Book Review

Parkinsonian Syndromes

N Engl J Med 1994; 330:1837June 23, 1994

Article

Parkinsonian Syndromes
(Neurological Disease and Therapy. Vol. 18.) Edited by Matthew B. Stern and William C. Koller. 555 pp., illustrated. New York, Marcel Dekker, 1993. $195. ISBN: 0-8247-8838-9

The editors of this book (which I reviewed in collaboration with the faculty and residents of the Department of Neurology, Boston University School of Medicine) identified an enthusiastic group of young neurologists, “a new breed of clinicians,” to contribute chapters about movement disorders similar to Parkinson's disease that have their own features and pathophysiologic mechanisms. Despite some confusion in nomenclature caused by their use of the term “parkinsonian syndromes,” the editors acknowledge that each of these syndromes must be differentiated from typical, idiopathic Parkinson's disease. This comprehensive book uses a classic clinical approach to distinguish and identify the various syndromes.

The book attempts to separate the various movement disorders into subgroups of parkinsonian syndromes. This plan works for the more common conditions included in the categories of Parkinson's disease, multisystem atrophy, and symptomatic parkinsonism, but it breaks down with other categories, such as the neurofibrillary diseases and parkinsonism, vascular parkinsonism, heredofamilial Parkinson's disease, Machado-Joseph disease, and dystonia.

As in many multiauthored books, the quality of the chapters is uneven. For example, that on Parkinson's disease emphasizes the clinical heterogeneity of the disorder and concludes that Parkinson's disease itself may eventually be considered a syndrome with pathophysiologically distinct subtypes that account for the variability in clinical presentation. Since the other diseases discussed in the book are to be differentiated from Parkinson's disease, a narrower set of inclusion and exclusion criteria would help set the stage for the rest of the book.

Each chapter in the section on multisystem atrophy is strong. A succinct review of clinical cases along with pathological descriptions explains the overlapping of neuronal-cell losses seen in striatonigral degeneration and other conditions involving multisystem atrophy (olivopontocerebellar atrophy and Shy-Drager syndrome). The authors conclude that striatonigral degeneration belongs in the general category of multisystem atrophy because of the similarity in the topographic distribution of pathologic lesions. The excellent chapter on autonomic failure in multisystem atrophy considers various aspects of Shy-Drager syndrome not often discussed elsewhere, such as testing of the cardiovascular system and autonomic nervous system, evaluation of the urinary system, and treatment of progressive autonomic failure. There is a nice correlation with anatomical lesions and distinctions between preganglionic and postganglionic dysfunction.

Three chapters on similar topics -- symptomatic Parkinson's disease, occupational and environmental causes of Parkinson's disease, and toxin-induced parkinsonism -- overlap, although they express different points of view. The importance of this section lies in the description of the several mechanisms that produce symptoms suggesting Parkinson's disease. The chapter on the rigid variant of Huntington's disease appropriately recognizes rigidity as a part of the continuum of the phenotypic expression of Huntington's disease. However, this otherwise comprehensive review does not include recent findings in the genetics of Huntington's disease. The chapter on Hallervorden-Spatz syndrome is well done and is superior to similar chapters in other books on movement disorders. It covers issues still being debated, and the author does not hesitate to admit that some data may remain inconclusive. The chapter on progressive supranuclear palsy divides the disease into its clinical symptoms, then offers pathological anatomy to explain them. The author describes cell loss in the substantia nigra to account for parkinsonism and mentions that striatal connections may account for some symptoms. Neurofibrillary tangles are discussed as pathological correlates of cognitive decline, although the tangles are a very important distinguishing pathological feature of the disease.

The strength of this book is that it reviews the large number of conditions that physicians must consider when diagnosing extrapyramidal disorders. This book presents information in greater detail than the reader might find in a general textbook of neurology, but it should not be considered a source of advanced neuroscientific research data about these conditions. General neurologists, nonneurologists, physicians in rehabilitation medicine and geriatric medicine, and residents and medical students interested in movement disorders will find this an excellent and useful survey of the field. It is written in a comfortable and practical style.

Robert G. Feldman, M.D.
Boston University School of Medicine, Boston, MA 02118