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).
(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.
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
Disputes & Debates: Rapid online correspondence
NOTE: All authors' disclosures must be entered and current in our database before comments can be posted. Enter and update disclosures at http://submit.neurology.org. Exception: replies to comments concerning an article you originally authored do not require updated disclosures.
- Stay timely. Submit only on articles published within 6 months of issue date.
- Do not be redundant. Read any comments already posted on the article prior to submission.
- 200 words maximum.
- 5 references maximum. Reference 1 must be the article on which you are commenting.
- 5 authors maximum. Exception: replies can include all original authors of the article.
- Submitted comments are subject to editing and editor review prior to posting.