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A critical evaluation of the Braak staging scheme for Parkinson's disease

Authors

  • Robert E. Burke MD,

    Corresponding author
    1. Department of Neurology, Columbia University Medical Center, New York, NY
    2. Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
    • Department of Neurology, Room 306, Black Building, Columbia University, 650 West 168th Street, New York, NY 10032
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  • William T. Dauer MD,

    1. Department of Neurology, Columbia University Medical Center, New York, NY
    2. Department of Pharmacology, Columbia University Medical Center, New York, NY
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  • Jean Paul G. Vonsattel MD

    1. Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY
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  • Potential conflict of interest: Nothing to report.

Abstract

Braak and colleagues have proposed that, within the central nervous system, Parkinson's disease (PD) begins as a synucleinopathy in nondopaminergic structures of the lower brainstem or in the olfactory bulb. The brainstem synucleinopathy is postulated to progress rostrally to affect the substantia nigra and cause parkinsonism at a later stage of the disease. In the context of a diagnosis of PD, made from current clinical criteria, the pattern of lower brainstem involvement accompanying mesencephalic synucleinopathy is often observed. However, outside of that context, the patterns of synucleinopathy that Braak described are often not observed, particularly in dementia with Lewy bodies and when synucleinopathy occurs in the absence of neurological manifestations. The concept that lower brainstem synucleinopathy represents “early PD” rests on the supposition that it has a substantial likelihood of progressing within the human lifetime to involve the mesencephalon, and thereby cause the substantia nigra pathology and clinical parkinsonism that have heretofore defined the disease. However, the predictive validity of this concept is doubtful, based on numerous observations made in populations of aged individuals who, despite the absence of neurological signs, have brain synucleinopathy ranging up to Braak stages 4 to 6 at postmortem. Furthermore, there is no relation between Braak stage and the clinical severity of PD. We conclude that the relation between patterns of abnormal synuclein immunostaining in the human brain and the disease entity now recognized as PD remains to be determined. Ann Neurol 2008;64:485–491

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