Where are the three main origins of movement disorders?
Corticospinal ie pyramidal
Basal Ganglia ie extrapyramidal
Cerebellum
What kind of symptoms occur in a corticospinal tract lesion
Weakness
Spasticity
What kind of symptoms occur in a basal ganglia lession
Hyperkinetic e.g. dystonia, tics, myoclonus, chorea
Hypokinetic e.g Parkinson’s
What symptoms occur due to cerebellar lesions
DANISH Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech -dysarthria Hypotonia
What is dystonia
prolonged muscle spasms and abnormal postures
What is chorea
fragments of movements flow irregularly from one body segment to another causing a dance-like appearance
what is ballismus
high amplitude choreo form movements
What is the parkinsonian syndrome
rigidity
akinesia/bradykinesia
resting tremor
What is Parkinson’s disease?
Tremor, rigidity, akinesia, impairement of locomotion and posture +non motor symptoms
Eventual dementia
What is the neurohistological hallmark of Parkinson’s disease
Lewy bodies
Which area of the basal ganglia is affect in parkinson’s
Loss of dopaminergic cells in substancia nigra
What are the strongest risk factors for parkinson’s
old age family history - in about 15 percent of cases of parkinsons there is a positive family history pesticide exposure (possibly)
What may be protective of parkinsons
smoking
NSAIDs
high uric acid levels
What are the motor symptoms of Parkinson;s
bradykinesia
rest tremor
rigidity
postural and gait impairement
What is bradykinesia
slowness of movement with progressive loss of amplitude or speed during attempted rapid alternating movement of body segments
what is hypomimia
decreased facial expression and eyeblinking
what is hypophonia
reduced voice volume
what is micrographia
progressively smaller handwriting
What are the characteristics of a resting tremor
Rhythmic oscillatory involuntary movement of affected body part at rest
vanishes with active movement
can ‘reemerge’ when hands held outstretched
What kind of resting tremors are there
pill rolling
finger- flexion extension or abduction and adduction
tremor can effect lower limbs, jaw or tongue
when is a resting tremor best seen
when patient is focused on a mental task such as counting back from 100
What is rigidity
increased muscle tone felt on passive movement throughout the full range of movement
does not increase with higher speed of movement - as such distinguishing it from spasticity
What is froment’s maneuver
rigidity increases in examined body segment by voluntary movement of other body parts
what kind of posture and gait occurs in parkinsonism
stooped posture- impaired postural reflexes
slow gait, narrow base, shuffling, decreased arm swing, slow turning with multiple steps
freezing
festination
what is camptocormia
extreme anterior tuncal flexion
Name some non motor features of parkinson’s
dementia, hallucinations, hyposmia, REM, constipation, depression
What is myoclonus
a rapid involuntary twitching motion by a muscle group
What is the disadvantage of dopamine functional imaging
unable to distinguish Parkinson’s from other causes of degenerative parkinsonism - however it will be normal in essential tremor, dystonic tremor, psychogenic parkinsonism
What investigations can be done if parkinsons disease is suspected
Rule out other cause of asthenia - hypothyroid, anaemia
Structural brain imaging
PET with fluoro-dopa
Dopamine transporter (DAT) imaging with single photon emission CT
Positive levodopa challenge
genetic testing where appropriate
What are the ‘red flag’ parkinsons presentations
Absence of asymmetry of symptoms severe axial or lower limb involvement fast progression frequent falls eye movement disorder Tics, myoclonus or chorea Pyramidal or cerebella dysfunction Bulbar/pseudobulbar features Parietal associative sensory disturbances apraxia cognitive disfunction or psychosis autonomic dysfunction negative levodopa challenge
what are the common causes of parkinsonism
PD drug induced progressive supranuclear palsy Lewy body dementia Vascular parkinsonism
what are the less common causes of parkinsonism
infectious and post infectious toxins eg heroine, manganism metabolic/endocrine eg carbon monoxide head trauma Hallervorden Spatz syndrome
what drugs can cause parkinsonism
prochlorperaziine metoclopramide antipsychotics calcium channel blockers amioderone
What may indicated it is more of a vascular parkinsonism? (rather than PD)
Affects mainly lower limbs
rest tremor uncommon
Other signs of lesion eg spastivity, hemiparesis
poor levodopa response
what is the features of drug induced parkinsonism
symmetrical
postural tremor
Other drug induced disorders may be present eg tardive dystonia, akathisia, orolingual dyskinesia
What is essential tremor
Not really seen at rest
Symmetric, postural or kinetic tremor with high frequency
alcohol responsiveness
what is SWEDDs
Scans without evidence of dopaminergic deficit Asymmetrical At rest No true bradykinesia Characteristivs of dystonia
What is multi system atrophy?
Dysautonimia +cerebellar disease+Parkinsonism
What is hot cross bun sign
MRI shows cerebellar and pontine atrophy - multisystem atrophy
What is progressive supranuclear palsy
symmetric akinetic rigid syndrome with predominantly axial involvement
gait imbalance prominent, rarely tremor
what is fragile x-tremor ataxia syndrome
late onset neurodegenerative disorder in patients with an abnormal number of CGG repeats in the FMR1 gene
symtoms=ataxic gait, postural/intention tremor, variably parkinsonism, dysautonomia, cognitive decline of frontal type, peripheral neuropathy
slow disease progression
What is MCP sign
middle cerebellar peduncles - FXTAS
