Progressive supranuclear palsy: loss of striatal dopamine receptors demonstrated in vivo by positron tomography

Progressive Supranuclear Palsy

Progressive supranuclear palsy (PSP) was first recognized as a distinct morbid entity by Richardson, Steele and Olszewski a quarter century ago. Subsequent experience has confirmed and extended their original observations. PSP has become familiar as a chronic progressive disorder with extrapyramidal rigidity, bradykinesia, gait impairment, bulbar palsy, dementia and a characteristic supranuclear ophthalmoplegia. It is an important cause of parkinsonism. Its etiology remains obscure. Familial concentrations have not been observed.

Some cases exhibit no oculomotor dysfunction. Dementia is usually mild. Recent neuropsychological studies have defined features consistent with frontal lobe cortical dysfunction. Seizures and paroxysmal EEG activity may occur.

CT and MRI scans show midbrain atrophy early and later atrophy of the pontine and midbrain tegmentum and the frontal and temporal lobes. PET scans have shown frontal hypometabolism and loss of striatal D-2 dopamine receptors. Postmortem studies have documented involvment of both dopaminergic and cholinergic systems. Treatment remains palliative and unsatisfactory.

[3H]CNQX and NMDA-sensitive [3H]glutamate binding sites and AMPA receptor subunit RNA transcripts in the striatum of normal and weaver mutant mice and effects of ventral mesencephalic grafts

Levels of excitatory amino acid receptors were studied in the weaver mouse model of DA deficiency after unilateral intrastriatal transplantation of E12+/+ mesencephalic cell suspensions. Graft integration was verified by turning behavior tests and from the topographical levels of the DA transporter, tagged autoradiographically with 3 nM [3H]GBR 12935 (average increase in grafted dorsal striatum compared to nongrafted side, 60%). Autoradiography of 80 nM [3H]CNQX and 100 nM NMDA-sensitive [3H]glutamate binding was carried out to visualize the topography of non-NMDA and NMDA receptors, respectively, in +/+ mice and in recipient weaver mutants 3 months after grafting. Increases of 30% or more were found for [3H]CNQX binding in the dorsal nongrafted weaver striatum compared to +/+, and a further 6-9% increase in grafted weaver compared to nongrafted side. The added increase of non-NMDA receptors in the transplanted striatum might be explained by a presence of such receptors on DA presynaptic endings of graft origin. A 20% increase in NMDA-sensitive [3H]glutamate binding was measured in the dorsal nongrafted weaver striatum compared to +/+. NMDA-sensitive [3H]glutamate binding in the transplanted side of weaver mutants tended to be slightly higher in all areas of the striatal complex compared to the nongrafted side, without reaching conventional levels of statistical significance. Using in situ hybridization histochemistry with synthetic 32p labeled oligonucleotide probes, we investigated RNA transcripts encoding the four AMPA receptor subunits. RNA transcripts in the striatum are seen with a decreasing signal intensity in the following order: GluRB > GluRA > GluRC > GluRD. The weaver caudate-putamen shows a 12% increase in GluRA subunit mRNA compared to +/+, whereas mesencephalic neuron transplantation leads to slight increases (3%) in the levels of GluRB mRNA in the nucleus accumbens. The results are placed in the context of the important interaction between the converging glutamatergic corticostriatal and the DAergic nigrostriatal pathways in controlling the functional output of the basal ganglia in Parkinson's disease and in experimental models of DA deficiency.

Differential diagnosis of PSP

The clinical diagnosis of PSP depends primarily on the history and the physical findings. Clinicians should be alerted to the possibility of this condition in assessing patients presenting with atypical parkinsonism and other complex extrapyramidal syndromes in late middle age or later. The differential diagnosis includes MSA (both OPCA and SND), PD, CBD and cerebrovascular disease. PD is probably the most common erroneous diagnosis. Unfortunately, pathognomonic signs do not usually appear until several years, after symptom onset. No specific laboratory test is yet available. Neuroimaging studies show characteristic anatomic alterations only late in the course of the illness and must be correlated with the clinical findings.

Changes in aminergic receptors in a PSP postmortem brain: correlation with pathological findings

The state of different aminergic receptors was assessed, by quantitative autoradiography in tissue sections, in several representative brain regions from a typical progressive supranuclear palsy (PSP) patient and from 9 matched brains. The densities of muscarinic receptors were within control limits in most of the brain areas of this PSP brain. Serotonin1 receptors were clearly reduced only in areas with very relevant neuropathological damage, such as locus niger and globus pallidus. The density of D1 dopamine receptors in the caudate-putamen and frontal cortex of the patient was within control limits. By contrast, nigral D1 and striatal D2 dopamine receptors were dramatically reduced in the patient as compared to controls. Finally, alpha 2-adrenoceptors were clearly reduced in all the examined areas of this PSP patient as compared to control group. Both the potential role of these receptor changes in the pathophysiology of the clinical features of PSP and their correlation with the neuropathological findings of this PSP patient are discussed.

Cholinergic and peptidergic systems in PSP

PSP is associated with a widespread cholinergic deficit likely corresponding to a loss in cholinergic neurons. The cholinergic damage dramatically affects the basal ganglia and specific cell groups of the mesencephalon and pons. This provides an anatomically defined basis for motor and supranuclear oculomotor syndromes characteristic of PSP. Unlike Alzheimer's disease and Parkinson's disease with dementia, the disease is not associated with a marked cholinergic deficiency in the cerebral cortex. Various peptides are present at normal concentrations in extrapyramidal and limbic subcortical areas in brains of patients with PSP. Of particular interest, is somatostatin, the levels of which are subnormal in cerebral cortex of patients with dementia of Alzheimer' or Parkinson's disease type.

Positron emission tomography studies of brain receptors

Probing the regional distribution and affinity of receptors in the brain, in vivo, in human and non human primates has become possible with the use of selective ligands labelled with positron emitting radionuclides and positron emission tomography (PET). After describing the techniques used in positron emission tomography to characterize a ligand receptor binding and discussing the choice of the label and the limitations and complexities of the in vivo approach, the results obtained in the PET studies of various neurotransmission systems: dopaminergic, opiate, benzodiazepine, serotonin and cholinergic systems are reviewed.

A method for the in vivo investigation of the serotonergic 5-HT2 receptors in the human cerebral cortex using positron emission tomography and 18F-labeled setoperone

Following previous validation in baboons, we have studied the characteristics of [18F]setoperone as a radioligand for investigating serotonergic 5-hydroxytryptamine2 (5-HT2) receptors in the normal, unmedicated human brain with positron emission tomography (PET); subjects orally pretreated with therapeutic amounts of ketanserin, sulpiride, or prazosin were also studied to evaluate the specificity and sensitivity of [18F]setoperone brain specific binding. In controls (n = 10), the tracer showed a clear-cut retention in both frontal cortex and striatum (known to contain a high density of 5-HT2 receptors) relative to cerebellum (known to be devoid of 5-HT2 receptors). In the seven young controls (20-39 years old), the frontal cortex/cerebellum and striatum/cerebellum ratios increased during the first hour to reach similar values of 2.53 +/- 0.12 and 2.38 +/- 0.11 (mean +/- SEM), respectively, and were essentially stable during the second hour. Pretreatment with ketanserin (a 5-HT2 blocker) significantly reduced the frontal cortex/cerebellum ratio to 0.7-1.0 at 65 min, whereas the striatum/cerebellum ratio was significantly, but only partially, reduced. During sulpiride treatment (a D2 blocker), the frontal cortex/cerebellum ratio was not altered, whereas the striatum/cerebellum ratio was significantly, but only partially, reduced. With prazosin pretreatment (an alpha 1-adrenergic blocker), neither the frontal cortex/cerebellum nor the striatum/cerebellum ratio was modified. These data in humans with PET demonstrate that [18F]setoperone labels with high sensitivity and selectivity 5-HT2 receptors in the frontal cortex; in striata, however, binding is to both 5-HT2 and D2 receptors. The deproteinated-to-whole plasma radio-activity concentration ratio increased with time following injection. The mean percentage of intact [18F]setoperone, in deproteinated plasma, was 82, 74, 53, 45, 30, and 22% at 5, 10, 20, 30, 60, and 110 min following injection, respectively. These data indicate that [18F]setoperone (a) is significantly bound to plasma proteins and (b) is significantly metabolized into several labeled metabolites that are much more hydrophilic than setoperone and, hence, presumably do not cross the blood-brain barrier. These results suggest the suitability of [18F]setoperone data for modeling of 5-HT2 receptor binding in brain.

Where have we got to with neuroreceptor mapping of the human brain?

In the past two decades, tritiated radioligand receptor binding, a tool commonly used to investigate the site of action of drugs in laboratory animals, has provided a vast body of information on neuropharmacology and neurobiology. Several neurological and psychiatric diseases have been related to neurotransmitter and receptor disorders. In order to study ligand interactions with receptors in vivo in humans, new tracers capable of carrying a gamma-emitting radionuclide to the receptor have been designed. Emission computerized tomography (ECT) techniques such as positron (PET) or single photon emission tomography (SPET) allow monitoring of the time-course of regional tissue concentration of these radiolabelled ligands. PET and SPET each have their inherent advantages and drawbacks. The cyclotron-based technology of PET is a demanding and expensive technique that, to date, is still mainly reserved for research purposes. It is hoped that once the scientific basis of a physiopathological study is established using PET, diagnostic information might be provided by the more readily available SPET technology. The purpose of this article is to review the current state of receptor-binding gamma-emitting radioligands and to present the clinical potential of these new kinds of radiopharmaceuticals in clinical investigation.

Striatal dopamine D2 receptors in tardive dyskinesia: PET study

The dopamine D2 receptors were investigated in vivo in eight neuroleptic-free patients with persistent tardive dyskinesia using positron emission tomography and 76Br-bromospiperone. The striatal receptor density, estimated by the striatum/cerebellum radioligand concentration ratio, was not elevated in patients as compared with age-matched controls but was positively correlated with the severity of orofacial dyskinesia assessed with the Abnormal Involuntary Movement Rating Scale. These results indicate that tardive dyskinesia is associated with normal levels of striatal D2 receptors but the severity of orofacial movements may depend on the relative density of striatal D2 receptors.

Dopamine receptors in human brain: autoradiographic distribution of D2 sites

We have studied the detailed anatomical distribution of D2 receptors in human post mortem brain tissue using quantitative autoradiographic techniques. D2 receptors were labeled using the specific D2 agonist [3H]CV 205-502 and the antagonist [3H]spiroperidol. The pattern of D2 receptor distribution observed with the two ligands was very similar. The highest densities were found in the nucleus caudatus, putamen, nucleus accumbens and olfactory tubercle followed by the substantia nigra, where D2 receptors were mainly concentrated in the pars compacta. Lower but still significant densities were associated with the lateral part of the globus pallidus and CA1 and CA3 fields of the hippocampus. The medial part of the globus pallidus, the dentate gyrus and the amygdala showed low to very low densities of D2 receptors. Almost negligible amounts of binding were observed in the olfactory bulb, diencephalon, brainstem, cerebellum and most parts of the neocortex. Our results are comparable with previously reported localizations of D2 receptors in the human and rat brain. We also report the lack of the so-called spirodecanone binding sites in the human brain. The localization of D2 receptors is compared with the distribution of D1 receptors.

[76Br]bromolisuride: a new tool for quantitative in vivo imaging of D-2 dopamine receptors

Bromolisuride, an ergoline derivative, was labeled with the positron emitter radionuclide, bromine 76. In vitro and in vivo binding and competition studies in rats demonstrated a high affinity (KD = 0.3 nM) and a high specificity of this new radioligand for D-2 dopamine receptors. PET kinetic studies in baboons showed an accumulation of [76Br]bromolisuride in the striatum which reached a maximum 30 min post-injection and which could be displaced by haloperidol. All these results indicated that this new ligand is certainly suitable for the non-invasive in vivo quantitative imaging of D-2 dopamine receptor sites in human brain.

Loss of striatal [76Br]bromospiperone binding sites demonstrated by positron tomography in progressive supranuclear palsy

Using positron tomography and 76Br-labeled bromospiperone, a neuroleptic drug with high affinity for the dopamine (DA) receptors, we have estimated the specific binding of the radiotracer to striatal DA receptors in seven patients suffering from progressive supranuclear palsy. Compared with age- and sex-matched control subjects, we found a significant (p less than 0.02) decrease of the striatum-cerebellum uptake ratio in progressive supranuclear palsy patients, suggesting loss of striatal DA receptors. This in vivo study confirms recent postmortem data on progressive supranuclear palsy patients and provides an explanation for the lack of benefit from L-DOPA and DA agonists in this condition, despite reduced nigrostriatal dopaminergic function.