Re
rt
Bre-vite
]D t
ltrasono gra phc
o pper u
e
Brent E.
n
v
0
ati ents
Burbridge, MD; J.
t
Kirk Wallace, MD;
Ali
minati*on
exa
Par
inson
Rajput, MD;
Linda
Burbridge, Wallace Department of Medical Imaging, Royal University Hospital; Rajput, Neurology, Royal University Hospital, Saskatoon, Sask.
Objective: ease.
To determine the incidence of
deep
venous
thrombosis
(DVT)
in
disease
McCulloch,
McCulloch
RN
Department
of
patients with Parkinson dis-
Design: Prospective study. Setting: Outpatient neurology clinic. Patients: Eighty-one patients with
Parkinson
disease. Outcome
compression images, Doppler had
leg DVT;
in 3 of the
the
superficial
femoral
had stage ference
in
However,
measures:
flow
patients the thrombi
vein. Of
2.5, and the other 2
the incidence of
overall
an
the
were
patients
incidence of DVT of 4.9% in
suggesting that patients with
Parkinson disease
(I.23%)
were
group
are at
of
risk for
There
more
was
severely
Results: Four
patients
patient the thrombosis
had stage 2
Conclusions:
who a
assessment.
in calf veins, whereas in
DVT,
had stage 4.
DVT among
scans consisting of M mode images and
augmentation of flow
and
patients with
(2.46%)
ultrasonographic
Duplex
assessment
Parkinson disease, no
statistically
disabled
by
asymptomatic patients is
was
in
(I.23%)
significant
dif-
Parkinson disease.
clinically
meaningful,
asymptomatic leg DVT.
Objectifo: Dterminer l'incidence de Ia thrombose veineuse profonde (TVP) chez les patients Ia maladie de Parkinson. Conceptiont:ttude prospective. Contexte: Clinique de neurologie
atteints de en
service
Patientsa Quatre-vingt-un patients atteints de Ia maladie de Parkinson. Mesures de rasultats: echographie duplex comportant des images en mode M des images comprimbles,bvaluation du debit
externe.
:
et
Doppler et augmentation de
1fvaluation
du
dEbit.
11rosultatsy: Quatre
patients avaient
une
TVP
A
Ia jambe;
dtaient situes dans des veines du mollet tandis que chez I'autre, thrombose se trouvait dans la veine fdmorale superficielle. Chez les patients qui avaient TVP, (I,23 %) avait la maladie de Parkinson stade 2, i (1,23Iuavait au stade 2,5 les deux %) (2,46 %) savaient stade 4. Conclusions le plan statistique dans l'incidence de n'y avait pas de diffErence significative TVP chez les patients handicapns plus sprieusement par la maladie de Parkinson. Une augmentation globale chez
trois des
patients,
les caillots
a
une
et
au
a
:ll
de
Ia TVP
de
4,9 % chez
nique et indique
matique d
Ia
que les
un
au
sur
groupe de
patients
autres
le plan clipatients asymptomatique est toutefois significative de ia maladie de Parkinson sont vulnErables A une TVP asymptosur
atteints
jambe.
Correspondence to: Dr. B. Burbridge, Department of Medical Imaging, S7N OW8; fax 306 655-2370;
[email protected]
Royal University Hospital,
Medical subject headings: leg; Parkinson disease; ultrasonography, Doppler, duplex;
venous
103
Hospital Drive, Saskatoon,
SK
thrombosis
J Psychiatry Neurosci 999;24(4):338-40. Submitted Sept. 24, 1998 Revised Feb. 4, 1999; Mar. 31, 1999 Accepted Apr. 6, 1999 1999 Canadian Medical Association
33
338
epyharee
enuocec
Revue & psychi"atn*e et de tieuiosc'l'ence
o.2,n
,19
Vo.2, n_4. 1999w7
Ultrasonography of leg veins in PakinsoIn disease
Introduction Patients who have had a stroke or an acute spinal cord injury have been shown to have an unusually high risk of deep venous thrombosis (DVT) in the lower limbs.' In patients with Parkinson disease, the incidence of DVT is unknown. In a recent study, the cause of death, as determined by autopsy, was described in 60 patients with Parkinson disease.4 Of the 60 patients, 13.3% died as a result of pulmonary embolism; in a subset of patients with pure Lewy body Parkinson disease, 23.1% died as a result of pulmonary embolism. If pulmonary embolism is a common cause of death in patients with Parkinson disease, one can assume that the incidence of DVT is also elevated in these patients. Previously, to assess DVT in patients, investigators had to rely on clinical examination, inaccurate noninvasive venous investigations, or invasive venous studies. a routine, safe, noninvaDoppler ultrasonography sive diagnostic procedure for the assessment of leg veins has proven to be a highly sensitive and specific method to detect venous thrombosis.5 We performed bilateral leg ultrasonographic examinations on outpatients with Parkinson disease to determine if these patients had asymptomatic DVT. The study was reviewed and approved by our local university ethics committee.
Methods Bilateral compression duplex Doppler ultrasonographic examinations were performed on the leg veins of 81
sequential volunteer patients with Parkinson disease between June 1994 and April 1996. Patients were enrolled in the study by the Movement Disorder Clinic nurse. Each patient was given an information package and signed a written consent form. Each patient was evaluated by a neurologist and an experienced nurse before entry into the study to assess the severity of Parkinson disease. At the time of enrolment, the severity of the patient's Parkinson disease was assessed using the Hoehn and Yahr scoring system (Table 1). Results of the leg vein ultrasonographic examinations were correlated with the Hoehn and Yahr score. The ultrasonographic examinations were performed by experienced ultrasonographic technologists and reviewed by a supervising radiologist practising in a tertiary care radiology department. The duplex ultrasonographic scans consisted of M mode images, compression images, Doppler flow assessment and augmentation of flow assessment. In all patients, the calf veins were visualized caudal to the popliteal veins, as distal as was possible.
Results Of the 81 patients, 49 were men and 32 were women. The age of the patients ranged from 48 to 86 years, with a mean age of 70 (SD 8.3) years. The Hoehn and Yahr scores ranged from 1 to 5, with a mean score of 2.44 (SD 0.77; n = 81); the median score was 2. The number of patients in each Hoehn and Yahr class are presented in Fig. 1. The duplex ultrasonographic examinations demonstrated that 4 (4.94%) of the patients had DVT. In 3 of the patients the thrombi were in calf veins, whereas in 1 patient the thrombosis was in the superficial femoral
Table 1: Hoehn andd Yahr scoring system for Parkinson disease Stage
Balance
Limb involvement NA*
Unilateral mild Bilateral mild Bilateral mild
1.5 2
2.5
NA Minimal impairment
Push/pull
4 steps or falling to severe Bilateral severe Impaired
3
::
>
3.5 4
Bilateral *NA
Vol. no 4, 1999 V,.-I. 24, ho
=
severe
Impaired
Very difficult to rise from Unassisted chair or bed Cannot rise from chair or Unassisted bed without assistance Impaired due to Wheelchair bedridden status bedridden
Unassisted
Unassisted or
Wheelchair bedridden
or
not applicable.
Neuroscieuce Psychiatry & Journal of psyphhitly & M#r"004041, jouma luir 4
339
E339
Burbridge .ta
vein. Of the 4 patients with DVT, 1 (1.23%) had stage 2 Parkinson disease, 1 (1.23%) had stage 2.5 Parkinson disease, and the other 2 (2.46%) had stage 4 Parkinson disease. The patient with DVT in the superficial femoral vein had stage 4 Parkinson disease. We classified patients with Hoehn and Yahr scores of 3.5 or greater as being severely affected by Parkinson disease. A X2 analysis of the incidence of DVT in patients with severe Parkinson disease (Hoehn and Yahr scores of 3.5 or greater) did not detect a statistically significant difference compared with the less severely affected patients.
Discussion Patients with Parkinson disease have an increased risk of dying from pulmonary embolism.4 Therefore, one would believe that these patients would also have an unusually high incidence of DVT. This appears not to be the case. We report an incidence of DVT in patients with Parkinson disease of 4.9%, which is not as high as that reported in patients with acute spinal cord injury or in patients who have had a stroke.1-3 However, an incidence of 4.9% DVT in a group of asymptomatic patients suggests that close surveillance of this patient population may be in order. Since only 1 of the patients had superficial femoral vein thrombosis, and if one believes that only thrombi proximal to the popliteal vein require anticoagulant therapy, then only 1 patient benefited from the ultrasonographic examina-
tion. Certainly, one could argue that the 3 patients who were at risk of proximal progression of thrombus were also identified, and thus could be followed clinically and with repeat ultrasonographic examinations. We did not attempt to screen individuals based on the presence or absence of symptoms of DVT. The inclusion of clinical assessment of the risk factors for DVT along with physical findings associated with DVT may significantly alter the incidence of DVT detected in this patient population. Certainly, the need to carefully assess this group of patients for the symptoms of DVT is highlighted by the increased incidence of fatal pulmonary embolism. Compared to venography, ultrasonography detects calf vein thrombi in the range of 50%.6 Therefore, despite the fact that 3 of the 4 DVTs found in our study group were in the calf veins, it is reasonable to surmise that there were other asymptomatic patients who had calf vein DVT that was not detected by the ultrasonographic examination. We failed to demonstrate a statistically significant correlation between the severity of Parkinson disease and the incidence of DVT. Two of the 10 patients with severe Parkinson disease had DVT, whereas only 2 of the 71 patients with less severe Parkinson had DVT. However, the number of patients severely affected by Parkinson disease was low (10 of 81 patients). The paramount reason for the small number of severely affected patients was the difficulty recruiting immobile, bedridden patients. We believe that further study of a more severely affected group of patients is warranted.
35
References
30-
1.
VI. 25 2.
~200 L.
3.
.0
E
0-
z
5G) IS ~ 0 Tabl 1.)-
~ 1.5
~ 2
4.
Sag 2.5
3
3.5
4
4.5
5
Stage Fig. I: Number of patients with Parkinson disease categorized by Hoehn and Yahr stage (for staging system, see Table I.)
340
5. 6.
Oczkowski WJ, Ginsberg JS, Shin A, Panju A. Venous thromboembolism in patients undergoing rehabilitation for stroke. Arch Phys Med Rehabil 1992;73:712-6. Merli GJ, Crabbe S, Paluzzi RG, Fritz D. Etiology, incidence, and prevention of deep venous thrombosis in acute spinal cord injury. Arch Phys Med Rehabil 1993;74:1199-1205. Gunduz S, Ogur E, Mohur H, Somuncu I, Acjksoz E, Ustunsoz B. Deep vein thrombosis in spinal cord injured patients. Paraplegia 1993;31:606-10. Mosewich R, Rajput AH, Shuaib A, Rozdilsky B, Ang L. Pulmonary embolism: an under-recognized yet frequent cause of death in patients with Parkinson disease. Mov Disord 1994;9:350-2. Cronan JJ. Venous thromboembolic disease: the role of ultrasound. Radiology 1993;186:619-30. Jongbloets LMM, Lensing AWA, Koopman MMW, Buller HR, ten Cate JW. Limitations of compression ultrasound for the detection of asymptomatic postoperative deep vein thrombosis. Lancet 1994;343:1142-4.
Vol 24,n.4.i.9.
