Often unilateral infarcts produce contralateral features of parkinsonism and for this reason, the features of bilateral parkinsonism was unique to our case. Infarction involving the putamen without such extension was seen in our patient. Infarctions affecting basal ganglia lacunae, including the thalamus, GPe and putamen that extend into the caudate and internal capsule, can mimic features of idiopathic PD. The second form often produces clinical features resembling the classical lower body parkinsonism and has a more relentless rather than stepwise progression. Two forms of VP have been described: one with acute onset, associated with basal ganglionic infarcts as in this case, and another with insidious onset, associated with more chronic and diffuse subcortical white matter ischaemia and involving the striatum, lentiform nucleus, or pons. VP has been associated with unilateral or bilateral infarcts in the striatum, lentiform nucleus, or pons. However the clinical features in this case was of upper body predominance which can be seen in 0–4%, compared to lower body predominance seen in 60–73.7%. The coexistence of lower body parkinsonism and cerebrovascular disease on imaging is suggestive of VP. It is usually bilateral, non-tremulous, and frequently associated with pyramidal signs, pseudo-bulbar palsy, incontinence, dementia, diabetes, and hypertension. Classically VP is described as lower body parkinsonism affecting predominantly the legs with broad-based, shuffling, and often freezing gait and postural instability. VP manifests clinically with features of parkinsonism, which could be due to a single vascular cause (suggested by history), as in this case, or due to multiple strokes. The above patient fulfills these criteria. Zijlmans et al., proposed possible criteria for the clinical diagnosis of VP and they are as follows: (a) parkinsonism, defined as bradykinesia, and at least one of the following: rest tremor, rigidity or postural instability (b) cerebrovascular disease, defined as evidence of relevant cerebrovascular disease by brain imaging or the presence of focal signs or symptoms consistent with stroke (c) a relationship between (a) and (b). The patient described presented with parkinsonian features of bradykinesia, rigidity, mild rest tremor and predominant jaw tremor which were acute in onset accompanied by imaging evidence of unilateral basal ganglia stroke raising the possibility of vascular parkinsonism (VP). The rest of the neurological examination was normal which included cognition, speech, cerebellar function and bladder function. When she was asked to open her mouth the tremor was re-emergent (Additional file 2). She had a marked tremor of the jaw at rest (Additional file 1). Neurological examination revealed hypomimia of the face with cogwheel rigidity and bradykinesia bilaterally (right more than left), predominantly in the upper limbs without pyramidal signs (the Unified Parkinson’s Disease Rating Scale (UPDRS) Part III item 18–32 was 36). She had not been on any medication which could cause extra-pyramidal symptoms. There was no history of previous stroke or vascular risk factors for stroke. She did not have features of non-motor symptoms to suggest a diagnosis of idiopathic PD. Her symptoms had progressed over a period of 24–48 h and remained static until the consultation. This case also stresses the importance of initiating a trial of levodopa as certain patients may respond well to medication.Ī 67 years old lady came to the out-patient department with a history of acute onset jaw tremor, with tremor predominantly in both upper limbs approximately 2 months prior to consultation. This case describes atypical clinical features which could be associated with VP including jaw tremor. She was treated with levodopa and responded well to medication. Non contrast CT scan of her brain revealed an infarction in the region of putamen on the left with no evidence of diffuse subcortical white matter ischemia or extension to the caudate nucleus. When she was asked to open her mouth the tremor was re-emergent. She had a marked tremor of the jaw at rest. Neurological examination revealed hypomimia of the face with cogwheel rigidity and bradykinesia bilaterally, predominantly in the upper limbs without pyramidal signs. Case presentationĪ 67 years old lady presented with a history of acute onset jaw tremor, with tremor predominantly in both upper limbs. Classically VP is described as lower body parkinsonism affecting predominantly the legs. It is usually bilateral, non-tremulous, and frequently associated with pyramidal signs. Vascular Parkinsonism (VP) is a heterogeneous group of conditions that manifest clinically in parkinsonian features, but are presumably of vascular cause.
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