Differential Diagnosis of Parkinson’s Disease and the Parkinsonism Plus Syndromes

Diagnostic performance of T2* gradient echo, susceptibility-weighted imaging, and quantitative susceptibility mapping for patients with multiple system atrophy-parkinsonian type: a systematic review and meta-analysis

OBJECTIVES

To investigate the diagnostic performance of T2*-weighted gradient echo (GRE) imaging, susceptibility-weighted imaging (SWI), or quantitative susceptibility mapping (QSM) in differentiating multiple system atrophy-parkinsonian type (MSA-P) from Parkinson's disease (PD).

METHODS

A systematic literature search through the MEDLINE and EMBASE databases was performed, starting on September 8, 2020, to identify studies evaluating the diagnostic performance of putaminal hypointensity on T2* GRE or SWI and phase shift on QSM in differentiating MSA-P from PD. The pooled sensitivity and specificity were obtained using hierarchical logistic regression modeling and hierarchical summary receiver operating characteristic (HSROC) modeling. The pooled diagnostic yields of T2* GRE, SWI, or QSM among MSA-P patients were calculated using the DerSimonian-Laird random-effects model.

RESULTS

Twelve original articles with 985 patients were finally included. SWI was performed in seven studies, T2* GRE was performed in three studies, and QSM was performed in two studies. The pooled sensitivity and specificity were 0.65 (95% CI 0.51-0.78) and 0.90 (95% CI 0.83-0.95), respectively. The area under the HSROC curve was 0.87 (95% CI 0.84-0.90). The Higgins I² statistic calculations revealed considerable heterogeneity in terms of both sensitivity (I² = 72.12%) and specificity (I² = 70.38%). The coupled forest plot revealed the threshold effect. For the nine studies in which area under the curve (AUC) was obtainable, the AUC ranged from 0.68 to 0.947, with a median of 0.819. The pooled diagnostic yield of T2* GRE, SWI, or QSM was 66% (95% CI 51-78%).

CONCLUSIONS

Putaminal hypointensity on T2* GRE or SWI and phase shift on QSM might be a promising diagnostic tool in differentiating MSA-P from PD. Further large multicenter prospective study is warranted.

KEY POINTS

• Three different index tests, definitions of positive image findings, thresholds, the way how to draw ROIs, reference standard, and MRI parameters could affect the heterogeneity of the study. • The pooled sensitivity and specificity were 0.65 (95% CI 0.51-0.78) and 0.90 (95% CI 0.83-0.95), respectively. • The pooled diagnostic yield of T2* GRE, SWI, or QSM was 66% (95% CI 51-78%).

Recall and Recognition Discriminability in Parkinson's Disease and Huntington's Disease

BACKGROUND

Parkinson's disease (PD) and Huntington's disease (HD) are two neurodegenerative diseases affecting frontal-striatal function and memory ability. Studies using the original California Verbal Learning Test (CVLT) to examine recall and recognition abilities between these groups have produced mixed findings. Some found that individuals with HD demonstrate worse recall and recognition than those with PD, whereas others reported comparable performance.

OBJECTIVE

We utilized multiple indices of recall and recognition discriminability, provided by the second and third editions of the CVLT (CVLT-II and CVLT-3, respectively), that allow for a more thorough assessment of more nuanced aspects of verbal memory function.

METHODS

We examined differences between individuals with PD (n = 72) and those with HD (n = 77) on CVLT-II indices of recall discriminability (immediate, short delay free and cued, long delay free and cued) and recognition discriminability (total, source, semantic, and novel) using standardized scores while controlling for education and Dementia Rating Scale-2 scores.

RESULTS

The HD group performed significantly worse than the PD group on all measures of recall and recognition discriminability (ps < 0.05), and group differences were associated with large Cohen's d effect sizes.

CONCLUSIONS

Our findings suggest that individuals with HD are more impaired than individuals with PD in more nuanced aspects of recall and recognition memory function. These CVLT indices yield more thorough assessments of recall and recognition memory function and have the potential to improve efforts to characterize and distinguish profiles of memory loss in different neurodegenerative populations, including PD and HD.

The Stroop Color and Word Test

The Stroop Color and Word Test (SCWT) is a neuropsychological test extensively used to assess the ability to inhibit cognitive interference that occurs when the processing of a specific stimulus feature impedes the simultaneous processing of a second stimulus attribute, well-known as the Stroop Effect. The aim of the present work is to verify the theoretical adequacy of the various scoring methods used to measure the Stroop effect. We present a systematic review of studies that have provided normative data for the SCWT. We referred to both electronic databases (i.e., PubMed, Scopus, Google Scholar) and citations. Our findings show that while several scoring methods have been reported in literature, none of the reviewed methods enables us to fully assess the Stroop effect. Furthermore, we discuss several normative scoring methods from the Italian panorama as reported in literature. We claim for an alternative scoring method which takes into consideration both speed and accuracy of the response. Finally, we underline the importance of assessing the performance in all Stroop Test conditions (word reading, color naming, named color-word).

A systematic review of lessons learned from PET molecular imaging research in atypical parkinsonism

PURPOSE

To systematically review the previous studies and current status of positron emission tomography (PET) molecular imaging research in atypical parkinsonism.

METHODS

MEDLINE, ISI Web of Science, Cochrane Library, and Scopus electronic databases were searched for articles published until 29th March 2016 and included brain PET studies in progressive supranuclear palsy (PSP), multiple system atrophy (MSA), and corticobasal syndrome (CBS). Only articles published in English and in peer-reviewed journals were included in this review. Case-reports, reviews, and non-human studies were excluded.

RESULTS

Seventy-seven PET studies investigating the dopaminergic system, glucose metabolism, microglial activation, hyperphosphorilated tau, opioid receptors, the cholinergic system, and GABA_A receptors in PSP, MSA, and CBS patients were included in this review. Disease-specific patterns of reduced glucose metabolism have shown higher accuracy than dopaminergic imaging techniques to distinguish between parkinsonian syndromes. Microglial activation has been found in all forms of atypical parkinsonism and reflects the known distribution of neuropathologic changes in these disorders. Opioid receptors are decreased in the striatum of PSP and MSA patients. Subcortical cholinergic dysfunction was more severe in MSA and PSP than Parkinson's disease patients although no significant changes in cortical cholinergic receptors were seen in PSP with cognitive impairment. GABA_A receptors were decreased in metabolically affected cortical and subcortical regions in PSP patients.

CONCLUSIONS

PET molecular imaging has provided valuable insight for understanding the mechanisms underlying atypical parkinsonism. Changes at a molecular level occur early in the course of these neurodegenerative diseases and PET imaging provides the means to aid differential diagnosis, monitor disease progression, identify of novel targets for pharmacotherapy, and monitor response to new treatments.

Rapidly progressive autosomal dominant Parkinsonism and dementia with Pallido-Ponto-Nigral Gegeneration (PPND) and Disinhibition-Dementia-Parkinsonism-Amyotrophy Complex (DDPAC) are clinically distinct conditions that are both linked to 17q21-22

Genetic analysis provides specific etiologic information about disease that cannot be deduced by clinical and pathologic investigations alone. Two large families have been characterized with multi-system degeneration: rapidly progressive autosomal dominant parkinsonism and dementia with pallido-ponto-nigral degeneration (PPND) and disinhibition-dementia-parkinsonism-amyotrophy complex (DDPAC). Linkage analysis identified a locus, wld, on-17q21-22 that is responsible for DDPAC. Analysis of a PPND family shows that PPND is also due to a gene on 17q21-22. Comparison of genealogic, clinical, diagnostic, and pathologic data shows that DDPAC and PPND are distinct disorders suggesting two different mutations in wld. Literature review identifies many kindreds with multi-system degeneration that may be allelic.

A longitudinal of Parkinson's disease: clinical and neuropsychological correlates of dementia

Neuropsychological assessments were performed in ninety-one de novo patients participating in the Sydney Multicentre Study of Parkinson's disease. Assessments were made at baseline and after 3 and 5 years. Performance at baseline and after 5 years was compared with controls. At baseline 37% of patients whose symptoms of Parkinson's disease had begun after the age of 70 years were demented. This compared with a prevalence of dementia of 8.8% in patients whose symptoms had begun before the age of 70 years. By 5 years the prevalence of dementia in the two groups had risen to 62.3% and 17.3% respectively. The death rate was higher over the 5 year period in the demented patients. Demented patients had more symmetrical signs, higher disability and bradykinesia scores and more impairment of gait and balance at baseline than non-demented patients. The presence of dementia at baseline predicted a poor response to treatment. The dementia at baseline had features of a subcortical dementia. Subsequently, aphasia, apraxia and agnosia emerged, making the dementia indistinguishable from that of Alzheimer's disease. Patients with well preserved cognitive function at baseline had a good response to levodopa and were more likely to develop levodopa induced dyskinesia. These results show that the clinical features of Parkinson's disease and response to treatment are influenced by the age of onset of symptoms and by the presence of dementia.

Typical cerebral metabolic patterns in neurodegenerative brain diseases

The differential diagnosis of neurodegenerative brain diseases on clinical grounds is difficult, especially at an early disease stage. Several studies have found specific regional differences of brain metabolism applying [(18)F]-fluoro-deoxyglucose positron emission tomography (FDG-PET), suggesting that this method can assist in early differential diagnosis of neurodegenerative brain diseases.We have studied patients who had an FDG-PET scan on clinical grounds at an early disease stage and included those with a retrospectively confirmed diagnosis according to strictly defined clinical research criteria. Ninety-six patients could be included of which 20 patients with Parkinson's disease (PD), 21 multiple system atrophy (MSA), 17 progressive supranuclear palsy (PSP), 10 corticobasal degeneration (CBD), 6 dementia with Lewy bodies (DLB), 15 Alzheimer's disease (AD), and 7 frontotemporal dementia (FTD). FDG PET images of each patient group were analyzed and compared to18 healthy controls using Statistical Parametric Mapping (SPM5).Disease-specific patterns of relatively decreased metabolic activity were found in PD (contralateral parietooccipital and frontal regions), MSA (bilateral putamen and cerebellar hemispheres), PSP (prefrontal cortex and caudate nucleus, thalamus, and mesencephalon), CBD (contralateral cortical regions), DLB (occipital and parietotemporal regions), AD (parietotemporal regions), and FTD (frontotemporal regions).The integrated method addressing a spectrum of various neurodegenerative brain diseases provided means to discriminate patient groups also at early disease stages. Clinical follow-up enabled appropriate patient inclusion. This implies that an early diagnosis in individual patients can be made by comparing each subject's metabolic findings with a complete database of specific disease related patterns.

The differential diagnoses of parkinsonism: findings from a cohort of 1528 patients and a 10 years comparison in tertiary movement disorders clinics

OBJECTIVE

To investigate the etiologic diagnoses of parkinsonism, underlining aspects of each form and comparing our findings with those published in a similar setting, 10 years before.

METHODS

A large cohort of 1528 patients with parkinsonism was analyzed, gathering data on demography, motor and non-motor characteristics, as well as the final etiologic diagnoses based on established criteria.

RESULTS

Parkinson's disease (PD) was the most common diagnosis representing 74.7%, followed by drug-induced parkinsonism (DIP) in 7.9%, vascular parkinsonism (VP) in 3.9%, other neurodegenerative disorders in 10%, and rare sporadic causes, divided as genetic, infectious and others, that summed 3.5%. Comparative analysis of these groups showed that each has particularities that extend beyond their diagnostic criteria.

CONCLUSIONS

The main conclusions are that the most important causes of parkinsonism in this setting are typical, with PD been the most common diagnosis, although other causes were frequent, encompassing one fourth of all cases. Although DIP was identified in a particularly large part of this cohort, this proportion is smaller than demonstrated previously in a Brazilian study conducted in the 90s. This decrease probably reflects higher awareness regarding the risk of this motor complication and the more widely used newer antipsychotics.

NMR-based metabolomic analysis of cerebrospinal fluid and serum in neurological diseases--a diagnostic tool?

We sought to evaluate the diagnostic accuracy of metabolomic biomarker profiles in neurological conditions (idiopathic intracranial hypertension (IIH), multiple sclerosis (MS) and cerebrovascular disease (CVD) compared to controls with either no neurological disease or mixed neurological diseases). Spectra of CSF (n = 87) and serum (n = 72) were acquired using (1)H NMR spectroscopy. Multivariate pattern recognition analysis was used to identify disease-specific metabolite biomarker profiles. The metabolite profiles were then used to predict the diagnosis of a second cohort of patients (n = 25). CSF metabolite profiles were able to predict diagnosis with a sensitivity and specificity of 80% for both IIH and MS. The CVD serum metabolite profile was 75% sensitive and specific. On analysing the second patient cohort, the established metabolite biomarker profiles generated from the first cohort showed moderate ability to segregate patients with IIH and MS (sensitivity:specificity of 63:75% and 67:75%, respectively). These findings suggest that NMR spectroscopic metabolic profiling of CSF and serum can identify differences between IIH, MS, CVD and mixed neurological diseases. Metabolomics may, therefore, have the potential to be developed into a clinically useful diagnostic tool. The identification of disease-unique metabolites may also impart information on disease pathology.

Posterior cortical brain dysfunction in cognitively impaired patients with Parkinson's disease--a rCBF scintigraphy study

OBJECTIVES

The aim of the study was to visualize cortical function in Parkinson's patients with various degrees of cognitive impairment.

MATERIALS AND METHODS

Thirty-seven patients with Parkinson's disease and three with Parkinson plus syndromes underwent cognitive assessment and rCBF using (99m)TC-HMPAO-SPECT.

RESULTS

Almost no regional reductions in cerebral blood flow were seen in patients without cognitive impairment (n = 16). Limited, mainly posterior, blood flow reductions were seen in patients with mild cognitive impairment (n = 14), whereas the reductions were extensive and bilaterally symmetric, involving both anterior and posterior brain regions in patients with dementia (n = 10).

CONCLUSIONS

The findings suggest a widespread cortical, mainly posterior type of dysfunction and a relationship between the degree of cognitive impairment and the magnitude of the dysfunction.

State-of-the-science review: Does manganese exposure during welding pose a neurological risk?

Recent studies report that exposure to manganese (Mn), an essential component of welding electrodes and some steels, results in neurotoxicity and/or Parkinson's disease (PD) in welders. This "state-of-the-science" review presents a critical analysis of the published studies that were conducted on a variety of Mn-exposed occupational cohorts during the last 100 yr, as well as the regulatory history of Mn and welding fumes. Welders often perform a variety of different tasks with varying degrees of duration and ventilation, and hence, to accurately assess Mn exposures that occurred in occupational settings, some specific information on the historical work patterns of welders is desirable. This review includes a discussion of the types of exposures that occur during the welding process--for which limited information relating airborne Mn levels with specific welding activities exists--and the human health studies evaluating neurological effects in welders and other Mn-exposed cohorts, including miners, millers, and battery workers. Findings and implications of studies specifically conducted to evaluate neurobehavioral effects and the prevalence of PD in welders are also discussed. Existing exposure data indicate that, in general, Mn exposures in welders are less than those associated with the reports of clinical neurotoxicity (e.g., "manganism") in miners and smelter workers. It was also found that although manganism was observed in highly exposed workers, the scant exposure-response data available for welders do not support a conclusion that welding is associated with clinical neurotoxicity. The available data might support the development of reasonable "worst-case" exposure estimates for most welding activities, and suggest that exposure simulation studies would significantly refine such estimates. Our review ends with a discussion of the data gaps and areas for future research.

Cognitive, Affective, and Psychiatric Features of Parkinson's Disease

Nonmotor symptoms, including cognitive deterioration and dementia, depression and apathy, and psychosis, are common in Parkinson's disease. Their presence is associated with a tremendous burden for the patient and family members. This article reviews the pathophysiololgy, risks, impact, major features, diagnosis, and treatment of these symptoms in Parkinson's disease.

The ubiquity of memory retrieval deficits in patients with frontal-striatal dysfunction

OBJECTIVE AND BACKGROUND

Previous studies have shown that patients with frontal-striatal dysfunction demonstrate improved performance on tests of recognition memory relative to free recall memory, suggesting deficits in retrieval processes. Not all studies, however, have indicated that all patients with frontal-striatal dysfunction display this profile. In this study, we examined the ubiquity of this "retrieval deficit" profile in a relatively large sample of patients with Parkinson disease (PD) or Huntington disease (HD).

METHODS

Participants included 150 patients with PD and 65 patients with HD. Patients were classified as demonstrating a retrieval deficit or not based on a comparison of their standardized performances on the Recognition Discriminability and Long-Delay Free Recall indices from the California Verbal Learning Test.

RESULTS

Results indicated that 1) a retrieval deficit was more prevalent in patients with HD than PD, 2) this group difference emerged only in patients with at least a mild level of global cognitive impairment, and 3) even when the profile did emerge more frequently in patients with HD, it was present in only 44% of the patients.

CONCLUSIONS

These findings suggest that not all patient groups with frontal-striatal dysfunction display a retrieval deficit profile, but in groups that do (ie, patients with HD), it is more likely to appear in individuals with greater cognitive impairment.

Evidence from biomarkers and surrogate endpoints

The use of physiological, anatomical, and other biological tests is commonplace in the practice of medicine. In neurology, objectively measured tests termed biomarkers (BMs) are playing an increasing role in diagnosis and management of disease, both in clinical practice and in experimental therapeutics. This article will discuss the various applications of BMs to the assessment of therapies for neurological diseases and will use examples from neurological diseases to elucidate the strengths and potential weaknesses of BMs. As the understanding of the pathophysiology of many neurological diseases has improved, new BMs have been developed, and efforts have been made to use these as proxies for clinical endpoints. A BM used in this manner is referred to as a surrogate endpoint (SE). There are many potential advantages and disadvantages of using SEs in the evaluation of new therapies, and these will be reviewed as well. Furthermore, the evidence required for the development of an SE and the nature of the evidence that can be derived from the use of BMs and SEs will be discussed.

Neuroimaging of Parkinson's disease and atypical parkinsonism

The basal ganglia and its associated circuitry can be assessed with a variety of neuroimaging methods that can provide information regarding specific neurotransmitter systems, the functional activity of brain regions, and the structural integrity of these regions. In Parkinson's disease (PD) and related atypical parkinsonian syndromes (APS), these imaging methods may be useful for many reasons, including aiding in differential diagnosis and measuring the efficacy of new therapies. This paper reviews recent developments in the application of neuroimaging to the assessment of PD and related APS.

Cutaneous sympathetic function and cardiovascular function in patients with progressive supranuclear palsy and Parkinson's disease

Some procedures, such as deep inspiration, increase sweat output (SSwR; sympathetic sweat response) and reduce cutaneous blood flow (SVR; skin vasomotor reflex) on the palm. We investigated SSwR, SVR, and cardiovascular function in 12 patients with progressive supranuclear palsy (PSP), 13 patients with Parkinson's disease (PD), and 9 healthy subjects. In the PSP patients, SSwR was severely diminished, whereas SVR was maintained and cardiovascular function was well preserved. In the PD patients, SSwR was relatively preserved, SVR was maintained, and some patients showed cardiovascular hypofunction. A combination of skin sympathetic and cardiovascular tests may be useful for distinguishing between PD and PSP.

Longitudinal evaluation of economic and physical impact of Parkinson's disease

The cost of parkinsonism and Parkinson's disease (PD) is largely unknown although clinical experience suggests that the impact of this disease is substantial. Longitudinal data is presented for health status, disease symptoms, functional status, and financial costs for 70 participants with PD or parkinsonism. The sample was dichotomized into those rating their health as excellent, good, or very good ('good health') and those rating their health as fair or poor ('poor health'). The 'poor health' group were significantly more disabled at baseline. Symptoms increased between year 1 and 3 with greatest increases in fatigue, pain, and depression for the 'good health' group. At year 1, total direct cost/capita was about dollars 5000/year for both groups; indirect costs were dollars 5000 for the 'good health' group and dollars 15,000/year for the 'poor health' group. By year 3, total expenditures increased over 25% for the 'good health' group and nearly doubled for the 'poor health' group, while percent costs that were compensated declined for groups. Out of pocket, expenses were as high as dollars 3000/year for the 'poor health' group by year 3. Through analysis of the broad impact of PD, including non-neurological symptoms and economic ramifications, it is possible to better appreciate the impact of this chronic condition on overall quality of life.

Neurobehavioral aspects of movement disorders

Cognitive, behavioral, affective, and psychiatric symptoms occur in almost all movement disorders. Diagnosis and management of movement disorders depends critically on an understanding of these neurobehavioral symptoms. This article reviews the neurobehavioral aspects of two representative movement disorders; Parkinson's disease and Huntington's disease.

Prevalence of Parkinson's disease in lower Aragon, Spain

OBJECTIVE

We attempted to measure the prevalence of Parkinson's disease (PD) and to improve PD diagnosis in Lower Aragon (LA), a rural area located in northeast Spain with an elderly population numbering 60,724.

METHODS

Hospital records and a questionnaire targeted at general practitioners and retirement home personnel were used for case finding. Neurologic diagnoses were ascertained by a neurologist using a clinicoepidemiologic protocol and established diagnostic criteria after examining 84% of patients diagnosed with PD. Using stratified analysis, a comparison was run against reported PD prevalence from worldwide door-to-door surveys.

RESULTS

On the prevalence date, 134 individuals were found to be affected with PD. The prevalence per 100,000 population was 220.6 (crude) and 121.9 when age-adjusted using the European Standard Population. Prevalence increased with age, declining at 90 years and over. Questionnaires returned by general practitioners disclosed 20% of the prevalent PD cases. The prevalence of PD in pooled European populations was 2.56 times (95% confidence interval [CI]: 2.02-3.24) greater than that found in our study.

CONCLUSION

PD prevalence in Lower Aragon ranks at levels similar to those reported for white populations (European and non-European). One out of two individuals with PD was estimated to be undiagnosed before and three out of eight after the study.

Clinical and genetic aspects of progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is, after Parkinson's disease, the most common form of degenerative parkinsonism. Several clinical features are used in the recognition of this disorder as well as in the differentiation from related disorders. Clinical criteria that could increase diagnostic accuracy in research studies are also emphasized. Due to a better understanding of the genetic aspects of PSP, recent studies have suggested that it is a recessive disorder in linkage disequilibrium with the tau (tau) gene, rather than a sporadic disorder. In addition, the recent identification of mutations in the tau gene associated with a similar neurodegenerative condition (frontotemporal dementia and parkinsonism linked to chromosome 17) has further strengthened the argument that tau dysfunction is somehow involved in the pathogenesis of PSP. Nongenetic factors that could trigger or perpetuate the cascade of events leading to neuronal degeneration in PSP are also reviewed.

Posteroventral medial pallidotomy for treatment of Parkinson's disease: preoperative magnetic resonance imaging features and clinical outcome

OBJECT

The goal of this study was to investigate the impact of mild or moderate degrees of degenerative or ischemic encephalopathy on predicting clinical outcome following unilateral posteroventral medial pallidotomy for treatment of advanced Parkinson's disease (PD).

METHODS

Thirty-five patients with PD were studied prospectively. The presence and degree of cortical atrophy, ventriculomegaly, deep white matter lesions (DWML), periventricular lucencies (PVL), and the presence of lacunes and status cribriformis (multiple and bilateral enlarged Virchow-Robin spaces) were determined by magnetic resonance (MR) imaging before the patients underwent stereotactic pallidotomy performed according to a standard protocol. Clinical outcome was measured using a standard battery of tests including application of the Unified Parkinson's Disease Rating Scale (UPDRS). The preoperative MR imaging features were correlated with UPDRS subscores such as motor "off' score, the activities of daily living (ADL) off score, the off subscore for bradykinesia, the percentage of "on" time dyskinesias, and a global outcome rating. The MR findings were also correlated with the occurrence of side effects. Global outcome was rated as markedly improved in 22 patients (63%) and as moderately improved in 12 patients (34%) 6 months postoperatively. At the 1-year follow-up examination, global outcome in 31 patients was rated as markedly improved in 14 patients (45%), as moderately improved in another 14 (45%), as slightly improved in two (6%), and as worse in one patient (3%). The mean UPDRS motor off score changed from 58.7 preoperatively to 33.2 at 6 months and 33.4 at 1 year (p < 0.0001), the ADL off score from 31.8 to 18.2 at 6 months and 18.6 at 1 year (p < 0.0001), the off score from contralateral bradykinesia from 11.6 to 5.6 at 6 months and 4.1 at 1 year (p < 0.0001), and the percentage of awake time with dyskinesias from 37.4 to 17.4% at 6 months and 21.1% at 1 year (p < 0.0001). The presence of mild or moderate degrees of cortical atrophy, PVL, and DWML had no effect on clinical outcome. Patients with status cribriformis and those with lacunes tended to show comparatively less improvement in the UPDRS ADL off score (p = 0.014 and p = 0.016, respectively) at 6 months. This tendency was also present in patients with status cribriformis 1 year postoperatively (p = 0.046). Patients with both status cribriformis and lacunes had a higher incidence of transient altered mental status immediately postoperatively (p = 0.05).

CONCLUSIONS

Mild-to-moderate degrees of cortical atrophy, ventriculomegaly, and ischemic encephalopathy do not predispose patients to less favorable outcomes following unilateral pallidotomy. Patients with both status cribriformis and lacunes have a higher risk of transient side effects; however, with regard to clinical outcome, these patients should not be denied surgical treatment.

Etiology of parkinsonism in a Brazilian movement disorders clinic

OBJECTIVE

The aim of the present study is to investigate whether there are geographic differences in the etiology of parkinsonism (PA).

BACKGROUND

72% of patients with PA evaluated at movement disorders clinics in the Northern Hemisphere are diagnosed with Parkinson's disease (PD). Data regarding other regions are not available.

METHODS

We reviewed the charts of all patients with PA seen at the Federal University of Minas Gerais Movement Disorders Clinic from July 1993 through October 1995. PA was diagnosed by the presence of at least two of the following: rest tremor, bradykinesia, rigidity, and postural instability. The different etiologies were diagnosed based on standard clinical criteria.

RESULTS

During the period of the study, PA was recognized in 338 subjects. The following clinical diagnoses were made: PD (68.9%), drug-induced PA (DIP) (13.3%), vascular PA (4.7%), Progressive supranuclear palsy (PSP) (2%), multiple system atrophy (MSA) (1.8%), others (9.7%). Cinnarizine, haloperidol and flunarizine were the commonest drugs related to DIP.

CONCLUSIONS

Similarly to other studies, PD accounts for about 70% of PA patients. However, there are differences between our results and previous series. DIP is much more common in the present series. This may be accounted for a more liberal use of antidopaminergic drugs in our environment, especially Calcium channel blockers. The lower frequency of MSA and PSP in our study may reflect a short follow-up, since many patients initially diagnosed with PD later are found to have Parkinson-plus syndromes.

Parkinson's disease

Parkinson's disease (PD) is one of the most common neurodegenerative diseases and affects 150 to 200 people per 100,000 population. Rapid advances have been made in the neurobiology of PD; this disorder is now recognized as a model of dysfunction in fronto-striatal circuits expressed by motor and behavioral symptoms. Several clinical and surgical strategies for the management of PD are discussed.

Microelectrode-guided posteroventral pallidotomy for treatment of Parkinson's disease: postoperative magnetic resonance imaging analysis

The authors report the postoperative magnetic resonance (MR) imaging findings in 36 patients with advanced Parkinson's disease who underwent unilateral microelectrode-guided posteroventral pallidotomy. The lesions were placed within 1 mm of the ventral border of the globus pallidus internus (GPi) to include pallidothalamic outflow pathways. Sequential MR studies were obtained within 1 to 3 days postoperatively and at 6-month follow-up examination. Thirty-four (94%) of the 36 patients enjoyed sustained moderate or marked improvement of their parkinsonian symptoms 6 months postoperatively. Transient side effects occurred in five patients (14%), but there were no persistent complications. The pallidal radiofrequency lesions were prolate spheroid shaped and were composed of three concentric zones in the early postoperative studies. The mean volume of the middle zone, corresponding to the area of hemorrhagic coagulation necrosis, was 44.4 +/- 17.6 mm3; the mean lesion volume as defined by the outer zone, corresponding to perilesional edema, was 262.2 +/- 111.6 mm3. Additional edema spreading to the internal capsule was noted in 32 of 34 cases and to the optic tract in 11 of 34 cases. In two patients small ischemic infarctions involving the corona radiata were found, and in one a venous infarction was detected. Ischemic infarction resulted in mild transient Broca's aphasia in one patient, but there was no detectable neurological deficit in the other two. The mean volume of late-phase (6 months) lesions was 22 +/- 28.8 mm3. In three patients no lesion was identified despite sustained clinical improvement. The lesion was located in the posteroventral GPi in all cases except in one patient in whom it was confined to the GP externus (GPe). This 49-year-old woman did not experience sustained benefit. The authors found no consistent correlations between lesion size and location and clinical outcome as measured by a global outcome score, the Unified Parkinson's Disease Rating Scale motor, activities of daily living, and bradykinesia "off" scores or rating of dyskinesias. Lesioning of pallidal and subpallidal pathways may contribute to the sustained clinical benefit in this series. Magnetic resonance imaging analysis showed that intraoperative microelectrode recording facilitated accurate placement of the lesion in this critical area.

The burden of Parkinson's disease on society, family, and the individual

OBJECTIVE

To examine the burden of Parkinson's Disease (PD) on society, family, and the individual.

SETTING

In-home interviews in Central North Carolina.

DESIGN

A cross-sectional, descriptive study.

PARTICIPANTS

A total of 109 people with PD.

MEASURES

Standard instruments used to assess income, health status, health-related costs, and household activities.

SAMPLE

The sample was weighted toward individuals who were within the first 5 years of post-PD diagnosis.

RESULTS

The total per capita societal burden was approximately $6000 per year, the greatest single element of which was compensation for earnings loss for those less than age 65. Government insurance covered 85% of our sample. The largest components of family burden were the burden of providing informal caregiving and that of earnings loss. Spouses providing informal care did so a mean of 22 hours per week. Compared with a random sample of older people, our respondents spent much less time on house and yard work.

CONCLUSION

The direct costs of the disease reflect a small portion of the burden. The hidden costs, in the form of lost wages, informal care, and changing roles are substantial. Their magnitude is even more important when we consider that the family generally lives on a fixed income, and the caregiver is an older aged spouse. Medical practitioners will best be able to intervene if they look holistically at the patient with this disease. When treating symptoms themselves, practitioners need to be aware of the high level of pain, fatigue, and depression associated with PD, even in the early stages. The results demonstrate clearly that family relationships are affected early, indicating the importance of providing early referrals to services such as home health, social workers/counseling, and well as PD support groups.

Microelectrode-guided posteroventral pallidotomy for treatment of Parkinson's disease: postoperative magnetic resonance imaging analysis

The authors report the postoperative magnetic resonance (MR) imaging findings in 36 patients with advanced Parkinson's disease who underwent unilateral microelectrode-guided posteroventral pallidotomy. The lesions were placed within 1 mm of the ventral border of the globus pallidus internus (GPi) to include pallidothalamic outflow pathways. Sequential MR studies were obtained within 1 to 3 days postoperatively and at 6-month follow-up examination. Thirty-four (94%) of the 36 patients enjoyed sustained moderate or marked improvement of their parkinsonian symptoms 6 months postoperatively. Transient side effects occurred in five patients (14%), but there were no persistent complications. The pallidal radiofrequency lesions were prolate spheroid-shaped and were composed of three concentric zones in the early postoperative studies. The mean volume of the middle zone, corresponding to the area of hemorrhagic coagulation necrosis, was 44.4 +/- 17.6 mm3; the mean lesion volume as defined by the outer zone, corresponding to perilesional edema, was 262.2 +/− 111.6 mm3. Additional edema spreading to the internal capsule was noted in 32 of 34 cases and to the optic tract in 11 of 34 cases. In two patients small ischemic infarctions involving the corona radiata were found, and in one a venous infarction was detected. Ischemic infarction resulted in mild transient Broca's aphasia in one patient, but there was no detectable neurological deficit in the other two. The mean volume of late-phase (6 months) lesions was 22 +/− 28.8 mm3. In three patients no lesion was identified despite sustained clinical improvement. The lesion was located in the posteroventral GPi in all cases except in one patient in whom it was confined to the GP externus (GPe). This 49-year-old woman did not experience sustained benefit. The authors found no consistent correlations between lesion size and location and clinical outcome as measured by a global outcome score, the Unified Parkinson's Disease Rating Scale motor, activities of daily living, and bradykinesia “off” scores or rating of dyskinesias. Lesioning of pallidal and subpallidal pathways may contribute to the sustained clinical benefit in this series. Magnetic resonance imaging analysis showed that intraoperative microelectrode recording facilitated accurate placement of the lesion in this critical area.

[Dementia in Parkinson's disease. Critical evaluation of the literature]

In the last 30 years, Parkinson's disease has been object of great progress. The majority of patients reaches a longer life with quality because of the modern therapeutic approach. However, dementia that can occur in the evolutive process, has its neuropathology not completely defined until now. There are lesions in the basal ganglia, in the ventral area of the mesencephalic tegmentum in the thalamus, in the substantia nigra and in the frontal cortex. The presence of Lewy bodies in the cortex is associated with dementia, in the same way that the anatomopathological features of Alzheimer's disease, in many cases. Dementia should have a multifactorial basis. Different types of neurotransmitters, like serotonin, acetylcholine and dopamine, or even hormones, like cortisol, may be altered in a great number of demented parkinsonians. Depression, found in up to 40% of patients, have been related as a risk factor for dementia, present approximately in 25% of cases. Studies in this area are still conflicting, with some confirming the relation among depression, cortical atrophy, hypercortisolemia and Parkinson's disease. Neuropsychologic studies show that the dementia in Parkinson's disease is of subcortical type. It is also known that parkinsonians, even those without cognitive deficiencies clinically significant, present deficits if submitted to more detailed neuropsychological tests. It is assumed, so, that cognitive impairments are intrinsic to the disease, varying its expression among patients. Dementia shall be diagnosed based on the criteria established in the diagnostic and statistical manual of mental disorders of the American Psychiatry Association, as well as computed tomography and magnetic resonance. For treatment, parkinsonian dementia does not recognize efficacious agents until now.

Age-standardized incidence and prevalence of Parkinson's disease in a Swedish community

Parkinson's disease (PD) shows a geographical variation. All prescriptions for anti-parkinsonian drugs were recorded for a half-year in a region with low L-dopa consumption. Hospital and outpatient records were studied and physicians were asked to supply details of PD patients in the region, with 147,777 inhabitants. The crude prevalence was 115 PD per 100,000 inhabitants, based on 170 cases. In contrast to other studies we report an age-standardized prevalence, which was 76 per 100,000, using the European Standard Population as reference. The corresponding approximate incidences were 11.0 (crude) and 7.9 (age-standardized) per 100,000 person-years. Male preponderance appeared in all age groups. Mean age at onset was 65.6 years, the highest figure reported. Variation between studies for age at onset, differences in prevalence, and male preponderance suggest environmental risk factors to be of importance for PD.

The neuropathology of chromosome 17-linked dementia

We recently described a family with chromosome 17-linked dementia, characterized clinically by disinhibition-dementia-parkinsonism-amyotrophy complex. We report now the neuropathology of 6 affected family members. This included semiquantitative scoring of neuronal loss, gliosis, and spongiosis and immunocytochemical and ultrastructural characterization of neuronal and glial inclusions. The changes consisted of circumscribed neuronal loss, gliosis, and spongiosis of limbic neocortical areas and frontal, temporal, and occipital association areas. Similar changes were present in subcortical nuclei, most severe in the substantia nigra, but also involved the ventral striatum and amygdala. The hippocampus was spared except for degeneration of the afferent perforant tract, secondary to entorhinal nerve cell loss. Argyrophilic neuronal inclusions, with a characteristic immunocytochemical profile, were found in brainstem nuclei, hypothalamus and basal ganglia. Ultrastructurally, in 3 patients these inclusions showed hitherto undescribed abnormally assembled filaments. Glial cytoplasmic inclusions were widespread in white matter structures. Immunocytochemistry failed to demonstrate the protease-resistant prion protein. The pathology appears to be unique, involving various cortical and subcortical structures, and is consistent with the clinical findings of Kluver-Bucy-like syndrome, parkinsonism, and frontal lobe dementia. For this entity we suggest the term "chromosome 17-linked dementia."

Neuropsychological trends in the parkinsonism-plus syndrome: a pilot study

Parkinsonism-Plus Syndrome (PPS) is a rare, degenerative disorder involving the subcortical structures of the brain. Little is known of the cognitive impairment, if any, that accompanies this syndrome. Initially PPS patients were thought to be cognitively intact; however, more recent research has suggested the presence of a frontal-lobe-like syndrome of intellectual deterioration. A battery of neuropsychological tests sensitive to subcortical dementia and frontal lobe deficit was administered to 4 female PPS patients aged between 35-49 years. The results of this pilot study indicated a distinct profile of memory dysfunction in PPS. The pattern observed differs from that seen in cortical disorders but is similar to that found in subcortical disorders. The hypothesis that a prominent frontal-lobe-like deficit exists in PPS was not supported.

Resting tremor only: a variant of Parkinson's disease or of essential tremor

Resting tremor is one of the characteristic features of Parkinson's disease. However, there are a number of patients who typically have resting tremor alone for at least 5 years without development of other parkinsonian signs or symptoms. The etiology of an isolated resting tremor is still obscure. Recently, positron emission tomography was used to study these patients with isolated resting tremor, and demonstrated a markedly decreased striatal uptake of fluoro-dopa to the range of Parkinson's disease. These findings suggested the existence of a separate subtype, namely, tremulous Parkinson's disease with a manifestation of resting tremor alone. In order to confirm the existence of this subgroup of tremulous Parkinson's disease and further investigate its morphological changes and the usefulness of magnetic resonance imaging, we collected 5 patients who typically have resting tremor for at least 8 years in the absence of other features of Parkinson's disease. MRI was performed and the results of the images showed typical findings of Parkinson's disease with smudging or decreased distance between substantia nigra and red nucleus. Quantitative analysis also demonstrated a significant decrease of the above-noted distance when the resting tremor group was compared to the essential tremor group. Therefore, patients with an isolated resting tremor can have morphological abnormalities in addition to functional disturbances shown by positron emission tomography. To our knowledge, this is the first paper to report that resting tremor is a variant of Parkinson's disease rather than essential tremor, by using a double-blind method, with magnetic resonance imaging to support.

Parkinsonian features of eight pathologically diagnosed cases of diffuse Lewy body disease

Premortem diagnosis of diffuse Lewy body disease (DLBD) is difficult, and knowledge of the parkinsonian features of DLBD might facilitate the diagnosis. In this study, we compared the parkinsonian syndrome of DLBD and Parkinson's disease (PD). We retrospectively reviewed the charts of Columbia-Presbyterian Medical Center (CPMC) Brain Bank cases (1989-1993) with pathologically diagnosed DLBD or PD, and the literature on the parkinsonian features in DLBD patients presenting with parkinsonism. Parkinsonism accompanied or preceded cognitive/psychiatric changes in most CPMC cases (DLBD 100%, PD 88%). DLBD had an earlier mean age of onset than PD did (57 versus 64 years), a similar male:female ratio (1.7:1 versus 1.9:1), and similar mean disease duration (12-13 years). Cognitive/psychiatric changes were less frequent in PD than in DLBD (65 versus 100%) (p = 0.025). Rest tremor was specifically mentioned in 29% of DLBD versus 56% of PD (p = 0.10). Bradykinesia was less common in PD (56% versus 86%) (p = 0.05). All those with PD responded to L-Dopa, as did all those with DLBD who received L-Dopa. In conclusion, there are subtle differences between PD and DLBD in age of onset, frequency of cognitive/psychiatric changes, bradykinesia, and rest tremor. However, even when taken together, these cannot be used to distinguish these entities.

Bilateral vocal cord paralysis with Shy-Drager syndrome

Shy-Drager syndrome consists of progressive autonomic nervous system failure with Parkinson's disease-like symptoms and orthostatic hypotension. It can also result in airway compromise from bilateral vocal cord paralysis. Fewer than 30 cases of severe bilateral vocal cord paresis or paralysis associated with the Shy-Drager syndrome have been reported in the English literature. We present a case of a 72-year-old man who had a 2-year history of orthostatic hypotension, neurogenic bladder, impotence, anhydrosis, and extremity weakness and paresthesias. Hoarseness and dyspnea with stridor developed as a result of bilateral vocal cord paralysis in the median position and required an emergency tracheotomy. This combination of symptoms resulted in the diagnosis of Shy-Drager syndrome. We present the case along with literature review of bilateral vocal cord paralysis with the Shy-Drager syndrome.

Neurogenic orthostatic hypotension: a double-blind, placebo-controlled study with midodrine

PURPOSE

To investigate the efficacy and safety of midodrine for treatment of patients with orthostatic hypotension due to autonomic failure.

PATIENTS

Ninety-seven patients with orthostatic hypotension were randomized in a 4-week, double-blinded, placebo-controlled study with a 1-week placebo run-in period. Patients ranged in age from 22 to 86 years (mean: 61 years).

METHODS

After a 1-week run-in phase, either placebo or midodrine at a dose of 2.5 mg, 5 mg, or 10 mg was administered three times a day for 4 weeks. Both the placebo group and the 2.5-mg midodrine group received constant doses throughout the double-blind phase. The patients receiving 5 mg or 10 mg of midodrine were given doses that were increased at weekly intervals by 2.5-mg increments until the designated dose was reached. Efficacy evaluations were based on an improvement at 1-hour postdose in standing systolic blood pressure and in symptoms of orthostatic hypotension (syncope, dizziness/lightheadedness, weakness/fatigue, and low energy level).

RESULTS

Midodrine (10 mg) increased standing systolic blood pressure by 22 mm Hg (28%, p < 0.001 versus placebo). Midodrine improved (p < 0.05) the following symptoms of orthostatic hypotension compared to placebo: dizziness/lightheadedness, weakness/fatigue, syncope, low energy level, impaired ability to stand, and feelings of depression. The overall side effects were mainly mild to moderate. One or more side effects were reported by 22% of the placebo group compared with 27% of the midodrine-treated group. Scalp pruritus/tingling, which was reported by 10 of 74 (13.5%) of the midodrine-treated patients, was most frequent. Other reported side effects included supine hypertension (8%) and feelings of urinary urgency (4%).

CONCLUSION

We conclude that midodrine is an effective and well-tolerated treatment for moderate-to-severe orthostatic hypotension associated with autonomic failure.

Striatal hypometabolism distinguishes striatonigral degeneration from Parkinson's disease

Regional and global metabolic rates for glucose were estimated using 18F-fluorodeoxyglucose and positron emission tomography in 10 patients with a clinical likelihood of striatonigral degeneration (2 men and 8 women; mean age, 61.8 +/- 6.9 years; mean disease duration, 4.7 +/- 2.2 years; mean Hoehn and Yahr score, 3.5 +/- 0.8). Measures of brain glucose metabolism in these patients were compared with those for 10 age-matched normal volunteers, 10 disease severity-matched patients with Parkinson's disease (PD), and 10 disease duration-matched patients with PD. Normalized glucose metabolism was significantly reduced in the caudate (p < 0.03) and putamen (p < 0.003) as compared with that in normal and PD control subjects, and discriminated patients with striatonigral degeneration from control subjects (p < 0.002). Putamenal hypometabolism in patients with striatonigral degeneration correlated significantly with quantitative ratings of motor disability (p < 0.02). These results suggest that quantitative 18F-fluorodeoxyglucose positron emission tomography techniques may be useful in supporting a diagnosis of striatonigral degeneration in life, and in objectively assessing disease severity and potential therapeutic interventions.