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Lower-body parkinsonism: reconsidering the threshold for external lumbar drainage

Nature Clinical Practice Neurology volume 4, pages 50–55 (2008)Cite this article

Abstract

Background An 80-year-old man with a 60 pack-year smoking habit, hypertension, and hypercholesterolemia presented to a movement disorders clinic with a 30-month history of step-wise progression of gait, balance, and memory impairment. He had experienced multiple falls and two hospitalizations for sudden-onset freezing of gait.

Investigations Neurological examination, brain MRI, neuropsychological evaluation, gait analysis, continuous external lumbar drainage of cerebrospinal fluid, and post-mortem neuropathological studies.

Diagnosis Vascular parkinsonism was diagnosed on the basis of the patient's history and imaging findings; however, post-mortem neuropathology was consistent with a diagnosis of normal pressure hydrocephalus and did not support that of vascular parkinsonism.

Treatment Ventriculoperitoneal shunt placement superseded tighter control of vascular risk factors, as judged by the patient's response to continuous lumbar drainage.

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Figure 1: Brain MRI scans of a patient with suspected vascular parkinsonism.
Figure 2: Photographs of two coronal sections of the patient's formalin-fixed cerebral hemispheres.
Figure 3: Diagram representing the clinical and pathologic spectrum in lower-body parkinsonism.

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Acknowledgements

The authors thank Martha Headworth, medical illustrator, and Mary Kemper, medical editor, of The Neuroscience Institute, University of Cincinnati, OH, for their expertise in organizing the figures and providing editorial review of this manuscript, respectively.

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Authors and Affiliations

  1. RK Narayan is the Frank H Mayfield Professor and Chairman of the Department of Neurosurgery, AJ Espay is Assistant Professor of Neurology, AP Duker is Assistant Professor of Neurology, ET Barrett Jr is Director of Neuropsychology at the Cincinnati Veterans Affairs Medical Center and Assistant Clinical Professor of Neurology at the University of Cincinnati, and G de Courten-Myers is Adjunct Professor Emeritus of Neuropathology at the University of Cincinnati, Cincinnati, OH, USA.,

    Alberto J Espay, Raj K Narayan, Andrew P Duker, Edwin T Barrett Jr & Gabrielle de Courten-Myers

Authors
  1. Alberto J Espay
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  2. Raj K Narayan
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  5. Gabrielle de Courten-Myers
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Corresponding author

Correspondence to Alberto J Espay.

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The authors declare no competing financial interests.

Supplementary information

Supplementary Video

Video clip of patient demonstrating markedly improved straight gait and turning following 3-day continuous external lumbar drainage (ELD). Segment 1: straight gait before and after ELD. Segment 2: turning, also before and after ELD. Gait parameters are displayed. (MPG 11286 kb)

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Espay, A., Narayan, R., Duker, A. et al. Lower-body parkinsonism: reconsidering the threshold for external lumbar drainage. Nat Rev Neurol 4, 50–55 (2008). https://doi.org/10.1038/ncpneuro0688

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