Matsuda et al recently reported three patients with a persistent vegetative state (PVS) after severe head injury who, after recovering from prolonged disturbance of consciousness, presented parkinsonian features (mainly rigidity and hypokinesia) which improved after levodopa treatment.¹ MRI studies showed lesions in the dorsolateral midbrain and cerebral peduncles suggesting axonal injury involving the dopaminergic system (substantia nigra and ventral tegmental area). Similar observations were made in a series of 125 patients with severe vegetative state following head injury (survival time 1–10 years). Nineteen of 49 patients surviving in fully developed or mild recovery stages of PVS initially presented with severe to moderate, mainly symmetrical, parkinsonian symptoms (amimia, rigidity, hypokinesia, convergence disorders). Following levodopa treatment, 11 patients showed incomplete and four full improvement of both the PVS and parkinsonism, while four patients showed complete recovery from both syndromes. However, in 15 patients—despite good recovery from the initial PVS and other neurological symptoms (spasticity, frontal and cerebellar symptoms), and long term levodopa treatment—a progressive parkinsonian syndrome (rigidity, hypokinesia) developed; in six patients this was associated with unilateral or bilateral resting tremor. In MRI studies done in 34 patients, 32 showed unilateral or bilateral lesions in the midbrain involving both the dorsolateral tegmentum and the cerebral peduncles. …