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Jellinger KA. Behavioral disorders in dementia with Lewy bodies: old and new knowledge. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02823-w. [PMID: 39237792 DOI: 10.1007/s00702-024-02823-w] [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: 07/04/2024] [Accepted: 08/07/2024] [Indexed: 09/07/2024]
Abstract
Dementia with Lewy bodies (DLB), the second most common primary degenerative neurocognitive disorder after Alzheimer disease, is frequently preceded by REM sleep behavior disorders (RBD) and other behavioral symptoms, like anxiety, irritability, agitation or apathy, as well as visual hallucinations and delusions, most of which occurring in 40-60% of DLB patients. Other frequent behavioral symptoms like attention deficits contribute to cognitive impairment, while attention-deficit/hyperactivity disorder (ADHD) is a risk factor for DLB. Behavioral problems in DLB are more frequent, more severe and appear earlier than in other neurodegenerative diseases and, together with other neuropsychiatric symptoms, contribute to impairment of quality of life of the patients, but their pathophysiology is poorly understood. Neuroimaging studies displayed deficits in cholinergic brainstem nuclei and decreased metabolism in frontal, superior parietal regions, cingulate gyrus and amygdala in DLB. Early RBD in autopsy-confirmed DLB is associated with lower Braak neuritic stages, whereas those without RBD has greater atrophy of hippocampus and increased tau burden. αSyn pathology in the amygdala, a central region in the fear circuitry, may contribute to the high prevalence of anxiety, while in attention dysfunctions the default mode and dorsal attention networks displayed diverging activity. These changes suggest that behavioral disorders in DLB are associated with marked impairment in large-scale brain structures and functional connectivity network disruptions. However, many pathobiological mechanisms involved in the development of behavioral disorders in DLB await further elucidation in order to allow an early diagnosis and adequate treatment to prevent progression of these debilitating disorders.
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Affiliation(s)
- Kurt A Jellinger
- Institute of Clinical Neurobiology, Alberichgasse 5/13, Vienna, A-1150, Austria.
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2
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Agnello L, Gambino CM, Ciaccio AM, Masucci A, Vassallo R, Tamburello M, Scazzone C, Lo Sasso B, Ciaccio M. Molecular Biomarkers of Neurodegenerative Disorders: A Practical Guide to Their Appropriate Use and Interpretation in Clinical Practice. Int J Mol Sci 2024; 25:4323. [PMID: 38673907 PMCID: PMC11049959 DOI: 10.3390/ijms25084323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/05/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Neurodegenerative disorders (NDs) represent a group of different diseases characterized by the progressive degeneration and death of the nervous system's cells. The diagnosis is challenging, especially in the early stages, due to no specific clinical signs and symptoms. In this context, laboratory medicine could support clinicians in detecting and differentiating NDs. Indeed, biomarkers could indicate the pathological mechanisms underpinning NDs. The ideal biofluid for detecting the biomarkers of NDs is cerebrospinal fluid (CSF), which has limitations, hampering its widespread use in clinical practice. However, intensive efforts are underway to introduce high-sensitivity analytical methods to detect ND biomarkers in alternative nonivasive biofluid, such as blood or saliva. This study presents an overview of the ND molecular biomarkers currently used in clinical practice. For some diseases, such as Alzheimer's disease or multiple sclerosis, biomarkers are well established and recommended by guidelines. However, for most NDs, intensive research is ongoing to identify reliable and specific biomarkers, and no consensus has yet been achieved.
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Affiliation(s)
- Luisa Agnello
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
| | - Caterina Maria Gambino
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
- Department of Laboratory Medicine, University Hospital “P. Giaccone”, 90127 Palermo, Italy
| | - Anna Maria Ciaccio
- Internal Medicine and Medical Specialties “G. D’Alessandro”, Department of Health Promotion, Maternal and Infant Care, University of Palermo, 90127 Palermo, Italy;
| | - Anna Masucci
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
| | - Roberta Vassallo
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
| | - Martina Tamburello
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
| | - Concetta Scazzone
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
| | - Bruna Lo Sasso
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
- Department of Laboratory Medicine, University Hospital “P. Giaccone”, 90127 Palermo, Italy
| | - Marcello Ciaccio
- Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Clinical Laboratory Medicine, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, 90127 Palermo, Italy; (L.A.); (C.M.G.); (A.M.); (R.V.); (M.T.); (C.S.); (B.L.S.)
- Department of Laboratory Medicine, University Hospital “P. Giaccone”, 90127 Palermo, Italy
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Koníčková D, Menšíková K, Klíčová K, Chudáčková M, Kaiserová M, Přikrylová H, Otruba P, Nevrlý M, Hluštík P, Hényková E, Kaleta M, Friedecký D, Matěj R, Strnad M, Novák O, Plíhalová L, Rosales R, Colosimo C, Kaňovský P. Cerebrospinal fluid and blood serum biomarkers in neurodegenerative proteinopathies: A prospective, open, cross-correlation study. J Neurochem 2023; 167:168-182. [PMID: 37680022 DOI: 10.1111/jnc.15944] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/27/2023] [Accepted: 08/02/2023] [Indexed: 09/09/2023]
Abstract
Neurodegenerative diseases are a broad heterogeneous group affecting the nervous system. They are characterized, from a pathophysiological perspective, by the selective involvement of a subpopulation of nerve cells with a consequent clinical picture of a disease. Clinical diagnoses of neurodegenerative diseases are quite challenging and often not completely accurate because of their marked heterogeneity and frequently overlapping clinical pictures. Efforts are being made to define sufficiently specific and sensitive markers for individual neurodegenerative diseases or groups of diseases in order to increase the accuracy and speed of clinical diagnosis. Thus said, this present research aimed to identify biomarkers in the cerebrospinal fluid (CSF) and serum (α-synuclein [α-syn], tau protein [t-tau], phosphorylated tau protein [p-tau], β-amyloid [Aβ], clusterin, chromogranin A [chromogrA], cystatin C [cyst C], neurofilament heavy chains [NFH], phosphorylated form of neurofilament heavy chains [pNF-H], and ratio of tau protein/amyloid beta [Ind tau/Aβ]) that could help in the differential diagnosis and differentiation of the defined groups of α-synucleinopathies and four-repeat (4R-) tauopathies characterized by tau protein isoforms with four microtubule-binding domains. In this study, we analyzed a cohort of 229 patients divided into four groups: (1) Parkinson's disease (PD) + dementia with Lewy bodies (DLB) (n = 82), (2) multiple system atrophy (MSA) (n = 25), (3) progressive supranuclear palsy (PSP) + corticobasal syndrome (CBS) (n = 30), and (4) healthy controls (HC) (n = 92). We also focused on analyzing the biomarkers in relation to each other with the intention of determining whether they are useful in distinguishing among individual proteinopathies. Our results indicate that the proposed set of biomarkers, when evaluated in CSF, is likely to be useful for the differential diagnosis of MSA versus 4RT. However, these biomarkers do not seem to provide any useful diagnostic information when assessed in blood serum.
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Affiliation(s)
- Dorota Koníčková
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Kateřina Menšíková
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Kateřina Klíčová
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Monika Chudáčková
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Michaela Kaiserová
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Hana Přikrylová
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Neurology Outpatient Clinic "St. Moritz", Olomouc, Czech Republic
| | - Pavel Otruba
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Martin Nevrlý
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Petr Hluštík
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Eva Hényková
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
- Laboratory of Growth Regulators, Institute of Experimental Botany of the Czech Academy of Sciences, Palacky University, Olomouc, Czech Republic
| | - Michal Kaleta
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
- Laboratory of Growth Regulators, Institute of Experimental Botany of the Czech Academy of Sciences, Palacky University, Olomouc, Czech Republic
| | - David Friedecký
- Laboratory of Inherited Metabolic Disorders, Faculty of Medicine and Dentistry, Palacky University, University Hospital Olomouc, Olomouc, Czech Republic
| | - Radoslav Matěj
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University, Thomayer University Hospital, Prague, Czech Republic
| | - Miroslav Strnad
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
| | - Ondřej Novák
- Laboratory of Growth Regulators, Institute of Experimental Botany of the Czech Academy of Sciences, Palacky University, Olomouc, Czech Republic
| | - Lucie Plíhalová
- Department of Chemical Biology, Faculty of Science, Palacky University, Olomouc, Czech Republic
| | - Raymond Rosales
- Department of Neurology and Psychiatry, Neuroscience Institute, University of Santo Tomas Hospital, Manila, Philippines
| | - Carlo Colosimo
- Department of Neurology, Santa Maria University Hospital, Terni, Italy
| | - Petr Kaňovský
- Department of Neurology, University Hospital Olomouc, Olomouc, Czech Republic
- Department of Neurology, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic
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4
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Woyk K, Sahlmann CO, Hansen N, Timäus C, Müller SJ, Khadhraoui E, Wiltfang J, Lange C, Bouter C. Brain 18 F-FDG-PET and an optimized cingulate island ratio to differentiate Lewy body dementia and Alzheimer's disease. J Neuroimaging 2023; 33:256-268. [PMID: 36465027 DOI: 10.1111/jon.13068] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE The diagnosis of Dementia with Lewy Bodies (DLB) is challenging due to various clinical presentations and clinical and neuropathological features that overlap with Alzheimer's disease (AD). The use of 18 F-Fluorodeoxyglucose-PET (18 F-FDG-PET) can be limited due to similar patterns in DLB and AD. However, metabolism in the posterior cingulate cortex is known to be relatively preserved in DLB and visual assessment of the "cingulate island sign" became a helpful tool in the analysis of 18F-FDG-PET. The aim of this study was the evaluation of visual and semiquantitative 18F-FDG-PET analyses in the diagnosis of DLB and the differentiation to AD as well as its relation to other dementia biomarkers. METHODS This retrospective study comprises 81 patients with a clinical diagnosis of DLB or AD that underwent 18 F-FDG-PET/CT. PET scans were analyzed visually and semiquantitatively and results were compared to clinical data, cerebrospinal fluid results, dopamine transporter scintigraphy, and 18F-Florbetaben-PET. Furthermore, different cingulate island ratios were calculated to analyze their diagnostic accuracy. RESULTS Visual assessment of 18F-FDG-PET showed an accuracy of 62%-77% in differentiating between DLB and AD. Standard uptake values were significantly lower in the primary visual cortex and the lateral occipital cortex of DLB patients compared to AD patients. The cingulate island ratio was significantly higher in the DLB group compared to the AD group and the ratio posterior cingulate cortex to visual cortex plus lateral occipital cortex showed the highest diagnostic accuracy to discriminate between DLB and AD at 81%. CONCLUSIONS Semiquantitative 18F-FDG-PET imaging and especially the use of an optimized cingulate island ratio are valuable tools to differentiate between DLB and AD.
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Affiliation(s)
- Katharina Woyk
- Department of Nuclear Medicine, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Carsten Oliver Sahlmann
- Department of Nuclear Medicine, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Charles Timäus
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Sebastian Johannes Müller
- Department of Neuroradiology, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Eya Khadhraoui
- Department of Neuroradiology, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany.,Neurosciences and Signaling Group, Department of Medical Sciences, Institute of Biomedicine, University of Aveiro, Aveiro, Portugal.,German Center for Neurodegenerative Diseases, Göttingen, Germany
| | - Claudia Lange
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
| | - Caroline Bouter
- Department of Nuclear Medicine, University Medical Center Göttingen (UMG), Georg-August-University, Göttingen, Germany
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Prasad S, Katta MR, Abhishek S, Sridhar R, Valisekka SS, Hameed M, Kaur J, Walia N. Recent advances in Lewy body dementia: A comprehensive review. Dis Mon 2022; 69:101441. [PMID: 35690493 DOI: 10.1016/j.disamonth.2022.101441] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Lewy Body Dementia is the second most frequent neurodegenerative illness proven to cause dementia, after Alzheimer's disease (AD). It is believed to be vastly underdiagnosed, as there is a significant disparity between the number of cases diagnosed clinically and those diagnosed via neuropathology at the time of postmortem autopsy. Strikingly, many of the pharmacologic treatments used to treat behavioral and cognitive symptoms in other forms of dementia exacerbate the symptoms of DLB. Therefore, it is critical to accurately diagnose DLB as these patients require a specific treatment approach. This article focuses on its pathophysiology, risk factors, differentials, and its diverse treatment modalities. In this study, an English language literature search was conducted on Medline, Cochrane, Embase, and Google Scholar till April 2022. The following search strings and Medical Subject Headings (MeSH) terms were used: "Lewy Body Dementia," "Dementia with Lewy bodies," and "Parkinson's Disease Dementia." We explored the literature on Lewy Body Dementia for its epidemiology, pathophysiology, the role of various genes and how they bring about the disease, biomarkers, its differential diagnoses and treatment options.
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Affiliation(s)
- Sakshi Prasad
- Faculty of Medicine, National Pirogov Memorial Medical University, 21018, Vinnytsya, Ukraine.
| | | | | | | | | | - Maha Hameed
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | | | - Namrata Walia
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center, Houston, Texas, United States of America
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6
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Haußmann R, Homeyer P, Brandt MD, Donix M. [Prognostic and diagnostic value of cerebrospinal fluid analysis in neurodegenerative dementia diseases]. DER NERVENARZT 2022; 93:1236-1242. [PMID: 35670835 DOI: 10.1007/s00115-022-01339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
Cerebrospinal fluid (CSF) analysis is an important diagnostic tool in the assessment of dementia. For the differentiation of Alzheimer's disease from other etiologies of dementia syndromes, established biological markers could be helpful to confirm a distinctive neuropathology. Whereas negative CSF findings can rule out the majority of primarily neurodegenerative disorders, overlapping biomarker profiles remain a diagnostic challenge. Therefore, it is important to interpret CSF results within a specific clinical context. Furthermore, atypical CSF data can be challenging and require profound knowledge of preanalytics, biomarker profiles and the broad spectrum of diseases associated with cognitive decline. Beyond the Alzheimer's disease clinical spectrum, current studies aim at investigating CSF biomarkers to better differentiate tauopathies, TDP43(Transactive response DNA binding protein 43 kDa)-proteinopathies and synucleinopathies.
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Affiliation(s)
- R Haußmann
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - P Homeyer
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - M D Brandt
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.,DZNE, Deutsches Zentrum für Neurodegenerative Erkrankungen, Dresden, Deutschland
| | - M Donix
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.,DZNE, Deutsches Zentrum für Neurodegenerative Erkrankungen, Dresden, Deutschland
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7
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Milán-Tomás Á, Fernández-Matarrubia M, Rodríguez-Oroz MC. Lewy Body Dementias: A Coin with Two Sides? Behav Sci (Basel) 2021; 11:94. [PMID: 34206456 PMCID: PMC8301188 DOI: 10.3390/bs11070094] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/12/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
Lewy body dementias (LBDs) consist of dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD), which are clinically similar syndromes that share neuropathological findings with widespread cortical Lewy body deposition, often with a variable degree of concomitant Alzheimer pathology. The objective of this article is to provide an overview of the neuropathological and clinical features, current diagnostic criteria, biomarkers, and management of LBD. Literature research was performed using the PubMed database, and the most pertinent articles were read and are discussed in this paper. The diagnostic criteria for DLB have recently been updated, with the addition of indicative and supportive biomarker information. The time interval of dementia onset relative to parkinsonism remains the major distinction between DLB and PDD, underpinning controversy about whether they are the same illness in a different spectrum of the disease or two separate neurodegenerative disorders. The treatment for LBD is only symptomatic, but the expected progression and prognosis differ between the two entities. Diagnosis in prodromal stages should be of the utmost importance, because implementing early treatment might change the course of the illness if disease-modifying therapies are developed in the future. Thus, the identification of novel biomarkers constitutes an area of active research, with a special focus on α-synuclein markers.
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Affiliation(s)
- Ángela Milán-Tomás
- Department of Neurology, Clínica Universidad de Navarra, 28027 Madrid, Spain;
| | - Marta Fernández-Matarrubia
- Department of Neurology, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - María Cruz Rodríguez-Oroz
- Department of Neurology, Clínica Universidad de Navarra, 28027 Madrid, Spain;
- Department of Neurology, Clínica Universidad de Navarra, 31008 Pamplona, Spain;
- IdiSNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- CIMA, Center of Applied Medical Research, Universidad de Navarra, Neurosciences Program, 31008 Pamplona, Spain
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