EpistemisIntentional tremor
Specialty: Neurology.
Why it occurs
- Multiple sclerosis (demyelination plaques in the superior cerebellar peduncle or deep cerebellar nuclei)
- Cerebellar ischemic or hemorrhagic stroke
- Wilson's disease (hepatolenticular degeneration with copper deposition in the basal ganglia and cerebellum, producing the classic "wing-beat" tremor)
- Chronic intoxication by drugs (lithium, phenytoin, amiodarone) or heavy metals (mercury)
- Degenerative spinocerebellar ataxias (SCA)
Initial workup
Finger-nose or finger-finger maneuver showing the increase in tremor amplitude as the limb approaches the target; brain MRI with emphasis on the posterior fossa and cerebellum; quantification of ceruloplasmin and serum free copper, as well as 24-hour urinary copper excretion; toxic screening and drug levels.
red flags
Violent intentional tremor of rapid unilateral onset associated with sudden headache, absolute inability to remain upright (astasia) and paralysis of conjugate lateral gaze, suggestive of infarction or acute cerebellar hemorrhage.
Standard management
- Clonazepam — 0.5-4 mg/day, can partially mitigate the amplitude of cerebellar tremor by GABAergic potentiation
- Primidone — 50-250 mg/day, moderate efficacy
- Propranolol — 40-120 mg/day, with less response than in essential tremor but useful in some patients
- Chelating treatment with Penicillamine or Trientine if Wilson's disease is confirmed.
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Neurology
- Listed causes
- 5
- Treatment options
- 4