Video Competition

MDS-PAS School For Young NeurologistAtlanta, GA, USA. 2015

Case 2

Case 2

Female 38 years old.

History

Hemiparesis after pituitary macro adenoma surgery followed months after by rest and postural tremor, right arm incoordination

and gait with mild dystonic posture on her right leg.

Video

Audience discussion

PhenommenologyDifferential diagnosis

Investigations

DiagnosisHolmes tremor

Lacunar right paramedic mesencefalic stroke

• Resting tremor of a limb with marked accentuation on action, intention, and goal-oriented movement.

• Irregular / low freq (4.5 Hz)

• Usually involves the upper extremities.

Phenomenology

Holmes´ Tremor (Rubral)

Groppa S, et al.Brain 2013Yan YW, et al. Acta Neurol Taiwan 2005

LocalizationThe most common lesions

are in the brainstem, cerebellum and thalamus.

These localizations suggest involvement of both the nigrostriatal and dentato-rubro-thalamic pathways.

The onset of Holmes’ tremor after stroke is typically delayed by

weeks to monthsGroppa S, et al.Brain 2013

Bansil S, et al. Tremor Other Hyperkinet Mov 2012

Treatment• Propranolol

• Clonazepam

• Levodopa and other dopaminergic agents

• Valproate

• Levetiracetam.

Response to drugs is usually poor in these patients

Many patients with Holmes’ tremor require surgical intervention, such as ventrointermedius

thalamotomy and thalamic DBSBansil S, et al. Tremor Other Hyperkinet Mov 2012