Lucien Cote for the determination of the patient ' s CSF HVA level

The young age of the patient, appearance of his symptoms after a stroke, spontaneous improvement unrelated to treatment, lucencies seen on CT within the basal ganglia, and a relatively high level of HVA in cerebrospinal fluid, higher than usually seen in idiopathic Parkinson's disease,9 are in favour of this diagnosis. Other causes of Parkinsonism, such as normal pressure hydrocephalus or neuroleptic treatment were excluded. While earlier reported cases of vascular Parkinsonism represent additional probable examples of this condition, they are open to question in a number of respects. Hughes and others described a 39-year-old hypertensive man who developed a Parkinsonian mask following a stroke, and who had bilateral caudate infarcts revealed at necropsy.'0 It is not clear from the report if the patient had Parkinsonian features beyond facial masking. Tolosa and Santamaria reported three elderly men, two of whom were hypertensive, who had the insidious onset of Parkinsonism and who had infarcts of the basal ganglia revealed by CT scan." Although these cases are likely to be valid examples of vascular Parkinsonism, the insidious onset at a late age makes it difficult to definitely exclude the coincidental occurrence of idiopathic Parkinson's disease with what could have been silent basal ganglia infarctions. The concept of vascular Parkinsonism is supported by the study of Parkes et al who noted higher CSF HVA levels in patients with vascular Parkinsonism, diagnosed by clinical criteria, as compared with patients with idiopathic Parkinson's disease."2