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The applause sign in frontotemporal lobar degeneration and related conditions. J Neurol 2018; 266:330-338. [PMID: 30506397 DOI: 10.1007/s00415-018-9134-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 11/09/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
Abstract
The applause sign, i.e., the inability to execute the same amount of claps as performed by the examiner, was originally reported as a sign specific for progressive supranuclear palsy (PSP). Recent research, however, has provided evidence for the occurrence of the applause sign in various conditions. The aim of this study was to determine the prevalence of the applause sign and correlate its presence with neuropsychological and MRI volumetry findings in frontotemporal lobar degeneration and related conditions. The applause sign was elicited with the three clap test (TCT), with a higher score indicating poorer performance. Data were recorded from 272 patients from the cohort of the German consortium for frontotemporal lobar degeneration (FTLDc): 111 with behavioral variant frontotemporal dementia (bvFTD), 98 with primary progressive aphasia (PPA), 30 with progressive supranuclear palsy Richardson's syndrome, 17 with corticobasal syndrome (CBS) and 16 with amyotrophic lateral sclerosis with frontotemporal dementia (ALS/FTD). For comparison, 29 healthy elderly control subjects (HC) were enrolled in the study. All subjects underwent detailed language and neuropsychological assessment. In a subset of 156 subjects, atlas-based volumetry was performed. The applause sign occurred in all patient groups (40% in PSP, 29.5% in CBS, 25% in ALS/FTD, 13.3% in PPA and 9.0% in bvFTD) but not in healthy controls. The prevalence was highest in PSP patients. It was significantly more common in PSP as compared to bvFTD, PPA and HC. The comparison between the other groups failed to show a significant difference regarding the occurrence of the applause sign. The applause sign was highly correlated to a number of neuropsychological findings, especially to measures of executive, visuospatial, and language function as well as measures of disease severity. TCT scores showed an inverse correlation with the volume of the ventral diencephalon and the pallidum. Furthermore the volume of the ventral diencephalon and pallidum were significantly smaller in patients displaying the applause sign. Our study confirms the occurrence of the applause sign in bvFTD, PSP and CBS and adds PPA and ALS/FTD to these conditions. Although still suggestive of PSP, clinically it must be interpreted with caution. From the correlation with various cognitive measures we suggest the applause sign to be indicative of disease severity. Furthermore we suggest that the applause sign represents dysfunction of the pallidum and the subthalamic nucleus, structures which are known to play important roles in response inhibition.
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Schönecker S, Neuhofer C, Otto M, Ludolph A, Kassubek J, Landwehrmeyer B, Anderl-Straub S, Semler E, Diehl-Schmid J, Prix C, Vollmar C, Fortea J, Huppertz HJ, Arzberger T, Edbauer D, Feddersen B, Dieterich M, Schroeter ML, Volk AE, Fließbach K, Schneider A, Kornhuber J, Maler M, Prudlo J, Jahn H, Boeckh-Behrens T, Danek A, Klopstock T, Levin J. Atrophy in the Thalamus But Not Cerebellum Is Specific for C9orf72 FTD and ALS Patients - An Atlas-Based Volumetric MRI Study. Front Aging Neurosci 2018; 10:45. [PMID: 29599716 PMCID: PMC5863593 DOI: 10.3389/fnagi.2018.00045] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 02/12/2018] [Indexed: 11/13/2022] Open
Abstract
Background: The neuropathology of patients with frontotemporal dementia (FTD) or amyotrophic lateral sclerosis (ALS) due to a C9orf72 mutation is characterized by two distinct types of characteristic protein depositions containing either TDP-43 or so-called dipeptide repeat proteins that extend beyond frontal and temporal regions. Thalamus and cerebellum seem to be preferentially affected by the dipeptide repeat pathology unique to C9orf72 mutation carriers. Objective: This study aimed to determine if mutation carriers showed an enhanced degree of thalamic and cerebellar atrophy compared to sporadic patients or healthy controls. Methods: Atlas-based volumetry was performed in 13 affected C9orf72 FTD, ALS and FTD/ALS patients, 45 sporadic FTD and FTD/ALS patients and 19 healthy controls. Volumes and laterality indices showing significant differences between mutation carriers and sporadic patients were subjected to binary logistic regression to determine the best predictor of mutation carrier status. Results: Compared to sporadic patients, mutation carriers showed a significant volume reduction of the thalamus, which was most striking in the occipital, temporal and prefrontal subregion of the thalamus. Disease severity measured by mini mental status examination (MMSE) and FTD modified Clinical Dementia Rating Scale Sum of Boxes (FTD-CDR-SOB) significantly correlated with volume reduction in the aforementioned thalamic subregions. No significant atrophy of cerebellar regions could be detected. A logistic regression model using the volume of the prefrontal and the laterality index of the occipital subregion of the thalamus as predictor variables resulted in an area under the curve (AUC) of 0.88 while a model using overall thalamic volume still resulted in an AUC of 0.82. Conclusion: Our data show that thalamic atrophy in C9orf72 mutation carriers goes beyond the expected atrophy in the prefrontal and temporal subregion and is in good agreement with the cortical atrophy pattern described in C9orf72 mutation carriers, indicating a retrograde degeneration of functionally connected regions. Clinical relevance of the detected thalamic atrophy is illustrated by a correlation with disease severity. Furthermore, the findings suggest MRI volumetry of the thalamus to be of high predictive value in differentiating C9orf72 mutation carriers from patients with sporadic FTD.
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Affiliation(s)
- Sonja Schönecker
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany
| | - Christiane Neuhofer
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany
| | - Markus Otto
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Albert Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Jan Kassubek
- Department of Neurology, University of Ulm, Ulm, Germany
| | | | | | - Elisa Semler
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Janine Diehl-Schmid
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Munich, Germany
| | - Catharina Prix
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany
| | - Christian Vollmar
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany
| | - Juan Fortea
- Hospital San Pau Barcelona, Barcelona, Spain
| | | | | | - Thomas Arzberger
- Center for Neuropathology and Prion Research, Ludwig Maximilians Universität München, Munich, Germany
| | - Dieter Edbauer
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Institute for Metabolic Biochemistry, Ludwig Maximilians Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Berend Feddersen
- Department of Palliative Medicine, Ludwig Maximilians Universität München, Munich, Germany
| | - Marianne Dieterich
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Matthias L Schroeter
- Max Planck Institute for Human Cognitive and Brain Sciences (MPG), Leipzig, Germany.,Clinic for Cognitive Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Alexander E Volk
- Institute of Human Genetics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Fließbach
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany
| | - Anja Schneider
- German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Department for Neurodegenerative Diseases and Geriatric Psychiatry, University Hospital Bonn, Bonn, Germany
| | - Johannes Kornhuber
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Manuel Maler
- Department of Psychiatry and Psychotherapy, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Prudlo
- Department of Neurology, Rostock University Medical Center, Rostock, Germany.,German Center for Neurodegenerative Diseases (DZNE), Rostock, Germany
| | - Holger Jahn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,AMEOS Klinikum Heiligenhafen, Heiligenhafen, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| | - Adrian Danek
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany
| | - Thomas Klopstock
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,Friedrich Baur Institute at the Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany
| | - Johannes Levin
- Department of Neurology, Ludwig Maximilians Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
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Additive value of amyloid-PET in routine cases of clinical dementia work-up after FDG-PET. Eur J Nucl Med Mol Imaging 2017; 44:2239-2248. [PMID: 28932894 DOI: 10.1007/s00259-017-3832-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE In recent years, several [18F]-labeled amyloid-PET tracers have been developed and have obtained clinical approval. Despite their widespread scientific use, studies in routine clinical settings are limited. We therefore investigated the impact of [18F]-florbetaben (FBB)-PET on the diagnostic management of patients with suspected dementia that was still unclarified after [18F]-fluordeoxyglucose (FDG)-PET. METHODS All subjects were referred in-house with a suspected dementia syndrome due to neurodegenerative disease. After undergoing an FDG-PET exam, the cases were discussed by the interdisciplinary dementia board, where the most likely diagnosis as well as potential differential diagnoses were documented. Because of persistent diagnostic uncertainty, the patients received an additional FBB-PET exam. Results were interpreted visually and classified as amyloid-positive or amyloid-negative, and we then compared the individual clinical diagnoses before and after additional FBB-PET. RESULTS A total of 107 patients (mean age 69.4 ± 9.7y) were included in the study. The FBB-PET was rated as amyloid-positive in 65/107. In 83% of the formerly unclear cases, a final diagnosis was reached through FBB-PET, and the most likely prior diagnosis was changed in 28% of cases. The highest impact was observed for distinguishing Alzheimer's dementia (AD) from fronto-temporal dementia (FTLD), where FBB-PET altered the most likely diagnosis in 41% of cases. CONCLUSIONS FBB-PET has a high additive value in establishing a final diagnosis in suspected dementia cases when prior investigations such as FDG-PET are inconclusive. The differentiation between AD and FTLD was particularly facilitated by amyloid-PET, predicting a considerable impact on patient management, especially in the light of upcoming disease-modifying therapies.
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