Neurology

Parkinson’s disease

Parkinson’s disease
The classic quintet of PD
1. tremor (at rest)
2. rigidity
3. bradykinesia
4. postural instability
5. gait freezing
≥2 signs = Parkinson disease

Parkinson’s disease
Pill-rolling
Tremor of fingers and hand
Cogwheel rigidity
Moving arms passively toward body

Parkinson’s disease
Levodopa + Carbidopa
Add more dopamine to brain
Don’t take with: MAO-Binhibitors, vitamins B6, protein food
Ropinirole
Dopamine agonist
SE: drowsiness
Amantadine
Stimulate dopaminergic activity in CNS
Anticholinergic
Not for patient’s with Glaucoma
Don’t quit taking suddenly

Parkinson’s disease
MAO Inhibiter Type B
Increase dopamine by stopping MAO activity
Foods with Tyramine
COMT Inhibiter
Blocks COMT enzyme
Surgery
Deep brain Stimulation

Huntington’s disease

Huntington’s disease
Insidious onset and progression of chorea
Onset most often between 35 and 55 years
Mental changes—change in behavior, intellectual deterioration leading to dementia
Family history present in the majority
Motor symptoms: flicking movements of arms, lilting gait, facial grimacing, ataxia, dystonia
Usually a fatal outcome 15–20 years from onset
DxT chorea + abnormal behavior + dementia + family
Treatment
There is no cure or specific treatment
Supportive treatment with agents such as haloperidol

Dystonia
The cause of most cases is unknown but sometimes are linked to genetic causes
Disorder of basal ganglia
Dystonias are sustained or intermittent abnormal repetitive movements or postures resulting from alterations in muscle tone.
There are different types of dystonia
May be painful or uncomfortable

Dystonia
Clinical characteristics:
Age of the patient when they start experiencing dystonia
Part of the body
Focal – one part of the body
Segmental / generalized- multiply parts of the body
Temporal course
Cause of dystonia (Parkinson’s disease, medications)

Dystonia
Management
Medication
Dopamine agents: levodopa
Anticholinergics: trihexyphenidyl
Benzodiazepines: clonazepam
Muscle relaxants: baclofen
Injectable biologics
Botulinum toxin
Physical, occupational and speech therapy
Complementary therapies (acupuncture, massage)
Deep brain stimulation

Tremor
Resting tremor—Parkinsonian
The tremor of PD is present at rest.
How to test
focusing attention on the left hand with a view to ‘examining’ the right hand or by asking the patient to turn the head from side to side
Worse with rest
Eases with activity
“pill rolling tremor”

Tremor
Postural tremor
Worse with a posture
This fine tremor is noted by examining the patient with the arms outstretched and the fingers apart
Treatment: Salbutamol
Caused by hyperthyroid, encephalopathy
Intention tremor (cerebellar disease)
Worse with “intension”
(voluntary movement)
It is tested by ‘finger–nose–finger’ touching or running the heel down the opposite shin, and past pointing of the nose is a feature

Tremor
Flapping (metabolic tremor)
A flapping or ‘wing-beating’ tremor is observed when the arms are
Extended with hyperextension of the wrists.
Essential tremor
No underlying cause
Increasing age
Treatment: Beta-blockers is the first line
Triad of features
Positive family history
Tremor with little disability
Normal gait

Tourette syndrome
Tourette syndrome is a neurological disorder characterized by sudden, repetitive, rapid, and unwanted movements or vocal sounds called tics
Tic
Quick, nonrhythmic movements or vocalizations
Happen over and over
Not cause
Diagnostic criteria
2 distinct motor tics and 1 vocal tic
Present for at least 1 year
Before age 18

Tourette syndrome
Most severe
Before puberty (10-12)
During periods of anxiety, excitement, or exhaustion
Management
Therapy
Cognitive behavior therapy
Habit reversal training
Reduce anxiety & depression
Medication
Anty-psychotics
Epilepsy medication
ADHD medication
Botox injection

Spasticity
Diffuse and focal
Affect the brain and/or spinal cord
Cerebral palsy, traumatic brain injury, stroke, spinal cord injury and multiple sclerosis
Increase muscle tone, involuntary movements (spasm, involuntary muscle contraction, clonus), pain or discomfort, less ability to function, abnormal pasture, contracture, bone and joint deformities

Spasticity
Diagnosis: history, clinical, MRI
Treatment
Not require
To stretch daily
Centrally Acting Drugs
Baclofen
Alpha-2 Agonists
Anticonvulsants: Benzodiazepines, Gabapentin
Peripherally Acting Drugs
Dantrolene Sodium
Interventional Treatments
Intrathecal Baclofen
Botulinum Toxin Injection
Phenol/Alcohol Injection

Cerebellar syndrome
Incoordination
Walking
Limb
Speech
Eves

Wernickle encephalopathy and Korsacoff syndrome
Is a brain disorder due to thiamine deficiency (vitamin B1)
including inadequate thiamine intake reduced thiamine absorption and reduced storage due to liver damage
Usually caused be long-term alcohol dependency
Diagnosis: clinical, toxicology screen or liver function test
Treatment: a diet rich in thymine

Spino-cerebellar ataxia
Progressive neurodegenerative diseases of genetic origin
Present of any age
Progressive loss of coordination of hands, speech, walking, eye movements
Diagnosis: neuroimaging and genetic sequencing
Treatment mostly supportive