Limb-Shaking Transient Ischaemic Attacks in Patients With Internal Carotid Artery Occlusion: A Case-Control Study

Abstract

Conclusion: Transient ischemic attacks (TIAs) marked by limb-shaking are associated with high-grade carotid stenosis or internal carotid artery occlusion and can be recognized by short duration and precipitation by rising or exercise. They are also accompanied frequently by paresis and indicate an impaired hemodynamic state of the brain. Summary: Case-reports have described limb-shaking as an unusual clinical feature of TIAs (Klijn CJ, et al [Neurology 2000; 55: 1806-12] and Firlik AD, et al [Neurosurgery 1996;39:607-11]). The limb-shaking characterizing these TIAs consists of brief, jerky, and coarse involuntary movements involving an arm or a leg and has been associated with high-grade stenosis or occlusion of the internal carotid artery (ICA). An unanswered question is whether patients with high-grade ICA stenosis or occlusion who have limb-shaking TIAs have a worse hemodynamic flow state than patients with ICA stenosis or occlusion who do not have limb-shaking TIAs. In this study the authors sought to describe clinical characteristics of limb-shaking in patients with TIAs or moderately disabling strokes associated with occlusion of the ICA. They also sought to investigate whether the hemodynamic state of the patients with limb-shaking is worse than in patients with symptomatic ICA occlusion without limb-shaking. The authors studied 34 patients (82% men; mean age, 62 ± 7 years) who had limb-shaking associated with ICA occlusion and 68 age-matched and sex-matched controls who had hemispheric TIAs or minor disabling strokes and ICA occlusion but who did not have limb-shaking. They investigated collateral pathways using contrast angiograms and also studied carbon dioxide reactivity measured by transcranial Doppler imaging. Limb-shaking TIAs were found to last <5 minutes and were often accompanied by paresis of the involved limb. Patients with limb-shaking TIAs compared with controls more frequently had symptoms precipitated by exercise or rising (odds ratio [OR], 14.2; 95% confidence interval [CI], 4.2-47.9). Patients with limb-shaking TIAs also more frequently had recurrent ischemic deficits after ICA occlusion before inclusion in this study (OR, 8.2; 95% CI, 2.3-29.3). Patients with limb-shaking TIA's also tended to have lower carbon dioxide reactivity (mean, 5% ± 16% vs 12% ± 17%; OR. 0.97 per 1% increase; 95% CI, 0.94-1.00). Patients with limb-shaking TIAs had a greater dependence on leptomeningeal collaterals (OR, 6.8; 95% CI, 2.0-22.7). Comment: Limb shaking as a manifestation of a TIA is a relatively unknown to most vascular surgeons. Most of these patients have ICA occlusion; 10% of patients with ICA occlusion will have limb-shaking TIAs. Some of these patients, however, have high-grade ICA stenosis rather than occlusion and therefore are of interest to the peripheral vascular surgeon. It is important to note that this particular form of TIA is likely hemodynamic and not embolic. Patients with limb-shaking TIAs undergoing carotid endarterectomy therefore, perhaps, should be strongly considered for shunting during the performance of the endarterectomy when technically feasible.