Knowing one’s limitations

As promised, here’s the next installment in my series on impactful posters on PSP from the annual conference of the International Parkinson’s and Movement Disorders Society that is winding up today on line.  This poster, like the one in my last post, is from Japan.

Most of you know that corticobasal degeneration (CBD) is very similar to PSP in many ways, though only about a tenth as common.  The most common typical clinical syndrome of PSP, called PSP-Richardson syndrome, correlates extremely closely with the typical pathological autopsy appearance that we call PSP.  But for CBD, the most common clinical syndrome, called corticobasal syndrome (CBS) has a much looser correspondence with the typical autopsy picture called CBD.  Only about half of all people with CBS have CBD at autopsy.  Of the rest, the most common autopsy picture is PSP, then Alzheimer’s disease, with a half-dozen or so others comprising the rest.  Unfortunately none are more treatable at present than CBD.  Here’s an up-to-date, authoritative, technical description of that for you to chew on if you want the details.

Here’s some more background:  One of the ways that PSP can present itself clinically is with the corticobasal syndrome.  In other words, about 3 percent of people with PSP in the brain look outwardly like they have the typical appearance of CBD.  How to tell if those folks have PSP-CBS or CBD-CBS itself?

The leading clinical PSP expert in Japan, in my biased opinion, is my friend Ikuko Aiba, MD.  She and her colleagues in Nagoya compared the medical records of 12 autopsy-proven patients with CBD with those from eight with autopsy-proven PSP-CBS.  The only clinical feature that was more common in the CBD-CBS patients was urinary incontinence and the only one more common in PSP-CBS was limitation of vertical gaze and slowed eye movements (“saccades”) in general.  The CBD-CBS patients tended to progress a little more quickly with regard to overall loss of mobility.

The take-home is that in the absence of specific treatment for either condition (i.e., treatment directed at the cause rather than the symptoms) this information could be useful in refining recruitment in clinical trials, in prevalence studies and diagnostic biomarker development, each of which would like to be able to create a patient series consisting purely of the disease under study.

The other take-home is that it’s actually next to impossible to distinguish PSP-CBS from CBD-CBS in the living patient.  Neurologists who claim to be able to do so, even with this bit of new information, are just kidding themselves — and their patients.  They should just diagnose “corticobasal syndrome” and leave it at that. Thanks to Ikuko Aiba and colleagues for pointing that out.

2 thoughts on “Knowing one’s limitations

  1. Wonderful blog—thanks so much. There seems to be no mention of micrographia, but it was first clue for me that my sister might have Parkinson’s, now diagnosed so far as PSP. NIMH study seems to indicate micrographia plus vertical gaze shifting difficulty initial hallmarks of PSP.

    Thanks

    • Mr. Holloway — Thanks for the compliment. I’ll resume posting soon.
      Micrographia is a part of all of the parkinsonian disorders, including PSP, and is one of the earliest-appearing features. As far as I know, it cannot distinguish between PSP and PD. But slowing of vertical eye movement, either when voluntarily shifting the gaze or when “involuntarily” shifting the gaze down to pick up the next object coming into view from below or above, is indeed an early feature that occurs more severely and sooner in PSP than in PD. Skilled neurologists know to look for this.

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