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These features, often labeled as atypical Parkinson's disease (PD), may instead represent a distinct neurovascular endophenotype, vascular parkinsonism (VP), driven by cerebral small\u2010vessel disease (SVD). We introduce the Neurovascular\u2013Locomotor Integration Failure (NLIF) hypothesis, which interprets VP symptoms\u2014especially freezing of gait (FOG)\u2014as manifestations of vascularly mediated network disconnection, rather than late\u2010stage dopaminergic decline. This disruption of fronto\u2010striatal and fronto\u2010parietal 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\u2010PD Stratification Score (VPDS) and the Neurovascular\u2013Degenerative Classification (NDC) delineates three mechanistic phenotypes: Type I\u2014Neuro\u2010Dominant (Idiopathic) PD, Type II\u2014Vascular\u2010Dominant Parkinsonism, and Type III\u2014Mixed Neurovascular PD, capturing the continuum from primary \u03b1\u2010synuclein neurodegeneration to cerebrovascular network injury and their intersection. This schema extends traditional nosologies by embedding vascular mechanisms within a unified, mechanism\u2010based diagnostic continuum. Evidence from multimodal neuroimaging, biomarker studies (NfL, homocysteine, VCAM\u20101, ICAM\u20101), and pharmacogenomic data (COMT, MAO\u2010B, CYP2D6) supports VP as a potentially modifiable disorder bridging vascular and neurodegenerative processes. Therapeutically, vascular\u2010targeted 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\u2010centric model to a precision neurovascular paradigm, enabling earlier diagnosis, stratified interventions, and improved patient outcomes.<\/jats:p>","DOI":"10.1111\/ejn.70381","type":"journal-article","created":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T09:51:21Z","timestamp":1767779481000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Neurovascular Integration Failure and Freezing of Gait: Rethinking Parkinsonism Through a Vascular Lens"],"prefix":"10.1111","volume":"63","author":[{"given":"Katherine","family":"Kim","sequence":"first","affiliation":[{"name":"Global Health Neurology Lab  Sydney New South Whales Australia"},{"name":"UNSW Medicine and Health University of New South Wales (UNSW), South Wes Sydney Clinical Campuses  Sydney New South Whales Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9783-3628","authenticated-orcid":false,"given":"Sonu\u00a0M.\u00a0M.","family":"Bhaskar","sequence":"additional","affiliation":[{"name":"Global Health Neurology Lab  Sydney New South Whales Australia"},{"name":"NSW Brain Clot Bank NSW Health Pathology  Sydney New South Whales Australia"},{"name":"Ingham Institute for Applied Medical Research Clinical Sciences Stream  Liverpool New South Whales Australia"},{"name":"Department of Neurology &amp; Neurophysiology Liverpool Hospital and South West Sydney Local Health District  Liverpool New South Whales Australia"},{"name":"Department of Neurology, Division of Cerebrovascular Medicine and Neurology National Cerebral and Cardiovascular Center (NCVC)  Suita Osaka Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,1,7]]},"reference":[{"key":"e_1_2_14_2_1","doi-asserted-by":"publisher","DOI":"10.1002\/prp2.1063"},{"key":"e_1_2_14_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.parkreldis.2018.11.006"},{"key":"e_1_2_14_4_1","doi-asserted-by":"publisher","DOI":"10.1093\/brain\/120.12.2187"},{"key":"e_1_2_14_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.parkreldis.2012.03.017"},{"key":"e_1_2_14_6_1","doi-asserted-by":"publisher","DOI":"10.1186\/s41021-017-0078-8"},{"key":"e_1_2_14_7_1","volume-title":"Cilostazol StatPearls","author":"Balinski A. 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