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Home , Akathisia, Athetosis, Tremor

Movement Disorders in

Cristian Falup-Pecurariu MD, PhD Associate Professor of Chair, Department of Neurology Faculty of Medicine, Transilvania University Brașov, Romania

MDS-ES online Teaching Course Movement Disorders in Neurological and Systemic Disorders October 31, 2020 Outline

1. Introduction – prevalence, classification, temporal relationship stroke – movement disorders 2. Lession patterns in subjects with stroke-related movement disorders - - - //ballism - Introduction

• Cerebrovascular diseases: 22% of secondary movement disorders – 1-4% patients with stroke • Most affected structures: – (44%) – (37%)

Gupta N, Pandey S. Eur Neurol 2018;79(5-6):303-314 Ghika-Schmid F, et al. J Neurol Sci 1997; 146: 109–116 Alarcón F, et al. J Neurol Neurosurg 2004;75:1568–1574 Classification Post-stroke movement disorders

Hyperkinesias Hypokinesias (parkinsonism)

Tremor, Chorea Dystonia ,

Nakawah MO, Lai EC. Neuropsychiatr Dis Treat. 2016 Nov 7;12:2885-2893 Prevalence of post-stroke movement disorders

Lausanne stroke registry Quito, Ecuador stroke (%) registry (%) Chorea 38 36 Dystonia 17 29 Limb shaking 10 Myoclonus - Dystonia 10 Stereotypic 7 Asterixis 7 Tremor 3 25 Hemi- 3 , dyskinetic hand 2 Parkinsonism 10

Park J. J Mov Disord 2016; 9(2): 71-79 Ghika-Schmid F et al. J Neurol Sci 1997;146:109-116 Alarcón F et al. J Neurol Neurosurg Psychiatry 2004;75:1568-1574 Temporal relationship between stroke and movement disorders

Park J. J Mov Disord 2016; 9(2): 71-79 Gupta N, Pandey S. Eur Neurol 2018;79(5-6):303-314

120% Ischemic stroke

100.00% Hemorrhagic 100% stroke 89.00% 82.50% 81.00% 78.80% 80%

61.10% 60% 57.20%

Type of stroke of Type 42.80% 38.90% 40%

19% 21.20% 20% 17.50% 11%

0% 0% Simultaneously Within 1 day 1 day - 1 week > 1 week - < 1 1 month - < 6 6-12 months > 1 year month months LATENCY PERIOD

Suri R et al. J Stroke Cerebrovasc Dis. 2018 Sep;27(9):2388-2397 90.00% Improved / 83.70% 81.90% Resolved 80.00% Persisted

Unknown 70.00%

60.00% 54.70%

50.00%

39.20% 38.34% 40.00% 38.40% 32.60% 30.00% 28.20% 23.80% 23.10% 21.40% 20.00% 15.10% 16.20%

10.00% 3.00% 0% 0.00% Dystonia Chorea Myoclonus Parkinsonism Tremor

Putamen: 30% Caudate: 40% Frontal lobe: 30.5% : 44% Midbrain: 31.25% : 30% Putamen: 30.7%, Glubus pallidus: 71.4% Posterolateral thalamus: 53.3% Parietal lobe: 50% Caudate: 30.7% Midbrain: 50% Suri R et al. J Stroke Cerebrovasc Dis. 2018 Sep;27(9):2388-2397 Lesion patterns in subjects with stroke-related movement disorders Handley A et al. Age Ageing 2009 May;38(3):260-6 Suri R et al. J Stroke Cerebrovasc Dis. 2018 Sep;27(9):2388-2397 Localization

Poewe W, Matosevic B in Movement Disorders in Neurologic and Systemic Disease. Cambridge University Press, 2014 Ghika-Schmid F et al. J Neurol Sci. 1997 Mar 10;146(2):109-16. Ghika-Schmid F et al. J Neurol Sci. 1997 Mar 10;146(2):109-16 1) Specific vascular movement disorders – tremor • Typically: 3-6 Hz resting tremor • Parkinsonian tremor (5Hz): contralateral /medial aspects of • Thalamic tremor: – Low frequency tremor – Prominent postural + intentional component – Postero-lateral thalamus • Cerebellar tremor – Action tremor (goal-directed movements); “” - < 5Hz • Holmes’ tremor =rubral or midbrain tremor <4 Hz; large amplitude – Unilateral; proximal + distal upper extremity; rarely – leg – Increasing severity:

resting postural intentional

• Palatal tremor (myoclonus) – / cerebellum 1.5 – 3 Hz Holmes’ tremor

Kipfer S, Frigerio SB. Mov Disord; 28:10, 2013

Thalamic tremor – examples (1)

Krystkowiak et al. Mov Disord. 2000 Sep;15(5):911-8. Thalamic tremor – examples (2)

Krystkowiak et al. Mov Disord. 2000 Sep;15(5):911-8. 2). Specific vascular movement disorders - dystonia • Hemidystonia: most common post-stroke dystonia – MCA territory: putamen, lentiform nucleus, , thalamus • Occurrence after complete or partial resolution of Arms: 50% Legs: 20% Both limbs simultaneously: 30%

• Less frequent: cranial dystonia (, oromandibular dystonia, focal dystonia of the tongue)

Poewe W, Matosevic B in Movement Disorders in Neurologic and Systemic Disease. Cambridge University Press, 2014 Handley A et al. Age Ageing 2009 May;38(3):260-6 Poewe W, Matosevic B in Movement Disorders in Neurologic and Systemic Disease. Cambridge University Press, 2014 Blepharospasm and jaw closing dystonia after parietal infarcts

Jacob PC, Chand RP. Mov Disord. 1995 Nov;10(6):794-5. Lingual dystonia as a manifestation of thalamic infarction

Kim HJ et al. Mov Disord. 2009 Aug 15;24(11):1703-4 Pandey S, Tater P. Tremor Other Hyperkinet Mov (N Y). 2019;8:610. 3) Specific vascular movement disorders – chorea/athetosis/ballism • May involve all body regions – proximal (and with high amplitude): ballism – dystal • involve MCA vascularization (subthalamic nucleus for ballism; thalamus, basal ganglia, subcortical white matter for chorea) • Face involvement: 1/3 of cases • Chorea + mixed movement disorders: choreo-athethosis – distal limb portions “piano-playing movements” – postero-lateral thalamus • More than ½ of cases: self-limited Hemichorea and hemiballism associated with contralateral hemiparesis and ipsilateral basal ganglia lesions

Krauss JK et al. Mov Disord. 1999 May;14(3):497-501.

Biballism caused by bilateral infarction in the substantia nigra

Caparros-Lefebvre D. et al. Mov Disord. 1994 Jan;9(1):108-10. Post-stroke unilateral ballism • male, 80 years old • old left MCA ischemic stroke • new ischemic stroke in the right frontal lobe, MCA territory • spontaneous recovery of choreo-athetosis Paroxysmal kinesigenic dystonic after thalamic infarct

Camac A et al. Mov Disord. 1990;5(3):235-8. Pseudochoreoathetosis as a result of a thalamic infarction

Lee MS et al. Mov Disord. 1998 Jan;13(1):184-6 Treatment of post stroke chorea

• Neuroleptics - typical – - atypical – , Olanzapine • Antiepileptic drugs – , Levetiracetam, • • D2 receptor antagonists – , 4) Specific vascular movement disorders – parkinsonism Thanvi B et al. Age Ageing 2005 Mar;34(2):114-9 5) Other movement disorders in stroke Simple phonic tic after caudate stroke

Gomis M et al.Mov Disord. 2008 Apr 15;23(5):765-6 Focal myoclonus associated with posterior thalamic hematoma

Gatto EM et al. Mov Disord. 1998 Jan;13(1):182-4. Cortical myoclonus following massive hemorrhagic stroke Conclusions

• is an important cause of secondary movement disorders • Chorea and dystonia are the most frequent movement disorders • The types of movement disorders depend on the topography of stroke

Thank you very much!