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Dopa‐responsive parkinsonism after acute subdural hematoma

On June 26, 2002, a previously healthy 37 years old nurse suddenly experienced severe headache then fell unconscious. Upon admission, Glasgow score was 4/15 with bilateral fixed mydriasis. Brain CT (Fig. 1) showed a left acute subdural hematoma (SDH) with marked midline shift. Left parietal craniotomy was performed within 1 h from admission. Two days later, the patient was fully conscious, but showed left-sided hemiparesis, i.e. on the side of the hematoma (Kernohan– Woltman notch phenomenon). There was no history of trauma, coagulopathy, illegal drug or anti-aggregants intake and angiograms were normal. She was transferred to a rehabilitation unit where a moderate left-sided paresis was noted, mostly affecting the upper limb. Four weeks later, the physiotherapist reported increased spasticity of left upper limb and baclofen was initiated, without relief. Reduced left arm swing and shuffling gait were also mentioned. In the meantime, the patient noticed the appearance of intermittent, then permanent left hand resting tremor. A brain MR scan (GE Sigma Horizon 1T, General Electric, Danbury, CT, USA) was reported normal in December 2002 (Fig. 2). Soon after, a neurological advice was sought about increasing spasticity of left upper and lower limbs . Neurological examination showed obvious left-sided parkinsonism: hand resting tremor, marked upper limb rigidity with coghweel phenomenon, moderate leg rigidity, severe hand bradykinesia with micrographia, shuffling gait, rare blinking, asymmetrical facial hypomimia. There were also subtle right-sided upper limb rigidity and bradykinesia. The rest of the neurological examination was normal, and in particular no pyramidal signs were detected. No familial history of parkinsonism was reported. In March 2003, the patient underwent a [123I] beta-CIT SPECT-scan ( DATscan ), to evaluate striatal dopamine transporter function. It revealed a severe loss of uptake in the right striatum, but also to a lesser extent on the left side (Fig. 3). Normal uptake ratios between striatum and occipital cortex (reference zone) are above 3.0. The values in our patient were the following: left caudate: 2.50, left putamen: 1.76, right caudate: 1.27, right putamen: 1.37. A full set of thin slice (3 mm) MRI scans, including diffusion-perfusion was repeated on a higher performance device (Philips Gyroscan Intera T15, 1.5 T, PhilipsMedical Systems, Bothell, WA, USA). It was again normal. Levodopa was started (50 mg t.i.d.) with immediate and spectacular benefit, with the exception of residual left hand tremor. UPDRS motor scores were 27 before levodopa and 10 two weeks later. Pramipexole was added (0.7 mg t.i.d.), with near-complete disappearance of tremor (UPDRS III score of 6) and the patient could return to full-time work. The clinical benefit remained sustained after 24 months, with only slight intermittent