Parkinsonism Improved With Levodopa After Endoscopic Third Ventriculostomy in Shunted Hydrocephalus Due to Aqueductal Stenosis.

INTRODUCTION: Levodopa-responsive parkinsonism has been reported following ventriculoperitoneal (VP) shunt in patients with obstructive hydrocephalus due to aqueductal stenosis. It has been thought to arise from injury to the global rostral midbrain including the nigrostriatal pathway by a transtentorial pressure gradient. We present a similar patient, but his parkinsonism resisted levodopa administration during the initial therapy. CASE REPORT: A 51-year-old man suffered from hydrocephalus due to secondary aqueductal stenosis presumably attributed to massive bleeding during surgery for a fourth ventricle hemangioblastoma. After resolution of the hydrocephalus with VP shunt, he developed severe parkinsonism, Parinaud syndrome, and hyperreflexia, suggesting global rostral midbrain dysfunction, but high-dosage levodopa therapy was not effective. An inverted transtentorial pressure gradient suggested by his unilateral slit-like ventricle was assumed to be the cause of the levodopa resistance. Also based on an assumption that the absorption of cerebrospinal fluid was impaired due to the intraoperative bleeding, a lumbar peritoneal shunt was added to the preexisting VP shunt, but it failed to control the ventricular size. Instead, endoscopic third ventriculostomy stabilized it, characteristically inducing levodopa responsiveness in our patient. An increase of the levodopa dosage led to clinical improvement, which needed a maintenance dosage because of dependency. CONCLUSION: The details of this patient suggest that a transtentorial pressure gradient may have impaired more distal basal ganglia connections over a global rostral midbrain including the nigrostriatal pathway, and that aggressive levodopa therapy after endoscopic third ventriculostomy can be effective for refractory parkinsonism.

Hearing screening for Japanese children and young adults using the automated auditory brainstem response.

OBJECTIVE: Hearing screening programs in schools are particularly important for children because they can enable early detection of hearing problems and early intervention. However, there has been little research on this topic. The MB11BERAphone(®) is a novel, accurate and efficient Automated Auditory Brainstem Response device for hearing screening in infants. The aim of this study was to investigate the validity of the MB11BERAphone(®) as a hearing screening device for pre-school, school-age and young-adult individuals. METHODS: Between January 2010 and March 2012, 163 normal and hearing impaired individuals, corresponding to 321 ears from subjects aged 3-22 years 11 months at Luther Aiji Kindergarten and Nakadori General Hospital in Akita, Japan, underwent primarily conditional play audiometry or conventional audiometry followed by the Automated Auditory Brainstem Response by MB11 BERAphone(®). The statistical analysis was performed with the Predictive Analytics Software (PASW Statistics 18) and presented as the mean, standard deviation (SD) and frequency distribution. The sensitivity, specificity and false-positive and false-negative rates were estimated to analyze the validity of the MB11 BERAphone(®) test over audiometry. RESULTS: Among the normal and hearing impaired ears, 140 were scored as "REFER" and 181 were scored as "PASS" during the hearing screening examination conducted using the MB11BERAphone(®) device. The specificity was 95.1%, and the sensitivity was 96.3%. The false positive rate was 5%, and the false negative rate was 4%. The overall timing without precise measurement was less than 7min. The individuals were divided into groups: pre-schoolers (3-5 years), school-age (6-17 years) and young-adults (18-22 years). When the audiometry and MB11BERAphone(®) results were compared, no statistically significant differences (p=ns) were detected among general (pre-schoolers+school-age+young-adult), pre-school, school-age, and young-adult groups. CONCLUSION: The results suggest that the MB11BERAphone(®) is not only useful for newborn hearing screening but also for hearing screening in older individuals, due to the low cost of the integrated electrodes and the speed with which the examination can be performed.