Striatal Blood Flow, Glucose Metabolism and and Atypical

898 Journal ofNeurology, Neurosurgery, and Psychiatry 1991;54:898-904 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from Striatal blood flow, glucose metabolism and 18F-Dopa uptake: difference in Parkinson's disease and atypical Parkinsonism

Makoto Otsuka, Yuichi Ichiya, Shinichi Hosokawa, Yasuo Kuwabara, Takashi Tahara, Toshimitsu Fukumura, Motohiro Kato, Kouji Masuda, Ikuo Goto

Abstract with 2-("F)fluoro-2-deoxy-D-glucose ("F- Striatal blood flow, glucose metabolism FDG) have been surveyed by many inves- and '5F-Dopa uptake were studied with tigators.5 Recently the levodopa analogue 6- positron emission tomography (PET) L-fluorodopa has been labelled with "F and a in eight non-demented patients with decreased uptake of 6-L-("F)fluorodopa ("F- idiopathic Parkinson's disease and eight Dopa) in the striatum has revealed the loss of with atypical Parkinsonism. Patients dopaminergic nerve terminals in patients with with atypical Parkinsonism had no Parkinson's disease in vivo.4"8 Furthermore, specific cause for the Parkinsonian symp- some studies have shown the difference of toms and were clinically different from caudate "F-Dopa uptake between Parkinson's Parkinson's disease with lack of resting disease and atypical Parkinsonism.9 Few tremor and a poor response to dopamin- reports, however, are available on the combin- ergic drugs. Decreased '5F-Dopa uptake ation of glucose metabolism and "F-Dopa in the putamen was observed in patients uptake in Parkinson's disease and atypical with Parkinson's disease and atypical Parkinsonism. Parkinsonism compared with normal We studied blood flow and glucose metab- controls. '5F-Dopa uptake in the head of olism in the head of the caudate and putamen the caudate was also significantly reduced separately for measuring the energy consump- in both conditions but relatively less in tion as a whole in each region and "F-Dopa Parkinson's disease. Decreased blood flow uptake for measuring the function of and glucose metabolism in the striatum dopaminergic nerve terminals in the head of associated with a global cerebral the caudate and putamen in patients with decrease were also observed in patients Parkinson's disease and atypical Parkinsonism with atypical Parkinsonism compared to clarify the pathophysiological similarity and with controls, while they were preserved difference between these conditions. in patients with Parkinson's disease, indicating affected neurons not only in the striatum but also in the cerebrum in Materials and methods patients with atypical Parkinsonism Patients http://jnnp.bmj.com/ compared with patients with Parkinson's Eight patients diagnosed clinically as Parkin- disease. The differences in the caudate son's disease and eight with atypical Parkin- '5F-Dopa uptake, and blood flow and sonism were studied (table 1). Patients were glucose metabolism in the cerebrum clinically classified in stage I, II or III from Faculty ofMedicine, including the striatum between Parkin- Hoehn and Yahr,'0 and none of them was Kyushu University, son's disease and atypical Parkinsonism demented. All patients with Parkinson's dis-

Fukuoka, Japan assessed by PET may be due to the ease had the three classic signs of resting on September 27, 2021 by guest. Protected copyright. Department of Radiology differences in the pathophysiological tremor, rigidity and akinesia with no M Otsuka mechanism between Parkinson's disease pyramidal signs, and responded well to Y Ichiya and atypical Parkinsonism. levodopa. Patients with atypical Parkinsonism Y Kuwabara were or T Tahara classified into either the akinetic type T Fukumura the akinetic rigid type. There might be a K Masuda There are "atypical" Parkinsonian patients criticism that patients with atypical Parkin- Department of who do not have any specific causes for the sonism were not classified into specific diseases Neurology Parkinsonian symptoms and are clinically dif- or syndromes, however, most cases with S Hosokawa I Goto ferent from idiopathic Parkinson's disease atypical Parkinsonism were in the early stages on not Department of based the lack of resting tremor and poor of their disease and could be categorised Neurophysiology response to dopaminergic drugs. The pure more precisely. Cases 9 and 10 with atypical M Kato akinetic type has been considered to be a Parkinsonism showed only akinesia without Correspondence to: different clinical entity from idiopathic Parkin- resting tremor nor rigidity. Case 11 had akin- Dr Otsuka, Department of Radiology, son's disease by some investigators.'2 Patients esia and neck rigidity without rigidity of the Faculty of Medicine, with atypical Parkinsonism may have the limbs. All three cases with the akinetic type Kyushu University, 3-1-1 Maidashi, Higashi-ku, other brain lesions with or without striatal showed impaired ocular movement. Cases 12, Fukuoka 812, Japan dopamine depletion and are poorly responsive 13, 14, 15 and 16 had akinesia and rigidity Received 20 July 1990 to levodopa. without resting tremor. All patients with and in final revised form 18 January 1991. In Parkinson's disease, regional cerebral atypical Parkinsonism had no specific cause, Accepted 24 January 1991 glucose metabolism (rCMRGlc) measured such as vascular damage, intoxication, Striatal bloodflow, glucose metabolism and '8F-Dopa uptake: difference in Parkinson's disease and atypical Parkinsonism 899 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from

Table 1 Clinicalfeatures ofpatients with Parkinson's disease (PD) (1-8) andpatients with atypical Parkinsonism (PKM) (9-16) PD PKM Akinetic type Akinetic rigid type Case number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Age/Sex 37/F 41/M 52/M 53/M 47/M 56/F 67/F 50/F 54/M 76/M 61/M 74/F 57/M 74/M 48/M 71/M Diseaseduration (yrs) 5 2 4 3 1 2 7 6 4 4 2 3 2 1 4 4 Clinical stage' I I I II III III III III II III III II II III III III Tremor + ** ** + + + ** + _ _ + d + d + d Rigidity + + ** + ** ** ** ** _ - ** + + + *** ** Akinesia ± ± ± ± ** ** + ** + ** ** + + ** ** ** Dysarthria - - - - - + - + ** ** + - + + + + Cerebellarfeatures ------+ - + - + + + Pyramidal sign ------+ Postural hypotension ------+ Urinary incontinence ------Decreased sweating ------Treatmentb 0 0 D,A P A P P, A D, P, A P P 0 P, A 0 0 P, A A Efficacyoflevodopa' E E EE E E E E NE NE NE NE NE NE NE NE CT finding Cortical atrophy ------+ + + + Cerebellar atrophy ------_ _ - _ + ***-marked; **-moderate; +-mild; --absent; aFrom Hoehn and Yahr'°; bO.no treatment; D-levodopa; P-bromocriptine, pergolide; M-amantadine; A-anticholinergic; CE-effective; NE-not effective; dpostural tremor; 'neck rigidity.

metabolic deficit, encephalitis or head injury, by walking difficulty, dysarthria and postural and levodopa was not effective in any of them. tremor. Postural tremor was dominant in his Cases 11, 12, 13 and 14 showed mild cortical left hand. On examination he showed mild atrophy, but the ventricular dilatation was cogwheel rigidity in his limbs and postural minimal in all four. Patients with any abnor- hypotension (112/80 mm Hg in supine posi- malities in the striatum on CT and/or MRI tion, 80/60 standing). He also showed impaired were excluded from this study. fine finger movement and adiadochokinesis. Case reports of patients with Parkinson's Deep tendon reflexes were increased and a disease are omitted as the inter-patient dif- Babinski's sign was present bilaterally. ferences in Parkinson's disease is not discus- Case 14 A 74 year old man started to sed in this study. Case reports for patients complain of difficulty in handwriting at the age with atypical Parkinsonism are as follows: of 73. This was followed by walking difficulty Case 9 A 54 year old right handed man and a tendency to fall. He also noticed dysarth- started to complain of writing difficulty at the ria. On examination he showed mild rigidity age of 50. This was followed by dysarthria of the limbs. No postural hypotension was (microphonia). There was a gradual progres- observed. His fine finger movement and coor- sion of his symptoms. He later began to drag dination was mildly disturbed. his right foot. On examination he showed Case 15 A 48 year old man complained of

impaired fine finger movement and adiado- clumsiness in the right hand at the age of 44. http://jnnp.bmj.com/ chokinesis. No postural hypotension was This was followed by short shuffling steps when observed. Vertical eye movement were walking. He also developed dysarthria. On slightly impaired. examination he showed marked cogwheel Case 10 A 76 year old man started to rigidity of extremities. No postural hypoten- complain ofwalking difficulty and a tendency to sion was observed. His fine finger movement fall, a few years previously. This was followed and coordination was mildly disturbed in the by dysarthria and difficulty in writing. Examin- right side and slightly disturbed in the left side. ation showed slightly impaired vertical eye Case 16 A 71 year old man complained of on September 27, 2021 by guest. Protected copyright. movement. He showed no resting tremor nor postural tremor of both hands at the age of 67. rigidity. No postural hypotension was This was followed by walking difficulty and observed. dysarthria. On examination he showed Case 11 A 61 year old man began to com- moderate cogwheel rigidity of the limbs. No plain of sleep apnoea at the age of 59. He also postural hypotension was observed. noticed dysarthria, difficulty in writing and Cases 1, 2, 11, 13 and 14 had received no double vision. On examination he showed mild treatment before the PET examination. The impairment of upgaze. He also showed neck other cases received medication before the rigidity without rigidity of the limbs. No PET examination as shown in table 1, and postural hypotension was observed. His fine medication was stopped at least 48 hours before finger movement and coordination was mildly the examination. disturbed. The "8F-Dopa uptake was measured in all Case 12 A 74 year old woman developed a cases except for cases 14 and 16, and regional slow gait at the age of 71. This was followed by cerebral blood flow (rCBF) was measured in all postural tremor. She also complained of cases except for cases 13, 14 and 16. The anorexia and lost 5 kg in a year. On examina- rCMRGlc was measured in all cases except for tion she showed mild rigidity in the limbs. No cases 4 and 15. postural hypotension was observed. For comparison eight, mean (SD) age, 47-3 Case 13 A 57 year old man had developed (15 8) years, eight, mean (SD) age, 49-6 (14-0) impotency at the age of 55. This was followed years, and seven, mean (SD) age, 52-1 (13 6) 900 Otsuka, Ichiya, Hfosokawa, Kuwabara, Tahara, Fukumura, Kato, Masuda, Goto J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from scanning. The region of interest (ROI) for cerebellar hemisphere was sited in the OM +2 cm plane with a 1-4 x 1-8 cm rectangle. The ROIs of the head of the caudate and putamen were outlined visually on the "8F- Dopa image by reference to the glucose or blood flow image and also the images of CT and/or MRI. They were generally sited in the OM + 5 cm plane, but another five slices in the OM +2-7 cm, +4-2 cm, +5 7 cm, +7-2 cm and + 8-7 cm planes were also taken and the most appropriate slice level ofcaudate head and putamen was sought. The ROI to the cerebral hemisphere was outlined visually on the glucose or blood flow image in the third slice, and excluded caudate and putamen to obviate the striatal difference among the groups (fig 1). Two to seven mCi (54 to 260 MBq) of '8F- Dopa was injected intravenously and PET data was obtained every two minutes for 20 minutes, ------, every four minutes for 40 minutes and at 70, 90, 120 minutes for 15 minutes. The tissue activity of '8F in the bilateral caudate and putamen was corrected by the non-specific retention of '8F in cerebellar hemispheres. The ratio of caudate or putamen to cerebellum increased steadily with time for 120 minutes after the injection (fig 2) and the ratio of caudate or putamen to cerebellum at 120 minutes was calculated. The rCBF was measured just before the "8F- Dopa study by the oxygen- 15 steady state technique, 2 using continuous inhalation of 100 mCi (3-7 GBq) of oxygen-15 labelled car- bon dioxide. Arterial blood sampling was per- Figure I The region of cerebellar hemisphere in the OM + 2 cm plane (rCe, ICe), formed from a catheter in the femoral artery and that of the head of the caudate (rC, IC), putamen (rP, IP) andglobal cerebral scan. hemisphere (excluding caudate head and putamen) (rH, 1H) in the OM + S cm plane. four times during six minutes of emission Upper twofigures are images of rCMRGlc and lower twofigures are images of '8F-Dopa The rCMRGlc was measured on a different uptake. day within a week from the '8F-Dopa and CBF study using '8F-FDG. Three to seven mCi (110 years, normal volunteers had dopamine, rCBF to 260 MBq) of '8F-FDG was injected and rCMRGlc studies, respectively. The intravenously, and arterial blood samples were obtained at predetermined intervals from the volunteers had no neurological deficit and CT http://jnnp.bmj.com/ scans without abnormality were taken in the time of injection until the end of scanning. The volunteers over 50 years old. rCMRGlc was determined from the emission scan and blood curve data by using the model of Methods Sokoloffet al 3 and Phelps et al 4 later modified PET was performed with a HEADTOME III by Brooks.'5 (Shimadzu Corporation, Japan) at a spacial Significant clinical asymmetry was observed solution of 8 2 mm full width at half maximum in cases 1, 2, 3, 9, 13 and 15, and '8F-Dopa (FWHM)." A transmission scan with a 'Ge/ uptake was decreased more in the contralateral on September 27, 2021 by guest. Protected copyright. 68Ga ring source was obtained for correction of side in all ofthem. As no significant asymmetry attenuation. Five slices were taken in the in the clinical features and in the '8F-Dopa orbitomeatal line (OM) + 2 cm, + 3-5 cm, uptake was observed in all the other cases, + 5 cm, + 6-5 cm and + 8 cm planes by a single values were calculated as the mean of the

Table 2 PET results in patients with Parkinson's disease (PD) (1-8) and patients with atypical Parkinsonism (PKM) (9-16) PD

Case number 1 2 3 4 5 6 7 8 Mean SD 8F-Dopa uptakeb Ca 2-68 2-48 2 06 2 25 2 03 1 84 1-84 1 93 2 14 0 31 FM 1-97 2-23 1-73 1-77 1-35 1-60 1-56 1 61 1 73 027 CBFc C 45-1 38 5 31 6 37-9 40 4 31.0 35-8 40 8 37.6 4 8 P 46-2 439 375 36-7 38-0 374 403 448 406 38 GC' 36-6 33.7 30 8 30-8 30 5 31-8 29-6 32.7 32-7 3-0 CMRGIcd C 7 50 7.79 7 76 6 98 8-90 8 01 7-32 7-75 0 61 P 8-64 8-55 8 18 7-29 8-41 8-87 8 82 8-39 0 54 GC 696 629 618 547 651 596 679 631 051 C-caudate; P-putamen; GC-global cerebrum (excluding caudate and putamen); buptake ratio to cerebellum; 'ml/min/100 ml; dmg/min/100 ml. Striatal bloodflow, glucose metabolism and '8F-Dopa uptake: difference in Parkinson's disease and atypical Parkinsonism 901 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from

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Figure 3 The '8F-Dopa uptake r'atio of the caudate to cerebellum (C) and putamen to cerebellum (P) at 120 PDI, 11(n=4) minutes after the administration in controls, patients with Parkinson's disease (PD) andpatients with atypical E: ^ + _ + k< (n=4) Parkinsonism (PKM). Means and SDs are shown. **, * indicate significant difference between the two indicated groups by Scheffe's F-test (**: p < 001, *: p < 0-05, -2 NS: not significant). 0 30 60 90 120 were shown in table 2. The uptake ratio of the Time after injection (min) caudate to cerebellum and the putamen to cerebellum at 120 minutes after the administra- Figure 2 Time courses of radioactivity on the ratio of the head of the caudate to tion of '8F-Dopa in patients with Parkinson's cerebellum (a), and that on the ratio ofputamen to cerebellum (b) in normal controls, patients with idiopathic Parkinson's disease stage I and II (PD I, II) andpatients with disease and atypical Parkinsonism were com- Parkinson's disease stage III (PD III). Means and SDs are generally shown except pared with normal controls in fig 3. Decreased where deviation bars are omittedfor clarity. '8F-Dopa uptake in both regions were observed in patients with Parkinson's disease and bilateral sides generally and values for the more atypical Parkinsonism compared with normal decreased side in the '8F-Dopa uptake were controls (p < 0 01) by Scheffe's F-test, evaluated in cases 1, 2, 3, 9, 13 and 15. however, the caudate '8F-Dopa uptake in Park- inson's disease was relatively spared. The '8F- Dopa uptake in the putamen decreased more Results than that in caudate significantly in Parkinson's Time courses of radioactivity on the ratio of disease by t test (p < 0-01). There was no caudate to cerebellum and putamen to statistical differences in theputaminal '8F-Dopa cerebellum in normal controls, patients with uptake between Parkinson's disease and Parkinson's disease stage I and II, and patients atypical Parkinsonism. http://jnnp.bmj.com/ with Parkinson's disease stage III are shown in There was no significant difference in the figs 2a and 2b, respectively. Although there was rCBF of the caudate and putamen in patients no difference between the caudate and putamen with Parkinson's disease compared with con- in normal controls, the radioactivity of the trols, but the rCBF of both regions in patients putamen decreased more than that of the with atypical Parkinsonism decreased in com- caudate in patients with Parkinson's disease. parison with controls (p < 0-01) and patients

Both of them decreased more in patients with with Parkinson's disease (p < 0-01) (fig 4). The on September 27, 2021 by guest. Protected copyright. Parkinson's disease stage III than in patients rCBF of the global cerebrum (excluding the with Parkinson's disease stage I and II. caudate and putamen) in patients with atypical All PET results in each patient with Parkin- Parkinsonism as well as that of the caudate and son's disease and with atypical Parkinsonism putamen decreased in comparison with con-

PKM Controls Akinetic type Akinetic rigid type 9 10 11 12 13 14 15 16 Mean SD Mean SD 1*49 1*55 1*79 1*65 1*85 2-19 1*76 0-25 2-69 0-11 1-51 1-30 1-73 1-68 1-89 2-20 1-72 0-31 2-80 0-36 19 9 24-0 24-4 22-4 24-5 23-0 1-9 35-5 6-5 25-0 25-9 32-9 26-5 33-2 28-7 4-0 39-1 4-8 23-5 24-6 25-2 25-4 27-4 25-2 1*4 30-1 3-3 5-47 5-94 5-52 5-40 6-38 6-09 5 20 5-71 0-43 7-58 0-33 6-42 6-88 5-99 6-44 6-92 6-00 5-29 6-28 0-57 7-86 0-53 5-67 5-35 4-78 5-35 5-61 5-35 4-49 5-23 0-43 6-62 0-98 902 Otsuka, Ichiya, Hosokawa, Kuwabara, Tahara, Fukumura, Kato, Masuda, Goto J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from Figure 4 Regional CBF FkV neurochemical studies showing that dopamine of the caudate (C) and wr wr putamen (P) in controls levels are depressed more in the putamen than andpatients with in the caudate in Parkinson's disease.'6 On the Parkinson's disease (PD) other hand, equally decreased '8F-Dopa uptake and patients with atypical Parkinsonism (PKM). in the putamen and in the caudate in atypical E Parkinsonism seems to reflectthedifferentpath- Means and SDs are 0 shown. **, NS as 0 ogenesis of Parkinson's disease and atypical indicated previously. v- .E_ Parkinsonism. The unchanged rCBF and rCMRGlc in the E putamen and caudate from normal controls, U-m assuming that there was no change in the cJ striatal energy consumption as a whole, in patients with Parkinson's disease was also shown in this study. Preserved function of dopaminergic receptors has been measured by Control PD PKM PET using "C-N-methylspiperone in patients (n=8) (n=8) (n=5) with Parkinson's disease,'7 and hypometab- olism of only dopaminergic nerve terminals trols (p < 0-01) and patients with Parkinson's might not affect the total metabolism of the disease (p < 0-01) (table 2). The rCMRGlc of putamen or caudate. Some reported increased caudate and putamen also decreased signifi- striatal CMRGlc34 and others decreased cantly in patients with atypical Parkinsonism striatal CMRGlc5 in patients with Parkinson's compared with controls (p < 0-01) and disease. This inconsistency with our study and patients with Parkinson's disease (p < 0-01) the others may be due to the different clinical (fig 5). The rCMRGlc of the global cerebrum stages at which the PET study was carried out. in patients with atypical Parkinsonism also Patients with Parkinson's disease in our study decreased in comparison with controls were in the relatively early stages and not (p < 0-01) and patients with Parkinson's dis- demented, while we have a different result of ease (p < 0-01) (table 2). decreased global cerebral glucose metabolism Images of '8F-Dopa uptake at 120 minutes in demented patients with Parkinson's disease after injection (obtained by the PET data from (Hosokawa et al, in preparation). 112 to 127 minutes after injection), rCBF and Cases 9, 10, and 11 were not responsive to rCMRGlc at a level of the striatum in a control levodopa and showed symptoms of pure akin- subject, in a patient with Parkinson's disease esia without resting tremor nor rigidity. This (Case 5) and in a patient with atypical Parkin- "pure akinetic" type may be a different clinical in which a sonism (Case 1 1) are shown in figs 6a, b, and c, entity from Parkinson's disease,'2 respectively. part ofearly phases ofprogressive supranuclear palsy (PSP) may be included.'8 Although the relationship between pure akinesia and PSP Discussion remains unclear, PET results in the previous Decreased '8F-Dopa uptake in the putamen in reports of decreased striatal CBF, oxygen and glucose metabolism in patients with pSpl9 20 are

patients with Parkinson's disease measured by http://jnnp.bmj.com/ to of rCBF and PET in this study and in previous reports,4 &8 is similar the present study coincident with the dopamine depletion prob- rCMRGlc in patients with atypical Parkinson- a ably due to the hypofunction or decreased ism. Akinetic rigid syndrome may be part of retention capacity of dopamine in dopaminer- spectrum of multiple system atrophy (MSA). gic nerve terminals in the putamen. Decreased Cases 12 and 16 may be close to striatonigral but relatively spared '8F-Dopa uptake in the degeneration (SND), case 13 was diagnosed as head ofthe caudate in patients with Parkinson's Shy-Drager's syndrome, and cases 14 and 15 disease is also coincident with the previous had additional cerebellar symptoms and signs on September 27, 2021 by guest. Protected copyright. PET studies, as well as with the previous and may be the early phase of olivopon- tocerebellar atrophy (OPCA). PET studies in patients with SND2' showed decreased striatal Figure 5 Regional CMRGlc of the caudate q glucose metabolism, which was consistent with (C) and putamen (P) in 12 NS S our results in patients with atypical Parkinson- controls and patients with ism. The clinical diagnosis of atypical Parkin- Parkinson's disease (PD) sonism may be replaced by the final diagnosis and patients with atypical 10 Parkinsonism (PKM). after specific symptoms and signs develop. Means and SDs are - The differentiation from Parkinson's disease NS as shown. **, E can be clinically performed and is of practical indicated previously. importance. 6 A decrease of rCBF and rCMRGlc in the E caudate and putamen in patients with atypical 4 Parkinsonism (in spite ofno focal abnormalities cx: in the striatum on CT and/or MRI), suggests cJ 2 the impairment of the total neuronal activity in the striatum, including the hypofunction of 0 striatal non-dopaminergic neurons since the dopaminergic neurons comprise 10% or less of (n=7) (n=7) (n=7) the striatal neurons from histological study of Striatal bloodflow,glucose metabolism and "F-Dopa uptake: difference in Parkinson's disease and atypical Parkinsonism 903 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from Figure 6 Images of 2.0 '8F-Dopa uptake at 120 minutes after injection (a), rCBF (b) and rCMRGlc (c) at a level of the striatum in a control subject, in a patient with Parkinson's disease (PD) (case 5) and in a patient M. with atypical trs Parkinsonism (PKM) I 1.L (case 11). Striatal '8F-Dopa uptake decreased in PD and PKM compared with that in a control. The '8F-Dopa uptake in caudate in PD seemed relatively spared in comparison with that in putamen (a). The rCBF and rCMRGlc in global cerebrum including the Corntr-oI PD P KMA caudate andputamen decreased in PKM compared to those in Q control and PD (b, c).

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the rat."2 Furthermore, a decrease of rCBF and patients with idiopathic Parkinson's disease, rCMRGlc in the cerebrum suggests the and equally decreased '8F-Dopa uptake in the hypofunction of not only the caudate and caudate and putamen in patients with atypical putamen but also of the cerebrum in patients Parkinsonism. 2) Normal rCBF and rCMRGlc with atypical Parkinsonism. in patients with Parkinson's disease and There was no dissociation between rCBF decreased rCBF and rCMRGlc of the caudate and rCMRGlc in this study and we have and putamen associated with global cerebral previously observed good coupling between decrease in patients with atypical Parkinson- rCBF, rCMRO2 and rCMRGlc in PSP ism. These results may underlie the similarity patients.'9 This is because all the patients in this and the difference in the pathophysiological study and in the previous report'9 were in the mechanism of idiopathic Parkinson's disease chronic state. and atypical Parkinsonism. In conclusion, our study has shown the different PET results between idiopathic Park- We thank Dr R Gunasekera for editorial assistance. This study inson's disease and atypical Parkinsonism. 1) was partly supported by Grant 62-10 from the Japanese Ministry of Health and Welfare and Grant-in Aid 63570493 for Decreased '8F-Dopa uptake in the caudate and Scientific Research from the Japanese Ministry of Education, putamen with relative sparing ofthe caudate in Science and Culture. 904 Otsuka, Ichiya, Hosokawa, Kuwabara, Tahara, Fukumura, Kato, Masuda, Goto J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.54.10.898 on 1 October 1991. Downloaded from 1 Barbeau A. Parkinson's disease: clinical features and J Comput Assist Tomogr 1980;6:727-36. etiopathology. In: Vinken PJ, et al, eds. Handbook of 13 Sokoloff L, Reivich M, Kennedy C, et al. The [14C] deoxy clinical neurology. 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