Epidemiology of PD

 The most common movement disorder

affecting 1-2 % of the general
population over the age of 65 years.

 The second most common

neurodegenerative disorder after
Alzheimer´s disease (AD).
 Prevalence / 100 000

Age
Prevalence of PD
 Parkinson’s disease

Primary symptoms

 Rigidity - increased tone or stiffness in the

muscles

 Tremor - 25% of patients experience very

slight tremor or none at all

 Bradykinesia - slowness of movement

 Akinesia - impaired movement initiation

and poverty of movement
 PD symptoms

Secondary symptoms

 Poor balance
 Depression
 Sleep disturbances
 Dizziness
 Stooped posture
 Constipation
 Dementia
 Problems with speech,
breathing, swallowing, and
sexual function
 Idiopathic PD
Diagnosis of Parkinsonian syndrome
 Bradykinesia and ≥ 1 of the following:

 Muscular rigidity
 4 to 6 Hz rest tremor
 Postural instability not caused by primary
vestibular, cerebellar, or proprioceptive
dysfunction
 Idiopathic PD exclusion criteria

 History of repeated  Early severe dementia

strokes with  Presence of cerebral
parkinsonian features tumor
 History of head injury
 Negative response to
doses of levodopa
 History of
encephalitis
 Idiopathic PD inclusion Criteria
Positive criteria PD
 Resting tremor
 Progressive disorder
 Persistent asymmetry
 Excellent response to l-dopa
 Parkinson pathology
 Degeneration of
dopaminergic neurons
of the nigrostriatal
pathway result in
decreased excitation
of the motor cortex

 Lewy bodies- abnormal

protein aggregates
comprised primarily of α-
synuclein
 Extra-nigral degeneration
 Basal Ganglia Circuit

• Striatum receives input from 
M1 most cortical areas inputs are 
SMA Cortex roughly topographical (multiple 
parallel circuits)
• GPi/SNr are the major output 
nuclei 
• Direct vs. indirect striatal 
pathways have opposing effects 
Striatum (inhib. vs. excit.)
Indirect  Direct  • Output of thalamus is primary to 
pathway SNc pathway
motor areas
GPe
Thalamus

STN

excitatory
inhibitory GPi/SNr
 Parkinson’s Disease

• Decreased output of SNc 
M1 dopaminergic projections
SMA Cortex • Decrease inhibition in direct 
pathway
• Increase excitation in indirect 
pathway
• Net effect: more inhibition of 
Striatum thalamus and therefore less 
excitatory input to motor cortex
Indirect  Direct 
pathway SNc pathway

GPe
Thalamus

STN

excitatory
inhibitory GPi/SNr
Histopathology of PD
Tyrosine Hydroxylase
MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine
induced loss of TH+ SNc neurons
Lapointe et al., 2004 FASEB
Methods- Behavioural Analysis

Micromax Pole Test

 Measure of total  Measure of motor
locomotor activity control
 Monitored 3 times for  Tested once
24 hours
Rotorod Apparatus
 PD causes?

Family history

?
Rural living

Pesticide exposure Gender (♂)

Diet (bad food)
Age

Head injury Non-smoking

Race (Caucasian)
 Etiology of Parkinson’s disease

 Environmental events: chemical toxins (pesticides),

metals (Manganese, iron)

 viral/bacterial agents Poliovirus, arbovirus, herpes

simplex virus and encephalitis

 Slowly developing early viral/bacterial infection ?

 Multi-hit hypothesis
Multi-hit Model of PD

Pesticides
Pesticides

Viruses
Viruses
PD Bacteria
Bacteria

Heavy
Heavy
Metals
Metals
 Multi-hit Hypothesis

Barlow et al., 2007

 Environmental Toxins
 ~95% of PD cases are sporadic
 Pesticides- paraquat, rotenone
 Heavy metals- welders, well-water
 Viruses and bacteria- influenza, LPS
Brown et al., 2006; Environ. Health Persp
 Gene- pesticide interactions and PD .
Number of risk Exposed Not exposed
alleles (DAT)
Cases Control OR (95% Cases Control OR (95%
(%) s (%) CI)a (%) s (%) CI)a

0 7 17 1.0 (ref.) 23 37 1.0 (ref.)

(14.9) (30.9) (17.6) (20.1)

1 14 23 1.63 (0.52– 49 60 1.21

(29.8) (41.8) 5.15) (37.4) (32.6) (0.62–
2.36)
2+ 26 15 5.66 (1.73– 59 87 1.17
(55.3) (27.3) 18.53) (45.0) (47.3) (0.62–
2.23)

Kelada et al., 2006

Paraquat and rotenone
 Rotenone and PD?

 Derived from South American roots (Tropical members

of pea family)
 Acts as a complex I inhibitor on mitochondria (like
MPTP)
 Reported to induce a-synuclein inclusions, whereas
MPTP cannont
 Used as insecticide (eg lettuce and tomatoes) and as
means of controlling fish populations
 Other toxins linked to PD
 Unique Parkinson-like symptoms (with dementia and motor neuron
disease) in Guam
 Possibly related to the consumption of animals that eat toxic cycad seeds
 Neurotoxins in flour from cycad plants induced PD-like symptoms in mice

 Viruses
 1918 influenza epidemic- Encephalopathy
 Severe, progressive Parkinson's-like symptoms
 Taiwanese women developed similar symptoms after herpes virus
infections
 Linked to a temporary (reversible) inflammation of the SN

 Prenatal exposure to bacterial toxin lipopolysaccharide (LPS)

 Animals with fewer DA neurones
 DA neuron loss persists and increases with age (mimics PD)
 Paraquat
N,N’-dimethyl-4,4’-bipyridylium ion

 One of the most

commonly used
herbicides worldwide
 Acts as a redox cycling
agent
 Increases microglial
activation and oxidative
stress
 Lewy body formation
Keane PC, Kurzawa M, Blain PG, (2011) Morris CM. Mitochondrial
dysfunction in Parkinson’s diasese. Parkinsons Dis. 2011:716871
PQ2+ (on the left), is reduced to PQ+ (on the right) and PQ+ then acts to
reduce molecular oxygen, O2 to O2- regenerating the parent PQ2+ in the
process (Inchem, 2009).
 Paraquat (PQ)
 One of the most wildly used herbicides around
the world.
 It is a fast acting, nonselective herbicide, that
kills green plant tissue on contact.
 It prevents photosynthesis from occurring.
 Structurally similar to MPP+, which is a know
dopaminergic neurotoxin
 In a class of redox cycling compounds that can
cause mitochondrial damage and oxidative
stress.
 What is Oxidative Stress?

 Occurs in the presence of excessive free radicals

Unpaired electron

 Reactive oxygen species

 Superoxide (•O2-)
 Hydroxyl (•OH)
 Hydrogen peroxide (H2O2) - non free radical

 Reactive nitrogen species

 Nitrogen oxide (NO•)
Where do free radicals come from?
 Mitochondrial electron transport chain

 Inflammatory response (released by e.g. microglia)

 Dopamine metabolism

 Arachidonic acid metabolism pathway (pain, fever, inflammation)

What do ROS do?

 Membrane disruption
 Changes to fluidity of membrane leads to changes in
 Ion channel conductivity
 Anchorage sites for enzymes/reactions

 Enzyme disruption
 Changes in activity, abnormal switching on/off etc

 DNA damage
 Abnormal transcription and therefore protein
expression
 Chronic Effects of Pesticide Exposure
 Patterns of exposure
 Cumulative effects over time of exposure to low
concentrations of pesticides
 Cumulative effects of repeated exposure to certain
mixtures of pesticides and heavy metals
 Persistent effects following exposure to a single high dose
of pesticide or other environmental toxin at a
developmentally sensitive time
Neurons surviving following paraquat

3 injections per week for 3 weeks

Hayley & Mangano

 How can pesticides kill neurons?
Paraquat causes oxidative stress in midbrain
neurons.

Superoxide + nitric oxide

Purisai et al., 2006,

Neurobiol Dis
Inflammation and PD

 Microglia: immune mediators of the brain

 ‘Double-edged sword’
 Release cytokines and reactive oxygen species
 Substantial microglial activation as well as
increased pro-inflammatory cytokine levels in
PD
 Inflammatory aspects of PD.

 NSAID users (2 or more pills per week) had reduced risk of

PD: 2 or more years of use (OR, 0.44; 95% CI, 0.26 to 0.74).
(Wahner et al., 2007)

 Signs of inflammation in PD brain (e.g. activated microglia

and pro-inflammatory cytokines) (Nagatsu et al., 2005)

 Animal models of PD involve microglial-dependent death of

DA neurons (prevented by anti-inflammatory drugs)
Microglial quantification
LPS pre-treatment augmented SNc
microglial cell reactivity.
LPS pretreatment augmented paraquat
induced loss of SNc TH+ neurons.

Mangano et al., 2008

 Cytokines and PD

Liu, AAPS, 2006

 Figure 2- poly(I:C) and paraquat
synergistically enhance dopamine
neuron loss in the SNc

Sal-Sal Paraquat Poly(I:C) Paraquat-Poly(I:C)

 Figure 3- poly(I:C)- and paraquat-
induced degeneration is
associated with increased
microglial activation

Sal-Sal Paraquat Poly(I:C) Paraquat-Poly(I:C)

 Figure 4- poly(I:C)- and paraquat-induced
degeneration is associated with increased
oxidative stress

Sal-Sal Paraquat Poly(I:C) Paraquat-Poly(I:C)

 Synuclein mutations

 3 different mutations in the a-Synuclein

 A53T
 A30P
 E46K

 All have been shown to be linked to familial PD

 What is synuclein?

 Synuclein
 Expressed in neuronal & non-neuronal cells

 a-synuclein self-aggregates

Linear Protofibril Fibril

Mutant a-synuclein forms fibrils.
Alpha-Synuclein

 The main constituent of LBs is

aggregated a-synuclein
Halo

 Protective?
 Do LBs sequester a toxic
protein

 Toxic?
 Are LB toxic (inhibiting cell
function or removing vital
proteins)
Core
A-synuclein: intra-cellular targets
A-synuclein: extra-cellular targets
Drug Therapy – L-DOPA
 Used with Carbidopa, which blocks the early
conversion of L-DOPA into dopamine.

Carbidopa
 L-DOPA is transported across the BBB by an amino
acid transport system (same one used for tyrosine
and phenylalanine)
 Once across, L-DOPA is decarboxylated to dopamine
by Dopa Decarboxylase (DDC).
 Therapy of PD: limitations of
levodopa

 Efficacy tends to decrease as the disease

progresses.

 Chronic treatment associated with adverse

events (motor fluctuations, dyskinesias and
neuropsychiatric problems).—”On and Off”
cycles
 Only manages symptoms
 Chronic high dose transdermal nicotine in Parkinson's disease: an open
trial

European Journal of Neurology

Volume 14, Issue 12, pages 1313-1316, 18 OCT 2007 DOI: 10.1111/j.1468-1331.2007.01949.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2007.01949.x/full#f1
 Surgery -
 Deep Brain Stimulation
 Brain pacemaker, sends electrical impulses to brain
to stimulate the subthalamic nucleus.
 Improves motor functions, particularly tremor

62
New Eng Jour Med, 2006
Fetal transplant

New Eng Med, 1992

 A double‐blind controlled trial of bilateral fetal nigral transplantation in
Parkinson's disease

Annals of Neurology
Volume 54, Issue 3, pages 403-414, 28 AUG 2003 DOI: 10.1002/ana.10720
http://onlinelibrary.wiley.com/doi/10.1002/ana.10720/full#fig1
Nat Med, 2009
Differentiation
 Induced pluripotent cells (iPSC)
A combination of several genes can re-program skin
fibroblasts into pluripotent cells

“Reprogramming”

(Takahashi and Yamanaka Cell 2007, Yu Science 07, Cowan Science 07, Wernig Nature 07, Okita Nature 07)
Stem cells + trophic factor

Nature 2011