Atormac
brintellex
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 2165  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (897 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusion
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed4534    
    Printed69    
    Emailed0    
    PDF Downloaded208    
    Comments [Add]    
    Cited by others 5    

Recommend this journal

 


 
Table of Contents    
ORIGINAL ARTICLE
Year : 2016  |  Volume : 64  |  Issue : 2  |  Page : 239-245

Diagnostic accuracy of Magnetic Resonance Parkinsonism Index in differentiating progressive supranuclear palsy from Parkinson's disease and controls in Indian patients


1 Department of Neurology, PD Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
2 Department of Neurology and Radiology, PD Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India
3 Department of Radiology, PD Hinduja National Hospital and Medical Research Center, Mumbai, Maharashtra, India

Date of Web Publication3-Mar-2016

Correspondence Address:
Charulata Savant Sankhla
Department of Neurology, PD Hinduja National Hospital and Medical Research Center, Veer Savarkar Marg, Mumbai - 400 016, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.177611

Rights and Permissions

 » Abstract 

Aims and Objectives: An assessment of the sensitivity and specificity of magnetic resonance (MR) imaging measurements of midbrain, pons, middle cerebellar peduncles (MCPs), and superior cerebellar peduncles (SCPs) and MR Parkinsonism Index (MRPI) in differentiating progressive supranuclear palsy (PSP) from Parkinson's disease (PD) and controls was performed. The correlation of these MR imaging measurements with the duration and severity of disease in the Indian patients using the PSP rating scale (PSPRS) was also performed.
Materials and Methods: Twenty-six consecutive patients were enrolled in this study, satisfying the diagnostic criteria by the National Institute for Neurological Disorders and Stroke, and the Society for PSP (NINDS-SPSP), along with 13 PD and 30 control patients. All PSP patients were assessed using the PSP rating scale and staging system. Radiologists were blinded to the clinical diagnoses. MRPI was calculated by multiplying the pons area/midbrain area ratio by MCP width/SCP width ratio. The midbrain/pons area (M/P) ratio was measured as the ratio of midbrain area to pons area.
Results: Mean MRPI in PSP patients (23.48 ± 9.61) was significantly higher than that in PD patients (9.07 ± 2.23) and controls (9.45 ± 1.87). In this study, MRPI was 100% sensitive, specific, and accurate in differentiating PSP from PD and was 96.3% sensitive, 100% specific, and 98.21% accurate in differentiating PSP from controls. No correlation was found between the duration of disease, PSP rating scale, PSP staging system, and MRPI in the present study. MRPI was only marginally superior to the M/P ratio in differentiating between PSP and PD patients on an individual basis. No overlapping values were observed in the PSP and PD patients.
Conclusion: Magnetic Resonance Parkinsonism Index is more sensitive, specific, and accurate in differentiating PSP from PD in the early stages on an individual basis.


Keywords: Magnetic resonance imaging; Magnetic Resonance Parkinsonism Index; progressive supranuclear palsy


How to cite this article:
Sankhla CS, Patil KB, Sawant N, Gupta S. Diagnostic accuracy of Magnetic Resonance Parkinsonism Index in differentiating progressive supranuclear palsy from Parkinson's disease and controls in Indian patients. Neurol India 2016;64:239-45

How to cite this URL:
Sankhla CS, Patil KB, Sawant N, Gupta S. Diagnostic accuracy of Magnetic Resonance Parkinsonism Index in differentiating progressive supranuclear palsy from Parkinson's disease and controls in Indian patients. Neurol India [serial online] 2016 [cited 2020 Nov 28];64:239-45. Available from: https://www.neurologyindia.com/text.asp?2016/64/2/239/177611



 » Introduction Top


Progressive supranuclear palsy is a neurodegenerative disorder characterized by postural instability with falls, supranuclear vertical gaze abnormalities with Parkinsonian features, and frontal cognitive disturbances. Symmetric onset, near absence of rest tremors, predominant axial involvement, and poor response to levodopa help in differentiating progressive supranuclear palsy (PSP) from Parkinson's disease (PD). The clinical differentiation between PSP and PD is difficult in the early stages. The management and prognosis of PSP differs significantly from PD, making it essential to make an early distinction between PSP and PD. The clinical diagnostic criteria developed during a workshop at the National Institute for Neurological Disorders and Stroke, and the Society for PSP (NINDS-SPSP) in 1996 has been the most widely accepted and validated methodology for differentiating between the two entities and includes “probable” clinical criteria with a high specificity necessary for a treatment trial, “possible” criteria sufficiently sensitive for use in a prevalence study, and “definite” criteria with histopathologic confirmation.[1]

Golbe and Ohman-Strickland proposed a clinical rating scale for PSP (the PSP rating scale [PSPRS]) to assess the disease severity. This scale also helps to predict survival. Studies have shown an association of the total score and the subscores of the PSP rating scale with structural damage of brain in PSP. The PSPRS is not a diagnostic tool, but a quantitative measure of disability. It includes all the important areas of clinical impairment in PSP.[2] The score on this scale increases at the rate of approximately 9 points per year in patients with probable PSP.[3]

Despite using the standard clinical criteria, a number of PSP patients are diagnosed at postmortem examination. Newer clinical phenotypes like PSP-Parkinsonism (PSP-P), characterized by asymmetric onset, early bradykinesia, tremors, late-onset falls, absent/late-onset eye abnormalities, and a good response to levodopa, do not satisfy the current clinical diagnostic criteria of PSP. In the the early stages, PSP-P may be difficult to distinguish from PD. Patients with PSP-P develop features of PSP in the late stages. Also, PSP still remains underdiagnosed due to lack of awareness and of diagnostic skills in most general physicians.

The routine magnetic resonance imaging (MRI) of the brain stem structures show midbrain and superior cerebellar peduncle (SCP) atrophy in PSP patients. These single measurements of brain stem structures fail to differentiate between PSP, PD and multiple system atrophy-P (MSA-P). The midbrain/pons (M/P) ratio was significantly smaller in PSP than in PD, MSA-P, or control patients. However M/P ratio failed to distinguish between PSP and PD on an individual basis. Magnetic Resonance Parkinsonism Index (MRPI), calculated by multiplying the pons-to-midbrain area ratio (P/M) to the middle cerebellar peduncle (MCP)-to-SCP width ratio, was introduced to circumvent this issue and has shown a high sensitivity, specificity, and diagnostic accuracy in differentiating PSP from other groups.[4] Other diagnostic modalities that help in diagnosing PSP are the cerebrospinal fluid (CSF) studies. The CSF neurofilament content is significantly higher in PSP and MSA-P, reflecting the degree of ongoing neuronal degeneration affecting mainly the axonal compartment.[5] The CSF levels of total tau protein in PSP were similar to those in controls.[6] The patterns of proteolytic tau fragments in CSF in PSP were different from that seen in other neurodegenerative conditions like frontotemporal dementia, corticobasal degeneration, and PD.[7] These are possible biomarkers for an early diagnosis of PSP, but are not accessible to an average physician.

The MRI findings in PSP are often absent in the early stages of the disease. The common MRI findings in PSP are midbrain atrophy particularly the dorsal portion, with enlargement of the third ventricle,[8] tegmental atrophy and hyperintense signal change in the periaqueductal gray matter [9] indicative of gliosis, superior cerebellar peduncle atrophy,[10] and frontal and temporal atrophy.[11] The other described MRI signs of PSP patients are the hummingbird sign, giant penguin appearance,[12],[13],[14] morning glory sign, and Mickey Mouse appearance,[9],[11],[15] reduced area of the midbrain on midline sagittal images, and reduced M/P ratio [approximately 0.12 (normal, approximately 0.24] on the midline sagittal image.[16] The accuracy of conventional MRI in predicting the neuropathological diagnosis of PSP and MSA, and the relationship between the MRI abnormalities and the macroscopic neuropathological findings have been studied. The conventional MRI predicted the diagnosis in approximately 66% of the PSP and MSA cases. Superior cerebellar peduncle atrophy and both the “hummingbird” and “morning glory” signs have a higher specificity but less sensitivity than the clinical diagnostic criteria.[17] The diffusion-weighted imaging (DWI) shows significantly higher regional apparent diffusion coefficient (rADC) values in the putamen and globus pallidus in PSP patients, probably indicating an ongoing striatal degeneration.[18] The volume loss of various supra- and infratentorial brain structures, measured by MR volumetry with semiautomatic segmentation techniques on a region-of-interest (ROI) approach, showed a significant reduction in the whole brain, striatal, brain stem (especially the midbrain), and frontal lobe volumes.[19]

Voxel based morphometry (VBM) used in detecting volume loss in Parkinsonian disorders showed a gray matter loss in PSP, particularly in the frontotemporal cortical areas such as the prefrontal cortex and insular region, whereas the white matter loss was additionally reported in the midbrain, including the cerebral peduncles.[20] Midbrain atrophy correlates with disease severity and motor deficits. Reduced anteroposterior (AP) midbrain diameter (<14 mm) and abnormal superior profile of the midbrain (flat or concave in PSP versus a convex aspect in healthy people) may assist in the differential diagnosis of PSP.[9],[21] Some PSP patients have increased signal changes in the SCP on fluid-attenuated inversion recovery images, a sign which is absent in PD and MSA.[22]

The data on MRI of PSP patients in India is scarce. Our study, was designed to study the sensitivity and specificity of MRPI in differentiating PSP patients from PD patients and controls.


 » Materials and Methods Top


This study enrolled 26 probable PSP patients, diagnosed as per the criteria proposed by NINDS-SPSP, and attending the outpatient clinic of the Department of Neurology at P. D. Hinduja National Hospital, Mumbai, from March 2012 to March 2014. Thirteen patients with PD fulfilling the UK brain bank criteria were also selected. Thirty age-matched controls included individuals of age >40 years and without any brain stem pathology or clinical Parkinsonian symptoms, who attended our outpatient clinic for other neurological disorders. The study was approved by the institutional review board. Informed consent of the participating patients was obtained.

PSPRS includes 28 items divided into 6 categories: Activities of daily living, mentation, bulbar function, ocular motor function, limb motor function, and gait/midline function. The scores range from 0 to 100 with each item graded as 0-2 (six items) or 0-4 (22 items). PSP staging system defines the broad categories of motor function.

The probable PSP diagnostic criteria by NINDS-SPSP should include all five of the following clinical features: Gradually progressive disorder, onset at age 40 years or later, no evidence of competing diagnostic possibilities, vertical gaze palsy, and, slowing of vertical saccades and prominent postural instability with falls in the first year.

Supportive features

These include symmetric akinesia or rigidity, proximal more than distal; an abnormal neck posture, especially retrocollis; a poor response or an absence of response of the Parkinsonism manifestations to levodopa therapy; the presence of an early dysphagia and dysarthria; and, the early onset of cognitive impairment, including at least two of the following: Apathy, impairment in abstract thought, decreased verbal fluency, an imitation behavior, or frontal lobe release signs.

Exclusion criteria

These include a recent history of encephalitis; the presence of alien limb syndrome, cortical sensory deficits, or focal frontal or temporoparietal atrophy; hallucinations or delusions unrelated to dopaminergic therapy; cortical dementia of the Alzheimer's type; prominent early cerebellar symptoms or prominent early and unexplained dysautonomia; severe, asymmetric Parkinsonian signs; neuroradiological evidence of relevant structural abnormalities; and, Whipple's disease, confirmed by polymerase chain reaction.

The patients with PSP included in the present study underwent assessment and staging, respectively, using the PSPRS and the PSP staging system by both the examiners independently. The demographic data including the age at presentation, sex, age at onset, and clinical features were recorded.

The PSP patients, PD patients, and age-matched controls underwent MRI of the brain using 1.5/3-T imager. The MRI examinations included T2-weighted images, T1-weighted volumetric spoiled-gradient echo images, and diffusion-weighted images. The area of the midbrain and pons were measured on midsagittal T1-weighted volumetric spoiled gradient (VSG) echo sequence. The measurement of width of the middle cerebellar peduncle (MCP) was done on sagittal T1-weighted VSG echo images, and of superior cerebellar peduncle (SCP) was measured on the T1-weighted VSG echo high-spatial-resolution oblique coronal image. Mean MCP and SCP widths were calculated by averaging values from the right and left sides. The M/P ratio was measured as the ratio of midbrain area to pons area. MRPI was calculated by multiplying pons area/midbrain area ratio by MCP width/SCP width ratio [Figure 1].
Figure 1: Sagittal and coronal T1-weighted volumetric spoiled gradient-echo MR images show (a) midbrain and pons area, (b) MCP width, and (c) SCP width in PSP patients. Images show marked atrophy of both midbrain and SCP in PSP patient. The values are as follows: MCP width, 7.57 mm; SCP width, 3.7 mm; midbrain area, 60.16 mm2; and pons area, 495.67 mm2

Click here to view


The MRPI and M/P ratio were calculated for all patients by a consultant radiologist blinded to the diagnoses of the patients. Also, similar measurements were calculated for patients with PD and controls.

Analysis

To evaluate the correlation between MRPI and PSPRS, duration of disease, and the PSP staging system, Spearman correlation coefficients were calculated. To compare the M/P ratio, one-way analysis of variance was used. To assess the differences in SCP width, MCP width, pons area, and MRPI among the groups, the Kruskal–Wallis test was used. The sensitivity, specificity, positive predictive value (PPV), and diagnostic accuracy were determined for differentiating PSP from PD and controls by using the optimal cutoff values determined with receiver operating characteristic (ROC) curve analysis. To verify the agreement between the two raters, the inter-rater correlation coefficient was calculated. All tests were two-tailed, and the α level was set at P < 0.05.

Clinical PSPRS and PSP staging was used as a quantitative measure of disability. Higher scores indicated a greater morbidity.


 » Results Top


The demographics of PSP, PD, and control patients are illustrated in [Table 1]. The mean PSPRS score by rater 1 and rater 2 were 43.81 and 43.65, respectively, with an excellent inter-rater correlation (correlation coefficient = 0.983). The mean and median PSP staging was 3.
Table 1: Demographic, clinical, and imaging data from patients with Parkinson's disease, patients with progressive supranuclear palsy, and controls

Click here to view


The difference in the midbrain area in PSP versus PD patients, and in PSP patients versus the control group was statistically significant (P < 0.001); whereas, the difference of the midbrain area in the PD patients versus the controls was not significant (P = 0.31) because the midbrain area is not affected in PD. There were overlapping values of the midbrain area between the PSP and the control group. The mean SCP width in PSP was significantly lower (P < 0.05) than that in PD and controls. The difference in mean SCP width in PD and controls was not statistically significant. Therefore, the SCP width was significantly smaller in PSP but normal in PD.

The cutoff value of 12.4 using ROC curve analysis was taken to differentiate between a higher and lower MRPI. All PSP patients had higher MRPI values than PD patients and controls. All PD and control subjects (except one) had MRPI values <12 .4. There were no overlapping values of MRPI between PSP and other groups [Figure 2]a. The mean MRPI in PSP was 23.48, whereas that in PD was 9.07 and in controls was 9.45 [Table 1]. The differences in mean MRPI between PSP versus PD and PD versus controls were statistically significant (P < 0.05), but the mean MRPI of PD versus controls was not significant [Table 2]. Therefore, MRPI was significantly higher in PSP but normal in PD. Only one control had a high MRPI value, though clinically, that patient had no features of PSP or PD. MRPI was 100% sensitive, specific, and accurate in differentiating PSP from PD when a cutoff level of 12.4 was used, and MRPI was highly sensitive (96.3%), specific (100%), and accurate (98.21%) [Table 3] in differentiating PSP from controls, with a PPV and NPV of 96.15% and 96.67%, respectively. When the cutoff value of 13.55 was taken to differentiate higher and lower MRPI, as per the earlier studies, all PSP patients in our study had higher MRPI values than that seen in PD and control patients. All PD and control patients (except one) had MRPI values <13 .55. There were no overlapping values of MRPI between the PSP and other groups. MRPI with a cutoff value of 13.55 was also 100% sensitive, specific, and accurate in differentiating PSP from PD when a cutoff level of 13.55 was used, and MRPI was also highly sensitive (96.3%), specific (100%), and accurate (98.21%) in differentiating PSP from controls, with a PPV and NPV of 96.15% and 96.67%, respectively. The value of MRPI in the current study was lower as compared with the earlier studies owing to lesser duration of illness in our PSP patients. The average duration of illness in the current study was 2.56 years [Table 1]. The mean duration of PSP was 3.57 years in a study by Morelli et al., and 4.8 years in a study by Massey et al.[4],[17],[23]
Figure 2: Box plots of (a) MRPI and (b) M/P ratio in PSP patients, PD patients, and controls

Click here to view
Table 2: Correlation of MRPI and M/P ratio in PSP patients, PD patients, and controls

Click here to view
Table 3: Sensitivity, specificity, and accuracy of MRPI and M/P ratio for differentiation PSP patients, PD patients, and controls

Click here to view


In comparison, the correlation of M/P ratio, with a cutoff value of 0.21, in PSP, PD and control patients

showed a good correlation between the control and PSP groups, as well as the PD and PSP groups (P < 0.001); no significant correlation was found in the PD and the control group. The mean M/P ratio in the PSP group was lower (0.16) than that in the PD (0.3) and control group (0.27). The difference was statistically significant (P < 0.001), but the difference in the mean M/P ratio between the PD and control groups was not significant (P = 0.052). The M/P ratio was decreased in PSP but normal in PD. The M/P ratio was 100% sensitive, 92.86% specific, and 97.44% accurate in differentiating PSP from PD when the cutoff level of 0.195 was used (PPV, 96.5%, and NPV, 100%). However, there were overlapping values in PSP and PD patients [Figure 2]b.

There was no significant correlation between MRPI and the duration of disease or between MRPI and and PSPRS using Spearman rho correlation coefficient, but there was a statistically significant correlation between the duration of disease and average PSPRS (correlation coefficient, 0.744; P < 0.001). There was no significant correlation between MRPI and the PSP staging [Table 4].
Table 4: Correlation of MRPI with PSPRS, duration of disease, and PSP staging system

Click here to view



 » Discussion Top


MRPI is proposed to differentiate PSP on an individual basis from PD and MSA-P. MRPI is significantly higher in PSP patients than in healthy controls, PD patients, or MSA-P patients. MRPI has a very high sensitivity, specificity, and positive predictive value when a cutoff of 12.4 was taken to differentiate these entities from PSP.[4],[24] In our study, PSP had a mean MRPI of 23.4 as opposed to 9.45 in controls and 9.07 in PD.

Most PSP patients have onset of disease in the seventh decade of life. The mean age at onset in our study was 63.58 years, which is comparable to that found in other studies.[4],[17],[25] The mean age at examination in our study was 66.15 years, with the average duration of the disease being 2.56 years. Other studies have reported a higher age at examination as well as longer duration of disease. Two of our patients had an abnormal MRPI (>20) within 6 months of the disease onset. Therefore, MRPI can be helpful in differentiating PSP from PD in the early stages of the disease.[4],[17],[25] However, further studies are required to confirm this finding.

Our study had an average PSPRS of 43.73 in comparison with 33.5 to 37 reported in other studies. This is due to the inclusion of only probable PSP patients in our study. Litvan et al., showed that the average PSPRS score at baseline was 33.5, and there was average worsening of score per year by 9 in the PSP patients.

Most patients in our study had the PSP staging score of 3. Calculation of M/P ratio can differentiate PSP from PD, MSA-P, or healthy controls.[16],[24] This is despite the fact that there were overlapping individual values in another study as well as this study.

Midbrain atrophy is a typical pathologic feature of PSP. In our study, the midsagittal MRI of the brain showed that midbrain area in PSP (mean, 71.88 mm 2) was almost half of the midbrain area in PD (mean, 143.15 mm 2) and controls (mean, 135.57 mm 2). This finding is consistent with the previous studies which had also shown that the midbrain area in PSP was significantly smaller than PD and controls. A midbrain area of <75 mm 2 is highly suggestive of PSP. The individual values of midbrain area measured in PSP, however, overlap with those in the control group, making the differentiation of PSP patients from other groups, on an individual basis, difficult.

In comparison with other studies, our study showed a lower mean pons area in PSP (461.9 mm 2) than in PD and controls (495.47 mm 2). There was no significant difference in the mean pons area in PSP and that in controls.[4],[23],[26] The mean SCP width in PSP in our study was 2.34 mm, which was significantly less than that seen in PD (3.1 mm) and control (3.46 mm) subjects. Previous studies have also shown the mean SCP width to be <3 mm in patients with PSP. However, there was no significant difference in the mean SCP width in patients with PD and that in controls. Also, on an individual basis, SCP width could not differentiate the patients with PSP from other groups.[4],[16],[24],[26]

As per the aforementioned data, the mean MCP width in PSP (7.85 mm) was smaller than that in PD (8.09 mm) and controls (8.62 mm), but with no significant difference. Previous studies also showed comparable results.[4],[23],[24],[26]

The average values obtained in other studies include an MRPI of 21.4 by Morelli et al., 20.7 by Longeni et al., 18.63 by Hussl et al., and 24.56 by Quattratone et al., These values are comparable to our current study where the average value was 23.48. The MRPI was 9.07 in patients with PD in our study, and 9.45 in controls, a finding similar to that seen in other studies.[4],[24],[26],[27]

The single brain measurements on MR images fail to aid in differentiating PSP from other groups. The combined assessment of all four brain structures involved in this neurodegenerative process overcomes this problem. The mean MRPI in PSP was 23.48, which was significantly higher than that in PD (9.07) and controls (9.45). On an individual basis, MRPI could differentiate all PSP patients from other groups, except for one control, where the person in focus had clinically no signs of Parkinsonism, but the MRPI value was >12.4.

Calculation of M/P ratio can differentiate PSP from PD, MSA-P, or healthy controls.[16],[24] The mean M/P ratio in PSP (0.16) was significantly lower than that in PD (0.3) and controls (0.27) in the present study. There were overlapping values between the PSP and the control groups. Other studies have also shown similar overlapping values between the PSP and other groups.[23] There was only a marginal reduction in the sensitivity of M/P ratio in predicting PSP on an individual basis.

Thus, MRPI is 100% sensitive, specific, and accurate in differentiating PSP from PD when a cutoff level of 12.4 was used; and, MRPI is highly sensitive (96.3%), specific (100%), and accurate (98.21%) in differentiating PSP from controls. This result was comparable to that obtained in the previous studies where sensitivity, specificity, and diagnostic accuracy were all more than 90%. One possible reason for this distinct differentiation of PSP from PD obtained with the MRPI measurement may be the smaller number of patients with PD, most of whom had a longer duration of disease.

In the present study, the M/P ratio was 100% sensitive in differentiating PSP from PD but showed less specificity and diagnostic accuracy as compared with MRPI in differentiating PSP from PD and controls (although it was more than 90% sensitive). Morelli et al., also showed that M/P ratio failed to distinguish PSP from PD on an individual basis, with a relatively lower sensitivity, specificity, and diagnostic accuracy of 92.9%, 85.3%, and 86.8%, respectively. Hussl et al., also reported a very low sensitivity and diagnostic accuracy of the M/P ratio in differentiating PSP from PD.[4],[27] The cutoff value for MRPI in the Indian patients with PSP was different from that seen in the earlier studies.[4],[27]

Previous studies have reported a significant correlation between MRPI and the duration of disease, but we found no correlation of MRPI with either PSPRS or the duration of disease [4],[24] [Table 4]. This discrepancy may be due to the shorter duration of disease in some of our patients. Litvan et al., have shown worsening of total PSPRS by an average of 9.1 per year.[3] There was significant correlation between PSPRS and the duration of disease in our study. We, however, did not find any correlation between MRPI and the PSP staging system.

MRPI improved the diagnostic accuracy much more than that seen with the use of M/P ratio in discriminating PSP from MSA-P because of the combined assessment of four brain structures involved in neurodegenerative disorders. Thus, atrophy of midbrain and SCP suggested the presence of PSP, and atrophy of pons and MCP suggested the presence of MSA. These brain structures are usually not involved in PD. However, calculation of MRPI is more time consuming than calculation of the M/P ratio because it involves measurement of additional brain structures. The limitation of our study was the lack of pathological confirmation of PSP and that patients with atypical presentations of PSP were not included in this study.


 » Conclusion Top


Magnetic Resonance Parkinsonism Index is more sensitive, specific, and accurate in differentiating PSP from PD in the early stages on an individual basis. This index may be an important diagnostic tool available to a physician for the diagnosis of PSP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Litvan I, Agid Y, Calne D, Campbell G, Dubois B, Duvoisin RC, et al. Clinical research criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome): Report of the NINDS-SPSP international workshop. Neurology 1996;47:1-9.  Back to cited text no. 1
    
2.
Golbe LI, Ohman-Strickland PA. A clinical rating scale for progressive supranuclear palsy. Brain 2007;130:1552-65.  Back to cited text no. 2
    
3.
Litvan I, Kong M. Rate of decline in progressive supranuclear palsy. Mov Disord 2014;29:463-8.  Back to cited text no. 3
    
4.
Morelli M, Arabia G, Salsone M, Novellino F, Giofrè L, Paletta R, et al. Accuracy of magnetic resonance parkinsonism index for differentiation of progressive supranuclear palsy from probable or possible Parkinson disease. Mov Disord 2011;26:527-33.  Back to cited text no. 4
    
5.
Holmberg B, Rosengren L, Karlsson JE, Johnels B. Increased cerebrospinal fluid levels of neurofilament protein in progressive supranuclear palsy and multiple-system atrophy compared with Parkinson's disease. Mov Disord 1998;13:70-7.  Back to cited text no. 5
    
6.
Urakami K, Mori M, Wada K, Kowa H, Takeshima T, Arai H, et al. A comparison of tau protein in cerebrospinal fluid between corticobasal degeneration and progressive supranuclear palsy. Neurosci Lett 1999;259:127-9.  Back to cited text no. 6
    
7.
Borroni B, Gardoni F, Parnetti L, Magno L, Malinverno M, Saggese E, et al. Pattern of tau forms in CSF is altered in progressive supranuclear palsy. Neurobiol Aging 2009;30:34-40.  Back to cited text no. 7
    
8.
Paviour DC, Price SL, Jahanshahi M, Lees AJ, Fox NC. Longitudinal MRI in progressive supranuclear palsy and multiple system atrophy: Rates and regions of atrophy. Brain 2006;129:1040-9.  Back to cited text no. 8
    
9.
Righini A, Antonini A, De Notaris R, Bianchini E, Meucci N, Sacilotto G, et al. MR imaging of the superior profile of the midbrain: Differential diagnosis between progressive supranuclear palsy and Parkinson disease. AJNR Am J Neuroradiol 2004;25:927-32.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Josephs KA. Frontotemporal lobar degeneration. Neurol Clin 2007;25:683-96.  Back to cited text no. 11
    
12.
Gröschel K, Kastrup A, Litvan I, Schulz JB. Penguins and hummingbirds: Midbrain atrophy in progressive supranuclear palsy. Neurology 2006;66:949-50.  Back to cited text no. 12
    
13.
Graber JJ, Staudinger R. Teaching NeuroImages: “Penguin” or “hummingbird” sign and midbrain atrophy in progressive supranuclear palsy. Neurology 2009;72:e81.  Back to cited text no. 13
    
14.
Kato N, Arai K, Hattori T. Study of the rostral midbrain atrophy in progressive supranuclear palsy. J Neurol Sci 2003;210:57-60.  Back to cited text no. 14
    
15.
Adachi M, Kawanami T, Ohshima H, Sugai Y, Hosoya T. Morning glory sign: A particular MR finding in progressive supranuclear palsy. Magn Reson Med Sci 2004;3:125-32.  Back to cited text no. 15
    
16.
Oba H, Yagishita A, Terada H, Barkovich AJ, Kutomi K, Yamauchi T, et al. New and reliable MRI diagnosis for progressive supranuclear palsy. Neurology 2005;64:2050-5.  Back to cited text no. 16
    
17.
Massey LA, Micallef C, Paviour DC, O'Sullivan SS, Ling H, Williams DR, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord 2012;27:1754-62.  Back to cited text no. 17
    
18.
Seppi K, Schocke MF, Esterhammer R, Kremser C, Brenneis C, Mueller J, et al. Diffusion-weighted imaging discriminates progressive supranuclear palsy from Parkinson's disease, but not from the Parkinson variant of multiple system atrophy. Neurology 2003;60:922-7.  Back to cited text no. 18
    
19.
Josephs KA, Xia R, Mandrekar J, Gunter JL, Senjem ML, Jack CR Jr, et al. Modeling trajectories of regional volume loss in progressive supranuclear palsy. Mov Disord 2013;28:1117-24.  Back to cited text no. 19
    
20.
Hotter A, Esterhammer R, Schocke MF, Seppi K. Potential of advanced MR imaging techniques in the differential diagnosis of Parkinsonism. Mov Disord 2009;24(Suppl 2):S711-20.  Back to cited text no. 20
    
21.
Warmuth-Metz M, Naumann M, Csoti I, Solymosi L. Measurement of the midbrain diameter on routine magnetic resonance imaging: A simple and accurate method of differentiating between Parkinson disease and progressive supranuclear palsy. Arch Neurol 2001;58:1076-9.  Back to cited text no. 21
    
22.
Kataoka H, Tonomura Y, Taoka T, Ueno S. Signal changes of superior cerebellar peduncle on fluid-attenuated inversion recovery in progressive supranuclear palsy. Parkinsonism Relat Disord 2008;14:63-5.  Back to cited text no. 22
    
23.
Morelli M, Arabia G, Messina D, Vescio B, Salsone M, Chiriaco C, et al. Effect of aging on magnetic resonance measures differentiating progressive supranuclear palsy from Parkinson's disease. Mov Disord 2014;29:488-95.  Back to cited text no. 23
    
24.
Quattrone A, Nicoletti G, Messina D, Fera F, Condino F, Pugliese P, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology 2008;246:214-21.  Back to cited text no. 24
    
25.
Osaki Y, Ben-Shlomo Y, Lees AJ, Daniel SE, Colosimo C, Wenning G, et al. Accuracy of clinical diagnosis of progressive supranuclear palsy. Mov Disord 2004;19:181-9.  Back to cited text no. 25
    
26.
Longoni G, Agosta F, Kostić VS, Stoiković T, Pagani E, Stošić-Opinćal T, et al. MRI measurements of brainstem structures in patients with Richardson's syndrome, progressive supranuclear palsy-parkinsonism, and Parkinson's disease. Mov Disord 2011;26:247-55.  Back to cited text no. 26
    
27.
Hussl A, Mahlknecht P, Scherfler C, Esterhammer R, Schocke M, Poewe W, et al. Diagnostic accuracy of the magnetic resonance Parkinsonism index and the midbrain-to-pontine area ratio to differentiate progressive supranuclear palsy from Parkinson's disease and the Parkinson variant of multiple system atrophy. Mov Disord 2010;25:2444-9.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

This article has been cited by
1 Specificity and sensitivity of magnetic resonance imaging findings in the diagnosis of progressive supranuclear palsy
Stephen Bacchi,Ivana Chim,Sandy Patel
Journal of Medical Imaging and Radiation Oncology. 2018; 62(1): 21
[Pubmed] | [DOI]
2 Radiological biomarkers for diagnosis in PSP: Where are we and where do we need to be?
Jennifer L. Whitwell,Günter U. Höglinger,Angelo Antonini,Yvette Bordelon,Adam L. Boxer,Carlo Colosimo,Thilo van Eimeren,Lawrence I. Golbe,Jan Kassubek,Carolin Kurz,Irene Litvan,Alexander Pantelyat,Gil Rabinovici,Gesine Respondek,Axel Rominger,James B. Rowe,Maria Stamelou,Keith A. Josephs
Movement Disorders. 2017; 32(7): 955
[Pubmed] | [DOI]
3 Magnetic Resonance Parkinsonism Index and midbrain to pons ratio: Which index better distinguishes Progressive Supranuclear Palsy patients with a low degree of diagnostic certainty from patients with Parkinson Disease?
Salvatore Nigro,Maurizio Morelli,Gennarina Arabia,Rita Nisticò,Fabiana Novellino,Maria Salsone,Federico Rocca,Aldo Quattrone
Parkinsonism & Related Disorders. 2017; 41: 31
[Pubmed] | [DOI]
4 The midbrain-to-pons ratio distinguishes progressive supranuclear palsy from non-fluent primary progressive aphasias
M. Silsby,R. Y. Tweedie-Cullen,C. R. Murray,G. M. Halliday,J. R. Hodges,J. R. Burrell
European Journal of Neurology. 2017; 24(7): 956
[Pubmed] | [DOI]
5 MRI measures of brainstem in Parkinsonian syndromes: Where we stand and where we need to go
Aldo Quattrone,Salvatore Nigro
Movement Disorders. 2017; 32(8): 1261
[Pubmed] | [DOI]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow