Clinical grand round: A rapidly progressive pyramidal and extrapyramidal syndrome with a supranuclear gaze palsy

Progressive supranuclear palsy: clinicopathological concepts and diagnostic challenges

Progressive supranuclear palsy (PSP) is a clinical syndrome comprising supranuclear palsy, postural instability, and mild dementia. Neuropathologically, PSP is defined by the accumulation of neurofibrillary tangles. Since the first description of PSP in 1963, several distinct clinical syndromes have been described that are associated with PSP; this discovery challenges the traditional clinicopathological definition and complicates diagnosis in the absence of a reliable, disease-specific biomarker. We review the emerging nosology in this field and contrast the clinical and pathological characteristics of the different disease subgroups. These new insights emphasise that the pathological events and processes that lead to the accumulation of phosphorylated tau protein in the brain are best considered as dynamic processes that can develop at different rates, leading to different clinical phenomena. Moreover, for patients for whom the diagnosis is unclear, clinicians must continue to describe accurately the clinical picture of each individual, rather than label them with inaccurate diagnostic categories, such as atypical parkinsonism or PSP mimics. In this way, the development of the clinical features can be informative in assigning less common nosological categories that give clues to the underlying pathology and an understanding of the expected clinical course.

Frontotemporal lobar degeneration with motor neurone disease (FTLD/MND): Presentations in psychiatric practice

Background. Concurrence of frontotemporal lobar degeneration with clinical features of motor neurone disease (FTLD/MND) is a recognised cause of dementia with widely accepted diagnostic criteria, but it is not mentioned in DSM-IV-TR. Aim. To draw attention to cases of FTLD/MND referred by psychiatrists, or already under the care of psychiatrists at time of referral, to a dedicated Cognitive Function Clinic. Methods. Prospective study of FTLD/MND cases, 1999-2007 inclusive; case note review. Results. Nine of 13 cases of FTLD/MND were either referred by or already under the care of a psychiatrist. Although most had been identified as having a dementia, in none had the correct diagnosis been made. All patients had signs of motor neurone pathology on clinical examination, sometimes subtle, in addition to cognitive and psychiatric features. A wide variety of drugs had been prescribed including antidepressants, antipsychotics, cholinesterase inhibitors, and memantine. Conclusions. A high index of clinical suspicion is required to identify cases of possible FTLD/MND, and thereby initiate appropriate investigations and management and avoid inappropriate medication. Absence of FTLD/MND in DSM-IV-TR may further handicap psychiatrists in making this diagnosis.