1. NEURO IMAGING IN
MOVEMENT DISORDERS
DR. A.V. SRINIVASAN

2. Clinical Syndrome Approach
2.1. WHAT ARE THE MOVEMENTS
AKINETIC OR DYSKINETIC
TREMOR
JERKS Myclonus
Chorea
Tic
SPASMS Dystonia
Rhythmic / arhythmic
Stereo typed / in consistant
Continous
Action
Paroxysms
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3. Clinical Syndrome Approach
 Akinetic rigid syndrome
 Dystonic syndrome
 Choreic syndrome
 Tic syndrome
 Myoclonic syndrome
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4. ODD DYSKINESIAS
 ODDTREMOR
 ODD JERKS
FOCAL MYOCLONUS
CORTICAL MYOCLONUS
 GIANT SOMATO SENSORY
 HYPEREXPLEXIA
 ODD SPASMS
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5. Brain Iron
 Iron is a key trace metal relating to brain function. The major
functions in which iron performs a role include:
Oxidative phosphorylation
Dopamine synthesis and degradation
Hydroxyl free-radical formation
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6. Brain Iron
A. Neurodegenerative
i. Parkinson’s Plus Putamen
a. Striatonigral Degeneration
b. Shy-Drager
c. Olivopontocerebellar Atrophy
ii. Hallervorden-Spatz Globus Pallidus
(+ Red Nucleus / Nigra)
iii.Alzheimer’s Cortical
B. Metabolic
i. Hypothyroidism Generalized
ii. [Hepatic failure exhibits signal hyperintensity in the globus pallidus on T1 images
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7. Brain Iron
 C. Hemorrhage
Intracerebral Hematoma Site of Bleed
Hemorrhagic Infarction Gyral
Vascular Malformation Interstices / Margin
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8. Brain Iron
D. Demyelination
i. Multiple Sclerosis (severe) Thalamus /Putamen
ii. Microangiopathic
Leukoencephalopathy Putamen
iii. Radiation injury White Matter/ Putamen
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9. INVESTIGATIONS FOR PRIMARY MOVEMENT
DISORDERS
 Imaging (MRI)
 Exclusion of Wilson <50)
 Genentic testing
 Routine blood wing Biochemistry
 Syphilis
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10. Investigation in Secondary Movement
Disorders
 GENERAL PLAN
Extent of nervous system involvement
Psychometric evaluation
EEG (epilepti form discharges)
ENMG (peripheral neruropathy)
EMG and VEP
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11. Role of CT
 CONDITIONS THAT MAY PRODUCE WHITE MATTER
CHANGE ON BRAIN CT OR MRI AND WHICH MAY CAUSE
MOVEMENT DISORDERS.
Alexander’s disease
Krabbe’s disease
Polycystic lipomembranous osteodyplasia
Adeno – myelo – Leukodystrophy
Metachromatic leukodystrophy
Mitrochondrial diorders.
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12. DEGENERATIVE AND SYSTEMIC DISORDERS
 Polyeystic lipomembraneous Hand X-rays, skin biopsy
 Degeneration
 Hallervorden Spatz disease Brain MRI
 Pallidal degenerations Brain MRI
 Alzheimer’s disease Brain MRI
 Multi – infarct state Brain MRI
 Binswanger’s subcortical arteriosclerotic Brain MRI
Encephalopathy
 Normal pressure hydrocephalus Brain MRI
 Dementia pugilistica Brain MRI
 Calcification of the basal ganglia Brain CT and MRI
 Cerebral anoxia
(Co and cyanide poisoning) Brain MRI
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13. Wilson’s Disease
 3 movement disorders
Akinetic-rigid syndrome resembling Parkinsonism
Dystonic syndrome
Postural and intentional tremor
 Clinical
Tremor, rigidity, gait difficulty
Bulbar signs: indistinct speech, dysphagia
Hepatic encephalopathy
Anemia (10%)
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14. Wilson’s Disease
 Dx
 Kayser-Fleischer ring
 Elevated urinary copper
 Decreased serum ceruloplasmin
 Elevated bepatic copper
 CT DDX
 Straiatonigraldegeneration
 Metabolic acidosis
 Leigh disease
 2o parkinsonism
 acquired hepatocerebral degeneration
 myeliolysis
 HIE
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15. Wilson’s Disease
 MR
Altered GM and WM signal intensities
Atrophy of caudate head, brain stem
Cerebral and cerebellar atrophy
 MR: 3 patterns
T1 PD/T2
Variable increased
increased variable
variable decreased
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16. Wilson’s Disease
 Type I
 Putamen, GP, thalamus
 Caudate, claustrum, subthalamus
 Red nucleus, substantia nigra
 Dentate
 Type II
 Globus pallidus
 Rarely putamen, caudate
 Type III
 Basalganglia
 Thalamus
 Dentate nucleus
 Superior colliculus
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17. Metabolic
 Metabolic disorders: Gray Matter
Huntington’s disease
Hepatocerebral disorders
Mitochondrial cytompathies
CO, CO3 poisoning
Striatonigral degeneration
Pyruvate dehydrogenase deficiency
Hallervorden-Spatz disease
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18. Wernicke-Korsakoff Syndrome
 MR
Abnormal signal in mamillary bodies
Periventricular thalamus
Periaqueductal gray
+ enhancement
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19. PRES: Posterior Reversible Encephalopathy
Syndrome
 Imaging
Subcortical involvement
Basal ganglia, brainstem unusual
Cerebellar involvement occasional
Enhancement/hemorrhage unusual
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20. Hemochromatosis
 MR
hypointensity of basal ganglia, thalami
central white matter
adenohypophysis
choroids plexus
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21. Degenerative Disorders
 Diseases of the Substantia Nigra
Parkinson’s disease
Progressive supranuclear palsy
Straitonigral degeneration
Hallervorden – Spatz disease
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22. Parkinson’s Disease
 MR
Diminished width of pars compacta
Normal putamina
 MR-guided Pharmacotherapy
Intracerebroventricular drug delivery
Parenchymal drug delivery
Huge population of new patients with neurodegenerative
disorders potentially amenable to targeted
pharmacotherapy
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23. Parkinson’s Disease
 Progressive Supranuclear Palsy
 Pathology
Atrophy of mesencephalon
Periaqueductal gliosis and neurofibrillary tangles
 MR
Subtle enlargement of aqueduct
Subtle atrophy of periaqueductal gray
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24. Parkinson’s Disease
 MR
Diminished width of pars compacta
Hypointense dorsolateral putamina
 Hallervorden – Spatz Disease
Gradual limb stiffness
Dysarthria, dementia
50% exhibit choreiform or athetosis
marked symmetric T2-shortening
 globipallidi
 + pars reticularis
eye of the tiger appearance
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25. Differentiation
 Signal Hypointensity T2 <Putamen>
 Parkinson’s Plus (Multiple System Atrophy)
 Hypothyroidism
 Signal Hyperintensity T2 <Putamen>
 Wilson’s
 Familial Striatal Degeneration
 Creutzfeldt jakob
 Anoxia
 Leigh’s
 Ophthalmoplegia Plus
 Pallidoluysian Degeneration
 Signal Hyperintensity T1 <Globus Pallidus>
 Hepatic insufficiency
 Anoxia (petechial hemorrhage)
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