Case Report
A 25-year-old male presented to the outpatient clinic with a chief complaint of increased tremor in both upper extremities (Right > Left) without any weakness. He had a history of recurrent seizures since childhood for which he was under antiepileptic medication (Sodium Valproate) but workup on cause of seizure was not done in the past. Left sided weakness was present at birth which resolved as stated by the patient. There was no significant family history of neurological or psychiatric disorders. The patient was unemployed, a non-smoker, non-drinker, and denied any history of recreational drug use.
On physical examination, the patient was alert and oriented, with no signs of distress. His vital signs were within normal limits. Neurological examination revealed high amplitude moderate frequency resting tremor of both upper extremities with left sided weakness (Power 4/5 in both left upper and lower limb). Babinski reflex was negative bilaterally. Considering the possibility of tremor due to Valproate, antiepileptic regimen was changed to Levetiracetam.
MRI brain showed subtle T2 hyper intense curvilinear cleft communicating the lateral ventricle and subarachnoid space of right fronto-parietal convexity which is lined by closely apposed grey matter. Absence of the septum pellucidum is noted resulting direct communication between the lateral ventricles and squaring off of the frontal horns. (Figure 1 and 2). MR axial images through the level of optic nerve shows their normal morphology and normal morphology of bilateral globes (Figure 3)