Complete Internal Carotid Artery Occlusion Presenting as “Seizures”

Abstract

Limb shaking is a rare and atypical presentation for a transient ischemic attack. It can be described as a "cerebral ischemic claudication" due to attenuation in an already compromised cerebral perfusion. The uncharacteristic presentation may lead to confusion and misdiagnosis, for example, focal epilepsy, delaying appropriate therapy. We describe such a case highlighting the clinical implications and options for addressing the underlying cerebrovascular pathology. A 57-years-old female with a 2 weeks history of slurred speech and involuntary shaking of the right upper and lower extremities lasting for a few minutes, which was not associated with loss of consciousness or amourosis fugax. Neuroimaging demonstrated a complete left internal carotid artery occlusion at its origin and a severe focal stenosis of the proximal external carotid artery. Supraclinoidal internal carotid artery was reconstituted via collaterals between ophthalmic artery and branches of left internal maxillary artery. The right internal carotid contributed via the anterior communicating artery. An external carotid endarterectomy was performed, resulting in a complete resolution of her symptoms. In conclusion, limb shaking as a manifestation of carotid occlusion is a rare phenomenon. To prevent misdiagnosis and appropriate treatment, cerebral ischemic claudication must always be considered in the appropriate setup. Any treatment must preserve the collaterals supplying the compromised cerebral vasculature.