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Maiti B, Perlmutter JS. Imaging in Movement Disorders. Continuum (Minneap Minn) 2023; 29:194-218. [PMID: 36795878 DOI: 10.1212/con.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article reviews commonly used imaging modalities in movement disorders, particularly parkinsonism. The review includes the diagnostic utility, role in differential diagnosis, reflection of pathophysiology, and limitations of neuroimaging in the setting of movement disorders. It also introduces promising new imaging modalities and describes the current status of research. LATEST DEVELOPMENTS Iron-sensitive MRI sequences and neuromelanin-sensitive MRI can be used to directly assess the integrity of nigral dopaminergic neurons and thus may reflect disease pathology and progression throughout the full range of severity in Parkinson disease (PD). The striatal uptake of presynaptic radiotracers in their terminal axons as currently assessed using clinically approved positron emission tomography (PET) or single-photon emission computed tomography (SPECT) imaging correlates with nigral pathology and disease severity only in early PD. Cholinergic PET, using radiotracers that target the presynaptic vesicular acetylcholine transporter, constitutes a substantial advance and may provide crucial insights into the pathophysiology of clinical symptoms such as dementia, freezing, and falls. ESSENTIAL POINTS In the absence of valid, direct, objective biomarkers of intracellular misfolded α-synuclein, PD remains a clinical diagnosis. The clinical utility of PET- or SPECT-based striatal measures is currently limited given their lack of specificity and inability to reflect nigral pathology in moderate to severe PD. These scans may be more sensitive than clinical examination to detect nigrostriatal deficiency that occurs in multiple parkinsonian syndromes and may still be recommended for clinical use in the future to identify prodromal PD if and when disease-modifying treatments become available. Multimodal imaging to evaluate underlying nigral pathology and its functional consequences may hold the key to future advances.
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Natera-Villalba E, Martínez-Castrillo JC, López-Sendón Moreno JL, Gómez-López A, Sánchez-Sánchez A, López-Martínez MJ, Rábano A, Alonso-Cánovas A. Eye-of-the-Tiger Sign with an Unexpected Pathological Diagnosis. Mov Disord Clin Pract 2022; 9:98-103. [PMID: 35005073 DOI: 10.1002/mdc3.13366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/27/2021] [Accepted: 10/10/2021] [Indexed: 11/08/2022] Open
Abstract
Background Clinical diagnosis of atypical parkinsonisms may be challenging. The eye-of-the-tiger sign on brain MRI, typical of neurodegeneration with brain iron accumulation, has been anecdotally observed in cases clinically diagnosed as atypical parkinsonisms. Objectives To show how clinical syndromes and even neuroimaging sometimes may lead the neurologist to a misunderstanding, just as to emphasize the important role of pathology to establish the final diagnosis in these cases. Methods Clinico-pathological case. Results A 67-year-old-woman presented with progressive painful stiffness and allodynia in her left arm. On examination, she presented parkinsonism without tremor with greater involvement of left limbs. She developed dystonia, with myoclonic tremor and hypoesthesia involving her left arm, as well as an impairment of balance with falls, a significant axial involvement with disabling rigidity, supranuclear gaze abnormalities, facial dystonia, dysphonia, severe dysphagia, and anarthria. There was no response to levodopa. Syndromic diagnosis and findings on neuroimaging are discussed. Afterwards, the underlying pathology is revealed. Conclusions We present the first case of neuropathologically confirmed multiple system atrophy with the eye-of-the-tiger sign on brain MRI. The presence of supranuclear vertical gaze palsy further complicated a correct clinical diagnosis. A pathological postmortem study remains essential to establish a definite diagnosis in atypical parkinsonisms.
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Affiliation(s)
| | - Juan Carlos Martínez-Castrillo
- Neurology Department Hospital Universitario Ramón y Cajal Madrid Spain.,IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria). Hospital Universitario Ramón y Cajal Madrid Spain
| | - José Luis López-Sendón Moreno
- Neurology Department Hospital Universitario Ramón y Cajal Madrid Spain.,IRYCIS (Instituto Ramón y Cajal de Investigación Sanitaria). Hospital Universitario Ramón y Cajal Madrid Spain
| | - Ana Gómez-López
- Neurology Department Hospital Universitario Ramón y Cajal Madrid Spain
| | | | | | - Alberto Rábano
- Neuropathology and Tissue Bank Foundation Neurological Diseases Research Center Madrid Spain
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Lee JH, Yun JY, Gregory A, Hogarth P, Hayflick SJ. Brain MRI Pattern Recognition in Neurodegeneration With Brain Iron Accumulation. Front Neurol 2020; 11:1024. [PMID: 33013674 PMCID: PMC7511538 DOI: 10.3389/fneur.2020.01024] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/05/2020] [Indexed: 01/08/2023] Open
Abstract
Most neurodegeneration with brain iron accumulation (NBIA) disorders can be distinguished by identifying characteristic changes on magnetic resonance imaging (MRI) in combination with clinical findings. However, a significant number of patients with an NBIA disorder confirmed by genetic testing have MRI features that are atypical for their specific disease. The appearance of specific MRI patterns depends on the stage of the disease and the patient's age at evaluation. MRI interpretation can be challenging because of heterogeneously acquired MRI datasets, individual interpreter bias, and lack of quantitative data. Therefore, optimal acquisition and interpretation of MRI data are needed to better define MRI phenotypes in NBIA disorders. The stepwise approach outlined here may help to identify NBIA disorders and delineate the natural course of MRI-identified changes.
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Affiliation(s)
- Jae-Hyeok Lee
- Department of Neurology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan-si, South Korea
| | - Ji Young Yun
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Allison Gregory
- Departments of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR, United States
| | - Penelope Hogarth
- Departments of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR, United States
| | - Susan J Hayflick
- Departments of Molecular and Medical Genetics, Oregon Health and Science University, Portland, OR, United States
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Eye of the tiger sign in a 23year patient with mitochondrial membrane protein associated neurodegeneration. J Neurol Sci 2015; 352:110-1. [DOI: 10.1016/j.jns.2015.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/10/2015] [Accepted: 03/12/2015] [Indexed: 11/23/2022]
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Abstract
Purpose of review The aims of this review is to suggest a new nomenclature and classification system for the diseases currently categorized as neurodegeneration with brain iron accumulation (NBIA) or dystonia-parkinsonism, and to discuss the mechanisms implicated in the pathogenesis of these diseases. Recent findings NBIA is a disease category encompassing syndromes with iron accumulation and prominent dystonia–parkinsonism. However, as there are many diseases with similar clinical presentations but without iron accumulation and/or known genetic cause, the current classification system and nomenclature remain confusing. The pathogenetic mechanisms of these diseases and the causes of gross iron accumulation and significant burden of neuroaxonal spheroids are also elusive. Recent genetic and functional studies have identified surprising links between NBIA, Parkinson's disease and lysosomal storage disorders (LSD) with the common theme being a combined lysosomal–mitochondrial dysfunction. We hypothesize that mitochondria and lysosomes form a functional continuum with a predominance of mitochondrial and lysosomal pathways in NBIA and LSD, respectively, and with Parkinson's disease representing an intermediate form of disease. Summary During the past 18 months, important advances have been made towards understanding the genetic and pathological underpinnings of the pallidopyramidal syndromes with important implications for clinical practice and future treatment developments.
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van den Bogaard SJA, Kruit MC, Dumas EM, Roos RAC. Eye-of-the-tiger-sign in a 48 year healthy adult. J Neurol Sci 2013; 336:254-6. [PMID: 24268924 DOI: 10.1016/j.jns.2013.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/25/2013] [Accepted: 10/02/2013] [Indexed: 10/26/2022]
Abstract
We report a healthy adult male, who underwent, as a control subject, part of a Huntington's disease study, extensive testing during three visits in a two year follow-up, including clinical examination and 3.0 T MRI scans. The T2-weighted MRI sequences revealed the "eye-of-the-tiger-sign". No clinical abnormalities in either motor, cognitive or behavioural domains were observed. PKAN2 and FTL gene mutation analysis were negative. This finding implies that an eye-of-the-tiger sign, which is considered a pathognomonic feature of neurodegeneration with brain iron accumulation (NBIA), can occur without any clinical symptoms.
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Affiliation(s)
| | - Mark C Kruit
- Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Eve M Dumas
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Raymund A C Roos
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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Late onset neurodegeneration with brain-iron accumulation presenting as parkinsonism. Case Rep Neurol Med 2013; 2012:387095. [PMID: 23316402 PMCID: PMC3535819 DOI: 10.1155/2012/387095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/07/2012] [Indexed: 11/17/2022] Open
Abstract
Neurodegeneration with brain-iron accumulation (NBIA) encompasses a family of neurodegenerative disorders connected by evidence of abnormal brain iron deposition. Advances in imaging and genetic testing expanded the clinical spectrum of these disorders. Here, a case of parkinsonism and dystonia with orofacial stereotypies is presented. While the patient was initially diagnosed with Parkinson's disease and placed on levodopa therapy, dopamine transporter imaging via (123)I-FP-CIT SPECT (DaTSCAN) was normal. MRI brain showed "eye of the tiger" sign on T2 weighted imaging. NBIA should be considered in the differential diagnosis of atypical parkinsonism.
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Schneider SA, Dusek P, Hardy J, Westenberger A, Jankovic J, Bhatia KP. Genetics and Pathophysiology of Neurodegeneration with Brain Iron Accumulation (NBIA). Curr Neuropharmacol 2013; 11:59-79. [PMID: 23814539 PMCID: PMC3580793 DOI: 10.2174/157015913804999469] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 06/06/2012] [Accepted: 07/03/2012] [Indexed: 01/19/2023] Open
Abstract
Our understanding of the syndromes of Neurodegeneration with Brain Iron Accumulation (NBIA) continues to grow considerably. In addition to the core syndromes of pantothenate kinase-associated neurodegeneration (PKAN, NBIA1) and PLA2G6-associated neurodegeneration (PLAN, NBIA2), several other genetic causes have been identified (including FA2H, C19orf12, ATP13A2, CP and FTL). In parallel, the clinical and pathological spectrum has broadened and new age-dependent presentations are being described. There is also growing recognition of overlap between the different NBIA disorders and other diseases including spastic paraplegias, leukodystrophies and neuronal ceroid lipofuscinosis which makes a diagnosis solely based on clinical findings challenging. Autopsy examination of genetically-confirmed cases demonstrates Lewy bodies, neurofibrillary tangles, and other hallmarks of apparently distinct neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer's disease. Until we disentangle the various NBIA genes and their related pathways and move towards pathogenesis-targeted therapies, the treatment remains symptomatic. Our aim here is to provide an overview of historical developments of research into iron metabolism and its relevance in neurodegenerative disorders. We then focus on clinical features and investigational findings in NBIA and summarize therapeutic results reviewing reports of iron chelation therapy and deep brain stimulation. We also discuss genetic and molecular underpinnings of the NBIA syndromes.
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Affiliation(s)
- Susanne A Schneider
- Department of Neurology; University of Kiel, 24105 Kiel, Germany
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, UK
| | - Petr Dusek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - John Hardy
- Department of Molecular Neuroscience, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, England
| | - Ana Westenberger
- Schilling Section of Clinical and Molecular Neurogenetics at the Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, Queen Square, London WC1N 3BG, UK
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Schneider SA, Bhatia KP. Syndromes of neurodegeneration with brain iron accumulation. Semin Pediatr Neurol 2012; 19:57-66. [PMID: 22704258 DOI: 10.1016/j.spen.2012.03.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In parallel to recent developments of genetic techniques, understanding of the syndromes of neurodegeneration with brain iron accumulation has grown considerably. The acknowledged clinical spectrum continues to broaden, with age-dependent presentations being recognized. Postmortem brain examination of genetically confirmed cases has demonstrated Lewy bodies and/or tangles in some forms, bridging the gap to more common neurodegenerative disorders, including Parkinson disease. In this review, the major forms of neurodegeneration with brain iron accumulation (NBIA) are summarized, concentrating on clinical findings and molecular insights. In addition to pantothenate kinase-associated neurodegeneration (PKAN) and phospholipase A2-associated neurodegeneration (PLAN), fatty acid hydroxylase-associated neurodegeneration (FAHN) NBIA, mitochondrial protein-associated neurodegeneration, Kufor-Rakeb disease, aceruloplasminemia, neuroferritinopathy, and SENDA syndrome (static encephalopathy of childhood with neurodegeneration in adulthood) are discussed.
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Affiliation(s)
- Susanne A Schneider
- Schilling Section of Clinical and Molecular Neurogenetics, Department of Neurology, University of Lübeck, Lübeck, Germany.
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Mascalchi M, Vella A, Ceravolo R. Movement disorders: role of imaging in diagnosis. J Magn Reson Imaging 2012; 35:239-56. [PMID: 22271273 DOI: 10.1002/jmri.22825] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Magnetic resonance imaging (MRI and single-photon emission computed tomography (SPECT) have a considerable role in the diagnosis of the single patient with movement disorders. Conventional MRI demonstrates symptomatic causes of parkinsonism but does not show any specific finding in Parkinson's disease (PD). However, SPECT using tracers of the dopamine transporter (DAT) demonstrates an asymmetric decrease of the uptake in the putamen and caudate from the earliest clinical stages. In other degenerative forms of parkinsonism, including progressive supranuclear palsy (PSP), multisystem atrophy (MSA), and corticobasal degeneration (CBD), MRI reveals characteristic patterns of regional atrophy combined with signal changes or microstructural changes in the basal ganglia, pons, middle and superior cerebellar peduncles, and cerebral subcortical white matter. SPECT demonstrates a decreased uptake of tracers of the dopamine D2 receptors in the striata of patients with PSP and MSA, which is not observed in early PD. MRI also significantly contributes to the diagnosis of some inherited hyperkinetic conditions including neurodegeneration with brain iron accumulation and fragile-X tremor/ataxia syndrome by revealing characteristic symmetric signal changes in the basal ganglia and middle cerebellar peduncles, respectively. A combination of the clinical features with MRI and SPECT is recommended for optimization of the diagnostic algorithm in movement disorders.
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Affiliation(s)
- Mario Mascalchi
- Radiodiagnostic Section, Department of Clinical Physiopathology, University of Florence, Florence, Italy.
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Iron dysregulation in movement disorders. Neurobiol Dis 2012; 46:1-18. [DOI: 10.1016/j.nbd.2011.12.054] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 12/22/2011] [Accepted: 12/31/2011] [Indexed: 01/04/2023] Open
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Schneider SA, Hardy J, Bhatia KP. Syndromes of neurodegeneration with brain iron accumulation (NBIA): An update on clinical presentations, histological and genetic underpinnings, and treatment considerations. Mov Disord 2011; 27:42-53. [DOI: 10.1002/mds.23971] [Citation(s) in RCA: 133] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 08/09/2011] [Accepted: 08/15/2011] [Indexed: 11/07/2022] Open
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Brüggemann N, Wuerfel J, Petersen D, Klein C, Hagenah J, Schneider SA. Idiopathic NBIA - clinical spectrum and transcranial sonography findings. Eur J Neurol 2011; 18:e58-9. [DOI: 10.1111/j.1468-1331.2010.03298.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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