ABSTRACT
Her general examination and vital signs were unremarkable. Her mentation and language were normal and her speech was fluent, but mildly dysarthric with occasional stuttering. The cranial nerves were significant for low visual acuity, bilateral paracentral scotomas, diplopia on upgaze, and hypometric saccades. She was mildly bradykinetic. Her muscle tone was increased. Muscle strength was normal. Her tremor was seen in the right hand and composed mainly of wrist flexion-extension, but occasionally involved the metacarpophalangeal joints, the left hand, and the right foot. The tremor could be seen at rest (see video, Case 35 ), while at other times the tremor could be triggered by tactile stimuli and passive or active hand movements, but this was not consistently reproducible. The rate of tremor was about 5 Hz. The tremor was slightly irregular and had a jerky quality. There were occasional larger amplitude jerks in phase with the tremor. She had mild finger incoordination and minimal limb ataxia. Other than the wrist tremor, there were no other abnormal movements. The sensory examination was significant for distal impairment of proprioception and vibration. Her gait was slow and minimally ataxic. Magnetic resonance imaging (MRI) of the brain showed hyperintense signal on T2 images in the basal ganglia and deep white matter in all lobes, consistent with hypoxic injury.
