[Intraoperative neuromonitoring during brain surgery].

Intraoperative neuromonitoring is a perioperative method, supplementary to stealth navigation and fluorescence microscopic imaging in brain surgery. It allows cortical and subcortical mapping, hence real time identification of eloquent brain areas through electrical stimulation of the cerebral cortex and subcortical areas. The method allows for functional guidance during both awake and asleep neurosurgery and aids in optimizing the extent of resection of the relevant pathology while preserving neurological function as summarised in this review.

Sympathetic block by metal clips may be a reversible operation.

OBJECTIVES: Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. Published results are excellent, but side effects, such as compensatory sweating, are also very frequent. The surgical techniques used and the levels of targeting the sympathetic chain vary tremendously. Most surgeons transect or resect the sympathetic chain, but application of a metal clip that blocks transmission of nerve impulses in the sympathetic chain is used increasingly worldwide. This approach offers potential reversibility if patients regret surgery, but the question of reversibility remains controversial. Two recent experimental studies found severe histological signs of nerve damage 4-6 weeks after clip removal, but they only used conventional histopathological staining methods. METHODS: Thoracoscopic clipping of the sympathetic trunk was performed in adult sheep, and the clip was removed thoracoscopically after 7 days. Following another 4 weeks (n = 6) or 12 weeks (n = 3), the sympathetic trunks were harvested and analysed by conventional and specific nerve tissue immunohistochemical stains (S100, neurofilament protein and synaptophysin). The contralateral sympathetic chains were used as controls. RESULTS: Conventional and immunohistochemical stains demonstrated severe signs of neural damage on the operated side 4 weeks after clip removal. After 12 weeks, these changes had decreased markedly and conventional histology had almost normalized. CONCLUSIONS: Conventional and immunohistochemical stains confirmed that application of metal clips to the sympathetic chain caused severe histological damage in the sympathetic trunk that remained visible 4 weeks after clip removal. However, after 12 weeks, these signs of damage had clearly decreased, which suggests in theory that application of metal clips to the sympathetic chain is a reversible procedure if only the observation period is prolonged. Further studies with longer periods between application and removal as well as investigations of nerve conduction should be encouraged, because we do not know whether histological reversibility at cellular level translates into physiological reversibility and possible correlation of nerve trauma with the duration of the applied clip.

Negative influence of L-dopa on subjectively assessed sleep but not on nocturnal polysomnography in Parkinson's disease.

BACKGROUND: Sleep disorders are highly prevalent among patients with Parkinson's disease (PD). Chronic medication with L-dopa may be one of the factors that contributes to poor sleep quality. The aim of this study was to assess the effects of long term use of L-dopa on objective and subjective measures of sleep quality in PD patients. METHODS: Twenty-seven PD patients (mean age 62.5 ± 8.6 years, mean disease duration 7.3 ± 5.9 years, 11 females) underwent nocturnal polysomnography. Their sleep was rated subjectively using the Parkinson's disease sleep scale (PDSS), and their disease severity was assessed using the unified Parkinson's disease severity scale (UPDRS) standard questionnaire. Doses of L-dopa and other medications were correlated with parameters of sleep quality. The polysomnographic recordings were compared with those from 24 age- and gender-matched normal controls. RESULTS: The patients showed decreased total sleep time (TST) and sleep efficiency (SE), prolonged sleep onset and REM sleep latency and wake after sleep onset (WASO). Parts I-III of the UPDRS scores correlated with TST, SE and WASO but not with PDSS scores. L-dopa dosage and part IV of the UPDRS correlated with PDSS scores but not with polysomnographic parameters. CONCLUSIONS: Higher doses of chronically administered L-dopa correlated with lower sleep quality according to the subjective measures but not according to the polysomnographic parameters, which were related to the severity of PD symptoms. The low sleep quality according to the subjective measurements may result from complications of therapy at high doses of L-dopa.

Corticomotor excitability in drug-naive patients with Parkinson disease.

BACKGROUND AND PURPOSE: This study aimed to assess the indices of corticomotor excitability (CE) in drug-naive Parkinson disease (PD) patients and to investigate its relationship with asymmetry and severity of clinical symptoms. MATERIAL AND METHODS: Eleven (4 men) drug-naive PD patients (mean age: 53.1 ± 9.8 years) and 13 (7 men) healthy controls (mean age: 51.7 ± 4.2 years) were included. All PD patients were rated on the motor section of the Unified Parkinson's Disease Rating Scale (UPDRS) with measurement of the side-specific score separately for arms and legs. Resting motor threshold (RMT), central silent period (CSP), amplitude of motor evoked potential (MEP) and central motor conduction time (CMCT) evoked by a single pulse of the transcranial magnetic stimulation were recorded in all subjects from the left and right abductor digiti minimi (ADM) and extensor digitorum brevis (EDB). RESULTS: Parkinson disease patients showed higher MEP (1.8 ± 0.9 vs. 1.1 ± 0.8 mV, p < 0.05) and shorter CMCT (6.1 ± 0.9 vs. 7.4 ± 1.0 ms, p < 0.05) recorded from the ADM on the more affected side. CSP recorded from the more affected ADM was under the normal range in five and from the less affected ADM in four PD patients. For CSP recorded from the EDB, respective values are four for the more affected side and three for the less affected side. The rigidity from the more affected arm and leg correlated negatively with the respective CSP recorded from the ADM (r = -0.74, p < 0.01) and EDB (r = -0.68, p < 0.04). CONCLUSIONS: In the early stage of untreated PD the CE parameters are altered only on the more affected side. The shortening of CSP reflects the severity of rigidity on the more affected side.

Safety of nerve conduction studies in patients with implantable cardioverter-defibrillators.

OBJECTIVE: A patient with an implantable cardioverter-defibrillator (ICD) may suffer from neuromuscular disorders and may need to undergo a nerve conduction study (NCS). However, a NCS may be a source of electromagnetic interference (EMI). The aim of the present study was to investigate whether the interference from NCS used in a standardised test protocol affects ICD function. METHODS: Twenty patients (19 males; mean age of 59.8±9.9 years) with implantable ICDs (eight with integrated and 12 with true bipolar leads), treated with amiodarone and with symptoms suggesting neuropathy were included. NCS were conducted using repetitive stimulation with frequency of 2 Hz and single, rectangular pulses of intensity up to 100 mA. Stimulation was performed in standard sites including proximal sites in the arm. RESULTS: The impulses generated NCS were not detected by the ICD, irrespective of the site, rate or stimulus intensity. CONCLUSIONS: Standardised test protocol for an NCS is safe in patients with an ICD regardless of the leads type. SIGNIFICANCE: Current guidelines which limitate the NCS in patients with ICD may be the subject of revision.

The influence of vascular risk factors and white matter hyperintensities on the degree of cognitive impairment in Parkinson's disease.

BACKGROUND AND PURPOSE: Vascular risk factors may contribute to deterioration of cognitive functions in Alzheimer's disease and vascular (or mixed) dementia. Parkinson's disease (PD) is an age-related disorder and vascular risk factors potentially might be the main co-morbidity responsible for motor and cognitive impairment. However, only a few studies focused on this problem have been published. The aim of the study was to assess the contribution of vascular risk factors and white matter abnormalities in magnetic resonance imaging (MRI) on cognitive impairment in PD patients. MATERIAL AND METHODS: Sixty consecutive patients (M: 35, F: 25), mean age 68.36 years (SD: 7.25, range: 51-81) with diagnosis of idiopathic PD underwent a semi-structured questionnaire on demographics and vascular risks factors, neurological, neuropsychological and neuroimaging (MRI) examinations with quantitative assessment according to the scale by Wahlund et al. According to cognitive status they were divided into 3 groups: without cognitive disability (I, n=17), with mild cognitive impairment (II, n=25) and with dementia (III, n=18). RESULTS: There were no significant differences between groups in terms of the number of vascular risk factors (except for the ischaemic heart disease difference between group I and III) and severity of white matter hyperintensities in MRI studies. CONCLUSIONS: Vascular risk factors along with white matter vascular abnormalities probably do not contribute to cognitive impairment in patients with PD. This is in concordance with previously published studies.

Regional cerebral blood flow in Parkinson's disease as an indicator of cognitive impairment.

OBJECTIVE: To investigate the pattern of regional cerebral blood flow (rCBF) deficits in Parkinson's disease patients in relation to cognitive decline and to assess the clinical usefulness of single photon emission tomography (SPET) scanning in differentiation between Parkinson's disease patients with dementia and those without cognitive deficits. METHODS: We performed Tc-ECD SPET in 60 patients with idiopathic Parkinson's disease (F: 25, M: 35), with average age of 68.4 years (SD+/-7.3, range 51-81 years). All patients were examined neurologically with the assessment of stage and severity of Parkinson's disease (Hoehn-Yahr scale, UPDRS, Schwab-England scale). Detailed neuropsychological examination was performed in each Parkinson's disease patient. On the basis of DSM-IV criteria of dementia and the results obtained in psychological examination, the whole group was divided into three subgroups: I, with no cognitive changes (n = 17); II, with mild cognitive impairment (n = 25); and III, with dementia (n = 18). RESULTS: There was noticeable significant decrease of perfusion in all areas in Parkinson's disease patients when compared to the age-matched control group of healthy volunteers (n = 20). In group III, perfusion was significantly decreased (when compared to groups I and II), particularly in parietal and temporal areas with the predominance of the left side. Regression analysis revealed two independent factors related to dementia: decrease of perfusion within left temporal lobe and its increase within left thalamus. CONCLUSION: Parkinson's disease patients with dementia showed left temporo-parietal hypoperfusion as compared to a group of patients without dementia, which resembles perfusion deficits described in Alzheimer's disease. The hypoperfusion of the left temporal lobe with increase of rCBF within the left thalamus might be clinically useful in discrimination of Parkinson's disease patients with dementia against those without cognitive impairment.

[The influence of vascular risk factors and white matter hyperintensities on the degree of motor impairment in Parkinson's disease]. / Wplyw naczyniowych czynników ryzyka i neuroradiologicznych zmian naczyniopochodnych w mózgu na nasilenie zaburzen ruchowych w chorobie Parkinsona.

BACKGROUND AND PURPOSE: The aim of the study was to assess the prevalence of vascular risk factors and white matter hyperintensities (WMH) in patients with Parkinson's disease (PD) and its impact on clinical features such as motor impairment. MATERIAL AND METHODS: 60 patients with PD [25 women and 35 men; mean age 68.4 (51-81) years, mean duration of disease 8.4 (1-27) years] with good response to L-Dopa were studied. Besides neurological examination, the degree of motor impairment was evaluated in all patients using UPDRS, Hoehn-Yahr, and Schwab-England scales. All patients underwent MRI to assess the degree of WMH using Age Related White Matter Changes (ARWMC) Wahlund scale. Moreover, the prevalence of classic vascular risk factors included arterial hypertension, diabetes mellitus t. 1 and 2; plasma cholesterol, cardiovascular diseases, alcohol abuse and smoking was assessed. RESULTS: Presence of at least one vascular risk factor was noted in 19 patients (31.7%). No significant differences were found between the groups of patients with and without vascular risk factors with regard to all clinical parameters and total ARWMC score. These factors did not differ between the groups of patients with more than 3 vascular risk factors and other patients. WMH (ARWMC > or =1) occurred in 33 patients (55%). No significant differences in all analysed clinical factors and the total number of vascular risk factors between the groups with (ARWMC > or =1) and without (ARWMC=0) WMH were found. The group of patients with at least one focus with score of 2 in the Wahlund scale did not differ significantly in all analysed clinical parameters from the rest of the patients. CONCLUSIONS: Our data suggest that the severity of WMH and incidence of vascular risk factors are not significantly related with the degree of motor disability in PD.

Factors associated with depression in Parkinson's disease: a cross-sectional study in a Polish population.

OBJECTIVE: The aim of this study was to assess the prevalence and factors influencing depression in PD patients in a cross-sectional outpatient clinic - based Polish patients sample. MATERIALS AND METHODS: One hundred consecutive PD patients were included in this study; 35 of them fulfilled DSM-IV criteria for Major Depression and its severity was assessed with Montgomery-Asberg Depression Rating Scale (MADRS). A structured interview and a neurological examination, including Hoehn and Yahr scale (H-Y), Schwab-England disability scale, II, III, IV parts of Unified Parkinson's Disease Rating Scale (UPDRS), and Mini-Mental State Examination (MMSE) were performed. The parameters obtained were analysed between the depressed and non-depressed PD patients. RESULTS: The prevalence of depression in PD in Polish population was established at the level of 35%. PD patients with depression scored significantly higher in all UPDRS scales (except for the subscale of clinical fluctuation) and in H-Y scale. PD with depression was also associated with longer PD duration, higher doses of L-dopa equivalents, patients' age, general impairment of daily living in Schwab and England disability scale, lower MMSE and higher clinical fluctuations. However, those six differences were insignificant. CONCLUSIONS: Depression prevalence rate among PD patients in Polish population is slightly lower than in most of other published studies. This may result from strict selection criteria, use of specific outcome measures and restricted criteria for depression that were applied.

Camptocormia or Pisa syndrome in multiple system atrophy.

Although a mild stooped posture is a hallmark of parkinsonism, extreme trunk forward flexion is not common. This phenomenon was described in different etiological entities and called camptocormia. Other similar presentations called Pisa syndrome and antecollis were described mainly in extrapyramidal disorders. Authors present two cases of probable multiple system atrophy (MSA) with predominant parkinsonism and Pisa syndrome (or camptocormia). Both of them were previously misdiagnosed as idiopathic Parkinson's disease (PD) and one was reported 1 year earlier. The typical clinical presentation fulfilling the diagnostic criteria for multiple system atrophy, rapid progression with lack of responsiveness to L-DOPA and apomorphine and typical MRI putaminal pathology observed in both cases allowed us to make a diagnosis. Accuracy of clinical diagnosis in multiple system atrophy is still very poor. Therefore, unusual or rare clinical presentations may support the final diagnosis. The camptocormia, Pisa syndrome and antecollis may represent the continuum of the same motor phenomenon and most of the authors refer them to unusual form of axial dystonia. According to many clinical presentations on different forms of camptocormia/Pisa syndrome authors conclude that not etiology, but the localization of specific lesion, probably within putamen is responsible for that form of dystonia. In cases of parkinsonism and severe forward flexion of trunk multiple system atrophy, diagnosis should be considered.

Cerebral blood flow changes in patients with dementia with Lewy bodies (DLB). A study of 6 cases.

BACKGROUND: The aim of this study was to show the application of cerebral blood flow SPECT (rCBF SPECT) study in dementia with Lewy bodies (DLB). MATERIAL AND METHODS: (99m)Tc-ECD regional cerebral blood flow SPECT scanning was performed using a triple head, high resolution gamma camera on a group of six patients who ful- -filled criteria for clinical diagnosis of DLB. All patients were examined neurologically by a neurologist specialized in movement disorders. Detailed neuropsychological examination was performed on each patient with a psychological tests battery by an experienced neuropsychologist. Qualitative and quantitative analysis was performed utilizing an asymmetry index for unilateral perfusion deficits and a comparison to cerebellar perfusion to assess regional cerebral perfusion. A control group of 20 patients was studied to assess normal values, utilizing an asymmetry index for unilateral perfusion deficits, and a comparison to cerebellar perfusion was performed to assess regional cerebral perfusion. RESULTS: In four cases rCBF SPECT images showed patterns of bilateral hypoperfusion of the temporal, parietal and occipital lobes. In two other cases parietal deficits were observed. CONCLUSIONS: Functional neuroimaging with the use of CBF SPECT may contribute to clinical diagnosis of DLB.

[The diagnostic and therapeutic application of transcranial magnetic stimulation]. / Przezczaszkowa stymulacja magnetyczna w diagnostyce i terapii choroby Parkinsona.

The functional abnormalities of the central motor structures and its contribution of rigidity, tremor and bradykinesia in Parkinson's disease seem mainly due to the degeneration of the nigro-striatal pathway. Transcranial magnetic stimulation (TMS) of the motor cortex may provide useful data on the pathophysiology of motor dysfunction in Parkinson's disease. Recent reviews on the basic mechanisms of TMS in Parkinson's disease show reduced inhibitory motor network at the cortical and spinal level. The observed changes are thought to be in relation with a dysfunction of subcortico-cortical and subcortico-spinal pathways. The abnormalities of the central motor function seem to be modified by several clinical related factors as prevalence of cardinal Parkinson's disease signs (e.g. rigidity versus tremor or bradykinesia), L-dopa therapy ('on/off' states) and laterality of the Parkinson's disease signs. Observations made using TMS give new pathophysiological insights in functioning of the central motor structures in Parkinson's disease and started new form of TMS - repetitive TMS (rTMS) as a treatment of the Parkinson's disease motor signs. A few studies using rTMS with repetition rate of 0.2, 1, and 5 Hz showed improvement of motor signs in the Parkinson's disease patients. Although these results support the beneficial effects of rTMS on parkinsonian symptoms, long-term studies with large numbers of subjects should be conducted to assess the efficacy of the rTMS on Parkinson's disease in future.

Factors affecting the quality of life of patients with idiopathic Parkinson's disease--a cross-sectional study in an outpatient clinic attendees.

PURPOSE: To determine the factors associated with poor quality of life (QoL) in patients with idiopathic Parkinson's disease (PD) in a clinic-based sample. SCOPE: One hundred patients were included in this study. To assess the quality of life the Parkinson's Disease Questionnaire (PDQ-39) was used. A structured questionnaire interview and a complete neurological examination, including the Hoehn and Yahr scale (H-Y), the Schwab and England disability scale, II, III, IV parts of the unified Parkinson's disease rating scale (UPDRS part II, III, IV), Montgomery-Asberg depression rating scale (MADRS) and the Mini-Mental state examination (MMSE) were performed. RESULTS AND CONCLUSIONS: The most important predictive factor was MADRS score, followed by clinical fluctuations as measured by UPDRS part IVB and the H-Y stage of disease, which account for 79% of the variance of QoL scores. Therefore, recognition of depression should become an important part of treatment of PD.

Quality of life in Polish patients with long-lasting Parkinson's disease.

The objective of this study was to evaluate possible relationships between quality of life (QoL) of Polish patients with long-lasting Parkinson's disease and various demographic and clinical factors. The study comprised 141 patients of Movement Disorders outpatient clinics in Warsaw and Gdansk with at least 5 years of the disease duration. Mean age of patients was 68.09 +/- 8.51 years, mean duration of disease was 11.87 +/- 5.14 years. To assess the quality of life, the Parkinson's Disease Questionnaire (PDQ-39) was used. Additional questions concerned duration of disease, initial and current treatment and expenses associated with therapy. Self-perceived symptoms of depression were in our study the most important factor determining QoL. Duration of the disease and expenses related to the treatment also have a significant impact on the QoL. Patient's age and presence of dyskinesia seem to be irrelevant to the quality of life.

[Parkinson's disease and depression: commorbidity, signs, etiology, clinical implications]. / Choroba parkinsona i depresja--wspólwystepowanie, objawy, przyczyny, implikacje kliniczne.

Depressive symptoms often occur in Parkinson' disease. They have negative influence for patients' quality of life. However, they are not sufficiently diagnosed nor correctly treated. Difficulties with the diagnosis could be a result of: partial confusion of symptoms of Parkinson's disease and depression and/or different clinical depressive symptoms, compared to "primary" affective disorder. Correlation between cognitive functions, Parkinson' disease and depression remains pretty unclear. Depression occurring during Parkinson's disease must be treated. Theoretically all kinds of treatment for depression can be applied. Nowadays, among antidepressive agents, SSRI's are preferred, mainly because of its good tolerance.

Application of rhenium-188 HEDP in bone metastases therapy.

Radionuclide bone metastases therapy is a major achievement of nuclear medicine. Development of less radiotoxic and more effective radiopharmaceuticals is therefore a challenge for radiopharmacists and industry. This paper reviews the application of rhenium-188 HEDP as a reactor- or generator-produced nuclide for bone metastases therapy.

[Depression in patients with Parkinson's disease]. / Depresja w chorobie Parkinsona.

The aim of our study was to assess the frequency of depression in group of patients with Parkinson's disease (PD) who fulfilled the diagnostic criteria of PD, had normal CT scans and responded well to L-dopa treatment. The sample consisted of 73 consecutive patients (34 women and 39 men), mean age 65.7 (41-81) years, mean duration of disease 6.7 years. Besides neurological examination, in all the patients the degree of motor impairment was evaluated using the UPDRS, H-Y, and SE scales. Moreover, a sociodemographic questionnaire, psychological tests (MADRS, MMSE), and a quality of life scale (PDQ-39) were used. Depression (MADRS scores > 19) was found in 25 (34.2%) of the patients, with major depression (scores > 28) diagnosed in 7 patients (9.5%) and moderate depression (scores between 20 and 28)--in 18 cases (24.6%). In comparison to non-depressed patients, those with depression were older by 0.9 years on the average, their onset of the disease occurred later by 1.7 years, and their mean duration of the disease was longer by 2.6 years. These differences were not statistically significant. Dementia (MMSE scores < or = 23) did not differentiate between the two groups: it was found in 27 depressed patients (37.4%) and in 26 (35.6%) of those without depression. Patients in the depressed group suffered statistically more often from sleep disorders (19 vs. 14; p < 0.001). In this group motor impairment was significantly more marked, as measured by the UPDRS (32.2 vs. 46.8; p < 0.001) and H-Y (2.54 vs 2.98; p < 0.007), and their quality of life as measured by PDQ-39 questionnaire was significantly lower (36.4 vs. 82.24; p < 0.00002). Our data indicate the presence of depression in 34.2% of the sample, i.e. a somewhat lower prevalence rate than that reported in other studies. This may be due to the fact that only outpatient population was analysed, and outpatients are seldom categorized as degree 4 and 5 on the H-Y scale. Depression on PD patients was correlated with their more severe motor disability and considerably lower quality of life. This may suggest a relationship with progression of the disease and more pronounced changes in cerebral neurotransmitters (i.e. endogenous origin), or PD patient's response to their limited mobility and isolation in later stages of the disease (i.e. reactive origin). However, the two factors--endogenous and reactive--may be overlapping, since a majority of PD patients suffer from mild to moderate depression.

[Depression and dementia: the most frequent non-motor symptoms of Parkinson disease]. / Depresja i otepienie--najczestsze pozaruchowe objawy choroby Parkinsona.

UNLABELLED: The aim of our study was to assess the frequency, risk factors, and interrelations between depression and dementia in P.D. MATERIAL AND METHODS: 100 consecutive patients with P.D. with good response to L-dopa and normal CT/MRI scans, mean age: 66 (41-81) years, mean disease duration 6.7 (0-24) years. Rating scales: for stage of disease and motor disability: Hoehn-Yahr (HY), Schwab-England (SE), Unified Parkinson's Disease Rating Scale (UPDRS), for depression: Montgomery-Asberg Depression Rating Scale (MADRS), for dementia: Mini Mental State Examination (MMSE), for quality of life: Parkinson's Disease Questionnaire (PDQ-39) and own questionnaire (demographic data and treatment). RESULTS: Depression (MADRS > 19) was revealed in 35% and dementia (MMSE < or = 23) in 19% of patients. Depressed and demented patients had significantly more advanced motor disability (UPDRS, HY, SE) and poor quality of life (PDQ-39). In group with dementia disease duration was longer (9.4 vs 6.0 years; p < 0.009), mean age was higher (71.3 vs 64.7 years; p < 0.002) and sleep disturbances, depression and hallucinations more frequent (p < 0.04). Groups with and without depression did not differ significantly in terms of dementia (MMSE). CONCLUSIONS: Depression and dementia are more frequent in patients with greater motor disability and correlated significantly with poor quality of life. Old age, longer disease duration, hallucinations and sleep disturbances are risk factors for dementia in P.D. In demented patients with P.D. depression is more frequent.

[Regional cerebral blood flow single photon emission tomography (SPECT) and magnetic resonance imaging (MRI) may be useful in the diagnosis of patients with cortico-basal degeneration, progressive supranuclear palsy and multiple system atrophy]. / Badanie mózgowego przeplywu krwi metoda SPECT oraz badanie MRI moga byc uzyteczne w ustalaniu rozpoznania zwyrodnienia korowo--podstawnego, postepujacego porazenia ponadjadrowego i zaniku wieloukladowego.

Differential diagnosis of idiopathic Parkinson's Disease is still very difficult. Even in movement disorders centers 25% of patients with clinical diagnosis of Parkinson's disease is misdiagnosed with other neurodegenerative disorders. Clinical symptoms of so called atypical parkinsonian disorders may emerge late in the course of the disease, not at the same time and good or moderate response to levodopa at early stages may be a source of misdiagnosis. Most difficult to differentiate seems to be Progressive supranuclear palsy (PSP), corticobasal degeneration (CBD) and multiple system atrophy (MSA). Authors present in selected cases usefulness of neuroimaging with rCBF SPECT and MRI in clinical diagnosis of these disorders. For PSP typical (although not pathognomonic) is decrease of metabolism and flow in frontal lobes (hypofrontalism), and in CBD asymmetrical, contralateral to the side of dominating symptoms cerebral (frontal, parietal, temporal and within striatum) atrophy. In MSA more useful (but not seen in all cases) is MRI examination with hyperintensities in putamen, pons and cerebellum or cerebellar atrophy. Due to low sensitivity of clinical criteria other tests (EMG of anal sphincter or clonidine test) with specially neuroimaging examination may be helpful in establishing of the diagnosis.