Pearls & Oy-sters: A Case Report of Holmes Tremor Due to Nigrostriatal Dopamine Disruption That Responded to Dopamine Replacement Therapy

Abstract

Holmes tremor (HT), also known as midbrain, rubral, or cerebellar pathway outflow tremor, occurs due to disturbances of the cerebellothalamic pathway. This tremor is usually related to lesions in the midbrain peduncular region involving the superior cerebellar peduncle, red nucleus, and possibly the nigrostriatal circuitry. Common etiologies resulting in HT include tumor, ischemia, and demyelination. We report a case of progressive left sided HT in an otherwise healthy male with additional symptoms of parkinsonism, hypoesthesia, right oculomotor nerve palsy, cognitive dysfunction and hypersomnolence. Imaging investigations revealed a right sided thalamic and midbrain glioma. Dopamine transport imaging demonstrated significant dopaminergic denervation in the right caudate and putamen. The degree of striatal dopamine transporter deficiency was more severe than expected in a Parkinson’s disease patient. A trial of dopaminergic agent resulted in significant improvement of the tremor and associated symptoms. Interruption of the nigrostriatal pathway can occur in cases of HT due to midbrain peduncular lesion. The striatal dopaminergic function imaging may have a role in assessing pre-synaptic dopamine dysfunction and guiding treatment.

The Correlation of Sleep Disturbance and Location of Glioma Tumors: A Narrative Review

“…Diurnal drowsiness or hypersomnia is another condition that can be correlated with gliomas found in the posterior fossa, hypothalamus, and thalamus/midbrain [ 57 , 63 , 64 , 65 , 66 , 67 ]. Hypersomnia is characterized by excessive daytime sleepiness that can impact academic or work performance.…”