Limb-shaking Transient Ischemic Attacks Research Articles

Limb-shaking transient ischemic attacks: case report and review of literature

BackgroundLimb shaking Transient Ischemic Attack is a rare manifestation of carotid-occlusive disease. The symptoms usually point towards a seizure like activity and misdiagnosed as focal seizures. On careful history the rhythmic seizure like activity reveals no Jacksonian march mainly precipitated by maneuvers which lead to carotid compression. We here present a case of an elderly gentleman who was initially worked up as suffering from epileptic discharge and then later on found to have carotid occlusion.Case presentationElderly gentleman presented with symptoms of rhythmic jerky movements of the left arm and both the lower limbs. Clinical suspicion of focal epilepsy was made and EEG, MRI-Brain with MRA were done. EEG and MRI-Brain revealed normal findings but the MRA revealed complete occlusion of right internal carotid artery. On a follow-up visit jerky movements of the left arm were precipitated by hyperextension and a tremor of 3–4 Hz was revealed. Based on this the diagnosis of low flow TIA was made the patient was treated conservatively with adjustment of his anti-hypertensive and anti-platelet medications.ConclusionDiagnosis of limb-shaking TIA is important and should be differentiated from other disorders presenting as tremors. Timely diagnosis is important as these patients are shown to benefit from reperfusion procedures either surgical or radiological reducing their risk of stroke.

Limb-shaking transient ischemic attacks: Two case reports with unusual pathogenesis

Limb-shaking transient ischemic attacks are associated with transient regional cerebral hypoperfusion and severe carotid stenosis. We report two patients with unusual pathogenesis of limb-shaking attacks, one a 73-year-old woman with right-sided limb-shaking attacks and normal carotid angiography (recently diagnosed with essential thrombocytosis, antiplatelet agents eliminated her attacks) and the other a 56-year-old woman with peptic ulcer disease and multiple episodes of left-sided limb-shaking. Severe anemia was found along with bilateral carotid stenoses >70%. Correction of her anemia abolished her limb-shaking episodes. The presumed pathogenesis of limb-shaking transient ischemic attacks is transient focal cerebral ischemia from severe occlusive disease. Our two patients demonstrate that the mechanisms of ischemia may include other factors that affect oxygen delivery such as anemia or platelet disorders.

Perfusion insufficiency in limb-shaking transient ischemic attacks.

We describe a 63-year-old man with severe bilateral internal carotid artery disease who presented with repeated, brief attacks of left limb shaking precipitated by his standing up. Cerebral blood flow measured by xenon-133 inhalation showed reduced resting flows and a focal perfusion deficit in the right dorsofrontal and upper rolandic regions. Blood flow velocity and pulsatility index of the right middle cerebral artery measured by transcranial Doppler ultrasonography were also reduced. With hypercapnic challenge, both hemispheric tissue perfusion and blood flow velocity showed impaired reactivity. With induced hypotension, the focal perfusion deficit in the right dorsofrontal region was accentuated. Following right internal carotid endartectomy, resting cerebral blood flow and blood flow velocity improved, as did hypercapnic vasoreactivity. These reversible deficits in cerebral blood flow and vasoregulation, which were maximal in the dorsofrontal region, are consistent with low perfusion in the border zone territory or the distal fields and demonstrate that hemodynamic failure is the likely mechanism for limb-shaking transient ischemic attacks from severe carotid artery disease.