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Kawazoe T, Sugaya K, Nakata Y, Okitsu M, Takahashi K. Two distinct degenerative types of nigrostriatal dopaminergic neuron in the early stage of parkinsonian disorders. Clin Park Relat Disord 2024; 10:100242. [PMID: 38405025 PMCID: PMC10883825 DOI: 10.1016/j.prdoa.2024.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction The present study characterized the degeneration of nigrostriatal dopaminergic neurons in the early stages of parkinsonian disorders using integrative neuroimaging analysis with neuromelanin-sensitive MRI and 123I-FP-CIT dopamine transporter (DAT) SPECT. Methods Thirty-one, 30, and 29 patients with progressive supranuclear palsy (PSP), corticobasal syndrome (CBS) with abnormal specific binding ratio (SBR) in either hemisphere (mean ± 2SD), and parkinsonism-predominant multiple system atrophy (MSA-P), respectively, were enrolled. Neuromelanin-related contrast (NRC) in the substantia nigra (NRCSN) and locus coeruleus (NRCLC) and the SBR of DAT SPECT were measured. All the patients underwent both examinations simultaneously within five years after symptom onset. After adjusting for interhemispheric asymmetry on neuromelanin-related MRI contrast using the Z-score, linear regression analysis of the NRCSN and SBR was performed for the most- and least-affected hemispheres, as defined by the interhemispheric differences per variable (SBR, NRCSN, standardized [SBR + NRCSN]) in each patient. Results Although the variables did not differ significantly between PSP and CBS, a significant correlation was found for CBS in the most-affected hemisphere for all the definitions, including the clinically defined, most-affected hemisphere. No significant correlation was found between the NRCSN and SBR for any of the definitions in either PSP or MSA-P. Conclusion Together with the findings of our previous study of dementia with Lewy bodies (DLB) and Parkinson's disease (PD), the present findings indicated that neural degeneration in the disorders examined may be categorized by the significance of the NRCSN-SBR correlation in PD and CBS and its non-significance in DLB, PSP, and MSA-P.
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Affiliation(s)
- Tomoya Kawazoe
- Department of Neurology, Tokyo Metropolitan Neurological Hospital (TMNH), Tokyo, Japan
| | - Keizo Sugaya
- Department of Neurology, Tokyo Metropolitan Neurological Hospital (TMNH), Tokyo, Japan
| | | | - Masato Okitsu
- Department of Neurology, Tokyo Metropolitan Neurological Hospital (TMNH), Tokyo, Japan
| | - Kazushi Takahashi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital (TMNH), Tokyo, Japan
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Gusinu G, Frau C, Trunfio GA, Solla P, Sechi LA. Segmentation of Substantia Nigra in Brain Parenchyma Sonographic Images Using Deep Learning. J Imaging 2023; 10:1. [PMID: 38276318 PMCID: PMC11154334 DOI: 10.3390/jimaging10010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 01/27/2024] Open
Abstract
Currently, Parkinson's Disease (PD) is diagnosed primarily based on symptoms by experts clinicians. Neuroimaging exams represent an important tool to confirm the clinical diagnosis. Among them, Brain Parenchyma Sonography (BPS) is used to evaluate the hyperechogenicity of Substantia Nigra (SN), found in more than 90% of PD patients. In this article, we exploit a new dataset of BPS images to investigate an automatic segmentation approach for SN that can increase the accuracy of the exam and its practicability in clinical routine. This study achieves state-of-the-art performance in SN segmentation of BPS images. Indeed, it is found that the modified U-Net network scores a Dice coefficient of 0.859 ± 0.037. The results presented in this study demonstrate the feasibility and usefulness of SN automatic segmentation in BPS medical images, to the point that this study can be considered as the first stage of the development of an end-to-end CAD (Computer Aided Detection) system. Furthermore, the used dataset, which will be further enriched in the future, has proven to be very effective in supporting the training of CNNs and may pave the way for future studies in the field of CAD applied to PD.
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Affiliation(s)
- Giansalvo Gusinu
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy; (G.G.); (G.A.T.)
| | - Claudia Frau
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy; (C.F.); (P.S.)
| | - Giuseppe A. Trunfio
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy; (G.G.); (G.A.T.)
| | - Paolo Solla
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Viale San Pietro 8, 07100 Sassari, Italy; (C.F.); (P.S.)
| | - Leonardo Antonio Sechi
- Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy; (G.G.); (G.A.T.)
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Monje MH, Sánchez‐Ferro Á, Pineda‐Pardo JA, Vela‐Desojo L, Alonso‐Frech F, Obeso JA. Motor Onset Topography and Progression in Parkinson's Disease: the Upper Limb Is First. Mov Disord 2021; 36:905-915. [DOI: 10.1002/mds.28462] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/08/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Mariana H.G. Monje
- HM‐CINAC. HM Puerta del Sur University Hospital, Móstoles, and CEU‐San Pablo University Madrid Spain
- Department of Anatomy, Histology and Neuroscience Universidad Autónoma Madrid Madrid Spain
| | - Álvaro Sánchez‐Ferro
- HM‐CINAC. HM Puerta del Sur University Hospital, Móstoles, and CEU‐San Pablo University Madrid Spain
| | - José A. Pineda‐Pardo
- HM‐CINAC. HM Puerta del Sur University Hospital, Móstoles, and CEU‐San Pablo University Madrid Spain
- CIBERNED (Center for Networked Biomedical Research on Neurodegenerative Diseases) Instituto Carlos III Madrid Spain
| | - Lydia Vela‐Desojo
- HM‐CINAC. HM Puerta del Sur University Hospital, Móstoles, and CEU‐San Pablo University Madrid Spain
- Department of Neurology Hospital Universitario Fundación Alcorcón Alcorcón Madrid Spain
| | - Fernando Alonso‐Frech
- HM‐CINAC. HM Puerta del Sur University Hospital, Móstoles, and CEU‐San Pablo University Madrid Spain
| | - José A. Obeso
- HM‐CINAC. HM Puerta del Sur University Hospital, Móstoles, and CEU‐San Pablo University Madrid Spain
- CIBERNED (Center for Networked Biomedical Research on Neurodegenerative Diseases) Instituto Carlos III Madrid Spain
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4
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Parambi DGT. Treatment of Parkinson's Disease by MAO-B Inhibitors, New Therapies and Future Challenges - A Mini-Review. Comb Chem High Throughput Screen 2020; 23:847-861. [PMID: 32238135 DOI: 10.2174/1386207323666200402090557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/30/2019] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND One of the most prevalent neurodegenerative diseases with increasing age is Parkinson's disease (PD). Its pathogenesis is unclear and mainly confined to glutamate toxicity and oxidative stress. The dyskinesia and motor fluctuations and neuroprotective potential are the major concerns which are still unmet in PD therapy. OBJECTIVE This article is a capsulization of the role of MAO-B in the treatment of PD, pharmacological properties, safety and efficiency, clinical evidence through random trials, future therapies and challenges. CONCLUSION MAO-B inhibitors are well tolerated for the treatment of PD because of their pharmacokinetic properties and neuroprotective action. Rasagiline and selegiline were recommended molecules for early PD and proven safe and provide a modest to significant rise in motor function, delay the use of levodopa and used in early PD. Moreover, safinamide is antiglutamatergic in action. When added to Levodopa, these molecules significantly reduce the offtime with a considerable improvement of non-motor symptoms. This review also discusses the new approaches in therapy like the use of biomarkers, neurorestorative growth factors, gene therapy, neuroimaging, neural transplantation, and nanotechnology. Clinical evidence illustrated that MAOB inhibitors are recommended as monotherapy and added on therapy to levodopa. A large study and further evidence are required in the field of future therapies to unwind the complexity of the disease.
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Affiliation(s)
- Della G T Parambi
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Jouf University, Sakaka, Jouf, Saudi Arabia
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5
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Yang Z, Li T, Cui Y, Li S, Cheng C, Shen B, Le W. Elevated Plasma microRNA-105-5p Level in Patients With Idiopathic Parkinson's Disease: A Potential Disease Biomarker. Front Neurosci 2019; 13:218. [PMID: 30936821 PMCID: PMC6431626 DOI: 10.3389/fnins.2019.00218] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 02/26/2019] [Indexed: 02/05/2023] Open
Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disease, which still lacks a biomarker to aid in diagnosis and to differentiate diagnosis at the early stage of the disease. microRNAs (miRNAs) are small and evolutionary conserved non-coding RNAs that are involved in post-transcriptional gene regulation. Several miRNAs have been proposed as potential biomarkers in several diseases. In the present study, we screened miRNAs using a network vulnerability analysis, to evaluate their potential as PD biomarkers. We first extracted miRNAs that were differentially expressed between PD and healthy controls (HC) samples. Then we constructed the PD-specific miRNA-mRNA network and screened miRNA biomarkers using a new bioinformatics model. With this model, we identified miR-105-5p as a putative biomarker for PD. Moreover, we measured miR-105-5p levels in the plasma of patients with idiopathic PD (IPD) (n = 319), neurological disease controls (NDC, n = 305) and HC (n = 273) using reverse transcription real-time quantitative PCR (RT-qPCR). Our data clearly demonstrated that the plasma miR-105-5p level in IPD patients was significantly higher than those of HC (251%, p < 0.001) and NDC (347%, p < 0.001). There was no significant difference in miR-105-5p expression between IPD patients with or without anti-PD medications. Interestingly, we found that the plasma miR-105-5p expression level may be able to differentiate IPD from parkinsonian syndrome, essential tremor and other neurodegenerative diseases. We believe that a change in the plasma miR-105-5p level is a potential biomarker for IPD.
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Affiliation(s)
- Zhaofei Yang
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Tianbai Li
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Yanhua Cui
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,International Education College, Dalian Medical University, Dalian, China
| | - Song Li
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Cheng Cheng
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China
| | - Bairong Shen
- Institute for Systems Genetics, West China Hospital, Sichuan University, Chengdu, China
| | - Weidong Le
- Center for Clinical Research on Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China.,Liaoning Provincial Key Laboratory for Research on the Pathogenic Mechanisms of Neurological Diseases, The First Affiliated Hospital, Dalian Medical University, Dalian, China
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Cilento EM, Jin L, Stewart T, Shi M, Sheng L, Zhang J. Mass spectrometry: A platform for biomarker discovery and validation for Alzheimer's and Parkinson's diseases. J Neurochem 2019; 151:397-416. [PMID: 30474862 DOI: 10.1111/jnc.14635] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022]
Abstract
Accurate, reliable, and objective biomarkers for Alzheimer's disease (AD), Parkinson's disease (PD), and related age-associated neurodegenerative disorders are urgently needed to assist in both diagnosis, particularly at early stages, and monitoring of disease progression. Technological advancements in protein detection platforms over the last few decades have resulted in a plethora of reported molecular biomarker candidates for both AD and PD; however, very few of these candidates are developed beyond the discovery phase of the biomarker development pipeline, a reflection of the current bottleneck within the field. In this review, the expanded use of selected reaction monitoring (SRM) targeted mass spectrometry will be discussed in detail as a platform for systematic verification of large panels of protein biomarker candidates prior to costly validation testing. We also advocate for the coupling of discovery-based proteomics with modern targeted MS-based approaches (e.g., SRM) within a single study in future workflows to expedite biomarker development and validation for AD and PD. It is our hope that improving the efficiency within the biomarker development process by use of an SRM pipeline may ultimately hasten the development of biomarkers that both decrease misdiagnosis of AD and PD and ultimately lead to detection at early stages of disease and objective assessment of disease progression. This article is part of the special issue "Proteomics".
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Affiliation(s)
- Eugene M Cilento
- Department of Pathology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Lorrain Jin
- Department of Pathology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Tessandra Stewart
- Department of Pathology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Min Shi
- Department of Pathology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Lifu Sheng
- Department of Pathology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Jing Zhang
- Department of Pathology, University of Washington, School of Medicine, Seattle, Washington, USA.,Department of Pathology, School of Basic Medicine, Peking University Health Science Center, Peking University Third Hospital and Peking Key Laboratory for Early Diagnosis of Neurodegenerative Disorders, Beijing, China
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7
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Sahli ZT, Tarazi FI. Pimavanserin: novel pharmacotherapy for Parkinson's disease psychosis. Expert Opin Drug Discov 2017; 13:103-110. [PMID: 29047301 DOI: 10.1080/17460441.2018.1394838] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Pimavanserin is the first FDA-approved atypical antipsychotic drug indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis (PDP). Areas covered: This review focuses on the preclinical discovery of pimavanserin. It analyzes the pharmacological, behavioral and molecular mechanisms of pimavanserin and their contribution to the therapeutic advantages of the drug as reported in published preclinical and clinical studies, press releases and product labels. Expert opinion: Pimavanserin exhibits a unique pharmacological profile with nanomolar affinity at serotonin 5-HT2A and 5-HT2C receptors. Functionally, it acts as a potent inverse agonist at 5-HT2A receptors, with selectivity over 5-HT2C receptors and no appreciable activity at other neurotransmitter receptors. Behavioral studies found that pimavanserin reversed impaired behaviors in animal models predictive of antipsychotic activity, and with no impairment of motor functions. The drug exhibits long plasma half-life (57 hours), which support its once/day administration. A pivotal phase III clinical trial demonstrated significant improvement in PDP symptoms in patients receiving pimavanserin compared to placebo-treated patients. The drug also displayed relatively benign safety and tolerability profiles. Pimavanserin's mechanism of action might contribute to its unique psychopharmacological properties in the improved treatment of PDP, and perhaps psychosis in other diseases including schizophrenia and dementia-related psychosis.
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Affiliation(s)
- Zeyad T Sahli
- a Department of Psychiatry and Neuroscience Program , Harvard Medical School, McLean Hospital , Belmont , MA , USA
| | - Frank I Tarazi
- a Department of Psychiatry and Neuroscience Program , Harvard Medical School, McLean Hospital , Belmont , MA , USA
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Neuroprotective and Therapeutic Strategies against Parkinson's Disease: Recent Perspectives. Int J Mol Sci 2016; 17:ijms17060904. [PMID: 27338353 PMCID: PMC4926438 DOI: 10.3390/ijms17060904] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 12/18/2022] Open
Abstract
Parkinsonism is a progressive motor disease that affects 1.5 million Americans and is the second most common neurodegenerative disease after Alzheimer’s. Typical neuropathological features of Parkinson’s disease (PD) include degeneration of dopaminergic neurons located in the pars compacta of the substantia nigra that project to the striatum (nigro-striatal pathway) and depositions of cytoplasmic fibrillary inclusions (Lewy bodies) which contain ubiquitin and α-synuclein. The cardinal motor signs of PD are tremors, rigidity, slow movement (bradykinesia), poor balance, and difficulty in walking (Parkinsonian gait). In addition to motor symptoms, non-motor symptoms that include autonomic and psychiatric as well as cognitive impairments are pressing issues that need to be addressed. Several different mechanisms play an important role in generation of Lewy bodies; endoplasmic reticulum (ER) stress induced unfolded proteins, neuroinflammation and eventual loss of dopaminergic neurons in the substantia nigra of mid brain in PD. Moreover, these diverse processes that result in PD make modeling of the disease and evaluation of therapeutics against this devastating disease difficult. Here, we will discuss diverse mechanisms that are involved in PD, neuroprotective and therapeutic strategies currently in clinical trial or in preclinical stages, and impart views about strategies that are promising to mitigate PD pathology.
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9
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An Expert Diagnosis System for Parkinson Disease Based on Genetic Algorithm-Wavelet Kernel-Extreme Learning Machine. PARKINSONS DISEASE 2016; 2016:5264743. [PMID: 27274882 PMCID: PMC4871978 DOI: 10.1155/2016/5264743] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 11/17/2022]
Abstract
Parkinson disease is a major public health problem all around the world. This paper proposes an expert disease diagnosis system for Parkinson disease based on genetic algorithm- (GA-) wavelet kernel- (WK-) Extreme Learning Machines (ELM). The classifier used in this paper is single layer neural network (SLNN) and it is trained by the ELM learning method. The Parkinson disease datasets are obtained from the UCI machine learning database. In wavelet kernel-Extreme Learning Machine (WK-ELM) structure, there are three adjustable parameters of wavelet kernel. These parameters and the numbers of hidden neurons play a major role in the performance of ELM. In this study, the optimum values of these parameters and the numbers of hidden neurons of ELM were obtained by using a genetic algorithm (GA). The performance of the proposed GA-WK-ELM method is evaluated using statical methods such as classification accuracy, sensitivity and specificity analysis, and ROC curves. The calculated highest classification accuracy of the proposed GA-WK-ELM method is found as 96.81%.
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10
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Brigo F, Turri G, Tinazzi M. 123I-FP-CIT SPECT in the differential diagnosis between dementia with Lewy bodies and other dementias. J Neurol Sci 2015; 359:161-71. [PMID: 26671107 DOI: 10.1016/j.jns.2015.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/20/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
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Georgiopoulos C, Davidsson A, Engström M, Larsson EM, Zachrisson H, Dizdar N. The diagnostic value of dopamine transporter imaging and olfactory testing in patients with parkinsonian syndromes. J Neurol 2015; 262:2154-63. [PMID: 26122543 DOI: 10.1007/s00415-015-7830-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/10/2015] [Accepted: 06/17/2015] [Indexed: 11/27/2022]
Abstract
The aim of the study was to compare the efficacy of olfactory testing and presynaptic dopamine imaging in diagnosing Parkinson's disease (PD) and atypical parkinsonian syndromes (APS); to evaluate if the combination of these two diagnostic tools can improve their diagnostic value. A prospective investigation of 24 PD patients, 16 APS patients and 15 patients with non-parkinsonian syndromes was performed during an 18-month period. Single photon emission computed tomography with the presynaptic radioligand (123)I-FP-CIT (DaTSCAN(®)) and olfactory testing with the Brief 12-item Smell Identification Test (B-SIT) were performed in all patients. DaTSCAN was analysed semi-quantitatively, by calculating two different striatal uptake ratios, and visually according to a predefined ranking scale. B-SIT score was significantly lower for PD patients, but not significantly different between APS and non-parkinsonism. The visual assessment of DaTSCAN had higher sensitivity, specificity and diagnostic accuracy compared to olfactory testing. Most PD patients (75%) had visually predominant dopamine depletion in putamen, while most APS patients (56%) had visually severe dopamine depletion both in putamen and in caudate nucleus. The combination of DaTSCAN and B-SIT led to a higher rate of correctly classified patients. Olfactory testing can distinguish PD from non-parkinsonism, but not PD from APS or APS from non-parkinsonism. DaTSCAN is more efficient than olfactory testing and can be valuable in differentiating PD from APS. However, combining olfactory testing and DaTSCAN imaging has a higher predictive value than these two methods separately.
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Affiliation(s)
- Charalampos Georgiopoulos
- Department of Radiology, Linköping University, 581 85, Linköping, Sweden. .,Department of Medical and Health Sciences, Linköping University, 581 85, Linköping, Sweden. .,Center for Medical Image Science and Visualization (CMIV), Linköping University, 581 85, Linköping, Sweden.
| | - Anette Davidsson
- Department of Clinical Physiology, Linköping University, 581 85, Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, 581 85, Linköping, Sweden
| | - Maria Engström
- Department of Medical and Health Sciences, Linköping University, 581 85, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, 581 85, Linköping, Sweden
| | - Elna-Marie Larsson
- Department of Surgical Sciences/Radiology, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
| | - Helene Zachrisson
- Department of Clinical Physiology, Linköping University, 581 85, Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, 581 85, Linköping, Sweden
| | - Nil Dizdar
- Department of Neurology, Linköping University, 581 85, Linköping, Sweden.,Department of Clinical and Experimental Medicine, Linköping University, 581 85, Linköping, Sweden
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Abstract
AIM The aims in this study were to evaluate the role of brain F-FDG PET imaging in differential diagnosis of parkinsonism and to correlate brain metabolism findings with patients' clinical findings. METHODS Brain F-FDG PET images were evaluated both visually and quantitatively using the NeuroQ software in 21 parkinsonism patients in whom final clinical diagnoses were established. RESULTS Final clinical diagnoses were idiopathic Parkinson disease in 7, multisystem atrophy (MSA) in 7, progressive supranuclear palsy (PSP) in 4, corticobasal degeneration in 2, and Lewy body disease in 1 patient. Asymmetrical cortical hypometabolism was observed in most of the patients in frontal and parietotemporal regions. Fifteen of 21 patients had basal ganglia involvement, which was bilateral in patients with MSA and more frequently unilateral in patients with idiopathic Parkinson disease and PSP. Four patients with PSP and 1 patient with corticobasal degeneration had thalamic hypometabolism. Cerebellar hypometabolism was observed in 4 patients with MSA. The Unified Parkinson Disease Rating Scale motor and bradykinesia scores were higher in patients with basal ganglia involvement. CONCLUSIONS Brain F-FDG PET findings in subcortical nuclei and cerebellum were found to be useful in differential diagnosis of patients with parkinsonism. The extent of cerebral cortical and basal ganglia hypometabolism showed correlation with the presentation and severity of clinical findings.
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13
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Tarazi FI, Sahli ZT, Wolny M, Mousa SA. Emerging therapies for Parkinson's disease: from bench to bedside. Pharmacol Ther 2014; 144:123-33. [PMID: 24854598 DOI: 10.1016/j.pharmthera.2014.05.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 05/01/2014] [Indexed: 02/08/2023]
Abstract
The prevalence of Parkinson's disease (PD) increases with age and is projected to increase in parallel to the rising average age of the population. The disease can have significant health-related, social, and financial implications not only for the patient and the caregiver, but for the health care system as well. While the neuropathology of this neurodegenerative disorder is fairly well understood, its etiology remains a mystery, making it difficult to target therapy. The currently available drugs for treatment provide only symptomatic relief and do not control or prevent disease progression, and as a result patient compliance and satisfaction are low. Several emerging pharmacotherapies for PD are in different stages of clinical development. These therapies include adenosine A2A receptor antagonists, glutamate receptor antagonists, monoamine oxidase inhibitors, anti-apoptotic agents, and antioxidants such as coenzyme Q10, N-acetyl cysteine, and edaravone. Other emerging non-pharmacotherapies include viral vector gene therapy, microRNAs, transglutaminases, RTP801, stem cells and glial derived neurotrophic factor (GDNF). In addition, surgical procedures including deep brain stimulation, pallidotomy, thalamotomy and gamma knife surgery have emerged as alternative interventions for advanced PD patients who have completely utilized standard treatments and still suffer from persistent motor fluctuations. While several of these therapies hold much promise in delaying the onset of the disease and slowing its progression, more pharmacotherapies and surgical interventions need to be investigated in different stages of PD. It is hoped that these emerging therapies and surgical procedures will strengthen our clinical armamentarium for improved treatment of PD.
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Affiliation(s)
- F I Tarazi
- Department of Psychiatry and Neuroscience Program, Harvard Medical School, McLean Hospital, Belmont, MA 02478, USA.
| | - Z T Sahli
- Department of Psychiatry and Neuroscience Program, Harvard Medical School, McLean Hospital, Belmont, MA 02478, USA; School of Medicine, American University of Beirut, Beirut, Lebanon
| | - M Wolny
- The Pharmaceutical Research Institute at Albany College of Pharmacy and Health Sciences, Rensselaer, NY 12144, USA
| | - S A Mousa
- The Pharmaceutical Research Institute at Albany College of Pharmacy and Health Sciences, Rensselaer, NY 12144, USA
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14
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Brigo F, Matinella A, Erro R, Tinazzi M. [¹²³I]FP-CIT SPECT (DaTSCAN) may be a useful tool to differentiate between Parkinson's disease and vascular or drug-induced parkinsonisms: a meta-analysis. Eur J Neurol 2014; 21:1369-e90. [PMID: 24779862 DOI: 10.1111/ene.12444] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/03/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Differentiating idiopathic Parkinson's disease from secondary parkinsonian syndromes is crucial since their management and prognosis differ considerably. Functional imaging of the dopaminergic pathway by means of [¹²³I]FP-CIT SPECT (DaTSCAN) might be useful in this regard, but its role is still controversial. The accuracy of DaTSCAN in the differential diagnosis between Parkinson's disease and vascular or drug-induced parkinsonism was therefore systematically reviewed. METHODS MEDLINE and CENTRAL were searched for studies aiming to determine accuracy measures (sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood ratios) of DaTSCAN in differentiating between Parkinson's disease and vascular or drug-induced parkinsonism. RESULTS Five studies were included. Pooled accuracy measures in differentiating between Parkinson's disease and vascular or drug-induced parkinsonism were relatively high, with sensitivity and specificity values above 85% and 80%, respectively. CONCLUSIONS DaTSCAN might accurately differentiate between early Parkinson's disease and secondary parkinsonian conditions, namely vascular or drug-induced, in patients with clinically unclear parkinsonism. However, all the studies reviewed here show several methodological limits, which prevent definitive conclusions on the role of DaTSCAN being drawn in this context. Further studies are needed to confirm our results and definitely evaluate the utility of DaTSCAN in differentiating between Parkinson's disease and vascular or drug-induced parkinsonism.
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Affiliation(s)
- F Brigo
- Divisione di Neurologia, Ospedale 'Franz Tappeiner', Merano, Italy; Dipartimento di Scienze Neurologiche e del Movimento, Università di Verona, Verona, Italy
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Bouwmans AEP, Vlaar AMM, Mess WH, Kessels A, Weber WEJ. Specificity and sensitivity of transcranial sonography of the substantia nigra in the diagnosis of Parkinson's disease: prospective cohort study in 196 patients. BMJ Open 2013; 3:bmjopen-2013-002613. [PMID: 23550093 PMCID: PMC3641465 DOI: 10.1136/bmjopen-2013-002613] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Numerous ultrasound studies have suggested that a typical enlarged area of echogenicity in the substantia nigra (SN+) can help diagnose idiopathic Parkinson's disease (IPD). Almost all these studies were retrospective and involved patients with well-established diagnoses and long-disease duration. In this study the diagnostic accuracy of transcranial sonography (TCS) of the substantia nigra in the patient with an undiagnosed parkinsonian syndrome of recent onset has been evaluated. DESIGN Prospective cohort study for diagnostic accuracy. SETTING Neurology outpatient clinics of two teaching hospitals in the Netherlands. PATIENTS 196 consecutive patients, who were referred to two neurology outpatient clinics for analysis of clinically unclear parkinsonism. Within 2 weeks of inclusion all patients also underwent a TCS and a (123)I-ioflupane Single Photon Emission CT (FP-CIT SPECT) scan of the brain (n=176). OUTCOME MEASURES After 2 years, patients were re-examined by two movement disorder specialist neurologists for a final clinical diagnosis, that served as a surrogate gold standard for our study. RESULTS Temporal acoustic windows were insufficient in 45 of 241 patients (18.67%). The final clinical diagnosis was IPD in 102 (52.0%) patients. Twenty-four (12.3%) patients were diagnosed with atypical parkinsonisms (APS) of which 8 (4.0%) multisystem atrophy (MSA), 6 (3.1%) progressive supranuclear palsy (PSP), 6 (3.1%) Lewy body dementia and 4 (2%) corticobasal degeneration. Twenty-one (10.7%) patients had a diagnosis of vascular parkinsonism, 20 (10.2%) essential tremor, 7 (3.6%) drug-induced parkinsonism and 22 (11.2%) patients had no parkinsonism but an alternative diagnosis. The sensitivity of a SN+ for the diagnosis IPD was 0.40 (CI 0.30 to 0.50) and the specificity 0.61 (CI 0.52 to 0.70). Hereby the positive predictive value (PPV) was 0.53 and the negative predictive value (NPV) 0.48. The sensitivity and specificity of FP-CIT SPECT scans for diagnosing IPD was 0.88 (CI 0.1 to 0.95) and 0.68 (CI 0.58 to 0.76) with a PPV of 0.75 and an NPV of 0.84. CONCLUSIONS The diagnostic accuracy of TCS in early stage Parkinson's disease is not sufficient for routine clinical use. CLINICALTRIALS.GOV IDENTIFIER: NCT0036819.
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Affiliation(s)
- Angela E P Bouwmans
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
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Automatic classification of early Parkinson's disease with multi-modal MR imaging. PLoS One 2012; 7:e47714. [PMID: 23152757 PMCID: PMC3494697 DOI: 10.1371/journal.pone.0047714] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 09/13/2012] [Indexed: 11/30/2022] Open
Abstract
Background In recent years, neuroimaging has been increasingly used as an objective method for the diagnosis of Parkinson's disease (PD). Most previous studies were based on invasive imaging modalities or on a single modality which was not an ideal diagnostic tool. In this study, we developed a non-invasive technology intended for use in the diagnosis of early PD by integrating the advantages of various modals. Materials and Methods Nineteen early PD patients and twenty-seven normal volunteers participated in this study. For each subject, we collected resting-state functional magnetic resonance imaging (rsfMRI) and structural images. For the rsfMRI images, we extracted the characteristics at three different levels: ALFF (amplitude of low-frequency fluctuations), ReHo (regional homogeneity) and RFCS (regional functional connectivity strength). For the structural images, we extracted the volume characteristics from the gray matter (GM), the white matter (WM) and the cerebrospinal fluid (CSF). A two-sample t-test was used for the feature selection, and then the remaining features were fused for classification. Finally a classifier for early PD patients and normal control subjects was identified from support vector machine training. The performance of the classifier was evaluated using the leave-one-out cross-validation method. Results Using the proposed methods to classify the data set, good results (accuracy = 86.96%, sensitivity = 78.95%, specificity = 92.59%) were obtained. Conclusions This method demonstrates a promising diagnosis performance by the integration of information from a variety of imaging modalities, and it shows potential for improving the clinical diagnosis and treatment of PD.
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Liu CH, Wang HM, Lin KJ, Kuo HC, Weng YH, Shih TS, Huang CC. Long-term neurotoxic effects of dimethylamine borane intoxication. J Neurol Sci 2012; 319:147-51. [DOI: 10.1016/j.jns.2012.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 04/26/2012] [Accepted: 05/04/2012] [Indexed: 12/12/2022]
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Smith Y, Wichmann T, Factor SA, DeLong MR. Parkinson's disease therapeutics: new developments and challenges since the introduction of levodopa. Neuropsychopharmacology 2012; 37:213-46. [PMID: 21956442 PMCID: PMC3238085 DOI: 10.1038/npp.2011.212] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/28/2011] [Accepted: 07/29/2011] [Indexed: 12/13/2022]
Abstract
The demonstration that dopamine loss is the key pathological feature of Parkinson's disease (PD), and the subsequent introduction of levodopa have revolutionalized the field of PD therapeutics. This review will discuss the significant progress that has been made in the development of new pharmacological and surgical tools to treat PD motor symptoms since this major breakthrough in the 1960s. However, we will also highlight some of the challenges the field of PD therapeutics has been struggling with during the past decades. The lack of neuroprotective therapies and the limited treatment strategies for the nonmotor symptoms of the disease (ie, cognitive impairments, autonomic dysfunctions, psychiatric disorders, etc.) are among the most pressing issues to be addressed in the years to come. It appears that the combination of early PD nonmotor symptoms with imaging of the nigrostriatal dopaminergic system offers a promising path toward the identification of PD biomarkers, which, once characterized, will set the stage for efficient use of neuroprotective agents that could slow down and alter the course of the disease.
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Affiliation(s)
- Yoland Smith
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322, USA.
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19
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Aberrant striatal synaptic plasticity in monogenic parkinsonisms. Neuroscience 2011; 211:126-35. [PMID: 21839811 DOI: 10.1016/j.neuroscience.2011.07.065] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/03/2011] [Accepted: 07/26/2011] [Indexed: 11/24/2022]
Abstract
In the recent past, the pathogenesis of Parkinson's disease (PD) has evolved from a neurodegenerative disorder considered entirely sporadic to a disease with an unequivocal genetic component. Indeed, different inherited forms of PD have been discovered and characterized, although the functional roles of the gene products identified are still under intense investigation. To gain a better understanding of the cellular and molecular pathogenic mechanisms of hereditary forms of PD, different animal models have been generated. Although most of the rodent models display neither obvious behavioral impairment nor evidence for neurodegeneration, remarkable abnormalities of dopamine-mediated neurotransmission and corticostriatal synaptic plasticity have been described, indicative of a fundamental distortion of network function within the basal ganglia. The picture emerging from a critical review of recent data on monogenic parkinsonisms suggests that mutations in PD genes might cause developmental rearrangements in the corticobasal ganglia circuitry, compensating the dopaminergic dysfunction observed both in mice and humans, in order to maintain proper motor function.
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[Transcranial sonography in diagnosis of movement disorders]. Neurol Neurochir Pol 2011; 44:574-9. [PMID: 21225520 DOI: 10.1016/s0028-3843(14)60155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Conventional methods of neuroimaging, such as computed tomography and magnetic resonance imaging, are mostly useful in exclusion of movement disorders with secondary aetiology. Recently, the application of transcranial sonography has been introduced to the diagnosis of extrapyramidal diseases. This valuable technique, with proven usefulness in the field of cerebrovascular events, may reveal some brain parenchymal structures. In this review the most important findings of ultrasonographic abnormalities in the brain, particularly hyperechogenicity of substantia nigra in Parkinson disease, are presented.
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Korchounov A, Meyer MF, Krasnianski M. Postsynaptic nigrostriatal dopamine receptors and their role in movement regulation. J Neural Transm (Vienna) 2010; 117:1359-69. [PMID: 21076988 PMCID: PMC3000910 DOI: 10.1007/s00702-010-0454-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 07/22/2010] [Indexed: 12/30/2022]
Abstract
The article presents the hypothesis that nigrostriatal dopamine may regulate movement by modulation of tone and contraction in skeletal muscles through a concentration-dependent influence on the postsynaptic D1 and D2 receptors on the follow manner: nigrostriatal axons innervate both receptor types within the striatal locus somatotopically responsible for motor control in agonist/antagonist muscle pair around a given joint. D1 receptors interact with lower and D2 receptors with higher dopamine concentrations. Synaptic dopamine concentration increases immediately before movement starts. We hypothesize that increasing dopamine concentrations stimulate first the D1 receptors and reduce muscle tone in the antagonist muscle and than stimulate D2 receptors and induce contraction in the agonist muscle. The preceded muscle tone reduction in the antagonist muscle eases the efficient contraction of the agonist. Our hypothesis is applicable for an explanation of physiological movement regulation, different forms of movement pathology and therapeutic drug effects. Further, this hypothesis provides a theoretical basis for experimental investigation of dopaminergic motor control and development of new strategies for treatment of movement disorders.
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Affiliation(s)
- Alexei Korchounov
- Parkinson Department, Marienhospital Kevelaer, Basilikastr. 55, 47612 Kevelaer, Germany.
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Abstract
Movement disorders are commonly encountered in the clinic. In this Review, aimed at trainees and general neurologists, we provide a practical step-by-step approach to help clinicians in their 'pattern recognition' of movement disorders, as part of a process that ultimately leads to the diagnosis. The key to success is establishing the phenomenology of the clinical syndrome, which is determined from the specific combination of the dominant movement disorder, other abnormal movements in patients presenting with a mixed movement disorder, and a set of associated neurological and non-neurological abnormalities. Definition of the clinical syndrome in this manner should, in turn, result in a differential diagnosis. Sometimes, simple pattern recognition will suffice and lead directly to the diagnosis, but often ancillary investigations, guided by the dominant movement disorder, are required. We illustrate this diagnostic process for the most common types of movement disorder, namely, akinetic-rigid syndromes and the various types of hyperkinetic disorders (myoclonus, chorea, tics, dystonia and tremor).
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Ishibashi K, Ishii K, Oda K, Kawasaki K, Mizusawa H, Ishiwata K. Regional analysis of age-related decline in dopamine transporters and dopamine D2-like receptors in human striatum. Synapse 2009; 63:282-90. [PMID: 19116949 DOI: 10.1002/syn.20603] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
UNLABELLED The purpose of this study was to evaluate the mechanisms of age-related decline of dopamine transporter (DAT) and dopamine D(2)-like receptor (D2R) densities in the human striatum by focusing on regional difference. METHODS Positron emission tomography (PET) with [(11)C]CFT and [(11)C]raclopride for measuring DATs and D2Rs, respectively, was performed on 16 healthy volunteers ranging from 21 to 74 years in age. To evaluate in detail the regional difference within the striatum, in addition to the conventional region-of-interest-based analysis, we created a parametric image that enabled us to visualize the regional decline rate on a voxel-by-voxel basis, mapping the slope of the regression line between the age and uptake index of each tracer. RESULTS The decreasing rates corresponded to 6.1, 5.5, and 5.6% per decade for DATs and 5.8, 4.9, and 4.8% per decade for D(2)Rs in the caudate nucleus, anterior putamen, and posterior putamen, respectively. The caudate nucleus for both DATs and D(2)Rs were the fastest among the striatum, and the regional difference of the decreasing rate for DATs was consistently associated with that for D2Rs. Meanwhile, previous histological studies have shown that age-related cell loss in the substantia nigra is likely to preferentially affect its dorsomedial part, which projects to the caudate nucleus. CONCLUSIONS These results suggested that neuronal cell loss in the substantia nigra may be associated with the age-related DAT decline, and DAT decline may be associated functionally with age-related D2R decline.
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Affiliation(s)
- Kenji Ishibashi
- Positron Medical Center, Tokyo Metropolitan Institute of Gerontology, Tokyo 173-0022, Japan
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25
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Siebner HR, Bergmann TO, Bestmann S, Massimini M, Johansen-Berg H, Mochizuki H, Bohning DE, Boorman ED, Groppa S, Miniussi C, Pascual-Leone A, Huber R, Taylor PCJ, Ilmoniemi RJ, De Gennaro L, Strafella AP, Kähkönen S, Klöppel S, Frisoni GB, George MS, Hallett M, Brandt SA, Rushworth MF, Ziemann U, Rothwell JC, Ward N, Cohen LG, Baudewig J, Paus T, Ugawa Y, Rossini PM. Consensus paper: combining transcranial stimulation with neuroimaging. Brain Stimul 2009; 2:58-80. [PMID: 20633405 DOI: 10.1016/j.brs.2008.11.002] [Citation(s) in RCA: 223] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 11/30/2008] [Indexed: 02/05/2023] Open
Abstract
In the last decade, combined transcranial magnetic stimulation (TMS)-neuroimaging studies have greatly stimulated research in the field of TMS and neuroimaging. Here, we review how TMS can be combined with various neuroimaging techniques to investigate human brain function. When applied during neuroimaging (online approach), TMS can be used to test how focal cortex stimulation acutely modifies the activity and connectivity in the stimulated neuronal circuits. TMS and neuroimaging can also be separated in time (offline approach). A conditioning session of repetitive TMS (rTMS) may be used to induce rapid reorganization in functional brain networks. The temporospatial patterns of TMS-induced reorganization can be subsequently mapped by using neuroimaging methods. Alternatively, neuroimaging may be performed first to localize brain areas that are involved in a given task. The temporospatial information obtained by neuroimaging can be used to define the optimal site and time point of stimulation in a subsequent experiment in which TMS is used to probe the functional contribution of the stimulated area to a specific task. In this review, we first address some general methodologic issues that need to be taken into account when using TMS in the context of neuroimaging. We then discuss the use of specific brain mapping techniques in conjunction with TMS. We emphasize that the various neuroimaging techniques offer complementary information and have different methodologic strengths and weaknesses.
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Affiliation(s)
- Hartwig R Siebner
- Danish Research Center for Magnetic Resonance, Copenhagen University Hospital-Hvidovre, Denmark; Department of Neurology, Christian-Albrechts-University, Kiel, Germany.
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Antoniades CA, Barker RA. The search for biomarkers in Parkinson's disease: a critical review. Expert Rev Neurother 2009; 8:1841-52. [PMID: 19086880 DOI: 10.1586/14737175.8.12.1841] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Parkinson's disease (PD) is a progressive neurodegenerative disorder that primarily presents with features of bradykinesia, rigidity and tremor, and has, as part of its core pathology, the degeneration of dopaminergic neurons in the substantia nigra pars compacta. There is a great need for the development of a reliable diagnostic tool to improve promptness of diagnosis, definition of disease subtypes, and to monitor disease progression and demonstrate treatment efficacy in the case of disease modifying therapies. Current biomarkers range from objective clinical tools, to neuroimaging, to 'wet' markers involving blood and cerebrospinal fluid. To date, all candidate biomarkers for PD have failed to be developed into a clinically useful tool. Ideally, a combination of sensitive markers will be needed, not only to predict the onset of PD, but also to help in subtype classification and to follow progression. Here, we critically review various PD biomarker studies.
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Affiliation(s)
- Chrystalina A Antoniades
- Cambridge Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, Forvie Site, Cambridge CB22PY, UK.
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Kassiou M, Banati R, Holsinger RD, Meikle S. Challenges in molecular imaging of Parkinson’s disease: A brief overview. Brain Res Bull 2009; 78:105-8. [DOI: 10.1016/j.brainresbull.2008.08.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Park HK, Kim JS, Im KC, Oh SJ, Kim MJ, Lee JH, Chung SJ, Lee MC. Functional brain imaging in pure akinesia with gait freezing: [18F] FDG PET and [18F] FP-CIT PET analyses. Mov Disord 2009; 24:237-45. [DOI: 10.1002/mds.22347] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Lauretani F, Maggio M, Nardelli A, Saccavini M, Ceda G. Should 3,4-dihydroxy-L-phenylalanine be used routinely in vascular Parkinson? J Am Geriatr Soc 2008; 56:1977-8. [PMID: 19054214 DOI: 10.1111/j.1532-5415.2008.01909.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gaenslen A, Unmuth B, Godau J, Liepelt I, Di Santo A, Schweitzer KJ, Gasser T, Machulla HJ, Reimold M, Marek K, Berg D. The specificity and sensitivity of transcranial ultrasound in the differential diagnosis of Parkinson's disease: a prospective blinded study. Lancet Neurol 2008; 7:417-24. [DOI: 10.1016/s1474-4422(08)70067-x] [Citation(s) in RCA: 175] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The aberrant expression and function of certain receptors in tumours and other diseased tissues make them preferable targets for molecular imaging. PET and SPECT radionuclides can be used to label specific ligands with high affinity for the target receptors. The functional information obtained from imaging these receptors can be used to better understand the systems under investigation and for diagnostic and therapeutic applications. This review discusses some of the aspects of receptor imaging with small molecule tracers by PET and SPECT and reviews some of the tracers for the receptor imaging of tumours and brain, heart and lung disorders.
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Affiliation(s)
- Aviv Hagooly
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8225, St. Louis, MO 63110, USA.
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Vlaar AM, de Nijs T, Kessels AG, Vreeling FW, Winogrodzka A, Mess WH, Tromp SC, van Kroonenburgh MJ, Weber WE. Diagnostic Value of 123I-Ioflupane and 123I-Iodobenzamide SPECT Scans in 248 Patients with Parkinsonian Syndromes. Eur Neurol 2008; 59:258-66. [DOI: 10.1159/000115640] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 09/18/2007] [Indexed: 11/19/2022]
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Vlaar AMM, Bouwmans AEP, van Kroonenburgh MJPG, Mess WH, Tromp SC, Wuisman PGWM, Kessels AGH, Winogrodzka A, Weber WEJ. Protocol of a prospective study on the diagnostic value of transcranial duplex scanning of the substantia nigra in patients with parkinsonian symptoms. BMC Neurol 2007; 7:28. [PMID: 17784944 PMCID: PMC2034584 DOI: 10.1186/1471-2377-7-28] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Accepted: 09/04/2007] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Parkinson's disease (PD) is the second most common neurodegenerative disorder. As there is no definitive diagnostic test, its diagnosis is based on clinical criteria. Recently transcranial duplex scanning (TCD) of the substantia nigra in the brainstem has been proposed as an instrument to diagnose PD. We and others have found that TCD scanning of substantia nigra duplex is a relatively accurate diagnostic instrument in patients with parkinsonian symptoms. However, all studies on TCD so far have involved well-defined, later-stage PD patients, which will obviously lead to an overestimate of the diagnostic accuracy of TCD. We have therefore set out to conduct a prospective study testing the diagnostic accuracy of TCD in patients with a parkinsonism of unclear origin. METHODS/DESIGN We will enroll 250 consecutive patients, who are referred to neurology outpatient clinics of two teaching hospitals, for analysis of clinically unclear parkinsonism. Patients, whose parkinsonism is clearly diagnosable at the first visit, will be excluded from the study. All patients will undergo a TCD of the substantia nigra. As a surrogate gold standard we will use the consensus clinical diagnosis reached by two independent, blinded, movement disorder specialist neurologists after 2 years follow-up. At the time of TCD, patients will also undergo a SPECT scan of the brain. DISCUSSION As this prospective trial enroll only patients with an early-stage parkinsonism, it will yield data on the diagnostic accuracy of TCD that is relevant to daily clinical practice: The neurologist needs a diagnostic tool that provides additional information in patients with a clinically indefinable parkinsonian syndrome. The above described observational longitudinal study was designed to explicitly study this aspect in the diagnostic process.
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Affiliation(s)
- Annemarie MM Vlaar
- Department of Neurology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Angela EP Bouwmans
- Department of Neurology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Marinus JPG van Kroonenburgh
- Department of Nuclear Medicine University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Werner H Mess
- Department of Clinical Neurophysiology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Selma C Tromp
- Department of Neurology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
- Department of Clinical Neurophysiology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Piet GWM Wuisman
- Department of Clinical Neurophysiology, Maasland Hospital, P.O. Box 5500 6130 MB Sittard, The Netherlands
| | - Alfons GH Kessels
- Department of Clinical Epidemiology and Technology Assessment, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Ania Winogrodzka
- Department of Neurology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Wim EJ Weber
- Department of Neurology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
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Vlaar AMM, van Kroonenburgh MJPG, Kessels AGH, Weber WEJ. Meta-analysis of the literature on diagnostic accuracy of SPECT in parkinsonian syndromes. BMC Neurol 2007; 7:27. [PMID: 17764571 PMCID: PMC2064928 DOI: 10.1186/1471-2377-7-27] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Accepted: 09/01/2007] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Parkinson's disease (PD) is the second most common neurodegenerative disorder. One of the most widely used techniques to diagnose PD is a Single Photon Emission Computer Tomography (SPECT) scan to visualise the integrity of the dopaminergic pathways in the brain. Despite this there remains some discussion on the value of SPECT in the differential diagnosis of PD. We did a meta-analysis of all the existing literature on the diagnostic accuracy of both pre- and post-synaptic SPECT imaging in the differential diagnosis of PD. METHODS Relevant studies were searched in Medline, EMBASE and Cochrane databases with back-searching of their reference lists. We limited our analysis to studies with a clinically relevant methodology: i.e. when they assessed the ability of the SPECT to provide 1. diagnosis of PD in an early phase vs. normalcy; 2 diagnostic differentiation between PD and essential tremor (ET); 3. distinguishing between PD and vascular parkinsonism (VP); 4. delineation of PD from atypical parkinsonian syndromes (APS). Gold standard was, dependent on the study type, clinical examination at initial visit or follow-up, and/or response to dopaminergic agents. RESULTS The search gave 185 hits, of which we deemed 32 suitable for our analysis. From these we recalculated the diagnostic odds ratio of SPECT for the clinical questions above. The pooled odds ratio (with 95%CI) for presynaptic SPECT scan's ability to distinguish between early PD and normalcy was 60 (13 - 277). For the ability to differentiate between PD and ET this ratio was 210 (79-562). The ratio for presynaptic SPECT's ability to delineate PD from VP was 105 (32 - 348). The mean odds ratio for the presynaptic SPECT scans to differentiate between PD and the two APS was 2 (1 - 4), and for the postsynaptic SPECT imaging this was 19 (9-36). CONCLUSION SPECT with presynaptic radiotracers is relatively accurate to differentiate patients with PD in an early phase from normalcy, patients with PD from those with ET, and PD from VP. The accuracy of SPECT with both presynaptic and postsynaptic tracers to differentiate between PD and APS is relatively low.
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Affiliation(s)
- Annemarie MM Vlaar
- Department of Neurology, University Hospital Maastricht, The Netherlands
| | | | - Alfons GH Kessels
- Department of Clinical Epidemiology and Technology Assessment, University Hospital Maastricht, The Netherlands
| | - Wim EJ Weber
- Department of Neurology, University Hospital Maastricht, The Netherlands
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Rite I, Argüelles S, Venero JL, García-Rodriguez S, Ayala A, Cano J, Machado A. Proteomic identification of biomarkers in the cerebrospinal fluid in a rat model of nigrostriatal dopaminergic degeneration. J Neurosci Res 2007; 85:3607-18. [PMID: 17705290 DOI: 10.1002/jnr.21452] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We have performed proteomic analysis in the cerebrospinal fluid in an animal model of Parkinson's disease induced by axotomy of the medial forebrain bundle. In this model, the degeneration of dopaminergic neurons was completed in 14 days, with a loss of about 50% dopaminergic neurons in the substantia nigra and a loss of more than 80% dopamine terminals in the striatum, with a similar diminution of dopamine levels in both structures. Proteins were separated by 2D electrophoresis and identified by matrix-assisted laser desorption-ionization time-of-flight (MALDI-TOF). We found significant increases of haptoglobin and transthyretin along with a decrease of Apo E concentrations in the cerebrospinal fluid of axotomized animals. Changes for haptoglobin and transthyretin were further confirmed in cerebrospinal fluid and plasma by Western blotting. These results suggest that monitoring plasma levels of these signals appears to be a promising biological marker of neuronal degeneration of the nigrostriatal dopaminergic system.
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Affiliation(s)
- I Rite
- Departamento de Bioquímica, Bromatología y Toxicología, Facultad de Farmacia, Universidad de Sevilla, C/Prof. Garcia Gonzalez 2, Seville, Spain
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Shahed J, Jankovic J. Motor symptoms in Parkinson's disease. HANDBOOK OF CLINICAL NEUROLOGY 2007; 83:329-42. [DOI: 10.1016/s0072-9752(07)83013-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Rodríguez-Gómez JA, Lu JQ, Velasco I, Rivera S, Zoghbi SS, Liow JS, Musachio JL, Chin FT, Toyama H, Seidel J, Green MV, Thanos PK, Ichise M, Pike VW, Innis RB, McKay RDG. Persistent dopamine functions of neurons derived from embryonic stem cells in a rodent model of Parkinson disease. Stem Cells 2006; 25:918-28. [PMID: 17170065 PMCID: PMC4151324 DOI: 10.1634/stemcells.2006-0386] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The derivation of dopamine neurons is one of the best examples of the clinical potential of embryonic stem (ES) cells, but the long-term function of the grafted neurons has not been established. Here, we show that, after transplantation into an animal model, neurons derived from mouse ES cells survived for over 32 weeks, maintained midbrain markers, and had sustained behavioral effects. Microdialysis in grafted animals showed that dopamine (DA) release was induced by depolarization and pharmacological stimulants. Positron emission tomography measured the expression of presynaptic dopamine transporters in the graft and also showed that the number of postsynaptic DA D(2) receptors was normalized in the host striatum. These data suggest that ES cell-derived neurons show DA release and reuptake and stimulate appropriate postsynaptic responses for long periods after implantation. This work supports continued interest in ES cells as a source of functional DA neurons.
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Affiliation(s)
- Jose A Rodríguez-Gómez
- Laboratory of Molecular Biology, National Institute of Neurological Disorders and Stroke, Porter Neuroscience Research Center, National Institute of Health, Bethesda, Maryland 20892, USA
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Verstappen CCP, Bloem BR, Haaxma CA, Oyen WJG, Horstink MWIM. Diagnostic value of asymmetric striatal D2 receptor upregulation in Parkinson's disease: an [123I]IBZM and [123I]FP-CIT SPECT study. Eur J Nucl Med Mol Imaging 2006; 34:502-7. [PMID: 17053905 DOI: 10.1007/s00259-006-0258-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2006] [Accepted: 07/30/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Striatal postsynaptic D2 receptors in Parkinson's disease (PD) are thought to be upregulated in the first years of the disease, especially contralateral to the clinically most affected side. The aim of this study was to evaluate whether the highest striatal D2 binding is found contralateral to the most affected side in PD, and whether this upregulation can be used as a diagnostic tool. METHODS Cross-sectional survey was undertaken of 81 patients with clinically asymmetric PD, without antiparkinsonian drugs and with a disease duration of < or = 5 years and 26 age-matched controls. Striatal D2 binding was assessed with [123I]IBZM SPECT, and severity of the presynaptic dopaminergic lesion with [123I]FP-CIT SPECT. RESULTS The mean striato-occipital ratio of [123I]IBZM binding was significantly higher in PD patients (1.56 +/-0.09) than in controls (1.53 +/-0.06). In PD patients, higher values were found contralateral to the clinically most affected side (1.57 +/-0.09 vs 1.55 +/-0.10 ipsilaterally), suggesting D2 receptor upregulation, and the reverse was seen using [123I]FP-CIT SPECT. However, on an individual basis only 56% of PD patients showed this upregulation. CONCLUSION Our study confirms asymmetric D2 receptor upregulation in PD. However, the sensitivity of contralateral higher striatal [123I]IBZM binding is only 56%. Therefore, the presence of contralateral higher striatal IBZM binding has insufficient diagnostic accuracy for PD, and PD cannot be excluded in patients with parkinsonism and no contralateral upregulation of D2 receptors, assessed with [123I]IBZM SPECT.
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Affiliation(s)
- C C P Verstappen
- Department of Neurology (935), Radboud University Nijmegen Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Hesse S, Oehlwein C, Barthel H, Schwarz J, Polster D, Wagner A, Sabri O. Possible impact of dopamine SPECT on decision-making for drug treatment in Parkinsonian syndrome. J Neural Transm (Vienna) 2006; 113:1177-90. [PMID: 16463120 DOI: 10.1007/s00702-005-0401-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Accepted: 09/26/2005] [Indexed: 10/25/2022]
Abstract
Single-photon emission computed tomography (SPECT) markers allow measuring the integrity of the brain dopaminergic system in vivo. We used dopamine transporter (DAT) SPECT with [(123)I]FP-CIT and dopamine D(2)/D(3) receptor SPECT with [(123)I]IBZM to evaluate whether there is a reduction of DAT and/or D(2)/D(3) receptor SPECT in treated and untreated patients with Parkinsonian syndrome (PS). We found that almost a quarter of our patients treated with anti-Parkinsonian medication prior to SPECT imaging did not show evidence of a presynaptic dopaminergic deficit while 37% of untreated patients were diagnosed as having Parkinson's disease. 17% of treated patients had additional loss of D(2)/D(3) receptor binding capacity in concordance with the clinical follow-up diagnoses of multiple system atrophy, progressive nuclear palsy, and vascular Parkinsonism. Apart from 38% clinically uncertain cases, SPECT was in concordance with 75% of initial clinical diagnoses. 25% were reclassified as indicated by SPECT findings and confirmed by a 1.5-year clinical follow-up. We conclude that dopamine SPECT may support establishing or refuting the clinical diagnosis and, therefore, help to make the decision for or against dopaminomimetic treatment in cases with PS.
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Affiliation(s)
- S Hesse
- Clinic for Nuclear Medicine, University Hospital, Leipzig, Germany.
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Müller CM, de Vos RAI, Maurage CA, Thal DR, Tolnay M, Braak H. Staging of Sporadic Parkinson Disease-Related α-Synuclein Pathology: Inter- and Intra-Rater Reliability. J Neuropathol Exp Neurol 2005; 64:623-8. [PMID: 16042314 DOI: 10.1097/01.jnen.0000171652.40083.15] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Sporadic Parkinson disease (sPD) is characterized by alpha-synuclein (alpha-syn) inclusions. The distribution of such inclusions appears to relate to disease progression and severity. We propose and test a simple staging protocol based on the presence of alpha-syn immunoreactivity in 5 paraffin sections that, taken together, contain up to 8 vulnerable brain regions. Six stages of alpha-syn pathology reminiscent for sPD are defined based on the presence or absence of inclusions in the assessed sections. Six observers from 5 different institutions rated 21 cases on the basis of written instructions only. The agreement of the raters was highly significant with a mean error below one stage. Both inter- and intra-rater reliability were also substantial to almost perfect as analyzed by paired comparison between all raters. We propose that the staging procedure for alpha-syn pathology is suitable for application in routine neuropathology and brain banking. Clearly defined stages of alpha-synpathology might aid the comparability between studies and also help to distinguish sPD from other synucleinopathies.
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Affiliation(s)
- Christian M Müller
- Institute for Clinical Neuroanatomy, J. W. Goethe University Clinic, Frankfurt/M., Germany.
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Abstract
AIMS To discuss the current methodological and conceptual difficulties inherent in characterizing the emotional manifestations of neurodegenerative disease through critically reviewing depression as a manifestation of idiopathic Parkinson's disease (PD). METHODS Selective literature review of the neurobiological, psychological, and physical basis of depressive symptoms in PD from 1993-2003, with reference to key earlier articles. CONCLUSIONS There are difficulties in defining the syndromes of PD itself as well as depression in PD. The use of more conceptually reductionistic definitions of emotion and behavior in comprehensive longitudinal studies of the natural history of PD is recommended.
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Affiliation(s)
- Jeffrey C Looi
- Faculty of Medicine and Centre for Mental Health Research, Australian National University (ANU), Canberra, ACT, Australia.
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Johnson AM, Vernon PA, Almeida QJ, Grantier LL, Singarayer R, Jog MS. Screening for Parkinson's disease with response time batteries: a pilot study. BMC Med Inform Decis Mak 2004; 4:14. [PMID: 15361256 PMCID: PMC518971 DOI: 10.1186/1472-6947-4-14] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Accepted: 09/13/2004] [Indexed: 11/22/2022] Open
Abstract
Background Although significant response time deficits (both reaction time and movement time) have been identified in numerous studies of patients with Parkinson's disease (PD), few attempts have been made to evaluate the use of these measures in screening for PD. Methods Receiver operator characteristic curves were used to identify cutoff scores for a unit-weighted composite of two choice response tasks in a sample of 40 patients and 40 healthy participants. These scores were then cross-validated in an independent sample of 20 patients and 20 healthy participants. Results The unit-weighted movement time composite demonstrated high sensitivity (90%) and specificity (90%) in the identification of PD. Movement time was also significantly correlated (r = 0.59, p < 0.025) with the motor score of the Unified Parkinson's Disease Rating Scale (UPDRS). Conclusions Measures of chronometric speed, assessed without the use of biomechanically complex movements, have a potential role in screening for PD. Furthermore, the significant correlation between movement time and UPDRS motor score suggests that movement time may be useful in the quantification of PD severity.
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Affiliation(s)
- Andrew M Johnson
- Faculty of Health Sciences, University of Western Ontario, London, ON, Canada
| | - Philip A Vernon
- Department of Psychology, University of Western Ontario, London, ON, Canada
| | - Quincy J Almeida
- Department of Kinesiology, Wilfrid Laurier University, Waterloo, ON, Canada
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University Campus, London, ON, Canada
| | - Linda L Grantier
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University Campus, London, ON, Canada
| | - Rene Singarayer
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University Campus, London, ON, Canada
| | - Mandar S Jog
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University Campus, London, ON, Canada
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Abstract
Parkinson's disease leads to major disability that impairs the quality of life of patients and leads to increased health-care costs. While there is no proven neuroprotective treatment, more basic-science research and clinical trials are needed to identify drugs that slow or halt the progression of the disorder. The mainstay of symptomatic treatment is levodopa. With long-term use, levodopa causes motor complications including involuntary movements and response fluctuations. These have lead to more cautious prescribing of levodopa. Dopamine agonists can be used as an alternative initial therapy to delay the onset of motor complications but at the expense of more dopaminergic adverse events, poorer control of motor symptoms, and increased cost. Once motor complications have developed, adjuvant therapy with dopamine agonists or entacapone can reduce off time and levodopa dose. Severe fluctuations that are not controlled by oral combination therapy can be controlled with subcutaneous apomorphine injections or infusions.
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