Incisionless MR-Guided Focused Ultrasound for Holmes Tremor in Multiple Sclerosis

A right-handed 30-year-old woman with relapsing-remitting multiple sclerosis had medically refractory, left-predominant Holmes tremor-resting, postural (3-4 Hz), and intention-with rightsided nystagmus.The diagnosis met the 2024 McDonald criteria: demyelinating lesions disseminated in space (periventricular, midbrain/red nucleus, and superior cerebellar peduncles, with a positive central vein sign) plus CSF-specific oligoclonal bands.These lesions localized the tremor.She underwent unilateral right MR-guided focused ultrasound (MRgFUS) thalamotomy. 1 Ablation was staged by intraoperative response at the ventral intermediate (VIM, distal) and ventral oral posterior (VOP, proximal wing-beating) nuclei-analogous to dual-lead VIM/VOP deep brain stimulation (DBS). 2 Three targets were planned; the posterior subthalamic area was not ablated because of procedural intolerance.Tremor resolved (Figure, Video) and then partially recurred at 1 month.Compared with DBS, MRgFUS can offer a multitarget approach in a single treatment session.However, it potentially causes irreversible adverse effects and less durable clinical outcomes.