Disclosures: Ramsay A. Elhindi, MD: Nothing to disclose

Case Description: Patient admitted to inpatient rehabilitation presenting with neurological exam findings including significant hypophonia, bradykinesia, and masked facies secondary to Parkinson’s, in addition to left upper extremity paresis secondary to acute cerebrovascular accident. Throughout rehabilitation course, neurological exam remained stable with the exception of waxing/waning exacerbations of Parkinsonian symptoms. This was secondary to dysphagia resulting in patient’s difficulty in consistently swallowing carbidopa-levodopa pharmacotherapy for treatment of Parkinsonian symptoms, confounding neurological findings. Patient continued to exhibit cognitive/functional improvements overall throughout rehabilitation course until she began exhibiting acute, progressively worsening responsiveness in addition to diffuse muscle rigidity with posturing. This was attributed to Parkinson’s exacerbation secondary to missed carbidopa-levodopa administration. Patient ultimately acutely declined neurologically and code stroke initiated.

Setting: Inpatient rehabilitation hospital

Patient: 80-year-old African American female with significant past medical history of hypertension, end-stage Parkinson’s, presenting with acute-onset right facial droop and dysphagia secondary to acute right posterior frontal centrum semiovale lacunar infarct.

Assessment/Results: Upon discharge to acute, neurological examination revealed fixed dilated pupils, absent corneal, vestibulo-ocular, and gag reflexes. Additionally, patient exhibited increased tone diffusely and absent responses to painful stimuli. Computed tomography of the head revealed massive acute right cerebral hemisphere hemorrhage with mass effect including significant midline shift and uncal herniation.

Discussion: Symptoms of end-stage Parkinson’s disease can mimic and/or mask signs/symptoms of acute cerebrovascular accident, delaying diagnostic workup and intervention. Therefore, it is important to perform regular neurological examinations on patients with end-stage Parkinson’s to ensure prompt identification of acute neurological changes indicative of acute cerebrovascular incidents.

Conclusion: Patient’s initial neurological presentation in the setting of missed carbidopa-levodopa administration appeared consistent with exacerbation of end-stage Parkinson’s symptoms. In Parkinson’s patients with new neurological examination findings, a low threshold for diagnostic workup and imaging should be maintained.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/end-stage-parkinsons-disease-masking-new-acute-cerebrovascular-accident-a-case-report/