Personal View

Are synucleinopathies prion-like disorders?

Elodie Angot*, Jennifer A Steiner*, Christian Hansen, Jia-Yi Li, Patrik Brundin

Lancet Neurol 2010; 9: 1128–38 A shared neuropathological feature of idiopathic Parkinson’s disease, dementia with Lewy bodies, and multiple system
Published Online atrophy is the development of intracellular aggregates of α-synuclein that gradually engage increasing parts of the nervous
September 15, 2010 system. The pathogenetic mechanisms underlying these neurodegenerative disorders, however, are unknown. Several
DOI:10.1016/S1474-
studies have highlighted similarities between classic prion diseases and these neurological proteinopathies. Specifically,
4422(10)70213-1
identification of Lewy bodies in fetal mesencephalic neurons transplanted in patients with Parkinson’s disease raised the
*These authors contributed
equally hypothesis that α-synuclein, the main component of Lewy bodies, could be transmitted from the host brain to a graft of
Neuronal Survival Unit,
healthy neurons. These results and others have led to the hypothesis that a prion-like mechanism might underlie
Wallenberg Neuroscience progression of synucleinopathy within the nervous system. We review experimental findings showing that misfolded
Centre, Lund University, Lund, α-synuclein can transfer between cells and, once transferred into a new cell, can act as a seed that recruits endogenous
Sweden (E Angot PhD, α-synuclein, leading to formation of larger aggregates. This model suggests that strategies aimed at prevention of cell-to-
J A Steiner PhD, C Hansen PhD,
J-Y Li MD, P Brundin MD)
cell transfer of α-synuclein could retard progression of symptoms in Parkinson’s disease and other synucleinopathies.
Correspondence to:
Patrik Brundin, Neuronal Survival Introduction In this Personal View, we first briefly introduce current
Unit, Wallenberg Neuroscience Protein misfolding is central to the pathogenesis of both knowledge on the mechanisms of spread of prion disease
Centre, Lund University, prion diseases and Parkinson’s disease and other related within and between animals. Next, we review the central
BMC A10, 221 84 Lund, Sweden
patrik.brundin@med.lu.se
neurodegenerative disorders. Some neurodegenerative role of α-synuclein in Parkinson’s disease and other Lewy
disorders, such as Parkinson’s disease, can be body-related disorders and discuss evidence suggesting
characterised by intracytoplasmic inclusions, named that α-synuclein could indeed be classified as a protein
Lewy bodies.1 A prion-like spread of misfolded α-synuclein with prion-like abilities. Furthermore, we identify gaps in
(the predominant protein in Lewy bodies)2 has been knowledge that must be filled in order to state definitively
proposed to contribute to the propagation of Lewy bodies that α-synuclein spreads within the nervous system in a
throughout the nervous system during progression of prion-like manner in synucleinopathies. Finally, we
Parkinson’s disease.3–9 discuss future research directions and their implications
How do synucleinopathies compare with prion diseases? for the development of novel therapeutic strategies.
The distinguishing feature of prion diseases resides in the
nature of the pathogen that spreads not only within the Prion propagation
affected organism but also between and within human Prion diseases in animals, such as scrapie and bovine
beings and animals. Unlike conventional pathogenic spongiform encephalopathy, are characterised by
organisms, such as viruses, bacteria, or yeast, a protein non-viral spread of diseased proteins from one animal to
was identified as the infectious and pathogenetic agent.10 another. The disease-causing pathogens can be
Although there is no evidence so far to support inter- transmitted infectiously within and between species.
individual or interspecies transmission of synucleino- Additionally, several familial and sporadic forms of
pathies, we discuss current evidence that α-synuclein human prion disease are well characterised, such as fatal
could act in a prion-like manner to transfer between cells familial insomnia and Creutzfeldt-Jakob disease.11 Once a
within an organism. Hence, we use the term prion-like to human being or animal acquires a prion disease,
indicate that α-synuclein might share some features with prognosis is poor; patients with Creutzfeldt-Jakob disease
prions, albeit without infectivity properties. typically die within a year after disease onset.12 Prion
diseases are progressive and incurable, and the prions
themselves are fairly resistant to methods that destroy
PrPSc viruses and bacteria.10,13
Genetic, dominantly inherited human prion diseases
PrPc are caused by mutations in the prion protein (PrP) gene
? (PRNP).14–16 PrP is expressed ubiquitously and its
functions are under active investigation;17,18 mice without
PrP have grossly normal development but are resistant to
scrapie.19–21 The typical cellular form of PrP is designated
PrPc, to distinguish it from the alternatively folded and
disease-related scrapie isoform (PrPSc). These two
isoforms share the same aminoacid sequence but differ
Figure 1: Model of templating and cell-to-cell transfer of prion proteins in their secondary structures: PrPc is rich in α-helices,
Exogenous PrPSc (red), acting as a seed, recruits intracellular PrPC (black) and
converts its three-dimensional structure into an elongated PrPSc, thus extending
whereas β-sheets dominate the structure of PrPSc.22,23
the amyloid aggregate. The aggregates transfer intercellularly via an unknown Additionally, PrPSc assumes different structures according
mechanism. to which prion disease it causes.11,24

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During sporadic, genetic, or infectious means of
disease acquisition, once the change in conformation
that creates PrPSc takes place, this protein isoform acts as
a template (also termed a seed), recruiting PrPc into
aggregates and causing its conversion to PrPSc (figure 1).
Details of this transition from PrPc to PrPSc are currently
unclear, but antibody and computational studies could
pave the way for ultrastructural determinations of
intermediate PrP structures.25,26 Accumulation of
aggregates of PrPSc and subsequent breakage of the
amyloid chains results in generation of more seeds,
which cause accelerated accumulation of PrPSc within
cells and propagation between cells, leading to widespread
accumulation of PrPSc and, thus, disease progression.24,27
The ability of the amyloid aggregates to break is vital;
brittle prion strains are most toxic, because they
contribute extra free ends for recruitment of PrPc and
amyloid extension.24,27
Transfer of PrPSc from one cell to another can take place
via various processes. Mechanisms mediated by receptors,
exosomes, and tunnelling nanotubes have all been
suggested to have a role.28–33 For example, neuronal
LDL-receptor-related protein 1 mediates endocytosis of
PrPSc from the extracellular space.31
Active research into exosomes has provided new insight
into protein transfer mechanisms. Both PrPSc and PrPc
can be released from non-neuronal29 and neuronal
cells28,32,33 and may be associated with exosomes. Exosomes
are small secreted vesicles that derive from the endosomal
pathway.34 Thus, as a first step, proteins endocytosed at
the plasma membrane are internalised in endocytic
vesicles that fuse with early endosomes in the cytoplasm.
During maturation of early endosomes, the molecules
they contain are sorted into smaller vesicles that bud
from the endosomal membrane into the lumen. When
these multiple intralumenal vesicles are secreted
extracellularly through exocytosis, they are called
exosomes. Once in the extracellular space, exosomes can
be taken up by neighbouring cells, probably after fusion
with the outer membrane of the recipient cell.34 Exosomes
carrying PrPSc are infectious in vitro and in vivo29,33 and
have been proposed as a vehicle for propagation of PrPSc
from one cell to another.35
Tunnelling nanotubes constitute another non-
conventional intercellular communication pathway that
has been implicated in PrPSc propagation.30 These
nanotubes are thin extensions of surface membrane
that connect cells over long distances. They are formed
either by actin-driven protrusion from one cell to
another and subsequent membrane fusion or during
cell division.36 Tunnelling nanotubes mediate spread of
PrPSc between co-cultured neuronal cells and from
bone-marrow-derived dendritic cells to primary
neurons.30 In bovine spongiform encephalopathy,
ingested PrPSc transfers from the gut to the lymphoid
system, then to the peripheral nervous system, and
finally to the CNS.37 In this disease, tunnelling
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Personal View
nanotubes have been suggested to participate in PrPSc
propagation not only within neurons in the CNS but
also from the lymphoid system to the peripheral
nervous system.30
Similarities of prion diseases and
neurodegenerative diseases
The lesions that characterise Alzheimer’s disease
histopathologically are senile plaques (which consist of
extracellular aggregated amyloid β peptides) and
neurofibrillary tangles (composed of intracellular
polymers of tau protein). Echoing the disease-associated
conformations of PrPSc, aggregation-prone amyloid β
(derived from amyloid precursor protein) adopts β-sheet
structures typically seen in all amyloid plaques.38 In view
of these commonalities, several research groups have
reported prion-like transmission for both amyloid β and
tau.39–42 One group showed that brain extracts from a
patient with Alzheimer’s disease—when injected into
the brains of transgenic mice that expressed amyloid
precursor protein—could induce aggregation
and deposition of amyloid β.39 Implantation of
amyloid-β-contaminated steel wires into the hippocampus
and cortex of transgenic mice is sufficient to transmit
amyloid β.40 Similarly, healthy mice that express non-
mutant human tau develop pathogenic tau inclusions in
their brains after injection with brain extracts from
mutant human tau-expressing mice.42 Findings of studies
also indicate that aggregates of misfolded tau can move
from the extracellular space into cultured cells and
between cells.41 Taken together, these results suggest that
exogenous aggregates of amyloid β or tau can induce
aggregation or formation of inclusions containing
endogenously expressed amyloid β or tau, possibly
leading to subsequent spreading of pathologies to
neighbouring cells.
Symptoms and neuropathology of
synucleinopathies
Similar to prion diseases and Alzheimer’s disease,
disorders characterised by Lewy body formation—such
as Parkinson’s disease, dementia with Lewy bodies, and
multiple system atrophy—involve aggregation of the
misfolded protein α-synuclein. Although these
synucleinopathies share the presence of Lewy bodies and
some symptoms, they also have many differences.43
The most common synucleinopathy, Parkinson’s
disease, is characterised by loss of pigmented dopamine
neurons in the substantia nigra pars compacta and by the
cardinal symptoms of bradykinesia, rigidity, and resting
tremor. Although traditional thinking emphasises motor
deficits in Parkinson’s disease, many non-motor
symptoms have been highlighted, such as loss of
olfaction, constipation, sleep disturbances, impotence,
and cognitive dysfunction.44 The average survival of an
affected individual from the first signs of Parkinson’s
disease is two to three decades.
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Misfolded and post-translationally modified α-synuclein
is the primary proteinaceous component of Lewy bodies
and Lewy neurites,2 the typical intracytoplasmic
inclusions that develop in the cell body and neurites,
respectively, of affected neurons. Whether Lewy bodies
and Lewy neurites are toxic or neuroprotective is unclear
and the subject of much debate.45 Lewy bodies and Lewy
neurites are found in patients with Parkinson’s disease,
dementia with Lewy bodies, and multiple system atrophy
but are distributed according to different patterns.43 As
described in detail below, Lewy bodies are present in
brainstem neurons early in Parkinson’s disease and then
in the cortex as disease progresses.46–48
Patients with dementia with Lewy bodies survive for
about 5–8 years and show early dementia, concurrent
with akinetic and rigid motor symptoms.43 Dopaminergic
neurons in the substantia nigra and cholinergic neurons
in the nucleus basalis of Meynert both degenerate in
people with this disorder. Lewy bodies are more
widespread and abundant than in other synucleino-
pathies, and amyloid plaques are also present in the
brain of these patients.43
Individuals with multiple system atrophy are diagnosed
on the basis of a combination of ataxia, parkinsonism,
and autonomic dysfunction due to neuron loss in the
olivopontocerebellar, striatonigral, brainstem, and
autonomic systems. The disease is characterised by
cytoplasmic inclusions found in glia and occasionally in
Olfactory bulb
Anosmia
Gut
Constipation
Figure 2: Dual-hit hypothesis of propagation of synucleinopathy during Parkinson’s disease
Parkinson’s disease-associated neuropathology originates in the gut (first hit) or the nose (olfactory bulb; second hit) and then propagates to the caudal brainstem
and the temporal lobe. Lewy body pathology then ascends to midbrain structures and cortical areas. Blue arrows depict the proposed ascending progression of
Parkinson’s disease pathology. Boxes indicate affected systems and main associated symptoms.
1130
neurons. Multiple system atrophy has been classified
into separate subtypes depending on the predominance
of symptoms.49 The disease course is shorter than that of
people with idiopathic Parkinson’s disease, with most
patients living less than a decade after diagnosis.
In-vivo evidence for α-synuclein spread
α-synuclein is an abundant protein in the brain, found in
most cellular compartments and enriched at presynaptic
terminals.50,51 It is believed to have a role in vesicular
transport and neurotransmitter release, although its
exact functions are unknown.2 The gene encoding human
α-synuclein (SNCA) can carry rare mutations or can be
duplicated or triplicated, changes which are all linked to
dominant forms of inherited Parkinson’s disease and
parkinsonism.52–56 α-synuclein is present in the
cerebrospinal fluid and plasma of both controls and
patients with neurodegenerative diseases,57–59 suggestive
of exocytosis. Concentrations of α-synuclein in neuronal
cell bodies increase during healthy ageing in human
beings and monkeys.60 Thus, a raised cytoplasmic
concentration of α-synuclein in neuronal cell bodies,
both as a result of ageing and of gene duplications and
triplications, seems to be a disease risk factor.
Dual-hit hypothesis
Braak and co-workers46–48 have suggested that α-synuclein
pathology spreads throughout the nervous system in
Neocortex
Cognitive decline
Midbrain
Motor symptoms
Caudal brainstem
Autonomic symptoms
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Dissection of ventral Transplant preparation
mesencephalic tissue Fresh or hibernated tissue is
One to eight donor embryos homogenised into cell suspension
used as a source of tissue or small tissue pieces
Figure 3: Grafting of neurons into brains of patients with Parkinson’s disease
(A) Summary of the procedure used to prepare long-term grafts.65–67 (B) Immunostaining with α-synuclein antibodies of sections from a 16-year-old graft (left panel).
Lewy bodies (arrows) in the graft are similar to those seen in the substantia nigra of the host (right panel).
Parkinson’s disease according to a stereotypic pattern
following long unmyelinated axons of known anatomical
pathways (figure 2). According to this so-called dual-hit
hypothesis,61,62 Parkinson’s disease pathology originates
in the nose and foregut after inhalation of an unknown
neurotropic pathogen and subsequent swallowing of
nasal mucus in saliva. Among many theories and
hypotheses, Braak and colleagues speculated that
“unconventional pathogens with prion-like properties”
might induce spreading of Parkinson’s disease
pathology.61,62 After crossing the epithelium, this
pathogenic agent could get access to and be transported
in an anterograde direction along axons of neurons
projecting from the olfactory epithelium to the temporal
lobe, and retrogradely from the enteric epithelium via
sympathetic fibres in the vagus nerve to the CNS
(figure 2).61,62
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Grafting procedure Immunosuppression
Stereotactic injection in caudate Ciclosporin for 6 months or long-term
and/or putamen triple drug therapy (ciclosporin, azathioprine,
Three to eight injection tracts per prednisolone) to prevent rejection
striatum
20 μm
Lewy bodies and Lewy neurites have been detected in
tufted neurons47 and mitral cells47,63 in the olfactory bulb of
patients with Parkinson’s disease; mitral cells receive
direct input from neurons of the olfactory epithelium.
Lewy body pathology is also apparent all along the
olfactory pathway (anterior olfactory nucleus, olfactory
tubercle, and cortices),64 even though the olfactory
epithelium itself seems devoid of α-synuclein aggregates.65
In the foregut, Lewy bodies and Lewy neurites have been
found in enteric nerve cell plexa in patients with
Parkinson’s disease.66
After reaching the CNS via nasal and gastric routes,
Lewy pathology has been proposed to ascend from the
medulla oblongata to midbrain structures, including the
substantia nigra, and finally to cortical areas, along a
network of neurons interconnecting all these regions
(figure 2).46–48 In view of the direct anatomical connection
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between the olfactory system and the temporal lobe of
the neocortex, temporal structures would be presumed to
display Lewy bodies and Lewy neurites earlier if inhalation
were the predominant mode of pathogen entry. Thus,
oral ingestion might be the main method of pathogen
access to the body. Moreover, the topography of Lewy
pathology could be correlated with the extent and severity
of symptoms. The chronology of appearance of
Parkinson’s disease symptoms can be described briefly
as follows: the presymptomatic phase occurs first, and it
is loosely defined by non-motor symptoms such as
olfactory deficits, sleep disturbances, constipation, and
erectile dysfunction, all of which can occasionally first
arise at later disease stages;67,68 the motor symptom phase,
occurs later, and includes bradykinesia and rigidity; and
finally, the late complication phase is characterised by
cognitive decline and psychiatric symptoms.69 During the
early non-motor phase of Parkinson’s disease, Lewy
bodies and Lewy neurites are restricted to the peripheral
enteric system,66 the olfactory bulb, and the caudal
brainstem.47 Next, Lewy pathology appears in the mid-
brain, especially in the substantia nigra pars compacta,
within the period of the onset of motor symptoms, and
eventually it reaches the neocortex at later stages
characterised by cognitive impairment (figure 2).47 In the
following sections, we discuss arguments for and against
the Braak hypothesis.
Lewy pathology in neural grafts
In some patients with Parkinson’s disease,
transplantation of embryonic dopamine neurons was
started more than two decades ago in an attempt to
restore dopaminergic neurotransmission (figure 3A).70–75
Findings of histological studies on post-mortem tissue
revealed Lewy bodies within the transplanted
dopaminergic neurons in eight patients who were
operated on in four centres worldwide and who died
more than a decade after surgery (figure 3B).73–75 The
Lewy bodies in the grafts shared classic features with
those in the substantia nigra of the host, including
α-synuclein and ubiquitin immunoreactivity.
Further studies characterised Lewy pathology in
transplanted neurons, with detection of α-synuclein
phosphorylated on serine 129,75,76 characteristic β-sheet
structures stained by thioflavine S,76,77 and α-synuclein
fibrils revealed by electron microscopy.77 Tyrosine
hydroxylase is rarely expressed in grafted neurons
containing Lewy bodies, although the fact that Lewy
bodies are seen in grafted cells containing neuromelanin
suggests that they are present in catecholaminergic
(presumed dopaminergic) neurons. These observations—
together with a reported decrease of dopamine
transporter immunoreactivity,73,74,76 and a reduction in
intensity of tyrosine hydroxylase immunostaining74,76 in
cells with Lewy pathology within a transplant from a
patient who survived 14 years after transplantation—
could indicate that the subset of transplanted cells
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carrying Lewy bodies is functionally impaired. In one
individual, Lewy bodies were noted in 1·9% and 5·0% of
pigmented neurons, which were grafted (into the right
and left striatum) 12 and 16 years, respectively, before
death.77 40% of transplanted dopaminergic neurons
showed cytoplasmic α-synuclein staining in the
12-year-old grafts versus 80% in the 16-year-old grafts.75
In other studies, cell bodies in 18-month-old grafts were
devoid of any immunoreactivity to α-synuclein whereas
neurons in 4-year-old and 16-year-old transplants showed
cytoplasmic α-synuclein staining and α-synuclein-positive
spherical aggregates, respectively.76
Taken together, these observations suggest that Lewy
body development in the grafted neurons is a gradual
process, and that whole Lewy bodies do not move between
cells.76,77 Prion-like spread of misfolded α-synuclein,
which might act as a seed and lead to progressive
accumulation of α-synuclein, could result in formation of
Lewy bodies in transplanted neurons.5,78
Animal models of synucleinopathy propagation
Researchers have reported a mouse model79 that
recapitulates some aspects of the pathological staging
described by Braak and collaborators in patients with
Parkinson’s disease.46,47 The model is based on
intragastric administration of rotenone, an inhibitor of
complex I of the mitochondrial respiratory chain.
Rotenone is a widely used pesticide that has been linked
to Parkinson’s disease in epidemiological studies.80–82 It
induces formation of large perinuclear α-synuclein
inclusions in cultured cells expressing human
α-synuclein.83 Chronic intravenous84 or intraperitoneal85
administration of rotenone in rats has been reported to
trigger α-synuclein aggregation in nigral neurons,
probably directly, in view of the capacity of rotenone to
cross the blood–brain barrier. In the new mouse model,
there is progressive development of α-synuclein
inclusions, starting in the enteric nervous system and
then arising sequentially in spinal cord, caudal
brainstem, and the substantia nigra79—ie, the
same structures that show Lewy pathology in
Parkinson’s disease. One possible explanation for
these results lies in the induction of α-synuclein
aggregation in enteric nerves by intragastric
administration of the toxin, and then propagation of
the pathology to vulnerable CNS areas via an unknown
mechanism that might include intercellular transfer of
α-synuclein aggregates.
The first experimental evidence for intercellular
transfer of α-synuclein in vivo came from a study on
mouse cortical neuronal stem cells grafted to the
hippocampus of transgenic mice overexpressing human
α-synuclein.86 At 1–4 weeks after grafting, 2·5–15% of
transplanted cells showed human α-synuclein staining,
indicating that α-synuclein can transfer from the host
brain to a graft of proliferating neuronal progenitors.
These results bear some resemblance to clinical
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findings with neural grafts described above, but differ
in the sense that no large aggregates resembling Lewy
bodies were seen and that proliferating rather than
post-mitotic cells were grafted.
Finally, in a report of transgenic mice that overexpress
human α-synuclein under the control of a neuronal
promoter, α-synuclein accumulation was detected not
only in neurons but also in glia.87 Because the promoter
was neuron-specific, glial cells were devoid of human
α-synuclein mRNA. These results suggest that glial cells
that do not express the α-synuclein transgene take up
α-synuclein released by neurons. The low basal expression
level of α-synuclein in glia88 raises the question of the
origin of glial α-synuclein inclusions characterising
multiple system atrophy. Propagation of α-synuclein
from neurons to glial cells, perhaps relying on prion-like
properties of α-synuclein, could account for the
appearance of widespread glial α-synuclein inclusions
during progression of multiple system atrophy.
In-vitro studies
Structure of α-synuclein
During the oligomerisation of α-synuclein into fibrils,
the structure of α-synuclein undergoes major
modifications that could underlie its toxic effects.
Accumulating evidence suggests that α-synuclein
oligomers, and possibly protofibrils, are the toxic species
that cause cell death.89 Therefore, deeper understanding
of the structure of α-synuclein and its changes during
oligomerisation could give fundamental insights into the
pathogenesis of synucleinopathies. α-synuclein is natively
unfolded at low concentrations but, on accumulation, it
self-aggregates into soluble oligomers and can eventually
form insoluble fibrillar aggregates90–94 with a typical
amyloid nature (figure 4A).95 As with PrPSc and amyloid β,
α-synuclein fibrils have unbranched morphology and an
antiparallel β-sheet structure,95 bind thioflavine S93 and
Congo red, and are resistant to proteolysis.95 Similar to
PrPSc propagation, α-synuclein fibrillisation is a
nucleation-dependent process starting with a lag-phase,
during which soluble α-synuclein oligomers assemble
and form a nucleus.96 Aggregates of α-synuclein then
grow rapidly around this nucleus during the growth or
elongation phase, until they reach a thermodynamic
equilibrium with monomers in a steady-state phase.96
Moreover, aggregation of recombinant α-synuclein
monomers can be seeded by addition of α-synuclein
aggregates acting as exogenous nuclei.96 The three
mutations of α-synuclein recorded in patients with
Parkinson’s disease—Ala53Thr, Ala30Pro, and
Glu46Lys—accelerate this process, indicating a probable
role for α-synuclein misfolding and aggregation in
familial Parkinson’s disease.90,94,97
Possible mechanisms of release and uptake
α-synuclein can access the extracellular space, consistent
with its reported presence in cerebrospinal fluid and
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A B
Donor cell
Natively unfolded
monomer
Release
α-synuclein
Self-aggregation
Soluble oligomer
Recipient cell
Entry
Insoluble amyloid fibril Seeding
Figure 4: Putative mechanisms of α-synuclein prion-like propagation
(A) The different species of α-synuclein assemblies coexist in a highly dynamic equilibrium. (B) According to the
prion-like hypothesis, a donor cell releases α-synuclein into the extracellular space via exocytosis or during its
death. Next, α-synuclein enters a recipient cell via passive membrane translocation or endocytosis. Alternative
mechanisms include exosomal release or transport along tunnelling nanotubes. Once in the recipient cell, the
transferred α-synuclein protein (blue) recruits the endogenous α-synuclein protein (red), induces misfolding, and
seeds aggregation. Green stars indicate possible targets for disease-modifying drugs to reduce, stop, or delay
systematic spread of α-synuclein throughout the human body.
plasma in human beings,57,58 and in the medium of
several neuronal culture models.57,98 The mechanism by
which α-synuclein is released from cells is unclear, but
exocytosis is likely to underlie this secretion (figure 4B),
given that the process is inhibited at low temperature
and α-synuclein can be detected in the lumen of vesicles
isolated from rat brain or neuroblastoma cells.98,99
Furthermore, α-synuclein translocation to vesicles and
subsequent vesicle release increase under conditions
that promote its misfolding and could be part of a
cellular quality-control system aimed at removal of
damaged proteins.99 Furthermore, researchers have
suggested that exosomes could have a role in secretion
of α-synuclein by cultured neuroblastoma cells.100
After release of α-synuclein, the next steps are crucial.
What are the mechanisms by which cells take up
extracellular α-synuclein? Similar to infection of new
cells by PrPSc, extracellular α-synuclein can be internalised
by surrounding cells (figure 4B). Whereas recombinant
α-synuclein monomers have been suggested to
translocate passively across plasma membranes of
neuroblastoma cells,101,102 an endocytic process is probably
needed for internalisation of larger order α-synuclein
assemblages.102 Uptake of recombinant α-synuclein
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oligomers and fibrils is indeed inhibited at low
temperatures and by expression of a dominant negative
mutant of dynamin 1, a neuron-specific GTPase
important for endocytosis, suggesting that uptake takes
place via an endocytic process.102 In co-cultured neuronal
cells, transmitted α-synuclein proteins colocalise with
the endosomal GTPases Rab5a and Rab7,86 and in
particular, Rab5a has been suggested to be vital for
α-synuclein endocytosis.103 In rat dopaminergic cells,
some internalised aggregates of α-synuclein are degraded
by a Rab11a-dependent endosome-lysosome pathway
and others are resecreted through exocytosis.104
In addition to α-synuclein transfer between neuronal
cells, glial cells might take up α-synuclein derived from
neurons via an endocytic mechanism that is blocked by
expression of a mutant form of dynamin 1.87 Moreover,
Lee and colleagues87 showed formation of Lewy body-like
aggregates after uptake of human α-synuclein into glial
cells. Thus, primary astrocytes co-cultured with
neuroblastoma cells overexpressing human α-synuclein
develop inclusions of human α-synuclein, which stain
with thioflavine S and contain some proteins found in
Lewy bodies, such as ubiquitin, the 20S proteasome
α-subunit, and the chaperone protein HSP/HSC70.87
Taken together, the mechanism by which cells take up
α-synuclein could be tightly linked with the putative next
steps of inclusion formation.
Potential seeding effect of α-synuclein
If intercellular transmission of aggregated α-synuclein is
governed by a prion-like mechanism, the ultimate step
would be the seeding effect—ie, recruitment of unfolded
α-synuclein proteins endogenously expressed by the
acceptor cell and their conversion into misfolded forms
that will aggregate around the nucleus of transmitted
α-synuclein (figure 4B). A few studies have looked at the
seeding effect of recombinant α-synuclein. Oligomers of
α-synuclein, thought to be the toxic species,89 seed the
aggregation of α-synuclein proteins endogenously
expressed by neuroblastoma cells105 and by primary
cortical neurons105,106 in a time-dependent and
concentration-dependent manner.106 In other studies,107,108
artificial techniques (such as cationic liposome-based
transduction) to load cells with exogenous fibrillised
α-synuclein proteins are needed for the seeding process
to take place.
Arguments against synucleinopathies being
prion-like disorders
As described in the previous section, evidence that
α-synuclein can transfer between co-cultured neurons
in vitro is compelling, and studies have provided some
insight into underlying mechanisms. Nonetheless, the
subsequent seeding activity of transferred α-synuclein
is a crucial prerequisite for propagation of α-synuclein
pathology to take place during progression of
Parkinson’s disease and other Lewy body-related
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neurodegenerative disorders. So far, in-vitro studies in
which seeding has been shown have used highly
artificial techniques for introduction of α-synuclein into
cells,107,108 which are not compatible with physiological
conditions. Similarly, studies that have shown seeding
of α-synuclein in vivo—and even more importantly,
animal work on α-synuclein intercellular transfer—are
currently sparse. So far, published data are restricted to
the study mentioned above,86 in which proliferative
neuronal stem cells are grafted into the hippocampus
of transgenic mice overexpressing human α-synuclein.
To date, no data are available to show that post-mitotic
dopaminergic neurons—the primary cell type affected
in Parkinson’s disease—can take up α-synuclein
released from donor neurons in an experimental animal
model, or that transferred α-synuclein can trigger
formation of Lewy bodies.
Even if future research establishes that α-synuclein
fulfils all criteria for a prion-like protein in culture and in
animals, the relevance of these discoveries in relation to
the pathogenesis of synucleinopathies will still be
questionable. The hypothesis that misfolded α-synuclein
accumulation is the central force driving the
neurodegenerative process is not adopted unanimously
in the field, and the correlation proposed by Braak and
collaborators46–48 between the spread of Lewy pathology
and the temporal pattern of development of symptoms
has been questioned.109 Thus, α-synuclein misfolding and
aggregation might alternatively be considered an
epiphenomenon of a pathological neuronal micro-
environment. For example, differences in distribution of
Lewy bodies in the synucleinopathies could be explained
by selective neuronal vulnerability in each disease,
underlying the characteristic temporal patterns of
progression of pathology. Alternatively, neuro-
inflammation, which leads to formation of intraneuronal
α-synuclein inclusions in animals110,111 and has been
detected in post-mortem analysis of brains of patients
with Parkinson’s disease,112 could lie upstream of
α-synuclein aggregation in the cascade of pathogenic
events leading to progression of Parkinson’s disease.
What makes prion-like propagation of α-synuclein an
especially interesting hypothesis is that it can account for
the sequence of appearance of symptoms and the
findings on neuropathological changes in grafts of
patients with Parkinson’s disease.73–75 Thus, this
hypothesis remains a highly attractive and promising
research axis.
Could interindividual infectivity be another feature
shared by PrPSc and misfolded α-synuclein? A paucity of
epidemiological evidence, or at least case reports,
suggesting that Parkinson’s disease can spread from one
person to another, however, argues against this notion.
How do the prion-like properties of α-synuclein differ
from those of PrPSc? Under what conditions might
α-synuclein act as an infectious agent? These questions
still need to be answered. By contrast with the instability
www.thelancet.com/neurology Vol 9 November 2010

of PrPSc assemblies, which readily break and generate
further free ends that act as seeds,23,24 the possible relative
stability of α-synuclein fibrils might account for both
non-infectivity of α-synuclein and the typical disease
course of the synucleinopathies (from several years to
decades), versus the fairly quick (within 1 year) duration of
prion disease. Alternatively, major differences in structure
and cellular localisation between α-synuclein and PrP
could account for the varying kinetics of conversion from
normal to misfolded protein, and hence could affect the
rate of disease progression. Similarly, variability in disease
duration of the synucleinopathies (5–8 years for dementia
with Lewy bodies after diagnosis, less than 10 years for
multiple system atrophy, decades for Parkinson’s disease)
might also rely on different forms of misfolded α-synuclein,
with various stabilities or intermediate species along the
conversion process of normal into pathogenic protein,
even if no evidence for such heterogeneity in α-synuclein
proteins has been reported so far.
In summary, the hypothesis that progression of
synucleinopathies relies on the same mechanisms as
prion disorders is highly attractive. However, it has
potential drawbacks and alternatives, which are currently
under investigation.
Conclusions and future perspectives
Connections between in-vitro studies and clinical
observations are important but in need of improvement
and extension. What are the next steps for basic science
research that will bring more insight to human disease
and, specifically, to synucleinopathies?
As described above, exocytosis and endocytosis seem
to have important roles in cell-to-cell transfer of
misfolded α-synuclein. However, in view of the
similarities between PrPSc and α-synuclein, other
mechanisms of cell-to-cell transfer reported to
contribute to PrPSc propagation should also be
considered. Both exosomes and tunnelling nanotubes
might contribute to intercellular transfer of PrPSc.28–30,32,33
A minute fraction of α-synuclein released from cultured
neuroblastoma cells is associated with extracellular
vesicles99 and exosomal secretion has been reported.100
The relevance of α-synuclein-containing exosomes in
other cell types, notably astrocytes (reported to secrete
exosomes),113 are worth examining both in cell culture
and in vivo. Furthermore, researchers revealed the
presence of α-synuclein within tunnelling nanotubes
that were interconnecting co-cultured glioblastoma
cells,114 warranting further investigation into whether
tunnelling nanotubes can convey α-synuclein from one
neuron to another.
As discussed above, the dual-hit theory suggests that
a pathogenic agent with prion-like properties penetrates
the body by the nasal or gastric route, or both, and then
leads to propagation of Lewy bodies and Lewy neurites
from the gut to the CNS.61,62 Clearly, misfolded
α-synuclein is a relevant candidate. Pathogenic forms
www.thelancet.com/neurology Vol 9 November 2010
Personal View
Search strategy and selection criteria
We searched PubMed from January, 1994, to July, 2010, with
the search terms: “alpha-synuclein”, “synuclein”, “Parkinson
disease”, “prion”, “scrapie”, “Creutzfeldt-Jakob”, “dementia
with lewy bodies”, “multiple systems atrophy”, “prion-like”,
“Alzheimer disease”, “Braak hypothesis”, “non-motor
symptoms”, “neural grafting”, “rotenone”, “fibrillization”,
“cell-to-cell transfer”, “exocytosis”, “endocytosis”, “seeding”,
“amyloid”, “tau”, “nanotube”, “exosome”, “biomarker”, and
“English”. We largely targeted publications from the past
10 years but did not exclude commonly referenced, highly
regarded, and relevant older publications. Furthermore, we
examined the search results obtained above and selected the
most relevant for this Personal View.
of α-synuclein are unlikely to enter the organism
through direct nasal inhalation. Instead, contact with
substances present in our environment—eg, specific
pesticides, which are known to be risk factors for
Parkinson’s disease80–82 and cause α-synuclein
aggregation83—could be an initial event that triggers
α-synuclein misfolding in the periphery. As a result, by
using exposure to a peripheral toxin and exploiting all
the aforementioned knowledge about the putative
prion-like mechanism of α-synuclein spread,
development of animal models that faithfully reproduce
all the characteristics of Parkinson’s disease might be
possible. One alternative could be to manipulate
selectively and transgenically the α-synuclein gene in
the periphery and cause a regional synucleinopathy
outside the CNS. Early gastrointestinal dysfunction and
aggregates of α-synuclein in enteric nervous system
ganglia have been reported in transgenic mice carrying
an artificial chromosome with Parkinson’s disease-linked
human mutations (Ala53Thr or Ala30Pro) of the
α-synuclein gene.115 These models might mimic not
only Parkinson’s disease-related neuropathological
changes and neurodegenerative events but also motor
and non-motor symptoms, and, thus, they would be
invaluable for assessment of the efficacy of new drugs
for Parkinson’s disease at early preclinical stages.
All current treatments for Parkinson’s disease, from
pharmaceutical to surgical, only alleviate motor
symptoms;116 to date, no disease-modifying treatment has
been able to stop or greatly delay neurodegeneration.
Although early treatment with rasagiline—a monoamine
oxidase type B inhibitor—might slow progression of
Parkinson’s disease slightly, further clinical investigations
are needed to assess the efficacy of this drug.117
Accumulating evidence supporting prion-like
properties of α-synuclein indicates that cell-to-cell
transfer of this protein might be worth targeting.
Intercellular transfer of misfolded proteins followed by
permissive templating could be a common pathogenetic
mechanism in several cerebral proteinopathies,3,4,6,8
1135
 Personal View
making this approach to new treatments even more
wide-reaching. Putative novel therapies that inhibit
transfer of disease-related proteins should ideally be
initiated even before the individual has met current
diagnostic criteria for Parkinson’s disease—ie, at the
very beginning of progression of Lewy pathology. These
limitations will require development of biomarkers for
early Parkinson’s disease—eg, brain imaging or
biological fluid biomarkers currently under development
for differential diagnosis118 and identification of a set of
non-motor symptoms (eg, olfactory or gastrointestinal
dysfunction) with high predictive value for Parkinson’s
disease. The theory of prion-like spread of misfolded
α-synuclein suggests the process will take place in three
steps: release, uptake, and seeding. Inhibition of
α-synuclein spread could interfere with one or another
of these processes (figure 4B). Exocytosis and endocytosis
inhibitors might be interesting candidates to investigate,
because both of these cellular mechanisms are proposed
to participate in α-synuclein intercellular transfer,98,99,102,103
but, of course, other treatments specific to exosomes,
tunnelling nanotubes, or receptors should be tested. In
conclusion, research into the mechanisms of α-synuclein
cell-to-cell transfer in combination with other ongoing
strategies could lead to promising advances in clinical
treatment of synucleinopathies.
Contributors
EA and JAS wrote the manuscript and prepared the figures, and CH,
JYL, and PB edited the paper.
Conflicts of interest
PB has received honoraria from Pfizer, H Lundbeck A/S, Roche, and
Orion Pharma, consultancy fees from Teva Pharmaceutical Industries
and H Lundbeck A/S, and research support from Teva. The other
authors have no conflicts of interest.
Acknowledgments
We thank the Human Frontier Science Program, the ERA-net Neuron
program MIPROTRAN, the Michael J Fox Foundation for Parkinson’s
Research, the Swedish Brain Foundation, the Swedish Parkinson
Foundation, the Ragnar and Thorsten Söderbergs Foundation,
Anna-Lisa Rosenberg Foundation, and the Swedish Research Council.
The funding sources had no role in preparation of this paper.
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