Unilateral parkinsonism and stereotyped movements following a right lenticular infarction

We Move or Are We Moved? Unpicking the Origins of Voluntary Movements to Better Understand Semivoluntary Movements

The capacity for voluntary control is seen as essential to human movements; the sense that one intended to move (willing) and those actions were self-generated (self-agency) gives the sense of voluntariness and of being in control. While the mechanisms underlying voluntary movement have long been unclear, recent neuroscientific tools have identified networks of different brain areas, namely, the prefrontal cortex, supplementary motor area, and parietal cortex, that underlie voluntary action. Dysfunction in these brain areas can result in different forms of semivoluntary movement as the borderland of voluntary and involuntary movement where a person may experience a disordered sense of will or agency, and thus the movement is experienced as unexpected and involuntary, for an otherwise voluntary-appearing movement. Tics, functional movement disorders, stereotypies, perseveration, compulsions, utilization behaviors, and motor mannerism have been described elsewhere in the context of psychoses, and are often mistaken for each other. Yet, they reflect an impairment of prefrontal cortices and related circuits rather than simple motor systems, which results in the absence of subjective recognition of the movements, in contrast to other neurological movement disorders where principal abnormalities are located within the basal ganglia and its connections. Therefore, their recognition is clinically important since they are usually associated with neurodevelopmental and neurodegenerative disorders. In this review, we first defined a conceptual framework, from both a neuroanatomical and a neurophysiological point of view, for the generation of voluntary movement. We then examined the evidence linking dysfunctions in different motor pathways to each type of movement disorder. We looked at common semivoluntary movement disorders providing an overview, where possible, of their phenomenology and brain network abnormalities for each condition. We also emphasized important clinical feature similarities and differences to increase recognition of each condition in practice.

Prevalence and determinants of motor stereotypies in autism spectrum disorder: A systematic review and meta-analysis

Stereotypies are frequently reported in people with autism spectrum disorder (ASD) but remain one of the less explained phenomena. We aimed to describe, through a systematic review and a meta-analysis, the prevalence of motor stereotypies in ASD and study the factors that influence this prevalence. Our literature search included MEDLINE, Scopus, and PsycINFO databases. Quality and risk of bias were assessed. Thirty-seven studies were included and the median prevalence of motor stereotypies in ASD was 51.8%, ranging from 21.9% to 97.5%. The most frequent determinants associated with a higher number of stereotypies in ASD were a younger age, lower intelligence quotient, and a greater severity of ASD. Moreover, gender did not seem to influence the prevalence of stereotypies. Meta-analytic analysis showed that lower IQ and autism diagnosis (independent of IQ) are associated with a higher prevalence of motor stereotypies (odds ratio = 2.5 and 4.7, respectively). Limitations of the reviewed literature include the use of convenience samples, with small sizes and heterogeneous inclusion criteria, and the predominance of high-functioning autism individuals.

Post-stroke Movement Disorders: The Clinical, Neuroanatomic, and Demographic Portrait of 284 Published Cases

PURPOSE

Abnormal movements are a relatively uncommon complication of strokes. Besides the known correlation between stroke location and certain movement disorders, there remain uncertainties about the collective effects of age and stroke mechanism on phenomenology, onset latency, and outcome of abnormal movements.

MATERIALS AND METHODS

We systematically reviewed all published cases and case series with adequate clinical-imaging correlations. A total of 284 cases were analyzed to evaluate the distribution of different movement disorders and their association with important cofactors.

RESULTS

Posterolateral thalamus was the most common region affected (22.5%) and dystonia the most commonly reported movement disorder (23.2%). The most common disorders were parkinsonism (17.4%) and chorea (17.4%) after ischemic strokes and dystonia (45.5%) and tremor (19.7%) after hemorrhagic strokes. Strokes in the caudate and putamen were complicated by dystonia in one third of the cases; strokes in the globus pallidus were followed by parkinsonism in nearly 40%. Chorea was the earliest poststroke movement disorder, appearing within hours, whereas dystonia and tremor manifested several months after stroke. Hemorrhagic strokes were responsible for most delayed-onset movement disorders (>6 months) and were particularly overrepresented among younger individuals affected by dystonia.

CONCLUSIONS

This evidence-mapping portrait of poststroke movement disorders will require validation or correction based on a prospective epidemiologic study. We hypothesize that selective network vulnerability and resilience may explain the differences observed in movement phenomenology and outcomes after stroke.

Stereotypic Movement Disorders

This review summarizes motor stereotypies in terms of description, prevalence, pathophysiology, diagnosis and management. They are fixed and persistent movements. Stereotypies begin before 3 years of age and continue into adulthood. Primary motor stereotypies occur in children of normal intelligence, whereas secondary stereotypies ensue in the setting of an additional diagnosis such as autism spectrum disorder or other neurologic disorders. They are highly associated with comorbidities such as anxiety, obsessive-compulsive symptoms, inattention, and tics. The pathophysiology of stereotypies involves fronto-striatal overactive dopaminergic pathways, and underactive cholinergic and GABAergic inhibitory pathways. No genetic markers have been identified despite a clear genetic predisposition. Behavioral therapy is the principle treatment. Future studies will focus on identifying genetic markers, and on better understanding the functional and structural neurobiology of these movements.

Punding following posterior cerebral artery infarction: a case report and literature review

INTRODUCTION

Punding is a complex stereotyped behavior, characterized by excessiveness, non-goal orientation, and repetitiveness. It is mostly associated with Parkinson's disease, and very few cases in non-Parkinson's disease have been reported. We report a case of punding associated with supratentorial ischemic stroke.

CASE PRESENTATION

We present a 70-year-old man with left posterior cerebral artery infarction with quetiapine-induced punding manifesting as repetitive unidirectional body turning. Remission of punding behavior ensued after cessation of quetiapine and administration of clonazepam.

CONCLUSION

This case describes the clinical course of quetiapine-induced punding in a patient with left posterior cerebral artery infarction. It suggests clonazepam may serve as a treatment option for poststroke punding.

Absent movement-related cortical potentials in children with primary motor stereotypies

The underlying pathophysiologic mechanism for complex motor stereotypies in children is unknown, with hypotheses ranging from an arousal to a motor control disorder. Movement-related cortical potentials (MRCPs), representing the activation of cerebral areas involved in the generation of movements, precede and accompany self-initiated voluntary movements. The goal of this study was to compare cerebral activity associated with stereotypies to that seen with voluntary movements in children with primary complex motor stereotypies. Electroencephalographic (EEG) activity synchronized with video recording was recorded in 10 children diagnosed with primary motor stereotypies and 7 controls. EEG activity related to stereotypies and self-paced arm movements were analyzed for presence or absence of early or late MRCP, a steep negativity beginning about 1 second before the onset of a voluntary movement. Early MRCPs preceded self-paced arm movements in 8 of 10 children with motor stereotypies and in 6 of 7 controls. Observed MRCPs did not differ between groups. No MRCP was identified before the appearance of a complex motor stereotypy. Unlike voluntary movements, stereotypies are not preceded by MRCPs. This indicates that premotor areas are likely not involved in the preparation of these complex movements and suggests that stereotypies are initiated by mechanisms different from voluntary movements. Further studies are required to determine the site of the motor control abnormality within cortico-striatal-thalamo-cortical pathways and to identify whether similar findings would be found in children with secondary stereotypies.

Complex motor stereotypies: an evolving neurobiological concept

Complex motor stereotypies are repetitive arm and/or hand flapping, waving and wiggling movements that begin before the age of 3 years, occur repeatedly throughout the day and stop with distraction. These movements are commonly seen in children with autism, but also appear in otherwise normally developing individuals labelled as primary. Although proposed to have a psychological and neurobiological mechanism, evidence suggests that there is an abnormality within the corticostriatal–thalamocortical circuitry or its connecting structures. Animal models include both drug-induced (i.e., via stimulants or cocaine) and spontaneously appearing prototypes. Neurochemical investigations, primarily in rodents, have identified a variety of neurotransmitter alterations, with an emphasis on dopamine or glutamate; however, findings are inconsistent. We hypothesize that, based on its various roles in controlling and modulating movements, the frontal cortex will ultimately be shown to be the prime site of abnormality in this disorder. Future studies investigating both humans and animal models are essential for attaining a greater understanding of the pathobiology underlying motor stereotypies.

Movement disorders in cerebrovascular disease

Movement disorders can occur as primary (idiopathic) or genetic disease, as a manifestation of an underlying neurodegenerative disorder, or secondary to a wide range of neurological or systemic diseases. Cerebrovascular diseases represent up to 22% of secondary movement disorders, and involuntary movements develop after 1-4% of strokes. Post-stroke movement disorders can manifest in parkinsonism or a wide range of hyperkinetic movement disorders including chorea, ballism, athetosis, dystonia, tremor, myoclonus, stereotypies, and akathisia. Some of these disorders occur immediately after acute stroke, whereas others can develop later, and yet others represent delayed-onset progressive movement disorders. These movement disorders have been encountered in patients with ischaemic and haemorrhagic strokes, subarachnoid haemorrhage, cerebrovascular malformations, and dural arteriovenous fistula affecting the basal ganglia, their connections, or both.

Post-stroke Movement Disorders: Clinical Manifestations and Pharmacological Management

Involuntary abnormal movements have been reported after ischaemic and haemorrhagic stroke. Post stroke movement disorders can appear as acute or delayed sequel. At the moment, for many of these disorders the knowledge of pharmacological treatment is still inadequate. Dopaminergic and GABAergic systems may be mainly involved in post-stroke movement disorders. This article provides a review on drugs commonly used in post-stroke movement disorders, given that some post-stroke movement disorders have shown a partial benefit with pharmacological approach.

Androgens exacerbate motor asymmetry in male rats with unilateral 6-hydroxydopamine lesion

Parkinson's disease (PD) is a progressive neurodegenerative disorder characterized by dopamine neuron loss in the nigrostriatal pathway that shows greater incidence in men than women. The mechanisms underlying this gender bias remain elusive, although one possibility is that androgens may increase dopamine neuronal vulnerability to oxidative stress. Motor impairment can be modeled in rats receiving a unilateral injection of 6-hydroxydopamine (6-OHDA), a neurotoxin producing nigrostriatal degeneration. To investigate the role of androgens in PD, we compared young (2 months) and aged (24 months) male rats receiving gonadectomy (GDX) and their corresponding intact controls. One month after GDX, rats were unilaterally injected with 6-OHDA, and their motor impairment and asymmetry were assessed 2 weeks later using the cylinder test and the amphetamine-induced rotation test. Plasma samples were also collected to assess the concentration of testosterone and advanced oxidation protein products, a product of oxidative stress. GDX decreased lesion-induced asymmetry along with oxidative stress and increased amphetamine-induced rotations. These results show that GDX improves motor behaviors by decreasing motor asymmetry in 6-OHDA-treated rats, an effect that may be ascribed to increased release of striatal dopamine and decreased oxidative stress. Collectively, the data support the hypothesis that androgens may underlie the gender bias observed in PD.

Stereotypic movement disorders

Stereotypic movements are repetitive, rhythmic, fixed, patterned in form, amplitude, and localization, but purposeless (e.g., hand shaking, waving, body rocking, head nodding). They are commonly seen in children; both in normal children (primary stereotypy) and in individuals with additional behavioral or neurological signs and symptoms (secondary stereotypy). They should be differentiated from compulsions (OCD), tics (tic disorders), trichotillomania, skin picking disorder, or the direct physiological effect of a substance. There is increasing evidence to support a neurobiological mechanism. Response to behavioral and pharmacological therapies is variable.

Motor stereotypies

Stereotypic movements are ubiquitous, occur in a variety of forms, and exist in different populations, ranging from individuals with autism to typically developing children. Although such movements are required to be restricted, repetitive, and purposeless, their definition and included activities remain broad and imprecise. Movements are typically classified into 2 groups, primary (physiological) and secondary (pathological), depending upon the presence of additional signs or symptoms. Although some view these movements as behaviors produced to alter a state of arousal, there is increasing evidence to support a neurobiological mechanism. Behavioral and pharmacological therapies have been used with varying effect.

Subacute hemicorporal parkinsonism in 5 patients with infarcts of the basal ganglia

In 1929, Critchley introduced the term "vascular parkinsonism" (VP), which has been the subject of considerable controversy in neurology. Parkinsonism does not appear to be a frequent consequence of striatal infarcts, although unilateral parkinsonism has been reported as an acute or subacute onset syndrome following strategic infarcts in the striatum. Previous 123-I ioflupane SPECT (DaTSCAN) studies involving radioisotope labeling of the dopamine transporter protein at presynaptic level in patients with IPD (idiopathic Parkinson's disease) have found this technique to be highly sensitive in exploring the nigrostriatal pathway. Previous studies of VP with DatSCAN have been inconclusive. The present study correlates clinical data (unilateral parkinsonism following contralateral lenticular infarction), and radiological (CT/MRI) and functional neuroimaging findings (DatSCAN) in 5 patients with CT/MRI criteria for striatal infarcts. Finally, in 2 of these patients a diagnosis of IPD was made because of the follow-up of clinical signs and pathological DaTSCAN findings not concordant with the size and location of the vascular lesion.

Systemic diseases that cause movement disorders

The present review is aimed at providing practical assistance to the clinical neurologist in reaching a diagnosis, understanding the pathogenic mechanisms of movement disorders associated with systemic diseases, and determining appropriate therapy. Infectious disease by direct effect or as an acquired autoimmune neurological disease, stroke, hypoxia-ischemia, paraneoplastic syndromes, collagen disorders, endocrine, liver and kidney diseases that may cause hypokinetic or hyperkinetic abnormal movement are considered separately. The type and evolution of abnormal movement caused by systemic disease vary with age and underlying pathology. Therapy for abnormal movements should include a primary treatment for the systemic disease.

Post-stroke movement disorders: report of 56 patients

BACKGROUND

Although movement disorders that occur following a stroke have long been recognised in short series of patients, their frequency and clinical and imaging features have not been reported in large series of patients with stroke.

METHODS

We reviewed consecutive patients with involuntary abnormal movements (IAMs) following a stroke who were included in the Eugenio Espejo Hospital Stroke Registry and they were followed up for at least one year after the onset of the IAM. We determined the clinical features, topographical correlations, and pathophysiological implications of the IAMs.

RESULTS

Of 1500 patients with stroke 56 developed movement disorders up to one year after the stroke. Patients with chorea were older and the patients with dystonia were younger than the patients with other IAMs. In patients with isolated vascular lesions without IAMs, surface lesions prevailed but patients with deep vascular lesions showed a higher probability of developing abnormal movements. One year after onset of the IAMs, 12 patients (21.4%) completely improved their abnormal movements, 38 patients (67.8%) partially improved, four did not improve (7.1%), and two patients with chorea died. In the nested case-control analysis, the patients with IAMs displayed a higher frequency of deep lesions (63% v 33%; OR 3.38, 95% CI 1.64 to 6.99, p<0.001). Patients with deep haemorrhagic lesions showed a higher probability of developing IAMs (OR 4.8, 95% CI 0.8 to 36.6).

CONCLUSIONS

Chorea is the commonest movement disorder following stroke and appears in older patients. Involuntary movements tend to persist despite the functional recovery of motor deficit. Deep vascular lesions are more frequent in patients with movement disorders.

Extrapyramidal motor symptoms versus striatal infarction volume after focal ischemia in mongolian gerbils

Few behavioral tests are available to evaluate extrapyramidal dysfunctions after focal cerebral ischemia in rodents, although extrapyramidal motor dysfunctions are often observed clinically in patients with cerebral infarction. We evaluated the methamphetamine (MP)-induced rotation test for the detection and quantification of extrapyramidal motor dysfunction induced by striatal infarction in gerbils after focal cerebral ischemia. Mongolian gerbils (n=79) underwent the left common carotid artery occlusion (CCAO) for 10, 15, or 20 min. Spontaneous and MP-induced rotation tests were repeated postischemia, and the results compared with the extent of ischemic tissue injury. The density of dopaminergic neurons immunostained with a tyrosine hydroxylase antibody in the substantia nigra pars compacta (SNpc) also was measured. Histological examination revealed selective neuronal death of the hippocampal cornu ammonis 1 (CA1) sector in 10-min CCAO animals, infarction confined to the striatum and hippocampal neuronal death in 15-min CCAO animals, and widespread hemispheric infarction in 20-min CCAO animals. Dopaminergic neurons in the SNpc were preserved in 10- and 15-min CCAO animals but were significantly reduced in 20-min CCAO animals. In MP-induced rotation tests, 15-min CCAO animals showed biased rotation ipsilateral to the lesioned side. Biased rotation persisted 4 weeks postischemia, and the number of rotations significantly correlated with the regional infarction volume of the striatum. Twenty-minute CCAO animals showed biased rotation contralateral to the lesioned side; rotation number was not correlated with the infarction volume. Our results show that biased rotation behavior is a sensitive parameter of the extent of striatal injury after focal cerebral ischemia provided the lesion is not extended to the ipsilateral cortex. MP-induced rotation in rodents probably coordinates with the extrapyramidal motor dysfunction after striatal infarction in patients with vascular Parkinsonism.

Vascular parkinsonism: a distinct, heterogeneous clinical entity

OBJECTIVES

The aim of this study was to define the symptoms and signs of suspected vascular parkinsonism (VP) which is still a debatable concept.

MATERIAL AND METHODS

Patients with parkinsonism were grouped into patients with suspected VP and Parkinson's disease (PD) after other causes for secondary parkinsonism, and parkinsonism-plus syndromes were excluded. The clinical features of 16 patients with suspected VP to those of 50 diagnosed with PD were compared. All patients were assessed using unified Parkinson's disease rating scale (UPDRS) and all had cerebral MRIs.

RESULTS

Patients with VP had significantly older onset age and shorter duration of disease with gait disorder as the most frequent initial symptom. All PD patients had satisfactory response to levodopa treatment, whereas only 38% VP patients had satisfactory response to levodopa treatment. Vascular risk factors were more common in VP (81%) than PD (32%). Postural instability, freezing, gait disturbance, pyramidal signs, and postural tremor were significantly more prevalent in patients with VP than in PD. In VP patients these features were more prominent in the lower limbs. Twenty-five percent had acute onset VP. All patients with VP had ischemic lesions, mainly in subcortical white matter, to a lesser extent basal ganglia and brainstem, in their cerebral MRIs, while 70% of PD patients had normal MRIs.

CONCLUSION

The differences in the clinical features support the concept that VP is a distinct clinical entity with heterogeneous clinical, MRI, and possibly pathophysiological features.