Temblor de Holmes, como manifestación única o predominante en lesiones cerebelosas de origen vascular / Holmes's Tremor as isolated or predominant manifestation in cerebellar lesions of vascular origin

Resumen El temblor de Holmes o rúbrico es infrecuente de ver como manifestación única o predominante de un accidente vascular encefálico cerebeloso. "Grosso modo" el temblor es un trastorno del movimiento habitual en la practica medica, siendo el fisiológico exacerbado el más frecuentemente visto; y el temblor esencial el más común de los movimientos involuntarios patológicos. Los estudios de neuroimágenes han concluido la importancia del cerebelo y de toda la vía cerebelotalámo-cortical en la patogénesis del temblor en general; sin dilucidar aun todas las estructuras involucradas entre las que se menciona a nivel molecular, las células de Purkinje. El temblor de Holmes es una manifestación extrapiramidal frecuente en lesiones cerebelosas de origen vascular; asociándose habitualmente a otra sintomatología de circulación posterior. Presentamos dos casos de temblor rúbrico o de Holmes como manifestación predominante de accidente vascular encefálico. Los autores concluyen que es posible este tipo de presentación, especialmente en pacientes con temblor de acción de inicio ictal, o en aquellos casos de temblor de reposo no parkinsoniano con mala respuesta a la L-Dopa; y en dichos casos, con lesión no mescencefálica, los pacientes podrían beneficiarse del uso de anticolinérgicos.

Holmes's tremor; or rubric tremor is infrequent as predominantly or unique manifestation of cerebellum stroke. Grosso modo tremor is a movement's disorder common in medical practice, being the physiological exacerbated type the most frequently seen, and the essential tremor the most frequently seen in pathological involuntary movements. Neuroimaging studies have concluded the importance of the cerebellum and of the entire cortical-cerebellar- thalamic pathway in the pathogenesis of tremor in general; without specifically of all the structures involved; but among which is mentioned at the molecular level the Purkinje cells. Holmes's tremor, is one of the frequently extrapyramidal manifestations of cerebellar lesions of vascular origin; and it is common to be associated with another symptomatology of posterior circulation. We present two cases of rubric Holmes tremor, as a predominant manifestation of stroke. The authors conclude that this type of presentation is possible, especially in patients with Holmes tremor with ictal onset, or in those cases of non-parkinsonian resting tremor that responds poorly to L-Dopa; and suggest that in such cases, with non-mesencephalic injury, patients could benefit from the use of anticholinergics.

Holmes' Tremor with Shoulder Pain Treated by Deep Brain Stimulation of Unilateral Ventral Intermediate Thalamic Nucleus and Globus Pallidus Internus

A 21-year-old male was admitted with severe right arm and hand tremors after a thalamic hemorrhage caused by a traffic accident. He was also suffering from agonizing pain in his right shoulder that manifested after the tremor. Neurologic examination revealed a disabling, severe, and irregular kinetic and postural tremor in the right arm during target-directed movements. There was also an irregular ipsilateral rest tremor and dystonic movements in the distal part of the right arm. The amplitude was moderate at rest and extremely high during kinetic and intentional movements. The patient underwent left globus pallidum internus and ventral intermediate thalamic nucleus deep brain stimulation. The patient improved by more than 80% as rated by the Fahn-Tolosa-Marin Tremor Rating Scale and Visual Analog Scale six months after surgery.

Holmes Tremor After Brainstem Hemorrhage, Treated With Levodopa

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.