Simultaneous intrastriatal and intranigral grafting (double grafts) in the rat model of Parkinson's disease

The management of risk and investment in cell therapy process development: a case study for neurodegenerative disease

Cell-based therapies must achieve clinical efficacy and safety with reproducible and cost-effective manufacturing. This study addresses process development issues using the exemplar of a human pluripotent stem cell-based dopaminergic neuron cell therapy product. Early identification and correction of risks to product safety and the manufacturing process reduces the expensive and time-consuming bridging studies later in development. A New Product Introduction map was used to determine the developmental requirements specific to the product. Systematic Risk Analysis is exemplified here. Expected current value-based prioritization guides decisions about the sequence of process studies and whether and if an early abandonment of further research is appropriate. The application of the three tools enabled prioritization of the development studies.

Transplantation in the nonhuman primate MPTP model of Parkinson's disease: update and perspectives

In order to calibrate stem cell exploitation for cellular therapy in neurodegenerative diseases, fundamental and preclinical research in NHP (nonhuman primate) models is crucial. Indeed, it is consensually recognized that it is not possible to directly extrapolate results obtained in rodent models to human patients. A large diversity of neurological pathologies should benefit from cellular therapy based on neural differentiation of stem cells. In the context of this special issue of Primate Biology on NHP stem cells, we describe past and recent advances on cell replacement in the NHP model of Parkinson's disease (PD). From the different grafting procedures to the various cell types transplanted, we review here diverse approaches for cell-replacement therapy and their related therapeutic potential on behavior and function in the NHP model of PD.

A Sequential Intrastriatal Dopaminergic Graft Strategy in the Rodent Model for Parkinson's Disease: Implications for Graft Survival and Targeting

Optimal placement of intrastriatal dopaminergic grafts is likely crucial to optimize clinical recovery in Parkinson's disease (PD). The target sites of dopaminergic grafts vary among clinical trials and may partially explain the variable results in clinical efficacy reported thus far. In this study we hypothesized that a subsequent dopaminergic graft may promote functional recovery following a suboptimal initial graft. To test this hypothesis, rats with unilateral 6-hydroxydopamine lesions of the right nigrostriatal pathway were randomly divided into three groups. The first group received 900,000 fetal nigral cells in the medial striatum only (n = 6). The second group received 900,000 cells in both the medial and lateral striatum simultaneously (1.8 million total; n = 8). The final group received a second graft of 900,000 cells in the lateral striatum 6 weeks following initial transplantation of a medial graft (n = 6). Amphetamine-induced circling behavior was significantly reduced in both simultaneous and sequential graft groups at 9 and 12 weeks following transplantation of the initial graft. However, no recovery was noted in the single medial graft group at those time points. Furthermore, increased survival of dopaminergic cells was observed in the lateral graft of sequentially grafted animals compared with the medial graft. We conclude that a well-positioned subsequent graft can restore function in animals with a suboptimal initial graft and that the initial graft may improve survival of the second graft. These results are further discussed in relation to their important clinical implication for neural transplantation in PD.

Recovery from experimental parkinsonism by semaphorin-guided axonal growth of grafted dopamine neurons

Cell therapy in animal models of Parkinson's disease (PD) is effective after intrastriatal grafting of dopamine (DA) neurons, whereas intranigral transplantation of dopaminergic cells does not cause consistent behavioral recovery. One strategy to promote axonal growth of dopaminergic neurons from the substantia nigra (SN) to the striatum is degradation of inhibitory components such as chondroitin sulphate proteoglycans (CSPG). An alternative is the guidance of DA axons by chemotropic agents. Semaphorins 3A and 3C enhance axonal growth of embryonic stem (ES) cell-derived dopaminergic neurons in vitro, while Semaphorin 3C also attracts them. We asked whether intranigral transplantation of DA neurons, combined with either degradation of CSPG or with grafts of Semaphorin 3-expressing cells, towards the striatum, is effective in establishing a new nigrostriatal dopaminergic pathway in rats with unilateral depletion of DA neurons. We found depolarization-induced DA release in dorsal striatum, DA axonal projections from SN to striatum, and concomitant behavioral improvement in Semaphorin 3-treated animals. These effects were absent in animals that received intranigral transplants combined with Chondroitinase ABC treatment, although partial degradation of CSPG was observed. These results are evidence that Semaphorin 3-directed long-distance axonal growth of dopaminergic neurons, resulting in behavioral improvement, is possible in adult diseased brains.

Transplantation of human retinal pigment epithelium cells in the treatment for Parkinson disease

BACKGROUND AND PURPOSE

To assess the clinical effect of transplantation of human retinal pigment epithelial (hRPE) cells into the unilateral postcommissural putamen for treatment for Parkinson disease (PD).

METHODS AND RESULTS

Cells from postmortem human eye tissue (10-20 weeks of gestation) were cultured in vitro. Cells from -generation passage were implanted in PD postcommissural putamen with stereotactic operation in 12 patients with PD. All patients tolerated surgery well, and no major adverse events occurred. Eleven patients showed improvement in the primary outcome measure at 3 months post-treatment, particularly the Unified Parkinson's Disease Rating Scale-M score in the off state. Response reached a peak at 12 months and declined during the next 24 months. At the 36-month endpoint, there were eight patients who felt better than at baseline. Positron emission tomography (PET) showed a trend with increased dopamine (DA) release during the first 6 months.

CONCLUSION

Human retinal pigment epithelial cells have the characteristics of neural progenitor cells and can be induced to differentiate into DA neurons. The results of this clinical trial suggest that the treatment of transplanted hRPE cells could improve symptoms of PD. These cells might serve as a useful source of DA neurons for neural graft in the treatment for PD.

Cellular repair in the parkinsonian nonhuman primate brain

Parkinson disease (PD) is a neurodegenerative disorder that provides a useful model for testing cell replacement strategies to rejuvenate the affected dopaminergic neural systems, which have been destroyed by aging and the disease. We first showed that grafts of fetal dopaminergic neurons can reverse parkinsonian motor deficits induced by the toxin, 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP), validating the feasibility of cellular repair in a primate nervous system. Subsequent clinical trials in Parkinson patients showed encouraging results, including long-term improvement of neurological signs and reduction of medications in some patients. However, many experienced little therapeutic benefit, and some recipients experienced dyskinesias, suggesting a lack of regulated control of the grafts. We have since attempted to improve cell replacements by placing grafts in their correct anatomical location in the substantia nigra and using strategies such as co-grafting fetal striatal tissue or growth factors into the physiologic striatal targets. Moreover, the use of fetal cells depends on a variable supply of donor material, making it difficult to standardize cell quality and quantity. Therefore, we have also explored possibilities of using human neural stem cells (hNSCs) to ameliorate parkinsonism in nonhuman primates with encouraging results. hNSCs implanted into the striatum showed a remarkable migratory ability and were found in the substantia nigra, where a small number appeared to differentiate into dopamine neurons. The majority became growth factor-producing glia that could provide beneficial effects on host dopamine neurons. Studies to determine the optimum stage of differentiation from embryonic stem cells and to derive useful cells from somatic cell sources are in progress.

Embryonic substantia nigra grafts in the mesencephalon send neurites to the host striatum in non-human primate after overexpression of GDNF

In spite of partial success in treating Parkinson's disease by using ectopically placed grafts of dopamine-producing cells, restoration of the original neuroanatomical circuits, if possible, might work better. Previous evidence of normal anatomic projections from ventral mesencephalic (VM) grafts placed in the substantia nigra (SN) has been limited to neonatal rodents and double grafting or bridging procedures. This study attempted to determine whether injection of a potent growth-promoting factor, glial cell line-derived neurotrophic factor (GDNF), into the target regions or placement of fetal striatal co-grafts in the nigrostriatal pathway might elicit neuritic outgrowth to the caudate nucleus. Four adult St. Kitts green monkeys received embryonic VM grafts into the rostral mesencephalon near the host SN, and injections of adeno-associated virus 2 (AAV2)/GDNF or equine infectious anemia virus (EIAV)/GDNF into the caudate. Three adult monkeys were co-grafted with fetal VM tissue near the SN and fetal striatal grafts (STR) 2.5 mm rostral in the nigrostriatal pathway. Before sacrifice, the striatal target regions were injected with the retrograde tracer Fluoro-Gold (FG). FG label was found in tyrosine hydroxylase-labeled neurons in VM grafts in the SN of only those monkeys that received AAV2/GDNF vector injections into the ipsilateral striatum. All monkeys showed FG labeling in the host SN when FG labeling was injected on the same side. These data show that grafted dopaminergic neurons can extend neurites to a distant target releasing an elevated concentration of GDNF, and suggest that grafted neurons can be placed into appropriate loci for potential tract reconstruction.

Pluripotent stem cells as new drugs? The example of Parkinson's disease

Cell replacement therapy is a widely discussed novel concept of medical treatment. The increased knowledge in the stem cell field, particularly pluripotent stem cells, potentially provides powerful tools for this therapeutic concept. A large number of disease characterized by the loss of functional cells are potential candidates for cell replacement therapy and, in this regards, Parkinson's disease is of particular interest. It is one of the most prevalent neurodegenerative diseases caused by the loss of dopaminergic neurons in the Substantia nigra pars compacta. Pharmacological therapies are valuable but suffer from the progressive decline of efficacy as the disease progresses. Cell therapy application has emerged about two decades ago as a valid therapeutic alternative and recent advances in stem cell research suggest that pluripotent stem cell transplantation may be a promising approach to replace degenerated neurons in Parkinson's disease. Various sources of pluripotent stem cells (PSC) currently tested in animal models of Parkinson's disease have proven their efficacy in relieving symptoms and restoring damaged brain function. This review summarizes and discusses the important challenges that actually must be solved before the first studies of PSC transplantation can be undertaken into humans.

Human neural progenitor cell transplants into the subthalamic nucleus lead to functional recovery in a rat model of Parkinson’s disease

Despite the success of foetal nigral transplantation for the treatment of Parkinson's disease, supply limitations of tissue means that alternative sources must be found. Transplantation of human neural progenitor cells (HNPCs) may offer a solution, however few studies have shown functional recovery in animal models of PD without cell modification. Here we show that unmodified HNPC grafted into the subthalamic nucleus (STN) show excellent survival of up to 5 months and induce significant functional recovery following amphetamine-induced rotations within 4 weeks. For the first time we also show that HNPCs, which remain in an immature nestin-positive state, produce VEGF in vivo allowing further modification of the host brain. This suggests that even in the absence of cell replacement strategies utilising immature progenitor cells could be of real therapeutic value.

Local effects of dexamethasone on immune reaction in neural transplantation

This study was performed to see whether local injection of dexamethasone may protect the neural grafts from immunological rejection and increase the successive rate of graft. Rats with unilateral 6-hydroxydopamine lesions of the mesostriatal dopamine pathway received fetal ventral mesencephalic (FVM) cells and dexamethasone in two regions of the striatum and showed significant (P<0.001) reduction in rotational asymmetry as compared to the non-immunosuppressed group. A significantly greater number of total TH-ir cells (P<0.001) and fewer number of total GFAP -ir cells (P<0.001) and inflammatory cells were observed in the striatum of animals in immunosuppressed group than those in non-immunosuppressed group. This results indicated that local injection of dexamethasone could not only reduce the immune rejection and increase the survival grafted cell but also avoid the side effects brought by long systemic administer of immunosuppressant.

Human embryonic stem cell therapy for Parkinson's disease

Human embryonic stem cells (hESCs) may serve as the most enduring source of transplantable cells for Parkinson's disease patients. Accumulating experience in the transplantation of fetal midbrain tissue or cells into Parkinson's disease patients has set the stage for hESC therapy, but has also opened new controversies on the value and appropriate design of cell therapy. hESCs can be directed to differentiate into nigral dopaminergic neurons with high efficiency. The clinical use of hESCs will depend on their growth in controlled conditions, on whether safety can be proven, and on improving the survival of hESC-derived dopaminergic neurons in the host brain.

Effects of intranigral vs intrastriatal fetal mesencephalic neural grafts on motor behavior disorders in a rat Parkinson model

BACKGROUND

Numerous experimental and clinical studies have shown that intrastriatal fetal mesencephalic grafts grow, survive, and reinnervate host brain tissue, resulting in partial recovery of motor deficits. In addition, pharmacological evidence indicates that these grafts increase dopamine secretion in lesioned brain. However, to date, no grafting method has completely restored the nigrostriatal pathway, and there is no consensus on optimal graft numbers or locations. This study compared outcomes with multiple striatal grafts vs a single intranigral graft in a rat model of Parkinson disease.

METHODS

Forty-one female Wistar rats weighing 200 to 250 g were used. First, baseline rotational behavior testing with amphetamine injection was done to identify each animal's dominant nigrostriatal pathway (left vs right hemisphere). Some rats then received a unilateral intranigral injection of 6-hydroxydopamine (4 microL [8 microg]) to produce the Parkinson model lesion, and rotational testing was repeated. One group of the lesioned rats received a single intranigral injection of suspended fetal ventral mesencephalic cells (n = 11), and another received multiple intrastriatal grafts of the same type (n = 11).

RESULTS

Both grafted groups showed significant improvement on rotational testing with amphetamine and apomorphine at 6 weeks "postgrafting" (P < .001 for "postlesioning" vs postgrafting results in each of the 2 groups); however, the animals with multiple intrastriatal grafts showed complete recovery from motor asymmetry, whereas the rats with single intranigral grafts showed only partial improvement.

CONCLUSION

The findings indicate that multiple intrastriatal grafts result in significantly greater functional improvement than single intranigral grafts in this rat Parkinson model.

Dopaminergic innervation of the human striatum in Parkinson's disease

In Parkinson's disease (PD), dopaminergic input to the caudate nucleus and a band of putaminal tissue abutting the external globus pallidus seems well preserved on immunohistochemical staining for the dopamine transporter. Counting of dopaminergic terminals showed that terminal density in these regions in PD was the same as that in controls, which indicates that input is truly preserved and not a consequence of a compensatory upregulation of metabolism in a reduced pool of surviving terminals. When the branching pattern of dopaminergic axons coursing through the globus pallidus was examined, we found no evidence for increased axonal sprouting in PD that might have contributed to preservation of dopaminergic input to the putamen or caudate nucleus. Although terminal counting indicated that anatomic input was preserved to parts of the striatum, dopamine uptake site density in these regions was reduced significantly. This suggests that the impact of disease in these areas is more profound than was thought previously.

Pathophysiological basis of drug-induced dyskinesias in Parkinson's disease

Drug-induced dyskinesias (DID) represent a troublesome, dose-limiting, and common complication of long-term pharmacotherapy in Parkinson's disease (PD) patients. The pathophysiological basis and clinical nature of DID is of major interest for clinicians and neuroscientists. In this review article, we evaluate the theories of pathophysiology and molecular basis of DID, validity of various animal models used in DID related research, and electrophysiological characteristics of various basal ganglia nuclei during DID. We also discuss the relevance of various treatment strategies to the pathophysiological mechanisms.

MRI guidance improves accuracy of stereotaxic targeting for cell transplantation in parkinsonian monkeys

Accuracy of targeting is critical for the success of cell transplantation in the central nervous system. We compared the accuracy of conventional atlas-guided stereotaxis to magnetic resonance imaging (MRI)-guided stereotaxic targeting in various basal ganglia nuclei in parkinsonian monkeys. 28 monkeys underwent unilateral striatal transplantation. High-resolution 3D MR images of the brain were used in 15 monkeys fitted with a MRI-compatible stereotaxic frame for target localization. This was immediately followed by cranial surgery with the frame "in situ". 13 additional monkeys underwent stereotaxic atlas-guided cranial surgery for placement of cell transplants. Following extensive behavioral testing and microelectrode recordings, all animals were perfused. The brains were sectioned coronally and stained to determine the morphology of needle tracts as an accuracy measure of stereotaxic placements. MRI-guided stereotaxy was completely accurate in 80% as compared to 38.5% in atlas-guided stereotaxis. The chance of missing a target completely was as high as 38.5% in atlas-guided stereotaxis, which was reduced to 6.67% when MRI was used for guidance. Targeting error occurred mostly in the anterior caudate and posterior putamen as against better accuracy in the anterior putamen. These results suggest that accuracy of stereotaxic unilateral cranial targeting into the putamen and the caudate in monkeys can be improved with high-resolution 3D MR imaging.

Simultaneous intrastriatal and intranigral fetal dopaminergic grafts in patients with Parkinson disease: a pilot study. Report of three cases

The main neural transplantation strategy in Parkinson disease (PD) has been focused on reinnervating the striatum. The clinical results reported in patients who receive transplants have been limited and do not justify the use of neural transplantation as a routine therapeutic procedure for PD. Identifying the optimal target for transplantation may be one of the critical factors for optimizing clinical outcomes. Evidence from preclinical studies indicates that simultaneous intrastriatal and intranigral grafts (double grafts) may produce a more complete functional recovery. The authors report the clinical and positron emission tomography (PET) scanning results in three patients enrolled in a safety and feasibility pilot study who received double grafts and who have been followed for up to 13 months posttransplantation. Patients included in the study had idiopathic PD. All patients underwent detailed assessments before and after surgery, in accordance with the Core Assessment Program for Intracerebral Transplantation. The patients received implants of fetal mesencephalic cell suspensions in the putamen and substantia nigra (SN) bilaterally. There were no intraoperative or perioperative complications. Follow-up PET scans demonstrated an increase in the mean fluorodopa uptake constant values in the putamen and SN 12 months postsurgery. Improvements were also noted in the total Unified Parkinson's Disease Rating Scale, Hoehn and Yahr, Schwab and England, and pronation/supination scores after transplantation. The authors demonstrate the feasibility of reinnervating the SN and striatum by using a double transplant strategy in humans.