Guidelines for the management of Parkinson's disease. The Parkinson's Disease Consensus Working Group.

Parkinson's disease is a chronic and disabling illness and there is currently wide variation in its management. This article presents the first UK-specific guidelines for the management of Parkinson's disease and it contains a treatment decision free to aid the physician in deciding when and how to treat patients. We hope this document will prove useful to all those involved in the planning and delivery of care to patients with Parkinson's disease.

Measuring the rate of progression and estimating the preclinical period of Parkinson's disease with [18F]dopa PET.

OBJECTIVES: To measure the rate of progression in striatal [18F]dopa metabolism in a large group (n=32) of patients with Parkinson's disease, to estimate the average duration of preclinical period, and to examine the influence of the PET method on the assessment of rate of progression and preclinical period. METHODS: Thirty two patients with Parkinson's disease (mean age 58 (SD 13) years, mean duration 39 (SD 33) months) were assessed with [18F]dopa PET and UPDRS scoring on two occasions a mean of 18 (SD 6) months apart. PET data were sampled with separate caudate and putamen and total striatal regions of interest, and both graphical (Ki) and ratio methods of analysis. RESULTS: The mean annual rate of deterioration in [18F]dopa uptake varied according to structure and method of analysis, with putamen Ki showing the most rapid mean rate of progression (4.7% of normal mean per year). The group showed a significant deterioration (p<0.0004, paired two tailed t test) in UPDRS and in the putamen (p=0.008) and total striatal (p=0.012) [18F]dopa uptake measured using a graphical analysis, but no significant change in caudate or putamen uptake measured by a ratio approach. A study of sensitivity confirmed that putamen Ki was the most sensitive measure of disease progression, caudate ratio the least. Symptom onset in Parkinson's disease was estimated at a mean putamen [18F]dopa uptake (Ki) of 75% of normal and a mean caudate [18F]dopa uptake (Ki) of 91% of normal. CONCLUSIONS: Estimation of mean rate of progression varies according to the sensitivity of a functional imaging method to clinical severity. Sensitivity and reproducibility of method must be considered when designing studies of disease progression and neuroprotection. The mean preclinical period in Parkinson's disease is unlikely to be longer than seven years.

Functional magnetic resonance imaging of single motor events reveals human presupplementary motor area.

Conventional functional imaging paradigms use periods of repetitive task performance to generate sustained functional signal changes. We have developed a technique of imaging the small, transient signal changes that occur after single cognitive events. The technique uses echo-planar imaging at 3 T to generate functional images of the whole brain with a temporal resolution of 3 seconds. It uses a signal averaging technique to create time sweeps of functional activity. After a single cognitive event, widely distributed patterns of brain activation can be detected and their time course measured. This technique enables the individual cognitive tasks that constitute a paradigm to be analyzed separately and compared. We describe the application of this new technique to separate the cognitive elements in a simple "go/no-go" motor paradigm. Comparison of activation patterns during "go" and "no-go" responses reveals hierarchical subdivision of the medial premotor cortex into an anterior region (presupplementary motor area) involved in movement decision making and a posterior region (supplementary motor area proper) directly involved in motor execution.

Dopaminergic function in familial Parkinson's disease: a clinical and 18F-dopa positron emission tomography study.

There is increasing evidence for familial aggregation in Parkinson's disease (PD). It is possible that some asymptomatic relatives of PD patients have subclinical nigral Lewy body pathology and their identification could help determine the true prevalence of the disease. We used 18F-dopa positron emission tomography to investigate nigrostriatal dopaminergic terminal function in asymptomatic members of 7 unrelated kindreds in which at least 2 members had parkinsonism. Eight (25%) of the 32 asymptomatic relatives showed abnormal putamen 18F-dopa uptake (2.5 standard deviations below the normal mean). When discriminant function analysis was applied, all of these 8 subjects plus another 3 were classified with high probability as having PD. On neurological examination, 5 of the 32 relatives scanned had an isolated mild postural tremor and 2 of these 5 had reduced putamen uptake. Our findings provide further support for a role of inheritance in the etiology of PD and suggest that the penetrance for nigrostriatal dopaminergic dysfunction in familial clusters of PD is higher than the prevalence of clinical parkinsonism reported in epidemiological surveys.

Regional changes in [18F]dopa metabolism in the striatum in Parkinson's disease.

We have investigated regional changes in dopamine metabolism within the basal ganglia with clinical progression of idiopathic Parkinson's disease, using coregistration of [18F]dopa-PET and MRI images and comparing six normal subjects with 15 Parkinson's disease patients in a cross-sectional study. We have demonstrated that [18F]dopa metabolism in the dorsal putamen is reduced to almost 50% of normal both caudally and rostrally early in the disease whilst the ventral putamen is not significantly affected. With progression of symptoms there is loss of dopa metabolism from the ventral putamen, the ventrocaudal putamen in advance of the ventrorostral putamen. Throughout the disease the ventrorostral putamen is relatively preserved; even in the most advanced group [18F]dopa uptake is reduced here by only 30%. We conclude that the progression of Parkinson's disease is associated with a focal process affecting only the dorsal putamen in its early (and preclinical) phase then affecting the ventral putamen with increasing disease severity.

An [18F]dopa-PET and clinical study of the rate of progression in Parkinson's disease.

We have studied disease progression in a group of 10 patients with recent onset idiopathic Parkinson's disease [mean age 53.7 +/- 12.6 years, mean duration 18.3 +/- 6.5 months, mean unified Parkinson's disease rating scale (UPDRS) 19.0 +/- 9.5], and a group of seven patients with established Parkinson's disease (mean age 60.1 +/- 15.1 years, mean duration 70.8 +/- 35.5 months, mean UPDRS 47.9 +/- 18.1), using both clinical assessment and [18F]dopa-PET. Results were compared with those of a group of 10 normal subjects (age 66 +/- 16 years). Mean putamen [18F]dopa influx constant (Ki) was a reliable measurement (R = 0.82) and the most sensitive marker of disease progression (r = -0.85, P < 0.0001). The mean annual rate of reduction in mean putamen Ki in the Parkinson's disease patients was 12.5% per annum, whereas the control group showed no significant change in Ki over a mean of 32 months follow up. The rate of progression was more rapid in the recent onset compared with the established disease group but this did not reach statistical significance. Assuming a linear progression for the entire group we estimate symptom onset at a mean putamen Ki 79% of normal with a mean preclinical period of 3.1 years.

Functional magnetic resonance imaging in clinical neurology.

Functional magnetic resonance imaging is a relatively new, noninvasive technique which has a maximum spatial resolution in the range of 1 mm and temporal resolution of 0.1-1 s. The technique is not quantitative but results have proved reliable and reproducible and studies are quick to perform. Already substantial progress has been made in mapping the visual, sensorimotor and auditory systems and promising results achieved in the study of higher cognitive function such as memory and linguistic processing. Clinical applications have been made in epilepsy surgery, the study of schizophrenia, genetic abnormality and cerebral injury.

Clinical and [18F] dopa PET findings in early Parkinson's disease.

Twenty seven patients with recent onset (mean symptom duration 22 (SD 14) months, Hoehn and Yahr score 1.8 (SD 0.7)) Parkinson's disease were studied with [18F]dopa PET. There was a correlation between putamen influx (Ki) and clinical rating, but not symptom duration. In 11 patients with hemi-Parkinson's disease of recent onset there were significant differences between normal (mean 0.0123 (SD 0.0023)), asymptomatic (mean 0.0099 (0.0020)) and symptomatic (mean 0.0070 (00.014)) putamen Kis. This suggests that Parkinson's disease has a widely variable rate of progression, and is most compatible with a short preclinical period. Symptom onset was estimated at a putamen Ki of between 57% and 80% of normal. Most ipsilateral putamen Ki values in early asymmetric Parkinson's disease fell within the normal range. The implication is that either the disease is not established in the ipsilateral putamen or that the technique is insufficiently sensitive to detect it. Discriminant analysis completely separated the normal and Parkinson's disease cohorts, but when a discriminant function from a previous study was used predictively four of the 27 patients with Parkinson's disease were incorrectly classified as normal.

The effect of entacapone (OR-611) on brain [18F]-6-L-fluorodopa metabolism: implications for levodopa therapy of Parkinson's disease.

We used PET and [18F]-6-L-fluorodopa ([18F]dopa) to measure the effect of a peripheral COMT inhibitor, entacapone, on the extracerebral metabolism and subsequent striatal uptake of [18F]dopa. Four parkinsonian patients and six age-matched normal controls were each scanned twice, once after carbidopa (150 mg) plus placebo and once after carbidopa (150 mg) plus entacapone (400 mg or 800 mg). Without entacapone premedication, by 90 minutes from injection, only 22% of the [18F] signal in plasma represented unmetabolized [18F]dopa (the balance being 3-O-methyl[18F]dopa). After entacapone medication, this fraction increased to 56% of the [18F] signal (p < 0.0001). We did not find any significant differences between the changes observed in patients versus controls or between those subjects who received 400 mg entacapone versus 800 mg in either this or any of the other reported measures. PET image contrast increased in all cases, reflecting an increase in the specific striatal signal ([striatum-occipital]:occipital ratio increased 38% [p < 0.0001]). Entacapone did not alter the rate of striatal uptake and decarboxylation of [18F]dopa as estimated using a graphic approach with metabolite-corrected plasma as input function to calculate the influx constant, Ki(p) (p = NS). This confirms that such an analytic approach adequately corrects for the effect of extracerebral [18F]dopa methylation. In contrast, the influx constant Ki(o) (calculated using occipital counts as the input function) increased 45% after entacapone (p < 0.0001). This demonstrates the sensitivity of this analytic approach to the presence of peripheral 3-O-methyl[18F]dopa and provides an estimate of the percentage increase in brain free [18F]dopa resulting from entacapone premedication.

PET studies of the presynaptic and postsynaptic dopaminergic system in Tourette's syndrome.

Dysfunction of the dopaminergic pathway has been postulated to underlie the symptomatology of Tourette's syndrome. Presynaptic functional integrity of dopaminergic terminals was assessed with 18F-dopa PET in 10 patients with Tourette's syndrome, three of whom were drug free and seven of whom were on neuroleptic treatment. Dopamine D2 receptor site density was measured with 11C-raclopride PET in a further group of five drug free patients with Tourette's syndrome. Mean caudate and putamen 18F-dopa influx constants were similar in patients with Tourette's syndrome and controls, and there was no difference in striatal 18F-dopa uptake between the treated and untreated Tourette's syndrome groups. Mean caudate and putamen 11C-raclopride binding potentials in patients with Tourette's syndrome were also similar to control values. The findings suggest that striatal metabolism of exogenous levodopa and the density of striatal D2 receptors are both normal in patients with Tourette's syndrome and that Tourette's syndrome does not arise from a primary dysfunction of dopaminergic terminals.

Differential diagnosis of Parkinson's disease, multiple system atrophy, and Steele-Richardson-Olszewski syndrome: discriminant analysis of striatal 18F-dopa PET data.

Clinicopathological series indicate that the clinical diagnosis of Parkinson's disease is correct in only 80% of cases. Multiple system atrophy (MSA) and Steele-Richardson-Olszewski syndrome (SRO) comprise most of the misdiagnoses. By means of 18F-dopa PET the pattern of nigrostriatal dopaminergic dysfunction in 28 patients with clinically probable Parkinson's disease, 25 with MSA, and 10 patients with SRO, was assessed and compared with the pattern in 27 normal subjects. Discriminant function analysis was used to assess the ability of 18F-dopa PET to categorize individual parkinsonian patients on the basis of their caudate and putamen tracer uptake. Discriminant function analysis assigned all control subjects a normal category. One Parkinsonian patient out of 63 was classified as "normal" on the basis of PET findings, although this patient had significantly reduced putamen 18F-dopa uptake. Discriminant function analysis was less effective at distinguishing different categories of akinetic-rigid syndrome on the basis of their striatal 18F-dopa uptake, as judged against clinical criteria. Patients clinically labelled as having typical or atypical Parkinsonian syndromes were assigned the same category on PET criteria 64% and 69% of the time, respectively. When all three categories of Parkinson's disease, MSA, and SRO were considered together, clinical and 18F-dopa PET findings correlated in 64% of patients assigned a diagnosis of Parkinson's disease and 70% of those given a diagnosis of SRO; MSA was less readily discriminated, patients with MSA being assigned to MSA, Parkinson's disease, and SRO groups with equal frequency. The correlation between clinical and discriminant function analysis assignment improved when separate comparisons were made between Parkinson's disease and MSA, or Parkinson's disease and SRO groups. In these analyses, clinical and PET categorisation of MSA and Parkinson's disease agreed in 60% of cases, and of SRO and Parkinson's disease in 90% of cases. In summary, (18)F-dopa PET successfully discriminates normal subjects from parkinsonian patients, and patients with Parkinson's disease from patients with SRO, but is less reliable in distinguishing Parkinson's disease from MSA. The concomitant assessment of striatal neuronal function with additional PET tracers may be necessary to reliably differentiate typical and atypical parkinsonian syndromes.

Separating Parkinson's disease from normality. Discriminant function analysis of fluorodopa F 18 positron emission tomography data.

OBJECTIVE: To explore the relationship between normal and parkinsonian fluorodopa F 18 (18F-6-L-fluorodopa [18F-dopa]) uptake data to identify clinically normal subjects who may have preclinical Parkinson's disease. DESIGN: A statistical comparison of striatal fluorodopa F 18 positron emission tomography scan data from patients with Parkinson's disease and normal controls. SETTING: Positron emission tomography unit within a postgraduate teaching hospital. MAIN OUTCOME MEASURES: Discriminant function analysis used to compare the pattern of striatal (left and right caudate and putamen) fluorodopa F 18 uptake in normal subjects and patients with Parkinson's disease. RESULTS: The discriminant score that best separates patients with Parkinson's disease from normal controls is a function of the lowest putamen influx constant minus a function of the caudate influx constant values. Borderline low normal subjects have slightly low fluorodopa F 18 uptake throughout the striatum, whereas patients with early Parkinson's disease have low fluorodopa F 18 uptake in one putamen with preserved uptake in the caudate (for normal subjects, subtracting the caudate influx constants from a function of the lowest putamen value lowers the discriminant score, although it remains positive; for patients, subtracting a larger caudate value from a function of the putamen uptake value leads to a negative score). One control subject had a borderline low discriminant score, compatible with focal nigral pathological changes as expected in preclinical Parkinson's disease. A repeated scan taken 3 years later showed a marked reduction in fluorodopa F 18 uptake, suggesting progressive nigral dysfunction. CONCLUSION: Normal and parkinsonian fluorodopa F 18 uptake data differ both in the overall level of tracer uptake and in its spatial distribution. Subjects whose overall striatal fluorodopa F 18 uptake falls at the borderline of normal and parkinsonian values are likely to be normal if they have uniformly low uptake, but may have early or preclinical Parkinson's disease if uptake into putamen is very much lower than uptake into caudate.

Investigation of the opioid system in absence seizures with positron emission tomography.

The neuroanatomical and pathophysiological basis of primary generalised absences is uncertain. Administration of endogenous opioids has been shown to result in absence-like seizures in animal models. Positron emission tomography scans were performed in eight patients with primary generalised epilepsy and eight control subjects. Regional cerebral blood flow was measured interictally with C15O2, after which a 90 minute dynamic study with the opioid-receptor ligand 11C-diprenorphine was performed. Serial absences were precipitated by hyperventilation for 10 minutes, starting 30-40 minutes after injection of diprenorphine. Absences, with generalised spike-wave discharges on the EEG, occurred for between 10% and 51% of the provocation period. No individual (normal or patient) had any interictal focal abnormalities of cerebral blood flow. After provocation of serial absence seizures, there was increased diprenorphine elimination from the association cortex, but not from the thalamus, basal ganglia, or cerebellum, compared with control subjects and patients scanned without provocation of absences. It was possible to simulate the observed increased diprenorphine elimination following seizures in cerebral cortex using a two tissue compartment model, with an estimated 15-41% decrease in the specific tracer uptake rate constant (k3). These results suggest that endogenous opioids are released in the association cortex at the time of serial absences, lead to increased receptor occupancy, and may have an important role in the pathophysiology of generalised absences.

Striatal [18F]dopa uptake in familial idiopathic dystonia.

It is known that most cases of idiopathic torsion dystonia (ITD) are inherited in an autosomal dominant fashion. Despite clarification of the underlying genetic defect, no consistent structural lesion has been identified in ITD, and it is probable that a biochemical disturbance is the basis of the disorder. To determine whether there is impaired function of the nigro-striatal dopaminergic terminals in ITD we studied 11 subjects with generalized ITD and a positive family history using [18F]dopa and PET scanning. Of these 11 patients, eight had putamen [18F]dopa uptake within the lower half of the normal range, while three had uptake reduced by > 2 SDs below the normal mean. The lowest putamen [18F]dopa influx constants were found in the most disabled patients. As these reductions were mild it is unlikely that abnormalities of the nigro-striatal dopaminergic pathway are the primary determinant of either the nature of the severity of dystonic symptoms. In addition, we studied three presumed carriers of the ITD gene. These subjects all had normal striatal [18F]dopa influx constants suggesting that [18F]dopa PET is unsuitable as a screening tool for ITD.