To describe a case of pontine ischemic stroke presenting with paradoxical resolution of contralateral essential tremor.

Pontine ischemic strokes typically present with weakness, sensory loss, cranial nerve palsies, and ataxia. Multiple essential cerebello-thalamo-cortical tracts pass through the pons and play a critical role in modulating coordination and motor function. Although pontine strokes are well characterized for their motor and sensory manifestations, variations in a patient’s baseline neurological status can significantly alter the overall presentation of an ischemic stroke.

An 86-year-old right-handed woman with a history of essential tremor and multiple prior lacunar infarcts presented one day after femoral fracture surgery with new-onset facial droop and transient right arm weakness. Her preexisting bilateral essential tremor had been refractory to primidone and had significantly impaired her ability to perform fine motor tasks such as writing and feeding herself.

Neurological examination revealed mild right-sided facial weakness without sensory loss, dysmetria, or dysarthria. Brain MRI demonstrated a new 3-mm left paramedian ventral pontine lacunar infarct, with redemonstration of chronic small vessel disease and prior infarcts in the basal ganglia, cerebellum, and occipital lobe. Following the stroke, the patient noted complete resolution of her right-hand tremor, resulting in marked improvement in fine motor function and daily activities.

This case highlights a paradoxical phenomenon of essential tremor resolution following a pontine ischemic stroke. The findings suggest that small pontine lesions may disrupt components of the cerebello-thalamo-cortical pathway involved in essential tremor pathophysiology. Further neuroimaging and neurophysiological studies are warranted to elucidate the mechanisms by which brainstem lesions can modulate tremor activity.