Movement Disorders in Non-Wilsonian Cirrhotic Patients: A Report of the Prevalence and Risk Factors from a Study Done in a Medical School in an Agricultural-Based Community

OBJECTIVE: Parkinsonism and other movement disorders have previously been reported in the acquired hepatocerebral degeneration associated with portosystemic shunting. However, there is no study to date about their prevalence as has been noted in general practice. METHODS: One hundred and forty-three patients with hepatic cirrhosis from the gastroenterology clinic and internal medicine wards were enrolled. Liver data included the diagnoses, etiologies, assessments of complications, and treatments for cirrhosis. Hepatic encephalopathy was classified with regard to the West Haven criteria for semi-quantitative grading for mental status. Neurological examination results and abnormal involuntary movements were recorded as primary outcomes. Neuro-radiology was used for the detection of severe brain lesions. RESULTS: Alcoholism was the most common cause of liver cirrhosis. Eighty-three patients (58%) presented with movement disorders. Asterixis was found in one of the cases. The most common movement disorder seen was an intentional tremor at 37.1%, which was followed by bradykinesia, Parkinsonism, and postural tremors at 29.4%, 10.5%, and 6.3%, respectively. The prevalence of movement disorders simultaneously increased with a high Child-Turcotte-Pugh score. The hepatic encephalopathy was grade 1 and 2. With the inclusion of age-range adjustments, we found that alcoholic cirrhosis and hepatic encephalopathy are statistically significant factors [p < 0.05, odds ratio (OR) = 6.41, 95% confidence interval (CI) 1.38-29.71 and p < 0.001, OR = 13.65, 95% CI 4.71-39.54] for the development of movement disorders in non-Wilsonian cirrhotic patients. CONCLUSIONS: Intentional tremor is a common abnormal movement. Alcoholic cirrhosis and hepatic encephalopathy are significant risk factors in the development of movement disorders in non-Wilsonian cirrhotic patients.

Movement Disorders in Non-Wilsonian Hepatic Cirrhotic Patients: The Subgroup Analysis of Various Phenotypes and Associated Risk Factors

OBJECTIVE: The aim of this subgroup analysis was to identify the risk factors associated with the development of various movement disorder phenotypes. METHODS: Eighty-three non-Wilsonian cirrhotic patients with abnormal movements were allocated into the following groups: intention tremor, bradykinesia, Parkinsonism, and abnormal ocular movements. These movement types were considered the primary outcomes as there was a sufficient sample size. Researchers took into consideration the gender, etiologies of cirrhosis, cirrhosis-related complications, hepatic encephalopathy, medical illness, and some neurological deficits as potential factors associated with these movement disorders. RESULTS: The male gender (p = 0.002) and alcoholic cirrhosis (p = 0.005) were significant factors for the prevalence of intention tremors. In bradykinesia, hepatic encephalopathy was highly statistically significant (p < 0.001), and females more commonly developed bradykinesia (p = 0.04). The Parkinsonism features in this study were confounded by hyperlipidemia (p = 0.04) and motor or sensory deficits (p = 0.02). Jerky pursuits and a horizontal nystagmus were detected. Jerky pursuits were significantly related to hepatic encephalopathy (p = 0.003) and bradykinesia, but there were no factors associated with the prevalence of nystagmus other than an intention tremor. CONCLUSIONS: The association of alcoholic cirrhosis with the development of intention tremor indicates that the persistent cerebellar malfunction in cirrhotic patients is due to alcohol toxicity. The slowness of finger tapping and jerky pursuit eye movements are significantly associated with hepatic encephalopathy. Thus, further studies are needed to evaluate the diagnostic value of these two signs for an early detection of mild hepatic encephalopathy.

Pseudoathetosis: three cases of delayed-onset movement disorder

Pseudoathetosis refers to choreoathetoid movements occurring in association with loss of proprioception. The responsible lesions can be located most anywhere and indicates a disruption of the proprioceptive pathway, from peripheral nerves to the parietal cortex. We describe the clinical courses, radiologic fi ndings and treatments of 3 patients with spinal pseudoathetosis. Patients 1 and 3 experienced the movement disorder 2 years and 6 months, respectively, after resections of spinocerebellar tumors. Patient 2 had bilateral arm weakness from cervical disc herniation one year prior to the onset of pseudoathetosis. MRI of the cervical spine revealed lesions in the dorsolateral column of the cervical cord as the cause of the impaired proprioceptive sensation. Since the clinical course of two patients had shown delayed onset following a neuro-surgical procedure, the consequent neuroplasticity of disruptive sensory pathways was thought to be the explanation for the development of the pseudoathetosis. Pseudoathetosis in the second case could be due to a natural course of progression from cervical cord compression. In conclusion, pseudoathetosis is a rare movement disorder and the pathophysiology remains an enigma.

อาการแขนขาซีกซ้ายอ่อนแรงเฉียบพลันที่เกิดตามหลังโรคไข้สมองอักเสบเจอี:รายงานผู้ป่วย 1 ราย (Delayed onset acute hemiparesis in Japanese Encephalitis: A case report and literature review)

Japanese encephalitis remains an important public health burden in Thailand despite japanese encephalitis vaccine has been employed in the Expanded Program of Immunization (EPI). Acute stroke or hemiparesis was an atypical feature in japanese encephalitis. We report a case of japanese encephalitis proven by demonstration of specific IgM antibody against JEV in serum with delayed presentation of left hemiparesis. No remarkably structural abnormality of brain parenchyma was detected by computer tomography (CT) and magnetic resonance imaging (MRI). With supportive treatment and physical rehabilitation, this patient has returned to fully normal neurological function.