480 a ground-shaking case limb-shaking as an unusual presentation of tias

Abstract

TIA is a very common reason for hospital admission, and typically presents with focal neurologic deficits including vision loss, limb weakness, and aphasia. Limb-shaking is a rare manifestation of TIA, and can easily be confused with a seizure. Distinction is critical, as Limb-Shaking TIAs are the result of severe carotid artery stenosis causing insufficient brain perfusion. In some rare instances, TIAs may be triggered by orthostatic situations. We present a case of repetitive Limb-Shaking TIAs secondary to critical left ICA steno-occlusive disease, and discuss the clinical manifestations, physiology, diagnosis, and management of this condition. A 65-year-old Caucasian female with a past medical history of hypertension, hyperlipidemia, pre-diabetes, migraine headaches, and tobacco use presented with frequent TIAs for 4 months. She reported weakness, numbness, and involuntary non-rhythmic shaking of her right arm and leg, disturbances in her left visual fields consisting of flashing lights, and diaphoresis for 4 months. Episodes would last less than 1 min and occur 1–2 times daily. Carotid ultrasound showed complete occlusion of left ICA, and 20%–30% narrowing of the right ICA. She was referred to vascular surgery, and started on 81 mg of Aspirin daily which resulted in decreased frequency episodes. Approximately 2 weeks later, she began to notice increased frequency of episodes up to 4 times daily, mainly occurring after standing from a supine position, or after walking long distances. The patient was subsequently noted to have postural tachycardia without postural hypotension. Due to concern for haemodynamic failure with activity, patient was placed on strict bed rest. CT angiography of the brain and neck matched ultrasound findings. EEG showed high amplitude, sharp contoured waves in the left temporal region without epileptiform phenomena. Additionally, MRI brain showed cerebral atrophy, bilateral small chronic ischaemic changes, and small subacute cerebral infarcts in the frontal lobes and left parietal lobe. Cervico-cerebral angiography revealed critical stenosis of the left ICA origin, and more than 80% stenosis of the right ICA origin. Patient was subsequently transferred to a different hospital for endarterectomy.