1. Video Competition MDS-PAS School For Young Neurologist Atlanta, GA, USA. 2015 Case 2

2. Female 38 years old. History

3. Video

4. Audience discussion Phenommenology Differential diagnosis Investigations

5. Diagnosis Holmes tremor Lacunar right paramedic mesencefalic stroke

6. Resting tremor of a limb with marked accentuation on action, intention, and goal-oriented movement.Resting tremor of a limb with marked accentuation on action, intention, and goal-oriented movement. Irregular / low freq (4.5 Hz)Irregular / low freq (4.5 Hz) Usually involves the upper extremities.Usually involves the upper extremities. Phenomenology Holmes´ Tremor (Rubral) Groppa S, et al.Brain 2013 Yan YW, et al. Acta Neurol Taiwan 2005

7. Localization The most common lesions are in the brainstem, cerebellum and thalamus. These localizations suggest involvement of both the nigrostriatal and dentato- rubro-thalamic pathways. The onset of Holmes’ tremor after stroke is typically delayed by weeks to months Groppa S, et al.Brain 2013 Bansil S, et al. Tremor Other Hyperkinet Mov 2012

8. Treatment PropranololPropranolol ClonazepamClonazepam Levodopa and other dopaminergic agentsLevodopa and other dopaminergic agents ValproateValproate Levetiracetam.Levetiracetam. Response to drugs is usually poor in these patients Many patients with Holmes’ tremor require surgical intervention, such as ventrointermedius thalamotomy and thalamic DBS Bansil S, et al. Tremor Other Hyperkinet Mov 2012