N/A

A 67-year-old male with history of pineal gland cyst (ventriculoperitoneal shunt) and hypertension developed acute right upper extremity rhythmic tremor that began 24 hours prior. Neurologic examination showed a 4.0 Hz rhythmic resting tremor throughout the exam that was non-distractible and remained consistent with kinetic movements and postures. EEG during the tremor did not show an epileptic basis. Head CT showed no acute abnormality. CT angiogram showed left proximal cervical ICA tapered occlusion, likely dissection. MRI Brain showed punctate foci of the precentral cortex of left frontal lobe consistent with acute ischemic infarctions. Encephalomalacia was present in bilateral posterior thalami and left midbrain consistent with chronic infarctions. He was not a thrombolytic candidate and began aspirin daily. Propranolol was initiated for the tremor however was ineffective. He is awaiting neurology follow-up.

This case suggests acute-onset Holmes tremor can be the sole presenting sign of an acute frontal cortical infarction. The pre-existing asymptomatic infarctions in the midbrain and thalamus suggest a “second hit” in the frontal cortex disinhibited a motor pathway between the cortex and rubral tract. We make two important points: (1)Holmes tremor may arise from a frontal cortical stroke, not just the more commonly known damage to the red nucleus or thalamic structures in the Mollaret triangle; (2)it can occur acutely as the primary manifestation of stroke, not just in a delayed manner.