Hand dystonia secondary to cervical demyelinating lesion

Cervical demyelinating lesion presenting with choreoathetoid movements and dystonia

Pseudoathetosis and dystonia are rare manifestations of spinal cord disease that have been already reported in lesions involving the posterior columns at the cervical level. We report two patients with a cervical demyelinating lesion at C3-C4 level presenting with hand dystonia and pseudoathetoid movements. The movement disorder disappeared after steroid treatment. The cases we described highlight the importance of identifying secondary causes of movement disorders that can be reversible with appropriate therapy.

The anatomical basis of upper limb dystonia: lesson from secondary cases

Upper limb dystonia is a focal dystonia that may affect muscles in the arm, forearm and hand. The neuroanatomical substrates involved in upper limb dystonia are not fully understood. Traditionally, dysfunction of the basal ganglia is presumed to be the main cause of dystonia but a growing body of evidence suggests that a network of additional cortical and subcortical structures may be involved. To identify the brain regions that are affected in secondary upper limb dystonia may help to better understand the neuroanatomical basis of the condition. We considered only patients with focal upper limb dystonia associated with a single localized brain lesion. To identify these patients, we conducted a systematic review of the published literature as well as the medical records of 350 patients with adult-onset dystonia seen over past 15 years at our movement disorder clinic. The literature review revealed 36 articles describing 72 cases of focal upper limb dystonia associated with focal lesions. Among patients at our clinic, four had focal lesions on imaging studies. Lesions were found in multiple regions including thalamus (n = 39), basal ganglia (n = 17), cortex (n = 4), brainstem (n = 4), cerebellum (n = 1), and cervical spine (n = 7). Dystonic tremor was not associated with any particular site of lesion, whereas there was a trend for an inverse association between task specificity and thalamic involvement. These data in combination with functional imaging studies of idiopathic upper limb dystonia support a model in which a network of different regions plays a role in pathogenesis.

Effect of Intrathecal Baclofen on Delayed-Onset Paroxysmal Dystonia due to Compression Injury Resulting From Congenital and Progressive Spinal Bone Deformities in Chondrodysplasia Punctata

BACKGROUND

Dystonia due to spinal lesions in adult patients is characterized by the provocation and/or amelioration of the spasm by somatosensory stimulation with a sensory trick.

PATIENT DESCRIPTION

An infant with brachytelephalangic chondrodysplasia punctata developed flaccid tetraplegia due to cervical cord compression resulting from congenital atlantoaxial dislocation. Episodic, tonic extension of the extremities, neck, and trunk had appeared daily since age two years and was often provoked by tactile stimulation. Although decompression surgery was performed at age three years, progressive spinal deformity resulted in the aggravation of episodic dystonia thereafter, lasting for hours. Foot dorsiflexion and wearing a truncal brace for scoliosis inhibited these spasms. Intrathecal baclofen bolus injection transiently ameliorated the paroxysmal dystonia and detrusor-sphincter dyssynergia in the lower urinary tract.

CONCLUSION

Paroxysmal dystonia is unusual in children with spinal cord lesions; however, it should be recognized for appropriate individualized clinical management.

Secondary dystonia in a botulinum toxin clinic: clinical characteristics, neuroanatomical substrate and comparison with idiopathic dystonia

The analysis of patients with secondary dystonia has been valuable to explore the anatomical, pharmacological and physiological bases of this disorder. The goal of this study is to compare the clinical characteristics of patients with primary and secondary dystonia and analyze the neuroanatomical bases of a subgroup of patients with lesion-induced dystonia. We identified patients evaluated in our Botulinum Toxin Clinic from 1/2000 to 7/2009 with an ICD code for "dystonia". Medical records of all subjects were reviewed, recording demographic, clinical, therapeutic and neuroimaging data. A total of 230 patients were included in the study. Idiopathic/primary dystonia was diagnosed in 162 and secondary dystonia in 58, while in 10 the etiology was uncertain. We found a female predominance (2.4:1 and 1.9:1 for primary and secondary dystonia, respectively). The cervical region was most commonly affected in primary dystonia and the limbs in secondary cases. The age at presentation was higher in primary (54.4 ± 14.1) than secondary (49 ± 17.9) dystonia. Among patients with secondary dystonia, a focal lesion was the presumed etiology in 32, with localizing diagnostic studies available in 16. The most common lesions were strokes involving the corticospinal pathway. All of those patients exhibited limb dystonia, except one with cervical dystonia following a thalamic infarct. In conclusion, primary and secondary dystonias are more prevalent in women, suggesting a sex-related predisposition to the development of this movement disorder. Lesion-induced dystonia most frequently involves the limbs and is caused by lesions in the cerebral cortex and subcortical white matter.

Movement disorders in patients with multiple sclerosis

Apart from tremor and restless-legs syndrome, abnormal involuntary movements are uncommon in patients with multiple sclerosis. A review of the literature in multiple sclerosis reveals case reports of a variety of other movement disorders such as myoclonus, spasmodic torticollis, paroxysmal dystonia, chorea, ballism, and parkinsonism. This chapter presents a thorough review of these movement disorders in multiple sclerosis patients and provides readers with potential underlying pathogenetic mechanisms.

Paroxysmal chorea as a relapse of myelopathy in a patient with neuromyelitis optica

Movement disorders secondary to intrinsic spinal cord disease are rare. Paroxysmal chorea has not yet been reported in the neuromyelitis optica (NMO). We report a 43-year-old woman with relapsing-remitting cervical myelopathy who developed paroxysmal chorea during clinical exacerbation of NMO. MRI scan of the cervical spine revealed a long segmental enhancing lesion, but brain MRI did not show any responsible abnormalities. Acute exacerbation of recurrent myelopathy in NMO may be associated with transient movement disorder.

The diagnosis of dystonia

Dystonia is a movement disorder with many presentations and diverse causes. A systematic approach to dystonia helps to ensure that patients with this disorder receive optimum care. This Review begins with a summary of the clinical features of dystonia, followed by a discussion of other disorders to be considered and excluded before assigning the diagnosis of dystonia. Next, we emphasise the importance of classifying dystonia along several dimensions, and we explain how doing so aids in narrowing the differential diagnosis. The more common forms of dystonia are discussed in detail. Finally, we describe how to apply the clinical information for selection of appropriate laboratory investigations.

Striatal deformities of the hand and foot in Parkinson's disease

Striatal deformities of the hand and foot are abnormal postures that are common in patients with advanced Parkinson's disease (PD); they can present in the early stages of PD and in other parkinsonian disorders. Over a century ago, Charcot and Purves-Stewart recognised these deformities, which cause substantial functional disability and discomfort. The term striatal is used because pathology in the neostriatum (putamen and caudate) has been suggested to cause the deformities, but the pathogenesis is unknown. Misdiagnosis of the deformities is common-particularly when they occur early and in the absence of cardinal parkinsonian signs, such as tremor, bradykinesia, and rigidity-because the hand deformities are similar to those in rheumatoid arthritis, equinovarus foot deformity typically suggests an orthopaedic problem, and toe extension may be thought to be the Babinski sign of upper-motor-neuron syndromes. Here we review the background and clinical features of these deformities to highlight these commonly unrecognised and poorly understood parkinsonian signs.

Transient movement disorders and multiple sclerosis

Movement disorders associated with multiple sclerosis (MS) are uncommon, except for tremor. We report two patients with relapsing-remitting MS, who developed either dystonia or chorea during clinical exacerbation of their MS. The movement disorders resolved during treatment with adrenocorticotropin hormone (ACTH). Acute exacerbations of MS may be associated with transient movement disorders, which are responsive to ACTH.

Dystonia and its disorders

Dystonia is a movement disorder characterized by sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures. The term dystonia does not signify a single disease, but instead describes a symptom and sign that may be part of many disorders with a variety of causes. Dystonia may be classified by age of onset, distribution of symptoms, or by etiology. An increasing number of genetic forms of dystonia have been recognized and the findings have advanced knowledge of underlying neural mechanisms of pathogenesis. Options for treatment of dystonia include pharmacological therapy, botulinum toxin injection, or neurosurgical procedures.

Hemidystonia secondary to cervical demyelinating lesions

Hemidystonia is usually associated with a structural lesion in the contralateral basal ganglia. We report a patient with definite multiple sclerosis, according to Poser's criteria, presenting with an acute-onset sustained left hemidystonia. Cranial T2-weighted magnetic resonance imaging (MRI) showed several hyperintense lesions in the centri semiovali and in the periventricular area without basal ganglia involvement. Moreover cervical spinal cord T2-weighted MRI showed two hyperintense lesions in the left posterolateral spine at C2 and C3, and one lesion in the right posterolateral spine at C4 levels. The hemidystonia improved completely after daily treatment with 1000 mg of methylprednisolone, and cervical MRI was performed after the improvement which showed that the lesions had become smaller and less intense. Finally we consider that the hemidystonia may be caused by the cervical spinal cord lesions of multiple sclerosis.

Painful tonic/dystonic spasms in Sjogren's syndrome

Three patients with Sjogren's syndrome are presented in whom frequent tonic/dystonic spasms of the limbs developed during the course of the illness. These patients' clinical findings suggested spinal cord involvement, a localization that was confirmed by magnetic resonance imaging in two patients. In one patient the painful movements responded to treatment with phenytoin and in one other to baclofen. Sjogren's syndrome should be considered in the differential diagnosis of conditions that produce tonic/dystonic limb spasms.

Acute and chronic pain syndromes in multiple sclerosis. A 5-year follow-up study

Forty-nine (22 males, 27 females) patients with definite multiple sclerosis were examined twice with 5 years interval regarding acute (less than 1 month duration) and chronic (more than 1 month duration) pain syndromes. From the first to the second examination a significant increase was found in the number of acute and chronic pain syndromes, including tension and pain in the extremities, spasms, low back pain, Lhermitte's sign and neuralgia. The increase included both men and women. The increase was especially found in patients with deterioration of disability.