This document summarizes key information about Parkinsonism and related neurological disorders. It provides clinical examination findings for different types of Parkinsonism, including rigidity, tremors, and limb stiffness. It also discusses diagnostic tests such as DAT scans and MRI findings. Deep brain stimulation is mentioned as a treatment for Parkinson's disease. Complications of therapy like levodopa-induced dyskinesia are also summarized. Clinical features of different Parkinson-plus syndromes like MSA, PSP, and CBS are outlined.

1. PARKINSONISM
Dr. Ahmad Shahir Mawardi
MD (UKM), MMED (UKM), CCST Neurology (Mal), Fellowship in Movement Disorders (UK)
Dr. Nor Amelia Mohd Fauzi
MBBChBAO (Ire), BMedSc (Ire), MRCP (UK), CCST Neurology (Mal), Fellowship of the European
Board of Neurology (FEBN), Fellowships in Epilepsy & Movement Disorders (London,UK)

3. Case 1

4. This gentleman complains
of right hand tremor.
Please examine his upper
limbs and proceed
accordingly.

6. How to examine for rigidity?

7. Face (motor)
• Hypomimia
• ↓ eye blinking
• Drooling of saliva
• Lips parted
• Voice: Hypophonia,
unclear

8. Limbs (motor)
UL
• Finger tapping
• Hand movement- open &
close
• Pronation-supination
• Micrographia
LL:
• Toe tapping
• Leg agility
• Arising from chair

10. How to make the diagnosis?

11. PD Stages

12. • Can it be so simple?
– Always think about complications of disease
– Treatment options

13. Deep Brain Stimulation
Target : Sub-thalamic nucleus or Globus
pallidus

14. Complication of Therapy
• Levodopa induced
dyskinesia
• Extra question: Types
of dyskinesia
– peak dose dyskinesia
– end dose dyskinesia
– biphasic dyskinesia

15. Possible questions
1. What are the causes of Parkinsonism?
2. What are the Parkinson-Plus syndromes?
3. List the non-motor symtoms
4. How would you investigate this patient? Which
investigation of choice to differentiate PD vs Essential
tremor?
5. What is the pharmacological management of
Parkinson’s disease?
6. What non-oral therapies are available for Parkinson’s
disease?
7. Is there any drug that should be avoided in PD patients?

16. Natural history of Parkinson's Disease
The Lancet

17. Dopamine Transporter Scan ( DAT Scan)

18. Sites of Action of
Anti-PD Drugs
18

19. Non-oral therapy
1. deep brain stimulation (DBS)
2. apomorphine infusion
3. jejunal L-dopa infusion

21. Case 2

22. This gentleman complains
of limbs stiffness.
Please examine his upper
limbs and proceed
accordingly.

24. MSA : Clinical Features
1. Symmetrical PD appearance.
2. Poor Levodopa response
3. Pill-rolling tremor (uncommon in patients with MSA-P).
4. Postural instability (later)
5. Speech : mixed spastic, hypokinetic dysarthria or dysphonia
6. Dysphagia
7. Respiratory or laryngeal stridor.
8. Other suggestive features :
hyperreflexia, Babinski signs, dystonia, anterocollis, and early striatal deformities.

26. MRI features?
• "Hot cross bun sign"
(Pontine atrophy and
gliosis )
• bilateral T2
hypointensity in the
posterolateral putamen,
representing iron
deposition, and slit
hyperintensity in the
lateral margin of the
putamen.

27. What other investigations that can
support the diagnosis?
• PET scans : decreased striatal and frontal metabolism.
• DAT (125I-ioflupane) SPECT : asymmetric reduced striatal binding.46
• Autonomic testing :
– tilt-table testing
– 24-hour ambulatory blood pressure and heart rate monitoring
– baroreceptor sensitivity (Sweat testing, gastric emptying study for gastroparesis, and
urodyamics for urinary dysfunction.

28. Case 3

29. This gentleman complains
of dysphagia and recurrent
falls.
Look at his face and please
proceed accordingly.

31. Hummingbird Sign Morning Glory Sign

32. • Symmetrical parkinsonism, usually without
tremor
• Prominent neck dystoniaretrocollis
• Markedly reduced blink rate
• Apraxia of eyelid opening
• Slowed vertical saccades progressing to vertical
supranuclear gaze palsy
• Postural instability (falls backward)
• Dementia
• Dysarthria & dysphagia
• Poor Levodopa response
PSP : Clinical Features

33. Case 4

34. This lady complains of
speech disturbance and
unsteady gait.
Look at her face and please
proceed accordingly.

36. Motor Symptoms:
•Asymmetrical parkinsonism – affecting one
limb
•Progressive dystonia
•The limb often described as “dead”,
“useless”, frequently held postured across
the body
•Myoclonus (distal, stimulus-sensitive)
•Alien-limb phenomena – in 50% patients
CBS : Clinical Features

38. Cortical Dysfunction:
•Apraxia – cardinal feature of CBD
– Can be difficult to demonstrate in the more affected
sign due to severe bradykinesia, rigidity, and dystonia
– However, usually present in the ‘good’ arm
•Cortical sensory loss
– Impaired 2-point discrimination, dysgraphaesthesia,
astereognosis
•Dementia
– Important phenotype, maybe the presenting or
predominant feature
– Neuropsychometry test – frontal executive + parietal
lobe dysfunction (episodic memory is preserved, in
contrast with AD)
CBS : Clinical Features

40. Eye Signs:
• Apraxia of eyelid
• Apraxia of eye movement
– Difficulty initiating saccade to command,
– Once initiated, usually normal velocity -the
converse of most PSP
CBS : Clinical Features

42. SUMMARY

43. SUMMARY