1. Ultrasound Brain Parenchyma Imaging in Parkinson's Disease I.Talaganova 1, S. Karakaneva 2, I. Milanov 1, N. Mlachkov 1, E. Titianova 2,3 1 Multiprofile Hospital for Active Treatment “St Naum”, Sofia, 2 Clinic of Functional Diagnostics of the Nervous System, Military Medical Academy, Sofia 3 Medical Faculty of Sofia University “St. Kl. Ohrisdski”, Sofia.. Index Patients with Parkinson’s disease Male n=3 Patient with Essential tremor Female n=1 Healthy controls between the age of 40 and 59 n=11 Healthy controls between the age of 60 and 70 n=7 Mean age (years) 47.3±6.11 66 48.5±6.468.3±6.5 Height (m) 1.76±0.08 1,60 1.72±0.09 1.76±0.05 Weight (kg) 76.7±6.7 66 77.3±19.3 79±10.7 Body mass index (kg/m 2 ) 24.7±0.4325,8 26.9±5.725.4±3.5. Table 1. Characteristics of the healthy controls and the patients Fig. 4 A. Ultrasound imaging of the brain parenchyma in mesencephalic plane in a patient with mild bilateral Parkinson’s disease (PD) with prevalance of the complaints in the left extremities. Measurement of the area and the circumference of the mesencephalon (1) and substantia nigra left (2) and right (3) with visible asymmetry using LTTA. B Measurement of the third ventricle’s diameter in the same patient. C. DaTscan of the same patient - evidence of dopaminergic neurons deficit in the striatums bilaterally R>L., contralateral to the affected side. Fig.3 А. Ultrasound B-mode imaging of the brain parenchyma in mesencephalic plane in a patient with Essential tremor (ET): 1. Measurement of the area (A) and the circumference (C) of the mesencephalon 2. Substantia nigra - not visible; [2,4,5,6,10]. B Measurement of the third ventricle’s diameter in axial plane at the level of the thalami in the same patient C. SPECT with DaTscan of the same patient - normal image. Transcranial sonography (TCS) of the brain parenchyma in patients with movement and other neurodegenerative disorders has developed with increasing dynamics during the past two decades [1,2,3,4]. The most widely recognized application of TCS is the diagnosis and differential diagnosis of Parkinsonian syndromes [4,5,6]. Distinguishing Parkinson’s disease from Essential tremor could be challenging, as well. Highest diagnostic accuracy can be obtained by means of single photon emission computed tomography imaging (SPECT) using a radiolabeled DAT ligand (DaTscan) [8]. Ultrasound brain imaging could also be useful in the distinction between these two diseases [8,9]. The severity of Parkinson’s disease was evaluated by the scales of Hoehn and Yahr and Unified Parkinson’s Disease Rating Scale (UPDRS), and the cognitive capacity – by Mini Mental State Examination Scale. The Hamilton Depression Rating Scale (HAMD) was used to register depression and smell test to detect olfactory dysfunction. A transcranial B mode imaging was performed in three patients with Parkinson's disease and one with Essential tremor, whose diagnoses had been confirmed by SPECT with DaTscan (Tabl. 1). The parameters were compared with heallthy controls of the same age group [10]. There were no statistically significant differences between the groups. The study shows that TCS is a non-invasive fast and efficient method which may serve as a practical neuroimaging tool in PD diagnosis and in distinguishing it from ET [8]. It is proven that combined assessment of mibrain hyperechogenicity, hyposmia and motor asymmetry improves the diagnostic accuracy in early Parkinson’s disease [13]. When the patients present with more subtle or ambiguous signs, transcranial brain parenchyma imaging in combination with smell test can be useful in evaluating which patients need to be examined by DaTSCAN [14,15]. Two of the patients had an insufficient acoustic bone window on the right side and a left transtemporal approach was used. The area and circumference of the mesencephalon, as well as the third ventricle were measured and compared with healthy controls [10]. No significant differences were found. None of the subjects had any cognitive deficit on MMSE which correlated with normal size of the third ventricle. Two of them showed mild depression on HAMD (8-16 p.) [12] which corresponded with reduced echogenicity or invisibility of BR in three of the patients [11]. There was one case of unilateral hyposmia detected by smell test. In contrast to controls and the patient with Essential tremor a hyperechogenicity of substantia nigra has been found in all three patients with Parkinson's disease. These data correlated with the results from DaTscan Imaging (fig. 3), (fig. 4). To demonstrate the diagnostic abilities of the multimodal neurosonography for imaging of brain parenchyma in Parkinson's disease. 1.Титянова E. Ултразвукова диагностика в неврологията, КОТИ ЕООД 2006:60-62. Титянова E., Нидеркон K., Христова E. Атлас по невросонология. КОТИ ЕООД 2008:109-110. 2.Titianova Е. Clinical application of transcranial colour-coded duplex imaging in neurology. Neurosonology and cerebral heamodynamics, Vol. 1,2005, 1:5-10. 3.Walter U., Behnke S., Eyding J.,Transcranial brain parenchyma sonography in movement disorders: state of the art. Ultrasound Med Biol. 2007.Jan;33(1):15-25. 4.Walter U. Transcranial sonography of the cerebral parenchyma: Update on clinically relevant applications, Perspectives in Medicine (2012) 1:334—343. 5.Walter U, Skoloudik D. Trancranial sonography (TCS) of brain parenchyma in movement disorders: quality standards, diagnostic applications and novel technologies. Ultraschall in Med 2014; 35:322-331 6.Trancranial sonography in movement disorders. International review of Neurobiology. Edited by Daniela Berg and Uwe Walters. Elsevier Inc. 2010, p.50-59 7.Brooks D, Neuroimaging inParkinson’s disease. NeuroRx. 2004 Apr; 1(2): 243–254. 8.Budisic M, Trkanjiec Z, Bosnjak J. Distinguishing Parkinson’s disease and essential tremor with transcranial sonography. Acta Neurol Scand 2009; 119(1):17-21 9.Doepp F, Plotkin M, Siegel L. Brain et al. Parenchyma sonography and 123I-FP-CIT SPECT in Parkinson's disease and essential tremor. Mov Disord 2008 Feb 15;23(3):405-10. 10. И. Талаганова, С. Каракънева, Ив. Миланов, Е. Титянова. Българска неврология 2015, том 16, доп. 1 11.Mijajlovic M. Ultrasound imaging of brain parenchyma, Temporal arteries and Orbita. Neurosonology and cerebral hemodynamics. Vol 10, 2,2014:138-144 12.Zimmerman M, Martinez J, Young D et al. Severity classification on Hamilton depression rating scale. J Affect Disord 2013 Sep 5;150(2):384-8. 13.Poewe P, Mahlknecht P. Combined assessment of midbrain hyperechogenicity, hyposmia and motor asymmetry improves diagnostic accuracy in early Parkinson’s disease. Expert Review of Neurotherapeutics 01/2014; 12(8) 14.Stockner H, Schwingenschuh P, Djamshidian A et al. Is Transcranial Sonography Useful to Distinguish Scans Without Evidence of Dopaminergic Deficit Patients From Parkinson’s Disease? Mov Disord, 08/2012; 27(9):1182-5. 15.Bradvica I, Mihaljević I, Butković-Soldo S. Transcranial sonography and the pocket smell test in the differential diagnosis between parkinson’s disease and essential tremor. Neurrological Sciences August 2015, Vol. 36, 8, pp 1403-1410 A multimodal high-definition ultrasound has been used for imaging the brain parenchyma at the level of the mesencephalon (fig 1A) and the thalami (fig.2). The B-mode scans has been compared with the DaTscan images of the selected patients (fig. 1B). Fig 2. Ultrasound imaging of the brain parenchyma in axial plane at the level of the thalami. Measurement of the third ventricle’s diameter.: A. Healthy control, 29Y B. Healthy control – 65Y. Fig 1. А. Ultrasound B-mode imaging of the brain parenchyma in mesencephalic plane: 1. Hypoechogenic butterfly shaped structure of the mesencephalon, surrounded by hyperechogenic basal cisterns 2. Substantia nigra; 3. Contralateral temporal lobe 4. Contralateral temporal bone [2,4,5,6,10]. B DaTscan – normal image. A. I.T., 29 Y, F.emale B. I.S., 65 Y, Male I.T., 29 Y, F.emale Y.B., 66 Y, F.emale; ET D.T., 42 Y, Male; PD, UPDRS=53 p., Hoehn and Yahr 2.5