Is There A Cure for Parkinson Disease

The Parkinson's Disease Protocol

Parkinson's Disease Protocol was authored by Jodi Knapp to help people heal and recover from Parkinson's disease. Thousand have since won the battle against this threatening disease using this same Protocol. Parkinson's disease is an illness characterized by the degeneration of brain cells, resulting in lower dopamine. This results in sleep problems, subsidence in the moods, anxiety, a weakened smelling ability, and severe memory lapses. Parkinson's disease is tackled through various approaches. However, Jodi Knapp, in her Parkinson's Disease Protocol, compiled the 12 simple steps that involve adjusting to new lifestyle habits and effortlessly eliminate the symptoms of brain degeneration. The steps are scientifically proven to work, and thousands of people have benefitted from the program. Consider using this powerful program to preserve the health of your brain cells, or recover them from degeneration, better mental and physical health, both today and years to come. Read more here...

The Parkinsons Disease Protocol Summary

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Antiparkinsonian Drugs

Parkinson's disease is a degenerative, slowly progressing illness of the CNS characterized by bradykinesia, shuffling gait, postural instability, tremor, and loss of automatic movement, which is associated with damaged basal ganglions. The etiology of this illness is not known. The most likely cause of the aforementioned motor problems could be a lack of dopamine, which has an inhibitory effect on the regulatory function of the spinal cord. On the other hand, cholinergic neurons act in regulating the extrapyramidal system. For more than a century, treatment of Parkinsonism was based on use of central anticholinergic substances. Up until recent times, various alkaloid drugs of belladonna, which have a characteristic cholinergic action (i.e. the ability to reduce sensitivity to acetylcholine, a neurotransmitter of cholinergic synapses) have been used for Parkinsonism. Currently, a sufficient quantity of facts have been established that support the idea that Parkinsonism is a consequence...

Pathophysiology of Dopamine Systems Parkinsons Disease

Parkinson's disease is characterized as a degenerative movement disorder that very clearly results from a loss of dopamine neurons in the substantia nigra and an ensuing loss of dopamine innervation to the basal ganglia. The motor disorder progresses from tremor and slurred speech to akinesia and rigidity. The treatment of Parkinson's disease is initially dopamine replacement in the form of the dopamine precursor l-dopa. However, to be effective, sufficient dopamine synthetic capacity must be available in axon terminals in the basal ganglia. Thus, as the degeneration progresses, l-dopa becomes a progressively less effective treatment. Based upon understanding of basal ganglia circuitry, manipulating other neurotransmitters such as acetylcholine is also useful in ameliorating the motor symptoms of Parkinson's disease. However, no treatment is available that reverses or inhibits the neurodegeneration.

Other cellbased approaches to transplantation in PD

The limited clinical benefits obtained with fetal nigral transplantation to date coupled with the societal and logistic issues involved in the use of human embryonic tissue, has led to a search for alternate sources of dopaminergic cell types for transplantation in PD. As previously discussed, adrenomedullary tissue has been abandoned as patients did not maintain long-term benefit and the procedure was associated with considerable morbidity. Extra-adrenal chromaffin tissue has attracted some attention. The organ of Zuckerkandl is a paired organ located adjacent to the abdominal aorta which represents a source of GDNF (Bohn et al., 1982). Transplant of this tissue has been reported to induce functional improvement in Parkinsonian rats (Espejo et al., 2001). Autologous sympathetic ganglia cells have been tested in small groups of patients with advanced PD. In one study, patients were reported to have a decrease in off time (Nakao et al., 2001), while another found amelioration of...

Idiopathic Parkinsonism

Vivid dreams are a feature of Parkinsonism. They usually have a strong visual content and are particularly marked during treatment with L-dopa or dopaminergic agents. Visual hallucinations also occur during wakefulness in around 25 of those with idiopathic Parkinsonism but especially in Lewy body disease. They often involve strangers, but are not frightening. They are probably due to brief episodes of REM sleep intruding into wakefulness and occur particularly in those who have sleep-onset REM during polysomnography 12 and REM sleep demonstrated during naps in the day. Cataplexy does not occur.

Parkinsons disease idiopathic Parkinsonism

Parkinson's disease (page 226) frequently causes excessive daytime sleepiness 49 . This is reported in around 40 of subjects and polysomnography reveals a reduced sleep efficiency proportional to the disease severity, and often markedly shortened MSLTs. There is a reduction in stages 3 and 4 NREM sleep and REM sleep, but sleep-onset REM sleep is common. The cerebrospinal fluid hypocretin concentration may be reduced in advanced disease, but there is no association with HLA DQB1*0602, unlike in narcolepsy. There are several causes for these abnormalities.

Parkinsonism Plus Syndromes

In addition to Parkinson's disease, parkinsonism is one of the major clinical features in several other primary neurodegenerative conditions. However, because they all have additional features not typical of Parkinson's disease and share an overall worse prognosis and poorer response to antiparkinsonian therapy, they are often grouped together under the conglomerate term parkinsonism-plus syndromes. Within this group, each condition has distinctive characteristics that must be recognized and distinguished from one another and from PD. Pathogenesis and Pathophysiology. Progressive supranuclear palsy (PSP) is the most common and best recognized entity among the parkinsonism-plus syndromes. PSP is an idiopathic condition with no known precipitant or strong genetic component. Postmortem analysis of the brains of PSP patients show neuronal loss, gliosis, and neurofibrillary tangles composed of straight and paired helical filaments. y The SN, subthalamic nucleus, globus pallidus, superior...

Parkinsons Disease with Dementia

Ihere are several forms of primary degenerative parkinsonism, including idiopathic (or sporadic) PD, sporadic PD with superimposed pathological features of AD, familial PD (or parkinsonian syndromes), and Parkinson's-ALS- dementia complex of Guam. Pathological substrates differ among these conditions, as do the frequency of cognitive disturbances. In patients with pathological evidence of AD, dementia is usually (but not invariably) present. In familial cases, genetic defects and pathological changes differ between kindreds, so it is difficult to generalize to sporadic PD. In each case of PD, however, when dementia is described, it is most consistent with a subcortical pattern to distinguish it from typical Alzheimer-type dementia. Pathogenesis and Pathophysiology. Memory performance in nondemented and demented patients with PD is qualitatively different, y , y suggesting that cognitive impairment in nondemented and demented PD patients reflects different anatomical or neurochemical...

Parkinsons disease

The etiology of Parkinson's disease remains unknown. In the substantia nigra of Parkinson's diseased brains, ubiquitin-conjugates accumulate in cytosolic inclusions known as Lewy bodies. These inclusions also contain a protein of unknown function, a-synuclein, an ubiquitin C-terminal hydrolase, UCH-L1 also known as PGP9.5, and proteasome subunits. These findings clearly implicate the ubiquitin proteasome pathway in the etiology of this disease.112 Mutations in a-synuclein were found to cause familial PD in four different families.113 In vitro studies demonstrated that mutant a-synuclein (A53T) is cleaved by the ubiquitin proteasome pathway at a slower rate than wild type, an event that provides a basis for its aggregation in intracellular inclusions.112 Deletions in the exon regions of the parkin gene were found to be associated with an autosomal recessive juvenile parkinsonism.114 Parkin, the protein product, is abundant in the brain and its N-terminal sequence is moderately similar...


Idiopathic Parkinsonism (Parkinson's disease) This is due to degeneration in the basal ganglia and related structures. The substantia nigra in the mid-brain has close relationships with the LDT PPT in the pons which controls REM sleep, and with the raphe nuclei and locus coeruleus which are involved with NREM sleep. The initial degeneration probably occurs in the pons, which may explain the frequency of postural hypotension and the appearance of the REM sleep behaviour disorder often several years before other features of Parkinsonism appear. As the disease advances it may extend into the dorsolateral prefrontal cerebral cortex. Several sleep abnormalities are associated with idiopathic Parkinsonism. The Parkinsonian tremor is most prominent at the moment of arousal from sleep, or at transitions from a deeper to a lighter stage of sleep, and in stages 1 and 2 NREM sleep. In 10-25 of subjects the dyskinesias improve initially after sleep for between 30 min and 3 h ('sleep benefit') and...

Physicochemical Properties Of Drugs

The l transporter at the blood-brain barrier has somewhat different Km values for its substrate amino acids than the Km values exhibited in other tissues hence it is regarded as a separate isoform and has been designated L1 (14). The general l transporter has recently been sequenced (15) and the three-dimensional structure of the binding site for neutral amino acids at the blood-brain barrier has been largely established by computer modeling (16). Marked preference for phenylalanine analogues was exhibited when a neutral substituent was at the meta position. The anticancer drugs melphalan and d,l-2-NAM-7 are appreciably transported by the L1 process. The latter drug has an exceptionally high affinity for the transporter, with a Km of about 0.2 J,M (17). The transporter also has pharmaceutical significance in that it carries l-Dopa, used in the therapy of Parkinson's disease.

AMPA Receptors as Pharmacotherapeutic Sites

AMPA receptors are widespread in the brain, including most regions of the cerebral cortex, hippocampus, amygdala, thalamus, hypothalamus, brain stem, and spinal cord. The regional variations in expression of the subunits, splice variants, and editing efficiency are apparent and are probably involved in local and global network function. AMPA receptors are being studied as potential therapeutic targets in diseases such as Alzheimer's disease, cerebrovascular disease (preventive and poststroke), epilepsy, schizophrenia, neural trauma, and other conditions involving cognitive impairments. Such promise has been raised by the successes reported for AMPA agonists (AMPAmimetics or AMPAkines) to enhance maze learning in age-associated memory impairment in mice and for antagonists (blockers) to prevent the spread of necrosis in ischemic events. Agonists (such as CX516 and aniracetam) and antagonists of varying specificity for AMPA receptor variants are being studied, with goals of safer and...

Subcortical Structures

Mood and affective changes are seen in patients with subcortical dementia syndromes resulting from a disconnection between the frontal lobes and the basal ganglia. Behavior has been investigated in patients with certain specific disorders including Parkinson's disease (PD), progressive supranuclear palsy (PSP), and Huntington's disease. In each, the pathology has been located primarily in the basal ganglia, and all patients have had associated disorders of affect and cognition. Parkinson's disease and PSP patients are often depressed or apathetic and may develop delusions and hallucinations with drug therapy. These patients, particularly those with PSP, may demonstrate a pathological affect known as pseudobulbar affect, whereby they intermittently exhibit primary emotional displays in response to trivial stimuli. This situation is also seen in any condition causing bilateral lesions involving the bulbar regions of the neocortical motor system or its descending connections. Patients...

Affective Disorder Syndromes

The differential diagnosis of depression includes primary psychiatric syndromes other than major depression such as behaviors associated with schizophrenia, generalized anxiety disorder, and obsessive-compulsive neuroses. Medical and neurological disorders either associated with or mimicking depression include malignancy, infections, medications (steroids, reserpine, levodopa, benzodiazepines, propranolol, anticholinesterases), endocrinological dysfunction (Cushing's disease, hypothyroidism, apathetic hyperthyroidism, diabetes), pernicious anemia, and electrolyte and nutritional disorders (inappropriate secretion of antidiuretic hormone, hyponatremia, hypokalemia, hypercalcemia). Depression is also associated with multiple sclerosis, Parkinson's disease, head trauma, stroke (particularly of the left frontal lobe), and Huntington's disease. Interictal changes in temporal lobe epilepsy may mimic depression, particularly with right-sided epileptic foci. Patients with diencephalic and...

Therapeutic Application Of Es Cell Technology By Cell Transplantation

Functional recovery of disease model animals has been reported after implantation of ES cell-derived cell populations, providing important proof of concept for the projected applications of cell therapy. Differentiating ES cells have been implanted into the sites of cellular damage in rats with 6-ODHA lesions in the striatum, a model for Parkinson disease, where they integrated, differentiated appropriately to dopaminergic neurons and, most important, reduced the phenotypic consequences of the lesion (Bjorklund et al., 2002). Behavioral recovery was accompanied by alterations in brain chemistry consistent with formation of functional dopaminergic neurons. Similarly, implantation of RA-induced ES cell-derived neural progenitors to sites of lesion in mechanically damaged spinal cords effected an improvement in locomotor function, consistent with differentiation of implanted

Memory Related Chemical Changes

The catecholamines appear to have an important role in working memory. Dopaminergic function is decreased in patients with Parkinson's disease, who have reduced working memory capacity. There is some evidence that dopamine agonists can improve working memory capacity in patients with Parkinson's disease y and in healthy subjects.y

Dopamine Autoreceptors

Dopamine neurons have autoreceptors of the D2 subtype located on their soma and dendrites. When activated by dopamine itself or by exogenous D2 agonists, such as apo-morphine, neuronal firing is attenuated. On the contrary, their antagonism with the prototypical antipsychotic drug haloperidol leads not only to an increased firing rate but also to a discharge pattern characterized by bursts that produce a greater release of dopamine than would the same number of action potentials occurring at regular intervals. Prolonged D2 antagonism leads to a depolarization of these neurons and thus a shutting off of their firing activity. Such a silencing of the mesolimbic-dopamine neurons likely plays an important role in mediating the antipsychotic response because it leads to a decrease of dopamine in post-synaptic structures, contributing to decreased dopamine neurotransmission. Because long-term administration of the atypical antipsychotic agent clozapine depolarizes mesolimbic-dopamine...

Implications for Psychiatric Diagnoses and Diagnostic Systems

In contrast to conditions such as Parkinson's Disease that are caused by a single gene, increasingly, data suggest that virtually all psychological traits and disorders are caused by a combination of many genetic and environmental risk factors. Moreover, it is likely that many of these genes increase risk for more than one disorder, suggesting that the boundaries between putatively distinct diagnoses may prove to be blurry. Behavioral and molecular genetic methods will provide an essential tool to improve the nosology of psychiatric diagnoses by revealing the common and unique risk factors that contribute to the development of complex disorders.

Associated Neurological Findings

Attention to ataxia, apraxia for orolingual movements, oculomotor abnormalities, coordination problems, gait disturbances, tremor, bradykinesia, and rigidity is critical, since alterations in the ability to smell are present in some patients with Huntington's chorea and multiple sclerosis, and in approximately 90 percent of patients with early-stage Parkinson's disease. In Korsakoff's syndrome, ataxia of the trunk but not of the limbs is frequently present, as are signs of acute alcohol withdrawal (e.g., tremor, delirium, and tachycardia).

Heterogeneity and Mitochondria

Genome showed accumulation of mtDNA deletions in COX-negative cells (Lee et al. 1998). The availability of microdissection techniques facilitated the direct analysis of single cells in histological sections. Using this technique (Cao et al. 2001, Wanagat et al. 2001), it was shown that all electron transport chain-deficient fibers in rat skeletal muscle contained mtDNA deletion mutations. In single neurons from substantia nigra of humans showing COX deficiency, an age-dependent increase in mtDNA deletions was found in two independent studies (Bender et al. 2006, Kraytsberg et al. 2006). Interestingly, these data reveal that interneuronal variation (measured as median absolute deviation) in the percentage of mtDNA deletions increased significantly with age.

Comparative Neuropsychology

Comparative neuropsychological research has provided a framework that is helpful for understanding memory dysfunction in neurodegenerative disorders. In some neurodegenerative diseases (e.g., Parkinson's disease and progressive supranuclear palsy), patients may have working-memory and attentional impairments resulting from prefrontal system damage. In other disorders (e.g., Kor-sakoff's syndrome and herpes encephalopathy), there are new-learning impairments suggestive of limbic system damage (Oscar-Berman & Bardenhagen, 1998).

Case Study 1 Deliriuma Common Disorder Of Attentional Function And Working Memory

Their middle and late stages, the distinction between baseline dementia and confusional states gradually disappears, as patients progressively lose working memory integrity and task behavioral organization. Diffuse Lewy body disease, more recently appreciated as a disorder distinct from classical Parkinson's disease, often produces a chronic confusional state after only 2 to 3 years of cognitive and behavioral declines, possibly due to its extensive disruption of numerous brainstem neuromodulatory systems, including ACh, DA, and NE (see chapter on neurodegenerative disorders).

Changing Concepts of the Reticular Activating System Arousal Revisited

The monoamine and acetylcholine nuclei are the classical neuromodulatory systems upon which psychiatry has focused much of its clinical intervention and research. They include three monoamine systems with differential projection targets and differential global modulatory functions. There are direct noradren-ergic (NE) and serotonergic (5-HT) projections from the locus coeruleus lateral tegmental area and rostral raphe systems, respectively, which spread to the cortical mantle. Dopaminergic (DA) projections are more targeted toward pre-frontal and paralimbic systems, with projections from the substantia nigra to putamen, caudate nucleus, nucleus accumbens, along with DA projections from the midbrain VTA to many cortical areas, with strong predominance toward prefrontal, cingulate, insular, and other paleocortical regions. There are also projections from brainstem DA, NE, and 5-HT nuclei to the basal forebrain, regulating key cholinergic systems in the basal forebrain. Cholinergic...

Potential For Cellbased Therapies

Animal models suggest that umbilical cord blood cells may be useful in treatment of amyotrophic lateral sclerosis by slowing motor neuron degeneration when injected intravenously (84). Ende and coworkers found that intravenous injection of umbilical cord blood cells could extend the survival of several mouse knockout models of human disease, including amyotrophic lateral sclerosis (85), Alzheimer's (85), Huntington's (86), Parkinson's (87), and type 1 diabetes (88). Human umbilical cord blood cells also improve the mobility of rats with spinal cord injuries when injected intravenously. Cord blood cells were observed in the areas of injury of spinal cord but not others and never seen in the control, uninjured animals (89). Similarly, umbilical cord blood cells were able to improve function in a stroke model in the rat when injected intravenously. The human umbilical cord blood cells differentiated into cells that expressed glial or neuronal markers (90). This suggests that umbilical...

Dopamine The Neurotransmitter Anatomical Organization

Akin to other monoaminergic transmitter systems, the dopamine neurons are located in discrete brain nuclei and are not widely distributed throughout the brain. The largest cluster of dopamine cells is located in the ventral midbrain. The medial portion of cells is located in the ventral tegmental area, while the lateral cluster is in the sub-stantia nigra. In addition, another large group of cells is located in the hypothalamus. This latter group functions primarily to regulate prolactin secretion from the pituitary, while the midbrain neurons project to areas of the forebrain and cortex involved in motor, emotional, and cognitive processing. This includes projections to aspects of the extrapyramidal motor system, prefrontal cortex, and various limbic structures such as the amygdala and hippocampus. These projections are topographically organized, with the more medial neurons providing innervation to the cortex and limbic nuclei, and the more lateral cell group providing innervation...

Receptor Localization

Tors are found both postsynaptically and as presynaptic au-toreceptors, while the D1 receptors are located postsynap-tically and heterosynaptically on nondopaminergic axon terminals. Thus D2 receptors, notably the D2 and perhaps D3 subtypes, regulate the release and synthesis of dopa-mine in response to stimulation by extracellular dopamine. Remarkably, in certain areas where dopamine receptors are in highest density, such as the striatum and substantia nigra, the cells expressing each receptor subtype are distinct. Within each family there also exist distinct distributions of receptors. For example, in the D1 family the D1 subtype is highest in the striatum, olfactory tubercle, amygdala, and parts of the cortex, whereas the D5 subtype is most dense in the thalamus and hippocampus. Similarly, for the D2 family, D2 receptors are dense throughout the basal ganglia, whereas D3 receptors are localized to the more limbic, ventral portions to the striatum and olfactory tubercle, and D4...

Open label human trials

Transplantation using fetal nigral dopamine cells derived from human ventral mesencephalon provides superior results in the laboratory (Dunnett and Annett, 1991 Olanow et al., 1996). In the clinic, several open label studies reported benefit following fetal nigral transplantation (Lindvall et al., 1990 1992 Freed et al., 1992 Peschanski et al., 1994 Freeman et al., 1995 Bjorklund et al., 2003). Improvement was observed in a variety of measures of motor function including motor score on the unified Parkinson's disease rating scale (UPDRS) performed in the practically defined off state (approximately 12 h after the last evening dose of levodopa) and in percent on time without dyskinesia based on home diary assessments. Benefits have been reported to be long-lasting (Lindvall et al., 1994 Hauser et al., 1999), and some transplanted patients no longer required levodopa. On the other hand, some patients did not improve following transplant, possibly reflecting differences in patient...

Anatomy Of The Basal Ganglia

Collectively known as the striatum the globus pallidus (both internal and external segments, termed GP i and GPe ) the subthalamic nucleus and the substantia nigra (pars compacta and pars reticulata). Figure 16-2 Cross section of a human midbrain with the black band of dark melanin-rich substantia nigra (SN) and the pyramidal tract that lies anteriorally.

Basal Gangliar Connections

Cortical afferents to the caudate and putamen are somatotopically organized and excitatory, using glutamate as the neurotransmitter. y The brain stem input is primarily from the pars compacta substantia nigra, a dopaminergic pathway. The substantia nigra is a melanin-rich structure located dorsal to the pyramidal tracts (crus cerebri) in the midbrain. Efferent pathways from the striatum are largely directed to the internal segment of the globus pallidus and the pars reticulata of the substantia nigra. There are two distinct pathways of primary importance, named conveniently the direct and the indirect pathways. The direct pathway is inhibitory and passes monosynaptically from the striatum to these nuclei. The indirect pathway reaches the same destination but synapses first in the external segment of the globus pallidus and then in the subthalamic nucleus. The direct and indirect pathways balance one another physiologically, because the indirect pathway functions in sum as Efferent...

Intrastriatal Structure

Within the striatum, there is a large neuronal matrix compartment, comprising approximately 80 of the striatum, and a smaller compartment interdigitated with the matrix and known as striosomes or patches. Both the matrix and striasomal neurons receive inputs from dopamine cells coming from the pars compacta of the substantia nigra. Both cell types send efferent projections to the GP e , and these cells all contain enkephalin. In contrast, however, the matrix population also sends efferents to the substantia nigra pars reticulata and the GP i , whereas the striasomal cells project in large part back to the pars compacta. These projection cells contain substance P and dynorphin. '25 Figure 16-3 Schema of anatomical nuclei and pathways involving the basal ganglia. Black arrows represent excitation, and speckled arrows represent inhibition. Note the two primary pathways that leave the striatum--the direct pathway that flows monosynaptically to the GP and the indirect pathway that has...

Offmedication dyskinesia

Off-medication dyskinesia is an important and potentially disabling side-effect of transplantation that currently represents a major obstacle to future studies of fetal nigral transplantation and other cell-based therapies in PD. The precise cause of off-medication dyskinesia is not known. Current evidence indicates that levodopa-induced on-medication dyskinesias are related to abnormal intermittent or pulsatile stimulation of denervated dopamine receptors (Obeso et al., 2000). Transplantation of functioning dopamine neurons and terminals might thus be expected to provide dopamine to the striatum in a more continuous and physiologic manner than regular oral formulations of levodopa and so reduce rather than increase the risk of dyskinesia. Indeed, Lee et al. found a reduction in levodopa-induced dyskinesia following transplantation of dopamine neurons in a rodent model of PD (Lee et al., 2000). However, patchy reinnervation of the striatum or abnormal synaptic connectivity such as...

Attempts to enhance survival of transplanted dopamine neurons

Increased expression or co-administration of anti-apoptotic and antioxidant agents is another approach that has been tried in an attempt to increase the survival of transplanted dopamine neurons. The Jun-N-terminal kinase (JNK) stress pathway is central to apoptotic neuronal death in several model systems (Chun et al., 2001 Gearan et al., 2001) and mixed lineage kinase (MLK) activation is a critical event in this sequence of events (Xu et al., 2001). MLK inhibitors have been shown to protect against dopaminergic cell death in culture systems (Harris et al., 2002 Murakata et al., 2002), and to improve long-term survival, graft size and fiber outgrowth following transplantation of rat ventral mesenecephalic cells (Boll et al., 2004). Caspase inhibitors also reduce apoptosis in many model systems and increase the survival of dopaminergic grafts in the 6-OHDA rat model (Schierle et al., 1999). Antioxidants also improve graft survival, striatal TH-immunoreactivity and behavioral function...

Directed General Examination

The general medical examination provides useful diagnostic information in patients with hypokinesia and hyperkinesia. The skin examination in patients with Parkinson's disease shows seborrhea, scaly skin, and often patches of excessive dryness. Increased salivation and drooling are typical. The eyes should be examined in patients with movement disorders to detect the presence of Kayser-Fleischer rings or copper deposits in the cornea (Wilson's disease), and proptosis

Reviews And Selected Updates

Lansek R, Bradshaw J, Phillips J, et al The functions of the basal ganglia and the paradox of stereotaxic surgery in Parkinson's disease. Brain 1995 118 1613-1617. Levy R, Hazrati LN, Herrero MT Reevaluation of the functional anatomy of the basal ganglia in normal and parkinsonian states. Neuroscience 1997 76 335-343.

Need for doubleblind controlled trials and sham surgery

Anecdotal observations that were discarded after negative results in more formal clinical trials (Freeman et al., 1999). In PD, we have recently seen that positive results in open label trials of human fetal nigral transplantation, porcine fetal nigral transplantation, and GDNF infusion were not confirmed in double-blind trials. Transplantation therapies in PD are particularly appropriate for evaluation in double-blind trials as the intervention is relatively standardized and the treatment has much in common with drug therapies issues such as dose, distribution, metabolism degeneration, delayed response, and immune reactivity must all be considered (Olanow, 2005). Indeed, a recent survey showed that 97 of PD investigators would insist on a doubleblind placebo-controlled trial before accepting that a cell-based or gene therapy procedure was efficacious, despite the need for a sham control (Kim et al., 2005). While a sham procedure is not fully without risk, the alternative is to expose...

Specific Activation Active Focus The Physiological Basis of a Drive

We first measured - in a special open field - the orienting-searching reflex activity of rats deprived of food for 48 and 72 h, respectively, and isolated thereafter the discrete brain areas from the mesencephalon and measured the amount of norepinephrine, dopamine, and serotonin released by the tissue samples into an organ bath. The orienting-searching reflex activity of the rats increased proportionally to the time elapsedfrom the lastfeed. Simultaneously the amount of 1. dopamine released from the striatum, substantia nigra, and tuberculum olfactorium, 2. norepinephrine released from the locus coeruleus and 3. serotonin released from the raphe also increased in the hungry rats proportionally to the time of fasting. For example, the amount of dopamine released from the substantia nigra of sated increased after fasting for 48 and 72 h from 4.62 0.20 nM g wet weight to 5.95 0.37 (P 0.05) and 10.67 0.44 (P 0.01), respectively. For details see Miklya et al. (2003b).

Why balance matters Introduction

Consider riding a bicycle, standing on one leg, or walking along a narrow beam. All of these tasks require active control of balance. In order to successfully complete these tasks one may have to make a conscious effort to keep from falling and practice may be necessary to improve performance. Next consider sitting on a stool, standing quietly, or walking across the floor. It may not be immediately obvious that these tasks also require active balance control and practice, as these tasks can often be performed without devoting attention specifically to the maintenance of an upright posture. However, all of the tasks mentioned above and most other tasks that we perform on a daily basis require the ability to maintain balance. Whether consciously or more automatically controlled, balance is a key, complex skill for successful movement within our changing environments. Although balance is generally viewed as a function of the cerebellum and the vestibular system, balance skills can be...

Differential Diagnosis

While depression is generally thought of as a primary psychiatric disorder, it is also commonly seen with a variety of neurological and medical illnesses (Starkstein and Robinson, 1993 Glassman and Shapiro, 1998 Meyers and Scheibel, 1990). Recognition of these comorbid conditions is critical since different treatment strategies may be necessary for optimal clinical response in different populations. In evaluating a newly depressed patient, drug-induced mood changes, comorbid general medical illnesses, and substance abuse should always be considered, particularly in patients whose symptoms are atypical or of uncharacteristic onset. A related problem is the recognition of depression in patients with certain neurological disorders such as dementia or Parkinson's disease, where the diagnosis of depression may be obscured by neurological findings such as inattention, memory loss, apathy, motor slowing, or bradyphrenia (Marin, 1990 Starkstein et al., 1990a). Similarly, the presence of these...

The Conception that Whatever Humans Achieved Derives from the Unrestricted Capacity of Their Brain to Acquire Drives

According to our present knowledge the nigrostriatal dopaminergic neurons that maintain the enhanced orienting-searching reflex activity indispensable for successful goal-seeking behavior are the most rapidly aging units in the human brain. Over age 45 the dopamine content of the human caudate nucleus decreases steeply, at a rate of 13 per decade. If dopamine sinks below 30 of the normal level, symptoms of Parkinson's disease appear. About 0.1 of the population over 40 years of age develops Parkinson's disease and prevalence increases sharply with age. Parkinson's disease is an especially convincing example of an age-related neurodegenerative disease due to the unusually fast deterioration of an enhancer-sensitive group of midbrain neurons (see Sect. for details).

Structural Abnormalities

Lesion deficit correlation studies demonstrate that certain disorders are more likely to be associated with a major depression than others (a) discrete brain lesions, as seen with trauma, surgery, stroke, tumors, and certain types of epilepsy (b) neurodegenerative diseases with regionally confined pathologies such as Parkinson's, Huntington's, and Alzheimer's diseases (c) disorders affecting diffuse or multiple random locations such as multiple sclerosis and (d) system illness with known central nervous system effects such as thyroid disease, cancer, and acquired immunodeficiency syndrome (AIDS) (Table 7.1). These limitations shifted focus to those diseases in which the neurochemical or neurodegenerative changes are reasonably well localized, as in many of the basal ganglia disorders. Notable is the high association of depression with Parkinson's disease (Mayberg and Solomon, 1995), Huntington's disease (Folstein et al., 1983), and others. These observations...

Other Transport Systems Responsible for Drug Transport at the Blood Brain Barrier

Although it has not been established whether the Na+-dependent hexose transporter SGLT is expressed at the BBB, a recent report suggested a participation of SGLT in the BBB transport of cycasin (58). Cycasin, methylazoxy-methanol-d-glucoside, is proposed to be a significant etiologic factor for the prototypical neurodegenerative disorder Western Pacific amyotrophic lateral sclerosis and for Parkinsonism-dementia complex. Cycasin is taken up into primary-cultured bovine BCECs in a dose-dependent manner with maximal uptake at a concentration of 10 M. Since cycasin uptake was significantly inhibited by a-methyl-d-glucoside, a specific analogue for the Na+-dependent glucose transporter, SGLT, as well as by phlorizin (a SGLT inhibitor), replacement of extracellular NaCl with LiCl, and dinitrophenol (an inhibitor of energy metabolism), cycasin is suggested to be transported across the BBB via a Na + energy-dependent SGLT (58).

Types of Detectable Abnormalities

SPECT and PET imaging have showed comparable detection of diseased states. In chronic pathological states, the cerebral blood flow demonstrated by SPECT correlates to abnormal metabolic activity that is shown by PET imaging. Unfortunately, PET imaging requires cyclotron produced nucleotides. This, as well as the great cost of this techniques, has limited this procedure to major research facilities. SPECT imaging is more accessible owing to recent advances in stability of radionucleotides and in computer technology. These factors have led to a significant increase in the resolution of the SPECT images. PET and SPECT can detect generalized hypometabolism in anoxia, degenerative disease, trauma, and aging or a focal hypometabolism. Hypermetabolism due to increased blood flow into tumor or infection can be detected as well as seizure foci. In degenerative illnesses with neurotransmitter defects (e.g., Parkinson's disease and Huntington's disease), focal deficits can be detected, although...

Neurological Applications in Diagnosis and Treatment

Characteristic patterns of decreased regional glucose metabolism within the parietal and temporal lobes have been described in patients with AD.y In these patients there is a relative preservation of the calcarine fissure region, sensory motor region, cerebellum, and the basal ganglion region. Decreased metabolic rates for oxygen have also been reported in the same regions that demonstrate areas of decreased glucose metabolism in patients with Alzheimer's disease. Patients with progressive Parkinson's disease have a similar pattern, as seen in patients with Alzheimer's disease. Multiple-infarct dementia occurs after multiple lacunar infarctions. PET generally demonstrates multifocal regions of decreased glucose metabolism y that typically correlate to focal lesions demonstrated on CT scans and MR images. A significant decrease in glucose metabolism within the frontal and temporal lobes has been described in patients with Pick's disease. y Patients with...

Somatic Treatments For Major Depression Electroconvulsive Therapy ECT

There is no widespread agreement on the underlying mechanism of action of ECT. Electrophysiological studies (Ishihara and Sasa, 1999) have shown that ECT increases the sensitivity of 5-HT3 receptors in the hippocampus, resulting in an increased release of glutamate and GABA. However, tryptophan depletion failed to reverse the improvement in mood seen in depressed patients after ECT (Cassidy et al., 1997) and does not support a primarily 5-HT-dependent mechanism. ECT has been shown to decrease the sensitivity of the noradrenergic and DA autoreceptors in the locus coeruleus and substantia nigra, resulting in an increased release of NE and DA (Ishihara and Sasa, 1999). Support for a noradrenergic mechanism also arises from a study showing a normalization of platelet alpha-2 receptors after a course of ECT (Werstiuk et al., 1996). However, the fact that ECT has efficacy in patients that fail treatment with medications argues against ECT having a similar mechanism of action (Persad, 1990)....

Summary And Conclusions

During this period, the focus of psychiatric research was on understanding the role of monoamine systems in the pathophysiology of mental illnesses. These efforts were greatly influenced by the discovery of the CNS DA deficiency in patients suffering from Parkinson's disease (Ehringer and Hornykiewicz, 1960) and the remarkable therapeutic effects of l-DOPA treatment (Cotzias et al., 1967). The discovery of a DA deficiency in Parkinson's disease led psychiatric investigators to hope that the pathophysiology of mental disorders would be discovered by understanding the pharmacology of our treatments. The research of the past 30 years suggests that new, more complex models are in order. We have begun to understand that mood disorders are not simply the result of a deficiency on monoamine neurotransmitters and that we have to better understand the anatomy and function of brain circuits regulating emotion and cognition as well as the molecular events that modulate the function and viability...

Dreamlike hallucinations

The processes responsible for dreams can be activated outside sleep by, for instance, drugs and by sensory, food or sleep deprivation, as well as in psychiatric and neurological disorders. In these situations sensory processing is disordered, and leads to unusual perceptions. These may be primarily visual, as in peduncular hallucinosis due to midline lesions of the midbrain, or in the Charles Bonnet syndrome in which visual hallucinations occur despite blindness. Degenerative disorders such as fatal familial insomnia, Parkinson's disease and Lewy body disease are also associated with hallucinations during wakefulness which are analogous to dreaming in sleep.

Orientation Attention and Vigilance

Trail Making Test.y There are two forms to this test Trail Making Tests A and B. Trail Making Test A provides an assessment of complex attention. This test requires the patient to connect randomly positioned numbered circles in numeric order as quickly as possible. Form B presents the patient with numbered circles and circles with letters. The patient is required to connect the circles in numeric and alphabetic order as quickly as possible, alternating between numbers and letters. Both Forms A and B require focused attention for successful performance. In addition, Form B requires the patient to switch cognitive sets between numbers and letters. Both forms of the Trail Making Test are highly dependent upon motoric speed, and may not be appropriate for patients with marked motor impairment (e.g., Parkinson's disease).

Other Potential Roles As A Neuropeptidase

Inflammation has been repeatedly proven to be a critical player in a number of neurodegenerative diseases, including Alzheimer's disease, Parkinson's disease, Amyotrophic Lateral Sclerosis, Multiple Sclerosis, and many others. Strangely, this diverse metallopeptidase 24.15 has a number of potential connections to the role of inflammation as well.

Tyrosinehydroxylase Immunoreactive Cells In The Rat Striatum Following Treatment With

Abstract Tyrosine Hydroxylase is the rate-limiting enzyme in the synthesis of dopamine, and as such, it is widely used as a marker of dopaminergic cells. Within the basal ganglia, the dopaminergic cells are located in the substantia nigra pars compacta, and project to the striatum. It is this pathway which degenerates during Parkinson's disease. The data presented here illustrate examples of tyrosine-hydroxylase immunoreactive cells in striatum following intrastriatal injection with the neurotoxin MPP+. We further show by electron microscopy that these cells are, in fact, neurons and that they possess ultrastructural features of interneurons.

Therapeutic Uses Of Botulinum Toxin

However paradoxical it may seem, botulinum toxin has over the past decade risen to the status of 'wonder drug'.47'48 It is used to treat a variety of diseases characterized by spasm or overactivity of a particular muscle or group of muscles. In many of these illnesses the muscular hyperactivity is the primary disorder (e.g., cervical dystonia), while in others, it is secondary to another disease (e.g., rigidity and tremor in Parkinson's disease). In most of these conditions intramuscular injection of botulinum toxin has become the treatment of choice and has replaced previous and much less satisfactory surgical or pharmacological alternatives. Clinically effective paralysis with type A botulinum toxin typically lasts three or four months, but it can be longer.47'48

Olfaction in Neurological Disorders

Deficits in olfaction (acuity, memory, and identification) appear early in the course of a number of neurodegenera-tive disorders, including cortical Dementia of the Alzheimer's Type, and some of the subcortical dementias, namely Parkinson's disease, Huntington's disease, and HIV-related dementia. However, such deficits have not been reported in patients with atypical parkinsonian syndromes, including corticobasal degeneration and progressive supranuclear palsy (see Doty, 2001 Pantelis, Brewer, & Maruff, 2000). These findings are consistent with the nature of involvement of the relevant olfactory circuits in these various disorders, and suggest that smell ability may assist in differential diagnosis. Studies have also found deficits in olfactory memory in chronic alcohol abusers and of identification ability in patients with Korsakoff syndrome (Potter & Butters, 1980). Olfactory identification deficits have also been found in motor neuron disease (MND), multiple sclerosis (MS), and...

Caspases In Neuronal Apoptosis And Neurodegenerative Disorders

Transgenic mice expressing exon 1 of the huntingin gene with an expanded polyglutamine repeat, a model of Huntington's disease, exhibit increased caspase- 1 activation in association with progressive neurodegeneration. Expression of a dominant negative caspase-1 mutant delays development of neurodegenerative changes and motor dysfunction118. Degeneration of dopaminergic neurons in the substantia nigra of rats induced by 6-hydroxydopamine, a model of Parkinson's disease, is greatly reduced in animals pretreated with the caspase inhibitor zVAD-fmk119.

Myoclonic Epilepsy and Ragged Red Fibers Syndrome

The majority of cases of MERRF syndrome have a heteroplasmic G to A point mutation at bp8344 in the tRNALys gene.y This results in protein synthesis defects involving primarily complexes I and IV, which have the greatest number of mtDNA coded subunits. Any quantitative measure of energy metabolism--y P-NMR, anerobic threshold determination, or biochemical analysis of skeletal muscle--shows decreased ATP-generating capacity. When mutant mtDNAs exceed 85 percent in a tissue, the patient becomes symptomatic. Neuropathology shows degeneration of cerebellar cortex, substantia nigra, dentatorubral and pallidoluysian systems, locus ceruleus, inferior olivary nucleus, and pontine tegmentum.

Calpains In Neurodegenerative Disorders

Several chronic neurodegenerative disorders are also characterized by altered levels of calpain and or calpastatin in vulnerable neuronal populations, including Alzheimer's disease140, amyotrophic lateral sclerosis141 and Parkinson's disease142, In the case of Alzheimer's disease, considerable data indicate that perturbed cellular calcium homeostasis contributes to the neurodegenerative process. In addition to evidence for activation of calpains in neurons in Alzheimer's patients, experimental studies have shown that amyloid 6-peptide increases intracellular calcium levels in cultured hippocampal and cortical neurons and thereby promotes apoptosis and excitotoxicity143,144 mutations in the amyloid precursor protein that are responsible for some cases of Alzheimer's disease result in increased production of neurotoxic amyloid 6-peptide and decreased production of the neuroprotective (and calcium-stabilizing) secreted form of amyloid precursor protein (Fig. 2)145 mutations in...

Other Antiobesity Pills

Another antiobesity drug, sibutramine, was approved for use in 2001. Sibutramine is meant for people whose body mass index (BMI) registers at 27 or higher. But if you're on thyroid hormone, as well as medications for depression, seizures, glaucoma, osteoporosis, gallbladder disease, liver disease, heart disease or stroke prevention, kidney disease, migraines, or Parkinson's disease, you should discuss whether sibutramine is appropriate.

Prognosis and Future Perspectives Prognostic con

Siderations are similar to those discussed for AD except that the combination of parkinsonism and dementia is a more difficult management problem, and because dementia is usually a late complication of PD, it may signify a shorter lifespan than for patients with either uncomplicated PD or AD.

Multiple System Atrophy

This is an uncommon and heterogeneous group of disorders generally characterized by atypical, relative dopamine-unresponsive parkinsonism with variable degrees of cognitive impairment. MSA includes olivopontocerebellar atrophy (OPCA), striatonigral degeneration, and parkinsonism with orthostatic hypotension and dysautonomia (Shy- Drager syndrome). Clinical Features and Associated Disorders. Patients with dominantly inherited OPCA (type IV) have frontal lobe-related cognitive impairments, y but the apparent mild intellectual decline in most OPCA may be related more importantly to motor impairment and depression without actual dementia and without evidence of aphasia, agnosia, or apraxia.y Multiple systems atrophy of the Shy- Drager variety has been less studied. Given the clinical similarities to other parkinsonian syndromes, as well as its clinical heterogeneity, mild subcortical patterns of cognitive impairment are possible, but it should not presently be regarded as a cause of...

Patients with specific complications

Patients on levodopa who develop motor fluctuations More frequent, small doses of levodopa or liquid Sinemet symptoms need urgent treatment to protect the patient's safety or job security, levodopa is introduced because it is the most effective drug with the most rapid onset of action. If symptoms can be treated more slowly, the use of anticholinergic drugs in young patients with tremor-predominant PD is often helpful, and amantadine or dopamine agonists can be used as dopamine drugs that may delay the need to start levodopa in other patients. In patients who are just starting Sinemet, the controlled-release form is often selected to minimize the number of doses needed each day. As the disease progresses, combinations of drugs are usually needed, and most patients will require both an agonist and Sinemet within the first 7 years of therapy. In elderly patients, especially those with hallucinations or dementia, however, Sinemet alone, usually in the regular formulation, is often the...

Huntingtons Disease

Besides HD, other less common heredofamilial choreas include hereditary benign chorea and neuroacanthocytosis (see later discussion in this chapter). If a family history of choreic or psychiatric disorders is lacking, numerous other disorders should be considered, including tardive dyskinesia, CNS vasculitis, Wilson's disease (WD), Sydenham's chorea, and toxin exposure. Drugs causing chorea include oral contraceptives, levodopa, CNS stimulants, neuroleptics, phenytoin, carbamazepine, and ethosuximide. If the diagnosis is approached from the perspective of genetic testing, other hereditary neurodegenerative conditions with expanded trinucleotide repeats of CAG include Kennedy's syndrome (X-linked spinal and bulbar muscular atrophy), myotonic dystrophy, spinocerebellar atrophy type 1, and dentato-rubro-pallidal- luysian atrophy ( ,Xa bJ.e,3.4-4 ). Management. DA receptor-blocking agents (e.g., haloperidol or fluphenazine) and dopamine-depleting agents (e.g.,...

Targets Of Pharmacological Treatment Clinical Substrate

Control of these symptoms is remarkably effective in reducing the need for inpatient treatment, thereby allowing patients to remain in community settings. All antipsychotics are effective in the treatment of positive symptoms. Negative symptoms can improve or worsen (because of parkinsonian side effects) with antipsychotic treatment (Miller and Tandon, 2000). Even with optimal antipsychotic treatment, negative symptoms tend to be present throughout the course of schizophrenia, including the premorbid and remission phases of the illness. This combination of pervasiveness, modest response to treatment, and enormous impact on quality of life make them a major challenge in the treatment of schizophrenia. Similarly, impaired cognition may be a primary symptom of the illness or may be a consequence of pharmacological treatment. The anticholinergic properties that are a prominent feature of many antipsy-chotics contribute directly to cognitive impairment, as do parkinsonian side effects...

Other Forms of Primary Dystonia

Several other forms of primary inherited degenerative syndromes are associated with dystonia. y Like the parkinsonism-plus syndromes, the major hallmark in these dystonia-plus syndromes is dystonia, but this is accompanied by movement disorders. Dopa-responsive dystonia (DRD) is also an autosomal dominant disorder caused by a mutation in the GTP cyclohydrolase I gene on chromosome 14q, which causes a defect in dihydrobiopterin synthesis. These patients present with dystonia and parkinsonism that has a marked diurnal fluctuation. In the early morning they may be symptom-free or only mildly affected, but then a progressive gait disorder and cramping and rigidity develop during the day. These patients are markedly sensitive to low doses of levodopa, and often doses of Sinemet as low as 25 100 mg day are effective in obliterating clinical signs. For this reason, it is particularly important to recognize DRD, and all children with dystonia and adults with leg or trunk dystonia deserve a...

Hallervorden Spatz Disease

Hallervorden- Spatz disease (HSD) is a rare autosomal recessive disorder associated with excessive iron deposition in the globus pallidus (GP). y The most striking autopsy finding in HSD patients is the asymmetrical rust-brown pigmentation of the GP and zona reticulata of the substantia nigra (SN). The iron pigmentation occurs both extracellularly and intracellularly but is predominantly found in astrocytes, microglia, and neurons. Mulberry concretions are also typically present in the extracellular space. Numerous and large spheroid bodies, identified by myelin staining and surrounded by pigment granules, are typically present throughout the medial GP, SN zona reticulata, cortex, and subthalamic nucleus. y The spheroid bodies apparently represent degenerating myelinated axons. developed athetosis, tremor, and visual difficulties. Dystonia and rigidity are the major hallmarks of this childhood illness, but other associated features include gait and...

Ldopa and dopamine agonists

Dopaminergic agents are preferable to other drugs in most situations if regular treatment is required, but should be avoided in angle closure glaucoma. They often cause nausea, which can be treated with domperidone 10 mg tds. They have been implicated, particularly ropinirole and pramipexole, as the cause of sleep attacks in Parkinson's disease, but these are unlikely to occur with the small doses used at night in RLS. Their effects on dopamine receptor function in the long term are uncertain. They could theoretically lead to an akinetic state, although this has not been documented. The ergot-derived dopamine receptor agonists such as pergolide, lisuride, cabergoline, and bromocriptine can cause fibrosis of the lungs and pleura, retroperitoneum and tricuspid and other cardiac valves. Dopaminergic agents have a teratogenic potential in children.

Spinocerebellar Ataxia Type 3Machado Joseph Disease

Neuropathologically, SCA3 is characterized by degeneration of the spinocerebellar tracts, vestibular nuclei, and dentate nucleus. The cerebellar cortex and the inferior olives are spared. In most cases, the pontine base is only moderately affected. The substantia nigra and the subthalamopallidal connections are frequently involved.y

Neuropathology of Picks Disease

Pick's disease results in atrophy of the anterior portion of the frontal lobe and a characteristic atrophy of the anterior portion of the superior temporal gyrus (anterior to the central sulcus) with preservation of the posterior portions of that gyrus. The parietal and occipital lobes are generally spared. The atrophy leaves the gyri with a knife-edge appearance. The lateral ventricles, particularly the frontal horns, are dilated due to the atrophic changes. There is also a characteristic severe loss of the granular neurons that comprise the dentate gyrus of the hippocampal complex. Subcortical structures in which neuronal loss occurs include the basal ganglia, amygdala, nucleus basalis of Meyn-ert, substantia nigra, and locus ceruleus (Hof, Bouras, Perl, & Morrison, 1994 Hansen, 1994). Brain stem and cerebel-lar areas with connections to the cortex are also typically involved (Braak, Arai, & Braak, 1999 Dickson, 1998). In contrast to severely abnormal computed tomography or magnetic...

Comparison of Picks and Other Neurodegenerative Diseases

In addition to the clinical overlap of Pick's disease with Alzheimer's disease, the neuropathologic features of Pick's disease overlap with those of frontal lobe dementia, primary progressive aphasia, corticobasal degeneration, and multisystem atrophy. Therefore, attempts have been made to differentiate Pick's disease from progressive supranu-clear palsy and corticobasal degeneration (Feany, Mattiace, & Dickson, 1996). All three disorders have abnormalities of cortical and subcortical regions however, Pick's disease has more cortical involvement, progressive supranuclear palsy has more subcortical damage, and corticobasal degeneration has equal cortical and subcortical pathology. The three disorders all have significant pathology in the substantia nigra, subthalamic nucleus, and locus ceruleus. However, Pick's disease has greater numbers of ballooned neurons than the other diseases corticobasal degeneration can be distinguished by numerous neuropil threads in gray and white matter and...

Effects of movement disorders on sleep

4 There may be indirect effects on sleep due to, for instance, dementia which alters the regulation of sleep. Changes in environmental stimuli such as a reduction in exposure to light may also affect sleep control, and other factors such as depression and sleep fragmentation due to discomfort and pain are features of many of these conditions, particularly Parkinsonism.

The Dopaminergic System

Some involvement of a dopaminergic system in the pathophysiology of RLS is undisputed. The strongest argument is based on the rapid and dramatic improvement of RLS with dopaminergic agents (151,152). As reviewed above, brain-imaging studies of the dopaminergic system in the basal ganglia have not revealed consistent abnormalities (see Section ''Basal Ganglia''). Another way to explore the integrity of the dopamine system is by measuring neuroendocrine responses to challenges with dopaminergic agonists or dopamine-blocking substances. For example, metoclopramide (a dopamine blocker) normally causes an increase in both prolactin and human growth hormone (hGH). Basic 24-hour time courses of prolactin and growth hormone do not differ between RLS subjects and controls (153). Furthermore, challenges with a dopamine antagonist in the early afternoon revealed a normal response in RLS subjects (154). Neuroendocrine response to a levodopa challenge was more pronounced during the night vs. the...

Patrice L Weiss1 Rachel Kizony12 Uri Feintuch23 and Noomi Katz2

Stuck in traffic, you have your digital agent make contact with the secretary at the Rehabilitation Center via your wireless palmtop. You are immediately provided with a verbal listing of your daily schedule. It is clear that you will have a tight timetable, and already anticipate a hectic day filled with clinical rounds, research meetings and an afternoon lecture for third year medical students. You request your digital agent to retrieve last year's lecture presentation on the rehabilitation of patients with Parkinson's disease, and to locate abstracts of the latest research on this topic. These files will be waiting for you on your office computer when you arrive at the Rehabilitation Center. Finally traffic starts to move, and you make it to your office. Clinical rounds have been delayed and you use the opportunity to complete your daily exercise routine on your stationary bike which is facing an omnisurround screen. Viewing a virtual mountain path...

First Clinical Applications

We were encouraged in our modeling approach by recent observations we made in patients with Parkinson's disease. The cardinal symptoms of these patients are hypokinesia and rigidity, but also stance control is impaired. The impairment includes abnormally large and abnormally fast spontaneous body sways. This appears to be paradoxical, because the rigidity entails an increased axial stiffness, which should lead to smaller rather than larger sways. A second apparent paradox is found after treatment (here with dopamine medication and or subthalamic nucleus stimulation). This leads subjectively, for the patients, as well as on clinical rating scales to an improvement, yet sway amplitude remains abnormally large or even becomes larger (see Maurer et al., 2003). Meanwhile we have established a method of parameter identification for non-linear models (non-linear because of the aforementioned thresholds in Fig. 16-5) and have successfully applied it to experimental data (Maurer et al., 2006)....

Subcortical Brain Pathology

A good model for studying cognitive disturbances due to subcortical damages is Parkinson's disease (PD Glozman, 1999b Korsakova & Moskovichyute, 1985). The pattern of cognitive disturbances in persons with PD is a specific combination of natural brain alterations appearing with age

The Role Of Oxidative Stress In Aging

Aging is also accompanied by changes in membrane fatty acid composition, including a decrease in the levels of polyunsaturated fatty acids (PUFAs) and an increase in monosaturated fatty acids. PUFAs, such as arachidonic acid (AA), are abundant in the aging brain and are highly susceptible to free radical attack. A correlation between the concentration of AA and LTP has been shown,8,26 suggesting that oxidative depletion of AA levels may relate to a cognitive deficit in rats. For example, levels of AA are decreased in the hippocampus of aged rats with impaired ability to sustain LTP. Oxidative damage to lipids can also occur indirectly through the production of highly reactive aldehydes. Peroxidation of AA forms malondialde-hyde (MDA), which induces DNA damage by reacting with amino acids in protein to form adducts that disrupt DNA base-pairing. Increased levels of MDA have been found in the aged canine brain.27 In the aged human brain, MDA has been found to be increased in inferior...

Attenuation of deep cerebral white matter Microscopic Examination

HIV-1 is most frequently localized in cells of bone marrow lineage (blood-derived macrophages), intrinsic microglia (the resident mononuclear phagocytic system of the brain), and multinucleated giant cells (formed by the fusion of these cell types). It is these cells that support productive infection. y , y , y By immunocytochemistry, HIV-1 antigen is localized most often in the basal ganglia, subthalamic nucleus, substantia nigra, dentate nucleus, and white matter. y PCR studies, though, show HIV to be more abundant in subcortical white matter than basal ganglia, deep white matter, or cortex. y With more sensitive and specific techniques of viral detection, both a greater number of infected cells and cell types infected have recently been demonstrated. These include endothelial cells, y astrocytes, y , y and neurons,y although this may be restricted infection.

CXCR4CXCL12 Linked to CNS Development and Much More

As mentioned previously, CXCR4 is expressed in glial cells (astrocytes and microglia but not oligodendrocytes) as well as in neurons. In the adult brain, neuronal expression of CXCR4 is localized to cerebral cortex, caudate putamen, globus pallidus, substantia innominata, supraoptic and paraventricular hypothalamic nuclei, ventromedial thalamic nucleus, dentate gyrus, cerebellum, ento-rhinal cortex, and substantia nigra. Astrocytes represent the major cellular source of the CXCR4 ligand CXCL12 in the brain. In vitro studies have demonstrated that CXCL12 is a potent chemoattractant for several types of neural cells, including neuronal precursor cells from the external germinal layer, cortical neuronal progenitors, cerebellar granule neurons, and dentate gyrus granular neurons (37,38). Disruption of either CXCR4 or CXCL12 in gene-targeted mice gives similar but not identical pathophysiologic outcomes mice died soon after birth and exhibited severe abnormalities in cerebellar development...

Emotional Regulatory Network

The prefrontal syndrome includes deficits in motor programming, especially evident in alternating, reciprocal, and sequential motor tasks. Executive function impairments include the inability to generate hypotheses and show flexibility in maintaining or shifting sets required by changes in the demands of a task. Patients also exhibit poor organizational strategies for learning tasks and copying complex designs, as well as diminished verbal and drawing fluency. Lesions span the circuit from BA 9 and 10 to the dorsolateral caudate nucleus, to the globus pallidus, and to the ventral anterior and dorsomedian thalamus and back to DLPFC. This circuit is shown to be hypometabolic in Figure 3-3 after an anterior thalamic stroke. Indirect pathways extend from globus pallidus externa to lateral subthalamic nucleus, then to globus pallidus interna and substantia nigra.

Stem Cell Sources And Preparation Before Therapeutic

Onic stem cells (ES cells) are derived from a very early embryonic cell population that is not yet committed to form a particular tissue of the body. Thus, ES cells are by nature thought to be more versatile than most of their adult counterparts. Mouse ES cells have now been used to treat several model diseases such as Parkinson's disease (Kim et al., 2002), myocardial infarction (Min et al., 2002), spinal injury (McDonald et al., 1999), and severe genetic immune disorder (Rideout et al., 2002). However, significant advances are still required before these approaches can be applied in the clinic. First, we need to be able to generate a sufficient number of the desired cell types in a homogeneous population and cautiously remove all undifferentiated cells in order to decrease the risk of teratoma formation after implantation (Thomson et al., 1998). Second, more progress needs to be made in order to identify what cell type or what intermediate precursor should be isolated and delivered...

The Potential of Stem Cells for Developing New Therapies

Because of their ability to reproduce themselves, and to differentiate into other cell types, stem cells offer the prospect of developing cell-based treatments, both to repair or replace tissues damaged by fractures, burns, and other injuries and to treat a wide range of very common degenerative diseases, such as Alzheimer's disease, cardiac failure, diabetes, and Parkinson's disease. These are some of the most common serious disorders, which affect millions of people in the United Kingdom alone, and for which there is at present no effective cure. Stem cell treatments, unlike most conventional drug treatments, have the potential to become a lifelong cure. 2. This is exemplified in recent debate over the efficacy or otherwise of stem cell transplants for Parkinson's disease. A 2001 study (reported in the New England Journal of Medicine (344 710-719)) suggesting that such a treatment had unwelcome side-effects has been cited by some as grounds for concern about the safety of embryonic...

Diffuse Autonomic Failure Pandysautonomia Central Preganglionic Disorders

Multiple system atrophy (MSA, Shy-Drager syndrome) is a degenerative disorder of the CNS that affects the extrapyramidal, cerebellar, and autonomic neurons (see Chaptei.34,). Autonomic dysfunction in patients with MSA is due to the loss of preganglionic neurons in the brain stem and spinal cord. Patients with MSA typically present with diffuse autonomic failure and parkinsonian, cerebellar, or pyramidal deficits in different combinations. y Autonomic features include orthostatic intolerance, erectile dysfunction in males, bowel hypomotility, urinary incontinence due to denervation of the external urinary sphincter, and respiratory disturbances (sleep apnea and laryngeal stridor). There is usually a poor response to levodopa. Pathologically, cell loss and gliosis in striatonigral, olivopontocerebellar, and autonomic neurons are evident, and intracytoplasmic oligodendroglial and neuronal inclusions are frequently present. Parkinson's Disease. Autonomic...

Anticholinergic Drugs Central Cholinoblockers

The first drugs used in treating parkinsonism were the alkaloids, atropine and scopo-lamine, and over the course of many years they were the only drugs used for this purpose. However, in treating Parkinsonism today, these alkaloids are used extremely rarely and have been practically replaced by synthetic drugs that exhibit central anticholinergic properties (central cholinoblockers). They suppress stimulatory cholinergic effects by suppressing cholinoreceptors. It is believed that they do not affect the synthesis, release, or hydrolysis of acetylcholine. Their action facilitates the reduction or alleviation of motor disturbances associated with damage to the extrapyramidal system. They reduce rigidity and to a lesser extent akinesia, and have a minimal effect on tremors. The therapeutic value of such drugs is relatively small and they are used either in combination with levodopa, or in cases of minor Parkinsonism, primarily for alleviating rigidity. In addition, they cause a number of...

Animal Species for the Model

There are other nonhuman primate models established for research in cell-based replacement therapies, including a model of radiation-induced myelo-suppression (ablation of hematopoiesis and blood cells) for bone marrow or hematopoietic stem cell transplantation (82,83), a model of Parkinson's disease (loss of dopaminergic neurons in the midbrain and striatum) induced by MPTP for preclinical trials of striatal transplantation of fetal mesencephalic neurons (84-86), and a model of Huntington's disease (loss of GABAergic and cholinergic neurons in the striatum and thalamus) induced by quinolinic acid administration is also available

Thyroid Hormones Increase Active Transport of Ions Through

Activator Inhibitor

One of the most characteristic signs of hyperthyroidism is a fine muscle tremor. This is not the coarse tremor that occurs in Parkinson's disease or in shivering, because it occurs at the rapid frequency of 10 to 15 times per second. The tremor can be observed easily by placing a sheet of paper on the extended fingers and noting the degree of vibration of the paper. This tremor is believed to be caused by increased reactivity of the neuronal synapses in the areas of the spinal cord that control muscle tone. The tremor is an important means for assessing the degree of thyroid hormone effect on the central nervous system.

Autonomic Neuropathy of Multiple System Atrophy Shy Drager Syndrome

On neurological examination, abnormalities of the pupil, including Horner's syndrome, alternating anisocoria, and abnormal responses to drugs may be seen. Mild parkinsonian features or cerebellar ataxia may accompany the condition, but dysautonomia is the predominant dysfunction. In the striatonigral degeneration variant, or multiple system atrophy, rigidity with little tremor, progressive loss of facial expression, limb akinesias, anterocollis, and gait instability predominate (see Chapter.,34 ). There is difficulty walking, standing, turning, and feeding oneself, and the speech is faint and slurred. With pyramidal lesions, there may be an increase in tone, along with impaired rapid hand and foot movements and exaggerated deep tendon reflexes and bilateral extensor responses. Primitive reflexes may be present, and amyotrophy is common. Dementia is not seen more often than would be expected by chance owing to the age of this population. When the olivopontocerebellar variant is...

How Relevant Are Heterodimers as Disease Targets

It is now well accepted that many GPCRs can exist as homo- and heterodimers. However, the physiologic relevance of receptor dimerization is still largely unknown. It is clear from some studies that GPCR dimerization can alter ligand function for example, a number of anti-parkinsonian agents have been reported to have a higher affinity with dopamine D3 D2 heterodimers than with the equivalent homodimers (31). Another example is provided by the receptors CB1 (cannabinoid) and orexin. When these are coexpressed, CBj enhances the ability of orexin A to activate the mitogen-activated protein (MAP) kinase pathway (32). This effect requires a functional CB1 receptor and is blocked by the specific antagonist rimonabant. Further studies have shown that the orexin receptor and the CB1 receptor form heterodimers and that the appetite suppression effect of the CB1 antagonist rimonabant targets this complex (G. Milligan, personal communication). This is a classic example of GPCR het-erodimers...

Prakash Kotagal Lerner College Of Medicine

Ray Chaudhuri Regional Movement Disorders Unit, National Parkinson Foundation Centre of Excellence, Department of Neurology, King's College Hospital, Denmark Hill, and University Hospital Lewisham, and Guy's, King's, and St. Thomas' School of Biomedical Medicine, London, U.K.

Anatomical and Physiological Hypotheses for Hypokinesia and Hyperkinesia

Physiologically, as predicted by a resultant enhancement of the indirect pathway and a diminished influence of the direct pathway, the and hyperkinesia. Evidence that this model is sound for at least some forms of hyperkinesia includes the known pathological changes in Huntington's disease, the cessation of hyperkinetic drug-induced dyskinesias in Parkinson's disease patients after lesions of the GP i , and the well-documented induction of ballistic hyperkinesias after destruction of the subthalamic nucleus. However, the large variety of dyskinesias are not explained by this model at the present time.

Euroform Health Sciences

Professor of Neurology, Director, Parkinson's Disease Center and Movement Disorders Clinic Director, NAF Center of Excellence, Baylor College of Medicine Senior Attending, The Methodist Hospital, Houston, Texas Movement Disorders Director, Muhammad Ali Parkinson Research Center, Barrow Neurological Institute, Phoenix, Arizona Movement Disorders Glenn T. Stebbins Ph.D. Director, Parkinson's and Movement Disorder Institute, Long Beach, California Cranial Nerves IX (Glossopharyngeal) andX (Vagus) Fong Y. Tsai M.D.

Language Related Disorders

Parkinsonism, dystonia, chorea Degenerative disease, Parkinson's disease, Huntington's disease, stroke Alzheimer's disease, fronto-temporal degeneration, Parkinson's disease, Huntington's disease Hallervorden-Spatz disease, Wilson's disease, progressive supranuelear palsy, Parkinson's disease, multiple system atrophy, Huntington's disease

Progressive Diseases of Infancy and Childhood

cogwheel rigidity appears ( Fig, 31-3 ). These are parkinsonian features caused by deficient dopamine. In fact, extensor posturing of the extremities, opisthotonic Differential Diagnosis. All infants with parkinsonian signs, myoclonic seizures, unexpected fair features, unexplained failure to thrive, unexplained severe bronchopneumonia or cardiopulmonary arrest, unexplained hyperthermia, and fluctuating blood pressure should be studied for the presence of 6PTS and DHPR deficiencies. Blood amino acids, particularly phenylalanine, should be determined in all children with mental retardation. Even when mild hyperphenylalaninemia is found, BH4 loading, DHPR activity in red blood cells, and pterin measurement in urine should be performed. Management. The patients with BH4 deficiency should be treated with BH4 , which is available from either Milupa, Hillington, Middlesex, UK, or Schirks Laboratories, Jona, Switzerland. The standard therapy is 20 mg kg day BH4 given in three to four equal...

Cortical Versus Subcortical Dementing Syndromes

A distinction has been noted between the cortical dementia typically seen in Alzheimer's or Pick's disease and the subcortical dementia typified by Huntington's and Parkinson's disease but noted also in progressive supranuclear palsy, multiple sclerosis, Wilson's disease, and human immunodeficiency virus (HIV) infection. y Dementia seen in diseases with primarily subcortical neuropathology feature slowed movement (bradykinesia) and thought (bradyphrenia), disproportionate problems in the efficient use of memory, poor planning, judgment, and reasoning, and often affective changes. When measured formally, impairments in speed of mental processing, working memory, reasoning, and strategic memory (e.g., recall) are evident in nondemented patients with striatal diseases, including patients with early Parkinson's disease. y These deficits are highly intercorrelated, suggesting that they reflect a family of interacting memory processes mediated by frontostriatal neural circuits. In...

Distribution and Physiological Function of the Serotonergic Neuron

The involvement of the serotonergic system in motor function in vertebrates was indicated initially by its dense axon terminal innervation of motoneurons in both the brain stem and spinal cord. Secondary motor structures, such as the basal ganglia, substantia nigra, and habenula, also receive significant serotonergic input as noted. Administration of serotonergic agonists produces a motor syndrome in rats head shakes, hyperreactivity, tremor, hindlimb abduction, lateral head weaving, and reciprocal forepaw treading. Extracellular recordings in conjunction with mi-croiontophoresis of serotonin onto motoneurons in the rat facial motor nucleus or in the spinal cord ventral horn showed that when serotonin interacts with excitatory influences on motoneurons, it produces a strong facilitation of neuronal activity (via 5-HT2 receptors). Administration of serotonergic agonists directly into the trigeminal nerve in cats produced an increase in the amplitude of the elec-tromyography (EMG) of...

Function of the Basal Ganglia in Executing Patterns of Motor Activity The Putamen Circuit

Basal Ganglia Circuitry

Inputs mainly from those parts of the brain adjacent to the primary motor cortex but not much from the primary motor cortex itself. Then its outputs do go mainly back to the primary motor cortex or closely associated premotor and supplementary cortex. Functioning in close association with this primary putamen circuit are ancillary circuits that pass from the putamen through the external globus pallidus, the subthalamus, and the substantia nigra finally returning to the motor cortex by way of the thalamus. Lesions of the substantia nigra lead to the common and extremely severe disease of rigidity, akinesia, and tremors known as Parkinson's disease, which we discuss in more detail later.

Metabolism Of Chemical Carcinogens

There are a number of these metabolic pathways that together are part of a more extensive defence system, the overall role of which is ideally to process and detoxify noxious chemicals. Enzyme-catalysed and diverse in nature, these reactions have been defined and split into what are called phase I and phase II metabolism (Williams, 1971). Phase I can be separated into oxidation, reduction and hydrolytic reactions and phase II comprises a series of conjugation reactions in which a polar endogenous group is added to the xenobiotic chemical. The overall effect of this biochemistry is to convert xenobiotics, which are often lipophilic molecules, into more polar water-soluble and therefore more readily excreted products. Generally, phase I reactions unmask or introduce a functional group into the molecule and phase II metabolism conjugates the derivative with a polar water-soluble endogenous molecule, that is often acidic in nature. However, it is these same pathways of detoxification...

Deprenyl the PEADerived Enhancer Substance

Significant enhancement of dopamine release from the substantia nigra, tuberculum olfactorium, and striatum of rats, respectively, isolated 30 min after the subcutaneous administration of a single dose of (-)-deprenyl. The amount of dopamine released from the tissue within 20 min following the administration of different doses of (-)-deprenyl was measured according to Knoll and Miklya (1995). Horizontal lines to the right of the graph bars show the SEM. Paired Student's f-test. *P 0.05, **P 0.02, ***P 0.01

Basal Ganglia Their Motor Functions

Circuitry Human Body

Figure 56-9 shows the anatomical relations of the basal ganglia to other structures of the brain. On each side of the brain, these ganglia consist of the caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nucleus. They are located mainly lateral to and surrounding the thalamus, occupying a large portion of the interior regions of both cerebral hemispheres. Note also that almost all motor and

Growth Hormone and Neurogenesis

GH also appears to play an important role in the newly described phenomenon termed neurogenesis, or new neuronal division in the CNS. A major mediator of the trophic effects of GH throughout the body is a mediating hormone, insulin-like growth factor-I (IGF-I), with increased gene expression of IGF-I through GH exposure (Pankov, 1999). It has been recently demonstrated that IGF-I has a clear stimulatory effect on both cell proliferation and neurogen-esis in the rodent hippocampus (Anderson, Aberg, Nilsson, & Eriksson, 2002), providing indirect confirmation of GH involvement in neurotrophic processes. Because it appears a range of antidepressant and mood stabilizing interventions increase neurogenesis, the blunted GH response to clonidine observed in PD, depression, and GAD should be considered within the context of GH-sensitive IGFs as promoters of neuroprotection and neurogenesis. Studies of GH secretion hyposecretion are therefore informative as a peripheral index of central...

Ian Wilmut and Lesley Ann Paterson phd

Human stem cells offer great potential for lifelong treatment of deteriorating and debilitating diseases such as Parkinson's disease, diabetes, multiple sclerosis, and heart disease. There are primarily two stem cell sources available those derived from embryos and those derived from adult tissues (including the umbilical vein). Investigations carried out using stem cells in mice have revealed their powerful therapeutic capabilities. Transfer of adult neural stem cells (Teng et al., 2002) and neural differentiated embryonic cells (McDonald et al., 1999) into spinal cord injury in rats resulted in hind-limb weight bearing, stepping, and enhanced coordination. Oligodendrocytes and insulin-secreting cells, both derived from embryonic stem (ES) cells, replaced lost myelin in rat spinal cords (Liu et al., 2000) and normalized glycemia in diabetic mice (Soria et al., 2000), respectively. In addition, following transplantation of partially differentiated mouse ES cells into the rat model of...

Action or Non Rest Tremors TabieMB

In contrast to the resting tremor characteristic of PD, EI is a postural tremor, which is characteristically present during maintenance of a position. This tremor is typically an alternating flexion-extension movement, whereas supination-pronation oscillation is more characteristic of Parkinson's tremor. EI is also faster (7 to 10 Hz) than the PD tremor (4 to 7 Hz), and when fully developed, it usually involves the head, neck, and voice. Tremor often interferes a. Parkinson's disease b. Other parkinsonian syndromes (less commonly) i. Parkinson's disease with handwriting, drawing, holding a spoon, using a drinking cup, and manipulating tools. 74I The vocal cords may be affected, resulting in a wavering voice. Although ET usually occurs in isolation, it can be associated with various other neurological conditions including dystonia, parkinsonism, and certain inherited peripheral neuropathies (e.g., Charcot-Marie-Tooth disease). The differential diagnosis includes normal physiological...

Case Study 32 Bilateral ILN LesionA Progressive Walk Through of the Taxonomy of Disorders of Consciousness1

Www Ant Commissure

CT Scan of ILN patient and Schematic Graphic of Mesodiencephalic Regions. Key for Mesodiencephalic Graphic CA anterior commissure CP posterior commissure ANT anterior thalamus IL intralaminar region CEM centromedian ILN VTA ventral tegmental area NRT reticular thalamus DL VL dorsolateral ventrolateral thalamus DM dorsomedial thalamus SN substantia nigra MT mamillothalamic tract EW Edinger-Westphal nucleus CS superior colliculus CI inferior colliculus F fornix, P pulvinar BAS basilar artery ACA anterior communicating artery ACP posterior communicating artery. (From van Domburg, P., ten Donkelaar, HJ, Notermans, SH 1996, with permission from Elsevier Science). Figure 3.2. CT Scan of ILN patient and Schematic Graphic of Mesodiencephalic Regions. Key for Mesodiencephalic Graphic CA anterior commissure CP posterior commissure ANT anterior thalamus IL intralaminar region CEM centromedian ILN VTA ventral tegmental area NRT reticular thalamus DL VL dorsolateral ventrolateral...

Cranial Nerve Dysfunction

Parkinson's diseas Not routinely performed. Abnormal CSF helps r o Parkinson's disease Various biogenic amines (and their metabolites) may be measured within the CSF, including dopamine (homovanillic acid HVA ), serotonin (5-hydroxyindoleacetic acid 5- HIAA ), and norepinephrine (3-methoxy-4-hydroxyphenylglycol MHPG ). Significant ventricular to lumbar gradients exist for HVA and 5-HIAA, although MHPG levels are nearly equivalent. Decreased lumbar CSF levels of HVA and 5-HIAA have been reported in patients with parkinsonism and Alzheimer's disease. Whereas decreased HVA levels have also been documented in the ventricular CSF of patients with dystonia, cerebral palsy, MS, and posthypoxic states, no significant differences in 5-HIAA levels are apparent. Biogenic amine levels have also been studied in psychiatric patients, and whereas normal HVA levels are present in the lumbar CSF of patients with schizophrenia, decreased 5-HIAA concentrations are present in depressed subjects....

Occlusive Disease of Small Penetrating Arteries

Recovery from lacunar infarctions or branch atheromatous diseases is usually better than that from cortical infarctions. However, many patients develop recurrent lacunar infarcts and white matter ischemia. Dementia, pseudobulbar dysarthria and dysphagia, gait abnormalities, and parkinsonian-like stiffness are common features in patients with extensive brain damage caused by penetrating artery disease.

Pharmacological Neuroanatomy

The CNS dopaminergic system is complex, and a proposed schema divides the anatomy into three systems including ultra-short, intermediate-length, and long-length systems. i9 The ultra-short systems encompass the interplexiform amacrine and periglomerular olfactory dopamine cells, which are unrelated to mood, emotion, or thought processes. The intermediate-length systems include the tuberohypophysial (connecting the arcuate and periventricular nuclei to the intermediate lobe of the pituitary and median eminence), the incertohypothalamic neurons (linking the dorsal-posterior hypothalamus with the dorsal anterior hypothalamus-lateral septal nuclei), and the medullary periventricular dopamine group (in the area of the dorsal motor nucleus, nucleus tractus solitarius, and periaqueductal gray). The long-length system connects the ventral tegmental and substantia nigra with the caudate-putamen (nigrostriatal) and limbic cortex-limbic system (mesocortical-mesolimbic). This long-length system...

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