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.
Arm ; Brain ; Brain Stem ; Brain Stem Hemorrhage, Traumatic ; Clonazepam ; Facial Paralysis ; Female ; Head ; Hemorrhage ; Humans ; Levodopa ; Magnetic Resonance Imaging ; Mesencephalon ; Muscles ; Paresis ; Posture ; Propranolol ; Tremor ; Upper Extremity

OBJECTIVES: To determine the prevalence, risk factors, etiology, location, and outcome of non-traumatic intracerebral hemorrhage (ICH) in young Filipino patients. To identify factors associated with poor outcome and mortality
METHODOLOGY: Review of charts of patients age /- 45 years admitted for acute non-traumatic intracerebral hemorrhage with neuroimaging evidence of symptomatic ICH was done. Data regarding risk factors, location, etiology and outcome were analyzed using SPSS 9.01 for Windows and Epi 6 for univariate and multiple regression analysis
RESULTS: Seventy subjects were included. 66 percent were males and 34 percent were females. The mean age of the subjects was 37 years old. Prevalence of non-traumatic ICH among stroke in young adults is 17 percent. The most frequent risk factors were hypertension, smoking, alcohol use, and family history of CVD. The common locations in order were basal ganglia/internal capsule (44 percent), thalamus (22 percent), lobar, and brainstem. The common causes of ICH were hypertension (46 percent), vascular malformations (16 percent) and hematologic/coagulation disorders (13 percent). Arteriography was done in 33 percent of cases. Overall in-hospital mortality rate was 8.5 percent in the acute stage of ICH. Factors independently associated with poor outcome and mortality on multivariate regression analysis were posterior circulation (p=0.005), presence of intraventricular extension (p=0.002), ICH volume 30 cc (p= 0.011), and smoking history (p=0.021)
CONCLUSION: Non-traumatic intracerebral hemorrhage in young Filipino adults has a heterogenous etiology. Non-traumatic ICH occurred in 17 percent of young stroke patients. Posterior circulation involvement, presence of intraventricular extension, ICH volume of 30cc and smoking history were significant factors associated with poor outcome.

Human ; Male ; Female ; Adult ; Adolescent ; Smoking ; Cerebral Hemorrhage ; Stroke ; Cerebral Hemorrhage, Traumatic ; Hypertension ; Brain Stem ; Vascular Malformations

Traumatic brainstem hemorrhage after blunt head injury is an uncommon event. The most frequent site of hemorrhage is the midline rostral brainstem. The prognosis of these patients is poor because of its critical location. We experienced a case of traumatic brainstem hemorrhage. A 41-year-old male was presented with drowsy mentality and right hemiparesis after blunt head injury. Plain skull radiographs and brain computerized tomography scans revealed a depressed skull fracture, epidural hematoma, and hemorrhagic contusion in the right parieto-occipital region. But, these findings did not explain the right hemiparesis. T2-weighted magnetic resonance (MR) image of the cervical spine demonstrated a focal hyperintense lesion in the left pontomedullary junction. Brain diffusion-weighted and FLAIR MR images showed a focal hyperintensity in the ventral pontomedullary lesion and it was more prominent in the left side. His mentality and weakness were progressively improved with conservative treatment. We should keep in mind the possibility of brainstem hemorrhage if supratentorial lesions or spinal cord lesions that caused neurological deficits in the head injured patients are unexplainable.
Adult ; Brain ; Brain Stem ; Brain Stem Hemorrhage, Traumatic ; Contusions ; Craniocerebral Trauma ; Head ; Head Injuries, Closed ; Hematoma ; Hemorrhage ; Humans ; Magnetic Resonance Spectroscopy ; Male ; Paresis ; Prognosis ; Skull ; Skull Fracture, Depressed ; Spinal Cord ; Spine

Cranial nerve palsies are relatively common after trauma, but trochlear nerve palsy is relatively uncommon. Although traumatic trochlear nerve palsy is easy to diagnose clinically because of extraocular movement disturbances, radiologic evaluations of this condition are difficult to perform because of the nerve's small size. Here, we report the case of a patient with delayed traumatic trochlear nerve palsy associated with a traumatic subarachnoid hemorrhage (SAH) and the related radiological findings, as obtained with high-resolution three-dimensional (3D) magnetic resonance imaging (MRI). A 63-year-old woman was brought to the emergency room after a minor head trauma. Neurologic examinations did not reveal any focal neurologic deficits. Brain computed tomography showed a traumatic SAH at the left ambient cistern. The patient complained of vertical diplopia at 3 days post-trauma. Ophthalmologic evaluations revealed trochlear nerve palsy on the left side. High-resolution 3D MRI, performed 20 days post-trauma, revealed continuity of the trochlear nerve and its abutted course by the posterior cerebral artery branch at the brain stem. Chemical irritation due to the SAH and the abutting nerve course were considered causative factors. The trochlear nerve palsy completely resolved during follow-up. This case shows the usefulness of high-resolution 3D MRI for evaluating trochlear nerve palsy.
Brain ; Brain Stem ; Cranial Nerve Diseases ; Craniocerebral Trauma ; Diplopia ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Humans ; Imaging, Three-Dimensional ; Magnetic Resonance Imaging* ; Middle Aged ; Neurologic Examination ; Neurologic Manifestations ; Posterior Cerebral Artery ; Subarachnoid Hemorrhage, Traumatic* ; Trochlear Nerve Diseases* ; Trochlear Nerve*