Teaching Video Neuro Images : The underrecognized diphasic dyskinesia of Parkinson disease

Dyskinesia is a common motor complication in levodopa-treated Parkinson disease (PD), associated with higher doses, greater disease severity, and longer disease duration.1 Often assumed to be a peak-dose phenomenon, the diphasic (beginning-of-dose or end-of-dose) variant may be ignored, as exemplified by a patient with PD whose dyskinesia was initially interpreted as peak-dose (video at [Neurology.org][1]). Rapid improvement with apomorphine, a short-acting levodopa-equipotent dopamine agonist, confirmed its diphasic nature.2 Recognition of dyskinesia subtype based on the relationship with levodopa dose cycles (figure) facilitates their differing management in PD: while dopaminergic stimulation needs reduction in peak-dose dyskinesia, it should be increased in diphasic. [1]: http://neurology.org/lookup/doi/10.1212/WNL.0000000000004238