Limb-shaking Transient Ischemic Attacks Research Articles

Physiological provocation compared to acetazolamide in the assessment of cerebral hemodynamics: a case report

BackgroundSevere large vessel disease may lead to cerebral hemodynamic failure that critically impairs cerebral blood flow (CBF) regulation elevating the risk of ischemic events. Assessment of the condition is often based on changes in CBF during vasodilatation; however, pharmacologically induced vasodilation does not reflect the physiological condition during an ischemic event caused by hemodynamic failure. We compared a [15O]H2O PET brain scan during vasodilation to a [99mTc]HMPAO SPECT brain scan during an ongoing transient ischemic attack (TIA).Case presentationA single patient presenting with limb-shaking TIA underwent CT, Digital Subtraction Angiography, and two different modalities of cerebral perfusion scans: [15O]H2O PET and [99mTc]HMPAO SPECT. Acetazolamide was used in the PET scan to induce vasodilatation, and during the SPECT scan physiological stress, standing up rapidly, was used to induce limb-shaking TIA. CT-angiography and Digital Subtraction Angiography revealed an occlusion in the distal part of the right A2 segment of the anterior cerebral artery, with a corresponding infarction in the watershed area. Collaterals supplied the main vascular territory of the anterior cerebral artery. During rest, neither perfusion modalities demonstrated reduced perfusion outside of the ischemic core. However, we found a pronounced difference between the PET utilizing acetazolamide and the SPECT during the TIA. The PET scan demonstrated relative hypoperfusion in vascular territory supplied by collaterals, while the area around the ischemic core was not affected. Contrary, the SPECT had only minor relative hypoperfusion in the collateral-supplied area, whereas the watershed area proximal to the infarct core had pronounced relative hypoperfusion.ConclusionsThe observed discrepancy in compromised areas during physiological provocation compared to pharmacological induced vasodilation questions the use of an unphysiological stressor for assessment of cerebrovascular hemodynamics. A physiological provocation test may achieve more clinically relevant evaluation.

An Unusual Presentation of Cryptogenic Pulmonary Mucormycosis Related to COVID-19 Infection - A Case Report

Introduction: We present a unique and rare case of post-COVID cryptogenic primary pulmonary mucormycosis manifesting with nonspecific 3-week history of low-grade fever and fatigue but without any localizing symptoms related to the chest. Material and Method: The first symptom which suggested a sinister underlying illness was limb-shaking TIAs (Transient Ischemic Attacks) related to hematogenous intracranial vascular spread of the infection. This was followed by a corpus callosal hemorrhage due to rupture of a mycotic aneurysm. Discussion: Mycotic intracranial aneurysm (MIA) from Mucor species is most often the result of extravascular spread from skull base infections though they may rarely occur due to hematogenous seeding. The case highlights the need for high index of suspicion in the appropriate clinical setting for a possible post-COVID cryptogenic pulmonary Mucor infection. We present a unique and rare case of an MIA in a patient with a cryptogenic primary pulmonary mucormycosis, without any evidence of associated sinus or skull base Mucor involvement.

Limb-shaking transient ischemic attack in posterior circulation ischemia: a case report

Limb-shaking transient ischemic attack (LS-TIA) is a rare clinical manifestation of steno-occlusive carotid lesions. Reports of LS-TIA caused by posterior circulation ischemia are rare. Here, the case of a 56-year-old male patient with a history of epilepsy, who presented with dizziness, nausea and vomiting, is reported. Initial brain magnetic resonance imaging (MRI) indicated no signs of acute ischemia, and the patient's symptoms had not relieved despite drug administration to treat dizziness. During a vestibular function test on the next day, he developed sudden left-limb shaking without disturbance of consciousness or facial twitching. Considering a seizure, an anti-epileptic drug was administered, but no improvement was observed. Eight hours later, the patient experienced left-limb paralysis, and re-examination of the MRI indicated brainstem infarction. The patient recovered well with antiplatelet and antiatherosclerotic therapy. While LS-TIA is a rare manifestation of TIA of the carotid arterial system, posterior circulation ischemia may also manifest as LS-TIA. If a patient presents with limb shaking due to postural changes despite a history of epilepsy, LS-TIA should be highly suspected.

Alien Limb Phenomenon After Diffuse Corpus Callosum Ischemic Stroke.

The alien limb is a phenomenon characterized by a cluster of clinical features wherein the limb behaves autonomously and as separated from a person's identity. We herein report a 36-year-old Indian female with multiple comorbidities who presented with recurrent episodes of limb-shaking transient ischemic attacks for 1year, followed by left-sided hemiplegia. During recovering, the patient noticed a feeling that as if her left hand did not belong to herself and acted autonomously (alien limb phenomenon) along with visuospatial deficits. Magnetic resonance imaging of the brain revealed ischemic stroke diffusely involving corpus callosum. Magnetic resonance angiography was suggestive of compromised right-sided anterior circulation. This was corroborated by digital subtraction angiography that revealed reduced flow in right internal carotid artery. Diffuse infarction of the corpus callosum requires involvement of both the anterior and the posterior circulation. Due to the lack of clinical features suggestive of chronic internal carotid artery dissection, occlusive atherosclerotic disease of the anterior cerebral circulation associated with possible steal phenomenon from the posterior circulation was the most probable underlying mechanism for the callosal stroke. Steal phenomenon has been proposed as a compensatory mechanism in hemodynamically compromised ischemic parenchyma and it can explain the co-existence of anterior and posterior circulation strokes. This case also highlights how both anterior and posterior types of the alien limb phenomenon can co-exist in a background of vascular insult, resulting from intra-cranial atherosclerotic disease.

Limb-Shaking Transient Ischemic Attack Presenting with Myoclonus

Limb-shaking transient ischemic attack is a rare disease, associated with the steno-occlusion of the internal carotid artery. It is caused by hemodynamic dysfunction in the anterior circulation. It is difficult to observe patients directly in clinical settings since they visit the hospital after symptoms have subsided which usually last less than 5 minutes. Here we report a atient who developed right arm dominant myoclonus related to left internal carotid artery occlusion along with a recorded video.

Rare tremor syndromes

There is a group of uncommon sporadic tremor syndromes, which are only partially taken into account in the current classification of tremor. Their knowledge is of diagnostic and therapeutic relevance and they should be considered in the differential diagnosis of frequent tremor syndromes. Differential diagnostics and treatment of uncommon tremor syndromes. Literature search (PubMed, Google Scholar). Holmes tremor, myorhythmia, palatal tremor, limb-shaking transient ischemic attack (TIA), tardive tremor, neuropathic tremor, tremor induced by peripheral trauma and orthostatic tremor syndrome are described. Uncommon sporadic tremor syndromes are mainly symptomatic with various underlying neurological or systemic pathologies. Their recognition accelerates the diagnostic process and has therapeutic relevance.

Movement symptoms in European Moyamoya angiopathy — First systematic questionnaire study

ObjectiveMovement disorders are a rare manifestation of Moyamoya angiopathy (MMA). Data on prevalence and clinical presentation are warranted. Possible involuntary movements include focal motor seizures, tremor, limb-shaking transient ischemic attacks, choreiform and spastic or dystonic movement disorders. Patients and methodsWe developed a questionnaire to systematically assess movement disorders in MMA. Patients’ history of involuntary movements and their clinical presentation were assessed systematically by interview. Additionally, demographic data were assessed as well as localization of movements, possible trigger factors and the presence of other symptoms. ResultsThe questionnaire was administered to 63 European patients with MMA. The response rate was high with 93.6% participating patients. Twenty-eight patients (47.4%) reported involuntary movement disorders including periodic tremor, irregular jerks, involuntary movements with loopy or pranced character, stiffness and muscle cramps. From those patients, 16 (57.1%) individuals had the symptoms prior to the diagnosis of MMA.The most common involuntary movements were irregular jerks witnessed by 17 (60.7%) patients, followed by stiffness and muscle cramps in 10 (35.7%). Eight (28.6%) Patients suffered from unintended loopy and pranced character, while 4 individuals (14.3%) remembered periodic tremor.Of the 28 patients who witnessed movement disorders, 23 had undergone revascularization surgery (82.1%). From the latter subgroup, movement disorders were reversed in 7 out of 12 patients (58.3%) with irregular jerks and 4 out of 7 patients (57.1%) with unintended loopy and pranced character. ConclusionsOur study elucidates the high incidence of movement disorders in an unselected consecutively recruited cohort of European MMA patients.

Internal Carotid Artery Stenosis Presenting with Limb Shaking TIA.

Internal carotid artery (ICA) stenosis may lead to a wide range of clinical symptoms. We describe the case of a 66-year-old female who experienced a transient ischemic attack (TIA) with episodes of limb shaking caused by ICA stenosis. After epilepsy had been suspected and ruled out, studies of her left ICA showed extensive blockage as a result of atherosclerosis. Magnetic resonance angiography (MRA) revealed total occlusion of the left ICA and the patient was eventually medically managed due to the strong possibility of surgical complications. We reported this patient's clinical course to shed light on a rare manifestation of carotid stenosis that may be confused with other diagnoses if not closely scrutinized.

A Rare Presentation of a Patient with Limb-Shaking TIA due to Severe Carotid Artery Stenosis

Background: A limb-shaking Transient Ischemic Attack (TIA) is a rare neurological symptom of hemodynamic origin caused by severe carotid artery disease. Physicians should be aware of its presence because it has a non-typical presentation and is cured by endarterectomy or stent- ing of the stenosed carotid artery. The aim of the present study was to describe a rare case of limb-shaking TIA. Description of case: A 76 year-old man with a 80% right internal carotid artery stenosis pre- sented with numerous episodes of involuntary jerky movements of his left arm and leg, associ- ated with episodes of brief weakness of the left leg, caused by preoperative optimization of his hypertension. No stroke ensued despite the daily appearance of symptoms for several months. Limb-shaking TIA was diagnosed and all symptoms disappeared immediately after an uncom- plicated carotid endarterectomy was performed. Conclusion: The clinical presentation of this limb-shaking TIA case, the first to our knowledge to appear during treatment of hypertension, supports further the hemodynamic theory of limb- shaking TIAs.

Association between clinical features and prognosis of patients with limb-shaking transient ischemic attack

Objective This review aims to illustrate the relationship between clinical features and the prognosis of patients with limb-shaking transient ischemic attack (LS-TIA). Data sources Relevant articles published in two main Chinese medical periodical databases (China National Knowledge Infrastructure and China Science Periodical Database) from 1986 to June 2013 were identified with keywords “limb shaking” and “transient ischemic attack”. Study selection Original articles and case reports about LS-TIA were selected. Results A total of 63 cases collected from 19 articles were included in the pooled analysis. LS-TIA presented in two cerebrovascular diseases, of which atherosclerotic high-grade stenosis or occlusion in carotid artery system and moyamoya disease formed 95.2% and 4.8%, respectively. Of 63 patients, 11 (17.5%) were once misdiagnosed as epileptic and prescribed useless antiepilepsy drugs. The multivariable Logistic regression model showed a significant protective effect of patients with revascularization therapy on prognosis, compared with patients treated with drugs (odds ratio 0.20, 95% CI 0.05-0.74, P=0.016). Conclusions Chronic carotid artery system hypoperfusion can induce limb(s) shaking, followed by high possibility of ischemic stroke in the same brain territorial. Revascularization of the responsible artery may work better than conservative drug-based therapy.

A Case of Limb Shaking Transient Ischemic Attacks Associated with Middle Cerebral Artery Stenosis and Functional Aortic Stenosis (P04.062)

A Case of Limb Shaking Transient Ischemic Attacks Associated with Middle Cerebral Artery Stenosis and Functional Aortic Stenosis (P04.062)

Limb-shaking transient ischemic attacks in an adult PHACE syndrome: a case report and review of the literature

PHACE syndrome is a neuro-cutaneous syndrome characterized by malformations of the Posterior fossa, facial Hemangiomas, Arterial anomalies, Cardiac anomalies, and abnormalities of the Eye. The arterial abnormalities usually involve the cervical and cerebral vasculature and include congenital abnormalities and progressive cerebral vasculopathy. The progressive cerebral vasculopathy leads to increased risk for arterial ischemic stroke (AIS) in patients with PHACE syndrome. Here we described the clinical neurological sequelae, the malformation of brain, the cervical and cerebral vasculopathy in a 23-year-old female of PHACE syndrome. Besides, she presented AIS with limb-shaking transient ischemic attack, a rare clinical presentation of AIS in patients of PHACE syndrome.

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

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.

Limb Shaking as a Manifestation of Low-flow Transient Ischemic Attacks

Limb shaking presenting as rhythmic involuntary hyperkinetic movements may represent as severe bilateral occlusive carotid disease. This unusual form of transient ischemic attack is often misdiagnosed as focal motor seizures. However, careful assessment reveals a lack of usual seizure characteristics such as a jacksonian march or facial involvement. The movements also appear to be precipitated by activities that lower blood pressure. We present two cases of patients with severe bilateral carotid stenosis leading to limb-shaking transient ischemic attacks. There was complete stenosis in the internal carotid artery (ICA) contralateral to the jerking limb, combined with significant stenosis in the ipsilateral ICA. Cerebral perfusion on the occluded ICA side was maintained through collateral circulation from the opposite ICA and posterior circulation. When blood pressure was lowered orthostatically or by medication, the resulting cerebral hypoperfusion manifested as limb jerking. Recognition of limb shaking as a rare form of transient ischemic attack and differentiating it from focal motor epilepsy can facilitate early identification of critical carotid stenosis, allowing for appropriate interventions and thus reducing the risk of a disabling stroke. We recommend that clinicians should consider carotid disease in elderly patients presenting with orthostatic or episodic movement disorders.

Limb-shaking Transient Ischemic Attack Masquerading as Lumbar Radiculopathy from Pericallosal Artery Stenosis Treated Successfully with Intracranial Angioplasty and Stenting

The pericallosal artery is rarely associated with intracranial atherosclerotic disease and, until recently, was usually not amenable to endovascular therapy with balloon angioplasty and stenting. We present an elderly patient with postural left leg-shaking episodes secondary to pericallosal artery stenosis, which was treated initially with primary intracranial balloon angioplasty, and subsequently, angioplasty and stenting as a result of recurrent stenosis. Both procedures were preformed without complications, and the patient remained free of symptoms on 6-month follow-up. This case demonstrates unique clinical and neuroendovascular aspects; the isolated postural leg-shaking transient ischemic attacks, initially mistaken for radiculopathy and local joint etiology, were found later to be cerebrovascular ischemic in origin. Moreover, the correlation between the findings of computed tomography perfusion and angiography localized the lesion into the medial frontal lobe and pericallosal artery territory. In addition, the technical aspect provides insight into the current state of neuroendovascular techniques, addressing the difficulty of access into very small and distal intracranial arteries affected by stenosis.

An Unusual Cause of Transient Neurologic Deficits: Compression of the Carotid Artery by a Thyroid Cystic Nodule

We report a case of a 93-year-old man, who presented with limb-shaking transient ischemic attacks (TIAs) after orthostatic position change or turning his head to the left. The limb-shaking TIAs resulted from external compression of the carotid artery. Contrast-enhanced magnetic resonance angiography of the head and neck and Doppler ultrasound examination of the thyroid gland revealed a large cystic nodule in the right thyroid lobe, resulting in compression and posterior displacement of the right common carotid artery. Clinicians should be aware that limb-shaking TIAs can not only result from obstructive extracerebral or intracerebral artery disease, but also from external compression of the carotid artery.

Cerebral Hemodynamic Compromise Associated with Limb Shaking TIA and Focal EEG Slowing

ABSTRACTWe report four cases of cerebral hemodynamic compromise identified over a five year period. Cerebral hemodynamic compromise is characterized by reversible attacks of regional cerebral ischemia affecting patients with occlusive disease of main arteries supplying blood to the brain. All four of our patients had occlusion of one internal carotid artery (ICA) often associated with high grade stenosis or occlusion of the contralateral internal carotid artery and/or major intracranial arteries. All patients developed likely limb shaking transient ischemic attacks (TIAs) which occur during acute exacerbation of regional cerebral hypoperfusion. These events often trigger EEG testing because of suspicion of seizures. Each patient also had focal delta EEG slowing without evidence of noteworthy structural lesions on imaging scans. A discrepancy or mismatch between these testing results occurred. The patients' focal delta EEG slowing was attributed primarily to resting regional cerebral hypoperfusion. Diagnosis of cerebral hemodynamic compromise may be delayed when limb shaking TIA is misdiagnosed as a seizure disorder or when regional cerebral hypoperfusion is not considered as a potential cause of focal delta EEG slowing in older patients that have normal structural imaging studies. Our cases are discussed in light of the relevant EEG and clinical characteristics that have been described in reports of limb shaking TIA and structural imaging/focal delta EEG slowing mismatches.

Treatment of limb-shaking TIAs with external carotid artery stenting

Limb-shaking transient ischemic attacks (TIAs) occur when perfusion is reduced to the cortical territory associated with the transient movements. We present a case in which a patient with preexisting left internal carotid artery (ICA) occlusion developed limb-shaking TIAs secondary to severe stenosis of her left external carotid artery (ECA). After angioplasty and stenting of her left ECA, her symptoms resolved.

Limb-Shaking Transient Ischemic Attacks: Diagnosis, Prognosis, and Management

Limb-shaking transient ischemic attacks (LSTIAs) are a rare manifestation of carotid occlusive disease. We report the case of an 81 year old woman who presented with recurrent LSTIAs and received conservative treatment with cessation of her antihypertensive medications. Multi-Slice Detector CT Angiography (MSCTA) demonstrated a right internal carotid artery occlusion with evidence of cerebral autoregulatory compensation via leptomeningeal vessels. This case characterizes LSTIAs and demonstrates the use of MSCTA in diagnosis, prognosis, and management.

Are Limb‐Shaking Transient Ischemic Attacks a Risk Factor for Postendarterectomy Hemorrhage? Case Report and Literature Review

Postoperative intracerebral hemorrhage occurs in about 0.5% of all carotid endarterectomies. There are no recognized risk factors for this complication. We report on a 74-year-old woman with right sided limb-shaking transient ischemic attacks and severe stenosis of the left internal carotid artery. She suffered a fatal intracerebral hemorrhage 11 days after endarterectomy. This case prompted a review of the literature to determine if limb-shaking transient ischemic attacks might be a risk factor for postoperative intracerebral hemorrhage. We propose that patients with limb-shaking transient ischemic attacks have loss of vasomotor reactivity placing them at high risk for carotid reperfusion syndrome and hemorrhage into the revascularized territory.