Sistema Nervoso Vegetativo Vademecum per la diagnosi differenziale

Transcription

1 Sistema Nervoso Vegetativo Vademecum per la diagnosi differenziale Pietro Cortelli IRCCS Istituto delle Scienze Neurologiche di Bologna DIBINEM, Alma Mater Studiorum - Università di Bologna Anatomo-Functional organization of the Autonomic Nervous System AFFERENTS CENTRAL AUTONOMIC NETWORK EFFERENTS 1

2 Drug related Part of PD process Dysautonomia Atypical PD syndr Comorbidity (diabetes) 2

3 ANS in Movement disorders Underused Complex physiology Multidisciplinarity Difficulty in clinical and lab diagnosis Critical for Understanding Premotor Diagnosis Early Differential diagnosis of synucleinopathy Management & Treatment of disabling symptoms PD & ANS dysfunction 3

4 Clinical features of cardiovascular autonomic failure Prevalence of NMS according to Parkinson s disease status Non-motor symptoms common across all stages of Parkinson s disease Barone P, et al. Mov Disord 2009;24: Copyright (2009 Movement Disorder Society); Reproduced with permission of John Wiley & Sons, Inc. 4

5 N = 1072 (%) Symptoms of autonomic failure in PD 53% of patients (and no controls) reported a lot or very much impact on daily life Magerkurth et al.,

6 Problems experienced by people who survive 15 years from diagnosis (52 over 126) Falls (?) occur in 81% and 23% sustained fractures Cognitive decline in 84%, and 48% dementia Hallucinations-depression are experienced by 50%. Choking has occurred in 50% symptomatic postural hypotension in 35% urinary incontinence in 41%. We conclude that the most disabling longterm problems of Parkinson s disease relate to the emergence of symptoms that are not improved by L-dopa. 6

7 Symptoms of cardiovascular autonomic dysfunction in PD The most frequent manifestation is orthostatic hypotension (OH) Usually mild (Thaisetthawatkul, 2004), can be asymptomatic Can occur at all stages of PD, but tends to be more severe with disease progression OH develop early in the disease course in 60%, and in 13% before motor symptoms onset (Goldstein, 2005) Associated with disease duration and severity (Magalhaes, 1998) Other disturbances of blood pressure regulation: Postprandial hypotension (Micieli, 1987) Nocturnal supine hypertension (Senard, 1992) Orthostatic hypotension Incidence Parkinson s disease Multiple system atrophy % % % 88 % Allcock, 2004 Colosimo, 2002 Presence of orthostatic hypotension 7

8 Symptoms of orthostatic hypotension Senard, 1997 Orthostatic Hypotension: symptoms Symptoms Weakness dizziness blurred vision difficulties to concentrate coat-hanger-like neck pain nausea palpitations syncope 8

9 Search for orthostatic symptoms The item 1.12 of the revised UPDRS scale rates presence and severity of postural symptoms (Goetz, 2008) Many other symptoms related to decreased perfusion of the brain, muscle, heart, spinal cord and kidney are omitted (Gupta and Nair, 2008) An autonomic function rating scale adapted to PD has been validated: SCOPA-AUT (Visser, 2004) COMPASS 31 (Sletten 2012) 9

10 How to diagnose orthostatic hypotension The search for orthostatic symptoms should be systematic Reduction of the systolic pressure of at least 20 mmhg or diastolic pressure of at least 10 mmhg after a standing position (stand/tilt 60 ) Within 3 minof standing It is a clinical signand can be asymptomatic Consensus statement on the definition of orthostatic hypotension, 1996 Recommendations: Structured history Detailed physical examination ECG and routine laboratory testing Cardiologic referral if heart disease or abnormal ECG is present or suspected BP measurements whilst supine and upright Active standing or head up tilt, ideally with continuous assessment of BP and HR for 3 min Further appropriate investigations of the ANS 10

11 AUTONOMIC INVESTIGATION METHODS (I Level) Routine tests based on physiological stimuli: Tilt test (65 x 10 min) Valsalva manoeuvre Deep breathing Isometric handgrip General aspects 1.Autonomic function tests should be an extension of the clinical autonomic history and examination. 2.Autonomic function tests will not be sufficiently comprehensive to evaluate all autonomic systems. The repertoire of tests is best interpreted together. 3.These tests are noninvasive tests of end organ function, so that conclusions on the autonomic reflexes are largely extrapolative. Some abnormalities will reflect abnormalities of end organ function. 4.Autonomic testing as any other investigations can give you reliable data for interpretation only when confounding factors are minimized 11

12 ANScovery System 12

13 Why should we make autonomic testing in patients presenting as Parkinsonian? To detect AF signs is critical for Prognosis Differential Diagnosis Ameliorate the treatment since autonomic dysfunction significantly contribute to morbidity, disability and even death Biomarker? Is cardiovascular autonomic failure useful for differentiating PD from MSA? 13

14 Early if the pt had OH before,concurrent with, or starting within 1 year after onset of a symptomatic movement disorder MSA excluded with myocardial PET; OH documented by autonomic testing Among the 35 PD+OH 60% had documentation of OH as an early finding. In 4 OH had preceded parkinsonism, and in 4 others, OH had dominated the early clinical picture, even after cessation of levodopa treatment. 14

15 Other useful tools to detect cardiovascular autonomic failure 15

16 Cardiac sympathetic denervation in PD more than a movement disorder, more than a brain disease Diagnostic Algorithm for interpreting OH 16

17 Persistent, consistent? Neurobiology of Disease Volume 46, Issue No If episodic & unexpected, consider neurocardiogenic syncope. Yes Identifiable cause? Drugs (e.g. vasodilators, chemotherapeutic, phenothiazines) Hypovolemia (e.g. dehydratation, blood loss, adrenal insufficiency) Cardiac pump failure (e.g. heart block, aortic stenosis) Venous pooling (e,g, prolonged recumbency, severe varicosities) Periph. Neurop. (e.g. diabetes, amyloidosis, alcohol) CNS lesion (e.g. spinal cord injury, syringomyelia) Yes Treat underlying cause. No Neurogenic? Beat-to-beat BP responses to Valsalva maneuver Orthostatic plasma norepinephrine Ortostatic vascular resistances No Rule out hypovolemia, other nonneurogenic causes. Yes Peripheral NE denervation? Cardiac sympathetic neuroimaging Supine plasma catechols Neuropharmacologic probes No Main diagnoses: If evidence of central neurodrgeneration, MSA If no central neurodegeneration, AAG Yes Main diagnoses: If evidence of central neurodegeneration, PD+NOH+LBD If no central neurodegeneration,paf OH Neurobiology of Disease Volume 46, Issue

18 OH Neurobiology of Disease Volume 46, Issue TAKE HOME MESSAGES 18

19 Why is critical to recognize early cardiovascular AF? OH may be an early sign of MSA, PD e DLB OH may be a side effect of dopaminergic drugs OH may cause syncope and its conseqences and postprandial drowsiness OH is associated to severe disability and increased mortality BLADDER 19

20 Nervous system controlling uro-ano-genital function Autonomic Somatic Lumbosacral nerve roots Sympathic nerves Parasympathic nerves Pudendal nerve Courtesy J.J. Labat History: Question set for evaluating lower urinary tract dysfunction Frequency Urgency Nocturia/enuresis Incontinence stress/urge Hesitancy Postvoid dribbling History of urological/obstetrical injury or surgery Drugs Urinary diary! (frequency voiding chart) Symptoms derived from history may tentatively be interpreted to signify particular LUT dysfunction. 20

21 History: Interpretation of urinary symptoms urge or stress incontinence enuresis frequency nocturia - abnormal storage straining hesitancy poor stream incomplete emptying postmicturition dribble - abnormal voiding Interpretation of urinary symptoms creating a working hypothesis; proceeding to tests? Diagnostic procedures Functional diagnostics (urodynamics) Neurological /electrophysiological diagnostics Etiological diagnostics Diagnostic categories LUT dysfunctional syndrome Neuromuscular lesion syndrome Condition / disease 21

22 The synthesis: The neuroanatomic syndrome associates with a LUT dysfunctional syndrome (but exceptions from the rule are frequent!) Suprapontine lesion (overactive bladder with synergic voiding); Pontine-suprasacral ( spinal ) lesion (overactive bladder with dyssynergic voiding); Sacral lesion (hypoactive bladder with poor emptying, overflow and stress incontinence) Urinary symptoms in PD Nicturia Urgency/frequency Incontinence due to urgency Prevalent reduction of storage (>50%) Incomplete empting urinary ritention (20%) Disfunction of storage and empting Symptoms (25%) 22

23 MSA: bladder at low compliance Increased postvoid residual urine Deficit of Bladder contractility Atonic Bladder 23