Lower-body parkinsonism: reconsidering the threshold for external lumbar drainage

Background An 80-year-old man with a 60 pack-year smoking habit, hypertension, and hypercholesterolemia presented to a movement disorders clinic with a 30-month history of step-wise progression of gait, balance, and memory impairment. He had experienced multiple falls and two hospitalizations for sudden-onset freezing of gait. Investigations Neurological examination, brain MRI, neuropsychological. evaluation, gait analysis, continuous external lumbar drainage of cerebrospinal fluid, and post-mortem neuropathological studies. Diagnosis Vascular parkinsonism was diagnosed on the basis of the patient's history and imaging findings; however, post-mortem neuropathology was consistent with a diagnosis of normal pressure hydrocephalus and did not support that of vascular parkinsonism. Treatment Ventriculoperitoneal shunt placement superseded tighter control of vascular risk factors, as judged by the patient's response to continuous lumbar drainage.