Co-occurrence of Parkinson's disease with progressive supranuclear palsy

Parkinson's disease (PD) and progressive supranuclear palsy (PSP) are distinct neurodegenerative disorders. We describe an 81-year-old woman with 3 years of progressive gait unsteadiness, frequent falls, and mild cognitive dysfunction, all considered clinically to be an early fronto-temporal neurodegenerative disorder. She died of an acute myocardial infarction. Examination of her brain revealed alpha-synuclein- and tau-positive inclusions diagnostic of PD and PSP. Immunoelectron microscopy and Western blot analysis confirmed combined PD/PSP. This case provides strategies for the reliable molecular validation of concomitant PD and PSP, and demonstrates the utility of these techniques in patients with atypical clinical presentations.     

An assessment of dysphagia using videofluorography in Parkinson's disease and progressive supranuclear palsy]

We assessed the oropharyngeal swallowing ability in 8 patients with Parkinson's disease (PD), 8 patients with progressive supranuclear palsy (PSP), and 10 age-matched healthy controls (CTL) using videofluorography (VF). In VF studies, PD and PSP patients demonstrated food pooling on the tongue, difficulty in bolus formation, and bolus falling into pharynx before swallow. PSP patients had a significantly longer delay in the pharyngeal phase and showed food falling into larynx more often than PD patients (p < 0.05). On measurement of swallowing time periods as proposed by Robbins et al., both patient groups showed significantly longer periods during many swallowing phases (P < 0.05) compared to those in the control group, but there were no significant differences between the PD and PSP groups. However, in PSP patients, the time for "transferring the food bolus from the oral cavity to pharynx" which we defined as a distinct stage was significantly longer (p < 0.05) than that in the PD group. We think that the difference in dysphagia characteristics between the two diseases arises from the variations in pathological changes in PSP, including those in the cerebral cortex, cerebellum, pons and medulla tegmentum in addition to the basal ganglia. Dystonia in the neck muscle also plays a role in dysphagia in PSP patients. Levodopa medication, changing the form of foods and training in rehabilitation techniques such as the chin down posture, supraglottic swallowing and ice-massage of the oral region are probably effective for dysphagia in PD patients. In patients with PSP, there are few research reports about the treatment of dysphagia. However, several dysphagia treatments seem to be useful depending on the abnormal patterns in the VF. Further studies are necessary to establish more effective treatments for dysphagia in PD and PSP.     

3H]MK-801 binding sites in neonate rat brain

[3H]MK-801 binding sites are present in neonate rat brain as early as 3 days after birth. Immature hippocampus and cortex contain approximately one sixth the concentration of binding sites of the adult, while brainstem concentration is twice as high as that of adult. [3H]MK-801 binding is stimulated by glutamate and glycine and blocked by phencyclidine and Mg2+ both in 7-day-old neonate and adult, indicating that as early as 7 days postnatally, the N-methyl-D-aspartate-type glutamate receptor and MK-801 binding site are functionally coupled.     

Brain iron deposition fingerprints in Parkinson's disease and progressive supranuclear palsy

It can be difficult to clinically distinguish between classical Parkinson's disease (PD) and progressive supranuclear palsy. Previously, there have been no biomarkers that reliably allow this distinction to be made. We report that an abnormal brain iron accumulation is a marker for ongoing neurodegeneration in both conditions, but the conditions differ with respect to the anatomical distribution of these accumulations. We analyzed quantitative T2' maps as markers of regional brain iron content from PD and progressive supranuclear palsy patients and compared them to age-matched control subjects. T2-weighted and T2*-weighted images were acquired in 30 PD patients, 12 progressive supranuclear palsy patients, and 24 control subjects at 1.5 Tesla. Mean T2' values were determined in regions-of-interest in the basal ganglia, thalamus, and white matter within each hemisphere. The main findings were shortened T2' values in the caudate nucleus, globus pallidus, and putamen in progressive supranuclear palsy compared to PD patients and controls. A stepwise linear discriminant analysis allowed progressive supranuclear palsy patients to be distinguished from PD patients and the healthy controls. All progressive supranuclear palsy patients were correctly classified. No progressive supranuclear palsy patient was classified as a healthy control, no healthy controls were incorrectly classified as having progressive supranuclear palsy, and only 6.7% of the PD patients were incorrectly classified as progressive supranuclear palsy. Regional decreases of T2' relaxation times in parts of the basal ganglia reflecting increased brain iron load in these areas are characteristic for progressive supranuclear palsy but not PD patients.     

Brain muscarinic receptors in progressive supranuclear palsy and Parkinson's disease: a positron emission tomographic study

OBJECTIVES—To assessmuscarinic acetylcholine receptors (mAChRs) in the brains of patientswith progressive supranuclear palsy and Parkinson's disease, and tocorrelate the cholinergic system with cognitive function in progressivesupranuclear palsy and Parkinson's disease.
METHODS— Positronemission tomography (PET) and [¹¹C]N-methyl-4-piperidylbenzilate ([¹¹C]NMPB) was used to measure mAChRs in thebrain of seven patients with progressive supranuclear palsy, 12 patients with Parkinson's disease, and eight healthy controls. All ofthe patients with progressive supranuclear palsy were demented. TheParkinson's disease group consisted of 11 non-demented patients andone demented patient. The mini mental state examination (MMSE) was usedto assess the severity of cognitive dysfunction in all of the subjects. The modified Wisconsin card sorting test (WCST) was used to evaluate frontal cognitive function in the non-demented patients withParkinson's disease and controls.
RESULTS—The meanK₃ value, an index of mAChR binding, was significantlyhigher for the frontal cortex in the patients with Parkinson's diseasethan in the controls (p<0.01). By contrast, the patients withprogressive supranuclear palsy had no significant changes in theK₃ values of any cerebral cortical regions. The mean score of the MMSE in the progressive supranuclear palsy group wassignificantly lower than that in the control group. Although there wasno difference between the Parkinson's disease and control groups inthe MMSE, the non-demented patients with Parkinson's disease showedsignificant frontal lobe dysfunction in the WCST.
CONCLUSIONS—Theincreased mAChR binding in the frontal cortex of the patients withParkinson's disease may reflect denervation hypersensitivity caused byloss of the ascending cholinergic input to that region from the basalforebrain and may be related to frontal lobe dysfunction inParkinson's disease. The cerebral cortical cholinergic system may nothave a major role in cognitive dysfunction in progressive supranuclear palsy.

     

Controlled trial of pergolide mesylate in Parkinson's disease and progressive supranuclear palsy

We evaluated pergolide in 22 patients with Parkinson's disease and 3 with progressive supranuclear palsy (PSP). After achieving an optimal dose of pergolide and Sinemet, a matching placebo was substituted in double-blind manner. The mean dose of levodopa (in Sinemet) was reduced by 68%; in eight patients, pergolide completely replaced levodopa. In parkinsonian patients, the mean Hoehn-Yahr stage decreased from 3.2 to 1.6, and the mean total disability score decreased from 48.3 to 17.8. In 10 patients with on-off phenomenon, the time on increased 174% with pergolide. There was little effect in PSP. Postural light-headedness and reversible mental changes were seen.     

Direct comparison between regional cerebral metabolism in progressive supranuclear palsy and Parkinson's disease.

The differentiation between progressive supranuclear palsy (PSP) and Parkinson's disease (PD) may be difficult, especially in the early stages of disease. Positron emission tomography potentially provides a tool for making such a distinction. To identify key features in the spatial distributions of cerebral glucose metabolism, 18F-fluorodeoxyglucose (FDG) measurements of 10 patients with probable or possible PSP were directly compared with those of 9 PD patients. This analysis was done with statistic parametric mapping. After normalization of global brain uptake, in PSP, relative uptake of FDG was reduced in the caudal (motor) part of the anterior cingulate gyrus (Brodmann's area BA 24; P < 0.05, corrected for multiple comparisons). At a lower threshold, an additional decrease was present in the dorsal mesencephalon. In PD, relative hypometabolism was seen in extrastriate visual, ventrolateral temporal, posterior parietal, and orbitofrontal regions. Only reduction in the right fusiform gyrus and the lateral extrastriate visual cortex reached statistical significance. We concluded that particularly the reduction of medial frontal metabolism may be a valuable diagnostic imaging parameter in distinguishing PSP from PD. For PD, a possible association between occipitotemporal FDG decrease and vulnerability to hallucinations is suggested.     

Neuropsychiatric symptoms of patients with progressive supranuclear palsy and Parkinson's disease

Neuropsychiatric symptoms are common in basal ganglia disorders and may have severe clinical consequences. The authors compared the neuropsychiatric manifestations of patients with Parkinson's disease (PD) and progressive supranuclear palsy (PSP). All 103 PD patients and 27 of the 61 PSP patients were taking dopaminergic agents. PSP patients showed significantly more apathy and disinhibition. Patients with PD had higher frequency of hallucinations, delusions, and depression. These results suggest that PSP patients show symptoms compatible with lesioned orbitofrontal and medial frontal circuits, such as disinhibition and apathy, whereas PD patients show symptoms associated with monoaminergic disturbances, such as psychosis and depression.     

The external globus pallidus in patients with Parkinson's disease and progressive supranuclear palsy.

Underactivity of the external segment of the globus pallidus is thought to contribute to the generation of parkinsonian hypokinetic symptoms in association with striatal dopaminergic dysfunction and overactivity of the subthalamus. These symptoms can be corrected by neurosurgical techniques aimed at normalizing subthalamic overactivity. The aim of the present study was to compare the amount of neurodegeneration and changes in the calcium-binding protein parvalbumin in the external segment of the globus pallidus in parkinsonian disorders. Cases with progressive supranuclear palsy were compared with cases with Parkinson's disease and control subjects. The number of neurones and neurofibrillary tangles was estimated using unbiased stereologic techniques. The external segment of the globus pallidus in Parkinson's disease was not significantly different from that in control subjects. In contrast, most patients with progressive supranuclear palsy had significant neurodegeneration of the external pallidum, particularly patients with significant degeneration of both the subthalamus and substantia nigra. These results suggest that the parkinsonian symptoms in progressive supranuclear palsy are caused by the degeneration of the external segment of the globus pallidus because such degeneration would increase thalamic inhibition through the basal ganglia output nuclei, particularly in patients with a loss of excitatory drive from the subthalamus.     

D1 and D2-type dopamine receptors in patients with Parkinson's disease and progressive supranuclear palsy

The densities of D1- and D2-type dopamine receptors were measured with [3H]SCH23390 and [3H]spiperone, in the caudate nucleus and putamen of a large series of patients with Parkinson's disease or progressive supranuclear palsy, in relation to markers of dopaminergic and cholinergic innervation of the striatum ([3H]dihydrotetrabenazine binding and choline acetyltransferase activity). Correlations were sought between these parameters and clinical characteristics of the patients (abnormal involuntary movements, dementia, confusional syndrome or treatment). In Parkinson's disease, the densities of both types of receptors were unchanged, whereas in PSP, the density of D2, but not D1-type dopamine receptors, was decreased in the caudate nucleus and the putamen. No correlations between the biochemical and clinical data were found.     

3H]MK-801 binding to the NMDA receptor complex, and its modulation in human frontal cortex during development and aging.

[3H]MK-801 binding was found to decline with age in well washed membranes from human frontal cortex taken from an age series from 24 weeks gestation to 100 years old. The decline was significant under basal conditions (no added modulators) (P less than 0.01), and highly significant under stimulation with glutamate, glycine and spermidine alone and in combination (P less than 0.001). Scatchard analysis in the presence of glutamate and glycine showed this decline was due to a loss in the number of [3H]MK-801 binding sites rather than a change in the affinity of the binding site. There was a highly significant age related reduction in the attenuation of [3H]MK-801 binding by zinc (P less than 0.001). In foetal and neonatal cases up to 7 weeks of age spermidine behaved in an antagonistic manner, inhibiting rather than stimulating [3H]MK-801 binding, when alone or in the presence of glutamate and glycine. The changes in influence of glutamate, glycine, spermidine and zinc on [3H]MK-801 binding during development and aging were not due to other pre- or postmortem factors. The reverse effect of spermidine in the foetal and neonatal cases has therapeutic implications in the treatment of neonates with antiischaemic agents whose action involves the polyamine site.     

The internal globus pallidus is affected in progressive supranuclear palsy and Parkinson's disease.

Our structural studies of the substantia nigra in parkinsonian patients identified previously unsuspected changes in the pars reticulata, suggesting significant dysfunction in this basal ganglia output. There have been few similar structural studies of the other major basal ganglia output, the internal segment of the globus pallidus. This is despite significant evidence that this basal ganglia region is crucially important for generating parkinsonian symptoms. In fact current surgical interventions target this region in Parkinson's disease. The cellular anatomy of the internal globus pallidus was compared among five controls, six patients with Parkinson's disease, and five patients with progressive supranuclear palsy. Neurons and pathological structures were quantified using the unbiased fractionator method. Only cases with progressive supranuclear palsy had detectable pathology within the internal globus pallidus in the form of tau-positive neuronal and glial tangles and substantial neurodegeneration. Cases with Parkinson's disease had a significant reduction in the proportion of neurons containing parvalbumin but were without significant neurodegeneration, consistent with dysfunction of both basal ganglia output nuclei in advanced parkinsonism. Surgical ablation of the internal globus pallidus for Parkinson's disease appears at odds with the significant neurodegeneration in the similarly akinetic and rigid patients with progressive supranuclear palsy. The results are discussed in association with current hypotheses of basal ganglia function and recent experimentation in patients undergoing pallidotomy for hyperkinetic disorders.     

Ontogeny of glycine-enhanced [3H]MK-801 binding to N-methyl-D-aspartate receptor-coupled ion channels.

The N-methyl-D-aspartate (NMDA) subtype of glutamate receptor is thought to play a critical role in neuronal development, differentiation and plasticity. A number of studies have shown an enhanced sensitivity to NMDA receptor ligands in neonatal animals. This study examined the ontogenetic changes in the glycinergic modulation of NMDA-coupled cation channels in the developing central nervous system of rat pups. The nonequilibrium binding of the specific channel ligand [3H]MK-801 was used as a measure of NMDA channel access. Glycine (10(-5) M) enhancement of [3H]MK-801 binding at 2 h in forebrain membranes from adult rats was significantly greater than that observed in tissues from 8- to 28-day-old rat pups. This difference was due to changes in the efficacy, but not potency of glycine. The observed ontogenetic changes in the efficacy of glycine-enhanced [3H]MK-801 binding were attributable to developmental changes in receptor site density, as determined by equilibrium [3H]MK-801 saturation isotherms. Kinetic studies revealed that glycine increased the association rate constants of [3H]MK-801 in 8-day and adult membranes by a similar magnitude (0.111 +/- 0.021 vs 0.094 +/- 0.009 nM-1 h-1, respectively). Similarly, the fractional amount of [3H]MK-801 bound (i.e., amount bound at time t normalized to amount bound at equilibrium) in the presence of glycine was relatively constant throughout neonatal development. These findings suggest that the allosteric modulation of the NMDA ionophore by glycine is similar in postnatal and adult rats.(ABSTRACT TRUNCATED AT 250 WORDS)     

The applause sign and neuropsychological profile in progressive supranuclear palsy and Parkinson's disease

Background

The applause sign has been associated with various neurodegenerative diseases. We investigate its validity in the differential diagnosis of progressive supranuclear palsy and Parkinson's disease, and its relationship with neuropsychological tests.

Patients and methods

23 patients with progressive supranuclear palsy and 106 patients with Parkinson's disease were included and administered the following scales: progressive supranuclear palsy rating scale, unified Parkinson's disease rating scale (UPDRS), mini-mental state examination (MMSE), frontal assessment battery (FAB), neuropsychiatric inventory and three-clap test.

Results

73.9% with progressive supranuclear palsy and 21.7% with Parkinson's disease showed a positive applause sign. Only a positive applause sign, UPDRS II score and disease duration were found to be predictors of progressive supranuclear palsy. Both patient-groups showed statistically significant correlations between the applause sign and neuropsychological tests: in progressive supranuclear palsy patients MMSE correlation coefficient: 0.62 (p: 0.002) and FAB correlation coefficient: 0.48 (p: 0.02), and in Parkinson's disease patients MMSE correlation coefficient: 0.47 (p < 0.001) and FAB correlation coefficient: 0.43 (p < 0.001). Verbal fluency and inhibitory control (FAB) and writing and orientation in time (MMSE) discriminated between patients with normal and positive applause sign.

Conclusions

A positive applause sign is not specific to progressive supranuclear palsy and may also be observed in Parkinson's disease patients with altered cognition, and it's related to cortical frontal abnormalities such as language disorders and inhibitory control.     

Slowing of cognitive processing in progressive supranuclear palsy. A comparison with Parkinson's disease

To investigate central processing time in patients with progressive supranuclear palsy and Parkinson's disease, reaction times were measured using tasks with different levels of cognitive complexity but with the same motor response. In patients with Parkinson's disease, the additional central processing time required for more complex situations was no different from that in control subjects, suggesting that cognitive aspects of the reaction time procedures tested were possibly too simple to reveal a slowing of thought processes in these patients. Conversely, the central processing time was increased in patients with progressive supranuclear palsy compared with both Parkinson's disease and control subjects. The increase was associated with impairment in frontal lobe test performance. These results confirm that a slowing of central processing is a prominent feature of the cognitive disturbances of progressive supranuclear palsy and, furthermore, suggest that this slowing may be related to striatofrontal dysfunction.     

PET imaging of the dopamine transporter in progressive supranuclear palsy and Parkinson's disease

OBJECTIVE: To differentiate the patterns of dopamine transporter loss between idiopathic PD and progressive supranuclear palsy (PSP). METHODS: We used the radiotracer [11C]-WIN 35,428 and PET. Regional striatal dopamine transporter binding was measured in the caudate, anterior putamen, and posterior putamen of six patients with L-dopa-responsive stage 2 PD, six patients with PSP, and six age-comparable healthy controls. RESULTS: In patients with idiopathic PD, the most marked abnormality was observed in the posterior putamen (77% reduction), whereas transporter density in the anterior putamen (60% reduction) and the caudate (44% reduction) was less affected. Unlike the patients with PD, the PSP group showed a relatively uniform degree of involvement in the caudate (40% reduction), anterior putamen (47% reduction), and posterior putamen (51% reduction). When posterior putamen/caudate ratios were calculated, these values were significantly lower in patients with PD than they were in patients with PSP (p = 0.0008) and the control group (p < 0.0001). CONCLUSIONS: Patients with PD have a more pronounced loss of dopamine transporters in the posterior putamen due to a subdivisional involvement of nigrostriatal dopaminergic projections in idiopathic PD. This technique is useful in the determination of neurochemical changes underlying PD and PSP, thus differentiating between them.     

Neuropsychological functions in progressive supranuclear palsy, multiple system atrophy and Parkinson's disease

BACKGROUND: Few studies have compared cognitive functions in multiple system atrophy (MSA), progressive supranuclear palsy (PSP) and Parkinson's disease (PD). AIM: To compare the results of cognitive function tests in the three diseases and examine their relation with the severity of parkinsonism. SETTINGS AND DESIGN: Clinic-based open prospective study. MATERIALS AND METHODS: Global cognitive function tests and tests specific for frontal lobe functions were used in 25 cases of each disease. UPDRS III was used to measure the severity of parkinsonism. STATISTICAL ANALYSIS: ANOVA was done for group comparisons, followed by t-test for independent samples with Bonferroni correction. Pearson's correlation test was done to assess the relation between severity of parkinsonism and cognitive functions. RESULTS: The severity of parkinsonism was worst in PD followed by PSP and least in MSA. Patients with PSP exhibited the worst performance in both sets of cognitive tests. Even though patients with MSA did better than PD in global function tests, they performed worse than PD in some frontal function tests. There was a negative correlation between severity of parkinsonism and scores in cognitive tests in the MSA group but not in others. CONCLUSIONS: Global and frontal dysfunction was worst in PSP. The frontal dysfunction in MSA was more severe than PD, correlated with the severity of parkinsonism and was worse in clinically probable than possible cases of MSA. The severity of cognitive dysfunction in these diseases may be related to the distribution and extent of pathological changes affecting the striato-frontal circuits in them.     

[H]MK-801 binding sites in neonate rat brain

[³H]MK-801 binding sites are present in neonate rat brain as early as 3 days after birth. Immature hippocampus and cortex contain approximately one sixth the concentration of binding sites of the adult, while brainstem concentration is twice as high as that of adult. [³H]MK-801 binding is stimulated by glutamate and glycine and blocked by phencyclidine and Mg²⁺ both in 7-day-old neonate and adult, indicating that as early as 7 days postnatally, theN-methyl-d-asparatate-type glutamate receptor and MK-801 binding site are functionally coupled.     

Heterogeneity of cognitive impairment in progressive supranuclear palsy, Parkinson's disease, and Alzheimer's disease

Patterns of cognitive and behavioral impairment were analyzed in patients with progressive supranuclear palsy (PSP), Parkinson's disease (PD), and senile dementia of Alzheimer's type (SDAT), matched for age, sex, manual laterality, educational level, and degree of intellectual deterioration. The scores of the three groups of patients were significantly lower than those of controls and were comparable on tests of verbal and visuospatial functions as well as global memory. Patients with SDAT could be distinguished by the severity of verbal memory disorders; patients with PSP, and to a lesser degree those with PD, by impaired performances on tests sensitive to frontal lobe dysfunction.