Objectives: Traumatic brain injury (TBI) increased risk of Parkinson disease (PD) in many but not all epidemiologic studies, giving rise to speculations about modifying factors. A recent animal study suggested that the combination of TBI with subthreshold paraquat exposure increases dopaminergic neurodegeneration. The objective of our study was to investigate PD risk due to both TBI and paraquat exposure in humans.Methods: From 2001 to 2011, we enrolled 357 incident idiopathic PD cases and 754 population controls in central California. Study participants were asked to report all head injuries with loss of consciousness for .5 minutes. Paraquat exposure was assessed via a validated geographic information system (GIS) based on records of pesticide applications to agricultural crops in California since 1974. This GIS tool assesses ambient pesticide exposure within 500 m of residences and workplaces.Results: In logistic regression analyses, we observed a 2-fold increase in risk of PD for subjects who reported a TBI (adjusted odds ratio [AOR] 2.00, 95% confidence interval [CI] 1.28-3.14) and a weaker association for paraquat exposures (AOR 1.36, 95% CI 1.02-1.81). However, the risk of developing PD was 3-fold higher (AOR 3.01, 95% CI 1.51-6.01) in study participants with a TBI and exposure to paraquat than those exposed to neither risk factor.Conclusions: While TBI and paraquat exposure each increase the risk of PD moderately, exposure to both factors almost tripled PD risk. These environmental factors seem to act together to increase PD risk in a more than additive manner. Neurology Parkinson disease (PD), the second most common neurodegenerative disorder affecting 1%-2% of the population over 65 years of age, is characterized by progressive loss of dopamine neurons in substantia nigra pars compacta, leading to bradykinesia, rigidity, postural instability, and resting tremor as the cardinal motor features. It is widely acknowledged that PD etiology is most likely multifactorial. Lifestyle habits such as smoking and caffeine intake, genetic polymorphisms, environmental exposures to pesticides or metals, long-term exposure to certain medications, and interactions between these factors collectively appear to contribute to disease development. We have previously reported 2-to 3-fold increases in risk of developing PD when exposed to specific types or classes of pesticides, especially for combined exposures to paraquat and maneb, and for patients who carry genetic polymorphisms in susceptibility genes. 1,2 In the past 20 years, many but not all studies of traumatic brain injury (TBI) have linked head injuries with or without loss of consciousness to PD. [3][4][5][6][7][8][9][10] We speculated that TBI may require additional risk or susceptibility factors in order to cause PD, which has sometimes been referred