Combination of thalamic Vim stimulation and GPi pallidotomy synergistically abolishes Holmes' tremor

The recent report of Kim et al ,1 who demonstrated that stereotactic surgical ablation of the thalamic nucleus ventrointermedius (Vim) markedly improved Holmes’ tremor in a patient with midbrain tumour, corroborated our earlier findings.2 In their patient, Vim thalamotomy alleviated tremor in both the distal and proximal segments of the upper extremity.1 However, controversy continues to surround the advisability of using this procedure for proximal tremors because the placement of larger lesions carries increased risks and the somatotopy of the proximal or truncal muscles remains obscure in the human Vim.3–5 Here we present a patient with a pontine haemorrhage in whom the combination of thalamic Vim deep brain stimulation (DBS) and globus pallidus internus (GPi) pallidotomy abolished Holmes’ tremor. This 53 year old right-handed man with a history of essential hypertension suddenly developed right hemiparesis and cerebellar ataxia in February 2000. He was admitted to a hospital where radiological examinations showed a left upper brainstem haemorrhage (fig 1A). His neurological state gradually improved. However, in October 2001 a coarse, slowly progressive tremor arose in his right upper extremity. It was severely disabling and he could not use his right arm. He was admitted to our hospital in December 2001. Figure 1  (A) Computed tomography (CT) scan showing a haematoma in the pontine tegmentum. (B, C) Axial views of T2-weighted magnetic resonance images at chronic stage (22 months after onset) demonstrating a haemosiderin ring around the lesion in the pontine tegmentum (B, arrow) and a high signal intensity area in the left …