Vascular parkinsonism

Author(s): Kurt A Jellinger

Vascular parkinsonism (VP), resulting from cerebrovascular disease, is a rare disorder showing a variety of clinical and pathological presentations distinct from sporadic Parkinson’s disease (PD). It accounts for 3–6% of all parkinsonian syndromes, and is difficult to diagnose with clinical certainty. Clinical features include: bilateral symmetrical rigidity; bradykinesia, predominantly involving lower limbs; postural instability; shuffling gait; falls; dementia; and corticospinal findings. Neuropathology shows multiple subcortical ischemic lesions owing to small vessel disease in striatum, globus pallidus, white matter and, less often, substantia nigra, involving cortico-striato-pallidal (nigral), thalamofrontal and other loops, without evidence of Lewy bodies. Cranial computed tomography and magnetic resonance imaging are useful tests to evaluate the vascular lesions. Functional imaging of presynaptic dopamine transporter may be useful in the differentiation of VP from PD. Response to levodopa treatment has been reported in up to 50% of VP patients, particularly in those with lesions in or close to nigrostriatal pathways, although only a few patients demonstrate long-term efficacy. There are no data on the efficacy of dopamine agonists; deep-brain stimulation appears to be ineffective. Major risk factors for VP are principally the same as those for cerebrovascular disease, and their prevention and treatment are of utmost importance. Higher cerebrovascular load is associated with less successful rehabilitation.