Objective: –

Background: Holmes tremor is a rare etiology defined as a unilateral, irregular, <4.5 Hz rest and intention tremor which typically presents 4 weeks to 2 years from occurrence of the inciting lesion. Patients with Holmes tremor have higher rates of functional neurologic features than other tremor types.

Method: –

Results: We present a 17-year-old patient who developed left upper extremity tremor 10 months after gamma knife radiosurgery (GKRS) of a right arteriovenous malformation in the midbrain thalamus and hypothalamus. Symptoms developed with the onset of intracranial edema leading to diplopia, left hemiparesis, left hemibody dystonia, and left upper extremity tremor. Her tremor rapidly progressed over 6 months despite treatment with propranolol, primidone, and gabapentin and occupational and physical therapy. Her tremor worsened with stress and finger movements. Her tremor improved with arm elevation, cold water application, tactile pressure, and carrying heavy objects. She was started on levetiracetam due to generalized discharges on electroencephalogram (EEG); however, the tremor did not have an EEG correlate. She saw four different neurologists due to the physical and psychological burden of the tremor. She had a 504 plan at school for her hemiparetic gait, diplopia, and headaches which was escalated to an Individualized Education Plan (IEP) due to increasing tremor and pain. Decreased independence, social stigma, and school absence significantly impacted her mental health. She re-presented to our institution after being given the diagnosis of functional neurologic disorder and an unsuccessful response to therapy. On exam, she had left upper extremity postural, action, and rest Holmes tremor, and left arm and leg dystonia leading to a spastic gait. Botulinum toxin injection and deep brain stimulation were considered. She was successfully implanted approximately 1.5 years after tremor onset in the right ventro-intermediate thalamic nucleus (VIM). She had complete tremor capture 3 months after implantation.

Conclusion: We highlight the diagnostic and social challenges of a misdiagnosed young patient. This case demonstrates the importance of distinguishing Holmes tremor from functional tremor. Holmes tremor is always associated with a structural lesion. Radiation necrosis is a unique cause that led to rapid onset of symptoms; another overlapping feature with functional tremors. North Carolina Neurologic Society, 2/28/26.

References: Deuschl, G., Bain, P., Brin, M. and Ad Hoc Scientific Committee (1998), Consensus Statement of the Movement Disorder Society on Tremor. Mov. Disord., 13: 2-23. https://doi.org/10.1002/mds.870131303

Baizabal-Carvallo JF, Alonso-Juarez M, Jankovic J. Functional Neurological Disorders Among Patients With Tremor. J Neuropsychiatry Clin Neurosci. 2025 Winter;37(1):61-66. doi: 10.1176/appi.neuropsych.20230126. Epub 2024 Jul 22. PMID: 39034668.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/life-changing-diagnoses-distinguishing-holmes-tremor-from-functional-tremor/