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Video Competition
MDS-PAS School For Young NeurologistAtlanta, GA, USA. 2015
Case 2
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Case 2
Female 38 years old.
History
Hemiparesis after pituitary macro adenoma surgery followed months after by rest and postural tremor, right arm incoordination
and gait with mild dystonic posture on her right leg.
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Video
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Audience discussion
PhenommenologyDifferential diagnosis
Investigations
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DiagnosisHolmes tremor
Lacunar right paramedic mesencefalic stroke
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• 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 2013Yan YW, et al. Acta Neurol Taiwan 2005
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LocalizationThe 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 monthsGroppa S, et al.Brain 2013
Bansil S, et al. Tremor Other Hyperkinet Mov 2012
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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 DBSBansil S, et al. Tremor Other Hyperkinet Mov 2012