Diagnostic usefulness of putaminal abnormality on diffusion- and susceptibility-weighted imaging: two illustrative cases
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LETTER TO THE EDITOR
Diagnostic usefulness of putaminal abnormality on diffusionand susceptibility-weighted imaging: two illustrative cases of multiple system atrophy-parkinsonian type Kyum-Yil Kwon 1
&
Mina Lee 1 & Hyunjin Ju 1 & Kayeong Im 1
Received: 25 February 2020 / Accepted: 25 September 2020 # Fondazione Società Italiana di Neurologia 2020
Introduction Brain magnetic resonance imaging (MRI) has been widely performed to evaluate patients with parkinsonism. Recently, putaminal changes, including putaminal atrophy, putaminal hypointensity, and hyperintense putaminal rim, have been investigated as characteristic radiological findings of the parkinsonian variant of multiple system atrophy (MSA-P) using various MRI modalities, including T2-weighted imaging (T2WI), fluid-attenuated inversion recovery (FLAIR) imaging, diffusion-weighted imaging (DWI), and susceptibilityweighted imaging (SWI) [1]. However, in clinical settings, the clinical usefulness of an individual assessment for putaminal abnormalities in those MRI modalities remains to be further elucidated. From our experiences with two patients with probable MSA-P, we found that not only SWI but also DWI might be more sensitive ways to identify putaminal abnormalities, than conventional MRIs. Moreover, we observed that DWI at B1000 might be more feasible than apparent diffusion coefficient (ADC) mapping when reading DWI for the visual assessment of putaminal abnormalities.
Case reports
history was notable for hypertension and depression, and he reported occasionally acting out his dreams while asleep for the past 10 years. Two years ago, the patient underwent surgery for benign prostate hyperplasia causing urinary symptoms that included urgency but no significant improvement resulted from the surgery. Upon neurological examination, the patient showed akinetic rigid parkinsonism, which was more prominent in the right-sided limbs than the left-sided limbs. Subtle postural instability and unsteadiness in tandem gait were noted. Extraocular movement examinations, including supranuclear gaze palsy, and limb ataxia tests were unremarkable. The patient also exhibited erectile dysfunction and urinary incontinence. Orthostatic hypotension was not prominent, although the patient experienced orthostatic dizziness. Deep tendon reflexes were normoactive, and pathologic reflexes were not checked in all extremities. The patient’s parkinsonian symptoms were not improved with levodopa administration. Various brain MRI modalities revealed a putaminal abnormality, which was prominent in the left posterior putamen (Fig. 1A–E). Intriguingly, we found that the left-sided putaminal abnormality seen on both DWI (Fig. 1C) and SWI (Fig. 1E) was more remarkable than that on other MRIs. The patient was finally diagnosed with probable MSAP, according to current diagnostic criteria [2].
Case 1
Case 2
A 63-year-old man was admitted with a 6-month history of progressive slowness and gait disturbance. His past medical
A 55-year-old woman was admitted to our hospital for treatment
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