A 76-year-old woman with a prior subcortical infarct was evaluated due to progressive decline in her ability to walk.

Our patient had a prior subcortical infarct and consulted us due to her severe gait difficulty and frequent falls. She did not complain of headaches, nausea, vomiting, or visual difficulties. She had no history of subarachnoid hemorrhage (SAH), meningitis, cranial radiation, cranial surgery, or head trauma. Despite her severe gait disorder, our patient could move her legs fairly well, particularly when lying on her back. She did not have ataxia or overt muscle weakness.

Although she was able to stand, she had marked difficulty in lifting her feet and walked as if her feet were glued to the floor. Arm swing during walking was relatively preserved, and she did not have resting tremor, bradykinesia, or rigidity. Turning was difficult, and it took several steps. Her gait difficulties and falling episodes persisted despite a trial of levodopa/carbidopa. Magnetic resonance imaging (MRI) showed no widening of cerebrospinal fluid (CSF) spaces at the high convexity, ventricular enlargement, or leukoaraiosis.
On T2-weighted images, there was no evidence of increased signal in the periventricular areas. There was no thinning or upward bowing of the corpus callosum. There was no prominent flow void noticed in the aqueduct and third ventricle. Isotope cisternography was reported as showing a “mixed pattern.”

Our patient had considerable difficulties in using her legs to walk out of proportion to that of other movements of her lower limbs when seated or lying, suggestive of apraxia of gait, a higher-level gait disorder diffusely localized to the medial frontal cortex or, in selected cases, higher brainstem structures (involving the pedunculopontine nucleus), and caused by a variety of frontal-predominant disorders, such as microangiopathic brain disease (vascular parkinsonism), hydrocephalus (e.g., normal pressure hydrocephalus and obstructive hydrocephalus), or neurodegenerative disorders highly selective to the frontal lobes and mesencephalic regions (frontotemporal dementia with parkinsonism and progressive supranuclear palsy).