NeuroAnatomy case of Tardive Dyskinesia (short)

1. NeuroAnatomy Case Report
GROUP 6

2. 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

3. 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

4. LEVEL OF LESION
CEREBRUM
BASAL GANGLIA
BRAINSTEM
CEREBELLUM
SPINAL CORD
PERIPHERAL

5. Why basal ganglia???

6. SUPRATENTORIAL
BASAL GANGLIA
Why supratentorial??
Basal ganglia is above tentorium
cerebelli

7. SUPRATENTORIAL
BASAL GANGLIA
FUNCTIONS
Control of posture and voluntary
movement
Coordinates Rapid and slow
movements
Regulation of voluntary movement and
learning of motor skills
Feed-back mechanism

8. Topography of the Lesion
Non- focal and diffusely located
 Manifestations include not only the face, but as well
as the arms and hands

9. Pathologic Lesion
Not a mass
Nor a non-mass

10. Etiology of Lesion
TOXIC/METABOLIC

11. ANTIPSYCHOTIC
MEDICATIONS

12. ANTIPSYCHOTIC
MEDICATIONS
TYPES:
 CONVENTIONAL
 High potency
 Low potency
 ATYPICAL

13. ANTIPSYCHOTIC
MEDICATIONS
MECHANISM 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.

14. 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…

15. 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

16. ANTIPSYCHOTIC
MEDICATIONS
TARDIVE 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

17. DIAGNOSIS
There 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

18. 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

19. In most severe and serious cases:
 Torticollis, retrocollis, trunk twisting, and pelvic
thrusting
 breathing and swallowing irregularities
 aerophagia, belching, and grunting

20. Laboratory Studies
Thyroid Function Test
Serum copper and Serum ceruloplasmin Test
Serum Calcium Test
RBC count
Connective tissue disease screening tests

21. Neuro-imaging Studies
CT Scan
MRI
PET Scan