The rest of his examination was normal.Ī basic work up, including TSH and T4 levels, as well as a complete blood cell count and comprehensive metabolic panel were normal.Ī brain MRI, ordered as part of the pre-operative work up, revealed bilateral globus pallidus heterogenous hyperintense lesions in the T2 sequence, surrounded by a hypointense rim ( Fig. Motor power, tone and bulk, sensory examination, deep tendon reflexes, coordination and gait were normal. His examination was remarkable for a bilateral 3–10 cm amplitude high frequency postural and kinetic hand tremor, as well as a 1–3 cm amplitude head tremor. There was no family history of dystonia, parkinsonism or chorea.Īt the time of his visit, the patient was on primidone 50 mg three times a day, topiramate 50 mg daily and propranolol 10 mg three times a day, in addition to niacin-simvastatin 500–20 mg daily and lisinopril 5 mg daily. His father was killed in a car accident at age 29 and did not have any tremor at that time. His paternal grandmother, 3 siblings and 2 of his 4 children were diagnosed with essential tremor. Objective quantification of the exposure was impossible, but the patient reported multiple exposures per week and enough exposure every time so that the cockpit would be full of smoke and he could barely see through it. The patient denied history of encephalitis or meningitis, head trauma, current or past exposure to dopamine receptor blocking agents, heavy metals, insecticides, pesticides or carbon monoxide, but reported massive exposure to Agent Orange he was spraying when serving as a helicopter pilot during the Viet Nam war. At 68 years of age, 15 years after the onset of his symptoms, the patient presented to our movement disorder center to be evaluated for Deep Brain Simulation for refractory tremor. Because of poor tremor control and worsening of his tremor with age, topiramate then propranolol were successively added without satisfactory response.
He was diagnosed with essential tremor and started on primidone with some benefits initially. He was never exposed to tremorigenic drugs. He denied any motor slowness, stiffness, gait change, cognitive complaints, depression or anxiety. Impact of caffeine on his tremor was unclear, since he rarely drank. The tremor worsened with anxiety and seemed to improve with alcohol. A 53 year old left - handed veteran developed left hand action tremor that subsequently involved his right hand and his head, while sparing his voice and legs.
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