EFNS/MDS-ES/ENS [corrected] recommendations for the diagnosis of Parkinson's disease

BACKGROUND

A Task Force was convened by the EFNS/MDS-ES Scientist Panel on Parkinson's disease (PD) and other movement disorders to systemically review relevant publications on the diagnosis of PD.

METHODS

Following the EFNS instruction for the preparation of neurological diagnostic guidelines, recommendation levels have been generated for diagnostic criteria and investigations.

RESULTS

For the clinical diagnosis, we recommend the use of the Queen Square Brain Bank criteria (Level B). Genetic testing for specific mutations is recommended on an individual basis (Level B), taking into account specific features (i.e. family history and age of onset). We recommend olfactory testing to differentiate PD from other parkinsonian disorders including recessive forms (Level A). Screening for pre-motor PD with olfactory testing requires additional tests due to limited specificity. Drug challenge tests are not recommended for the diagnosis in de novo parkinsonian patients. There is an insufficient evidence to support their role in the differential diagnosis between PD and other parkinsonian syndromes. We recommend an assessment of cognition and a screening for REM sleep behaviour disorder, psychotic manifestations and severe depression in the initial evaluation of suspected PD cases (Level A). Transcranial sonography is recommended for the differentiation of PD from atypical and secondary parkinsonian disorders (Level A), for the early diagnosis of PD and in the detection of subjects at risk for PD (Level A), although the technique is so far not universally used and requires some expertise. Because specificity of TCS for the development of PD is limited, TCS should be used in conjunction with other screening tests. Conventional magnetic resonance imaging and diffusion-weighted imaging at 1.5 T are recommended as neuroimaging tools that can support a diagnosis of multiple system atrophy (MSA) or progressive supranuclear palsy versus PD on the basis of regional atrophy and signal change as well as diffusivity patterns (Level A). DaTscan SPECT is registered in Europe and the United States for the differential diagnosis between degenerative parkinsonisms and essential tremor (Level A). More specifically, DaTscan is indicated in the presence of significant diagnostic uncertainty such as parkinsonism associated with neuroleptic exposure and atypical tremor manifestations such as isolated unilateral postural tremor. Studies of [(123) I]MIBG/SPECT cardiac uptake may be used to identify patients with PD versus controls and MSA patients (Level A). All other SPECT imaging studies do not fulfil registration standards and cannot be recommended for routine clinical use. At the moment, no conclusion can be drawn as to diagnostic efficacy of autonomic function tests, neurophysiological tests and positron emission tomography imaging in PD.

CONCLUSIONS

The diagnosis of PD is still largely based on the correct identification of its clinical features. Selected investigations (genetic, olfactory, and neuroimaging studies) have an ancillary role in confirming the diagnosis, and some of them could be possibly used in the near future to identify subjects in a pre-symptomatic phase of the disease.

Parkinson's disease and predictors of impulse control disorders in MMPI-2

This was a case control study involving 46 patients suffering from Parkinson disease (PD); 13 with impulse control disorder (ICD) and 33 without ICD; and 56 controls. The personality traits in these groups were analyzed using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). 46 patients with PD and 56 control group subjects were included into study. ICD were identified in 13 patients from PD group. There were higher scores than pathological threshold (65) in four domains of MMPI-2 Clinical scales: D (Depression), Pt (Psychastenia), Sc (Schizophrenia) and SI (Social introversion) in PD patients with ICD; but there were not statistical difference in any of these scales in comparison with the group of PD patients without ICD. In the case of MMPI-2 Subscales and Content scales there were higher scores than pathological threshold in eight domains of MMPI-2: SOD (Social Discomfort), PD4 (Psychopatic deviate - social alienation), PA1 (Paranoia - persecutory ideas), SC1 (Schizophrenia), PA_O (Paranoia - subtle), MA_O (Hypomania - obvious), SI1 (Syness/Self-Consciousness), SI3 (Alienation self and others) and Ho (Hostility), but there were statistical differences only in one of these domains in comparison with the PD patients without ICD: SI3 (alienation self and others). There was earlier onset of the disease and higher dose of levodopa in PD patients with ICD than in PD patients without ICD.

Supported by project IGA MZ ČR NS 10301-3/2009

Thrombolytic treatment of ischaemic stroke occurring during a migrainous attack: a case report

Authors report a case of young female suffering from the acute ischaemic stroke with right-sided hemiplegia, hemianopsia and hemihypoaesthesia during a migrainous attack without aura. Magnetic resonance imaging detected infarction in the left occipital lobe and occlusion of branches of the posterior cerebral artery (PCA). Combined treatment with systemic thrombolysis and sonothrombolysis was used, leading to the early PCA recanalization, and to a favourable clinical outcome after 1 month. Intravenous thrombolytic treatment administered within the therapeutic window may be useful in cerebral ischaemia associated with migraine when an arterial occlusion is documented.

New laboratory markers in diagnosis of alzheimer dementia

OBJECTIVES

The aim of our work was to assess the role of tau protein, beta amyloid and cystatin C in diagnosis of Alzheimer dementia (AD) and other neurodegenerative diseases (NDs).

METHODS

The levels of tau protein, beta amyloid and cystatin C were assessed in a set of 79 patients with ND (38 men and 41 women; aged 22-90 years; mean, 61.6 +/- 15.6 years) and in a control group of 79 subjects with a healthy central nervous system (38 men and 41 women; aged 20-91 years; mean, 61.5 +/- 15.1 years).

RESULTS

When compared with the subjects in the control group, a statistically significant decrease in tau protein levels was found in patients with ND, an increase in tau protein levels in patients with AD and an increase in cystatin C cerebrospinal fluid/serum index in the ND + AD group.

DISCUSSION

Our work only confirmed the previously reported results in part. Although tau protein seems to be a quite reliable marker of AD, the role of beta amyloid in AD diagnosis remains at the least questionable. In the case of cystatin C, our results would seem to confirm the views of certain authors that cystatin C will probably not become a new 'revolutionary' marker contributing to differential diagnostics.

The assessment of beta amyloid, tau protein and cystatin C in the cerebrospinal fluid: laboratory markers of neurodegenerative diseases

To assess the role of tau protein, beta-amyloid(1-42) and cystatin C in the diagnostics of Alzheimer dementia (AD) and other neurodegenerative diseases (ND) by comparing to the control groups (CG). The levels of tau protein, beta-amyloid(1-42) and cystatin C were assessed in the set of 69 patients (AD + ND, 33 males, 36 females, aged 22-90, mean 60.5 + 16.1 years), and in a control group of 69 subjects without the affection of the central nervous system (CGAD + CGND, 33 males, 36 females, aged 20-91, mean 60.5 + 16.0 years). Statistically significant increased tau protein levels (P = 0.0001) and index tau/beta-amyloid(1-42) levels (P = 0.0002) were shown in the group of AD patients, compared to the group of ND patients. One-way ANOVA analysis with Bonferonni post hoc test did not show any significant differences of the cystatin C values between any of the compared groups. ROC analysis showed at least one tie between the positive actual state group (AD) and the negative actual state group (ND) by CSF cystatin C and at least one tie between the positive actual state group and the negative actual state group by CSF tau protein. Our study confirmed previously reported results only in part. While tau protein seems to be quite a reliable marker of AD, the role of beta-amyloid(1-42) and cystatin C in AD diagnosis remains at least questionable.