Limb shaking--a carotid TIA.

Abstract

SUMMARY Eight patients are described with an unusual form of carotid transient ischemic attack, limb shaking. The basic features included a brief, involuntary, coarse, irregular, wavering movement or tremble involving arm-hand alone, or arm-hand and leg together. In 2 patients limb shaking was the initial manifestation of carotid occlusive disease, and all but one patient had other typical carotid transient ischemic attacks.Major atheromatous carotid occlusive disease was present in all patients on the side opposite the limb movements. Four patients had bilateral carotid occlusive disease.Cerebral ischemia from a carotid territory low-perfusion state may be the pathogenesis of these limb movements, an idea supported by the apparent benefit of surgical revascularization in abolishing or reducing the limb shaking in 6 patients. There was no clinical or EEG evidence to document an epileptiform etiology.Recognition of this uncommon form of carotid transient ischemic attack may be important in the early diagnosis and treatment of carotid occlusive disease.Stroke Case Reports Patient 1An 88-year-old man had a three week history of intermittent episodes of right-sided weakness and speaking difficulty. The episodes, lasting only seconds, involved weakness of the right arm and hand, buckling of the right knee, and speaking difficulty. The usual patterns were right arm and leg, sometimes only the right arm, and rarely the right leg alone. Thick and hesitant speech was associated with some of these events. Involuntary trembling movements of the right arm and hand frequently accompanied the right arm weakness, and prompted a trial of phenytoin treatment on the suspicion these were focal seizures. The phenytoin was discontinued, however, when he became toxic. There was no history of transient monocular blindness. A CT scan and EEG were both normal.On admission evaluation, blood pressure was 200/90. The general physical examination was negative except for loud bilateral carotid bifurcation bruits. The neurologic examination was remarkable only for an occasional hesitancy and stammering quality in his speech, and mild right lower face weakness. Strength in arms and legs was normal.During hospitalization four episodes of right arm and hand shaking were observed when the patient was either supine or sitting, all occurring during intravenous heparin anticoagulation. The movements were wavering, shaking excursions of the arm and hand which lasted 4-5 seconds. During one episode, there were 10 second wavering movements of the right hand, at which time he had difficulty holding a fork. He could talk during the shaking, although speech was more hesitant and several verbal paraphasic errors occurred. His right arm could be lifted on its own power to the horizontal during the shaking, but a lateral drift and wavering-shaking movements of a nonrhythmic nature were observed. Cerebral angiography demonstrated severe stenosis of the left internal carotid artery. Technical difficulties prevented further angiographic studies. Repeat CT scan...

Perfusion insufficiency in limb-shaking transient ischemic attacks.

“…Attacks appear to cease following carotid endarterectomy. 5 Transient focal cerebral ischemia has been the presumed explanation for these attacks, although hemodynamic studies have not been previously reported to support the specific role of perfusion insufficiency in the border zone territory.…”

Complete Internal Carotid Artery Occlusion Presenting as “Seizures”

“…When there is ipsilateral ICA occlusion, collateral flow to the MCA can occur from the contralateral ICA via the anterior communicating artery, the vertebrobasilar circulation via posterior communicating artery, or leptomeningeal anastomosis (LMA) from the above mentioned areteries [1,3]. The ECA can also supply collaterals from its maxillary or facial branches via ophthalmic artery, from the pterygopalatine network formed by the distal maxillary branches or, the oropharyngeal network formed by the ascending pharyngeal artery.…”

“…Limb shaking is a rare manifestation of a transient ischemic attack (TIA) [1]. The atypical presentation in a patient with carotid occlusive disease may be mistaken for focal epilepsy, resulting in confusion or delayed diagnosis [1].…”

“…The atypical presentation in a patient with carotid occlusive disease may be mistaken for focal epilepsy, resulting in confusion or delayed diagnosis [1]. It is believed to occur because of the low perfusion of the brain [2].…”

The Extracranial–Intracranial Bypass Trial: implications for future investigations

“…8,12,40 A more specific type of TIA that has been documented in a few case reports is "orthostatic limb shaking" 13 which occurs on standing or neck-bending in 1 or more extremities, and is without electroencephalography correlate. 5,48,49,51 In the 3 most notable studies, 5 patients with limb-shaking were also shown to have decreased reactivity after inhaling CO 2 , 48 and another patient's symptoms resolved after endarterectomy. 51 In a study in which patients with this presentation were followed up over 2 years, the authors found that there was a 5-to 6-fold increased risk of stroke in these patients over those with carotid stenosis only.…”