Holmes’ tremor refers to an unusual combination of rest, postural and kinetic tremor of extremities. Common causes of Holmes’ tremor include stroke, trauma, vascular malformations and multiple sclerosis, with lesions involving the thalamus, brain stem or cerebellum.¹ Although some drugs (eg, levodopa and dopaminergic drugs, clonazepam and propranolol) have been occasionally reported to give some benefit, medical treatment of Holmes’ tremor is unsatisfactory, and many patients require thalamic surgery to achieve satisfactory control.²

We report a patient in whom post-ischaemic Holmes’ tremor dramatically responded to levetiracetam treatment.

A 61-year-old right-handed man with a history of polycythaemia vera suddenly developed dizziness, diplopia and ataxia in February 2006. A CT scan showed a left cerebellar haemorrhagic infarction. Within a few days, his neurological state gradually improved. However, in March 2006, a coarse, slowly progressive tremor arose in his left upper extremity. On admission to our hospital, the man was alert and orientated. His blood pressure was 130/85 mm Hg and pulse 80/min. Serum electrolytes, urea, creatinine, bicarbonate, liver transaminases, thyroxine, triiodothyronine, and thyroid-stimulating hormone were normal. Blood analysis showed 5.8×10³ cells/mm³ of red blood cells, 17 g/dl …