Teaching Video NeuroImage: Reversible Parkinsonism Caused by Lumboperitoneal Shunt Overdrainage

Abstract

A 51-year-old woman presented with apraxia of eyelid opening, followed by slowly progressive masked facies, tongue tremor, dysphagia, neck and upper extremity rigidity, and bradykinesia 6 months after lumboperitoneal shunt placement for hydrocephalus after subarachnoid hemorrhage. An MRI examination of the brain showed midbrain compression, brainstem displacement inferiorly, and cistern effacement, consistent with infratentorial hypotension. 123I-ioflupane SPECT imaging showed reduced striatal dopamine transporter binding bilaterally. All symptoms and findings ameliorated after increasing shunt pressure (Figures 1 and 2 and Video 1). UPDRS Part III score improved from 24 to 5. Intracranial hypotension with midbrain sagging can cause reversible parkinsonism1,2 when displacement shear forces impair the nigrostriatal dopamine pathway.