Ethan Izu, BS
Medical Student
California University of Science and Medicine
Irvine, California, United States
Brian Moreno, MD
Resident Physician
Shirley Ryan AbilityLab
Chicago, Illinois, United States
Priya V. Mhatre, MD
Attending Physician; Assistant Professor
Shirley Ryan AbilityLab/Northwestern University
Chicago, Illinois, United States
67 year-old female with Holmes tremor status post meningioma resection.
Case Description:
The patient presented with right-sided facial numbness and ataxia. MRI revealed a 2.6 x 3.5 x 3.1 cm dural-based mass along the right tentorial leaflet, suggestive of a giant meningioma, with mass effect on the temporal lobe, brainstem, and cerebellar peduncle. The meningioma was subsequently resected via a right retrosigmoid approach, complicated by postoperative left hemiparesis and a new, involuntary tremor affecting the entire right side of her body. Neurological evaluation revealed a low-frequency (< 4.5 Hz), large amplitude resting, postural, and action tremor, consistent with Holmes tremor (HT). Postoperative imaging showed new hypoattenuation in the right cerebral peduncle and restricted diffusion along the resection cavity margins. Gradual to near-complete improvement was observed with escalating doses of amantadine.
Discussions:
Holmes tremor is a rare tremor, with 155 cases reported between 1904 and 2016. Documented etiologies leading to HT include vascular changes, neoplasms, and neurodegenerative conditions. Although the pathophysiology is poorly understood, previously documented cases were attributed to midbrain lesions. Given HT’s prevalence following cerebrovascular accidents, we postulate that the perioperative changes affecting the midbrain most likely led to the tremor. However, it is known that HT can also arise with neoplasms, so the presence of space occupying meningioma potentially contributed. The tremor impaired the patient’s self-care activities of daily living (ADLs): on admission, she required primarily dependent to substantial/maximal assistance. Her progress in occupational therapy was initially limited due to frequent tremor with activity and rest; with uptitration of amantadine, the tremor showed gradual improvement. On discharge, she required partial/moderate to supervision assistance for ADLs.
Conclusions:
Holmes tremor is a rare, slow frequency, large amplitude tremor that arises from various etiologies and can affect self-care skills. Treatment with amantadine and occupational therapy within an acute inpatient rehabilitation setting can improve functional independence.
