Deep Brain Stimulation Target Selection in Co-Morbid Essential Tremor and Parkinson's Disease.

Clinical Vignette: A 64-year-old man with essential tremor (ET) and Parkinson's disease (PD) presented with medically refractory, large amplitude, debilitating rest and action tremor in his extremities. Clinical Dilemma: Ventral intermediate nucleus of the thalamus (VIM) deep brain stimulation (DBS) improves tremor in ET and PD but does not ameliorate bradykinesia and rigidity in PD. The comparative efficacy of subthalamic nucleus (STN) DBS in managing action ET tremor remains unclear. Clinical Solution: Bilateral STN was selected as the DBS target. Moderate improvement in rest tremor and mild improvement in action tremor were noted following initial programming. Gap In Knowledge: There are no head-to-head trials to guide DBS target selection in patients with both ET and PD. Current evidence is limited to a few small head-to-head trials that have demonstrated equivalent efficacy in tremor reduction in PD patients using VIM as DBS target and in ET patients using STN. Expert Commentary: Due to limited evidence, DBS treatment of complex cases, such as combined Parkinson's disease and essential tremor, remains based on expert consensus at each institution. Further multi-approach efforts, using imaging, electrophysiologic, and animal data, will be needed to answer the identified gap in knowledge. Highlights: There is limited evidence to guide deep brain target selection in patients with essential tremor and Parkinson's disease. We review existing literature and propose strategies to manage tremor in these patients.

Successful Treatment of Primary Orthostatic Tremor Using Perampanel.

Background: Primary orthostatic tremor (POT) remains a therapeutic conundrum. Various medication classes have been tried, yielding modest results at best. Case Report: A 62-year-old female with a 13-year history of POT, refractory to clonazepam up to 20 mg/day, was treated with perampanel 1-2 mg/day. She reported 90% subjective symptomatic improvement. Discussion: This case highlights the potential for use of perampanel, a novel AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) receptor antagonist for the treatment of POT. There has been one prior report citing its use for POT with complete resolution of symptoms. We encourage further studies to highlight its efficacy for POT.

Multiple Cranial Neuropathies in a Patient with Diffuse Large B-cell Lymphoma: Case Report and Review of Literature.

Neuropathies can occur in patients with diffuse large B-cell lymphoma (DLBCL) at any stage of the disease as a presenting symptom or during later stages of illness. A wide spectrum of neurological association is known to occur with DLBCL, ranging from cranial nerve palsies to peripheral neuropathies. Evaluation of cranial and peripheral neuropathies in patients with DLBCL requires meticulous clinical, imaging, and electrodiagnostic testing. A 75-year-old right-handed female with a known history of multiple cranial neuropathies and DLBCL presented with acute dysphagia and upper extremity weakness of one-week duration. On evaluation, she was found to have right vagal nerve palsy. Cerebrospinal fluid (CSF) analysis along with flow cytometry testing showed CD19 and CD20 positive B cells, confirming neoplastic infiltration of CSF. We describe the case and review the literature of the association of cranial nerve palsies with DLBCL.