Perfusion insufficiency in limb-shaking transient ischemic attacks

Postprandial limb-shaking: an unusual presentation of transient cerebral ischemia

We describe a 61-year-old woman with complete occlusion of the left carotid artery who presented with shaking of the right limbs after eating. She was found to have profound postprandial hypotension, and the episodes were interpreted as an unusual transient ischemic attack.

Intracranial angioplasty and stenting for cerebral atherosclerosis: new treatments for stroke are needed!

INTRODUCTION

Intracranial atherosclerosis is a common cause of stroke.

INTRACRANIAL ANGIOPLASTY AND STENT REVASCULARIZATION

Recent technological developments offer improved methods for endovascular revascularization of symptomatic and asymptomatic cerebral artery stenosis. Identification of appropriate patients remains a diagnostic challenge, and our knowledge about the natural history of the disease remains limited.

RECOMMENDATIONS

At this time, patients with significant intracranial stenosis should receive counseling on the benefits and risks of revascularization therapy. Ultimately, determination of which patients should undergo revascularization procedures will require carefully planned, randomized clinical trials.

A case of moyamoya disease presenting with chorea

CASE REPORT

We describe a 15-year-old girl with moyamoya disease whose initial manifestation was chorea-like involuntary movements. T2-weighted magnetic resonance imaging showed high signal intensity lesions in the left frontal lobe, right parieto-occipital lobes, and frontal subcortical white matter. Single-photon emission computed tomography (SPECT) showed diffuse hypoperfusion of the whole brain. Bilateral direct and indirect cerebrovascular bypass surgeries were performed. Chorea disappeared 2 days after the surgery. Follow-up SPECT demonstrated increased cerebral perfusion in the bilateral frontal, temporal, and parietal regions.

CONCLUSIONS

Chorea accompanied with moyamoya disease can be properly managed by revascularization surgery. Moyamoya disease should be remembered as being one of the differential diagnoses of chorea, which is treatable by surgery.

Limb-shaking Transient Ischemic Attacks: case report and review of literature

Background

Limb 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 presentation

Elderly 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.

Conclusion

Diagnosis 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.

Critical analysis of hemodynamic insufficiency by head-up tilt in patients with carotid occlusive disease

BACKGROUND

The objective of this study was to evaluate the diagnostic value of the head-up-tilt (HUT) test for detecting cerebral hemodynamic insufficiency in patients with major cerebral artery occlusion disease because such patients may benefit from extracranial - intracranial bypass surgery.

METHODS AND RESULTS

In 13 cases of transient ischemic attacks in patients with carotid or middle cerebral artery occlusive disease, the HUT test was used to determine whether or not the symptoms appear during induced hypotension before investigating cerebral hemodynamics with positron emission tomography. Three of the 13 patients showed focal symptoms such as hemiparesis and limb shaking during the HUT test. In all 3 patients, the oxygen extraction fraction (OEF) increased beyond 53.3% (ie, misery perfusion), whereas only 2 of the other 10 patients without focal symptoms showed an increase in OEF during HUT.

CONCLUSIONS

The HUT test was highly useful for screening patients with cerebral hemodynamic insufficiency in carotid occlusive disease.

Limb shaking transient ischemic attack—an unusual presentation of carotid occlusive disease. A case report and review of the literature

Limb shaking transient ischemic attack (TIA) is an uncommon presentation of carotid occlusive disease. This unusual form of TIA is not well recognized and may be mistaken for focal epilepsy, delaying proper diagnosis and treatment. In this communication, we present such a case, together with a review of the literature, a brief account of pathophysiology and an outline of appropriate clinical management.

Carotid transient ischemic attacks presenting as limb-shaking syndrome: report of two cases

Limb shaking syndrome (LSS) is a rare presentation of transient ischemic attacks (TIAs), usually secondary to a critical carotid stenosis compromising intracranial circulation, first described 40 years ago. Two additional cases are described herein, aiming to add on to previous descriptions, and to warn physicians about this potentially harming and rather uncommon condition.

Intracranial Revascularization Therapy: Angioplasty and Stenting

Depending on the population studied, intracranial atherosclerosis accounts for 10% to 29% of ischemic brain events. A significant number of patients with intracranial atherosclerosis continue to suffer from repeated strokes or transient ischemic attacks despite optimal medical management. In selected patients, intracranial angioplasty with or without stenting is a promising treatment option. Patient selection, careful periprocedural medical management, and a highly skilled neuroendovascular interventionalist are required in order to perform the procedure with an acceptable risk.

Involuntary movement induced by cerebral ischemia: pathogenesis and surgical outcome

Object. Involuntary movement is an uncommon manifestation of a transient ischemic attack. It may be induced by cerebral hemodynamic insufficiency, which is associated with several cerebral ischemic diseases. The authors present three cases of limb shaking due to moyamoya disease (MMD) or radiation-induced middle cerebral artery stenosis, and three additional cases of choreic movement due to MMD. Neuroimaging studies and surgical outcomes in these patients were retrospectively analyzed to investigate the pathological mechanism underlying the symptoms and to provide guidance for the management of involuntary movement disorders in cases of ischemic cerebral disease.

Methods. The patient population included two children and four adults with ages at presentation ranging between 7 and 50 years. The initial presenting symptoms were involuntary movements in all six cases. A magnetic resonance imaging finding common in all cases was a small infarct in the frontal corona radiata, which did not extend to the cortex or basal ganglia. A perfusion defect in the frontoparietal cortical and subcortical regions was demonstrated by singlephoton emission computerized tomography in all patients. Improved hemodynamic circulation in the frontoparietal cortical and subcortical regions occurred in parallel with clinical improvement following indirect or direct bypass surgery.

Conclusions. Ischemic dysfunction of the frontal cortical and subcortical motor pathways rather than that of the basal ganglia was suspected to be the cause of the observed contralateral involuntary movements. Direct and indirect bypass surgery can be used effectively to treat involuntary movements in patients with cerebral ischemic diseases such as MMD and in those with stenosis of an intracranial major artery.

Orthostatic paroxysmal dystonia

A 52-year-old man with a history of cerebrovascular disease presented with a 3-year history of paroxysmal hemidystonia precipitated by assuming an upright position after sitting or lying down. MRA showed occlusion of the contralateral internal carotid artery (ICA) and near-total occlusion of the ipsilateral ICA. Subtraction single proton emission computed tomography demonstrated decreased perfusion in the contralateral frontoparietal cortex during the typical dystonic spell. We have coined the term "orthostatic paroxysmal dystonia" for this phenomenon.

Stroke: pathogenesis, investigations, and prognosis--Part II of III

The aim of this review is to present the current knowledge regarding stroke. It will appear in three parts (in part I the epidemiology, clinical picture, and risk factors were discussed, while part III will consist of the management and rehabilitation). In the present part (II) the pathogenetic and pathophysiologic aspects of stroke are described. Regarding the investigations apart from the history and clinical examination and general investigations, the following specialized investigations and their role are discussed in detail: Computed tomography (CT), magnetic resonance imaging (MRI), xenon-blood-flow, positron emission tomography (PET), cerebral angiography, magnetic resonance angiography (MRA), ultrasonography, transcranial Doppler (TCD), echocardiography, Holter monitoring, and biopsies. In addition, taking into account the information from the above-cited modalities a prognosis for the final outcome is presented.

Outcome in patients with symptomatic occlusion of the internal carotid artery

OBJECTIVES

to assess whether the risk of recurrent ischaemic stroke in patients with symptomatic internal carotid artery (ICA) occlusion has changed over the past decades, to determine risk factors for the occurrence of ischaemic stroke and to assess the risk of endarterectomy (CEA) of a severe contralateral ICA stenosis.

DESIGN

retrospective cohort study.

PATIENTS AND METHODS

patients with symptomatic ICA occlusion were identified from duplex registry files between 1991 and 1995. Information was obtained on vascular risk factors, performance of CEA for a contralateral ICA stenosis and on recurrence of ischaemic stroke. The rate of complications occurring within 30 days after CEA of the contralateral ICA in patients with symptomatic ICA occlusion was compared with the risk of CEA in patients with asymptomatic ICA occlusion and severe contralateral ICA stenosis (symptomatic or asymptomatic).

RESULTS

ninety-seven patients were identified. Mean follow-up time was 26 months. The annual risk of (non-)fatal stroke was 5.3% for all strokes (95% CI 2. 9%-9.6%) and 3.8% for ipsilateral stroke (95% CI 1.9%-7.7%). Hyperlipidaemia and severe stenosis of the contralateral ICA were independent risk factors. Twenty-two of 32 patients with a severe stenosis of the contralateral ICA underwent CEA, of which one patient died and three suffered a minor ischaemic stroke. The perioperative risk of CEA in the control group of 20 patients with asymptomatic contralateral ICA occlusion was 0% (0 of 20).

CONCLUSIONS

outcome in patients with symptomatic ICA occlusion has not substantially improved over the years. CEA for severe stenosis of the contralateral ICA carried a relatively high risk in our series, but deserves to be studied in a controlled design.

Orthostatic-mediated hypoperfusion in limb-shaking transient ischemic attack

In patients with severe carotid stenosis or total occlusion, episodic contralateral motor dysfunction is more likely related to cerebral hypoperfusion than epileptogenic activity. A man with orthostatic-mediated right-sided limb shaking was found to have total left internal carotid artery occlusion. There was prominent reduction of cerebrovascular reserve seen on single photon emission computed tomography (SPECT) performed with and without acetazolomide. During assumption of an upright position transcranial Doppler (TCD) revealed a marked attenuation of the left middle cerebral artery flow pattern not associated with changes during electroencephalographic monitoring, even after administration of acetazolomide. In this man, limb shaking episodes were attributed to hypoperfusion of the contralateral cerebral hemisphere, and not to epileptogenic activity.

Role of collateral flow on cerebral hemodynamics in patients with unilateral internal carotid artery occlusion

The objective of this study was to evaluate the role of collateral blood flow via the anterior and posterior communicating arteries (ACoA and PCoA) and via the ophthalmic artery (OphA) on cerebral hemodynamics, metabolism, and border zone infarcts in 57 patients with unilateral symptomatic occlusions of the internal carotid artery. Collateral flow via the ACoA and PCoA was determined with magnetic resonance angiography (MRA) and collateral flow via the OphA with transcranial Doppler (TCD). Volume flow was studied with MRA, metabolism with 1H MR spectroscopy, CO2 reactivity with TCD, and the incidence of border zone infarcts with MRI. Compared with controls, patients had deteriorated volume flow, metabolism, and CO2 reactivity. No differences were found between patients with and patients without collateral flow through the ACoA and/or PCoA, or between patients with or without collateral flow via the OphA. Patients without collateral flow via any of these collaterals had decreased volume flow in the middle cerebral artery, decreased N-acetylaspartate/choline, and increased lactate/N-acetylaspartate, compared with the other patients. Patients with symptomatic internal carotid artery occlusion have deteriorated cerebral hemodynamics and metabolism. Different collateral flow patterns via the ACoA, PCoA, or OphA have no effect on the hemodynamic and metabolic parameters, as long as one of these pathways is present.

Physiological diagnosis and surgical treatment of recurrent limb shaking: case report

OBJECTIVE AND IMPORTANCE

Although recurrent limb shaking has been observed in patients with carotid occlusion, its cause, method of diagnosis, and definitive treatment have yet to be fully elucidated. This report examines the cerebrovascular physiology of a patient with recurrent limb shaking by means of xenon-enhanced computed tomographic (XeCT) scanning. By measuring cerebral blood flow (CBF) and cerebrovascular reserve capacity, we were able to confirm both the clinical diagnosis and the response to treatment on physiological grounds.

CLINICAL PRESENTATION

The patient is a 49-year-old man who presented with frequent brief attacks of left arm and leg shaking that occurred at standing or coughing. After cervical radiation therapy for a laryngeal carcinoma, he was found to have bilateral carotid occlusion with minimal collateral development. XeCT scans revealed borderline ischemic perfusion and lack of cerebrovascular reserve in response to an acetazolamide vasodilatory challenge.

INTERVENTION

The patient underwent a right superficial temporal artery to middle cerebral artery bypass to augment cerebral perfusion.

CONCLUSION

After the procedure, the patient's limb shaking attacks ceased. The postoperative XeCT scan showed improved CBF and a return of cerebrovascular reserve capacity. Recurrent limb shaking is a manifestation of decreased CBF. Quantitative XeCT CBF studies coupled with vasodilatory challenge is an important way to assess patients with cerebrovascular disorders and thus identify individuals who will benefit from cerebral revascularization.

Dementia associated with bilateral carotid occlusions: neuropsychological and haemodynamic course after extracranial to intracranial bypass surgery

A 55 year old man with bilateral internal carotid and unilateral vertebral artery occlusions presented subacutely with profound behavioural and cognitive changes featuring frontal lobe deficits. Neuropsychological testing showed severe cognitive impairment compatible with dementia. Anatomical imaging showed only a small right superior frontal infarction. Cerebral blood flow was severely reduced, with profound hypofrontality and limited hypercapnic reactivity, and cerebral metabolism was reduced primarily in the medial frontal lobes. After right sided extracranial to intracranial cerebral bypass surgery, both flow and metabolism improved, as did behavioural and neuropsychological deficits. Perfusion insufficiency from bilateral carotid occlusions, with secondarily reduced metabolism in the frontal zones bilaterally, may be an unusual cause of a reversible frontal dementia syndrome.

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.

Glioblastoma multiforme presenting with recurrent neurological deficits: Transient ischemic attacks or tumor attacks

Transient ischemic attacks result from the temporary focal interruption of blood flow to the brain. We present three patients with glioblastoma multiforme and recurrent speech arrests or right-sided numbness. The clinical diagnosis of "transient ischemic attack" was made in each patient. This diagnosis remained unchanged for months to 2 years after initial presentation and investigations. The correct diagnosis was made with a brain biopsy in two patients and as a result of additional investigations in the third patient. It is important to remember brain tumor in the differential diagnosis of patients presenting with recurrent brief neurological symptoms.

Safety of hypercapnic challenge: cardiovascular and neurologic considerations

The hemodynamic, cerebrovascular, and neurologic effects of hypercapnia with 4% and 6% CO2 were retrospectively reviewed in 217 patients referred for regional CBF (rCBF) procedures. Inhalation of CO2 significantly increased rCBF, blood pressure, and pulse from baseline. The findings suggest a higher incidence of side effects with 6% CO2 concentration and an equivalent vasoreactivity to 4%. We recommend the use of 4% CO2 for hypercapnic stimulation, and present safety guidelines for its use.