WELCOME

Scientific Seminar
Department of Neuro-Medicine
Rajshahi Medical College Hospital
 ATYPICAL
PARKINSONISM
Presented By:
Dr. Ahmed Tanjimul Islam (Ovi)
MD (Thesis) Student Neurology
James Parkinson (1817)
Case 1
Case 1: ‘C. Dickens’ 58 yrs
History

Examination

Investigation
Case 1
MRI Case 1:
Case 2: Alicia 61 yrs
History

Examination

Investigation
MRI Case 2
Case 3: Alicia ‘64 years’
History

Examination

Investigation
Case 2:
MRI Case 3:
 1st Diagnosis:
Parkinson’s Disease
 1st Diagnosis:
Parkinson’s Disease

Unique Unique
Clinical Imaging
Findings Findings
 1st Diagnosis:
Parkinson’s Disease

Unique Unique
Clinical Imaging
Findings Findings

Rapid
Progression
 1st Diagnosis:
Parkinson’s Disease

Unique Unique
Clinical Imaging
Findings Findings

Rapid
Progression

Bad response
to Levadopa
Diagnostic Criteria of PSP
1. Yes
2. Yes
3. Yes
4. NO
5. Yes
 Case 1:
Diagnosis:
PSP
(Progressive Supra-Nuclear Palsy)
PSP Case
 Signs PD PSP
Eye signs - +++
Postural Instability - (late) +++
Axial rigidity + +++
Resting Tremor +++ -
Levadopa response +++ +
Diagnostic criteria of MSA
 Signs PD MSA
Autonomic + +++
Cerebellar - +++
Postural instability + +++
Dementia - ++
Levadopa response +++ + (Transient)
Diagnostic Criteria of CBD
1.
2.
3.
4.
5.
6.
 Case 3:
Diagnosis:
CBD
(Cortico-Basal Degeneration)
Hand posture in CBD
CBD Case
CBD Case
CBD Case
Parkinsonism
 Parkinsonism

Atypical
PD Parkinsonism
 Parkinsonism

Atypical
PD Parkinsonism

Sporadic Familial
 Parkinsonism

Atypical
PD Parkinsonism

Sporadic Familial Sporadic Familial Secondary

 Parkinsonism

Atypical
PD Parkinsonism

Sporadic Familial Sporadic Familial Secondary

PSP
MSA
CBD
 Parkinsonism

Atypical
PD Parkinsonism

Sporadic Familial Sporadic Familial Secondary

PSP Vascular
Trauma
MSA Tumor
Toxins
CBD Infections
Parkinsonism

Atypical
Parkinsonism

Sporadic

PSP
MSA
CBD
BASIC PATHOLOGY
Synucleino-pathy Tau-pathy
Synucleino-pathy Tau-pathy
Synucleino-pathy Tau-pathy
Synucleino-pathy Tau-pathy
 Synucleino-pathy Tau-pathy

Parkinsonism

Cognitive
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism

PD
Cognitive
Cognitive
impairment
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism
MSA

PD
Cognitive
Cognitive
impairment
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism
MSA
PSP
PD
Cognitive
Cognitive
impairment
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism
MSA
PSP
PD CBD
Cognitive
Cognitive
impairment
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism
MSA
PSP
PD CBD
Cognitive
Cognitive
impairment
impairment DLB AD
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism
MSA
PSP

CBD
Cognitive
Cognitive
impairment
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism

MSA PSP
PD
Cognitive
Cognitive CBD
impairment
impairment
 Synucleino-pathy
Synucleino-pathy Tau-pathy
Tau-pathy

Parkinsonism
Parkinsonism
PSP
MSA

PD
Cognitive
Cognitive
impairment
impairment
CBD
 Average Cases in Daily practice

Atypical Parkinsonism

Secondary PD

PD

0 10 20 30 40 50 60 70 80 90
 Average Cases in Daily practice

Atypical Parkinsonism 5
Secondary PD 10
PD 85
0 10 20 30 40 50 60 70 80 90
 Percentage of Atypical Parkinsonism
varients

CBD

MSA

PSP
0 10 20 30 40 50 60 70 80
 Percentage of Atypical Parkinsonism
varients

CBD 5

MSA 25

PSP 70
0 10 20 30 40 50 60 70 80
 Average years of response to Levadopa

CBD

PSP

MSA

PD
0 10 20 30 40 50 60 70 80
 Average years of response to Levadopa

CBD 0.4

PSP 1.5
MSA 3
PD 72
0 10 20 30 40 50 60 70 80
 Average years of response to Levadopa

CBD 0.4

PSP 1.5
MSA
3
PD
0 10 20 30 40 50 60 70
72
80
 Average survival years from symptom
onset

CBD

PSP

MSA

PD
0 2 4 6 8 10 12 14 16
 Average survival years from symptom onset

CBD 7
PSP 7
MSA 8
PD 15
0 2 4 6 8 10 12 14 16
When to suspect Atypical Parkinsonism

Motor Ocular Behavioral Autonomic

 When to suspect Atypical Parkinsonism

Motor Ocular Behavioral Autonomic

Early Falls • Orthostatic

Cerebellar Signs
Vertical Gaze Palsy Early Dementia Hypotension
Pyramidal Signs • Incontitence
Slow Saccades Hallucination
Axial Rigidity • Impotency
 When to suspect Atypical Parkinsonism

Motor Ocular Behavioral Autonomic

Early Falls • Orthostatic

Cerebellar Signs
Vertical Gaze Palsy Early Dementia Hypotension
Pyramidal Signs • Incontitence
Slow Saccades Hallucination
Axial Rigidity • Impotency

• Response to Levadopa
• Rapid Progression of disease
 When to suspect Atypical Parkinsonism

Motor Ocular Behavioral Autonomic

Early Falls
Orthostatic
Cerebellar Signs
Vertical Gaze Palsy Early Dementia Hypotension
Pyramidal Signs
Slow Saccades Hallucination Incontinence
Axial Rigidity
Impotency

• Response to Levadopa
• Rapid Progression of disease

Imaging (MRI, PET Scan findings)

When to suspect Atypical Parkinsonism

Motor Ocular Behavioral Autonomic

A=
B=
C=
D=
E=
F=
Response to Levadopa
Rapid Progression of disease
Imaging (MRI, PET Scan findings)
 Signs PD PSP MSA CBD
Symmetry + +++ +++ _
Axial Rigidity + +++ ++ +
Palsy Vertical Gaze + +++ + +
Postural instability + +++ +++ +
Autonomic +- + +++ -
features
L Dopa response +++ + + -
Early
L Dopa response ++ - + -
late
Limb dystonia - - - +++
Alien limb
MRI findings + ++ ++ +++
Treatment of Atypical Parkinsonism:
Actor ‘Kader Khan’: Diagnosed as PSP
Thank You