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

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 as an 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.