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Essential tremor (ET) is the commonest movement disorder in adults. However, the precise localisation of the primary pathology is poorly understood. ET is not generally believed to be associated with significant basal ganglia dysfunction,1 although an early PET study demonstrated an association with overactivation of not only the cerebellum but also the contralateral striatum (as well as thalamus and sensorimotor cortex).2 Neurophysiological studies suggest the involvement of a central oscillator within the olivocerebellothalamocortical circuit.3 In line with this, vascular lesions of the cerebellum, pons, thalamus, corona radiata and frontal cortex have been reported to result in unilateral resolution of tremor.4 To date, the commonest target for control of tremor using stereotactic lesions or deep brain stimulation (DBS) surgery is the thalamic ventral intermediate (Vim) nucleus (the cerebellar-receiving area of the thalamus).5 Our report of a case of putaminal ischaemic stroke resulting in marked improvement of contralateral ET suggests that the basal ganglia may also be important in the pathogenesis of ET.
The patient is a 75-year-old left-handed man who was first seen in our clinic in 1993, aged 60. Symptoms began at age 10 with right-hand tremor, but the left hand soon became involved. Many activities were affected, but writing was the most impaired. Subsequently, he developed …