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Schröter N, van Eimeren T, Classen J, Levin J, Redecker C, Wolz M, Tönges L. Significance of clinical symptoms and red flags in early differential diagnosis of Parkinson's disease and atypical Parkinsonian syndromes. J Neural Transm (Vienna) 2023; 130:839-846. [PMID: 37046147 PMCID: PMC10199882 DOI: 10.1007/s00702-023-02634-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/05/2023] [Indexed: 04/14/2023]
Abstract
The clinical presentation of Parkinson's disease and atypical Parkinsonian syndromes is often heterogeneous. Additional diagnostic procedures including brain imaging and biomarker analyses can help to appreciate the various syndromes, but a precise clinical evaluation and differentiation is always necessary. To better assess the relevance of distinct clinical symptoms that arose within 1 year of disease manifestation and evaluate their indicative potential for an atypical Parkinsonian syndrome, we conducted a modified Delphi panel with seven movement disorder specialists. Five different topics with several clinical symptom items were discussed and consensus criteria were tested. This resulted in distinct symptom patterns for each atypical Parkinsonian syndrome showing the multitude of clinical involvement in each neurodegenerative disease. Strongly discriminating clinical signs were few and levels of indication were variable. A prospective validation of the assessments made is needed. This demonstrates that both clinical evaluation and elaborate additional diagnostic procedures are needed to achieve a high diagnostic standard.
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Affiliation(s)
- Nils Schröter
- Department of Neurology and Clinical Neuroscience, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| | - Thilo van Eimeren
- Department of Neurology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Joseph Classen
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Johannes Levin
- Department of Neurology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- German Center for Neurodegenerative Diseases, Site Munich, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | | | - Martin Wolz
- Department of Neurology, Elblandklinikum Meißen, Meissen, Germany
| | - Lars Tönges
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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2
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Belić M, Radivojević Z, Bobić V, Kostić V, Đurić-Jovičić M. Quick computer aided differential diagnostics based on repetitive finger tapping in Parkinson’s disease and atypical parkinsonisms. Heliyon 2023; 9:e14824. [PMID: 37077676 PMCID: PMC10107087 DOI: 10.1016/j.heliyon.2023.e14824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 03/06/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Background Parkinson's disease (PD) is the second most common neurodegenerative disorder whose prevalence rises with age, yet clinical diagnosis is still a challenging task due to similar manifestations of other neurodegenerative movement disorders. In untreated patients or those with unclear responses to medication, correct percentages of early diagnoses go as low as 26%. Technology has been used in various forms to facilitate discerning between persons with PD and healthy individuals, but much less work has been dedicated to separating PD and atypical parkinsonisms. Methods A wearable system was developed based on inertial sensors that capture the movements of fingers during repetitive finger tapping. A k-nearest-neighbor classifier was used on features extracted from gyroscope recordings for quick aid in differential diagnostics, discerning patients with PD, progressive supranuclear palsy (PSP), multiple system atrophy (MSA) and healthy controls (HC). Results The overall classification accuracy achieved was 85.18% in the multiclass setup. MSA and HC groups were the easiest to discern (100%), while PSP was the most elusive diagnosis, as some patients were incorrectly assigned to MSA and HC groups. Conclusions The system shows potential for use as a tool for quick diagnostic aid, and in the era of big data, offers a means of standardization of data collection that could allow scientists to aggregate multi-center data for further research.
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Coughlin DG, Litvan I. Investigational therapeutics for the treatment of progressive supranuclear palsy. Expert Opin Investig Drugs 2022; 31:813-823. [DOI: 10.1080/13543784.2022.2087179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David G Coughlin
- Department of Neurosciences, University of California San Diego, San Diego, 92093, CA
| | - Irene Litvan
- Department of Neurosciences, University of California San Diego, San Diego, 92093, CA
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McCarter SJ, Savica R. Autopallidotomy: From Colloquial Term to Scientific Theory. JOURNAL OF PARKINSON'S DISEASE 2022; 12:2009-2013. [PMID: 36120793 PMCID: PMC9661314 DOI: 10.3233/jpd-223491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Levodopa-induced dyskinesia (LID), a frequent complication of Parkinson's disease (PD), occurs in ∼30% of patients after five years' treatment with levodopa. In atypical parkinsonism, LID occurs less frequently than in PD. Lower frequency of LID in atypical parkinsonism has traditionally been attributed to lower amounts of levodopa used by these patients; however, recent studies have shown lower frequency of LID in atypical parkinsonism compared with PD when adjusting for levodopa dose. The mechanism of LID is complex but requires pulsatile levodopa stimulation, progressive presynaptic dopaminergic degeneration, and a relatively intact postsynaptic dopaminergic system. The globus pallidus internus (GPi), the main inhibitory nucleus of the basal ganglia, may play a major role in the development and treatment of LID. Surgical lesioning of the posteroventral GPi is directly antidyskinetic; animal models showing GPi-associated striatal neurons are directly responsible for the development of LID. However, other cortical areas, particularly the primary sensory and motor cortices may also play a role in LID. In some cases of atypical parkinsonism, particularly progressive supranuclear palsy and corticobasal degeneration, severe degeneration of the GPi, a so-called "autopallidotomy," may explain the absence of LID in these patients. In other atypical parkinsonisms, such as PD dementia and dementia with Lewy bodies, the lower incidence of LID may partly be attributed to more striatal degeneration but likely also relates to the degeneration of the motor cortex and resultant network dysfunction. Overall, atypical parkinsonism serves as a natural model that may ultimately reveal more effective therapies for LID.
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Affiliation(s)
| | - Rodolfo Savica
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
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Bluett B, Pantelyat AY, Litvan I, Ali F, Apetauerova D, Bega D, Bloom L, Bower J, Boxer AL, Dale ML, Dhall R, Duquette A, Fernandez HH, Fleisher JE, Grossman M, Howell M, Kerwin DR, Leegwater-Kim J, Lepage C, Ljubenkov PA, Mancini M, McFarland NR, Moretti P, Myrick E, Patel P, Plummer LS, Rodriguez-Porcel F, Rojas J, Sidiropoulos C, Sklerov M, Sokol LL, Tuite PJ, VandeVrede L, Wilhelm J, Wills AMA, Xie T, Golbe LI. Best Practices in the Clinical Management of Progressive Supranuclear Palsy and Corticobasal Syndrome: A Consensus Statement of the CurePSP Centers of Care. Front Neurol 2021; 12:694872. [PMID: 34276544 PMCID: PMC8284317 DOI: 10.3389/fneur.2021.694872] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/10/2021] [Indexed: 11/16/2022] Open
Abstract
Progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS; the most common phenotype of corticobasal degeneration) are tauopathies with a relentless course, usually starting in the mid-60s and leading to death after an average of 7 years. There is as yet no specific or disease-modifying treatment. Clinical deficits in PSP are numerous, involve the entire neuraxis, and present as several discrete phenotypes. They center on rigidity, bradykinesia, postural instability, gait freezing, supranuclear ocular motor impairment, dysarthria, dysphagia, incontinence, sleep disorders, frontal cognitive dysfunction, and a variety of behavioral changes. CBS presents with prominent and usually asymmetric dystonia, apraxia, myoclonus, pyramidal signs, and cortical sensory loss. The symptoms and deficits of PSP and CBS are amenable to a variety of treatment strategies but most physicians, including many neurologists, are reluctant to care for patients with these conditions because of unfamiliarity with their multiplicity of interacting symptoms and deficits. CurePSP, the organization devoted to support, research, and education for PSP and CBS, created its CurePSP Centers of Care network in North America in 2017 to improve patient access to clinical expertise and develop collaborations. The directors of the 25 centers have created this consensus document outlining best practices in the management of PSP and CBS. They formed a writing committee for each of 12 sub-topics. A 4-member Steering Committee collated and edited the contributions. The result was returned to the entire cohort of authors for further comments, which were considered for incorporation by the Steering Committee. The authors hope that this publication will serve as a convenient guide for all clinicians caring for patients with PSP and CBS and that it will improve care for patients with these devastating but manageable disorders.
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Affiliation(s)
- Brent Bluett
- Neurology, Pacific Central Coast Health Center, Dignity Health, San Luis Obispo, CA, United States
- Neurology, Stanford University, Stanford, CA, United States
| | - Alexander Y. Pantelyat
- Neurology, The Johns Hopkins Hospital, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Irene Litvan
- Neurology, University of California, San Diego, San Diego, CA, United States
| | - Farwa Ali
- Neurology, Mayo Clinic, Rochester, MN, United States
| | - Diana Apetauerova
- Neurology, Lahey Hospital and Medical Center, Burlington, MA, United States
| | - Danny Bega
- Ken and Ruth Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Lisa Bloom
- Neurology, Surgery, University of Chicago, Chicago, IL, United States
| | - James Bower
- Neurology, Mayo Clinic, Rochester, MN, United States
| | - Adam L. Boxer
- Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Marian L. Dale
- Neurology, Oregon Health and Science University, Portland, OR, United States
| | - Rohit Dhall
- Neurology, University of Arkansas for Medical Sciences, Little Rock, AK, United States
| | - Antoine Duquette
- Service de Neurologie, Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Service de Neurologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Hubert H. Fernandez
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Jori E. Fleisher
- Neurological Sciences, Rush Medical College, Rush University, Chicago, IL, United States
| | - Murray Grossman
- Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael Howell
- Neurology, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Diana R. Kerwin
- Geriatrics, Presbyterian Hospital of Dallas, Dallas, TX, United States
| | | | - Christiane Lepage
- Service de Neurologie, Département de Médecine, Unité de Troubles du Mouvement André-Barbeau, Centre Hospitalier de l'Université de Service de Neurologie, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | | | - Martina Mancini
- Neurology, Oregon Health and Science University, Portland, OR, United States
| | - Nikolaus R. McFarland
- Neurology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Paolo Moretti
- Neurology, The University of Utah, Salt Lake City, UT, United States
| | - Erica Myrick
- Neurological Sciences, Rush Medical College, Rush University, Chicago, IL, United States
| | - Pritika Patel
- Neurology, Lahey Hospital and Medical Center, Burlington, MA, United States
| | - Laura S. Plummer
- Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | | | - Julio Rojas
- Neurology, University of California, San Francisco, San Francisco, CA, United States
| | | | - Miriam Sklerov
- Neurology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Leonard L. Sokol
- Ken and Ruth Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Paul J. Tuite
- Neurology, Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Lawren VandeVrede
- Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jennifer Wilhelm
- Neurology, Oregon Health and Science University, Portland, OR, United States
| | - Anne-Marie A. Wills
- Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Tao Xie
- Neurology, Surgery, University of Chicago, Chicago, IL, United States
| | - Lawrence I. Golbe
- Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Martin WRW, Miles M, Zhong Q, Hartlein J, Racette BA, Norris SA, Ushe M, Maiti B, Criswell S, Davis AA, Kotzbauer PT, Cairns NJ, Perrin RJ, Perlmutter JS. Is Levodopa Response a Valid Indicator of Parkinson's Disease? Mov Disord 2021; 36:948-954. [PMID: 33253432 PMCID: PMC8046721 DOI: 10.1002/mds.28406] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 11/07/2020] [Accepted: 11/10/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The clinical diagnosis of Parkinson's disease (PD) requires the presence of parkinsonism and supportive criteria that include a clear and dramatic beneficial response to dopaminergic therapy. Our aim was to test the diagnostic criterion of dopaminergic response by evaluating its association with pathologically confirmed diagnoses in a large population of parkinsonian patients. METHODS We reviewed clinical data maintained in an electronic medical record from all patients with autopsy data who had been seen in the Movement Disorders Center at Washington University, St. Louis, between 1996 and 2018. All patients with parkinsonism who underwent postmortem neuropathologic examination were included in this analysis. RESULTS There were 257 unique parkinsonian patients with autopsy-based diagnoses who had received dopaminergic therapy. Marked or moderate response to dopaminergic therapy occurred in 91.2% (166/182) of those with autopsy-confirmed PD, 52.0% (13/25) of those with autopsy-confirmed multiple systems atrophy, 44.4% (8/18) of those with autopsy-confirmed progressive supranuclear palsy, and 1 (1/8) with autopsy-confirmed corticobasal degeneration. Other diagnoses were responsible for the remaining 24 individuals, 9 of whom had a moderate response to dopaminergic therapy. CONCLUSION A substantial response to dopaminergic therapy is frequent but not universal in PD. An absent response does not exclude PD. In other neurodegenerative disorders associated with parkinsonism, a prominent response may also be evident, but this occurs less frequently than in PD. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- W R Wayne Martin
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Michael Miles
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Qiaonan Zhong
- Department of Medicine, Mayo Clinic, Rochester, Missouri, USA
| | - Johanna Hartlein
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Brad A Racette
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
- Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Parktown, South Africa
| | - Scott A Norris
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mwiza Ushe
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Baijayanta Maiti
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Susan Criswell
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Albert A Davis
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Paul T Kotzbauer
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Nigel J Cairns
- College of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Richard J Perrin
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joel S Perlmutter
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri, USA
- Departments of Neuroscience, Physical Therapy and Occupational Therapy, Washington University in St. Louis, St. Louis, Missouri, USA
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Coughlin DG, Dickson DW, Josephs KA, Litvan I. Progressive Supranuclear Palsy and Corticobasal Degeneration. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1281:151-176. [PMID: 33433875 DOI: 10.1007/978-3-030-51140-1_11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) are neurodegenerative tauopathies with neuronal and glial lesions composed of tau that is composed predominantly of isomers with four repeats in the microtubule-binding domain (4R tau). The brain regions vulnerable to pathology in PSP and CBD overlap, but there are differences, particularly with respect to distribution of neuronal loss, the relative abundance of neuronal and glial lesions, the morphologic features of glial lesions, and the frequency of comorbid pathology. Both PSP and CBD have a wide spectrum of clinical manifestations, including disorders of movement and cognition. Recognition of phenotypic diversity in PSP and CBD may improve antemortem diagnostic accuracy, which tends to be very good for the most common presentation of PSP (Richardson syndrome), but poor for the most characteristic presentation of CBD (corticobasal syndrome: CBS). Development of molecular and imaging biomarkers may improve antemortem diagnostic accuracy. Currently, multidisciplinary symptomatic and supportive treatment with pharmacological and non-pharmacological strategies remains the standard of care. In the future, experimental therapeutic trials will be important to slow disease progression.
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Affiliation(s)
| | | | | | - Irene Litvan
- UC San Diego Department of Neurosciences, La Jolla, CA, USA.
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Caixeta L, Caixeta VDM, Nogueira YL, Aversi-Ferreira TA. Pharmacological interventions in corticobasal degeneration: a review. Dement Neuropsychol 2020; 14:243-247. [PMID: 32973978 PMCID: PMC7500816 DOI: 10.1590/1980-57642020dn14-030006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Corticobasal degeneration (CBD) is a sporadic tauopathy that presents with a
varied combination of motor, cognitive, and behavioral features, making its
diagnosis difficult. CBD has high morbidity and poor prognosis, with no
effective therapy at present. We searched the PubMed/MEDLINE database for
articles published from 1990 to 2019, using the keywords “corticobasal
degeneration” AND “treatment.” The PRISMA method was adopted. Retrieved articles
were characterized as having one of two methodological approaches: (1) studies
aimed at primary tauopathy treatment and (2) symptomatic management. Review
articles (based on CBD expert groups), case reports, case series, and pilot
clinical trials were selected. Few attempts have been made to study drug options
and drug efficacy in CBD systematically, and an effective treatment is not yet
available. Treatment is symptomatic and based on similarity with other diseases
due to the scarcity of studies specifically addressing CBD. CBD seems not to
spark interest in more clinical trials for its low prevalence and reliability in
clinical diagnosis.
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Affiliation(s)
- Leonardo Caixeta
- Department of Neurology, School of Medicine, Universidade Federal de Goiás - Goiânia, GO, Brazil.,Dementia Outpatient Clinic, Hospital das Clínicas, Universidade Federal de Goiás - Goiânia, GO, Brazil
| | - Victor de Melo Caixeta
- Department of Neurology, School of Medicine, Universidade Federal de Goiás - Goiânia, GO, Brazil.,Dementia Outpatient Clinic, Hospital das Clínicas, Universidade Federal de Goiás - Goiânia, GO, Brazil.,ASMIGO Hospital, Neuropsychology Research Center - Goiânia, GO, Brazil
| | | | - Tales Alexandre Aversi-Ferreira
- Laboratory of Biomathematics and Physical Anthropology, Department of Structural Biology, Institute of Biomedical Sciences, Universidade Federal de Alfenas - Alfenas, Brazil
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Coughlin DG, Litvan I. Progressive supranuclear palsy: Advances in diagnosis and management. Parkinsonism Relat Disord 2020; 73:105-116. [PMID: 32487421 PMCID: PMC7462164 DOI: 10.1016/j.parkreldis.2020.04.014] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 02/07/2023]
Abstract
Progressive supranuclear palsy (PSP) is a complex clinicopathologic disease with no current cure or disease modulating therapies that can only be definitively confirmed at autopsy. Growing understanding of the phenotypic diversity of PSP has led to expanded clinical criteria and new insights into etiopathogenesis that coupled with improved in vivo biomarkers makes increased access to current clinical trials possible. Current standard-of-care treatment of PSP is multidisciplinary, supportive and symptomatic, and several trials of potentially disease modulating agents have already been completed with disappointing results. Current ongoing clinical trials target the abnormal aggregation of tau through a variety of mechanisms including immunotherapy and gene therapy offer a more direct method of treatment. Here we review PSP clinicopathologic correlations, in vivo biomarkers including MRI, PET, and CSF biomarkers. We additionally review current pharmacologic and non-pharmacologic methods of treatment, prior and ongoing clinical trials in PSP. Newly expanded clinical criteria and improved specific biomarkers will aid in identifying patients with PSP earlier and more accurately and expand access to these potentially beneficial clinical trials.
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Affiliation(s)
- David G Coughlin
- Department of Neurosciences, University of California San Diego, San Diego, CA, 92093, USA
| | - Irene Litvan
- Department of Neurosciences, University of California San Diego, San Diego, CA, 92093, USA.
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Fernández-Ferreira R, García-Santos RA, Rodríguez-Violante M, López-Martínez C, Becerra-Laparra IK, Torres-Pérez ME. Progressive supranuclear palsy as differential diagnosis of Parkinson's disease in the elderly. Rev Esp Geriatr Gerontol 2019; 54:251-256. [PMID: 31324404 DOI: 10.1016/j.regg.2019.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/28/2019] [Accepted: 04/24/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Progressive supranuclear palsy (PSP) is a syndrome characterized by progressive parkinsonism with early falls due to postural instability, typically vertical gaze supranuclear ophthalmoplegia, pseudobulbar dysfunction, neck dystonia and upper trunk rigidity as well as mild cognitive dysfunction. Progressive supranuclear palsy must be differentiated from Parkinson's disease taking into account several so-called red flags. MATERIALS AND METHODS We report a case series hallmarked by gait abnormalities, falls and bradykinesia in which Parkinson's disease was the initial diagnosis. RESULTS Due to a torpid clinical course, magnetic resonance imaging (MRI) was performed demonstrating midbrain atrophy, highly suggestive of progressive supranuclear palsy. CONCLUSION The neuroradiological exams (magnetic resonance imaging, single photon emission computer tomography, and positron emission tomography) can be useful for diagnosis of PSP. Treatment with levodopa should be considered, especially in patients with a more parkinsonian phenotype.
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Affiliation(s)
| | - Raúl Anwar García-Santos
- Neurology Department, National Institute of Neurology and Neurosurgery, PC 14269, Mexico City, Mexico
| | - Mayela Rodríguez-Violante
- Clinical Laboratory of Neurodegenerative Diseases, National Institute of Neurology and Neurosurgery, PC 14269, Mexico City, Mexico
| | - Coral López-Martínez
- Geriatrics Department, Médica Sur Clinic & Foundation, PC 14050, Mexico City, Mexico
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11
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Marsili L, Bologna M, Kojovic M, Berardelli A, Espay AJ, Colosimo C. Dystonia in atypical parkinsonian disorders. Parkinsonism Relat Disord 2019; 66:25-33. [PMID: 31443953 DOI: 10.1016/j.parkreldis.2019.07.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 02/06/2023]
Abstract
Dystonia is common in the classic atypical parkinsonian disorders such as multiple system atrophy, progressive supranuclear palsy and corticobasal degeneration, and to a lesser extent in dementia with Lewy bodies. Its clinical phenomenology, including body distribution, timing of appearance, severity, and relationship to dopaminergic and other medications may vary considerably within and between atypical parkinsonian disorders. From a pathophysiological standpoint, the coexistence of dystonia with parkinsonism challenges the functional model of the basal ganglia. Clinical recognition of specific dystonic features may assist in the differential diagnosis of atypical parkinsonian disorders and in distinguishing them from Parkinson's disease. The presence of dystonia in atypical parkinsonian disorders informs management decisions. Reduction or withdrawal of levodopa should be considered if there is a close relationship between the onset of dystonia with periods of high dopaminergic tone. Botulinum neurotoxin may be considered in focal presentations. We here provide an updated overview of dystonia arising in the setting of atypical parkinsonian disorders, summarizing relevant clinical and clinicopathological studies, underlying pathophysiological mechanisms, diagnostic clues and potential pitfalls in the diagnosis. Finally, we suggest a tailored therapeutic approach for the management of these patients.
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Affiliation(s)
- Luca Marsili
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Matteo Bologna
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli (IS), Italy
| | - Maja Kojovic
- Department of Neurology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy; IRCCS Neuromed, Pozzilli (IS), Italy
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, Italy.
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12
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Jost WH, Lingor P, Tönges L, Schwarz J, Buhmann C, Kassubek J, Schrag A. Dyskinesia in multiple system atrophy and progressive supranuclear palsy. J Neural Transm (Vienna) 2019; 126:925-932. [PMID: 31087195 DOI: 10.1007/s00702-019-02012-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/06/2019] [Indexed: 01/06/2023]
Abstract
In the differential diagnosis of Parkinson syndromes, the response to L-Dopa is an essential criterion for the diagnosis of idiopathic Parkinson's syndrome (IPS), and the presence of L-Dopa-induced dyskinesia (LID) is considered a supportive criterion. This implies that in the presence of LID an atypical Parkinson-syndrome (APS) is unlikely. However, dyskinesia, and in particular LID, can also be present in APS such as MSA and PSP, although less frequently, and with varying clinical appearance. We conclude that whilst presence of dyskinesia provides support for a diagnosis of IPD, they do not allow reliable differentiation from APS.
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Affiliation(s)
- Wolfgang H Jost
- Parkinson-Klinik Ortenau, Kreuzbergstr. 12, 77709, Wolfach, Germany.
| | - Paul Lingor
- Klinik für Neurologie, Klinikum Rechts der Isar der TU München, Munich, Germany
| | - Lars Tönges
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
- Neurodegeneration Research, Protein Research Unit Ruhr (PURE), Ruhr University Bochum, Bochum, Germany
| | | | - Carsten Buhmann
- Department of Neurology, University Clinic Eppendorf, Hamburg, Germany
| | - Jan Kassubek
- Department of Neurology, University of Ulm, Ulm, Germany
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Moretti DV. Available and future treatments for atypical parkinsonism. A systematic review. CNS Neurosci Ther 2019; 25:159-174. [PMID: 30294976 PMCID: PMC6488913 DOI: 10.1111/cns.13068] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/01/2018] [Accepted: 09/05/2018] [Indexed: 01/02/2023] Open
Abstract
AIMS Success in treating patients with atypical parkinsonian syndromes, namely progressive supranuclear palsy (PSP), cortico-basal degeneration (CBD), multiple system atrophy (MSA), Parkinson's disease with dementia (PDD), and Lewy body dementia with (LBD), remains exceedingly low. The present work overviews the most influential research literature collected on MEDLINE, ISI Web of Science, Cochrane Library, and Scopus for available treatment in atypical parkinsonisms without time restriction. DISCUSSION Transdermal rotigotine, autologous mesenchymal stem cells, tideglusib, and coenzyme Q10 along with donepezil, rivastigmine, memantine, and the deep brain stimulation have shown some benefits in alleviating symptoms in APS. Moreover, many new clinical trials are ongoing testing microtubule stabilizer, antitau monoclonal antibody, tau acetylation inhibition, cell replacement, selective serotonin reuptake inhibitor, active immunization, inhibition of toxic α-synuclein oligomers formation, and inhibition of microglia. CONCLUSION A detailed knowledge of the pathological mechanism underlying the disorders is needed, and disease-modifying therapies are required to offer better therapeutic options to physician and caregivers of APS patients.
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Shoeibi A, Litvan I. Therapeutic options for Progressive Supranuclear Palsy including investigational drugs. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1335596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Ali Shoeibi
- Movement Disorder Center, UC San Diego Department of Neurosciences, La Jolla, CA, USA
- Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Irene Litvan
- Movement Disorder Center, UC San Diego Department of Neurosciences, La Jolla, CA, USA
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Schreglmann SR, Bhatia KP, Stamelou M. Advances in the Clinical Differential Diagnosis of Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 132:79-127. [PMID: 28554422 DOI: 10.1016/bs.irn.2017.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The differential diagnosis of Parkinson's disease has widened considerably in recent years. This chapter aims to summarize the current knowledge on the clinical differential diagnoses of sporadic Parkinson's disease. As the number of monogenic familial Parkinson's disease variants and risk factors is growing, so is the number of appreciated etiologies of atypical parkinsonian and other pallidopyramidal syndromes. This work aims at summarizing the current knowledge on both motor and nonmotor neurological signs and symptoms that aid the clinical diagnosis of Parkinson's disease and its differential diagnoses.
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Affiliation(s)
| | | | - Maria Stamelou
- University of Athens Medical School, Hospital Attikon, Athens, Greece; HYGEIA Hospital, Athens, Greece; Philipps University, Marburg, Germany.
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16
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Lopez G, Bayulkem K, Hallett M. Progressive supranuclear palsy (PSP): Richardson syndrome and other PSP variants. Acta Neurol Scand 2016; 134:242-9. [PMID: 27070344 DOI: 10.1111/ane.12546] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2015] [Indexed: 01/05/2023]
Abstract
Phenotypic heterogeneity of progressive supranuclear palsy (PSP) has been increasingly reported in the literature and can be the source of incorrect clinical diagnosis particularly in the early stages of the disease when the classically associated symptoms of early falls and supranuclear gaze palsy may not be apparent. In addition to Richardson syndrome (RS), several atypical clinical phenotypes have been described. Advances in genetic, neuroimaging, and biochemical/molecular technologies contribute to the identification of these clinical subtypes in the context of typical PSP pathological findings. Our goal is to review the phenomenology reported in the literature that is associated with confirmed histopathological changes consistent with a PSP diagnosis and to highlight the clinical spectrum of PSP. A systematic review of the literature in PubMed through July 2015 using MeSH terms and key words related to PSP was conducted. Articles describing PSP classifications, diagnostic criteria, and case reports were reviewed and summarized. Additional PSP phenotypes not seen in recent clinicopathological studies are included. These include primary lateral sclerosis, pallido-nigro-luysian degeneration, axonal dystrophy, and multiple system atrophy in the spectrum of atypical PSP variants beyond the traditionally classified PSP subtypes. This review is intended to help with the diagnostic challenges of atypical PSP variants. We believe that large multicenter clinicopathological studies will help expand our understanding of etiology and specific mechanisms of neurodegeneration and will aid in the appropriate interpretation of outcomes when conducting clinical and basic science research.
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Affiliation(s)
- G. Lopez
- Section on Molecular Neurogenetics; Medical Genetics Branch; NHGRI Intramural Research Program; National Institutes of Health; Bethesda MD USA
| | - K. Bayulkem
- Human Motor Control Section; National Institute of Neurological Disorders and Stroke; National Institutes of Health; Bethesda MD USA
| | - M. Hallett
- Human Motor Control Section; National Institute of Neurological Disorders and Stroke; National Institutes of Health; Bethesda MD USA
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Lamb R, Rohrer JD, Lees AJ, Morris HR. Progressive Supranuclear Palsy and Corticobasal Degeneration: Pathophysiology and Treatment Options. Curr Treat Options Neurol 2016; 18:42. [PMID: 27526039 PMCID: PMC4985534 DOI: 10.1007/s11940-016-0422-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OPINION STATEMENT There are currently no disease-modifying treatments for progressive supranuclear palsy (PSP) or corticobasal degeneration (CBD), and no approved pharmacological or therapeutic treatments that are effective in controlling their symptoms. The use of most pharmacological treatment options are based on experience in other disorders or from non-randomized historical controls, case series, or expert opinion. Levodopa may provide some improvement in symptoms of Parkinsonism (specifically bradykinesia and rigidity) in PSP and CBD; however, evidence is conflicting and where present, benefits are often negligible and short lived. In fact, "poor" response to levodopa forms part of the NINDS-SPSP criteria for the diagnosis of PSP and consensus criteria for the diagnosis of CBD (Lang Mov Disord. 20 Suppl 1:S83-91, 2005; Litvan et al. Neurology. 48:119-25, 1997; Armstrong et al. Neurology. 80(5):496-503, 2013). There is some evidence that intrasalivery gland botulinum toxin is useful in managing problematic sialorrhea and that intramuscular botulinum toxin and baclofen are helpful in reducing dystonia, including blepharospasm. Benzodiazepines may also be useful in managing dystonia. Myoclonus may be managed using levetiracetam and benzodiazepines. Pharmacological agents licensed for Alzheimer's disease (such as acetylcholinesterase inhibitors and N-Methyl-D-aspartate receptor antagonists) have been used off-label in PSP, CBD, and other tauopathies with the aim of improving cognition; however, there is limited evidence that they are effective and risk of adverse effects may outweigh benefits. The use of atypical antipsychotics for behavioural symptoms is not recommended in the elderly or those with demetia associated conditions and most antipsychotics will worsen Parkinsonism. Antidepressants may be useful for behavioral symptoms and depression but are often poorly tolerated due to adverse effects. In the absence of an effective drug treatment to target the underlying cause of CBD and PSP, management should focus on optimizing quality of life, relieving symptoms and assisting patients with their activities of daily living (ADL). Patients should be managed by a multidisciplinary team consisting of neurologists, physiotherapists (PT), occupational therapists (OT), speech and language therapists (SALT), dieticians, ophthalmologists, psychologists, and palliative care specialists.
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Affiliation(s)
- Ruth Lamb
- Department of Clinical Neuroscience, UCL Institute of Neurology, Queen Square, London, UK
| | - Jonathan D. Rohrer
- Dementia Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Andrew J. Lees
- Department of Molecular Neuroscience, Queen Square Brain Bank for Neurological Disorders, University College London, London, UK
| | - Huw R. Morris
- Department of Clinical Neuroscience, UCL Institute of Neurology, Queen Square, London, UK
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Abstract
Progressive supranuclear palsy (PSP) is an atypical parkinsonian condition characterized by a symmetric akinetic-rigid syndrome, early falls, supranuclear gaze palsy, and a frontotemporal behavioral syndrome. The typical phenotype is termed Richardson's syndrome, but numerous other phenotypes have been described. The pathophysiology of PSP is not fully understood, but dysfunction of the tau protein seems to play a central role. Despite exciting new knowledge on the pathophysiology of PSP, there is still no highly effective symptomatic or disease-modifying treatment. We review the evidence on pharmacotherapy and experimental therapies in PSP and provide levels of recommendation for the off-label use of commonly used drugs in this disorder.
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Sterling N, Lewis M, Du G, Huang X. Structural Imaging and Parkinson's Disease: Moving Toward Quantitative Markers of Disease Progression. JOURNAL OF PARKINSON'S DISEASE 2016; 6:557-67. [PMID: 27258697 PMCID: PMC5008231 DOI: 10.3233/jpd-160824] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 12/16/2022]
Abstract
Parkinson's disease (PD) is a progressive age-related neurodegenerative disorder. Although the pathological hallmark of PD is dopaminergic cell death in the substantia nigra pars compacta, widespread neurodegenerative changes occur throughout the brain as disease progresses. Postmortem studies, for example, have demonstrated the presence of Lewy pathology, apoptosis, and loss of neurotransmitters and interneurons in both cortical and subcortical regions of PD patients. Many in vivo structural imaging studies have attempted to gauge PD-related pathology, particularly in gray matter, with the hope of identifying an imaging biomarker. Reports of brain atrophy in PD, however, have been inconsistent, most likely due to differences in the studied populations (i.e. different disease stages and/or clinical subtypes), experimental designs (i.e. cross-sectional vs. longitudinal), and image analysis methodologies (i.e. automatic vs. manual segmentation). This review attempts to summarize the current state of gray matter structural imaging research in PD in relationship to disease progression, reconciling some of the differences in reported results, and to identify challenges and future avenues.
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Affiliation(s)
- N.W. Sterling
- Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
| | - M.M. Lewis
- Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Pharmacology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
| | - G. Du
- Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
| | - X. Huang
- Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Pharmacology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Radiology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Neurosurgery, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Kinesiology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA, USA
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20
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Tomita S, Oeda T, Umemura A, Kohsaka M, Park K, Yamamoto K, Sugiyama H, Mori C, Inoue K, Fujimura H, Sawada H. Impact of Aspiration Pneumonia on the Clinical Course of Progressive Supranuclear Palsy: A Retrospective Cohort Study. PLoS One 2015; 10:e0135823. [PMID: 26270456 PMCID: PMC4536232 DOI: 10.1371/journal.pone.0135823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/27/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Although aspiration pneumonia is the most common complication of progressive supranuclear palsy (PSP), the clinical impact of aspiration pneumonia on disease course and survival has not been fully estimated. Thus, we retrospectively analyzed the prognostic factors and clinical consequences of pneumonia in PSP. Methods The clinical course of patients with aspiration pneumonia was surveyed. The association between baseline clinical features (2 years from disease onset) and latency to the initial development of pneumonia was investigated using survival time and Cox regression analyses. Results Ninety patients with a clinical diagnosis of PSP were observed for 5.1±3.8 years (mean±SD), and 22 had aspiration pneumonia. Subsequently, 20 patients (91%) had to discontinue oral feeding entirely and 13 (59%) died, whereas, of 68 patients without pneumonia, only three patients (4%) died. Time to initial development of pneumonia was strongly correlated with survival time (Spearman R = 0.92, P<0.001), with a mean latency of 2.3 years to death. Among baseline clinical features, early fall episodes and cognitive decline were significant predictors of pneumonia (P = 0.001 and P<0.001, respectively, log rank test). Cox regression analysis demonstrated that early fall episodes (adjusted hazard ratio: 3.9, 95% confidence interval: 1.2–12.5, P = 0.03) and cognitive decline (adjusted hazard ratio: 5.2, 95% confidence interval: 1.4–19.3, P = 0.02) independently predicted pneumonia. By contrast, dysphagia was not associated with pneumonia (P = 0.2, log rank test). Conclusion Initial development of pneumonia indicates an unfavorable clinical course and predicts survival time (mean survival time 2.3 years). Patients with early falls and cognitive decline were at high risk of early development of pneumonia.
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Affiliation(s)
- Satoshi Tomita
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Tomoko Oeda
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Atsushi Umemura
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Masayuki Kohsaka
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Kwiyoung Park
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Kenji Yamamoto
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Hiroshi Sugiyama
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
| | - Chiaki Mori
- Department of Neurology, Toneyama National Hospital, Osaka, Japan
| | - Kimiko Inoue
- Department of Neurology, Toneyama National Hospital, Osaka, Japan
| | | | - Hideyuki Sawada
- Clinical Research Center, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- Department of Neurology, National Regional Center for Neurological Disorders and Utano National Hospital, Kyoto, Japan
- * E-mail:
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Aarsland D, Taylor JP, Weintraub D. Psychiatric issues in cognitive impairment. Mov Disord 2014; 29:651-62. [PMID: 24757113 DOI: 10.1002/mds.25873] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 02/20/2014] [Accepted: 03/03/2013] [Indexed: 01/08/2023] Open
Abstract
Neuropsychiatric symptoms (NPS) such as depression, hallucinations and apathy commonly occur in Parkinson's disease (PD) and have major clinical consequences including a negative impact on quality of life. This review discusses the epidemiology, clinical features, diagnostic procedures and treatment issues of NPS in PD and related disorders in the perspective of cognitive impairment, focusing on depression, anxiety, visual hallucinations, apathy, sleep disturbances, impulse control disorder and non-motor fluctuations. The majority of NPS are more common in PD patients with dementia, possibly related to shared underlying pathologies. Recent studies also suggest that NPS are associated with mild cognitive impairment in PD, in particular with the amnestic type. Accurate diagnosis of NPS is important but can be difficult, due to overlapping symptoms and similar appearance of symptoms of motor symptoms of parkinsonism, cognitive impairment, mood disorders and apathy. There are few systematic studies focusing on the management of NPS in PD with cognitive impairment.
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Affiliation(s)
- Dag Aarsland
- Alzheimer's Disease Research Centre, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Geriatric Psychiatry, Akershus University Hospital, Oslo, Norway
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22
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Servello D, Zekaj E, Saleh C, Menghetti C, Porta M. Long-term follow-up of deep brain stimulation of peduncolopontine nucleus in progressive supranuclear palsy: Report of three cases. Surg Neurol Int 2014; 5:S416-20. [PMID: 25289173 PMCID: PMC4173638 DOI: 10.4103/2152-7806.140208] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 04/04/2014] [Indexed: 11/23/2022] Open
Abstract
Background: Progressive supranuclear palsy (PSP) is a neurodegenerative disease due to mitochondrial dysfunction. The PSP syndrome presents generally with gait disorder, Parkinsonism, ophthalmoparesis and cognitive alteration. Few reports exist on deep brain stimulation (DBS) in patients with atypical Parkinsonism. The aim of our study was to evaluate further the potential role of DBS in PSP. Case Description: We report three patients with PSP with long-term follow up undergoing DBS. Two patients had right peripedunculopontine nucleus (PPN) stimulation and one patient had simultaneous right PPN and bilateral globus pallidus internus DBS. DBS of the PPN alone or combined with globus pallidus internus (GPi) determined an improvement in gait and a reduction in falls sustained over time. Combined target stimulation (GPi-PPN) was correlated with better clinical outcome than single target (PPN) DBS for PSP. Conclusions: Although few data on DBS for PSP exist, reported clinical results are encouraging. DBS might be considered as an alternative therapeutic option for patients with PSP presenting with relevant gait imbalance and frequent falls, who fail to respond to pharmacological treatment. Larger cohorts with longer follow-ups are needed to evaluate more exhaustively the efficacy of DBS in PSP.
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Affiliation(s)
- Domenico Servello
- Departments of Neurosurgery and Neurology, IRCCS Galeazzi, Milan, Italy
| | - Edvin Zekaj
- Departments of Neurosurgery and Neurology, IRCCS Galeazzi, Milan, Italy
| | - Christian Saleh
- Departments of Neurosurgery and Neurology, IRCCS Galeazzi, Milan, Italy
| | - Claudia Menghetti
- Departments of Neurosurgery and Neurology, IRCCS Galeazzi, Milan, Italy
| | - Mauro Porta
- Departments of Neurosurgery and Neurology, IRCCS Galeazzi, Milan, Italy
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Tsai RM, Boxer AL. Clinical trials: past, current, and future for atypical Parkinsonian syndromes. Semin Neurol 2014; 34:225-34. [PMID: 24963682 DOI: 10.1055/s-0034-1381739] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There are currently no effective Food and Drug Administration-approved treatments for atypical parkinsonian disorders such as progressive supranuclear palsy, corticobasal degeneration, dementia with Lewy bodies, or multiple system atrophy. Previous treatment trials for these disorders were focused on symptomatic support and did not affect disease progression. Recent breakthroughs in neuropathology and pathophysiology have allowed a new understanding of these disorders and investigation into potentially disease modifying therapies. Randomized, placebo-controlled clinical trials of these disorders will be reviewed here. Suggestions for future therapeutic targets and clinical trial design (with a focus on progressive supranuclear palsy) will also be provided.
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Affiliation(s)
- Richard M Tsai
- Department of Neurology, University of California San Francisco, San Francisco, California
| | - Adam L Boxer
- Department of Neurology, University of California San Francisco, San Francisco, California
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Choi SW, Park KB, Woo SK, Kang SK, Ra JC. Treatment of progressive supranuclear palsy with autologous adipose tissue-derived mesenchymal stem cells: a case report. J Med Case Rep 2014; 8:87. [PMID: 24594311 PMCID: PMC3977942 DOI: 10.1186/1752-1947-8-87] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 12/26/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Progressive supranuclear palsy is a relentlessly progressive neurodegenerative disorder and is clinically characterized by parkinsonism. Adipose tissue-derived mesenchymal stem cells have recently demonstrated the possibility of treating neurological disorders. Therefore, autologous adipose tissue-derived mesenchymal stem cells transplantation can be an alternative method for treating progressive supranuclear palsy. CASE PRESENTATION This study was approved by the Korea Food and Drug Administration through the Emergency Use Investigational New Drug Application. A 71-year-old Asian man from South Korea with progressive supranuclear palsy was treated with five intravenous infusions (each time 2×108 cells) and four intrathecal infusions (each time 5×107 cells) with autologous adipose tissue-derived mesenchymal stem cells expanded under good manufacturing practice conditions. Clinical examinations were performed immediately before treatment and throughout the six months of follow-up. The tests included: 1) Progressive Supranuclear Palsy Rating Scale; 2) Berg Balance Scale; 3) Korean Mini Mental State Examination; 4) Modified Barthel Index; 5) grip strength; 6) Box and Block Test; and 7) Nine-Hole Peg Test.The Progressive Supranuclear Palsy Rating Scale results gradually decreased, and the clinical rating scale scores of the Berg Balance Scale, Korean Mini Mental State Examination, and Modified Barthel Index gradually increased. Grip strength was maintained. Performance in the Box and Block Test and Nine-Hole Peg Test improved after adipose tissue-derived mesenchymal stem cells treatment compared to baseline throughout the six months of follow-up. Except for the intermittent mild fever and transient elevated blood pressure, the treatment of our patient with progressive supranuclear palsy with autologous adipose tissue-derived mesenchymal stem cells showed no significant adverse events, and delayed the progression of neurological deficits by achieving functional improvement in the follow-up period. CONCLUSIONS These results are encouraging and hopeful for further studies in patients with progressive supranuclear palsy using autologous adipose tissue-derived mesenchymal stem cells as a safe and effective therapy. This case report is the first known study of adipose tissue-derived mesenchymal stem cells safely delaying the progression of progressive supranuclear palsy with functional improvement during the follow-up period.
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Affiliation(s)
| | | | | | | | - Jeong Chan Ra
- Stem Cell Research Center, K-STEMCELL, 2-305 IT Castle, Gasan-dong, Geumcheon-gu, Seoul 153-768, Republic of Korea.
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Abstract
BACKGROUND Progressive supranuclear palsy (PSP) is a neurodegenerative extrapyramidal syndrome. Studies have demonstrated that PSP can present clinically as an atypical dementing syndrome dominated by a progressive apraxia of speech (AOS) and aphasia. AIM We aimed to investigate the clinical presentation of PSP, using a comprehensive multidimensional evaluation, and the disease response to various pharmacological treatments. METHODS A 72-year-old right-handed male, with 17 years education, who first presented with aphasia, AOS, depression, apathy, and postural instability at 69 years; a complete neuropsychological evaluation, tapping the different cognitive domains, was performed. RESULTS Testing revealed a moderate global cognitive deficit (Mini-Mental State Examination test score =20), low memory test scores (story recall, Rey's 15-word Immediate and Delayed Recall), and poor phonemic and semantic fluency. The patient's language was characterized by AOS, with slow speech rate, prolonged intervals between syllables and words, decreased articulatory accuracy, sound distortions, and anomia. Behavioral changes, such as depression, anxiety, apathy, and irritability, were reported. The neurological examination revealed supranuclear vertical gaze palsy, poor face miming, and a mild balance deficit. Magnetic resonance imaging showed only widespread cortical atrophy. Single photon emission computed tomography demonstrated left > right frontotemporal cortical abnormalities. After 6 months, a further neuropsychological assessment showed a progression in cognitive deficits, with additional attention deficits. The patient reported frequent falls, but the neurological deficits remained unchanged. Neuroimaging tests showed the same brain involvement. CONCLUSION Our case highlights the heterogeneity of the clinical features in this syndrome, demonstrating that atypical PSP can present as AOS and aphasia, without the classical features or involvement of the subcortical gray and brainstem region, commonly affected in typical PSP.
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Affiliation(s)
| | | | - Angela Craca
- IRCCS Salvatore Maugeri Foundation, Cassano Murge, Bari, Italy
| | - Anna Loverre
- IRCCS Salvatore Maugeri Foundation, Cassano Murge, Bari, Italy
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dell'Aquila C, Zoccolella S, Cardinali V, de Mari M, Iliceto G, Tartaglione B, Lamberti P, Logroscino G. Predictors of survival in a series of clinically diagnosed progressive supranuclear palsy patients. Parkinsonism Relat Disord 2013; 19:980-5. [DOI: 10.1016/j.parkreldis.2013.06.014] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 05/21/2013] [Accepted: 06/24/2013] [Indexed: 11/26/2022]
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Gold M, Lorenzl S, Stewart AJ, Morimoto BH, Williams DR, Gozes I. Critical appraisal of the role of davunetide in the treatment of progressive supranuclear palsy. Neuropsychiatr Dis Treat 2012; 8:85-93. [PMID: 22347799 PMCID: PMC3280109 DOI: 10.2147/ndt.s12518] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Progressive supranuclear palsy (PSP) is a rare neurodegenerative disease characterized by the accumulation of tau protein aggregates in the basal ganglia, brainstem and cerebral cortex leading to rapid disease progression and death. The neurofibrillary tangles that define the neuropathology of PSP are comprised of aggregated 4R tau and show a well-defined distribution. Classically, PSP is diagnosed by symptoms that include progressive gait disturbance, early falls, vertical ophthalmoparesis, akinetic-rigid features, prominent bulbar dysfunction and fronto-subcortical dementia. There are currently no effective therapies for the treatment of this rapidly degenerating and debilitating disease. Davunetide is a novel neuroprotective peptide that is thought to impact neuronal integrity and cell survival through the stabilization of microtubules. Preclinical activity in models of tauopathy has been translated to clinical studies, demonstrating pharmacologic activity that has supported further development. Davunetide's efficacy and tolerability are being tested in a placebo-controlled study in PSP patients, making it the most advanced drug candidate in this indication. This review examines the disease characteristics of PSP, the rationale for treating PSP with davunetide and assesses some of the challenges of clinical trials in this patient population.
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Affiliation(s)
| | - Stefan Lorenzl
- Interdisciplinary Center for Palliative Medicine, Munich University Hospital Klinikum Grosshadern, Munich, Germany
| | | | | | - David R Williams
- Van Cleef/Roet Centre for Nervous Diseases, Monash University, Melbourne, Australia
| | - Illana Gozes
- Allon Therapeutics Inc, Vancouver, BC, Canada
- The Dr Diana and Zelman Elton (Elbaum) Laboratory for Molecular Neuroendocrinology, The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, The Adams Super Center for Brain Studies, and the Department of Human Molecular Genetics and Biochemistry, School of Neuroscience, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Boelmans K, Holst B, Hackius M, Finsterbusch J, Gerloff C, Fiehler J, Münchau A. Brain iron deposition fingerprints in Parkinson's disease and progressive supranuclear palsy. Mov Disord 2012; 27:421-7. [PMID: 22290788 DOI: 10.1002/mds.24926] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 12/16/2011] [Accepted: 12/26/2011] [Indexed: 11/11/2022] Open
Abstract
It can be difficult to clinically distinguish between classical Parkinson's disease (PD) and progressive supranuclear palsy. Previously, there have been no biomarkers that reliably allow this distinction to be made. We report that an abnormal brain iron accumulation is a marker for ongoing neurodegeneration in both conditions, but the conditions differ with respect to the anatomical distribution of these accumulations. We analyzed quantitative T2' maps as markers of regional brain iron content from PD and progressive supranuclear palsy patients and compared them to age-matched control subjects. T2-weighted and T2*-weighted images were acquired in 30 PD patients, 12 progressive supranuclear palsy patients, and 24 control subjects at 1.5 Tesla. Mean T2' values were determined in regions-of-interest in the basal ganglia, thalamus, and white matter within each hemisphere. The main findings were shortened T2' values in the caudate nucleus, globus pallidus, and putamen in progressive supranuclear palsy compared to PD patients and controls. A stepwise linear discriminant analysis allowed progressive supranuclear palsy patients to be distinguished from PD patients and the healthy controls. All progressive supranuclear palsy patients were correctly classified. No progressive supranuclear palsy patient was classified as a healthy control, no healthy controls were incorrectly classified as having progressive supranuclear palsy, and only 6.7% of the PD patients were incorrectly classified as progressive supranuclear palsy. Regional decreases of T2' relaxation times in parts of the basal ganglia reflecting increased brain iron load in these areas are characteristic for progressive supranuclear palsy but not PD patients.
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Affiliation(s)
- Kai Boelmans
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Effectiveness of an inpatient movement disorders program for patients with atypical parkinsonism. PARKINSONS DISEASE 2011; 2012:871974. [PMID: 22135763 PMCID: PMC3216254 DOI: 10.1155/2012/871974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Accepted: 09/17/2011] [Indexed: 11/19/2022]
Abstract
This paper investigated the effectiveness of an inpatient movement disorders program for patients with atypical parkinsonism, who typically respond poorly to pharmacologic intervention and are challenging to rehabilitate as outpatients. Ninety-one patients with atypical parkinsonism participated in an inpatient movement disorders program. Patients received physical, occupational, and speech therapy for 3 hours/day, 5 to 7 days/week, and pharmacologic adjustments based on daily observation and data. Differences between admission and discharge scores were analyzed for the functional independence measure (FIM), timed up and go test (TUG), two-minute walk test (TMW), Berg balance scale (BBS) and finger tapping test (FT), and all showed significant improvement on discharge (P > .001). Clinically significant improvements in total FIM score were evident in 74% of the patients. Results were similar for ten patients whose medications were not adjusted. Patients with atypical parkinsonism benefit from an inpatient interdisciplinary movement disorders program to improve functional status.
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Welter ML, Westby G, Chastan N. Les troubles de la marche et de l’équilibre dans les syndromes parkinsoniens « plus ». Rev Neurol (Paris) 2010; 166:188-95. [DOI: 10.1016/j.neurol.2009.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 05/11/2009] [Accepted: 05/25/2009] [Indexed: 10/20/2022]
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Sakamoto R, Tsuchiya K, Mimura M. Clinical heterogeneity in progressive supranuclear palsy: Problems of clinical diagnostic criteria of NINDS-SPSP in a retrospective study of seven Japanese autopsy cases. Neuropathology 2010; 30:24-35. [DOI: 10.1111/j.1440-1789.2009.01032.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
BACKGROUND Progressive supranuclear palsy (PSP) is the second most common cause of parkinsonism after Parkinson's disease (PD). The classic syndrome of PSP is widely recognized by neurologists as a combination of down gaze palsy with progressive rigidity and imbalance leading to falls. At the same time, few clinicians are proficient at treating PSP and recognizing the nonclassic presentations of this debilitating disorder often resulting in delays in diagnosis and misguided treatment. REVIEW SUMMARY Over the last decade many lines of investigation have helped refine PSP at the clinical, neuroimaging, pharmacologic and molecular levels. It is the purpose of this literature review to help clinicians identify PSP earlier in its course, to better understand its pathophysiology, and to provide a more focused, symptom-based treatment approach. Eighty-two peer-reviewed articles on the topic of PSP and other neurodegenerative disorders have been reviewed. CONCLUSION It is clear that PSP continues to be an under-recognized disorder with multilevel involvement of the neuraxis that helps differentiate it from other akinetic rigid syndromes such as PD. A greater appreciation of its atypical presentations, more attention to its neurobehavioral signs and better imaging techniques are some of the advances that will help facilitate earlier detection, which may reduce morbidity by helping anticipate early falls and minimizing unnecessary diagnostic procedures. Surgical approaches to PSP have been ineffective so far. Carefully targeted symptomatic treatment with drugs and other therapies is available and effective at reducing morbidity and improving quality of life.
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Chand P, Litvan I. Progressive supranuclear palsy and corticobasal degeneration: similarities and differences. FUTURE NEUROLOGY 2008. [DOI: 10.2217/14796708.3.3.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) are sporadic four-repeat tauopathies that have characteristic clinical and neuropathologic profiles, but also share overlapping features. Both present with various clinical phenotypes, but while the clinical diagnostic criteria of the classical and most frequent presentation of PSP have optimal specificity, the diagnostic accuracy of the various CBD phenotypes is suboptimal. On the other hand, neuropathologic diagnostic criteria for PSP and CBD have been validated and have appropriate accuracy. This article discusses the similarities and differences between these two disorders in clinical manifestations, neuroimaging and neuropathology and provides a perspective on possible future developments that may help in their diagnosis and treatment.
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Affiliation(s)
- Pratap Chand
- University of Louisville School of Medicine, Division of Movement Disorders, Frazier Rehab Neuroscience Institute, 220 Abraham Flexner Way, Ste 1503 Louisville, KY 40202, USA
| | - Irene Litvan
- University of Louisville School of Medicine, Division of Movement Disorders, Frazier Rehab Neuroscience Institute, 220 Abraham Flexner Way, Ste 1503 Louisville, KY 40202, USA
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Constantinescu R, Richard I, Kurlan R. Levodopa responsiveness in disorders with parkinsonism: a review of the literature. Mov Disord 2008; 22:2141-8; quiz 2295. [PMID: 17534959 DOI: 10.1002/mds.21578] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A literature review was conducted to investigate whether or not levodopa (LD) responsiveness (LR) is a useful criterion in the diagnosis of parkinsonian disorders. Although LR does appear to differ among the parkinsonian disorders, there is considerable confusion in the literature. While most patients with Parkinson's disease (PD) have a sustained benefit from LD, a small minority of patients with documented PD do not respond. The literature suggests that the LR rate is higher for multiple system atrophy (MSA), progressive supranuclear palsy (PSP), and corticobasal degeneration (CBD) than based on published diagnostic criteria. Magnitude and duration of response to LD and tolerability (time course, type and distribution of dyskinesias, mental effects and motor worsening) may be useful features in distinguishing PD, MSA, PSP, and CBD. Efforts should be directed toward better defining LR when used for diagnostic purposes and in scientific publications.
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Affiliation(s)
- Radu Constantinescu
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York, USA
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van Balken I, Litvan I. Current and future therapeutic approaches in progressive supranuclear palsy. HANDBOOK OF CLINICAL NEUROLOGY 2008; 89:493-508. [PMID: 18631772 DOI: 10.1016/s0072-9752(07)01246-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Irene van Balken
- Movement Disorders Program, University of Louisville School of Medicine, Department of Neurology, Louisville, KY 40202, USA
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Liepelt I, Maetzler W, Blaicher HP, Gasser T, Berg D. Treatment of dementia in parkinsonian syndromes with cholinesterase inhibitors. Dement Geriatr Cogn Disord 2007; 23:351-67. [PMID: 17389795 DOI: 10.1159/000101337] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2006] [Indexed: 12/13/2022] Open
Abstract
In Parkinsonian syndromes behavioural symptoms and dementia can be even more debilitating than motor symptoms and are an important predictor for nursing home placement and mortality. Neuropathologically, dementia seems to be primarily related to cortical changes rather than to subcortical alterations. Concerning neurotransmitter systems, the cholinergic system has been proposed to play a key role in cognitive disturbances. Based on studies with patients with Alzheimer disease, the application of cholinesterase inhibitors is vividly discussed also for dementia associated with parkinsonian syndromes. This review focuses on the specific symptoms of dementia in different parkinsonian syndromes and critically questions the effect of cholinergic treatment on cognitive functions in patients with extrapyramidal syndromes and dementia. There is evidence that medication with some cholinesterase inhibitors can enhance cognition as well as activities of daily living in dementia with Parkinson's disease and seems to reduce behavioural disturbances in both dementia with Parkinson's disease and dementia with Lewy bodies. The effect of treatment with cholinesterase inhibitors in progressive supranuclear palsy and corticobasal degeneration warrants carefully designed studies including a sufficient number of patients and symptom-adopted dementia scales.
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Affiliation(s)
- Inga Liepelt
- Hertie Institute for Clinical Brain Research, University of Tubingen, Tubingen, Germany.
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van Balken I, Litvan I. Current and future treatments in progressive supranuclear palsy. Curr Treat Options Neurol 2006; 8:211-23. [PMID: 16569380 DOI: 10.1007/s11940-006-0012-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Progressive supranuclear palsy (PSP) is an atypical parkinsonian disorder that, in spite of its growing recognition, is still underdiagnosed. For management, prognosis, and research, an accurate and early diagnosis is essential. PSP is a relentlessly progressive neurodegenerative disorder, clinically characterized by parkinsonism with prominent axial involvement and postural instability, bulbar symptoms, supranuclear ophthalmoplegia, and executive dysfunction. Abnormal neuronal and glial four-repeat tau aggregations affecting the basal ganglia and selective brainstem structures result in dysfunction of the five frontosubcortical circuits and brainstem functions. Primary therapeutic approaches are based on neurotransmitter replacement and palliative strategies. This article reviews the experience and challenges with neurotransmitter replacement and palliative strategies through an extensive literature search of studies published between 1965 and 2005. The role of and limited experience with alternative therapies, such as deep brain stimulation and pallidotomy, are also discussed. Advances in the development of biological therapies for PSP and a better understanding of its etiopathogenesis will likely result from epidemiologic studies and developed four-repeat tau-transgenic animal models. The management of patients with this disorder poses a considerable challenge and includes symptomatic and palliative strategies, as well as education and support, to improve the quality of life for patients and their caregivers.
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Affiliation(s)
- Irene van Balken
- University of Louisville School of Medicine, Department of Neurology, A Building, Room 113, 500 South Preston, Louisville, KY 40202, USA
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