03 April 2010

Cysticcercosis



CYSTICERCOSIS
By:Palak Parikh

EPIDEMIOLOGY
* Found in approximately 50 million people worldwide (probably an underestimate)
* Endemic in several countries in Central and South America, sub-Saharan Africa, India, and Asia
* Prevalence in this country often higher in rural areas
* 221 deaths identified in the US from 1990-2002 (62% had emigrated from Mexico)

CYSTICERCOSIS TRANSMISSION
* Caused by the larval stage of Taenia solium, the pork tapeworm
* Humans develop by ingestion of T. solium eggs; they can spread infection by:
o Egg-containing feces contaminating water supplies in endemic areas
o Contaminating food directly, as eggs are sticky and can often be found under the fingernails of tapeworm carriers.

LIFE CYCLE
* Once eggs ingested, embryos are released in the small intestine and invade the bowel wall.
* They then disseminate hematogenously to other tissues and develop into cysticerci over 3 weeks to 2 months.
* Cysticerci – liquid-filled vesicles consisting of a membranous wall and a nodule containing the invaginated scolex.
* Scolex – head armed with suckers and hooks and a rudimentary body.

PATHOGENESIS
* Cysticerci initially viable but do not cause much inflammation in surrounding tissues – asymptomatic infection
* Host develops immune tolerance to cysticerci, which remain in this stage for several years.
o Postulated mechanisms of tolerance:
+ Taenia elaborate substances that inhibit or divert complement pathways away from parasite
+ Humoral antibodies do not kill mature taenia.
+ Poorly defined factors may interfere with lymphocyte proliferation and macrophage function, inhibiting normal cellular immune defenses.
* Clinical manifestations occur when inflammatory response develops around degenerating cysticercus.

SYMPTOMATIC DISEASE
* Divided into:
o Neurocysticercosis
o Extraneural cysticercosis

NEUROCYSTICERCOSIS
* 80% of infections are asymptomatic
* Symptoms mainly due to mass effect, inflammatory response, or obstruction of foramina and ventricular system of brain.
* Most common symptoms:
o Seizures
o Focal neurological signs
o Intracranial hypertension
* Peak estimated to occur 3-5 years after infection

NEUROCYSTICERCOSIS
* Increased risk of seizures with a single calcific granuloma.
* Risk of seizures highest when lesions are degenerating and are surrounded by inflammation.
* Encephalitis and diffuse brain edema most common in children and young females.
* 1-3% of cases involve the spinal cord, with thoracic lesions the most common.

NEUROCYSTICEROSIS IN ENDEMIC COUNTRIES
* Most common cause of adult-onset seizures
* Risk of seizures in seropositive individuals 2-3 times higher than seronegative controls.
* Punctate calcifications most frequent finding on neuroimaging of brain.

EXTRANEURAL CYSTICERCOSIS
* Typically involves:
o Eyes – in 1-3% of all infections
o Muscle
o Subcutaneous tissue – nodules most common in patients from Asia and Africa than from Latin America

DIAGNOSIS
* Serologic testing
* Peripheral eosinophilia only if cyst is leaking
* CT scan or MRI
o Pathognomonic Lesion: Scolex – mural nodule within a cyst
* Brain biopsy (only in symptomatic patients with equivocal serology and radiologic tests)

SEROLOGIC TESTING
* ELISA
* Complement fixation (CF)
* Radioimmunoassay
* Enzyme linked immunoelectrotransfer blot (EITB) assay – test of choice

EITB ASSAY
* Enzyme-linked immunoelectrotransfer blot assay
* Test of choice for detecting anticysticercal antibodies
* Uses affinity-purified glycoprotein antigens
* Higher sensitivity (83-100%) and specificity (93-98%) than ELISA
* Can be performed on serum or CSF but has a higher sensitivity on serum.
* Detected 94% of pathologically confirmed NCC with 2 or more lesions compared to only 28% with a single lesion in one study.

CT VS MRI
* MRI preferred since it is more sensitive in detecting:
o small lesions
o brainstem or intraventricular lesions
o perilesional edema around calcific lesions
o scolex
o degenerative changes in the parasite
* CT scan cheaper and better at detecting:
o small areas of calcifications.
o cysticercal infestation of extraocular muscles.

* Perform CT scan first followed by MRI in patients with inconclusive findings or in those with negative CT scans where strong clinical suspicion persists.

PERUVIAN STUDY
POTENTIAL TREATMENTS
* Albendazole (15 mg/kg/day) X 15 days + corticosteroids (30-40 mg prednisolone or 12-16 mg dexamethasone daily) – per UpToDate
* Praziquantel (50 mg/kg/day) X 15 days + corticosteroids (30-40 mg prednisolone or 12-16 mg dexamethasone daily) – per UpToDate
* Corticosteroids alone
* Anticonvulsants in patients who present with seizures or are at high risk for seizures
* Surgery

ALBENDAZOLE VS PRAZIQUANTEL
* Albendazole
o Destroys 75-90% of parenchymal brain cysts
o Does not interact with anticonvulsants
o Levels not adversely affected w/ co-administration of corticosteroids
* Praziquantel
o Destroys 60-70% of cysts 3 months after administration
o Decreased efficacy compared to Albendazole
o Available for oral administration
o Does not cross the blood-brain barrier well, so CSF levels only approx 20% of plasma levels.
o Involves cytochrome P-450 hepatic metabolism, which is induced by corticosteroids, phenytoin, and phenobarbital

* No blinded randomized controlled trials comparing albendazole to praziquantel.
Because of the above, praziquantel is generally considered second-line therapy.

TREATMENT
* One randomized, double-blind, placebo-controlled trial
o 120 pts with living cysticerci in the brain and seizures treated with antiepileptic drugs
+ Randomized to either albendazole (800 mg qd) and dexamethasone (6 mg qd X 10 days) or double placebo
+ Followed for 30 months or until they were seizure-free for 6 months after tapering of antiepileptic drugs
o Results:
+ Resolution of intracranial cystic lesions more common in treatment arm
+ Number of patients experiencing generalized seizures declined in the treatment arm
+ No significant change between the two groups in patients experiencing partial seizures

NEUROCYSTICERCOSIS
* Treatment in those with:
o 5-50 cysts (both antiparasitic and steroids)
o Steroids alone in patients w/ > 50 cysts
* No Treatment in those with:
o Asymptomatic nonviable neurocysticercosis
o Calcified cysts
o Single viable cysts
o Fewer than 5 cysts

ANTICONVULSANTS
* Recommended for patients who present with seizures
* Should be stopped if patient remains seizure-free during therapy to see if the patient remains asymptomatic
* Should be reinitiated chronically if the patient has recurrent seizures
* Should be considered in patients w/ multiple cysts who have no history of seizure activity

SURGICAL INTERVENTION
* Used in some patients with intracranial hypertension
* Shunting improves hydrocephalus, although recurrent blockages of shunts common
* Surgical intervention recommended for cysts:
o Located in the 4th ventricle
o Attached to middle cerebral artery
o Compressing the optic chiasm
o Located in the spine

TREATMENT OF EXTRANEURAL CYSTICERCOSIS
* None if pt asymptomatic
* Surgical excision for intraocular disease
* Medical therapy for involvement of extraocular muscles or optic nerve.
* NSAIDs for patients w/ symptomatic subcutaneous or intramuscular lesions.
* Excision of solitary lesions if NSAIDs fail or not tolerated.

BEFORE INITIATING MEDS…
* Apply PPD.
* Consider treating with a single dose of ivermectin before beginning corticosteroids, as many patients have risk factors for strongyloidiasis.
* Consult ophthalmology to rule out ocular cysticercosis.

PATIENT MONITORING
* Intermittent surveillance w/ imaging until cyst(s) resolve(s).
o Perhaps every 3-6 months if patient improving or earlier if patient symptomatic.
* Reimaging of brain 2 months after completion of treatment
* Consider antiparasitic therapy if cysts growing off therapy

POSSIBLE PREVENTION
* Human Tapeworm Infections
o Inspection of pork for cysticerci
o Freezing or adequately cooking meat to destroy cysticerci
o Administering antiparasitic agents to pigs
* Infection in Pigs
o Confining animals and not allowing them to roam freely
o Improved sanitary conditions
* Egg Transmission to Humans
o Good personal hygiene and hand washing prior to food preparation
o Identifying human carriers of tapeworms
o Mass community programs to treat tapeworm carriers.
* Possible Vaccine – porcine vaccine currently in the works

TAKE HOME POINTS
* Cysticercosis caused by the larval stage of Taenia solium, the pork tapeworm
* Pay special attention if pt from Central and South America, sub-Saharan Africa, India, and Asia, as neurocysticercosis is the most common cause of adult-onset seizures in these endemic areas.
* Order Head CT first to diagnose neurocysticercosis; if negative and suspicion still high, order Brain MRI.
* EITB test of choice for serology.
* Place PPD before starting treatment.
* Obtain Ophthalmology consult before starting treatment.
* Albendazole and Dexamethasone comprise first-line treatment for symptomatic cysticercosis. Consider concurrent anticonvulsants if pt presents with seizures.

REFERENCES
* aapredbook.aappublications.org
* UpToDate.
* www.dpd.cdc.gov
* www.e-radiology.net
* www.parasite-diagnosis.ch
* www.stanford.edu/class/cysticercosis/symptoms

CYSTICERCOSIS.ppt

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02 April 2010

The Basal Ganglia



The Basal Ganglia

Outline
* Components of the basal ganglia
* Arrangement of basal ganglia components in the brain
* Architecture: cytology & neurochemistry
* Pathways & circuitry
* Function(s) of the basal ganglia
* Dysfunction and pathology
* Differences between human and rodent basal ganglia?

What are the Basal Ganglia?
The basal ganglia include…
* Neostriatum
o Caudate nucleus
o Putamen
o Nucleus Accumbens
* Globus Pallidus
o Internal segment
o External segment
o Ventral pallidum
* Subthalamic nucleus
* Substantia nigra
o Pars compacta
o Pars reticulata
* Pedunculopontine nucleus**
Subgroups of the basal ganglia
* Striatum
o Caudate nucleus
o Putamen
* Lenticular nuclei
o Globus pallidus
o Putamen
* Corpus striatum
o Caudate
o Lenticular nuclei

How are the basal ganglia arranged in the brain?
Caudate Nucleus
o C shaped structure
o Lateral wall of lateral ventricle
o Head, body and tail of caudate

Putamen and Globus Pallidus
* Putamen + Globus Pallidus = lentiform or lenticular nuclei
* Fills in space between the inferior horn and the anterior horn and body of the lateral ventricle.
* Gap between the lentiform nuclei and the lateral ventricle filled by the caudate nucleus.
* The posterior limb of the internal capsule separates the lentiform nuclei from the thalamus.

* Claustrum
* Septum pellucidum
* Insular cortex
* Corpus callosum
* Caudate nucleus
* Putamen
* Nucleus accumbens
* Internal capsule
* External capsule
* Extreme capsule
* Caudate nucleus
* Putamen
* Globus pallidus external (GPe)
* Globus pallidus internal (GPi)
* Ventral pallidum
* Anterior commissure
* Substantia innominata
* Internal capsule
* Lentiform nucleus**
* Caudate (Head, body, tail)
* Putamen
* GPe & GPi
* Lateral ventricle, anterior and temporal horn
* Internal capsule, anterior and posterior horn
* Caudate nucleus (body and tail)
* Putamen
* Globus pallidus
* Subthalamic nucleus
* Substantia nigra

- Pars compacta
- Pars reticulata
* Subthalamic nucleus
* Substantia nigra
* Globus pallidus external
* Subthalamic nucleus
* Substantia nigra
* Ventral tegmental area

Functions of the Basal Ganglia
* Extrapyramidal motor system
* Motor planning, sequencing and learning
* Striatal neuronal activity is not sufficiently explained by the stimuli presented or the movements performed
* Dependent on certain behavioral situations, certain conditions or particularly types of trials
+ -sensory stimuli but only when they elicit movements
+ -instruction cues (go-no go)
+ -memory related cues
+ -reward (especially ventral striatum)
+ -self-initiated moves
* Basal ganglia distinguished from cerebellum by connections with limbic system

Architecture of the basal ganglia: cellular and neurochemistry

Cytoarchitecture
* Main neurotransmitter in basal ganglia is GABA
* 95% of neurons in neostriatum are medium spiny neurons
o Contain GABA
o Principal neurons: project to globus pallidus and SNpr
o Subpopulations are distinguished by peptides, neurotransmitter receptors and connections
o Receive bulk of afferent input
* Several populations of interneurons
o aspiny
o ACh, somatostatin, GABA/parvalbumin
Neuronal circuitry of the basal ganglia
The Neostriatal Mosaic
* Neostriatum divided into two compartments:
patch (striosome) & matrix
* First described by Ann Graybiel in 1978 using AChE stain
* Not visible in Nissl stains (“hidden chemoarchitecture”)
* Define input/output architecture of neostriatum

Neostriatal Mosaic and Input/Output Organization
* Most inputs to the neostriatum terminate in a patchy fashion (“matrisomes”)
* Input from a given cortical region terminates over an extended anterior-posterior extent
* Functionally related cortical areas project to the same patches
* Output neurons to a given efferent subregion are also arranged in patches
* Neurons in patches project to both GPi/SNpr and GPe

Functional subdivisions
* Sensorimotor
o Putamen + globus pallidus/SNpr
o SNpc
* Association
o Caudate nucleus + globus pallidus/SNpr
o SNpc
* Limbic
o Nucleus accumbens + ventral pallidum
o VTA

Basal ganglia connections and pathways
Connections
* Afferents/inputs (neostriatum):
o Cerebral cortex (entire cortex)
o Thalamus (intralaminar and midline nuclei)
o Amygdala (basolateral nucleus)
o Raphe, substantia nigra pars compacta, VTA
* Efferents/output (GPi, VP, SNpr)
o Ventral tier nuclei of thalamus
o Subthalamic nucleus
o Superior colliculus
Organization of inputs to basal ganglia
Organization of basal ganglia outputs

All regions of cerebral cortex project to the basal ganglia, but output of basal ganglia is directed towards the frontal lobe, particularly pre-motor and supplementary motor cortex
Basic Circuit of Basal Ganglia

Neostriatum
GPi/SNpr
Cerebral Cortex
VA/VL thalamus
Direct vs. indirect pathways
* Different populations of spiny neurons
* Neuromodulators/co-transmitters
* Striosomes vs. matrix
* Dopamine receptor subtypes
Both

Recurrent loops
* Motor loop
o sensorimotor areas 1,2,3,4,5,6 -> putamen -> GP -> VA ->SMA
* Ocularmotor loop
o prefrontal cortex & ppc 9,12, 7 -> caudate -> GP -> VA -> frontal eye fields & SC
* Cognitive loop
o prefrontal cortical areas 9,12 -> caudate -> GP -> VA -> prefrontal cortex
* Limbic loop
o cingulate -> caudate (striosomes)-> GP -> MD -> ant. cingulate.
Topography is maintained within each loop!

Motor loop
Somatotopic subdivisions of the input remain segregated throughout the circuit.
Adapted from Rothwell, 1994; from Alexander and Crutcher, 1990
Processing in the basal ganglia
Huntington’s and Parkinson’s diseases
* Neurodegenerative diseases
* Motor dysfunction
* Brainwide pathology with focus on basal ganglia elements
* Genetic and/or environmental causes
Huntington’s Disease
Clinical symptoms
* Hyperkinetic & hemiballistic movements

Pathology hallmarks
* Striopallidal degeneration
* Decreased striatal volume
* Decrease in 5-HT1B receptors in ventral pallidum
Hyperkinetic hypothesis
* Reduced Glu (+) from STN to GPi, due either to STN lesions or reduced striatopallidal inhibitory influences along the in direct pathway lead to reduced inhibitory outflow from GPi/SNr and excessive disinhibition of the thalamus.
* Increased Glu (+) to cortical areas engaged by the motor circuit (SMA, PMC, MC) results in hyperkinetic movements.
Parkinson’s Disease
Clinical symptoms
* Hypokinetic movement
* Cogwheel rigidity

Pathology hallmarks
* Nigostriatal degeneration
* DA neuronal degeneration in SN
Hypokinetic hypothesis
* Inhibition of GPe within the indirect pathway leads to disinhibition of the STN
* Increased STN to the basal ganglia output nuclei (Gpi/SNr), leads to excessive thalamic inhibition.
* This is reinforced by reduced inhibitory input to Gpi/SNr through the direct pathway.
* Overall result is a reduction in reinforcing influence of the motor circuit upon cortically initiated movements.

PD Therapeutics: The approaches
* Pharmacology
o DA, mGluR, MAO(B) inhibitors, antioxidants, iron chelators
* Surgical
o Pallidal ablation
o DBS of globus pallidus or STN
* Transplantation
o Fibroblast cells
o Stem cells
* Vaccines
* RNA interference (RNAI)-based treatments

DBS: Deep Brain Stimulation of STN
Common themes in neurodegeneration
* Neurotoxicity
* Inflammation (glia)
* Apoptosis
* Abnormal protein aggregation
Thank you!
Notable differences between basal ganglia of human and rodents …..
There are differences in:
* Divisions & nomenclature
* Proportions
* Topography of afferent and efferent projections
Globus pallidus and entopeduncular nucleus (rodent)
vs.
Globus pallidus (external) and Globus pallidus (internal) (primate)
Regional proportion by volume
(% of total volume)
Spinal Cord

Major projection differences

* Neurons projecting to the motor and associative striatum
o Rats: reside in distinct regions
o Primates: arranged in interdigitating clusters.
* Terminal fields of projections arising from the motor and associative striatum
o rats: largely segregated
o Primates: not segregated
* Organization of patch- and matrix-projecting dopamine cells
o Rats: organized in spatially, morphologically, and histochemically distinct ventral and dorsal tiers,
o Primates: no (bi)division of the dopaminergic system that results in two areas which have all the characteristics of the two tiers in rats.

The Basal Ganglia.ppt
http://login.ncmir.ucsd.edThe Basal Ganglia

Outline
* Components of the basal ganglia
* Arrangement of basal ganglia components in the brain
* Architecture: cytology & neurochemistry
* Pathways & circuitry
* Function(s) of the basal ganglia
* Dysfunction and pathology
* Differences between human and rodent basal ganglia?

What are the Basal Ganglia?
The basal ganglia include…
* Neostriatum
o Caudate nucleus
o Putamen
o Nucleus Accumbens
* Globus Pallidus
o Internal segment
o External segment
o Ventral pallidum
* Subthalamic nucleus
* Substantia nigra
o Pars compacta
o Pars reticulata
* Pedunculopontine nucleus**
Subgroups of the basal ganglia
* Striatum
o Caudate nucleus
o Putamen
* Lenticular nuclei
o Globus pallidus
o Putamen
* Corpus striatum
o Caudate
o Lenticular nuclei

How are the basal ganglia arranged in the brain?
Caudate Nucleus
o C shaped structure
o Lateral wall of lateral ventricle
o Head, body and tail of caudate

Putamen and Globus Pallidus
* Putamen + Globus Pallidus = lentiform or lenticular nuclei
* Fills in space between the inferior horn and the anterior horn and body of the lateral ventricle.
* Gap between the lentiform nuclei and the lateral ventricle filled by the caudate nucleus.
* The posterior limb of the internal capsule separates the lentiform nuclei from the thalamus.

* Claustrum
* Septum pellucidum
* Insular cortex
* Corpus callosum
* Caudate nucleus
* Putamen
* Nucleus accumbens
* Internal capsule
* External capsule
* Extreme capsule
* Caudate nucleus
* Putamen
* Globus pallidus external (GPe)
* Globus pallidus internal (GPi)
* Ventral pallidum
* Anterior commissure
* Substantia innominata
* Internal capsule
* Lentiform nucleus**
* Caudate (Head, body, tail)
* Putamen
* GPe & GPi
* Lateral ventricle, anterior and temporal horn
* Internal capsule, anterior and posterior horn
* Caudate nucleus (body and tail)
* Putamen
* Globus pallidus
* Subthalamic nucleus
* Substantia nigra

- Pars compacta
- Pars reticulata
* Subthalamic nucleus
* Substantia nigra
* Globus pallidus external
* Subthalamic nucleus
* Substantia nigra
* Ventral tegmental area

Functions of the Basal Ganglia
* Extrapyramidal motor system
* Motor planning, sequencing and learning
* Striatal neuronal activity is not sufficiently explained by the stimuli presented or the movements performed
* Dependent on certain behavioral situations, certain conditions or particularly types of trials
+ -sensory stimuli but only when they elicit movements
+ -instruction cues (go-no go)
+ -memory related cues
+ -reward (especially ventral striatum)
+ -self-initiated moves
* Basal ganglia distinguished from cerebellum by connections with limbic system

Architecture of the basal ganglia: cellular and neurochemistry

Cytoarchitecture
* Main neurotransmitter in basal ganglia is GABA
* 95% of neurons in neostriatum are medium spiny neurons
o Contain GABA
o Principal neurons: project to globus pallidus and SNpr
o Subpopulations are distinguished by peptides, neurotransmitter receptors and connections
o Receive bulk of afferent input
* Several populations of interneurons
o aspiny
o ACh, somatostatin, GABA/parvalbumin
Neuronal circuitry of the basal ganglia
The Neostriatal Mosaic
* Neostriatum divided into two compartments:
patch (striosome) & matrix
* First described by Ann Graybiel in 1978 using AChE stain
* Not visible in Nissl stains (“hidden chemoarchitecture”)
* Define input/output architecture of neostriatum

Neostriatal Mosaic and Input/Output Organization
* Most inputs to the neostriatum terminate in a patchy fashion (“matrisomes”)
* Input from a given cortical region terminates over an extended anterior-posterior extent
* Functionally related cortical areas project to the same patches
* Output neurons to a given efferent subregion are also arranged in patches
* Neurons in patches project to both GPi/SNpr and GPe

Functional subdivisions
* Sensorimotor
o Putamen + globus pallidus/SNpr
o SNpc
* Association
o Caudate nucleus + globus pallidus/SNpr
o SNpc
* Limbic
o Nucleus accumbens + ventral pallidum
o VTA

Basal ganglia connections and pathways
Connections
* Afferents/inputs (neostriatum):
o Cerebral cortex (entire cortex)
o Thalamus (intralaminar and midline nuclei)
o Amygdala (basolateral nucleus)
o Raphe, substantia nigra pars compacta, VTA
* Efferents/output (GPi, VP, SNpr)
o Ventral tier nuclei of thalamus
o Subthalamic nucleus
o Superior colliculus
Organization of inputs to basal ganglia
Organization of basal ganglia outputs

All regions of cerebral cortex project to the basal ganglia, but output of basal ganglia is directed towards the frontal lobe, particularly pre-motor and supplementary motor cortex
Basic Circuit of Basal Ganglia

Neostriatum
GPi/SNpr
Cerebral Cortex
VA/VL thalamus
Direct vs. indirect pathways
* Different populations of spiny neurons
* Neuromodulators/co-transmitters
* Striosomes vs. matrix
* Dopamine receptor subtypes
Both

Recurrent loops
* Motor loop
o sensorimotor areas 1,2,3,4,5,6 -> putamen -> GP -> VA ->SMA
* Ocularmotor loop
o prefrontal cortex & ppc 9,12, 7 -> caudate -> GP -> VA -> frontal eye fields & SC
* Cognitive loop
o prefrontal cortical areas 9,12 -> caudate -> GP -> VA -> prefrontal cortex
* Limbic loop
o cingulate -> caudate (striosomes)-> GP -> MD -> ant. cingulate.
Topography is maintained within each loop!

Motor loop
Somatotopic subdivisions of the input remain segregated throughout the circuit.
Adapted from Rothwell, 1994; from Alexander and Crutcher, 1990
Processing in the basal ganglia
Huntington’s and Parkinson’s diseases
* Neurodegenerative diseases
* Motor dysfunction
* Brainwide pathology with focus on basal ganglia elements
* Genetic and/or environmental causes
Huntington’s Disease
Clinical symptoms
* Hyperkinetic & hemiballistic movements

Pathology hallmarks
* Striopallidal degeneration
* Decreased striatal volume
* Decrease in 5-HT1B receptors in ventral pallidum
Hyperkinetic hypothesis
* Reduced Glu (+) from STN to GPi, due either to STN lesions or reduced striatopallidal inhibitory influences along the in direct pathway lead to reduced inhibitory outflow from GPi/SNr and excessive disinhibition of the thalamus.
* Increased Glu (+) to cortical areas engaged by the motor circuit (SMA, PMC, MC) results in hyperkinetic movements.
Parkinson’s Disease
Clinical symptoms
* Hypokinetic movement
* Cogwheel rigidity

Pathology hallmarks
* Nigostriatal degeneration
* DA neuronal degeneration in SN
Hypokinetic hypothesis
* Inhibition of GPe within the indirect pathway leads to disinhibition of the STN
* Increased STN to the basal ganglia output nuclei (Gpi/SNr), leads to excessive thalamic inhibition.
* This is reinforced by reduced inhibitory input to Gpi/SNr through the direct pathway.
* Overall result is a reduction in reinforcing influence of the motor circuit upon cortically initiated movements.

PD Therapeutics: The approaches
* Pharmacology
o DA, mGluR, MAO(B) inhibitors, antioxidants, iron chelators
* Surgical
o Pallidal ablation
o DBS of globus pallidus or STN
* Transplantation
o Fibroblast cells
o Stem cells
* Vaccines
* RNA interference (RNAI)-based treatments

DBS: Deep Brain Stimulation of STN
Common themes in neurodegeneration
* Neurotoxicity
* Inflammation (glia)
* Apoptosis
* Abnormal protein aggregation
Thank you!
Notable differences between basal ganglia of human and rodents …..
There are differences in:
* Divisions & nomenclature
* Proportions
* Topography of afferent and efferent projections
Globus pallidus and entopeduncular nucleus (rodent)
vs.
Globus pallidus (external) and Globus pallidus (internal) (primate)
Regional proportion by volume
(% of total volume)
Spinal Cord

Major projection differences

* Neurons projecting to the motor and associative striatum
o Rats: reside in distinct regions
o Primates: arranged in interdigitating clusters.
* Terminal fields of projections arising from the motor and associative striatum
o rats: largely segregated
o Primates: not segregated
* Organization of patch- and matrix-projecting dopamine cells
o Rats: organized in spatially, morphologically, and histochemically distinct ventral and dorsal tiers,
o Primates: no (bi)division of the dopaminergic system that results in two areas which have all the characteristics of the two tiers in rats.

The Basal Ganglia.ppt

Read more...

Anxiety Disorders



Anxiety Disorders

* Panic disorder
o Can be induced by lactate or CO2 in PD sufferers (only occasionally in normal people)
o Increased activity in parahippocampal gyrus,
o Decreased activity in anterior temporal cortex & amygdala (seems odd!)
o May have 3, rather than 2, repeats of a section on chromosome 15
+ Also have joint laxity (bend too far)

* Treatments for panic disorder
o Benzodiazepines (e.g., Valium)
+ Increase frequency of Cl- channel openings in response to GABA
+ Have little or no effect alone: safer than barbiturates
+ Allopregnanolone = endogenous agonist at benzodiazepine binding site.
o Buspirone (Buspar): 5-HT1a agonist (GI/O)
o SSRIs: fluoxetine (Prozac), paroxetine (Paxil)

Benzodiazepine receptors in brain
PTSD
* Monozygotic > dizogotic concordance
o Genetics 1/3 of variance
* NMDA mechanisms in amygdala
o May mediate both the conditioning and the extinction
+ NMDA antagonists in amygdala prevent extinction
+ Hippocampus and PFC also lose effectiveness in extinction
* Not due to high levels of glucocorticoids:
o Usually PTSD sufferers have LOWER than normal cortisol levels, despite high CRH
+ Maybe it’s the high CRH that  symptoms
+ Or maybe it’s increased responsiveness to CRH or cortisol
* Individual differences in responsiveness to trauma
* Sometimes treated with β NE antagonists (propranolol) or protein synthesis inhibitors soon after the trauma or during recall of the trauma
OCD
* Increased metabolism in orbitofrontal cortex, cingulate, and caudate nuclei.
* Decreased REM latency (~ to depression)
* At least 2 gene polymorphisms:
o For BDNF, 5-HT2A receptor
* Treatment: SSRIs
Cingulotomy to treat OCD
Tourette’s Syndrome
* In many ways opposite Parkinson’s disease
* Treated with dopamine antagonists
* Monozygotic concordance: 53-77%; dizygotic concordance: 8-23%
* Witty Ticcy Ray (by Oliver Sacks): “We Touretters…are forced into levity by our Tourette’s and forced into gravity when we take Haldol….You have a natural balance: we must make the best of an artificial balance.”

THE NIGROSTRIATAL AND MESOLIMBIC DOPAMINE SYSTEMS
* Nigrostriatal and mesolimbic tracts are parallel.
o Begin in midbrain (substantia nigra & ventral tegmental area, VTA)
o End in dorsal (caudate & putamen) and ventral (N. accumbens) striatum
o Cortico-striato-pallido-thalamic-cortical loops

Nigrostriatal system
* Plans and triggers self-initiated movements
* Adjusts posture
* Degeneration  Parkinson’s disease
o Tremor at rest
o Difficulty initiating movements

Mesolimbic system
* Increases responsiveness to external and internal stimuli
* Motivation
* Motor activity
* Reward
* Drug addiction
* Schizophrenia
Nigrostriatal dopamine tract
Mesolimbic dopamine tract

Direct pathway
* Positive feedback loop
* Cortical areas that initiated the activity are further excited.
* 2 consecutive inhibitory influences
* Then an excitatory influence
* Stimulating the first inhibitory path inhibits the second inhibitory path: disinhibits the excitatory path.

Sensorimotor Cortex
Striatum
Direct pathway
* Stimulate putamen
* Inhibits GPi/SNr
via D1 receptors
Sensorimotor Cortex
Striatum
Direct Pathway
When putamen inhibits
GPi/SNr, VL/VA
is disinhibited.
Thus, VL/VA excites
sensory motor cortex.
Indirect Pathway
Negative feedback
Begins with 2
inhibitory paths:
1. Putamen to GPe
2. GPe to STN
Sensorimotor Cortex
Indirect Pathway
Those inhibitory paths disinhibit an excitatory path.
But that exc. path ends on another inhibitory path!
Function
* Direct path excites cortex; indirect path inhibits it: opposing functions.
* May “sharpen” influence on behavior
o (similar to “sharpening” receptive fields).
* May provide greater control over movement
o (similar to having both EPSPs and IPSPs on same neuron).

Effects of Dopamine
* D1 receptors excite the Direct Pathway
o (i.e., increase excitation of the cortex).
* D2 receptors inhibit the Indirect Pathway
o (i.e., decrease the inhibition of thalamus and therefore increase excitation of cortex).
* Therefore, both effects increase excitation of cortex
o (i.e., increase either movement or motivation).

The Mesolimbic System
* Circuit is parallel to nigrostriatal system:
o Direct and indirect pathways
o Prefrontal cortex vs. sensory motor
o N. accumbens (ventral striatum), vs. caudate & putamen (dorsal striatum)
o Ventral pallidum vs. GPi and GPe
o Mediodorsal thalamus vs. VL/VA
Prefrontal Cortex
VP normally inhibits

Effects of Dopamine
* D1 receptors excite the Direct Pathway
o (i.e., increase excitation of the cortex).
* D2 receptors inhibit the Indirect Pathway
o (i.e., decrease the inhibition of thalamus and therefore increase excitation of cortex).
* Therefore, both effects increase excitation of cortex
o (i.e., increase either movement or motivation).

Glutamate/DA balance in schizophrenia
* Cortical or hippocampal hypofunction may  decrease glutamate in NAcc and striatum
* decrease tonic DA release
* increase DA receptor sensitivity
* hyperresponsive to phasic input

Anxiety Disorders.ppt

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