Světlana
Skutilová
University
Hospital Brno
MOVEMENT DISORDERS
 Striatum ( ncl caudatus + putamen), palidum, ncl
subtalamicus L., substantia nigra, ncl ruber, ncl basalis
Meynerti, ncl accumbens
 A. HYPOKINETIC- HYPERTONIC SYNDROME
 (parkinsonism)
 limited voluntary movement
 B. HYPERKINETIC- HYPOTONIC SYNDROME
 abnormal involuntary movement
DYSFUNCTION OF BG
 The most frequently cause of parkinsonism (about 70%)
 Chronic slowly progressive neurodegenerative brain disease
 Patology: neurodegeneration pars compacta SN, dicreased
production of dopamin (less than 50%), deficit in striatum
(dopaminergic receptors, responsibility intact , presynaptic
disturbance)
 Neuropatologic finding: Lewy bodies in neuron cytoplasma
primary in SN (SYNUKLEIN) + locus coeruleus
 Etiology: ?
IDIOPATIC PARKINSON´S DISEASE
 Prevalence – 360 per 100 000

 Incidence - 18 per 100 000 per year
 Age of starting - 5. a 6. decenium : 10% early onset
 10% late onset
 1. DOMINANT MOTOR SYMPTOMS
 BRADYKINESIA
TREMOR (rest, slowly, asymetric) especially upper limb
 RIGIDITY (axial muscles, limb flexors )
 POSTURAL INSTABILITY, gait disturbance
 Hesitation ….. freezing
 Pulse ….. festination
CLINICAL FEATURES
 2. SIDE MOTOR SYMPTOMS
 Hypomimia
 Hypokinetic Dysarthria Hypofonia
 Micrografia
UPDRS Unifed Parkinson disease rating scale
 3. NON-MOTOR SYMPTOMS
 A) MENTAL Disturbance : ncl b. Meynerti
 depression, anxiety 50%
 Executive cognitive dysfunction
 Wild dreams..(pseudo)halucination..psychosis (side efect of
antiparkinsonian drugs ! )
 B) SENSORIC Disturbance:
 Olfactorial dysfunction
 C) AUTONOMIC SYMPTOMS : ncl dorsalis vagi
 Constipation
 Urinary urgency
 Sialorrhoea
 Hyperhidrosis
 Dysfagia
 Ortostatic hypotension
 Sleep disturbance, daily sleeping
 + motor fluctuation (on-off state)
 + dyskinesias (chorea, dystonia)
 + dementia PDD ( 40%)
LATE STADIUM
A. CLINIC NEUROLOGIC EXAM!
UPDRS Unifed Parkinson disease rating scale
 We do not need……………….
 Hemiparkinsonism
 Diagnostic-treatment test (DOPARESPONSIBILITY)
 (750mg -1g …. 2 months)
DIAGNOSTIC
B. NEUROIMAGING
1. Brain DAT SCAN
 2. Brain MRI
 3. (Transcranial duplex sono)
 Expensive
 Binding radionuklidu
 on presynaptic
 ending
 nigrostriatal
 neurons
DAT SCAN
 NO CURE
 NO STOP
 SYMPTOMATIC (substitution of dopamin) - significant
reduction of troubles
 NO Neuroprotectiv drug
Individual (age, another illnes, cognitive function..)
 Strategy … early contra late stadium
TREATMENT
OPTIMAL IN SPECIALIZED SURGERY
 DA - AGONIST L-DOPA
 dopamin prekursor
 penetration H-E barrier
DOPA-dekarboxylasa
 PRAMIPEXOL ISICOM
 ROPINIROL NAKOM
 ROTIGOTINE MADOPAR
 SINEPAR (retard)


 HONEY MOON…..
FARMAKOTHERAPY
EARLY STADIUM
 1. MONOTHERAPY L-DOPA (DuoDopa)
 or
 2. INHIBITORS COMT - ENTACAPON
 Blockade of enzym COMT increasse level of L-Dopa
STALEVO ( L-Dopa + entacapone)
 (3.) AMANTADINE- VIREGYT K, PK-MERZ
 Antagonist NMDA receptors, increasse level of dopamin in
synapsy
 I: choreatic dyskinesias
FARMAKOTHERAPY
LATE STADIUM
 DEMENTIA TREATMENT: ACETYLCHOLINESTERASE INHIBITORS
 Donepezil - ARICEPT, KOGNEZIL
 Rivastigmin- EXELON (Caution ex py AE)
 Galantamin - GALANTAMIN
 PSYCHOSIS TREATMENT:
 Reduction of antiparkinson drugs – only monotherapy L-Dopa
 ATYPICAL! Neuroleptic drugs – Quetiapin,Tiaprid
 (do not block DA receptors in striatum)
 Typical n. – risk of akinetic crisis or neuroleptic malignat
syndrome)
 Refractory tremor – BTX

DO NOT prescribe anticholinergic drug (Akineton)
 Caution ! sudden take off drug
 Lowprotein diet
DBS …(Deep Brain Stimulation)
 functional stereotactic operation
 Bilateral electric stimulation from 1 neurostimulator (PM)
 TARGET: STN (ncl.subtalamicus) VIM talamus Palidum
 Contraindication: age (more than 70)
 serious depression
 dementia

 BENEFIT : reduction of antiparkinson drug
 reduction of motor fluctuation
NEUROSURGICAL THERAPY