Holmes tremor is a rare, low-frequency, high-amplitude tremor that appears weeks to months after injury to the brainstem, thalamus or cerebellum — typically after stroke, haemorrhage, trauma, cavernoma or multiple sclerosis. It is present at rest, on posture and on action, is severely disabling, and responds poorly to medication. Deep brain stimulation is the most effective option available, and often requires more than one target.
At a glance
- Also called
- Rubral tremor, midbrain tremor
- Typical causes
- Brainstem or thalamic stroke or haemorrhage, cavernoma, head trauma, multiple sclerosis, tumour
- Delay after injury
- Usually weeks to months, sometimes longer
- Distinguishing feature
- Tremor present at rest, on posture and on action — unlike most other tremors
- Medication response
- Generally poor
- DBS targets used
- VIM; posterior subthalamic area (PSA/cZi); GPi — alone or in combination
- Expected outcome
- Meaningful reduction in most patients; complete abolition is less common than in essential tremor
Why Holmes tremor is difficult
Most tremors are generated by a relatively predictable circuit. Holmes tremor is generated by damage — the lesion disrupts cerebellar outflow and nigrostriatal pathways together, and the resulting tremor has components of several tremor types at once. That is why it appears at rest, on posture and on action, why it is so large in amplitude, and why a single classical target sometimes controls only part of it.
There is also an anatomical problem: the lesion that caused the tremor may itself distort the anatomy used for targeting, so standard atlas coordinates are less reliable and individual image-based planning matters more.
A case for double targeting
This is precisely the group that motivated the double-target approach published by Prof. YILMAZ and colleagues in Stereotactic and Functional Neurosurgery: a single electrode trajectory passing through both the VIM and the posterior subthalamic area, so that different contacts can address different tremor components, and the balance between them can be adjusted during programming without a second brain pass. Where a dystonic component is present, pallidal stimulation may be added.
In this practice's experience the double-target approach has changed what can be offered to this group. Patients who were told their tremor was untreatable have regained enough control to eat, dress and write again. Because Holmes tremor mixes rest, postural and action components, having two targets available on one lead means each component can be addressed in turn during programming rather than accepting whichever one a single target happens to control.
Peer-reviewed publicationDeep Brain Stimulation with Double Targeting of the VIM and PSA for the Treatment of Rare Tremor SyndromesYilmaz A, Eray HA, Çakır M, Ceylan M, Blomstedt P. Stereotactic and Functional Neurosurgery, 2024 · doi:10.1159/000539162 · PubMed 38934181Honest expectations
Patients with Holmes tremor are often severely disabled and have usually been told nothing can be done. It is important to be precise about what stimulation can offer. Substantial reduction in tremor amplitude — enough to restore feeding, dressing and basic independence — is a realistic goal in most appropriately selected patients. Complete abolition of tremor is less common than in essential tremor. Weakness, ataxia or sensory loss caused by the original lesion will not be improved by stimulation.
Timing also matters: it is usual to wait for the neurological picture to stabilise after the causative injury, since some spontaneous improvement can occur.
Frequently asked questions
What causes Holmes tremor?
Injury to the brainstem, thalamus or cerebellum — most often stroke or haemorrhage, cavernoma, head trauma, multiple sclerosis or tumour. The tremor typically appears weeks to months after the original event.
Can Holmes tremor be treated with DBS?
Yes, and DBS is currently the most effective treatment available for it, since medication rarely helps. Because the tremor has several components, a combined or double-target approach is often required.
Will DBS remove the tremor completely?
Substantial reduction is realistic in most selected patients; complete abolition is less common than in essential tremor. Weakness or coordination problems caused by the original brain injury will not improve.