Initial Versus Follow-up Sequential Myocardial 123I-MIBG Scintigraphy to Discriminate Parkinson Disease From Atypical Parkinsonian Syndromes

Purpose Previous single-center or meta-analysis studies analyzed myocardial ¹²³I-metaiodobenzylguanidine (¹²³I-MIBG) scintigraphy in a single image session and demonstrated low sensitivity and high specificity for discriminating Parkinson disease (PD) from atypical Parkinsonian syndromes (APS). This study aimed to assess diagnostic ability of myocardial ¹²³I-MIBG scintigraphy at 2 phases to discriminate PD from APS. Patients and Methods This hospital-based prospective study enrolled 162 PD and 26 APS patients who underwent 2 sequential ¹²³I-MIBG scintigraphy evaluations. Patients were stratified into normal and decreased ¹²³I-MIBG groups according to early and delayed heart-to-mediastinum (H/M) ratios. Patients with PD and normal ¹²³I-MIBG uptake (initial delayed H/M ratio, ≥1.78) were considered scans without evidence of cardiac norepinephrine deficit (SWEND). Early and delayed H/M ratios on the initial and 2-year follow-up scintigraphs were studied. The diagnostic sensitivity and specificity were calculated from these confusion matrices and were analyzed according to receiver-operating characteristic curve analysis. A repeated-measures general linear model was used to investigate differences among groups over time in H/M ratio changes and washout rates. Results Follow-up ¹²³I-MIBG scintigraphy analysis had a higher diagnostic sensitivity (89.5%) than the initial imaging (72.2%). The improved sensitivity was associated with a steeper decrease in H/M ratio in the SWEND group than in the APS group. Conclusions Follow-up ¹²³I-MIBG scintigraphy can identify cardiac sympathetic denervation and its progression in patients with PD and may be effective in discriminating PD from APS. A later decrease in myocardial ¹²³I-MIBG uptake in the group with SWEND meets the Braak staging threshold hypothesis for synucleinopathy.