1) A 50-year-old female patient presented with postural instability, frequent falling, and vertical gaze palsy with a preserved oculocephalic reflex. Clinical examination revealed mild parkinsonian features. 2) MRI images showed selective atrophy of the midbrain tegmentum, producing the "Mickey Mouse" sign, which is highly specific for progressive supranuclear palsy (PSP). 3) The case report discusses the characteristic MRI findings of PSP and provides references and links for additional information.

1. Short case publication... Version 4.3 | Edited by professor Yasser Metwally | November 2010
Short case
Edited by
Professor Yasser Metwally
Professor of neurology
Ain Shams university school of medicine
Cairo, Egypt
Visit my web site at:
http://yassermetwally.com
A 50 years old female patient presented clinically with postural instability with frequent falling, and Vertical gave palsy with
preserved oculocephalic reflex. Clinical examination revealed mild parkinsonian features.
DIAGNOSIS:PROGRESSIVE SUPRANUCLEAR PALSy (PSP)

2. Figure 2. MRI FLAIR images. On axial views, the selective atrophy of the midbrain tegmentum with relative
preservation of the tectum and cerebral peduncles produces the “Mickey mouse” sign. Sometimes, the concavity
of the lateral margin of the midbrain tegmentum is referred to as the “morning glory” sign and has high
specificity but rather low sensitivity for PSP. Notice the periaqueductal signal changes representing astrogliosis.
Also notice the dilatation of the aqueduct of Sylvius. Also notice evidence of central and cortical atrophy.
Figure 1. Precontrast MRI T1 images. The characteristic MR imaging feature is selective atrophy of the midbrain
in association with preservation of the pons. The resulting atrophy of the midbrain tegmentum gives a distinctive
concavity with the appearance of the beak of a hummingbird or king penguin, and is termed the “hummingbird”
or “penguin” sign. Notice dilatation of the aqueduct of Sylvius and the superior cerebellar peduncle.

3. Figure 3. On axial views, the selective atrophy of the midbrain tegmentum with relative preservation of the
tectum and cerebral peduncles produces the “Mickey mouse” sign (see Fig. 1B). Sometimes, the concavity of
the lateral margin of the midbrain tegmentum is referred to as the “morning glory” sign and has high
specificity but rather low sensitivity for PSP. Notice the periaqueductal signal changes representing
astrogliosis. Also notice the dilatation of the aqueduct of Sylvius. Also notice evidence of central and cortical
atrophy.
References
1. Metwally, MYM: Textbook of neurimaging, A CD-ROM publication, (Metwally, MYM editor) WEB-CD agency for
electronic publishing, version 11.4a October 2010
Figure 4. MRI T2 images
showing Vircho Robin spaces
scsttered in the region of the
midbrain. (Type III VR
spaces)

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