Vascular parkinsonism: a case series of 17
          patients

All patients had arterial hypertension. Ten patients were male and the mean age of the whole sample was 75.8±10.1 years. The mean age of parkinsonism onset was 72.2±10.0 years. Common clinical features were urinary incontinence (88.2%), lower limb parkinsonism with freezing of gait and falls (82.3%), and pyramidal signs (76.4%). The mean Unified Parkinson’s Disease Rating Scale (UPDRS) and Hoehn-Yahr scores were 72.5±21.6 points and 3.3±0.9 points, respectively. Sixteen (94.1%) patients had freezing of gait and executive dysfunction. Twelve (70.5%) patients had probable vascular dementia. The mean dose of levodopa was 530.9 mg/day. Unresponsiveness to the drug was confirmed by a 6.9 mean point reduction in the UPDRS score after the “practically defined off” test.

Conclusion

This series provides a profile of VP with predominant lower-limb involvement, freezing of gait and falls, pyramidal signs, executive dysfunction, concomitant vascular dementia, and poor levodopa response.

cerebrovascular; disorders; dementia; movement disorders; parkinsonian disorders

Study/Year	Design	Subjects	Diagnostic criteria	Clinical findings
FitzGerald and Jankovic ²⁹ /1989	Hospital-based cross-sectional (tertiary referral center)	10 VP 100 PD	Marked gait difficulty with lack of or with only minimal upper limb involvement (i.e. lower body parkinsonism)	Patients with VP have a significantly shorter symptom duration, present with gait difficulty, have less levodopa responsiveness. There is no difference in risk factors, except for hypertension.
Zijlmans et al. ³⁰ /1995	Cross-sectional	15 VP 15 DP	Parkinsonism with dominant frontal gait disorder, aged >60 years, and the exclusion of other secondary parkinsonism types	There is no difference between patients with VP and patients with PD or hypertensive controls in age or BP. Patients with VP have more subcortical lesions than patients with PD. A cutoff of 0.6% lesioned ischemic brain volume is suggested. Clinical severity is not correlated with lesion volume or location.
Yamanouchi and Nagura ³¹ /1997	Clinicopathological	24 VP 30 PD ^c	Parkinsonism with evidence of cerebrovascular lesions and lack of depigmentation or Lewy bodies in the substantia nigra	Of the patients with VP, 17% of the patients had tremor (versus 73% of the PD patients), 38% of the patients had hemiparesis, and 63% of the patients had pyramidal signs (versus 0% in the PD patients). One-half of the patients with VP had pseudobulbar palsy; 27% of patients with PD had dysphasia or dysarthria. Dementia was present in 71% of patients with VP and 43% of patients with PD. Only one-fifth of the patients with VP showed a transient response to levodopa. Asymmetry of limb rigidity was present in 29% of the patients with VP versus 73% of the patients with PD. There was no difference in gait disorders between VP and PD.
Winikates and Jankovic ² /1999	Retrospective, cross-sectional, hospital-based	69 VP 277 PD	Patients with parkinsonism and a vascular score of 2 points or more on a vascular rating scale ^a	Patients with VP were significantly older and had gait difficulty, less levodopa responsiveness, symmetrical predominant lower body involvement, postural instability, falls, dementia, corticospinal findings, incontinence, and pseudobulbar palsy.
Demirkiran et al. ³² /2001	Review of medical records, cross-sectional	16 VP 50 PD	Parkinsonism, presence of vascular lesions on brain MRI, and the exclusion of other causes of secondary parkinsonism	Patients with VP were significantly older, had a shorter disease duration, had a gait disorder as the most frequent initial symptom, and 38% of the patients were levodopa responsive. Vascular risk factors were more common in patients with VP. Postural instability, freezing, gait disturbance, pyramidal signs, postural tremor were significantly more prevalent in VP. Patients with VP have more prominent features in the lower limbs.
Rampello et al. ³³ /2005	Hospital-based cohort	39 VP 28 PD ^b	Parkinsonism with vascular lesions on brain MRI	Patients with VP were older and 29% of the patients were levodopa responsive. Vascular risk factors, postural tremor, gait disorder, pyramidal signs, and lower body predominance more frequent in VP. The UPDRS scores at baseline were higher in patients with VP than in patients with PD. After 2 years, patients with VP had greater lower limb involvement than patients with PD.
Okuda et al. ³⁴ /2008	Cross-sectional	55 VP 132 PD	Lower body parkinsonism with frontal gait disorder, postural instability, lack of resting tremor, symmetrical progression, poor response to levodopa, and multiple basal ganglia or subcortical infarctions	There was no difference in age or MMSE score between patients with VP, PD, and hypertensive controls. Primitive reflexes (i.e. snout, palmomental), jaw jerk, Hoffmann’s score, and extensor plantar response were significantly higher in VP.

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[1] Correspondence: Francisco Cardoso, MD, PhD; Avenida Pasteur 89/1107; 30150-290 Belo Horizonte MG - Brasil ; E-mail: cardosofe@terra.com.br