1. A 76 year old female with sudden cessation of Parkinsonian tremor
Teaching NeuroImages
Neurology
Resident and Fellow Section

2. Vignette
76-yo female w/ right-sided tremor-dominant idiopathic Parkinson’s disease admitted due to sudden-onset
right leg palsy
hemihypesthesia
slurred speech
cessation of resting tremor
Horn et al. 2016

3. Imaging
T2-weighted MRI (A-B). C) DWI MRI of the left thalamus with isovolume at intensity value of 280 used to delineate the stroke lesion (fig. 2). D) atlas structures locate the lesion to VLp/VP nuclei (Jones nomenclature) which correspond to the VIM in Walker nomenclature. For abbreviations see1.
Horn et al. 2016

4. Imaging
Visualization of stroke lesion, nuclei defined by the Morel atlas1 and two pathways of the dentatorubrothalamic tract2. The nd-DRTT passes through the lesion. The enlarged picture shows the typical location of a VIM-DBS electrode as placed in patients predominantly suffering from tremor, falling inside the stroke lesion.
Horn et al. 2016

5. Stroke mimicking thalamotomy – cessation of tremor following ventrolateral thalamic ischemia
Spatial analysis of lesion performed with Lead-DBS software ( located lesion to left ventrolateral and ventroposterior nuclei (Jones nomenclature)
This corresponds to the ventrointermediate nucleus (VIM; Walker nomenclature)
The VIM is the typical deep brain stimulation target for tremor
Analysis further showed that the (non-decussating) dentatothalamic tract, which plays a prominent role in tremor pathophysiology, passes through the lesion
References
1) Krauth, A., Blanc, R., Poveda, A., Jeanmonod, D., Morel, A., & Székely, G. (2010). A mean three-dimensional atlas of the human thalamus: Generation from multiple histological data, 49(3), 2053–2062.
2) Meola, A., Comert, A., Yeh, F.-C., Sivakanthan, S., & Fernandez-Miranda, J. C. (2015). The nondecussating pathway of the dentatorubrothalamic tract in humans: human connectome-based tractographic study and microdissection validation. Journal of Neurosurgery, 1-7.
Horn et al. 2016