Limb Shaking and Orbital Bruit: Uncommon Manifestations of Severe Carotid Occlusive Disease (P05.220)

Abstract

Objective: To highlight the features of limb shaking transient ischemic attacks (TIA9s), an uncommon but treatable condition. Background Since Miller Fisher9s first description of limb-shaking syndrome in 1962, there have been less than 50 such cases reported in literature. Prompt recognition of this condition is important, as treatment is needed to prevent future ischemic stroke. Cephalic auscultation can serve as an invaluable clinical clue in making this diagnosis. Design/Methods: Case report. Results: A 72 year-old woman presented for evaluation of orthostatic spells of right leg clumsiness and rhythmic flailing, resulting in falls. Initial evaluation revealed a new iron-deficiency anemia. Colonoscopy revealed a malignant-appearing mass, suspicious for primary adenocarcinoma of the colon. Her spells became more frequent after starting metoprolol. Spell frequency decreased with blood transfusions. Neurologic examination revealed a harsh right orbital bruit and a soft left cervical bruit. MRI demonstrated subacute infarction of the left parieto-occipital region. MRA revealed a critical stenosis of the proximal left internal carotid artery (ICA) and a moderate stenosis of the right ICA. She was diagnosed with right-sided limb shaking TIA9s, culminating in infarction of the watershed territory between the left middle cerebral and posterior cerebral arteries. Conclusions: Often confused with focal motor seizures, limb shaking TIA9s are an uncommon manifestation of cerebral ischemia. The distinction is critical, as this form of TIA can indicate severe carotid occlusive disease, warranting urgent revascularization. A meticulous history reveals the rhythmic activity is not associated with a Jacksonian march and is mainly precipitated by orthostatic maneuvers. An orbital bruit is often associated with either stenosis or occlusion of the ipsilateral or contralateral ICA. Orbital bruits are attributed to turbulent blood flow through the collateral intracranial system. Such a technique can help neurologists to more promptly diagnose and treat this condition, preventing future ischemic stroke. Disclosure: Dr. Morparia has nothing to disclose.