Prodromal Variability in Huntington\u27s Disease Progression and Resistance

Huntington’s disease (HD) is a neurodegenerative movement disorder caused by abnormal cytosine-adenine-guanine (CAG) expansion on the HTT gene. As both a proteinopathy and the most common PolyQ disease, HD shares key features with several disorders that disproportionately affect the growing elderly population in the United States, including delayed-onset, selective neuronal death, and protein misfolding. Across these conditions, there are few treatments and no known cures; however, their shared features suggest common underlying mechanisms, and delayed-onset hints at possible prevention or reversal. CAG-expansion-number and age are related to diagnosis and can be used to estimate age-of-onset for prodromal (pre-diagnosis) individuals, who possess the causal mutation but have not manifested diagnosis-associated motor symptoms. Over a decade before diagnosis, prodromal individuals differ from controls in brain structure and connectivity, cognition, and motor functioning. Although age and CAG-number account for most observed variability in HD-onset, persons with identical CAG-numbers often develop symptoms at different ages, indicating that additional genetic and environmental factors also mediate decline. Little is known about detrimental and protective genetic factors in HD. Studying prodromal progression can inform interventions by highlighting early prevention targets. This research leverages advanced multivariate techniques applied to legacy PREDICT-HD data to characterize brain structure, cognition, and motor functioning across prodromal HD and investigate genetic factors accounting for variability in these domains. Regarding brain structure, these experiments provide evidence for: regional co-occurrence in prodromal decline, early fronto-striatal degradation, dorso-ventral reduction gradients, and delayed atrophy in certain movement-related and subcortical regions. The genetic findings suggest a protective role of NTRK2 and identify NCOR1 and ADORA2B variants with early, CAG-independent detrimental effects on gray matter. Previously identified onset-delaying variants are also confirmed as CAG-independent modulators of brain structure and clinical functioning. Clinical findings highlight motor functioning as the best indicator of brain-structural integrity until the late prodrome and demonstrate that distinct regions coincide with cognitive compared to motor functioning; furthermore, regions that most align with clinical functioning vary at different prodromal stages

Brain structure and function in Huntington's disease gene carriers far from predicted disease onset

Whilst there are currently no available disease modifying therapies for Huntington’s Disease (HD), recent progress in huntingtin-lowering strategies hold great promise. Initiating therapies early in the disease course will be important and a complete characterisation of the premanifest period will help inform when to initiate disease modifying therapies and the biomarkers that may be useful in such trials. Previous research has characterised the premanifest period up to approximately 15 years from predicted onset, but even at this early stage the disease process is already underway as evidenced by striatal and white matter atrophy, reductions in structural connectivity within brain networks, rising biofluid biomarkers of neuronal dysfunction, elevations in psychiatric symptoms and emerging subtle cognitive impairments. In order to understand how early neurodegeneration can be detected and which measures are most sensitive to the early disease processes, we need to look even earlier in the disease course. This thesis documents the recruitment and analysis of the HD Young Adult Study: a premanifest cohort further from predicted clinical onset than previously studied with an average of 24 years prior to predicted onset. Differences between gene carriers and controls were examined across a range of imaging, cognitive, neuropsychiatric and biofluid measures. The structural and functional brain connectivity in this cohort is then investigated in further detail. By providing a detailed characterisation of brain structure and function in the early premanifest period along with the most sensitive biomarkers at this stage, this work will inform future treatment strategies that may seek to delay the onset of functional impairments in HD