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(Steele-Richardson-Olszewski Syndrome) and Clinical Predictors of Survival: a Clinicopathological Study

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(Steele-Richardson-Olszewski Syndrome) and Clinical Predictors of Survival: a Clinicopathological Study 3'ournal ofNeurology, Neurosurgery, and Psychiatry 1996;61:615-620 615 Natural history of progressive supranuclear palsy J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.6.615 on 1 June 1996. Downloaded from (Steele-Richardson-Olszewski syndrome) and clinical predictors of survival: a clinicopathological study I Litvan, C A Mangone, A McKee, M Veiny, A Parsa, K Jellinger, L D'Olhaberriague, K Ray Chaudhuri, R K B Pearce Abstract Keywords: progressive supranuclear palsy; natural his- Objective-To analyse the natural history tory; survival ofprogressive supranuclear palsy (PSP or Steele-Richardson-Olszewski syndrome) Progressive supranuclear palsy (PSP or Steele- and clinical predictors of survival in 24 Richardson-Olszewski syndrome) causes patients with PSP confirmed by necropsy, postural instability, supranuclear vertical oph- who fulfilled the NINDS criteria for a thalmoplegia, parkinsonism unresponsive to neuropathological diagnosis of typical levodopa, pseudobulbar palsy, and mild PSP. dementia.' 2 However, patients with PSP with- Methods-Patients were selected from the out ophthalmoplegia or dementia, or present- research and clinical files of seven med- ing only with dementia or akinesia, have also ical centres involving tertiary centres of been reported.3-7 Austria, England, France, and the United In the absence of laboratory markers for the States. Clinical features were analysed in diagnosis of PSP, neuropathological examina- Neuroepidemiology detail. The patients' mean age at onset of tion remains the "gold standard" for its diag- Branch, National PSP was 63 (range 45-73) years. nosis. Neuropathologically confirmed cases of Institute of Results-The most frequent clinical fea- corticobasal degeneration, multiple system Neurological Disorders tures in at least of the and Stroke, National (occurring 75% atrophy, diffuse Lewy body disease, cere- Institutes ofHealth, patients) were early postural instability brovascular disease, subcortical gliosis, and Bethesda, Maryland, and falls, vertical supranuclear palsy, aki- prion disease have been clinically misdiag- USA netic-rigid predominant parkinsonian I Litvan nosed as PSP.8-'4 Thus PSP can be difficult to C A Mangone disorder characterised by symmetric diagnose because of its increasingly recognised L D'Olhaberriague bradykinesia and axial rigidity unrelieved clinical diversity and because the topographic A Parsa by levodopa, pseudobulbar palsy, and distribution of lesions in the basal ganglia and Department of frontal release signs. Occasionally, seg- Neuropathology, brainstem overlaps with what is found in other Massachusetts General mental dystonia or myoclonus were parkinsonian syndromes.'5 16 Moreover, PSP Hospital, Boston, described, but neither aphasia nor alien may be associated with more than one neu- Massachusetts, USA limb syndrome was reported. Fractures ropathological diagnosis, such as Alzheimer's http://jnnp.bmj.com/ A McKee occurred in 25% of the patients but were or Parkinson's disease.'7 Raymond Escourolle unrelated to the severity of the gait or to Neuropathology To develop a clinically useful description of Laboratory, Inserm U the presence of falls. Median survival the natural history of PSP which could 360, Hopital de la time was 5*6 (range 2-16-6) years. Onset improve the accuracy of its early diagnosis,'6 Salpetriere, Paris, offalls during the first year, early dyspha- France we reviewed the records of the first and last M Veiny gia, and incontinence predicted a shorter visits of 24 patients with neuropathologically time. at on September 29, 2021 by guest. Protected copyright. Ludwig Boltzmann survival Age onset, sex, early typical PSP confirmed at necropsy,'8 and com- Institute of Clinical onset of dementia, vertical supranuclear pared our findings with those of other con- Neurobiology, Vienna, palsy, or axial rigidity had no effect on firmed series.'5 19-22 We also evaluated the Austria prognosis of survival. Pneumonia was the cause of death and clinical predictors of sur- K Jellinger most common immediate cause of death. Department of vival in these patients because both may pro- Neurology, Institute of PSP was most often clinically misdiag- vide useful insights into the management of Psychiatry, London, nosed as Parkinson's disease. Errors in patients with PSP. UK diagnosis suggest that PSP is underdiag- K Ray Chaudhuri nosed. Parkinson's Disease Conclusion-Progressive onset of early Society Brain Tissue Methods Bank, Institute of postural instability with falls or supranu- Patients were selected from the research and Neurology, London, clear vertical palsy in the fifth decade, clinical neuropathological files of seven.med- UK should suggest the diagnosis of PSP. ical centres of four countries (Austria, R K B Pearce Onset of falls during the first year are Correspondence to: England, France, and the United States) by Dr Irene Iitvan, Federal emphasised, as they could lead to an early neuropathologists who based their selection on Building, Room 714, diagnosis and influence the prognosis of National Institute of the recently published National Institute of Neurological Disorders and patients with PSP. Whether appropriate Neurological Disorders and Stroke (NINDS) Stroke, National Institutes of treatment of the dysphagia could prolong Health, Bethesda, Maryland neuropathological criteria for the diagnosis of 20892, USA. the survival of PSP patients needs to be PSP.18 Only neuropathologically typical cases Received 23 November 1995 explored. of PSP, which were shown to have substantial and in revised form 5 February 1996 reliability,23 were included in the study. Accepted 8 February 1996 (7 Neurol Neurosurg Psychiatry 1996;61:615-620) Briefly, neuropathologically typical PSP 616 Litvan, Mangone, McKee, Vemny, Parsa, _Jellinger, et al J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.60.6.615 on 1 June 1996. Downloaded from includes a high density of neurofibrillary tan- women and 15 men, a typical sex distribution gles and neuropil threads in at least three of for patients with PSP. The mean age at onset of the following areas: pallidum, subthalamic PSP was 63 (SD 7) years; mean age at the first nucleus, substantia nigra, and pons, and a low visit was 66-4 (SD 7) years; and mean age at to high density of neurofibrillary tangles or death was 69-6 (SD 6 6) years. None of the neuropil threads in at least three of the follow- patients had a familial parkinsonian disorder. ing areas: striatum, oculomotor complex, Of the 24 patients, 21 were right handed, one medulla, and dentate nucleus. It also requires was left-handed, one was ambidextrous, and the exclusion of other disorders including large one had no record of handedness. or numerous infarcts; profound diffuse or focal atrophy; Lewy bodies; changes diagnos- INITIAL SYMPTOMS OF PSP tic of Alzheimer's disease; oligodendroglial The onset of PSP symptoms was insidious and argyrophilic inclusions; Pick bodies; diffuse disease progression was steady. The initial spongiosis; or prion P positive amyloid symptom was most often (63%, n = 15) pos- plaques. All cases met the criteria for inclusion tural instability. Both postural instability and in the study-that is, neuropathological diag- falls occurred during the first year in 58% of nosis of PSP made with at least a 75% degree the patients. Dysarthria was the second most of certainty by the neuropathologists who pro- common symptom (33%, n = 8), followed by vided the cases, and detailed neurological bradykinesia (13%, n = 3). Visual distur- examinations, including neurooculomotor bances (diplopia, blurred vision, burning eyes, examination, on the first and last visits. light sensitivity) were the first symptoms in The patients' records were abstracted on 13% (n = 3) of the patients. Cognitive or standardised forms by eight of us (AM, MV, behavioural changes generally followed these KJ, KRC, RKBP, LD, IL, or CAM), who fol- initial symptoms, but were the first symptoms lowed strict instructions. Signs or symptoms in 8% (n = 2) of the patients. were recorded as missing data if they were not mentioned in the records. However, as the SYMPTOMS AT FIRST VISIT data were retrospectively collected, we The first clinical visit occurred a mean of 3-7 assumed that neurologists performed com- years (range 1-11 years) after onset of disease. plete examinations and considered that a fea- At the first visit, most of the patients with PSP ture (for example, supranuclear palsy) was had gait disorder and postural instability, a absent when they reported that the examina- history of falls, bilateral bradykinesia, a pre- tion was "within normal limits" (for example, dominant akinetic-rigid course, axial rigidity, cranial nerves). For the purpose of this study, vertical supranuclear palsy, and dysarthria upward gaze limitation was considered abnor- (table 2). Gait was unstable (n = 23), small mal when either a restriction, in pursuit, or stepped (n = 12), or broad based (n = 5). voluntary gaze, or both, of at least 50% of the Falls were backwards in eight of 11 patients normal range was described, or the upward for whom the direction of the falls was supranuclear palsy was rated as moderate to described. severe. The severity of gait disturbance was Supranuclear gaze deficits involved initially classified as follows: 0 = not affected; 1 = min- either downward or upward gaze and, later, imal (impaired but no assistance is needed); 2 horizontal gaze. The patients rarely presented http://jnnp.bmj.com/ = mild (needs the use of a stick or walker);
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