Parkinsonian-Like Syndrome Caused by Cyst in Posterior Fossa

Symptomatic hemiparkinsonism due to extensive middle and posterior fossa arachnoid cyst: case report

Introduction

Intracranial neoplasms are an uncommon cause of symptomatic parkinsonism. We here report a patient with an extensive middle and posterior fossa arachnoid cyst presenting with parkinsonism that was treated by neurosurgical intervention.

Methods

Retrospective chart review and clinical examination of the patient.

Case report

This 55-year-old male patient with hemiparkinsonism and recurrent bouts of headaches was first diagnosed in 1988. CT scans revealed multiple cystic lesions compressing brainstem and basal ganglia, which were partially resected. Subsequently, the patient was free of complaints for 20 years. In 2009 the patient presented once more with severe unilateral tremor and thalamic pain affecting the right arm. Despite symptomatic treatment with L-Dopa and pramipexole symptoms worsened over time. In 2014 there was further progression with increasing hemiparkinsonism, hemidystonia, unilateral thalamic pain and pyramidal signs. Repeat CT scanning revealed a progression of the cysts as well as secondary hydrocephalus. Following repeat decompression of the brainstem and fenestration of all cystic membranes parkinsonism improved with a MDS- UPDRS III score reduction from 39 to 21. Histology revealed arachnoid cystic material.

Conclusion

We report on a rare case of recurrent symptomatic hemiparkinsonism resulting from arachnoid cysts.

Parkinsonism and midbrain dysfunction after shunt placement for obstructive hydrocephalus

We report a patient in whom placement of a ventriculoperitoneal shunt for obstructive hydrocephalus secondary to non-neoplastic aqueductal stenosis was complicated by progressive parkinsonism and midbrain dysfunction. These sequelae were refractory to treatment, including shunt revision and levodopa therapy. These findings contradict the opinion from the literature that this type of parkinsonism is a reversible condition and levodopa therapy is effective for managing the symptoms. We discuss the pathophysiological mechanism of this complication.

"Hydrocephalus-parkinsonism complex": progressive hydrocephalus as a factor affecting extrapyramidal tract disorder-an experimental study

OBJECTIVE

To experimentally clarify the symptomatological and pathophysiological aspects of a newly proposed clinical entity, we produced an experimental rat "hydrocephalus-parkinsonism complex" model.

METHODS

A total of 60 male Sprague-Dawley rats were used. Twenty rats were treated with only kaolin as controls. Hemiparkinsonism was induced in the other 40 rats by stereotactic injection of 6-hydroxydopamine (6-OHDA) directly into the right substantia nigra. Twenty of these 40 rats were then treated with an injection of kaolin into the cisterna magna 3 days after the induction of parkinsonism. Neurological features were assessed weekly for 1 to 6 weeks after 6-OHDA injection by an apomorphine-induced turning test.

RESULTS

The mortality rate was 25% in the rats injected with kaolin and 10% in those with the 6-OHDA injection. The frequency of the induction of parkinsonism-like signs was minimal in the first 2 weeks and reached a maximum point 4 weeks after the 6-OHDA injection. In contrast, the rats injected with both 6-OHDA and kaolin developed hemiparkinsonism-like signs in the early stage of the progression of hydrocephalus, and the peak incidence was reached in the 2nd week after induction ( p<0.05 compared with the 6-OHDA group). The severity of the neurological disturbance was also significantly more prominent in the latter group.

CONCLUSION

These results suggest that the hydrodynamic effect in the early period of ventriculomegaly is the mechanism for signs of parkinsonism in 6-OHDA-treated rats. It could be concluded that the hydrocephalic state aggravates parkinsonism, if any as the associated condition, and it may be a new clinical entity of hydrocephalus symptomatology with a specific pathophysiology.

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.

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.

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.

Tremor as the result of shunt obstruction: four patients with cysticercosis and secondary parkinsonism: report of four cases

In four patients, shunt obstruction was accompanied by severe resting tremor involving principally the head, the jaw, the tongue, and the right upper extremity. Shunt revision resulted in improvement in each patient. Five similar patients have been reported. Although rare, the occurrence of parkinsonian tremor in a previously shunted patient suggests obstruction and requires prompt evaluation.

Parkinsonian syndromes associated with hydrocephalus: case reports, a review of the literature, and pathophysiological hypotheses

We present nine cases of obstructive hydrocephalus (OH) associated with marked parkinsonism. Four patients had noncommunicating OH (NCOH) [three nontumoral aqueductal stenosis (AS), one tumoral AS]. The presentation was that of acute or subacute parkinsonism, usually at the time of acute recurrent ventricular obstruction. Three had a marked response to levodopa and required short-term treatment after shunting. However, one has remained levodopa dependent after 2 1/2 years. Three of the five patients with communicating OH (COH) presented with shunt-responsive normal pressure hydrocephalus (NPH), only later to develop progressive parkinsonism. One of these was found to have progressive supranuclear palsy (PSP) at autopsy and PSP was clinically suspected in one other patient. A third had an atypical course suggestive of PSP; however, autopsy demonstrated the combination of Lewy body parkinsonism and the sequelae of hydrocephalus. The remaining two COH patients presented with levodopa-responsive parkinsonism. Subsequent clinical features and imaging studies suggested the presence of NPH. The pathophysiology of hydrocephalic parkinsonism probably involves variable sites of dysfunction in the nigrostriatal pathway and/or the cortico-striato-pallido-thalamo-cortical circuit. At certain locations these pathways lie in close proximity to the ventricular system and may be subjected to mass effects and ischemic changes secondary to ventriculomegaly. The additional importance of possible associations between subcortical cerebral ischemia, NPH, and "degenerative" disorders such as PSP and Parkinson's disease is discussed.

[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.

Blepharoclonus and parkinsonism associated with aqueductal stenosis

A 28-year-old man with a history of congenital hydrocephalus due to aqueductal stenosis shunted at 45 days of age is presented. At age 4 years the valve had to be removed because of septicemia. Twenty-three years later he developed parkinsonian signs and abnormal, involuntary rhythmic contractions of the eyelids. The latter were elicited on gentle eye closure. Parkinsonism promptly improved after ventriculoperitoneal shunting, but blepharoclonus persisted unchanged.

Obstructive hydrocephalus-induced parkinsonism. I: Decreased basal ganglia regional blood flow

A 17-year-old male developed acute parkinsonism after obstruction of a ventriculoperitoneal shunt with subsequent hydrocephalus. Following a previous shunt replacement, he developed florid parkinsonism which was associated with Parinaud syndrome. The initial single-photon emission computed tomography of the brain using 99mTc-hexamethylpropylenamine oxime demonstrated decreased cerebral blood flow in the regions of the left caudate and putamen. The patient underwent shunt revision with minimal improvement and therefore levodopa/carbidopa (Sinemet 100/25) was administered. Subsequently, he experienced almost complete recovery which may have been correlated with probable improvement of the basal ganglia regional cerebral blood flow. Parkinsonism associated with ventriculoperitoneal shunt obstruction is a rare but reversible disorder that is responsive to shunt replacement and antiparkinsonian drug administration. Cerebral perfusion studies may prove to be of value in delineating the pathophysiology of this complication.

Parkinsonism and acquired hydrocephalus

Left hemiparkinsonism was the first symptom of increased intracranial pressure in a 14-year-old girl. The parkinsonism resolved when the increased intracranial pressure was relieved by a ventriculo-peritoneal shunt. This is the first case of parkinsonism associated with hydrocephalus caused by non-neoplastic aqueductal stenosis.

Reversible parkinsonism from shunt failure

Parkinsonism developed as the result of shunt malfunction in a 16-year-old girl with aqueductal stenosis. Her symptoms responded to levodopa and shunt revision. Possible pathogenetic mechanisms are discussed.

Infratentorial arachnoid cysts

The infratentorial compartment represents the second most common location of arachnoid malformations. Ten arachnoid cysts of the posterior fossa, operated on between 1970 and 1983, are reviewed. These lesions, although congenital and developmental in nature, may present at any age, and males are more frequently affected. A high rate of birth-related trauma (50% in this series) is conceivably due to fetal macrocranium, and the enlarged head and psychomotor retardation prevail in infancy and childhood. In arachnoid cysts occurring during adulthood, symptoms and signs more clearly indicate a dysfunction of the posterior fossa. Besides computerized tomography, pneumoencephalography and metrizamide techniques are recommended to rule out a Dandy-Walker syndrome in doubtful cases, and to obtain information about the cerebrospinal fluid (CSF) circulation. It is particularly important to establish the presence and type of communication of cysts with the CSF pathways. Although infratentorial cysts often communicate, they can be space-occupying masses because of increasing CSF retention, which may be due to a ball-valve mechanism or to inadequate communication. The frequently associated hydrocephalus (seven of the 10 cases in this series had hydrocephalus) seemed to be dependent mainly upon mechanical factors. The authors discuss the indications for intracranial surgery versus shunting procedures and report the results achieved by direct cyst excision.

Parkinsonism as a manifestation of brain tumor

Neoplasm is an uncommon cause of the parkinsonian syndrome. We are presenting three cases of intracranial tumors whose major manifestations included parkinsonism. Surgical treatment resulted in control of the extrapyramidal symptoms in two of our patients. Because no curative treatment is available for the vast majority of parkinsonian patients, early detection of an underlying neoplasm may offer a most rewarding outcome. Unilaterality of the symptoms, overwhelming dementia, or suspicion of a mass should lead to the performance of computed tomography.

Parkinsonian syndrome and central nervous system lymphoma involving the substantia nigra. A case report

The clinical history and postmortem neuropathologic findings of a case of cerebral lymphoma revealed by a typical parkinsonian syndrome are reported. The clinical symptoms initially improved with dopa therapy. The tumor was classified as a diffuse, non-cleaved, large-cell lymphoma of B-cell origin producing monoclonal lambda light chains. The substantia nigra was infiltrated by the tumor and showed neuronal loss and extraneuronal pigment. The most striking histological feature was the presence of neuronophagic-like nodules composed of lymphomatous cells both in the locus niger and in the left thalamus. No tumoral mass effect and no histological stigmata of other etiologies of parkinsonian syndromes were observed. A hypothesis is that the neuronophagic-like nodules may reflect a neuronotoxic activity of the lymphoma and may be considered at the origin of parkinsonism.

Non-communicating supratentorial subarachnoid cysts

The clinical and radiological features and operative treatment of six patients with supratentorial subarachnoid cysts are reviewed. Five were adults aged 37 to 57 years and the other a male infant, aged 8 months. Three patients presented with epilepsy and hemiparesis, one with epilepsy without signs, another as Parkinsonian syndrome, and the infant with hydrocephalus. Diagnosis was revealed at operation in four cases, in one case by ventriculography, and in one case the lesion was strongly suspected on angiographic appearances. Surgical treatment is highly effective, since the cystic lesion is benign in nature, but recurrence of symptoms is not unusual and repeated evacuation of the cyst may be required. It is, therefore, considered essential to conduct a prolonged and careful follow-up.