Objective: To describe a case of acute parkinsonism following an obstructive hydrocephalus and ventriculoperitoneal (VP) shunt revision.

Background: Acute parkinsonism is a rare complication of obstructive hydrocephalus and rapid changes in intracranial pressure (ICP) (1). It has been suggested that hydrocephalus may cause shear, torsion or ischemia, or negative infra-supratentorial pressure gradient may damage the nigrostriatal neurons (2). We describe a patient who developed acute levodopa-responsive parkinsonism following a shunt revision with repeated structural neuroimaging.

Method: Case report.

Results: Our patient is a 22-year-old male who was diagnosed with obstructive hydrocephalus caused by a tectal glioma at the age of 10. VP shunt was placed at the time of diagnosis. After years of uncomplicated treatment, he presented at the emergency room because of decreased consciousness due to shunt malfunction and acute obstructive hydrocephalus. Immediate external CSF drainage and shunt revision provided a good response. However, due to shunt malfunctions and infection, he was operated three more times (external ventricular drain, shunt revision). The patient was scanned repeatedly either with CT or MRI that showed ventricle size ranging from severe hydrocephalus to slit ventricles. Four days after the last shunt revision, the patient developed severe hypomimia, bradykinesia and rigidity in all extremities together with bradyphasia, bradyphagia and sialorrhea. Repetitive finger movements had low amplitude with arrests. Pharmacological treatment with 100/25 mg levodopa/carbidopa and 1 mg lorazepam three times per day each provided a good clinical response. Parkinsonism resolved during the next weeks and medications were discontinued without deterioration of the symptoms. Control brain MRI was unremarkable.

Conclusion: Our patient showed an acute onset of parkinsonism after ICP fluctuations associated with obstructive hydrocephalus and multiple surgical operations. Poor brain compliance due to shunt dependency and chronic CSF over drainage could make periventricular brain tissue more prone to damage after changes in ICP and ventricular size. These patients often benefit from levodopa and the prognosis of parkinsonism is good if there is no permanent damage to the nigrostriatal tract (3).

References: (1) Zeidler et al. J Neurol Neurosurg Psychiatry 1998;64:657–659 (2) Kinugava et al. Movements Disorders 2009;24:2438–2440 (3) Kim et al. Movement Disorders 2006;21:1279–1281

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MDS Abstracts - https://www.mdsabstracts.org/abstract/acute-parkinsonism-following-an-obstructive-hydrocephalus-and-a-ventriculoperitoneal-shunt-revision-a-case-report/