movement disorders Namasivayam balamurugan

1. Movement disorder
Emergencies
Dr.N.Balamurugan, MD., DM (Neuro)
Consultant Neurologist Salem

2. Movement disorder
Emergencies
Any neurological disorder evolving acutely or
sub acutely
in which the clinical presentation is dominated
by a primary movement disorder and
in which failure to accurately diagnose and
manage the patient may result in significant
morbidity or mortality.
Balamurugan NamasivayamBalamurugan Namasivayam 22

3. Purpose
1) Identify the most important movement
disorder emergencies
2) Understand how are they managed
3) Recognize certain rare movement
disorders that should not be missed
(what I call, “don’t miss diagnoses”).
Balamurugan NamasivayamBalamurugan Namasivayam 33

4. Hyper kinetic
Dystonia
Chorea
Ballismus
Athetosis
Tics
Tremor
Myoclonus
Hypo kinetic
Parkinsonism
44

5. Balamurugan NamasivayamBalamurugan Namasivayam 55
Dystonia
Involuntary, sustained muscle contractions
that resulted in abnormal, often repetitive
and twisting postures.

6. Oculogyric crisis or
Acute dystonic reaction
A form of acute dystonia, it takes its name
from the tendency of the eyes to deviate
eye movements are only part of the
syndrome
opisthotonus and generalized rigidity,
anguish, multiple autonomic symptoms
Akathisia, forced gasping,gagging, loud
phonation, pallilalia
66

7. Acute Dystonic reaction
Neuroleptic exposure (acute or tardive).
Drugs
(Perinorm,prochlorperazine,lisuride).
Encephalitis lethargica.
Structural (paramedian thalamic
infarction, cystic glioma of 3rd ventricle,
Wilson’s disease).
77

8. Balamurugan NamasivayamBalamurugan Namasivayam 88
Acute Dystonic Reaction

9. Acute Dystonic Reaction
99

10. Rx: Acute dystonic reaction
I.V. treatment to terminate the attack:
Lorazepam, Midazolam
diphenhydramine (25 or 50 mg),
benztropine (1 or 2 mg), or biperiden (2 m g).
 Oral maintenance therapy:
anticholinergics,
 clonazepam.
1010

11. “Donot Miss” diagnoses
in dystonia
1111

12. Acute dystonic reaction causing
TMJ Dislocation
Dislocation
1212

13. Balamurugan NamasivayamBalamurugan Namasivayam 1313
Dopa Responsive Dystonia

14. Balamurugan NamasivayamBalamurugan Namasivayam 1414
Wilsons disease

15. 1515

16. Balamurugan NamasivayamBalamurugan Namasivayam 1616

17. Balamurugan NamasivayamBalamurugan Namasivayam 1717
Dystonia sec to hypocalcemia

18. Balamurugan NamasivayamBalamurugan Namasivayam 1818
Hand dystonia not due to hypocalcemia

19. Balamurugan NamasivayamBalamurugan Namasivayam 1919
Hand dystonia – Cervical myelopathy-
NMO

20. Atalo axial dislocation(AAD)
2020

21. Paroxysmal autonomic
instability with dystonia. PAID
A complication of severe brain injury
Syndrome of
intermittent agitation,
diaphoresis,
hyperthermia,
hypertension,
tachycardia,
tachypnea, and extensor posturing.

22. Pathophysiology of PAID
Dysfunction of autonomic centers in the
diencephalon (thalamus or hypothalamus)
or their connections to cortical, subcortical,
and brainstem loci that mediate autonomic
function.

23. Criteria for PAID
Signs of PAID syndrome include
(1) severe brain injury,
(2) temperature > 38.5°C,
(3) Pulse > 130beats/min,
(4) respiratory rate > 40 breaths/ min,
(5) agitation,
(6) diaphoresis, and
(7) dystonia (ie, rigidity or decerebrate posturing).
The duration is at least 1 cycle per day for at least
3 days.
Finally, other conditions must be ruled out.

27. Follow up by 1 month

29. Sri Gokulam Hospital,SalemSri Gokulam Hospital,Salem Balamurugan NamasivayamBalamurugan Namasivayam 2929

30. Sri Gokulam Hospital,SalemSri Gokulam Hospital,Salem Balamurugan NamasivayamBalamurugan Namasivayam 3030
Athetosis
Ballismus
Chorea
Topography is different and Clinical settings
are different.

31. 3131
Athetosis
 Birth injury
 Kericterus
 Post hemiplegic

32. 3232
Chorea
Sporadic
Drug induced
Sydenham’s
OCP
Hyperthyroidism
Lupus
APLS
Family history-
HD,HCA,BHC,
WD,HSD

33. Hemiballismus
3333

34. “Donot Miss” diagnoses
in ABC
3434

35. Hemiballismus in Nonketotic
Hyperosmolar Hyperglycemia
3535

36. 3636

37. Management of ABC
Tetrabenazine
(Revovon)
Sodium valproate
Carbamazepine
3737
Haloperidol
Pimozide

38. Parkinsonism as movement
disorder emergencies
3838

39. Parkinsonism as movement
disorder emergencies
1. Fluctuations in response to levodopa
(new onset or sudden changes)
2. Involuntary movements (dyskinesia):
choreic or dystonic
3939

40. 4040
Late stage motor problems
Motor fluctuations
Related to duration and dosage of
levodopa therapy
Dyskinesias
Related to severity of the
disease

41. 4141
Parkinsonism Hyperpyrexia
Syndrome(PHS)

42. Situation leading to PHS
Stopping dopaminergic medications
Neuroleptic use
Motor fluctuations-
off periods, peri menstrural off
Metabolic disturbances
Dehydration
hypernatremia
4242

43. Management of PHS
Reintroduction of antiparkinsons
medications
Supportive care
Antipyretics
Rehydration
Bromocriptine 2.5mg tds
Dantrolene sodium10mg IV tds
4343

44. 4444
Freezing improves with visual cues

45. 4545
6 8 10 82
6412 10
Combination of motor fluctuation & Dyskinesias
YO-YO-ING

46. 4646
Combination of motor fluctuation &
Dyskinesias
YO-YO-ING
 Repeated ups and downs of a yo yo
 Dopamine receptors are intact but supersensitive
to allow dyskinesia (Pharmaco dynamic)
 Short plasma off life leads to “OFF” state
(Pharmaco kinetic)
 Plain levodopa Or Liquid preparation
 (Not carbidopa/ COMT- prolonged unpredictable action)
 Long acting DA may be tried (dopa sparing)
 Levo dopa infusion via Intra duodenal pump
 Surgery

47. 4747
“ON” and Dyskinesia “OFF” and Dyskinesia
YO-YO-ING
6 8 10 82
6412 10

48. 4848
“ON” and No dyskinesia

49. “Donot Miss” diagnoses
in Parkinsonism
4949

50. 5050
Parkinsonism -Wilson

51. 5151
Parkinsonism –Toxin induced
Bhatt MH, Elias MA, Mankodi AK. Acute and reversible parkinsonism due to organophosphate pesticide intoxication: five cases. Neurology
1999; 52(7):1467–1471.
Balamurugan N, Karthikeyan V, Bhaskar C. 1st Asian & oceanian parkinsons disease & movement disorders congress
2007 held at Singapore, Reversible Dystonic Parkinsonism after Organophosphate Poisoning,

52. 5252
1st
and 2nd
MRI : Comparison

53. Emergency?!
5353

54. Balamurugan NamasivayamBalamurugan Namasivayam 5454
Acknowlegement
All patients
My neuro team