Figure 1
Axial brain magnetic resonance imaging (MRI) T1 (A), coronal T2 (B), axial susceptibility-weighted imaging (SWI) (C) and axial fluid-attenuated inversion recovery (FLAIR) (D) sequences at the time of the patient’s second stroke, showing acute intracerebral hemorrhage in the left thalamus (white arrow), accompanied by smaller foci of microhemorrhages in left globus pallidus and right inferior putamen. Multiple signal changes in the external capsule, periventricular areas, and centrum semiovale are also observed.
Video 1
Pre-DBS evaluation demonstrates dystonic posturing of the right upper limb with predominant distal limb involvement, with superimposed mild rest tremor. Tremor emerges during posture and increases with action and intention, accompanied by marked dysmetria of the right upper limb. Post-DBS evaluation shows a significant reduction of tremor in the DBS-ON state, particularly during posture, with no appreciable improvement in dysmetria. A longer version of the examination, including gait assessment, is available as Supplementary Video online.
Figure 2
Axial brain MRIs performed at ages 46 (A), 47 (B), and 49 (C) years demonstrating the evolution of neuroimaging findings over time, including hemorrhagic subcortical lesions, especially in the left thalamus, and subcortical white matter lesions (A and B, axial FLAIR sequences and C, axial SWI and FLAIR sequences).
Figure 3
Electromyography and accelerometry recording from the right upper limb prior to deep brain stimulation surgery. Each figure depicts a power spectrum, with the x-axis displaying tremor frequency, and the y-axis depicting tremor power, which is the standard measure of tremor amplitude when quantified using accelerometers. At rest during distraction maneuvers (serial seven subtraction), there is a 2.5 Hz right hand tremor detected by the accelerometer (A). During posture with the arm extended, there is a large amplitude 2.5 Hz tremor with a wide peak involving the proximal arm muscles (biceps and triceps) (B). With the addition of 1.5 lbs. to the right hand, the postural tremor frequency remains unchanged (2.5 Hz) (C). There is also a 2.5 Hz right hand kinetic tremor (D). This 2.5 Hz tremor primarily involves the proximal muscles, is present at rest and during posture and kinetic maneuvers, and does not change with weight-loading, consistent with Holmes tremor. Abbreviations: Acc: accelerometer, BCP: biceps EDC: extensor digitorum communis; FCU: flexor carpi ulnaris; TCP: triceps.