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Conventional MR Imaging (cMR) of Parkinson disease and Parkinsonian syndromes
December 4th, 2009 by Administrator

The author: Professor Yasser Metwally

http://yassermetwally.com


INTRODUCTION

November 28, 2009 —  In PD, standard T2-weighted, T1-weighted, and proton-density sequences at 1.5 T do not show disease-specific changes. Because Conventional MR Imaging (cMR)  is usually normal in early PD, Conventional MR Imaging (cMR)  takes a major part in excluding underlying pathologies such as vascular lesions, multiple sclerosis, brain tumors, normal pressure hydrocephalus, bilateral striopallidodentate calcinosis, and other potential, but rare causes of symptomatic parkinsonism such us Wilson disease, manganese-induced parkinsonism, or different subtypes of neurodegeneration associated with brain iron accumulation. [7, 8, 9, 10, 11, 12, 13] Furthermore, visual assessment of MR imaging can point toward alternative diagnosis from PD, when abnormalities that are characteristic of one of the atypical parkinsonian disorders (APDs) are seen.

Left, pathological specimen and right MRI T2 image ,notice the less hypointense band that separates the red nucleus from the substantia nigra. Left, pathological specimen and right MRI T2 image ,notice the less hypointense band that separates the red nucleus from the substantia nigra.

Figure 1. Left, pathological specimen and right MRI T2 image ,notice the less hypointense band that separates the red nucleus from the substantia nigra.

At 1.5 T, patients with advanced PD, and sometimes those with atypical parkinsonian disorders (APDs), may show distinct abnormalities of the substantia nigra (SN), including signal increase on T2-weighted MR images or smudging of the hypointensity in the substantia nigra toward the red nucleus. [1, 14, 15, 16, 17] By using inversion recovery ratio imaging, structural changes in the substantia nigra have been reported in patients with PD. [5, 6, 18, 19] Although some investigators were able to discriminate completely between PD patients and controls by using inversion recovery ratio imaging, [5, 6] there was considerable overlap between normal and PD values in some of the studies published. [18, 19,51,52,53]

MRI T2 IMAGES left ,normal and right a, case with idiopathic parkinson disease.Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other [left] MRI T2 IMAGES left ,normal and right a, case with idiopathic parkinson disease.Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other [left]

Figure 2. MRI T2 images left ,normal and right a, case with idiopathic parkinson disease.Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other.

MRI T2 images of two cases with idiopathic parkinson disease.  Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other MRI T2 images of two cases with idiopathic parkinson disease.  Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other

Figure 3. MRI T2 images of two cases with idiopathic parkinson disease.  Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other

MRI T2 IMAGES [left ,normal and right a case with idiopathic parkinson disease.] Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other [left] MRI T2 IMAGES [left ,normal and right a case with idiopathic parkinson disease.] Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other [left]

Figure 4. MRI T2 images [left ,normal and right a case with idiopathic parkinson disease.] Notice absence of the band that separates the red nucleus from the substantia nigra,both are in touch with each other.

Several findings on conventional structural MR imaging have been described as diagnostic pointers for Parkinson variant of MSA (MSA-P). These pointers include atrophy and signal alterations (at 1.5 T) in the putamen (Fig. 5) and several infratentorial regions, such as the presence of a hyperintense putaminal rim with or without hypointensity in the dorsolateral part of the putamen, pontine atrophy, the “hot-cross bun” sign of the pons (Fig. 6,7), atrophy of the cerebellum, and hyperintensity in the middle cerebellar peduncle (MCP). [1, 2, 20, 21, 22, 23, 24, 25, 26, 27] Whereas putaminal atrophy appears to discriminate MSA from PD, T2 putaminal hypointensity and a putaminal hyperintense rim may be observed also in PD. [25, 26, 27, 28, 29] In fact, on T2-weighted images at 3.0 T a hyperintense putaminal rim seems to be a nonspecific, normal finding. [33] Specificity of the aforementioned abnormalities to differentiate Parkinson variant of MSA (MSA-P) from PD and healthy controls is considered high, whereas sensitivity, especially in the early disease stages, seems to be insufficient. [17, 27, 30, 31, 32] Sensitivity of signal alterations, however, can be somewhat improved by modifying technical aspects such as spatial resolution by using thinner slices, or relaxation contrast by using conventional spin-echo (CSE) or T2-weighted gradient echo sequences. [3, 27, 33, 34]

Click to enlarge figure

Figure 5. Brain MR imaging of a healthy 46-year-old woman. A, There are grade 2 hyperintense putaminal rim (HPRs) on the right and grade 3 on the left and grade 2 dorsolateral putaminal hypointensities. B, FLAIR image demonstrates grade 1 hyperintense putaminal rim (HPR) on left side only. C, Signal intensity changes of bilateral hyperintense putaminal rim (HPR). The dorsolateral putaminal hypointensities become brighter signals than those in A. (Click to enlarge figure)

Click to enlarge figure

Figure 6.  A hot cross bun, or cross-bun, is a type of sweet spiced bun made with currants or raisins and leavened with yeast. It has a cross marked on the top which might be effected in one of a variety of ways including: pastry, flour and water mixture, rice paper, icing, or intersecting cuts. (Click to enlarge figure)

Click to enlarge figure

Figure 7. "hot cross bun" sign seen in pons on T2 MRI. (c) (Click to enlarge figure)

Specific brain MR imaging findings associated with progressive supranuclear palsy (PSP) include midbrain atrophy with enlargement of the third ventricle and tegmental atrophy, signal increase in the midbrain and in the inferior olives, atrophy of the superior cerebellar peduncle (SCP) as well as frontal and temporal lobe atrophy. [16, 20, 35, 36, 37, 38, 39, 40, 41, 42, 43] Indirect parameters of midbrain atrophy comprising reduced anteroposterior (AP) midbrain diameter, dilated third ventricle, and abnormal superior profile of the midbrain (flat or concave versus convex aspect in healthy people) may assist in the differential diagnosis of progressive supranuclear palsy (PSP). [17, 44, 45] Another indirect sign of midbrain atrophy in patients with progressive supranuclear palsy (PSP) is the “penguin silhouette” or “hummingbird” sign (Fig. 8), [36, 46, 47] where the shape of the midbrain tegmentum (the bird’s head) and pons (the bird’s body) on midsagittal MR images resemble a lateral view of a standing king penguin or hummingbird.

Click to enlarge figure

Figure 8. Midsagittal T1-weighted MR images in a patient with PD (A), a patient with Parkinson variant of MSA (MSA-P) (B), and a patient with PSP (C). (A) There is no pontine or midbrain atrophy in the patient with PD. (B) Pontine atrophy (arrow) without midbrain atrophy in the Parkinson variant of MSA (MSA-P) patient. (C) Midbrain atrophy without pontine atrophy (divided by the white line) in the PSP patient, forming the silhouette of the “penguin” or “hummingbird” sign, with the shapes of midbrain tegmentum (bird’s head; above the white line) and pons (bird’s body; below the white line) looking like the lateral view of a standing penguin (especially the king penguin) or hummingbird, with a small head and big body. (Click to enlarge figure)

Visual assessment of atrophy of the superior cerebellar peduncle has been shown to distinguish PSP patients from controls and patients with other parkinsonian disorders including MSA and PD, with a sensitivity of 74% and a specificity of 94%. [37] Moreover, some of the PSP patients may have increased signal changes in the superior cerebellar peduncle on fluid-attenuated inversion recovery (FLAIR) images, which seem to be absent in PD and MSA. [48 ]

In patients with cortico-basal ganglionic degeneration (CBD), only few studies have investigated the role of Conventional MR Imaging (cMR), showing cortical (especially frontoparietal) atrophy, which tends to be asymmetric, putaminal hypointensity as well as hyperintense signal changes in the motor cortex or subcortical white matter on T2-weighted images. [17, 40, 42, 49, 50] However, none of these Conventional MR Imaging (cMR) abnormalities seems to be of diagnostic relevance for cortico-basal ganglionic degeneration. [40, 50] Indeed, a review of 40 autopsy cases presenting with a corticobasal syndrome in life and with different pathologies at postmortem confirms that MR imaging findings are similar regardless of the differing underlying pathology. [48]

Overall, although specificity of Conventional MR Imaging (cMR)  for discriminating the different atypical parkinsonian disorders (APD) from PD or healthy controls has been shown to be high, specificity of Conventional MR Imaging (cMR)  between the different atypical parkinsonian disorders (APD) is inefficient. [4, 17, 20, 25, 27, 30, 31, 32, 40]. See table 1 for summary.

Table 1. Summary (Click to enlarge table)

Click to enlarge table

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