Teaching Video NeuroImages: Spasmodic dysphonia preceding idiopathic parkinsonism

An 83-year-old woman presented initially with a 20-year history of phonatory breaks (video e-1 on the Neurology ® Web site at [www.neurology.org][1]), exacerbated by stress, and then recently a left hand rest tremor. After the onset of rest tremor, DaTscan SPECT of the brain, obtained in the Parkinson's Progression Markers Initiative clinical research trial,1 revealed near symmetrical loss of dopaminergic terminals in the striata (figure), supporting a diagnosis of idiopathic Parkinson disease (PD). Most patients with PD will demonstrate vocal difficulties during their disease course,2 including some with spasmodic dysphonia (focal dystonia of the intrinsic laryngeal muscles arising from a dysfunction of the basal ganglia/extrapyramidal tract), which may precede PD by many years. [1]: http://www.neurology.org/