The clinical diagnosis of Parkinson's disease

Munhoz, Renato P.; Tumas, Vitor; Pedroso, José Luiz; Silveira-Moriyama, Laura

doi:10.1055/s-0043-1777775

person Renato P. Munhoz

conceptualization · formal analysis · project · writing – original draft · writing – review & editing

schoolUniversity Health Network, Toronto Western Hospital, Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto, ON, Canada.schoolKrembil Research Institute, Toronto, ON, M5T 2S8, Canada.

0000-0002-4783-4067

person Vitor Tumas

conceptualization · formal analysis · project · writing – original draft · writing – review & editing

schoolUniversidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil.

0000-0003-2402-2709

person José Luiz Pedroso

conceptualization · formal analysis · project · writing – original draft · writing – review & editing

schoolUniversidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.

0000-0002-1672-8894

person Laura Silveira-Moriyama

conceptualization · formal analysis · project · writing – original draft · writing – review & editing

schoolUniversidade Estadual de Campinas, Campinas SP, Brazil.schoolUCL Queen Square Institute of Neurology, London, United Kingdom.

0000-0003-2184-626X

Address for correspondence Renato P. Munhoz (email:
renato.munhoz@uhn.ca)

Conflict of Interest

There is no conflict of interest to declare.

Criteria	Queen Square Brain Bank Criteria (Gibb & Lees, 1988)¹⁰	MDS criteria for Parkinson's disease (Postuma et al., 2015)²⁵
Chore findings	STEP 1: identification of Parkinsonian syndrome. Defined as bradykinesia and at least one of the following: Muscular rigidity. 4-6 Hz rest tremor. Postural instability not caused by primary visual, vestibular, cerebellar, or proprioceptive dysfunction.	The first essential criterion is parkinsonism, which is defined as bradykinesia, in combination with at least 1 of rest tremor or rigidity.
Negative features used as	Step 2: Exclusion Criteria	Absolute exclusion criteria or Red flags (when combined with supportive criteria do not exclude PD)
Positive features used as	Step 3: Supportive Criteria	Supportive Criteria
Ancillary tests	Imaging used to exclude differential diagnosis (Step 2)	Olfactory loss or cardiac sympathetic denervation on MIBG scintigraphy are supportive criteria Normal functional neuroimaging of the presynaptic dopaminergic system is an exclusion criteria
Certainty levels	Definite PD (three or more positive supportive findings)	Clinically Established PD: Absence of absolute exclusion criteria At least two supportive criteria, and No red flags Clinically Probable PD: Absence of absolute exclusion criteria Presence of red flags counterbalanced by supportive criteria red flag requires at least 1 supportive criterion red flags require at least 2 supportive criteria no more than 2 red flags are allowed for this category

	PD	DIP	VP	PSP	MSA-P	LBD	CBD
Mean age of onset (SD)	59.4 (11.5)	60.6 (13.4)	70.6 (6.4)	66.9 (7.6)	55.5 (6.5)	67.8 (9.2)	63 (7.7)
Tremor	Pure rest (30%), pure action (20%), mixed (20%)	Pure rest (35%), pure action (10%), mixed (30%)	Pure rest (4%), pure action (10%), mixed (2%)	Pure rest (10%)a, pure action (20%), mixed (20%)	Rest (5%), Action (80%)f, mixed (10%)f	Pure rest (3%), pure action (7%), mixed (24%)	Rest (2%), Action (10%)g, mixed (55%)g
Postural instability	Common but late feature	Rare	Prominent / early or presenting sign	Prominent / early or presenting sign	Prominent / early	Prominent / early	Prominent / early
Asymmetry	+++	0	+	0a	+	0	+++
Survival – Mean (SD)	Variableb	N/A	8 (4.1)	8.6 (5.7)	7.5 (4)	4.1 (4.1)	8 (0.7)
Levodopa response	Marked / sustained	None to moderatec	None to moderatec	Mild to moderated	Mild to moderated	Mild to moderated	Mildd
LID e	++ + +	0	+	+a	++	+	+
Dementia	Common in advanced stages	0	Very common, presenting as VD	Very common, early, fast decline	Less common than PD	Part of diagnostic criteria; may fluctuate	Common, may be early, fast decline
RBD	Very common	0	0	Unusual	Very common	Very common	0
Additional clinical features	Slower progression compared to other degenerative forms.	Onset during treatment with offending drug; improvement / resolution after withdrawal.	Pyramidal and pseudobulbar signs; lower body predominant.	Supranuclear gaze palsy; disproportional axial (nuchal) rigidity; photophobia / blepharospasm;	Profound early dysautonomia; anterocollis; pseudobulbar affect; pyramidal signs.	Early well-formed visual hallucinations; neuroleptic sensitivity; dysautonomia.	Limb dystonia; apraxia; cortical sensory loss; alien limb phenomena.
Brain MRI findings	No specific findings on standard imaging.	No change	Periventricular white matter lesions, lacunar infarcts in BG, ventricular dilation.	Predominant midbrain atrophy; superior cerebellar peduncle atrophy.	Putaminal atrophy; OPCA and "hot cross bum sign" in advanced stages.	Global atrophy.	Asymmetric fronto-parietal atrophy.

[TFN1] Abbreviations: PD, Parkinson's disease; DIP, drug-induced parkinsonism; VP, vascular parkinsonism; PSP, progressive supranuclear palsy; MSA-P, Parkinsonian form of multiple system atrophy; LBD, Lewy body dementia; CBD, corticobasal degenerartion; SD, standard deviation; LID, levodopa-induced dyskinesia; RBD, REM-sleep behavior disorder; MRI, magnetic resonance imaging; BG, basal ganglia; OPCA, olivo-ponto-cerebellar atrophy.

[TFN2] ^a)
Notes: PSP-P variant presents with asymmetric features, rest tremor, levodopa response and LID;

[TFN3] ^b)
widely dependent on age of onset, ranging from 38 (5) years for early onset (25-39 years old) to 5 (4) for late onset (≥ 65 years old);

[TFN4] ^c)
may be sustained in responders;

[TFN5] ^d)
typically in early stages, not sustained;

[TFN6] ^e)
in levodopa responders under long term treatment;

[TFN7] ^f)
jerky postural tremor / polyminimyoclonus;

[TFN8] ^g)
jerky action tremor / myoclonus.

The clinical diagnosis of Parkinson's disease

O diagnóstico clínico da doença de Parkinson

Abstract