Subsequent mutation analyses of genes encoding for iron-transport and iron-regulatory proteins known to be associated with Parkinsonism led to the discovery of specific mutations in the ferritin-H, the iron-regulatory protein 2, and the hemochromatosis gene, respectively, in single PD patients with SN hyperechogenicity [64], [65] and [66]. The most striking association was found in the this website ceruloplasmin gene: of five exonic missense mutations,

the I63T mutation was only found in one PD patient, the D544E and R793H mutations in far more PD patients than in ethnically matched controls [67]. The ceruloplasmin gene mutations were clearly associated to the TCS finding of SN hyperechogenicity Epacadostat datasheet in PD patients and healthy control subjects [67]. The question of whether the TCS finding of SN hyperechogenicity, present in 90% of PD patients but also in 9% of healthy adults, really indicates an increased risk of later developing PD is currently being studied in

large longitudinal studies. First clues were reported by Becker et al. [47] who observed that one of the healthy subjects in whom marked SN hyperechogenicity was detected in an early TCS study, two years later developed PD [22]. Meanwhile, there is growing evidence supporting the idea that SN hyperechogenicity indeed is an indicator for an increased risk of PD. FDOPA-PET studies in young healthy adults as well as in young asymptomatic parkin mutation carriers Casein kinase 1 revealed that SN hyperechogenicity is associated with a subclinical malfunction of the nigrostriatal dopaminergic system [22] and [68]. In psychiatric patients the degree of SN hyperechogenicity was clearly correlated with the severity of Parkinsonian symptoms induced by neuroleptic therapy [69]. SN hyperechogenicity was related to subtle motor asymmetry in non-depressive and, even more frequently, in depressive subjects

[70] and [71]. TCS studies in populations known to have an increased risk of PD showed 2- to 4-fold increased frequencies of SN hyperechogenicity in first-degree relatives of PD patients [63], in individuals with idiopathic hyposmia [72], in patients with unipolar depressive disorders [73], individuals with essential tremor [24], and individuals with idiopathic REM sleep behavior disorder [74] and [75]. In these groups, the subjects with SN hyperechogenicity were more liable to show subtle Parkinsonian motor signs and reduced striatal radiotracer uptake on FP-CIT SPECT or F-DOPA PET studies than subjects with normal SN echogenicity [63], [71], [72], [73], [74] and [75]. Recently, the first follow-up data came out of an ongoing longitudinal study since 2004, conducted at the Universities of Tübingen (Germany), Innsbruck (Austria) and Homburg (Germany) [76] and [77].