CLINICAL IMPLICATIONS OF BASIC NEUROSCIENCE RESEARCH

SECTION EDITOR: HASSAN M. FATHALLAH-SHAYKH, MD, PhD

Central Role of ␣-Synuclein Oligomers

in Neurodegeneration in Parkinson Disease
Aleksey G. Kazantsev, PhD; Alexander M. Kolchinsky, PhD

S
elective death of nigrostriatal neurons, which leads to Parkinson disease, is explained
by misfolding of brain protein ␣-synuclein. Herein, we review the data supporting
this concept, propose a scheme of events leading to synuclein-induced neuronal
death, and discuss protein deacetylase sirtuins as new potential therapeutic targets
involved in this process. Arch Neurol. 2008;65(12):1577-1581

Since the original clinical description of The molecular mechanism or mecha-

“shaking palsy” by James Parkinson al-
most 200 years ago, substantial progress
has been achieved in the treatment of
symptoms of Parkinson disease (PD), the
most common movement disorder. In
about 95% of cases, symptoms of PD re-
sult from sporadic disease of unknown eti-
ology. In addition, similar symptoms can
be caused by certain infections and intoxi-
cation with some chemicals; in these cases,
the condition is called secondary parkin-
sonism.
Modern treatment of PD and parkin-
sonism is based on the discovery that PD
is caused by selective death of dopamin-
ergic neurons in the substantia nigra pars
compacta, which is responsible for initia-
tion of intentional movements. As a re-
sult of this selective loss of neurons, an
acute shortage of a major neurotransmit-
ter dopamine (DA) develops. For partial
compensation of this shortage, DA pre-
cursor levodopa is administered to pa-
tients, resulting in major improvement in
symptoms. Over time, however, the loss
of dopaminergic neurons continues, cor-
responding neural circuits become com-
promised, and the drug becomes ineffec-
tive. Advanced stages of PD are treated by
implantation of electrodes to compen-
sate for the damaged circuits by means of
electrical stimulation.
Author Affiliations: Department of Neurology, Harvard Medical School,
Massachusetts General Hospital, MassGeneral Institute for Neurodegenerative
Disease, Charlestown, Massachusetts (Dr Kazantsev); Health Front Line, Ltd,
Champaign, Illinois (Dr Kolchinsky).
nisms of neurodegeneration in PD, the
original cause of the selective dopamin-
ergic neuronal loss, are mostly un-
known. Many important findings have
been reported; however, no unifying and
universal theory has been proposed and
accepted. The most plausible explana-
tion is that these dopaminergic neurons
contain the highest concentration of DA,1
which, it is presumed, increases their vul-
nerability. The DA itself is not toxic at
physiologic concentrations. However, it is
actively metabolized, primarily by mono-
amine oxidase, producing toxic deriva-
tives, of which the most damaging are al-
dehydes. Normally, these derivatives are
polymerized to form dark nontoxic neu-
romelanin, which is deposited in the cells.
The earliest pathologic finding related to
PD was the depigmentation of the sub-
stantial nigra in patients with parkinson-
ism of infectious origin. In the early 1920s,
it was considered improbable that a change
in such a tiny area of the brain could cause
the dramatic symptoms; as we now know,
there are only about 5⫻105 pigmented do-
paminergic neurons in normal substan-
tia nigra.2 The depigmentation probably
indicates the decrease in the concentra-
tion of DA or the inability of the cells to
polymerize its toxic derivatives, or both.
A condition similar to PD can be
imitated by administration of MPTP
(1-methyl-4-phenyl-1, 2, 3, 6-tetrahy-
dropyridine), a synthetic compound that
disrupts the work of the mitochondria. The

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 action of MPTP can be prevented by
simultaneous administration of
monoamine oxidase inhibitors;
therefore, not the MPTP but its oxi-
dized metabolites are toxic, simi-
larly to DA. Administration of MPTP
inhibits the mitochondrial com-
plex I, and this inhibition results in
increased generation of reactive oxy-
gen species (ROS). Other inhibi-
tors of complex I, for example,
chronic manganese intoxication or
chronic administration of rotenone
in experimental animals, also may
cause parkinsonism and selective
death of dopaminergic neurons.
These basic data suggest that ROS
have a special function in the loss of
dopaminergic neurons, although this
connection has not been proved un-
equivocally and the major distur-
bance in the generation of energy
and maintenance of proper redox
potential of the pairs NADH/NAD⫹
(NADH dehydrogenase/nicotin-
amide adenine dinucleotide) and re-
duced or oxidized glutathione could
be no less important.
Another conspicuous patho-
logic feature of neuronal damage in
PD, formation of dense protein in-
clusions known as Lewy bodies
(LBs), in affected cells has been
known for some time. Lewy bodies
consist primarily of ␣-synuclein (␣-
Syn) protein and components of pro-
teasome machinery, chaperones, and
␣-tubulin. The exact role(s) of the
inclusion bodies in disease patho-
genesis, whether harmful, benign, or
protective, was unknown for many
years.
The important role of the major LB
component, ␣-Syn protein, in PD
pathogenesiswasfirstelucidatedinge-
netic studies. In familial PD, the most
common causative mutations have
been found in ␣-Syn gene product.
Expression of mutant ␣-Syn
protein (or alternatively ␣-Syn pro-
tein) was demonstrated to be selec-
tively toxic for dopaminergic neu-
rons in some models, for example,
when expressed from an engi-
neered virus injected in rat brain. It
is toxic to dopaminergic neurons of
Drosophila when driven by a neuron-
specific promoter.3 At the same time,
mutant ␣-Syn expressed in mice
causes various abnormalities in their
nervous system, including aggrega-
tion and formation of LBs but not
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loss of dopaminergic neurons. The
effect of mutant ␣-Syn in different
species may depend on its specific
modifications, processing, or inter-
action with other proteins, down-
stream agents of cytotoxicity.
Recently it became clear that LBs
may not be the major toxic species
of ␣-Syn and its complexes with other
proteins. Lewy body–positive dopa-
minergic neurons seem to be
healthier than their inclusion-free
neighbors. Furthermore, the in-
crease in the size of LBs and de-
creased concentration of soluble ␣-
Syn correlate with reduction of
cytotoxic effects. These observa-
tions are consistent with the protec-
tive role of inclusion formation, a self-
defense mechanism to remove
neurotoxic soluble ␣-Syn from a cel-
lular milieu.4
The current theory of the origin
of PD places it in a large category of
neurodegenerative diseases caused
by protein misfolding.5 Proteins im-
plicated in neurodegeneration can be
neither efficiently refolded by chap-
erones to their normal conforma-
tion nor degraded by proteasomes,
leading to their abnormal turn-
over, elevated concentration, aggre-
gation, and accumulation of in-
soluble protein deposits. In PD, the
cause is a high level of misfolded ␣-
Syn molecules, which subse-
quently leads to formation of neu-
rotoxic aggregated intermediates,
that is, oligomers and probably small
soluble complexes of ␣-Syn with
other proteins, in particular, ␣-
tubulin (Figure 1).
Mutant ␣-Syn protein tends to ac-
quire abnormal conformation sub-
stantially easier than its wild-type
counterpart. Gradual accumula-
tion of misfolded ␣-Syn molecules
promotes their oligomerization and
formation of toxic species. High con-
centration of overexpressed nor-
mal ␣-Syn also causes cytotoxicity,
which suggests a shift in equilib-
rium between normal and mis-
folded conformations and in-
creased rate of oligomerization of the
misfolded proteins. In some famil-
ial cases of PD, multiplication of the
normal α-Syn gene, leading to pro-
tein overexpression from several
chromosomal gene copies, has been
found to be the causative muta-
tion.6 Negative pleiotropic effects of
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1578
oligomers on diverse cellular path-
ways were observed, including bind-
ing to cytoskeleton components, ␣-
tubulin and microtubules, and
damaging of mitochondrial and cel-
lular membranes.
Although mutations and multi-
plication of α-Syn genes are the
cause of most familial PD, the ␣-
Syn protein is ubiquitously ex-
pressed at fairly high levels through-
out the brain; therefore, its mere
presence cannot be the only reason
for selective death of dopaminergic
neurons. ␣-Syn misfolding and
oligomerization may be acceler-
ated by several factors in dopamin-
ergic neurons. For example, ␣-Syn
can be modified by highly reactive
aldehyde derivatives of DA, and as
a result, modified ␣-Syn readily ac-
quires the misfolded conforma-
tion. This hypothesis offers a plau-
sible explanation for the selectivity
of neuronal death in the substantia
nigra pars compacta and has been re-
viewed in detail by Galvin.7
The most important risk factor for
sporadic PD is age. Aging could
promote the accumulation of mis-
folded ␣-Syn by slowing its turn-
over, by lowering the level of respi-
ration accompanied by diminishing
the amount of energy resources, or
by other metabolic changes. It is rea-
sonable to assume that these changes
are regulated by the general mecha-
nisms of aging.
After many years of intensive
research, caloric restriction was
found to be the only environmental
factor that can delay aging and
substantially extend the lifespan
of all studied organisms from
yeast to mammals. In mammals, a
restricted-calorie regimen provides
about 70% of calories compared
with ad libitum nutrition. One
could expect that, among other dis-
eases associated with aging, caloric
restriction should affect the inci-
dence and the course of PD. Caloric
restriction alleviates symptoms of
parkinsonism in MPTP-induced
animal models of PD8 ; however,
epidemiologic studies failed to
demonstrate a correlation between
diet and incidence of PD.
Caloric restriction is a major fac-
tor that determines the concentra-
tions of NADH/NAD⫹. It stimulates
respiration and, by doing so, in-
 Mutant
α-Syn

Chemically
modified
α-Syn

α-Syn

Chaperones
Proteasome

Misfolded
α-Syn

Overexpressed α-Syn

α-Syn oligomer

Formation of Lewy bodies

Cell survival

Toxic complex
Neurotoxicity

α-Tubulin oligomer
Microtubule instability
Neurotoxicity

Cell death

Figure 1. Role of ␣-synuclein (␣-Syn) in neuronal death in Parkinson disease. Neurotoxic oligomers of ␣-Syn are shown as the key factors of neurodegeneration.
One potential mechanism leading to neuronal death is invasion of ␣-tubulin polymers, which affects the dynamics and stability of microtubules.

creases the concentration of NAD⫹;
it decreases the concentration of oxy-
gen and generation of ROS.9 In yeast,
these changes translate into a longer
lifespan through regulatory func-
tions of sirtuins (SIRTs). Sirtuins are
NAD⫹-dependent protein deacety-
lases. In the course of reaction, the
acetyl group is transferred from pro-
tein to the adenosine diphosphate
(ADP)–ribose moiety of NAD⫹ and
nicotinamide is released. This reac-
tion controls the acetylation of his-
tones, chromatin condensation, and
other aspects of global regulation of
cell functions. Similar proteins are
probably responsible for the effect of
caloric restriction on longevity in
higher organisms as well, although it
remains to be proved in mammals.
During the last decade, several
families of proteins similar to yeast
proteins responsible for aging were
discovered in mammals. These dis-

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 A

α-Syn oligomer

Formation of Lewy bodies

Cell survival

Toxic complex

α-Tubulin oligomer

Cell death

Deacetylation by SIRT2
Ac

α-Tubulin

α-Syn oligomer

Formation of Lewy bodies

Cell survival

α-Tubulin oligomer

Cell death

Inhibition of SIRT2 deacetylation

Ac

α-Tubulin

Figure 2. Modulation of ␣-synuclein (␣-Syn) neurotoxicity by inhibition of sirtuin-2 (SIRT2) deacetylation activity. A, Sirtuin-2–dependent deacetylation of
␣-tubulin promotes formation of a toxic complex with ␣-Syn oligomers. B, Sirtuin-2 inhibition leads to reduction of toxic complex formation, promotion of Lewy
body formation, and decreased neurotoxicity.

coveries led to the search for poten-
tial therapeutic targets among SIRTs
for pharmaceutical intervention and
development of neuroprotective
therapy for PD.10 The most promis-
ing current pharmacologic ap-
proaches are stimulation of SIRT1,
which imitates caloric restriction
conditions, and inhibition of
␣−tubilin deacetylase SIRT2, which
rescues ␣-Syn toxicity, possibly by
facilitating ␣-Syn inclusion forma-
tion or by stabilizing microtubules
(Figure 2).11,12
The finding that SIRT2 activity
modulates the toxicity of ␣-Syn may
shed some light on the central prob-
lem in PD research, “the relation-
ship between previously identified
factors in PD neurodegeneration (eg,
mitochondrial dysfunction or ROS)
and the molecular events provoked by
disease alleles.”12(p889) The deacety-
lase activity of SIRT2 is NAD⫹ con-

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 centration dependent,13 which sug-
gests a possible link between energy
metabolism and ␣-Syn toxicity. How-
ever, whether mammalian SIRTs in
general and SIRT2 in particular func-
tion as sensors of intracellular NAD⫹
concentration is unclear (for discus-
sion, see Buck et al14). In addition,
most NAD⫹ in the cell seems to be
bound with proteins, while experi-
mental determination of free NAD⫹
concentration is not a trivial task.15
Thus, it is uncertain whether fluctua-
tion of intracellular NAD⫹ would sub-
stantially modulate sirtuin activities.
At the same time, epidemiologic
studies suggest that another regula-
tory function of NAD⫹, its role as a
substrate for poly(ADP-ribose)
(PARP) polymerase, is involved in
PD. Only a few environmental fac-
tors were proved beyond doubt to
influence the incidence of PD. Con-
sumption of the 2 most common ad-
dictive substances, nicotine and caf-
feine, both substantially decrease the
risk of developing PD.16 While the
mechanism of nicotine action is un-
clear, the role of caffeine can be ex-
plained by the ability of its metabo-
lites at physiologic concentrations to
inhibit PARP polymerase, the en-
zyme of first response to genotoxic
stress.17 The substrate of PARP poly-
merase is NAD⫹; therefore, the en-
zyme depends on its availability and
rapidly depletes its cellular pool. In-
asmuch as the enzyme PARP poly-
merase is the key trigger of apopto-
sis, it is conceivable that suppression
of PARP polymerase prevents the
loss of dopaminergic neurons with
their enhanced sensitivity to ROS
and other genotoxic agents.
In conclusion, despite substan-
tial progress in recent years, the re-
lationship remains to be clarified be-
tween the major components of PD
pathogenesis: selective vulnerabil-
ity and loss of dopaminergic neu-
rons; ␣-Syn homeostasis and chap-
erone and proteasome dysfunction;
energy depletion; generation of ROS;
and aging, which may incorporate
some or all of these factors. The
SIRTs may be a missing link inter-
connecting these aspects of the dis-
ease, and further investigation of
these pathways can provide fruitful
insights in PD pathology.
Accepted for Publication: June 12,
2008.
Correspondence: Aleksey G.
Kazantsev, PhD, Department of Neu-
rology, Massachusetts General Hos-
pital, Bldg 114, 3300 16th St,
Charlestown, MA 02129-4404
(akazantsev@partners.org).
Author Contributions: Dr Kazantsev
had full access to all of the data in
the study and takes responsibility for
the integrity of the data and the ac-
curacy of the data analysis. Study
concept and design: Kazantsev and
Kolchinsky. Analysis and interpre-
tation of data: Kazantsev. Drafting of
the manuscript: Kazantsev and
Kolchinsky. Critical revision of the
manuscript for important intellec-
tual content: Kazantsev. Obtained
funding: Kazantsev. Administrative,
technical, and material support:
Kazantsev and Kolchinsky. Study su-
pervision: Kazantsev.
Financial Disclosure: None re-
ported.
Funding/Support: This study was
supported by the Michael J. Fox
Foundation for Parkinson’s Re-
search and the RJG Foundation.
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