Objective: To report a case of resolution of contralateral essential tremor (ET) after a cerebral cortical infarction. The restricted nature of the clinical and radiologic findings in this case is unique.

Background: Anatomic analysis of lesions altering the clinical expression of movement disorders provides insight into their pathophysiology. Prior reports of cerebral infarctions that abolished ET have mapped a series of structures that constitute a pathway of neuronal circuitry that modulates the clinical manifestations of ET.  Here a case is presented that contributes to that body of knowledge.

Method: Case report

Results: A 93 yo right-handed widower with insulin-dependent diabetes mellitus lived a fully independent life. He had a 20-year history of asymmetric upper limb tremor, predominantly right-sided. He was an avid golfer, though his tremor caused him trouble putting. Primidone 250 mg qAM provided nearly complete resolution of tremor for all tasks except handwriting. One warm summer morning he was sitting outdoors waiting to play a round of golf when he stood up and felt dizzy. Witnesses were alarmed enough to call for emergency services. His random blood sugar was 65, not unusually low for him. He was taken to an Urgent Care station where he received an IV infusion of fluids. After 90 minutes he was discharged home. He felt well with no other complaints.  About 3-4 days later, he grasped a glass of water with his right hand (when normally he would use his left) and noted that his hand did not shake. He subsequently found that he could eat with a spoon or drink a beverage with his right hand, which he had been unable to do for years.  Examination disclosed absence of right upper limb tremor, including for handwriting and drawing tasks on the right, while his tremor was unchanged on the left. Brain MRI revealed a small subacute infarction in the upper half of the left postcentral gyrus.

Conclusion: Of fewer than 20 previously reported cases of cerebral infarction abolishing ET, 4 infarcts were localized to the cerebral cortex. Two of those patients developed a hemiparesis, while the other 2 showed mixed sensorimotor deficits. This patient is unique in that the clinical manifestation of his cerebral infarct was limited to resolution of ET on the contralateral side. This patient represents the most restricted clinical and radiologic lesion responsible for resolution of ET yet reported.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/improvement-of-essential-tremor-after-cortical-cerebral-infarction/