Jamir Pitton Rissardo

@theneurolander

Nov 29, 2022 • 21 tweets • 11 min read • Read on X

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Wing-beating tremor!!!

“pseudosclerotic, parkinsonism, and dystonic/choreic forms of Wilson’s disease”

American-born British neurologist Samuel Alexander Kinnier Wilson (1878–1937)

#MedTwitter #neurotwitter #EndNeurophobia #tweetorials

1/

Pathophysiology

“lesion in the dentatorubrothalamic pathway”

- cerebellar outflow pathway

Complex phenomenology
- dystonic, myoclonic, rhythmic tremor?

https://twitter.com/theneurolander/status/1591933986753880067

2/

Definition

“low-frequency, high-amplitude, posture-induced proximal arm tremor, elicited by sustained abduction of the arms, with flexed elbows and palms facing downward”

- postural tremor
- wing-beating posture

3/

Wing-beating tremor – features

- low frequency & high amplitude
> inc amplitude w/ inc duration of posture holding

- posture-induced
- proximal arm tremor

4/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

doi.org/10.1056/nejmic… via: NEJM

5/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor
💡double panda sign

doi.org/10.1002%2Fmdc3… via: Mov Disord Clin Pract

6/

Wing-beating tremor: Creutzfeldt-Jakob Disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor
💡myoclonus?

doi.org/10.1001/jamane… via: JAMA Neurol

7/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor
💡zolpidem-responsive

doi.org/10.1002%2Fmdc3… via: Mov Disord Clin Pract

8/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor
💡after liver transplantation

doi.org/10.1016/j.jocn… via: Journal of Clinical Neuroscience

9/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

doi.org/10.1007/978-1-… via: Movement Disorders: A Video Atlas

10/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor
💡dimercaprol-responsive

doi.org/10.4103%2F0972… via: Ann Indian Acad Neurol

11/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor
💡 Face of a Giant Panda

doi.org/10.7759/cureus… via: Cureus

12/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

doi.org/10.1016/j.ncl.… via: Neurologic Clinics

13/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Neurology Made Interesting

14/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Neurology Made Interesting

15/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Dr Zubin Sharma

16/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Kaveh Shafiei

17/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Prakash Harischandra

18/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Dr. Waqas Khan

19/

Wing-beating tremor: Wilson's disease

- low frequency & high amplitude
- posture-induced
- proximal arm tremor

via: Dr.Syed Raza Hussain

20/

“We don't always observe true 'wing beating tremor' like Kinnier Wilson described, however when we see it; it can be dramatic”

@MichaelOkun @VUMCneurology

https://twitter.com/MichaelOkun/status/1568644652777230337

21/

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More from @theneurolander

Jamir Pitton Rissardo

@theneurolander

Feb 1

Syncope vs Seizure

Fainting by love in Philadelphia Museum of Art
The Doctor's Visit by Jan Steen

#Neurology #Seizure #Syncope #Neuroscience

1/

Syncope spectrum

-Normal
-Prodrome→ early autonomic sx
-Presyncope→ near-syncope
-Intermediary→ gray-out/ syncope threshold
-Syncope
-Recovery

2/

Clinical history

What EXACTLY happened before, during, and after the event?

-open-ended quest at begining, than close
-LOC, incotinence
-Witness and recurrence
*avoid term fainting
-Triggers (sleep dep, drugs, stand) vs premonitory symptoms

3/

Jamir Pitton Rissardo

@theneurolander

Jan 29

Cognitive Changes

Alois Alzheimer (1864 – 1915), German psychiatrist and neuropathologist

1/

Referral

-word-finding difficulty (tip-of-the-tongue phenomenon)
-memory complaints (often vague, sometimes language-related)
-dissect complaints into domains

2/

Cognitive Domains

Use SAMPLE

-Social→ behavior
-Attention→ focus
-Memory→ retention
-Perceptual/ visuospatial→ navigation
-Language→ only language
-Executive function→ multisteps

3/

Jamir Pitton Rissardo

@theneurolander

Jan 25

Headache - Basics

Figure from Codex Vindobonensis 93 (12th century)

1/

Primary or Secondary?

1st question - onset

Hyperacute→ think vascular
Acute/subacute→ broader ddx
Chronic→ reassure if unchanged

Use SNOOP4 for screen secondary causes

2/

Characterize

-Pain features - "SOCRATES"
> quality (throbbing, pressure, stabbing)
> duration & frequency
> associated sx (photo/phonophobia, N/V, auto sx)

3/

Jamir Pitton Rissardo

@theneurolander

Jan 19

Diagnosing Neuropathy
Clinical Pearls

"There are numbness, tingling, and burning pains in the feet, with weakness of the legs, so that the patient walks with difficulty and unsteadiness"

Sir William Osler (1849 – 1919), Canadian physician

1/

Presentation
Referral "neuropathy," self-dx googling numbness/tingling
-hard≠numbness≠tingling≠weak

-true negative sx (loss) are more specific
>unable feel floor T°
>unable sense sand/cold surfaces

-positive sx (gain) are non-SP
>dd: CVI, MSK, compression, positional
2/

Localizing

P.neuropathy patterns
-stocking-glove distribution
>1st stocking (knee) level → 2nd hands: likely DM
-dist → prox progression in limbs
-symmetric sensory loss

3/

Jamir Pitton Rissardo

@theneurolander

Jan 12

Tuning Forks

"If you want to find the secrets of the universe, think in terms of energy, frequency, and vibration"

Nikola Tesla (1856 –1943), Serbian-American engineer

1/

History

1550 Gerolamo Cardano - transmission of sound per skull
1684 Schelhammer - fork to differentiate hearing disorders
1711 John Shore - invented TF
1834 Johann Heinrich Scheibler - different frequencies
1855 - Weber test
1870 - technical improvements

2/

TF Parts

Prongs (wings), stem (handle), and foot (base)

3/

Jamir Pitton Rissardo

@theneurolander

Oct 12, 2025

Head (Holocephalic) tremor

"... is just an irritation..."

Katherine Hepburn

1/

imdb.com/pt/name/nm0000031/?reasonForLanguagePrompt=browser_header_mismatch

ET

- no-no
- type 1 (enhanced) & 2 (msc activation not req for posture)
- ET meds, if no response botox

2/ youtube.com/shorts/uMA_wPY…

PD

- yes-yes
- jaw & lip→ PD

3/

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