Atlanta GA USA 2015 Case 2 Case 2 Female 38 years old History Hemiparesis after pituitary macro adenoma surgery followed months after by rest and postural tremor right a rm incoordination ID: 742615
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Slide1
Video Competition
MDS-PAS School For Young NeurologistAtlanta, GA, USA. 2015
Case 2Slide2
Case 2
Female 38 years old.
History
Hemiparesis after pituitary macro adenoma surgery followed months after by rest and postural tremor, right
a
rm
incoordination
and
gait with mild dystonic posture on her right leg.Slide3
VideoSlide4
Audience discussion
PhenommenologyDifferential diagnosis
InvestigationsSlide5
Diagnosis
Holmes tremor
Lacunar right paramedic mesencefalic strokeSlide6
Resting tremor of a limb with marked accentuation on action, intention, and goal-oriented movement.
Irregular / low freq
(4.5 Hz)
Usually involves the upper extremities.
Phenomenology
Holmes´ Tremor (Rubral)
Groppa S, et al.Brain 2013
Yan YW, et al. Acta Neurol Taiwan 2005Slide7
Localization
The most common lesions are in the brainstem, cerebellum and thalamus
.
These localizations suggest involvement of both the nigrostriatal and dentato-rubro-thalamic pathways.
The onset of Holmes’ tremor after stroke is typically delayed by
weeks to months
Groppa S, et al.Brain 2013
Bansil S, et al. Tremor Other Hyperkinet Mov 2012Slide8
Treatment
Propranolol
Clonazepam
Levodopa and other dopaminergic agents
Valproate
Levetiracetam.
Response to drugs is usually poor in these patients
Many patients with Holmes’ tremor require surgical intervention, such as ventrointermedius thalamotomy and thalamic DBS
Bansil S, et al. Tremor Other Hyperkinet Mov 2012