It is well known that neuroleptics (phenothiazines, butyrophenones) may trigger events and parkinsonian tremor by blocking postsynaptic dopamine receptors in the striatum. The same happens with the depleting dopamine (reserpine, tetrabenazine).

Selective blockers of calcium channels (cinnarizine, flunarizine), masked in various commercial preparations of routine administration can produce similar manifestations full or partial recovery in all patients after discontinuation of medication and within a variable.

Some authors argue that drug-induced parkinsonism may be a latent or subclinical parkinsonism revealed by antidopaminergic medication. It is noteworthy that late buccolingual dyskinesia caused by prolonged use of neuroleptics may be associated with parkinsonian manifestations but hardly reason for misdiagnosis is the presence of stereotyped slow and continuous movements that occur in the lower face (lips , jaw and tongue).

The distal parts of the body and trunk tend to show small movements of flexion and extension, while the proximal muscles are not compromised. When the patient is standing may have repetitive movements of the lower extremities (go hard). The patient often develops secondary akathisia. It is assumed that tardive dyskinesia was given to a hypersensitivity of postsynaptic receptors for dopamine and its increased secretion secondary to blockade of these receptors.

In particular, nerve tracts and neural systems involved in the pathophysiology of the disease: the efferent fibers of the substantia nigra to the anterior horn cells of spinal cord, the substantia nigra receives numerous stimuli of various cortical regions and striatum inhibitory stimuli ; the efferent fibers pass from the front of the substantia nigra to the medial region of the globus pallidus, where stimuli are converted into impulses that are transmitted to the premotor cortex.

These circuits may explain the different symptoms of the disease. The akinesia may be explained by the lack of stimuli that regulate involuntary automatic movements, since the passage through the substantia nigra to the bone is altered. The stiffness is the result of hyperactivity, producing clumsy movements.

“The treatment of Parkinson’s disease is symptomatic. Levodopa combined with peripheral decarboxylase inhibitor is the most effective medicine. These are enzyme inhibitors carbidopa and benzeracida. By not crossing the blood brain barrier preventing thus, the metabolism of levodopa to dopamine outside the central nervous system, allowing a higher concentration of levodopa in the latter, favoring its conversion to dopamine in the striatum (JCFustinoni).

Although the diagnosis of Parkinson’s disease is largely clinical, can take account of hyposmia (may precede up to 20 years to your appearance), positron emission tomography showing decrease of dopamine in the striatum, markers recently biological and electromyography to show subclinical tremor.

An important chapter of this issue is that of drug-induced parkinsonism, which generally refers to the interruption but not always. Drugs that can induce are neuroleptics (phenothiazines, butyrophenones), depleting dopamine (reserpine, tetrabenazine) and calcium channel blockers (cinnarizine, flunarizine).

The clinician, before diagnosing Parkinson’s disease, should take into account the possibility cited in the preceding paragraph as well as a number of neurological disorders that are targets of specialized study.

Fustinoni (in Semiology Nervous System [1997]) says the following signs and symptoms exclude the diagnosis of Parkinson’s disease:

Signs and Symptoms that exclude Parkinson

l buccolingual dyskinesia (parkinsonism drug)

l hyperreflexia not justified by previous stroke (Vascular parkinsonism)

l pseudobulbar syndrome (vascular parkinsonism)

l or intentional tremor predominant attitude (Essential tremor)

l Paralysis of vertical gaze downward or lateral (Progressive supranuclear palsy)

l Early by gait disorders (Hakim-Adams syndrome)

l Early urinary incontinence (Hakim-Adams syndrome)

l marked orthostatic hypotension (Shy-Drager syndrome)

l Cognitive discordant severity or prominence in connection with rigidity, bradykinesia or tremor (DAT)

l oculogyric crisis (parkinsonism drug, posencefalítico)

Inhibition and excitation – dopamine and acetylcholine

In a normal brain, the levels of dopamine and acetylcholine, are in equilibrium and equal in their inhibitory and excitatory roles. When lower levels of dopamine, this balance is broken, because the acetylcholine begins to have an excess of excitatory activity, which causes Parkinson’s disease. Dopamine is found in the pars compacta of the substantia nigra and ignored the reasons why their neurons die and cease to keep the system balanced on the striatum.

Since the caudate nucleus and putamen, there is a path to the black substance secreted by the inhibitory neurotransmitter GABA (gamma aminobutyric acid). In turn, a series of fibers originating in the substantia nigra send axons to the caudate and putamen, secreting an inhibitory neurotransmitter from their terminals, dopamine. This pathway maintains a degree of mutual inhibition of the two areas and the injury causes a series of neurological syndromes, among which is Parkinson’s disease.

The fibers from the cerebral cortex secrete acetylcholine, an excitatory neurotransmitter, in the neostriatum. The causes of abnormal motor activities that make up Parkinson’s disease are related to the loss of the secretion of dopamine by nerve endings in the substantia nigra on the neostriatum (nigrostriatal tract) to the left of suppression.

Thus, neurons that secrete predominantly acetylcholine, excitatory signals broadcast to all basal ganglia, responsible in whole, motor planning and some cognitive functions. It requires a loss of approximately 80% of striatal dopamine to the symptoms.

Histologically, the disease is characterized by the presence of Lewy bodies in the substantia nigra and locus coeruleus, but can also appear in other locations of the extrapyramidal system. These intracytoplasmic inclusions composed of protein, free fatty acids, sphingomyelin, and polysaccharides.

The incidence of Parkinson’s disease, assessment difficult, is variable ranging from 4.5 to 21 cases per 100,000 population per year. It is the most accurate estimate of the disease and the extent of new cases in a period of time. Prevalence is the total number of cases in a population and at the same time.

It can be set in four ways:

1. For the reference of medical centers, as does the Italian National Health System, statistics are borne by general practitioners (found a prevalence of 1.48 to 1.90 patients per 1,000 people)

2. Done in similar fashion but with doctors specializing in neurology (in closed groups of neurological patients the prevalence is, obviously, greater)

3. For the individual test door to door in a given population (the average is higher because they include parkinsonism of various etiologies), and

4. It is based on the amount of anti-parkinsonian drugs consumed by a particular community. The geographic distribution is variable: a range of prevalence of 18 cases per 100,000 people in China to 234 in Montevideo, Uruguay. It is a fact difficult to assess because the low prevalence rate may reflect worsening economic conditions and, consequently given the incidence of Parkinson’s disease in the elderly, short life expectancy.

In Europe, seems to increase towards the north of the continent, along with the United States, report the highest mortality rate (increases above 75 years). In the countries studied deaths from this disease increased between 1920 and 1950. This has been reduced after the introduction of levodopa.

Patients usually suffer from panic to see in the mirror and keeps your eyelid contract without being able to control is sometimes close to a patient that you mentioned this annoying condition. The patient will automatically think the worst diagnosis: brain tumors, epilepsy, the onset of facial paralysis, etc., But fortunately is very wrong.

For peace of patients by far the most common cause of PD is anxiety or stress. Most patients are tired, has not slept well for several days or had problems at work or home. Then the treatment is first of all try to relax, try to disconnect (it is that you can) the problems, sports, etc.

If the MP is very upset or ashamed to have her patient, anxiety may be indicated to lower your anxiety level. the problem with anxiety is that people are very sensitive to them and are permanently “dazed” after taking the drug. In addition, the MP does not disappear immediately after taking the anti-anxiety, it is usual to take several days before this contraction is reduced involuntary “nervous.”

As it is extremely rare to find an organic cause of the MP, it is rare that additional tests are needed to make the diagnosis.

So the advice is to relax and if they have at some point the MP, is a good time to take a break or decrease engine speed, is the easiest way to get better.

The nervous system consists of the central nervous system (brain and spinal cord), peripheral nervous system (nerve roots, nerves, union muscle and nerve and muscles) and autonomic nervous system (responsible for regulating blood pressure, heart rate, sweating, etc.).

Neurological diseases are many, some common (migraine, stress and depression, stroke and cerebral hemorrhage, etc.). And not so common (multiple sclerosis, Parkinson’s disease, Guillain Barre syndrome, etc.)..

The diagnosis of these diseases is first of all clinical, ie, based on history and patient history and physical examination. Then, when the neurologist sees fit, request more specific examinations such as computed tomography, MRI, EEG, EMG, transcranial Doppler, etc.

Once the diagnosis, the neurologist will find the most effective treatment for the patient. As every patient is different each other, the physician should indicate the drug that creates more appropriate for your patient.

Once the treatment, the patient must go to his neurologist checks prompted. Some diseases require a few checks (eg attacks of vertigo or dizziness) and others require more controls (epilepsy, cerebral vascular attacks, etc.)..

Finally, the main objective is to solve the problem the patient, and if there is no definitive treatment for their disease and find ways to best manage the symptoms the patient may have.

The extrapyramidal motor system is the set of motor pathways that exert a major influence on spinal motor circuits, brain stem, cerebellum and cortex. Has fibers from the motor cortex that connect with the basal ganglia, particularly the caudate and putamen, as well as bulbar nuclei (red nucleus, substantia nigra and reticular formation) or midbrain and terminate in the anterior horn of the spinal cord.

Several hypotheses attribute the disease to genetic factors (genes have been identified as responsible mutants), metabolic (oxidative stress) or environmental (pesticides, aluminum). 10% of patients exhibit genetic predisposition. One out of every thousand people with the disease is less common in blacks and Japanese.

The onset of the disease is insidious and, retrospectively, patients may report having suffered from hyposmia, pain erratic confused as arthritic origin, dysesthesias burning sensations, depression, mental or seborrheic dermatitis, which can not always be taken into account as a prodrome.

The fall in the content of dopamine in the striatum will generate later, the symptoms suffered three out of four patients: resting tremor that typically is unilateral in its infancy (hands have made the movement of currencies .) In almost all cases the upper limbs are involved.

When will this disease progresses to muscle rigidity and bradykinesia (delay in the initiation of an involuntary movement or sudden inhibition during the same), the amimia and bradilalia. When walking there is a lack of arm swing.

Neurovegetative symptoms are also characteristic: seborrhea, excessive salivation, sweating, feeling hot, flushing.

What would be the most frequent pathologies in this specialty.

There are two groups of diseases which, by their frequency in childhood and adolescence, represent the main reasons for consultation in the neurological specialty: developmental disorders and so encompass the paroxysms.

A substantial proportion of children has a developmental disorder of sufficient magnitude to require a specialized evaluation. The reasons for consultation vary by age:

In infants: is manifested in the acquisition of maturational patterns, especially motor. In Pre-school stage in the development of language disorders. By school age and adolescence: for disorders of learning and behavior.

A similar or lower rate at some time, a transient paroxysmal episode. These are manifested as a change at the level of motor behavior (convulsions, tics, etc..) Perceptual (headache, dizziness) of impaired breathing (apneas, breath) or level of consciousness (syncope). Within the spectrum of seizures, which may have different ways of presenting stand-febrile seizures.

What other causes of consultations may be cited?

Although less common genetic and chromosomal diseases and central nervous system malformations (Down syndrome, myelomeningocele) and neuromuscular diseases (muscular dystrophy, neuropathies, spinal atrophy), neurodegenerative diseases, some with known metabolic error (phenylketonuria, galactosemia , etc.).
The importance of technological advances.

In the late ’70s, the development of computerized tomography have allowed for the first time “live” a direct image of the brain.

In recent years there have been some changes with regard to neurological diseases. From a cultural standpoint, today’s parents, educators and the general population have more information, which makes the children come to the consultation in early stages, therefore, with greater likelihood of appropriate intervention.

As for the scientific field there is greater knowledge of the various neurodevelopmental problems and further development of methods of diagnosis and treatment.

Since diseases of the nervous system are closely linked to overall health, change in perinatal care, greater coverage and the development of new vaccines, prevention of accidents and general health care have led to a change in their incidence.

DIAGNOSTIC TECHNIQUES

Child neurology is a specialty clinic and is likely to remain as such. The most important stages of the process diagnosis is based on the interview and physical examination, new diagnostic methods, especially in the field of imaging, neurophysiology and laboratory techniques have no value when applied indiscriminately and without proper clinical criteria .

Then with the advent of MRI and recently with positron emission tomography (PET) provides a range of methods, and shows the structure of the nervous system to assess the performance of certain specific areas.

CORRECT INFORMATION

In neurophysiology, there has also been important advances. From conventional electroencephalogram (EEG), which today provides important information, a more prolonged development on an outpatient basis, which can be done while the children make their activities, even during sleep or sleep deprivation.

In addition, polysomnography, simultaneous recording of EEG and other physiological parameters such as breathing, heart rate, arterial oxygen saturation, etc. It is very useful for the diagnosis of sleep-related pathology (ej.apneas).

Finally, the EEG recording combined with the image of the patient (videoelectroencephalogram) has made it possible to define more precisely the paroxysmal episodes and is a fundamental element for children with epilepsy are difficult to control.

And THE TREATMENT?

The development of new treatments has not been of the desired magnitude and in many areas, such as neuromuscular diseases and genetics, are experimental. The situation has been more advantageous for patients with epilepsy, and in recent years have developed new anticonvulsant drugs.

WHAT IS PREVENTION?

There is a group of diseases that can be prevented and for this the best advice is to follow the advice of your doctor: Regular monitoring of the pregnancy and birth by a team of professionals. Compliance with the immunization schedule

Accident prevention.

On the other hand there are some neurological conditions in which early diagnosis allows appropriate treatment and better prognosis. Therefore periodic monitoring health and timely consultation with your pediatrician to borderline situations should be a priority.
Dr. Pedro Barreda