(Kiosk 4) Parkinsonian Features After Elective Carotid Endarterectomy: A Case Report

Case Diagnosis: Parkinson’s disease

Case Description or Program Description: 80 year old man with history of bilateral carotid artery disease s/p bilateral carotid endarterectomy (CEA), coronary artery disease, aortic stenosis, atrial fibrillation who presented with generalized weakness and tremors three days after elective right sided CEA.

Setting: Tertiary Care Academic Hospital

Assessment/Results: MRI brain without contrast, MRI Thoracic and lumbar spine with and without contrast showed no acute findings. Symptoms were thought to be due to essential tremors and started on propranolol and cyclobenzaprine with no improvement. He was evaluated by Physiatry 4 days after admission and found to have bilateral lower extremity rigidity, shuffling gait, bradykinesia, bilateral resting hand tremor, and masked facies. Carbidopa/Levodopa was started at 1 tablet 3 times a day and symptoms improved within 2 days.

Discussion (relevance): This patient clinically presented with Parkinsonian features with no known history of Parkinson’s disease prior to surgery. There is no known mechanism of action but Parkinsonian features have been seen in other cases after surgery. Current theories revolve around use of anesthetic agents or stress of surgery can precipitate underlying Parkinsonism. Symptoms improved quickly after starting Carbidopa/Levodopa.

Conclusions: Parkinsonian features have been seen to arise or worsen after undergoing surgery. The exact mechanism of action is unknown but maybe due to use of anesthetic agents or from stress of the surgery. Further research is required to determine the mechanism. However, it is important to recognize that this can occur and correct diagnosis is prudent for adequate treatment.