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From the Neuroepidemiology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (Drs. Litvan, D'Olhaberriague, and Mangone); the Federation de Neurologie and INSERM U289, Hopital de la Salpetriere, Paris, France (Drs. Agid and Brandel); the Department of Neurology, Baylor College of Medicine, Houston, TX (Drs. Jankovic and Lai); Department of Neurology, Rush Medical College, Chicago, IL (Dr. Goetz); the Parkinson's Disease Society Brain Tissue Bank, Institute of Neurology, London, UK (Drs. Wenning and Pearce); the Department of Neurology, Institute of Psychiatry, London, UK (Dr. Ray Chaudhuri); the Raymond Escourolle Neuropathology Laboratory, INSERM U360, Hopital de la Salpetriere, Paris, France (Dr. Verny); the Department of Neuropathology, Massachusetts General Hospital, Boston, MA (Dr. McKee); the Ludwig Boltzmann Institute of Clinical Neurobiology, Vienna, Austria (Dr. Jellinger); and the Division of Epidemiology and Services Research, National Institute of Mental Health, Bethesda, MD (Dr. Bartko).
Presented in part at the World Federation of Neurology, Seattle, WA, May 12, 1995.
Received June 29, 1995. Accepted in final form July 24, 1995.
Address correspondence and reprint requests to Dr. Irene Litvan, Federal Building, Room 714, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814-3559.
We assessed the validity and interrater reliability of neurologists who, using four different sets of previously published criteria for the clinical diagnosis of progressive supranuclear palsy (PSP), also called Steele-Richardson-Olszewski syndrome, rated 105 autopsy-proven cases of PSP (n equals 24), Lewy body disease (n equals 29), corticobasal ganglionic degeneration (n equals 10), postencephalitic parkinsonism (n equals 7), multiple system atrophy (n equals 16), Pick's disease (n equals 7), and other parkinsonian or dementia disorders (n equals 12). Cases were presented in random order to six neurologists. Information from each patient's first and last visits to the medical center supplying the case was presented sequentially to the rater, and the rater's diagnosis was compared with the neuropathologic diagnosis of each case. Interrater agreement for the diagnosis of PSP varied from substantial to near perfect, but none of the criteria had both high sensitivity and high predictive value. Because of these limitations, we used a logistic regression analysis to identify the variables from the data set that would best predict the diagnosis. This analysis identified vertical supranuclear palsy with downward gaze abnormalities and postural instability with unexplained falls as the best features for predicting the diagnosis. From the results of the regression analysis and the addition of exclusionary features, we propose optimal criteria for the clinical diagnosis of PSP.
NEUROLOGY 1996;46: 922-930.
TX.-
In 1964, Steele, Richardson, and Olszewski described progressive supranuclear palsy (PSP), a brain neuro-degenerative disorder characterized by postural instability, parkinsonism, vertical supranuclear palsy, pseudobulbar palsy, and mild dementia. [1,2] However, the first clinical report on PSP [3,4] (also called Steele-Richardson-Olszewski syndrome) was published in 1904 and was soon followed by others. [5-7] When fully expressed, the clinical signs and symptoms of PSP are usually reliable for making the correct diagnosis, but cardinal signs, such as ophthalmoplegia, may be absent, or the only symptoms may be dementia or akinesia. [7-13] Neuropathologic examination remains the ``gold standard'' for the diagnosis of PSP. A clinical diagnosis can be mistakenly applied to pathologically determined diffuse Lewy body disease, corticobasal ganglionic degeneration (CBGD), cerebrovascular disease, Pick's disease, or subcortical gliosis. [14-20] Conversely, neuropathologically confirmed PSP may be clinically mistaken for idiopathic Parkinson's disease (PD), pallidonigroluysial atrophy, cerebrovascular disease, Alzheimer's disease (AD), or CBGD. [20-26]
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