O papel da difusão por ressonância magnética na doença de Parkinson e no diagnóstico diferencial com parkinsonismo atípico

Oliveira, Romulo Varella de; Pereira, João Santos

doi:10.1590/0100-3984.2016-0073

Romulo Varella de Oliveira Endereço para correspondência: Dr. Romulo Varela de Oliveira. Hospital Universitário Pedro Ernesto – Serviço de Imagem. Boulevard 28 de Setembro, 77, Vila Isabel. Rio de Janeiro, RJ, Brasil, 20551-030. E-mail: romulovarella@hotmail.com.

Membro Titular do Colégio Brasileiro de Radiologia e Diagnóstico por Imagem (CBR), Mestrando do Programa de Pós-Graduação em Ciências Médicas da Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (PGCM-FCM-UERJ), Médico Radiologista do Hospital Universitário Pedro Ernesto (HUPE) e da Clínica Alta Excelência Diagnóstica - DASA, Rio de Janeiro, RJ, Brasil

João Santos Pereira

Doutor, Membro Titular da Academia Brasileira de Neurologia (ABN), Professor Associado, Coordenador do Setor de Distúrbios do Movimento do Serviço de Neurologia do Hospital Universitário Pedro Ernesto (HUPE), Rio de Janeiro, RJ, Brasil

Endereço para correspondência: Dr. Romulo Varela de Oliveira. Hospital Universitário Pedro Ernesto – Serviço de Imagem. Boulevard 28 de Setembro, 77, Vila Isabel. Rio de Janeiro, RJ, Brasil, 20551-030. E-mail: romulovarella@hotmail.com.

Figuras (3)
Tabelas (1)

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Figura 1
RM convencional e ITD na doença de Parkinson. A substância negra normal apresenta-se como uma faixa hipointensa nas sequências pesadas em T2 e em suscetibilidade magnética entre o pedúnculo cerebral e o tegmento mesencefálico. Em um paciente sem doença de Parkinson de 66 anos (A), no corte axial do mesencéfalo na sequência pesada em suscetibilidade magnética está bem delimitada a substância negra (círculo preto), que apresenta espessura preservada e plano de clivagem bem definido com o núcleo rubro (círculo branco). Em um paciente com doença de Parkinson de 68 anos (B), no mesmo plano e sequência que em A, a substância negra não é bem delimitada e encontra-se afilada, enquanto seu plano com o núcleo rubro é indefinido. O sinal da substância negra no paciente com doença de Parkinson é reduzido devido ao depósito de ferro. As regiões de interesse na substância negra nos pacientes de A e B (círculos pretos) foram copiadas e coladas no mapa de anisotropia fracionada (C e D, respectivamente), que demonstraram um valor menor no paciente com doença de Parkinson (0,425) do que no paciente sem doença de Parkinson (0,581), indicando perda da integridade neuronal. A avaliação do lado contralateral mostrou achados semelhantes tanto no paciente sem doença de Parkinson quanto no paciente com doença de Parkinson (não demonstrado).

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Figura 2
RM convencional na paralisia supranuclear progressiva. O sinal do beija-flor pode ser visualizado na sequência pesada em T1 no plano sagital (A), devido à redução volumétrica do mesencéfalo (asterisco branco) em relação à ponte (asterisco preto), diferente do que ocorre no tronco encefálico normal (B). No plano axial o sinal do Mickey Mouse (C) ocorre devido ao alargamento da cisterna interpeduncular (seta) e à retração das porções dorsolaterais do mesencéfalo, achados não encontrados no paciente normal (D).

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Figura 3
Alterações morfológicas e de sinal na atrofia de múltiplos sistemas na RM convencional. O sinal da cruz é demonstrado como duas linhas perpendiculares na ponte, hiperintensas na sequência pesada em T2 no plano axial, além da acentuação das cisternas da base, sulcos cerebelares e quarto ventrículo (A). Na sequência pesada em T1 no plano sagital (B) pode ser visualizada a redução volumétrica da ponte em relação ao mesencéfalo (comparar com o tronco encefálico normal na ).

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Tabela 1
Resumo dos achados da RM convencional e difusão por RM na doença de Parkinson e parkinsonismos atípicos.

	RM convencional		Difusão por RM
	Achados	Considerações	Achados	Considerações
DP	- Afilamento da parte compacta da substância negra, mais bem visualizado nas sequências pesadas em T2 e em suscetibilidade magnética no plano axial⁽¹²12 Meijer FJ, Goraj B. Brain MRI in Parkinson's disease. Front Biosci (Elite Ed). 2014;6:360-9.⁾	- Especificidade muito alta, porém sensibilidade muito baixa, encontrado apenas nas fases mais avançadas⁽¹²12 Meijer FJ, Goraj B. Brain MRI in Parkinson's disease. Front Biosci (Elite Ed). 2014;6:360-9.⁾	- Redução da AF na substância ne-gra, mais evidente na porção caudal⁽⁸8 Cochrane CJ, Ebmeier KP. Diffusion tensor imaging in parkinsonian syndromes: a systematic review and meta-analysis. Neurology. 2013;80:857-64.^,¹⁰10 Modrego PJ, Fayed N, Artal J, et al. Correlation of findings in advanced MRI techniques with global severity scales in patients with Parkinson disease. Acad Radiol. 2011;18:235-41.^,¹¹11 Jiang MF, Shi F, Niu GM, et al. A novel method for evaluating brain function and microstructural changes in Parkinson's disease. Neural Regen Res. 2015;10:2025-32.^,²¹21 Zhan W, Kang GA, Glass GA, et al. Regional alterations of brain microstructure in Parkinson's disease using diffusion tensor imaging. Mov Disord. 2012;27:90-7. 22 Vaillancourt DE, Spraker MB, Prodoehl J, et al. High-resolution diffusion tensor imaging in the substantia nigra of de novo Parkinson disease. Neurology. 2009;72:1378-84. 23 Lenfeldt N, Larsson A, Nyberg L, et al. Fractional anisotropy in the substantia nigra in Parkinson's disease: a complex picture. Eur J Neurol. 2015;22:1408-14. 24 Zhang K, Yu C, Zhang Y, et al. Voxel-based analysis of diffusion tensor indices in the brain in patients with Parkinson's disease. Eur J Radiol. 2011;77:269-73.^-²⁵25 Schwarz ST, Abaei M, Gontu V, et al. Diffusion tensor imaging of nigral degeneration in Parkinson's disease: a region-of-interest and voxel-based study at 3 T and systematic review with meta-analysis. Neuroimage Clin. 2013;3:481-8.⁾	- Alta sensibilidade e especificidade, mesmo em fases iniciais da doença. Dados mais estabelecidos na literatura⁽⁸8 Cochrane CJ, Ebmeier KP. Diffusion tensor imaging in parkinsonian syndromes: a systematic review and meta-analysis. Neurology. 2013;80:857-64.^,¹⁰10 Modrego PJ, Fayed N, Artal J, et al. Correlation of findings in advanced MRI techniques with global severity scales in patients with Parkinson disease. Acad Radiol. 2011;18:235-41.^,¹¹11 Jiang MF, Shi F, Niu GM, et al. A novel method for evaluating brain function and microstructural changes in Parkinson's disease. Neural Regen Res. 2015;10:2025-32.^,²¹21 Zhan W, Kang GA, Glass GA, et al. Regional alterations of brain microstructure in Parkinson's disease using diffusion tensor imaging. Mov Disord. 2012;27:90-7. 22 Vaillancourt DE, Spraker MB, Prodoehl J, et al. High-resolution diffusion tensor imaging in the substantia nigra of de novo Parkinson disease. Neurology. 2009;72:1378-84. 23 Lenfeldt N, Larsson A, Nyberg L, et al. Fractional anisotropy in the substantia nigra in Parkinson's disease: a complex picture. Eur J Neurol. 2015;22:1408-14. 24 Zhang K, Yu C, Zhang Y, et al. Voxel-based analysis of diffusion tensor indices in the brain in patients with Parkinson's disease. Eur J Radiol. 2011;77:269-73.^-²⁵25 Schwarz ST, Abaei M, Gontu V, et al. Diffusion tensor imaging of nigral degeneration in Parkinson's disease: a region-of-interest and voxel-based study at 3 T and systematic review with meta-analysis. Neuroimage Clin. 2013;3:481-8.⁾
			- Redução da AF nos lobos frontais (córtex motor, pré-motor e motor suplementar)⁽¹⁸18 Gattellaro G, Minati L, Grisoli M, et al. White matter involvement in idiopathic Parkinson disease: a diffusion tensor imaging study. AJNR Am J Neuroradiol. 2009;30:1222-6.^,²¹21 Zhan W, Kang GA, Glass GA, et al. Regional alterations of brain microstructure in Parkinson's disease using diffusion tensor imaging. Mov Disord. 2012;27:90-7.^,²⁷27 Kendi ATK, Lehericy S, Luciana M, et al. Altered diffusion in the frontal lobe in Parkinson disease. AJNR Am J Neuroradiol. 2008;29:501-5.⁾	- Baixa sensibilidade e especificidade⁽¹⁸18 Gattellaro G, Minati L, Grisoli M, et al. White matter involvement in idiopathic Parkinson disease: a diffusion tensor imaging study. AJNR Am J Neuroradiol. 2009;30:1222-6.^,²¹21 Zhan W, Kang GA, Glass GA, et al. Regional alterations of brain microstructure in Parkinson's disease using diffusion tensor imaging. Mov Disord. 2012;27:90-7.^,²⁷27 Kendi ATK, Lehericy S, Luciana M, et al. Altered diffusion in the frontal lobe in Parkinson disease. AJNR Am J Neuroradiol. 2008;29:501-5.⁾
			- Redução da AF no corpo estriado e hemisférios cerebelares⁽²⁸28 Péran P, Cherubini A, Assogna F, et al. Magnetic resonance imaging markers of Parkinson's disease nigrostriatal signature. Brain. 2010;133:3423-33.^,²⁹29 Mormina E, Arrigo A, Calamuneri A, et al. Diffusion tensor imaging parameters' changes of cerebellar hemispheres in Parkinson's disease. Neuroradiology. 2015;57:327-34.⁾	- Pouco estudado na literatura, podendo estar associado a sinais específicos da doença⁽²⁸28 Péran P, Cherubini A, Assogna F, et al. Magnetic resonance imaging markers of Parkinson's disease nigrostriatal signature. Brain. 2010;133:3423-33.^,²⁹29 Mormina E, Arrigo A, Calamuneri A, et al. Diffusion tensor imaging parameters' changes of cerebellar hemispheres in Parkinson's disease. Neuroradiology. 2015;57:327-34.⁾
			- Redução da AF no joelho do corpo caloso, giro do cíngulo, hipocampos, fascículos longitudinais superior e inferior e fascículos fronto-occipital inferior e uncinado⁽³⁰30 Kamagata K, Motoi Y, Abe O, et al. White matter alteration of the cingulum in Parkinson disease with and without dementia: evaluation by diffusion tensor tract-specific analysis. AJNR Am J Neuroradiol. 2012;33:890-5. 31 Matsui H, Nishinaka K, Oda M, et al. Dementia in Parkinson's disease: diffusion tensor imaging. Acta Neurol Scand. 2007;116:177-81. 32 Zheng Z, Shemmassian S, Wijekoon C, et al. DTI correlates of distinct cognitive impairments in Parkinson's disease. Hum Brain Mapp. 2014;35:1325-33. 33 Duncan GW, Firbank MJ, Yarnall AJ, et al. Gray and white matter imaging: a biomarker for cognitive impairment in early Parkinson's disease? Mov Disord. 2016;31:103-10. 34 Wiltshire K, Concha L, Gee M, et al. Corpus callosum and cingulum tractography in Parkinson's disease. Can J Neurol Sci. 2010;37:595-600. 35 Hattori T, Orimo S, Aoki S, et al. Cognitive status correlates with white matter alteration in Parkinson's disease. Hum Brain Mapp. 2012;33:727-39.^-³⁶36 Carlesimo GA, Piras F, Assogna F, et al. Hippocampal abnormalities and memory deficits in Parkinson disease: a multimodal imaging study. Neurology. 2012;78:1939-45.⁾	- Parece estar relacionado a demên-cia na DP, mas carece de mais estudos⁽30^-³⁶36 Carlesimo GA, Piras F, Assogna F, et al. Hippocampal abnormalities and memory deficits in Parkinson disease: a multimodal imaging study. Neurology. 2012;78:1939-45.⁾
			- Redução da AF nas porções medio-dorsal do tálamo e anterior do giro do cíngulo⁽¹¹11 Jiang MF, Shi F, Niu GM, et al. A novel method for evaluating brain function and microstructural changes in Parkinson's disease. Neural Regen Res. 2015;10:2025-32.^,³¹31 Matsui H, Nishinaka K, Oda M, et al. Dementia in Parkinson's disease: diffusion tensor imaging. Acta Neurol Scand. 2007;116:177-81.^,³⁷37 Li W, Liu J, Skidmore F, et al. White matter microstructure changes in the thalamus in Parkinson disease with depression: a diffusion tensor MR imaging study. AJNR Am J Neuroradiol. 2010;31:1861-6.⁾	- Pode estar relacionado a depres-são, mais esse tema ainda não foi muito estudado⁽¹¹11 Jiang MF, Shi F, Niu GM, et al. A novel method for evaluating brain function and microstructural changes in Parkinson's disease. Neural Regen Res. 2015;10:2025-32.^,³¹31 Matsui H, Nishinaka K, Oda M, et al. Dementia in Parkinson's disease: diffusion tensor imaging. Acta Neurol Scand. 2007;116:177-81.^,³⁷37 Li W, Liu J, Skidmore F, et al. White matter microstructure changes in the thalamus in Parkinson disease with depression: a diffusion tensor MR imaging study. AJNR Am J Neuroradiol. 2010;31:1861-6.⁾
	- Atrofia cortical difusa, predominando nos lobos frontais⁽¹²12 Meijer FJ, Goraj B. Brain MRI in Parkinson's disease. Front Biosci (Elite Ed). 2014;6:360-9.⁾	- Baixa sensibilidade e especifici-dade, ocorre em fase terminal⁽¹²12 Meijer FJ, Goraj B. Brain MRI in Parkinson's disease. Front Biosci (Elite Ed). 2014;6:360-9.⁾	- Redução da AF nos bulbos olfató-rios, substância branca adjacente ao córtex olfatório primário e giros retos⁽³⁸38 Skorpil M, Söderlund V, Sundin A, et al. MRI diffusion in Parkinson's disease: using the technique's inherent directional information to study the olfactory bulb and substantia nigra. J Parkinsons Dis. 2012;2:171-80.^,⁴⁰40 Rolheiser TM, Fulton HG, Good KP, et al. Diffusion tensor imaging and olfactory identification testing in early-stage Parkinson's disease. J Neurol. 2011;258:1254-60.^,⁴¹41 Ibarretxe-Bilbao N, Junque C, Marti MJ, et al. Olfactory impairment in Parkinson's disease and white matter abnormalities in central olfactory areas: a voxel-based diffusion tensor imaging study. Mov Disord. 2010;25:1888-94.⁾	- Pode estar presente em indivíduos com testes olfatórios alterados, com potencial para identificar pacientes na fase pré-motora da DP⁽³⁸38 Skorpil M, Söderlund V, Sundin A, et al. MRI diffusion in Parkinson's disease: using the technique's inherent directional information to study the olfactory bulb and substantia nigra. J Parkinsons Dis. 2012;2:171-80.^,⁴⁰40 Rolheiser TM, Fulton HG, Good KP, et al. Diffusion tensor imaging and olfactory identification testing in early-stage Parkinson's disease. J Neurol. 2011;258:1254-60.^,⁴¹41 Ibarretxe-Bilbao N, Junque C, Marti MJ, et al. Olfactory impairment in Parkinson's disease and white matter abnormalities in central olfactory areas: a voxel-based diffusion tensor imaging study. Mov Disord. 2010;25:1888-94.⁾
AMS	- Sinal da cruz em T2 no plano axial e atrofia da ponte⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾	- Todos têm boa especificidade, porém podem ser encontrados em outras condições⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾	- Redução da AF e aumento do CDA no putâmen⁽⁴³43 Ito M, Watanabe H, Kawai Y, et al. Usefulness of combined fractional anisotropy and apparent diffusion coefficient values for detection of involvement in multiple system atrophy. J Neurol Neurosurg Psychiatry. 2007;78:722-8. 44 Köllensperger M, Seppi K, Liener C, et al. Diffusion weighted imaging best discriminates PD from MSA-P: a comparison with tilt table testing and heart MIBG scintigraphy. Mov Disord. 2007;22:1771-6. 45 Pellecchia MT, Barone P, Mollica C, et al. Diffusion-weighted imaging in multiple system atrophy: a comparison between clinical subtypes. Mov Disord. 2009;24:689-96. 46 Seppi K, Schocke MFH, Prennschuetz-Schuetzenau K, et al. Topography of putaminal degeneration in multiple system atrophy: a diffusion magnetic resonance study. Mov Disord. 2006;21:847-52. 47 Tsukamoto K, Matsusue E, Kanasaki Y, et al. Significance of apparent diffusion coefficient measurement for the differential diagnosis of multiple system atrophy, progressive supranuclear palsy, and Parkinson's disease: evaluation by 3.0-T MR imaging. Neuroradiology. 2012;54:947-55.^-⁴⁸48 Barbagallo G, Sierra-Peña M, Nemmi F, et al. Multimodal MRI assessment of nigro-striatal pathway in multiple system atrophy and Parkinson disease. Mov Disord. 2016;31:325-34.⁾	- Alta sensibilidade e especificidade, principalmente na AMS-P, mas também pode ocorrer na PSP⁽⁴³43 Ito M, Watanabe H, Kawai Y, et al. Usefulness of combined fractional anisotropy and apparent diffusion coefficient values for detection of involvement in multiple system atrophy. J Neurol Neurosurg Psychiatry. 2007;78:722-8. 44 Köllensperger M, Seppi K, Liener C, et al. Diffusion weighted imaging best discriminates PD from MSA-P: a comparison with tilt table testing and heart MIBG scintigraphy. Mov Disord. 2007;22:1771-6. 45 Pellecchia MT, Barone P, Mollica C, et al. Diffusion-weighted imaging in multiple system atrophy: a comparison between clinical subtypes. Mov Disord. 2009;24:689-96. 46 Seppi K, Schocke MFH, Prennschuetz-Schuetzenau K, et al. Topography of putaminal degeneration in multiple system atrophy: a diffusion magnetic resonance study. Mov Disord. 2006;21:847-52. 47 Tsukamoto K, Matsusue E, Kanasaki Y, et al. Significance of apparent diffusion coefficient measurement for the differential diagnosis of multiple system atrophy, progressive supranuclear palsy, and Parkinson's disease: evaluation by 3.0-T MR imaging. Neuroradiology. 2012;54:947-55.^-⁴⁸48 Barbagallo G, Sierra-Peña M, Nemmi F, et al. Multimodal MRI assessment of nigro-striatal pathway in multiple system atrophy and Parkinson disease. Mov Disord. 2016;31:325-34.⁾
	- Sinal hiperintenso em T2 e atrofia do putâmen⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾	- Apresentam moderada sensibilidade, visto que normalmente não são visualizados nas fases iniciais da doença⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾	- Redução da AF e aumento do CDA na ponte, cerebelo e pedúnculos ce-rebelares médios⁽⁴³43 Ito M, Watanabe H, Kawai Y, et al. Usefulness of combined fractional anisotropy and apparent diffusion coefficient values for detection of involvement in multiple system atrophy. J Neurol Neurosurg Psychiatry. 2007;78:722-8.^,⁵⁰50 Paviour DC, Thornton JS, Lees AJ, et al. Diffusion-weighted magnetic resonance imaging differentiates Parkinsonian variant of multiple-system atrophy from progressive supranuclear palsy. Mov Disord. 2007;22:68-74. 51 Yang H, Wang X, Liao W, et al. Application of diffusion tensor imaging in multiple system atrophy: the involvement of pontine transverse and longitudinal fibers. Int J Neurosci. 2015;125:18-24.^-⁵²52 Blain CRV, Barker GJ, Jarosz JM, et al. Measuring brain stem and cerebellar damage in parkinsonian syndromes using diffusion tensor MRI. Neurology. 2006;67:2199-205.⁾	- Alta sensibilidade e especificidade, principalmente na AMS-C. Junto com as alterações putaminais, aumentam muito a especificidade⁽⁴³43 Ito M, Watanabe H, Kawai Y, et al. Usefulness of combined fractional anisotropy and apparent diffusion coefficient values for detection of involvement in multiple system atrophy. J Neurol Neurosurg Psychiatry. 2007;78:722-8.^,⁵⁰50 Paviour DC, Thornton JS, Lees AJ, et al. Diffusion-weighted magnetic resonance imaging differentiates Parkinsonian variant of multiple-system atrophy from progressive supranuclear palsy. Mov Disord. 2007;22:68-74. 51 Yang H, Wang X, Liao W, et al. Application of diffusion tensor imaging in multiple system atrophy: the involvement of pontine transverse and longitudinal fibers. Int J Neurosci. 2015;125:18-24.^-⁵²52 Blain CRV, Barker GJ, Jarosz JM, et al. Measuring brain stem and cerebellar damage in parkinsonian syndromes using diffusion tensor MRI. Neurology. 2006;67:2199-205.⁾
	- Atrofia dos hemisférios cerebelares e dos pedúnculos cerebelares médios⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾			- As medidas na difusão, somadas às medidas na RM convencional, apresentam alta acurácia no diagnóstico diferencial com DP⁽⁵³53 Nair SR, Tan LK, Mohd Ramli N, et al. A decision tree for differentiating multiple system atrophy from Parkinson's disease using 3-T MR imaging. Eur Radiol. 2013;23:1459-66.⁾
PSP	- Sinal do beija-flor (ou do pinguim) no plano sagital⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾	- Todos têm especificidade muito alta, entretanto, podem não ser visualizados em fase precoce⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾	- Redução da AF no mesencéfalo e nos pedúnculos cerebelares superiores⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.^,⁴⁹49 Nicoletti G, Tonon C, Lodi R, et al. Apparent diffusion coefficient of the superior cerebellar peduncle differentiates progressive supranuclear palsy from Parkinson's disease. Mov Disord. 2008;23:2370-6.^,⁵²52 Blain CRV, Barker GJ, Jarosz JM, et al. Measuring brain stem and cerebellar damage in parkinsonian syndromes using diffusion tensor MRI. Neurology. 2006;67:2199-205.⁾	- Alta sensibilidade e especificidade⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.^,⁴⁹49 Nicoletti G, Tonon C, Lodi R, et al. Apparent diffusion coefficient of the superior cerebellar peduncle differentiates progressive supranuclear palsy from Parkinson's disease. Mov Disord. 2008;23:2370-6.^,⁵²52 Blain CRV, Barker GJ, Jarosz JM, et al. Measuring brain stem and cerebellar damage in parkinsonian syndromes using diffusion tensor MRI. Neurology. 2006;67:2199-205.⁾
	- Sinal do Mickey Mouse no plano axial⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾
	- Atrofia do mesencéfalo e dos pedúnculos cerebelares superiores⁽¹³13 Massey LA, Micallef C, Paviour DC, et al. Conventional magnetic resonance imaging in confirmed progressive supranuclear palsy and multiple system atrophy. Mov Disord. 2012;27:1754-62. 14 Quattrone A, Nicoletti G, Messina D, et al. MR imaging index for differentiation of progressive supranuclear palsy from Parkinson disease and the Parkinson variant of multiple system atrophy. Radiology. 2008;246:214-21.^-¹⁵15 Paviour DC, Price SL, Jahanshahi M, et al. Regional brain volumes distinguish PSP, MSA-P, and PD: MRI-based clinico-radiological correlations. Mov Disord. 2006;21:989-96.⁾		- Redução da AF no globo pálido e núcleo caudado⁽⁴⁷47 Tsukamoto K, Matsusue E, Kanasaki Y, et al. Significance of apparent diffusion coefficient measurement for the differential diagnosis of multiple system atrophy, progressive supranuclear palsy, and Parkinson's disease: evaluation by 3.0-T MR imaging. Neuroradiology. 2012;54:947-55.^,⁴⁹49 Nicoletti G, Tonon C, Lodi R, et al. Apparent diffusion coefficient of the superior cerebellar peduncle differentiates progressive supranuclear palsy from Parkinson's disease. Mov Disord. 2008;23:2370-6.^,⁵⁰50 Paviour DC, Thornton JS, Lees AJ, et al. Diffusion-weighted magnetic resonance imaging differentiates Parkinsonian variant of multiple-system atrophy from progressive supranuclear palsy. Mov Disord. 2007;22:68-74.^,⁵⁴54 Focke NK, Helms G, Pantel PM, et al. Differentiation of typical and atypical Parkinson syndromes by quantitative MR imaging. AJNR Am J Neuroradiol. 2011;32:2087-92.⁾	- Podem auxiliar no diagnóstico dife-rencial, mas foi pouco estudado até o momento⁽⁴⁷47 Tsukamoto K, Matsusue E, Kanasaki Y, et al. Significance of apparent diffusion coefficient measurement for the differential diagnosis of multiple system atrophy, progressive supranuclear palsy, and Parkinson's disease: evaluation by 3.0-T MR imaging. Neuroradiology. 2012;54:947-55.^,⁴⁹49 Nicoletti G, Tonon C, Lodi R, et al. Apparent diffusion coefficient of the superior cerebellar peduncle differentiates progressive supranuclear palsy from Parkinson's disease. Mov Disord. 2008;23:2370-6.^,⁵⁰50 Paviour DC, Thornton JS, Lees AJ, et al. Diffusion-weighted magnetic resonance imaging differentiates Parkinsonian variant of multiple-system atrophy from progressive supranuclear palsy. Mov Disord. 2007;22:68-74.^,⁵⁴54 Focke NK, Helms G, Pantel PM, et al. Differentiation of typical and atypical Parkinson syndromes by quantitative MR imaging. AJNR Am J Neuroradiol. 2011;32:2087-92.⁾
DCB	- Atrofia assimétrica dos lobos pa-rietais⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.⁾	- Estes achados apresentam baixa sensibilidade e especificidade⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.⁾	- Redução da AF e aumento do CDA no corpo caloso e nos lobos frontais, predominando no trato corticoespinhal contralateral aos sintomas⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.^,⁵⁵55 Boelmans K, Kaufmann J, Bodammer N, et al. Involvement of motor pathways in corticobasal syndrome detected by diffusion tensor tractography. Mov Disord. 2009;24:168-75.⁾	- Baixa sensibilidade e especificidade, mas pode ser encontrado em fases iniciais, mesmo sem atrofia⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.^,⁵⁵55 Boelmans K, Kaufmann J, Bodammer N, et al. Involvement of motor pathways in corticobasal syndrome detected by diffusion tensor tractography. Mov Disord. 2009;24:168-75.⁾
DCB	- Afilamento do corpo caloso⁽¹⁶16 Rizzo G, Martinelli P, Manners D, et al. Diffusion-weighted brain imaging study of patients with clinical diagnosis of corticobasal degeneration, progressive supranuclear palsy and Parkinson's disease. Brain. 2008;131(Pt 10):2690-700.⁾		- Aumento do CDA no tálamo motor e nos giros pré- e pós-centrais⁽⁵⁶56 Erbetta A, Mandelli ML, Savoiardo M, et al. Diffusion tensor imaging shows different topographic involvement of the thalamus in progressive supranuclear palsy and corticobasal degeneration. AJNR Am J Neuroradiol. 2009;30:1482-7.⁾	- Pouco estudados, podem auxiliar no diagnóstico diferencial com PSP, principalmente se for assimétrico⁽⁵⁶56 Erbetta A, Mandelli ML, Savoiardo M, et al. Diffusion tensor imaging shows different topographic involvement of the thalamus in progressive supranuclear palsy and corticobasal degeneration. AJNR Am J Neuroradiol. 2009;30:1482-7.⁾

[1] Endereço para correspondência: Dr. Romulo Varela de Oliveira. Hospital Universitário Pedro Ernesto – Serviço de Imagem. Boulevard 28 de Setembro, 77, Vila Isabel. Rio de Janeiro, RJ, Brasil, 20551-030. E-mail: romulovarella@hotmail.com.