Holmes Tremor Secondary to Brainstem Hemorrhage Responsive to Levodopa

Raina, Gabriela; Vélez, Miriam; Pardal, Manuel Fernández; Micheli, Federico

doi:10.1097/01.wnf.0000240957.56939.e6

Cited by 22 publications

(15 citation statements)

References 17 publications

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“…Causative lesions in Holmes’ tremor include multiple sclerosis [2], brainstem hemorrhage [3], ischemia, trauma [4], abscess, vascular malformations, and even neuroleptic or paraneoplastic disorders. To our knowledge, the current patient is only the second report of Holmes’ tremor secondary to intracranial germinoma [5].…”

Section: Discussionmentioning

confidence: 99%

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Steroid-responsive intracranial germinoma presenting as Holmes’ tremor: Importance of a tissue diagnosis

Strowd

Burger

Holdhoff

et al. 2015

Journal of Clinical Neuroscience

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Holmes’ tremor (rubral or midbrain outflow tremor) refers to a hyperkinetic movement disorder characterized by mild resting and more severe postural and action tremor often with associated brainstem symptoms, dystonia and cerebellar deficits. This syndrome should prompt lesional evaluation with neuroimaging focused on the dorsal midbrain, cerebellar outflow tracts, and thalamus. Herein we report a 26-year-old previously healthy male who presented with 4 years of progressive horizontal diplopia, right Parinaud syndrome, and appendicular ataxia. Neuroimaging revealed a right dorsal midbrain enhancing lesion which completely resolved with intravenous methylprednisolone prompting a diagnosis of neuroinflammatory syndrome. Subsequent clinical and radiographic evaluations, however, revealed steadily progressive left dorsal midbrain syndrome with an expansile enhancing lesion which culminated 4 years from symptom onset with a right upper extremity low-frequency rest, postural and action tremor, ataxic dysarthria, and mild right dystonia with dysdiadochokinesia. Uncomplicated brainstem biopsy confirmed intracranial germinoma and the patient underwent definitive radiation therapy with dramatic radiographic response and partial clinical improvement. This case, which to our knowledge is only the second report of intracranial germinoma presenting as Holmes’ tremor, highlights the critical importance of definitive tissue diagnosis in the evaluation of lesional brainstem pathology presenting as Holmes’ tremor. Steroid responsiveness can be seen in non-inflammatory pathology including intracranial germinoma. Prompt evaluation and appropriate treatment are important as Holmes’ tremor responds poorly to symptomatic therapies and response to radiation therapy is favorable for germinomas.

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Section: Discussionmentioning

confidence: 99%

“…In general, response to pharmacologic interventions in Holmes’ tremor is frequently unsatisfactory [3]. Biopsy of the causative lesion is mandatory in cases of diagnostic uncertainty so as to guide appropriate therapy.…”

Section: Discussionmentioning

confidence: 99%

Steroid-responsive intracranial germinoma presenting as Holmes’ tremor: Importance of a tissue diagnosis

Strowd

Burger

Holdhoff

et al. 2015

Journal of Clinical Neuroscience

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“…Some isolated cases of treatment with levodopa have occasionally been reported [9,10]. However, the therapeutic response to levodopa is variable.…”

Section: Discussionmentioning

confidence: 99%

Holmes Tremor After Brainstem Hemorrhage, Treated With Levodopa

et al. 2013

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Holmes tremor is a rare movement phenomenon, with atypical low-frequency tremor at rest and when changing postures, often related to brainstem pathology. We report a 70-year-old female patient who was presented with dystonic head and upper limb tremor after brainstem hemorrhage. The patient had experienced a sudden onset of left hemiparesis and right facial paralysis. Brain magnetic resonance imaging showed an acute hemorrhage from the brachium pontis through the dorsal midbrain on the right side. Several months later, the patient developed resting tremor of the head and left arm, which was exacerbated by a sitting posture and intentional movement. The tremor showed a regular low-frequency (1-2 Hz) for the bilateral sternocleidomastoid and cervical paraspinal muscles at rest. The patient's symptoms did not respond to propranolol or clonazepam, but gradually improved with levodopa administration. Although various remedies were attempted, overall, the results were poor. We suggest that levodopa might be a useful remedy for Holmes tremor. The curative or relieving effect of the dopaminergic agent in Holmes tremor needs more research.

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“…It is characterised by a 2–5 Hz, upper extremity tremor present at rest and exacerbated by posture or movement. Most commonly this tremor is associated with pathology of the upper brainstem including tumours, vascular insults and multiple sclerosis 6 , 7. Pathology in the thalamus is a less common cause although tumours, cysts, vascular insults and abscesses leading to Holmes’ tremor have been described 4 , 8 , 9.…”

Section: Discussionmentioning

confidence: 99%

“…Functional stereotactic surgery has also been used in the past and more recently deep brain stimulation has shown efficacy in a case of Holmes’ tremor caused by a thalamic abscess 9. Pharmacological treatment of Holmes’ tremor with levodopa or dopamine agonists may be beneficial, but results are disappointing in non-vascular aetiologies 7. We felt that, given the longstanding nature of the lesion and the minimal impact on the patient’s quality of life, watchful waiting was the appropriate management plan in this case.…”

Section: Discussionmentioning

confidence: 99%