Using imaging to identify psychogenic parkinsonism before deep brain stimulation surgery

Report of 2 cases

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The frequency with which patients with atypical parkinsonism and advanced motor symptoms undergo deep brain stimulation (DBS) procedures is unknown. However, the potential exposure of these patients to unnecessary surgical risks makes their identification critical. As many as 15% of patients enrolled in recent early Parkinson disease (PD) trials have been found to lack evidence of a dopaminergic deficit following PET or SPECT imaging. This suggests that a number of patients with parkinsonism who are referred for DBS may not have idiopathic PD. The authors report on 2 patients with probable psychogenic parkinsonism who presented for DBS surgery. They found that both patients had normal caudate and putamen [18F]-fluorodopa uptake on PET imaging, along with normal expression of specific disease-related metabolic networks for PD and multiple system atrophy, a common form of atypical neurodegenerative parkinsonism. The clinical and PET findings in these patients highlight the role of functional imaging in assisting clinical decision making when the diagnosis is uncertain.

Abbreviations used in this paper: DBS = deep brain stimulation; MSA = multiple systemic atrophy; MSARP = MSA-related spatial covariance pattern; PD = Parkinson disease; PDRP = PD-related metabolic spatial covariance pattern; SPM = statistical parametric mapping; UPDRS = Unified Parkinson's Disease Rating Scale.

Article Information

Address correspondence to: Michael Pourfar, M.D., 865 Northern Boulevard, Suite 201, Great Neck, New York 11021. email: mpourfar@nshs.edu.

Please include this information when citing this paper: published online November 11, 2011; DOI: 10.3171/2011.10.JNS11554.

© AANS, except where prohibited by US copyright law.

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Figures

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    Fluorodopa (FDOPA; A and B) and FDG (C and D) PET scans obtained in Case 1 (left) and Case 2 (right). Quantitative PET measurements from both scans were normal in the 2 cases.

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    A: Single-case SPMs of the FDG-PET scans obtained in Cases 1 and 2 compared with those obtained in healthy individuals. The patient in Case 1 exhibited increases in metabolic activity in motor cortical regions. Increases in metabolic activity in the cerebellar vermis are evident in both cases without accompanying changes in the basal ganglia. A representative single-case SPM obtained in a patient with classic symptoms of PD (age 43.5 years, disease duration 8 years) is presented for comparison. Metabolic increases (red voxels) are displayed at p < 0.05 (uncorrected) and overlaid on a standard MR imaging template. GP = globus pallidus. B: Network scores quantifying the expression of the disease-related metabolic patterns for PD (PDRP; top) and MSA (MSARP; bottom) are measured for the patients in Cases 1 and 2 (Patients 1 and 2; squares). These network values are compared with analogous measures from 25 patients with PD (triangles), 23 patients with MSA (diamonds), and 25 healthy volunteers (circles). Subject scores for both patterns are normal for our 2 patients. Error bars represent the mean ± SD for the PD, MSA, and healthy control groups. The horizontal broken line represents 2 SDs above the normal mean for each pattern. PDRP and MSARP subject scores for the patient with PD depicted in panel A are delineated by the short arrows.

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    Flow diagram illustrating clinical and imaging considerations when determining patient suitability for DBS surgery for medication refractory parkinsonism. LD = levodopa.

References

1

Benaderette SZanotti Fregonara PApartis ENguyen CTrocello JMRemy P: Psychogenic parkinsonism: a combination of clinical, electrophysiological, and [(123)I]-FP-CIT SPECT scan explorations improves diagnostic accuracy. Mov Disord 21:3103172006

2

Dhawan VEidelberg DPET imaging in Parkinson's disease and other neurodegenerative disorders. Gilman S: Neurobiology of Disease San DiegoElsevierAcademic Press2007. 821828

3

Dhawan VMa YPillai VSpetsieris PChaly TBelakhlef A: Comparative analysis of striatal FDOPA uptake in Parkinson's disease: ratio method versus graphical approach. J Nucl Med 43:132413302002

4

Eckert TBarnes ADhawan VFrucht SGordon MFFeigin AS: FDG PET in the differential diagnosis of parkinsonian disorders. Neuroimage 26:9129212005

5

Eckert TFeigin ALewis DEDhawan VFrucht SEidelberg D: Regional metabolic changes in parkinsonian patients with normal dopaminergic imaging. Mov Disord 22:1671732007

6

Eckert TTang CMa YBrown NLin TFrucht S: Abnormal metabolic networks in atypical parkinsonism. Mov Disord 23:7277332008

7

Eidelberg D: Metabolic brain networks in neurodegenerative disorders: a functional imaging approach. Trends Neurosci 32:5485572009

8

Factor SAPodskalny GDMolho ES: Psychogenic movement disorders: frequency, clinical profile, and characteristics. J Neurol Neurosurg Psychiatry 59:4064121995

9

Freed CRGreene PEBreeze RETsai WYDuMouchel WKao R: Transplantation of embryonic dopamine neurons for severe Parkinson's disease. N Engl J Med 344:7107192001

10

Gaig CMartí MJTolosa EValldeoriola FParedes PLomeña FJ: 123I-Ioflupane SPECT in the diagnosis of suspected psychogenic Parkinsonism. Mov Disord 21:199419982006

11

Lang AEKoller WCFahn S: Psychogenic parkinsonism. Arch Neurol 52:8028101995

12

Ma YTang CChaly TGreene PBreeze RFahn S: Dopamine cell implantation in Parkinson's disease: long-term clinical and (18)F-FDOPA PET outcomes. J Nucl Med 51:7152010

13

Ma YTang CSpetsieris PGDhawan VEidelberg D: Abnormal metabolic network activity in Parkinson's disease: test-retest reproducibility. J Cereb Blood Flow Metab 27:5976052007

14

Marek KJennings DSeibyl J: Long-term follow-up of patients with scans without evidence of dopaminergic deficit (SWEDD) in the ELLDOPA study. Neurology 64:1 SupplA2742005

15

Marek KSeibyl J: Beta-CIT scans without evidence of dopaminergic deficit (SWEDD) in the ELLDOPA-CIT and CALM-CIT study: long-term imaging assessment. Neurology 60:1 SupplA2932003

16

Marshall VLPatterson JHadley DMGrosset KAGrosset DG: Two-year follow-up in 150 consecutive cases with normal dopamine transporter imaging. Nucl Med Commun 27:9339372006

17

Marshall VLReininger CBMarquardt MPatterson JHadley DMOertel WH: Parkinson's disease is overdiagnosed clinically at baseline in diagnostically uncertain cases: a 3-year European multicenter study with repeat [123I]FPCIT SPECT. Mov Disord 24:5005082009

18

Piccini PBrooks DJ: New developments of brain imaging for Parkinson's disease and related disorders. Mov Disord 21:203520412006

19

Poston KLTang CEckert TMa YFrucht SEidelberg D: Longitudinal changes in regional metabolism and network activity in multiple system atrophy. Neurology 72:Suppl 3A672009

20

Spetsieris PGMa YDhawan VEidelberg D: Differential diagnosis of parkinsonian syndromes using PCA-based functional imaging features. Neuroimage 45:124112522009

21

Tang CCPoston KLEckert TFeigin AFrucht SGudesblatt M: Differential diagnosis of parkinsonism: a metabolic imaging study using pattern analysis. Lancet Neurol 9:1491582010

22

Whone ALWatts RLStoessl AJDavis MReske SNahmias C: Slower progression of Parkinson's disease with ropinirole versus levodopa: The REAL-PET study. Ann Neurol 54:931012003

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