Holmes tremor is a rare movement phenomenon, with atypical low-frequency tremor at rest and when changing postures, often related to brainstem pathology. We report a 70-year-old female patient who was presented with dystonic head and upper limb tremor after brainstem hemorrhage. The patient had experienced a sudden onset of left hemiparesis and right facial paralysis. Brain magnetic resonance imaging showed an acute hemorrhage from the brachium pontis through the dorsal midbrain on the right side. Several months later, the patient developed resting tremor of the head and left arm, which was exacerbated by a sitting posture and intentional movement. The tremor showed a regular low-frequency (1-2 Hz) for the bilateral sternocleidomastoid and cervical paraspinal muscles at rest. The patient's symptoms did not respond to propranolol or clonazepam, but gradually improved with levodopa administration. Although various remedies were attempted, overall, the results were poor. We suggest that levodopa might be a useful remedy for Holmes tremor. The curative or relieving effect of the dopaminergic agent in Holmes tremor needs more research.
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A 62-year-old female patient diagnosed with left brain stem stroke 2 months ago was admitted to our clinic for rehabilitation. She had no generalized spasticity on both extremities, but could open her mouth only approximately 2 mm between her upper and lower teeth due to severe trismus. On needle electromyography, the left masseter muscle showed paradoxically increased muscle activity during mouth opening. We injected 50 units of type A botulinum toxin (Botox®) into the left masseter muscle, and 20 units into the left temporalis muscle with guidance of ultrasonography. The interincisal distance increased to 8 mm on the 3rd day after injection, and 9 mm on the 4th day. One month later, the interincisal distance increased to 14 mm. The increased interincisal distance was maintained for 13 months after injection, and the quality of hygienic care and compliance of oral stimulation therapy also improved.
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A 53-year-old man abruptly developed headache and unconsciousness. Brain computed tomography (CT) and CT angiography showed subarachnoid hemorrhage, intraventricular hemorrhage, and multiple tortuous vascular structures on the brain stem and upper cervical spinal cord. Four-vessel angiography displayed intradural ventral arteriovenous fistula, supplied by the left vertebral and occipital arteries. Drainage was via both sigmoid sinus and cervical venous plexus. He had been treated with transarterial coil embolization of the left vertebral artery. Subsequently, he suffered from left hemiplegia and cognitive problem. Brain magnetic resonance (MR) and MR angiography performed 4 weeks later revealed multiple infarctions on the left cerebellum, left upper cervical spinal cord, and both medial thalamus, as well as occlusion of the left vertebral artery with reduction in varix size. After rehabilitative management, his muscle strength and cognitive function improved. We report a very rare case of dural arteriovenous fistula on the brain stem and upper cervical spinal cord.
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Objective: This study was designed to investigate the effect of different sites of recording electrodes on auditory evoked potentials (AEPs) in healthy adults and to analyse these potentials properly.
Method: Eleven healthy adults, 7 males and 4 females, without any history of disease or conditions causing hearing difficulties were selected. AEPs were performed on these subjects with 4 different methods, i.e. different recording sites, Cz-Ai, Cz-Fpz, Ai-Ac, and Ai-Cs7. Auditory stimulation was given by rarefaction clicks of 75dB intensity and 11.1 Hz frequency, and responses were recorded with surface electrodes.
Results: The amplitudes of peak I and V were larger with vertical recordings, that is the vertex-auricle (Cz-Ai) or vertex-7th cervical spine (Cz-Cs7) recordings, compared to horizontal recordings of both auricle (Ai-Ac) or extracephalic electrodes. The largest amplitude ratio of peak V/I was with vertex-7th cervical spine (Cz-Cs7) recording.
Conclusion: Changes in AEPs with respect to the sites of recording and reference electrodes are thought to be due to the vector of brain stem auditory nuclei and pathways. It might be helpful to consider these changes in the evaluation of brain stem lesions.
Vestibulocollic reflex(VCR) which stabilizes head position in space is essential for an adequate motor performance, and maintenance of balance and posture. The purpose of this study was to measure the VCR in brain stem lesion patients and to evaluate the usefulness of the VCR study in the evaluation of brain stem lesions.
The VCR evoked by free fall of the head was measured by the electromyographic signal of the sternocleidomastoid muscles. Twenty normal and ten brain stem lesion subjects were studied by lying supine with the head cradled in a sling, and the VCR was evoked by an abrupt head drop while the sling was released. The electromyographic signal was recorded with surface electrodes from the sternocleidomastoid muscles.
In normal subjects, the initial small burst with an onset latency at 20.61⁑3.25 msec was obtained followed by the later larger burst of sternoceidomastoid electromyographic response. But in the subjects with a brain stem lesion, the initial latency was delayed to 46.10⁑10.65 msec and the waveform was smaller and dispersed than that of the normal subjects.
The VCR evoked by free fall of the head showed delayed latency and dispersed waveform in patients with a brain stem lesion. This method could be used for the evaluation of brain stem lesions.
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