DSA 32 Movement Disorders Flashcards
what is most common movement disorder?
postural tremor
identify: increased by stress, fatigue, or caffeine. also called action tremor
postural tremor
identify: disappears with complete relaxation
postural tremor
how do you test for postural tremor?
ask the patient to draw a spiral without allowing the hand or arm to touch the paper
patient presents with tremor at rest and with movement. neuro exam is otherwise normal. what is the likely type of tremor?
postural tremor
etiology: over-activity of the beta-sympathetic nervous system
postural tremor
treatment for postural tremor?
usually the treatment can be worse than the symptom but if they want a drug usually benzodiazepines (alprazolam), beta-blockers, primidone (barbiturate) or botox, Gabapentin
when do patients notice a resting tremor?
usually NOT the first symptom; preceded by bradykinesia, and stiffness of movement
how does a resting tremor begin?
unilaterally
why can you not just assume resting tremor has to do with parkinsons?
may be other medication causing these symptoms such as haloperidol or metoclopramide, compazine because these drugs are dopamine receptor antagonists
What if the patient has a resting tremor and their neuro exam is normal?
essential tremor with an atypical appearance
what if the patient has a resting tremor and an abnormal neuro exam?
think Parkinson’s although in rare cases it can present with a normal neuro exam
masked facies
bradykinesia which precedes the tremor in parkinson’s
triad of Parkinson’s
resting tremor, bradykinesia, and cogwheel rigidity
what is an advanced symptom of Parkinson’s
memory loss
What does brain imaging look like for parkinson’s
normal; done to rule out other causes
etiology of parkinson’s
neurodegeneration causes loss of the pigmented neurons of the zona compacta of the substantia nigra in the midbrain
slow, zig zag motion when pointing/extending toward a target
intention tremor
what does a intention tremor indicate?
cerebellar dysfunction
What is important to ask when someone comes in with an intention tremor?
family history
How does an intention tremor differentiate from a postural tremor?
intention tremor is like postural tremor in that a tremor occurs with attempt at movement however intention tremor worsens as the target is reached (increases in amplitude and frequency)
also there will be an abnormal neuro exam on someone with a intention tremor while a postural tremor will have a normal neuro exam
What test is abnormal in a patient with intention tremor?
physical exam will reveal abnoramlities of coordination
What will you see on imaging for someone with a intention tremor?
cerebellar lesion or cerebellar atrophy
What other disease is associated with intention tremor?
spinocerebellar ataxia whichiis a genetic abnormality
what is the onset for cerebellar ataxia?
adult or childhood
what are possible causes of acute cerebellar ataxia?
trauma or stroke
what are possible causes of subacute cerebellar ataxia?
intoxication or abscess
what are possible causes of chronic cerebellar ataxia?
hereditary, degenerative, or neoplasm
Cerebellar ataxia: dominant hereditary
will show in family history
cerebellar ataxia: recessive hereditary
may not show in family history
What degenerative disease can cause cerebellar ataxia?
MS
frequent spinal cord sensation and motor dysfunction + cerebellar dysfunction
spinocerebellar ataxia
etiology of spinocerebellar ataxia
usually hereditary
What is imaging like for spinocerebellar ataxia?
normal
What is a spinocerebellar ataxia that is inherited?
Friedreich ataxia
What are the symptoms of someone with Friedreich ataxia?
staggering gait, frequent falling, diabetes, hypertrophic cardiomyopathy
What is the mutation in Friedreich ataxia?
frataxin (iron binding protein)
sensory ataxia: onset
subacute or chronic
how do you separate sensory ataxia from spinocerebellar or cerebellar ataxia?
NO complaint of dysarthria or nystagmus
How is sensory ataxia distinguished from cerebellar ataxia?
coordination with eyes shut vs. open
disease that causes sensory ataxia?
Tabes Dorsalis
What affects the DTRs?
sensory ataxia; usually absent
What previous or current health conditions may cause sensory ataxia?
toxic-metabolic diseases such as DM, hypothyroidism, B12, HIV
Huntington’s age of onset
40s to 50s
gradual onset of fidgetiness giving way to jerky movements; personality changes leading to dementia
huntington’s
Imaging for Huntington’s
atrophy of the caudate nuclei with enlargement of the anterior horns of the lateral ventricles
genetics of Huntington’s
CAG trinucleotide repeat of >38 on chromosome 4
chorea
sudden jerky purposeless movements
what lesion does chorea indicate?
basal ganglia
progressive supranuclear palsy: age of onset
6th decade or older
progressive supranuclear palsy: onset of symptoms
gradual
symptoms of progressive supranuclear palsy
increased axial muscle tone unstable gait and falls dysarthric sppech dysphagia impaired eye movement (downward eye movements first affected)
eventually ALL eye movmeents will be affected
dystonia
sustained, involuntary muscle contraction; writer’s cram; or sustained eyelid twitch (blepharospasm)
usual etiology of dystonia/dyskinesia?
due to anti-dopaminergic antipsychotics or antiemetics drugs
dyskinesias
focal asyncrhonous msucle movements which may occur in any muscle group but are particularly common in the oral/facial/lingual and limb muscles
generalized dystonia
Dystonia musculorum deformans
What if dystonia/dyskinesia is not caused by drugs?
idiopathic
how do you differentiate between a pathologic tremor and a physiologic one?
pathologic tremors will disappear during sleep but physiologic tremors will remain
What is the first line drugs for tourette Syndrome?
alpha adrenergic agonists: clonidine and guanfacine Tenex (less sedating an done daily dosing)
What is second line therapy for TS?
atypical antipsychotic olanzapine or risperidone
What are the third line agents for TS?
haloperidol, pimozide, fluphenazine–block D2 receptors
identify: this tremor may occur with posture holding, but worsens as the patient gets closer to the target.
intention tremor
what is the anatomical diagnosis of essential tremor?
believed to be sympathetic NS mediated
what is the etiology of essential tremor?
idiopathic
what is the most effective treatment for essential tremor?
beta blockers, benzodiazepines, and barbiturates–these drugs have to be central acting
how do we distinguish Parkinson’s disease from drug induced Parkinson’s?
stop the antipsychotic drug and see what happens–the patient’s psychosis might get worse
where is the lesion likely to be in drug-induced Parkinson’s?
basal ganglia
where is the lesion in progressive supranuclear palsy?
in the midbrain
what is the anatomic pathophysiology of Parkinson’s disease?
substantia nigra and multiple other areas of the CNS are affected
what is an intention tremor a sign of?
cerebellar dysfunction
what would brain CT scan of patient with normal pressure hydrocephalus show?
enlarged ventricles. no cortical atrophy (normal cortical markings)
identify: asynchronous, focal abnormal movements.
tics
how long does transient tic disorder last?
a year at most
what is the difference between acute dyskinesia and tardive dyskinesia?
acute dyskinesia disappears when the patient stops taking antipsychotics. tardive dyskinesia is often irreversible even when you stop the medication.
what is the most effective treatment for cervical dystonia?
botulinum toxin injection into the muscles
patient presents with tremor at rest and with movement. exam shows rigidity and slowness of movement. what is the likely type of tremor?
Parkinsonian tremor
patient presents with tremor at rest and with movement. exam reveals ataxia. what is the likely type of tremor?
intention tremor
contrast rigidity in Parkinson’s disease to rigidity in progressive supranuclear palsy.
PSP rigidity is usually in extension while PD rigidity is usually in flexion
what is the clinical presentation of progressive supranuclear palsy?
gait disturbance and falls, rigidity, dysarthria and dysphagia, difficulty with eye movements (particularly downward vertical gaze)
what are the clinical features of cerebellar disease?
ataxia, intention tremor, dysarthria, ocular movement abnormalities, hypotonia
what is the clinical presentation of normal pressure hydrocephalus?
dementia, gait disturbances, urinary incontinence
what will be present on brain imaging of NPH?
ventricular enlargement and absence of atrophy
what are the treatment options for dystonias?
anticholinergics, benzodiazepine, botox
