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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 -- ******************************************************** 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" ********************************************************