Successful treatment of tremor by endoscopic third ventriculostomy in an adolescent with obstructive hydrocephalus due to tectal glioma: case report

Treatment-responsive Holmes tremor in a child with low-pressure hydrocephalus: video case report and systematic review of the literature

OBJECTIVE

Holmes tremor (HT) is a rare and debilitating movement disorder comprising both rest and action tremor, and it is known for its resistance to treatment. Its most common causes include ischemic or hemorrhagic insults and trauma. Mechanistically, the combined rest and action tremor is thought to require a double lesion of both the dopaminergic nigrostriatal system and the dentatorubrothalamic pathways, often near the midbrain where both pathways converge. The aim of this study was to characterize HT as a presenting sign in cases of hydrocephalus and to discuss potential pathomechanisms, clinical presentations, and treatment options.

METHODS

MEDLINE and Web of Science were searched for cases of HT with hydrocephalus from database inception to August 2021, and these were compiled along with the authors' own unique case of treatment-responsive HT in a child with low-pressure obstructive hydrocephalus secondary to a tectal tumor. Patient characteristics, presenting signs/symptoms, potential precipitating factors, interventions, and patient outcomes were recorded.

RESULTS

Nine patients were identified including the authors' video case report. All patients had a triventriculomegaly pattern with at least a component of obstructive hydrocephalus, and 4 patients were identified as having low-pressure hydrocephalus. Parinaud's syndrome and bradykinesia were the most commonly associated signs. Levodopa and CSF diversion were the most commonly used and effective treatments for HT in this population. This review was not registered and did not receive any funding.

CONCLUSIONS

HT is a poorly understood and probably underrecognized presentation of hydrocephalus that is difficult to treat, limiting the strength of the evidence in this review. Treatment options include CSF diversion, antiparkinsonian agents, antiepileptic agents, deep brain stimulation, and MR-guided focused ultrasound, and aim toward the nigrostriatal and dentatorubrothalamic pathways hypothesized to be involved in its pathophysiology.

Paroxysmal Lower Limb Tremor as a Rare Presentation of Colloid Cyst of the Third Ventricle: A Case Report and Literature Review

Objective:

Colloid cysts of the third ventricle are benign intracranial tumors. They are most commonly presented with signs of intracranial hypertension due to obstructive hydrocephalus, including headache, nausea/vomiting and vision disturbances, whereas extrapyramidal symptoms such as tremor are very rare. Sudden death, due to abruptly developed hydrocephalus, can be also observed. Although paroxysmal symptomatology attributed to the intermittent obstruction of the foramen of Monro is considered the “classical” clinical presentation, it is rather the exception in clinical practice.

Case Report:

A 42-year-old woman with no medical history was admitted to the neurology department as suffering from a potential demyelinating disease due to episodes of paroxysmal tremor of her right lower limb and persistent mild gait instability, which presented 15 days prior to her arrival. She also complained of episodes of partially position-dependent bilateral headache over the last 10 years, as well as episodes of vertigo over the last 4 years. On arrival, her gait was shuffling and mildly wide-based and an intermittent tremor of her right lower limb was observed in supine and sitting positions, but not in a prone position. Brain magnetic resonance imaging (MRI) demonstrated a round cystic lesion of the third ventricle, accompanied by hydrocephalus with enlargement of lateral ventricles. MRI findings were highly indicative of a colloid cyst. The patient underwent resection of the mass and the tremor resolved after surgery.

Conclusion:

Given the greatly heterogeneous clinical presentation of colloid cysts, our case highlights the significance of the prompt diagnosis of this rare but potentially fatal cause of paroxysmal limb tremor.

Bobble-head doll syndrome in an 80-year-old man, associated with a giant arachnoid cyst of the lamina quadrigemina, treated with endoscopic ventriculocystocisternotomy and cystoperitoneal shunt

Bobble-head doll syndrome (BHDS) is a rare entity, characterized by antero-posterior head bobbing, which is of the type "yes-yes." Less frequently, having a head movement of the type "no-no" is described. We report an unusual case of an 80-year-old man with a cystic mass of the lamina quadrigemina, extending to the posterior fossa. We conclude that ventriculocystocisternotomy associated with a cystoperitoneal shunt is an effective treatment for a symptomatic giant arachnoid cyst in the lamina quadrigemina.

Endoscope-Assisted Microsurgical Removal of an Intraventricular Ependymal Cyst That Manifested with Tremor

BACKGROUND

Intraventricular ependymal cysts (ECs) are rare, histologically benign neuroepithelial cysts. Most of these cysts are clinically silent and discovered incidentally. Rarely, they become symptomatic, leading to obstruction of the cerebrospinal fluid circulation. ECs located inside the ventricles may manifest with signs of increased intracranial pressure.

CASE DESCRIPTION

A 32-year-old woman presented with a 6-year history of tremor affecting her left hand. In the last month, she had been experiencing headache as well, and the tremor of the left hand was affecting her quality of life. The patient demonstrated a fine resting and intention tremor of the left hand and a voice tremor. Magnetic resonance imaging revealed a large cystic, nonenhancing lesion within the right lateral ventricle. The fluid within the cyst was isointense to cerebrospinal fluid on all sequences. Because of the rapid progression of her symptoms and no response to medication, surgical decompression of the cyst was considered. The cyst was removed by an endoscope-assisted microsurgical technique. Her postoperative course was uneventful. A marked reduction in her tremor was noted in the immediate postoperative period. Histopathologic diagnosis was of an EC. During the follow-up period, the patient's tremor, although still present, had improved dramatically. At 6 months postoperatively, she could hold a drinking glass without spilling.

CONCLUSIONS

This is a unique case of an intraventricular EC that manifested with tremor, which improved by endoscope-assisted microsurgical removal of the cyst. This case also supports the important role of endoscopic surgery in the treatment of intraventricular cystic lesions.