METHODS

Subjects.Gene samples were obtained from the gene bank at the Movement Disorder Division of Seoul National University Hospital. All of the patients were native Koreans. All patients were personally observed and have been followed-up regularly by the senior neurologist at Seoul National University Hospital since 1993. Blood samples were collected after written informed consent was obtained from each participant. The institutional review board of Seoul National University Hospital approved this genetic study and the use of DAT SPECT. PD was diagnosed according to the United Kingdom Parkinson Disease Society Brain Bank criteria, with the exception of the positive family history criterion.1 All MSA subjects (except for one who had a family history) were diagnosed with MSA according to the Consensus Criteria.2

A total of 1155 parkinsonian patients (PD=931, MSA=224) were included in the initial study.In the PD patients, the mean age at onset was 55.9 ±11.1 years (age range =12-81 years). A total of 278 patients were younger than 50 years old at the onset of PD. The PD patient group comprised 413 men (age at onset = 55.5±12.1 years) and 518 women (age at onset = 56.1±10.4 years). In the MSA patients, the age at onset was 60.4 ± 8.1 years (age range = 36-83 years). The MSA patient group comprised 111 men (age at onset = 61.2±8.3 years) and 113 women (age at onset = 59.7±7.8 years). Twenty-seven of the 931 PD patients and one of the 224 MSA patients had at least one first-degree relative (parent or sibling) with parkinsonism. After the initial study of 1155 parkinsonian patients,genetic analysis and DAT SPECT were performed in the family members of the proband patients after explaining the genetic implications of the study and informed consent was obtained.

DNA from the 400 healthy subjects who did not have a family history of parkinsonism or ataxia was analyzed. DNA from 100 healthy subjects was obtained from the gene database at the Department of Laboratory Medicine, Seoul National University Hospital. All of the subjects were healthy individuals who visited our hospital for annual routine health check-ups.Three hundreds of the subjects were spouses of the parkinsonian patients. The mean ageof the control subjects was 60.8 ± 11.1 years (meanstandard deviation), and the ratio of males to females was 44:56.

References

1. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson's disease:a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992;55:181–184.

2. Gilman S, Low PA, Quinn N, et al. Consensus statement on the diagnosis of multiple system atrophy. J Neurol Sci 1999;163:94–98.

Genetic analysis. Polymerase chain reaction (PCR) amplification of the TNR in the TBP gene was performed using a modification of the protocol described previously.3,4PCR was performed using the following primers: forward, 5’-ATGCCTTATGGCACTGGACTG-3’ (6-FAM labeled); and reverse, 5’-CTGCTGGGACGTTGACTGCTG-3’.

References

3. Fujigasaki H, Martin JJ, De Deyn PP, et al. CAG repeat expansion in the TATA box-binding protein gene causes autosomal dominant cerebellar ataxia.Brain 2001;124:1939–1947.

4. Kim JM, Hong S, Kim GP, et al. Importance of low-range CAG expansion and CAA interruption in SCA2 Parkinsonism.Arch Neurol 2007;64:1510–1518.

DAT SPECT. DAT SPECT images were obtained using a triple-headed gamma camera (Triad XLT, Trionix Research Laboratory, Twinsburg, Ohio, USA) equipped with parallel-hole, low-energy, high-resolution collimators. Image acquisition began approximately 3 hours after intravenous injection of 850.9 ± 167.0 MBq (23.0 ± 4.5 mCi) of 99mTc–TRODAT-1 (2 beta[N, N'-bis(2-mercaptoethyl) ethylenediamino] methyl, 3 beta-(4-chlorophenyl) tropane). A total of 120 projection images over 360 in a 128 x 128 matrix were acquired in step-and-shoot mode over the course of 30 minutes. Reconstruction was performed using filtered back-projection with a Butterworth filter (cut-off frequency, 0.6 cycle/cm, 10th order). The Chang method was used for attenuation correction (attenuation coefficient, 0.12 cm-1). Reconstructed images were reoriented according to the plane connecting the frontal and occipital poles.