Williams David R, Lees Andrew J
Queen Square Brain Bank for Neurological Disorders and Institute of Neurology, University College London, London, UK.
Lancet Neurol. 2005 Oct;4(10):605-10. doi: 10.1016/S1474-4422(05)70146-0.
For many years, visual hallucinations (VH) in idiopathic Parkinson's disease (PD) were thought to be a complication of antiparkinsonian treatment. The cause of VH is now thought to be nerve-cell loss and Lewy-body pathology in the ventral-temporal regions of the brain. However, the use of VH as a clinical sign of PD has not been investigated.
788 cases with parkinsonism archived at the Queen Square Brain Bank for Neurological Diseases were identified for study. Patients had not been given standardised antemortem assessments. Clinical records were assessed for reports of VH. The incidence of VH in pathologically diagnosed cases was calculated, and factors affecting onset of VH were investigated.
VH occurred in 50% (221/445) of patients with PD, in 73% (32/44) with dementia with Lewy bodies (DLB), and in only 7% (18/255) of patients with non-Lewy-body parkinsonism. The specificity of VH for Lewy-body parkinsonism (PD and DLB combined) was 92.9% (95% CI 89.1-95.8) and the positive predictive value was 93.4% (89.7-95.8). VH were associated with cognitive dysfunction (hazard ratio 5.62, 3.37-9.35), autonomic dysfunction (3.13, 1.77-5.52), axial rigidity (2.22, 1.26-3.85) within the first 2 years of disease onset and also age of onset (1.05, 1.03-1.07). In PD, the onset of VH typically occurred in the second half of the disease course, and time to onset of VH was only weakly correlated with use of selegiline (Spearman's rho 0.22, p=0.005) and ergot dopamine agonists (0.24, p=0.006) but not correlated with use of levodopa, amantadine, or anticholinergic drugs.
The presence of VH is helpful in the differentiation of PD from other non-Lewy-body causes of parkinsonism. We propose that VH be added, as a supportive criterion, to the operational clinical criteria for the diagnosis of PD.
多年来，特发性帕金森病（PD）中的视幻觉（VH）一直被认为是抗帕金森病治疗的一种并发症。现在认为VH的病因是大脑腹颞区的神经细胞丢失和路易小体病理改变。然而，VH作为PD临床体征的应用尚未得到研究。
从女王广场神经疾病脑库存档的788例帕金森综合征患者中确定进行研究。患者生前未接受标准化评估。评估临床记录中VH的报告情况。计算病理诊断病例中VH的发生率，并调查影响VH发病的因素。
VH发生在50%（221/445）的PD患者中，73%（32/44）的路易体痴呆（DLB）患者中，而仅7%（18/255）的非路易体帕金森综合征患者中。VH对路易体帕金森综合征（PD和DLB合并）的特异性为92.9%（95%CI 89.1-95.8），阳性预测值为93.4%（89.7-95.8）。VH与疾病发作后前2年内的认知功能障碍（风险比5.62，3.37-9.35）、自主神经功能障碍（3.13，1.77-5.52）、轴性强直（2.22，1.26-3.85）以及发病年龄（1.05，1.03-1.07）相关。在PD中，VH通常在疾病病程的后半期出现，VH的发病时间与司来吉兰的使用（Spearman相关系数0.22，p=0.005）和麦角多巴胺激动剂的使用（0.24，p=0.006）仅呈弱相关，而与左旋多巴、金刚烷胺或抗胆碱能药物的使用无关。
VH的存在有助于将PD与其他非路易体原因的帕金森综合征相鉴别。我们建议将VH作为一项支持性标准添加到PD诊断的操作性临床标准中。
