Günther Deuschl

Background Re‐emergent tremor is characterized as a continuation of resting tremor and is often highly therapy refractory. This study examines variations in brain activity and oscillatory responses between resting and re‐emergent tremors in Parkinson's disease. Methods Forty patients with Parkinson's disease (25 males, mean age, 66.78 ± 5.03 years) and 40 age‐ and sex‐matched healthy controls were included in the study. Electroencephalogram and electromyography signals were simultaneously recorded during resting and re‐emergent tremors in levodopa on and off states for patients and mimicked by healthy controls. Brain activity was localized using the beamforming technique, and information flow between sources was estimated using effective connectivity. Cross‐frequency coupling was used to assess neuronal oscillations between tremor frequency and canonical frequency oscillations. Results During levodopa on, differences in brain activity were observed in the premotor cortex and cerebellum in both the patient and control groups. However, Parkinson's disease patients also exhibited additional activity in the primary sensorimotor cortex. On withdrawal of levodopa, different source patterns were observed in the supplementary motor area and basal ganglia area. Additionally, levodopa was found to suppress the strength of connectivity ( P < 0.001) between the identified sources and influence the tremor frequency‐related coupling, leading to a decrease in β ( P < 0.001) and an increase in γ frequency coupling ( P < 0.001). Conclusions Distinct variations in cortical–subcortical brain activity are evident in tremor phenotypes. The primary sensorimotor cortex plays a crucial role in the generation of re‐emergent tremor. Moreover, oscillatory neuronal responses in pathological β and prokinetic γ activity are specific to tremor phenotypes. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.