Neuro Images Figure. (A) Axial diffusion-weighted MRI demonstrates an acute to subacute lacunar infarct in the left midbrain. (B) Axial FLAIR (fluid-attenuated inversion recovery) MRI of the brain demonstrates hyperintensity predominantly involving the left red nucleus and the left substantia nigra. The infarct extended rostrally to just below the subthalamic nucleus and laterally to the margin of the cerebral peduncle. Midbrain infarct with parkinsonism John C. Morgan, MD, PhD; and Kapil D. Sethi, MD, FRCP A 65-year-old dextral woman with hypertension presented with a 5-day history of difficulty writing. On examination, she had impaired adduction of her left eye and micrographia. MRI demonstrated an acute to subacute lacunar infarct involving predominantly the left red nucleus and the substantia nigra pars From the Department of Neurology (Dr. Morgan), University of Virginia, Charlottesville; and Department of Neurology (Dr. Sethi), Medical College of Georgia, Augusta. Downloaded from https://www.neurology.org by 185.107.56.163 on 11 April 2024 Received September 23, 2002. Accepted in final form January 16, 2003. Address correspondence and reprint requests to Dr. J.C. Morgan, Department of Neurology, University of Virginia, Box 800394, Charlottesville, VA 22908; e-mail: jcm8e@virginia.edu E10 Copyright © 2003 by AAN Enterprises, Inc. compacta (figure). Three weeks later, her extraocular movements were normal; however, she had bradykinesia and micrographia in her right arm (without tremor). She was treated with carbidopa/ levodopa, and her bradykinesia and micrographia improved. Treatment with carbidopa/levodopa was discontinued after 2 months without worsening of her clinical condition. Parkinsonism due to a focal ischemic lesion is very rare, and only about one-third of patients with all forms of vascular parkinsonism respond to levodopa treatment.1,2 The majority of patients with parkinsonism due to a focal ischemic lesion do not exhibit tremor, unlike patients with idiopathic PD.1,2 1. Winikates J, Jankovic J. Clinical correlates of vascular parkinsonism. Arch Neurol 1999,56:98 –102. 2. Demirkiran M, Bozdemir H, Sarica Y. Vascular parkinsonism: a distinct, heterogeneous clinical entity. Acta Neurol Scand 2001;104:63– 67.