Use of carbidopa levodopa in a patient with hydrocephalus and frozen movement

Abstract

While movement disorders are frequently encountered after brain injuries, and may create a host of complicated problems for the clinician, only a few cases of Parkinsonism associated with hydrocephalus have ever been described in the literature. Parkinsonism-like syndrome complicating hydrocephalus is a rare disorder, especially when associated with nontumoral aqueductal stenosis. Yet as this case report discusses, hdyrocephalus-induced Parkinsonism may be responsive to levodopa-carbidopa administration. This report describes a perplexing case of persistent akinesis following corrective surgery for aqueductal stenosis and the subsequent response to levodopa-carbidopa administration. We present the case of a 28-year-old male with a history of non-tumoral aqueductal stenosis diagnosed at age 12. As a child, he underwent a ventriculo-peritoneal shunt placement for obstructive hydrocephalus followed by multiple shunt revisions over the next several years. Sixteen years after his initial shunt placement, the patient presented with a decline in mental status. A third ventriculocisternostomy was performed rather than another shunt revision. Following surgery, the patient remained obtunded, and displayed profound hypokinesis, best described as freezing in movement. Upon admission to a rehabilitation unit 2 weeks later, he had made only minimal progress. A SPECT (single-photon emission computed tomography) brain scan revealed decreased basal ganglia perfusion. Levodopa/carbidopa therapy was initiated and within 2 weeks, the patient showed improvement in speed of movement, facial expression and verbal output. Eight weeks later, the patient could independently complete his basic activities of daily living and demonstrated little, if any, disordered movement. This report illustrates how dopaminergic agents may be useful in cases of hypokinesis following corrective surgery for aqueductal stenosis. SPECT may further aid in the diagnosis and management of Parkinsonism-like syndromes in brain injuries.

Neuroimaging of Freezing of Gait

“…Similar approaches have been used to explore the effect of medications (levodopa in normal pressure hydrocephalus [ 37 ], tandospirone in PSP [ 38 ], donepezil in PAFG [ 26 ], rasagiline in PPFG [ 39 ], selegiline in PD [ 4 ]) or other experimental procedures (e.g. motor cortex stimulation [ 34 ]).…”