'Hummingbird sign', 'penguin sign' and 'Mickey mouse sign' in progressive supranuclear palsy.

Fig 1: Midsagittal section through brainstem showing prominent midbrain atrophy without pontine atrophy resembling a hummingbird (arrow showing the beak) and a penguin Fig 2: Axial MRI showing selective atrophy of the midbrain tegmentum, with relative preservation of the tectum and cerebral peduncles resembling Mickeymouse (Arrow) A fifty year old male was brought by his wife with insidious onset forgetfulness, slurring of speech, slowness of movements and frequent falls. There was no history of vomiting, seizures, limb weakness, diplopia, dysarthria, dysphagia, nasal regurgitation or facial asymmetry. Examination findings were remarkable for borderline impairment of memory (MMSE score= 27 / 30), slurred speech, conjugate vertical gaze palsy, slowness of horizontal saccades and bradykinesia. Glabellar tap was positive. His blink rate was 6-8/min. Cogwheel rigidity, tremors or autonomic features were not present in this patient.MRI Brain revealed flattening of superior profile of midbrain due to midbrain tegmental atrophy with widening of interpedencular cistern giving the impression of a hummingbird and Mickey mouse appearance of the brainstem (Figures 1 and 2).Based on the clinical and radiographic features , he was diagnosed as a case of Progressive Supranuclear Palsy ( Steele-Richardson-Olszewski syndrome). Progressive supranuclear palsy (PSP) is a form of Parkinsonism which is a neurodegenerative disorder. Along with diseases like multisystem atrophy, corticobasal degeneration, dementia with Lewy bodies and frontotemporal dementia, it constitutes the Parkinsonplus syndromes. The ensuing Table 1 compares this disorder with idiopathic Parkinson disease