A 60-year-old woman with a several year decline in gait and cognition developed a Holmes tremor in the weeks prior to presentation (video). Her right arm tremor predated the left arm tremor. She had no neurologic evaluation prior this presentation. MRI brain revealed lesions disseminated in time and space (figure 1) and CSF analysis revealed oligoclonal bands, confirming the diagnosis of multiple sclerosis.1 We implicate a lesion in the left inferior cerebellar peduncle (ICP) with associated fluid-attenuated inversion recovery hyperintensity in the contralateral inferior olivary nucleus in the pathogenesis of the left-sided rest, postural, and action tremor (figure 2). Lesions of the cerebellar circuits, including cerebello-thalamic and cerebello-olivary circuits, can manifest as a Holmes tremor.2 Our case of Holmes tremor due to an ICP lesion completes the discourse between Drs. Albin and Savoiardo3 in 1998.

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