAP1 leads to mild, persistent oxidative stress in the peripheral nervous system, which can be compensated by GDAP1L1 in the unaffected central nervous system. We conclude that members of the GDAP1 family are responsive and protective against stress associated with increased levels of oxidized glutathione.
High-Dose Capsaicin for the Treatment of Neuropathic Pain: What We Know and What We Need to Know
(2014)
Neuropathic pain is a frequent and disabling condition with diverse underlying etiologies and is often difficult to treat. Systemic drug treatment is often limited in efficacy. Furthermore, adverse effects may be a limiting factor when trying to reach the necessary dose. Analgesics that can be applied topically have the potential to largely overcome this problem. They may be of particular advantage in localized neuropathic pain syndromes such as postherpetic neuralgia or small fiber neuropathy. Capsaicin, the pungent component of chili peppers, is a natural ligand of the transient receptor potential vanilloid 1 channel and has long been used as topically applicable cream with concentrations of 0.025 to 0.075%. In 2009, a high-concentration transdermal capsaicin 8% patch (Qutenza ; Acorda Therapeutics, Inc., Ardsley, NY, USA; Astellas Pharma Europe Ltd., Chertsey, Surrey, UK) was introduced for the treatment of peripheral neuropathic pain syndromes other than of diabetic origin in adults. It has since been widely used in diverse neuropathic pain disorders. In this review article, we summarize current knowledge on Qutenza, its advantages and problems, and expose unmet needs.
INTRODUCTION:
B cells are attracting increasing attention in the pathogenesis of multiple sclerosis (MS). B cell-targeted therapies with monoclonal antibodies or plasmapheresis have been shown to be successful in a subset of patients. Here, patients with either relapsing-remitting (n = 24) or secondary progressive (n = 6) MS presenting with an acute clinical relapse were screened for their B cell reactivity to brain antigens and were re-tested three to nine months later. Enzyme-linked immunospot technique (ELISPOT) was used to identify brain-reactive B cells in peripheral blood mononuclear cells (PBMC) directly ex vivo and after 96 h of polyclonal stimulation. Clinical severity of symptoms was determined using the Expanded Disability Status Scale (EDSS).
RESULTS:
Nine patients displayed B cells in the blood producing brain-specific antibodies directly ex vivo. Six patients were classified as B cell positive donors only after polyclonal B cell stimulation. In 15 patients a B cell response to brain antigens was absent. Based on the autoreactive B cell response we categorized MS relapses into three different patterns. Patients who displayed brain-reactive B cell responses both directly ex vivo and after polyclonal stimulation (pattern I) were significantly younger than patients in whom only memory B cell responses were detectable or entirely absent (patterns II and III; p = 0.003). In one patient a conversion to a positive B cell response as measured directly ex vivo and subsequently also after polyclonal stimulation was associated with the development of a clinical relapse. The evaluation of the predictive value of a brain antigen-specific B cell response showed that seven of eight patients (87.5%) with a pattern I response encountered a clinical relapse during the observation period of 10 months, compared to two of five patients (40%) with a pattern II and three of 14 patients (21.4%) with a pattern III response (p = 0.0005; hazard ratio 6.08 (95% confidence interval 1.87-19.77).
CONCLUSIONS:
Our data indicate actively ongoing B cell-mediated immunity against brain antigens in a subset of MS patients that may be causative of clinical relapses and provide new diagnostic and therapeutic options for a subset of patients.