NeuroAnatomy Case Report

GROUP 6

Case:A 55 YEAR OLD WOMAN IN A PSYCHIATRIC

WARD RECEIVED A DRUG FOR TREATMENT OF HER BIZARRE BEHAVIOR AND HALLUCINATIONS. AFTER THE TREATMENT WAS INITIATED, SHE HAD DECREASED FACIAL EXPRESSION AND AN ABSENCE OF ARM SWING WHILE WALKING. AFTER 6 MONTHS OF TREATMENT, STEREOTYPED, REPETITIVE INVOLUNTARY MOVEMENTS OF THE TONGUE, MOUTH AND FACE DEVELOPED. OTHER FINDINGS WERE NORMAL EXCEPT FOR MINIMAL PIANO PLAYING MOVEMENTS OF THE FINGERS

MANIFESTATIONSAfter initiation of treatment

Decreased facial expression Absence of arm swing while walking

After 6 months of treatment Stereotyped, repetitive involuntary movement

of tongue, mouth and face Minimal piano playing movements

LEVEL OF LESION

CEREBRUM

BASAL GANGLIA

BRAINSTEM

CEREBELLUM

SPINAL CORD

PERIPHERAL

Why basal ganglia???

SUPRATENTORIAL BASAL GANGLIA

Why supratentorial??Basal ganglia is above

tentorium cerebelli

SUPRATENTORIAL BASAL GANGLIA

FUNCTIONSControl of posture and voluntary

movementCoordinates Rapid and slow

movementsRegulation of voluntary movement

and learning of motor skillsFeed-back mechanism

Topography of the LesionNon- focal and diffusely located

Manifestations include not only the face, but as well as the arms and hands

Pathologic LesionNot a mass

Nor a non-mass

Etiology of LesionTOXIC/METABOLIC

ANTIPSYCHOTIC MEDICATIONS

ANTIPSYCHOTIC MEDICATIONSTYPES:

CONVENTIONAL High potency Low potency

ATYPICAL

ANTIPSYCHOTIC MEDICATIONSMECHANISM OF ACTION:

The therapeutic action of the conventional antipsychotic medications is correlated best with antagonist activity at postjunctional dopamine D-2 receptors, where dopamine normally inhibits adenylyl cyclase activity.

The therapeutic action of atypical antipsychotic drugs is correlated with antagonistic activity at both 5-HT-receptors and dopamine D2 or D4 receptors.

THE THERAPEUTIC ACTION IS BEST CORRELATED WITH THE ACTIONS OF THESE DRUGS IN THE MESOLIMBIC AND MESOCORTICAL AREAS OF THE CNS.

MANIFESTATIONS After initiation of treatment

Decreased facial expression Absence of arm swing while walking

After 6 months of treatment Stereotyped, repetitive involuntary movement

of tongue, mouth and face Minimal piano playing movements

Second Look…

ADVERSE EFFECTS: Central Nervous System

Extrapyramidal Syndromes Acute Dystonia Akathisia Parkinsonian-like syndrome (tremors, bradykinesia, rigidity, etc.

Tardive Dsykinesia Neuroleptic Malignant Syndrome Sedation Confusion / Memory Impairment Seizures

ANTIPSYCHOTIC MEDICATIONS

ANTIPSYCHOTIC MEDICATIONSTARDIVE DYSKINESIA

Likely with conventional drugs Characterized by disfiguring orofaciolingual movements and at

times dystonic movements of the trunk Result of developing supersensitivity of the postjunctional

dopamine receptors in the CNS, perhaps in the basal ganglia. Occurs months to years of drug exposure Often irreversible More likely to occur in elderly or institutionalized patients who

receive long term, high-dose therapy

DIAGNOSISThere is no single test for tardive dyskinesia

Diagnostic process may involve more than one physician

Requires thorough review of medical history

Physical examination and neuro-psychological evaluation is needed

Physical Exam abnormal, involuntary, irregular choreoathetoid

movements muscles of the head, limbs, and trunk

Perioral movements are the most common and darting, twisting, and protruding movements of

the tongue chewing and lateral jaw movements;

lip puckering; and facial grimacing Finger movements and hand clenching

In most severe and serious cases: Torticollis, retrocollis, trunk twisting, and pelvic

thrusting breathing and swallowing irregularities

aerophagia, belching, and grunting

Laboratory StudiesThyroid Function Test

Serum copper and Serum ceruloplasmin Test

Serum Calcium Test

RBC count

Connective tissue disease screening tests

Neuro-imaging StudiesCT Scan

MRI

PET Scan