Swallow Tail Sign: Revisited

The loss of the radiologic swallow tail sign on MRI scans of the substantia nigra is a promising diagnostic marker of Parkinson disease (1), although its anatom-ic underpinning is unclear. An early influential study showed that the hyperintense inner part of the swallow tail sign on T2*-weighted images (STh) corresponds to iron-poor areas in substantia nigra and suggested it to equal nigrosome 1, the dopaminergic region affected earliest and strongest in Parkinson disease (2). This would render the STh a cellularly specific marker (2). However, recent postmortem tissue studies have chal-lenged this interpretation, reporting that nigrosome 1 is hypointense in T2*-weighted images (3,4). We com-bined three-dimensional histology with 7-T in vivo and postmortem MRI to demonstrate that nigrosome 1 and the radiologic STh are partially overlapping but distinct.