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The Problems
Published in John Greene, Ian Bone, Understanding Neurology a problem-orientated approach, 2007
Holmes tremor was previously labelled as rubral, thalamic, and midbrain tremor and is caused by a lesion of the brainstem/cerebellum and thalamus. It is a slow (<4.5 Hz) rest and intention tremor which may not be as rhythmic as other tremors. There may be some delay between lesion (for example stroke) and tremor onset. Orthostatic tremor may present with a feeling of unsteadiness and is a fine fast tremor of the thighs on standing. Electromyography is required to confirm the typical 13–18 Hz frequencies.
MRI-verified “asleep” deep brain stimulation in Malta through cross border collaboration: clinical outcome of the first five years
Published in British Journal of Neurosurgery, 2018
Charmaine Chircop, Nicola Dingli, Annelise Aquilina, Ludvic Zrinzo, Josanne Aquilina
Other indications included in the first years of our functional neurosurgery programme were one patient with Primary Generalised Dystonia who received bilateral GPi DBS and one patient with left Holmes Tremor from a right subthalamic infarct sustained in early childhood. Both patients experienced improvement with a marked improvement of quality of life. The patient with Primary Generalised Dystonia that was crippling mobility to such an extent that she required institutionalisation now has an upright posture, normal mobility and lives independently with her new partner. The patient with Holmes Tremor is in gainful employment and is satisfied with the improvement in symptoms.
Magnetic resonance-guided focused ultrasound for the treatment of tremor
Published in Expert Review of Neurotherapeutics, 2022
Kazuaki Yamamoto, Can Sarica, Aaron Loh, Artur Vetkas, Nardin Samuel, Vanessa Milano, Ajmal Zemmar, Jürgen Germann, Cletus Cheyuo, Alexandre Boutet, Gavin JB Elias, Hisashi Ito, Takaomi Taira, Andres M Lozano
To understand the current landscape of research related to MRgFUS for tremors, we conducted a comprehensive search for active and previously registered clinical trials using two major trial databases: ClinicalTrials.gov and the World Health Organization’s International Clinical Trials Registry Platform (ICTRP). This search was conducted on 10 May 2022 using the search terms ‘tremor’ and ‘focused ultrasound’ or ‘FUS’ or ‘MRgFUS’ or ‘HIFU.’ We sought to reduce geographical bias by searching both major clinical trial registry databases. The results are summarized in Table 2 and Figure 2b. In total, 65 trials were identified (54 from ClinicalTrials.gov and 11 from the ICTRP). Removal of duplicate trials narrowed this count to 32, while the exclusion of unrelated trials resulted in a final selection of 29 clinical trials related to MRgFUS for tremor. Of these, the status was ‘completed’ in six trials (20.7%), while eight (27.6%) were ‘recruiting.’ Other statuses included ‘not recruiting’ in 11 trials (37.9%) and ‘unknown’ in four (13.8%). In four trials, staged bilateral thalamotomy for ET is being investigated. Although preliminary 3-month follow-up results have already been published, longer-term outcomes are awaited. While three trials employed nonspecific conditions and targets, other trials specified indications including ET in 20 trials, PD in 8 trials, and MS in 2 trials (trials involving multiple indications were counted in duplicate). The status of both trials of MRgFUS for tremor in patients with MS are marked ‘unknown,’ however, their results have not been published yet. As mentioned previously, MRgFUS for Holmes tremor has been published on a case report basis. The challenges of Holmes tremor include associated symptoms such as ataxia. This means that treating tremor may not improve patients’ quality of life when non-tremor symptoms are disabling in their daily life. Future investigations of MRgFUS for Holmes tremor may be appropriate in cases where the tremor is the major disabling factor and where treatment is likely sufficient to improve the patients’ quality of life.