Review
Transcranial brain parenchyma sonography in movement disorders: State of the art

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Abstract

The present paper summarizes recommendations on transcranial sonography (TCS) application in neurodegenerative diseases, resulting from a consensus meeting of the European Society of Neurosonology and Cerebral Hemodynamics. TCS of distinct infra- and supratentorial brain structures detects characteristic changes in several movement disorders, such as abnormal hyperechogenicity of substantia nigra (SN) in Parkinson’s disease and of lenticular nucleus in dystonia, Wilson’s disease and atypical Parkinsonian disorders. In healthy adults, the TCS finding of marked SN hyperechogenicity indicates a subclinical functional impairment of the nigrostriatal dopaminergic system. The finding of marked SN hyperechogenicity in combination with normal lenticular-nucleus echogenicity discriminates idiopathic Parkinson’s disease from multiple-system atrophy and progressive supranuclear palsy with a positive predictive value of more than 90%. As TCS is a quick and noninvasive method, using the same duplex-ultrasound machines as for investigation of intracranial vessels, applicable even in agitated patients, this method has a great potential to be more widely used. (E-mail: http://[email protected])

Introduction

For many y, the intact skull was regarded as an insurmountable problem to obtaining high-resolution sonographic images of the adult brain. However, after first attempts in the 1970s and 1980s (Berland et al 1988, Furuhata 1989, Kamphuisen et al 1972), transcranial sonography (TCS) of the brain parenchyma has developed with increasing dynamics. Today’s modern ultrasound systems allow high-resolution TCS of the brain structures. In comparison with conventional neuroimaging methods such as CT and MRI, advantages of TCS are low costs, short investigation times, noninvasiveness, unlimited repeatability, bedside availability and lower dependency on patient’s compliance. Disadvantages are dependency on acoustic temporal bone windows, which accounts for missing or only partial accessibility of 10% to 20% of patients (Becker and Berg 2001), and dependency on examiner’s skills. An important argument in favor of TCS is that the physical principle (a reflection of ultrasound waves at interfaces with diverse acoustic impedances) differs from other imaging methods and thereby delivers new and complementary findings.

In recent y, TCS has been proven to be reliable and useful in detecting basal ganglia alterations in several movement disorders. Pathbreaking was the finding of increased echogenicity of substantia nigra in Parkinson’s disease (PD) (Becker et al. 1995a). Since then, characteristic TCS findings have been reported for other movement disorders such as idiopathic dystonia and Huntington’s disease (Naumann et al 1996, Postert et al 1999). TCS findings led to new insights and pathophysiological concepts, especially in PD and dystonia (Becker and Berg 2001). In the clinical setting, use of TCS for early recognition and differential diagnosis of neurodegenerative disorders is promising. This necessitates methodological standardization and definition of clinical applications.

On May 11, 2004, on the occasion of the Ninth Meeting of the European Society of Neurosonology and Cerebral Hemodynamics (ESNCH) in Wetzlar, Germany, the ESNCH sponsored a workshop to develop a standardized procedure of TCS in neurodegenerative diseases. This paper presents the consensus findings on application of TCS in movement disorders resulting from the workshop and reviews the main studies that led to their development.

Section snippets

Methods

To achieve consensus on application of TCS in movement disorders in adults, the chairs of the planned consensus meeting (D.B., U.W.) at first searched the Medline database for all research papers in this field that have been published until end of year 2003, including TCS studies of healthy adults. For this, the keywords “sonography” and “ultrasound” were combined sequentially with each of the following keywords: “substantia nigra,” “brainstem raphe,” “cerebellum,” “lenticular nucleus” and

Evaluation of TCS studies and issues to be standardized

Database research detected 11 reports on substantia nigra (SN) TCS (Becker et al 1995a, Berg et al 1999a, Berg et al 2001a, Berg et al 2001b, Berg et al 2001c, Berg et al 2002, Jabs et al 2001, Postert et al 1999, Ruprecht-Dorfler et al 2003, Walter et al 2002, Walter et al 2003), four on brainstem raphe (BR) TCS (Becker et al 1994, Becker et al 1995b, Becker et al 1997a, Berg et al 1999b), seven on lenticular nucleus (LN) TCS (Becker et al 1997b, Becker et al 2002, Berg et al 2000a, Naumann et

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