PARKINSON 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 IPD
 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/ SECONDARY parkinson syndrome
 Side effects of drug, vascular, NPH
DRUG INDUCED
FARMAKOLOGIC ANAMNESIS
 TYPICAL NEUROLEPTIC !!
 Haloperidol,Chlorpromazin,Chlorprotixen,Tisercin
 TREATMENT: Akineton
 ANTIEMETIC,PROKINETIC
 Cerucal, Degan, Torecan
 ANTIHISTAMINIC
 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 :dementia
 urinal incontinency
 gait apraxia
 (bradykinezia,wide base)
 MRI comunicated hydrocephalus
 TREATMENT- lumbal punction (- 50ml CSF)….
 gait improvement ….. V-P shunt
MSA
MULTIPLE SYSTEM ATROPHY
 STN ….. first s. parkinson sy MSA type P
 OPCA….first s. cerebellar sy MSA type C
 Shy-Drager sy….autonomic sy MSA type A
 (ortostatic hypotension, incontinency)
The possibility : combination or isolated
 Initial stadium: 50% autonomic sy
 45% parkinson sy
 ( 5% cerebellar sy)
 SYNUKLEINOPATHY
 - prevalence 5-15/100 000, 8%
- cerebellar + brainstem SN,striatum,palidum,
- ONUF´s ncl (segment S2-S4)
 - doparesponsibility in the early stadium
29%...differentiation from PD difficult
 Clinical Feautures: dystonia, pseudobulbar
palsy, inspiration stridor, polyneuropathy
 - no dementia!
EXAMINATION
 Brain MRI – cerebellar + brainstem atrophy
 - EMG anal external sphincter – denervation of
Onuf´s ncl.
 - EMG for diagnostic Polyneuropathy
 - test of Vegetative system (EKG variability R-R
interval)
 - Orthostatic test (BP while lying down and 1 min after
 posture …..differences 30/15)
PSP
PROGRESSIVE SUPRANUCLEAR PALSY
 - prevalence 7/100 000, 7-12%
 - midle and old age
 - Atrophy mesencephalon + pons
tegmentum + F polar part of cortex
 TAUOPATHY
CLINICAL FEATURES
 - pa sy with dominant axial rigidity without
tremor
 - extended trunk
 - early falls due to postural instability
 - vertical gaze palsy, hypometric saccades
 - apraxia eye lids, retraction of upper eye lids
(surprised look)
 - subcortical dementia (F lobe)
 - pseudobulbar palsy
 - dystonia (focal cervical )
 - inspiratory stridor
 - nondoparesponsibility
 - Hearing EP …..central lesion
 - Brain MRI… mesencephalon atrophy
 enlarged III. ventricule

EXAMINATION
DLBD
DIFFUSE LEWY BODY DISEASE
CBD
CORTICOBASAL DEGENERATION
 - prevalence 0,5%
 - age over 70 years
 - unilateral cortical atrophy F+P
 - atrophy SN

 TAUOPATHY
 - contralateral hemiparkinsonism
 - cortical (limb apraxia..alien hand syndrome,
hemihypestesia, symbolic function disturbance)
 - dementia
 - cortical myoklonus
 - dystonia
 - pyramidal syndrome
CLINICAL FEATURES
EXAMINATION
 Brain MRI - asymetric cortical atrophy P + F
 Brain PET - (hypometabolism F-P cortex)
WESTPHAL VARIANT HUNTINGTON D.
 - Autosomal Dominant
 - 5% patient of HD
 - young age (manifestation before 20 years)
 - the first symptom parkinsonism (rigidity +
hypokinezia)
 - later chorea + dementia
 - rapid progression
 - genetic test
ADVANTAGE OF DAT SCAN IN PARKINSON
SYNDROME
 PD asymetric re-uptake in striatum

 MSA,PSP symetric re-uptake in striatum +
postsynaptic disturbance
DLBD asymetric re-uptake in striatum
VASCULAR pa sy normal
DRUG INDUCED pa sy normal