- Symptoms of Vascular parkinsonism
- Reasons of Vascular parkinsonism
- Treatment of Vascular parkinsonism
The Sousdisty Parkinsonism (SP) – rather rare option of secondary (symptomatic) parkinsonism caused by ischemic or hemorrhagic defeat basal ганглиев, a mesencephalon and (or) their bonds with frontal lobes.
Symptoms of Vascular parkinsonism:
Features of a parkinsonchesky syndrome:
• bilateral beginning of a disease and relative symmetry of symptomatology
• lack of a tremor of rest
• a low performance of dofaminergichesky means (lack of deterioration at their cancellation)
• dominance of symptomatology in axial departments and the lower extremities
• prematurity of postural disturbances and changes of walking
• lack of fluctuations and diskineziya at long reception of a levodopa
The accompanying syndromes:
• prematurity of a heavy pseudobulbar syndrome
• prematurity of neurogenic disturbances of an urination
• dementia prematurity
• pyramidal syndrome
• frontal signs (grasp reflex, paratonian Period)
• cerebellar ataxy
• other extrapyramidal syndromes (gemidistoniya, myoclonia)
• focal disturbances of the highest brain functions (aphasia, apraxia, etc.)
Features of a current:
• the acute or subacute beginning with the subsequent stabilization and (or) partial regress of symptoms
• (fluctuating) current progressing stupeneobrazny with alternation of the periods of bystry progressing, stabilization and partial regress
It is possible to allocate several main clinical options of the joint venture:
1. Typical option of the joint venture: it is characterized by the symmetric or asymmetric akineto-rigid syndrome which was more expressed in the lower extremities, debuting from walking disturbance, not decreasing under the influence of a levodopa.
2. Vascular parkinsonism – plus: it is characterized by parkinsonism combination with pyramidal, cerebellar, others the extrapyramidal sindromay, expressed oculomotor disorders, focal disturbances of the highest brain functions. This option of the joint venture clinically imitates some multisystem degenerations, first of all the progressing nadjyaderny paralysis and a kortikobazalny degeneration.
3. The vascular parkinsonism imitating Parkinson's disease: it is characterized by the unilateral beginning, a rest tremor, good reaction to levodopa drugs, slowly progressing current, meets exclusively seldom.
4. "Parkinsonism of a lower body": parkinsonopodobny disturbance of walking and postural instability (for lack of any symptomatology is characteristic from upper extremities), diffusion defeats of periventrikulyarny white matter (according to KT or MPT), lack of effect on levodopa drugs.
Reasons of Vascular parkinsonism:
Vascular parkinsonism can be caused by various cerebrovascular diseases (the striking zones, "strategic" for parkinsonism):
1. Damage of small brain arteries (mikroangiopatiya):
• gipertonicheskayamikroangiopatiya (липогиалиноз)
• senile mikroangiopatiya (senile arteriolosclerosis, senile crimpiness of arterioles)
• amyloid angiopatiya
• vasculites and vasculopathies (nodular polyarteritis, primary angiitis of TsNS, system lupus erythematosus)
• the mikroangiopatiya connected with pseudoxanthoma elasticum, and other hereditary arteriopatiya
• etat crible
2. Damage of large brain arteries:
• atherosclerosis large brain (extra-or intracranial) arteries
• meningovaskulyarny syphilis
3. Cardiogenic damages of a brain:
• cardiogenic embolism
• hypoxemic encephalopathy (necrosis basal ганглиев)
4. Other diseases:
• arteriovenous malformation
• anti-phospholipidic syndrome
Especially often there is parkinsonism at damage of small brain arteries, krovosnabzhayushchy deep departments of a brain.
The hypertensive mikroangiopariya (arteriopatiya) arising at patients with arterial hypertension is the most common cause of the joint venture.
Treatment of Vascular parkinsonism:
Symptomatic therapy consists first of all in use of protivoparkinsonichesky drugs.
At patients with the joint venture it is necessary to use all arsenal of protivoparkinsonichesky means:
• levodopa drugs
• agonists of dopamine receptors
• MAO B inhibitors
At a nazancheniya of protivoparkinsonichesky means it is necessary to uchityat a possibility of their side effect on cognitive functions and a condition of cardiovascular system. Especially it otnostitsya to cholinolytics which are usually not appointed the elderly patient having at least moderate cognitive disturbances. Besides they are shown mainly at the rest tremor (which is seldom found at the joint venture) and to a lesser extent influence other displays of parkinsonism. Though at most of patients any of protivoparkinsonichesky means does not bring effect, but in some cases nevertheless it is possible to pick up drug or a combination of the drugs having positive effect.
According to the Japanese neurologists, expressiveness of postural instability and changes of walking which quite often dominate at the joint venture decrease under the influence of the predecessor of noradrenaline of L - treo-3,4 – a digidroksifenilserina (L – DOPS) that can indicate an important role of deficit of noradrenaline in genesis of motive disturbances. At the heart of positive action of L – DOPS can lie strengthening of noradrenergichesky influence on frontal bark, a thalamus, a striatum, a spinal cord. However the antidepressants which are slowing down the return capture of noradrenaline (desipramine, Maprotilinum) were ineffective. Strengthening it is possible to strive for noradrenergichesky transfer by means of antagonists of presynaptic a2-adrenoceptors, however still prematurely to recommend these drugs for use in clinical practice.
At an apato-abulichesky syndrome a certain effect can be gained by means of agonists of the dopamine receptors (a piribedil, a pramipeksol) activating mesolimbic dofaminergichesky influences.
At a depression antidepressants (amitriptyline, fluoxetine, sertraline, etc.) are shown
The special remedial gymnastics directed to a training of skills of initiation of walking and maintenance of balance is essential.
Possibilities of stereotaxic interventions at the joint venture are not studied. Meanwhile some patients with limited defeat basal ганглиев can have them effective.