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sikandar adwani

@SikandarAdwani • 5,705 subscribers

🧠 Neurologist ( Gold Medalist) | 📺 Host of "Grey Matters" on you tube | Advocate for Brain Health and Awareness 🌟 Inspiring Minds, Empowering Communities

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A 62 year old man comes to OPD with a simple complaint. Doctor, my left hand does not stay still. I watch him quietly before examining him. When his left hand rests on the chair, there is a slow, coarse tremor. When he stretches his arms forward, the tremor continues. When he is asked to touch his nose, the tremor markedly increases as the finger approaches the target. This is not a single tremor. This is rest, postural, and intention tremor together. Then comes the old history that changes everything. Eight months ago, he had a right thalamic hemorrhage. There was weakness initially, which slightly improved. The tremor appeared only months later. That delay is important. This is not Parkinson’s disease, because the tremor does not settle with movement. This is not a pure cerebellar tremor, because it is present even at rest. This pattern fits Holmes tremor. Now the localisation becomes clear. The lesion was in the right thalamus. The thalamus is the final relay for two major motor systems. The cerebellothalamic pathway carries coordination signals from the cerebellum. Its disruption explains why the tremor worsens during target-directed movement. The basal ganglia thalamic motor modulation controls stability at rest. Its disruption explains why the tremor is present even when the hand is relaxed. A single thalamic lesion can disturb both systems at once. Because motor control is contralateral, a right thalamic hemorrhage produces symptoms in the left hand. The tremor appears late because this is not just tissue damage. It reflects delayed maladaptive reorganisation of motor networks. The final diagnosis is left-hand Holmes tremor due to a right thalamic hemorrhage. Permission taken for the vdo #Neurotwitter #Medtwitter #Holmes

A 62 year old man comes to OPD with a simple complaint. Doctor, my left hand does not stay still. I watch him quietly before examining him. When his left hand rests on the chair, there is a slow, coarse tremor. When he stretches his arms forward, the tremor continues. When he is asked to touch his nose, the tremor markedly increases as the finger approaches the target. This is not a single tremor. This is rest, postural, and intention tremor together. Then comes the old history that changes everything. Eight months ago, he had a right thalamic hemorrhage. There was weakness initially, which slightly improved. The tremor appeared only months later. That delay is important. This is not Parkinson’s disease, because the tremor does not settle with movement. This is not a pure cerebellar tremor, because it is present even at rest. This pattern fits Holmes tremor. Now the localisation becomes clear. The lesion was in the right thalamus. The thalamus is the final relay for two major motor systems. The cerebellothalamic pathway carries coordination signals from the cerebellum. Its disruption explains why the tremor worsens during target-directed movement. The basal ganglia thalamic motor modulation controls stability at rest. Its disruption explains why the tremor is present even when the hand is relaxed. A single thalamic lesion can disturb both systems at once. Because motor control is contralateral, a right thalamic hemorrhage produces symptoms in the left hand. The tremor appears late because this is not just tissue damage. It reflects delayed maladaptive reorganisation of motor networks. The final diagnosis is left-hand Holmes tremor due to a right thalamic hemorrhage. Permission taken for the vdo #Neurotwitter #Medtwitter #Holmes

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How to approach tremor in Neuro OPD Consent taken for the video - Diagnosis #Tremor #Neurotwitter #Medtwitter

How to approach tremor in Neuro OPD Consent taken for the video - Diagnosis #Tremor #Neurotwitter #Medtwitter

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In a busy OPD, chorea is usually not missed because it is rare. It is missed because it looks like restlessness. The patient is sitting in front of you. A finger moves. Then the wrist. Then the shoulder. Then there is a small facial movement. Nothing seems dramatic. But watch carefully. The important thing is this: The next movement is not like the previous one. It changes in timing. It changes in direction. It changes in distribution. There is no fixed rhythm. There is no same movement repeating again and again. That is when I start thinking of chorea. I remember it this way: Tremor repeats. Chorea keeps changing. Now don't rush into a detailed examination. In OPD, five simple things are enough to recognise the phenomenology. 1. Just watch Keep talking to the patient. Watch the fingers, face, shoulders and feet. Mild chorea may simply look like fidgeting. 2. Ask the patient to stretch both hands forward And wait. Not for two seconds. Small irregular movements may start appearing in different fingers, wrist or shoulder. 3. Look for apparently purposeful movements This is a beautiful feature of chorea. An involuntary movement may get converted into touching the face, adjusting the clothes or changing posture. So what looks voluntary may actually have started as chorea. 4. Ask the patient to keep the tongue out The patient may bring it back repeatedly despite trying to maintain it. 5. Test sustained grip Instead of a constant grip, you may feel tightening and loosening. This is motor impersistence. The classical bedside description is the milkmaid grip. Then make the patient walk. A small extra step, shoulder movement, hand movement or sudden change in posture may get mixed into an otherwise normal gait. The important point is that chorea is not one particular movement. It is a pattern of unpredictability. Irregular. Non-rhythmic. Non-repetitive. Moving from one body part to another. And once I am sure that the movement is chorea, only then do I ask the next question: Why does this patient have chorea? Acute or chronic? One side or both? Drug related? Metabolic? Autoimmune? Structural? Genetic? In a busy OPD, don't begin with the disease name. First spend 30 seconds watching the movement. #NeuroX #MedX #Chorea

In a busy OPD, chorea is usually not missed because it is rare. It is missed because it looks like restlessness. The patient is sitting in front of you. A finger moves. Then the wrist. Then the shoulder. Then there is a small facial movement. Nothing seems dramatic. But watch carefully. The important thing is this: The next movement is not like the previous one. It changes in timing. It changes in direction. It changes in distribution. There is no fixed rhythm. There is no same movement repeating again and again. That is when I start thinking of chorea. I remember it this way: Tremor repeats. Chorea keeps changing. Now don't rush into a detailed examination. In OPD, five simple things are enough to recognise the phenomenology. 1. Just watch Keep talking to the patient. Watch the fingers, face, shoulders and feet. Mild chorea may simply look like fidgeting. 2. Ask the patient to stretch both hands forward And wait. Not for two seconds. Small irregular movements may start appearing in different fingers, wrist or shoulder. 3. Look for apparently purposeful movements This is a beautiful feature of chorea. An involuntary movement may get converted into touching the face, adjusting the clothes or changing posture. So what looks voluntary may actually have started as chorea. 4. Ask the patient to keep the tongue out The patient may bring it back repeatedly despite trying to maintain it. 5. Test sustained grip Instead of a constant grip, you may feel tightening and loosening. This is motor impersistence. The classical bedside description is the milkmaid grip. Then make the patient walk. A small extra step, shoulder movement, hand movement or sudden change in posture may get mixed into an otherwise normal gait. The important point is that chorea is not one particular movement. It is a pattern of unpredictability. Irregular. Non-rhythmic. Non-repetitive. Moving from one body part to another. And once I am sure that the movement is chorea, only then do I ask the next question: Why does this patient have chorea? Acute or chronic? One side or both? Drug related? Metabolic? Autoimmune? Structural? Genetic? In a busy OPD, don't begin with the disease name. First spend 30 seconds watching the movement. #NeuroX #MedX #Chorea

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