Asymmetric and Upper Body Parkinsonism in Patients with Idiopathic Normal-Pressure Hydrocephalus

Abstract

Background and PurposeOur aims were to analyze the characteristics of parkinsonian features and to characterize changes in parkinsonian motor symptoms before and after the cerebrospinal fluid tap test (CSFTT) in idiopathic normal-pressure hydrocephalus (INPH) patients.MethodsINPH subjects were selected in consecutive order from a prospectively enrolled INPH registry. Fifty-five INPH patients (37 males) having a positive response to the CSFTT constituted the final sample for analysis. The mean age was 73.7±4.7 years. The pre-tap mean Unified Parkinson's Disease Rating Scale motor (UPDRS-III) score was 24.5±10.2.ResultsThere was no significant difference between the upper and lower body UPDRS-III scores (p=0.174). The parkinsonian signs were asymmetrical in 32 of 55 patients (58.2%). At baseline, the Timed Up and Go Test and 10-meter walking test scores were positively correlated with the total motor score, global bradykinesia score, global rigidity score, upper body score, lower body score, and postural instability/gait difficulties score of UPDRS-III. After the CSFTT, the total motor score, global bradykinesia score, upper body score, and lower body score of UPDRS-III significantly improved (p<0.01). There was a significant decrease in the number of patients with asymmetric parkinsonism (p<0.05).ConclusionsIn the differential diagnosis of elderly patients presenting with asymmetric and upper body parkinsonism, we need to consider a diagnosis of INPH. The association between gait function and parkinsonism severity suggests the involvement of similar circuits producing gait and parkinsonian symptoms in INPH.

Gait in normal pressure hydrocephalus: characteristics and effects of the CSF tap test

“…The incidence of the classical triad is unknown; however, the presence of three concomitant symptoms has been reported in approximately 60% of cases 3 , although the triad is not required for a diagnosis of INPH 3 . Ishii et al 22 and Kang et al 23 reported that the presence of parkinsonism characteristics was frequent in patients with INPN. However, consistent with findings from another Table 1.…”

Grooved pegboard test performance before and after cerebral-spinal fluid tap test in patients with normal pressure hydrocephalus

“…Tsakanikas D et al reported that these upper extremity motor tests may be useful as sensitive markers of change after shunt placement in iNPH patients (e.g., line tracing tasks) [22]. Kang et al reported the upper limb motor function was improved after CSF TT and shunting and correlated with the gait parameters [7]. Liouta E et al also found that nger tapping improvements after CSF TT were useful for the differential diagnosis and prediction of shunt treatment outcomes [35].…”

“…Normal pressure hydrocephalus (NPH) patients present disturbances in gait and balance, cognition and/or control of urination with neuroimaging characterized by enlargement of the cerebral ventricles [1][2][3]. Typically, gait disturbance in NPH patients is the initial and most prominent symptom [4,5], but motor impairments can also extend to include upper extremity dysfunction [6][7][8][9]. Cognitive impairment in NPH patients is generally characterized by frontal system de cits that may include slowing of information processing, task shifting, reduced learning and executive abilities [10][11][12].…”

Letter to the Editor: Asymmetric and Upper-Body Parkinsonism in Patients with Idiopathic Normal-Pressure Hydrocephalus

“…Kang et al 1 have illustrated asymmetric and upper-body parkinsonism signs in detail via follow-up clinical assessments [before and after cerebrospinal fluid-tap test (CSFTT)] in a large number of patients with idiopathic normal-pressure hydrocephalus (INPH). I would like to make some comments in order to add new perspectives to aid the understanding of that report.…”

“…As also emphasized in the report, a probable explanation for the motor function recovery in INPH could be the reversible suppression of frontal periventricular corticobasal ganglia-thalamo-cortical circuits. 1 It has also been suggested that postsynaptic D2 receptors in the putamen can be damaged by hydrocephalus, and that a pressure load on the midbrain and the floor of the third ventricle may result in parkinsonian symptoms in patients with severe NPH. 7 However, conflicting with this hypothesis, the patients in Kang et al 1 did not have severe NPH-their score on the INPH grading scale was 5.7±1.9 (mean±SD).…”