Dementia in Parkinson's disease: diffusion tensor imaging

An update on brain imaging in parkinsonian dementia

Disturbances of cognition are frequent in Parkinson's disease (PD). Unlike severe loss of dopamine early in PD, extensive cholinergic losses have been consistently reported in PD with dementia. Cholinergic imaging suggests that basal forebrain cholinergic system degeneration appears early in PD and worsens with dementia development. Cortical cholinergic denervation is similar in PD with dementia and dementia with Lewy bodies, supporting a common disease spectrum, at least with respect to cholinergic pathology. Presence of cerebral amyloidopathy in the setting of parkinsonism may accelerate cognitive decline. Novel MRI techniques illustrate the widespread presence of neurodegeneration in PD with dementia, affecting white matter tracts and connectivity functions. This review will outline current concepts regarding dementia development in PD and discuss their correlation with functional and structural neuroimaging including PET and MRI.

White matter alteration of the cingulum in Parkinson disease with and without dementia: evaluation by diffusion tensor tract-specific analysis

BACKGROUND AND PURPOSE

In PD, the neurodegenerative process begins in the brain stem and extends to the limbic system and finally into the cerebral cortex. We used diffusion tensor tractography to investigate the FA of the cingulate fiber tracts in patients with PD with and without dementia.

MATERIALS AND METHODS

Fifteen patients with PD, 15 patients with PDD, and 15 age-matched healthy controls underwent diffusion tensor imaging with a 3T MR imager. Diffusion tensor tractography images of the anterior and posterior cingulate fiber tracts were generated. Mean diffusivity and FA were measured along the tractography of the anterior and posterior cingulate fiber tracts. One-way ANOVA with the Scheffé post hoc test was used to compare results among the groups.

RESULTS

FA was significantly lower in patients with PDD than in healthy controls in both the anterior and the posterior cingulate fiber tracts (P = .003, P = .015) and significantly lower in patients with PD than in healthy controls (P = .003) in the anterior cingulate fiber tract. There were no significant mean diffusivity differences among the groups. MMSE and FA values of the anterior cingulate fiber tracts in patients with PDD were significantly correlated (r = 0.633, P < .05).

CONCLUSIONS

The reduced FA in patients with PD and PDD might reflect neuropathologic changes such as Lewy body pathology in the cingulate fibers. This abnormality might contribute to the dementing process in PD.

Functional network disruption in the degenerative dementias

Despite advances towards understanding the molecular pathophysiology of the neurodegenerative dementias, the mechanisms linking molecular changes to neuropathology and neuropathological changes to clinical symptoms remain largely obscure. Connectivity is a distinctive feature of the brain and the integrity of functional network dynamics is crucial for normal functioning. A better understanding of network disruption in the neurodegenerative dementias might help bridge the gap between molecular changes, pathological changes, and symptoms. Recent findings on functional network disruption as assessed with resting-state or intrinsic connectivity functional MRI and electroencephalography and magnetoencephalography have shown distinct patterns of network disruption across the major neurodegenerative diseases. These network abnormalities are somewhat specific to the clinical syndromes and, in Alzheimer's disease and frontotemporal dementia, network disruption tracks the pattern of pathological changes. These findings might have practical implications for diagnostic accuracy, allowing earlier detection of neurodegenerative diseases even at the presymptomatic stage, and tracking of disease progression.

Diffusion tensor imaging of cerebral white matter integrity in cognitive aging

In this article we review recent research on diffusion tensor imaging (DTI) of white matter (WM) integrity and the implications for age-related differences in cognition. Neurobiological mechanisms defined from DTI analyses suggest that a primary dimension of age-related decline in WM is a decline in the structural integrity of myelin, particularly in brain regions that myelinate later developmentally. Research integrating behavioral measures with DTI indicates that WM integrity supports the communication among cortical networks, particularly those involving executive function, perceptual speed, and memory (i.e., fluid cognition). In the absence of significant disease, age shares a substantial portion of the variance associated with the relation between WM integrity and fluid cognition. Current data are consistent with one model in which age-related decline in WM integrity contributes to a decreased efficiency of communication among networks for fluid cognitive abilities. Neurocognitive disorders for which older adults are at risk, such as depression, further modulate the relation between WM and cognition, in ways that are not as yet entirely clear. Developments in DTI technology are providing a new insight into both the neurobiological mechanisms of aging WM and the potential contribution of DTI to understanding functional measures of brain activity. This article is part of a Special Issue entitled: Imaging Brain Aging and Neurodegenerative disease.

Development of Parkinson's disease biomarkers

Parkinson's disease (PD) is the most common neurodegenerative movement disorder, affecting over 6 million people worldwide. It is anticipated that the number of affected individuals may increase significantly in the most populous nations by 2030. During the past 20 years, much progress has been made in identifying and assessing various potential clinical, biochemical, imaging and genetic biomarkers for PD. Despite the wealth of information, development of a validated biomarker for PD is still ongoing. It is hoped that reliable and well-validated biomarkers will provide critical clues to assist in the diagnosis and management of Parkinson's disease patients in the near future.

Neuroimaging and cognition in Parkinson's disease dementia

The prevalence of cognitive impairment and dementia in Parkinson's disease (PD) is high and can potentially occur as the result of multiple differing pathologies. Neuroimaging has provided evidence of decreased cortical volume, increased white matter diffusion changes, and decreased resting metabolic activity that appears to begin prior to the onset of dementia in PD patients. Cognitive impairment has been found to be associated with multiple neurotransmitter transmission deficiencies, including dopamine and acetylcholine, indicating a widespread neurotransmitter dysfunction in PD-related dementia. Findings of increased Pittsburgh Compound B (PiB) binding in subjects with Lewy Body Disease (LBD) compared with Parkinson's disease and dementia (PDD) may explain phenotype differences in the spectrum of Dementia with Lewy Bodies (DLB), and show promise in guiding future therapeutic trials aimed at this disease. Advances in neuroimaging now allow for the detection of volumetric, pharmacologic, and pathological changes that may assist in the diagnosis and prediction of cognitive impairment in Parkinson's patients so that better evaluation of disease progression and treatment can be obtained.

T1rho (T1ρ) MR imaging in Alzheimer's disease and Parkinson's disease with and without dementia

In the current study, we aim to measure T1rho (T (1ρ)) in the hippocampus in the brain of control, Alzheimer's disease (AD), Parkinson's disease (PD), and PD patients with dementia (PDD), and to determine efficacy of T (1ρ) in differentiating these cohorts. With informed consent, 53 AD patients, 62 PD patients, 11 PDD patients, and 46 age-matched controls underwent a standardized clinical assessment including mini-mental state examination (MMSE) and brain T (1ρ) MRI on a 1.5-T clinical-scanner. T(1ρ) maps were generated by fitting each pixel's intensity as a function of the spin-lock pulse duration. In control, AD, PD and PDD, mean ± SE T (1ρ) values in the right hippocampus (RH) were 92.15 ± 2.00, 99.65 ± 1.98, 85.68 ± 1.87, 102.47 ± 4.66 ms while in the left hippocampus (LH) these values were 90.16 ± 1.82, 99.53 ± 1.91, 84.33 ± 2.03, 95.33 ± 4.64 ms. Significant difference for both RH and LH T (1ρ) across the groups (p < 0.001) was observed. Both RH and LH T (1ρ) were significantly increased in AD compared to control (p = 0.034, p = 0.001) and PD (p < 0.001, p < 0.001). In control, both RH and LH T (1ρ) values were significantly increased compared to PD (p = 0.031, p = 0.027) while compared to PDD only the RH T (1ρ) value was significantly decreased (p = 0.043). Both RH and LH T (1ρ) values in PD were significantly lower than PDD (p = 0.004, p = 0.032). No significant correlation between the T (1ρ) and age as well as between T (1ρ) and MMSE scores was observed. The serial measurement of T(1ρ) in both AD and PD may provide the nature of disease progression and may contribute to their early diagnosis.

Neuroimaging for Lewy body disease: is the in vivo molecular imaging of α-synuclein neuropathology required and feasible?

Alpha-synuclein aggregation is a neuropathological hallmark of many neurodegenerative diseases including Parkinson's disease (PD), Parkinson's disease with dementia (PDD) and dementia with Lewy bodies (DLB), collectively termed the α-synucleinopathies. Substantial advances in clinical criteria and neuroimaging technology over the last 20 years have allowed great strides in the detection and differential diagnosis of these disorders. Nevertheless, it is clear that whilst the array of different imaging modalities in clinical use allow for a robust diagnosis of α-synucleinopathy in comparison to healthy subjects, there is no clear diagnostic imaging marker that affords a reliable differential diagnosis between the different forms of Lewy body disease (LBD) or that could facilitate tracking of disease progression. This has led to a call for a biomarker based on the pathological hallmarks of these diseases, namely α-synuclein-positive Lewy bodies (LBs). This potentially may be advantageous in terms of early disease detection, but may also be leveraged into a potential marker of disease progression. We here aim to firstly review the current status of neuroimaging biomarkers in PD and related synucleinopathies. Secondly, we outline the rationale behind α-synuclein imaging as a potential novel biomarker as well as the potential benefits and limitations of this approach. Thirdly, we attempt to illustrate the likely technical hurdles to be overcome to permit successful in vivo imaging of α-synuclein pathology in the diseased brain. Our overriding aim is to provide a framework for discussion of how to address this major unmet clinical need.

Cocaine addiction: diffusion tensor imaging study of the inferior frontal and anterior cingulate white matter

Inferior frontal and anterior cingulate white matter integrity in 32 cocaine-dependent subjects was compared with that in 33 age-matched healthy control subjects. Diffusion tensor imaging data were acquired with a 1.5-T magnetic resonance imaging system. Cocaine-dependent subjects presented significantly lower fractional anisotropy values in inferior frontal white matter at the anterior-posterior commissure plane and higher anterior cingulate white matter values than control subjects. White matter integrity was also associated with impulsivity and motivation to change (Readiness to Change Questionnaire). These findings support the hypothesis that cocaine dependence involves a disruption of orbitofrontal connectivity and suggest that the anterior cingulate brain area might play a role in the motivation to change.

Imaging neurodegeneration in Parkinson's disease

Neuroimaging techniques have evolved over the past several years giving us unprecedented information about the degenerative process in Parkinson's disease (PD) and other movement disorders. Functional imaging approaches such as positron emission tomography (PET) and single photon emission computerised tomography (SPECT) have been successfully employed to detect dopaminergic dysfunction in PD, even while at a preclinical stage, and to demonstrate the effects of therapies on function of intact dopaminergic neurons within the affected striatum. PET and SPECT can also monitor PD progression as reflected by changes in brain levodopa and glucose metabolism and dopamine transporter binding. Structural imaging approaches include magnetic resonance imaging (MRI) and transcranial sonography (TCS). Recent advances in voxel-based morphometry and diffusion-weighted MRI have provided exciting potential applications for the differential diagnosis of parkinsonian syndromes. Substantia nigra hyperechogenicity, detected with TCS, may provide a marker of susceptibility to PD, probably reflecting disturbances of iron metabolism, but does not appear to correlate well with disease severity or change with disease progression. In the future novel radiotracers may help us assess the involvement of non-dopaminergic brain pathways in the pathology of both motor and non-motor complications in PD.