Clinical Reasoning: A 60-Year-Old Woman With a Palpable Tremor of the Lower Extremities Upon Standing, 2025, Lucia Liao et al

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Mij

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Abstract​

We present the case of a 60-year-old woman with a palpable leg tremor on standing. This case highlights the need to consider a broad range of potential causes, particularly in cases with atypical presentations. The discussion offers an overview of how the final diagnosis was evaluated and treated.

Section 1​

A 60-year-old woman with diabetes and a family history of Parkinson disease presented with a six-month history of progressive unsteadiness, stiffness, and fatigue in her legs. Her symptoms were most pronounced while standing and walking long distances and were relieved by sitting or leaning. She denied any symptoms of headaches, cognitive deficits, falls, pain, vision changes, sensory changes, tremors, muscle cramps, weakness, dizziness, lightheadedness, or numbness. She reported no recent illness or changes in medications, diet, or daily routine. Medications, caffeine, and walking in place had no effect on the patient's symptoms.

Neurologic examination revealed normal muscle tone and bulk, full upper and lower extremity strength, and intact sensation. Reflexes assessed at the triceps, biceps, brachioradialis, patellar, and Achilles tendons were graded as 3+ on the left and 2+ on the right. There was no clonus, and plantar reflexes were downward bilaterally.

No visible tremor was noted in the head, jaw, or limbs, and no vocal tremor was present. However, a widened stance was observed on standing, and a high-frequency tremor was detected with palpation of the bilateral lower extremities. Gait was narrow and steady, and heel and toe walking were intact. She was able to tandem walk with mild difficulty. There were no cranial nerve deficits, fasciculations, gait disturbances, bradykinesia, dystonia, or signs of ataxia.
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Questions for Consideration:​

1.
What are the characteristic imaging findings for spontaneous intracranial hypotension?
2.
What are the possible clinical presentations of spontaneous intracranial hypotension?

Section 4​

Diffuse and smooth thickening of the pachymeninges with gadolinium enhancement, as seen on this patient's MRI, is pathognomonic for spontaneous intracranial hypotension (SIH). Additional brain MRI features associated with SIH can be remembered using the mnemonic SEEPS: subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain. However, it is important to note that brain MRI findings are normal in approximately 20% of patients with SIH

MRI of the complete spine without contrast with fat-suppressed T2-weighted sequences is also an appropriate initial imaging test for suspected SIH. Supporting findings may include dilated veins, dural enhancement, meningeal diverticula, syringomyelia, or extradural fluid collections. A CT myelogram is the gold standard for spinal CSF leak localization.

However, like MRI brain imaging, spine imaging findings can be normal in patients with SIH.
SIH typically presents with orthostatic headache, or headache that occurs with upright positioning and resolves when lying flat. However, brain descent and traction on cranial structures from low CSF pressure on standing can lead to a wide clinical spectrum of orthostatic symptoms, including neck pain, nausea, interscapular pain, diplopia, tinnitus, changes in hearing, dizziness, and cranial nerve findings.

While head pain is common, presentations without head pain have also been documented. In this case, the patient denied head pain or other orthostatic features but noted mild left-sided tinnitus and muffled hearing.

The patient was treated with a CT-guided high-volume, untargeted epidural blood patch. Four weeks later, her symptoms significantly improved, and the orthostatic tremor resolved over several months.

A follow-up brain MRI at 4 months confirmed the resolution of abnormal findings
 

Conclusion​

This patient fit the classic demographic profile for primary orthostatic tremor; however, the presence of hyperreflexia on examination raised concern for a secondary cause. MRI brain imaging suggestive of SIH and the resolution of symptoms after SIH treatment indicate that the patient's orthostatic tremor was secondary to SIH.

While SIH without head pain is uncommon, its presentation as orthostatic tremor is even rarer. This case underscores the broad spectrum of clinical manifestations associated with SIH and highlights the role of neuroimaging in raising the suspicion of SIH in patients who otherwise lack classic symptoms.
 
That leg tremor only showing up when standing and the stronger reflexes on one side make me think there might be some subtle nervous system involvement, maybe early Parkinson’s or something else affecting the spinal cord or nerves. The fact that strength and sensation are normal is a good sign, but the tremor and stiffness still need a closer look.
 
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