DIPHASIC DYSKINESIA
MORE IN LEGS
CAN BEHAVE AS PEAK DOSE WHEN NO ON
STEREOTYPE
2ND PHASE STRONGER
MSA DIAGNOSTIC CRITERIA
PROBABLE MSA
A sporadic, progressive, adult (>30 y)– onset disease characterized by
● Autonomic failure involving urinary incontinence (inability to control the release of urine from the bladder, with erectile dysfunction in males) or an orthostatic decrease of blood pressure within 3 min of standing by at least 30 mm Hg systolic or 15 mm Hg diastolic and
● Poorly levodopa-responsive parkinsonism (bradykinesia with rigidity, tremor, or postural instability) or
● A cerebellar syndrome (gait ataxia with cerebellar dysarthria, limb ataxia, or cerebellar oculomotor dysfunction)
POSSIBLE MSA
A sporadic, progressive, adult (>30 y)– onset disease characterized by
● Parkinsonism (bradykinesia with rigidity, tremor, or postural instability) or
● A cerebellar syndrome (gait ataxia with cerebellar dysarthria, limb ataxia, or cerebellar oculomotor dysfunction) and
● At least one feature suggesting autonomic dysfunction (otherwise unexplained urinary urgency, frequency or incomplete bladder emptying, erectile dysfunction in males, or significant orthostatic blood pressure decline that does not meet the level required in probable MSA) and
● At least one of the additional features shown in table below
Possible MSA-P or MSA-C
● Babinski sign with hyperreflexia
● Stridor
Possible MSA-P
● Rapidly progressive parkinsonism
● Poor response to levodopa
● Postural instability within 3 y of motor onset
● Gait ataxia, cerebellar dysarthria, limb ataxia, or cerebellar oculomotor dysfunction
● Dysphagia within 5 y of motor onset
● Atrophy on MRI of putamen, middle cerebellar peduncle, pons, or cerebellum
● Hypometabolism on FDG-PET in putamen, brainstem, or cerebellum
Possible MSA-C
● Parkinsonism (bradykinesia and rigidity)
● Atrophy on MRI of putamen, middle cerebellar peduncle, or pons
● Hypometabolism on FDG-PET in putamen
● Presynaptic nigrostriatal dopaminergic denervation on SPECT or PET
Gilman et al. Neurology 2008
MSA CLUES
Striatal toe
Hyperextension of hand fingers, pointing up (scooping)
Hand contractures
Orofacial dystonia
BLADDER DYSFUNCTION TYPE
Detrusor underactivity
Detrusor sphincter dyssynergia,
Urethral hypertonia in the voiding phase
Detrusor hyperreflexia : common in both PD and MSA (early stage)
PVV > 100 ml 91%PPV , <100 ml 60%NPV : MSA vs PD
MSA COGNITION
Mild single domain deficits
Multiple domains
Frank dementia in rare cases.
Executive more common
Memory and VS may be impaired
SUPPORTING FEATURES
● Orofacial dystonia
● Disproportionate antecollis
● Camptocormia (severe anterior flexion of the spine) and/or Pisa syndrome (severe lateral
flexion of the spine)
● Contractures of hands or feet
● Onset before age 75 y
● Inspiratory sighs
● Severe dysphonia
● Severe dysarthria
● New or increased snoring
● Cold hands and feet
● Pathologic laughter or crying
● Jerky, myoclonic postural/action tremor
CHA2DS2VASc score FOR AF (RISK OF STROKE)
C Congestive heart failure (or Left ventricular systolic dysfunction) 1
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) 1
A2 Age ≥75 years 2
D Diabetes mellitus 1
S2 Prior stroke or TIA or thromboembolism 2
V Vascular disease (e.g. peripheral artery disease, myocardial infarction, aortic plaque) 1
A Age 65-74 years 1
Sc Sex category (i.e., female sex) 1
Score Risk
0 (male) or 1 (female): Low risk
No anticoagulant
1 (male): moderate risk
Oral anticoagulation should be recommended
For patients with non-valvular AF, a CHA2DS2-VASc score of 1, aspirin therapy may be considered.
2 or greater: High risk
Oral anticoagulation is recommended
For patients with non-valvular AF, a CHA2DS2-VASc score of > 2 and acceptably low risk for hemorrhagic complications, oral anticoagulants (either vitamin K antagonists or newer anticoagulants) are recommended.
ABCD2 FOR TIA (RISK OF STROKE)
Age (years) > 60 1
BP (mmHg) SBP > 140 or DBP > 90 1
Clinical features
Unilateral weakness 2
Speech disturbance without weakness 1
Duration of symptoms (minutes)
≥ 60 2
10–59 1
Diabetes 1
Score 1-3 (low)
2 day risk = 1.0%
7 day risk = 1.2%
Score 4-5 (moderate)
2 day risk = 4.1%
7 day risk = 5.9%
Score 6–7 (high)
2 day risk = 8.1%
7 day risk = 11.7%