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Background: Progressive supranuclear palsy (PSP) is a primary four-repeat tauopathy characterized by marked clinical heterogeneity, resulting in substantial diagnostic challenges. Over the past three decades, understanding of PSP has evolved from a classical Richardson syndrome-centered concept to a broader clinicopathological spectrum encompassing multiple motor, cognitive, behavioral, speech-language, and cortical phenotypes. Methods: A narrative review of the literature was performed to examine the historical development of PSP diagnostic frameworks, including the Hauw neuropathologic criteria, NINDS-SPSP criteria, variant PSP (vPSP) framework, Movement Disorder Society PSP (MDS-PSP) criteria, and Maximum Allocation Extinction (MAX) rules. Relevant clinicopathological studies, consensus statements, validation studies, and biomarker investigations were reviewed. Results: The Hauw criteria established the first standardized neuropathological definition of PSP, whereas the NINDS-SPSP criteria provided a highly specific clinical diagnostic framework for classical PSP-Richardson syndrome. Subsequent recognition of PSP-parkinsonism, progressive gait freezing, frontal, speech-language, corticobasal, and cerebellar variants revealed the limitations of phenotype-restricted diagnostic models and led to the development of the vPSP framework. These observations informed the 2017 MDS-PSP criteria, which incorporated multiple phenotypes, four core functional domains, supportive features, and graded levels of diagnostic certainty. The MAX rules subsequently standardized phenotype allocation among patients fulfilling multiple diagnostic categories. Conclusions: Contemporary PSP diagnostic frameworks have substantially improved recognition of atypical and early-stage disease; however, diagnosis remains primarily clinical and lacks definitive ante-mortem pathological confirmation. Emerging MRI, fluid, and tau PET biomarkers may facilitate biomarker-supported and pathology-informed diagnostic paradigms, enabling earlier diagnosis, improved patient stratification, and more effective therapeutic trials.
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