Clinical features and natural history of multiple system atrophy. An analysis of 100 cases

MR imaging of middle cerebellar peduncle width: differentiation of multiple system atrophy from Parkinson disease

PURPOSE

To prospectively assess if middle cerebellar peduncle (MCP) atrophy, evaluated at magnetic resonance (MR) imaging, can help differentiate multiple system atrophy (MSA) from Parkinson disease (PD).

MATERIALS AND METHODS

All participants provided informed consent for participation in the study, which was approved by the institutional review board. Sixteen consecutive patients with MSA, 26 consecutive patients with PD, and 14 healthy control subjects were examined with MR imaging. Images were interpreted independently by two experienced neuroradiologists blinded to clinical information, who visually inspected the images for the presence or absence of putaminal atrophy, putaminal hypointensity, slitlike hyperintensity in the posterolateral margin of the putamen, brainstem atrophy, hyperintensity of the MCP, and cruciform hyperintensity of the pons. Measurements of MCP width on T1-weighted volumetric spoiled gradient-echo images were performed in all subjects. Differences in MCP width among the groups were evaluated by using the Kruskall-Wallis test, followed by the Mann-Whitney U test for multiple comparisons and Bonferroni correction.

RESULTS

All patients (mean age, 63.88 years; range, 55-72 years) with MSA had at least one of the features commonly observed in this disease on MR images, whereas control subjects (mean age, 66.93 years; range, 61-77 years) and all but one patient with PD (mean age, 65.31 years; range, 51-79 years) had normal MR images. The average MCP width was significantly smaller in patients with MSA (6.10 mm+/-1.18 [standard deviation]) than in those with PD (9.32 mm+/-0.77, P<.001) or control subjects (9.80 mm+/-0.66, P<.001).

CONCLUSION

Measurement of MCP width on MR images may be useful for distinguishing patients with MSA from those with PD.

[Subthalamic stimulation in a patient with multiple system atrophy: a clinicopathological report]

INTRODUCTION

Efficacy of high frequency subthalamic nucleus (STN) stimulation has been demonstrated in idiopathic Parkinson's disease (IPD). However, since it may be difficult to differentiate IPD from multiple system atrophy with parkinsonian presentation (MSA-P), a few cases of MSA-P has been treated by deep brain stimulation (DBS) and showed no sustained improvement of clinical signs. We report a patient with a clinical misdiagnosed MSA-P, later confirmed by neuropathological study, who was improved by DBS for one year.

CASE REPORT

A 63-year-old parkinsonian patient had been treated by levodopa for 6 years with a persistent good response. Over one year he progressively developed disabling fluctuations with severe axial syndrome and vegetative non motor symptoms in off periods. After checking usual contraindications, he was included in surgical procedure protocol (bilateral STN stimulation). During the first year after surgery, the clinical status improved with disappearance of non motor fluctuations, a 45 percent decrease of the OFF UPDRS III score, and a 39 percent reduction of the treatment. However after one year, axial symptoms reappeared with recurrent falls, as well as increasing dysarthry and swallowing difficulties which were only slightly improved by levodopa. He developed severe urinary disorders increased by a prostatic adenoma which led to surgical treatment. During the post operative period, 2 years after DBS, he died suddenly from an unexplained cause. A cerebral autopsy was performed and showed a good position of the two electrodes in the STN. Microscopic studies revealed severe neuronal depletion in the substantia nigra but no Lewy bodies. Immunohistochemical methods demonstrated numerous argyrophilic glial cytoplasmic inclusions positive for alpha-synuclein and ubiquitin in the STN, putamen, globus pallidus, pontine nuclei and cerebellar white matter, significant of MSA.

CONCLUSION

This case shows that DBS can improve parkinsonian signs in MSA-P with persistent dopa sensitivity. However, probably because of striatal degeneration progression, this improvement is time limited and STN DBS cannot be recommended in MSA.

CSF neurofilament light chain and tau differentiate multiple system atrophy from Parkinson's disease

BACKGROUND

In early disease stages it can be clinically difficult to differentiate idiopathic Parkinson's disease (IPD) from patients with multiple system atrophy predominated by parkinsonism (MSA-P).

METHODS

In CSF of 31 patients with IPD, 19 patients with MSA-P, we analyzed tau, neurofilament light chain (NFL) and heavy chain (NFHp35) and the noradrenergic metabolite 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG).

RESULTS

CSF levels of NFL, NFHp35, and tau were significantly increased in MSA-P (all p<0.0001), whereas, MHPG levels were significantly decreased in MSA-P (p<0.0001). Optimal discriminative cut-off values for the differentiation between MSA-P and IPD were calculated resulting in high sensitivity (76-94%) and specificity (83-97%) levels. Multivariate logistic regression resulted in the combination of NFL and tau as independent contributors in differentiating between MSA-P and IPD.

DISCUSSION

Higher CSF levels of axonal biomarkers could reflect advanced axonal degeneration in MSA-P. Differentiating MSA-P from IPD could be accurately possible with CSF analysis of a combination of axonal and neurotransmitter biomarkers.

Anterior semicircular canal benign paroxysmal positional vertigo and positional downbeating nystagmus

PURPOSE

The aim of this study was to describe the clinical features and video-oculographic findings in patients with anterior semicircular canal benign paroxysmal positional vertigo (BPPV).

MATERIALS AND METHODS

STUDY DESIGN

This is a prospective case series.

SETTING

The study was set at an outpatient clinic in a general hospital.

PATIENTS

Fourteen individuals with symptoms of BPPV and positional downbeating nystagmus (pDBN) were included in the study. The diagnosis was based on a history of brief episodes of vertigo and the presence of pDBN confirmed in the video-oculographic examination during Dix-Hallpike test (DH) or head-hanging maneuver.

INTERVENTION

Patients were treated by particle repositioning maneuver and the effectiveness was evaluated at 7, 30, and 180 days posttreatment. The treatment was repeated up to 4 times if pDBN was persistent.

MAIN OUTCOME MEASURES

The main outcome measure is the number of patients without pDBN at 30 and 180 days.

RESULTS

Video-oculography showed a predominant pDBN in response to DH. Of the 14 patients, 7 had arterial hypertension, and 5 of 14 cases presented abnormalities on the caloric test. Horizontal spontaneous nystagmus was found in 3 of 14 individuals. Positional nystagmus at different positional test was observed in 5 of 14 individuals, suggesting the involvement of several canals. Of the 14 patients, 10 (71%) did not present vertigo, and the positional tests were negative at 30 days. However, 3 cases presented a positive DH with persistence of BPPV episodes and pDBN at 30 days, and another developed a contralateral posterior canal affectation. One of the patients maintained a persistent pDBN at 180 days despite the repeated maneuvers.

CONCLUSIONS

Video-oculography demonstrates that anterior canal BPPV is characterized by a predominant downbeating nystagmus in response to DH. These individuals may show alterations in the vestibular caloric, and they can have multicanal affectation.

Very late-onset Friedreich's ataxia with minimal GAA1 expansion mimicking multiple system atrophy of cerebellar type

Very late-onset Friedreich's ataxia (VLOFA) is characterized by symptomatic onset after 40 years of age and, usually, a benign phenotype. We describe a sporadic case with onset at 53 years of age and a novel VLOFA phenotype mimicking multiple system atrophy (MSA) of cerebellar type associated with minimal GAA1 expansion. We detected several atypical features for a diagnosis of MSA, which should alert to the possibility of an inherited ataxia.

Ancient descriptions of movement disorders: Cathedral el Burgo de Osma (Soria, Spain)

El Burgo de Osma (Soria, Spain) offers one of the best preserved medieval structures in Spain. The interior of the building conserves abundant samples of Romanesque art, and the tomb in polychromatic stone of the founder, San Pedro de Osma. We have classified those pieces of art that could represent descriptions of movement disorders. In the main façade of the Cathedral, several statues representing prophets can be seen one of them is clearly different to the rest. This statue represents a man with abnormal cervical posture characterized by right rotation, head tilt and elevation of right shoulder. The tomb includes several statues representing fragments of the life of San Pedro de Osma. Some of these figures show movement disorders. First, a woman with a baby in her arms who has marked head tilt to the left. Second a peasant without hands, perhaps amputated, this man has a head tilt to the right. We suggest that in the latter case ergotism can explain both manifestations: peripheral vascular disease leading to amputation, and cervical dystonia.Finally, a statue of polychromatic wood represents a priest with stooped posture, half open mouth, staring expression and a very notorious anterocollis. The author probably depicted a man with parkinsonism.

Chromatic pattern-reversal electroretinograms (ChPERGs) are spared in multiple system atrophy compared with Parkinson's disease

Idiopathic Parkinson's disease (IPD) patients have abnormal visual evoked potentials (VEPs) and pattern electroretinograms (PERGs), attributed to dopaminergic transmission deficiency in visual pathway, probably the retina. VEP abnormalities are not reported in multiple system atrophy (MSA). The aim of this study was to investigate and compare chromatic (Ch) red-green (R-G) and blue-yellow (B-Y), and luminance yellow-black (Y-Bk) PERGs in patients with MSA and IPD. We investigated 6 MSA patients (mean age: 62+/-7.4 years) not undergoing any pharmacological treatment, as well as 12 early IPD patients (mean age: 60.1+/-8.3 years) and 12 age-matched normal observers. ChPERGs were recorded monocularly in response to full-field equiluminant R-G, B-Y and Y-Bk horizontal gratings. In MSA only responses to R-G stimuli showed minimal insignificant changes (slight but not significant amplitude reduction without any significant latency delay); no significant abnormality was detected for B-Y and luminance Y-Bk stimuli. By contrast, in IPD all responses were reduced in amplitude and delayed in latency, above all for B-Y stimuli. Present data indicate that both chromatic and achromatic PERGs are virtually unaffected in MSA, whereas in early IPD they are clearly impaired, suggesting different pathogenic retinal mechanisms and a useful simple tool for distinguishing MSA from IPD.

Progression of putaminal degeneration in multiple system atrophy: a serial diffusion MR study

By using diffusion-weighted imaging (DWI), we have recently shown abnormal diffusivity in the putamen of patients with the Parkinson variant of multiple system atrophy (MSA-P) which also correlated with disease severity, indicating the capability of putaminal diffusivity to serve as a marker for disease progression. We therefore performed a serial DWI study in 10 patients with MSA-P compared to 10 patients with Parkinson's disease (PD) to evaluate the dynamic evolution of diffusion properties in the basal ganglia including putamen, caudate nucleus and globus pallidum by means of the trace of the diffusion tensor (Trace(D)). For comparison, we have also analyzed the frequency and semiquantitative grading of MSA-P-related structural changes on conventional MRI including putaminal atrophy, lateral hyperintense margination of the putamen and putaminal signal hypointensity relative to the globus pallidum on T2 MR images. None of the Trace(D) values in the basal ganglia regions in the PD group changed significantly at follow-up compared to baseline. In MSA-P, a significant increase of the Trace(D) was found in the putamen, which correlated with motor progression as assessed by the Unified Parkinson's Disease Rating Scale (UPDRS). No significant change of any of the abnormal putaminal findings on routine MRI was obtained. We suggest that abnormal diffusivity in the putamen is sensitive to change over time in MSA-P and correlates with motor progression indicating that DWI may serve to monitor disease progression in MSA-P in an objective and quantitative manner.

Placebo-controlled trial of amantadine in multiple-system atrophy

OBJECTIVE

Multiple-system atrophy (MSA) often presents as atypical parkinsonian syndrome with rapid progression and poor response to levodopa. Reports on the open-label use of amantadine in MSA suggest variable antiparkinsonian efficacy. The authors therefore conducted a double-blind, placebo-controlled crossover trial of amantadine in MSA patients.

METHODS

Eight patients were enrolled in this study. They received either amantadine 200 mg twice daily or placebo for 3 weeks, followed by a 1-week washout and the alternate treatment of 3 weeks. Antiparkinsonian effects were evaluated using the Unified Parkinson's Disease Rating Scale part II (UPDRS-II, activities of daily living) and UPDRS-III (motor examination) before and at the end of each treatment phase. Timed tests were also performed according to the CAPIT protocol.

RESULTS

There was a trend toward reduction of UPDRS-III scores during amantadine treatment (P = 0.058). Delta values of the treatment arm were higher than those of the placebo arm. However, this difference (-2.25 pt; 95% CI, -6.7-2.2) failed to reach significance. Reduction of UPDRS-III subscores for akinesia, rigidity, tremor, postural instability, and gait disorder failed to reach significance too. The hand-arm movement test revealed nonsignificant improvement in the amantadine arm.

CONCLUSION

This study suggests that amantadine fails to provide clinically significant antiparkinsonian benefit to patients with MSA. The authors cannot exclude mild effects due to the limited sample size.

Deep brain stimulation: Preoperative issues

Numerous factors need to be taken into account in deciding whether a patient with Parkinson's disease (PD) is a candidate for deep brain stimulation. Patient-related personal factors including age and the presence of other comorbid disorders need to be considered. Neuropsychological and neuropsychiatric concerns relate both to the presurgical status of the patient and to the potential for surgery to result in new problems postoperatively. A number of factors related to the underlying PD need to be considered, including the specific parkinsonian motor indications (e.g., tremor, bradykinesia, gait dysfunction), previous medical therapies, including benefit from current therapy and adverse effects, and past surgical treatments. Definable causes of Parkinsonism, particularly atypical Parkinsonisms, should be considered. Finally, methods of evaluating outcomes should be defined and formalized. This is a report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society (MDS). The report has been endorsed by the Scientific Issues Committee of the MDS and the American Society of Stereotactic and Functional Neurosurgery. It outlines answers to a series of questions developed to address all aspects of deep brain stimulation preoperative decision-making.

The diagnosis of Parkinson's disease

The correct diagnosis of Parkinson's disease is important for prognostic and therapeutic reasons and is essential for clinical research. Investigations of the diagnostic accuracy for the disease and other forms of parkinsonism in community-based samples of patients taking antiparkinsonian medication confirmed a diagnosis of parkinsonism in only 74% of patients and clinically probable Parkinson's disease in 53% of patients. Clinicopathological studies based on brain bank material from the UK and Canada have shown that clinicians diagnose the disease incorrectly in about 25% of patients. In these studies, the most common reasons for misdiagnosis were presence of essential tremor, vascular parkinsonism, and atypical parkinsonian syndromes. Infrequent diagnostic errors included Alzheimer's disease, dementia with Lewy bodies, and drug-induced parkinsonism. Increasing knowledge of the heterogeneous clinical presentation of the various parkinsonisms has resulted in improved diagnostic accuracy of the various parkinsonian syndromes in specialised movement-disorder units. Also genetic testing and various other ancillary tests, such as olfactory testing, MRI, and dopamine-transporter single-photon-emission computed-tomography imaging, help with clinical diagnostic decisions.

Olivopontocerebellar atrophy: Toward a better nosological definition

Olivopontocerebellar atrophy (OPCA) is a pathological label implying not only olivopontocerebellar changes, but also cases with more widespread lesions involving the CNS. This polytopic pathological background accounts for clinical complexity, essentially defined as cerebellar-plus syndrome. The term "OPCA" is applicable to an increasing number of neurodegenerative syndromes, including autosomal dominant ataxia, complicated spastic paraplegia, multiple-system atrophy (MSA), and many cases of idiopathic late-onset cerebellar ataxia (ILOCA), some of whom also turn out to have MSA. OPCA may also be part of the pathological hallmark of other disorders, such as prion disorders, mitochondrial encephalomyopathies, and hereditary metabolic diseases. Sporadic OPCA and ILOCA with cerebellar-plus presentation and neuroimaging evidence of brainstem and cerebellar atrophy may represent interchangeable eponyms. Just a quarter of such cases evolve to MSA within 5 years of the onset of symptoms. Therefore, the assumption that MSA and sporadic OPCA necessarily are one and the same disease is no longer tenable. Our review suggests that the label "OPCA" is useful to designate a clinicopathological syndrome that has a variety of etiologies carrying a poor prognosis, particularly if associated with autonomic failure as occurs in MSA.

Progression of multiple system atrophy (MSA): A prospective natural history study by the European MSA Study Group (EMSA SG)

The disease-specific Unified Multiple System Atrophy Rating Scale (UMSARS) has been developed recently and validated for assessing disease severity in multiple system atrophy (MSA). Here, we aimed at (1) assessing rates of disease progression in MSA and (2) validating UMSARS for sensitivity to change over time. Impairment was assessed at two time points 12 months apart using UMSARS Part I (historical review), UMSARS Part II (motor examination), as well as measures of global disease severity, including UMSARS Part IV, Hoehn and Yahr (HY) Parkinson's disease staging, Schwab England Activities of Daily Living (SE ADL), and a three-point global Severity Scale (SS3). Fifty patients (male:female ratio, 1:0.9; possible MSA, 16%; probable MSA, 84%; MSA-parkinsonian, 58%; MSA-cerebellar, 42%) were assessed twice with an interval of 12.3 months. UMSARS II scores progressed by 57.3% (P<0.0001) and UMSARS I scores by 35.6% (P<0.0001) in relation to the respective baseline scores with no differences between motor subtypes, diagnostic categories and gender. Significant inverse correlations between (1) UMSARS I or UMSARS II progression and (2) baseline disability measures (i.e., the respective UMSARS or SS3 scores) and disease duration were found. Furthermore, the increases in HY staging, SE ADL and SS3 correlated significantly with UMSARS I, UMSARS II, and UMSARS IV progression. This report is the first prospective study showing rapid annual UMSARS rates of decline in MSA. Our data contribute to the ongoing validation process of UMSARS, and they facilitate the planning and implementation of future neuroprotective intervention trials.

Update on the neurology of Parkinson's disease

The differential diagnosis of a patient with apparent Parkinson's Disease (PD) and bladder symptoms is considered and the bladder dysfunction of Multiple System Atrophy (MSA) is reviewed. Recent insights into the progression of the neuropathology of PD have enabled thinking about the stage of the disease at which bladder dysfunction is likely to occur and the expected clinical context of the problem. Bladder symptoms of neurological origin are likely in a patient who has had treated motor symptoms for some years and in whom the ongoing neuropathology has progressed beyond involvement of the basal ganglia, so that symptoms due to cortical dysfunction as well as the adverse effects of dopaminergic medication are also confounding factors. Bladder symptoms in a man with lesser neurological disability should be investigated to exclude underlying outflow obstruction. Possible management options are considered.

Grading of neuropathology in multiple system atrophy: proposal for a novel scale

Multiple system atrophy (MSA), a sporadic progressive synucleinopathy of advanced age, is separated into two clinic opathological subtypes: MSA-P (striatonigral degeneration [SND]) with predominant parkinsonian features and MSA-C (olivopontocerebellar atrophy [OPCA]) with predominant cerebellar ataxia. We propose a novel morphological grading system for both subtypes to compare lesion intensities and their possible clinical validity. Forty-two autopsy cases of MSA were separated into four grades (SND 0-III and OPCA 0-III) based on semiquantitative assessment of neuronal loss, astrogliosis, and presence of alpha-synuclein-positive glial cytoplasmic inclusions (GCI) in striatum, globus pallidus, substantia nigra, pontine basis, cerebellum, and inferior olives. Whereas a recent grading system restricted to SND reflected disease progression and dopa-responsiveness, there was considerable variation in the morphological combination between SND and OPCA, with only around half the cases with OPCA II (moderate) and III (severe) showing comparable grades of both types, whereas OPCA 0 and I (no or little degeneration) was combined with all grades of SND. Twenty-two cases showing OPCA 0 + SND II (n = 3), OPCA I + SND I-II (n = 11), and OPCA I + SND III (n = 8) were classified as pure or predominant SND, consistent with MSA-P. Twenty cases showing OPCA II + SND II/III (n = 7) and OPCA III + SND III (n = 13) were classified as predominant OPCA, consistent with MSA-C. In MSA-P, the mean age of onset was higher than it was in MSA-C (55.1 vs. 50.5 years), but the mean duration of illness was shorter in MSA-P (5.3 vs. 6.7 years). Presenting symptoms in MSA-P were mainly parkinsonism, whereas in MSA-C they were mainly gait disorders (14 vs. 1; P < 0.001). Among clinical key symptoms, parkinsonism was more frequent than were cerebellar signs in MSA-P; in MSA-C it was the reverse (P < 0.01), whereas other symptoms (autonomic/urinary failure) showed no differences. Parkinsonism was infrequent in MSA-C even when OPCA was associated with SND, suggesting a masking effect by cerebellar system involvement. High terminal Hoehn and Yahr stages were more frequent in MSA-P (P < 0.01), some with good-to-moderate initial levodopa (L-dopa) response. Although the proposed morphological grading of both MSA-P and -C correlates well with initial symptoms and clinical key features of both types, further prospective studies are required to validate the clinical utility of the proposed MSA grading scales for future intervention studies.

In vivo models of multiple system atrophy

Multiple system atrophy (MSA) is a sporadic adult-onset neurodegenerative disorder of unknown etiology clinically characterized by a combination of parkinsonian, pyramidal, and cerebellar signs. Levodopa-unresponsive parkinsonism is present in 80% of MSA cases, and this dominant clinical presentation (MSA-P) is associated with a combined degeneration of the substantia nigra pars compacta and the striatum in anatomically related areas. The limited knowledge of the pathophysiology of MSA and the lack of therapeutic strategies prompted the development of lesion models reproducing striatonigral degeneration, the substrate of levodopa-unresponsive parkinsonism in MSA-P. This method was carried out first in rats with two different stereotaxic strategies using either two neurotoxins ("double toxin-double lesion") or a single neurotoxin ("single toxin-double lesion"). Double-lesioned rat models showed severe motor impairment compared to those with a single nigral or striatal lesion and helped to mimic different stages of the disease. Systemic models were also developed in mice and primates using the nigral toxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and the striatal toxin 3-nitropropionic (3-NP). In mice, although MPTP reduced the subsequent sensitivity to 3-NP in a sequential lesion, simultaneous nigral and striatal insults were shown to exacerbate striatal damage. MPTP-treated monkeys displayed a significant worsening of parkinsonism and a loss of levodopa-responsiveness after the appearance of hindlimb dystonia and striatal lesion formation induced by subsequent 3-NP intoxication. The different species and intoxication paradigms used will be useful to investigate functional changes in substantia nigra and striatum and to define neuroprotective, neurorestorative, or symptomatic therapeutic strategies.

Autonomic nervous evaluation in the early stages of olivopontocerebellar atrophy

The clinical significance of evaluating autonomic nervous system functions in the early stages of olivopontocerebellar atrophy (OPCA) has been investigated in 13 OPCA out-patients (7 males and 6 females, mean age: 51.0 years). We have employed measurements of blood pressure, plasma norepinephrine (NE), CVR-R, low-frequency power/high-frequency power ratio (L/H), high-frequency power (HF) score and heart rate (HR) monitoring using Holter ECG recording for evaluation of CVR-R. We have also carried out urodynamic examinations, focusing on the possible existence of bladder dysfunction. Although no significant changes were noted between control and OPCA groups concerning HR, CVR-R, L/H, plasma levels of norepinephrine and systolic blood pressure, HF (high-frequency power) (ms(2)), especially at night time, invariably showed a significant decline in OPCA groups. All OPCA patients who showed a decreased circadian HF also exhibited a tendency towards urinary bladder dysfunction. The present results appear to relate to disorder of the parasympathetic autonomic nervous system and neuromuscular dysfunction in the lower urinary tract. In conclusion, HRV (heart rate variability) analysis is a useful and safe tool and a keen predictor for evaluating functional states of autonomic nervous activity, especially in the early stages of OPCA. This study has also suggested the possible efficacy of urodynamic measurements in OPCA patients as an indicator of neuromuscular dysfunction in the lower urinary tract and of parasympathetic malfunction.

When is Onuf's nucleus involved in multiple system atrophy? A sphincter electromyography study

BACKGROUND

External anal sphincter (EAS) electromyography (EMG) abnormalities can distinguish multiple system atrophy (MSA) from Parkinson's disease in the first five years after disease onset. However, the prevalence of the abnormalities in the early stages of MSA is unknown.

OBJECTIVES

To present EAS-EMG data in the various stages of MSA.

METHODS

84 patients with "probable" MSA were recruited (42 men, 42 women; mean age 62 years (range 47 to 78); mean disease duration 3.2 years (0.5 to 8.0; <1 year in 25%); 50 cerebellar form (MSA-C), 34 parkinsonian form (MSA-P)). EAS motor unit potential (MUP) analysis and EMG cystometry were carried out in all patients.

RESULTS

The overall prevalence of neurogenic change of the EAS MUP was 62%-52% in the first year after disease onset, increasing to 83% by the fifth year (p<0.05); it also increased with severity of gait disturbance (p<0.05), storage and voiding disorders, and detrusor sphincter dyssynergy (NS). The neurogenic change was not correlated with sex, age, MSA-P/C, postural hypotension, constipation, erectile dysfunction in men, underactive or acontractile detrusor, or detrusor overactivity. In 17 incontinent patients without detrusor overactivity or low compliance, urinary incontinence was more severe in those with neurogenic change than in those without (p<0.05).

CONCLUSIONS

Involvement of Onuf's nucleus in MSA is time dependent. Before the fifth year of illness, the prevalence of neurogenic change does not seem to be high, so a negative result cannot exclude the diagnosis of MSA.

How to diagnose MSA early: the role of sphincter EMG

Multiple system atrophy (MSA) is a degenerative disease manifesting a combination of parkinsonism, cerebellar, pyramidal, and autonomic (including urinary, sexual and anorectal) dysfunction. It is pathomorphologically defined, but lacks a definitive clinical diagnostic test. In patients with probable MSA, abnormal sphincter EMG, as compared to control subjects, has been found in the majority of patients in all the different forms of the disease in most studies, including patients who, as yet, have no urological or anorectal problems. Patients with Parkinson's disease (PD) as a rule do not show marked sphincter EMG abnormalities in the first five years of the disease. Thus, abnormal spontaneous activity or marked motor unit potential changes in sphincter muscles are helpful in distinguishing MSA from PD in the first five years after the onset of symptoms and signs, and from pure autonomic failure, as well as from cerebellar ataxias, if other causes for sphincter denervation have been ruled out. EMG does not distinguish MSA from progressive supranuclear palsy. How early in the course of MSA these abnormalities become significant enough to support diagnosis remains to be established by prospective studies.

Management of multiple system atrophy: state of the art

Multiple system atrophy (MSA) is a sporadic neurodegenerative disease of undetermined aetiology presenting with parkinsonian, autonomic, cerebellar, and pyramidal signs. Despite the lack of any effective therapy to reverse MSA, some of the symptoms may be improved with adequate symptomatic therapies. Medical treatment is largely aimed at mitigating the parkinsonian and autonomic features. The therapeutic results of levodopa therapy in cases of MSA are difficult to interpret because of their variability. Nevertheless, the simple statement that patients with MSA do not respond to levodopa is false. Clinical and pathologically proven series document levodopa efficacy in about 40-60% of patients with MSA and predominant parkinsonian features. Other antiparkinsonian compounds (dopamine agonists, amantadine) may also be employed, but they are not more effective than levodopa. Orthostatic hypotension (OH) can be suspected from the patient s history and subsequently documented in the clinic by measuring lying and standing blood pressure. The diagnosis ideally should be confirmed with additional laboratory tests to determine the cause and evaluate the functional deficit, so as to aid treatment. A number of pharmacological agents with different mechanisms of action have been used in MSA to reduce OH when this is symptomatic. OH can also be alleviated by avoiding aggravating factors, such as the effects of food, micturition, exposure to a warm environment, and physiological diurnal changes, and by using other non-pharmacological strategies. The treatment of the very common genitourinary symptoms (incontinence, retention, impotence) should also be considered in order to improve the quality of life of these patients.

Heredity in multiple system atrophy

We investigated the family histories of 157 Japanese patients with probable or possible multiple system atrophy (MSA). A family history of neurodegenerative disorders was only detected in three MSA patients (1.9%). We evaluated these patients by careful neurological examination, neuroimaging studies, and genetic studies to exclude hereditary spinocerebellar ataxia with a similar clinical phenotype to MSA. The results indicated that one of them had a family history of MSA. Although the familial presence of neurodegenerative disorders is rare in MSA patients, the existence of such cases suggests that MSA may have a genetic background.

Depressive symptoms and life satisfaction in patients with multiple system atrophy

Multiple system atrophy (MSA) is a progressive neurodegenerative disorder characterized by extrapyramidal signs, prominent autonomic failure, and a poor prognosis. In the absence of restorative treatment, management is aimed at improving quality of life. Little is known about modifiable factors, such as depression, that may affect quality of life in MSA. The present study investigated the rate of depressive symptoms and their relationship to life satisfaction in patients with MSA. Ninety-nine patients with MSA (54% women; mean age, 67.8 +/- 8.8) completed measures of depressive symptoms, life satisfaction, physical function, and disease and demographic factors. Objective autonomic indices were abstracted from the medical chart. Participants reported a high rate of depressive symptoms, with 39% endorsing moderate to severe depressive symptoms on the Beck Depression Inventory (BDI > or = 7). Reported life satisfaction was low, with a mean of 38.8 on a 100-point visual analogue scale (0 = Extremely Dissatisfied, 100 = Extremely Satisfied). The SF-36 Physical Component Scale was approximately 1.5 standard deviations below the mean of a normative sample of healthy adults the same age. Regression analysis revealed that autonomic disease parameters accounted for 22% of the variance in life satisfaction. Physical function did not account for any additional variance; however, depressive symptoms accounted for an additional 15%. Depressive symptoms are common, often severe, and an important determinant of life satisfaction in patients with MSA. Adequate treatment of comorbid depression may improve quality of life in this population, despite the presence of other debilitating deficits.

Characteristic signal changes in the pontine base on T2- and multishot diffusion-weighted images in spinocerebellar ataxia type 1

The aim of the present study was to demonstrate characteristic signal changes of the pontine base on T2-weighted images of patients with SCA 1, and to elucidate the relationship between abnormal high-intensities of the pontine base on T2-weighted images and the findings on multishot diffusion-weighted images. We assessed abnormal signals of the pontine base on T2-weighted images from 50 controls and six patients with SCA 1 diagnosed by genetic analysis. At the same time, we evaluated the degeneration of the transverse pontine fibers in the pontine base by multishot diffusion-weighted imaging. A midline high-intensity was seen in the pontine base on T2-weighted images in two of the 50 controls and five of the six patients with SCA 1. The midline high-intensity had a sensitivity of 83.3% for patients and a specificity of 96.0% for controls. Multishot diffusion-weighted imaging demonstrated the degeneration--the amorphous-pattern signal--of the transverse pontine fibers in four (66.7%) of the six patients. In the other two patients, the zebra-pattern signal was seen in the pontine base. The midline high-intensity on T2-weighted images appears to be one of characteristic MRI findings of SCA 1. Multishot diffusion-weighted imaging suggested that the midline high-intensity should reflect the degeneration of the transverse pontine fibers.

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo

CONCLUSION

Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals.

OBJECTIVE

To analyse the video-oculographic findings of positional tests in patients with BPPV.

MATERIAL AND METHODS

Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix-Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days.

RESULTS

Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix-Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.

Segmentale Schweißsekretionsstörung bei Multisystematrophie

There are many different causes of anhidrosis. Sweat glands can be absent, atrophic or blocked; sympathetic innervation may be disturbed, or central nervous system damage may prevent perspiration. We present a patient with multiple system atrophy ( MSA) who presented with unilateral anhidrosis of the trunk. MSA is a sporadic neurodegenerative disorder of adults involving the pyramidal, extrapyramidal, cerebellar and/or autonomic system. The findings in our patient could be explained by a depletion of catecholaminergic sympathetic neurons of the thoracic spinal neurons.

An autopsy case of early ("minimal change") olivopontocerebellar atrophy (multiple system atrophy-cerebellar)

We report a 57-year-old woman with multiple system atrophy (MSA) of 15-month duration. The patient developed dysarthria, followed by impaired balance of gait, mild limb ataxia, and saccadic eye movement. A postmortem examination performed after she was found dead in a bathtub revealed neuronal loss restricted to the olivopontocerebellar system, being more severe in the pontine nucleus. Mild neuronal loss was also found in the anterior vermis and inferior olivary nucleus. Alpha-synuclein immunohistochemistry demonstrated widespread occurrence of glial cytoplasmic inclusions in the central nervous system, which were more numerous in the pontine base and cerebellar white matter. In contrast, neuronal alpha-synuclein accumulation was confined to the pontine and inferior olivary nuclei. The number of neuronal intranuclear inclusions was much higher than that of neuronal cytoplasmic inclusions. Moreover, alpha-synuclein accumulation was more severe in the neurites than in the cytoplasm or nucleus. This case demonstrates the early pattern of brain pathology in MSA-cerebellar (olivopontocerebellar atrophy).

Pallidal stimulation reduces treatment-induced dyskinesias in “minimal-change” multiple system atrophy

Deep brain stimulation therapy is increasingly gaining acceptance in the management of levodopa-induced dyskinesia and fluctuations in idiopathic Parkinson's disease. It is generally not recommended for the other forms of parkinsonism such as progressive supranuclear palsy or multiple system atrophy where the response to levodopa is usually poor and disease progression more rapid, making any benefit short-lived. Here, we present an autopsy-confirmed case of "minimal-change" multiple system atrophy in whom pallidal stimulation surgery was effective in abolishing severe levodopa-induced dyskinesia.

An update on conventional and advanced magnetic resonance imaging techniques in the differential diagnosis of neurodegenerative parkinsonism

PURPOSE OF REVIEW

The clinical differentiation between Parkinson's disease and atypical parkinsonian disorders (APD) remains a challenge for every neurologist. Conventional magnetic resonance imaging (MRI) and different advanced MRI techniques offer the potential for objective criteria in the differential diagnosis of neurodegenerative parkinsonism. The aim of this article is to review the recent literature on the role of conventional and advanced MRI techniques in the differential diagnosis of neurodegenerative parkinsonian disorders.

RECENT FINDINGS

An important role of MRI is the exclusion of symptomatic parkinsonism due to other pathologies. Over the past two decades, conventional MRI and different advanced MRI techniques, including proton magnetic resonance spectroscopy (1H-MRS), diffusion-weighted imaging (DWI), magnetization transfer imaging (MTI) and magnetic resonance volumetry (MRV) have been found to show abnormalities in the substantia nigra and basal ganglia, especially in APD. Recent studies using MRV, MTI, DWI and 1H-MRS to discriminate Parkinson's disease from APD are discussed extensively.

SUMMARY

Research findings suggest that novel MRI techniques such as MTI, DWI and MRV have superior sensitivity compared to conventional MRI in detecting abnormal features in neurodegenerative parkinsonian disorders. Whether these techniques will emerge as standard investigations in the work-up of patients presenting with parkinsonism requires further prospective magnetic resonance studies during early disease stages.

How to diagnose MSA early: the role of magnetic resonance imaging

The clinical differentiation between Parkinson's disease (PD) and multiple system atrophy (MSA) remains a challenge for each neurologist. The use of different magnetic resonance imaging (MRI) techniques including conventional MRI, proton magnetic resonance spectroscopy (MRS), diffusion-weighted imaging (DWI), magnetization transfer imaging (MTI) and MR volumetry (MRV) offer the potential for objective criteria in the differential diagnosis of neurodegenerative parkinsonism. The aim of this article is to review the role of different MRI techniques in the differential diagnosis of PD and MSA.

Voxel based comparison of glucose metabolism in the differential diagnosis of the multiple system atrophy using statistical parametric mapping

OBJECTIVE

A differential diagnosis of idiopathic parkinsonian disease (IPD) and multiple system atrophy (MSA) is difficult due to their common signs and symptoms. The aim of this 18F-2-fluoro-2 deoxyglucose (18F-FDG) positron emission tomography (PET) study was to compare the regional cerebral glucose metabolism in MSA with that in IPD by statistical parametric mapping (SPM) and image registration.

METHODS

The 18F-FDG PET images of MSA and IPD patients were assessed by SPM and image registration to determine metabolic patterns that may be useful in differentiating between the two groups. Eleven patients with MSA, eight patients with IPD and 22 healthy controls participated in the study.

RESULTS

The IPD patients were found to have a significant glucose hypometabolism in comparison with the healthy controls in the prefrontal, lateral frontal, and parietotemporal cortices, and the cingulate and caudate areas (p< or =0.01, 100 voxel-level). In patients with MSA, hypometabolism was observed in the putamen, pons, and cerebellum in comparison with the healthy controls and IPD patients.

CONCLUSION

The voxel-based analysis of 18F-FDG PET images showed detailed differences between IPD and MSA, which may be useful in differentiating the two disease entities, as evidenced by the correlation of glucose metabolism with disease severity and dopamine agonist medication. The mapping analysis of 18F-FDG PET images might be a useful adjunctive method of a differential diagnosis for parkinsonism in a clinical setting.

Comparison of diffusion-weighted imaging and [123I]IBZM-SPECT for the differentiation of patients with the Parkinson variant of multiple system atrophy from those with Parkinson's disease

Both dopamine D2 receptor (D2R) binding single-photon emission computed tomography (SPECT) with [123I]iodobenzamide (IBZM) and diffusion-weighted imaging (DWI) have been shown to contribute to the differential diagnosis of patients with the Parkinson variant of multiple system atrophy (MSA-P) and Parkinson's disease (PD). We aimed to compare these two routinely available functional imaging modalities in differentiating patients with MSA-P from PD. For this purpose, results obtained by DWI and IBZM-SPECT were intraindividually compared in a cross-sectional study of 15 MSA-P and 17 PD patients matched for age and disease duration. The activity ratios of striatal to frontal cortex uptake (S/FC ratio) were used as a semiquantitative measure of the relative density of basal ganglia dopamine receptors labeled by IBZM. Regional apparent diffusion coefficients (rADC) were determined in the striatum. MSA-P patients had significantly lower S/FC ratios and significantly higher striatal rADCs than both PD patients and healthy volunteers. There were no significant differences in S/FC ratios and striatal rADC between PD patients and healthy volunteers. Sensitivity of IBZM-SPECT versus DWI for the differentiation of MSA-P from PD was 80% versus 93%, specificity 71% versus 100%, the predictive accuracy 75% versus 97%, the positive predictive value 71% versus 100%, and the negative predictive value 80% versus 94%. Striatal rADCs had a significant higher overall predictive accuracy than D2R binding with IBZM. In summary, our data suggest that DWI may be more accurate compared to IBZM-SPECT in the differential diagnosis of MSA-P versus PD.

Growth hormone response to arginine test distinguishes multiple system atrophy from Parkinson's disease and idiopathic late-onset cerebellar ataxia

OBJECTIVE

Multiple system atrophy (MSA) is difficult to distinguish from idiopathic Parkinson's disease (PD) and idiopathic late-onset cerebellar ataxia (ILOCA). This study aimed to evaluate GH response to three different GH stimulation tests in order to establish a reliable test to differentiate these degenerative disorders.

DESIGN

Twelve patients with MSA, 10 with PD, eight with ILOCA and 30 healthy controls entered the study. They were submitted to clonidine, arginine, and GH-releasing-hormone (GHRH) + arginine tests in a random manner on three different nonconsecutive days. The peak serum GH response was used as a primary variable for analysis of stimulation tests. By ROC analysis, the optimum cut-off level was considered as the cut-off with the maximal sum of sensitivity and specificity.

RESULTS

After clonidine administration, GH peak was significantly lower in patients with MSA than in those with ILOCA (P < 0.05) and in the controls (P < 0.001). At the optimum cut-off level of 5 mU/l, the clonidine test distinguished patients with MSA from those with PD with a sensitivity and specificity of 78%. Moreover, this test distinguished patients with MSA from those with ILOCA with a sensitivity of 100% and a specificity of 75% at a cut-off level of 5 mU/l, and with a sensitivity of 75% and a specificity of 100% at the cut-off level of 7.6 mU/l. After arginine administration, the GH peak was significantly lower in patients with MSA than in those with ILOCA (P = 0.001) and in controls (P < 0.001). At the optimum cut-off level of 5 mU/l, the arginine test distinguished patients with MSA from those with PD with a sensitivity and a specificity of 100%. At a GH peak cut-off value of 3.6 mU/l the arginine test distinguished patients with MSA from those with ILOCA with a sensitivity and specificity of 100%. After GHRH + arginine administration, a significant GH increase was found in all groups of patients and controls.

CONCLUSIONS

The GH response to arginine administration is impaired in MSA. Therefore, the arginine test showed the highest diagnostic accuracy to distinguish MSA from both PD and ILOCA, and could be used in the clinical practice of these neurodegenerative diseases.

Heterogeneity of Parkinson's disease in the early clinical stages using a data driven approach

OBJECTIVE

To investigate the heterogeneity of idiopathic Parkinson's disease (PD) in a data driven manner among a cohort of patients in the early clinical stages of the disease meeting established diagnostic criteria.

METHODS

Data on demographic, motor, mood, and cognitive measures were collected from 120 consecutive patients in the early stages of PD (Hoehn and Yahr I-III) attending a specialist PD research clinic. Statistical cluster analysis of the data allowed the existence of the patient subgroups generated to be explored.

RESULTS

The analysis revealed four main subgroups: (a) patients with a younger disease onset; (b) a tremor dominant subgroup of patients; (c) a non-tremor dominant subgroup with significant levels of cognitive impairment and mild depression; and (d) a subgroup with rapid disease progression but no cognitive impairment.

CONCLUSIONS

This study complements and extends previous research by using a data driven approach to define the clinical heterogeneity of early PD. The approach adopted in this study for the identification of subgroups of patients within Parkinson's disease has important implications for generating testable hypotheses on defining the heterogeneity of this common condition and its aetiopathological basis and thus its treatment.

Swallowing function in patients with multiple-system atrophy with a clinical predominance of cerebellar symptoms (MSA-C)

We investigated the swallowing function of 21 patients with multiple system atrophy with a clinical predominance of cerebellar symptoms (MSA-C) by videofluoroscopy (VF). Twenty-six VF examinations were performed at various time points, and they were divided into three groups according to the duration following disease onset: Group A had 1 to 3 years following disease onset (the early stage of the disease), group B had 4 to 6 years following disease onset (the middle stage of the disease), and group C had more than 7 years following disease onset (the late stage of the disease). Swallowing function in the oral phase became gradually disturbed over the progression of MSA. Delayed bolus transport from the oral cavity to the pharynx was already seen in 50% of the patients in group A, and it was seen in more than 85% of the patients in group C. Bolus holding in the oral cavity was slightly disturbed in group A, but it was seen in 57% of the patients in group C. Our study shows that parkinsonism is related to swallowing dysfunction in MSA, but cerebellar dysfunction also affects coordination of the tongue; bolus transport in the oral cavity was disturbed in the early stage of disease. Progression of cerebellar dysfunction and overlapped parkinsonism will worsen tongue movement, and in the late stage of the disease, swallowing function of the oral phase (bolus transport and bolus holding) was remarkably disturbed. Swallowing function in the pharyngeal phase was not significantly correlated to the duration of the disease; however, our study showed that swallowing function in the pharyngeal phase was not assessed fully by VF examination in MSA-C only. Combination with other examinations, such as manometry and electromyography, may be useful, especially in the late stage of the disease. In addition, an analysis concerning the relationship between aspiration seen on VF examination and a history of aspiration pneumonia in MSA-C patients suggested that the sensory system at the larynx and trachea should also be assessed in patients in the late stage of MSA-C.

Sensorimotor integration in patients with parkinsonian type multisystem atrophy

Sensorimotor integration is an essential feature of the central nervous system that contributes to the accurate performance of motor tasks. Some patients with multiple system atrophy with parkinsonian features (MSAp) exhibit clinical signs compatible with an abnormal central nervous system excitability to somatosensory inputs, such as action myoclonus or enhanced cutaneo-muscular reflexes. To investigate further the site where such dysfunction in sensorimotor integration takes place, we examined the inhibitory effects of a cutaneous afferent volley at two different levels of the motor system in 10 MSAp patients and in 10 age-matched healthy volunteers. Electrical digital nerve stimuli were given as the conditioning stimulus for the motor evoked potentials (MEP) elicited by transcranial magnetic stimulation in hand muscles, and for the blink reflex responses obtained in the orbicularis oculi muscles by supraorbital nerve stimulation. Intervals for the conditioning were 20 to 50 ms for the MEP and 90 to 110 ms for the blink reflex. The MEP was significantly inhibited in test trials in healthy volunteers, reaching a mean of 32% of the baseline values at the ISI of 35 ms. Significant inhibition occurred also in the blink reflex, in which the R2 response was a mean of 12% of baseline values at the ISI of 100 ms. The inhibitory effects were abnormally reduced in 8 patients on the MEP, and in 7 patients on the blink reflex. There were significant group differences between patients and control subjects in the size of the conditioned MEP and blink reflex. These results suggest that sensorimotor integration is abnormal in patients with MSAp in at least two central nervous system sites: the sensorimotor cortex, and the brainstem reticular formation.

Occupational therapy in multiple system atrophy: a pilot randomized controlled trial

There is some evidence that rehabilitation therapies may be useful in progressive neurological conditions, but this usefulness has not been studied in multiple system atrophy (MSA) to date. The aim of this small pilot study was to identify the feasibility of a larger randomized controlled trial of occupational therapy and to report preliminary data on the impact of occupational therapy on disability, mood, and health-related quality of life in patients with MSA. Patient groups were comparable for age, gender distribution, type of MSA, and severity. The active occupational therapy intervention group experienced a significant reduction of Unified Parkinson's Disease Rating Scale (total score and Activities of Daily Living [ADL] section), and PDQ-39 scores (total scores and ADL subsection). An occupational therapy program may improve functional abilities in patients with mild to moderate MSA. A larger multicenter study is needed.

Sonographic assessment of urinary retention in multiple system atrophy and idiopathic Parkinson's disease

Sonography of the bladder was performed before and after voluntary voiding in 20 subjects with possible/probable multiple system atrophy (MSA), 20 patients with idiopathic Parkinson's disease (PD), and 20 healthy controls. Mean residual volume was 173 ml (SD, 194) in MSA and significantly increased compared to both PD (21 ml; SD, 49) and controls (13 ml; SD, 12). Incomplete voiding (>100 ml of residual volume) was found in 11 subjects with MSA but only in 1 patient with PD. Positive predictive value of increased residual volume for MSA was 91.6% in this study, whereas negative predictive value was only 67.8. Bladder sonography is an objective, simple, and safe tool that allows one to screen for urinary retention, which is highly suggestive but incompletely sensitive for MSA. Because sonography is easily accessible and rapidly performed, it is feasible for routine assessment of atypical Parkinsonism.

Sleep apnea syndrome in Parkinson's disease. A case-control study in 49 patients

In PD, the impact of nocturnal respiration on sleep continuity and architecture has not been systematically investigated by polysomnography (PSG). We performed a case-control study with retrospective analysis of PSG data of 49 PD patients. After classifying the PD patients according to their apnea/hypopnea index (AHI), they were matched with 49 controls in terms of age, gender, and AHI. There were 21 PD patients (43%) who had sleep apnea syndrome (SAS), classified as mild (AHI, 5-15) in 10 patients, moderate (AHI, >15-30) in 4 patients, and severe (AHI, > 30) in 7 patients. PD patients had more deep sleep (P = 0.02) and more nocturnal awakenings (P < 0.001) than the controls. Their body mass index (BMI) was lower (P = 0.04), and they maintained a more favorable respiratory profile, with higher mean and minimal oxygen saturation values (P = 0.006 and 0.01, respectively). These differences were preserved when only considering PD patients with AHI > 15. PD patients had less obstructive sleep apneas (P = 0.035), independently from the factor AHI. Only the respiratory changes of 4 PD patients with BMI > 27 and AHI > 15 (8%) approximated those seen in the controls. At an early or middle stage of the disease, non-obese PD patients frequently have AHI values suggesting SAS, however, without the oxygen desaturation profile of SAS. Longitudinal studies of patients with such "abortive" SAS are warranted to establish if this finding reflects benign nocturnal respiratory muscle dyskinesia or constitutes a precursor sign of dysautonomia in PD.

Myoclonic tremulous movements in multiple system atrophy are a form of cortical myoclonus

We prospectively studied the clinical and electrophysiological features of myoclonic tremulous movements in patients with multiple system atrophy (MSA). Among 42 consecutive patients, 12 MSA-p (parkinsonian type) and 3 MSA-c (cerebellar type) patients showed small-amplitude myoclonic movements. These movements occurred in the distal part of the arms and fingers, particularly in posture or during voluntary movements. We conducted detailed electrophysiological studies in 11 patients. Electromyographic recordings showed irregular bursts of brief duration often synchronously involving the antagonistic muscles. Somatosensory evoked responses were slightly enlarged in some patients. Long-latency reflexes were enhanced in 7 patients. A jerk-locked averaging technique revealed premyoclonic cortical potentials in 9 patients. These findings suggest that small-amplitude myoclonic movements in MSA are a form of cortical myoclonus.

Therapeutic strategies in multiple system atrophy

This review provides an update on therapeutic principles and their implications for practical management in multiple system atrophy (MSA), a sporadic neurodegenerative disorder characterized clinically by various combinations of dysautonomia, Parkinsonism, or cerebellar ataxia, often associated with other warning features (red flags), and pathologically by cell loss, gliosis, and glial cytoplasmic inclusions in selected multiple regions of the brain and spinal cord. Because of the small number of randomized controlled trials, the management of MSA is largely based on empirical or open-label evidence. Parkinsonism often shows a poor or unsustained response to chronic levodopa therapy, although more patients than previously recognized may experience an initial moderate-to-good dopaminergic response. There is no effective drug treatment for cerebellar ataxia. However, features of dysautonomia such as orthostatic hypotension, urinary retention or incontinence, constipation, and impotence, may often be relieved if recognized by the treating physician. Because no drug treatment consistently benefits patients with this disease in the long-term, palliative therapies are all the more important. Novel symptomatic and neuroprotective therapies are urgently required.

How to diagnose multiple system atrophy

The diagnosis of multiple system atrophy (MSA) in life remains entirely clinical. Consensus diagnostic criteria have been developed, but their use does not particularly render a diagnosis of MSA more accurate than are clinicians' diagnoses. Some patients may not fulfill the stipulated core diagnostic criteria, yet display many so-called red flags pointing toward MSA. The additional usefulness of these red flags and of a variety of investigations currently is being investigated, with a view to some of them being incorporated in future sets of diagnostic criteria.

Progression of parkinsonism in multiple system atrophy

BACKGROUND

Progression of parkinsonian motor impairment is usually rapid and relentless in multiple system atrophy (MSA). However, it may also be subject to considerable variation. Prospective natural history studies using validated rating scales are required to accurately determine the progression of parkinsonism in MSA.

OBJECTIVE

To assess the progression of parkinsonism in patients with the Parkinson variant of MSA.

METHODS

Parkinsonian motor impairment was assessed on regular therapy at two time points (mean follow-up 11.8 months, SD 1.4) using the Hoehn and Yahr scale (H&Y), the Schwab and England ADL scale (SES) and the motor examination section of the UPDRS (UPDRS-III) in 38 patients with clinically probable MSA-P.

RESULTS

We examined 38 patients with probable MSA-P (mean age 63.2 years, SD 7.4; mean disease duration 4.1 years, SD 3.0). The mean difference of UPDRS-III between baseline and follow-up was 10.8 (95% CI 8.6-12.9), consistent with an average annual 28.3 % increase of UPDRS-III baseline scores. Several variables were associated with faster progression of parkinsonism including low baseline global motor disability as assessed by H&Y and SES, low baseline UPDRS-III score, and short disease duration. UPDRS-III progression was unrelated to gender, age at symptom onset, and age at baseline visit.

CONCLUSION

This is the first observational study on UPDRS rates of decline in MSA. The observed 28.6% annual increase of UPDRS-III scores illustrates the rapid progression of motor impairment in MSA. Furthermore, motor progression appeared to be accelerated during the early disease stages. Our data allow sample size calculations that may be helpful for the planning of future therapeutic trials.

Reduced cerebellar vermis activation during urinary storage and micturition in multiple system atrophy: 99mTc-labelled ECD SPECT study

Single-photon emission computed tomography brain imaging with special reference of bladder function was performed in eight multiple system atrophy (MSA) patients (two men, six women; mean age, 61 years) and age-matched five normal control subjects (three men, two women; 62 years). In both groups imagings were obtained in three conditions; empty bladder, storage, and micturition. [99mTc]-labelled ECD (555 MBq) was intravenously injected, which was immediately trapped and stabilized within the brain. Using NEUROSTAT software, which could also cancel morphologic differences between MSA and canonical brain, statistical difference between normalized mean tracer counts of both groups in each phase was calculated and visualized. In the storage phase, there was a significant decrease in tracer activity in bilateral cerebellar vermis, particularly of the right side in the MSA group (P < 0.05), which is also known to be involved in the neural control of micturition. In the micturition phase, the area of decrease in tracer activity in the cerebellar vermis became wider in the MSA group. In the resting state, no statistically significance was seen between both groups. In conclusion, it is suggested that the decrease in tracer activity in the cerebellar vermis during urinary storage and micturition is contributing to the micturitional disturbance in this disorder.

The neuropsychiatry of Parkinson's disease and related disorders

Parkinson's disease is associated with classical Parkinsonian features that respond to dopaminergic therapy. Neuropsychiatric sequelae include dementia, major depression, dysthymia, anxiety disorders, sleep disorders, and sexual disorders. Panic attacks are particularly common. With treatment, visual hallucinations, paranoid delusions, mania, or delirium may evolve. Psychosis is a key factor in nursing home placement, and depression is the most significant predictor of quality of life. Clozapine may be the safest treatment for psychotic features, but more research is needed to establish the efficacy of antidepressant treatments. Dementia with Lewy bodies, the second most common dementia in the elderly, may present in association with systematized delusions, depression, or RBD. Early evidence suggests the utility of rivastigmine, donepezil, low-dose olanzapine, and quetiapine in treating DLB. Parkinson-plus syndromes generally lack a good response to dopaminergic treatment and evidence additional features, including dysautonomia, cerebellar and pontine features, eye signs, and other movement disorders. MSA is associated with dysautonomia and RBD. SND (MSA-P) is associated with frontal cognitive impairments, but dementia, psychosis, and mood disorders have not been strikingly apparent unless additional pathological findings are present. In SDS (MSA-A), impotence is almost ubiquitous; urinary incontinence is frequent; depression is occasional, and sleep apnea should be treated to avoid sudden death during sleep. OPCA neuropsychiatric correlates await further definition. Progressive supranuclear palsy neuropsychiatric features include apathy, subcortical dementia, pathological emotionality, mild depression and anxiety, and lack of appreciable response to donepezil. CBD usually is recognized by early frontal dementia with ideomotor apraxia, often in the right upper extremity, attended later by poorly responsive unilateral Parkinsonism, with additional signs including cortical reflex myoclonus, limb dystonia, alien limb, oculomotor apraxia when asked to look horizontally, depression, personality changes, and, occasionally, Kluver-Bucy syndrome. The neuropsychiatry of FTDP-17 involves apraxia, executive impairment, personality changes, hyperorality, and occasional psychosis. Future research in these Parkinsonian disorders should target the characterization of neuropsychiatric sequelae and their treatment.

Myoclonus: current concepts and recent advances

Myoclonus presents as a sudden brief jerk caused by involuntary muscle activity. An organisational framework is crucial for determining the medical significance of the myoclonus as well as for its treatment. Clinical presentations of myoclonus are divided into physiological, essential, epileptic, and symptomatic. Most causes of myoclonus are symptomatic and include posthypoxia, toxic-metabolic disorders, reactions to drugs, storage disease, and neurodegenerative disorders. The assessment of myoclonus includes an initial screening for those causes that are common or easily corrected. If needed, further testing may include clinical neurophysiological techniques, enzyme activities, tissue biopsy, and genetic testing. The motor cortex is the most commonly shown myoclonus source, but origins from subcortical areas, brainstem, spinal, and peripheral nervous system also occur. If treatment of the underlying disorder is not possible, treatment of symptoms is worthwhile, although limited by side-effects and a lack of controlled evidence.

Cerebrospinal fluid analysis differentiates multiple system atrophy from Parkinson's disease

We investigated whether cerebrospinal fluid (CSF) analysis discriminates between idiopathic Parkinson's disease (PD; n = 35) and multiple system atrophy (MSA; n = 30). The median CSF concentration of the neurotransmitter metabolites 5-hydroxyindolacetic acid (5-HIAA) and 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) was reduced significantly (49-70%) in MSA compared to PD. In contrast, several brain-specific proteins (tau, neuron-specific enolase, myelin basic protein) were elevated (130-230%) in MSA compared with those in PD. A combination of CSF tau and MHPG discriminated PD from MSA (adjusted odds ratios: tau, 27.2; MHPG, 0.14). Our data suggest that the more progressive and widespread neurodegenerative nature of MSA, as compared with PD, is reflected in the composition of CSF. We propose that CSF analysis may become part of the diagnostic work-up of patients with parkinsonian syndromes.

Effects of pulsatile L-DOPA treatment in the double lesion rat model of striatonigral degeneration (multiple system atrophy)

We examined the role of a striatal lesion in the development of L-DOPA-induced abnormal involuntary movements (AIMs) using the double lesion rat model of striatonigral degeneration (SND), the underlying neuropathological substrate of parkinsonism associated with multiple system atrophy (MSA-P), in comparison to a Parkinson's disease (PD) rat model. L-DOPA administration reliably induced AIMs in SND and PD rats in a dose-dependent fashion. AIMs occurred significantly earlier in SND compared to PD rats. There was a mild, but significant, transient increase of orolingual AIMs during the first week of low-dose L-DOPA treatment in SND. Whereas L-DOPA significantly improved contralateral forelimb akinesia in PD rats, there was no beneficial effect in SND rats. Striatal FosB/Delta FosB up-regulation in SND and PD rats correlated with the severity of L-DOPA-induced dyskinesias. Pulsatile L-DOPA administration in the double lesion SND rat model replicates salient features of the human disease MSA-P, including loss of the anti-akinetic L-DOPA response and induction of dyskinesias with transient orolingual predominance.