Movement disorders

Question 1

movement disorder

Answer 1

disorder of BG. often called extrapyramidal disorder bc don’t affect pyramidal system aka corticospinal tract

Question 2

BG

Answer 2

structures involved in motor ctrl and planning + emotion, cognition, eye mvt. putamen, globes plaids, caudate nucleus, sub thalamic nucleus, substantial nigra. doesn’t directly proj to periphery, instead has reciprocal cxn to cortex via thalamus.
main site of dopamine production of 3/4 dopamine pathways in brain (nigrostriatal, mesolimbic, mesocortical)

Question 3

striatum

Answer 3

caudate + putamen

Question 4

lenticular nuc

Answer 4

putamen + globus pallidus

Question 5

hypokinetic disorder

Answer 5

decr o or slowed mvt

Question 6

hyperkinetic disorder

Answer 6

abn, extra mvt.

Question 7

tremor

Answer 7

most common mvt disorder. rhythmic mvt due to alternating contractions btw agonist and antagonist M

Question 8

chorea and athetosis

Answer 8

chorea- irreg, asym, random, continuous. athetosis- snake like slow twisting - more in distal M.

Question 9

ballism

Answer 9

violent, involuntary flailing of extremities - extreme form of chorea

Question 10

tics

Answer 10

random, repetitive, rapid, purposeless mvt at random interval. involve motor or vocal (grunting, sniffing). semi voluntary bc can be temporality suppressed with great effort unlike other mvt D.

Question 11

myoclonus

Answer 11

rapi, brief, unctrl jerks

Question 12

dystonia

Answer 12

sustaiend, abn posture caused by simultaneous activation of both agonist and antagonist M

Question 13

akathisia

Answer 13

subjective sense of inner restlessness in which pt feels compelled to move continuously

Question 14

festinating gait

Answer 14

slow start. then fast. then prob stopping.

Question 15

idiopathic parkinson’s gait

Answer 15

small steps and doesn’t lift feet. festinating gait

Question 16

parkinson’s dx criteria

Answer 16

TRAP
tremor (unilateral at onset, wose at rest, disappear with mvt)
rigidity (cogwheel rigidity)
akinesia/bradykinesia,
postural instbaility (lose postural reflexes)
shuffling gait with decr arm sling. festinating gait or freezing epic. but can ride bike.
other sx: depression, apathy, masked facial expression, anosmia, dysphagia/ dysarthria, urinary dusfunc/ constipation, autonomic dysfunc, sleep disruotion, REM sleep. micrographic (small handwriting) is often 1st syndrome

Question 17

resting tremor

Answer 17

vanishes in sleep

Question 18

parkinson’s path

Answer 18

idiopathic destruction of dopamine making neurons in substantial nigra of midbrain. sx start with >80% drop making neurons are destroyed

Question 19

lewy body

Answer 19

intracytoplasmic inclusion composed of alpha synuclein. pathological hallmark of PD.

Question 20

PD dx

Answer 20

mostly clinical. ioflupane iodine-123 injection or DaTscan- contract agent use with SPECT for detecting dopamine transporters DaT in suspected parkinsonian syndromes

Question 21

progressive supranuclear palsy

Answer 21

reptilian state. tauopathy,no tx. look up. midbrain atrophy. MRI-penguin sign

Question 22

Parkinson’s disease DD

Answer 22

1) medication induced parkinsonism- high potency typical antipsychotics and antiemetics
2) parkinson -plus syndrome
3) essential tremor
4) progressive supranuclear palsy

Question 23

parkinson plus syndrome

Answer 23

div into multi system atrophy, cerebellar type and multi system atrophy parkinsonian type.
clues: lack of response to parkinson meds, wide based gait, eye mv abn, symmetrical onset of sx, rapid onset of disability- w/in 5y of sx onset, early onset dementia, early onset falling, prominent autonomic dysfunction

Question 24

essential tremor

Answer 24

action tremble, often bilateral, w/ head tremor or voice tremor, often familiar, improve with alf, lack of bradykinesia rigidity, gait ab. more common
alcohol alleviates it. tx with propranolol/ inderal. primidone, non selective beta blocker.

Question 25

progressive supranuclear palsy

Answer 25

parkinsonian sx marked by vertical gaze palsies, with downward gaze. spectacular falls, alter mood/ behavior, depression, apthy, progressive dementia.

Question 26

dopamine agonist therapy SE

Answer 26

impulse control disorders like pathological gambling or hyper sexuality

Question 27

sinemet

Answer 27

combo of carbidopa/levadopa. carbidopa prevent conversion of levodopa to dopamine by dopa decarboxylase - preventing emesis “sin emesis). carbodipa doesn’t cross BBB, so levodopa can be converted to dopa in CNS.
SE: paranoia and hallucination.
if SE, lower dose. if low dose doesn’t tx sx then raise dose + add antipsychotic- quetiapine/seroquel or chlozaril
if get hypotension, add fludrocortisone

Question 28

deep brain stimulation in PD targets_

Answer 28

subthalamic nucleus. bc lesions there cause hemiballism- wild, flinging mvt of CL extremities. this tx is for ppl with on-off response to med. dyskinesia and tremors are responsive this this therapy

Question 29

PD tx

Answer 29

1) dopamine agonist: requip/ropinirole and mirapex/pramipexole. CI in elderly due to psychiatric sc. as progress tx with carbadopa-levadopa- most effective but cause dev of dyskinesia
honey moon period- initial tx element sx for many years
snippet can be combined with COMT inhibitors to prolong.
MAO inhibitor

Question 30

multiple system atrophy MSA

Answer 30

show hot cross buns sign. orthostatic hypotension

Question 31

huntington’s disease

Answer 31

dementia, psychosis, choreiform mvt -irregular, rapid, uncontrolled, involuntary. mvt flow randomly from one part of body to another.
caudate nucleaus atrophy –> enlarged ventricles
auto DOm CAG repeat.
show anticipation- early generation affected earlier than previous
give haloperidol to improve chorea

Question 32

chorea gravidarum

Answer 32

why always get pregnancy test.

Question 33

sydenham’s chorea

Answer 33

result from childhood infection with group A beta -hemolytic streptococci and occur in pt with rheumatic fever

Question 34

wilson’s disease

Answer 34

auto R –> cu accumulate in liver, brain, eyes. primary liver disease in late childhood-early adolescent as acute hepatitis/ cirrhosis.
classic presentation- wing flapping tremor. hepatolenticular degeneration. midbrain- face of the giant panda sign. present with irritability, personality change, enlarge liver, coarse tremor in arms. mvt are slow and dysarthria. kayser fletcher ring around cornea bc deposit copper in descent’s membrane.
labs- low serum cerloplasmin, incr urinary coper, incr LFT

Question 35

wilson’s disease tx

Answer 35

1) lo cu diet
2) zinc salts block cu absorption
3) penicillamine and trientine incr excretion of cu in urine
4) in severe disease liver transplantation is indicated
give lactulose

Question 36

botox as tx

Answer 36

for spastic torticollis- painful spasm of neck M that force head to rotate and tilt, imaging normal. blepherospasm- forceful eyelid closure

Question 37

restless leg syndrome

Answer 37

1) starts during inactivity
2) relief with mvt
3) worsening in evening
1st line tx- dopamine agonist- roperinole.
precede more serious illness like PD. can be SE of SSRI. should test for Fe def.

Question 38

reglan/metoclopramide

Answer 38

tx acid reflux. SE: sudden twisting of neck, protruded tongue, N, migraine.
tx SE with diphenhydramine

Question 39

haloperidol SE

Answer 39

akathisia. tx with propranolol/inderal.

if dev fever and rigidity use dopamine agonist like dromocriptine. or dantrolene- Ca ch blocker

Question 40

copropraxia

Answer 40

the finger. n touter’s D.

Question 41

tourette’s disorder tx

Answer 41

alpha adrenergic agnoist has best risk/benefit ratio.

most commonly used med- guanfacine/ tenet or clonidine. also use anti psych.

Question 42

tourrette’s disoder dx criteria

Answer 42

1) both multiple motor and at least 1 vocal tic
2) tics occur many times a day, nearly daily or intermittently throughout a period of >1y. never more than 3mo tic free
3) onset bf 18 and not due to other cause
4) PANDAS is neuropsychiatric D manifest by ticks and OCD