Inducible limb-shaking transitory ischemic attacks: a video-documented case report and review of the literature

Abstract

Background: Limb-shaking transient ischemic attack (TIA) is a well-recognized, but rare observation in contralateral carotid steno-occlusive disease. Consequently, most clinicians have not had the chance to witness an attack.

Case presentation: We present the story of a 64-year old gentleman with exercise-induced weakness associated with tremor in his right arm. His left internal carotid artery was occluded at the bifurcation. Administration of statin and antiplatelet did not relieve his symptoms, and his stereotypic, exercise-induced "limb-shaking" episodes persisted. He underwent successful extracranial to intracranial (EC-IC) bypass, which stopped his symptoms. The patient, however, returned to our department and reported that he was able to recreate his original symptoms by compressing the bypass graft manually.

Conclusion: To our knowledge, this is the first case with video documentation of the clinical appearance of a limb-shaking TIA. We hope this case report will increase the physicians' understanding of the clinical nature of limb-shaking TIAs.

Keywords: Carotid occlusion; EC-IC bypass; Limb-shaking TIA; Stroke.

Fig. 1

Initial MRI FLAIR sequence. MRI FLAIR sequence showing several bilateral areas of discreet cerebral ischemia. The diffusion weighted images were negative, suggesting an absence of acute cerebral infarction related to the continued limb-shaking TIAs

Fig. 2

Initial CT-angiography showing left carotid occlusion. CT-angiography of the left carotid artery demonstrates calcified plaque of the left carotid bulb with atherosclerotic occlusion of the internal carotid artery (a). Of note the left external carotid artery is patent and there is robust filling of its branches (b)

Fig. 3

CT-angiography demonstrating the patency of the by-pass graft. CT-angiography after EC-IC bypass shows left craniotomy defect with pronounced distal MCA flow from the left superior temporal artery (arrow)

Fig. 4

Transcranial doppler flow patterns. Sequential transcranial doppler (TCD) flow patterns are displayed. The left MCA is imaged via temporal bone window at a depth of approximately 5 cm. Panel a shows anterograde flow through the left MCA with the patient manually occluding the bypass graft (flow pattern above the line). The significance of the wave form is uncertain. Panel b display the retrograde flow pattern in the left MCA delivered through a patent EC-IC bypass graft (flow pattern below the line). In panel c is TCD done over the contralateral MCA showing a normal flow pattern