Rubral tremors, or Holmes’ tremors, are a type of movement disorder that appear post-cerebellar/thalamic injury. Optimal treatment approaches for rubral tremors are still being understood and include pharmacological options such as dopamine precursors, anticonvulsants, and anticholinergics, as well as deep brain stimulation of thalamic nuclei. Our patient was a 72-year old man who presented to the E.D. for evaluation after new-onset unilateral jerking and tremors, two months after a hemorrhagic cerebrovascular accident with craniotomy and residual deficits including right-sided upper extremity hyperflexion & hemineglect, right-sided lower extremity motor weakness, and aphasia. The tremors were visibly present in his right lower extremity, occurring every 2-3 seconds with a sharp amplitude of 3-5 inches, present at rest and worsening with intentional movement. The tremors were not visibly present in his right upper extremity, likely due to stiffness from previous CVA deficits, but tremors were easily felt through palpation. Our patient was previously able to ambulate on his own; however, after onset of these tremors, he was no longer able to ambulate. Our patient was first treated with levetiracetam, to which he reported minimal improvement in tremor frequency, amplitude, and pain. However, tremors were still observed. Levetiracetam was discontinued, and our patient was started on divalproex sodium. He reported resolution of symptoms within 24 hours, with continued improvement persisting over the next week. The right lower extremity tremors were no longer visibly present and were only mildly present upon palpation, occurring every 5-6 seconds with a pulsing sensation. Our patient reported immense relief in pain and discomfort and was able to safely ambulate with assistance. Per this case, divalproex sodium has shown to be highly effective in resolving symptoms of rubral tremors. No pharmacological agent has been formally identified as a first-line agent for rubral tremors, with most references typically suggesting levadopa for treatment. In our patient, divalproex sodium was chosen over levadopa to avoid the large side effect profile of levadopa. Because divalproex sodium was so efficacious in our patient, we suggest that further study would be beneficial to understand the safety and generalizability of divalproex sodium treatment for other cases of rubral tremors, especially when compared with other pharmacological agents.
What will audience learn from your presentation?
? Minimal cases of rubral tremor resolution have been described in literature, most of which describe effectiveness of levodopa and/or deep brain stimulation. Only 2-3 case reports specifically describe benefits of valproic acid therapy. This abstract offers more evidence for the effectiveness of divalproex sodium, allowing a more comprehensive understanding and contribution to the library of pharmacological treatments available for rubral tremors.
? Levodopa and deep brain stimulation include many side effects, such as dizziness, forgetfulness, and confusion, as well as the risks of surgical procedures. Divalproex sodium allows efficacious therapy with minimal side effects. As a result, it would be worthwhile to compare the effectiveness of levodopa, deep brain stimulation, and divalproex sodium in order to maximize the efficacy of therapy while decreasing side effects.
? This abstract can raise awareness that divalproex sodium is an efficacious agent in treating rubral tremors. 6th International Conference on Neurology and Brain Disorders | October 24-26, 2022 Further study of divalproex sodium can contribute to shaping guidelines for treatment for rubral tremor treatment within an in-patient setting, providing physicians with evidence-based information to properly care for their patients.
? This abstract also opens up many other avenues regarding exploring the pharmacological effects and functions of divalproex sodium within the human body, specifically with movement disorders.