Friday, January 20, 1995
 
 
Dear Ann:
 
This is a follow-up to what you have written regarding your mother and a
possible mis-diagnosis of Parkinson's Disease.  I am taking the liberty
(I hope that you don't mind) of sending a copy of this post to the List,
as there was a follow-up to your original posting from Warren Whitney of
Ann Arbor, Michigan, concerning his father, and a similar lack of
response to Sinemet.  I do not have any "pat answers" for either of you,
but I have some suggestions.
 
The symptoms that both of you discuss (tremor, voice changes, gait
problems, dementia, incontinence, depression, etc.) are all compatible
with Parkinson's Disease; but they could also be associated with other
conditions.  They all suggest problems with function of the "basal
ganglia", structures deep within the brain (globus pallidus, putamen,
substantia nigra, etc.) and while Parkinson's Disease is a common cause
of these symptoms, *any* condition affecting the above brain structures
can cause similar symptoms.  For example, there is a condition called
"normal pressure hydrocephalus" (NPH) that causes an increase of
localized pressure on these structures because of decreased absorption
of spinal fluid in older people, and the symptoms can be *identical* to
those of Parkinson's Disease.  Since the dysfunction in NPH is *not* due
to a dopamine problem (as is PD), a drug such as Sinemet would not help.
 The treatment of NPH is *surgical*, with the placement of a "shunt", a
device to "short-circuit" the partially obstructed spinal fluid flow
around the area of obstruction; and the results of shunt surgery (a
major but not extremely hazardous operation) are often dramatic.  There
are a number of diagnostic studies that are essential in the diagnosis
of NPH (and other conditions), and the first one to consider is an
imaging study such as a CT or MRI scan.  If hydrocephalus is suggested,
then another study, involving a spinal puncture, injection of a
radioisotope into the spinal fluid followed by a series of nuclear scans
to trace the pathways, is indicated to confirm the diagnosis of NPH.
Other conditions, such as chronic subdural hematoma (blood clot over the
surface of the brain), may also respond to surgical intervention; and
other conditions, such as multiple small stroke syndrome or partial
obstructions in the neck vessels (which supply the brain), may also
respond to medical or surgical treatment.  In short, an *adequate and
complete diagnosis* is the vital factor; and, in these days of "cost
containment", may be difficult to obtain for elderly people.  Push for a
complete diagnostic workup - you can always decide to be "conservative"
(and not do anything "radical"), but it is always important to have
intelligent information before making such decisions.
 
I will close this post by relaying to you (and the List), a classical
story which was told to us when we were medical students in the fifties,
and which has been "burned into my mind" by quite a bit of experience
since.  The story is:
 
"Uncle Charlie was 85 years old and sharp as a tack.  Then, one day,
Uncle Charlie fell down the stairs and broke his hip.  His hip was
fixed, but Uncle Charlie suddenly began to "get old".  After a few
months, he was "senile" and they put him in a nursing home because he
couldn't take care of himself.  A few months later, Uncle Charlie died
quietly in his sleep.  At autopsy, Uncle Charlie was found to have a
subdural hematoma (blood clot on the brain), this the result of the same
trauma which occurred when he fell down the stairs.  Had this clot been
recognized, a relatively simple operation would have not only saved his
life, but would have restored Uncle Charlie to the "sharp as a tack"
status which he enjoyed prior to the fall."
 
This is a story well worth remembering.  I urge you to keep it in mind
as you press the physicians taking care of your mother/father, etc. and
I would suggest that, if you do not get what you want from the first
doctor, keep trying!  Please keep me posted as to what happens.
 
 
Best wishes,
 
Bob
 
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Robert A. Fink, M. D., F.A.C.S.   Phone: 510-849-2555
Neurological Surgery              FAX:  510-849-2557
2500 Milvia Street  Suite 222
Berkeley, California 94704-2636
USA
 
E-Mail:  [log in to unmask]
CompuServe:  72303,3442
America Online:  BobFink          "Ex Tristitia Virtus"
 
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