Cortical tumor presenting with Parkinsonism

Parkinsonism is a syndrome with six major characteristics: Tremor at rest, rigidity, bradykinesia, loss of postural reflexes, flexed posture, and freezing. 1 Parkinson's disease (PD) is the most common form of Parkinsonism, 1 but there are many other causes (i.e., drugs), 2 clinician should be alert to alternative diagnoses, especially if patients with Parkinsonism have atypical findings for PD. Parkinsonism due to brain tumor is very rare. 3,4 Postulated mechanism was the compression of the basal ganglia. 3 We would like to report an interesting case with intra-axial brain tumor presenting with Parkinsonism. In our case, the brain tumor did not compress the basal ganglia. We will discuss the possible mechanism. A 55-year-old, right-handed man visited our hospital because he had a 1-month history of subjective motor weakness in the right extremities. He described that his handwriting became slow on writing long sentences and that he felt dragging of his right leg when walking for a long time. He said that he did not drag his foot at the beginning of the walk. He denied sudden onset and reported that the symptom had become worse. There were no vascular risk factors. There was no medication history. On detailed neurological examination, he was alert and fully oriented. There was no motor weakness. Mild sensory deficits for all modalities in the right extremities were seen. There was no cerebellar dysfunction. Deep tendon reflex was normal. Pathologic reflexes were not seen. He showed motor slowness in right finger tapping test and hand movements during the repetitive movements (bradykinesia). Rigidity was also observed on the right arm and leg. On his gait, there was no noticeable problem (i.e., hemiparetic gait, freezing, hesitation, etc.). There was no tremor. Brain magnetic resonance imaging (MRI) showed an enhancing mass lesion in the left paracentral area (Figure 1). We could not proceed further evaluation, because he wanted to go another tertiary hospital. Our case illustrates two important clinical points. The first, the brain tumor in the paracentral area can cause Parkinsonism. The second, a high index of clinical suspicion is important for proper diagnosis and management, in particular, in the case that patients have unusual findings. In our case, unilateral sensory deficits and too short disease duration might raise suspicion of secondary Parkinsonism. Parkinsonism caused by brain tumor is uncommon. 3-7 Brain tumors showing Parkinsonism were various such as astrocytoma, meningiomas, craniopharyngiomas, and metastasis. They were usually supratentorial …