Yuan-Yang Lai

Rapid eye movement sleep behavior disorder: Devising controlled active treatment studies for symptomatic and neuroprotective therapy-a consensus statement from the International Rapid Eye Movement Sleep Behavior Disorder Study Group

OBJECTIVES We aimed to provide a consensus statement by the International Rapid Eye Movement Sleep Behavior Disorder Study Group (IRBD-SG) on devising controlled active treatment studies in rapid eye movement sleep behavior disorder (RBD) and devising studies of neuroprotection against Parkinson disease (PD) and related neurodegeneration in RBD. METHODS The consensus statement was generated during the fourth IRBD-SG symposium in Marburg, Germany in 2011. The IRBD-SG identified essential methodologic components for a randomized trial in RBD, including potential screening and diagnostic criteria, inclusion and exclusion criteria, primary and secondary outcomes for symptomatic therapy trials (particularly for melatonin and clonazepam), and potential primary and secondary outcomes for eventual trials with disease-modifying and neuroprotective agents. The latter trials are considered urgent, given the high conversion rate from idiopathic RBD (iRBD) to Parkinsonian disorders (i.e., PD, dementia with Lewy bodies [DLB], multiple system atrophy [MSA]). RESULTS Six inclusion criteria were identified for symptomatic therapy and neuroprotective trials: (1) diagnosis of RBD needs to satisfy the International Classification of Sleep Disorders, second edition, (ICSD-2) criteria; (2) minimum frequency of RBD episodes should preferably be ⩾2 times weekly to allow for assessment of change; (3) if the PD-RBD target population is included, it should be in the early stages of PD defined as Hoehn and Yahr stages 1-3 in Off (untreated); (4) iRBD patients with soft neurologic dysfunction and with operational criteria established by the consensus of study investigators; (5) patients with mild cognitive impairment (MCI); and (6) optimally treated comorbid OSA. Twenty-four exclusion criteria were identified. The primary outcome measure for RBD treatment trials was determined to be the Clinical Global Impression (CGI) efficacy index, consisting of a four-point scale with a four-point side-effect scale. Assessment of video-polysomnographic (vPSG) changes holds promise but is costly and needs further elaboration. Secondary outcome measures include sleep diaries; sleepiness scales; PD sleep scale 2 (PDSS-2); serial motor examinations; cognitive indices; mood and anxiety indices; assessment of frequency of falls, gait impairment, and apathy; fatigue severity scale; and actigraphy and customized bed alarm systems. Consensus also was established for evaluating the clinical and vPSG aspects of RBD. End points for neuroprotective trials in RBD, taking lessons from research in PD, should be focused on the ultimate goal of determining the performance of disease-modifying agents. To date no compound with convincing evidence of disease-modifying or neuroprotective efficacy has been identified in PD. Nevertheless, iRBD patients are considered ideal candidates for neuroprotective studies. CONCLUSIONS The IRBD-SG provides an important platform for developing multinational collaborative studies on RBD such as on environmental risk factors for iRBD, as recently reported in a peer-reviewed journal article, and on controlled active treatment studies for symptomatic and neuroprotective therapy that emerged during the 2011 consensus conference in Marburg, Germany, as described in our report.

Enhanced glutamate release during REM sleep in the rostromedial medulla as measured by in vivo microdialysis

Anatomical studies and stimulation studies in the decerebrate animal have suggested that the muscle atonia of rapid eye movement (REM) sleep is mediated by a projection from cholinoceptive glutamatergic neurons in the pons to the nucleus magnocellularis (NMC) of medulla. This model suggests that glutamate release in NMC should be enhanced in REM sleep. In the present study, glutamate release across the sleep-wake cycle in NMC was measured by in vivo microdialysis. We found that glutamate release in NMC was significantly higher (p=0.0252) during REM sleep than during wakefulness (W). Glutamate release during REM sleep was not elevated either in nucleus paramedianus (NPM) or in the pontine inhibitory area (PIA) regions where cholinergic stimulation suppresses muscle tone. Acetylcholine (ACh) microinjection into PIA enhanced glutamate release in NMC. These results support the hypothesis that a glutamatergic pathway from PIA to NMC is responsible for the suppression of muscle tone in REM sleep.

Physiological and anatomical link between Parkinson-like disease and REM sleep behavior disorder

Parkinson’s disease (PD) is a progressive neurodegenerative disease that is caused by a loss of neurons in the ventral midbrain. Parkinsonian patients often experience insomnia, parasomnias, and daytime somnolence. REM sleep behavior disorder (RBD) is characterized by vigorous movements during REM sleep, and may also be caused by neuronal degeneration in the central nervous system (CNS); however, the site of degeneration remains unclear. Both Parkinsonism and RBD become more prevalent with aging, with onset usually occurring in the sixties. Recent findings show that many individuals with RBD eventually develop Parkinsonism. Conversely, it is also true that certain patients diagnosed with Parkinsonism subsequently develop RBD. Postmortem examination reveals that Lewy bodies, Lewy neurites, and α-synuclein are found in brainstem nuclei in both Parkinsonism and RBD patients. In this article, we will discuss evidence that Parkinsonism and RBD are physiologically and anatomically linked, based on our animal experiments and other studies on human patients.

Cardiovascular and muscle tone changes produced by microinjection of cholinergic and glutamatergic agonists in dorsolateral pons and medial medulla.

Cardiovascular and muscle responses to L-glutamic acid (Glut) and cholinergic agonists injected into the dorsolateral pontine tegmentum and medial medullary reticular formation (MMRF) were examined in unanesthetized, decerebrated cats. Glut, or cholinergic agonists acetylcholine (ACh) or carbachol (Carb), were injected into pons and MMRF at sites from which electrical stimulation produced bilateral suppression of muscle tone. Glut injection in MMRF produced hypotension without change in heart rate at doses as low as 1 mM. At higher doses (0.1-0.4 M), Glut induced hypotension with bradycardia in 23 out of 40 injections in both pons and MMRF. High concentrations of microinjected Glut decreased muscle tone or produced complete atonia in pons and rostral MMRF. Both N-methyl-D-aspartic acid (NMDA) and non-NMDA receptor blockers attenuated or completely blocked the cardiovascular response, while only non-NMDA antagonists blocked muscle inhibition to Glut injection. Microinjection of cholinergic agonists produced consistent hypotension in all of the injections in pons and MMRF, however, the heart rate response was variable with increase (27/42), decrease (2/42), or no change (13/42) in rate seen. Cholinergic injection produced muscle atonia in pons and caudal MMRF but not in rostral MMRF. Both muscle and cardiovascular responses were blocked by atropine but not by hexamethonium. The time course of muscle atonia and cardiovascular change differed in most of the experiments. We conclude that muscle tone suppression and cardiovascular response to Glut or cholinergic agonists use different receptor mechanisms and possibly different neurons. However, the co-localization of these mechanisms suggests that neuronal networks in the medial medulla and dorsolateral pons coordinate motor and cardiovascular responses.

Brainstem projections to the ventromedial medulla in cat: Retrograde transport horseradish peroxidase and immunohistochemical studies

Stimulation of the nucleus magnocellularis (NMC) of the medulla produces changes in locomotion, muscle tone, heart rate, and blood pressure. Glutamatergic input has been found to modulate muscle tone, whereas cholinergic input has been found to mediate cardiovascular changes produced by stimulation of the NMC. The current study was designed to identify the brainstem afferents to NMC by using retrograde transport of wheat germ agglutinin and horseradish peroxidase (WGA‐HRP) combined with glutamate and choline acetyltransferase (ChAT) immunohistochemical and nicotinamide adenine dinucleotide phosphate‐diaphorase (NADPH‐d) histochemical techniques. Fifty nanoliters of 2.5% WGA‐HRP were microinjected into the NMC in the cat. A heavy density of WGA‐HRP‐labeled neurons was found in the ipsilateral mesencephalic reticular formation (MRF), periaqueductal gray, Kolliker‐Fuse nucleus, and pontis centralis caudalis (PoC), in the contralateral pontis centralis oralis (PoO), and bilaterally in the nucleus paragigantocellularis lateralis. A moderate density of retrogradely labeled neurons was found in the ipsilateral side of the nuclei parvocellularis, retrorubral (RRN), PoO, and vestibular complex, in the contralateral PoC and nucleus gigantocellularis, and bilaterally in the inferior vestibular nucleus. Retrograde HRP/glutamate‐positive cells could be found throughout the brainstem, with a high percentage in RRN, PoO, PoC, and MRF. Double‐labeled WGA‐HRP/ChAT neurons were found in the pedunculopontine nucleus. Double‐labeled WGA‐HRP/NADPH‐d‐positive neurons could be seen in many nuclei of the brainstem, although the number of labeled neurons was small. The dense glutamatergic projections to the NMC support the hypothesis that rostral brainstem glutamatergic mechanisms regulate muscle activity and locomotor coordination via the NMC, whereas the pontine cholinergic projections to the NMC participate in cardiovascular regulation. J. Comp. Neurol. 408:419–436, 1999. Published 1999 Wiley‐Liss, Inc.

NEUROTOXIC LESIONS AT THE VENTRAL MESOPONTINE JUNCTION CHANGE SLEEP TIME AND MUSCLE ACTIVITY DURING SLEEP : AN ANIMAL MODEL OF MOTOR DISORDERS IN SLEEP

There is no adequate animal model of restless legs syndrome (RLS) and periodic leg movements disorder (PLMD), disorders affecting 10% of the population. Similarly, there is no model of rapid eye movement (REM) sleep behavior disorder (RBD) that explains its symptoms and its link to Parkinsonism. We previously reported that the motor inhibitory system in the brainstem extends from the medulla to the ventral mesopontine junction (VMPJ). We now examine the effects of damage to the VMPJ in the cat. Based on the lesion sites and the changes in sleep pattern and behavior, we saw three distinct syndromes resulting from such lesions; the rostrolateral, rostromedial and caudal VMPJ syndromes. The change in sleep pattern was dependent on the lesion site, but was not significantly correlated with the number of dopaminergic neurons lost. An increase in wakefulness and a decrease in slow wave sleep (SWS) and REM sleep were seen in the rostrolateral VMPJ-lesioned animals. In contrast, the sleep pattern was not significantly changed in the rostromedial and caudal VMPJ-lesioned animals. All three groups of animals showed a significant increase in periodic and isolated leg movements in SWS and increased tonic muscle activity in REM sleep. Beyond these common symptoms, an increase in phasic motor activity in REM sleep, resembling that seen in human RBD, was found in the caudal VMPJ-lesioned animals. In contrast, the increase in motor activity in SWS in rostral VMPJ-lesioned animals is similar to that seen in human RLS/PLMD patients. The proximity of the VMPJ region to the substantia nigra suggests that the link between RLS/PLMD and Parkinsonism, as well as the progression from RBD to Parkinsonism may be mediated by the spread of damage from the regions identified here into the substantia nigra.

Brainstem-mediated locomotion and myoclonic jerks. I. Neural substrates

Eleven of 40 decerebrated cats were found to exhibit periods of spontaneous or sensory myoclonus and locomotion beginning 24 h after decerebration. Histological analysis showed that the cats generating myoclonus hemorrhagic lesions in the retrorubral nucleus (RRN) and ventral mesopontine junction (vMPJ). However, with intact RRN and vMPJ never showed myoclonus. To verify that the lesions were responsible for myoclonus, 6 additional cats received N-methyl-D-aspartate (NMDA, 0.5 M/0.5 microliter) injections in the areas of RRN and vMPJ to produce bilateral lesions. Coordinated rhythmic leg movement (locomotion) or myoclonic twitches developed in all of these cats beginning 3 hours after NMDA injection. These NMDA lesion-induced movements appeared either spontaneously (5 out of 6 cats) or after sensory stimulation (1 cat). Four cats received saline control injections in the RRN and vMPJ and did not have spontaneous, or sensory stimulation-induced, myoclonic twitches during the 48 h observation period. These results indicate that the RRN and vMPJ have a suppressive effect on myoclonic twitches and rhythmic leg movement. Dysfunction of these regions could release motor activity into sleep and waking states.

Descending projections from the dorsolateral pontine tegmentum to the paramedian reticular nucleus of the caudal medulla in the cat.

We examined whether the dorsolateral pontine cholinergic cells project to the paramedian reticular nucleus (PRN) of the caudal medulla. In 3 cats, wheat germ agglutinin-conjugated horseradish peroxidase (WGA-HRP) was injected into the PRN and we noted cells in the dorsolateral pons that contained the HRP reaction product, cells that were immunolabeled for choline acetyltransferase (ChAT), and cells that contained the HRP reaction product and were ChAT positive. We found cholinergic projections from the pedunculopontine tegmental and laterodorsal tegmental nuclei to the PRN. This finding is consistent with studies indicating a cholinoceptive region in the medial medulla mediating suppression of muscle tone. Our results demonstrate that this medullary region has monosynaptic input from pontine neurons implicated in generating the atonia of rapid eye movement sleep.

Enhancement of acetylcholine release during REM sleep in the caudomedial medulla as measured by in vivo microdialysis

Previous studies in our laboratory have found that muscle atonia could be triggered by two distinct areas of the medial medulla, a caudal region, corresponding to the nucleus paramedianus (NPM) and a rostral region, corresponding to the nucleus magnocellularis (NMC). The former region is responsive to acetylcholine (ACh) and the latter region is responsive to glutamate. In this study we have measured the endogenous ACh release across the sleep-wake cycle in these two areas with the microdialysis technique in unanesthetized, freely moving cats. We found that ACh release in NPM was state-dependent and was about 30% higher (P less than 0.001) during rapid eye movement (REM) sleep than during slow-wave sleep and wakefulness. However, ACh release in NMC was not selectively elevated in REM sleep. The enhancement of ACh release in NPM during REM sleep supports our hypothesis that ACh release onto cholinoceptive neurons in this area mediates the muscle atonia of REM sleep.

Neurotoxic N-methyl-D-aspartate lesion of the ventral midbrain and mesopontine junction alters sleep-wake organization.

The dorsal regions of the midbrain and pons have been found to participate in sleep regulation. However, the physiological role of the ventral brainstem in sleep regulation remains unclear. We used N-methyl-D-aspartate-induced lesions of the ventral midbrain and pons to address this question. Unlike dorsal mesencephalic reticular formation lesions, which produce somnolence and electroencephalogram synchronization, we found that ventral midbrain lesions produce insomnia and hyperactivity. Marked increases in waking and decreases in slow wave sleep stage 1 (S1), stage 2 (S2) and rapid eye movement sleep were found immediately after the lesion. Sleep gradually increased, but never returned to baseline levels (baseline/month 1 post-lesion: waking, 30.6 +/- 4.58%/62.3 +/- 10.1%; S1, 5.1 +/- 0.74/3.9 +/- 1.91%; S2, 46.2 +/- 4.74%/23.1 +/- 5.47%; rapid eye movement sleep, 14.1 +/- 3.15%/7.2 +/- 5.42%). These changes are comparable in magnitude to those seen after basal forebrain lesions. Neuronal degeneration was found in the ventral rostral pons and midbrain, including the substantia nigra, ventral tegmental area, retrorubral nucleus, and ventral mesencephalic and rostroventral pontine reticular formation. We conclude that nuclei within the ventral mesencephalon and rostroventral pons play an important role in sleep regulation.