Objective: To report a case of an adult Filipino male who developed delayed complex post-stroke movement disorders following a pontine hemorrhage.

Background: Holmes tremor (HT) is a rare, delayed-onset movement disorder most often associated with structural brain lesions, particularly involving brainstem–cerebellar networks. Palatal tremor (PT) is another uncommon post-lesional movement disorder, typically linked to hypertrophic olivary degeneration (HOD) following disruption of the Guillain–Mollaret triangle (GMT). The coexistence of HT and PT is exceedingly rare, and their concurrence with additional movement disorders has not been well described.

Method: *case report*

Results: We report a 37-year-old Filipino man who developed a complex constellation of delayed post-stroke movement disorders following a hypertensive pontine hemorrhage. Six months after stroke onset, he developed a disabling right upper-limb Holmes tremor, followed by palatal tremor, blepharoclonus, and post-facial palsy synkinesis. Neuroimaging demonstrated bilateral hypertrophic olivary degeneration, supporting involvement of the dentato–rubro–olivary network. Medical therapies were largely ineffective. Given severe functional impairment, the patient underwent dual-target deep brain stimulation of the contralateral ventral intermediate nucleus of the thalamus and posterior subthalamic area, with initial improvement in tremor.

Conclusion: This case highlights a unique and previously unreported combination of post-stroke movement disorders arising from a single pontine lesion. Disruption of the Guillain–Mollaret triangle and adjacent brainstem motor pathways, such as the eyelid and facial motor pathways, provides a unifying anatomical and pathophysiological framework for this presentation and underscores the importance of network-based mechanisms in delayed post-stroke movement disorders.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/disabling-holmes-tremor-following-pontine-hemorrhage-accompanied-by-a-unique-constellation-of-movement-disorders/