Διαγνωστικά κριτήρια Πάρκινσον

Διαγνωστικά κριτήρια για την Ιδιοπαθή Νόσο Πάρκινσον

Η κλινική διάγνωση της νόσου Πάρκινσον επιβεβαιώνεται παθολογοανατομικά σε ένα ποσοσοτό γύρω στα 80% των περιπτώσεων. Αυτη η διαπίστωση οδήγησε την Διεθνή Εταιρεία Κινητικών Διαταραχών (MDS) να ορίσει ειδική ομάδα εργασίας (task force) για την επεξεργασία πληρέστερων διαγνωστικών κριτηρίων για την νόσο. Από όσο γνωρίζουμε, η σελίδα αυτή είναι η πρώτη στο ελληνικό διαδίκτυο (Οκτ.2016) που παρουσιάζει σε ελληνική απόδοση αυτή την εργασία ανασκόπησης του task force της MDS που δημοσιεύτηκε το 2015.

Οσον αφορά τη βεβαιότητα της διάγνωσης, για λόγους ευχρηστίας στο ερευνητικό αλλά και στο κλινικό πεδίο, διακρίνονται δύο επίπεδα βεβαιότητας:

  1. Πολύ πιθανή (probable) νόσος Πάρκινσον
  2. Κλινικά βέβαια νόσος Πάρκινσον

Ως πρώτο και απαραίτητο στοιχείο είναι η ύπαρξη “παρκινσονισμού”, δηλαδή η ύπαρξη βραδυκινησίας σε συνδυασμό με τρόμο ή δυσκαμψία ή και με τα δύο μαζί. Αυτό είναι το “Βήμα 1” στον αλγόριθμο που ακολουθεί. Αν δεν υπάρχει δεν μιλάμε για νόσο Πάρκινσον.

Στο “Βήμα 2¨ εξετάζεται η τυχόν παρουσία κριτηρίων αποκλεισμού. Έστω και ένα αν υπάρχει αποκλείεται και πάλι η νόσος Πάρκινσον.

Τέλος στο “Βήμα 3” γίνεται η συσχέτιση των θετικών κριτηρίων και των κριτηρίων αμφισβήτησης της νόσου (Red flags) όπου ανάλογα με το αποτέλεσμα καταλήγουμε στη διάγνωση.

 

Διάγραμμα ροής (flow chart) για τη διάγνωση νόσου Πάρκινσον

 

bbkmdscriteria1

 

 

Για την αποτελεσματική χρήση του πιό πάνω αλγόριθμου παραθέτουμε τις ομάδες των κριτηριών της Διεθνούς Εταιρείας Κινητικών Διαταραχών (MDS), όπως αυτές καθορίζονται στην εργασία.

Θετικά (supportive) κριτήρια
  1. Θεαματική βελτίωση με τη λήψη της L-Dopa.
  2. Εμφανιση υπερκινησιών οφειλομένων στην L-Dopa
  3. Τρόμος ηρεμίας σε κάποιο άκρο
  4. Ανοσμία
Κριτήρια αποκλεισμού (absolute exclusion of PD)
  1. Αναμφισβήτητες παρεγκεφαλιδικές διαταραχές (αταξία, νυσταγμός κλπ)
  2. Παράλυση της προς τα κάτω στροφής του βλέμματος (υπερπυρηνική παράλυση)
  3. Υπαρξη μετωποκροταφικής άνοιας (συμπεριφορικός τύπος), πρωτοπαθής αφασική διαταραχή
  4. Παρκινσονισκά ευρήματα μόνο από τα κάτω άκρα για διάστημα >3 έτη
  5. Φαρμακευτικός παρκινσονισμός
  6. Απουσία αισθητής βελτίωσης ακόμη και με υψηλές δόσεις L-Dopa
  7. Βεβαιωμένες αγνωσο-απρακτικές διαταραχές οφειλόμενες σε φλοιϊκές βλάβες
  8. Φυσιολογική λειτουργική νευροαπεικόνιση του προσυναπτικού ντοπαμινεργικού συστήματος
  9. Τεκμηριωμένη ύπαρξη άλλης νόσου η κατάστασης που μπορεί να σχετίζεται με τη συμπωματολογία του ασθενούς
Κριτήρια που αμφισβητούν τη διάγνωση (Red flags)
  1. Ραγδαία επιδείνωση της βάδισης – μετακίνηση με αμαξίδιο μέσα σε 5 χρόνια
  2. Πλήρης απουσία επιδείνωσης των κινητικών συμπτωμάτων χωρίς θεραπεία επί 5 και πλέον χρόνια
  3. Πρώιμες προμηκικές διαταραχές: οξεία δυσφωνία ή δυσαρθρία ή δυσφαγία (χρειάζεται ειδική κατεργασία του φαγητού ή και ρινογαστρικό σωλήνα)
  4. Αναπνευστικές διαταραχές (εισπνευστικός συριγμός κλπ)
  5. Εντοντες διαταραχές από το Αυτονομο Νευρικό Σύστημα στα πρώτα 5 χρόνια πχ.
    • ορθοστατική υπόταση που δεν οφείλεται σε χορήγηση φαρμάκων ή αφυδάτωση
    • οξεία κατακράτηση ούρων ή ακράτεια ούρων που δεν οφείλεται σε προστάτη ή άλλα άσχετα αίτια
  6. Συχνές πτώσεις από αστάθεια μέσα στα 3 πρώτα χρόνια έναρξης των συμπτωμάτων
  7. Ασύμμετρες δυστονίες και συσπάσεις των άκρων τα πρώτα 10 χρόνια
  8. Πλήρης απουσία μη κινητικών συμπτωμάτων της νόσου τα πρώτα 5 χρόνια (διακεκομμένος ύπνος, υπερβολική υπνηλία την ημέρα, δυσκοιλιότητα, ημερήσια συχνουρία, ορθοστατική υπόταση, υποσμία, ψυχιατρικές διαταραχές κλπ.
  9. Μή εξηγήσιμα πυραμιδικά σημεία όπως μυϊκή αδυναμία, μεγάλη ζωηρότητα τενοντίων αντανακλάσεων κλπ
  10. Τελείως συμμετρικός αμφοτερόπλευρος παρκινσονισμός
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