Perfusion insufficiency in limb-shaking transient ischemic attacks.

Abstract

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. (Stroke 1990;21:341-347)A ttacks of limb-shaking are an uncommon manifestation of transient cerebral ischemia, L characterized by brief, repetitive jerking movements of the arm or leg, resembling simple partial motor seizures. 1 Since the first recognition of this phenomenon by Fisher, 2 subsequent observations 3 " 5 have firmly established its association with severe carotid occlusive disease. 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.We describe an unusual patient with limb-shaking transient ischemic attacks (TIAs) whose symptoms occurred repeatedly upon his standing up. Hemodynamic findings from xenon-133 cerebral blood flow Received July 10, 1989; accepted October 3, 1989. (CBF) and transcranial Doppler ultrasonography (TCD) studies obtained during hypercapnia and induced hypotension support the mechanism of distalfield ischemia in the pathogenesis of these attacks. Case ReportA 63-year-old right-handed man with hypertension (treated with o-methyldopa) and diet-controlled diabetes mellitus presented with recurrent, brief, stereotypical attacks of left limb shaking precipitated by his standing up. He described "buckling and jerking" of his left leg, without weakness, which interfered with ambulation; he was unable to grasp objects with his left hand because of clumsiness. Each attack occurred reliably on his standing up from either a supine or a sitting position, with a 5-second latency. Each attack usually lasted no longer than 10 seconds; a few attacks lasted as long as 1-2 minutes. He experienced as many as six attacks daily; during each attack he remained fully alert and was ca...

Complete Internal Carotid Artery Occlusion Presenting as “Seizures”

“…Limb shaking, also called, cerebral ischemic claudication, is believed to occur because of the low perfusion of the brain [2]. Symptoms typically occur upon sitting up or standing with a resultant "minor" compromise of cerebral perfusion, with rapid resolution on lying down.…”

“…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]. We describe the presentation, neuroimaging and treatment of such a case.…”

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

“…1 Contrary to the vast majority of TIAs, hemodynamic mechanisms are thought to be involved in the pathogenesis of LS-TIAs. [2][3][4] Because LS-TIA may mimic focal motor seizures, clinicians should be aware of its existence and make the correct diagnosis. 2 Timely carotid endarterectomy can not only cure LS-TIA, but also prevent carotid occlusion and/or stroke.…”

Critical Analysis of Hemodynamic Insufficiency by Head-up Tilt in Patients With Carotid Occlusive Disease

“…8 Because focal neurological signs in hemodynamic TIA are often precipitated by standing up, [9][10][11] orthostatic stress with HUT tests may reproduce the clinical symptoms in patients with cerebral hemodynamic insufficiency.…”