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)