Editing Progressive supranuclear palsy

{{Short description|Medical condition of the brain}}
{{cs1 config|name-list-style=vanc|display-authors=6}}
{{Infobox medical condition (new)
| name            = Progressive supranuclear palsy
| synonyms        = Steele–Richardson–Olszewski syndrome, frontotemporal dementia with parkinsonism
| image           = Steele-olszewski-richardson disease.jpg
| caption         = MRI demonstrating the hummingbird sign of supranuclear palsy due to atrophy of the midbrain
| pronounce       =
| field           = [[Neurology]]
| width           = 280px
| symptoms        = Impaired balance, [[Hypokinesia|slowed movements]], [[Ophthalmoparesis|difficulty moving eyes]], [[dementia]]
| complications   =
| onset           = 60–70 years
| duration        =
| types           =
| causes          = Unknown
| risks           =
| diagnosis       =
| differential    = [[Parkinson's disease]], [[corticobasal degeneration]], [[FTDP-17]], [[Alzheimer's disease]]
| prevention      =
| treatment       = Medication, physical therapy, occupational therapy
| medication      = [[L-DOPA|Levodopa]], [[amantadine]]
| prognosis       = Fatal (usually 7–10 years after  diagnosis)
| frequency       = 6 per 100,000
| deaths          =
}}

'''Progressive supranuclear palsy''' ('''PSP''') is a late-onset [[neurodegenerative disease]] involving the gradual deterioration and death of specific volumes of the [[brain]], linked to 4-repeat tau pathology.<ref name="Golbe20142">{{cite journal |vauthors=Golbe LI |date=April 2014 |title=Progressive supranuclear palsy |journal=Seminars in Neurology |volume=34 |issue=2 |pages=151–9 |doi=10.1055/s-0034-1381736 |pmid=24963674 |doi-access=free}}</ref><ref name="ICD112">{{cite web |title=ICD-11 - Mortality and Morbidity Statistics |url=https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1493396558 |website=icd.who.int}}</ref><ref name=":0">{{Cite journal |last1=Boxer |first1=Adam L |last2=Yu |first2=Jin-Tai |last3=Golbe |first3=Lawrence I |last4=Litvan |first4=Irene |last5=Lang |first5=Anthony E |last6=Höglinger |first6=Günter U |date=July 2017 |title=Advances in progressive supranuclear palsy: new diagnostic criteria, biomarkers, and therapeutic approaches |journal=The Lancet Neurology |language=en |volume=16 |issue=7 |pages=552–563 |doi=10.1016/S1474-4422(17)30157-6|pmid=28653647 |pmc=5802400 }}</ref> The condition leads to symptoms including [[Balance disorder|loss of balance]], [[Hypokinesia|slowing of movement]], [[Ophthalmoparesis|difficulty moving the eyes]], and [[cognitive impairment]].<ref name="Golbe20142" />  PSP may be mistaken for other types of neurodegeneration such as [[Parkinson's disease]], [[frontotemporal dementia]] and [[Alzheimer's disease]]. It is the second most common tauopathy behind [[Alzheimer's disease]]. The cause of the condition is uncertain, but involves the accumulation of [[tau protein]] within the brain.  Medications such as [[L-DOPA|levodopa]] and [[amantadine]] may be useful in some cases.<ref name="Golbe20142" />

PSP was first officially described by Richardson, Steele, and Olszewski in 1963 as a form of progressive parkinsonism.<ref name=":3">{{Cite journal |last1=Lopez |first1=G. |last2=Bayulkem |first2=K. |last3=Hallett |first3=M. |date=October 2016 |title=Progressive supranuclear palsy (PSP): Richardson syndrome and other PSP variants |journal=Acta Neurologica Scandinavica |language=en |volume=134 |issue=4 |pages=242–249 |doi=10.1111/ane.12546|pmid=27070344 |pmc=7292631 }}</ref>  However, the earliest known case presenting clinical features consistent with PSP, along with pathological confirmation, was reported in France in 1951.<ref name=":13">{{Cite journal |last1=Brusa |first1=Adolfo |last2=Stoehr |first2=Rolf |last3=Pramstaller |first3=Peter P. |date=March 2004 |title=Progressive supranuclear palsy: New disease or variant of postencephalitic parkinsonism? |url=https://movementdisorders.onlinelibrary.wiley.com/doi/10.1002/mds.10699 |journal=Movement Disorders |language=en |volume=19 |issue=3 |pages=247–252 |doi=10.1002/mds.10699 |pmid=15022178 |issn=0885-3185}}</ref> Originally thought to be a more general type of atypical parkinsonism, PSP is now linked to distinct clinical phenotypes including '''PSP-Richardson's syndrome (PSP-RS)''', which is the most common sub-type of the disease.<ref name=":6">{{Cite journal |last1=Coughlin |first1=David G. |last2=Litvan |first2=Irene |date=April 2020 |title=Progressive supranuclear palsy: Advances in diagnosis and management |journal=Parkinsonism & Related Disorders |language=en |volume=73 |pages=105–116 |doi=10.1016/j.parkreldis.2020.04.014|pmid=32487421 |pmc=7462164 }}</ref> As PSP advances to a fully symptomatic stage, many PSP subtypes eventually exhibit the clinical characteristics of PSP-RS.<ref name=":0" />

PSP, encompassing all its phenotypes, has a prevalence of 18 per 100,000, whereas PSP-RS affects approximately 5 to 7 per 100,000 individuals.<ref name="Golbe20142" /><ref name=":0" /> The first symptoms typically occur at 60–70 years of age. [[Male|Males]] are slightly more likely to be affected than [[Female|females.]]<ref name="Golbe20142" /> No association has been found between PSP and any particular race, location, or occupation.<ref name="Golbe20142" />

==Signs and symptoms==
The initial symptoms in two-thirds of cases are loss of balance, lunging forward when mobilizing, fast walking, bumping into objects or people, and falls.<ref name=":2">{{Cite book|title=Bradley's neurology in clinical practice|vauthors=Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC|publisher=Elsevier Saunders|year=2012|isbn=978-1-4377-0434-1|edition=6th |pages=1778}}</ref><ref name=":0" /><ref name=":3" /> [[Dementia]] symptoms are also initially seen in about one in five cases.<ref name=":1">{{cite journal | vauthors = Finger EC | title = Frontotemporal Dementias | journal = Continuum | volume = 22 | issue = 2 Dementia | pages = 464–89 | date = April 2016 | pmid = 27042904 | pmc = 5390934 | doi = 10.1212/CON.0000000000000300 }}</ref>

Other common early symptoms are changes in personality, general slowing of movement, and visual symptoms. The most common behavioural  symptoms in patients with PSP include [[apathy]], [[disinhibition|a lack of inhibition]], [[anxiety]], and [[dysphoria|a profound state of unease or dissatisfaction]].<ref name=":1" />

Later symptoms and signs can include, but do not necessarily include dementia (typically including loss of inhibition and ability to organize information), [[Dysarthria|slurring of speech]], [[difficulty swallowing]], and difficulty [[Eye movement (sensory)|moving the eyes]], particularly in the vertical direction.  The latter accounts for some of the falls experienced by these patients, as they find it difficult to look up or down.<ref name="NHS">{{cite web |title=Symptoms - Progressive supranuclear palsy |url=https://www.nhs.uk/conditions/progressive-supranuclear-palsy-psp/symptoms/ |website=NHS |date=14 August 2018 |access-date=19 January 2021}}</ref>

Some of the other signs are poor [[eyelid]] function, [[contracture]] of the [[facial muscles]], a backward tilt of the head with stiffening of the [[Table of muscles of the human body: Neck|neck muscles]], [[Sleep disorder|sleep disruption]], [[urinary incontinence]], and [[constipation]].<ref name="NHS" />  Some patients retain full cognitive function up to the end.<ref name=":7">{{Cite journal |last1=Dunning |first1=Elise E. |last2=Decourt |first2=Boris |last3=Zawia |first3=Nasser H. |last4=Shill |first4=Holly A. |last5=Sabbagh |first5=Marwan N. |date=August 2024 |title=Pharmacotherapies for the Treatment of Progressive Supranuclear Palsy: A Narrative Review |journal=Neurology and Therapy |language=en |volume=13 |issue=4 |pages=975–1013 |doi=10.1007/s40120-024-00614-9 |pmid=38743312 |pmc=11263316 |issn=2193-8253}}</ref>

The visual symptoms are of particular importance in the diagnosis of this disorder.  Patients typically complain of difficulty reading due to the inability to look downwards. The [[ophthalmoparesis]] experienced by these patients mainly concerns voluntary eye movement and the inability to make vertical [[saccade]]s, which is often worse with downward saccades.  Patients tend to have difficulty looking down (a downgaze [[:wikt:palsy|palsy]]) followed by the addition of an upgaze palsy. This vertical gaze [[paresis]] will correct when the examiner passively rolls the patient's head up and down as part of a test for the [[oculocephalic reflex]].  Involuntary eye movement, as elicited by [[Bell's phenomenon]], for instance, may be closer to normal.<ref name=":7" />

On close inspection, eye movements called "square-wave jerks" may be visible when the patient fixes gaze at distance. These are fine movements, that can be mistaken for [[nystagmus]], except that they are saccadic in nature, with no smooth phase. Although healthy individuals also make square-wave jerk movements, PSP patients make slower square-wave jerk movements, with smaller vertical components.<ref name="Ophthalmic Disease 2018">{{cite journal | vauthors = Alexander RG, Macknik SL, Martinez-Conde S | title = Microsaccade Characteristics in Neurological and Ophthalmic Disease | journal = Frontiers in Neurology | volume = 9 | issue = 144 | pages = 144 | date = 2018 | pmid = 29593642 | pmc = 5859063 | doi = 10.3389/fneur.2018.00144 | doi-access = free }}</ref> Assessment of these square-wave jerks and diminished vertical saccades is especially useful for diagnosing progressive supranuclear palsy, because these movements set PSP patients apart from other parkinsonian patients.<ref name="Ophthalmic Disease 2018"/> Difficulties with [[Convergence (eye)|convergence]] (convergence insufficiency), where the eyes come closer together while focusing on something near, like the pages of a book, is typical.  Because the eyes have trouble coming together to focus at short distances, the patient may complain of [[diplopia]] (double vision) when reading.<ref name="NHS"/>

A characteristic facial appearance known as [[procerus sign]], with a wide-eye stare, furrowing of forehead with a frowning expression, and deepening of other facial creases, is also diagnostic of PSP.<ref name="Bradley">{{Cite book|title=Bradley's neurology in clinical practice|edition=7th|vauthors=Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL|publisher=Elsevier|year=2016|isbn=978-0-323-28783-8|volume=2|pages=1439 |oclc=932031625}}</ref>

=== Signs and Symptoms of PSP-RS Subtype ===
PSP-RS is characterized by a combination of motor, ocular, cognitive, and speech-related impairments, that typically emerge in early stages of the disease. Symptoms of PSP-RS usually begin after 60 and steadily progress over time.<ref name=":0" /> Clinical symptoms of PSP-RS often include unexplained falls, unsteady gait, bradykinesia, apathy, disinhibition, cognitive dysfunction, difficulty planning or multitasking, slow speech, and impaired ocular movement.<ref name=":0" /><ref name=":3" /><ref name=":4">{{Cite journal |last1=Krzosek |first1=Patrycja |last2=Madetko |first2=Natalia |last3=Migda |first3=Anna |last4=Migda |first4=Bartosz |last5=Jaguś |first5=Dominika |last6=Alster |first6=Piotr |date=2022-02-09 |title=Differential Diagnosis of Rare Subtypes of Progressive Supranuclear Palsy and PSP-Like Syndromes—Infrequent Manifestations of the Most Common Form of Atypical Parkinsonism |journal=Frontiers in Aging Neuroscience |volume=14 |doi=10.3389/fnagi.2022.804385 |doi-access=free |pmid=35221993 |pmc=8864174 |issn=1663-4365}}</ref> PSP-RS is also characterized by unresponsiveness to dopamine therapies often prescribed for those with [[Parkinson's disease]].<ref name=":5">{{Cite journal |last=Armstrong |first=Melissa J. |date=March 2018 |title=Progressive Supranuclear Palsy: an Update |url=http://link.springer.com/10.1007/s11910-018-0819-5 |journal=Current Neurology and Neuroscience Reports |language=en |volume=18 |issue=3 |page=12 |doi=10.1007/s11910-018-0819-5 |pmid=29455271 |issn=1528-4042|url-access=subscription }}</ref> Patients can present initially with symptoms more characteristic of the PSP-Parkinson (PSP-P) subtype which is characterized by asymmetric rigidity, resting tremor, and are more responsive to dopamine therapies such as [[Levodopa|levadopa]] compared to PSP-RS.<ref>{{Cite journal |last1=Coughlin |first1=David G. |last2=Litvan |first2=Irene |date=April 2020 |title=Progressive supranuclear palsy: Advances in diagnosis and management |journal=Parkinsonism & Related Disorders |language=en |volume=73 |pages=105–116 |doi=10.1016/j.parkreldis.2020.04.014|pmid=32487421 |pmc=7462164 }}</ref> Clinical and pathological differences between PSP-P and PRSP-RS occur within the first year of the disease, with individuals with PSP-RS exhibiting faster progression of symptoms and lower survival rates after diagnosis. Diagnostic criteria distinguish between '''probable''' and '''possible''' PSP-RS, as definitive diagnosis requires post-mortem neuropathological confirmation.<ref name=":5" /> The NINDS-SPSP criteria define probable PSP-RS as requiring both vertical supranuclear gaze palsy and early postural instability with falls, while possible PSP-RS requires either vertical gaze palsy or slowed vertical saccades combined with early falls.<ref name=":5" /><ref name=":4" /> PSP-RS effects more Males than Females, with a Male to Female ratio of 1.8:1.<ref name=":3" /> Symptom progression tends to occur more quickly in PSP-RS than other sub-types with the average disease duration being 5.9 years and an average age of death of 72.1 years.<ref name=":3" /><ref name=":7" />

==== Motor Symptoms in PSP-RS ====
One of the key features of PSP-RS that occurs within the first year of symptom onset, is early postural instability which often leads to unexplained falls.<ref name=":6" /><ref name=":5" /><ref name=":8">{{Cite journal |last1=Alster |first1=Piotr |last2=Madetko |first2=Natalia |last3=Koziorowski |first3=Dariusz |last4=Friedman |first4=Andrzej |date=2020-03-10 |title=Progressive Supranuclear Palsy—Parkinsonism Predominant (PSP-P)—A Clinical Challenge at the Boundaries of PSP and Parkinson's Disease (PD) |journal=Frontiers in Neurology |volume=11 |page=180 |doi=10.3389/fneur.2020.00180 |doi-access=free |pmid=32218768 |pmc=7078665 |issn=1664-2295}}</ref> Additionally, patients present with axial rigidity, which is characterized by stiffness in the neck and body.<ref name=":5" /> This is often accompanied with [[bradykinesia]] which is slowness of movement. Although PSP-RS is often misdiagnosed as Parkinson's disease, tremors are uncommon in PSP-RS.<ref name=":3" /> Motor symptoms are often symmetrical in PSP-RS with both sides of the body being affected.<ref name=":10">{{Cite journal |last1=Chunowski |first1=Patryk |last2=Madetko-Alster |first2=Natalia |last3=Alster |first3=Piotr |date=2024-09-28 |title=Asymmetry in Atypical Parkinsonian Syndromes-A Review |journal=Journal of Clinical Medicine |volume=13 |issue=19 |pages=5798 |doi=10.3390/jcm13195798 |issn=2077-0383 |pmc=11477316 |pmid=39407856 |doi-access=free}}</ref>

===== Ocular Symptoms in PSP-RS =====
A defining feature of PSP-RS is vertical supranuclear gaze palsy, which is difficulty with voluntary downward gaze.<ref name=":9">{{Cite journal |last1=Krzosek |first1=Patrycja |last2=Madetko |first2=Natalia |last3=Migda |first3=Anna |last4=Migda |first4=Bartosz |last5=Jaguś |first5=Dominika |last6=Alster |first6=Piotr |date=2022-02-09 |title=Differential Diagnosis of Rare Subtypes of Progressive Supranuclear Palsy and PSP-Like Syndromes—Infrequent Manifestations of the Most Common Form of Atypical Parkinsonism |journal=Frontiers in Aging Neuroscience |volume=14 |doi=10.3389/fnagi.2022.804385 |doi-access=free |pmid=35221993 |pmc=8864174 |issn=1663-4365}}</ref> Vertical supranuclear gaze palsy, a symptom characterized by decreased velocity and amplitude of vertical eye movements (saccades) is often the prominent diagnostic feature of PSP-RS. Approximately 40% of patients with PSP-RS experiencing supranuclear gaze palsy, but it may not present until 3–4 years after disease onset.<ref name=":0" /><ref name=":9" /> Individuals with PSP-RS also display other ocular motor symptoms such as dry, red and sore eyes, blurred vision, and difficulty focusing.<ref name=":7" /> They may also experience spontaneuous and involuntary eye-lid closure or apraxia of the eyelid opening.<ref name=":7" />

===== Cognitive and Behavioral Symptoms in PSP-RS =====
Cognitive changes are frequent in PSP-RS compared to other PSP subtypes and include slowed thinking (bradyphrenia), executive dysfunction, and difficulty with planning or problem-solving.<ref name=":5" /><ref name=":8" /> Some patients exhibit apathy, emotional blunting, or involuntary episodes of laughing or crying unrelated to mood.<ref name=":7" /> Some studies report that around half the individuals with PSP-RS develop these personality changes within 2-years of diagnosis.<ref name=":7" /> Dementia is not typically a dominant feature early on but may develop in later stages.

==Cause==
The cause of PSP is unknown. Fewer than 1% of those with PSP have a family member with the same disorder.  A variant in the MAPT [[Tau protein#Genetics|gene for tau protein]] called the ''H1'' [[haplotype]], located on [[Chromosome 17 (human)|chromosome 17]] ([https://www.snpedia.com/index.php/Rs1800547 rs1800547]), has been linked to PSP.<ref>{{OMIM|601104|Supranuclear Palsy, Progressive, 1; PSNP1}}</ref> Nearly all people with PSP received a copy of that variant from each parent, but this is true of about two-thirds of the general population. The H1 haplotype of the ''MAPT'' gene has been identified in approximately 94% of individuals with PSP, compared to around 78% in healthy adults.<ref name=":11">{{Cite journal |last1=Rösler |first1=Thomas W. |last2=Tayaranian Marvian |first2=Amir |last3=Brendel |first3=Matthias |last4=Nykänen |first4=Niko-Petteri |last5=Höllerhage |first5=Matthias |last6=Schwarz |first6=Sigrid C. |last7=Hopfner |first7=Franziska |last8=Koeglsperger |first8=Thomas |last9=Respondek |first9=Gesine |last10=Schweyer |first10=Kerstin |last11=Levin |first11=Johannes |last12=Villemagne |first12=Victor L. |last13=Barthel |first13=Henryk |last14=Sabri |first14=Osama |last15=Müller |first15=Ulrich |date=September 2019 |title=Four-repeat tauopathies |url=https://linkinghub.elsevier.com/retrieve/pii/S0301008219300863 |journal=Progress in Neurobiology |language=en |volume=180 |pages=101644 |doi=10.1016/j.pneurobio.2019.101644|pmid=31238088 }}</ref> Therefore, the ''H1'' haplotype appears to be [[Necessity and sufficiency|necessary but not sufficient]] to cause PSP.  Other genes, as well as [[Pollution|environmental toxins]], are being investigated as other possible contributors to the cause of PSP.<ref>{{Cite web |title=Progressive Supranuclear Palsy |url=https://rarediseases.org/rare-diseases/progressive-supranuclear-palsy/ |access-date=2022-03-18 |website=NORD (National Organization for Rare Disorders) |language=en-US}}</ref>

Additionally, the ''H2'' [[haplotype]], combined with vascular dysfunction, seems to be a factor of vascular progressive supranuclear palsy.<ref>{{Cite journal|pmid = 12374498|year = 2002|last1 = Josephs|first1 = K. A.|last2 = Ishizawa|first2 = T.|last3 = Tsuboi|first3 = Y.|last4 = Cookson|first4 = N.|last5 = Dickson|first5 = D. W.|title = A clinicopathological study of vascular progressive supranuclear palsy: A multi-infarct disorder presenting as progressive supranuclear palsy|journal = Archives of Neurology|volume = 59|issue = 10|pages = 1597–601|doi = 10.1001/archneur.59.10.1597|doi-access = free}}</ref>

=== Genetic Mechanisms in PSP-RS ===
Although there is a strong correlation between the H1 haplotype and PSP, the exact molecular mechanism remains unclear. Some individuals with PSP-RS have reported a family history of the disease, suggesting the possibility that genetic factors, such as the H1 haplotype, may contribute to inherited susceptibility in certain cases.<ref name=":11" /><ref name=":15">{{Cite journal |last1=Wen |first1=Yafei |last2=Zhou |first2=Yafang |last3=Jiao |first3=Bin |last4=Shen |first4=Lu |date=2021 |title=Genetics of Progressive Supranuclear Palsy: A Review |journal=Journal of Parkinson's Disease |volume=11 |issue=1 |pages=93–105 |doi=10.3233/JPD-202302 |issn=1877-718X |pmc=7990399 |pmid=33104043}}</ref> The PSP-RS subtype is known for a buildup of the 4R tau protein, which does not dissolve properly and forms insoluble aggregates in the brain. In healthy brains, there is typically a balanced ratio of 3-repeat (3R) and 4-repeat (4R) tau isoforms, resulting from the regulated inclusion or exclusion of exon 10 on the ''MAPT'' gene.<ref name=":11" /> Inclusion of exon 10 promotes the production of 4R tau, while its exclusion favors 3R tau.<ref name=":11" /><ref name=":15" /> In PSP-RS, this balance is disrupted. Certain genetic variations in MAPT, most notably the H1/H1 haplotype, are associated with increased inclusion of exon 10, leading to elevated levels of 4R tau relative to 3R tau.<ref name=":11" /> The resulting overproduction of 4R tau is believed to contribute to the pathological accumulation of tau aggregates observed in PSP-RS.

=== Risk Factors ===
Risk factors for PSP are still being explored, but research has begun to uncover potential genetic, environmental, and biological contributors that may increase the likelihood of developing this condition. Associations between [[hypertension]] and increased risk for PSP development have been uncovered.<ref name=":7" /> Additionally, ties to [[cerebrovascular disease]] and [[diabetes mellitus]] has been discovered, with type 2 diabetes being associated with increased brain atrophy and neurodegeneration.<ref name=":7" /> Cerebrovascular disease may increase risk of vascular pathology and enhance disease burden through decreased blood flow and secondary injury.<ref name=":7" />

Besides [[tauopathy]], [[mitochondrial dysfunction]] seems to be a factor involved in PSP. Especially, [[mitochondrial complex I]] inhibitors (such as [[acetogenin]]s and [[quinoline]]s contained in ''[[Annonaceae]]'' plants, as well as [[rotenoid]]s) are implicated in PSP-like brain injuries.<ref>{{cite journal | vauthors = Caparros-Lefebvre D, Sergeant N, Lees A, Camuzat A, Daniel S, Lannuzel A, Brice A, Tolosa E, Delacourte A, Duyckaerts C | title = Guadeloupean parkinsonism: a cluster of progressive supranuclear palsy-like tauopathy | journal = Brain | volume = 125 | issue = Pt 4 | pages = 801–11 | date = April 2002 | pmid = 11912113 | doi = 10.1093/brain/awf086 | doi-access = free }}</ref>

==Pathophysiology==
[[File:Taupathy.svg|thumb|The image illustrates abnormal aggregation of 4-repeat (4R) tau protein (blue) disrupting microtubule structures (red), which impairs neuronal stability and function. Tau accumulation is a key pathological hallmark of PSP-RS and contributes to neurodegeneration.]]
The affected brain cells are both [[neurons]] and [[glial cells]]. The neurons display [[neurofibrillary tangles]] (NFTs), which are clumps of [[tau protein]], a normal part of a brain cell's internal structural skeleton.<ref name=":7" /> These tangles are often different from those seen in Alzheimer's disease, but may be structurally similar when they occur in the cerebral cortex.<ref>{{cite journal |vauthors=Amano N, Iwabuchi K, Yokoi S, Yagishita S, Itoh Y, Saitoh A, Nagatomo H, Matsushita M |date=January 1989 |title=[The reappraisal study of the ultrastructure of Alzheimer's neurofibrillary tangles in three cases of progressive supranuclear palsy] |journal=No to Shinkei = Brain and Nerve |language=ja |volume=41 |issue=1 |pages=35–44 |pmid=2655673}}</ref> Their chemical composition is usually different, however, and is similar to that of tangles seen in [[corticobasal degeneration]].<ref>{{cite journal |vauthors=Buée L, Delacourte A |date=October 1999 |title=Comparative biochemistry of tau in progressive supranuclear palsy, corticobasal degeneration, FTDP-17 and Pick's disease |journal=Brain Pathology |volume=9 |issue=4 |pages=681–93 |doi=10.1111/j.1750-3639.1999.tb00550.x |pmc=8098140 |pmid=10517507 |s2cid=10711305}}</ref> Individuals with PSP typically exhibit reduced levels of total tau and phosphorylated tau in CSF compared to the elevated levels observed in Alzheimer’s disease, but these levels are still higher than those found in healthy controls.<ref name=":7" /> One biomarkers for PSP is '''neurofilament light chain (NfL)''', a non-specific marker of axonal damage.<ref name=":7" /> NfL levels in the CSF of individuals with PSP are reported to be two to five times higher than those in healthy individuals or patients with Parkinson’s disease, [[Parkinson's dementia|Parkinson’s dementia]], or [[dementia with Lewy bodies]].<ref name=":7" /> However, NfL levels are similar in PSP and other disorders like [[corticobasal syndrome]] (CBS) and MSA, limiting its utility for differential diagnosis among these conditions.<ref name=":7" /> Still, NfL might help track how PSP gets worse over time.<ref name=":7" /> Blood-based measurements of NfL have also shown promise, with plasma levels strongly correlating with CSF concentrations.<ref name=":7" />
[[File:PSP_Tau_tufted_astrocyte.jpg|thumb|Immunohistochemical image of a tau-positive tufted astrocyte in a brain sample from a patient with PSP-RS. Tufted astrocytes are a pathological hallmark of PSP and are characterized by abnormal accumulation of 4-repeat (4R) tau protein within astrocytic processes.]]
Tufts of [[tau protein]] in [[Astrocyte|astrocytes]], or tufted astrocytes, are also considered diagnostic. '''Tufted astrocytes''' are astrocytes that accumulate abnormally phosphorylated 4R tau in their proximal processes.<ref name=":5" /> These astrocytic inclusions are considered a key distinguishing pathological marker of PSP-RS and are particularly concentrated in affected subcortical regions.<ref name=":5" /><ref name=":11" /> PSP is specifically associated with an increase in the deposition of 4R tau proteins, which differ from other tauopathies such as Alzheimer’s disease, where both 3-repeat and 4-repeat tau are present.<ref name=":5" /> Unlike globose NFTs, tau depositions may be more widespread in the cortex.<ref name=":11" /><ref>{{cite journal |vauthors=Feany MB, Mattiace LA, Dickson DW |date=January 1996 |title=Neuropathologic overlap of progressive supranuclear palsy, Pick's disease and corticobasal degeneration |journal=Journal of Neuropathology and Experimental Neurology |volume=55 |issue=1 |pages=53–67 |doi=10.1097/00005072-199601000-00006 |pmid=8558172 |doi-access=free}}</ref> [[Lewy bodies]] are seen in some cases, but whether this is a variant or an independent co-existing process is not clear, and in some cases, PSP can coexist with [[corticobasal degeneration]], Parkinson's, and/or [[Alzheimer's disease]], particularly with older patients.<ref>{{cite journal |vauthors=Uchikado H, DelleDonne A, Ahmed Z, Dickson DW |date=April 2006 |title=Lewy bodies in progressive supranuclear palsy represent an independent disease process |journal=Journal of Neuropathology and Experimental Neurology |volume=65 |issue=4 |pages=387–95 |doi=10.1097/01.jnen.0000218449.17073.43 |pmid=16691119 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Keith-Rokosh J, Ang LC |date=November 2008 |title=Progressive supranuclear palsy: a review of co-existing neurodegeneration |url=http://cjns.metapress.com/openurl.asp?genre=article&issn=0317-1671&volume=35&issue=5&spage=602 |journal=The Canadian Journal of Neurological Sciences |volume=35 |issue=5 |pages=602–8 |doi=10.1017/S0317167100009392 |pmid=19235444 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Rigby HB, Dugger BN, Hentz JG, Adler CH, Beach TG, Shill HA, Driver-Dunckley E, Sabbagh MN, Sue LI, Caviness JN |date=March 2015 |title=Clinical Features of Patients with Concomitant Parkinson's Disease and Progressive Supranuclear Palsy Pathology |journal=Movement Disorders Clinical Practice |volume=2 |issue=1 |pages=33–38 |doi=10.1002/mdc3.12104 |pmc=6183005 |pmid=30363831}}</ref><ref>{{cite journal |vauthors=Gearing M, Olson DA, Watts RL, Mirra SS |date=June 1994 |title=Progressive supranuclear palsy: neuropathologic and clinical heterogeneity |journal=Neurology |volume=44 |issue=6 |pages=1015–24 |doi=10.1212/wnl.44.6.1015 |pmid=8208392 |s2cid=20622672}}</ref><ref>{{cite journal |vauthors=Dugger BN, Adler CH, Shill HA, Caviness J, Jacobson S, Driver-Dunckley E, Beach TG |date=May 2014 |title=Concomitant pathologies among a spectrum of parkinsonian disorders |journal=Parkinsonism & Related Disorders |volume=20 |issue=5 |pages=525–9 |doi=10.1016/j.parkreldis.2014.02.012 |pmc=4028418 |pmid=24637124 |collaboration=Arizona Parkinson's Disease Consortium}}</ref> Additional pathological features include oligodendroglial coiled bodies, neuronal loss, and gliosis.<ref name=":5" /><ref name=":7" /> These changes contribute to the characteristic symptoms of the disease, such as postural instability (from midbrain atrophy), gaze palsy (due to involvement of vertical gaze centers), and cognitive decline (from frontal lobe degeneration).<ref name=":5" />

The principal areas of the brain affected are the:<ref name=":7" /><ref name=":5" />
* [[basal ganglia]], particularly the [[subthalamic nucleus]], [[substantia nigra]], and [[globus pallidus]]
* [[brainstem]], particularly the [[tectum]] (the portion of the midbrain where "supranuclear" eye movement resides), as well as [[dopaminergic]] nuclei
* [[cerebral cortex]], particularly that of the [[frontal lobe]]s and the [[limbic system]] (similarly to [[frontotemporal degeneration]])
* [[dentate nucleus]] of the [[cerebellum]]
* [[spinal cord]], particularly the area where some control of the bladder and bowel resides
The progression of tau pathology in PSP is thought to follow a pattern that begins in the striatum and advances to the frontal and parietal lobes, then to the temporal and occipital lobes, and ultimately the brainstem.<ref name=":11" />

Some consider PSP, [[corticobasal degeneration]], and [[frontotemporal dementia]] (especially [[FTDP-17]]) to be variations of the same disease.<ref>{{cite journal | vauthors = Kertesz A, Munoz D | title = Relationship between frontotemporal dementia and corticobasal degeneration/progressive supranuclear palsy | journal = Dementia and Geriatric Cognitive Disorders | volume = 17 | issue = 4 | pages = 282–6 | year = 2004 | pmid = 15178937 | doi = 10.1159/000077155 | s2cid = 21017979 }}</ref><ref>{{cite journal | vauthors = Katsuse O, Iseki E, Arai T, Akiyama H, Togo T, Uchikado H, Kato M, de Silva R, Lees A, Kosaka K | title = 4-repeat tauopathy sharing pathological and biochemical features of corticobasal degeneration and progressive supranuclear palsy | journal = Acta Neuropathologica | volume = 106 | issue = 3 | pages = 251–60 | date = September 2003 | pmid = 12802605 | doi = 10.1007/s00401-003-0728-8 | s2cid = 20275104 }}</ref> Others consider them separate diseases.<ref>{{cite journal | vauthors = Hattori M, Hashizume Y, Yoshida M, Iwasaki Y, Hishikawa N, Ueda R, Ojika K | title = Distribution of astrocytic plaques in the corticobasal degeneration brain and comparison with tuft-shaped astrocytes in the progressive supranuclear palsy brain | journal = Acta Neuropathologica | volume = 106 | issue = 2 | pages = 143–9 | date = August 2003 | pmid = 12732936 | doi = 10.1007/s00401-003-0711-4 | s2cid = 25741692 }}</ref><ref>{{cite journal | vauthors = Komori T, Arai N, Oda M, Nakayama H, Mori H, Yagishita S, Takahashi T, Amano N, Murayama S, Murakami S, Shibata N, Kobayashi M, Sasaki S, Iwata M | title = Astrocytic plaques and tufts of abnormal fibers do not coexist in corticobasal degeneration and progressive supranuclear palsy | journal = Acta Neuropathologica | volume = 96 | issue = 4 | pages = 401–8 | date = October 1998 | pmid = 9797005 | doi = 10.1007/s004010050911 | s2cid = 7265831 }}</ref><ref>{{cite journal | vauthors = Zhu MW, Wang LN, Li XH, Gui QP | title = [Glial abnormalities in progressive supranuclear palsy and corticobasal degeneration] | language = zh | journal = Zhonghua Bing Li Xue Za Zhi = Chinese Journal of Pathology | volume = 33 | issue = 2 | pages = 125–9 | date = April 2004 | pmid = 15132848 | doi = 10.3760/j.issn:0529-5807.2004.02.008 | trans-title = Glial abnormalities in progressive supranuclear palsy and corticobasal degeneration }}</ref> PSP has been shown occasionally to co-exist with [[Pick's disease]].<ref>{{cite journal | vauthors = Wang LN, Zhu MW, Feng YQ, Wang JH | title = Pick's disease with Pick bodies combined with progressive supranuclear palsy without tuft-shaped astrocytes: a clinical, neuroradiologic and pathological study of an autopsied case | journal = Neuropathology | volume = 26 | issue = 3 | pages = 222–30 | date = June 2006 | pmid = 16771179 | doi = 10.1111/j.1440-1789.2006.00671.x | s2cid = 25562683 }}</ref>

=== Pathophysiology in PSP-RS Subtypes ===
Tau pathology in PSP-RS is generally more severe than in other subtypes and frequently involves regions such as the basal ganglia, subthalamic nucleus, tectum, locus coeruleus, and dentate nucleus.<ref name=":8" /> These differences are captured by the PSP-tau score, a semiquantitative 12-point scale used to assess the extent and distribution of tau pathology, with scores ranging from 0 (minimal involvement) to 12 (widespread and severe involvement). <ref name=":8" /> While individuals with PSP-P typically have PSP-tau scores greater than 5, PSP-RS cases often present with higher scores, reflecting a greater overall tau burden in this subtype.<ref name=":8" />
[[File:Acetylcholine_Pathway.png|thumb|Diagram of central cholinergic pathways that may be disrupted in PSP-RS. Degeneration in regions such as the pedunculopontine nucleus and nucleus basalis of Meynert can impair acetylcholine transmission to cortical and subcortical structures involved in memory, attention, and motor control.]]
Individuals with PSP-RS also exhibit early neuronal loss in the pedunculopontine tegmentum (PPT), an area of the brain responsible for producing acetylcholine, a neurotransmitter involved in memory, learning, and motor function.<ref name=":52">{{Cite journal |last1=Priyanka |first1=null |last2=Qamar |first2=Syeda Hania |last3=Visanji |first3=Naomi P. |date=2024 |title=Toward an animal model of Progressive Supranuclear Palsy |journal=Frontiers in Neuroscience |volume=18 |pages=1433465 |doi=10.3389/fnins.2024.1433465 |issn=1662-4548 |pmc=11484047 |pmid=39420986 |doi-access=free}}</ref> The PPT sends cholinergic projections to several regions commonly affected by tau pathology in PSP, including the globus pallidus, substantia nigra, and pons.<ref name=":52" /> Degeneration of cholinergic neurons in the PPT can also disrupt the function of other neurotransmitter systems, particularly dopamine, which plays a key role in motor regulation. In PSP-RS, dopaminergic neuronal loss has been partly attributed to reduced cholinergic input to the substantia nigra, further contributing to motor impairments characteristic of the disease.<ref name=":52" />

==Diagnosis==
[[Magnetic resonance imaging]] (MRI) is often used to diagnose PSP. MRI may show atrophy in the midbrain with preservation of the [[pons]] giving a "hummingbird" sign.<ref name=":0" /><ref>{{cite journal | vauthors = Sonthalia N, Ray S | title = The Hummingbird sign: a diagnostic clue for Steele-Richardson-Olszweski syndrome | journal = BMJ Case Reports | volume = 2012 | pages = bcr2012006263 | date = September 2012 | pmid = 22987902 | pmc = 4543120 | doi = 10.1136/bcr-2012-006263 }}</ref>

===Differential diagnosis===
PSP is frequently misdiagnosed as [[Parkinson's disease]] because they both involve slowed movements and gait difficulty, with PSP being one of a collection of diseases referred to as [[Parkinson plus syndrome]]s. Both Parkinson's and PSP have an onset in late middle age and involve slowing and rigidity of movement. However, several distinguishing features exist. Tremor is very common with Parkinson's, but rare with PSP. Speech and swallowing difficulties are more common and severe with PSP and the abnormal eye movements of PSP are essentially absent with PD.<ref>{{cite web |title=Progressive Supranuclear Palsy Fact Sheet |url=https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Progressive-Supranuclear-Palsy-Fact-Sheet |access-date=19 February 2019 |publisher=National Institute of Neurological Disorders and Stroke}}</ref> A poor response to [[levodopa]], along with symmetrical onset can also help differentiate PSP from PD.<ref>{{cite journal |vauthors=Litvan I, Campbell G, Mangone CA, Verny M, McKee A, Chaudhuri KR, Jellinger K, Pearce RK, D'Olhaberriague L |date=January 1997 |title=Which clinical features differentiate progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome) from related disorders? A clinicopathological study |journal=Brain |volume=120 |issue=Pt 1 |pages=65–74 |doi=10.1093/brain/120.1.65 |pmid=9055798 |doi-access=free}}</ref>

PSP can also be misdiagnosed as Alzheimer's disease because of the behavioral changes.<ref>{{Cite web |last=Elble |first=Rodger J. |title=Progressive Supranuclear Palsy |url=https://rarediseases.org/rare-diseases/progressive-supranuclear-palsy/ |website=www.rarediseases.org}}</ref>

[[Chronic traumatic encephalopathy]] (CTE) shows many similarities with PSP, because both share the following attributes:<ref>{{cite journal |vauthors=McKee AC, Cantu RC, Nowinski CJ, Hedley-Whyte ET, Gavett BE, Budson AE, Santini VE, Lee HS, Kubilus CA, Stern RA |date=July 2009 |title=Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury |journal=J Neuropathol Exp Neurol |volume=68 |issue=7 |pages=709–35 |doi=10.1097/NEN.0b013e3181a9d503 |pmc=2945234 |pmid=19535999}}</ref>
* Accumulations of [[hyperphosphorylated]] [[tau protein]] in neurons or glial cells
* Accumulation of tau-[[immunoreactive]] [[astrocyte]]s
* Involve the superficial [[cortical layers]]

===Types===
Based on the pathological findings in confirmed cases of PSP, it is divided into the following categories:
* Classical Richardson syndrome (PSP-RS) <ref name=":3" />
* PSP-parkinsonism (PSP-P) and PSP-pure akinesia with gait freezing (PSP-PAGF)<ref name=":3" />
* Frontal PSP, PSP-corticobasal syndrome (PSP-CBS), PSP-behavioural variant of frontotemporal dementia (PSP-bvFTD) and PSP-progressive non-fluent aphasia (PSP-PNFA)<ref>{{cite journal | vauthors = Ling H | title = Clinical Approach to Progressive Supranuclear Palsy | journal = Journal of Movement Disorders | volume = 9 | issue = 1 | pages = 3–13 | date = January 2016 | pmid = 26828211 | pmc = 4734991 | doi = 10.14802/jmd.15060}}</ref>
* PSP-C<ref name=":3" />
* PSP induced by [[Annonaceae]]<ref>{{cite journal|url=https://academic.oup.com/brain/article/125/4/801/260717|doi = 10.1093/brain/awf086|title = Guadeloupean parkinsonism: A cluster of progressive supranuclear palsy-like tauopathy|year = 2002|last1 = Caparros-Lefebvre|first1 = Dominique|last2 = Sergeant|first2 = Nicolas|last3 = Lees|first3 = Andrew|last4 = Camuzat|first4 = Agnes|last5 = Daniel|first5 = Susan|last6 = Lannuzel|first6 = Annie|last7 = Brice|first7 = Alexis|last8 = Tolosa|first8 = Eduardo|last9 = Delacourte|first9 = Andre|last10 = Duyckaerts|first10 = Charles|journal = Brain|volume = 125|issue = 4|pages = 801–811|pmid = 11912113|doi-access= free}}</ref>

=== Diagnostic differences between PSP subtypes ===
PSP-RS is the most common subtype of PSP. In PSP-P features of Parkinson's Disease overlap with the clinical presentation of PSP and follows a more benign course. In both PSP-P and PSP- PAGF distribution of abnormal tau is relatively restricted to the brain stem. Frontal PSP initially presents with behavioral and cognitive symptoms, with or without [[ophthalmoparesis]] and then evolve into typical PSP.<ref name="Bradley" /> The phenotypes of PSP-P and PSP-PAGF are sometimes referred as the "brain stem" variants of PSP, as opposed to the "cortical" variants which present with predominant cortical features, including PSP-CBS, PSP-bvFTD, and PSP-PNFA.<ref>{{cite journal | vauthors = Dickson DW, Ahmed Z, Algom AA, Tsuboi Y, Josephs KA | title = Neuropathology of variants of progressive supranuclear palsy | journal = Current Opinion in Neurology | volume = 23 | issue = 4 | pages = 394–400 | date = August 2010 | pmid = 20610990 | doi = 10.1097/WCO.0b013e32833be924 }}</ref> [[Cerebellar ataxia]] as the predominant early presenting feature is increasingly recognized as a very rare subtype of PSP (PSP-C) which is associated with severe neuronal loss with [[gliosis]] and higher densities of coiled bodies in the cerebellar [[dentate nucleus]].<ref>{{cite journal|vauthors=Kanazawa M, Tada M, Onodera O, Takahashi H, Nishizawa M, Shimohata T|date=2013|title=Early clinical features of patients with progressive supranuclear palsy with predominant cerebellar ataxia.|journal=Parkinsonism Relat Disord|volume=19|issue=12|pages=1149–51|pmid=23916652|doi=10.1016/j.parkreldis.2013.07.019}}</ref>

The "humming-bird" imaging feature, indicative of midbrain degeneration, supports early diagnosis of both PSP-RS and PSP-P.<ref name=":3" /><ref name=":82">{{Cite journal |last1=Spiegel |first1=Chloe |last2=Marotta |first2=Cassandra |last3=Bertram |first3=Kelly |last4=Vivash |first4=Lucy |last5=Harding |first5=Ian H. |date=2025 |title=Brainstem and cerebellar radiological findings in progressive supranuclear palsy |journal=Brain Communications |volume=7 |issue=1 |pages=fcaf051 |doi=10.1093/braincomms/fcaf051 |issn=2632-1297 |pmc=11829206 |pmid=39958262}}</ref> One commonly used quantitative measure is the '''midbrain-to-pons area ratio''', which is calculated by measuring the cross-sectional areas of the midbrain and pons on midsagittal MRI images.<ref name=":5" />In healthy individuals, the midbrain and pons are proportionally sized, but in PSP-RS, the midbrain undergoes significant atrophy while the pons remains relatively spared.<ref name=":5" /><ref name=":4" /><ref name=":82" /><ref name=":112">{{Cite journal |last1=Whitwell |first1=Jennifer L. |last2=Höglinger |first2=Günter U. |last3=Antonini |first3=Angelo |last4=Bordelon |first4=Yvette |last5=Boxer |first5=Adam L. |last6=Colosimo |first6=Carlo |last7=van Eimeren |first7=Thilo |last8=Golbe |first8=Lawrence I. |last9=Kassubek |first9=Jan |last10=Kurz |first10=Carolin |last11=Litvan |first11=Irene |last12=Pantelyat |first12=Alexander |last13=Rabinovici |first13=Gil |last14=Respondek |first14=Gesine |last15=Rominger |first15=Axel |date=July 2017 |title=Radiological biomarkers for diagnosis in PSP: Where are we and where do we need to be? |journal=Movement Disorders |language=en |volume=32 |issue=7 |pages=955–971 |doi=10.1002/mds.27038 |issn=0885-3185 |pmc=5511762 |pmid=28500751}}</ref> As a result, the ratio is markedly reduced in PSP-RS, distinguishing it from other neurodegenerative conditions such as Parkinson’s disease, multiple system atrophy (MSA), and even PSP-P, which typically exhibit less pronounced midbrain atrophy.<ref name=":5" /><ref name=":4" /><ref name=":82" /><ref name=":112" /> To improve diagnostic specificity, the '''magnetic resonance parkinsonism index (MRPI)''' incorporates the midbrain-to-pons area ratio along with measurements of the widths of the middle and superior cerebellar peduncles.<ref name=":5" /> The MRPI has been shown to enhance discrimination between PSP-RS and other forms of atypical parkinsonism.<ref name=":5" /> Additional MRI findings associated with PSP-RS may include third ventricle enlargement, thinning of the superior cerebellar peduncles, and frontal lobe atrophy, all of which are consistent with the underlying tau pathology seen in the disease.<ref name=":5" /> Brain atrophy in PSP-RS is generally symmetrical, which may correspond to the bilateral presentation of motor and cognitive symptoms.<ref name=":10" />

PSP-RS is thought to follow a grading system that reflects the progressive nature of the disease.<ref name=":11" /> In the early stages, atrophy affects midbrain structures such as the pons, and then progresses to involve the basal ganglia and pontine nuclei.<ref name=":112" /> In later stages, the dentate gyrus of the hippocampus and the cerebral cortices exhibit cell death and atrophy.<ref name=":112" /><ref name=":82" /> PSP-RS is also associated with more widespread and severe cortical volume loss, particularly in the frontal pole, inferior frontal gyrus, globus pallidus, amygdala, and thalamus.<ref name=":82" /> Additionally, '''diffusion tensor imaging (DTI)''' studies show significant reductions in '''[[fractional anisotropy]],''' a measure of white matter integrity, in the body of the corpus callosum, superior cerebellar peduncles, dentatorubrothalamic tract, and anterior thalamic radiation, indicating extensive white matter disruption in PSP-RS.<ref name=":42">{{Cite journal |last1=Krzosek |first1=Patrycja |last2=Madetko |first2=Natalia |last3=Migda |first3=Anna |last4=Migda |first4=Bartosz |last5=Jaguś |first5=Dominika |last6=Alster |first6=Piotr |date=2022-02-09 |title=Differential Diagnosis of Rare Subtypes of Progressive Supranuclear Palsy and PSP-Like Syndromes—Infrequent Manifestations of the Most Common Form of Atypical Parkinsonism |journal=Frontiers in Aging Neuroscience |volume=14 |doi=10.3389/fnagi.2022.804385 |doi-access=free |pmid=35221993 |pmc=8864174 |issn=1663-4365}}</ref><ref name=":112" />

Positron emission tomography (PET) imaging has been used to detect tau accumulation in PSP-RS. The use of various tracers such as 18F-5105, 18F-FDDNP, 18F-THK523, 11C-PBB3 have shown increased binding in PSP-RS patients compared to healthy controls, reflecting elevated levels of 4R tau.<ref name=":6" /> Brain scans called SPECT have been used to help diagnose different types of Parkinson-like conditions, including PSP-RS.<ref name=":7" /> These scans show areas of reduced blood flow in the brain, but they aren’t specific enough to clearly tell PSP-RS apart from other similar conditions like PSP-P or corticobasal syndrome (CBS).<ref name=":7" /> Additionally, SPECT revealed greater perfusion deficits in PSP-RS than in PSP-P, although CBS showed the most frontal lobe deterioration overall.<ref name=":7" />

==== Differential diagnosis between PSP-Subtypes ====
The table below summarizes key clinical, pathological, and imaging differences between the main subtypes of PSP, including PSP-RS, PSP-P, and other variant forms. While all subtypes share the underlying 4-repeat tau pathology characteristic of PSP, they differ in symptom onset, disease progression, anatomical vulnerability, and response to treatment. Patients with the Richardson variant of PSP tend to have an upright posture or [[Lordosis|arched back]], as opposed to the [[Kyphosis|stooped-forward]] posture of other Parkinsonian disorders, although PSP-Parkinsonism (see below) can demonstrate a stooped posture.<ref>{{cite book |last1=Moore |first1=David P. |title=Textbook of Clinical Neuropsychiatry and Behavioral Neuroscience |last2=Puri |first2=Basant K. |date=2012 |publisher=CRC Press |isbn=978-1-4441-6494-7 |pages=400–1 |doi=10.1201/b13258 |oclc=799764189}}</ref> Early falls are also more common with PSP, especially with Richardson syndrome.<ref>{{cite journal |vauthors=Williams DR, Watt HC, Lees AJ |date=April 2006 |title=Predictors of falls and fractures in bradykinetic rigid syndromes: a retrospective study |journal=Journal of Neurology, Neurosurgery, and Psychiatry |volume=77 |issue=4 |pages=468–73 |doi=10.1136/jnnp.2005.074070 |pmc=2077491 |pmid=16543524}}</ref>
{| class="wikitable"
!Feature
!PSP-RS
!PSP-P
!Other PSP Subtypes (e.g., PSP-SL, PSP-CBS, PSP-F, PSP-PG)
|-
|Prevalence<ref name=":3" /><ref name=":8" /><ref name=":14">{{Cite journal |last1=Ichikawa-Escamilla |first1=Eduardo |last2=Velasco-Martínez |first2=Rodrigo A. |last3=Adalid-Peralta |first3=Laura |date=June 2024 |title=Progressive Supranuclear Palsy Syndrome: An Overview |journal=IBRO Neuroscience Reports |language=en |volume=16 |pages=598–608 |doi=10.1016/j.ibneur.2024.04.008 |pmc=11126858 |pmid=38800085}}</ref>
|5-7 per 100,000
24-54% of all PSP cases
|13-45% of all PSP cases
|Less than 50% of PSP cases collectively
|-
|Onset and Progression<ref name=":3" /><ref name=":8" /><ref name=":14" />
|Early falls, gaze palsy, early axial rigidity
Faster overall progression
|Slower progression with symptoms mimicking Parkinson's disease
|Variable depending on the subtype
|-
|Motor Symptoms<ref name=":3" /><ref name=":8" /><ref name=":14" />
|Early axial rigidity, bradykinesia, postural instability, rare tremor
|Asymmetric rigidity, resting tremor, better levodopa response
|PSP-PGF: progressive gait freezing
PSP-CBS: limb apraxia
|-
|Ocular Symptoms<ref name=":3" /><ref name=":8" /><ref name=":14" />
|Early vertical gaze palsy; eyelid apraxia; blurred vision
|Gaze palsy appears later or less severe
|Variable; may be absent or delayed onset
|-
|Cognitive Symptoms<ref name=":3" /><ref name=":8" /><ref name=":14" />
|Prominent early executive dysfunction, apathy, emotional blunting
|Milder or later cognitive issues
|PSP-F: early behavioral symptoms such as apathy PSP-SL: language decline
|-
|Dopaminergic Response<ref name=":3" /><ref name=":8" />
|Poor or minimal response to levodopa
|Often initially responsive to levodopa
|Generally poor response
|-
|PSP-Tau Score (0–12)<ref name=":8" />
|Typically >7; widespread tau pathology
|≤5; limited tau burden
|Variable; usually less than PSP-RS
|-
|Affected Brain Regions (Path)<ref name=":8" />
|Frontal pole, globus pallidus, thalamus, subthalamic nucleus, tectum
|Substantia nigra, subthalamic nucleus more selectively involved
|PSP-SL: perisylvian cortex; PSP-CBS: motor cortex
|-
|Disease Duration<ref name=":8" />
|Around 5.9 years
|around 7-9 years
|Variable
|}

==Management==

===Treatment===
[[File:3,4-Dihydroxy-L-phenylalanin_(Levodopa).svg|thumb|Chemical structure of levodopa (L-DOPA), a precursor to dopamine used in the treatment of Parkinsonian disorders, including PSP-RS. Levodopa crosses the blood–brain barrier and is converted to dopamine in the brain, temporarily alleviating motor symptoms.<ref name=":12">{{Cite journal |last1=Armstrong |first1=Melissa J. |last2=Okun |first2=Michael S. |date=2020-02-11 |title=Diagnosis and Treatment of Parkinson Disease: A Review |url=https://jamanetwork.com/journals/jama/fullarticle/2760741 |journal=JAMA |language=en |volume=323 |issue=6 |pages=548–560 |doi=10.1001/jama.2019.22360 |pmid=32044947 |issn=0098-7484|url-access=subscription }}</ref>]]
Management is only supportive as no [[cure]] for PSP is known. PSP cases are often split into two subgroups, PSP-RS and PSP-P, where a short-term response to [[levodopa]] can be obtained.<ref name=":7" /><ref name="ReferenceA2">{{cite journal |vauthors=O'Sullivan SS, Massey LA, Williams DR, Silveira-Moriyama L, Kempster PA, Holton JL, Revesz T, Lees AJ |date=May 2008 |title=Clinical outcomes of progressive supranuclear palsy and multiple system atrophy |journal=Brain |volume=131 |issue=Pt 5 |pages=1362–72 |doi=10.1093/brain/awn065 |pmid=18385183 |doi-access=free}}</ref> [[Dyskinesia]] is an occasional but rare complication of treatment.<ref>{{cite journal |vauthors=Williams DR, de Silva R, Paviour DC, Pittman A, Watt HC, Kilford L, Holton JL, Revesz T, Lees AJ |date=June 2005 |title=Characteristics of two distinct clinical phenotypes in pathologically proven progressive supranuclear palsy: Richardson's syndrome and PSP-parkinsonism |journal=Brain |volume=128 |issue=Pt 6 |pages=1247–58 |doi=10.1093/brain/awh488 |pmid=15788542 |doi-access=free}}</ref> Other variants have been described.<ref>{{cite web |title=Orphanet: Progressive supranuclear palsy |url=http://www.orpha.net/consor/cgi-bin/OC_Exp.php?Lng=EN&Expert=683 |access-date=2017-01-08 |website=Orpha.net}}</ref><ref>{{cite web |title=What's New in Progressive Supranuclear Palsy? |url=http://www.acnr.co.uk/10%20JF12/ACNR%20JF12%2008%20rittman%20art.pdf |url-status=dead |archive-url=https://web.archive.org/web/20160909133729/http://www.acnr.co.uk/10%20JF12/ACNR%20JF12%2008%20rittman%20art.pdf |archive-date=2016-09-09 |access-date=2017-01-08 |website=Acnr.org}}</ref><ref>{{cite web |title=Progressive Supranuclear Palsy – NORD (National Organization for Rare Disorders) |url=https://rarediseases.org/rare-diseases/progressive-supranuclear-palsy/ |access-date=2017-01-08 |website=Rarediseases.org}}</ref><ref>{{cite journal |vauthors=Williams DR, Lees AJ |date=March 2009 |title=Progressive supranuclear palsy: clinicopathological concepts and diagnostic challenges |journal=The Lancet. Neurology |volume=8 |issue=3 |pages=270–9 |doi=10.1016/S1474-4422(09)70042-0 |pmid=19233037 |s2cid=1417930}}</ref> [[Botox]] can be used to treat neck [[dystonia]] and [[blepharospasm]], but this can aggravate [[dysphagia]].<ref>{{cite journal |vauthors=Barsottini OG, Felício AC, Aquino CC, Pedroso JL |date=December 2010 |title=Progressive supranuclear palsy: new concepts |journal=Arquivos de Neuro-Psiquiatria |volume=68 |issue=6 |pages=938–46 |doi=10.1590/s0004-282x2010000600020 |pmid=21243256 |doi-access=free}}</ref>

Two studies have suggested that [[rivastigmine]] may help with cognitive aspects, but the authors of both studies have suggested that larger studies are needed.<ref name="pmid197317492">{{cite journal |vauthors=Nijboer H, Dautzenberg PL |date=June 2009 |title=[Progressive supranucleair palsy: acetylcholineeserase-inhibitor a possible therapy?] |journal=Tijdschrift voor Gerontologie en Geriatrie |volume=40 |issue=3 |pages=133–7 |doi=10.1007/BF03079574 |pmid=19731749 |s2cid=140525754}}</ref><ref>{{cite journal |vauthors=Liepelt I, Gaenslen A, Godau J, Di Santo A, Schweitzer KJ, Gasser T, Berg D |date=January 2010 |title=Rivastigmine for the treatment of dementia in patients with progressive supranuclear palsy: Clinical observations as a basis for power calculations and safety analysis |journal=Alzheimer's & Dementia |volume=6 |issue=1 |pages=70–4 |doi=10.1016/j.jalz.2009.04.1231 |pmid=20129321 |s2cid=33349776}}</ref> There is some evidence from small-scale studies that the hypnotic [[zolpidem]] may improve motor function and eye movements.<ref>{{cite journal |vauthors=Abe K |date=January 2008 |title=Zolpidem therapy for movement disorders |journal=Recent Patents on CNS Drug Discovery |volume=3 |issue=1 |pages=55–60 |doi=10.2174/157488908783421519 |pmid=18221242}}</ref><ref>{{cite journal |vauthors=Barsottini OG, Felício AC, Aquino CC, Pedroso JL |date=December 2010 |title=Progressive supranuclear palsy: new concepts |journal=Arquivos de Neuro-Psiquiatria |volume=68 |issue=6 |pages=938–46 |doi=10.1590/S0004-282X2010000600020 |pmid=21243256 |doi-access=free}}</ref>

Current clinical trials focus on disease modifying treatments but there are currently no FDA approved disease modifying treatments for PSP-RS.<ref name=":52" /> Recent trials have focused on therapies targeting the 4R tau accumulation in the brain of those with PSP-RS. These therapies include microtubule-stabilizing agents, tau gain-of-function therapies, and monoclonal antibodies.<ref name=":7" /><ref name=":52" /> These therapies are currently being tested in clinical trials.<ref name=":7" /><ref name=":52" />

===Rehabilitation===
Patients with PSP usually seek or are referred to [[occupational therapy]], speech-language pathology for motor speech changes (typically a spastic-ataxic [[dysarthria]]), and physical therapy for balance and [[gait]] problems with reports of frequent falls.<ref name="Zampieri">{{cite journal | vauthors = Zampieri C, Di Fabio RP | title = Progressive supranuclear palsy: disease profile and rehabilitation strategies | journal = Physical Therapy | volume = 86 | issue = 6 | pages = 870–80 | date = June 2006 | pmid = 16737412 | doi = 10.1093/ptj/86.6.870 | doi-access = free }}</ref> There has been research in the use of robot-assisted gait training.<ref>{{cite journal |vauthors=Sale P, Stocchi F, Galafate D, De Pandis MF, Le Pera D, Sova I, Galli M, Foti C, Franceschini M |title=Effects of robot assisted gait training in progressive supranuclear palsy (PSP): a preliminary report |journal=Front Hum Neurosci |volume=8 |issue= |pages=207 |date=2014 |pmid=24860459 |pmc=4029018 |doi=10.3389/fnhum.2014.00207 |doi-access=free }}</ref> Evidence-based approaches to rehabilitation in PSP are lacking and, currently the majority of research on the subject consists of case reports involving only a small number of patients.<ref>{{Cite web |title=Progressive Supranuclear Palsy |url=https://pspawareness.com/pages/progressive-supranuclear-palsy |access-date=2023-07-11 |website=CCF for PSP Awareness |language=en}}</ref>

Case reports of rehabilitation programs for patients with PSP generally include limb-coordination activities, tilt-board balancing, [[gait training]], strength training with progressive resistive exercises, and isokinetic exercises and stretching of the neck muscles.<ref name="Zampieri"/> While some case reports suggest that physiotherapy can offer improvements in balance and gait of patients with PSP, the results cannot be generalized across all PSP patients, as each case report followed only one or two patients.<ref name="Zampieri"/> The observations made from these case studies can be useful however, in helping to guide future research concerning the effectiveness of balance and gait training programs in the management of PSP.<ref name=":52" />

Individuals with PSP are often referred to occupational therapists to help manage their condition and to help enhance their independence. This may include being taught to use [[mobility aid]]s.<ref name="van Balken">{{cite journal | vauthors = van Balken I, Litvan I | title = Current and future treatments in progressive supranuclear palsy | journal = Current Treatment Options in Neurology | volume = 8 | issue = 3 | pages = 211–23 | date = May 2006 | pmid = 16569380 | doi = 10.1007/s11940-006-0012-z | s2cid = 30537997 }}</ref><ref name="Golbe2001">{{cite journal | vauthors = Golbe LI | title = Progressive Supranuclear Palsy | journal = Current Treatment Options in Neurology | volume = 3 | issue = 6 | pages = 473–7 | date = November 2001 | pmid = 11581524 | doi = 10.1007/s11940-001-0010-0 | s2cid = 36973020 }}</ref>  Due to their tendency to fall backwards, the use of a walker, particularly one that can be weighted in the front, is recommended instead of a cane.<ref name="van Balken"/>  The use of an appropriate mobility aid helps to decrease the individual's risk of falls and makes them safer to [[ambulate]] independently in the community.<ref name="Golbe2001"/>
Due to their balance problems and irregular movements, individuals need to spend time learning how to safely transfer in their homes and in the community.<ref name="van Balken"/> This may include rising from and sitting in chairs safely.<ref name="Golbe2001"/>

Due to the progressive nature of this disease, all individuals eventually lose their ability to walk and will need to progress to using a wheelchair.<ref name="van Balken"/> Severe [[dysphagia]] often follows, and at this point [[death]] is often a matter of months.<ref name="ReferenceA">{{cite journal |vauthors=O'Sullivan SS, Massey LA, Williams DR, Silveira-Moriyama L, Kempster PA, Holton JL, Revesz T, Lees AJ |date=May 2008 |title=Clinical outcomes of progressive supranuclear palsy and multiple system atrophy |journal=Brain |volume=131 |issue=Pt 5 |pages=1362–72 |doi=10.1093/brain/awn065 |pmid=18385183 |doi-access=free}}</ref>

==Prognosis==
No effective treatment or cure has been found for PSP, although some of the [[symptom]]s can respond to nonspecific measures. The poor prognosis is predominantly attributed to the serious impact this condition has on the quality of life.<ref name=":2"/> The average age at symptoms onset is 63 and survival from onset averages seven years with a wide variance.<ref>{{Cite web|url=https://www.independent.ie/life/health-wellbeing/health-features/i-dont-want-to-believe-i-have-an-incurable-brain-disease-but-i-know-i-have-former-rte-presenter-kieron-wood-38614857.html|title='I don't want to believe I have an incurable brain disease, but I know I have' - former RTE presenter Kieron Wood|date=21 October 2019 }}</ref> [[Pneumonia]] is a frequent cause of death, often caused by accidental aspiration of food particles.<ref>{{cite journal | vauthors = Tomita S, Oeda T, Umemura A, Kohsaka M, Park K, Yamamoto K, Sugiyama H, Mori C, Inoue K, Fujimura H, Sawada H | title = Impact of Aspiration Pneumonia on the Clinical Course of Progressive Supranuclear Palsy: A Retrospective Cohort Study | journal = PLOS ONE | volume = 10 | issue = 8 | pages = e0135823 | date = August 13, 2015 | pmid = 26270456 | pmc = 4536232 | doi = 10.1371/journal.pone.0135823 | bibcode = 2015PLoSO..1035823T | doi-access = free }}</ref>

== History ==
In 1877, Charcot described a 40-year-old woman who had rigid-akinetic parkinsonism, neck dystonia, dysarthria, and eye-movement problems. In 1951, Chavany and others reported the clinical and pathologic features of a 50-year-old man with a rigid and akinetic form of parkinsonism with postural instability, neck dystonia, dysarthria, and staring gaze.<ref name=":13" /> In 1974, Albert and colleagues first described the unique frontal lobe cognitive changes of progressive supranuclear palsy—apathy, loss of spontaneity, slowing of thought processes, and loss of [[executive functions]].<ref name=":13" /><ref>{{Cite journal|vauthors=Albert ML, Willis A, Feldman RG|date=1974|title=The "subcortical dementias"of progressive supranuclear palsy|journal=Journal of Neurology, Neurosurgery, and Psychiatry|volume=37|issue=2|pages=121–130|doi=10.1136/jnnp.37.2.121|pmid=4819905|pmc=494589}}</ref>

Between 1877 and 1963, 22 well-documented case reports of PSP, although not described as a distinct disorder, had been identified in the literature of neurology.<ref>{{cite journal | vauthors = Brusa A, Stoehr R, Pramstaller PP | title = Progressive supranuclear palsy: new disease or variant of postencephalitic parkinsonism? | journal = Movement Disorders | volume = 19 | issue = 3 | pages = 247–52 | date = March 2004 | pmid = 15022178 | doi = 10.1002/mds.10699 | s2cid = 41907329 | doi-access = free }}</ref> Progressive supranuclear palsy was first described as a distinct disorder by neurologists John Steele, John Richardson, and Jerzy Olszewski in 1963.<ref name="Golbe2014">{{cite journal | vauthors = Golbe LI | title = Progressive supranuclear palsy | journal = Seminars in Neurology | volume = 34 | issue = 2 | pages = 151–9 | date = April 2014 | pmid = 24963674 | doi = 10.1055/s-0034-1381736 | doi-access = free }}</ref><ref name=richardson>{{cite journal | vauthors = Richardson JC, Steele J, Olszewski J | journal = Transactions of the American Neurological Association | volume = 88 | pages = 25–9 | year = 1963 | pmid = 14272249 | title = Supranuclear Ophthalmoplegia, Pseudobulbar Palsy, Nuchal Dystonia and Dementia. A Clinical Report on Eight Cases of 'heterogenous System Degeneration' }}</ref><ref>{{cite journal | vauthors = Steele JC, Richardson JC, Olszewski J | journal = Archives of Neurology | volume = 10 | issue = 4 | pages = 333–59 | date = April 1964 | pmid = 14107684 | doi = 10.1001/archneur.1964.00460160003001 | title = Progressive Supranuclear Palsy }}</ref><ref>{{Cite journal|url=https://www.medlink.com/article/progressive_supranuclear_palsy_cognitive_and_behavioral_changes|title=Progressive supranuclear palsy: cognitive and behavioral changes|vauthors=Hershey L, Lichter D|journal=MedLink Neurology|date=10 June 2016|pages=1–37}}</ref> They recognized the same clinical syndrome in eight patients, and described the autopsy findings in six of them.<ref name=richardson/>

==Society and culture==
There are several organizations around the world that support PSP patients and the research into PSP and related diseases, such as [[corticobasal degeneration]] (CBD) and [[multiple system atrophy]] (MSA).
* Canada: PSP Society of Canada, a federally registered non-profit organization which serves patients and families dealing with PSP, CBD and MSA, set up in 2017 through the help of CurePSP in the USA<ref>[http://www.pspsocietycanada.ca/ PSP Society of Canada], re-linked 2020-01-20</ref>
* France: Association PSP France, a nonprofit patient association set up in 1996 through the help of PSPA in the UK. It also gives support to French speaking patients in Quebec, Morocco, Algeria, Belgium and Lebanon<ref>[http://www.pspfrance.org/m-243-notre-histoire.html PSP France - Notre histoire], re-linked 2020-01-20</ref>
* UK: PSPA, a national charity for information, patient support and research of PSP and CBD, set up in 1995<ref>[https://pspassociation.org.uk/ PSPA], re-linked 2020-01-20</ref>
* Ireland: PSPAI, an organization which aims to increase public awareness of PSP<ref>{{Cite web|url=https://pspaireland.ie/what-is-psp/|title = What is PSP|date = 18 October 2013}}</ref>
* US: CurePSP, a nonprofit organization for promoting awareness, care and research of PSP, CBD, MSA "and other prime of life neurodegenerative diseases"<ref>[https://www.psp.org/  CurePSP], re-linked 2020-01-20</ref>

===In popular culture===
In the 2020 American [[musical film|musical]] [[comedy-drama]] television series, ''[[Zoey's Extraordinary Playlist]]'', the title character's father (Mitch Clarke, played by [[Peter Gallagher]]) has PSP.<ref>{{Cite web|title='Zoey's Extraordinary Playlist' Boss on That Devastating Finale and Season 2 Plans|url=https://www.hollywoodreporter.com/live-feed/zoeys-extraordinary-playlist-finale-explained-austin-winsberg-interview-1292766|last=Bentley|first=Jean|date=May 3, 2020|website=The Hollywood Reporter|language=en|access-date=2020-05-04}}</ref>

===Notable cases===
* [[Dudley Moore]] (1935–2002) : English actor, comedian, musician and composer
* [[Peter Sarstedt]] (1941-2017) : English singer and songwriter
* [[Linda Ronstadt]] (b. 1946) : American singer<ref>{{Cite magazine|title=Linda Ronstadt Has Found Another Voice|url=https://www.newyorker.com/culture/the-new-yorker-interview/linda-ronstadt-has-found-another-voice|last=Schulman|first=Michael|date=September 1, 2019|magazine=The New Yorker|language=en}}</ref>
* [[Jennifer Wexton]] (b. 1968) : [[United States House of Representatives|US Representative]]<ref>{{cite news |last1=Portnoy |first1=Jenna |title=Rep. Jennifer Wexton will not seek reelection as diagnosis changes |url=https://www.washingtonpost.com/dc-md-va/2023/09/18/jennifer-wexton-parkinsons-diagnosis-progressive-supranuclear-palsy/ |newspaper=Washington Post |date=18 September 2023}}</ref>
* [[Phyllis Frelich]] (1944–2014) : Tony Award-winning actor
* [[Lee Wei Ling]] (1955–2024) : Singaporean neurologist<ref>{{Cite news |last1=Tham |first1=Yuen-C |last2=Mujibah |first2=Fatimah |date=2024-10-09 |title=Lee Wei Ling, Lee Kuan Yew's daughter, dies at 69 |url=https://www.straitstimes.com/singapore/lee-kuan-yew-s-daughter-lee-wei-ling-dies-at-the-age-of-69 |access-date=2024-10-09 |work=The Straits Times |language=en |issn=0585-3923}}</ref>
* [[Richard Rainwater]] (1944-2015) : American investor and philanthropist
* [[Jeff Golub]] (1955-2015) : American Rock and Jazz guitar musician

==See also==
* [[Lytico-bodig disease]] (Parkinsonism-Dementia Complex of Guam)
* [[Annonacin]]

== References ==
{{Reflist}}

{{Medical resources
| DiseasesDB      = 10723
| ICD10           = {{ICD10|G|23|1|g|20}}
| ICD9            = {{ICD9|333.0}}
| OMIM            = 601104
| MedlinePlus     = 000767
| GeneReviewsName =
| ICDO            =
| eMedicineSubj   = neuro
| eMedicineTopic  = 328
| MeshID          = D013494
| Orphanet        = 683
}}
{{Diseases of the nervous system}}

{{DEFAULTSORT:Progressive Supranuclear Palsy}}
[[Category:Cognitive disorders]]
[[Category:Corticobasal syndrome]]
[[Category:Extrapyramidal and movement disorders]]
[[Category:Rare diseases]]
[[Category:Syndromes]]