UCLA uses PET scans to study tau tangles

This news out of UCLA on Monday February 13th has relevance for the PSP (progressive supranuclear palsy) and CBD (corticobasal degeneration) communities.  Both PSP and CBD are disorders of tau.  In Alzheimer’s Disease (AD), tau is a problem along with a second protein called beta amyloid.  A couple of years ago, researchers out of the University of Pittsburgh developed a compound that attaches itself to amyloid in the brain such that PET scans can help identify those with a high chance of having Alzheimer’s Disease.  A year or so ago, it was announced that researchers at UCLA had developed a compound that attaches itself to tau in the brain such that PET scans can help identify those with tauopathies, such as AD, PSP, and CBD.

This study published out of UCLA this week is about using this new PET scan compound to identify which subjects had tau tangles in the brain and predicted which subjects would experience cognitive decline.  Though this particular study focused on mild cognitive impairment (which can “convert” to Alzheimer’s Disease), it has implications for the PSP and CBD communities.

The full press release is copied below.  (Note that there are quite a few typos in this press release.)

Robin

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newsroom.ucla.edu/portal/ucla/ucla-imaging-technique-predicts-220856.aspx

UCLA brain-imaging technique predicts who will suffer cognitive decline over time
By Rachel Champeau
UCLA Newsroom
February 13, 2012

Cognitive loss and brain degeneration currently affect millions of adults, and the number will increase, given the population of aging baby boomers. Today, nearly 20 percent of people age 65 or older suffer from mild cognitive impairment and 10 percent have dementia.

UCLA scientists previously developed a brain-imaging tool to help assess the neurological changes associated with these conditions. The UCLA team now reports in the February issue of the journal Archives of Neurology that the brain-scan technique effectively tracked and predicted cognitive decline over a two-year period.

The team has created a chemical marker called FDDNP that binds to both plaque and tangle deposits — the hallmarks of Alzheimer’s disease — which can then be viewed using a positron emission tomography (PET) brain scan, providing a “window into the brain.” Using this method, researchers are able to pinpoint where in the brain these abnormal protein deposits are accumulating.

“We are finding that this may be a useful neuro-imaging marker that can detect changes early, before symptoms appear, and it may be helpful in tracking changes in the brain over time,” said study author Dr. Gary Small, UCLA’s Parlow–Solomon Professor on Aging and a professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA.

Small noted that FDDNP–PET scanning is the only available brain-imaging technique that can assess tau tangles. Autopsy findings have found that tangles correlate with Alzheimer’s disease progression much better than do plaques.

For the study, researchers performed brain scans and cognitive assessments on the subjects at baseline and then again two years later. The study involved 43 volunteer paricipants, with an average age of 64, who did not have dementia. At the start of the study, approximately half (22) of the participants had normal aging and the other half (21) had mild cognitive impairment, or MCI, a condition that increases a person’s risk of developing Alzheimer’s disease.

Researchers found that for both groups, increases in FDDNP binding in the frontal, posterior cingulate and global areas of the brain at the two-year follow-up correlated with progression of cognitive decline. These areas of the brain are involved in decision-making, complex reasoning, memory and emotions. Higher initial baseline FDDNP binding in both subject groups was associated with a decline in cognitive functioning in areas such as language and attention at the two-year follow-up.

“We found that increases in FDDNP binding in key brain areas correlated with increases in clinical symptoms over time,” said study author Dr. Jorge R. Barrio, who holds UCLA’s Plott Chair in Gerentology and is a professor of molecular and medical pharmacology at the David Geffen School of Medicine at UCLA. “Initial binding levels were also predictive of future cognitive decline.”

Among the subjects with mild cognitive impairment, the level of initial binding in the frontal and parietal areas of the brain provided the greatest accuracy in identifying those who developed Alzheimer’s disease after two years. Of the 21 subjects with MCI, six were diagnosed with Alzheimer’s at follow-up, and these six subjects had higher initial frontal and parietal binding values than the other subjects in the MCI group.

In the normal aging subjects, three developed mild cognitive impairment after two years. Two of these three participants had had the highest baseline binding values in the temporal, parietal and frontal brain regions among this group.

Researchers said the next step in research will involve a longer duration of follow-up with larger samples of subjects. In addition, the team is using this brain-imaging technique in clinical trials to help track novel therapeutics for brain aging, such as curcumin, a chemical found in turmeric spice.

“Tracking the effectiveness of such treatments may help accelerate drug discovery efforts,” Small, the author of the new book “The Alzheimer’s Prevention Program,” said. “Because FDDNP appears to predict who will develop dementia, it may be particularly useful in tracking the effectiveness of interventions designed to delay the onset of dementia symptoms and eventually prevent the disease.”

Small recently received research approval from the U.S. Food and Drug Administration to use FDDNP–PET to study people with mild cognitive impairment to determine whether a high-potency form of curcumin — a spice with anti-amyloid, anti-tau and anti-inflammatory properties — can prevent Alzheimer’s disease and the accumulation of plaques and tangles in the brain.

UCLA owns three U.S. patents on the FDDNP chemical marker. The Office of Intellectual Property at UCLA is actively seeking a commercial partner to bring this promising technology to market.

Small and study authors Jorge R. Barrio and S. C. Huang are among the inventors. Disclosures are listed in the full study.

Additional authors included Prabha Siddarth, Linda M. Ercoli, Alison C. Burggren, Karen J. Miller, Dr. Helen Lavretsky and Dr. Susan Y. Bookheimer, all of the UCLA Department of Psychiatry and Biobehavioral Sciences, and Vladimir Kepe and S.C. Huang, who are part of the UCLA Department of Molecular and Medical Pharmacology.

The study was funded by the National Institutes of Health and the U.S. Department of Energy.

Treatment Options for PSP, CBD, and FTD (Review)

This medical journal article is a review of what we know about treatment of PSP (progressive supranuclear palsy), CBD (corticobasal degeneration), and FTD (frontotemporal dementia). Some general statements are made about “diet and lifestyle,” then several medications are discussed including anti-depressants (SSRIs in particular), dementia medications, antipsychotics, and levodopa. Finally, “emerging therapies” are briefly described.

I’ve copied the abstract below.

For me, the one new piece of information is that Abilify and Seroquel are the two most commonly prescribed antipsychotics “in parkinsonian disorders.” It would be interesting to know how frequently they are prescribed in PSP and CBD. Certainly most of the prescriptions are for Parkinson’s Disease and Parkinson’s Disease Dementia (Lewy Body Dementia). Though we have a few local support group members with PSP and CBD taking these medications, the majority do not.

Robin

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Current Treatment Options in Neurology. 2012 Feb 4. [Epub ahead of print]

Treatment Options for Tauopathies.

Karakaya T, Fußer F, Prvulovic D, Hampel H.
Department of Psychiatry, J.W. Goethe-University, Frankfurt, Germany.

Abstract
OPINION STATEMENT: To date, there are no approved and established pharmacologic treatment options for tauopathies, a very heterogenous group of neuropsychiatric diseases often leading to dementia and clinically diagnosed as atypical Parkinson syndromes.

Among these so-called Parkinson plus syndromes are progressive supranuclear palsy (PSP), also referred to as Steele-Richardson-Olszewski syndrome; frontotemporal dementia (FTD); and corticobasal degeneration (CBD).

Available treatment strategies are based mainly on small clinical trials, miscellaneous case reports, or small case-controlled studies. The results of these studies and conclusions about the efficacy of the medication used are often contradictory.

Approved therapeutic agents for Alzheimer´s dementia, such as acetylcholinesterase inhibitors and memantine, have been used off-label to treat cognitive and behavioral symptoms in tauopathies, but the outcome has not been consistent.

Therapeutic agents for the symptomatic treatment of Parkinson’s disease (levodopa or dopamine agonists) are used for motor symptoms in tauopathies.

For behavioral or psychopathological symptoms, treatment with antidepressants-especially selective serotonin reuptake inhibitors-could be helpful.

Antipsychotics are often not well tolerated because of their adverse effects, which are pronounced in tauopathies; these drugs should be given very carefully because of an increased risk of cerebrovascular events.

In addition to pharmacologic options, physical, occupational, or speech therapy can be applied to improve functional abilities.

Each pharmacologic or nonpharmacologic intervention should be fitted to the specific symptoms of the individual patient, and decisions about the type and duration of treatment should be based on its efficacy for the individual and the patient’s tolerance.

Currently, no effective treatment is available that targets the cause of these diseases. Current research focuses on targeting tau protein pathology, including pathologic aggregation or phosphorylation; these approaches seem to be very promising.

PubMed ID: #22307450 (see pubmed.gov for this abstract only)

Dopamine Transporter Loss Differs in MSA, PSP and PD

With a special PET scan that focuses on dopamine transport, these Korean researchers concluded that PSP (progressive supranuclear palsy) patients showed “more prominent and earlier dopamine transporter loss” in the anterior caudate, a region of the brain, and that MSA (multiple system atrophy) patients showed “more prominent and earlier dopamine transporter loss” in the ventral putamen, another region of the brain, when compared to Parkinson’s Disease.

None of the diagnoses are autopsy-confirmed, which is what is needed for the medical community to embrace this sort of PET scan.

I’ve copied the abstract below.

Robin

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Journal of Nuclear Medicine. 2012 Feb 9. [Epub ahead of print]

Subregional Patterns of Preferential Striatal Dopamine Transporter Loss Differ in Parkinson Disease, Progressive Supranuclear Palsy, and Multiple-System Atrophy.

Oh M, Kim JS, Kim JY, Shin KH, Park SH, Kim HO, Moon DH, Oh SJ, Chung SJ, Lee CS.
Department of Nuclear Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.

Abstract
Parkinson disease (PD), progressive supranuclear palsy (PSP), and multiple-system atrophy (MSA) are known to affect dopaminergic neurons of the brain stem and striatum with different preferential involvement. Here we investigated differences in striatal subregional dopamine transporter loss in PD, PSP, and MSA and assessed the diagnostic value of (18)F-fluorinated-N-3-fluoropropyl-2-beta-carboxymethoxy-3-beta-(4-iodophenyl)nortropane ((18)F-FP-CIT) PET in differentiating PSP and MSA from PD.

METHODS:
Forty-nine patients with PD, 19 patients with PSP, 24 patients with MSA, and 21 healthy people (healthy controls) were examined with (18)F-FP-CIT PET.

The PET images were spatially normalized and analyzed with 12 striatal subregional volume-of-interest (VOI) templates (bilateral ventral striatum [VS], anterior caudate [AC], posterior caudate, anterior putamen, posterior putamen [PP], and ventral putamen [VP]) and 1 occipital VOI template. The nondisplaceable binding potential (BP(ND)) and intersubregional ratio (ISR; defined as the ratio of the BP(ND) of one striatal subregion to that of another striatal subregion) of subregional VOIs were calculated.

RESULTS:
The BP(ND) of all VOIs in the PD, MSA, and PSP groups were significantly lower than those in the healthy controls (P < 0.05). The BP(ND) of AC and the AC/VS ISR in the PSP group were significantly lower than those in the PD group. The BP(ND) of VP was significantly lower, but the PP/VP ISR was significantly higher in the MSA group than in the PD group. At the cutoff value for the AC/VS ISR (<0.7), the sensitivity and specificity for differentiating PSP from PD were 94% and 92%, respectively. At the cutoff value for the PP/VP ISR (>0.65), the sensitivity and specificity for differentiating MSA from PD were 90% and 45%, respectively.

The diagnostic accuracy of visual analysis was similar to that of quantitative analysis for differentiating PSP from PD but was significantly higher for differentiating MSA from PD.

CONCLUSION:
Compared with PD, PSP and MSA showed more prominent and earlier dopamine transporter loss in the AC and VP, respectively. These findings could be useful for suggesting PSP or MSA in parkinsonian cases without characteristic atypical features.

PubMed ID#: 22323779 (see pubmed.gov for this abstract only)

Differential diagnosis – PSP, CBD, MSA, DLB, and PD

The recent issue of the journal Swiss Medical Weekly offers a great overview of the terms “parkinsonism” and “atypical parkinsonism.”

The article also offers very detailed explanations of how to differentially diagnose the atypical parkinsonism disorders (PSP, CBD, MSA, and DLB) and Parkinson’s Disease. The authors give three reasons why they believe it’s important to identify the subtype of parkinsonism at the time of diagnosis:

* “the prognosis can be estimated.”

* “some of the atypical features such as autonomous or cognitive problems may be targeted by pharmacological treatment”

* because “identification of atypical parkinsonism may prevent unnecessary iatrogenic harm from ineffective drugs, to which these patients typically react very sensitively.”

The full article is available in English at no charge on the Swiss Medical Weekly’s website:
http://www.smw.ch/content/smw-2011-13293/

Note that in a section on the role of imaging in the differential diagnosis of parkinsonism, an MRI is shown with the “hummingbird sign” of PSP.

I’ve copied some excerpts below as well as the abstract.

Robin

Swiss Medical Wkly. 2011 Nov 1;141.

Parkinsonism: heterogeneity of a common neurological syndrome.

Bohlhalter S, Kaegi G.
Division of Restorative and Behavioral Neurology, Department of Internal Medicine, Luerner Kantonsspital, Luzern, Switzerland

Abstract
Parkinsonism refers to a neurological syndrome embracing bradykinesia, muscle rigidity, tremor at rest and impaired postural reflexes, and involving a broad differential diagnosis.

Having ruled out secondary causes (most importantly drugs), distinguishing levodopa-responsive idiopathic parkinson’s disease (PD) from chiefly treatment-resistant and hence atypical parkinsonism is essential.

Recent clinico-pathological studies using data-driven approaches have refined the traditional classifications of parkinsonism by identifying a spectrum of subtypes with different prognoses. For example, progressive supranuclear palsy (PSP), characterised by early vertical gaze limitation and falls, probably has a milder variant with predominant parkinsonism (PSP-P) which may respond quite well to levodopa before converting to the classical disease, relabelled Richardson syndrome (PSP-RS).

Analysis of PD subcategories has shown that tremor-dominant forms are probably less benign than was hitherto thought and that in mild cases dystonia should rather be considered. In addition, life expectancy in early onset PD may be shortened.

Despite the clinical and pathological overlap of the various subtypes, appreciating the heterogeneity of parkinsonism also includes identifying non-motor features such as early autonomous or cognitive problems which are potentially amenable to pharmacological treatment. Not least, non-motor symptoms, along with postural instability, render the patient particularly vulnerable to side effects, and hence avoiding unnecessary treatment is equally important in the management of parkinsonian disorders.

PubMed ID#: 22052571

PSP, CBD, MSA, + LBD are approved for Compassionate Allowance

I received this email today from Richard Zyne of CurePSP about PSP, CBD, and MSA being added to the list of disorders approved for Compassionate Allowance by the Social Security Administration.  In the attachment that accompanied the email (which I haven’t provided here), all four of the disorders in our support group — PSP (progressive supranuclear palsy), CBD (corticobasal degeneration), MSA (multiple system atrophy), and LBD (Lewy body dementia) — are on the Compassionate Allowance list, effective 12/10/11.  This means that those diagnosed with any of these four disorders will have an easier time to be approved for Social Security Disability.

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To All Board Members and Staff:

Good News—all of our Atypical Parkinsonisms have just been approved by the Social Security Administration for Compassionate Allowance.  Commissioner Astrue made the announcement today and I just got off the phone with Art Spencer, Associate Commissioner, Office of Disability Programs.

The four disorders include PSP, CBD, MSA, and ALS/PDC [ALS/Parkinsonism Dementia Complex].

Social Security has an obligation to provide benefits quickly to applicants whose medical conditions are so serious that their conditions obviously meet disability standards.

Compassionate Allowances (CAL) are a way of quickly identifying diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal objective medical information. Compassionate Allowances allow Social Security to quickly target the most obviously disabled individuals for allowances based on objective medical information that we can obtain quickly.

CAL conditions are developed as a result of information received at public outreach hearings, comments received from the Social Security and Disability Determination Service communities, counsel of medical and scientific experts, and our research with the National Institutes of Health (NIH). Also, SSA considered which conditions are most likely to meet current definitions of disability.

Commissioner Astrue has held seven Compassionate Allowances public outreach hearings. The hearings were on rare diseases, cancers, traumatic brain injury (TBI) and stroke, early-onset Alzheimer’s disease and related dementias, schizophrenia, cardiovascular disease and multiple organ transplants and autoimmune diseases.

The decision to include our neurodegenerative disorders was based on the clinical information which we have provided over the past couple of years (Thank you Drs. Golbe and Steele) and it became clearly obvious to the Commissioner that they qualified for this program.  I have attached the new list of disorders, which was sent to me by Art Spencer.  See the last four on the list.

I am very pleased that CurePSP has been able to advocate on behalf of our patients for this important benefit.

Richard

Richard Gordon Zyne, DMin
President-CEO