Dropped Head Syndrome after Minor Trauma in a Patient with Levosulpiride-Aggravated Vascular Parkinsonism

JMD Dropped head syndrome (DHS) is commonly observed in patients with parkinsonism, including those with multiple system atrophy and Parkinson's disease (PD). In PD, DHS is aggravated during off period or develops after the introduction of do-pamine agonists (DAs). 1 Although DHS is considered as dystonia by some authors, clinical and laboratory findings supporting this view remain controversial. 2 Herein, we describe the emergence of levosulpiride-aggravated DHS in a patient with vascular par-kinsonism (VP) after minor trauma. A 78-year-old female was admitted due to involuntary neck flexion. Her medical history revealed hypertension and atrial fibrillation. Ten days prior to admission, she visited our clinic with gait disturbance. Her first neurological examination revealed mild kyphosis and symmetric lower body parkinsonism [Unified Parkinson Disease Rating Scale Part III (UPDRS III) = 17]. She was unable to stand unassisted. Resting tremor and other atypical features, such as downward gaze impairment, were absent. The patient had been taking levosulpiride for over 3 months. Her parkinsonism had begun to improve after the discontinuation of levosulpiride. However, 2 days prior to admission , she slipped and fell. She did not lose consciousness, but her face and neck hit a table as she fell, and involuntary neck flexion began the same day. A follow-up neurologic examination upon admission revealed DHS and parkinsonism (UPDRS III = 18). Her Mini-Mental Status Examination score was 20/30, and her DHS could be relieved by lying down. A brain MRI showed multiple lesions in the subcortical and periventricular areas (Figure 1A), and a spine X-ray showed rotoscoliosis and compression fractures of T11 and L1 vertebrae (Figure 1B). Her cervical MRI was normal. A needle electromyography (EMG) 4 days after the onset of DHS failed to demonstrate dystonic contraction in various muscles, including the sternocleidomas-toid, splenius capitis, trapezius, and scalene muscles but showed positive sharp waves (PSWs) in the paraspinal muscles, including splenius capitis, with normal morphology of motor unit action potential without early recruitment. Levodopa was administered (200 mg/day), and the patient's parkinsonism and DHS improved over the course of 1 week (Supplementary Video 1 and 2 in the online-only Data Supplement). Levodopa was tapered 3 weeks later, and DHS did not recur. A follow-up neurologic examination 1 year later revealed mild parkinson-ism characterized by postural and gait problems without any evidence of atypical parkinsonism (UPDRS III = 9). In this patient, parkinsonism was persistent even after the resolution of DHS. Her …