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Hamaguchi T, Sanjo N, Ae R, Nakamura Y, Sakai K, Takao M, Murayama S, Iwasaki Y, Satoh K, Murai H, Harada M, Tsukamoto T, Mizusawa H, Yamada M. MM2-type sporadic Creutzfeldt-Jakob disease: new diagnostic criteria for MM2-cortical type. J Neurol Neurosurg Psychiatry 2020; 91:1158-1165. [PMID: 32839349 DOI: 10.1136/jnnp-2020-323231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/05/2020] [Accepted: 07/08/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To clinically diagnose MM2-cortical (MM2C) and MM2-thalamic (MM2T)-type sporadic Creutzfeldt-Jakob disease (sCJD) at early stage with high sensitivity and specificity. METHODS We reviewed the results of Creutzfeldt-Jakob disease Surveillance Study in Japan between April 1999 and September 2019, which included 254 patients with pathologically confirmed prion diseases, including 9 with MM2C-type sCJD (MM2C-sCJD) and 10 with MM2T-type sCJD (MM2T-sCJD), and 607 with non-prion diseases. RESULTS According to the conventional criteria of sCJD, 4 of 9 patients with MM2C- and 7 of 10 patients with MM2T-sCJD could not be diagnosed with probable sCJD until their death. Compared with other types of sCJD, patients with MM2C-sCJD showed slower progression of the disease and cortical distribution of hyperintensity lesions on diffusion-weighted images of brain MRI. Patients with MM2T-sCJD also showed relatively slow progression and negative results for most of currently established investigations for diagnosis of sCJD. To clinically diagnose MM2C-sCJD, we propose the new criteria; diagnostic sensitivity and specificity to distinguish 'probable' MM2C-sCJD from other subtypes of sCJD, genetic or acquired prion diseases and non-prion disease controls were 77.8% and 98.5%, respectively. As for MM2T-sCJD, clinical and laboratory features are not characterised enough to develop its diagnostic criteria. CONCLUSIONS MM2C-sCJD can be diagnosed at earlier stage using the new criteria with high sensitivity and specificity, although it is still difficult to diagnose MM2T-sCJD clinically.
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Affiliation(s)
- Tsuyoshi Hamaguchi
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Nobuo Sanjo
- Department of Neurology and Neurological Science, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Ryusuke Ae
- Department of Public Health, Jichi Medical University, Shimotsuke, Japan
| | - Yosikazu Nakamura
- Department of Public Health, Jichi Medical University, Shimotsuke, Japan
| | - Kenji Sakai
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Masaki Takao
- Department of Neurology and Cerebrovascular Medicine, Saitama International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Shigeo Murayama
- Department of Neurology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Yasushi Iwasaki
- Department of Neuropathology, Aichi Medical University, Nagakute, Japan
| | - Katsuya Satoh
- Department of Locomotive Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroyuki Murai
- Department of Neurology, International University of Health and Welfare, Narita, Japan
| | - Masafumi Harada
- Department of Radiology, Tokushima University Graduate School, Tokushima, Japan
| | - Tadashi Tsukamoto
- Department of Neurology, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Hidehiro Mizusawa
- Department of Neurology, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Masahito Yamada
- Department of Neurology and Neurobiology of Aging, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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Baldelli L, Provini F. Fatal familial insomnia and Agrypnia Excitata: Autonomic dysfunctions and pathophysiological implications. Auton Neurosci 2019; 218:68-86. [PMID: 30890351 DOI: 10.1016/j.autneu.2019.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/23/2019] [Accepted: 02/24/2019] [Indexed: 01/26/2023]
Abstract
Fatal Familial Insomnia (FFI) is a hereditary prion disease caused by a mutation at codon 178 of the prion-protein gene leading to a D178N substitution in the protein determining severe and selective atrophy of mediodorsal and anteroventral thalamic nuclei. FFI is characterized by physiological sleep loss, which polygraphically appears to be a slow wave sleep loss, autonomic and motor hyperactivation with peculiar episodes of oneiric stupor. Alteration of autonomic functions is a great burden for FFI patients consisting in sympathetic overactivation, dysregulation of its physiological responses and disruption of circadian rhythms. The cardiovascular system is the most frequently and severely affected confirming the increased sympathetic drive with preserved parasympathetic responses. Sleep loss, autonomic and motor hyperactivation define Agrypnia Excitata (AE), which is not exclusive to FFI, but it has been canonically described also in Morvan Syndrome and Delirium Tremens. These three conditions present different pathophysiological mechanisms but share the same thalamo-limbic impairment of which AE is one of the possible clinical presentations. FFI, and consequently also AE, is a model for the investigation of the essential role of the thalamus in the organization of body homeostasis, integrating both sleep and autonomic function control.
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Affiliation(s)
- Luca Baldelli
- Department of Biomedical and NeuroMotor Sciences (DiBiNeM), University of Bologna, Italy
| | - Federica Provini
- Department of Biomedical and NeuroMotor Sciences (DiBiNeM), University of Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
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Abu-Rumeileh S, Redaelli V, Baiardi S, Mackenzie G, Windl O, Ritchie DL, Didato G, Hernandez-Vara J, Rossi M, Capellari S, Imperiale D, Rizzone MG, Belotti A, Sorbi S, Rozemuller AJM, Cortelli P, Gelpi E, Will RG, Zerr I, Giaccone G, Parchi P. Sporadic Fatal Insomnia in Europe: Phenotypic Features and Diagnostic Challenges. Ann Neurol 2018; 84:347-360. [PMID: 30048013 DOI: 10.1002/ana.25300] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 06/28/2018] [Accepted: 07/22/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Comprehensively describe the phenotypic spectrum of sporadic fatal insomnia (sFI) to facilitate diagnosis and management of this rare and peculiar prion disorder. METHODS A survey among major prion disease reference centers in Europe identified 13 patients diagnosed with sFI in the past 20 years. We undertook a detailed analysis of clinical and histopathological features and the results of diagnostic investigations. RESULTS Mean age at onset was 43 years, and mean disease duration 30 months. Early clinical findings included psychiatric, sleep, and oculomotor disturbances, followed by cognitive decline and postural instability. In all tested patients, video-polysomnography demonstrated a severe reduction of total sleep time and/or a disorganized sleep. Cerebrospinal fluid (CSF) levels of proteins 14-3-3 and t-tau were unrevealing, the concentration of neurofilament light protein (NfL) was more consistently increased, and the real-time quaking-induced conversion assay (RT-QuIC) revealed a positive prion seeding activity in 60% of cases. Electroencephalography and magnetic resonance imaging showed nonspecific findings, whereas fluorodeoxyglucose positron emission tomography (FDG-PET) demonstrated a profound bilateral thalamic hypometabolism in 71% of cases. Molecular analyses revealed PrPSc type 2 and methionine homozygosity at PRNP codon 129 in all cases. INTERPRETATION sFI is a disease of young or middle-aged adults, which is difficult to reconcile with the hypothesis of a spontaneous etiology related to stochastic, age-related PrP misfolding. The combination of psychiatric and/or sleep-related symptoms with oculomotor abnormalities represents an early peculiar clinical feature of sFI to be valued in the differential diagnosis. Video-polysomnography, FDG-PET, and especially CSF prion RT-QuIC and NfL constitute the most promising supportive diagnostic tests in vivo. Ann Neurol 2018;84:347-360.
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Affiliation(s)
- Samir Abu-Rumeileh
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Veronica Redaelli
- Neurology and Neuropathology Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Simone Baiardi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Graeme Mackenzie
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, Scotland, United Kingdom
| | - Otto Windl
- Center for Neuropathology and Prion Research, Ludwig Maximilian University, Munich, Germany
| | - Diane L Ritchie
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, Scotland, United Kingdom
| | - Giuseppe Didato
- Clinical and Experimental Epileptology, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | | | - Marcello Rossi
- IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Sabina Capellari
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | | | | | | | - Sandro Sorbi
- Department of Neuroscience, Psychology, Drug Research, and Child Health, University of Florence, Florence, Italy.,IRCCS Don Gnocchi, Florence, Italy
| | | | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Ellen Gelpi
- Neurological Tissue Bank of the Biobanc, - Hospital Clínic - Institut d'Investigacions Biomédiques, August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain.,Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Robert G Will
- National CJD Research & Surveillance Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, Scotland, United Kingdom
| | - Inga Zerr
- Department of Neurology, University Medical School, Göttingen, Germany
| | - Giorgio Giaccone
- Neurology and Neuropathology Unit, IRCCS Foundation Carlo Besta Neurological Institute, Milan, Italy
| | - Piero Parchi
- IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy.,Department of Experimental, Diagnostic, and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
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de la Torre JC. Are Major Dementias Triggered by Poor Blood Flow to the Brain? Theoretical Considerations. J Alzheimers Dis 2018; 57:353-371. [PMID: 28211814 DOI: 10.3233/jad-161266] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
There is growing evidence that chronic brain hypoperfusion plays a central role in the development of Alzheimer's disease (AD) long before dyscognitive symptoms or amyloid-β accumulation in the brain appear. This commentary proposes that dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), and Creutzfeldt-Jakob disease (CJD) may also develop from chronic brain hypoperfusion following a similar but not identical neurometabolic breakdown as AD. The argument to support this conclusion is that chronic brain hypoperfusion, which is found at the early stages of the three dementias reviewed here, will reduce oxygen delivery and lower oxidative phosphorylation promoting a steady decline in the synthesis of the cell energy fuel adenosine triphosphate (ATP). This process is known to lead to oxidative stress. Virtually all neurodegenerative diseases, including FTD, DLB, and CJD, are characterized by oxidative stress that promotes inclusion bodies which differ in structure, location, and origin, as well as which neurological disorder they typify. Inclusion bodies have one thing in common; they are known to diminish autophagic activity, the protective intracellular degradative process that removes malformed proteins, protein aggregates, and damaged subcellular organelles that can disrupt neuronal homeostasis. Neurons are dependent on autophagy for their normal function and survival. When autophagic activity is diminished or impaired in neurons, high levels of unfolded or misfolded proteins overwhelm and downregulate the neuroprotective activity of unfolded protein response which is unable to get rid of dysfunctional organelles such as damaged mitochondria and malformed proteins at the synapse. The endpoint of this neuropathologic process results in damaged synapses, impaired neurotransmission, cognitive decline, and dementia.
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Abstract
Fatal familial insomnia (FFI) and sporadic fatal insomnia (sFI), or thalamic form of sporadic Creutzfeldt-Jakob disease MM2 (sCJDMM2T), are prion diseases originally named and characterized in 1992 and 1999, respectively. FFI is genetically determined and linked to a D178N mutation coupled with the M129 genotype in the prion protein gene (PRNP) at chromosome 20. sFI is a phenocopy of FFI and likely its sporadic form. Both diseases are primarily characterized by progressive sleep impairment, disturbances of autonomic nervous system, and motor signs associated with severe loss of nerve cells in medial thalamic nuclei. Both diseases harbor an abnormal disease-associated prion protein isoform, resistant to proteases with relative mass of 19 kDa identified as resPrPTSE type 2. To date at least 70 kindreds affected by FFI with 198 members and 18 unrelated carriers along with 25 typical cases of sFI have been published. The D178N-129M mutation is thought to cause FFI by destabilizing the mutated prion protein and facilitating its conversion to PrPTSE. The thalamus is the brain region first affected. A similar mechanism triggered spontaneously may underlie sFI.
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Hayashi Y. Pathological examination is required for the case of rapidly progressive dementia with only positive result of RT-QUIC assay. Prion 2017; 11:469-470. [PMID: 29095104 DOI: 10.1080/19336896.2017.1398879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Yuichi Hayashi
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
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Hayashi Y, Yamada M, Kimura A, Asano T, Satoh K, Kitamoto T, Yoneda M, Inuzuka T. Clinical findings of a probable case of MM2-cortical-type sporadic Creutzfeldt-Jakob disease with antibodies to anti-N-terminus of α-enolase. Prion 2017; 11:454-464. [PMID: 28967811 DOI: 10.1080/19336896.2017.1377876] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
We report the case of a 76-year-old woman presenting with 47-month history of progressive dementia and cortical blindness with no family history. Antibodies against thyroid glands and the N-terminus of α-enolase (NAE) were detected in her serum. Neurological examination revealed progressive dementia, frontal signs, visual disturbance, and exaggerated bilateral tendon reflexes in both legs. Diffusion MRI showed cortical hyper-intensities in the bilateral occipital and parietal, and the left frontal and temporal cortices. 99mTc-ethyl cysteinate dimer-single photon emission computed tomography indicated decreased regional cerebral blood flow throughout the bilateral parietal lobes and partially in the left frontal and temporal lobes. PRNP gene analysis showed no mutations with methionine homozygosity at codon 129 in peripheral blood. Cerebrospinal fluid examination, including 14-3-3 and total tau protein detection, revealed normal levels; however, prion proteins were amplified by the real-time quaking-induced conversion method. Hashimoto's encephalopathy was excluded on the basis of unresponsiveness to corticosteroids. The symptoms progressed slowly. Periodic sharp-wave complexes were observed on electroencephalogram 36 months after the onset of symptoms; the patient reached a state of akinetic mutism at 47 months. This was a probable case of MM2-cortical-type sCJD with anti-NAE antibodies based on the World Health Organization (WHO) diagnostic criteria for sCJD, genetic information, and the slowly progressive course. However, this case did not meet with the probable WHO diagnostic criteria until 3 years after symptom onset, highlighting the difficulty of diagnosing a living case of the MM2-type of sCJD. Therefore, establishment of clinical diagnostic criteria for MM2-type of sCJD is required.
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Affiliation(s)
- Yuichi Hayashi
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Megumi Yamada
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Akio Kimura
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Takahiko Asano
- b Department of Radiology , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Katsuya Satoh
- c Department of Locomotive Rehabilitation Sciences , Nagasaki University Graduate School of Medicine , Nagasaki , Japan
| | - Tetsuyuki Kitamoto
- d Division of CJD Science and Technology , Department of Prion Research, Center for Translational and Advanced Animal Research on Human Diseases, Tohoku University School of Medicine , Sendai , Japan
| | - Makoto Yoneda
- e Faculty of Nursing and Social Welfare Science/ Department of Nursing Sciences , Fukui Prefectural University , Fukui , Japan
| | - Takashi Inuzuka
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
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Hayashi Y, Inuzuka T. A multidisciplinary medical network approach is crucial for increasing the number of autopsies for prion disease [Reply to: How can we increase the numbers of autopsies for prion disease? A model system in Japan]. J Neurol Sci 2017; 377:95-96. [PMID: 28477717 DOI: 10.1016/j.jns.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/05/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Yuichi Hayashi
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan.
| | - Takashi Inuzuka
- Department of Neurology and Geriatrics, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu 501-1194, Japan
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Hayashi Y, Iwasaki Y, Takekoshi A, Yoshikura N, Asano T, Mimuro M, Kimura A, Satoh K, Kitamoto T, Yoshida M, Inuzuka T. An autopsy-verified case of FTLD-TDP type A with upper motor neuron-predominant motor neuron disease mimicking MM2-thalamic-type sporadic Creutzfeldt-Jakob disease. Prion 2016; 10:492-501. [PMID: 27929803 DOI: 10.1080/19336896.2016.1243192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Here we report an autopsy-verified case of frontotemporal lobar degeneration (FTLD)-transactivation responsive region (TAR) DNA binding protein (TDP) type A with upper motor neuron-predominant motor neuron disease mimicking MM2-thalamic-type sporadic Creutzfeldt-Jakob disease (sCJD). A 69-year-old woman presented with an 11-month history of progressive dementia, irritability, insomnia, and gait disturbance without a family history of dementia or prion disease. Neurological examination revealed severe dementia, frontal signs, and exaggerated bilateral tendon reflexes. Periodic sharp-wave complexes were not observed on the electroencephalogram. Brain diffusion MRI did not reveal abnormal changes. An easy Z score (eZIS) analysis for 99mTc-ECD-single photon emission computed tomography (99mTc-ECD-SPECT) revealed a bilateral decrease in thalamic regional cerebral blood flow (rCBF). PRNP gene analysis demonstrated methionine homozygosity at codon 129 without mutation. Cerebrospinal fluid (CSF) analysis showed normal levels of both 14-3-3 and total tau proteins. Conversely, prion protein was slowly amplified in the CSF by a real-time quaking-induced conversion assay. Her symptoms deteriorated to a state of akinetic mutism, and she died of sudden cardiac arrest, one year after symptom onset. Despite the SPECT results supporting a clinical diagnosis of MM2-thalamic-type sCJD, a postmortem assessment revealed that this was a case of FTLD-TDP type A, and excluded prion disease. Thus, this case indicates that whereas a bilateral decreasing thalamic rCBF detected by 99mTc-ECD-SPECT can be useful for diagnosing MM2-thalamic-type sCJD, it is not sufficiently specific. Postmortem diagnosis remains the gold standard for the diagnosis of this condition.
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Affiliation(s)
- Yuichi Hayashi
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Yasushi Iwasaki
- b Department of Neuropathology , Institute for Medical Science of Aging, Aichi Medical University , Nagakute , Japan
| | - Akira Takekoshi
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Nobuaki Yoshikura
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Takahiko Asano
- c Department of Radiology , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Maya Mimuro
- b Department of Neuropathology , Institute for Medical Science of Aging, Aichi Medical University , Nagakute , Japan
| | - Akio Kimura
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
| | - Katsuya Satoh
- d Department of Locomotive Rehabilitation Sciences . Nagasaki University Graduate School of Medicine , Nagasaki , Japan
| | - Tetsuyuki Kitamoto
- e Division of CJD Science and Technology, Department of Prion Research , Center for Translational and Advanced Animal Research on Human Diseases, Tohoku University School of Medicine , Sendai , Japan
| | - Mari Yoshida
- b Department of Neuropathology , Institute for Medical Science of Aging, Aichi Medical University , Nagakute , Japan
| | - Takashi Inuzuka
- a Department of Neurology and Geriatrics , Gifu University Graduate School of Medicine , Gifu , Japan
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Preserved regional cerebral blood flow in the occipital cortices, brainstem, and cerebellum of patients with V180I-129M genetic Creutzfeldt-Jakob disease in serial SPECT studies. J Neurol Sci 2016; 370:145-151. [PMID: 27772745 DOI: 10.1016/j.jns.2016.09.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/13/2016] [Accepted: 09/21/2016] [Indexed: 12/12/2022]
Abstract
Creutzfeldt-Jakob disease (CJD) with a causative point mutation of valine to isoleucine at codon 180 (V180I) is one of the major types of genetic CJD (gCJD) in Japan. V180I gCJD is rarely accompanied by a family history, and its clinical characteristics include late-onset, long disease duration, and edematous cortical hyperintensity in diffusion, fluid attenuate inversion and T2-weighted MRI. We performed serial imaging with single-photon emission computed tomography (SPECT) and MRI in three V180I gCJD cases over long-term observation. All cases were characterized by progressive dementia, parkinsonism, and the absence of cerebellar signs or cortical visual dysfunction in their clinical courses. Moreover, during the end-stage, SPECT findings showed preserved regional cerebral blood flow (rCBF) in the occipital cortices, brainstem, and cerebellum. Similarly, no apparent atrophy or increased signal intensities were observed in MRI images of the occipital and cerebellar regions. In conclusion, we report a decrease in rCBF predominantly in the frontal and temporal cortices during the early-stage, which became more widespread as the disease progressed. Importantly, rCBF was preserved in the occipital cortices, brainstem, and cerebellar regions until the end-stage, which may be distinct to V180I gCJD cases.
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