Parkinsonism as a manifestation of brain tumor

Secondary parkinsonism associated with focal brain lesions

Focal imaging abnormalities in patients with parkinsonism suggest secondary etiology and require a distinctive clinical approach to diagnosis and treatment. We review different entities presenting as secondary parkinsonism associated with structural brain lesions, with emphasis on the clinical course and neuroimaging findings. Secondary parkinsonism may be due to vascular causes, hydrocephalus, space-occupying lesions, metabolic causes (including acquired hepatocerebral degeneration, diabetic uremic encephalopathy, basal ganglia calcifications, osmotic demyelination syndrome), hypoxic-ischaemic brain injury, intoxications (including methanol, carbon monoxide, cyanide, carbon disulfide, manganese poisoning and illicit drugs), infections and immune causes. The onset can vary from acute to chronic. Both uni-and bilateral presentations are possible. Rigidity, bradykinesia and gait abnormalities are more common than rest tremor. Coexisting other movement disorders and additional associated neurological signs may point to the underlying diagnosis. Neuroimaging studies are an essential part in the diagnostic work-up of secondary parkinsonism and may point directly to the underlying etiology. We focus primarily on magnetic resonance imaging to illustrate how structural imaging combined with neurological assessment can lead to diagnosis. It is crucial that typical imaging abnormalities are recognized within the relevant clinical context. Many forms of secondary parkinsonism are reversible with elimination of the specific cause, while some may benefit from symptomatic treatment. This heterogeneous group of acquired disorders has also helped shape our knowledge of Parkinson's disease and basal ganglia pathophysiology, while more recent findings in the field garner support for the network perspective on brain function and neurological disorders.

Secondary parkinsonism due to drugs, vascular lesions, tumors, trauma, and other insults

In addition to neurodegenerative disorders, there are many secondary forms of parkinsonism. The most common cause for secondary parkinsonism is the intake of distinct drugs. Neuroleptics and calcium channel blockers have been mainly described to induce parkinsonism, but also other drugs were suspected to cause or worsen parkinsonism. Another common cause for secondary parkinsonism are vascular lesions (i.e. vascular parkinsonism). Furthermore, also brain tumors have been described as rare causes for parkinsonism. Moreover, parkinsonism can be caused by chronic traumatic encephalopathy, which is a special case, since secondary insults to the brain leads to the occurrence of a neuropathologically defined disease. Other rare causes for secondary parkinsonism are lesions caused by infectious or immunological diseases as well as toxins or street drugs.

Large left posterior fossa meningioma presenting with quadriplegia in a woman with history of carbidopa-levodopa resistant parkinsonism

A 56-year-old Afro-Trinidadian woman with a history of a carbidopa-levodopa resistance Parkinsonian-like syndrome for 2 years, presented with acute onset spastic quadriplegia and decreased responsiveness. Diagnosis involved clinical and MR-imaging correlation consistent with a large left posterior fossa meningioma. Surgical removal of the tumor led to complete reversibility of the neurological manifestations associated with cerebellar tonsillar herniation beyond the foramen magnum and mass effect on the brainstem, cerebellum and midbrain regions. Pathological findings were typical of a meningioma. This case demonstrates the association of a large left posterior fossa meningioma and carbidopalevodopa resistant parkinsonism in an Afro-Trinidadian woman who presented with acute onset acute quadriplegia and decreased responsiveness. This case reminds clinicians that patients with dopa unresponsiveness and/or acute neurological deficit or deterioration should be worked up for other possible causes and adds to the literature on the association of parkinsonism and intracranial space occupying lesions.

Parkinsonism: a rare manifestation of craniopharyngioma

Craniopharyngioma is a non-glial, non-malignant intracranial tumor of ectodermal origin, which arises from a remnant of Rathke’s pouch. This tumor accounts for 5.6 to 13% of intracranial tumors in children. This paper discusses a case of craniopharyngioma in a five-year-old boy. An MRI scan of his brain showed a huge sella and supra sella cystic-solid lesion that had invaded the prepontine and interpeduncular cisterns, filling of 3rd ventricle and hydrocephalus. The patient operated via interhemispheric subfrontal through lamina terminalis and the tumor dissected from all part of brain stem and total resection achieved. After surgery Parkinsonism was worse for 3 days and levodopa started for 3 days. Parkinsonism was gone and after one week levodopa discontinued. This case practically implied that decompression of mass effect of tumor on brain stem and short-term management with levodopa can improve Parkinsonism due to midline compressive brain tumors without basal ganglia involvement.

Hemiballismus due to contralateral sphenoid ridge meningioma

Primary intracranial tumour is a very uncommon cause of hemiballismus. In our review of the literature only two verified cases were found: one meningioma and one meningoblastoma. We report a patient with right hemiballismus due to a contralateral meningioma of the sphenoid ridge. His symptoms disappeared completely after resection of the tumour. The patient had no signs of increased intracranial pressure. Possible pathogenic mechanisms are briefly discussed. A consequence of such an experience is that magnetic resonance imaging or computed tomography scans should be made of every patient with uncommon extrapyramidal disorders, particularly if they do not respond to drug therapy.

Apparently ipsilateral parkinsonism in a patient with chronic subdural hematoma

Symptomatic parkinsonism secondary to ipsilateral lesion is rarely reported. Although the contribution of the contralateral lesions was assumed in some cases, the pathomechanism remains undetermined. Herein we report a patient with a subdural hematoma, who developed parkinsonism in the ipsilateral hemibody. Structural and functional imaging suggests the contralateral dopaminergic dysfunction as the major culprit of apparently ipsilateral parkinsonism.

Astrocytoma in the third ventricle and hypothalamus presenting with parkinsonism

Parkinsonism secondary to intracranial mass lesions usually results from compression or distortion of the basal ganglia. Secondary parkinsonism due to midbrain infiltration or compression is rare and generally associated with other neurologic signs caused by pyramidal tract and/or cranial nerve involvement. We report a case of 30-year-old woman in whom mild parkinsonism was the major clinical manifestation of an astrocytoma in the anterior third ventricle and hypothalamus. She underwent surgical resection, ventriculoperitoneal shunt and radiation therapy. All symptoms of parkinsonism were completely recovered 3 months after the treatment. Brain tumors can be manifested only by the symptoms of parkinsonism. This case emphasizes the significance of neuroimaging in the evaluation of parkinsonism.

Thalamic tumour presenting with Holmes' tremor: diagnostic difficulties

The presentation of intracerebral tumours with tremor is rare. A case is described of a 78-year-old woman presenting with Holmes' tremor who was found to have a thalamic tumour. The diagnostic context of tumours that present with tremor is discussed along with the pathophysiology and management of this case.

Hemiparkinsonism due to a pontomesencephalic cavernoma: improvement after resection. Case report

Cavernous angiomas of the upper brainstem causing hemiparkinsonism are very rare. Due to their difficult-to-reach localization, brainstem cavernomas, in particular those in anterior locations, continue to present a therapeutic challenge. The authors report on a 16-year-old boy with a pontomesencephalic cavernoma who developed hemiparkinsonism and hemiparesis after hemorrhage. After complete surgical removal of the pontomesencephalic cavernoma via a pterional transsylvian approach, his symptoms resolved. Although pontomesencephalic cavernomas occupying the ventral portion of the brainstem are regarded as problematic for resection, the pterional transsylvian approach provides an excellent route for removal of cavernomas that are in contact with the ventral surface of the midbrain in the interpeduncular cistern. Surgical removal of this type of lesion is recommended because resolution of clinical symptoms, including hemiparkinsonism, can be achieved.

Hemiparkinsonism secondary to an infiltrative astrocytoma

BACKGROUND

Brain tumors are uncommon etiologies of parkinsonism. The clinical manifestations of tumoral parkinsonism may sometimes resemble those of idiopathic origin. Increased awareness of this rare entity is important for an earlier prompt diagnosis and treatment.

REVIEW SUMMARY

A previously healthy, 60-year-old man developed slowly progressive right-sided resting tremor and bradykinesia over 8 months. Although idiopathic Parkinson disease was the initial diagnosis, the parkinsonian symptoms were not responsive to medical treatment with levodopa and a dopamine agonist. Brain computed tomography failed to reveal an intracranial lesion. Brain magnetic resonance imaging demonstrated an infiltrative, slightly enhancing mass in the left mesial temporal lobe extending to the left basal ganglion and insula. Histopathologic findings confirmed the diagnosis of high-grade astrocytoma. The parkinsonian symptoms subsided after tumor removal; however, ipsilateral hemiparesis developed postoperatively.

CONCLUSIONS

Neuroimaging is recommended for investigation of atypical parkinsonism. We suggest that brain magnetic resonance imaging is preferred for patients with drug-resistant parkinsonism or concurrent signs apart from extrapyramidal symptoms, because some mass lesions are not observed by computed tomography scan.

Impact of surgical treatment on tremor due to posterior fossa tumors

Object

The object of this study was to investigate the impact of surgical treatment on tremor caused by posterior fossa tumors.

Methods

The authors performed a retrospective evaluation of 6 cases involving patients with tremors due to posterior fossa tumors. Patients who had been treated with neuroleptic medication or had a family history of movement disorders were excluded. All patients had postural or kinetic tremors. Tremor was mainly unilateral. The study group included 5 women and 1 man. Mean age at surgery was 59 years. Five patients underwent total or subtotal tumor resection, and 1 patient underwent stereotactic biopsy only. The histological diagnosis was epidermoid tumor in 2 patients, metastasis in 2 others, and vestibular schwannoma and low-grade glioma in 1 each.

Results

Two patients had no improvement of tremor, postoperatively. In both of these patients the tumor (low-grade glioma in 1, metastasis in the other) involved the dentate nucleus directly. In the other patients, a compressive effect on the dentate nucleus or the dentatothalamic pathways was present without invasion of the cerebellar structures, and immediate or gradual amelioration of the tremor was observed postoperatively.

Conclusions

The prognosis of tremor due to posterior fossa tumors appears to depend mainly on the involvement of tremor-generating structures. The prognosis appears to be favorable in those patients with compression of these substrates, whereas primary invasion by tumor has a poor prognosis. Caution must be used in generalizing the findings of this study because of the small number of cases in the series.

Primary central nervous system lymphoma in the SMA presenting as rapidly progressive parkinsonism

We report on a 56-year-old man who developed a rapidly progressive parkinsonism and apraxia over 2 months due to biopsy confirmed cerebral non-Hodgkin lymphoma primarily involving the SMA and parts of the superior frontal gyrus bilaterally.

Pineal cavernous angioma presenting with Parkinsonism

Cavernous angioma of the pineal region is rare, as is brain tumour coincident with Parkinsonism. The authors describe the case of a 55 year old woman with a pineal region cavernous angioma, who subsequently developed Parkinsonism after her increased intracranial pressure was relieved. The cause of Parkinsonian syndrome is unclear, but compression of the posterior thalamus and upper mid-brain with congestion of the deep venous system may have caused vascular disturbance of the nigro-striate-pallidal system. Her symptoms gradually improved after total excision of the lesion.

Parkinsonian syndrome in a patient with a pterional meningioma: case report and review of the literature

The onset of a Parkinsonism in a patient with intracranial meningioma is definitely rare. The authors described the case of a patient suffering from a Parkinsonian syndrome for 10 years with no evidence of clinical improvement after medical treatment. A CT-scan of the brain evidenced a right pterional intracranial meningioma. The complete surgical removal of the neoplasm succeeded in resolving the Parkinsonian syndrome. The extension of the neoplasm and of the peritumoral edema may play an important role in compressing and consequently impairing perfusion of the basal ganglia region.

Parkinsonism in children resulting from mesencephalic tumors

Parkinsonism secondary to intrinsic brain stem mass lesions is rare. Two children with parkinsonism caused by mesencephalic tumors are reported. The pathophysiological mechanisms of this association are discussed and the literature describing similar cases is reviewed.

Differential diagnosis of Parkinson's disease

The differential diagnosis of PD includes other neurodegenerative disorders; hereditary disorders; and symptomatic causes, such as structural lesions, infections, metabolic abnormalities, hydrocephalus, and drugs or toxins. A good history of symptom evaluation, drug use, and family illness is just as essential as a careful neurologic examination when evaluating a patient with parkinsonism. Although there is no definitive diagnostic test for PD at this time, tests to rule out other causes should be considered and then treatment started.

Apomorphine and levodopa challenge in patients with a focal midbrain lesion

Three patients who presented with parkinsonian signs resulting from a focal midbrain lesion are reported. In all patients parkinsonian features occurred acutely and improved following acute challenge with apomorphine but not with levodopa. Remission of parkinsonian signs occurred spontaneously to a different degree. Inconsistent clinical response following administration of levodopa has been well documented in patients with focal midbrain lesions associated with parkinsonian signs; however, the efficacy of apomorphine has not been tested before. Anatomic or etiologic features do not allow us to predict in which cases parkinsonian signs secondary to a midbrain lesion would respond to levodopa or to dopamine agonists. A trial with apomorphine is warranted in all such cases.

Asymmetric predominantly ipsilateral blepharospasm and contralateral parkinsonism in an elderly patient with a right mesencephalic cyst

A 66-year-old woman presented with a 3-year history of predominantly right-sided blepharospasm and a 1-year history of progressive predominantly left-sided hemiparkinsonism manifested by a left upper extremity resting tremor and left-sided bradykinesia. Magnetic resonance imaging of the brain revealed a large right mesencephalic cyst with mass effect. Positron emission tomography revealed bilateral striatal hypometabolism consistent with nigrostriatal dopaminergic dysfunction. The association of predominantly ipsilateral blepharospasm and predominantly contralateral hemiparkinsonism is very rare, and its association with a posterior fossa space-occupying lesion has been reported only once. This is the second report of such an association and the first description of adult-onset symptomatology.

Parkinsonism and rest tremor secondary to supratentorial tumours sparing the basal ganglia

Intracranial neoplasms are an uncommon cause of symptomatic Parkinsonism and rest tremor. We found an incidence of 0.3% in a prospective evaluation of 907 patients with supratentorial tumours. Eight patients with Parkinsonism and rest tremor secondary to supratentorial tumours sparing the basal ganglia are reported. Neuro-imaging revealed compression and distortion of the basal ganglia by large tumours which were identified histopathologically as meningiomas in four patients and as an epidermoid, a fibrillary astrocytoma, an anaplastic oligodendroglioma and a glioblastoma. Six patients underwent tumour removal by craniotomy, in two the histopathology was obtained by stereotactic biopsy. Four patients were free of Parkinsonian symptoms and signs on long-term follow-up. The possible pathophysiological mechanisms involved are discussed. Since some of these patients closely resemble cases of idiopathic Parkinson's disease, and the movement disorder can precede other symptoms and signs or will remain isolated in the further course, the diagnosis of an intracranial neoplasm was generally delayed in these patients. Increased awareness of this rare entity may lead to an earlier diagnosis. Early computed tomography in patients with Parkinsonism might help to detect these patients with a potentially curable cause of their condition.

Dystonia-parkinsonism syndrome resulting from a bullet injury in the midbrain

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Striatal glucose metabolism and [18F]fluorodopa uptake in a patient with tumor-induced hemiparkinsonism

We studied a patient with a falx meningioma in the right supplementary motor area and a left-sided hemiparkinsonism that resolved after the tumor was removed. Because there was no evidence of distortion of the basal ganglia and midbrain by the tumor on neuroradiological examination, the possible mechanism of parkinsonism is an impairment of the basal ganglia output to the supplementary motor area. Positron emission tomography scans with 2-[18F]fluoro-2-doxy-D-glucose and 6-L-[18F]fluorodopa were performed to measure regional cerebral glucose metabolism and striatal dopamine metabolism, respectively. Regional cerebral glucose metabolism was decreased in the striatum of the side of the lesion, although dopamine metabolism was normal. These data suggest that the tumor may have impaired synaptic function of the striatum as a whole, giving rise to contralateral hemiparkinsonism without an impairment of the presynaptic dopaminergic nerve terminals in the striatum.

Movement disorders in astrocytomas of the basal ganglia and the thalamus

In a series of 225 patients with astrocytomas (grades I-IV) of the basal ganglia and the thalamus, 20 had a movement disorder. In all patients the histological diagnosis was verified by stereotactic biopsy. Tremor was observed in twelve patients, dystonia in eight, chorea in three, and chorea/ballismus and myoclonus in one. The tumour involved the thalamus in 16 patients. Corticospinal tract dysfunction was evident in 70% of the patients with movement disorders and in 73% of those without. Demographic, clinical, histological and neuroradiological data of the patients with a movement disorder were compared with the data of patients without. CT data yielded no differences with respect to the involvement of anatomical structures. Movement disorders were significantly associated with low-grade astrocytomas.

[Parkinson disease associated to a brain tumor: a case report]

We are presenting an uncommon case of cerebral tumor whose major manifestation was parkinsonism. The patient was a 50-year-old woman presented with a 5-month history of tremor of the right hand, particularly at rest, and headache. On neurological examination of March, 1987 there were: slight right-sided hemiparesis with symmetrical hyperreflexia; discrete bradykinesia in combination with cogwheel rigidity also on the right-side; resting tremor of the right hand; and bilateral papilledema. The neuropsychological examination disclosed: nominative aphasia, impaired recent memory and right-left disorientation. The computed tomography showed a large, left frontotemporal tumor. Angiograms of the left internal and external carotid arteries revealed a tumor blush in the left frontotemporal region supplied by a enlarged middle meningeal artery. An electromyogram revealed a 4-6 HZ tremor on right hand. A course of treatment with dexamethasone 16 mg/day and levodopa plus benzerazine (500 mg/day) was unsuccessful. A left fronto-temporo-parietal craniotomy was performed and an attached sphenoid wing tumor was macroscopically completely removed. Microscopy indicated that the tumor was a meningioma. Postoperatively, the patient made an uneventful recovery. After two weeks, her right-sided palsy and parkinsonism had disappeared, and neuropsychological deficits improved. Two months later there was no abnormalities on neurological and neuropsychological examination. It was concluded that the parkinsonism was caused by mechanical pressure on the basal ganglia.

Ipsilateral hemi-parkinsonism secondary to an astrocytoma

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Spontaneous intraneural haematoma of the optic nerve

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Giant middle cerebral aneurysm presenting as hemiathetosis in a child and its spontaneous thrombosis

A 10-year-old girl presented with a 6-week history of gradually increasing, abnormal movements and weakness of the right upper and lower limbs. There were no features of raised intracranial pressure. Computed tomography scan and magnetic resonance imaging (MRI) of the brain showed the features of a partially thrombosed giant middle cerebral artery aneurysm, located deep in the left lentiform region and compressing the basal ganglia and the mesencephalon. The angiogram confirmed the aneurysm and its origin from the main trunk of the artery with occlusion of all the branches. A direct approach was unsuitable for the treatment of the aneurysm, so an embolization procedure to occlude the neck of the aneurysm was considered. During the waiting period, the patient improved and became asymptomatic. Follow-up MRI showed complete thrombosis of the aneurysm and eventually, reduction in its size and mass effect. The hemiathetosis may have been the result of direct pressure on the basal ganglia by the aneurysm. The spontaneous intra-aneurysmal thrombosis may have been due to the massive size of the aneurysm and its narrow neck.

Parkinsonian symptoms in a patient with AIDS and cerebral toxoplasmosis

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Parkinsonism secondary to bilateral striatal fungal abscesses

A 24-year-old man with an 11-year history of i.v. drug use rapidly developed parkinsonism clinically indistinguishable from MPTP toxicity and Parkinson's disease. Although tests were negative for the human immunodeficiency virus, radiologic evaluation revealed bilateral striatal lesions. Stereotactic biopsy demonstrated septate hyphae consistent with either aspergillosis or mucormycosis. Gradual improvement followed systemic therapy with amphotericin B.

Parkinsonian syndrome caused by a tumour of the left supplementary motor area

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Giant middle cerebral aneurysm presenting as hemiparkinsonism

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Parkinsonism due to corpus callosum astrocytoma: case report

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