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October 25, 2016; 87 (17) Resident and Fellow Section

Teaching NeuroImages: Stroke mimicking thalamotomy

Cessation of tremor following ventrolateral thalamic ischemia

Andreas Horn, Laura Kipp, Antonio Meola, Andrea A. Kühn, Christoph Leithner
First published October 24, 2016, DOI: https://doi.org/10.1212/WNL.0000000000003263
Andreas Horn
From the Department of Neurology (A.H., L.K., A.A.K., C.L.), Charité–University Medicine (CVK), Berlin, Germany; Movement Disorders Unit (A.H., A.A.K.), Charité–University Medicine (CVK), Berlin, Germany; Berenson-Allen Center for Noninvasive Brain Stimulation (A.H.), Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurosurgery (A.M.), Brigham and Women's Hospital, Boston, MA; NeuroCure–Cluster of Excellence (A.A.K.); Berlin School of Mind and Brain (A.A.K.); and Deutsches Zentrum für Neurodegenerative Erkrankungen (A.A.K.), Berlin, Germany.
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Laura Kipp
From the Department of Neurology (A.H., L.K., A.A.K., C.L.), Charité–University Medicine (CVK), Berlin, Germany; Movement Disorders Unit (A.H., A.A.K.), Charité–University Medicine (CVK), Berlin, Germany; Berenson-Allen Center for Noninvasive Brain Stimulation (A.H.), Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurosurgery (A.M.), Brigham and Women's Hospital, Boston, MA; NeuroCure–Cluster of Excellence (A.A.K.); Berlin School of Mind and Brain (A.A.K.); and Deutsches Zentrum für Neurodegenerative Erkrankungen (A.A.K.), Berlin, Germany.
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Antonio Meola
From the Department of Neurology (A.H., L.K., A.A.K., C.L.), Charité–University Medicine (CVK), Berlin, Germany; Movement Disorders Unit (A.H., A.A.K.), Charité–University Medicine (CVK), Berlin, Germany; Berenson-Allen Center for Noninvasive Brain Stimulation (A.H.), Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurosurgery (A.M.), Brigham and Women's Hospital, Boston, MA; NeuroCure–Cluster of Excellence (A.A.K.); Berlin School of Mind and Brain (A.A.K.); and Deutsches Zentrum für Neurodegenerative Erkrankungen (A.A.K.), Berlin, Germany.
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Andrea A. Kühn
From the Department of Neurology (A.H., L.K., A.A.K., C.L.), Charité–University Medicine (CVK), Berlin, Germany; Movement Disorders Unit (A.H., A.A.K.), Charité–University Medicine (CVK), Berlin, Germany; Berenson-Allen Center for Noninvasive Brain Stimulation (A.H.), Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurosurgery (A.M.), Brigham and Women's Hospital, Boston, MA; NeuroCure–Cluster of Excellence (A.A.K.); Berlin School of Mind and Brain (A.A.K.); and Deutsches Zentrum für Neurodegenerative Erkrankungen (A.A.K.), Berlin, Germany.
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Christoph Leithner
From the Department of Neurology (A.H., L.K., A.A.K., C.L.), Charité–University Medicine (CVK), Berlin, Germany; Movement Disorders Unit (A.H., A.A.K.), Charité–University Medicine (CVK), Berlin, Germany; Berenson-Allen Center for Noninvasive Brain Stimulation (A.H.), Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Neurosurgery (A.M.), Brigham and Women's Hospital, Boston, MA; NeuroCure–Cluster of Excellence (A.A.K.); Berlin School of Mind and Brain (A.A.K.); and Deutsches Zentrum für Neurodegenerative Erkrankungen (A.A.K.), Berlin, Germany.
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Citation
Teaching NeuroImages: Stroke mimicking thalamotomy
Cessation of tremor following ventrolateral thalamic ischemia
Andreas Horn, Laura Kipp, Antonio Meola, Andrea A. Kühn, Christoph Leithner
Neurology Oct 2016, 87 (17) e208-e209; DOI: 10.1212/WNL.0000000000003263

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A 76-year-old woman with right-sided tremor-dominant idiopathic Parkinson disease was admitted due to sudden-onset right leg palsy, right hemihypesthesia, and slurred speech but cessation of resting tremor. MRI showed recent infarction in the left thalamus (figure 1). Spatial analysis performed with Lead-DBS software (www.lead-dbs.org) located the lesion to left ventrolateral and ventroposterior nuclei1 (Jones nomenclature), corresponding to the ventrointermediate nucleus (Walker nomenclature), the typical deep brain stimulation target for tremor. The analysis showed that the (nondecussating) dentatothalamic tract,2 which plays a prominent role in tremor pathophysiology, passes through the lesion (figure 2).

Figure 1
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Figure 1 MRI slice views show stroke lesion site and spatial overlap with thalamic nuclei

(A, B) T2-weighted MRI. (C) Diffusion-weighted MRI of the left thalamus with isovolume at intensity value of 280 used to delineate the stroke lesion (figure 2). (D) Atlas structures locate the lesion to ventral lateral/ventral posterior nuclei (Jones nomenclature), which correspond to the ventralis intermedius in Walker nomenclature. For abbreviations, see reference 1.

Figure 2
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Figure 2 3D visualization of the stroke lesion, subcortical nuclei, and dentatothalamic tracts

Visualization of stroke lesion, nuclei defined by the Morel atlas,1 and 2 pathways of the dentatorubrothalamic tract.2 The nondecussating dentatorubrothalamic (nd-DRTT) tract passes through the lesion. The enlarged picture shows the typical location of a DBS electrode with target nucleus ventralis intermedius electrode as placed in patients predominantly suffering from tremor, falling inside the stroke lesion. DN = dentate nucleus. For other abbreviations, see reference 1.

AUTHOR CONTRIBUTIONS

Dr. Horn wrote the manuscript and performed spatial analyses. L. Kipp provided and worked up the clinical case as physician of care together with Dr. Leithner. Dr. Meola provided the atlas of the dentatorubrothalamic tract and revised the manuscript. Prof. Kühn revised the manuscript and provided advice regarding spatial analyses. Dr. Leithner supervised and planed the manuscript, revised the manuscript, and worked up the clinical case as principal physician of care.

STUDY FUNDING

No targeted funding reported.

DISCLOSURE

A. Horn is supported by a grant from the German Research Association (DFG grant KFO247), Stiftung Charité, Berlin Institute of Health, and Prof. Klaus Thiemann Foundation. L. Kipp reports no disclosures relevant to the manuscript. A. Meola is supported by an NIH award (R25CA089017) and reports no conflicts of interest. A. Kühn received honoraria from St Jude Medical and Medtronic, travel grants from Ipsen Pharma and Boston Scientific, consultancies from Boston Scientific, and is supported by a grant from the German Research Association (DFG grant KFO247). C. Leithner reports no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Download teaching slides: Neurology.org

  • © 2016 American Academy of Neurology

REFERENCES

  1. 1.↵
    1. Krauth A,
    2. Blanc R,
    3. Poveda A,
    4. Jeanmonod D,
    5. Morel A,
    6. Székely G
    . A mean three-dimensional atlas of the human thalamus: generation from multiple histological data. Neuroimage 2010;49:2053–2062.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Meola A,
    2. Comert A,
    3. Yeh FC,
    4. Sivakanthan S,
    5. Fernandez-Miranda JC
    . The nondecussating pathway of the dentatorubrothalamic tract in humans: human connectome-based tractographic study and microdissection validation. J Neurosurg 2015;124:1406–1412.
    OpenUrlPubMed
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