Progressive supranuclear palsy: clinico-pathological and biochemical studies

Is brain banking of psychiatric cases valuable for neurobiological research?

It is widely accepted that neurobiological abnormalities underlie the symptoms of psychiatric disorders such as schizophrenia and unipolar or bipolar affective disorders. New molecular methods, computer-assisted quantification techniques and neurobiological investigation methods that can be applied to the human brain are all used in post-mortem investigations of psychiatric disorders. The following article describes modern quantitative methods and recent post-mortem findings in schizophrenia and affective disorders. Using our brain bank as an example, necessary considerations of modern brain banking are addressed such as ethical considerations, clinical work-up, preparation techniques and the organization of a brain bank, the value of modern brain banking for investigations of psychiatric disorders is summarized.

Parkinsonism and tremor disorders. A clinical approach

Differentiation of idiopathic Parkinson's disease from other causes of Parkinsonism, such as Multiple System Atrophy, Progressive Supranuclar Palsy and Vascular Parkinsonism can be difficult. Clinicopathological studies suggest that the clinical diagnosis of idiopathic Parkinson's disease is 76% reliable. Also, clinical differentiation of tremor prominent Parkinsonism from Essential Tremor or Drug induced Parkinsonism may be problematic, especially in the early stages of the disease. Since these disorders are obviously different in clinical progress, it is important for the clinician to address the patient's and family's concerns about prognosis from a firm diagnostic footing. In this article the clinical features of the common and important causes of Parkinsonism and tremor disorders are reviewed and a practical approach is suggested.

How a neuropsychiatric brain bank should be run: a consensus paper of Brainnet Europe II

The development of new molecular and neurobiological methods, computer-assisted quantification techniques and neurobiological investigation methods which can be applied to the human brain, all have evoked an increased demand for post-mortem tissue in research. Psychiatric disorders are considered to be of neurobiological origin. Thus far, however, the etiology and pathophysiology of schizophrenia, depression and dementias are not well understood at the cellular and molecular level. The following will outline the consensus of the working group for neuropsychiatric brain banking organized in the Brainnet Europe II, on ethical guidelines for brain banking, clinical diagnostic criteria, the minimal clinical data set of retrospectively analyzed cases as well as neuropathological standard investigations to perform stageing for neurodegenerative disorders in brain tissue. We will list regions of interest for assessments in psychiatric disorder, propose a dissection scheme and describe preservation and storage conditions of tissue. These guidelines may be of value for future implementations of additional neuropsychiatric brain banks world-wide.

Significance of 123I-MIBG scintigraphy as a pathophysiological indicator in the assessment of Parkinson's disease and related disorders: it can be a specific marker for Lewy body disease

Recently, reliable and clear evidence for the usefulness of 123I-MIBG scintigraphy in the diagnosis of Parkinson's disease (PD) has been accumulated and it has become increasingly popular as one of the most accurate means of diagnosing the disease. PD, one of the most common neurodegenerative disorders, is characterized by resting tremor, rigidity, bradykinesia or akinesia, and postural instability. The disease is characterized pathologically by distinctive neuronal inclusions called Lewy bodies in many surviving cells of dopaminergic neurons of the substantia nigra pars compacta and other specific brain regions. Furthermore Lewy body type degeneration in the cardiac plexus has been observed in PD. In PD, cardiac MIBG uptake is reduced markedly even in the early disease stages; therefore, MIBG imaging can be used as an indicator of the presence of PD rather than disease severity. Other parkinsonian syndromes such as multiple system atrophy, progressive supranuclear palsy, and corticobasal degeneration demonstrate normal cardiac MIBG uptake or only mild reduction of MIBG uptake, indicating that MIBG imaging is a powerful method to differentiate PD from other parkinsonian syndromes. Dementia with Lewy bodies (DLB) also shows severe reduction of MIBG uptake, whereas Alzheimer's disease (AD) demonstrates normal MIBG uptake, permitting differentiation of DLB from AD using MIBG scintigraphy. In pure autonomic failure, which shares similar pathological findings with PD and is thought to be associated with diffuse loss of sympathetic terminal innervation, cardiac MIBG uptake also decreases markedly. Considering all the data together, marked reduction of cardiac MIBG uptake seems to be a specific marker of Lewy body disease and thus extremely useful in the differentiation from other diseases with similar symptoms without Lewy bodies.

Functional imaging techniques in the diagnosis of non-Alzheimer dementias

Functional imaging (positron emission tomography -- PET, single photon emission tomography -- SPECT, magnetic resonance spectroscopy -- MRS) enables regional cerebral function to be assessed in vivo in dementias. There are three basic approaches to examining the patterns of cerebral function associated with specific disorders: First, abnormalities in resting levels of regional cerebral metabolism and blood flow can be examined. Second, patients can be asked to perform cognitive tasks with a view to demonstrating aberrations in their pattern of cerebral activation. Third, resting dysfunction of brain pharmacology can be revealed. The bulk of the research on non-Alzheimer dementias has been performed with PET and SPECT and this review will concentrate on these two modalities.

Progressive supranuclear palsy: neuropathologically based diagnostic clinical criteria

All cases examined postmortem at the Mayo Clinic that met the classic neuropathological criteria for progressive supranuclear palsy (PSP) were identified for retrospective clinical analyses. The necropsy material was re-examined by a second neuropathologist to confirm the pathological diagnosis of PSP, yielding 12 cases. A range of clinical signs were documented in these patients, with numerous findings beyond those noted in the original descriptions of this disorder. Atypical clinical findings included absence of supranuclear gaze palsy (two cases), prominent asymmetry (two), arm dystonia (two), upper limb apraxia (two), myoclonus (two), chorea (one), eyelid opening apraxia (one), and respiratory disturbance (one). A definite clinical diagnosis of PSP had been made during life in only eight of the 12 patients. From the retrospective analysis of these 12 cases, a set of clinical criteria were developed for the premortem diagnosis of PSP emphasising differences from other akinetic-rigid disorders.

Familial progressive supranuclear palsy

A progressive extrapyramidal syndrome and dementia occurred in three members of one family. The age of onset was in the seventh decade and the affected individuals showed many of the clinical features of progressive supranuclear palsy (PSP). Necropsy of one individual revealed the neuropathological features of PSP. We propose that this family has a familial form of PSP and review the evidence in the literature that a familial form exists.

Neurofibrillary tangles in the neurons of spinal dorsal root ganglia of patients with progressive supranuclear palsy

Neurofibrillary tangles (NFTs) occur in neurons of human central nervous system (CNS) both in aged subjects and patients with several degenerative diseases, with a certain topographical predilection. In surveying the NFT distribution in nervous tissue of patients with progressive supranuclear palsy (PSP), we found silver-positive fibrillary tangles in the neurons of dorsal root ganglia (DRG) in two of five patients. By immunohistochemistry, these tangles were stained with antibodies to human tau protein, paired helical filaments (PHFs) and ubiquitin. Electron microscopy revealed that they were mainly composed of PHFs that were morphologically indistinguishable from PHFs in the NFTs of CNS typically seen in Alzheimer's disease brains. Our data demonstrate for the first time that the neurons of DRG produce NFTs in PSP and suggest that the pathological process(es) leading to tangle formation can occur in the neurons of the peripheral nervous system in this disease condition.

Further observations on Tau-positive glia in the brains with progressive supranuclear palsy

The previously reported unusual, Tau-positive glia with astrocytic morphology seen in brain tissues from cases of progressive supranuclear palsy (PSP) were re-examined immunohistochemically using antibodies to CD44 and vimentin, as well as Alz-50. Four brains of PSP cases, one of whom had atypical clinical features, were examined. All four cases showed the unusual glia which were positive to Alz-50 and anti-CD44 antibodies, but negative to anti-vimentin antibody. Ultrastructurally, they had either paired nucleated or lobulated nuclei and the cytoplasm frequently contained lipofuscin pigment. The CD44 was located on the surface of the cell bodies and their processes. Such glia were most numerous in the striatum in all cases. They also appeared in the cortex and some subcortical nuclei in the three typical cases. They were not seen in the lower brain stem or cerebellum. In their morphological characteristics and regionally specific appearance, these unusual glia seemed similar to the Alzheimer type I glia which are commonly seen in hepatic encephalopathy or Wilson's disease.

Pure akinesia: an atypical manifestation of progressive supranuclear palsy

Two patients with "pure akinesia" who showed the characteristic changes of progressive supranuclear palsy (PSP) at necropsy are described. They had akinesia but no rigidity or tremor, and ophthalmoplegia was not observed during the course of illness. The symptoms of "pure akinesia" was not improved by levodopa therapy but was considerably improved by L-threo-3,4-dihydroxy-phenylserine. At necropsy, pathological findings were not different from those reported for PSP. It is suggested that "pure akinesia" is an atypical manifestation of PSP, and that norepinephrinergic neurons may be involved in some types of PSP.

The pedunculopontine nucleus in Parkinson's disease, progressive supranuclear palsy and Alzheimer's disease

Significant loss of neurons in the pedunculopontine nucleus pars compacta (PPNc), a putative cholinergic nucleus involved in modulating somatic motor activities, has been demonstrated in progressive supranuclear palsy (PSP) and Parkinson's disease but not in Alzheimer's disease. A morphometric study of this nucleus was performed in two cases of PSP and in a cohort of cases of Parkinson's disease, Alzheimer's disease, senile dementia of Alzheimer type (SDAT), and age-matched controls. In PSP a significant 60% neuronal loss in PPNc was associated with neurofibrillary tangles in 40 to 64% of the remaining neurons. In Parkinson's disease there was a significant decrease in cell numbers and density by 53 and 51%, respectively, with Lewy bodies involving 6 to 39% of all neurons. In Alzheimer's disease and SDAT, large neurons were reduced by 29 and 33.8%, respectively, with tangles in 9 to 38% of the remaining cells. The selective affection of this putative cholinergic nucleus in PSP and Parkinson's disease appears to be related to motor dysfunctions in these disorders.

Idiopathic Parkinson's disease and the Lewy body disorders

A common clinical manifestation of idiopathic Lewy body disease is levodopa responsive idiopathic Parkinson's disease. Infrequently features such as dementia or autonomic failure predominate. The Lewy body is also reported; as an incidental finding in 7-10% of normal individuals mostly over the age of 60 as an incidental sporadic finding in Parkinson's syndrome from other causes, mostly over the age of sixty; in an additional group of degenerative disorders at a younger age, some with familial inheritance. The incidental finding of Lewy bodies can precede clinical Parkinson's disease. It is though they do not occur as an age-related feature, although this cannot be stated with certainty. Current evidence suggests that about 10% of the population may possess the pathological substratum for idiopathic Parkinson's disease.

Progressive supranuclear palsy and In111-DTPA cisternography

Three cases of progressive supranuclear palsy are reported in which In111-DTPA cisternography showed slow diffusion, ventricular reflux and failure of isotope clearance. The clinical diagnosis of progressive supranuclear palsy was confirmed histologically in two of these patients. The possible causes of the cisternographic changes and their relationship to the changes of CSF dynamics in progressive supranuclear palsy are discussed.

Neurofibrillary pathology in progressive supranuclear palsy

We describe the fine structure of the subcortical neurofibrillary tangles (NFT) in 2 cases of progressive supranuclear palsy (PSP). In case 1 (69-year-old man) about one half of the NFT in the midbrain and pons examined were composed of 13-16 nm straight filaments and the other were made up of paired helical filaments (PHF) of Alzheimer type. The NFT in case 2 consisted of straight tubules with infrequent segments of unusual twisted fibril of unknown nature. The simultaneous occurrence of straight and PHF in one of these cases suggests that the NFT in PSP may be similar to those of Alzheimer type occurring in various conditions.