Aus der Abteilung Stereotaktische Neurochirurgie der Neurochirurgischen Universitätsklinik der Albert-Ludwigs-Universität Freiburg i. Br. Huntington's and Parkinson's disease: Clinical and Experimental Transplantation Present Clinical Protocol and Recent Advances in the use of Adrenal Chromaffin Cells as an Experimental Alternative Tissue Source INAUGURAL-DISSERTATION Zur Erlangung des Medizinischen Doktorgrades der Medizinischen Fakultät der Albert-Ludwigs-Universität Freiburg i. Br. Vorgelegt 20.08.2013 von William Omar Contreras Lopez geboren in Bucaramanga/Colombia Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 2 Dekan: Prof. Dr. Dr. h.c. mult. Hubert E. Blum 1. Gutachter: Prof. Dr. Guido Nikkhah 2. Gutachter: Prof. Dr. Andreas Schulze-Bonhage Jahr der Promotion: 2013 Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 3 Erklärung nach § 2 Abs. 2 Nr. 5 und 6 Ich erkläre, dass ich die der Medizinischen Fakultät der Albert - Ludwigs- Universität Freiburg i.Br. zur Promotion eingereichte Dissertation mit dem Titel Huntington's and Parkinson's disease: Clinical and Experimental Transplantation Present Clinical Protocol and Recent Advances in the use of Adrenal Chromaffin Cells as an Experimental Alternative Tissue Source in der Abteilung Stereotaktische Neurochirurgie der Neurochirurgischen Klinik des Universitätsklinikums Freiburg unter der Betreuung von Prof. Dr. Guido Nikkhah ohne sonstige Hilfe durchgeführt und bei der Abfassung der Dissertation keine anderen als die dort aufgeführten Hilfsmittel benutzt habe. Ich habe diese Dissertation bisher an keiner in - oder ausländischen Hochschule zur Promotion eingereicht. Weiterhin versichere ich, daß ich den beantragten Titel bisher noch nicht erworben habe. Freiburg, den 20.08.2013 William Omar Contreras Lopez Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 4 This page intentionally left Blank Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 5 Dedicated to Colombia Life is the window of time; the universe gives us, to try to beat mortality by means of the contributions we left to society once we are gone Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 6 This page intentionally left Blank Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 7 TABLE OF CONTENTS SUMMARY……………………………………………………………………………………… 9 ZUSAMMENFASSUNG………………………………………………………………………. 11 ABBREVIATIONS…………………………………………………………………………….. 13 LIST OF FIGURES……………………………………………………………………………. 15 LIST OF TABLES …………………………………………………………………………….. 18 1. INTRODUCTION……………………………………………………………………... 19 1.1 Basal ganglia circuitry and function………………………………………….. 19 1.1.1 Nomenclature…………………………………………………………………... 19 1.1.2 Functional organization of the basal ganglia………………………………….21 1.1.3 Cytoarchitecture……………………………………………………………….. 22 1.1.4 Summary……………………………………………………………………….. 30 1.2 Parkinson’s disease (PD)………………………………………………………. 32 1.2.1 Epidemiology of Parkinson’s disease…………………………………………. 32 1.2.2 Etiology and pathogenesis of Parkinson’s disease…………………………… 34 1.2.3 Therapies for Parkinson´s disease…………………………………………….. 40 1.2.4 Cell replacement therapy and its clinical effects…………………………….. 44 1.2.5 The 6•OHDA lesion model…………………………………………………….. 45 1.3 Huntington’s disease (HD)…………………………………………………….. 47 1.3.1 Epidemiology of Huntington’s disease………………………………………… 47 1.3.2 Etiology and pathogenesis of Huntington’s disease………………………….. 47 1.3.3 Therapies for Huntington´s disease………………………………….…………48 1.3.4 Cell replacement therapy and its clinical effects……………………………...49 1.4 Cell Transplantation in the central nervous system…………………………. 51 1.4.1 History………………………………………………………………………….. 51 1.4.2 Lessons learned for successful Grafting …………………………………….. 52 Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 8 1.4.3 Sources of CNS for transplantation……………………………………………53 1.4.4 Techniques of transplantation………………………………………………….54 1.4.5 Immunosuppresion and Immune response…………………………………....54 1.4.6 Mechanisms of Graft function………………………………………………….55 1.4.7 Theoretical therapeutic applications…………………………………………………..55 1.4.8 Restoration of the CNS using progenitor cells from adrenal medulla……… 61 2. OBJECTIVES……………………………………………………………………….......67 3. MATERIALS……………………………………………………………………………68 4. METHODS…………………………………………………………………………........78 4.1 Project I “Human Clinical Neurotransplantation Protocol for Huntington’s and Parkinson’s disease” 4.2 Project II “Stereotactic Planning Software for Human Neurotransplantation: Suitability in 22 surgical cases of Huntington’s disease” 4.3 Project III “Experimental Intrastriatal Transplantation of Neural Crest Derived Chromaffin Progenitors cells in Parkinson’s disease” 5. RESULTS………………………………………………………………………………118 5.1 Project I……………………………………………………………………….. 118 5.2 Project II………………………………………………………………………. 140 5.3 Project III………………………………………………………………………148 6. DISCUSSION…………………………………………………………………………. 158 REFERENCES………………………………………………………………………………...161 PUBLICATIONS………………………………………………………………………………194 ACKNOWLEDGEMENTS…………………………………………………………………...195 CURRICULUM VITAE………………………………………………………………………196 Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 9 SUMMARY Since 1987 an estimated 450 patients with Parkinson’s (PD) and Huntington’s (HD) diseases have been transplanted with human fetal mesencephalic tissue, rich in post mitotic primary dopamine (DA) neurons, or with ganglionic eminences harboring precursors of striatal GABA-ergic medium spiny interneurons respectively. Clinical outcome has been variable, ranging from case reports of PD patients dropping out medication following transplantation up to negative results in two prospective randomized double-blinded trials. Analyzing the results across studies, it becomes apparent that procedures used in different centers vary greatly. However few efforts have been made to standardize the procedure, probably due also to the wider range of different results and the lack of expertise, limitation of tissue, and ethical and legal concerns, creating a vicious cycle between lack of standardized protocols and conclusive results. This thesis was elaborated having in mind such concerns; the thesis is composed of three projects. The work described in the first project of this thesis was aimed at reviewing the clinical neurotransplantation protocol for PD and HD. Two detailed step-wise neurotransplantation protocols are presented, outlining strategies facilitating the avoidance of possible procedure-related complications. Some crucial technical factors enabling the execution of a safe and effective neural transplantation trial were delineated. Special emphasis in understanding the anatomical relationships of the human fetal tissue that are relevant for selection of the desired cells population was also addressed. The protocols reviewed here might contribute to further development of the experimental clinical neurotransplantation towards a routine therapeutic procedure. The second project presents self-developed software optimizing the surgical stereotactic planning for bilateral neurotransplantation procedures. It allows close to symmetrical distribution of the stereotactic coordinates in relation to the mid-commissural point (MCP), proposing automatically the planning coordinates for the first hemisphere to be transplanted and mirrored coordinates for the contra- lateral hemispheres. An analysis of its applicability in twenty-two consecutive human HD patients who underwent bilateral stereotactic striatal transplantation was performed. Intra-individual comparison between software given coordinates and final used coordinates was performed as well as a safety analyses. Project number three examined, via in vitro and in vivo studies, the ability of neural crest-derived sympathoadrenal (SA) progenitor cells to reinnervate the striatum, after a stepwise isolation, propagation and transplantation protocol. The cells were enriched and propagated in chromosphere cultures prior to transplantation. Mastering the isolation of these chromaffin progenitor cells and controlling their differentiation might open new avenues for regenerative therapies. Huntington's and Parkinson's disease: Clinical and Experimental Transplantation 10 ZUSAMMENFASSUNG Seit 1987 wurden etwa 450 Patienten mit Parkinson- bzw. Huntington-Erkrankung mit fötalem menschlichem mesencephalem Gewebe, oder mit Vorläufern der GABA-ergen striatalen Interneuronen der „ganglionic eminence“ transplantiert. Bei genauerer Analyse der Ergebnisse zeigte sich, dass die angewandten Verfahren in den verschiedenen Zentren sehr stark variierten. Bislang wurden nur wenige Anstrengungen unternommen, um diese Verfahren zu standardisieren, vermutlich wegen den großen Unterschieden an Erfahrung, den ethischen Aspekten der Benutzung des nur begrenzt zur Verfügung stehenden fötalen menschlichen Gewebes und den landesspezifischen Rechtsgrundlagen. Unter Berücksichtigung dieser Voraussetzungen wurden in der hier vorliegenden Arbeit drei Themenschwerpunkte behandelt: In dem ersten Projekt wurden die klinischen Neurotransplantations- Protokolle für Patienten mit Parkinson’scher und Huntington’sche -Erkrankung genauer analysiert. Es wurden zwei ausführliche und schrittweise gegliederte Neurotransplantations-Protokolle vorgestellt, welche Strategien aufzeigen, um mögliche verfahrensbedingte Probleme und Komplikationen zu vermeiden. Die hier analysierten