SECTION II: ESSENTIAL TREMOR
4. TREMOR AFTER CEREBRAL INFARCT
4.1. Incidence, Characteristics, and Pathophysiology of Tremor After Stroke
Stroke is the second leading cause of death in the world, and affects 700,000 people in the United States annually (81). Movement disorders are a rare complication of acute stroke affecting only 29 of 2500 patients experiencing a first stroke (82). Only 9 of these 29 patients had tremors, asterixis, or limb-shaking disorders, and all but three of 29 experienced resolution of the dystonic symptoms within 6 months (82).
Thalamic infarction can cause disruption of the dentatorubrothalamic tract, resulting in Holmes’ tremor in children (83) and adults (84–87). It is more likely to occur after hemorrhagic strokes resulting in dense hemiplegia and sensory loss, and may be part of a more complex movement disorder or delayed-onset cerebellar syndrome occurring at a latency of 3 weeks to 2 years after ischemic insult (88,89).
Infarct in the anterior cerebral artery distribution can also cause supplementary motor area lesions resulting in a resting tremor similar to that of idiopathic PD. Such tremors are levodopa-unresponsive, and resolve spontaneously (90). There are also case reports of anterior thalamic stroke resulting in hand tremor (91), and focal tremor following striatal infarct (92).
4.2. Nonsurgical Treatment of Post-Stroke Tremor
After thalamic stroke, somatotopic reorganization can occur as evidenced by nuclear mapping during stimulation for lead placement (93). Such reorgani-zation may be part of the mechanism underlying spontaneous tremor resolu-tion. Additionally, physical therapy, in conjunction with electromyographic biofeedback, has been shown to be of benefit for post-thalamic stroke move-ment disorders and their related pain (94). Haloperidol and dopamine therapy have been used to treat post-stroke tremor in a few patients (95).
4.3. Surgical Treatment of Post-Stroke Tremor
The rarity of stroke-related tremor, and likelihood of symptoms resolving spontaneously, contribute to an overall low number of patients with intract-able post-stroke tremor. Gamma-knife thalamotomy has been performed in at least one post-stroke patient for tremor (78). DBS for post-stroke tremor
Tremor: Patient Selection and Surgical Results 129
with cathodal Vop and anodal VIM revealed that while tremor improved in all six patients, two required dual-lead stimulation and one required a stimulation intensity high enough to provoke unpleasant parasthesias (96).
Other studies suggest that while tremor may be improved by Vop or VIM DBS, movement disorder related pain after stroke may require motor cortex stimulation (97).
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8
Dystonia: Classification, Etiology, and Therapeutic Options
Galit Kleiner-Fisman
Parkinson’s Disease Research Education and Clinical Center (PADRECC), Philadelphia Veterans Administration Hospital, University of Pennsylvania,
Philadelphia, Pennsylvania, U.S.A.
Santiago Figuereo
Department of Neurosurgery, Philadelphia Veterans Administration Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.
1. INTRODUCTION
Dystonia is characterized by sustained involuntary postures and excessive movements of muscles. The movements may be fixed or mobile and often are increased with voluntary action. In some cases dystonia, especially if axial, is severely disabling. Severe dystonia may compromise individuals’ self-care abilities and may be life-threatening. The term ‘‘dystonia’’ can be used to describe a symptom, a sign, a diagnosis, or a syndrome.
This chapter will provide an approach to the classification of dystonia, discuss pathophysiologic and etiological considerations, and outline the best medical therapy for dystonia and its limitations. We will then review sur-gical indications, anatomical targets, and sursur-gical techniques, followed by a summary of available results of deep brain stimulation (DBS) and ablative surgeries to date. This chapter will exclude cervical dystonia (CD), which is addressed separately in chapter 9.