Early Recurrence of Holmes Tremor after Radiofrequency Thalamotomy

A‐25‐year‐old male patient admitted due to right‐sided tremor which had started 8 years ago in his hand and progressed over the period spreading also to the lower limb within the last 5 years. The patient stated that the tremor disturbed seriously his daily living activities and that he could not maintain his job as a construction worker over the last 2 years due to tremor. The patient was born from consanguineous parents, and the medical or family history was unremarkable. The neurological exam at admission showed unilateral, high‐amplitude rhythmic oscillatory movements, present at rest and exacerbated with posture and additionally intensified with action on his right hand and leg. However, also a jerky component in the postural and action tremor causing repetitive, abnormal postures was observed considering dystonic features [Video 1]. Besides, a right‐sided dysmetria was also observed during the finger‐to‐nose testing. Other examinations including motor and sensory tests were within the normal limits. The cranial magnetic resonance imaging (MRI) was within normal limits without a lesion in the midbrain and thalamus. Based on the accompanying dystonia and dysarthria, primary dystonia was also considered among the differential diagnoses; however, the patient did not accept further genetic investigations. Previous medication attempts including levodopa/benserazide, baclofen, and clonazepam had not yielded any amelioration. The patient was re‐evaluated and radiofrequency (RF) thalamotomy was decided after obtaining the informed consent. During the operation, target coordinates were obtained by indirect Cartesian measuring based on schaltenbrand stereotactic brain atlas. The coordinates of target for thalamotomy were defined as: 6.3 mm posterior to the midpoint of anterior commissure (AC) and posterior commissure (PC) line and 14 mm lateral and parallel to AC–PC line. The microelectrode‐test‐stimulation was serially performed starting from 5 mm superior (−5 mm) to the target point and serially down within 0.5 mm intervals. The RF lesioning was performed when the patient was awake and the process was required to administer three times in distinct points to provide the desired clinical response (−4 mm, −3.5 mm, −3 mm). Permanent ablations were performed with a bipolar RF lesioning probe at 60–70°C and have lasted for longest 55 s for a unique target (−4 mm: 54 s, 60°C; −3.5 mm: 55 s 60°C + 15 s 70°C; −3 mm: 55 s 60°C + 15 s 70°C). The tremor had improved dramatically soon after the operation [Video 2]. The improvement was apparent in all types of tremors that was more significant at resting tremor; however, the leg tremor improved to a lesser degree. The patient stated that he could use his hand more comfortably and he defined marked improvement in his daily activities. However, the patient re‐admitted 1.5 months later after the operation due to re‐emerging of tremor [Video 3]. The deterioration was apparent at resting tremor. The jerky muscle contractions in his hand and marked dystonic posturing also accompanied to the clinic and, therefore, an additional globus pallidus internus‐deep brain stimulation (GPİ‐DBS) was considered to treat accompanying dystonic movements. However, the phenomenology of the clinic and the neuroimaging data were re‐evaluated. The recurrence had occurred rapidly, and the control MRI showed marked resolution of the lesion [Figure 1]. Taken together, the clinical recurrence was associated with acute resolution of the edema associated with the lesion and, considering that the patient was at the early period after surgery and RF associated lesion was at the dynamic phase, clinical follow‐up without an intervention was decided.