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Table 1 Clinical pointers and radiological features in parkinsonian syndromes by various imaging techniques [55]

From: Imaging modalities in differential diagnosis of Parkinson’s disease: opportunities and challenges

Syndrome Clinical pointers Radiological features
Multiple system atrophy ➢ May be indistinguishable from PD in early stages
➢ Jerky finger tremor related to mini-polymyoclonus
➢ “Strangulated” dysarthria
➢ Axial/craniocervical levodopa-induced dyskinesia
➢ Cerebellar atrophy
➢ T2 high signal in degenerating pontocerebellar fibers leading to “hot-cross bun” sign (Fig. 2)
➢ T2 low signal in putamen with rim of increased signal on lateral edge
Progressive supranuclear palsy ➢ Erect posture with good step size at presentation
➢ Frequent falls and injuries early in the disease course
➢ Slowed saccadic eye movements may be subtle in early disease
➢ Midbrain atrophy (with “hummingbird” sign on sagittal brainstem images, Fig. 3)
➢ 3rd ventricle dilatation
Corticobasal degeneration ➢ Markedly asymmetrical rigid/akinetic/apraxic limb with relatively normal contralateral limb in early disease ➢ Asymmetric frontoparietal atrophy on MRI
Essential tremor ➢ High-frequency tremor
➢ The tremor is postural and kinetic, and improves with rest
➢ Absent PD non-motor features
➢ Head and neck tremor
➢ May have a long and benign course
➢ DaTscan is normal
Dystonic tremor ➢ Thumb extension tremor
➢ Jerky tremor with flurries of tremor
➢ May be task-specific or task-exacerbated
➢ DaTscan is normal
Vascular parkinsonism ➢ Presents as gait disorder
➢ “Lower body” parkinsonism with mild or absent upper body parkinsonism
➢ Neuroimaging shows variable degrees of small-vessel ischemic changes
  1. PD Parkinson’s disease