Objective: To assess differences in cranial MRI between progressive supranuclear palsy (PSP), multisystem atrophy (MSA) and Parkinson’s disease (PD) that support the clinical diagnosis.

Background: Differentiating a patient with PSP from MSA or PD can be difficult because of overlapping symptoms, mainly in early stages. Midbrain-pons ratio (MPR) and Magnetic Resonance Parkinsonism Index (MRPI:pons area–midbrain area ratio multiplied by middle cerebellar peduncles [MCP] width–superior cerebellar peduncles [SCP] width ratio) have shown to be effective in differentiating radiologically PSP from MSA and PD. Recently it has emerged an interest in defining new morphological quantitative MRI parameters to help to differentiate parkinsonisms and to avoid misdiagnosis.

Method: Retrospective study patients diagnosed of PD, PSP and MSA in our Movement Disorders Unit using the international diagnostic criteria, who had undergone a cranial MRI with a 1.5T scanner. Two neurologists with experience in MD, blinded to patient´s diagnoses evaluated the MRIs. MRI parameters evaluated: MPR, MCP, SCP, third ventricle (3V) and frontal horn (FH) width, 3V/FH ratio, MRPI, cerebral interpeduncular angle (CIA). Interobserver concordance was evaluated. Data were analyzed through STATA14.

Results: We studied 32 patients: 14 EP, 10 PSP, 8 MSA. Mean age: 71,2 (66,8-76.1). PD patients were older (p=0,0498). No significant differences in gender or time the evolution of the disease were found. PSP patients showed lower midbrain length and MPR (0,47), with higher MRPI, width of the 3V, 3V/FH ratio and MRPI 2.0, a combined evaluation of MRPI and 3V width (p<0,01 for all). CIA, FH width and P/M 2.0 showed a tendency to be higher in PSP patients. In MSA patients, MPC-width was lower (p<0,01) and hot cross bun was found more frequently (p<0,01) respect from the other groups. A significant interobserver concordance was found for CIA, MCP, MRPI, MRPI 2.0, 3V and FH width, and MPR, P/M 2.0, MCP/SCP and 3V/FH ratio.

Conclusion: Our study corroborates that MRI parameters are useful to differentiate PSP from MSA and PD. Their measurement does not take long so it would be interesting to incorporate them into routine clinical practice to help in differential diagnosis between the different forms of parkinsonism.

References: [1] Massey LA, Jäger HR, Paviour DC, O’Sullivan SS, Ling H, Williams DR, Kallis C, Holton J, Revesz T, Burn DJ, Yousry T, Lees AJ, Fox NC, Micallef C. The midbrain to pons ratio: a simple and specific MRI sign of progressive supranuclear palsy. Neurology. 2013 May 14;80(20):1856-61. doi: 10.1212/WNL.0b013e318292a2d2. [2] Eraslan C, Acarer A, Guneyli S, Akyuz E, Aydin E, Colakoglu Z, Kitis O, Calli MC. MRI evaluation of progressive supranuclear palsy: differentiation from Parkinson’s disease and multiple system atrophy. Neurol Res. 2019 Feb;41(2):110-117. doi: 10.1080/01616412.2018.1541115. [3] Quattrone A, Morelli M, Nigro S, Quattrone A, Vescio B, Arabia G, Nicoletti G, Nisticò R, Salsone M, Novellino F, Barbagallo G, Le Piane E, Pugliese P, Bosco D, Vaccaro MG, Chiriaco C, Sabatini U, Vescio V, Stanà C, Rocca F, Gullà D, Caracciolo M. A new MR imaging index for differentiation of progressive supranuclear palsy-parkinsonism from Parkinson’s disease. Parkinsonism Relat Disord. 2018 Sep;54:3-8. doi: 10.1016/j.parkreldis.2018.07.016.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/differentiation-of-progressive-supranuclear-paralysis-from-multisystem-atrophy-and-parkinsons-disease-by-cranial-mri/