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A Multi-infarct Disorder Presenting as Progressive Supranuclear Palsy

Keith A. Josephs, MD; Takashi Ishizawa, MD; Yoshio Tsuboi, MD; Natalie Cookson, BSc; Dennis W. Dickson, MD

Arch Neurol. 2002;59:1597-1601.

Background  Clinical features suggesting a diagnosis of progressive supranuclear palsy (PSP) include early falls, axial rigidity, vertical supranuclear ophthalmoplegia, and levodopa unresponsiveness. When these clinical features are present, the diagnosis is almost always PSP, yet vascular disease sometimes has a similar presentation, referred to as vascular PSP.

Objective  To evaluate clinical and pathologic features of cases of vascular PSP submitted to a PSP brain bank.

Design  Review of gross and microscopic neuropathological features, determination of haplotype, and medical record review of 4 patients with an antemortem diagnosis of PSP who did not meet the pathologic criteria for PSP and instead had vascular pathologic abnormalities.

Results  All patients had vertical supranuclear ophthalmoplegia, a history of falls, and a gradually progressive disease course. Falls began 1 year after symptom onset, and all patients had asymmetric findings on a neurological examination. A magnetic resonance imaging scan revealed lacunar basal ganglia infarcts in one patient and an increased T2-weighted signal in the corona radiata and centrum semiovale in another. Gross and microscopic neuropathological studies demonstrated infarcts in the cerebral cortex (n = 4), thalamus (n = 4), basal ganglia (n = 3), and cerebellum (n = 4). The brainstem was affected in one patient, but no infarcts were detected in the subthalamic nucleus or substantia nigra. Of the 4 patients, 3 carried an H2 haplotype, a rare occurrence in the general population.

Conclusions  Asymmetric signs, falls after 1 year of symptom onset, vascular lesions on a magnetic resonance imaging scan, and an H2 haplotype may help differentiate vascular PSP from PSP. Thalamic and basal ganglia infarcts are common in patients with vascular PSP and, when present, may contribute to misdiagnosis.

From the Departments of Neurology (Drs Josephs and Tsuboi) and Pathology (Neuropathology) (Drs Ishizawa and Dickson and Ms Cookson), Mayo Clinic, Jacksonville, Fla.

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