MRI for the differential diagnosis of neurodegenerative parkinsonism in clinical practice

Parkinson's disease (PD) is the most common neurodegenerative cause of parkinsonism, followed by progressive supranuclear palsy (PSP) and multiple system atrophy (MSA). Despite the publication of consensus operational criteria for the diagnosis of PD and the various atypical parkinsonian disorders (APD) such as PSP, MSA and corticobasal degeneration, an accurate diagnosis of neurodegenerative parkinsonian syndromes remains a challenge for each neurologist. Particularly in the early disease stages the clinical separation of APDs from PD carries a high rate of misdiagnosis. However, an early differentiation between APD and PD, each characterized by completely different natural histories, is crucial for determining the prognosis and choosing a treatment strategy. MRI plays an important role in the exclusion of symptomatic parkinsonism due to other pathologies. Over the past two decades, conventional MRI and advanced MRI techniques, including proton magnetic resonance spectroscopy (1H-MRS), diffusion-weighted imaging (DWI), magnetization transfer imaging (MTI), and magnetic resonance volumetry (MRV) have shown abnormalities in the substantia nigra and basal ganglia, especially in APD. Furthermore, in accordance with neuropathological studies suggesting that the olfactory system is an early target of the disease, recent studies using advanced MRI techniques have shown abnormalities in the olfactory system in the early disease stages of patients with PD. Given that olfactory deficits may be a premotor marker of the disease, such methods may eventually evolve into an early screening tool for PD.