Cerebral activation pattern in primary writing tremor

A connectivity model of the anatomic substrates underlying Gerstmann syndrome

The Gerstmann syndrome is a constellation of neurological deficits that include agraphia, acalculia, left-right discrimination and finger agnosia. Despite a growing interest in this clinical phenomenon, there remains controversy regarding the specific neuroanatomic substrates involved. Advancements in data-driven, computational modelling provides an opportunity to create a unified cortical model with greater anatomic precision based on underlying structural and functional connectivity across complex cognitive domains. A literature search was conducted for healthy task-based functional MRI and PET studies for the four cognitive domains underlying Gerstmann's tetrad using the electronic databases PubMed, Medline, and BrainMap Sleuth (2.4). Coordinate-based, meta-analytic software was utilized to gather relevant regions of interest from included studies to create an activation likelihood estimation (ALE) map for each cognitive domain. Machine-learning was used to match activated regions of the ALE to the corresponding parcel from the cortical parcellation scheme previously published under the Human Connectome Project (HCP). Diffusion spectrum imaging-based tractography was performed to determine the structural connectivity between relevant parcels in each domain on 51 healthy subjects from the HCP database. Ultimately 102 functional MRI studies met our inclusion criteria. A frontoparietal network was found to be involved in the four cognitive domains: calculation, writing, finger gnosis, and left-right orientation. There were three parcels in the left hemisphere, where the ALE of at least three cognitive domains were found to be overlapping, specifically the anterior intraparietal area, area 7 postcentral (7PC) and the medial intraparietal sulcus. These parcels surround the anteromedial portion of the intraparietal sulcus. Area 7PC was found to be involved in all four domains. These regions were extensively connected in the intraparietal sulcus, as well as with a number of surrounding large-scale brain networks involved in higher-order functions. We present a tractographic model of the four neural networks involved in the functions which are impaired in Gerstmann syndrome. We identified a 'Gerstmann Core' of extensively connected functional regions where at least three of the four networks overlap. These results provide clinically actionable and precise anatomic information which may help guide clinical translation in this region, such as during resective brain surgery in or near the intraparietal sulcus, and provides an empiric basis for future study.

Is essential tremor a family of diseases or a syndrome? A family of diseases

It is now well-established that essential tremor (ET) can manifest with different clinical presentations and progressions (i.e., upper limb tremor, head tremor, voice tremor, lower limb tremor, task- or position-specific tremor, or a combination of those). Common traits and overlaps are identifiable across these different subtypes of ET, including a slow rate of progression, a response to alcohol and a positive family history. At the same time, each of these manifestations are associated with specific demographic, clinical and treatment-response characteristics suggesting a family of diseases rather than a spectrum of a syndrome. Here we summarize the most important clinical, demographic, neuropathological and imagingfeatures of ET and of its subtypes to support ET as a family of identifiable conditions. This classification has relevance for counseling of patients with regard to disease progression and treatment response, as well as for the design of therapeutic clinical trials.

A Critical Review of Alien Limb-Related Phenomena and Implications for Functional Magnetic Resonance Imaging Studies

Consensus criteria on corticobasal degeneration (CBD) include alien limb (AL) phenomena. However, the gist of the behavioral features of AL is still “a matter of debate.” CBD-related AL has so far included the description of involuntary movements, frontal release phenomena (frontal AL), or asomatognosia (posterior or “real” AL). In this context, the most frequent symptoms are language and praxis deficits and cortical sensory misperception. However, asomatognosia requires, by definition, intact perception and cognition. Thus, to make a proper diagnosis of AL in the context of CBD, cognitive and language dysfunctions must be carefully verified and objectively assessed. We reviewed the current literature on AL in CBD and now propose that the generic use of the term AL should be avoided. This catchall AL term should instead be deconstructed. We propose that the term AL is appropriate to describe clinical features associated with specific brain lesions. More discrete sets of regionally bound clinical signs that depend on dysfunctions of specific brain areas need to be assessed and presented when posing the diagnosis. Thus, in our opinion, the AL term should be employed in association with precise descriptions of the accompanying involuntary movements, sensory misperceptions, agnosia-asomatognosia contents, and the presence of utilization behavior. The review also offers an overview of functional magnetic resonance imaging-based studies evaluating AL-related phenomena. In addition, we provide a complementary set of video clips depicting CBD-related involuntary movements that should not mistakenly be interpreted as signs of AL.

Primary Writing Tremor: Current Concepts

Primary Writing Tremor (PWT) is a type of task specific tremor which happens only while writing (Type A PWT) or assuming a writing position of the hand (Type B PWT). There is a considerable overlap of clinical features between PWT and writer's cramp which creates difficulty in diagnosing this condition in the clinic. PWT usually affects the dominant hand and is typically 5-7hz in frequency, worsened by anxiety, temporarily relieved by alcohol and associated with reduced writing speeds. There are a variety of hypotheses about the phenomenology of PWT (regarding whether it is a variant of essential tremor, focal dystonia or an independent entity). Unlike writer's cramp, PWT shows normal reciprocal inhibition of H reflex, does not exhibit excessive EMG activity in proximal muscles, and on fMRI shows underactivation of cingulum and overactivation of primary motor and supplementary areas. There are no randomised controlled trials currently for the treatment of PWT. Treatment modalities available are: medical treatment, botulinum toxin, surgical management (including DBS) as well as adaptive strategies and occupational therapy.

Altered brain network measures in patients with primary writing tremor

PURPOSE

Primary writing tremor (PWT) is a rare task-specific tremor, which occurs only while writing or while adopting the hand in the writing position. The basic pathophysiology of PWT has not been fully understood. The objective of this study is to explore the alterations in the resting state functional brain connectivity, if any, in patients with PWT using graph theory-based analysis.

METHODS

This prospective case-control study included 10 patients with PWT and 10 age and gender matched healthy controls. All subjects underwent MRI in a 3-Tesla scanner. Several parameters of small-world functional connectivity were compared between patients and healthy controls by using graph theory-based analysis.

RESULTS

There were no significant differences in age, handedness (all right handed), gender distribution (all were males), and MMSE scores between the patients and controls. The mean age at presentation of tremor in the patient group was 51.7 ± 8.6 years, and the mean duration of tremor was 3.5 ± 1.9 years. Graph theory-based analysis revealed that patients with PWT had significantly lower clustering coefficient and higher path length compared to healthy controls suggesting alterations in small-world architecture of the brain. The clustering coefficients were lower in PWT patients in left and right medial cerebellum, right dorsolateral prefrontal cortex (DLPFC), and left posterior parietal cortex (PPC).

CONCLUSION

Patients with PWT have significantly altered small-world brain connectivity in bilateral medial cerebellum, right DLPFC, and left PPC. Further studies with larger sample size are required to confirm our results.

A preliminary study of the neuroanatomical correlates of primary writing tremor: role of cerebellum

INTRODUCTION

To explore the neuroanatomical correlates of primary writing tremor (PWT) and the role of cerebellum, using advanced structural neuroimaging. Till date, there are no studies exploring the gray and white matter changes using voxel-based morphometry (VBM) and diffusion tensor imaging (DTI) in PWT.

METHODS

Ten male patients with PWT were evaluated clinically and with magnetic resonance imaging. VBM and DTI images of patients were compared with that of 10 healthy male subjects. Spatially unbiased infra-tentorial template (SUIT) analysis was done to investigate the alterations of cerebellar gray matter. Region-of-interest analysis was performed on regions observed to be significantly different on DTI analysis.

RESULTS

The mean duration of illness and mean age of the patients were 3.5 ± 1.9 and 51.7 ± 8.6 years, respectively. On VBM analysis, the cluster of gray matter atrophy was found in bilateral cerebellar areas of culmen and left declive, right superior and medial frontal gyrus, bilateral middle frontal gyrus, bilateral anterior cingulate gyrus, and bilateral parahippocampal gyrus. DTI showed significantly reduced fractional anisotrophy of the anterior thalamic radiation, cingulum, and inferior fronto-occipital fasciculus in PWT patients compared to controls. The axial diffusivity, mean diffusivity, and radial diffusivity maps did not reveal any significant differences. On SUIT analysis, significant atrophy was found in right uvula and semilunar lobule in patients with PWT compared to controls.

CONCLUSIONS

Our study found that patients with PWT had predominant gray matter atrophy in parts of cerebellum and frontal lobe along with white matter changes of the cingulum and frontal lobe connections.

Epidemiology and treatment of 23 musicians with task specific tremor

BACKGROUND

Task specific tremors in musicians have been mainly described as primary bowing tremor in string instrumentalists in relatively small sample sizes. Our aim was to describe epidemiology, risk factors, phenomenology and treatment options of this disorder in 23 musicians of different instruments.

METHODS

We included 23 professional musicians (4 female, 19 male; mean age 51.5 ± 11.4 years) with a TSTM. During anamnesis, clinical examination, by mail or via telephone patients were asked for epidemiological, phenomenological information, risk factors and treatments. We then compared our findings to primary writing tremor, the most common task specific tremor.

RESULTS

Age at onset of the TST was 44.6 ± 13.6 years and tremor appeared 35.1 ± 13.5 years after beginning to play the instrument. The majority of patients were string instrumentalists, followed by woodwind instrumentalists. Other instrumentalists were a guitarist, pianist and percussionist respectively. In contrast to primary writing tremor, we also found proximal muscles of the upper extremity involved in tremor. A positive family history was found in Prior trauma was more common than in primary writing tremor. Treatment with a positive effect on tremor were in order of efficacy: Botulinumtoxin, Primidone, Propranolol, Trihexyphenidyl. No patient had undergone deep brain stimulation.

CONCLUSION

Task specific tremor in musicians is a heterogeneous disorder with a male gender predominance that shares many commonalities with PWT. The onset age as well as the time between starting to play the instrument and tremor onset has a wide range. Because previous trauma and overuse appear to be risk factors, preventive measures against playing related injuries are necessary. There appears to be a genetic predisposition for TST. No single beneficial medication exists and treatment of patients remains highly individual. It should be discussed, whether deep brain stimulation should be offered not only to patients that do not respond to any other medication but early in the course of the disease.

Novel magnetomechanical MR compatible vibrational device for producing kinesthetic illusion during fMRI

PURPOSE

Functional MRI (fMRI) can provide insights into the functioning of the sensorimotor system, which is of particular interest in studying people with movement disorders or chronic pain conditions. This creates a demand for manipulanda that can fit and operate within the environment of a MRI scanner. Here, the authors present a magnetomechanical device that delivers a vibrotactile sensation to the skin with a force of approximately 9 N.

METHODS

MRI compatibility of the device was tested in a 3 T scanner using a phantom to simulate the head. Preliminary investigation into the effectiveness of the device at producing cortical and subcortical activity was also conducted with a group of seven healthy subjects. The vibration was applied to the right extensor carpi ulnaris tendon to induce a kinesthetic illusion of flexion and extension of the wrist.

RESULTS

The MRI compatibility tests showed the device did not produce image artifacts and the generated electromagnetic field did not disrupt the static magnetic field of the scanner or its operation. The subject group results showed activity in the contralateral putamen, premotor cortex, and dorsal lateral prefrontal cortex. Ipsilaterally, there was increased activity in the superior and inferior parietal lobules. Areas that activated bilaterally included the thalamus, anterior cingulate, secondary somatosensory areas (S2), temporal lobes, and visual association areas.

CONCLUSIONS

This device offers an effective tool with precise control over the vibratory stimulus, delivering higher forces than some other types of devices (e.g., piezoelectric actuators). It can be useful for investigating sensory systems and sensorimotor integration.

Electrophysiological characteristics of task-specific tremor in 22 instrumentalists

Our aim was to address three characteristics of task-specific tremor in musicians (TSTM): First, we quantified muscular activity of flexor and extensor muscles, of coactivation as well as tremor acceleration. Second, we compared muscular activity between task-dependent and position-dependent tremor. Third, we investigated, whether there is an overflow of muscular activity to muscles adjacent to the affected muscles in TSTM. Tremor acceleration and muscular activity were measured in the affected muscles and the muscles adjacent to the affected muscles in 22 patients aged 51.5 ± 11.4 years with a task-specific tremor. We assessed power of muscular oscillatory activity and calculated the coherence between EMG activity of affected muscles and tremor acceleration as well as between adjacent muscles and tremor acceleration. This was done for task-dependent and position-dependent tremor. We found the highest power and coherence of muscular oscillatory activity in the frequency range of 3-8 Hz for affected and adjacent muscles. No difference was found between task-dependent and position-dependent tremor in neither power nor coherence measures. Our results generalize previous results of a relation between coactivation and tremor among a variety of musicians. Furthermore, we found coherence of adjacent muscles and TSTM. This indicates that overflow exists in TSTM and suggests an association of TST with dystonia.

Task-specific tremor

Task-specific tremor is a form of action tremor that occurs only or mainly when a person is performing a specific skilled task. The most frequently encountered form of task-specific tremor is primary writing tremor (PWT). Currently, there is debate about whether PWT is a variant of essential tremor, writer's cramp (dystonia), a separate entity, or in some cases related to essential tremor and in others to dystonia. PWT typically occurs at a frequency of 5-7Hz and has been subdivided into to two types: Type A, task-induced tremor, and type B, positionally sensitive tremor. Temporary suppression of the tremor by alcohol is seen in about one-third of cases. There are no randomized controlled therapeutic studies involving patients with PWT, although anecdotal reports of beneficial responses to propranolol, primidone, anticholinergics, botulinum toxin treatment, and stereotactic surgery have been reported. Reciprocal inhibition of the H-reflex and intracortical excitability are normal in PWT, unlike writer's cramp. Hyperactivity in the cerebellar hemispheres has been demonstrated with positron emission tomography in PWT. Other task-specific tremors have been described but have not been studied in detail.

Changes in resting-state brain networks in writer's cramp

OBJECTIVES

Writer's cramp (WC) is characterized by excessive cocontractions of agonist and antagonist hand and forearm muscles during writing. Changes in functional magnetic resonance imaging activation patterns in such conditions can be ambiguous as they might either reflect some aspect of the primary pathophysiological mechanism or, alternatively, may be the result of adaptive actions during task execution. To circumvent this problem, we examined WC patients during rest, i.e., without a task, using independent component analysis (ICA) applied to the blood oxygen level-dependent time series.

METHODS

Functionally connected brain networks during rest were defined by ICA to assess differences between WC patients (n = 16) and healthy controls (n = 16). Analysis was carried out using FMRIB's Software Library.

RESULTS

Two functional networks showed between-group differences, the sensorimotor network and the default-mode network. In WC patients, the connectivity was reduced in the left postcentral area and increased in basal ganglia in contrast to healthy controls. These changes were not reversed after treatment with botulinum toxin.

CONCLUSIONS

In line with other studies, the results show a dysfunction in cortico-subcortical circuits in WC involving somatosensory cortex, areas interfacing the sensory and motor systems, and putamen contralateral to symptomatic hand.

Functional magnetic resonance imaging in primary writing tremor and writer's cramp: A pilot study

OBJECTIVES

The precise pathophysiology of primary writing tremor (PWT) and writer's cramp (WC) is not known. The aim of this study is to compare the cerebral activation patterns in patients of PWT, WC and healthy controls, during a task of signing on paper, using functional magnetic resonance imaging (fMRI).

MATERIALS AND METHODS

Six subjects with PWT, three with WC and six healthy volunteers were examined using a 1.5-Tesla scanner. The paradigm consisted of three times repetition of a set of period of rest and activity. Each set consisted of 10 blood oxygen level dependent (BOLD) echo-planar imaging (EPI) acquisitions at rest followed by 10 BOLD EPI acquisitions while signing their names on paper using the dominant right hand. Entire brain was covered. SPM99 analysis was done.

RESULTS

IN COMPARISON TO THE HEALTHY CONTROLS, THE FOLLOWING DIFFERENCES IN CEREBRAL ACTIVATION WERE NOTED IN THE PATIENTS: (a) primary and supplementary motor areas showed overactivation in patients of PWT and underactivation in patients of WC, (b) the cingulate motor area showed underactivation in patients of PWT and overactivation in patients of WC and (c) the cerebellar activity was reduced in both WC and PWT.

CONCLUSION

Our preliminary findings suggest that the cerebral and cerebellar activation patterns in PWT and WC during signing on paper are distinct from each other and from healthy controls. There may be cerebellar dysfunction in addition to motor dysfunctions in the pathogenesis of these disorders.

Current role of functional MRI in the diagnosis of movement disorders

The functional magnetic resonance (fMR) technique for brain mapping is a valuable tool for understanding both normal physiology and the dysfunction taking place in disorders of the brain. This article provides an overview of fMR imaging methods and their applications in the study of neurologic movement disorders. The article also reviews the current neuroimaging literature regarding parkinsonisms, dystonia, essential tremor, and Huntington disease, and includes a discussion of current methodological limitations and future directions for this exciting field.

Changes in cortical inhibition during task-specific contractions in primary writing tremor patients

Primary writing tremor (PWT) is a rare disease of unknown pathophysiology. We studied changes in silent period (SP) duration, after transcranial magnetic stimulation (TMS), set at 20% above the motor threshold in 6 PWT patients and 7 healthy control subjects. SP duration was tested during a task-specific act, i.e., writing that induced tremor in all patients in the affected hand (Wr); nonspecific voluntary contraction of intensity, matching that developed during writing (VCWr); and during near maximal voluntary contraction (VCNmax). There were no differences in SP duration during Wr and VCWr contraction on the right affected side or between sides in both PWT patients and control subjects, nor between the groups. However, during VCNmax, SP significantly shortened on both sides in PWT patients, whereas there were no changes in control subjects. Although it appears that inhibitory mechanism are not directly involved in the generation of the tremulous activity, the shortening of SP indicates that central inhibitory mechanisms are affected in PWT patients. Therefore, whereas the underlying pathophysiological mechanisms in PWT and writer's cramp may share common features, the results indicate that PWT is not a variant of focal task-specific dystonia but rather a separate nosological entity.

Primary writing tremor: motor cortex reorganisation and disinhibition

BACKGROUND

Primary writing tremor (PWT) is a task-specific tremor of uncertain origin. There has been debate as to whether PWT represents a variant of essential tremor or a tremulous form of focal dystonia related to writer's cramp. In writer's cramp there is evidence of changes in intracortical inhibition (ICI), as well as cortical motor reorganisation.

OBJECTIVE

To study corticomotor organisation and short-latency ICI in a patient with typical task-specific PWT.

METHODS

Transcranial magnetic stimulation mapping of the corticomotor representation of the hand and studies of ICI using paired-pulse stimulation were performed in a 47-year-old right-handed woman with a pure task-specific writing tremor.

RESULTS

The motor maps for the hand were displaced posteriorly on both sides and reverted to a normal position after treatment with botulinum toxin. Short-latency ICI was reduced for the dominant hand.

CONCLUSION

The findings indicate reorganisation and disinhibition of the corticomotor projection to the hand and point to the participation of cortical centres in the origin of PWT.

Neurophysiological investigations in patients with primary writing tremor

The pathophysiology of primary writing tremor (PWT) is still unknown: it has been classified as a focal form of essential tremor and as a tremulous form of writer's cramp. We studied cortical and spinal excitability in patients with PWT and compared the results with published data of patients with essential tremor, and writer's cramp. We used electrical stimulation of median and radial nerve to study reciprocal inhibition of forearm antagonist muscles and paired transcranial magnetic stimulation at short and long interstimulus intervals (ISIs) to assess intracortical excitability. Both studies were conducted on patients with PWT and on control subjects. The early (presynaptic) and late (disynaptic) phases of reciprocal inhibition were normal as was intracortical excitability at short and long ISIs. Our study suggests that the pathophysiology of PWT is different from that of writer's cramp and partially also from that of essential tremor.

Deep brain stimulation for tremor [correction of trauma]: patient selection and evaluation

The selection of patients with movement disorders for deep brain stimulation is becoming a common neurological and neurosurgical task. Deep brain stimulation is suitable for different forms of tremor, which can often not be treated with medication. This suitability applies for essential tremor, monosymptomatic tremor at rest, cerebellar or multiple sclerosis tremor, Holmes' tremor, primary writing tremor or tremor in neuropathies. The appropriate selection of patients is critical for the outcome of surgical relief of tremors. Considering the risks of any stereotactic intervention, the following must apply: (1) motor symptoms lead to a relevant disability in activities of daily living, despite optimal medical treatment; (2) biological age of the patient; (3) neurosurgical contraindications; (4) the patient is neither demented nor severely depressed. If these conditions are fulfilled, the individual chances of improvement of the target symptoms need to be checked, based on the following guidelines: (1) the kind of tremor, (2) the natural course of the tremor, (3) the chances for medical treatment in a particular patient, (4) the outcome of surgery in a specific condition, (5) the individual risks for a patient to suffer from complications. The outcome of surgery for tremor depends on the clinical type and distribution. Distal limb tremors are easier to treat than proximal limb tremors. Intention tremor is more difficult to treat than rest or postural tremor. The indication for surgical treatment depends on the analysis of the individual risk-benefit ratio, which also has to take into account the patients' social, professional, and familial background. The patient needs to be well informed about his individual risk-benefit ratio and of alternative treatments, before undergoing stereotactic surgery.