II. Causes
- Cerebellar Lesion (CVA or Tumor)
- Lesions of lateral cerebellar nuclei
- Lesions of cerebellar peduncle
- Lesions of red nucleus (Causes Rubral Tremor)
- Wing-beating type Tremor
- Rubral Tremor also seen in Wilson's Disease
- Cerebellar Postural Tremor
- Multiple Sclerosis with cerebellar Plaques (most common etiology)
- Frequency
- Mild: 10 Hz
- Severe: 2.5-4 Hz
- Amplitude waxes and wanes
- Wilson's Disease
- Psychogenic Tremor
-
Drug-Induced Tremor
- Lithium
- Alcoholism
- Dystonic Tremor (estrapyramidal side effect)
- Typically drug induced, with onset age <50, with abnormal wrist flexion and jerky hand or arm positions
III. Findings: Symptoms and signs
- Intention Tremor on ipsilateral side of lesion
- Exacerbated Tremor at end of goal directed movement
- Low to Medium frequency Tremor
- Example: Finger-Nose-Finger
- Midline disease causes bilateral Tremor
- Contrast with Rest Tremor
- Rest Tremor improves with goal directed movement
- Tremor increases as extremity reaches target (with secondary dysmetria or over-shooting)
- Concurrent Cerebellar signs
- Abnormal Gait
- Speech abnormalities
- Ocular movement abnormalities
- Rapid Alternating Movements abnormal
- Abnormal Tandem Walk (esp. Multiple Sclerosis)
- Other findings
- Hypotonia
IV. Labs: Directed by suspected diagnosis
- Multiple Sclerosis: CSF for IgG gamma globulins
- Lithium Toxicity: Lithium Level
VI. Management
- Identify Etiology
- Rule-out Cerebellar tumor
-
Multiple Sclerosis
- Isoniazid (INH) 600-1200 mg qd
- Pyridoxine
VII. Resources
- Intention Tremor Video