Holmes Tremor Secondary to a Brainstem Haemorrhage With Partial Symptomatic Improvement Following Levetiracetam Use

Holmes tremor is a rare movement disorder linked to brainstem pathology and characterised by a combination of rest, postural, and intention tremors. These tremors are typically low frequency (<5 Hz), high amplitude, and often debilitating, significantly impairing rehabilitation and functional recovery. We present a man in his 30s with a right-sided brainstem haemorrhage of unknown aetiology who developed a delayed-onset, left-sided proximal upper limb tremor approximately one month after the initial insult. The tremor was initially attributed to anxiety and neuropathic pain, and treatment with gabapentin was ineffective. On specialist review, the tremor was identified as a high-amplitude, irregular, low-frequency 3 Hz tremor occurring at rest and exacerbated by posture and action, consistent with Holmes tremor. The patient was treated with titrated levetiracetam, resulting in partial but clinically meaningful symptomatic improvement, enabling greater participation in neurorehabilitation and discharge to a level 2a neurorehabilitation facility. Follow-up magnetic resonance imaging demonstrated hypertrophic olivary degeneration, supporting the diagnosis. Although tremor persisted and remained functionally intrusive, this case highlights the clinical features, underlying pathophysiology, and potential role of levetiracetam as a therapeutic option in the management of post-stroke Holmes tremor.