Clinicoradiological comparison between vascular parkinsonism and Parkinson's disease.

OBJECTIVE: To compare the clinical and radiological features of vascular parkinsonism (VP) and Parkinson's disease (PD). METHODS: Cross-sectional study where 15 patients with VP (8 (53.3%) men; aged 75.7 ± 10.4 years) and 30 patients with PD (17 (56.7%) men; aged 67.3 ± 7.5 years) underwent motor and cognitive evaluation and brain MRI. RESULTS: Patients with VP were, on average, 8.4 years older (p = 0.004); all had arterial hypertension. They presented with a sudden onset of parkinsonism (80%) and a rapidly progressive clinical course (53.3%). Predominant lower body parkinsonism (p<0.001), postural instability (p=0.003) with freezing of gait (p<0.001) and falls (p<0.001), urinary incontinence (p < 0.001) and pyramidal signs (p<0.001) were more common in patients with VP. Movement Disorders Society's Unified PD Rating Scale (MDS-UPDRS) scores were higher in patients with VP (p=0.005 in 'OFF' state and p<0.001 in 'ON' state). They had greater cognitive impairment and 12 (80%) fulfilled diagnostic criteria for probable vascular dementia. Most patients with VP had brain MRI changes: multiple lacunar infarcts (66.7%) or extensive white matter disease (26.7%). CONCLUSIONS: VP can be clinically distinguished from PD based on sudden onset of parkinsonism at an older age, characterised by lower body predominance, urinary incontinence, pyramidal signs, postural instability with freezing of gait and falls, and dementia.

Manganese and Parkinson's disease: a critical review and new findings.

The goal of this review was to examine whether chronic Mn exposure produces dopamine neuron degeneration and PD or whether it has a distinct neuropathology and clinical presentation. I reviewed available clinical, neuroimaging, and neuropathological studies in humans and nonhuman primates exposed to Mn or other human conditions that result in elevated brain Mn concentrations. Human and nonhuman primate literature was examined to compare clinical, neuroimaging, and neuropathological changes associated with Mn-induced parkinsonism. Clinical, neuroimaging, and neuropathological evidence was used to examine whether Mn-induced parkinsonism involves degeneration of the nigrostriatal dopaminergic system as is the case in PD. The overwhelming evidence shows that Mn-induced parkinsonism does not involve degeneration of midbrain dopamine neurons and that l-dopa is not an effective therapy. New evidence is presented on a putative mechanism by which Mn may produce movement abnormalities. Confirmation of this hypothesis in humans is essential to make rational decisions about treatment, devise effective therapeutic strategies, and set regulatory guidelines.

Manganese and Parkinson's disease: a critical review and new findings / Manganês e doença de Parkinson: uma revisão crítica e novas descobertas

The goal of this review was to examine whether chronic Mn exposure produces dopamine neuron degeneration and PD or whether it has a distinct neuropathology and clinical presentation. I reviewed available clinical, neuroimaging, and neuropathological studies in humans and nonhuman primates exposed to Mn or other human conditions that result in elevated brain Mn concentrations. Human and nonhuman primate literature was examined to compare clinical, neuroimaging, and neuropathological changes associated with Mn-induced parkinsonism. Clinical, neuroimaging, and neuropathological evidence was used to examine whether Mn-induced parkinsonism involves degeneration of the nigrostriatal dopaminergic system as is the case in PD. The overwhelming evidence shows that Mn-induced parkinsonism does not involve degeneration of midbrain dopamine neurons and that l-dopa is not an effective therapy. New evidence is presented on a putative mechanism by which Mn may produce movement abnormalities. Confirmation of this hypothesis in humans is essential to make rational decisions about treatment, devise effective therapeutic strategies, and set regulatory guidelines.

O objetivo desta revisão foi examinar se a exposição crônica ao Mn produz degeneração do neurônio pela dopamina e DP ou se é apenas uma apresentação neuropatológica e clínica diferente. Foram revisados estudos clínicos, de neuroimagens e neuropatológicos disponíveis sobre humanos e primatas expostos ao Mn ou outras condições humanas que resultam em concentrações elevadas de Mn no cérebro. Foi examinada a literatura sobre humanos e primatas e comparadas as mudanças clínicas de neuroimagem e neuropatológicas associadas com o "parkinsonimo" induzido por Mn, envolvendo a degeneração do sistema dopaminérgico nigro-estriatal como no caso da DP. as evidências decisivas mostram que o "parkinsonismo" induzido pelo Mn não envolve a degeneração dos neurônios de dopamina do mesencéfalo e que o dopa-1 não é uma terapia eficaz. Novas evidências estão presentes em um mecanismo putativo pelo qual o Mn pode produzir anormalidades de movimento. A confirmação desta hipótese em humanos é essencial para tomar decisões adequadas sobre o tratamento, planejar estratégias terapêuticas eficazes e estabelecer guias regulatórios.

Pyramidal tract degeneration in multiple system atrophy: the relevance of magnetization transfer imaging.

The clinical features of multiple system atrophy (MSA) include four domains: autonomic failure/urinary dysfunction, Parkinsonism, cerebellar ataxia, and corticospinal tract dysfunction. Although the diagnosis of definite MSA requires pathological confirmation, magnetic resonance imaging (MRI) studies have been shown to contribute to the diagnosis of MSA. Although pyramidal tract dysfunction is frequent in MSA patients, signs of pyramidal tract involvement are controversially demonstrated by MRI. We evaluated the pyramidal involvement in 10 patients (7 women) with clinically probable MSA, detecting the presence of spasticity, hyperreflexia, and Babinski sign, as well as demonstrating degeneration of the pyramidal tract and primary motor cortex by MRI in all of them. Our article also discusses key radiological features of this syndrome. In MSA, pyramidal tract involvement seems to be more frequent than previously thought, and the clinicoradiological correlation between pyramidal tract dysfunction and degeneration may contribute to the understanding of the clinical hallmarks of MSA. MRI may also add information regarding the differential diagnosis of this syndrome.

Vascular parkinsonism: analysis of seven cases.

INTRODUCTION: Neuroimaging studies of elderly individuals reveal alterations in the white matter that are incompatible with the patients parkinsonism, mistakenly classified as vascular parkinsonism (VP). METHOD: This study was conducted on a population composed of 20 patients with Parkinsons disease (PD) whose neuroimaging exams revealed vascular alterations in the white matter and seven patients with VP in order to compare diagnostic criteria. RESULTS: Age at disease onset of patients with PD was 55+/-12 years and patients with VP it was 62+/-13 years. Twelve patients with PD and five patients with VP presented arterial hypertension; three patients with VP and two patients with PD presented gait impairment; all patients with VP presented rigidity and bradykinesia, six of them presented resting tremor; 19 patients with PD presented tremor and 19 of them presented rigidity, while 17 presented bradykinesia. When the symptoms and evolution of both diseases were compared, the vascular alterations in the white matter were considered unspecific. CONCLUSION: Since clinical symptoms are unspecific, a differential diagnosis requires neuroimaging, good response to levodopa and clinical evolution.

Vascular parkinsonism: analysis of seven cases / Parkinsonismo vascular: análise de sete casos

INTRODUCTION: Neuroimaging studies of elderly individuals reveal alterations in the white matter that are incompatible with the patientÆs parkinsonism, mistakenly classified as vascular parkinsonism (VP). METHOD: This study was conducted on a population composed of 20 patients with ParkinsonÆs disease (PD) whose neuroimaging exams revealed vascular alterations in the white matter and seven patients with VP in order to compare diagnostic criteria. RESULTS: Age at disease onset of patients with PD was 55±12 years and patients with VP it was 62±13 years. Twelve patients with PD and five patients with VP presented arterial hypertension; three patients with VP and two patients with PD presented gait impairment; all patients with VP presented rigidity and bradykinesia, six of them presented resting tremor; 19 patients with PD presented tremor and 19 of them presented rigidity, while 17 presented bradykinesia. When the symptoms and evolution of both diseases were compared, the vascular alterations in the white matter were considered unspecific. CONCLUSION: Since clinical symptoms are unspecific, a differential diagnosis requires neuroimaging, good response to levodopa and clinical evolution.

INTRODUÇÃO: Estudos de neuroimagem em idosos mostram alterações na substância branca que são incompatíveis com o parkinsonismo do paciente, erroneamente classificado como parkinsonismo vascular (PV). MÉTODO: Este estudo foi conduzido a partir de uma população de 20 pacientes com doença de Parkinson (DP) cujos exames de neuroimagem revelaram alterações vasculares na substância branca e sete pacientes com PV para comparar os critérios diagnósticos. RESULTADOS: A idade de início da doença dos pacientes com DP foi 55±12 anos e pacientes com PV foi 62±13 anos. Doze pacientes com DP e cinco pacientes com PV apresentaram hipertensão arterial; três pacientes com PV e dois pacientes com DP apresentaram alteração da marcha; todos os pacientes com PV apresentaram rigidez e bradicinesia, seis deles apresentaram tremor de repouso; 19 pacientes com DP apresentaram tremor e 19 deles apresentaram rigidez, enquanto 17 apresentaram bradicinesia. Quando os sintomas e a evolução de ambas as doenças foram comparadas, as alterações vasculares na substância branca foram consideradas inespecíficas. CONCLUSÃO: Como os sintomas clínicos são inespecíficos, um diagnóstico diferencial requer neuroimagem, boa resposta a levodopa e evolução clínica da doença.

[Is the glabellar reflex a component of neuroleptic-induced Parkinsonism?]. / Es el reflejo glabelar un componente del parkinsonismo inducido por neurolépticos?

INTRODUCTION: Some neurological findings have been attributed to neuroleptics as secondary manifestations of psychotic disorders. OBJECTIVE: In the current study, the role of the glabelar sign was evaluated as a clinical component of the secondary parkinsonism induced by neuroleptics. MATERIALS AND METHODS: Patients with psychosis having secondary parkinsonism induced by neuroleptics were evaluated with the Simpson-Angus Rating Scale for extrapyramidal side effects. The contribution of the glabelar syndrome in the overall syndrome was evaluated using factor analysis methods. RESULTS: One hundred three patients having secondary parkinsonism induced by neuroleptics were evaluated. The sample had nearly equal gender representation: with 52.4% women. A majority of patients had received haloperidol as antipsychotic treatment. Bipolar disorders and schizophrenia were the most frequent diagnostic groups. The item corresponding to glabelar sign showed the lower average inter item covariance and the higher uniqueness score. Cronbach alpha scores increased when the item corresponding to glabelar sign was retired from the scale. CONCLUSIONS: These results suggested that glabelar sign measures a condition different from secondary parkinsonism induced by neuroleptics. This clinical finding is not recommended for evaluating the evolution of neurological response to neuroleptics, however.

Flunarizine and cinnarizine-induced parkinsonism: a historical and clinical analysis.

BACKGROUND: Drug-Induced Parkinsonism (DIP) represents the second leading cause of Parkinsonism (PK) in several countries. Flunarizine and cinnarizine are some of the most common drugs that cause DIP. This paper reviews the first description of Flunarizine and Cinnarizine-Induced Parkinsonism (FCIP), as well as the subsequent literature, emphasizing epidemiological, clinical and diagnostic aspects. METHODS: We reviewed the literature on the subject, with special emphasis on the first description and the later definition of the clinical syndrome that results from chronic use of flunarizine and cinnarizine. RESULTS: In 1984, De Melo-Souza reported the first description of flunarizine-induced PK in five patients. Other reports followed on FCIP, emphasizing the clinical features, which are symmetrical parkinsonism, and depression, affecting mainly elderly women. CONCLUSIONS: Eighteen years after the original description, FCIP is a recognized condition with specific clinical features, and is the second most common cause of parkinsonism in many countries.

Possible relation of atypical parkinsonism in the French West Indies with consumption of tropical plants: a case-control study. Caribbean Parkinsonism Study Group.

BACKGROUND: In Europe and North America, Parkinson's disease is the major form of parkinsonism; less than 4% of cases are progressive supranuclear palsy (PSP) and about 20% are atypical parkinsonism. The distribution of these subgroups is different in the French West Indies. We aimed to define the clinical and demographic specificity of these disorders in Guadeloupe and to investigate a postulated link with consumption of herbal tea and fruits from the Annonaceae family (Annona muricata and Annona squamosa), which contain neurotoxic benzyltetrahydroisoquinoline alkaloids. METHODS: Between September, 1996, and August, 1998, 87 consecutive patients with parkinsonism were referred to the single neurological department in Guadeloupe. After detailed clinical, neurophysiological, cognitive, and neuroradiological assessment, they were classified by generally accepted criteria as having Parkinson's disease, PSP, or atypical parkinsonism. We compared the amount of tropical fruits and herbal tea consumed by the various parkinsonian subgroups and by frequency-matched controls (patients with benign symptoms and no neurodegenerative disease). FINDINGS: Of the 87 patients, 22 had Parkinson's disease, 31 had PSP, 30 had atypical parkinsonism, and four had atypical parkinsonism associated with motor neuron disease, 44 of the patients with PSP or atypical parkinsonism were male. The patients with atypical parkinsonism had symmetrical rigidity and bradykinesia, and no levodopa peak-dose dyskinesias. Patients with PSP differed from those with atypical parkinsonism because they had supranuclear vertical down-gaze palsy, severe gait and balance problems, and frontal-lobe syndrome. 29 patients with PSP reported regular consumption of pawpaw fruit, and 26 drank herbal tea. 30 patients with atypical parkinsonism reported regular consumption of pawpaw fruit, and 24 drank herbal tea. Both of these groups consumed significantly more fruit and herbal tea than patients with Parkinson's disease (fruit: odds ratio 23.6; herbal tea: 28.2); and controls (fruit: 20.7; herbal tea: 6.48). INTERPRETATION: Our study confirms the over-representation of atypical parkinsonism and PSP in patients with parkinsonism in the French West Indies. Chronic exposure to neurotoxic alkaloids could be an important aetiological factor because these compounds induce parkinsonism in animals. A larger epidemiological study, to clarify the link between these fruits with atypical parkinsonism and PSP, is proposed.

Pilot study with clozapine in patients with HIV-associated psychosis and drug-induced parkinsonism.

Clozapine (CZP) is an atypical antipsychotic drug that does not appear to block striatal dopamine receptors. In six patients who met the criteria of HIV-associated psychosis and who had previously developed moderate parkinsonism as a result of the use of typical neuroleptic agents, CZP was added in an open, rising dose study. Subjects were evaluated at baseline after at least 7 days without neuroleptic drugs and then monthly for 3 months of the experimental treatment using three rating scales: Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression (CGI), and motor examination of the Unified Parkinson's Disease Rating Scale (UPDRS). A significant reduction in psychopathology as represented in the BPRS total score (54.2 at baseline versus 23.9 at month 3) and CGI (2 and 8, respectively) was obtained with a mean CZP dose of 27.08 mg/day. Parkinsonism also improved by an average of 76.5% at the end of the study. One patient did not complete the study as a result of a progressive decrease in leukocyte count while on CZP. These preliminary results suggest that the pharmacologic properties of CZP may be of value in the management of HIV-psychotic patients.

Etiology of parkinsonism in a Brazilian movement disorders clinic.

OBJECTIVE: The aim of the present study is to investigate whether there are geographic differences in the etiology of parkinsonism (PA). BACKGROUND: 72% of patients with PA evaluated at movement disorders clinics in the Northern Hemisphere are diagnosed with Parkinson's disease (PD). Data regarding other regions are not available. METHODS: We reviewed the charts of all patients with PA seen at the Federal University of Minas Gerais Movement Disorders Clinic from July 1993 through October 1995. PA was diagnosed by the presence of at least two of the following: rest tremor, bradykinesia, rigidity, and postural instability. The different etiologies were diagnosed based on standard clinical criteria. RESULTS: During the period of the study, PA was recognized in 338 subjects. The following clinical diagnoses were made: PD (68.9%), drug-induced PA (DIP) (13.3%), vascular PA (4.7%), Progressive supranuclear palsy (PSP) (2%), multiple system atrophy (MSA) (1.8%), others (9.7%). Cinnarizine, haloperidol and flunarizine were the commonest drugs related to DIP. CONCLUSIONS: Similarly to other studies, PD accounts for about 70% of PA patients. However, there are differences between our results and previous series. DIP is much more common in the present series. This may be accounted for a more liberal use of antidopaminergic drugs in our environment, especially Calcium channel blockers. The lower frequency of MSA and PSP in our study may reflect a short follow-up, since many patients initially diagnosed with PD later are found to have Parkinson-plus syndromes.

Etiology of parkinsonism in a Brazilian movement disorders clinic

Objective: The aim of the present study is to investigate whether there are geographic differences in the etiology of parkinsonism (PA). Background: 72 percent of patients with PA evaluated at movement disorders clinics in the Northern Hemisphere are diagnosed with Parkinson's disease (PD). Data regarding other regions are not available. Methods: We reviewed the charts of all patients with PA seen at the Federal University of Minas Gerais Movement Disorders Clinic from July 1993 through October 1995. PA was diagnosed by the presence of at least two of the following: rest tremor, bradykinesia, rigidity, and postural instability. The different etiologies were diagnosed based on standard clinical criteria Results: During the period of the study, PA was recognized in 338 subjects. The following clinical diagnoses were made: PD (68.9 percent), drug-induced PA (DIP) (13,3 percent), vascular PA (4.7 percent), progressive supranuclear palsy (PSP) (2 percent), multiple system atrophy (MSA) (1.8 percent), others (9.7 percent). Cinnarizine, haloperidol and flunarizine were the commonest drugs related to DIP. Conclusions: Similarly to other studies, PD accounts for about 70 percent of PA patients. However, there are differences between our results and previous series. DIP is much more common in the present series. This may be accounted for a more liberal use of antidopaminergic drugs in our environment, especially Calcium channel blockers. The lower frequency of MSA and PSP in our study may reflect a short follow-up, since many patients initially diagnosed with PD later are found to have Parkinson-plus syndromes.

[Tool for the quantitative evaluation of symptoms in defined idiopathic Parkinson's disease]. / Un instrumento para la evaluación cuantitativa de los síntomas en la enfermedad de Parkinson idiopática definida.

OBJECTIVE: To determine the reliability of a clinical quantitative instrument for assessing the symptoms of Defined Idiopathic Parkinson Disease (DIPD). PATIENTS AND METHODS: From 148 patients with parkinsonism syndrome, the best 62 EPID cases, according to Calne et al (1992), and Larsen et al (1994) criteria--37 males and 25 females--were selected. RESULTS: The age mean was 68.4 (7.4) year-old, the age of onset was 64 (7.2) years, the time of evolution was 4.3 (2.9) years. 98.4% of the sample was in 1 to 3 Hoehn and Yahr clinical state. Right parkinsonism score (RPS) was 8.2 (4.2), and left (LPS) was 6.7 (4.8). Significant differences between right and left tremor, rigidity and dyskinesia scores were found (ji-squared, p < 0.05). Total parkinsonism score (TPS) was 14 (6.9). Several significant and high correlated coefficients were found between most of the scale's components and Hoehn and Yahr clinical state, TPS, and time of evolution (r > 0.40, p < 0.0001). Total 21 items scale Cronbach's alpha coefficient was 0.92. A stepwise multiple regression model showed that rigidity, postural reflex disorder, and micrography were able to predict the Hoehn and Yahr clinical state (81.4%, p < 0.0001). A principal component analysis showed that akinesia explained more than 59% of the instrument variance, while micrography only explained 0.57% of the variance (100 time lesser). CONCLUSION: A reliability structure of the instrument was demonstrated for assessing parkinsonism symptoms in DIPD subjects.

The inter-relationships of tardive dyskinesia, parkinsonism, akathisia and tardive dystonia: the Curaçao Extrapyramidal Syndromes Study II.

A study of the four extrapyramidal syndromes (EPS), tardive dyskinesia, parkinsonism, akathisia and tardive dystonia, was performed in the Netherlands Antilles, a well-defined catchment area with only one psychiatric hospital. The population under study (N = 194; mean age 53.1) was mainly Afro-Caribbean, and most patients were chronic. The severity of each EPS was measured with valid and reliable rating scales. The purpose was to study both the strength of the inter-relationships of EPS and the prevalence of combinations of EPS. The inter-relationships between the EPS were analyzed by means of logistic regression. The adjusted odds ratios between the various EPS revealed strong connections between the hyperkinetic syndromes (tardive dyskinesia, tardive dystonia and akathisia). Parkinsonism was found to be inversely related to tardive dyskinesia and to tardive dystonia. Almost 30% of the patients suffered from two or more EPS. The highest prevalence rates of combinations were: tardive dyskinesia combined with parkinsonism 12.9%, tardive dyskinesia combined with tardive dystonia 9.8%, and tardive dyskinesia combined with akathisia 5.2%. Our findings show a strong positive correlation between hyperkinetic forms of EPS. Furthermore, chronic psychiatric inpatients regularly suffer from combinations of EPS. Different treatment strategies are suggested for various combinations of EPS.

Prevalence of Parkinson's disease in Junín, Buenos Aires Province, Argentina.

We investigated the prevalence of Parkinson's disease (PD) in a South American city: Junín, Buenos Aires Province, Argentina. At dwellings systematically selected, the case finding involved household screenings and neurological examinations (i.e., a two-phase survey approach). Only persons 40 years of age or older were eligible (N = 7,765). There were 51 cases of PD identified, yielding a crude prevalence of 656.8 per 100,000 population. The age-specific prevalence was consistently higher in men than women, and it increased with advancing age for both sexes. In addition to prevalence figures. we present tallies related to clinical features of PD, as well as tallies related to other subtypes of parkinsonism.

[Precocious Parkinson's disease associated with "eye-of-the-tiger" type pallidal lesions]. / Parkinsonismo precoce associado a lesões palidais de tipo "eye-of-the-tiger".

We report the case of a 56-years-old woman patient, born to unrelated parents, who since 26-years-old gradually developed bradykinesia, rigidity, tremor of both hands, and speech and gait difficulties. Her past history was unremarkable. There was no family history of neurologic disease. She was admitted to our Hospital at age 39 and at that time she presented a full parkinsonian syndrome. The following tests were normal or negative: routine blood studies, serum copper, ceruloplasmin and cerebrospinal fluid examination. There was not Kayser-Fleicher ring, and fundoscopic examination revealed no abnormalities. Levodopa was introduced and response was good for more than ten years, despite early-onset of dyskinesias (three months after the introduction of the drug). After 30 years under levodopa she still presents a moderate response but with severe fluctuations of the motor performance. Except for slowness of cognition she developed no other neuropsychological impairments, and a recent neurological examination disclosed no abnormalities besides a parkinsonian syndrome. One year ago, a magnetic resonance imaging (MRI) was performed and showed bilateral, symmetrical lesions with "eye-of-the-tiger" pattern. This case illustrates the pathological heterogeneity of early-onset parkinsonism and suggests the possibility to find the typical MRI lesions seen in Hallervorden-Spatz disease in other degenerative affections involving globus pallidus.

Parkinsonismo precoce associado a lesöes palidais de tipo eye-of-the-tiger / Precocious Parkinson's disease associated to eye-of-the-tiger type pallidal lesions

Relata-se o caso de uma paciente com quadro parkinsoniano instalado aos 26 anos de idade, 30 anos de evoluçäo, boa reposta à levodopa e desenvolvimento precose de discinesias induzidas por essa droga. Essas características associadas à ausência de outras manifestaçöes neurológicas ao longo de todo o curso da moléstia sugeriam substrato anátomo-patológico superponível ao da forma clássica da doença de Parkinson. Entretanto, as imagens de ressonância magnética mostraram lesöes palidais do tipo "eye-of-the-tiger", semelhantes às observadas na doença de Hallervorden-Spatz. O presenta caso ilustra a heterogeneidade patológica dos casos de parkinsonismo de instalaçäo precoce e a possibilidade do encontro desse padräo de lesöes palidais em outras doenças degenerativas dos gânglios da base

[Treatment of Parkinson disease]. / Tratamento da doença de Parkinson.

Parkinson's disease (PD) accounts for 58% of patients with Parkinsonism. The second most common cause is drug-induced Parkinsonism, diagnosed in 20% of patients. Levodopa remains as the mainstay of PD treatment. Although there is controversy regarding the timing for beginning levodopa, it should be used when the patient develops significant disability. Other drugs that may be used are anticholinergic agents, useful for tremor; amantadine, for rigidity and bradykinesia; dopamine agonists, for the management of levodopa complications; and selegiline which may be a neuroprotector agent. Problems in the management of PD include primary failure, secondary failure and levodopa complications. Antidopaminergic drugs, severe rest tremor and diagnosis error may lead to primary failure. Progression of PD is the most common explanation for secondary failure. The most important levodopa therapy complications are dyskinesias and fluctuations. Other common problems are dysautonomia, depression, psychosis and dementia. The author discusses the phenomenology and management of these complications. Future perspectives include brain repair surgeries.

Tratamento da doença de Parkinson / Treatment of Parkinson disease

Doença de Parkinson (DP) é a causa mais freqüente de parkinsonismo em nosso meio, responsável por 58 por cento dos casos. Devem-se excluir outras causas, como uso de drogas antidopaminérgicas (20 por cento dos casos). Levodopa é o agente mais importante para o tratamento de DP. Há controvérsia sobre quando se introduzir esta droga mas deve-se reservá-la para quando surgir substancial comprometimento funcional. Drogas acessárias säo anticolinérgicos, úteis para o tremor, amantadina, para bradicinesia e rigidez; e agonistas dopaminérgicos que ajudam no manuseio de complicaçöes da levodopa. A selegelina tem discreta açäo sintomática e possível açäo neuroprotetora. O tratamento de DP pode ser complicado por falha primária, falha secundária e problemas do uso da levodopa. A falha primária pode ser causada por uso de agentes antidopaminérgicos, presença de tremor de repouso severo ou erro diagnóstico. A causa mais comum de falha secundária é progressäo da DP. As principais complicaçöes do uso da levodopa säo flutuaçöes e discinesias. Outros problemas comuns säo disautonomia, depressäo, psicose e demência. Fenomenologia e manuseio destas complicaçöes säo discutidos. Perspectivias futuras incluem cirurgias para reversäo de patologia