KISEP J Korean Neurosurg Soc 37 :

Obstructive Hydrocephalus Induced Tremor

Case Report in Patient with Mesencephalic Lacunae
Kyung Jin Lee, M.D., Won Il Joo, M.D.,
Moon Chan Kim, M.D., Chang Rak Choi, M.D.
Department of Neurosurgery, Catholic Neuroscience Center, The Catholic University of Korea, Seoul, Korea

We report a case of hydrocephalus in a 8-year-old boy who presented bilateral hand tremor. The hydrocephalus was
caused by the aqueductal stenosis due to expanding lacunae in the mesencephalothalamic area on MR findings. The
tremor was improved after CSF drainage by spinal tap and ventriculoperitoneal shunt. The authors present the possible
mechanism of hydrocephalus induced tremor

KEY WORDS : Hydrocephalus Tremor Ventriculoperitoneal shunt Lacunae .

Introduction appeared when the patient sustained posture and tried to write,
draw and pour. The tremor had a frequency of 2 to 4Hz. The

H ydrocephalus is one of the most common and treatable

conditions encountered in neurosurgical practice6).
Hydrocephalus typically produces headache, nausea and
patient's score on the Mini-Mental State Examination(MMSE)
was 23.5/30, which is at the lower limit of the normal range.
The patient's score on the Fahn's tremor scale1) was 16. All fi-
vomiting, and progressive obtundation5). Papilledema, gait ndings of routine blood laboratory examinations were normal.
difficulties, and hyperactive tendon reflexes may occur, but
tremor is a rare and little-known sign of obstructive hydroce- Radiological findings
phalus5). In our case, hydrocephalus was induced by aqueductal Cranial MR imaging revealed triventricular hydrocephalus
obstruction. The tremor was improved as hydrocephalus was and effaced cerebral cortical sulci and demonstrated, in the
resolved by cerebrospinal fluid(CSF) drainage by spinal tap mesencephalothalamic region, a 3mm -sized, round well-
or ventriculoperitoneal shunt. The cause is unclear. The tremor defined areas, that exhibited a signal intensity identical to CSF.
may be caused by lacunae at the pretectile lesion or pure hyd- No enhancement was seen after intravenous administration of
rocephalus. In the current report we describe a patient in whom contrast agent within or near the lacunae (Fig. 1). The lesion
mesencephalic lacunae was observed on magnetic resonance was located in the mesencephalic tegmentum, creating an ob-
(MR) imaging and in whom the referring complaints were struction of the cerebral aqueduct and displacing the quad-
related to obstructive hydrocephalus induced tremor. rigeminal plate posteriorly. A portion of this lesion occupied
the posterior portion of the left red nucleus. No focal lesion
Case Report was seen on chest x-ray films.

Clinical history
An 8-year-old man was admitted to our hospital because of
tremor of the both arms. The symptoms appeared 2 years
earlier. The past history was nonspecific. The patient's ne-
urological examination showed no gait disturbance, brady-
kinesia or rigidity. An intentional tremor of the both hands

J Korean Neurosurg Soc 37

 KJ Lee, et al.

Preoperative treatment and shunt placement rivascular (Virchow-Robin) spaces. The tiny perivascular
CSF drainage of 30cc was done by lumbar puncture. The spaces (expanding lacunae) had no clinical correlate7).
patient's CSF pressure in lumbar puncture was 38mmHg The expanding lacunae in the mesencephalic tegmentum
(normal 15mmHg). The CSF analysis showed 11.4g/L proteins can be regarded as an additional rare cause of benign aque-
(normal 0.1~0.45g/L), 73mg/dl glucose (normal 50~80mg/dl), ductal obstrunction and noncommunicating normal-pressure
and no leukocyte (normal 10); no tumor cells or microorg- hydrocephalus4,8). In our patient, mesencephalothalamic la-
anisms were observed during the microscopic examination. cunae caused aqeuductal stenosis, therefore triventricular
After CSF drainage, the patient's score on the tremor scale was hydrocephalus developed. Hydrocephalus is a well-known
improved 16 to 7 and aggravated to 20 after 3 days. A CSF clinical entity comprising disorder of stance and gait, urinary
ventriculoperitoneal shunt with a programmable valve was urgency or incontinence, and dementia associated with vent-
inserted via a left Kocher's point. ricular enlargement3,10). In addition to the impairment of gait,
many patients with NPH complain of imbalance of stance,
Postoperative course difficulties with fine finger movements, tremor of the hands,
Neurological examination showed improvement of the both and impairment of handwriting2). The impairment of motor
hand tremor. The patient denied having any gait disturbance, function in the upper extremities and hand tremor were found
urinary urgency, or sudden falls. His score on the tremor scale in some patients, indicating that hydrocephalus may cause a
was 8 and his score on the MMSE 30/30. The shunt pressure more generalized motor disorder10). But like our case, only
was changed from 100mmH2O to 110mmH2O. Postoperative tremor is a rare and little-known sign of hydrocephalus.
MR imaging demonstrated resolution of the triventricular The mechanism by which the ventricular enlargement pr-
hydrocephalus and no interval change in the size of the me- oduces motor disturbances is not fully elucidated. The gait
sencephalic lacunae, which failed to enhance after admin- disturbances have been ascribed to stretching of fibers from
istration of contrast agent (Fig. 2). the precentral motor cortex as they course around the enlarged
lateral ventricles2). Although exact pathogeneses of hydroc-
ephalic tremor are uncertain, probably a fine, rapid hand
tremor may indicate involvement of frontal premotor areas
due to ventricular enlargement10). Therefore, the tremor was
successfully treated by CSF ventriculoperitoneal shunt pla-
cement if expanding lacunae do not cause symptoms per se.
The persistence of dorsal mesencephalic syndrome or rubral
tremor after CSF shunt placement indicate that expanding
lacunae may cause focal neurological dysfunction7). In our
case, tremor improved after CSF diversion.

Conclusion

Discussion R are cases of tremors that have resulted from hydroce-

phalus was reported. The tremor may be a result of hy-
drocephalus or lacunae at the mesencephalothalamic area on

T he lacuna is an uncommon cavity of the brain that is

filled with cerebrospinal fluid9). The cause is unclear, al-
though they are possibly a result of abnormally dilated periva-
MR findings. When located in the mesencephalothalamic
region, expanding lacunae can become symptomatic, pr-
oducing either triventricular hydrocephalus due to aqueductal
scular (Virchow-Robin) spaces that exert a mass effect on ad- obstruction or focal symptoms and signs due to the com-
jacent parenchyma and typically bulge into the ventricular pressive effect on adjacent brain parenchyma. Placement of a
cavities9). Based on pathological features, Poirier and Dero- CSF shunt or ventriculocisternostomy can treat the hydro-
uesn9) classified brain lacunae into three fundamental types : cephalus syndrome but does not modify the focal symptoms
Type I lacunae correspond to lacunar infarction; Type II and signs due to expanding lacunae in mesencephalic region.
lacunae correspond to small intraparenchymal hematomas; In our case, the expanding lacunae cause hydrocephalic
and Type III (expanding) lacunae correspond to dilated pe- tremor, and do not produce neurological symptom per se.
Hydrocephalus Induced Tremor

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