Brain stem bleeding after a few months of suffering from side limb tremor, the main culprit is ...

The woman, 65, was admitted to hospital on June 18, 2019 for "remaining for three months of tremors on her left limb"patients began to appear before the hospital in the remaining months of left limb tremor, movement and maintenance posture is more obvious, when not paid attention to, after the symptoms gradually aggravated, lying quiet when there is tremor, affecting life self-carehad a history of hypertension for 6 years, and on August 31, 2018 had a history of cerebral stem bleeding, left with vague speech, right peripheral facial palsy and left limb paraplegianervous system check body: clear mind, vague tone, eyes see vertical eye shock, right forehead, nasal lip ditch shallow, tongue-in-the-middle, left limb see obvious tremor, quadriplegic muscle tension is normal, left limb muscle strength 4, right limb muscle strength 5, double-sided body feel normal, double tendon reflection normal, double-sided Cheeky negative, both side of the KerpisThe left finger nose and rotation test are not stableassisted examination: 2018.8.31 cranial CT: brain stem haemorrhage (see Figure 1)Figure 1 Brain CT: brain stem bleedingafter admission to improve the relevant examination: blood routine, urine routine, stool routine, blood lipids, kidney function, electrolyte, cardiomyoma spectrum, glycetic hemoglobin, a three normalLiver function: total protein 63.00g/L, albumin 37.30g/Lcranial brain MRI shows that the extension of myelin to the right side of the abnormal signal, taking into account the hypertrophic under-olive degeneration (see Figure 2)Figure 2 Cranial MRI shows: the late myelin side of the right abdomen see a slightly lower signal of the flaky T1WI, T2WI high signal, T2Flair high signal, DWI and other signalsdiagnosis: hypertrophic olivary degeneration (HOD), Holmes tremortreatment: Try to give dobastine tablet syllables treatment, the patient tremor part lyngvesy improvement1the hypertrophic under-olive nuclear degenerationHOD is a secondary brain, brain bridge or cerebellum lesions and toothy nucleus-red core-under-olive nuclear loop (i.e., The Guillain-Mollaret triangle, see Figure 3), the extension of the olive nucleus loss of the upper neuron in the incoming impulse nerve, resulting in a secondary trans-synapssive nature, most commonly found in adultsFigure 3 Guillain-Mollaret triangle, quoted from reference 2incidence patterns:mainly divided into three types:lesions and one side of the red core or central cover bundle, secondary side HOD;lesions affect one side of the toothed nucleus or the upper foot of the cerebellum, causing the side HOD;lesions at the same time with two-sided red core, two-sided central cover bundle, two-sided toothed core or central cover bundle and the upper part of the microcephaly sufferated at the same time, secondary double-sided HODthis case is the first pattern of morbidityPathology:Irregular increase of neuronal cells, vagon destenology of cytoplasm and significant growth of astrocytes glial cellsetiology:Bleeding, infarction, vascular malformation, tumors, infections, trauma or surgery, inflammation, demyelination, Wilson's disease, minzole poisoning and neurowhite congestion, among which cerebral hemorrhage is most commonClinical Performance:In addition to the symptoms caused by the original onset, the main symptoms of HOD are palate myoclonus, Holmes tremor, cerebellum cogens and eye myoclonusAmong them, myoclonus is representative, but also most common, its characteristics are rigid frequency of 1 to 3Hz rhythmic muscle contraction of the palate muscle, can occur in 2 to 49 months after the original disease, the average incidence time is 10 to November, but not all patients will appearHolmes tremor is a combination of static, intentional and posture tremor, frequency of 4.5Hz, non-rhythmic, usually in the original disease 4 weeks to 2 years after the diseaseIn this case, the left limb tremor in the patient was considered Holmes tremor Imaging Performance: The characteristic MRI is characterized by the limitation of The Olive Core Region T2WI high signal, T2Flair slightly higher or higher signal, T1WI, etc or slightly lower signal, DWI and other signals, generally no enhancement effect, with or without the increase of olive core volume This is related to the onset time, the general original disease after 1 month only as a high signal of T2WI outside the myelin abdomen, 4 to 6 months after the emergence of olive core enlargement, 3 to 4 years after the olive core to restore normal volume or atrophy to determine whether there is a toothy core-red core-under-olive core loop is destroyed, it is possible to have magnetic resonance dispersion volume imaging (DTI) (see Figure 4) or diffuse volume fiber beam imaging (DTT) examination Figure 4 DTI shows: The right center cover beam reduced, quoted from the reference 7 2 treatment HOD there is no effective treatment, benzodiazepine and carmaipin only a few reported treatment is effective If the condition is severe, try to inject botulinum toxin As for Holmes tremors, which are mainly drug treatments, levodoba is currently considered to be a more effective drug, but there are also patients who are ineffective or less responsive to them in addition, drugs such as Praxo, piberace, phenylhenoso, clonitrosse, sodium valproate, zoeracetam, tobrace, botulinum and other drugs may also be effective In general, the efficacy of drug treatment varies widely among individuals, and the overall effect is not ideal For patients with drug incurable Holmes tremors, neural nucleomuscular damage and DBS are available author: Jane Jane Source: