Alex Alikiotis
Stroke patients may experience involuntary muscle contractions, known as muscle spasticity, which can cause their legs to shake. This occurs when the part of the brain that controls movement is damaged by a stroke, affecting the messages sent to the muscles. Muscle spasticity can cause stiffness and tightness, and the muscles may resist movement or not work as intended. It can also make walking difficult, affect balance and increase the risk of falling. Physiotherapy, occupational therapy, and medication are often used to treat muscle spasticity in stroke patients.
| Characteristics | Values |
|---|---|
| Prevalence | 1-4% of stroke survivors |
| Description | Uncontrollable, rhythmic shaking of one or more body parts |
| Types | Action tremors, rest tremors, postural tremors, kinetic tremors, intention tremors |
| Affected body parts | Hands, arms, legs, head, soft palate of the mouth |
| Onset | Delayed, occurring 1 month to 4 years after the stroke |
| Causes | Damage to the thalamus, basal ganglia, cerebellum, brainstem, frontal lobe |
| Treatment | Physical therapy, medication (anti-seizure, tranquilizers, beta blockers), deep brain stimulation, Botox, Baclofen, behavioural techniques, compensation techniques |
Hemiballism/hemichorea
The prognosis for hemiballism/hemichorea is generally positive, with complete resolution in about 50% of cases. In most patients, the symptoms resolve either with or without treatment. Medical treatment can help reduce or improve the movements in patients with severe movement disorders. The primary treatment for hemiballism/hemichorea is anti-dopaminergic therapy with typical and atypical neuroleptics and catecholamine-depleting agents. Other effective medications include tetrabenazine, reserpine, clonazepam, sodium valproate, levetiracetam, and topiramate.
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Dystonia
The symptoms of dystonia can vary depending on the location of the lesion. Dystonia can affect the face, arm, leg, hand, foot, or tongue. It can also be segmental or focal, affecting multiple non-contiguous body regions. In the case of leg dystonia, it can cause difficulty walking, affect balance, and increase the risk of falling. Treatment options for dystonia include botulinum toxin injections, oral medications such as muscle relaxants and anticholinergic drugs, and physiotherapy and occupational therapy.
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Myoclonus and asterixis
The treatment for myoclonus and asterixis depends on their severity and impact on the patient's functional abilities. Myoclonus often does not require treatment. Asterixis, on the other hand, may be treated with medications such as clonazepam and sodium valproate, which are GABAergic drugs that increase GABAergic neurotransmission. In some cases, a combination of medications may be required.
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Holmes' tremor
Holmes tremor is a rare condition, with only 155 cases reported between 1904 and 2016. It is a combination of rest, action, and postural tremors, with a frequency of 2-5Hz, and is aggravated by posture and movement. It is caused by lesions in the midbrain, thalamus, cerebellum, and other areas. The tremors are worsened by sustained posture and have a slow frequency of less than 4.5Hz, with a large amplitude.
The pathophysiology of Holmes tremor is complex and requires multiple subcortical regions within the basal ganglia to be lesioned, including the dopaminergic nigrostriatal system, dentatorubro-olivary pathways, and the cerebellothalamic system. The cerebellothalamic system is particularly important, as it controls voluntary precision movements.
The most common causes of Holmes tremor are vascular lesions, including ischaemic and haemorrhagic strokes, which account for 48% of cases. Traumatic brain injury accounts for 17% of cases, and other causes include demyelinating diseases, AIDS with associated opportunistic infections, arteriovenous malformations, and cerebral cystic lesions of unknown origin. The median time from lesion occurrence to the onset of tremors is 2.6 months, but this can range from one month to two years.
The diagnosis of Holmes tremor is based on clinical examination, neurophysiological studies, and radiological assessment. Treatment options include medication such as levetiracetam, trihexyphenidyl, levodopa, dopamine agonists, anticholinergics, and topiramate, as well as surgical interventions such as stereotactic lesions and deep brain stimulation.
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Palatal tremor
Symptomatic palatal tremor is caused by a lesion in the brainstem or upper cerebellar peduncle (the dentato-rubro-olivary triangle of Guiliian and Mollaret). This type of palatal tremor often results in objective tinnitus, which is more commonly reported by patients with this condition. In symptomatic palatal tremor, the patient's brain images will show abnormal findings.
On the other hand, essential palatal tremor occurs when no discrete lesion can be identified in brain imaging. This type of palatal tremor is usually benign and disappears spontaneously or during sleep. However, it can be very annoying due to the persistent clicking noise caused by the rapid opening and closing of the eustachian tube.
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