PARKINSONS SYNDROME
70%  Parkinson's d. 30%  Other disease
RED FLAGS
- - MEDICATION (NEUROLEPTIC!!)
■ - positive familial history
■ - early falls, postural instability
■ - rapid progression
■ - nondoparesponsibility
■ - early autonomic disturbance
■ - oculomotor disturbance
■ - serious pseudobulbar syndrome
■ - early dementia
■ - separate leg disability
■ - pyramidal or cerebellar syndrome
DIFFERENTIAL DIAGNOSIS IPN
■ A/ other NEURODEGENERATIV Disorders
■ ( PARKINSON PLUS d.)
■ - rare,nondoparesponsibility, rapid progression, serious prognossis
1. Synukleinopathy (MSA, DLBD)-
intracytoplasmatic inclusion alfa-synuklein
■ 2. Tauopathy (PSP, CBD) - intracytoplasmatic inclusion tau-protein
- B/ Other NEUROLOGIC Disorders
■ HD Westphal variant - familial
■ (Wilson's disease)
■ C/ SECUNDARY parkinson syndrome
■ Side effects of drug, vascular, NTH
DRUG INDUCED
Farmakologic anamnesis
■ TYPICAL NEUROLEPTIC !!
■ Haloperidol, Chlorpromazin,Chlorprotixen, Tisercin
■ TREATMENT: Akineton
■ ANTIEMETIC,PROKINETIC
■ Cerucal, Degan, Torecan
■ ANTIHISTAMINE
■ Prothazin
BLOCK of Calcium channels cinarizin, flunarizin
VASCULAR
- OFTEN
■ MRI finding: multiinfarct changes -status lacunaris
■ - development gradually or as a stroke
■ - Pa sy UNILATERAL during the first year after stroke      after stadium of hemiparesis
■ - Pa sy BILATERAL (frontal only gait disturbance
■ LOWER BODY parkinsonismus
■ other signs: pseudobulbar palsy, dementia,incontinency
■ - rapid progression
- - TREATMENT : low effect of amantadin
■ NO! L-Dopa because of postsynaptic DA receptors lesion
NORMOPRESSURE HYDROCEPHALUS
■ Disproportion : production X absorption of CSF
(liquor pressure is not increased ) Old aged mostly men
■ Hakimo clinical features idementia
urinal incontinency gait apraxia
(bradykinezia,wide base)
■ MRI comunicated hydrocephalus
- TREATMENT- lumbal punction (- 50ml CSF)....
■ gait improvement.....V-P shunt
MSA
Multiple system atrophy
o STN.....first s. parkinson sy
msa type P
o opca....first s. cerebellar sy
MSA type C
o Shy-Drager sy....autonomic sy
o (ortostatic hypotension, incontinency)
MSA type A
The possibility : combination or isolated
o Initial stadium: 50% autonomic sy O 45% parkinson sy
O ( 5% cerebellar sy)
o SYNUKLEINOPATHY
O - prevalence 5-15/100 000, 8%
- cerebellar + brainstem SN,striatum,palidum,
- ONUF's ncl (segment S2-S4)
o - doparesponsibility in the early stadium 29%...differentiation from PD difficult
O Clinical Feautures: dystonia, pseudobulbar palsy, inspiration stridor, polyneuropathy
o - no dementia! m
EXAMINATION
o Brain MRI — cerebellar + brainstem atrophy
o - EMG anal external sphincter - denervation cm
Onuf s ncl.
o - EMG for diagnostic Polyneuropathy
o - test of Vegetative system (EKG variability R-R
interval)
O - Orthostatic test (BP while lying down and 1 min after posture .....differences 30/15)
PSP
PROGRESSIVE SUPRANUCLEAR PALSY
o - prevalence 7/100 000, 7-12% o - midle and old age
o - Atrophy mesencephalon + pons tegmentum + F polar part of cortex
o TAUOPATHY
CLINICAL FEATURES
o - pa sy with dominant axial rigidity without tremor
o - extended trunk
o - early falls due to postural instability
o - vertical gaze palsy, hypometric saccades
o - apraxia eye lids, retraction of upper eye lids (surprised look)
o - subcortical dementia (F lobe)
o - pseudobulbar palsy
o - dystonia (focal cervical)
o - inspiratory stridor
o - nondoparesponsibility
EXAMINATION
o - Hearing EP.....central lesion
o - Brain MRI... mesencephalon atrophy
o enlarged III. ventricule
o
DLBD
Diffuse lewy body disease
CBD
CORTICOBASAL DEGENERATION
o - prevalence 0,5% o - age over 70 years
o - unilateral cortical atrophy F+P
o - atrophy SN
o
o TAUOPATHY
CLINICAL FEATURES
o - contralateral hemiparkinsonism
o - cortical (limb apraxia..alien hand syndrome, hemihypestesia, symbolic function disturbance)
o - dementia
o - cortical myoklonus
o - dystonia
o - pyramidal syndrome
EXAMINATION
o Brain MRI - asymetric cortical atrophy P + F
o Brain PET - (hypometabolism F-P cortex)
WESTPHAL variant Huntington D.
o - Autosomal Dominant o - 5% patient of HD
o - young age (manifestation before 20 years) o - the first symptom parkinsonism (rigidity +
hypokinezia)
o - later chorea + dementia o - rapid progression o - genetic test
ADVANTAGE of DAT SCAN inpakkinson
syndrome
o PD asymetrie re-uptake in striatum
o
o MSA,PSP    symetrie re-uptake in striatum + postsynaptic disturbance
DLBD asymetrie re-uptake in striatum
VASCULAR pa sy normal
DRUG INDUCED   pa sy normal