Journal of Neurology

, Volume 259, Issue 2, pp 251–260

Visual assessment of dopaminergic degeneration pattern in 123I-FP-CIT SPECT differentiates patients with atypical parkinsonian syndromes and idiopathic Parkinson's disease

  • Deniz Kahraman
  • Carsten Eggers
  • Harald Schicha
  • Lars Timmermann
  • Matthias Schmidt
Original Communication


The aim of this study was to investigate whether visual assessment of 123I-N-ω-fluoropropyl-2β-carbomethoxy-3β-(4-iodophenyl)nortropan (123I-FP-CIT) single photon emission computed tomography (SPECT) in addition to quantitative analyses can help to differentiate idiopathic Parkinson's disease (PD) from atypical parkinsonian syndromes (APS). From a consecutive series of patients examined with 123I-FP-CIT SPECT (n = 190) over a three-year period we identified 165 patients with a clinical diagnosis of PD (n = 120) or APS (n = 45). 123I-FP-CIT SPECT results were analysed visually and quantitatively and compared for PD and APS and for the subgroup of patients with early PD and APS (disease duration <5 years). According to predefined visual patterns of dopaminergic degeneration the results were graded as normal (grade 5) or abnormal (grade 1–4), distinguishing a posterior-anterior degeneration pattern (“egg shape”) from a global and severe degeneration pattern (“burst striatum”). Visual assessment of 123I-FP-CIT SPECT showed significant different dopaminergic degeneration patterns for PD and APS patients. A grade 1 (“burst striatum”) degeneration pattern was predominantly associated with APS patients. In contrast to that, a grade 2 (egg shape) degeneration pattern was the characteristic finding in PD patients. In a subgroup of patients with early disease, visual assessment with identification of the burst striatum degeneration pattern provided 90% positive predictive value and 99% specificity for the diagnosis of APS. Quantitative analysis of striatal binding ratios failed to depict these different degeneration patterns in PD and APS patients. Visual assessment of the pattern of dopaminergic loss in 123I-FP-CIT SPECT shows different patterns of dopaminergic degeneration for PD and APS patients. Therefore, it could provide valuable information to distinguish APS from PD patients, especially in early stages of disease. Within the first 5 years of disease, the occurrence of a burst striatum degeneration pattern has a high positive predictive value of APS.


123I-FP-CIT SPECT Idiopathic Parkinson's disease Atypical parkinsonian syndromes Visual pattern assessment Dopaminergic degeneration pattern 


  1. 1.
    Gelb DJ, Oliver E, Gilman S (1999) Diagnostic criteria for Parkinson disease. Arch Neurol 56(1):33–39PubMedCrossRefGoogle Scholar
  2. 2.
    Goetz CG (1986) Charcot on Parkinson’s disease. Mov Disord 1(1):27–32PubMedCrossRefGoogle Scholar
  3. 3.
    Daniel SE, Lees AJ (1993) Parkinson’s Disease Society Brain Bank, London: overview and research. J Neural Transm Suppl 39:165–172PubMedGoogle Scholar
  4. 4.
    Hughes AJ, Daniel SE, Kilford L, Lees AJ (1992) Accuracy of clinical diagnosis of idiopathic Parkinson’s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry 55(3):181–184PubMedCrossRefGoogle Scholar
  5. 5.
    Rajput AH, Rozdilsky B, Rajput A (1991) Accuracy of clinical diagnosis in parkinsonism—a prospective study. Can J Neurol Sci 18(3):275–278PubMedGoogle Scholar
  6. 6.
    Hughes AJ, Daniel SE, Ben-Shlomo Y, Lees AJ (2002) The accuracy of diagnosis of parkinsonian syndromes in a specialist movement disorder service. Brain 125(Pt 4):861–870PubMedCrossRefGoogle Scholar
  7. 7.
    Hughes AJ, Daniel SE, Lees AJ (2001) Improved accuracy of clinical diagnosis of Lewy body Parkinson’s disease. Neurology 57(8):1497–1499PubMedGoogle Scholar
  8. 8.
    Gilman S, Wenning GK, Low PA, Brooks DJ, Mathias CJ, Trojanowski JQ, Wood NW, Colosimo C, Durr A, Fowler CJ, Kaufmann H, Klockgether T, Lees A, Poewe W, Quinn N, Revesz T, Robertson D, Sandroni P, Seppi K, Vidailhet M (2008) Second consensus statement on the diagnosis of multiple system atrophy. Neurology 71(9):670–676PubMedCrossRefGoogle Scholar
  9. 9.
    Litvan I, Agid Y, Calne D, Campbell G, Dubois B, Duvoisin RC, Goetz CG, Golbe LI, Grafman J, Growdon JH, Hallett M, Jankovic J, Quinn NP, Tolosa E, Zee DS (1996) Clinical research criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome): report of the NINDS-SPSP international workshop. Neurology 47(1):1–9PubMedGoogle Scholar
  10. 10.
    Litvan I, Agid Y, Goetz C, Jankovic J, Wenning GK, Brandel JP, Lai EC, Verny M, Ray-Chaudhuri K, McKee A, Jellinger K, Pearce RK, Bartko JJ (1997) Accuracy of the clinical diagnosis of corticobasal degeneration: a clinicopathologic study. Neurology 48(1):119–125PubMedGoogle Scholar
  11. 11.
    Litvan I, Goetz CG, Jankovic J, Wenning GK, Booth V, Bartko JJ, McKee A, Jellinger K, Lai EC, Brandel JP, Verny M, Chaudhuri KR, Pearce RK, Agid Y (1997) What is the accuracy of the clinical diagnosis of multiple system atrophy? A clinicopathologic study. Arch Neurol 54(8):937–944PubMedCrossRefGoogle Scholar
  12. 12.
    Litvan I, Bhatia KP, Burn DJ, Goetz CG, Lang AE, McKeith I, Quinn N, Sethi KD, Shults C, Wenning GK (2003) Movement Disorders Society Scientific Issues Committee report: SIC Task Force appraisal of clinical diagnostic criteria for Parkinsonian disorders. Mov Disord 18(5):467–486PubMedCrossRefGoogle Scholar
  13. 13.
    Wenning GK, Litvan I, Jankovic J, Granata R, Mangone CA, McKee A, Poewe W, Jellinger K, Ray Chaudhuri K, D’Olhaberriague L, Pearce RK (1998) Natural history and survival of 14 patients with corticobasal degeneration confirmed at postmortem examination. J Neurol Neurosurg Psychiatry 64(2):184–189PubMedCrossRefGoogle Scholar
  14. 14.
    Ben-Shlomo Y, Wenning GK, Tison F, Quinn NP (1997) Survival of patients with pathologically proven multiple system atrophy: a meta-analysis. Neurology 48(2):384–393PubMedGoogle Scholar
  15. 15.
    Santacruz P, Uttl B, Litvan I, Grafman J (1998) Progressive supranuclear palsy: a survey of the disease course. Neurology 50(6):1637–1647PubMedGoogle Scholar
  16. 16.
    Daniel SE, de Bruin VM, Lees AJ (1995) The clinical and pathological spectrum of Steele-Richardson-Olszewski syndrome (progressive supranuclear palsy): a reappraisal. Brain 118(Pt 3):759–770PubMedCrossRefGoogle Scholar
  17. 17.
    Wenning GK, Tison F, Ben Shlomo Y, Daniel SE, Quinn NP (1997) Multiple system atrophy: a review of 203 pathologically proven cases. Mov Disord 12(2):133–147PubMedCrossRefGoogle Scholar
  18. 18.
    Gibb WR, Luthert PJ, Marsden CD (1990) Clinical and pathological features of corticobasal degeneration. Adv Neurol 53:51–54PubMedGoogle Scholar
  19. 19.
    Gibb WR (1992) Neuropathology of Parkinson’s disease and related syndromes. Neurol Clin 10(2):361–376PubMedGoogle Scholar
  20. 20.
    Goto S, Hirano A, Matsumoto S (1989) Subdivisional involvement of nigrostriatal loop in idiopathic Parkinson’s disease and striatonigral degeneration. Ann Neurol 26(6):766–770PubMedCrossRefGoogle Scholar
  21. 21.
    Jellinger KA (1999) Post mortem studies in Parkinson’s disease—is it possible to detect brain areas for specific symptoms? J Neural Transm Suppl 56:1–29PubMedGoogle Scholar
  22. 22.
    Kaufman MJ, Madras BK (1991) Severe depletion of cocaine recognition sites associated with the dopamine transporter in Parkinson’s-diseased striatum. Synapse 9(1):43–49PubMedCrossRefGoogle Scholar
  23. 23.
    Niznik HB, Fogel EF, Fassos FF, Seeman P (1991) The dopamine transporter is absent in parkinsonian putamen and reduced in the caudate nucleus. J Neurochem 56(1):192–198PubMedCrossRefGoogle Scholar
  24. 24.
    Benamer TS, Patterson J, Grosset DG, Booij J, de Bruin K, van Royen E, Speelman JD, Horstink MH, Sips HJ, Dierckx RA, Versijpt J, Decoo D, Van Der Linden C, Hadley DM, Doder M, Lees AJ, Costa DC, Gacinovic S, Oertel WH, Pogarell O, Hoeffken H, Joseph K, Tatsch K, Schwarz J, Ries V (2000) Accurate differentiation of parkinsonism and essential tremor using visual assessment of [123I]-FP-CIT SPECT imaging: the [123I]-FP-CIT study group. Mov Disord 15(3):503–510PubMedCrossRefGoogle Scholar
  25. 25.
    Vlaar AM, de Nijs T, Kessels AG, Vreeling FW, Winogrodzka A, Mess WH, Tromp SC, van Kroonenburgh MJ, Weber WE (2008) Diagnostic value of 123I-ioflupane and 123I-iodobenzamide SPECT scans in 248 patients with parkinsonian syndromes. Eur Neurol 59(5):258–266PubMedCrossRefGoogle Scholar
  26. 26.
    Plotkin M, Amthauer H, Klaffke S, Kuhn A, Ludemann L, Arnold G, Wernecke KD, Kupsch A, Felix R, Venz S (2005) Combined 123I-FP-CIT and 123I-IBZM SPECT for the diagnosis of parkinsonian syndromes: study on 72 patients. J Neural Transm 112(5):677–692PubMedCrossRefGoogle Scholar
  27. 27.
    Hoehn MM, Yahr MD (1967) Parkinsonism: onset, progression and mortality. Neurology 17(5):427–442PubMedGoogle Scholar
  28. 28.
    Tatsch K, Asenbaum S, Bartenstein P, Catafau A, Halldin C, Pilowsky LS, Pupi A (2002) European Association of Nuclear Medicine procedure guidelines for brain neurotransmission SPET using (123)I-labelled dopamine D(2) transporter ligands. Eur J Nucl Med Mol Imaging 29(10):BP30–BP35PubMedGoogle Scholar
  29. 29.
    Hawkes CH, Del Tredici K, Braak H (2010) A timeline for Parkinson’s disease. Parkinsonism Relat Disord 16(2):79–84PubMedCrossRefGoogle Scholar
  30. 30.
    Koch W, Radau PE, Hamann C, Tatsch K (2005) Clinical testing of an optimized software solution for an automated, observer-independent evaluation of dopamine transporter SPECT studies. J Nucl Med 46(7):1109–1118PubMedGoogle Scholar
  31. 31.
    Eggers C, Kahraman D, Fink GR, Schmidt M, Timmermann L (2011) Akinetic-rigid and tremor-dominant Parkinson’s disease patients show different patterns of FP-CIT Single photon emission computed tomography. Mov Disord 26(3):416–423PubMedCrossRefGoogle Scholar
  32. 32.
    Benamer HT, Patterson J, Wyper DJ, Hadley DM, Macphee GJ, Grosset DG (2000) Correlation of Parkinson’s disease severity and duration with 123I-FP-CIT SPECT striatal uptake. Mov Disord 15(4):692–698PubMedCrossRefGoogle Scholar
  33. 33.
    Kish SJ, Shannak K, Hornykiewicz O (1988) Uneven pattern of dopamine loss in the striatum of patients with idiopathic Parkinson’s disease. Pathophysiologic and clinical implications. N Engl J Med 318(14):876–880PubMedCrossRefGoogle Scholar
  34. 34.
    Brooks DJ, Ibanez V, Sawle GV, Quinn N, Lees AJ, Mathias CJ, Bannister R, Marsden CD, Frackowiak RS (1990) Differing patterns of striatal 18F-dopa uptake in Parkinson’s disease, multiple system atrophy, and progressive supranuclear palsy. Ann Neurol 28(4):547–555PubMedCrossRefGoogle Scholar
  35. 35.
    Rajput AH, Voll A, Rajput ML, Robinson CA, Rajput A (2009) Course in Parkinson disease subtypes: a 39-year clinicopathologic study. Neurology 73(3):206–212PubMedCrossRefGoogle Scholar
  36. 36.
    Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ (1992) What features improve the accuracy of clinical diagnosis in Parkinson’s disease: a clinicopathologic study. Neurology 42(6):1142–1146PubMedGoogle Scholar
  37. 37.
    Litvan I, Agid Y, Jankovic J, Goetz C, Brandel JP, Lai EC, Wenning G, D’Olhaberriague L, Verny M, Chaudhuri KR, McKee A, Jellinger K, Bartko JJ, Mangone CA, Pearce RK (1996) Accuracy of clinical criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome). Neurology 46(4):922–930PubMedGoogle Scholar
  38. 38.
    O’Sullivan SS, Massey LA, Williams DR, Silveira-Moriyama L, Kempster PA, Holton JL, Revesz T, Lees AJ (2008) Clinical outcomes of progressive supranuclear palsy and multiple system atrophy. Brain 131(Pt 5):1362–1372PubMedGoogle Scholar
  39. 39.
    Wenning GK, Colosimo C, Geser F, Poewe W (2004) Multiple system atrophy. Lancet Neurol 3(2):93–103PubMedCrossRefGoogle Scholar
  40. 40.
    Burn DJ, Warren NM (2005) Toward future therapies in progressive supranuclear palsy. Mov Disord 20(Suppl 12):S92–S98PubMedCrossRefGoogle Scholar
  41. 41.
    Katzenschlager R, Lees AJ (2002) Treatment of Parkinson’s disease: levodopa as the first choice. J Neurol 249(Suppl 2):II19–II24PubMedGoogle Scholar
  42. 42.
    Fahn S (2006) Levodopa in the treatment of Parkinson’s disease. J Neural Transm Suppl 71:1–15PubMedCrossRefGoogle Scholar
  43. 43.
    Fahn S, Oakes D, Shoulson I, Kieburtz K, Rudolph A, Lang A, Olanow CW, Tanner C, Marek K (2004) Levodopa and the progression of Parkinson’s disease. N Engl J Med 351(24):2498–2508PubMedCrossRefGoogle Scholar
  44. 44.
    Olanow CW, Rascol O, Hauser R, Feigin PD, Jankovic J, Lang A, Langston W, Melamed E, Poewe W, Stocchi F, Tolosa E (2009) A double-blind, delayed-start trial of rasagiline in Parkinson’s disease. N Engl J Med 361(13):1268–1278PubMedCrossRefGoogle Scholar
  45. 45.
    Van Laere K, Everaert L, Annemans L, Gonce M, Vandenberghe W, Vander Borght T (2008) The cost effectiveness of 123I-FP-CIT SPECT imaging in patients with an uncertain clinical diagnosis of parkinsonism. Eur J Nucl Med Mol Imaging 35(7):1367–1376PubMedCrossRefGoogle Scholar
  46. 46.
    Staff RT, Ahearn TS, Wilson K, Counsell CE, Taylor K, Caslake R, Davidson JE, Gemmell HG, Murray AD (2009) Shape analysis of 123I-N-omega-fluoropropyl-2-beta-carbomethoxy-3beta-(4-iodophenyl) nortropane single-photon emission computed tomography images in the assessment of patients with parkinsonian syndromes. Nucl Med Commun 30(3):194–201PubMedCrossRefGoogle Scholar
  47. 47.
    Goethals I, Ham H, Dobbeleir A, Santens P, D’Asseler Y (2009) The potential value of a pictorial atlas for aid in the visual diagnosis of 123I FP-CIT SPECT scans. Nuklearmedizin 48(4):173–178PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Deniz Kahraman
    • 1
  • Carsten Eggers
    • 2
  • Harald Schicha
    • 1
  • Lars Timmermann
    • 2
  • Matthias Schmidt
    • 1
  1. 1.Department of Nuclear MedicineUniversity Hospital of CologneCologneGermany
  2. 2.Department of NeurologyUniversity Hospital of CologneCologneGermany

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