Approach Considerations

Parkinson disease is a clinical diagnosis. No

laboratory biomarkers exist for the condition, and
findings on routine magnetic resonance imaging
(MRI) and computed tomography (CT) scan are
unremarkable. Positron emission tomography
(PET) and single-photon emission CT (SPECT) may
show findings consistent with Parkinson disease,
but these studies are not routinely needed.
In patients with an unusual presentation,
diagnostic testing may be indicated to exclude
other disorders in the differential diagnosis.

Magnetic Resonance
Imaging (MRI)
useful to exclude strokes, tumors,
multi-infarct state, hydrocephalus,
and the lesions of Wilson disease.
MRI should be obtained in patients
whose clinical presentation does not
allow a high degree of diagnostic
certainty, including those who lack
tremor, have an acute or stepwise
progression, or are younger than 55
years.

Postoperative coronal
magnetic resonance
image (MRI)
demonstrating desired
placement of bilateral
subthalamic nucleideep brain stimulation
(STN-DBS) leads.

Axial, fast spin-echo

inversion recovery
magnetic resonance
image at the level of the
posterior commissure.
The typical target for
placing a thalamic
stimulator is
demonstrated (crosshairs).

Positron emission tomography (PET)

and single-photon emission
computed tomography (SPECT)
scanning
PET Scanning
Onset of motor signs patients with Parkinson
disease show an approximately 30% decrease
inF-dopa (fluorodopa) uptake on PET imaging in
the contralateral putamen.
F-Dopa is taken up by the terminals of dopamine
neurons and converted to18F-dopamine
F-dopa PET imaging provides an index of
remaining dopamine neurons.

SPECT Scanning
Ioflupane(I) is a radiopharmaceutical agent that is
indicated for striatal dopamine transporter visualization
using SPECT brain imaging to assist in the evaluation of
adults with suspected Parkinsonian syndromes (PSs). This
agent may be used to help differentiate essential tremor
from tremor due to PSs (idiopathic Parkinson disease [IPD]
and Parkinson-plus syndromes [PPS])
Parkinson disease, MSA, PSP, corticobasal ganglionic
degeneration, and Lewy body disease dopamine
deficiency
essential tremor, dystonic tremor, medication-induced
parkinsonism or tremor, psychogenic disorders, and in
normal individuals. normal result

Histological Findings
Classic pathologic findings in Parkinson disease include
degeneration of the neurons containing neuromelanin,
especially in the substantianigra and the locus ceruleus.
Surviving neurons often contain eosinophilic cytoplasmic
inclusions (Lewy bodies) .
Lewy bodies within pigmented neurons of the
substantianigra is characteristic, but not pathognomonic,
of Parkinson disease.
The primary biochemical defects are loss of striatal
dopamine, which results from degeneration of dopamineproducing cells in the substantianigra, as well as
hyperactivity of the cholinergic neurons in the caudate
nucleus.

Lewy bodies are

intracytoplasmiceosinophilic
inclusions, often with halos,
easily seen in pigmented
neurons

Lewy bodies in the

locus coeruleus from a
patient with Parkinson
disease. Alphasynuclein is a major
structural component of
Lewy bodies

Lumbal Puncture
Lumbar puncture should be considered if signs of normal-pressure
hydrocephalus (NPH) are observed (eg, incontinence, ataxia,
dementia). In NPH, clinical signs characteristically improve after
removal of about 20 mL of cerebrospinal fluid.
In the "Parkinson's Progression Markers Initiative" cross-sectional
study of 63 drug-naive patients with early-stage PD and 39 healthy
controls, CSF levels of the Alzheimer's biomarkers -amyloid 1-42
(A1-42), total tau (T-tau), tau phosphorylated at threonine 181 (Ptau181), and -synuclein were lower in the PD patients than in the
controls. A1-42 and P-tau181 were significant predictors of
Parkinson's disease, and T-tau and -synuclein were associated with
the severity of motor dysfunction. In particular, lower A1-42 and Ptau181 concentrations were associated with the postural instability
gait disturbancedominant PD phenotype, but were not associated
with the tremor-dominant or intermediate phenotypes.

Diagnosis

Differential
Diagnosis