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Semiautomated Algorithm for the Diagnosis of Multiple System Atrophy With Predominant Parkinsonism
Woong-Woo Lee, Han-Joon Kim, Hong Ji Lee, Han Byul Kim, Kwang Suk Park, Chul-Ho Sohn, Beomseok Jeon
J Mov Disord. 2022;15(3):232-240.   Published online July 26, 2022
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  • 1 Web of Science
AbstractAbstract PDFSupplementary Material
Putaminal iron deposition is an important feature that helps differentiate multiple system atrophy with predominant parkinsonism (MSA-p) from Parkinson’s disease (PD). Most previous studies used visual inspection or quantitative methods with manual manipulation to perform this differentiation. We investigated the value of a new semiautomated diagnostic algorithm using 3T-MR susceptibility-weighted imaging for MSA-p.
This study included 26 MSA-p, 68 PD, and 41 normal control (NC) subjects. The algorithm was developed in 2 steps: 1) determine the image containing the remarkable putaminal margin and 2) calculate the phase-shift values, which reflect the iron concentration. The next step was to identify the best differentiating conditions among several combinations. The highest phaseshift value of each subject was used to assess the most effective diagnostic set.
The raw phase-shift values were present along the lateral margin of the putamen in each group. It demonstrates an anterior- to-posterior gradient that was identified most frequently in MSA-p. The average of anterior 5 phase shift values were used for normalization. The highest area under the receiver operating characteristic curve (0.874, 80.8% sensitivity, and 86.7% specificity) of MSA-p versus PD was obtained under the combination of 3 or 4 vertical pixels and one dominant side when the normalization methods were applied. In the subanalysis for the MSA-p patients with a longer disease duration, the performance of the algorithm improved.
This algorithm detected the putaminal lateral margin well, provided insight into the iron distribution of the putaminal rim of MSA-p, and demonstrated good performance in differentiating MSA-p from PD.
Putaminal Hypointensity in the Parkinsonian Variant of Multiple System Atrophy: Simple Visual Assessment Using Susceptibility-Weighted Imaging
Jae-Hyeok Lee, Seung-Kug Baik
J Mov Disord. 2011;4(2):60-63.
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  • 206 Download
  • 21 Crossref
AbstractAbstract PDF
Background and Purpose

Susceptibility-weighted imaging (SWI) has been shown to be superior in its ability to demonstrate brain mineralization than other conventional MR imaging. The goal of our study was therefore to assess the frequency and extent of putaminal hypointensity in parkinsonian variant MSA using SWI.


11 patients with multiple system atrophy-parkinsonian type (MSA-p), 30 patients with Parkinson’s disease (PD), and age matched 30 controls were investigated using 3 Tesla MRI. The pattern of putaminal hypointensity was measured using a visual grading scale and scored from 0 to 3.


Hemi- or bilateral putaminal hypointensity (a score of ≥ 2) and hyperintense rim were recognized in 81.8% and 54.5% of 11 MSA-p, respectively. The scores of putaminal hypointensity of MSA-p were significantly higher than other groups (p < 0.001), a score of ≥ 2 differentiated MSA-p from other groups. And all five patients with early disease stage also showed these characteristic findings.


SWI appears to be useful for depicting putaminal hypointensity even in early stage of MSA-p. This finding suggests that iron deposition associated putaminal degeneration can occur early in the disease process.


Citations to this article as recorded by  
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    Seojin Lee, Ivan Martinez-Valbuena, Anthony E. Lang, Gabor G. Kovacs
    Neurobiology of Disease.2024; 197: 106535.     CrossRef
  • The Irony of Iron: The Element with Diverse Influence on Neurodegenerative Diseases
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    Shuting Bu, Huize Pang, Xiaolu Li, Mengwan Zhao, Juzhou Wang, Yu Liu, Hongmei Yu
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  • Automated Differentiation of Atypical Parkinsonian Syndromes Using Brain Iron Patterns in Susceptibility Weighted Imaging
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    Diagnostics.2022; 12(3): 637.     CrossRef
  • The “Black Straight-Line Sign” in the Putamen in Diffusion-Weighted Imaging: A Potential Diagnostic MRI Marker for Multiple System Atrophy
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    The FASEB Journal.2020; 34(9): 10702.     CrossRef
  • Current Management and Emerging Therapies in Multiple System Atrophy
    Matthew R. Burns, Nikolaus R. McFarland
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  • Morphology and signal changes of the lentiform nucleus based on susceptibility weighted imaging in parkinsonism-predominant multiple system atrophy
    Qingguo Ren, Xiangshui Meng, Bin Zhang, Jianyuan Zhang, Xinyan Shuai, Xiaomin Nan, Cuiping Zhao
    Parkinsonism & Related Disorders.2020; 81: 194.     CrossRef
  • Abnormalities on structural MRI associate with faster disease progression in multiple system atrophy
    Florian Krismer, Klaus Seppi, Gregor K. Wenning, Spyridon Papapetropoulos, Victor Abler, Georg Goebel, Michael Schocke, Werner Poewe
    Parkinsonism & Related Disorders.2019; 58: 23.     CrossRef
  • Brain Iron Accumulation in Atypical Parkinsonian Syndromes: in vivo MRI Evidences for Distinctive Patterns
    Jae-Hyeok Lee, Myung-Sik Lee
    Frontiers in Neurology.2019;[Epub]     CrossRef
  • Quantitative Validation of a Visual Rating Scale for Defining High-Iron Putamen in Patients With Multiple System Atrophy
    Myung Jun Lee, Tae-Hyung Kim, Seung Joo Kim, Baik-Kyun Kim, Chi-Woong Mun, Jae-Hyeok Lee
    Frontiers in Neurology.2019;[Epub]     CrossRef
  • Looking Deep into the Eye-of-the-Tiger in Pantothenate Kinase–Associated Neurodegeneration
    J.-H. Lee, A. Gregory, P. Hogarth, C. Rogers, S.J. Hayflick
    American Journal of Neuroradiology.2018; 39(3): 583.     CrossRef
  • The Relevance of Iron in the Pathogenesis of Multiple System Atrophy: A Viewpoint
    Christine Kaindlstorfer, Kurt A. Jellinger, Sabine Eschlböck, Nadia Stefanova, Günter Weiss, Gregor K. Wenning
    Journal of Alzheimer's Disease.2018; 61(4): 1253.     CrossRef
  • Using ‘swallow-tail’ sign and putaminal hypointensity as biomarkers to distinguish multiple system atrophy from idiopathic Parkinson’s disease: A susceptibility-weighted imaging study
    Na Wang, HuaGuang Yang, ChengBo Li, GuoGuang Fan, XiaoGuang Luo
    European Radiology.2017; 27(8): 3174.     CrossRef
  • Magnetic resonance imaging for the diagnosis of Parkinson’s disease
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    Journal of Neural Transmission.2017; 124(8): 915.     CrossRef
  • Utility of susceptibility-weighted imaging in Parkinson’s disease and atypical Parkinsonian disorders
    Zhibin Wang, Xiao-Guang Luo, Chao Gao
    Translational Neurodegeneration.2016;[Epub]     CrossRef

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