Parkinsonism-like features following reconstructive cranioplasty
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LETTER TO THE EDITOR
Parkinsonism-like features following reconstructive cranioplasty Mayank Tyagi 1 & Charu Mahajan 1
&
Indu Kapoor 1 & Hemanshu Prabhakar 1
Received: 31 July 2020 / Accepted: 7 October 2020 # Fondazione Società Italiana di Neurologia 2020
Reconstructive cranioplasty is carried out for repairing cranial bone defect to provide protection to underlying vital structures and for esthetic purpose. The risk of infection is lower, and potential for bone regrowth is higher when an autologous bone is used, compared to artificial implants [1]. Bone resorption is one of the major complications of autologous bone cranioplasty. A significant resorption all-around can result in micro-movement of the bone flap over the underlying dura and brain, leading to the appearance of progressive neurological symptoms [2]. We report such a case where patient being inadvertently treated for parkinsonism was later diagnosed to have “sinking bone syndrome.” A 39-year-old male, weighing 50 kg, presented with a history of progressive slowing of speech, headache, and rightsided motor weakness. The resting tremors and bradykinesia started on the right side that eventually spread to the other side over the last 2 years and were aggravated in sitting position. He was diagnosed as having levodopa resistant parkinsonism (unresponsive to other antiparkinsonism drugs and levodopa challenge test of 1000 mg per day). The patient was started on oral propanolol (20 mg twice daily) and trihexyphenidyl (6 mg/day) and found to have only slight improvement in tremors. He had a past history of left fronto-temporo-parietal craniectomy for the evacuation of acute subdural hematoma (SDH) 4 years ago and cranioplasty 4 months later to injury. A follow-up computed tomography (CT) of the head done few months later showed a sunken bone flap for which he underwent redo-cranioplasty with polymethylmethacrylate implant. Following this, the parkinsonism-like symptoms improved gradually. Now, the patient had a recurrence of symptoms along with resinking of bone flap for which he was scheduled for reconstructive cranioplasty using a titanium
* Charu Mahajan [email protected] 1
Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi, India
mesh implant. On neurological examination, he was alert with no apparent cognitive deficit, had right-sided motor weakness, normal plantar reflex, orthostatic-induced resting tremors, bradykinesia, rigidity, and left eye mydriasis with oculomotor nerve palsy with no gait problem or postural instability. Preoperative CT brain was suggestive of bilateral basifrontal gliosis with effacement of lateral ventricle and left-sided cortical sulci and left-sided descending transtentorial herniation causing quadrigeminal cistern asymmetry. Bilateral basal ganglia and thalamus appeared normal with no shift of midline structures (Fig. 1). The MRI brain confirmed these findings. Diagnosis of normal pressure hydrocephalus (NPH) was ruled out on clinical (negative h
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