Progressive supranuclear palsy (PSP) is a neurodegenerative disease described by vertical supranuclear gaze paralysis, axial
rigidity and postural instability involving falls in the early stage of the disease. Imaging studies present brain atrophy in especially
midbrain, premotor cortex, basal ganglia and thalamus. There is no bioindicator of the disease although it is clinically identified. PSP
is also classified as tauopathy. However, no specific indicator for tau protein could be identified. Hence, imaging findings, especially
midbrain atrophy, functions as a biomarker in clinical practice and determination of disease prognosis. It has been shown that
midbrain atrophy has a diagnostic value for PSP accompanied with the finding of “hummingbird” or “penguin” encountered by
magnetic resonance imaging (MRI).
In this case report, we have aimed to review the diagnostic features of the disease based on the results of clinical and radiological
results and to demonstrate the “penguin” sign and midbrain atrophy as a biomarker for clinical follow-up process. We have also
detected a correlation with the results of clinical and neuropsychological tests.
We have analyzed a 61-year-old male patient who was a retired teacher for the complaints of progressive difficulty in walking
since the recent year, slowness in speech fluency, forgetfulness and easy falling. Our patient was performed 1.5 Tesla Cranial MRI
study due to the signs of postural instability, easy falling backward while walking, cognitive impairment, apathia, conjugate vertical
gaze palsy, disinhibition and anxiety. T1W, T2W, T2 flair and diffusion sections on the axial plane were obtained in this imaging
study. In addition, Mini-Mental State Examination and neuropsychological test were also performed in our patient.
The patient had particularly diffuse cerebral atrophy in predominantly frontal and parietal lobes. Peripheral CSF spaces were
enlarged due to atrophy. Brainstem also showed atrophy and particularly mesencephalon atrophy was more remarkable. The
appearance of brainstem in the sagittal slices due to mesencephalon atrophy were termed as “penguin” sign. A mild atrophy was
also encountered in the bilateral cerebellar hemispheres. As a result of neuropsychological evaluation, mild to moderate cognitive
impairment were detected.
We have evaluated with this case that atrophy of midbrain and mesencephalon which presented a significant visuality with
classic “penguin” sign has an important diagnostic value in the PSP cases. Additionally, we have reviewed the fact in the light of
literature data that imaging of midbrain atrophy may play a role as a biomarker in performing clinical follow-up and determination
of the prognostic features of the PSP cases.