Echoes of Childhood Trauma - A Rare Case of Holmes Tremor With Neuroanatomic Imaging and Video Evidence

Q: What distinguishes Holmes (rubral) tremor from essential and cerebellar tremors?

Holmes tremor is characterized by an irregular, low-frequency (about 2–4 Hz) tremor with high amplitude that can occur at rest, with posture, or with action, producing a distinctive diagnostic profile compared with essential and cerebellar tremors.

Q: What role did imaging and treatment play in the case?

MRI showed a small right thalamic lesion in 1997 that remained unchanged on a 2022 MRI. The tremor showed partial responsiveness to levodopa therapy, supporting the clinical relevance of the underlying neuroanatomic cause.

Sep 28, 2026

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Neurologic tremors represent a heterogeneous group of movement disorders that are difficult to classify because clinical signs often overlap. Parkinsonian, essential, and cerebellar tremors are commonly recognized, while less frequent causes, including thalamic infarction, may be missed. The report describes a 53-year-old woman with a coarse low-frequency Holmes (rubral) tremor linked to a right thalamic lesion, partial levodopa responsiveness, and imaging stability from 1997 to 2022.

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CategoryHealthcare

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Abstract

Introduction

Case Presentation

How to Cite This Article

Review began 11/06/2025 Review ended 11/27/2025 Published 12/03/2025 © Copyright 2025 Prasad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98408 Open Access Case Report Echoes of Childhood Trauma: A Rare Case of Holmes Tremor With Neuroanatomic Imaging and Video Evidence Ridhika Prasad 1 , Dalia Gazallo 1, Robert J. Coni 2 1. School of Medicine, Burrell College of Osteopathic Medicine, Las Cruces, USA 2. Preclinical Medicine, Burrell College of Osteopathic Medicine, Melbourne, USA Corresponding author: Robert J. Coni, [bconi@burrell.edu](bconi@burrell.edu) Abstract Neurologic tremors constitute a heterogeneous group of movement disorders that are often challenging to classify due to overlapping clinical presentations. While Parkinsonian, essential, and cerebellar tremors are among the most frequently encountered types, rarer causes such as thalamic infarction may be easily overlooked. We describe a rare case of tremor secondary to thalamic infarction, emphasizing its relevance asan uncommon yet clinically important etiology within the spectrum of neurologic tremors. Focal midbrain lesions can produce a distinctive coarse tremor, referred to as Holmes or rubral tremor, arising from disruption of the dentatorubrothalamic pathway. We report the case of a 53-year-old right-handed woman who presented with a left-sided, 4-Hz coarse tremor evident at rest and with action, demonstrating partial responsiveness to levodopa therapy. The tremor began shortly after a closed head injury at age six, accompanied by left-sided numbness and persistent motor control difficulties beginning within a few weeks. An MRI in 1997 revealed a small infarct-like lesion in the right thalamus, unchanged on a 2022 MRI. Misdiagnosed initially as a conversion reaction, she later received a diagnosis of "essential tremor with Parkinsonian features " and was treated with primidone and intermittent carbidopa-levodopa. The tremor impacts her work as a dental hygienist, but levodopa provides partial relief. Holmes tremor, characterized by low-frequency (2-4 Hz) high-amplitude tremors at rest, with movement, or in posture, is distinct from essential and cerebellar tremors. This case illustrates the rarity of this particular tremor, highlights its distinction from other tremors, and demonstrates potential treatments, including levodopa, thalamotomy, and deep brain stimulation. Categories: Neurology, Trauma, Internal Medicine Keywords: clinical neuroanatomy, closed head injury, holmes tremor, levodopa-carbidopa, neurology case report, post-traumatic movement disorder Introduction Holmes tremor (HT), also called “rubral tremor,” was first described in 1904 by Dr. Gordon Morgan Holmes and is a rare and complex clinical phenomenon characterized by an irregular, low-frequency tremor (2-4 Hz) with high amplitude. This tremor may manifest as resting, postural, or intentional components, either independently or concurrently, and it predominantly involves the proximal limbs [1] . Unlike essential tremor, which is higher in frequency (6-12 Hz) and affects multiple body parts, or cerebellar tremor, which is similarly low-frequency (<5 Hz) but primarily occurs during voluntary movements or while maintaining posture, HT presents a unique diagnostic challenge [2] . The etiology of HT is diverse, encompassing traumatic injuries, infections, demyelination, and ischemic or hemorrhagic cerebrovascular disorders [1] . It typically emerges following a latent period of 1 to 24 months after an initial neurological insult, during which time the tremor begins to develop. HT is frequently attributed to structural lesions within the upper brainstem, thalamus, or cerebellum, disrupting the cerebellar outflow pathways [3] . Alt

FAQs

What distinguishes Holmes (rubral) tremor from essential and cerebellar tremors?

Holmes tremor is characterized by an irregular, low-frequency (about 2–4 Hz) tremor with high amplitude that can occur at rest, with posture, or with action, producing a distinctive diagnostic profile compared with essential and cerebellar tremors.

How did the patient’s tremor begin and what early event was linked to it?

The tremor began shortly after a closed head injury at age six, when she was struck on the head, lost consciousness, and later developed persistent difficulty with motor control alongside left-sided numbness.

What role did imaging and treatment play in the case?

MRI showed a small right thalamic lesion in 1997 that remained unchanged on a 2022 MRI. The tremor showed partial responsiveness to levodopa therapy, supporting the clinical relevance of the underlying neuroanatomic cause.

Sep 28, 2026

Uploaded by Kurz