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Murphy KT, Lynch GS. Impaired skeletal muscle health in Parkinsonian syndromes: clinical implications, mechanisms and potential treatments. J Cachexia Sarcopenia Muscle 2023; 14:1987-2002. [PMID: 37574254 PMCID: PMC10570091 DOI: 10.1002/jcsm.13312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 04/27/2023] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
There is increasing evidence that neurodegenerative disorders including the Parkinsonian syndromes are associated with impaired skeletal muscle health, manifesting as wasting and weakness. Many of the movement problems, lack of muscle strength and reduction in quality of life that are characteristic of these syndromes can be attributed to impairments in skeletal muscle health, but this concept has been grossly understudied and represents an important area of unmet clinical need. This review describes the changes in skeletal muscle health in idiopathic Parkinson's disease and in two atypical Parkinsonian syndromes, the most aggressive synucleinopathy multiple system atrophy, and the tauopathy progressive supranuclear palsy. The pathogenesis of the skeletal muscle changes is described, including the contribution of impairments to the central and peripheral nervous system and intrinsic alterations. Pharmacological interventions targeting the underlying molecular mechanisms with therapeutic potential to improve skeletal muscle health in affected patients are also discussed. Although little is known about the mechanisms underlying these conditions, current evidence implicates multiple pathways and processes, highlighting the likely need for combination therapies to protect muscle health and emphasizing the merit of personalized interventions for patients with different physical capacities at different stages of their disease. As muscle fatigue is often experienced by patients prior to diagnosis, the identification and measurement of this symptom and related biomarkers to identify early signs of disease require careful interrogation, especially for multiple system atrophy and progressive supranuclear palsy where diagnosis is often made several years after onset of symptoms and only confirmed post-mortem. We propose a multidisciplinary approach for early diagnosis and implementation of personalized interventions to preserve muscle health and improve quality of life for patients with typical and atypical Parkinsonian syndromes.
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Affiliation(s)
- Kate T. Murphy
- Department of Anatomy and Physiology, Centre for Muscle ResearchThe University of MelbourneMelbourneAustralia
| | - Gordon S. Lynch
- Department of Anatomy and Physiology, Centre for Muscle ResearchThe University of MelbourneMelbourneAustralia
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Todisco M, Cosentino G, Scardina S, Fresia M, Prunetti P, Pisani A, Alfonsi E. Diagnostic and Prognostic Value of External Anal Sphincter
EMG
Patterns in Multiple System Atrophy. Mov Disord 2022; 37:1069-1074. [PMID: 35122320 PMCID: PMC9305564 DOI: 10.1002/mds.28938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 11/08/2022] Open
Abstract
Background It is debated whether external anal sphincter (EAS) electromyography can distinguish between multiple system atrophy (MSA) and Parkinson's disease (PD), whereas its usefulness for MSA prognosis is unknown. Objectives We explored the diagnostic and prognostic value and clinical correlations of EAS electromyography patterns in MSA. Methods We collected clinical data and EAS electromyography findings in 72 patients with MSA and 21 with PD. Results We identified four EAS patterns. The normal pattern was frequently observed in PD and associated with prolonged survival when identified in MSA. Abnormal patterns were predominant in MSA. The most severe pattern was associated with the highest likelihood of MSA diagnosis and with the worst prognosis in the MSA cohort. MSA patients with EAS abnormalities often showed urogenital symptoms and fecal incontinence. Conclusions The increasing severity of EAS electromyography patterns paralleled diagnostic accuracy and survival in MSA, and correlated with prevalence of bladder and bowel symptoms. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
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Affiliation(s)
- Massimiliano Todisco
- Translational Neurophysiology Research Unit IRCCS Mondino Foundation Pavia Italy
- Movement Disorders Research Center IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - Giuseppe Cosentino
- Translational Neurophysiology Research Unit IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - Serena Scardina
- Department of Biomedicine, Neuroscience and advanced Diagnostics (BIND) University of Palermo Palermo Italy
| | - Mauro Fresia
- Translational Neurophysiology Research Unit IRCCS Mondino Foundation Pavia Italy
| | - Paolo Prunetti
- Translational Neurophysiology Research Unit IRCCS Mondino Foundation Pavia Italy
| | - Antonio Pisani
- Movement Disorders Research Center IRCCS Mondino Foundation Pavia Italy
- Department of Brain and Behavioral Sciences University of Pavia Pavia Italy
| | - Enrico Alfonsi
- Translational Neurophysiology Research Unit IRCCS Mondino Foundation Pavia Italy
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Prevalence and Characteristics of Polyneuropathy in Atypical Parkinsonian Syndromes: An Explorative Study. Brain Sci 2021; 11:brainsci11070879. [PMID: 34209067 PMCID: PMC8301815 DOI: 10.3390/brainsci11070879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/24/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Peripheral nerve involvement is increasingly recognized in Parkinson's disease (PD). Although non-motor symptoms and postural instability are early features of atypical parkinsonian syndromes (APS), peripheral neuropathies in APS have not been addressed in detail thus far. Therefore, the aim of this study was to investigate the prevalence and characteristics of polyneuropathies (PNP) in multiple system atrophy (MSA) and progressive supranuclear palsy (PSP), as representative syndromes of APS. (2) Methods: In total, 8 MSA and 6 PSP patients were comprehensively analyzed regarding subjective, clinical (motor and non-motor) and paraclinical PNP features using nerve conduction studies and high resolution nerve ultrasounds (HRUS). (3) Results: A total of 87.5% of MSA and 66.7% of PSP patients complained of at least one neuropathic symptom, with electrophysiological confirmation of PNP in 50.0% of both, MSA and PSP patients. PNP symptom severity in PSP and motor nerve amplitude in MSA were associated with compromised motor function. Morphologic nerve examination by HRUS showed few alterations according to the axonal type of PNP. (4) Conclusions: The overall high PNP symptom burden may be partially credited to the significant prevalence of electrophysiologically diagnosed PNP, and impact motor aspects of APS. The findings of this exploratory study reinforce further investigations on a larger scale, in order to elucidate peripheral nerve involvement and the underlying pathophysiological mechanisms of APS.
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Jang M, Kim HJ, Kim A, Jeon B. Urinary Symptoms and Urodynamic Findings in Patients with Spinocerebellar Ataxia. THE CEREBELLUM 2021; 19:483-486. [PMID: 32193855 DOI: 10.1007/s12311-020-01126-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Urinary dysfunctions are not considered symptoms of spinocerebellar ataxias (SCAs). However, given that a patient with SCAs without a family history might be misdiagnosed as MSA-C when having urinary dysfunctions, characterization of urinary dysfunctions in SCAs is needed not only to understand SCAs but also to correctly diagnosis patients with ataxia. We retrospectively reviewed medical records of 143 patients with genetically confirmed SCA1, 2, 3, 6, 7, 17, and DRPLA. Twenty-two patients (men n = 9; age 62.1 ± 10.9; disease duration 8.2 ± 2.9 years) who had lower urinary track symptoms (LUTS) were included in this study. Six patients underwent urodynamic study (UDS), and 2 underwent uroflowmetry. LUTS was present in 1 of 11 patients with SCA1, in 4 of 51 with SCA2, in 2 of 26 with SCA3, in 3 of 20 with SCA6, in 2 of 4 with SCA7, in 8 of 26 with SCA17, and in 2 of 5 with DRPLA. Overall, urinary frequency was the most common symptom (16 patients, 72.7%) followed by voiding difficulty. In three of the 6 patients with UDS, post-micturition residuals were > 100 ml. Detrusor overactivity was noted in three patients. Detrusor areflexia was observed in one. Four patients were diagnosed with a neurogenic bladder, 3 with a storage problem, and 1 with both storage and voiding problems. Fifteen percent of the patients with SCAs had LUTS, and LUTS occurred in various types of SCAs. Our results indicate that SCAs should be considered in patients with progressive cerebellar ataxia and urinary dysfunctions.
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Affiliation(s)
- Mihee Jang
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Han-Joon Kim
- Department of Neurology, Movement Disorder Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
| | - Aryun Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, South Korea
| | - Beomseok Jeon
- Department of Neurology, Movement Disorder Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Stankovic I, Fanciulli A, Kostic VS, Krismer F, Meissner WG, Palma JA, Panicker JN, Seppi K, Wenning GK. Laboratory-Supported Multiple System Atrophy beyond Autonomic Function Testing and Imaging: A Systematic Review by the MoDiMSA Study Group. Mov Disord Clin Pract 2021; 8:322-340. [PMID: 33816659 DOI: 10.1002/mdc3.13158] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/24/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Abstract
Background Neuroimaging has been used to support a diagnosis of possible multiple system atrophy (MSA). Only blood pressure changes upon standing are included in the second consensus criteria but other autonomic function tests (AFT) are also useful to diagnose widespread and progressive autonomic failure typical of MSA. Additional diagnostic tools are of interest to improve accuracy of MSA diagnosis. Objectives To assess the utility of diagnostic tools beyond brain imaging and AFT in enhancing a laboratory-supported diagnosis of MSA to support the upcoming revision of the consensus criteria. Methods The International Parkinson and Movement Disorders Society MSA Study Group (MoDiMSA) performed a systematic review of original papers on biomarkers, sleep studies, genetic, neuroendocrine, neurophysiological, neuropsychological and other tests including olfactory testing and acute levodopa challenge test published before August 2019. Results Evaluation of history of levodopa responsiveness and olfaction is useful in patients in whom MSA-parkinsonian subtype is suspected. Neuropsychological testing is useful to exclude dementia at time of diagnosis. Applicability of sphincter EMG is limited. When MSA-cerebellar subtype is suspected, a screening for the common causes of adult-onset progressive ataxia is useful, including spinocerebellar ataxias in selected patients. Diagnosing stridor and REM sleep behavior disorder is useful in both MSA subtypes. However, none of these tools are validated in large longitudinal cohorts of postmortem confirmed MSA cases. Conclusions Despite limited evidence, additional laboratory work-up of patients with possible MSA beyond imaging and AFT should be considered to optimize the clinical diagnostic accuracy.
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Affiliation(s)
- Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, School of Medicine University of Belgrade Belgrade Serbia
| | | | - Vladimir S Kostic
- Neurology Clinic, Clinical Center of Serbia, School of Medicine University of Belgrade Belgrade Serbia
| | - Florian Krismer
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
| | - Wassilios G Meissner
- Department of Neurology for Neurodegenerative Diseases, French Reference Center for MSA University Hospital Bordeaux Bordeaux France.,Institute of Neurodegenerative Diseases, University Bordeaux, CNRS, UMR 5293 Bordeaux France.,Department of Medicine University of Otago Christchurch New Zealand.,New Zealand Brain Research Institute Christchurch New Zealand
| | - Jose Alberto Palma
- Department of Neurology, Dysautonomia Center, Langone Medical Center New York University School of Medicine New York New York USA
| | - Jalesh N Panicker
- UCL Institute of Neurology London United Kingdom.,Department of Uro-Neurology The National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Klaus Seppi
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
| | - Gregor K Wenning
- Department of Neurology Medical University of Innsbruck Innsbruck Austria
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Gastrointestinal dysfunction in the synucleinopathies. Clin Auton Res 2020; 31:77-99. [PMID: 33247399 DOI: 10.1007/s10286-020-00745-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022]
Abstract
Interest in gastrointestinal dysfunction in Parkinson's disease has blossomed over the past 30 years and has generated a wealth of investigation into this non-motor aspect of the disorder, research that has encompassed its pathophysiology, its clinical features, and its impact on quality of life. The question of gastrointestinal dysfunction in the other synucleinopathies has not received nearly as much attention, but information and knowledge are growing. In this review, the current knowledge, controversies, and gaps in our understanding of the pathophysiology of gastrointestinal dysfunction in Parkinson's disease and the other synucleinopathies will be addressed, and extended focus will be directed toward the clinical problems involving saliva management, swallowing, gastric emptying, small intestinal function, and bowel function that are so problematic in these disorders.
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Fanciulli A, Stankovic I, Krismer F, Seppi K, Levin J, Wenning GK. Multiple system atrophy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2019; 149:137-192. [PMID: 31779811 DOI: 10.1016/bs.irn.2019.10.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, adult-onset, relentlessly progressive neurodegenerative disorder, clinically characterized by various combinations of autonomic failure, parkinsonism and ataxia. The neuropathological hallmark of MSA are glial cytoplasmic inclusions consisting of misfolded α-synuclein. Selective atrophy and neuronal loss in striatonigral and olivopontocerebellar systems underlie the division into two main motor phenotypes of MSA-parkinsonian type and MSA-cerebellar type. Isolated autonomic failure and REM sleep behavior disorder are common premotor features of MSA. Beyond the core clinical symptoms, MSA manifests with a number of non-motor and motor features. Red flags highly specific for MSA may provide clues for a correct diagnosis, but in general the diagnostic accuracy of the second consensus criteria is suboptimal, particularly in early disease stages. In this chapter, the authors discuss the historical milestones, etiopathogenesis, neuropathological findings, clinical features, red flags, differential diagnosis, diagnostic criteria, imaging and other biomarkers, current treatment, unmet needs and future treatments for MSA.
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Affiliation(s)
| | - Iva Stankovic
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Florian Krismer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-Universität München, Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) e.V., Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
| | - Gregor K Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Bianchi F, Squintani GM, Osio M, Morini A, Bana C, Ardolino G, Barbieri S, Bertolasi L, Caramelli R, Cogiamanian F, Currà A, de Scisciolo G, Foresti C, Frasca V, Frasson E, Inghilleri M, Maderna L, Motti L, Onesti E, Romano MC, Del Carro U. Neurophysiology of the pelvic floor in clinical practice: a systematic literature review. FUNCTIONAL NEUROLOGY 2018; 22:173-193. [PMID: 29306355 DOI: 10.11138/fneur/2017.32.4.173] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neurophysiological testing of the pelvic floor is recognized as an essential tool to identify pathophysiological mechanisms of pelvic floor disorders, support clinical diagnosis, and aid in therapeutic decisions. Nevertheless, the diagnostic value of these tests in specific neurological diseases of the pelvic floor is not completely clarified. Seeking to fill this gap, the members of the Neurophysiology of the Pelvic Floor Study Group of the Italian Clinical Neurophysiology Society performed a systematic review of the literature to gather available evidence for and against the utility of neurophysiological tests. Our findings confirm the utility of some tests in specific clinical conditions [e.g. concentric needle electromyography, evaluation of sacral reflexes and of pudendal somatosensory evoked potentials (pSEPs) in cauda equina and conus medullaris lesions, and evaluation of pSEPs and perineal sympathetic skin response in spinal cord lesions], and support their use in clinical practice. Other tests, particularly those not currently supported by high-level evidence, when employed in individual patients, should be evaluated in the overall clinical context, or otherwise used for research purposes.
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Sakakibara R, Tateno F, Yamamoto T, Uchiyama T, Yamanishi T. Urological dysfunction in synucleinopathies: epidemiology, pathophysiology and management. Clin Auton Res 2017; 28:83-101. [PMID: 29124503 DOI: 10.1007/s10286-017-0480-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 10/24/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Parkinson's disease (PD) and multiple system atrophy (MSA) are major neurogenerative diseases characterized pathologically by abnormal alpha-synuclein aggregation. PD and MSA are clinically characterized by motor disorder and bladder dysfunction (mainly urinary urgency and frequency, also called overactive bladder). However, few literatures are available concerning bladder dysfunction in PD or MSA. METHOD A systematic review. RESULTS The bladder dysfunction in MSA is more severe than that in PD for large post-void residual or urinary retention. These bladder dysfunctions presumably reflect the different nervous system pathologies. Overactive bladder in PD reflects lesions in the brain, e.g., in the prefrontal-nigrostriatal D1 dopaminergic bladder-inhibitory pathway. Overactive bladder in MSA reflects lesions similar to PD and the cerebellum (bladder-inhibitory), and the urinary retention in MSA presumably reflects lesions in the pontine micturition center and the sacral intermediolateral nucleus of the spinal cord (bladder-facilitatory). Bladder dysfunction not only impairs an individual's quality of life, it can also cause emergency hospitalizations due to acute retention and early institutionalization. Anticholinergics are the first-line treatment for bladder dysfunction in PD and MSA patients, but care should be taken for the management of bladder dysfunction-particularly in MSA patients due to the high prevalence of difficult emptying, which needs clean, intermittent catheterization. CONCLUSIONS This review summarizes the epidemiology, pathophysiology, and management of bladder dysfunction in individuals with PD or MSA.
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Affiliation(s)
- Ryuji Sakakibara
- Neurology, Internal Medicine, Sakura Medical Center, Toho University, 564-1 Shimoshizu, Sakura, 285-8741, Japan.
| | - Fuyuki Tateno
- Neurology, Internal Medicine, Sakura Medical Center, Toho University, 564-1 Shimoshizu, Sakura, 285-8741, Japan
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Kuzdas-Wood D, Irschick R, Theurl M, Malsch P, Mair N, Mantinger C, Wanschitz J, Klimaschewski L, Poewe W, Stefanova N, Wenning GK. Involvement of Peripheral Nerves in the Transgenic PLP-α-Syn Model of Multiple System Atrophy: Extending the Phenotype. PLoS One 2015; 10:e0136575. [PMID: 26496712 PMCID: PMC4619736 DOI: 10.1371/journal.pone.0136575] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/05/2015] [Indexed: 11/18/2022] Open
Abstract
Multiple system atrophy (MSA) is a fatal, rapidly progressive neurodegenerative disease with (oligodendro-)glial cytoplasmic α-synuclein (α-syn) inclusions (GCIs). Peripheral neuropathies have been reported in up to 40% of MSA patients, the cause remaining unclear. In a transgenic MSA mouse model featuring GCI-like inclusion pathology based on PLP-promoter driven overexpression of human α-syn in oligodendroglia motor and non-motor deficits are associated with MSA-like neurodegeneration. Since α-syn is also expressed in Schwann cells we aimed to investigate whether peripheral nerves are anatomically and functionally affected in the PLP-α-syn MSA mouse model.
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Affiliation(s)
- Daniela Kuzdas-Wood
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Regina Irschick
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Department of Anatomy, Histology and Embryology, Division of Neuroanatomy, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Markus Theurl
- Department of Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Philipp Malsch
- Department of Physiology and Medical Physics, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Norbert Mair
- Department of Physiology and Medical Physics, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Christine Mantinger
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Julia Wanschitz
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Lars Klimaschewski
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Nadia Stefanova
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
| | - Gregor K. Wenning
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Tirol, Austria
- * E-mail:
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Ciolli L, Krismer F, Nicoletti F, Wenning GK. An update on the cerebellar subtype of multiple system atrophy. CEREBELLUM & ATAXIAS 2014; 1:14. [PMID: 26331038 PMCID: PMC4552412 DOI: 10.1186/s40673-014-0014-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/24/2014] [Indexed: 01/05/2023]
Abstract
Multiple system atrophy is a rare and fatal neurodegenerative disorder characterized by progressive autonomic failure, ataxia and parkinsonism in any combination. The clinical manifestations reflect central autonomic and striatonigral degeneration as well as olivopontocerebellar atrophy. Glial cytoplasmic inclusions, composed of α-synuclein and other proteins are considered the cellular hallmark lesion. The cerebellar variant of MSA (MSA-C) denotes a distinctive motor subtype characterized by progressive adult onset sporadic gait ataxia, scanning dysarthria, limb ataxia and cerebellar oculomotor dysfunction. In addition, there is autonomic failure and variable degrees of parkinsonism. A range of other disorders may present with MSA-C like features and therefore the differential diagnosis of MSA-C is not always straightforward. Here we review key aspects of MSA-C including pathology, pathogenesis, diagnosis, clinical features and treatment, paying special attention to differential diagnosis in late onset sporadic cerebellar ataxias.
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Affiliation(s)
- Ludovico Ciolli
- Sapienza University, Via di Grottarossa, 1035-00189 Rome, Italy ; Department of Neurology, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Florian Krismer
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ferdinando Nicoletti
- IRCSS NEUROMED, Pozzilli, Isernia Italy ; Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University, School of Medicine and Psychology, Rome, Italy
| | - Gregor K Wenning
- Department of Neurology, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria
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Berardelli A, Wenning GK, Antonini A, Berg D, Bloem BR, Bonifati V, Brooks D, Burn DJ, Colosimo C, Fanciulli A, Ferreira J, Gasser T, Grandas F, Kanovsky P, Kostic V, Kulisevsky J, Oertel W, Poewe W, Reese JP, Relja M, Ruzicka E, Schrag A, Seppi K, Taba P, Vidailhet M. EFNS/MDS-ES/ENS [corrected] recommendations for the diagnosis of Parkinson's disease. Eur J Neurol 2013; 20:16-34. [PMID: 23279440 DOI: 10.1111/ene.12022] [Citation(s) in RCA: 335] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 09/18/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND A Task Force was convened by the EFNS/MDS-ES Scientist Panel on Parkinson's disease (PD) and other movement disorders to systemically review relevant publications on the diagnosis of PD. METHODS Following the EFNS instruction for the preparation of neurological diagnostic guidelines, recommendation levels have been generated for diagnostic criteria and investigations. RESULTS For the clinical diagnosis, we recommend the use of the Queen Square Brain Bank criteria (Level B). Genetic testing for specific mutations is recommended on an individual basis (Level B), taking into account specific features (i.e. family history and age of onset). We recommend olfactory testing to differentiate PD from other parkinsonian disorders including recessive forms (Level A). Screening for pre-motor PD with olfactory testing requires additional tests due to limited specificity. Drug challenge tests are not recommended for the diagnosis in de novo parkinsonian patients. There is an insufficient evidence to support their role in the differential diagnosis between PD and other parkinsonian syndromes. We recommend an assessment of cognition and a screening for REM sleep behaviour disorder, psychotic manifestations and severe depression in the initial evaluation of suspected PD cases (Level A). Transcranial sonography is recommended for the differentiation of PD from atypical and secondary parkinsonian disorders (Level A), for the early diagnosis of PD and in the detection of subjects at risk for PD (Level A), although the technique is so far not universally used and requires some expertise. Because specificity of TCS for the development of PD is limited, TCS should be used in conjunction with other screening tests. Conventional magnetic resonance imaging and diffusion-weighted imaging at 1.5 T are recommended as neuroimaging tools that can support a diagnosis of multiple system atrophy (MSA) or progressive supranuclear palsy versus PD on the basis of regional atrophy and signal change as well as diffusivity patterns (Level A). DaTscan SPECT is registered in Europe and the United States for the differential diagnosis between degenerative parkinsonisms and essential tremor (Level A). More specifically, DaTscan is indicated in the presence of significant diagnostic uncertainty such as parkinsonism associated with neuroleptic exposure and atypical tremor manifestations such as isolated unilateral postural tremor. Studies of [(123) I]MIBG/SPECT cardiac uptake may be used to identify patients with PD versus controls and MSA patients (Level A). All other SPECT imaging studies do not fulfil registration standards and cannot be recommended for routine clinical use. At the moment, no conclusion can be drawn as to diagnostic efficacy of autonomic function tests, neurophysiological tests and positron emission tomography imaging in PD. CONCLUSIONS The diagnosis of PD is still largely based on the correct identification of its clinical features. Selected investigations (genetic, olfactory, and neuroimaging studies) have an ancillary role in confirming the diagnosis, and some of them could be possibly used in the near future to identify subjects in a pre-symptomatic phase of the disease.
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Affiliation(s)
- A Berardelli
- Dipartimento di Neurologia e Psichiatria and IRCCS NEUROMED Institute, Sapienza, Università di Roma, Rome, Italy.
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Li WJ, Oh SJ. Management of lower urinary tract dysfunction in patients with neurological disorders. Korean J Urol 2012; 53:583-92. [PMID: 23060994 PMCID: PMC3459999 DOI: 10.4111/kju.2012.53.9.583] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 07/18/2012] [Indexed: 01/29/2023] Open
Abstract
The proper performance of the lower urinary tract is dependent on an intact neural innervation of the individual structures involved. Therefore, any congenital neurological anomalies, diseases, or lesions of the central, peripheral, or autonomic nervous systems can result in lower urinary tract symptoms. Lower urinary tract dysfunction (LUTD) secondary to neurological disorders can significantly reduce quality of life (QoL) and may also give rise to serious complications and psychological and social sequelae. The goals of management of LUTD in patients with neurological disorders are to prevent serious complications and to improve the patient's QoL. Understanding the physiology and pathophysiology of micturition is critical to selecting appropriate treatment options. This article provides an overview of the clinical characteristics, diagnosis, and management of LUTD in patients with certain central and peripheral neuropathies and common lesions.
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Affiliation(s)
- Wen Ji Li
- Department of Urology, Seoul National University Hospital, Neuroscience Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea. ; Department of Urology and Andrology, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Is peripheral neuron degeneration involved in multiple system atrophy? A clinical and electrophysiological study. J Neurol Sci 2012; 319:81-5. [DOI: 10.1016/j.jns.2012.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/30/2012] [Accepted: 05/04/2012] [Indexed: 11/23/2022]
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15
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Jecmenica-Lukic M, Poewe W, Tolosa E, Wenning GK. Premotor signs and symptoms of multiple system atrophy. Lancet Neurol 2012; 11:361-8. [PMID: 22441197 DOI: 10.1016/s1474-4422(12)70022-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Diagnostic criteria for multiple system atrophy are focused on motor manifestations of the disease, in particular ataxia and parkinsonism, but these criteria often cannot detect the early stages. Non-motor symptoms and signs of multiple system atrophy often precede the onset of classic motor manifestations, and this prodromal phase is estimated to last from several months to years. Autonomic failure, sleep problems, and respiratory disturbances are well known symptoms of established multiple system atrophy and, when presenting early and preceding ataxia or parkinsonism, should be regarded as evidence of premotor multiple system atrophy. An early and accurate diagnosis is becoming increasingly important as new neuroprotective agents are developed.
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Sakurai K, Yamawaki T, Okita K, Kato D, Matsukawa N, Kawaguchi T, Kobayashi S, Nagai K, Muto M, Hosono A, Shibamoto Y. Utility of the fluid-attenuated inversion recovery sequence in detecting a hyperintense putaminal rim in multiple system atrophy-parkinsonism: a preliminary study. Eur Neurol 2011; 66:42-6. [PMID: 21757916 DOI: 10.1159/000328674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 04/18/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the utility of fluid-attenuated inversion recovery (FLAIR) imaging for diagnosing multiple system atrophy-parkinsonism (MSA-P). METHODS We retrospectively evaluated 49 subjects (19 with MSA-P including 11 with early-stage disease, 15 with Parkinson's disease and 15 matched controls) in order to compare the diagnostic value of FLAIR imaging to detect a hyperintense putaminal rim (HPR) with that of T(2)-weighted (T2W) imaging. RESULTS Compared with T2W imaging, FLAIR imaging detected HPR more conspicuously in the 19 MSA-P patients (p = 0.01); this trend was also observed in 11 early-stage MSA-P patients (p = 0.01). Furthermore, FLAIR imaging tended to increase sensitivity of detecting HPR compared with T2W imaging (all patients: 89 vs. 58%, p = 0.07; early-stage patients: 100 vs. 55%, p = 0.06). CONCLUSIONS FLAIR imaging might be more useful for detecting HPR in MSA-P patients, even though they are at an early stage.
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Affiliation(s)
- Keita Sakurai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Nagoya, Japan.
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17
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Winge K, Jennum P, Lokkegaard A, Werdelin L. Anal sphincter EMG in the diagnosis of parkinsonian syndromes. Acta Neurol Scand 2010; 121:198-203. [PMID: 19785640 DOI: 10.1111/j.1600-0404.2009.01169.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The role of electromyography (EMG) recorded from the external anal sphincter (EAS) in the diagnosis of atypical parkinsonian syndromes is a matter for continuous debate. Most studies addressing this issue are retrospective. METHODS In this study, we prospectively investigated six patients with Parkinson's Disease (IPD), 14 patients with multiple system atrophy (MSA) and eight with progressive supranuclear palsy (PSP) using EMG of the EAS, motor-evoked potential (MEP) to the EAS and EMG of m. gastrocnemius and nerve conduction velocity measured at the sural nerve. Patients were followed up for 2 years to secure correct diagnosis. RESULTS The mean duration of motor unit potentials (MUPs) recorded from the EAS was significantly longer in patients with MSA and PSP compared with MUPs recorded from patients with PD (P < 0.005 for both). There were no signs of diffuse loss of motor neurons or peripheral neuropathy. MEP revealed signs of supranuclear affection in patients with MSA, whereas in patients with PSP the mechanism is a focal loss of motor neurons in Onuf's nucleus. CONCLUSION Abnormal EMG of the EAS is strongly suggestive of atypical parkinsonism and the pathophysiology may be different in patients with MSA and PSP.
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Affiliation(s)
- K Winge
- Copenhagen Movement Disorders Centre, Bispebjerg University Hospital, Copenhagen NV, Denmark.
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18
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Krim E, Tison F. Atrofia multisistemica. Neurologia 2009. [DOI: 10.1016/s1634-7072(09)70517-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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Abstract
BACKGROUND It has been almost 4 decades since the descriptions of the 3 parts of multiple system atrophy (MSA) have taken place, characterized clinically by dysautonomia, parkinsonism, and cerebellar dysfunction. The discovery of a distinctive pathologic maker has finally provided the conceptual synthesis of these 3 entities into the universal designation of MSA as a distinct disease process with a complex combination of clinical presentations. Although advances have been made in terms of awareness and knowledge concerning the clinical features and pathophysiology of MSA, it remains challenging for neurologists who treat these patients to differentiate MSA from its mimics as well as providing them with effective treatment. REVIEW SUMMARY The aim of this review is to provide an overview of the advances in the knowledge of the disease, to highlight typical features useful for the recognition of its entity, and to enlist different treatment options. CONCLUSION Despite the fact that there is still no treatment modality that can alter the disease progression, a number of useful symptomatic treatment measures are available and should be offered to patients to ameliorate the nonmotor features of MSA and even the motor features that may at least transiently respond to treatment.
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20
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Yamanaka Y, Asahina M, Mathias CJ, Akaogi Y, Koyama Y, Hattori T. Skin vasodilator response to local heating in multiple system atrophy. Mov Disord 2008; 22:2405-8. [PMID: 17894341 DOI: 10.1002/mds.21742] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Local heating of nonglabrous skin increases skin blood flow (SkBF) in two phases. The initial peak (P1) is mediated by a sensory-axon reflex and the plateau phase (P2) by local production of substances such as nitric oxide. We evaluated the SkBF response to local heating in 15 multiple system atrophy (MSA) patients with autonomic failure and 12 age-matched healthy controls. The mean ratio of SkBF at P1 to that at baseline (SkBF(P1)/SkBF(base) ratio) in MSA was significantly lower than that in controls (P < 0.01). The mean ratio of SkBF at P2 seemed to be slightly reduced in the MSA patients, compared with controls, although there was no significant difference. The P1 phase is thought to be mediated by a sensory-axon reflex modulated by sympathetic nerve activity. These findings are indicative of the skin sympathetic vasomotor dysfunction in MSA.
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Affiliation(s)
- Yoshitaka Yamanaka
- Department of Neurology, Chiba University Graduate School of Medicine, Chiba, Japan.
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Vassel P, Robain G, Pichon J, Chartier-Kastler E, Ruffion A. Chapitre I - Troubles vésico-sphintériens des syndromes parkinsoniens. Prog Urol 2007; 17:393-8. [PMID: 17622065 DOI: 10.1016/s1166-7087(07)92336-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Lower urinary tract dysfunction is frequent in Parkinson's disease and other Parkinsonian syndromes and can cause urinary incontinence complicating a urgency-frequency syndrome or on the contrary, dysuria. These disorders are a frequent urological presenting complaint due to their impact on the patient's quality of life. Urologists must be aware of the different natural histories of diseases such as Parkinson's disease and Parkinsonian syndromes such as multisystem atrophy, which often have a severe course and are marked by resistance to neuropharmacological treatments. These various diseases can also directly induce urinary symptoms, independently of urological complications. Inversely, the development of urinary disorders, especially obstructive symptoms, in a patient with Parkinsonian syndrome may require review of the neurological diagnosis. Finally, therapeutic management is complex due to the difficulty of using pharmacological treatments, and the risk of deterioration after surgical treatment of obstructive uropathy.
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Affiliation(s)
- Ph Vassel
- Centre de médecine physique et de réadaptation de Coubert, France.
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Cilia R, Marotta G, Benti R, Pezzoli G, Antonini A. Brain SPECT imaging in multiple system atrophy. J Neural Transm (Vienna) 2006; 112:1635-45. [PMID: 16284908 DOI: 10.1007/s00702-005-0382-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Accepted: 09/13/2005] [Indexed: 12/30/2022]
Abstract
Clinical diagnosis of multiple system atrophy (MSA) relays on signs and symptoms that are often difficult to identify particularly at early stage. Indeed neuropathological studies have demonstrated that MSA is the first cause of misdiagnosis in a cohort of patients presenting with parkinsonian features. Dopamine transporter imaging (DAT) shows striatal decrements in both MSA and Parkinson's disease (PD) making it not sensitive for differential diagnosis. Studies of dopamine D2 receptors with IBZM may help revealing striatal degeneration but a large overlap exist particularly if PD patients with advanced disease are included. We have measured brain flow with technetium-99m ethyl cysteinate dimer (ECD-SPECT) in 36 MSA patients and compared it with 43 PD and 39 age-matched controls. Using Statistical Parametric Mapping (SPM99) we found areas of significant reduced perfusion in the striatum, brain stem and cerebellum in MSA compared to the other groups. We believe that ECD-SPECT imaging may offer significant advantages compared to other imaging techniques in the assessment of neuronal degeneration in MSA and may help the clinician in the diagnostic characterization of patients presenting with atypical parkinsonism.
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Affiliation(s)
- R Cilia
- Parkinson Institute, Instituti Clinici di Perfezionamento, Milan, Italy
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Vodusek DB. How to diagnose MSA early: the role of sphincter EMG. J Neural Transm (Vienna) 2005; 112:1657-68. [PMID: 16284909 DOI: 10.1007/s00702-005-0377-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2005] [Accepted: 09/10/2005] [Indexed: 10/25/2022]
Abstract
Multiple system atrophy (MSA) is a degenerative disease manifesting a combination of parkinsonism, cerebellar, pyramidal, and autonomic (including urinary, sexual and anorectal) dysfunction. It is pathomorphologically defined, but lacks a definitive clinical diagnostic test. In patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the majority of patients in all the different forms of the disease in most studies, including patients who, as yet, have no urological or anorectal problems. Patients with Parkinson's disease (PD) as a rule do not show marked sphincter EMG abnormalities in the first five years of the disease. Thus, abnormal spontaneous activity or marked motor unit potential changes in sphincter muscles are helpful in distinguishing MSA from PD in the first five years after the onset of symptoms and signs, and from pure autonomic failure, as well as from cerebellar ataxias, if other causes for sphincter denervation have been ruled out. EMG does not distinguish MSA from progressive supranuclear palsy. How early in the course of MSA these abnormalities become significant enough to support diagnosis remains to be established by prospective studies.
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Affiliation(s)
- D B Vodusek
- Division of Neurology, University Medical Center, Ljubljana, Slovenia.
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Kamm C, Healy DG, Quinn NP, Wüllner U, Moller JC, Schols L, Geser F, Burk K, Børglum AD, Pellecchia MT, Tolosa E, del Sorbo F, Nilsson C, Bandmann O, Sharma M, Mayer P, Gasteiger M, Haworth A, Ozawa T, Lees AJ, Short J, Giunti P, Holinski-Feder E, Illig T, Wichmann HE, Wenning GK, Wood NW, Gasser T. The fragile X tremor ataxia syndrome in the differential diagnosis of multiple system atrophy: data from the EMSA Study Group. ACTA ACUST UNITED AC 2005; 128:1855-60. [PMID: 15947063 DOI: 10.1093/brain/awh535] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The recent identification of fragile X-associated tremor ataxia syndrome (FXTAS) associated with premutations in the FMR1 gene and the possibility of clinical overlap with multiple system atrophy (MSA) has raised important questions, such as whether genetic testing for FXTAS should be performed routinely in MSA and whether positive cases might affect the specificity of current MSA diagnostic criteria. We genotyped 507 patients with clinically diagnosed or pathologically proven MSA for FMR1 repeat length. Among the 426 clinically diagnosed cases, we identified four patients carrying FMR1 premutations (0.94%). Within the subgroup of patients with probable MSA-C, three of 76 patients (3.95%) carried premutations. We identified no premutation carriers among 81 patients with pathologically proven MSA and only one carrier among 622 controls (0.16%). Our results suggest that, with proper application of current diagnostic criteria, FXTAS is very unlikely to be confused with MSA. However, slowly progressive disease or predominant tremor are useful red flags and should prompt the consideration of FXTAS. On the basis of our data, the EMSA Study Group does not recommend routine FMR1 genotyping in typical MSA patients.
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Affiliation(s)
- C Kamm
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, Hoppe-Seyler-Strasse 3, University of Tübingen, 72086 Tübingen, Germany
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Neurophysiology of Parkinson's disease, levodopa-induced dyskinesias, dystonia, Huntington's disease and myoclonus. NEURODEGENER DIS 2005. [DOI: 10.1017/cbo9780511544873.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Sakakibara R, Uchiyama T, Arai K, Yamanishi T, Hattori T. Lower urinary tract dysfunction in Machado-Joseph disease: a study of 11 clinical-urodynamic observations. J Neurol Sci 2004; 218:67-72. [PMID: 14759635 DOI: 10.1016/j.jns.2003.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2003] [Revised: 10/31/2003] [Accepted: 11/03/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Machado-Joseph disease (MJD), or hereditary spinocerebellar ataxia type 3, is the most common dominantly inherited ataxia. However, lower urinary tract (LUT) dysfunction in MJD has not been fully delineated. We investigated LUT dysfunction in MJD by clinical-urodynamic observations. METHODS In 24 genetically diagnosed MJD, we recruited all 11 patients with LUT symptoms (six men, five women; age, 18-61 [mean 48] years; disease duration, 2-24 [mean 9] years; voiding difficulty, 7, urinary incontinence, 4). Urodynamic studies consisted of uroflowmetry, measurement of post-void residuals and electromyography (EMG)-cystometry. Neurophysiology tests consisted of motor unit potential (MUP) analysis of the sphincter and extremity muscles, tibial nerve somatosensory evoked potentials (SEP) and nerve conduction studies (NCS) of the extremities. RESULTS Urodynamic abnormalities were seen in all 11 patients studied. Maximum or average flow rate was decreased in five. Post-void residual was noted in three but residual urine volume > 100 ml was noted in only one patient. Maximum urethral closure pressure was low in one and high in one of five patients studied. EMG-cystometry during filling showed detrusor overactivity in five, impaired bladder sensation in four, low compliance detrusor in one, uninhibited sphincter relaxation in one and incompetent urethra in one. Voiding phase abnormalities included detrusor areflexia in three and detrusor-sphincter dyssynergia in two. Bethanechol supersensitivity of the bladder was noted in one of three patients studied. Bulbocavernosus reflex was absent in two of five patients studied. MUP analysis showed neurogenic changes in six of nine sphincter muscles and in all six extremity muscles studied. Five patients had prolonged or absent cortical response in SEP and four had sensory axonal neuropathy in NCS, which were relevant to the impaired bladder sensation. CONCLUSION In the present study, a half of MJD patients had LUT symptoms and they showed various urodynamic abnormalities. Detrusor overactivity, impaired bladder sensation, and neurogenic sphincter EMG were common findings, and large post-void residuals were rare. These findings are relevant to central and peripheral nervous system pathology of MJD.
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Affiliation(s)
- Ryuji Sakakibara
- Department of Neurology, Chiba University, 1-8-1 Inohana Chuo, Chiba 260-8670, Japan.
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Abstract
OBJETIVO: Avaliar a doença de Parkinson pela ressonância magnética. MATERIAIS E MÉTODOS: De outubro de 1999 a outubro de 2002, foram estudados 42 pacientes com parkinsonismo, por meio de um aparelho de ressonância magnética de 1,5 T. Os pacientes foram divididos em dois grupos: grupo com doença de Parkinson (n = 26) e grupo com síndrome parkinsoniana atípica (n = 16), sendo os resultados comparados com um grupo controle (n = 18). Foram avaliadas as seguintes variáveis: espessura da pars compacta do mesencéfalo, grau de hipointensidade de sinal no putâmen, grau de atrofia cerebral, lesões no mesencéfalo, lesões na substância branca e a presença de lesão na borda póstero-lateral do putâmen. A análise estatística dos dados foi realizada, com a utilização do programa SPSS. RESULTADOS: A média de idade foi de 58,2 anos nos grupos com doença de Parkinson e controle, e 60,5 anos no grupo com síndrome parkinsoniana atípica. Os pacientes com doença de Parkinson e síndrome parkinsoniana atípica apresentaram redução da espessura da pars compacta e maior grau de hipointensidade de sinal no putâmen. O grau de atrofia cerebral foi maior nos pacientes com síndrome parkinsoniana atípica. As lesões no mesencéfalo e na substância branca foram semelhantes entre os grupos. O sinal hiperintenso na borda póstero-lateral do putâmen foi um achado pouco freqüente na população estudada, mas sugestivo de atrofia de múltiplos sistemas. CONCLUSÃO: Desta forma, a ressonância magnética detectou alterações morfológicas cerebrais que podem auxiliar no diagnóstico por imagem das síndromes parkinsonianas.
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Abstract
Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder characterised clinically by any combination of parkinsonian, autonomic, cerebellar, or pyramidal signs and pathologically by cell loss, gliosis, and glial cytoplasmic inclusions in several CNS structures. Owing to the recent advances in its molecular pathogenesis, MSA has been firmly established as an alpha-synucleinopathy along with other neurodegenerative diseases. In parallel, the clinical recognition of MSA has improved and the recent consensus diagnostic criteria have been widely established in the research community as well as movement disorders clinics. Although the diagnosis of this disorder is largely based on clinical expertise, several investigations have been proposed in the past decade to assist in early differential diagnosis. Symptomatic therapeutic strategies are still limited; however, several candidate neuroprotective agents have entered phase II and phase III clinical trials.
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Affiliation(s)
- Gregor K Wenning
- Department of Neurology, University Hospital, A-6020 Innsbruck, Austria
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Kirchhof K, Apostolidis AN, Mathias CJ, Fowler CJ. Erectile and urinary dysfunction may be the presenting features in patients with multiple system atrophy: a retrospective study. Int J Impot Res 2003; 15:293-8. [PMID: 12934060 DOI: 10.1038/sj.ijir.3901014] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Multiple system atrophy (MSA) is a progressive neurodegenerative disease characterized by parkinsonism and cerebellar, autonomic, urinary, and/or pyramidal dysfunction. Urinary and erectile dysfunction (ED) symptoms are prominent early features in men with MSA. Autonomic failure, considered until recently to be the cause of ED in these men, is commonly expressed through symptoms of orthostatic hypotension (OH). The aim of this retrospective study is to examine the chronological relationship between the development of urogenital symptoms and those of OH in patients diagnosed with MSA and discuss its significance in the aetiology of ED in these patients. A total of 71 male patients, referred to a Uro-Neurology department with a diagnosis of 'probable MSA', were reviewed in terms of 'autonomic' symptoms only--OH and lower urinary tract symptoms, accompanied by ED--present at the time of their referral. Laboratory investigations including anal sphincter EMG and/or autonomic function tests (AFTs) were performed in 75 and 90% of the patients, respectively. At presentation, urinary complaints were recorded in 96% of patients and ED in all patients that this was inquired about. The onset of ED had preceded the onset of bladder symptoms in 58% and the onset of OH symptoms in 91% of these men. Bladder symptoms also preceded symptoms of OH in 76% of patients. Sphincter EMG was abnormal in 91% and AFTs in 77% of the patients tested. Almost all patients with abnormal EMG had troublesome urinary symptoms. AFTs showed similar sensitivity relating to symptoms. At presentation, urogenital symptoms are common in patients with probable MSA and are often not accompanied by symptoms of OH. The earlier occurrence of ED in men with MSA suggests a lack of a causal relationship to hypotension. The notion that MSA possibly affects the dopaminergic mechanism of erectile function is discussed.
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Affiliation(s)
- K Kirchhof
- Department of Neurology, Division of Neuroradiology, University of Heidelberg Medical Center, Heidelberg, Germany
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Heldoorn M, Marani E, Leeuwen JL, Vanderschoot J. A compartmental model of an external urethral sphincter motoneuron of Onuf's nucleus. Arch Physiol Biochem 2003; 111:193-201. [PMID: 14972739 DOI: 10.1076/apab.111.3.193.23462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This article discusses a model of the electrical behavior of an external urethral sphincter motoneuron, based on morphological parameters like soma size, dendritic diameters and spatial dendritic configuration, and several electrical parameters. Because experimental data about the exact ion conductance mix of external urethral sphincter neurons is scarce, the gaps in knowledge about external urethral sphincter motoneurons were filled in with known data of alpha-motoneurons. The constructed compartmental model of motoneurons of Onuf's nucleus contains six voltage-dependent ionic conductances: a fast sodium and potassium conductance and an anomalous rectifier in the soma; a fast delayed rectifier type potassium conductance and a fast sodium conductance in the initial axon segment; an L-type calcium channel in the dendritic compartments. This paper considers the simulation of external urethral sphincter motoneuron responses to current injections that evoke bistable behavior. Simulations show self-sustained discharge following a depolarizing pulse through the microelectrode; the firing was subsequently terminated by a short hyperpolarizing pulse. This behavior is highly functional for neurons that have to exhibit prolonged activation during sphincter closure. In addition to these 'on' and 'off ' responses, we also observed a particular firing behavior in response to long-lasting triangular current pulses. When the depolarizing current was slowly increased and then decreased (triangular pulse) the firing frequency was higher during the descending phase than during the initial ascending phase.
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Affiliation(s)
- M Heldoorn
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Electromyographic studies of the sphincter in patients with multiple system atrophy have shown increased duration and polyphasia of motor unit potentials. These electrophysiological markers have been used to argue for the selective degeneration of sacral motor neurons in Onuf's nucleus in patients with multiple system atrophy. Studies comparing sphincter electromyographic changes in patients with multiple system atrophy and Parkinson's disease have shown significant differences between these two patient populations. Despite the controversy surrounding this claim, recent studies using quantitative electromyographic techniques support the view that reinnervation of the anal sphincter muscles may be a useful diagnostic marker for distinguishing multiple system atrophy from Parkinson's disease. A critical review of these data is needed to assess the validity and reliability of electromyographic changes in multiple system atrophy.
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Affiliation(s)
- Frederick Nahm
- Center for Peripheral and Autonomic Nerve Disorders, Harvard Medical School, Beth Israel Deaconess Medical Center, One Deaconess Road, Palmer 111, Boston, Massachusetts 02215, USA
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Abstract
The most common disorder in a patient presenting to a movement disorder clinic will be parkinsonism. The challenge is to provide the patient with the most accurate diagnosis and prognosis possible. The assumption at the time of initial presentation of the clinical diagnosis of Parkinson's disease is often wrong (20-25%). Waiting to see the pattern of progression, and response to medication provides invaluable additional information. This manuscript summarizes the clinical manifestations of Parkinson's disease and the main akinetic-rigid syndromes (progressive supranuclear palsy, multiple system atrophy, cortical-basal ganglionic degeneration, and dementia with Lewy bodies) that make up the differential diagnosis.
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Abstract
To store and expel urine at appropriate intervals, the lower urinary tract requires extensive input and control from the peripheral autonomic, somatic, and central nervous systems. Neurological disorders, such as cerebrovascular disease and Parkinson's disease, often cause functional disturbances of the lower urinary tract.
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Affiliation(s)
- Mike B Siroky
- Boston University School of Medicine, 80 East Concord Street, Boston, MA 02118, USA.
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Podnar S, Fowler CJ. Sphincter electromyography in diagnosis of multiple system atrophy: technical issues. Muscle Nerve 2003; 29:151-6. [PMID: 14694513 DOI: 10.1002/mus.10478] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Possible technical reasons for the controversy over the role of sphincter electromyography (EMG) in the diagnosis of multiple system atrophy (MSA) were analyzed. In a review of the literature, a high sensitivity (>60%) was found reported in 11 studies that included late components, and no value of the test was found in 4 studies that excluded them. This was also corroborated in a pilot study of 5 patients with probable MSA. With late components included, the mean motor unit potential (MUP) duration was prolonged in all 4 patients with an adequate single-MUP analysis sample and, with late components excluded, in 2 of 5 patients on multi-MUP analysis. At least in diagnostic EMG of MSA patients, late components should be included in the measurement of MUP duration.
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Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, University Medical Center Ljubljana, SI-1525 Ljubljana, Slovenia.
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Del Rey AP, Entrena BF. Reference values of motor unit potentials (MUPs) of the external anal sphincter muscle. Clin Neurophysiol 2002; 113:1832-9. [PMID: 12417239 DOI: 10.1016/s1388-2457(02)00268-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To provide reference values for the isolated motor unit potentials (MUPs) in the external anal sphincter (EAS) muscle, as mean duration, mean amplitude, mean area, number of turns and number of phases, related to the age of the patient. These data are not available in worldwide literature in spite of the fact that the EAS muscle is being increasingly mentioned in relation to differential diagnosis. METHODS Study of 235 subjects aged 0-80 years using an automated analysis program. RESULTS The study performed shows a clear gradual progression of the mean duration with patient age. The variability of all other parameters tested is also analyzed. CONCLUSIONS Our study shows that the classical values of MUPs isolated in the EAS muscle are directly related to age, and that this method is fully reliable to study its pathological conditions.
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Affiliation(s)
- A Piqueras Del Rey
- Neurophysiology Department, Hospital Universitario La Fe, Reina, 100-4a, 46011 Valencia, Spain
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Lee EA, Kim BJ, Lee WY. Diagnosing multiple system atrophy with greater accuracy: combined analysis of the clonidine-growth hormone test and external anal sphincter electromyography. Mov Disord 2002; 17:1242-7. [PMID: 12465063 DOI: 10.1002/mds.10225] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The clonidine-growth hormone test (CGHT) has been proposed as a means of differentiating multiple system atrophy (MSA) from idiopathic Parkinson's disease (PD). However, it is controversial whether the CGHT is valid. We sought to confirm the validity of the CGHT and to compare the diagnostic accuracy of the CGHT with that of external anal sphincter electromyelography (Sph-EMG) for MSA. We performed the CGHT and the Sph-EMG on 21 PD patients, 23 patients with probable MSA of parkinsonian type (MSA-p), and 22 patients with probable MSA of cerebellar type (MSA-c). We compared the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of CGHT, Sph-EMG, and a combination of the two tests. We also evaluated the correlations of Unified Parkinson's Disease Rating Scale (UPDRS) scores with the results of the two tests. There was no significant difference between the UPDRS scores for the PD and MSA-p groups. Serum growth hormone concentrations after clonidine significantly increased in PD (mean increase +/- SEM, 4.19 +/- 0.92 ng/ml; P < 0.0001), but remained unchanged in both MSA-p (0.83 +/- 0.61 ng/ml) and MSA-c (1.45 +/- 0.58 ng/ml). The growth hormone responses to clonidine in MSA-p were significantly different from those in PD (P < 0.05). Abnormal, denervated Sph-EMG was observed in 95.7% of MSA-p, 86.4% of MSA-c, and 33.3% of PD patients. Compared to Sph-EMG, the CGHT was less sensitive but more specific in both MSA-p and MSA-c. The result of neither test correlated with the severity of parkinsonism. Interestingly, combining the results of the CGHT and Sph-EMG markedly increased the specificity (85.7% in the CGHT and 66.7% in Sph-EMG vs. 95.2% in the combination study) and the PPV in both MSA-p (85.7% and 75.9% vs. 94.4%) and MSA-c (82.4% and 73.1% vs. 91.7%). We confirm that the CGHT can distinguish MSA-p from PD. Its sensitivity is lower and its specificity higher than Sph-EMG. Compared to either test alone, combined testing with the CGHT and Sph-EMG increased specificity and PPV, thereby enhancing accuracy in the diagnosis of MSA.
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Affiliation(s)
- Eun Ah Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Isozaki E, Naito R, Kanda T, Mizutani T, Hirai S. Different mechanism of vocal cord paralysis between spinocerebellar ataxia (SCA 1 and SCA 3) and multiple system atrophy. J Neurol Sci 2002; 197:37-43. [PMID: 11997064 DOI: 10.1016/s0022-510x(02)00046-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While multiple system atrophy (MSA) is frequently associated with vocal cord paralysis (VCP) causing severe respiratory failure, it is still unknown whether hereditary types of spinocerebellar degeneration develop similar laryngeal paralysis. We analyzed the laryngeal function from the viewpoints of fiberoptic laryngoscopy and laryngeal myopathology and then attempted to clarify the difference of the mechanism of VCP among the patients with spinocerebellar ataxia type 1 (SCA 1), type 3 (SCA 3), and MSA. Seven patients with SCA 1, nineteen with SCA 3, and eleven with MSA were studied. Vocal cord movement was analyzed by fiberoptic laryngoscopy during wakefulness and diazepam-induced sleep (sleep load test). Paraffin-embedded sections or cryosections of the intrinsic laryngeal muscles from five autopsied cases (one with SCA 1 and four with SCA 3) were histologically examined. VCP was found in two of the seven SCA 1 patients (29%), three of the nineteen SCA 3 patients (16%), and in nine of the eleven MSA patients (82%). VCP observed in SCA 1 and SCA 3 was various in the severity and showed no exacerbation on sleep load test in all of the eight patients but one SCA 3 patient. In this patient, the findings of fiberoptic laryngoscopy were quite similar to those found in MSA. All the intrinsic laryngeal muscles including cricothyroid (CT), interarytenoid (IA), and posterior cricoarytenoid (PCA) muscles showed neurogenic atrophy in one autopsied SCA 1 and four SCA 3 patients. Our conclusion is that VCP in SCA 1 and SCA 3 contrasts with that in MSA in its occurrence, response to the sleep load test, and the distribution of the neurogenic abnormalities among the intrinsic laryngeal muscles.
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Affiliation(s)
- Eiji Isozaki
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, 2-6-1, Musashidai, Fuchu, Tokyo 183-0042, Japan.
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Abstract
Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder that usually manifests when an individual is in his/her early fifties and progresses relentlessly with a mean survival of 9 years. Clinically, MSA is dominated by autonomic/urogenital failure which may be associated with either parkinsonism (MSA-P subtype) in 80% of cases or with cerebellar ataxia (MSA-C subtype) in 20% of cases. Pathologically, MSA is characterised by a neuronal multisystem degeneration and abnormal glial cytoplasmic inclusions containing alpha-synuclein aggregates. Autonomic and urogenital features of MSA should be identified early on because they can be treated effectively in many instances. In contrast, pharmacological treatment of motor features is often disappointing, except for a minority of patients with MSA-P who derive transient benefit from levodopa treatment. In the future, neurotransplantation may extend or improve the treatment response in MSA-P, but further preclinical evidence is required prior to clinical application. Neuroprotection strategies may slow down disease progression in MSA and the results of the first double-blind trial of riluzole (an inhibitor of glutamate release) in patients with MSA will be available in 2004.
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Affiliation(s)
- G K Wenning
- Department of Neurology, University Hospital, Innsbruck, Austria.
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Sakakibara R, Hattori T, Uchiyama T, Yamanishi T. Videourodynamic and sphincter motor unit potential analyses in Parkinson's disease and multiple system atrophy. J Neurol Neurosurg Psychiatry 2001; 71:600-6. [PMID: 11606669 PMCID: PMC1737611 DOI: 10.1136/jnnp.71.5.600] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Urinary dysfunction is a prominent autonomic feature in Parkinson's disease (PD) and multiple system atrophy (MSA), which is not only troublesome but also a cause of morbidity in these disorders. Recent advances in investigative uroneurology offer a better insight into the underlying pathophysiology and appropriate management for urinary dysfunction. METHODS twenty one patients with PD (15 men, six women, mean age 64 (49-76), mean disease duration 4 years (1-8 years), median Hoehn and Yahr grade 3 (1-4), all taking 300 mg/day of levodopa (100-500 mg)) and 15 with MSA (eight men, seven women, mean age 59 (48-72), mean disease duration 3 years (0.5-6 years)) were recruited. Videourodynamic and sphincter motor unit potential analyses in the patients with PD and MSA were carried out, looking for distinguishing hallmarks that might be useful in the differential diagnosis of these two diseases. RESULTS Urinary symptoms were found in 72% of patients with PD and in 100% with MSA. Filling phase abnormalities in the videourodynamic study included detrusor hyperreflexia in 81% of patients with PD and 56% with MSA, and uninhibited external sphincter relaxation in 33% of patients with PD and 33% of those with MSA. However, open bladder neck at the start of filling was not seen in patients with PD but was present in 53% of those with MSA, suggestive of internal sphincter denervation. Sphincter motor unit potential analysis showed neurogenic motor unit potentials in 5% of patients with PD and in 93% of those with MSA, suggestive of external sphincter denervation. On voiding, detrusor-external sphincter dyssynergia was not seen in patients with PD but was present in 47% of those with MSA. Pressure-flow analysis showed that the Abrams-Griffiths number, a grading of urethral obstruction (outflow obstruction >40), in PD (40 in women and 43 in men) was larger than that in MSA (12 in women and 28 in men). Weak detrusor in PD (66% of women and 40% of men) was less common than that in MSA (71% of women and 63% of men). Postmicturition residuals >100 ml were absent in patients with PD but were present in 47% of patients with MSA. CONCLUSION Patients with PD had less severe urinary dysfunction with little evidence of internal or external sphincter denervation, by contrast with the common findings in MSA. The findings of postmicturition residuals >100 ml, detrusor-external sphincter dyssynergia, open bladder neck at the start of bladder filling, and neurogenic sphincter motor unit potentials are highly suggestive of MSA.
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Affiliation(s)
- R Sakakibara
- Department of Neurology, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670 Japan.
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Gilad R, Giladi N, Korczyn AD, Gurevich T, Sadeh M. Quantitative anal sphincter EMG in multisystem atrophy and 100 controls. J Neurol Neurosurg Psychiatry 2001; 71:596-9. [PMID: 11606668 PMCID: PMC1737580 DOI: 10.1136/jnnp.71.5.596] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate data of quantitative anal sphincter EMG in normal controls and to compare them with patients with multiple system atrophy (MSA). METHODS Quantitative anal sphincter EMG were performed on 100 normal controls and 11 patients with MSA to characterise EMG data in these two groups. RESULTS In the normal controls, there was a trend for increased motor unit potential (MUP) amplitude, duration, area, and polyphasicity with advancing age. Patients with MSA exhibited similar MUP size and fibre density. Significant differences were found only in parameters of the recruitment pattern, which were reduced in MSA, with a diminution in the number of active MUPs during rest. CONCLUSIONS These results may reflect either decreased number of motor cells in Onuf's nucleus without significant consequential reinnervation, or upper motor neuron involvement affecting the anal sphincter in MSA. They further underline the importance of comparative data for age matched controls.
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Affiliation(s)
- R Gilad
- Department of Neurology, Wolfson Medical Center, Holon 58100, Israel.
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Holmberg B, Johnels B, Ingvarsson P, Eriksson B, Rosengren L. CSF-neurofilament and levodopa tests combined with discriminant analysis may contribute to the differential diagnosis of Parkinsonian syndromes. Parkinsonism Relat Disord 2001; 8:23-31. [PMID: 11472877 DOI: 10.1016/s1353-8020(00)00083-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The differentiation between Parkinson's disease (PD), progressive supranuclear palsy (PSP) and multiple system atrophy (MSA) is important for prognostic and therapeutic purposes. In order to evaluate the diagnostic capability of two tests reflecting these items, patients fulfilling strict clinical criteria for PD (n=35), MSA (n=36) and PSP (n=14), were consecutively included. An analysis of neurofilament protein (NFL), a marker of axonal degeneration in the cerebrospinal fluid (CSF) and a levodopa test, recorded with optoelectronic technique were performed. Using discriminant analyses, the test's abilities to predict the clinical PD or non-PD (MSA and PSP) diagnoses were compared. Whereas the CSF-NFL and levodopa tests predicted 79 and 85% correct diagnoses respectively, the combined test predicted 90% correct diagnoses. We conclude that the CSF-NFL and levodopa tests provide detailed information of clinical variables on which the clinical diagnostic criteria are based. As they are pathologically unrelated, the diagnostic precision increases compared to clinical diagnoses when they are combined.
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Affiliation(s)
- B Holmberg
- Institute of Clinical Neuroscience, Department of Neurology, University of Göteborg, Sahlgrenska University Hospital, 413 45, Sweden.
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Mark MH. Lumping and splitting the Parkinson Plus syndromes: dementia with Lewy bodies, multiple system atrophy, progressive supranuclear palsy, and cortical-basal ganglionic degeneration. Neurol Clin 2001; 19:607-27, vi. [PMID: 11532646 DOI: 10.1016/s0733-8619(05)70037-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The atypical parkinsonian or Parkinson Plus syndromes are often difficult to differentiate from Parkinson's disease and each other. In this article, the clinicopathological characteristics of dementia with Lewy bodies, multiple system atrophy, progressive supranuclear palsy, and cortical-basal ganglionic degeneration are discussed. These disorders, although clinically distinct, may have more similarities than previously thought, based on modern immunocytochemical techniques and new genetic findings. These intriguing interconnections at a basic molecular level have provided the scientific rationale for lumping these diseases into two groups, the synucleinopathies and the tauopathies.
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Affiliation(s)
- M H Mark
- Department of Neurology, Robert Wood Johnson Medical School, New Brunswick, New Jersey 08901, USA.
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Abstract
Multiple system atrophy (MSA) is a degenerative disease manifesting a combination of parkinsonism, cerebellar, pyramidal, and autonomic (including urinary, sexual, and anorectal) dysfunction. It is pathomorphologically defined, but lacks a definitive clinical diagnostic test. Sphincter electromyography (EMG), reflecting Onuf's nucleus degeneration, has been proposed as a helpful test; its value has been reevaluated by a critical review of the literature. In patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the majority of patients in all the different forms of the disease in most studies, including patients who, as yet, have no urological or anorectal problems. The prevalence of abnormalities in the early stages of MSA is as yet unclear. Patients with Parkinson's disease (PD) as a rule do not show severe sphincter EMG abnormalities in the early stage of the disease. Anal sphincter EMG abnormalities (abnormal spontaneous activity or motor unit potential changes three standard deviations above valid control data) distinguish MSA from PD in the first 5 years after the onset of symptoms and signs, and from pure autonomic failure, as well as from cerebellar ataxias, if other causes for sphincter denervation have been ruled out. With such criteria, the sensitivity of the method is, however, low. EMG does not distinguish MSA from progressive supranuclear palsy. Future studies should use standardized anal sphincter EMG to better compare results from different centers and precisely define the sensitivity and specificity of the method.
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Affiliation(s)
- D B Vodusek
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Center, Ljubljana, Slovenia.
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Rodolico C, Toscano A, De Luca G, Mazzeo A, Di Leo R, Baldari S, Girlanda P, Vita G. Peripheral neuropathy as the presenting feature of multiple system atrophy. Clin Auton Res 2001; 11:119-21. [PMID: 11570601 DOI: 10.1007/bf02322056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors report a case of multiple system atrophy (MSA) with an onset as a peripheral nerve involvement. Their patient, a 55-year-old man, had a 3-year history of distal weakness and atrophy in upper limbs with dysesthesia in the feet. Other identifiable causes of peripheral neuropathy were ruled out. The authors postulate that peripheral nervous system impairment can anticipate the typical appearance of MSA, and they suggest that, in peripheral neuropathies with autonomic system dysfunction, after excluding main causes of autonomic neuropathy, MSA may need to be suspected.
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Affiliation(s)
- C Rodolico
- Institute of Neurologic and Neurosurgical Sciences, University of Messina, Italy.
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Holmberg B, Kallio M, Johnels B, Elam M. Cardiovascular reflex testing contributes to clinical evaluation and differential diagnosis of Parkinsonian syndromes. Mov Disord 2001; 16:217-25. [PMID: 11295773 DOI: 10.1002/mds.1062] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The differentiation between Parkinson's disease (PD), progressive supranuclear palsy (PSP), and multiple system atrophy (MSA) may be difficult but is important for prognostic and therapeutic purposes. Varying degrees of autonomic failure have been described in PD and MSA, whereas its involvement in PSP remains controversial. The aim of this study was to investigate autonomic function in patients fulfilling strict clinical diagnostic criteria for the disorders above, to evaluate the diagnostic capacity of laboratory autonomic tests. The study group was consecutively recruited among patients referred to a movement disorder unit. Thirty-four patients with PD, 15 patients with PSP, and 47 patients with MSA were compared with 18 healthy age-matched controls. Autonomic tests included analysis of heart rate variability (HRV) in temporal domain, at rest and during forced respiration, as well as blood pressure (BP) changes during 75 degrees head-up tilt. HRV did not differ between groups during quiet breathing but was significantly reduced during forced respiration in MSA (P < 0.01), while PD and PSP groups did not differ from controls. Hypotensive responses during orthostatic provocation were seen in PD (P < 0.01) and MSA (P < 0.001), whereas BP remained stable in most PSP patients, not differing from the healthy control group. On an individual basis, decreased HRV and severe hypotensive responses were seen in MSA patients regardless of age and disease duration, whereas PD patients showed this combination only at high age and long duration. In PSP, only a few cases with decreased HRV and limited hypotensive responses were found. We conclude that cardiovascular reflex tests can supplement the clinical differentiation of Parkinsonian syndromes.
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Affiliation(s)
- B Holmberg
- Department of Neurology, Institute of Clinical Neuroscience, University of Göteborg, Sahlgren's Hospital, Sweden
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Podnar S, Vodusek DB, Stâlberg E. Standardization of anal sphincter electromyography: normative data. Clin Neurophysiol 2000; 111:2200-7. [PMID: 11090773 DOI: 10.1016/s1388-2457(00)00416-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Electromyography (EMG) of the external anal sphincter (EAS) is important in the evaluation of conus/cauda lesions, the differential diagnosis of parkinsonism and anal incontinence. The aim of our study was to establish normative data in a sufficiently large group of healthy subjects, using a rigorously standardized examination technique. METHODS Sixty-four subjects (aged 19-83 years) without pelvic or neurological disorders were included. Motor unit potentials (MUPs)/interference pattern (IP) samples were obtained from the EAS using multi-MUP and turn/amplitude analyses, respectively. The effect of age, gender, parity, and constipation on MUP/IP parameters was studied. For MUP parameters the lower/upper limits for mean values, and 'outlier' limits, and for IP parameters normal 'clouds' were calculated. RESULTS From 112 muscles 15-30 MUPs were sampled. As no effect of evaluated factors on mean values could be demonstrated, common reference values were calculated. Lower/higher limits for mean values were: amplitude 148/661 microV, duration 3.2/7.8 ms, area 87/625 microVms, and number of phases 2. 3/3.7. 'Outlier' limits for individual MUPs were: amplitude 84/1315 microV, duration 1.6/13.8 ms, area 46/1222 microVms, number of phases 2/6. From 95 muscles 2706 IP samples were obtained. CONCLUSIONS The presented normative data should allow valid quantitative EMG of the EAS muscle in patients.
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Affiliation(s)
- S Podnar
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Centre Ljubljana, SI-1525, Ljubljana, Slovenia.
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Tison F, Arne P, Sourgen C, Chrysostome V, Yeklef F. The value of external anal sphincter electromyography for the diagnosis of multiple system atrophy. Mov Disord 2000; 15:1148-57. [PMID: 11104199 DOI: 10.1002/1531-8257(200011)15:6<1148::aid-mds1014>3.0.co;2-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To assess the value of external anal sphincter electromyography (ASEMG) for the diagnosis of multiple system atrophy (MSA) among various causes of parkinsonism. ASEMG denervation profiles have previously been proposed as a diagnosis test for MSA, but their specificity is disputed. METHODS ASEMG variables of 52 parkinsonian patients were analyzed according to the clinical diagnosis: MSA (n = 31) or no MSA (n = 21). Mean motor unit potential duration, percentage of polyphasicity, and the electromyographer's interpretation were analyzed according to clinical diagnosis, disease duration, genitourinary symptoms, gender, parity, and history of pelvic surgery. RESULTS All patients with MSA showed ASEMG denervation. Mean motor unit potential duration was the most discriminant variable. No patient with MSA had a mean duration less than 12 ms and no patient without MSA had one greater than 16 ms. ASEMG discriminates between patients with MSA and Parkinson's disease. Using a threshold of 13 ms, the sensitivity was 80% and specificity was almost 70% (positive predictive value, 80%) for the diagnosis of MSA. Age, history of pelvic surgery, and to a lesser extent, female gender, parity, disease duration, and presence of urinary symptoms increased the likelihood of abnormal ASEMG. CONCLUSION ASEMG was highly sensitive and rather specific for the diagnosis of MSA.
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Affiliation(s)
- F Tison
- Service de Neurologie, INSERM U-330, Centre Hospitalier Universitaire, Bordeaux, France
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