Posttraumatic akinetic-rigid syndrome resembling Parkinson's disease: a report on three patients

Systematic Review of Post-Traumatic Parkinsonism, an Emerging Parkinsonian Disorder Among Survivors of Traumatic Brain Injury

This systematic review focuses on an increasing subset of traumatic brain injury (TBI) survivors who develop post-traumatic parkinsonism (PTP), characterized by slowness of movement (bradykinesia), rigidity (stiffness), postural instability, and resting tremors caused by obstruction or damage to deep brain structures of the basal ganglia. PTP is rare, and one hypothesis to explain PTP rarity is that TBIs severe enough to affect deep brain structures are often lethal; however, with increasing survivability of TBIs, these numbers are expected to increase. The goal of this review is to raise awareness of an expected global increase of a subgroup of TBI patients who are treatment responsive and report therapeutic results aiding providers in diagnosing, educating, and treating PTP patients. Literature over the past 100 years was considered, and 44,663 peer-reviewed articles were identified. Inclusion criteria required a clinical indication of parkinsonian signs and TBI. Twenty-six case reports were ultimately included from which 36 individual patient data points were extracted for this review. Between 1980 and 2010, there has been an increase in reporting of PTP decade after decade. Forty-seven percent of PTP cases have 1-6 months of latency to symptom onset, and 83% of cases were male. PTP can occur with or without presence of brain lesions, and the most common type of injuries that cause PTP are motor vehicle accidents followed by falls. PTP patients are responsive to surgery or medication treatments. Further detail on PTP symptomology, treatment responsiveness, and injury types is provided.

Acute Movement Disorders in Childhood: A Cohort Study and Review of the Literature

OBJECTIVES

Acute movement disorders (AMD) are frequent in neurological and pediatric emergencies. Few studies analyzed AMD in children, none in Tunisia or other African country. The purpose of this study was to describe the peculiarities of AMD in a Tunisian pediatric population with a literature review.

METHODS

We conducted a retrospective descriptive study over 8 years including 80 children (sex ratio, 1.05; mean age of onset, 4.8 years) with AMD, followed in tertiary referral Child Neurology Department in North Tunisia.

RESULTS

Acute movement disorders were mainly hyperkinetic (n = 67 with dystonia (n = 33; mostly due to inherited metabolic diseases (IMD) in 11; with status epilepticus in 10 children), chorea (n = 14; with Sydenham chorea in 5); myoclonus (n = 14; mostly with opsoclonus-myoclonus syndrome in 10) and tremor (n = 6; of posttraumatic origin in half). Hypokinetic movement disorder (MD) included acute parkinsonism in 5 children of infectious (n = 3), postinfectious (n = 1, malaria) and posttraumatic origin (n = 1). Mixed MD, found in 8 children, were mainly due to IMD in half of them, and to familial lupus in two. Paroxysmal MDs were seen in 2 children, one with multiple sclerosis and one of idiopathic origin. Psychogenic MDs were found in 7 patients mainly of dystonic type. Management of AMD comprised symptomatic treatment according to the phenomenology of the MD and causative treatment depending on its etiology.

CONCLUSIONS

Our study illustrated the broad range of AMD in children and the wide spectrum of their etiologies. In our series, we described some exceptional findings and etiologies of AMD in children. These findings may denote a specific profile in of AMD in our country with predominant infectious, postinfectious, and IMD.

The cross-hemispheric nigrostriatal pathway prevents the expression of levodopa-induced dyskinesias

Parkinson's disease (PD) is a neurodegenerative movement disorder that is routinely treated with levodopa. Unfortunately, long-term dopamine replacement therapy using levodopa leads to levodopa-induced dyskinesias (LID), a significant and disabling side-effect. Clinical findings indicate that LID typically only occurs following the progression of PD motor symptoms from the unilateral (Hoehn and Yahr (HY) Stage I) to the bilateral stage (HY Stage II). This suggests the presence of some compensatory interhemispheric mechanisms that delay the occurrence of LID. We therefore investigated the role of interhemispheric connections of the nigrostriatal pathway on LID expression in a rat model of PD. The striatum of one hemisphere of rats was first injected with a retrograde tracer to label the ipsi- and cross-hemispheric nigrostriatal pathways. Rats were then split into groups and unilaterally lesioned in the striatum or medial forebrain bundle of the tracer-injected hemisphere to induce varying levels of hemiparkinsonism. Finally, rats were treated with levodopa and tested for the expression of LID. Distinct subsets emerged from rats that underwent the same lesioning paradigm based on LID. Strikingly, non-dyskinetic rats had significant sparing of their cross-hemispheric nigrostriatal pathway projecting from the unlesioned hemisphere. In contrast, dyskinetic rats only had a small proportion of this cross-hemispheric nigrostriatal pathway survive lesioning. Crucially, both non-dyskinetic and dyskinetic rats had nearly identical levels of ipsi-hemispheric nigrostriatal pathway survival and parkinsonian motor deficits. Our data suggest that the survival of the cross-hemispheric nigrostriatal pathway plays a crucial role in preventing the expression of LID and represents a potentially novel target to halt the progression of this devastating side-effect of a common anti-PD therapeutic.

Localizing parkinsonism based on focal brain lesions

Bradykinesia, rigidity, and tremor frequently co-occur, a clinical syndrome known as parkinsonism. Because this syndrome is commonly seen in Parkinson's disease, symptoms are often attributed to cell loss in the substantia nigra. However, parkinsonism occurs in several other neurological disorders and often fails to correlate with nigrostriatal pathology, raising the question of which brain region(s) cause this syndrome. Here, we studied cases of new-onset parkinsonism following focal brain lesions. We identified 29 cases, only 31% of which hit the substantia nigra. Lesions were located in a variety of different cortical and subcortical locations. To determine whether these heterogeneous lesion locations were part of a common brain network, we leveraged the human brain connectome and a recently validated technique termed lesion network mapping. Lesion locations causing parkinsonism were functionally connected to a common network of regions including the midbrain, basal ganglia, cingulate cortex, and cerebellum. The most sensitive and specific connectivity was to the claustrum. This lesion connectivity pattern matched atrophy patterns seen in Parkinson's disease, progressive supranuclear palsy, and multiple system atrophy, suggesting a shared neuroanatomical substrate for parkinsonism. Lesion connectivity also predicted medication response and matched the pattern of effective deep brain stimulation, suggesting relevance as a treatment target. Our results, based on causal brain lesions, lend insight into the localization of parkinsonism, one of the most common syndromes in neurology. Because many patients with parkinsonism fail to respond to dopaminergic medication, these results may aid the development of alternative treatments.10.1093/brain/awy161_video1awy161media15815555971001.

[Clinical syndromes of neurotransmitter system dysfunction in severe brain injury]

AIM

To explore neurotransmitter system dysfunctions involved in maintaining of consciousness and motor functions in patients with severe traumatic brain injury (TBI) and to assess their severity and predictive value.

MATERIAL AND METHODS

Authors examined 100 patients (34 women and 66 men), aged 32.0 ± 13.0 years, with severe TBI. Eighty-eight patients (31 women and 57 men) were studied in the acute stage (1-15 days, mean 5.8 ± 3.7 days) and 70 patients (24 women and 46 men) in the subacute stage (18-70 days, mean 30.4 ± 12.7 days). Inclusion criteria were: severe TBI with depression of consciousness (≤ 7 scores on the Glasgow Coma Scale), admission to the hospital in acute and subacute stages. Outcome of TBI was evaluated using the Glasgow Outcome Scale.

RESULTS AND CONCLUSION

The following clinical syndromes of neurotransmitter system dysfunction were singled out: excess or insufficiency of glutamate, cholinergic deficit, excess or insufficiency of dopamine. Their transformation during disease was identified. Predictive value of neurotransmitter dysfunctions for TBI is emphasized.

Movement disorders secondary to craniocerebral trauma

Over the past few decades it has been recognized that traumatic brain injury may result in various movement disorders. In survivors of severe head injury, post-traumatic movement disorders were reported in about 20%, and they persisted in about 10% of patients. The most frequent persisting movement disorder in this population is kinetic cerebellar outflow tremor in about 9%, followed by dystonia in about 4%. While tremor is associated most frequently with cerebellar or mesencephalic lesions, patients with dystonia frequently have basal ganglia or thalamic lesions. Moderate or mild traumatic brain injury only rarely causes persistent post-traumatic movement disorders. It appears that the frequency of post-traumatic movement disorders overall has been declining which most likely is secondary to improved treatment of brain injury. In patients with disabling post-traumatic movement disorders which are refractory to medical treatment, stereotactic neurosurgery can provide long-lasting benefit. While in the past the primary option for severe kinetic tremor was thalamotomy and for dystonia thalamotomy or pallidotomy, today deep brain stimulation has become the preferred treatment. Parkinsonism is a rare consequence of single head injury, but repeated head injury such as seen in boxing can result in chronic encephalopathy with parkinsonian features. While there is still controversy whether or not head injury is a risk factor for the development of Parkinson's disease, recent studies indicate that genetic susceptibility might be relevant.

Peripherally induced movement disorders

Peripherally induced movement disorders may be defined as involuntary or abnormal movements triggered by trauma to the cranial or peripheral nerves or roots. Although patients often recall some history of trauma before the onset of a movement disorder, determining the true relationship of the disorder to the earlier trauma is often difficult. The pathophysiology of these disorders is reviewed.

Levodopa treatment for patients in persistent vegetative or minimally conscious states

The persistent vegetative state (PVS) and the minimally conscious state (MCS) are conditions of altered consciousness after severe brain damage due to a variety of pathologies. However, the specific pathophysiological mechanisms and a therapeutic strategy for intervention have not as yet been established. We review previous reports of levodopa treatment for patients in PVS, MCS, or other mental disorders, and have focused on five representative cases: four of PVS and one of MCS after severe brain injury. In summary, our review suggests the effectiveness of levodopa treatment is probably dependent upon the following criteria: (1) Diagnosis of PVS or MCS as distinct from other related conditions, (2) Concomitant symptoms of parkinsonism, and (3) Concomitant neuroradiological findings of high intensity lesions in the dopaminergic pathway on T2 weighted MRI. The apparent success of levodopa in the five cases described may reflect a specific subgroup of PVS and MCS patients, where the administration of levodopa is effective. However, we should not regard PVS or MCS as a single entity, since levodopa is unlikely to be effective in all cases. Therapeutic strategies should aim to identify the key pathophysiological mechanism for each patient and target interventions accordingly.

Deep brain stimulation for idiopathic or secondary movement disorders

Deep brain stimulation has gained increasing interest in the treatment of movement disorders. Presenting our clinical series of 179 patients operated upon since 1999, the indications, risks and benefits for the patients are discussed in order to further improve the techniques and their applications.

Movement Disorders After Head Injury

Head injury can cause extrapyramidal movement disorders such as tremors, parkinsonism, dystonia, chorea, myoclonus, and tics. Pure adventitious movements are rare, but combinations with paresis, spasticity, apraxia, or ataxia occur in approximately 20% of cases of severe head injury, in many cases appearing or evolving in the months following the injury. Tremors may improve in time but many of the other syndromes tend to persist. Reversible causes such as medications or metabolic derangements are occasionally identifiable. Some of these adventitious movements can be improved using neuroactive drugs, botulinum toxin injections, or stereotactic brain surgery.

Update on epidemiological aspects of progressive supranuclear palsy

The cause of progressive supranuclear palsy (PSP), the most common form of the atypical parkinsonian disorders, is unknown. PSP is characterized by four-repeat tau aggregates in neurons (neurofibrillary tangles) and glia in specific basal ganglia and brainstem areas. A thorough literature review led us to hypothesize that genetic and/or environmental factors contribute to its development. It is likely that inheritance of the H1/H1 tau genotype represents a predisposition to develop PSP requiring other environmental or genetic factors. Less likely, a relatively rare mutation with low penetrance could contribute to the abnormal tau aggregation present in this disorder. The possible role of chemicals in the diet or occupation, hypertension, traumatic brain injury, coffee, and inflammation or oxidative injury are reviewed.

Epidemiology and treatment of Parkinson's disease in India

Parkinson's disease (PD) has a low prevalence in India except in the small Parsi community where Bharucha et al. found a high prevalence. Although early onset PD and familial cases have been described from India, no genetic mutations have as yet been identified. PD has been known in India since ancient days and the powder of Mucuna Pruriens seeds was used for its treatment. The present day management of PD in India is similar to that in the other countries. Unfortunately, lack of awareness, limitation of human resources and cost factors deny the benefits of therapy to many patients.

Parkinson's disease and exposure to infectious agents and pesticides and the occurrence of brain injuries: role of neuroinflammation

Idiopathic Parkinson's disease (PD) is a devastating movement disorder characterized by selective degeneration of the nigrostriatal dopaminergic pathway. Neurodegeneration usually starts in the fifth decade of life and progresses over 5-10 years before reaching the fully symptomatic disease state. Despite decades of intense research, the etiology of sporadic PD and the mechanism underlying the selective neuronal loss remain unknown. However, the late onset and slow-progressing nature of the disease has prompted the consideration of environmental exposure to agrochemicals, including pesticides, as a risk factor. Moreover, increasing evidence suggests that early-life occurrence of inflammation in the brain, as a consequence of either brain injury or exposure to infectious agents, may play a role in the pathogenesis of PD. Most important, there may be a self-propelling cycle of inflammatory process involving brain immune cells (microglia and astrocytes) that drives the slow yet progressive neurodegenerative process. Deciphering the molecular and cellular mechanisms governing those intricate interactions would significantly advance our understanding of the etiology and pathogenesis of PD and aid the development of therapeutic strategies for the treatment of the disease.

Head injury and posttraumatic movement disorders

WE REVIEW THE phenomenology, pathophysiology, pathological anatomy, and therapy of posttraumatic movement disorders with special emphasis on neurosurgical treatment options. We also explore possible links between craniocerebral trauma and parkinsonism. The cause-effect relationship between head injury and subsequent movement disorder is not fully appreciated. This may be related partially to the delayed appearance of the movement disorder. Movement disorders after severe head injury have been reported in 13 to 66% of patients. Although movement disorders after mild or moderate head injury are frequently transient and, in general, do not result in additional disability, kinetic tremors and dystonia may be a source of marked disability in survivors of severe head injury. Functional stereotactic surgery provides long-term symptomatic and functional benefits in the majority of patients. Thalamic radiofrequency lesioning, although beneficial in some patients, frequently is associated with side effects such as increased dysarthria or gait disturbance, particularly in patients with kinetic tremor secondary to diffuse axonal injury. Deep brain stimulation is used increasingly as an option in such patients. It remains unclear whether pallidal or thalamic targets are more beneficial for treatment of posttraumatic dystonia. Trauma to the central nervous system is an important causative factor in a variety of movement disorders. The mediation of the effects of trauma and the pathophysiology of the development of posttraumatic movement disorders require further study. Functional stereotactic surgery should be considered in patients with disabling movement disorders refractory to medical treatment.