If you follow the latest in neurodegenerative disease research, you’ve heard the “prion hypothesis” or “pathogenic spread hypothesis.”  For the past five or six years, it’s been widely claimed, and almost as widely accepted, that the proteins that mis-fold and aggregate in the brain cells in PSP, as well as in its big brothers Alzheimer’s and Parkinson’s and the rest, spread through the brain in a way similar to how prion protein spreads through the brain in the prion diseases such as Creutzfeldt-Jakob disease, mad cow disease and kuru.  A respectable body of experimental evidence supports — or at least is compatible with —  this idea.

But now a pair of highly respected Harvard neuroscientists, Dominic Walsh and Dennis Selkoe, have said not so fast.  In a very well-balanced and dispassionate review of the prion hypothesis in Nature Reviews / Neuroscience, they show that while the existing evidence is compatible with cell-to-cell spread of toxic protein aggregates, there is still plenty of room for a hypothesis that posits selective cell vulnerability with a more generalized toxic influence.  I won’t get into the technical weeds, but here are their major points:

1. Even in the classical prion disorders, it is well-accepted that “cell-autonomous” factors, rather than just spread from nearby cells, determines which cells are and are not involved.  The salient example is that the asparagine-for-aspartate mutation at position 178 in the prion protein causes familial CJD when the person has a valine at position 129 in the same protein but causes fatal familial insomnia with there’s a methionine at 129.  (Neither of the latter substitutions by itself is pathogenic.)
2. The “pathogenic spread” hypothesis rests in no small part on the observations of Braak and colleagues that early-stage Alzheimer’s or Parkinson’s pathology in people dying from other causes is confined to certain specific brain areas, suggesting that the process starts there and spreads.   But Walsh and Selkoe point out that those early sites of pathology may merely be the areas most sensitive to a generalized insult.  Furthermore, only about half of the cases of each of those diseases followed that pattern.
3. Another buttress for the pathogenic spread hypothesis is the observation that 5-10% of fetal substantia nigra cells transplanted into the striatum of patients with Parkinson’s developed Lewy bodies themselves after a number of years. But this need not be the result of spread of pathogenic alpha-synuclein; it could be the result of a more generic insult such as inflammation in the injection site, where most of the injected cells have died.  They cite evidence that activation of microglia (the brain’s inflammatory cells) in other types of neural grafts can produce Lewy bodies in those grafts.
4. The experiments showing that injected alpha-synuclein or tau protein can induce the formation of aggregates in host brain is incomplete because they do not adequately demonstrate actual cell loss or impairment of brain function in the host animal. We know from other lines of experiment that aggregates alone do not correlate well with neurological impairment in human or experimental neurodegenerative disease.
5. The pathologic anatomy of rare, dominantly inherited forms of Alzheimer’s, Parkinson’s and frontotemporal dementia fits well within the spectrum of their corresponding sporadic conditions. A genetic cause, producing the same intense pressure for protein aggregation in many areas of the brain simultaneously, would not be expected to mimic the anatomic pattern of a single-anatomic-source process posited by the pathogenic spread hypothesis.
6. There are still many questions left unanswered by the pathogenic spread hypothesis. This doesn’t directly contradict its other tenets, but it weakens its explanatory power. It cannot explain the initial protein misfolding; how the aggregates are released; how they remain aggregated in the interstitial fluid where the concentration of the protein is far less; why they don’t stick to the outsides of cells after being excreted, as their physical chemical characteristics suggest they should; how they choose only certain target cells to penetrate; and how the aggregates escape into the cytoplasm from the membrane vesicles that presumably would be the vehicles by which they penetrate their targets.

As a final point, Walsh and Selkoe make a case for avoiding the term “prion-like” or “prion-oid” with reference to neurodegenerative diseases unrelated to the prion protein itself.  They list several known features of prion protein spread in the known prion diseases that as far as we know are absent in PSP, Alzheimer’s, Parkinson’s, etc.  They also cite the absence of any known transmissibility of the non-prion-protein and point out that we don’t know enough about either group of diseases to equate them at that level of terminology.

Excellent scientists that they are, Walsh and Selkoe describe a set of experiments to undertake and new research tools to develop in order to strengthen or reject the pathogenic spread hypothesis.  Maybe I’ll get to that in another post.  But they end with the hope that the pathogenic spread hypothesis is true, for that would provide many potential therapeutic targets that would not otherwise exist.