Neurovascular Integration Failure and Freezing of Gait: Rethinking Parkinsonism Through a Vascular Lens

A subset of patients with parkinsonian syndromes, particularly older adults, present with early gait dysfunction, postural instability, cognitive-motor dissonance, and limited dopaminergic responsiveness. These features, often labeled as atypical Parkinson's disease (PD), may instead represent a distinct neurovascular endophenotype, vascular parkinsonism (VP), driven by cerebral small-vessel disease (SVD). We introduce the Neurovascular-Locomotor Integration Failure (NLIF) hypothesis, which interprets VP symptoms-especially freezing of gait (FOG)-as manifestations of vascularly mediated network disconnection, rather than late-stage dopaminergic decline. This disruption of fronto-striatal and fronto-parietal integration impairs coordination between cortical motor planning and subcortical execution, producing gait disturbances often refractory to conventional PD therapies. An integrated framework combining the Vasc-PD Stratification Score (VPDS) and the Neurovascular-Degenerative Classification (NDC) delineates three mechanistic phenotypes: Type I-Neuro-Dominant (Idiopathic) PD, Type II-Vascular-Dominant Parkinsonism, and Type III-Mixed Neurovascular PD, capturing the continuum from primary α-synuclein neurodegeneration to cerebrovascular network injury and their intersection. This schema extends traditional nosologies by embedding vascular mechanisms within a unified, mechanism-based diagnostic continuum. Evidence from multimodal neuroimaging, biomarker studies (NfL, homocysteine, VCAM-1, ICAM-1), and pharmacogenomic data (COMT, MAO-B, CYP2D6) supports VP as a potentially modifiable disorder bridging vascular and neurodegenerative processes. Therapeutically, vascular-targeted interventions offer dual neuroprotective and vasculoprotective benefits, while pharmacogenomic stratification may assist in individualized levodopa optimization in mixed phenotypes. By reframing VP and FOG as outcomes of neurovascular integration failure, this framework transitions parkinsonism from a dopamine-centric model to a precision neurovascular paradigm, enabling earlier diagnosis, stratified interventions, and improved patient outcomes.