Unilateral Tremor Research Articles

TENM4 gene mutation in a case of unilateral essential tremor

Essential tremor (ET) is a prevalent hyperkinetic movement disorder of clinical practice. The exact aetio-pathogenesis of ET is unknown. Genetics has shown a proven role in approximately 50% cases of ET. Different loci of genes are associated with ET, but wide-scale validation into generalized population is lacking. This is primarily due to biodiversity in genetic milieu in different population, environmental factors as well as detection of newer mutations. In this case we described a 19 year old male presenting with progressive hand tremors without familial history and tried to explore genetics for aiding the diagnosis.

Comparing Essential Tremor with and without Soft Dystonic Signs and Tremor Combined with Dystonia: The TITAN Study.

Tremor disorders remain as clinical diagnoses and the rate of misdiagnosis between the commonest non-parkinsonian tremors is relatively high. To compare the clinical features of Essential Tremor without other features (pure ET), ET plus soft dystonic signs (ET + DS), and tremor combined with dystonia (TwD). We compared the clinical features of patients with pure ET, ET + DS, and TwD enrolled in The ITAlian tremor Network (TITAN). Linear regression models were performed to determine factors associated with health status and quality of life. Three-hundred-eighty-three patients were included. Sex distribution was significantly different between the groups with males being more represented in pure ET and females in TwD. The initial site of tremor was different between the groups with about 40% of TwD having head tremor and ET + DS unilateral upper limb tremor at onset. This pattern mirrored the distribution of overt dystonia and soft dystonic signs at examination. Sensory trick, task-specificity, and position-dependence were more common, but not exclusive, to TwD. Pure ET patients showed the lowest degree of alcohol responsiveness and ET + DS the highest. Midline tremor was more commonly encountered and more severe in TwD than in the other groups. Regression analyses demonstrated that tremor severity, sex, age, and to a lesser degree the variable "group", independently predicted health status and quality of life, suggesting the existence of other determinants beyond tremor. Pure ET and TwD manifest with a phenotypic overlap, which calls for the identification of diagnostic biomarkers. ET + DS shared features with both syndromes, suggesting intra-group heterogeneity.

Unilateral deep brain stimulation (DBS) of nucleus ventralis intermedius thalami (Vim) for the treatment of post-traumatic tremor in children: a multicentre experience.

Deep brain stimulation (DBS) of nucleus ventralis intermedius thalami (Vim) is a validated technique for the treatment of essential tremor (ET) in adults. Conversely, its use for post traumatic tremor (PTT) and in paediatric patients is still debated. We evaluated the efficacy of Vim-DBS for lesional tremor in three paediatric patients with drug-resistant post-traumatic unilateral tremor. We retrospectively collected data regarding three patients with unilateral tremor due to severe head injury, with no MRI evidence of basal ganglia lesions. The three patients underwent stereotactic frame-based robot-assisted DBS of Vim contralateral to the tremor side. Mean follow-up was 48months (range: 36-60months). Tremor was reduced in all patients with a better control of voluntary movements and improvement of functional status (mean FIM scale improvement + 7 points). No surgical complications occurred. Unilateral contralateral DBS of Vim could be efficacious in post-traumatic tremor, even in paediatric patients and should be offered in PTT drug-resistant patients.

Bedside clinical assessment of patients with common upper limb tremor and algorithmic approach.

The diagnostic approach for patients with tremor is challenging due to the complex and overlapping phenotypes among tremor syndromes. The first step in the evaluation of tremor is to identify the tremulous movement and exclude the tremor mimics. The second step is to classify the tremor syndrome based on the characteristics of tremor from historical clues and focused examination (Axis 1). Comprehensive tremor examinations involve the assessment of tremor in different conditions (rest, action or mixed, position or task-specific), distribution of tremor (upper limb, lower limb, head, jaw), positive signs for functional tremor (FT) if suspected (distractibility, entrainment, co-contraction), and associated neurological signs including parkinsonism, dystonic posture, cerebellar/brainstem signs, neuropathy, and cognitive impairment. A pivotal feature in this step is to determine any distinct feature of a specific isolated or combined tremor syndrome. In this review, we propose an algorithm to assess upper limb tremors. Ancillary testing should be performed if clinical evaluation is unclear. The choice of investigation depends on the types of tremors considered to narrow down the spectrum of etiology (Axis 2). Laboratory blood tests are considered for acute onset and acute worsening of tremors, while structural neuroimaging is indicated in unilateral tremors with acute onset, nonclassical presentations, and a combination of neurological symptoms. Neurophysiological study is an important tool that aids in distinguishing between tremor and myoclonus, etiology of tremor and document specific signs of FT. Treatment is mainly symptomatic based depending on the etiology of the tremor and the patient's disabilities.

Long-term follow-up study of SWEDD patients with mild parkinsonian signs

BackgroundWhether scan without evidence of dopaminergic deficit (SWEDD) can be a reliable indication of a clinical entity of Parkinson’s disease (PD) is controversial.ObjectiveTo evaluate the proportion of SWEDD patients with...

98 Cognitive Outcomes Following Bilateral Focused Ultrasound Thalamotomy for Tremor

Objective:Essential tremor (ET) is the most common movement disorder, characterized by bilateral action tremors of the upper extremities. Surgical interventions can be considered for severe cases that are refractory to medication. Magnetic resonance-guided focused ultrasound (MRgFUS) of the ventral intermediate nucleus of the thalamus (Vim) is a recently approved, minimally invasive treatment for unilateral tremor. While patients are generally pleased with unilateral treatment, many patients are bothered by tremor on the untreated side. Historically, bilateral thalamotomy has been associated with a higher rate of adverse events, including cognitive impairment. MRgFUS Vim thalamotomy for bilateral tremor is currently being investigated. The goal of the present study was to evaluate the effect of bilateral MRgFUS Vim thalamotomy on cognition.Participants and Methods:Twelve patients with medication-refractory essential tremor (mean age = 68.77 +/- 11.78 years, mean education = 14.34 +/- 2.71 years, 8 male) were included in the present study. Three of the 12 patients met criteria for mild cognitive impairment (MCI). All patients successfully underwent unilateral MRgFUS thalamotomy at least 48 weeks before the second thalamotomy. A battery of neuropsychological tests was administered to patients before (considered baseline in the present study) and three months following the second thalamotomy. Baseline evaluations occurred on average 144.64 +/- 91.53 weeks (range: 55.00 - 346.58) after the first thalamotomy. The neuropsychological battery assessed domains of processing speed (Oral Symbol Digit Modalities Test, D-KEFS Color-Word Naming and Reading), attention (WAIS-IV Digit Span Forward), executive function (D-KEFS Color-Word Inhibition and Inhibition/Switching), working memory (WAIS-IV Digit Span Backward and Sequencing), verbal fluency (D-KEFS Letter Fluency and Animal Fluency), confrontation naming (Boston Naming Test), verbal memory (Hopkins Verbal Learning Test-Revised), and visuospatial perception (Judgment of Line Orientation). Alternate versions of tests were used when possible. Cognitive changes were analyzed at the group and individual level. Group level changes were assessed with paired sample t-tests (corrected for multiple comparisons). At the individual level, postoperative declines > 1.5 SD from baseline were considered clinically significant.Results:Participants’ baseline intellectual functioning ranged from low average to superior (as measured by the WTAR). The mean baseline score on the Montreal Cognitive Assessment was 24.58 (range: 17 - 30). At the group level, there were no significant changes in cognitive scores from baseline to follow-up (all p values > 0.635). At the individual level, one patient with MCI declined > 1.5 SD on the verbal memory composite. No other patients showed declines > 1.5 SD.Conclusions:Our preliminary findings suggest that bilateral MRgFUS Vim thalamotomy is relatively safe from a cognitive perspective. However, a single patient with MCI exhibited clinically significant postoperative decline in verbal memory. Future studies with larger sample sizes are needed to investigate the factors that increase the risk of postoperative cognitive decline, including pre-existing cognitive impairment, older age, and lesion size.

Using of MRI-guided focused ultrasound treatment for Parkinson’s disease tremor. Clinical case and literature review

MRI-guided high-intensity focused ultrasound (MRgFUS) is a new emerging and promising procedure applied in a wide range of clinical fi elds in modern medicine. This innovative treatment method follows is an important step towards the ideal surgery of the future: non-invasive, targeted, safe, controlled, eff ective and ambulatory. Randomized studies show high effi cacy in the treatment of tremor for Parkinson disease and essential tremor. Safety is also having similar profi le with other surgical procedures and has a mostly transient character of complications. Such advantages as a non-invasive treatment, controlled eff ect and the safety profi le of the procedure made it popular in the treatment of movement disorders. This article demonstrates a clinical case of the fi rst using of MRgFUS for the treatment of Parkinson’s disease tremor at the Federal Center for Brain Research and Neurotechnologies of the Federal Medical and Biological Agency of Russia in Moscow. The 54-year-old patient with Parkinson disease, 2 Hoehn–Yahr, admitted to our hospital. Severe tremor of right upper extremity impaired his life. Neurosurgical procedure was considered due to medication failed. Patient underwent focused ultrasound thalamotomy with totally tremor relief. No additional neurological impairment was noted, only bradykinesia and rigidity were improved. Patient discharged on 3rd day after the procedure.Conclusions. MRgFUS is an innovative surgical procedure. Advantages of these methods such as non-invasive manner, controlled, safety allowed to be priority procedure for patients with unilateral tremor.

Presynaptic Hemiparkinsonism Following Cerebral Toxoplasmosis: Case Report and Literature Review.

Cerebral toxoplasmosis (CTx) is a central nervous system opportunistic infection with variable neurological manifestations. Although tropism of Toxoplasma gondii for the basal ganglia is well known, movement disorders (MDs) represent only a small percentage of CTx-related neurological complications. CTx-associated MDs are usually hyperkinetic, whereas parkinsonism associated with evidence of presynaptic dopaminergic deficit has never been described. We report a human immunodeficiency virus-positive patient who developed a complex MD featuring unilateral tremor combined with parkinsonism and dystonia following an acute episode of disseminated CTx. Her dopamine transporter scan (DaTscan) documented contralateral presynaptic dopaminergic deficit. Levodopa initiation improved both tremor and parkinsonism after ineffective trials of several other medications over the years. A total of 64 patients presenting with CTx-related MDs have been described. The most common MD was chorea (44%), followed by ataxia (20%), parkinsonism (16%), tremor (14%), dystonia (14%), myoclonus (3%), and akathisia (2%). DaTscan was performed only in 1 case, of Holmes tremor, that demonstrated reduced presynaptic dopaminergic uptake. Positive response to dopaminergic treatment was reported in 3 cases of Holmes tremor and 2 cases of parkinsonism. Presynaptic dopaminergic deficit may occur in CTx-related tremor combined with parkinsonism. Its identification should prompt initiation of levodopa, thus avoiding unnecessary trials of other drugs.

PO053 / #833 COGNITIVE OUTCOMES FOLLOWING BILATERAL MR-GUIDED FOCUSED ULTRASOUND THALAMOTOMY FOR TREMOR: E-POSTER VIEWING

Essential tremor (ET) is the most common movement disorder, characterized by bilateral action tremors of the upper extremities. Surgical interventions can be considered for severe cases that are refractory to medication. Magnetic resonance-guided focused ultrasound (MRgFUS) of the ventral intermediate nucleus of the thalamus (Vim) is a recently approved, minimally invasive treatment for unilateral tremor. MRgFUS for bilateral tremor is currently being investigated. Historically, bilateral thalamotomy has been associated with a higher rate of adverse events, including cognitive impairment.

Related Factors and Outcome of Spinal Cord Stimulation Electrode Deviation in Disorders of Consciousness.

Background and PurposeSpinal cord stimulation (SCS) has been reported to be a promising neuromodulation method for patients with disorders of consciousness (DOC). Our previous studies found that clinical characteristics of patients and SCS stimulation parameters could affect the therapeutic effects of SCS, while surgical-related factors remain unknown. Through the improvement of surgical procedures, most of the SCS electrodes are implanted in the middle, while a small number of electrodes have still deviated.MethodsA total of 137 patients received SCS treatment in our institutions from 1 January 2010 to 31 December 2020. Among them, 27 patients were found with electrode deviation and met the inclusion criteria. Patients were grouped according to whether the electrode deviation angle (EDA) is >30°, respectively. Clinical characteristics of patients and SCS stimulation parameters were compared. Potential related factors and outcomes were evaluated by Chi-square test or two-way repeated measures analysis.ResultsTwenty seven patients receiving cervical SCS treatment were found to have electrode deviation postoperatively. Among them, 12 patients were classified into the more deviation group. No significant difference was found among age, sex, pathogeny, course of DOC, C2–C5 distance, spinal cord to spinal canal ratio at C2 level, and preoperative JFK Coma Recovery Scale-Revised (CRS-R) scores. We found that the electrode direction significantly deviated to the contralateral side in the lateral decubitus position (P = 0.025). The maximum tolerant stimulation intensity in the less deviation group (1.70 ± 0.41) was significantly higher than that in the more deviation group (1.25 ± 0.34) (P = 0.006). Under the strongest stimulation, less unilateral limb tremor (P = 0.049) and paroxysmal sympathetic hyperactivity (PSH) episodes (P = 0.030) were found. EDA had a significant effect on postoperative CRS-R in patients, and patients in the less deviation group had significantly higher postoperative CRS-R (P < 0.01). There was also an interaction effect between EDA and postoperative time. With the prolonged postoperative time, the CRS-R improvement rate of patients with different EDA was different, and the CRS-R improved faster in patients with less EDA (P < 0.05).ConclusionsElectrode deviation will affect the outcome of patients receiving cervical SCS treatment. The intraoperative surgical position is associated with postoperative electrode deviation direction. The reduction of EDA under 30° can increase maximum tolerant stimulation intensity, reduce complications, and further improve patients' outcomes.

Magnetic Resonance Image Guided Focused Ultrasound Thalamotomy. A Single Center Experience With 160 Procedures.

IntroductionMRgFUS thalamotomy has gained popularity as an FDA approved, non-invasive treatment for patients with Essential Tremor and tremor predominant Parkinson's Disease. We present our initial clinical experience with 160 consecutive cases of MRgFUS thalamotomy and describe the clinical outcomes with long term follow-up.MethodsA retrospective chart review of all patients who underwent MRgFUS thalamotomy at our institution was performed. CRST Part A tremor scores were obtained pre-operatively and at each follow-up visit along with an assessment of side effects (SE). All patients had a post-operative MRI within 24 h to determine the location, size, and extent of the MRgFUS lesion.ResultsOne hundred and sixty unilateral MRgFUS Thalamotomies (Left, n = 128; Right, n = 32) were performed for medically refractory essential Tremor (n = 150) or tremor predominant Parkinson's disease (n = 10). Mean age at surgery was 75 Years (range: 48-93) and the mean skull density ratio (SDR) was 0.48 (range: 0.32-0.75; median: 0.46). In ET patients, both rest and postural tremor was abolished acutely and remained so at follow-up whereas intention tremor was reduced acutely by 93% below baseline, 87% at 3 months, 83.0% at 1-year, and 78% at 2 years. On post-operative day 1, the most common SE's included imbalance (57%), sensory disturbances (25%), and dysmetria (11%). All adverse events were rated as mild on the Clavien-Dindo Scale and improved over time. At 2-years follow-up, imbalance was seen in 18%, sensory disturbance in 10% and dysmetria in 8% patients. Mean clinical follow-up for all patients was 14 months (range: 1-48 months).ConclusionMRgFUS thalamotomy is a safe and effective procedure for long term improvement of unilateral tremor symptoms, with the most common side-effects being imbalance and sensory disturbance.

Double lesion MRgFUS treatment of essential tremor targeting the thalamus and posterior sub-thalamic area: preliminary study with two year follow-up

Background MR-guided focused ultrasound (MRgFUS) is an effective treatment for essential tremor (ET). However, the optimal intracranial target sites remain to be determined. Objective To assess MRgFUS induced sequential lesions in (anterior-VIM/VOP nuclei) the thalamus and then posterior subthalamic area (PSA) performed during the same procedure for alleviating ET. Methods 14 patients had unilateral MRgFUS lesions placed in anterior-VIM/VOP then PSA. Bain-Findley Spirals were collected during MRgFUS from the treated arm (BFS-TA) and throughout the study from the treated (BFS-TA) and non-treated (BFS-NTA) arms and scored by blinded assessors. Although, the primary outcome was change in the BFS-TA from baseline to 12 months we have highlighted the 24-month data. Secondary outcomes included the Clinical Rating Scale for Tremor (CRST), Quality of Life for ET (QUEST) and PHQ-9 depression scores. Results The mean improvement in the BFS-TA from baseline to 24 months was 41.1% (p < 0.001) whilst BFS-NTA worsened by 8.8% (p < 0.001). Intra-operative BFS scores from the targeted arm showed a mean 27.9% (p < 0.001) decrease after anterior-VIM/VOP ablation and an additional 30.1% (p < 0.001) reduction from post anterior-VIM/VOP to post-PSA ablation. Mean improvements at 24 month follow-up in the CRST-parts A, B and C were 60.7%, 30.4% and 65.6% respectively and 37.8% in QUEST-tremor score (all p < 0.05). Unilateral tremor severity scores decreased in the treated arm (UETTS-TA) 72.9% (p = 0.001) and non-treated arm (UETTS-NTA) 30.5% (p = 0.003). At 24 months residual adverse effects were slight unsteadiness (n = 1) and mild hemi-chorea (n = 1). Conclusion Unilateral anterior-VIM/VOP and PSA MRgFUS significantly diminished contralateral arm tremor with improvements in arm function, tremor related disability and quality of life, with an acceptable adverse event profile.

Characterizing the protracted neurobiological and neuroanatomical effects of paraquat in a murine model of Parkinson's disease

The primary motor symptoms of Parkinson's disease (PD) result from the degeneration of dopamine-producing neurons of the substantia nigra pars compacta (SNc), and often, the loss is asymmetrical, resulting in unilateral tremor presentation. Notably, age is the primary risk factor for PD, and it is likely that the disease ultimately stems from the impact of environmental factors, which interact with the aging process. Recent research has focused on the role of microglia and pro-oxidative responses in dopaminergic neuronal death. In this study, we sought to examine the neurodegenerative, inflammatory, and stress effects of exposure to the etiologically relevant pesticide, paraquat, over time (up to 6 months after injections). We also were interested in whether a high-resolution, 7-Tesla animal magnetic resonance imaging would be sensitive enough to detect the degenerative impact of paraquat. We found that paraquat induced a loss of dopaminergic SNc neurons and activation of microglia that surprisingly did not change over 6 months after the last injection. A long-lasting reduction was evident for body weight, and alterations in organ (lung and heart) weight were evident, which reflect the peripheral impact of the toxicant. The microglial proinflammatory actin-remodeling factor, WAVE2, along with the inflammatory transcription factor, nuclear factor kappa B were also elevated within the brain. Remarkably, the stress hormone, corticosterone, was still significantly elevated 1 month after paraquat, whereas the inflammasome factor, caspase-1, and antigen presentation factor, MFG-E8, both displayed delayed rises after the 6-month time. Using high-resolution magnetic resonance imaging, we detected no striatal changes but modest hemispheric differences in the SNc and time-dependent volumetric enlargement of the ventricles in paraquat-treated mice. These data suggest that paraquat induces long-term nigrostriatal pathology (possibly asymmetric) and inflammatory changes and stress and trophic/apoptotic effects that appear to either increase with the passage of time or are evident for at least 1 month. In brief, paraquat may be a useful nonspecific means to model widespread stress and inflammatory changes related to PD or age-related disease in general, but not the progressive nature of such diseases.

Neuromodulation of the subthalamic nucleus in Parkinson\u2019s disease: the effect of fiber tract stimulation on tremor control

BackgroundTherapeutic effects of deep brain stimulation (DBS) of the subthalamic nucleus (STN) in Parkinson’s disease (PD) may in parts be attributed to the stimulation of white matter near the targeted structure. The dentato-rubro-thalamic (DRT) tract supposed to improve tremor control in patients with essential tremor could be one candidate structure. The aim of this study was to investigate the effect of stimulation proximity to the DRT on tremor control in PD patients treated with STN-DBS.MethodsFor this retrospective analysis, we included 36 consecutive patients (median age 65.5 years) treated with STN-DBS for disabling motor symptoms including tremor. Stereotactic implantation of DBS electrodes into the motor area of the STN was performed using direct MRI-based targeting and intraoperative microelectrode recording. Tremor severity was assessed preoperatively and at regular intervals postoperatively (Unified Parkinson’s Disease Rating Scale III). The DRT was visualized in 60 hemispheres after probabilistic fiber tracking (3-T MRI). The position of active electrode contacts was verified on intraoperative stereotactic X-rays and postoperative CT images after co-registration with 3D treatment planning MRI/CT images. We determined the shortest distance of active contacts to the ipsilateral DRT tracts on perpendicular view slices and correlated this value with tremor change percentage.ResultsTwelve patients had unilateral tremor only, and accordingly, 12 hemispheres were excluded from further imaging analysis. The remaining 60 hemispheres were associated with contralateral resting tremor. Active brain electrode contacts leading to resting tremor improvement (46 hemispheres) had a significantly shorter distance to the DRT (1.6 mm (0.9–2.1) [median (25th–75th percentiles)]) compared with contacts of non-responders (14 hemispheres, distance: 2.8 mm (2–4.6), p < 0.001).ConclusionThis retrospective analysis suggests that in STN-DBS, better tremor control in PD patients correlates with the distance of active electrode contacts to the DRT. Tractography may optimize both individually DBS targeting and postoperative adjustment of stimulation parameters.

Polymyoclonus aggravated by neck flexion as the isolated presenting symptom of Hirayama disease: case report

BackgroundWe report a rare case of an 18-year-old male with unilateral hand tremor who was finally diagnosed with Hirayama disease (HD).Case presentationAn 18-year-old male presented with unilateral polymyoclonus that aggravated with neck flexion. The patient did not complain of muscle weakness or muscle atrophy. The needle electromyography showed giant motor unit potentials in right cervical 7 and 8 innervated muscles. The cervical magnetic resonance imaging on supine and flexion state showed prominent forward effacement of posterior dural sac that was compatible with HD.ConclusionsHD usually presents with unilateral distal hand weakness, muscle atrophy and tremor. Although it is a benign and self-limiting disease, early diagnosis may lead to less clinical deterioration. Moreover, electromyography should be completed in the differentiation of young male patients who present with polymyoclonus without hand weakness or atrophy.

Radiofrequency Ablation of Prelemniscal Radiations for the Treatment of Non-Parkinsonian Tremor

Objective: Previous reports proposed prelemniscal radiations (Raprl) as a target to treat motor symptoms of Parkinson’s disease, and this was found particularly effective to control rest and postural tremor. However, tremor of other etiologies has been seldom treated with deep brain stimulation or ablation in this target. We present a series of such cases successfully treated by Raprl radiofrequency (RF) lesions. Material and Methods: Six patients with predominant unilateral tremor on the right arm: 4 intention, 1 cerebellar and 1 rubral tremor, incapacitating in spite of at least 2 regimes of medical treatment at maximal tolerated doses, were operated under local anesthesia. RF lesions were performed in Raprl contralateral to most prominent symptoms. Patients had monthly evaluation of tremor severity through the Fahn-Tolosa-Marin Tremor Rating Scale and disability through the Tremor Disability Scale along a 1-year follow-up. Results: In 4/6 patients tremor was stopped by the simple insertion of an RF electrode in Raprl; in the other 2 cases, stimulation through the RF electrode at 100 Hz, with 100 µs and 1.0–1.5 V, stopped the tremor without side effects. Tremor disappeared in all cases immediately after surgery and partially reappeared in 2 cases with an amplitude about 20% of the preoperative condition. RF lesions in postoperative MRI ranked from 1.8 to 2.6 mm in diameter. Conclusions: RF lesioning in Raprl is a simple, highly effective, inexpensive way to treat tremor of different etiologies.

Symptomatic hemiparkinsonism due to extensive middle and posterior fossa arachnoid cyst: case report

IntroductionIntracranial neoplasms are an uncommon cause of symptomatic parkinsonism. We here report a patient with an extensive middle and posterior fossa arachnoid cyst presenting with parkinsonism that was treated by neurosurgical intervention.MethodsRetrospective chart review and clinical examination of the patient.Case reportThis 55-year-old male patient with hemiparkinsonism and recurrent bouts of headaches was first diagnosed in 1988. CT scans revealed multiple cystic lesions compressing brainstem and basal ganglia, which were partially resected. Subsequently, the patient was free of complaints for 20 years. In 2009 the patient presented once more with severe unilateral tremor and thalamic pain affecting the right arm. Despite symptomatic treatment with L-Dopa and pramipexole symptoms worsened over time. In 2014 there was further progression with increasing hemiparkinsonism, hemidystonia, unilateral thalamic pain and pyramidal signs. Repeat CT scanning revealed a progression of the cysts as well as secondary hydrocephalus. Following repeat decompression of the brainstem and fenestration of all cystic membranes parkinsonism improved with a MDS- UPDRS III score reduction from 39 to 21. Histology revealed arachnoid cystic material.ConclusionWe report on a rare case of recurrent symptomatic hemiparkinsonism resulting from arachnoid cysts.

Diagnostic value of tremor analysis in identifying the early Parkinson's syndrome

OBJECTIVE To investigate the diagnostic value of tremor analysis in early stages of Parkinson's syndrome, when the clinical symptoms of tremor onset are not unilaterally often able for a definite diagnosis to be made. METHODS We included 70 patients with unilateral tremor, under 45 years old and disease duration within 3 years enrolled in Peking University Third Hospital from January, 2014 to December 2015. We recorded clinical features, unified Parkinson's disease rating scale (UPDRS)-III, non-motor symptom (NMS) scores. Tremor analysis and transcranial sonography were performed for all the patients. Based on the results of tremor analysis, we arbitrarily divided the patients into 3 groups: (1) The patients with classical Parkinson's syndrome manifestations on one side (25 cases); (2) The patients with classical Parkinson's syndrome manifestations on both sides (15 cases); (3) The patients with no classical Parkinson's syndrome manifestations (30 cases). The patients were monitored every 6 months to 3 years, until the final diagnosis was made. RESULTS There was no significant difference in age, gender distribution, Hamilton depression scale (HAMD) scores and H-Y scores among the three groups (P>0.05). The average UPDRS-III motor scores of the three groups were significantly different (P=0.001), with 18.23, 18.79 and 14.67, respectively. The average scores of NMS were significantly different, with 15.81, 17.07 and 9.90, respectively (P<0.001). The positive rates of transcranial sonography (TCS) in the three groups were 48.0%, 60.0% and 26.67%, with no significant difference (P=0.702). After three years of follow-up, 35 patients (50%) met the diagnostic criteria of Parkinson's disease of International Parkinson and Movement Disorder Society (MDS) in 2015, 19 patients (27.1%) met the criteria of idiopathic tremor, and 7 patients (10%) met the criteria of Parkinson's plus syndrome. The sensitivity and specificity of tremor analysis for early diagnosis of Parkinson's disease were 82.8% and 68.6%, respectively. Compared with TCS, the sensitivity and specificity of TCS were 65.7% and 62.9%. There were consistency (Kappa=0.568) and significant difference (P=0.031) between the two methods. CONCLUSION Tremor analysis is sensitive and a superior way in identifying early Parkinson's syndrome patients with tremor dominant manifestation. The combination of non-motor symptoms and transcranial sonography are also needed at diagnosis.

Unilateral Pseudo-Orthostatic Tremor Provoked by a Remote Limb Movement in Parkinson's Disease.

Unilateral Pseudo-Orthostatic Tremor Provoked by a Remote Limb Movement in Parkinson's Disease.

Manganism without Parkinsonism: Isolated Unilateral Upper Limb Tremor in a Welder.

Manganism without Parkinsonism: Isolated Unilateral Upper Limb Tremor in a Welder.