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ARTICLES: H. Oba, A. Yagishita, H. Terada, A. J. Barkovich, K. Kutomi, T. Yamauchi, S. Furui, T. Shimizu, M. Uchigata, K. Matsumura, M. Sonoo, M. Sakai, K. Takada, A. Harasawa, K. Takeshita, H. Kohtake, H. Tanaka, and S. Suzuki New and reliable MRI diagnosis for progressive supranuclear palsy Neurology 2005; 64: 2050-2055 [Abstract] [Full text] [PDF]

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Reply to Wszolek et al

Hiroshi Oba, MD, Hitoshi Terada, MD, Second Department of Radiology (Dr. Terada), Toho University School of Medicine, Tokyo, Japan   (14 September 2005)

New and reliable MRI diagnosis for progressive supranuclear palsy

Zbigniew K Wszolek, MD, FAAN, Jerzy Slowinski, MD, Akiko Imamura, MD, Yoshio Tsuboi, MD, Daniel F Broderick (Jacksonville, FL)   (14 September 2005)

Reply to Wszolek et al 14 September 2005
Hiroshi Oba, MD, Department of Radiology, Teikyo University 2-11-1 Kaga, Tokyo-Itabashi, 1738605 Japan, Hitoshi Terada, MD, Second Department of Radiology (Dr. Terada), Toho University School of Medicine, Tokyo, Japan Send Correspondence to journal: Re: Reply to Wszolek et al oba{at}med.teikyo-u.ac.jp Hiroshi Oba, MD, et al.	We appreciate the comments made by Dr. Wszolek et al and their interest in our study. [1] We agree that "Hummingbird sign" [2] is an elegant and useful sign for the diagnosis of the progressive supranuclear palsy (PSP). The sign was originally proposed by Iwata [6] and represents marked thinning of anterior part of the midbrain resembling the bill of hummingbird on mid-sagittal MR image. "Penguin silhouette sign" represents the small midbrain of PSP patients. [1] We believe both signs are useful tools for the imaging diagnosis of PSP. We agree that quantitative volumetric measurement is a promising method for evaluation of superior cerebellar peduncles (SCP) and midbrain atrophy seen in PSP [3,4] and that radiological and pathological correlation studies including a comparison between PSP and corticobasal degeneration are necessary to establish diagnostic criteria for parkinsonian syndromes. [5] We continue to perform neuroimaging studies with postmortem confirmation of the presence or absence of midbrain and SCP atrophy in parkinsonian syndromes. Reference 6. Iwata M. Humming-bird appearance of mid-brain in MRI of progressive supranuclear palsy. Annual Report of the Research of CNS Degenerative Disease, the Ministry of Health and Welfare of Japan. 1994, pp. 48-50 (Japanese). The authors report no conflicts of interest.
New and reliable MRI diagnosis for progressive supranuclear palsy 14 September 2005
Zbigniew K Wszolek, MD, FAAN, Department of Neurology, Mayo Clinic 4500 San Pablo Road, 32224 Jacksonville, FL, Jerzy Slowinski, MD, Akiko Imamura, MD, Yoshio Tsuboi, MD, Daniel F Broderick (Jacksonville, FL) Send Correspondence to journal: Re: New and reliable MRI diagnosis for progressive supranuclear palsy wszolek.zbigniew{at}mayo.edu Zbigniew K Wszolek, MD, FAAN, et al.	We read with interest the recent article by Oba et al who report that in patients with clinical diagnosis of progressive supranuclear palsy (PSP), the average midbrain area measured on mid-sagittal MRI is statistically smaller than that of patients with Parkinson disease (PD), multiple-system atrophy (MSA) of the Parkinson type and age-matched control subjects.[1] Midbrain atrophy is a well known, radiologically and pathologically confirmed feature of PSP. An observation similar to that of Oba et al was reported earlier by another group. [2] However, they used a slightly different midbrain measurement technique with subdivisions into the rostral and caudal tegmentum and tectum. The characteristic shape of the brainstem seen on MRI images of PSP patients, with a reduced midbrain/pons ratio, referred to as the “penguin silhouette sign” by Oba et al was described earlier by Kato et al as the “hummingbird sign”. [2] Pathological studies of PSP brains demonstrate the presence of superior cerebellar peduncles (SCP) atrophy. [3] SCP atrophy in patients with clinical diagnosis of PSP was recently demonstrated on MRI images with both quantitative volumetric measurement and qualitative visual assessment and was found to be a useful marker in differentiating PSP from MSA and PD. [4] It would be important to perform combined radiological assessment of both midbrain and SCP atrophy with the hope that MRI of the brain will assist clinicians in making a more accurate diagnosis, particularly in the early stages of the disease when the diagnostic errors are most likely to occur. The cited studies 1,2,4 did not include a comparison between PSP and corticobasal degeneration (CBD). Since PSP and CBD are both 4R tauopathies and may be confused in the initial stages, performing a similar combined radiological analysis may lead to more reliable diagnostic criteria for both diseases. The study of Gröschel et al [5] of both PSP and CBD cases showed the usefulness of the profile of atrophic brain changes (including midbrain) measured with MR imaging-based volumetry in a differentiation between these diseases. While their material included autopsy confirmed cases, they did not specifically show changes in the SCP. It would be helpful to verify the detailed radiological findings reported in clinically and radiologically diagnosed PSP patients with neuropathologic correlation to further reinforce diagnostic criteria for parkinsonian syndromes. Specifically, a neuroimaging study with postmortem confirmation of the presence or absence of midbrain and SCP atrophy is required. References 1. Oba H, Yagishita A, Terada H, Barkovich AJ, Kutomi K, Yamauchi T, Furui S, Shimizu T, Uchigata M, Matsumura K, Sonoo M, Sakai M, Takada K, Harasawa A, Takeshita K, Kohtake H, Tanaka H, Suzuki S. New and reliable MRI diagnosis for progressive supranuclear palsy. Neurology 2005;64:2050- 2055. 2. Kato N, Arai K, Hattori T. Study of the rostral midbrain atrophy in progressive supranuclear palsy. Neurol Sci 2003;210:57-60. 3. Tsuboi Y, Slowinski J, Josephs KA, Honer WG, Wszolek ZK, Dickson DW. Atrophy of superior cerebellar peduncle in progressive supranuclear palsy. Neurology 2003;60:1766-9. 4. Paviour DC, Price SL, Stevens JM, Lees AJ, Fox NC. Quantitative MRI measurement of superior cerebellar peduncle in progressive supranuclear palsy. Neurology 2005;64:675-9. 5. Gröschel K, Hauser TK, Luft A, Patronas N, Dichgans J, Litvan I, Schulz JB. Magnetic resonance imaging-based volumetry differentiates progressive supranuclear palsy from corticobasal degeneration. Neuroimage 2004;21:714- 24. Disclosure: The authors report no conflicts of interest.