Parkinson

Question 1

Def

Answer 1

neurodegenerative condition that involves the progressive depletion of dopaminergic neurons in the basal ganglia, particularly the substantia nigra

Question 2

Parkinsonism

Answer 2

syndrome that comprises bradykinesia along with resting tremor and/or rigidity

Question 3

secondary parkinsonism

Answer 3

Parkinsonism that results from medication, intoxication, or traumatic brain injury

Question 4

atypical parkinsonism

Answer 4

Or parkinson Plus syndromes
Parkinsonism due to neurodegenerative disorders other than PD is called atypical parkinsonism and manifests with features that are not characteristic of PD, such as
A) vertical gaze palsy in progressive supranuclear palsy and
B) apraxia and agnosia in corticobasal degeneration.
When doesn’t respond to tx, if dementia progresses rapidly or when early occurence of gait instability

Question 5

progressive supranuclear palsy

Question 6

Apraxia

Question 7

agnosia

Question 8

corticobasal degeneration

Question 9

Genetic factors

Answer 9

α-Synuclein (SNCA)
• Glucocerebrosidase (GBA) gaucher – m/c
• Dardarin (LRRK2): A mutation in LRRK2 gene is the most common cause of dominantly inherited PD.
• Parkin (PARK2): A mutation in PARK2 gene is the most common cause of recessively inherited PD.

Question 10

Secondary induced parkinsonism (drug-induced parkinsonism or pseudoparkinsonism)

Answer 10

• antidopaminergic effects: typical antipsychotics(e.g., haloperidol), some antiemetics (e.g., metoclopramide), some calcium channel blockers (e.g., flunarizine), amiodarone, valproate, and lithium [3][4]
• MPTP: an illegal drug that metabolizes to MPP+, damaging the substantia nigra
• Wilson disease, hemochromatosis, Niemann-Pick disease
• vascular parkinsonism: subcortical arteriosclerotic encephalopathy
• CNS infections (HSV, HIV, TB, Treponema, Toxoplasma, Plasmodium
Toxins: e.g., manganese, carbon monoxide, carbon disulfide

Question 11

Preclinical stage

Answer 11

Constipation
Anosmia
Sleep disturbances
-REM sleep behavior disorder (RBD)
-Restless leg syndrome
-Excessive daytime sleepiness
Mood disorders (most commonly depression, apathy, and/or anxiety)

Question 12

Tests

Answer 12

Pull test (instability)
Froment maneuver (repetitive movements eg. Opening-closing the fist - rigidity)

Question 13

Signs in PD (motor)

Answer 13

Bradykinesia: slowed movements in combination with decreased amplitude/speed when moving
Resting tremor (4–6 Hz)
Rigidity
Instability, falls
shuffling gait with quickened and shortened steps
-Freezing: sudden inability to start or continue movements
-Festination: gait pattern characterized by small, increasingly quick steps
-Propulsion: forward-leaning gait with a risk of a patient falling forward
-Decreased arm swing
Unhabituated glabellar reflex
Signs of dystonia
Stooped posture
Abnormal flexor posturing of hands and feet (i.e., striatal deformities)
Micrographia: size of handwriting is reduced
Hypomimia: low degree of facial expression

Question 14

Nonmotor signs

Answer 14

Autonomic symptoms

Orthostatic hypotension
Oily skin
Urinary urgency
Impaired sexual function

Neuropsychiatric symptoms
Depression
Cognitive problems, e.g., decreased attention and concentration, executive dysfunction, impaired memory (Parkinson dementia): develop in advanced disease [5]
Apathy
Behavioral changes (e.g., irritability, impulsivity)

Disordered sleep (sleep fragmentation, vivid dreams)
Fatigue
Hyposmia, anosmia

Question 15

Dx

Answer 15

Parkinson disease is a clinical diagnosis. A definitive diagnosis requires postmortem confirmation of Lewy bodies.

Supportive features include:
Clear benefit from dopaminergic medication
Resting tremor
Levodopa-induced dyskinesia (typically occurs during later stages of PD - tics, involuntary movements, twitching)
Olfactory loss

Question 16

Lewy bodies

Answer 16

Aggregates of misfolded α-synuclein and other proteins, such as ubiquitin and neurofilament protein within the neural cell bodies
May be found in brainstem, substantia nigra, and cortex

Question 17

Carbidopa

Answer 17

decarboxylase inhibitor

Question 18

Honeymoon period

Answer 18

beneficial effect in early phase of treatment with L-DOPA

Question 19

Nonergot dopamine receptor agonists

Answer 19

In younger Pt

Pramipexole

Ropinirole

Apomorphine

Question 20

MAO i

Answer 20

Selegiline
Rasagiline

Question 21

Anti ACh

Answer 21

Benztropine
Trihexyphenidyl

Question 22

COMT inhibitors

Answer 22

Entacapone

Question 23

Amantadine

Answer 23

NMDA antagonist

Question 24

Deep brain stimulation (DBS

Answer 24

Stereotactic implantation of stimulating electrode(s) targeting the subthalamic nucleus or internal globus pallidus

Question 25

DDX

Answer 25

Vascular parkinsonism Multiple system atrophy Progressive supranuclear palsy Corticobasal degeneration

Question 26

Vascular parkinsonism

Answer 26

>70yo Symmetric , Limited to lower limbs Starts with Gait impairment Spasticity, w/o tremor Multiple periventricular lesions Lacunar infarcts in the basal ganglia Cognitive impairment

Question 27

Multiple system atrophy

Answer 27

50y/o progressive degeneration of neurons in several parts of the brain including the basal ganglia, striatum, inferior olivary nucleus, and cerebellum. Symetric Starts with Autonomic dysfunction (e.g., postprandial hypotension, anhidrosis, erectile dysfunction in men) Rigidity>spacticity Instability Hypermetric saccades Vestibuloocular reflex suppression Early dysarthria and dysphonia parkinsonism (muscle rigidity +/ tremor and slow movement: MSA-P) cerebellar ataxia (Poor coordination/unsteady walking: MSA-C) MSA-P: predominantly parkinsonian features (previously referred to as striatonigral degeneration) MSA-C: predominantly cerebellar features (previously referred to as olivopontocerebellar atrophy) MRI: hot cross bun sign

Question 28

PSP

Answer 28

Starts with Postural instability with falls Axial rigidity Vertical supranuclear gaze palsy Decreased velocity of saccades Square wave jerks Reduced blinking Pseudobulbar palsy is common Apraxia of eyelid opening Procerus sign: deep vertical wrinkles at the base of the eyebrows Neuropsychiatric symptoms (depression, dementia, sleep disorders) Asymmetric cortical atrophy (parietal is most prominent) Hummingbird sign

Question 29

Corticobasal degeneration

Answer 29

50-70 yo Assymetric Upper limb clumsiness (apraxia) and bradykinesia Rigidity Alien limb phenomenon Ideomotor apraxia Aphasia Rest and/or induced myoclonus

Question 30

Parkinson-plus syndromes

Answer 30

Dementia with Lewy bodies Multiple system atrophy Progressive supranuclear palsy Corticobasal degeneration

Question 31

P+ features

Answer 31

Poor response to levodopa Dementia Early involvement of the autonomic nervous system, including: Orthostatic hypotension Impotence Incontinence Anhidrosis Early onset of postural instability with frequent falls Visual hallucinations Signs of cerebellar involvement Presence of pathological reflexes, such as: Babinski sign Enhanced proprioceptive reflexes Eating and swallowing disorders Pronounced dysarthria Supranuclear vertical gaze palsy Apraxia

Question 32

Dementia with Lewy bodies

Answer 32

Lewy body dementia if the onset of both cognitive and motor symptoms is within 1 year Dementia secondary to Parkinson disease if cognitive symptoms occur > 1 year after the onset of motor symptoms Cerebral atrophy, particularly of the frontal lobe Relative sparing of the hippocampi Lewy bodies in cortical Dementia + parkinsonism, visual hallucinations, cognitive impairment, falls, psychotic symptoms