2Journal ofNeurology, Neurosurgery, and Psychiatry 1997;62:622-625

[18F]Fluorodopa PET shows striatal dopaminergicdysfunction in juvenile neuronal ceroidlipofuscinosis

H M Ruottinen, J 0 Rinne, M Haaparanta, 0 Solin, J Bergman, V J Oikonen, I Jiirvela,P Santavuori

Department ofNeurology, UniversityofTurku, Turku,FinlandH M RuottinenJ 0 RinneTurku PET Center,RadiopharmaceuticalChemistry andAcceleratorLaboratory, AboAkademi University,Turku, FinlandM HaaparantaO SolinJ BergmanTurku PET Center,PET Unit, Turku,FinlandV J OikonenDepartment ofHumanMolecular Genetics,National Public HealthInstitute, Helsinki,FinlandI JarvelaChildren's Hospital,Paediatric Neurology,University of Helsinki,Helsinki, FinlandP SantavuoriCorrespondence to:Dr H M Ruottinen,Department of Neurology,University of Turku, FIN-20520 Turku, Finland.

Received 28 August 1996and in revised form21 January 1997Accepted 31 January 1997

AbstractObjectives-To investigate whethernigrostriatal dopaminergic hypofunctionis related to the extrapyramidal symp-toms in patients with juvenile neuronalceroid lipofuscinosis (JNCL).Methods-Nine patients with JNCL andseven healthy controls were studied using['8F]fluorodopa PET.Results-In the patients with JNCL['8F]fluorodopa uptake (K.-c) in the puta-men was 60% of the control mean and thecorresponding figure in the caudatenucleus was 79%. There was a weak corre-lation between putamen KY°c values andextrapyramidal symptoms of the patientsevaluated by the motor part of the unifiedParkinson's disease rating scale (r =-0-57, P < 0.05). The overall severity ofthe disease also displayed a negative cor-relation with the K,°cC values in the puta-men (r = -0.71, P < 0.05).Conclusion-In patients with JNCL therewas reduced striatal [I"Ffluorodopauptake, which had a modest correlationwith extrapyramidal symptoms. Dys-function of nigrostriatal dopaminergicneurons is therefore not the only cause ofthe patients' extrapyramidal symptoms,but degenerative changes in other brainareas are also contributory.

(7 Neurol Neurosurg Psychiatry 1997;62:622-625)

Keywords: dopamine; fluorodopa positron emissiontomography; neuronal ceroid lipofuscinosis

The neuronal ceroid lipofuscinoses (NCLs) area group of recessively inherited progressiveencephalopathies characterised by neural andextraneural accumulation of cytosomes storingceroid and lipofuscin.' The diseases are consid-ered to be among the most common progres-sive encephalopathies during childhood in thewestern world.2 Three major childhood typesare known as infantile (INCL), late infantile(LINCL), and juvenile types (JNCL).Synonyms for JNCL are Spielmeyer-(Vogt)-Sjogren disease and late onset Batten disease.JNCL is characterised by increasing visual

failure (with an onset at ages between four andeight years), epilepsy, progressive dementia,dysarthric speech, and development of slight tomoderate ataxia. In addition, extrapyramidalsymptoms occur with increasing frequency dur-ing the course of the disease. In a series of 53patients with JNCL3 the mean age of the

patients when a parkinsonian type walk wasfirst seen was 13-7 years. The patients lost theirability to walk at a mean age of 17-3 years.3The gene responsible for JNCL has recently

been identified at chromosome 16p12 andshows no homology with previously known pro-teins.4 One founder mutation, a 1 02 kb dele-tion, causes the disease in about 80% ofaffected chromosomes worldwide.4 Because ofthe unknown biochemical defect, there is nospecific treatment, and available therapiesremain largely only symptomatic.3The effect of antiparkinsonian drugs has

been variable.!8 Despite the importance ofextrapyramidal symptoms in patients withJNCL, little attention has been paid to them.The motor dysfunction, which is added to theclinical picture as the disease progresses, itselfsets a major therapeutic problem: extrapyrami-dal signs associated with amblyopia lead tosevere disturbance of locomotion. However, thepathophysiological mechanisms responsible fortheir appearance in JNCL are not known.Therefore, to assess whether a striatal dopamin-ergic dysftunction is present in some patientswith JNCL is particularly relevant as such dys-function might explain their extrapyramidalsymptoms. It is also necessary before consideringsymptomatic treatment with substitutivedopaminergic drugs.The purpose of the present study was to find

out whether patients with JNCL show evidenceof presynaptic dopaminergic hypofunction,evaluated with [18F]fluorodopa PET, andwhether that is related to the extrapyramidalsymptoms of the patients.

Patients and methodsPATIENTSWe studied nine patients with JNCL (onefemale, eight male). The age of the patients was19 1 (SD 4.7) years, ranging from 15 to 27years. Table 1 presents their clinical characteris-tics. All patients had a normal early develop-ment and were able to walk and run well untilgait problems developed and first signs of aparkinsonian walk (slightly flexed posture, slowsteps with flexion in hips and knees, and failureof arm swing) were noticed. Unlike idiopathicParkinson's disease, tremor was an uncommonsign. All the patients were initially investigatedbecause they had severe visual failure. They allshowed tapetoretinal degeneration with abol-ished electroretinograms. Vacuolated lympho-cytes in peripheral blood were found onrepeated examinations. The diagnosis was con-firmed from a rectal biopsy specimen by elec-

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P8F]Fluorodopa PET shows striatal dopaminergic dysfunction in juvenile neuronal ceroid lipofuscinosis

Table 1 Clinical characteristics of the patients with juvenile neuronal ceroid lipofuscinosis(JNCL)

Age at Totalonset Motor minus

Age ofJNCL UPDRS Total epilepsyPatient No (y) (y) score score score

1 19 4 28 9 72 27 6 21 8 83* 27 6 0 3 34 15 5 28 11 95* 16 4 23 5 36 18 4 35 9 87 15 5 12 6 58 19 4 16 6 69 16 4 19 6 5Total 19.1 (4 7) 4-7 (0 9) 20-2 (10-3) 7-0 (2 4) 6-0 (2 2)

*Heterozygous; all the others are homozygous.Total results are mean (SD).

tron microscopy, which showed characteristiccurvilinear and fingerprint profiles.9 The muta-tion analysis showed that seven of the patientswith JNCL were homozygous and two were

heterozygous for the major mutation, a 1 02 kbdeletion of the CLN3 gene.'0

Extrapyramidal symptoms (rigidity, hypoki-nesia, slightly flexed posture, and impaired bal-ance) were noted in all but one of the patients,without any clinically relevant asymmetries insymptoms. The severity of the extrapyramidalsymptoms was evaluated using the motor partof the unified Parkinson's disease rating scale(UPDRS)."1 All the patients were on antioxi-dant medication and eight patients receivedantiepileptic drugs, but none of them wasreceiving antiparkinsonian treatment. Theoverall severity of the disease was evaluatedusing a scale taking into account motor perfor-mance, balance, coordination, speech, and thefrequency of epileptic seizures.6 Each item wasscored from zero to four and thus the scaleranged from zero to 20: the higher the score thegreater the severity.The controls (one woman, six men) were

healthy volunteers aged 34-6 (SD 12-9) years,ranging from 23 to 50 years. They had no neu-rological or psychiatric diseases and were notunder regular medication. Informed consent forall subjects was obtained.

METHODSAll the subjects underwent an [18F]fluorodopaPET investigation according to a protocoldescribed previously by Ruottinen et al'2 withtwo modifications: arterial blood sampling wasnot performed and the dose of carbidopa was100 mg instead of 150 mg. The PET investiga-tions were performed using an eight ring wholebody ECAT 931/08 tomograph (Siemens/CTICorp, Knoxville, TN, USA), described ear-lier.'2 The scanner gives 15 simultaneoustransaxial slices with final in plane resolution of8 mm after reconstruction. The subjects werepositioned in the tomograph in an individuallyprepared head holder with three dimensionallaser alignment with reference to the orbito-meatal line.The synthesis of ['8F]F2 gas for labelling"3

and ['8F]fluorodopa production were carriedout according to the methods of Namavari etal 4 and Bergman et al."5 At the end of the syn-thesis the mean batch size was 1190 (SD 610)MBq with a specific radioactivity of 2510 (SD

970) MBq/pmol. The radiochemical purityexceeded 98% in every case. On average 172(SD 31) MBq ['8F]fluorodopa (range 107-204MBq) was injected intravenously into patientsand controls. The specific radioactivity of the['8F]fluorodopa was 830 (SD 500) MBq/pmolat the time of injection.A dynamic study of 37 time frames (12 x 15

s, 4 x 30 s, 5 x 60 s, and 16 x 300 s) with atotal duration of 90 minutes'2 was performedfor each subject. The trace regions of interest(ROIs) were drawn bilaterally on the head ofthe caudate nucleus (with an average of 140MM2), putamen (330 mm2), and lateral occipi-tal region containing both grey and white matter.The ROIs were identified by visual inspection,with reference to the neuroanatomical atlas ofAquilonius and Eckernms,'6 on the integratedPET images representing activity concentra-tion, from 20-90 minutes after ['8F]fluorodopainjection. The ROIs were placed on two adja-cent transaxial slices and the average radioactiv-ity concentration was computed for each ROI.The values of the corresponding ROIs for leftand right structures were averaged. To ensurethat there was no difference between patientsand controls in the occipital region, the areaunder the time activity curve from 0 to 90 min-utes (AUCGo9o) of the occipital reference areawas calculated. The AUCo9o was corrected forthe subject's weight and injected ['8F]fluo-rodopa dose.The graphical analysis method was used to

calculate the metabolic rate of ['8F]fluorodopa(Kiocc),171 which reflects the decarboxylationrate of ['8F]fluorodopa to [18F]fluorodopamine.In this analysis the time course of occipitalradioactivity was used as input function; thetime course of striatal/occipital activity wasplotted against the ratio of integrated occipitalto occipital activity. The YI'cc, defined in thetime range from 10 to 90 minutes after the['8Flfluorodopa injection, was calculated fromthe slope of the graphical plot.'7-19 All the sub-jects underwent a brain MRI (1-5 tesla) andone patient had a brain CT.The difference in the ['8F]fluorodopa uptake

values between patients and controls was com-pared using Student's unpaired t test.Correlations were calculated using Pearson'scorrelation coefficients. Statistical significancewas defined as P < 0-05.

ResultsTable 2 presents the ['8F]fluorodopa uptakevalues (KI,-c) in patients with JNCL and con-trols. The putaminal K,- was 7 1 (SD 1.9) x1 0-3 min-' for the patients with JNCL, which

Table 2 f]8F]fluorodopa uptake values (KI<Cc) inpatients with juvenile neuronal ceroid lipofuscinosis(_NCL) and healthy controls

I<;OCC (X l10-3 min -

Group Putamen Caudate nucleus

JNCL 7-1 (1.9)*** 9-2 (1-6)**Control 11*7 (0 7) 11*6 (0 9)

Results are means (SD).**P < 0-01; ***P < 0 001 v controls.

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Ruottinen, Rinne, Haaparanta, Solin, Bergman, Oikonen, et al

Figure 1 Comparison ofindividual '8F]fluorodopaKi-' values ( x 10- I

min ') in patients withjuvenile neuronal ceroidlipofuscinosis (JNCL) andhealthy controls. EP- =the patient withoutextrapyramidal symptoms.Bar = mean.

.c 14E 13o 12X 1

O._ 10

(UCL 806o 7O 6LL 5

Putamen

0l _

EP-. 0

0

0.

0

Caudate0

0

0

0

EP- t. °°°

0.

t.

14131211

109

87

65

Patients Controls Patients Controls

was significantly lower than the correspondingvalue for the controls (11-7 (SD 0-7) x 10min-', P < 0-01). The mean putaminal K,°ccwas 60% of the control mean. Figure 1 showsthe individual Wocc values. The patient withoutextrapyramidal symptoms had the highestvalue among the patients with JNCL, whichwas at the lower border of the control range.In the other patients with extrapyramidalsymptoms the putaminal K°CC was below 3 SDof the control mean.

In the caudate nucleus the average Kocc forthe patients with JNCL was reduced to 79% ofthe control mean. The absolute values were9-2 (SD 1-6) x 10-3 min-' for the patientswith JNCL and 11-6 (SD 0-9) x 10-3 min-for the controls (P < 0-01). The Kocc valuefound in the caudate nucleus for the patientwithout extrapyramidal symptoms (EP -) wasin the upper patient range. However, thisvalue did not differentiate this patient fromother patients with JNCL as clearly as did theputamen KOcc value. Figure 2 shows thereduced striatal [18F] fluorodopa accumulationin one patient with JNCL compared with ahealthy control.

There was a significant correlation betweenthe putamen and caudate YJocc values of the

patients with JNCL (r = +0 79, P < 0-05). Aweak inverse correlation was noted betweenthe putamen K-°cc values and the UPDRSmotor score (r = -0 57, P < 0 05). The over-all severity of the disease had a weak negativecorrelation with the K,'cc values in the putamen(r = -0-64, P = 0 06), and when the score"total minus epilepsy" was used, the cor-relation was more obvious (r = -0 71,P < 0 05). The mean AUCO-90 of the occipitaltime activity curves was not significantly dif-ferent between patients and controls(P > 0-1).

DiscussionOur results show that there is reduced uptakeof [18F]fluorodopa in the putamen and, to alesser degree, also in the caudate nucleus, inpatients with JNCL. This most probably indi-cates hypofunction of nigrostriatal dopaminer-gic projections. We emphasise that this studyconcerns the juvenile type of NCL disease,and that the applicability of the results to theother subtypes ofNCL needs further study.

There was a slight correlation between theextrapyramidal symptoms assessed by themotor part of the UPDRS and the putaminal['8F]fluorodopa uptake. This association is lessstriking than that reported for patients withParkinson's disease or multiple system atro-phy.'8 Most probably degeneration of striataland other brain areas and their connectionsalso contribute to the extrapyramidal symp-toms of the patients with JNCL. This may alsoexplain why the patients' response to levodopais variable, usually fair to moderate.6 820

Philippart et a 21 investigated brain meta-bolic activity in seven patients withSpielmeyer-Vogt disease, using fluoro-deoxyglucose (FDG) PET, and found reducedmetabolism in the calcarine area, cingulatecortex, and thalamus, but basal ganglia and

Figure 2 Ademonstration off8F]fluorodopa PETimage in a healthy controland in a patient withjuvenile neuronal ceroidlipofuscinosis aNCL).Note the reduced traceruptake both in theputamen and caudatenucleus of the patient withJ7NCL. The PET imagesare scaled to identicaloccipital counts. Theactivity concentrationdeclines along the colourscale red-yellow-green-blue.

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58F]Fluorodopa PETshows striatal dopaminergic dysfunction in juvenile neuronal ceroid lipofuscinosis

brainstem uptake remained normal. In foursiblings with neuronal ceroid lipofuscinosis thegreatest decrease in glucose utilisation studiedwith FDG was seen in the thalamus and poste-rior association cortex.7 In a case of the lateinfantile form a widespread reduction of corti-cal and thalamic FDG uptake was reported.22

In our study we used [18F]fluorodopa, theuptake of which reflects its decarboxylationand storage to [18F]fluorodopamine. Thus it isa marker of the functional activity of dopamin-ergic nerve endings. The use of radioactivityconcentration in the occipital cortex as inputfunction in ['8F]fluorodopa PET instead ofmetabolite corrected arterial plasma has beenvalidated.1819 The reference area used in thisstudy was in the lateral occipital cortex, whichshows less atrophy and FDG uptake impair-ment than the primary visual cortex.21 Possibleatrophic or other changes in the reference areadid not bias the results, as the AUC,90 of[18F]fluorodopa in the occipital region did notdiffer significantly between the patients andthe controls. Potential atrophy in the corticalor subcortical region would have increased thestriatal to occipital ratios, and thus it wouldhave rather underestimated the difference in['8F]fluorodopa uptake between patients withJNCL and control subjects. Our controls wereolder than the patients, as we did not considerit ethical to study controls below the age of 20;but this would, if anything, underestimate thedecline in ['5F]fluorodopa uptake, as inhealthy persons the [18F]fluorodopa uptake hasbeen reported to decline slightly2' or to remainvirtually unchanged with age.2425 The medica-tion used by the patients with JNCL is pre-sumed not to affect the presynapticdopaminergic system nor the KOcc values.

Autti et al26 found only a slight signal inten-sity change in basal ganglia studied with MRI(1-0 tesla). However, there was a correlationbetween the overall motor impairment and areduced signal intensity in the putamen andthalamus. A similar association was seen withmotor performance and increased signal inten-sity of the white matter and atrophic changesin the pons, mesencephalon, and medullaoblongata.26 This may reflect overall severity ofthe disease process without a causal relation,but in any case factors other than degenerationof the nigrostriatal dopamine system mostprobably contribute to the extrapyramidalsymptoms of patients with JNCL. Similarly, inour study the overall severity of the diseasehad a significant correlation with ['8F]fluo-rodopa uptake in the putamen, especiallywhen a score including motor performance,balance, coordination, and speech was used.

In conclusion, patients with JNCL have areduced [18'F]fluorodopa uptake in the puta-men and to a lesser degree in the caudatenucleus. This decline showed a modest corre-lation with extrapyramidal symptoms of thepatients. Therefore, most probably dysfunc-tion of nigrostriatal dopaminergic neurons isnot the only cause of the patients' extrapyra-midal symptoms, but degenerative changes inother brain areas are also contributory.

The assistance by the staff of the Turku PET Center and thefinancial support from the Foundation for Paediatric Research(Ulla Hjelt Fund) are gratefully acknowledged.

1 Zeman W, Donohue S, Dyken P, Green J. The neuronalceroid-lipofuscinoses (Batten-Vogt syndrome). In: VinkenP, Bruyn GW, eds. Handbook of clinical neurology. Vol X.Amsterdam: North Holland, 1970:588-679.

2 Rider JA, Rider DL. Batten disease: past, present, andfuture. AmJMed Genet 1988;5(suppl):21-6.

3 Santavuori P, Westermarck T, Rapola J, et al. Antioxidanttreatment in Spielmeyer-Sjogren's disease. Acta NeurolScand 1985;71:136-45.

4 The International Batten Disease Consortium. Isolation of anovel gene underlying Batten disease, CLN3. Cell 1995;82:949-57.

5 Santavuori P, Heiskala H, Autti T, Johansson E,Westermarck T. Comparison of the clinical courses inpatients with juvenile neuronal ceroid lipofuscinosisreceiving antioxidant treatment and those without antioxi-dant treatment. Adv Exp Med Biol 1990;266:273-82.

6 Santavuori P, Heiskala H, Westermarck T, Sainio K, MorenR. Experience over 17 years with antioxidant treatment inSpielmeyer-Sjogren disease. Am J Med Genet 1988;5(suppl):265-74.

7 De Volder AG, Cirelli S, de Barsy Th, et al. Neuronalceroid-lipofuscinosis: preferential metabolic alterations inthalamus and posterior association cortex demonstrated byPET. J Neurol Neurosurg Psychiatry 1990;53: 1063-7.

8 Zweije-Hofman IL, van der Zee HJ, van Nieuwenhuizen 0.Anti-parkinson drugs in the Batten-Spielmeyer-Vogt syn-drome; a pilot trial. Clin Neurol Neurosurg 1982;84:101-5.

9 Rapola J, Santavuori P, Savilahti E. Suction biopsy of rectalmucosa in the diagnosis of infantile and juvenile types ofneuronal ceroid lipofuscinoses. Hum Pathol 1984;15:352-60.

10 Jarvela I, Mitchison HM, Munroe PB, O'Rawe AM, MoleSE, Syvanen A-C. Rapid diagnostic test for the majormutation underlying Batten disease. JMed Genet 1996;33:1041-2.

11 Fahn S, Elton RL, Members of the LPDRS DevelopmentCommittee. Unified Parkinson's disease rating scale. In:Fahn S, Marsden CD, Goldstein M, Calne DB, eds.Recent developments in Parkinson's disease. Vol II. FlorhamPark, NJ: Macmillan Healthcare Information, 1987:153-63.

12 Ruottinen HM, Rinne JO, Ruotsalainen UH, et al. Striatal['1F]fluorodopa utilization after COMT inhibition withentacapone studied with PET in advanced Parkinson'sdisease. JfNeural Transm [P-D Sect] 1995;10:91-106.

13 Bergman J, Killman K-M, Solin 0, DeJesus OT, Oakes TR,Nickles RJ. A new method for the production ofelectrophilic F-18 starting from aqueous [F-18]fluoride[abstract]. J NuclMed 1993;34:69.

14 Namavari M, Bishop A, Satyamurthy N, Bida G, Barrio JR.Regioselective radiofluorodestannylation with ['8F]F2 and['8F]CH,COOF: a high yield synthesis of 6-["8F]fluoro-L-dopa. ApplRadiat Isot 1992;43:989-96.

15 Bergman J, Haaparanta M, Lehikoinen P, Solin 0.Electrophilic synthesis of 6-["8F]fluoro-L-dopa, startingfrom aqueous ["IFl-fluoride [abstract]. Journal of LabeUledCompounds and Radiopharmaceuticals 1994;35:476-7.

16 Aquilonius S-M, Eckernas S-A. A colour atlas of the humanbrain. Stockholm, Sweden: Esselte studium, 1980.

17 Patlak CS, Blasberg RG. Graphical evaluation of blood-to-brain transfer constants from multiple-time uptake data.Generalizations. JfCereb Blood Flow Metab 1985;5:584-90.

18 Brooks DJ, Salmon EP, Mathias CJ, et al. The relationshipbetween locomotor disability, autonomic dysfunction, andthe integrity of the striatal dopaminergic system in patientswith multiple system atrophy, pure autonomic failure, andParkinson's disease, studied with PET. Brain 1990;113:1539-52.

19 Hartvig P, Agren H, Reibring L, et al. Brain kinetics of L-[/3-'lC]DOPA in humans studied by positron emissiontomography. JNeural Transm [Gen Sect] 1991;86:25-41.

20 Santavuori P. The management of Spielmeyer-Sj6gren dis-ease. In: Uvebrandt P, Svensson H, eds. Proceedings ofNordic Meeting on Spielmeyer-Vogt Disease. Almasa,Sweden: Society for Visually Handicapped, Sweden, 1987:15-17.

21 Philippart M, Messa C, Chugani HT. Spielmeyer-Vogt(Batten, Spielmeyer-Sjogren) disease. Distinctive patternsof cerebral glucose utilization. Brain 1994;117: 1085-92.

22 Iannetti P, Messa C, Spalice A, Lucignani G, Fazio F.Positron emission tomography in neuronal ceroid lipofusci-nosis (Jansky-Bielschowsky disease): a case report. BrainDev 1994;16:459-62.

23 Martin WRW, Palmer MR, Patlak CS, Calne DB.Nigrostriatal function in humans studied with positronemission tomography. Ann Neurol 1989;26:535-42.

24 Sawle GV, Colebatch JG, Shah A, et al. Striatal function innormal aging: implications for Parkinson's disease. AnnNeurol 1990;28-799-804.

25 Eidelberg D, Takikawa S, Dhawan V, et al. Striatal "IF-DOPA uptake: absence of an aging effect. _J Cereb BloodFlow Metab 1993;13:881-8.

26 Autti T, Raininko R, Vanhanen S-L, Santavuori P. MRI ofneuronal ceroid lipofuscinosis 1. Cranial MRI of 30patients with juvenile neuronal ceroid lipofuscinosis.Neuroradiology 1996;38:476-82.

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