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Bolton TAW, Van De Ville D, Régis J, Witjas T, Girard N, Levivier M, Tuleasca C. Dynamic functional changes upon thalamotomy in essential tremor depend on baseline brain morphometry. Sci Rep 2024; 14:2605. [PMID: 38297028 PMCID: PMC10831051 DOI: 10.1038/s41598-024-52410-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 01/18/2024] [Indexed: 02/02/2024] Open
Abstract
Patients with drug-resistant essential tremor (ET) may undergo Gamma Knife stereotactic radiosurgical thalamotomy (SRS-T), where the ventro-intermediate nucleus of the thalamus (Vim) is lesioned by focused beams of gamma radiations to induce clinical improvement. Here, we studied SRS-T impacts on left Vim dynamic functional connectivity (dFC, n = 23 ET patients scanned before and 1 year after intervention), and on surface-based morphometric brain features (n = 34 patients, including those from dFC analysis). In matched healthy controls (HCs), three dFC states were extracted from resting-state functional MRI data. In ET patients, state 1 spatial stability increased upon SRS-T (F1,22 = 19.13, p = 0.004). More frequent expression of state 3 over state 1 before SRS-T correlated with greater clinical recovery in a way that depended on the MR signature volume (t6 = 4.6, p = 0.004). Lower pre-intervention spatial variability in state 3 expression also did (t6 = - 4.24, p = 0.005) and interacted with the presence of familial ET so that these patients improved less (t6 = 4.14, p = 0.006). ET morphometric profiles showed significantly lower similarity to HCs in 13 regions upon SRS-T (z ≤ - 3.66, p ≤ 0.022), and a joint analysis revealed that before thalamotomy, morphometric similarity and states 2/3 mean spatial similarity to HCs were anticorrelated, a relationship that disappeared upon SRS-T (z ≥ 4.39, p < 0.001). Our results show that left Vim functional dynamics directly relates to upper limb tremor lowering upon intervention, while morphometry instead has a supporting role in reshaping such dynamics.
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Affiliation(s)
- Thomas A W Bolton
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, 1011, Lausanne, Switzerland.
- Department of Radiology, Lausanne University Hospital and University of Lausanne (CHUV-UNIL), 1011, Lausanne, Switzerland.
| | - Dimitri Van De Ville
- Neuro-X Institute, Ecole Polytechnique Fédérale de Lausanne, 1202, Geneva, Switzerland
- Department of Radiology and Medical Informatics, University of Geneva, 1202, Geneva, Switzerland
| | - Jean Régis
- Stereotactic and Functional Neurosurgery Service and Gamma Knife Unit, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire de la Timone, 13005, Marseille, France
| | - Tatiana Witjas
- Neurology Department, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire de la Timone, 13005, Marseille, France
| | - Nadine Girard
- Department of Diagnostic and Interventional Neuroradiology, Centre de Résonance Magnétique Biologique et Médicale, Assistance Publique-Hôpitaux de Marseille, Centre Hospitalier Universitaire de la Timone, 13005, Marseille, France
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), 1015, Lausanne, Switzerland
| | - Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, 1011, Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), 1015, Lausanne, Switzerland
- Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne, 1015, Lausanne, Switzerland
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Erro R, Picillo M, Pellecchia MT, Barone P. Diagnosis Versus Classification of Essential Tremor: A Research Perspective. J Mov Disord 2023; 16:152-157. [PMID: 37258278 DOI: 10.14802/jmd.23020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/07/2023] [Indexed: 06/02/2023] Open
Affiliation(s)
- Roberto Erro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Baronissi, Italy
| | - Marina Picillo
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Baronissi, Italy
| | - Maria Teresa Pellecchia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Baronissi, Italy
| | - Paolo Barone
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Neuroscience Section, University of Salerno, Baronissi, Italy
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Huang YH, Lee MT, Hsueh HY, Knutson DE, Cook J, Mihovilovic MD, Sieghart W, Chiou LC. Cerebellar α6GABA A Receptors as a Therapeutic Target for Essential Tremor: Proof-of-Concept Study with Ethanol and Pyrazoloquinolinones. Neurotherapeutics 2023; 20:399-418. [PMID: 36696034 PMCID: PMC10121996 DOI: 10.1007/s13311-023-01342-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 01/26/2023] Open
Abstract
Ethanol has been shown to suppress essential tremor (ET) in patients at low-to-moderate doses, but its mechanism(s) of action remain unknown. One of the ET hypotheses attributes the ET tremorgenesis to the over-activated firing of inferior olivary neurons, causing synchronic rhythmic firings of cerebellar Purkinje cells. Purkinje cells, however, also receive excitatory inputs from granule cells where the α6 subunit-containing GABAA receptors (α6GABAARs) are abundantly expressed. Since ethanol is a positive allosteric modulator (PAM) of α6GABAARs, such action may mediate its anti-tremor effect. Employing the harmaline-induced ET model in male ICR mice, we evaluated the possible anti-tremor effects of ethanol and α6GABAAR-selective pyrazoloquinolinone PAMs. The burrowing activity, an indicator of well-being in rodents, was measured concurrently. Ethanol significantly and dose-dependently attenuated action tremor at non-sedative doses (0.4-2.4 g/kg, i.p.). Propranolol and α6GABAAR-selective pyrazoloquinolinones also significantly suppressed tremor activity. Neither ethanol nor propranolol, but only pyrazoloquinolinones, restored burrowing activity in harmaline-treated mice. Importantly, intra-cerebellar micro-injection of furosemide (an α6GABAAR antagonist) had a trend of blocking the effect of pyrazoloquinolinone Compound 6 or ethanol on harmaline-induced tremor. In addition, the anti-tremor effects of Compound 6 and ethanol were synergistic. These results suggest that low doses of ethanol and α6GABAAR-selective PAMs can attenuate action tremor, at least partially by modulating cerebellar α6GABAARs. Thus, α6GABAARs are potential therapeutic targets for ET, and α6GABAAR-selective PAMs may be a potential mono- or add-on therapy.
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Affiliation(s)
- Ya-Hsien Huang
- Department and Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, No. 1, Jen-Ai Rd., Section 1, Taipei, 10051, Taiwan
| | - Ming Tatt Lee
- Department and Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, No. 1, Jen-Ai Rd., Section 1, Taipei, 10051, Taiwan
- Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, 56000, Malaysia
| | - Han-Yun Hsueh
- Department and Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, No. 1, Jen-Ai Rd., Section 1, Taipei, 10051, Taiwan
| | - Daniel E Knutson
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, 53211, USA
| | - James Cook
- Department of Chemistry and Biochemistry, Milwaukee Institute for Drug Discovery, University of Wisconsin-Milwaukee, Milwaukee, WI, 53211, USA
| | | | - Werner Sieghart
- Center for Brain Research, Department of Molecular Neurosciences, Medical University Vienna, Vienna, 1090, Austria
| | - Lih-Chu Chiou
- Department and Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, No. 1, Jen-Ai Rd., Section 1, Taipei, 10051, Taiwan.
- Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, 10051, Taiwan.
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, 40402, Taiwan.
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Rekik A, Nasri A, Mrabet S, Gharbi A, Souissi A, Gargouri A, Kacem I, Gouider R. Non-motor features of essential tremor with midline distribution. Neurol Sci 2022; 43:5917-5925. [DOI: 10.1007/s10072-022-06262-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
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Pandey S. Is essential tremor a family of diseases or a syndrome? A syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 163:31-59. [PMID: 35750367 DOI: 10.1016/bs.irn.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In a consensus statement, a task force of the "International Parkinson and Movement Disorder Society" (IPMDS) has recently proposed a two axes classification for tremor: axis I (clinical manifestations) and axis II (etiology). In the axis, I, the clinical features of tremor in a given patient are specified in terms of medical history, tremor characteristics, associated signs, and laboratory tests for some tremors leading to the discovery of axis 2 etiologies. Based on axis I sign and symptoms a specific clinical syndrome is diagnosed which have been categorized as isolated tremor syndrome (a syndrome consisting only of tremor) and combined tremor syndrome (consisting of tremor and other systemic or neurological signs). The IPMDS task force defined essential tremor as an isolated tremor syndrome of bilateral upper limb action tremor of at least 3years duration with or without a tremor in other locations (e.g., head, voice or lower limbs) in absence of other neurological signs, such as dystonia, ataxia, or parkinsonism. Patients with neurological signs of uncertain significance (such as impaired tandem gait, questionable dystonic posturing, or memory impairment) are classified as essential tremor plus. In this paper, the author will make the argument that essential tremor is a syndrome with multiple causes.
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Affiliation(s)
- Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India.
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Moskalenko AN, Filatov AS, Fedotova EY, Konovalov RN, Illarioshkin SN. Visual analysis of nigrosome-1 in the differential diagnosis of Parkinson's disease and essential tremor. BULLETIN OF RUSSIAN STATE MEDICAL UNIVERSITY 2022. [DOI: 10.24075/brsmu.2022.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Differentiation between Parkinson’s disease, especially in its early stages, and essential tremor, which is a phenotypically similar movement disorder, still remains an unsolved challenge for neurology. The aim of this study was to assess the diagnostic significance of nigrosome imaging (nigrosomes are dopaminergic neuron clusters in the substantia nigra of the midbrain) using 3T high-resolution SW-MRI. The study was conducted in 20 patients with Parkinson’s disease and 10 patients with essential tremor. Visual analysis of the acquired nigrosome-1 images was performed using a 4-point ordinal rating scale. Differences in sex, age and duration of the disease were calculated using the Fisher exact test and the Mann–Whitney U test. The diagnostic value of the method was assessed using Pearson’s chisquared test. Nigrosome-1 was bilaterally or unilaterally absent in 70% of parkinsonian patients. Less specific changes to the substantia nigra (SN) were observed in two more parkinsonian patients (10%), whose nigrosome-1 appeared reduced in size. By contrast, nigrosome-1 was bilaterally intact in all patients (100%) with essential tremor (p < 0.001). Our preliminary findings demonstrate the high potential of noninvasive nigrosome-1 imaging in the differential diagnosis of Parkinson’s disease and essential tremor.
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Affiliation(s)
| | - AS Filatov
- Research Center of Neurology, Moscow, Russia
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Vetterick C, Lyons KE, Matthews LG, Pendal R, Ravina B. The Hidden Burden of Disease and Treatment Experiences of Patients with Essential Tremor: A Retrospective Claims Data Analysis. Adv Ther 2022; 39:5546-5567. [PMID: 36239902 PMCID: PMC9618517 DOI: 10.1007/s12325-022-02318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/06/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Essential tremor (ET) affects approximately 7 million people in the USA, yet public recognition of the disease and its impact remain low. METHODS A retrospective observational study examined US claims data from 2015 to 2019 using the Compile database. ET diagnoses were captured using longitudinal data from 2015 to 2019 and for the year 2019, with diagnosis estimates extrapolated to the general US population. Confirmed ET was identified by an ET diagnosis code with at least two relevant prescriptions or by two diagnosis codes for ET and unspecified tremor at least 90 days apart. Comorbidity and treatment use data were extracted, and medication compliance and 2-year treatment persistence were assessed as measures of treatment adherence. RESULTS A total of 1,336,183 patients with ET diagnoses codes were identified from 2015 through 2019, corresponding to 2,226,971 projected US diagnoses. In 2019, 128,263 patients had a confirmed ET diagnosis, corresponding to 213,772 projected US confirmed diagnoses. Of these, 96% had at least one comorbidity, and 64% received at least one pharmacologic treatment. Propranolol (24%) and primidone (20%) comprised the most common ET prescriptions. Two-year medication discontinuation rates were approximately 40%. CONCLUSION Our findings revealed that 1 million people were diagnosed and sought treatment for ET in the USA from 2015 to 2019. Projected population estimates of approximately 2 million people diagnosed suggest a further 1 million remain untreated. Our findings highlight the complexity of patient care in ET, complicated by delayed diagnoses, multiple comorbidities, and lack of effective and tolerable therapies that can mitigate treatment adherence limitations.
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Affiliation(s)
- Christine Vetterick
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA
| | - Kelly E Lyons
- University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Lillian G Matthews
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA
| | - Robert Pendal
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA
| | - Bernard Ravina
- Praxis Precision Medicines, 99 High Street, 30th Floor, Boston, MA, 02110, USA.
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Fra̧czek TM, Ferleger BI, Brown TE, Thompson MC, Haddock AJ, Houston BC, Ojemann JG, Ko AL, Herron JA, Chizeck HJ. Closing the Loop With Cortical Sensing: The Development of Adaptive Deep Brain Stimulation for Essential Tremor Using the Activa PC+S. Front Neurosci 2021; 15:749705. [PMID: 34955714 PMCID: PMC8695120 DOI: 10.3389/fnins.2021.749705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Deep Brain Stimulation (DBS) is an important tool in the treatment of pharmacologically resistant neurological movement disorders such as essential tremor (ET) and Parkinson's disease (PD). However, the open-loop design of current systems may be holding back the true potential of invasive neuromodulation. In the last decade we have seen an explosion of activity in the use of feedback to "close the loop" on neuromodulation in the form of adaptive DBS (aDBS) systems that can respond to the patient's therapeutic needs. In this paper we summarize the accomplishments of a 5-year study at the University of Washington in the use of neural feedback from an electrocorticography strip placed over the sensorimotor cortex. We document our progress from an initial proof of hardware all the way to a fully implanted adaptive stimulation system that leverages machine-learning approaches to simplify the programming process. In certain cases, our systems out-performed current open-loop approaches in both power consumption and symptom suppression. Throughout this effort, we collaborated with neuroethicists to capture patient experiences and take them into account whilst developing ethical aDBS approaches. Based on our results we identify several key areas for future work. "Graded" aDBS will allow the system to smoothly tune the stimulation level to symptom severity, and frequent automatic calibration of the algorithm will allow aDBS to adapt to the time-varying dynamics of the disease without additional input from a clinician. Additionally, robust computational models of the pathophysiology of ET will allow stimulation to be optimized to the nuances of an individual patient's symptoms. We also outline the unique advantages of using cortical electrodes for control and the remaining hardware limitations that need to be overcome to facilitate further development in this field. Over the course of this study we have verified the potential of fully-implanted, cortically driven aDBS as a feasibly translatable treatment for pharmacologically resistant ET.
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Affiliation(s)
- Tomasz M. Fra̧czek
- Neuroscience Program, University of Washington, Seattle, WA, United States
| | - Benjamin I. Ferleger
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
| | - Timothy E. Brown
- Department of Philosophy, University of Washington, Seattle, WA, United States
| | - Margaret C. Thompson
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
| | - Andrew J. Haddock
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
| | - Brady C. Houston
- Neuroscience Program, University of Washington, Seattle, WA, United States
| | - Jeffrey G. Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Andrew L. Ko
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Jeffrey A. Herron
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Howard J. Chizeck
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
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Lopez-de-Ipina K, Solé-Casals J, Sánchez-Méndez JI, Romero-Garcia R, Fernandez E, Requejo C, Poologaindran A, Faúndez-Zanuy M, Martí-Massó JF, Bergareche A, Suckling J. Analysis of Fine Motor Skills in Essential Tremor: Combining Neuroimaging and Handwriting Biomarkers for Early Management. Front Hum Neurosci 2021; 15:648573. [PMID: 34168544 PMCID: PMC8219239 DOI: 10.3389/fnhum.2021.648573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/19/2021] [Indexed: 12/22/2022] Open
Abstract
Essential tremor (ET) is a highly prevalent neurological disorder characterized by action-induced tremors involving the hand, voice, head, and/or face. Importantly, hand tremor is present in nearly all forms of ET, resulting in impaired fine motor skills and diminished quality of life. To advance early diagnostic approaches for ET, automated handwriting tasks and magnetic resonance imaging (MRI) offer an opportunity to develop early essential clinical biomarkers. In this study, we present a novel approach for the early clinical diagnosis and monitoring of ET based on integrating handwriting and neuroimaging analysis. We demonstrate how the analysis of fine motor skills, as measured by an automated Archimedes' spiral task, is correlated with neuroimaging biomarkers for ET. Together, we present a novel modeling approach that can serve as a complementary and promising support tool for the clinical diagnosis of ET and a large range of tremors.
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Affiliation(s)
- Karmele Lopez-de-Ipina
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- EleKin Research Group, Department of System Engineering and Automation, University of the Basque Country UPV/EHU, Donostia-San Sebastian, Spain
| | - Jordi Solé-Casals
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- Data and Signal Processing Research Group, University of Vic-Central University of Catalonia, Barcelona, Spain
| | - José Ignacio Sánchez-Méndez
- EleKin Research Group, Department of System Engineering and Automation, University of the Basque Country UPV/EHU, Donostia-San Sebastian, Spain
| | | | - Elsa Fernandez
- EleKin Research Group, Department of System Engineering and Automation, University of the Basque Country UPV/EHU, Donostia-San Sebastian, Spain
| | - Catalina Requejo
- Cajal Institute, Consejo Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Anujan Poologaindran
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
- The Alan Turing Institute, British Library, London, United Kingdom
| | | | - José Félix Martí-Massó
- Neurodegenerative Disorders Area, Biodonostia Health Research Institute, Donostia-San Sebastian, Spain
- Movement Disorders Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
- Biomedical Research Networking Centre Consortium for the Area of Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Alberto Bergareche
- Neurodegenerative Disorders Area, Biodonostia Health Research Institute, Donostia-San Sebastian, Spain
- Movement Disorders Unit, Department of Neurology, Donostia University Hospital, Donostia-San Sebastian, Spain
- Biomedical Research Networking Centre Consortium for the Area of Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - John Suckling
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
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Sepúlveda Soto MC, Fasano A. Tremor: so common, so difficult. J Neurol Neurosurg Psychiatry 2020; 91:809-810. [PMID: 32457088 DOI: 10.1136/jnnp-2020-323189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 11/04/2022]
Affiliation(s)
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Toronto, Ontario, Canada .,Division of Neurology, University of Toronto, Toronto, ON, Canada.,Krembil Brain Institute, Toronto, ON, Canada.,The Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
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Elhassanien MEM, Rashed KH, Bahnasy WS, El-Heneedy YAE, El-Seidy EAS, Tomoum MO, Ramadan KM, Kotait MA, Amer RAR, ELAhwal SA. Essential tremor: what is beyond the oscillatory monosymptomatic illness? THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00200-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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