Introduction: Neuroimaging studies of elderly individuals reveal alterations in the white matter that are incompatible with the patient's parkinsonism, mistakenly classified as vascular parkinsonism (VP). Method: This study was conducted on a population composed of 20 patients with Parkinson's disease (PD) whose neuroimaging exams revealed vascular alterations in the white matter and seven patients with VP in order to compare diagnostic criteria. Results: Age at disease onset of patients with PD was 55 +/- 12 years and patients with VP it was 62 +/- 13 years. Twelve patients with PD and five patients with VP presented arterial hypertension; three patients with VP and two patients with PD presented gait impairment; all patients with VP presented rigidity and bradykinesia, six of them presented resting tremor; 19 patients with PD presented tremor and 19 of them presented rigidity, while 17 presented bradykinesia. When the symptoms and evolution of both diseases were compared, the vascular alterations in the white matter were considered unspecific. Conclusion: Since clinical symptoms are unspecific, a differential diagnosis requires neuroimaging, good response to levodopa and clinical evolution.643A56857

da Silva, EG

Quagliato, EMAB

Viana, MA

Arquivos de Neuro-Psiquiatria

Repositorio da Producao Cientifica e Intelectual da Unicamp

Arq Neuropsiquiatr 2006;64(3-A):568-571
D e p a rtment of Neuro l o g y, School of Medicine, State University of Campinas, Campinas SP, Brazil (FCM/UNICAMP): 1Medical Student;
2MD; 3Adjunct Professor, responsible for the Movement Disorders Unit, Clinics Hospital, UNICAMP.
Received 11 October 2005, received in final form 1 March 2006. Accepted 4 May 2006.
D r. Elton Gomes da Silva - Departamento de Neurologia, FCM/UNICAMP - Caixa Postal 6111 - 13083-970 Campinas SP - Brasil.
E-mail: elgosi@yahoo.com.br
VASCULAR PARKINSONISM
Analysis of seven cases
Elton Gomes da Silva1, Maura Aparecida Viana2,
Elizabeth Maria Aparecida Barasnevicius Quagliato3
ABSTRACT - I n t roduction: N e u roimaging studies of elderly individuals reveal alterations in the white mat-
ter that are incompatible with the patient’s parkinsonism, mistakenly classified as vascular parkinsonism
(VP). Method: This study was conducted on a population composed of 20 patients with Parkinson’s dis-
ease (PD) whose neuroimaging exams revealed vascular alterations in the white matter and seven patients
with VP in order to compare diagnostic criteria. Results: Age at disease onset of patients with PD was
5 5±12 years and patients with VP it was 62±13 years. Twelve patients with PD and five patients with VP
presented arterial hypertension; three patients with VP and two patients with PD presented gait impair-
ment; all patients with VP presented rigidity and bradykinesia, six of them presented resting tremor; 19
patients with PD presented tremor and 19 of them presented rigidity, while 17 presented bradykinesia.
When the symptoms and evolution of both diseases were compared, the vascular alterations in the white
matter were considered unspecific. Conclusion: Since clinical symptoms are unspecific, a diff e rential diag-
nosis requires neuroimaging, good response to levodopa and clinical evolution.
KEY WORDS: vascular parkinsonism, Parkinson’s disease, diagnosis, neuroimaging.
Parkinsonismo vascular: análise de sete casos
RESUMO - Introdução: Estudos de neuroimagem em idosos mostram alterações na substância branca que
são incompatíveis com o parkinsonismo do paciente, erroneamente classificado como parkinsonismo vas-
cular (PV). Método: Este estudo foi conduzido a partir de uma população de 20 pacientes com doença
de Parkinson (DP) cujos exames de neuroimagem revelaram alterações vasculares na substância branca e
sete pacientes com PV para comparar os critérios diagnósticos. Resultados: A idade de início da doença
dos pacientes com DP foi 55±12 anos e pacientes com PV foi 62±13 anos. Doze pacientes com DP e cinco
pacientes com PV apresentaram hipertensão arterial; três pacientes com PV e dois pacientes com DP apre-
sentaram alteração da marcha; todos os pacientes com PV apresentaram rigidez e bradicinesia, seis deles
a p resentaram tremor de repouso; 19 pacientes com DP apresentaram tremor e 19 deles apre s e n t a r a m
rigidez, enquanto 17 apresentaram bradicinesia. Quando os sintomas e a evolução de ambas as doenças
foram comparadas, as alterações vasculares na substância branca foram consideradas inespecíficas. C o n -
clusão: Como os sintomas clínicos são inespecíficos, um diagnóstico diferencial requer neuroimagem, boa
resposta a levodopa e evolução clínica da doença.
PALAVRAS-CHAVE: parkinsonismo vascular, doença de Parkinson, diagnóstico, neuroimagem.
Vascular parkinsonism (VP), first described in 1929
by Critchley1, is still viewed as a nosological entity.
VP related lesions are considered multiple micro in-
f a rcts in the subcortical white matter or in the sub-
stantia nigra but their pathophysiology is hetero g e-
neous and it is not always possible to correlate ische-
mic lesions with clinical symptoms2 - 5. On the basis of
the diagnostic criteria for VP, 4% to 12% of patients
with Parkinson’s syndrome are thought to have a vas-
cular etiology that occurs more frequently in the
more aged population1,4,6-10.
Despite the criteria utilized, clinical data very often
do not help in the diagnosis of VP as shown by patho-
logical studies in which patients with VP were not
diagnosed antemort e m1 1 , 1 2. Computerized tomogra-
phy (CT) and magnetic resonance imaging (MRI) of
Arq Neuropsiquiatr 2006;64(3-A) 569
the elderly reveal alterations in the white matter that
a re often correlated with parkinsonian symptoms1 2 , 1 3.
Lesions with ischemic characteristics revealed by the
n e u roimaging exams should not be the main crite-
ria for diff e rential diagnosis of VP and other form s
of parkinsonism since 20% to 30% of the Parkinson’s
disease (PD) exams present ischemic alterations2,3.
These exams are useful for determining localized
vascular lesions and excluding other causes of secon-
d a ryparkinsonism such as normal pre s s u re hydro c e-
phaly and lesions with mass effect.
METHOD
This study was designed to describe the clinical symp-
toms and the MRI of seven patients with VP and compare
them with 20 patients with PD whose neuroimaging exams
revealed vascular lesions with ischemic characteristics. This
study also evaluated the criteria for a differential diagno-
sis of these two forms of parkinsonism and verified the exis-
tence of a clinical-radiological distincti on between these
two etiologies. 
This comparison was proposed so that the clinical dif-
f e rences between the two forms of parkinsonism could be
evaluated because the neuroimaging results of all the
patients revealed vascular alterations that did not allow
for a definite diagnosis of the cause.
The inclusion criteria used for the diagnosis of PD were :
p resence of at least two of the following signs - tremor at
rest, akinesia / bradykinesia, rigidity and altered postural
reflexes; unilateral onset of the symptoms and asymmetri-
cal development of the disease; a good response to L-dopa.
The criteria for exclusion were: pyramidal symptoms, cere-
bellar symptoms and autonomic failure at disease onset; a
h i s t o ryof drug and substance abuse, encephalitis and/or a
relationship between cerebral vascular accident (CVA) and
onset of Parkinson’s syndrome8,12,14,15.
The inclusion criteri a for VP were: acute or sub-acute
evolution; presence of rigidity or bradykinesia, focal signs
or symptoms consistent with stroke such as pyramidal with
symmetric compromise, vascular risk factors - systemic art e-
rial hypertension (SAH), prior ischemic CVA and athero s c l e-
rotic disease; association with pseudobulbar paralysis and
spontaneous improvement of the symptoms; unsatisfacto-
ry or absence of response to L-dopa; MRI that revealed at
least two basal ganglia infarcts or diffused disease of the
white matter. The criteria for exclusion were: antecedents
of cranioencephalic traumatism, defined encephalitis, tre a t-
ment with neurolepti cs at onset of symptoms, CT or MRI
demonstrating presence of cerebral tumor or communicat-
ing hydrocephaly1,4,6,7,12.
The criteria established by the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) were used to classi-
fy dementia and depression16.
Follow up of all the patients was perf o rmed at the Mo-
vement Disorders Outpatient Unit of the Department of
N e u ro l o g y, Clinics Hospital, State University of Campinas
(HC/UNICAMP) and the patients also underwent MRI exams.
The PD cases whose MRI exams revealed vascular lesions
and all the VP cases were selected from a list of patients
t reated between 1999 and 2001 at the Outpatient Unit,
and this study was initially approved for the Committee of
Ethics in Research of School of Medicine of UNICAMP (CEP/
FCM/UNICAMP).
The magnetic resonance equipment ELSCINT with po-
tency of two Tesla was used for the neuroimaging exams. 
The factors analyzed in both groups were: age at dis-
ease onset, time of evolution, sex, clinical symptoms and
localization, related comorbidities and MRI alterations.
The chi-square test was applied for analyzing the vari-
ables. The significance level established was p<0.05.
RESULTS
Twenty patients with PD were compared with sev-
en patients with VP. Table 1 presents the mean age
at disease onset, duration of disease, sex and clinical
symptoms.
Five patients with VP presented acute onset of
symptoms post CVA and two patients presented a
p ro g ressive condition that stabilized after six months.
Six of the patients with VP presented symmetry of
symptoms at disease onset.
In the group of patients with VP, one patient pre-
sented partial response to L-dopa, which was lost
three months after disease onset. 
Both groups were evaluated re g a rding vascular
risk factors and associated comorbidities such as: CVA
antecedents, dementia, SAH, and depression. These
values are presented in Table 2. 
Table 1. Age at onset, duration of disease, sex and clinical symp -
toms of PD and VP.
Diagnosis PD VP
Age at onset (years) 55.5±12.2 61.8±13.7
Duration of disease (years) 11.2±8.6 8.5±3.9
Sex (M/F) 11/9 4/3
Tremor 19 (95%) 6 (85.7%)
Rigidity 19 (95%) 7 (100%)
Bradykinesia 17 (85%) 5 (71.4%)
Posture instability 7 (35%) 2 (28.6%)
*p<0.05; PD, Parkinson’s disease; VP, vascular parkinsonism; M, male; F,
female.
Table 2. PD and VP associated comorbidities.
Comorbidity PD VP
Cerebral vascular accident 8 (40%) 7 (100%)*
Dementia 1 (5%) 3 (43%)*
Systemic arterial hypertension 12 (60%) 5 (71%)
Depression 1 (5%) 3 (43%)*
*p<0.05; PD, Parkinson’s disease; VP, vascular parkinsonism.
The MRI exams revealed lesions compatible with
vasculopathy in the periventricular white matter
(PVWM), subcortical white matter (SCWM) and basal
nuclei (BN) as shown in Table 3.
The MR images of the patients are shown in Figs
1 and 2.
DISCUSSION
Since VP is very often sub-diagnosed or mimics PD
or some other degenerative disease such as pro g re s-
sive supranuclear paralysis or corticobasal degenera-
tion, it is rarely cited as the cause of PD4 , 1 1 , 1 7. Our stu-
dy population, which consisted of PD and VP gro u p s ,
did not demonstrate a statistically significant diff e r-
ence between disease onset and sex or clinical symp-
toms, contradicting reports that symptom onset oc-
c u rred at a more advanced age and that there was
a discreet male predominance in the VP gro u p1 , 2 , 8 , 1 0.
Resting tremor was less frequently encountered in
other studies, which was probably due to the fact
that posture tremor is common in patients with VP,
but it was a factor observed in this study11,12. There-
f o re, it should not be used as a criterion of exclusion
for VP since it may be observed in some patients12.
Other symptoms were found in similar pro p o r-
tions in both groups. A typical history of acute and
symmetrical symptoms was observed in the patients
with VP, although the acute condition occurred in
less than half of the patients in the other studies2 , 3 , 1 2.
The presence of comorbidities (CVA, dementia,
SAH, depression) was significantly greater in patients
with VP, which was similar to other studies2,3,10-12.
570 Arq Neuropsiquiatr 2006;64(3-A)
Table 3. Number of patients with PD or VP demonstrating vas -
cular alterations in MRI. 
Vascular lesions PD VP
PVWM 9 0
SCWM 5 5
BN 3 0
PVWM + SCWM 1 0
PVWM + BN 0 2
SCWM + BN 2 0
MRI, magnetic resonance imaging; PD, Parkinson’s disease; VP, vascular
parkinsonism; PVWM, periventricular white matter; SCWM, subcort i c a l
white matter; BN, basal nucleus.
Fig 1. Magnetic resonance imaging of a 69 year-old patient
with Parkinson’s disease revealed multiple ischemic lesions in
the subcortical white matter.
Fig 2. Sixty five year-old patient with a diagnosis of vascular parkinsonism. The magnetic re s o n a n c e
image revealed perivascular space enlargement in the basal nuclei and cerebral peduncles as well
as ischemic lesions in the white periventricular and subcortical matter.
Arq Neuropsiquiatr 2006;64(3-A) 571
T h e reare re p o rts in the literature of a clinical im-
p rovement in some patients with VP when subject-
ed to dopaminergic therapy. This was observed in
one patient in our study, but loss of response occurre d
t h ree months after treatment began4 , 1 2 , 1 8. The lesions
revealed in the exams of patients with PD did not
alter disease evolution or the severity of the clinical
symptoms as observed in another study19.
Although the majority of the patients with PD
p resented vascular lesions in the periventricular white
m a t t e r, lesions were also found in the basal nuclei
and subcortical white matter, which made it a com-
p l e m e n t a ryexam in the etiology of the condition -
useful for the confirmation and localization of vascu-
lar lesions and exclusion of other causes for sympto-
m a t o l o g y, but didn’t help in obtaining a diff e re n t i a l
diagnosis for PD and VP2,4,12,20.
D i ff e rential diagnosis was based on the clinical
symptoms that were present, L-dopa response and
clinical evolution of patients with altered exam re-
sults, the latter was used for triage of the patients2 , 3 , 1 2.
It must be re m e m b e red that VP is an import a n t
cause of parkinsonism although it is underd i a g n o s e d .
It has typical characteristics of bilateral and symmetri-
cal onset, rigidity or bradykinesia, absence of re s p o n-
se to L-dopa and altered neuroimaging exams com-
patible with vascular lesions.
Underdiagnosis is common, since the right diag-
nosis for VP is pathological, but a presumptive diagn-
sis can be made based on clinical data assessment
and neuroimaging exams since together they enhan-
ce diagnostic clarity despite symptom hetero g e n e i t y.
Since vascular alterations in the white matter may
be found in the same locality in the brain imaging
exams in PD and VP with diff e rent symptoms, they
cannot be used as the only parameter for VP diag-
nosis, making it necessary to have an assessment of
clinical evolution as well as altered exams and the
presence of vascular risk factors. Further studies are
being conducted to increase the sensitivity of the cri-
teria being used for the diagnosis of VP and also to
enhance knowledge re g a rding the pathophysiology
of this disease. 
REFERENCES
1. Critchley M. Arteriosclerotic parkinsonism. Brain 1929;52:23-83.
2. Winikates J, Jankovic J. Clinical correlates of vascular parkinsonism.
Arch Neurol 1999;56:98-102.
3. Demirkiran M, Bozdemir H, Sarica Y. Vascular parkinsonism: a dis-
tinct, heterogeneous clinical entity. Acta Neurol Scand 2001;104:63-67.
4. Thanvi B, Lo N, Robinson T. Vascular parkinsonism: an important cause
of parkinsonism in older people. Age Ageing 2005;34:114-119.
5. Zijlmans JCM, Thijssen HOM, Vogels OJM, et al. MRI in patients with
suspected vascular parkinsonism. Neurology 1995;45:2183-2188.
6. Bennet DA, Wilson RS, Gilley DW, Fox JH. Clinical diagnosis of Bins-
wanger disease. J Neurol Neurosurg Psychiatry 1990;53:961-965.
7. Hurtig HI. Vascular parkinsonism. In: Stern MB, Koller WC (eds). Par-
kinsonian syndromes. New York: Marcel Dekker, 1993:81-83.
8. B a l d e reschi M, Di Carlo A, Rocca WA, et al. Parkinson’s disease and
parkinsonism in a longitudinal study: two-fold higher incidence in
men. Neurology 2000;55:1358-1363.
9. Foltynie T, Barker R, Brayne C. Vascular parkinsonism: a review of the
p recision and frequency of diagnosis. Neuroepidemiology 2002;21:
1-7.
10. Benito-Leon J, Bernejo-Pareja F, Moralez-Gonzalez JM, et al. Incidence
of Parkinson’s disease and parkinsonism in three elderly populations
of central Spain. Neurology 2004;62:734-741.
11. Bower JH, Dickson DW, Taylor L, Maraganore DM, Rocca WA. Clinical
c o r relates of the pathology underlyng parkinsonism: a population per-
pective. Mov Disord 2002;17:910-916.
12. Zijlmans JCM, Daniel Se, Hughes AJ, Révész T, Lees AJ. Clinicopatho-
logical investigation of vascular parkinsonism, including clinical cri-
teria for diagnosis. Mov Disord 2004;19:630-640.
13. Fazekas F, Niederkorn K, Schmidt R, et al. White matter signal abnor-
malities in normal individuals: correlation with carotid ultrasound,
c e rebral blood flow measurements, and cere b rovascular disease risk
factors. Stroke 1988;19:1285-1288.
14. Larsen JP, Dupont E, Ta n d b e rg E. Clinical diagnosis of Parkinson’s dis-
ease: proposal of diagnostic subgroups classified at different levels of
confidence. Acta Neurol Scand 1994;89:242-251.
15. Elbaz A, Bower JH, Maraganore DM, et al. Risk tables for parkinson-
ism and Parkinson’s disease. J Clin Epidemiol 2002;55:25-31.
16. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. fourth edition. Washington, DC: American Psy-
chiatric Association, 1994.
17. Sibon I, Fenelon G, Quinn NP, Tison F. Vascular parkinsonism. J Neuro l
2004;251:513-524.
18. Zijlmans JCM, Katzenschlager R, Daniel SE, Lees AJL. The L-dopa re s-
ponse in vascular parkinsonism. J Neurol Neuro s u rg Psychiatry 2004;
75:545-547.
19. Piccini P, Pavese N, Canapichi R, et al. White matter hiperintensities
in Parkinson’s disease. Arch Neurol 1995;52:191-194.
20. M u r row RW, Schweiger GD, Kepes JJ, Koller WC. Parkinsonism due
to basal lacunar state: a clinicopathological correlation. Neurology 1990;
40:897-900.


Vascular parkinsonism - Analysis of seven cases

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Vascular parkinsonism - Analysis of seven cases

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