Cerebral hemodynamic failure presenting as limb-shaking transient ischemic attacks

Limb-shaking transient ischemic attack with facial muscles involuntary twitch successfully treated with internal carotid artery stenting

INTRODUCTION

Limb-shaking transient ischemic attack (LS-TIA) is a clinical disease with severe carotid stenosis, which is characterized by unilateral rhythmic dance or tremor like involuntary movements of arms and/or legs, but facial muscles are usually unaffected.

METHODS

Today, we report a 42-year-old man with transient ischemic attack who suffered from right limb shaking and right facial muscle twitching due to the obvious stenosis of left internal carotid artery (ICA). Written informed consent was obtained from participants according to the Declaration of Helsinki, and a local ethic committee approved the study. ICA angioplasty and stent implantation were performed as treatment attempts. A brain protection device was navigated through the lesion and placed at the distal end of the stenosis.

RESULT

The patient successfully completed the recanalization through stent placement, and the involuntary shaking of limbs and face was improved. During the 3-month follow-up, the patient's symptoms disappeared completely and did not attack again.

CONCLUSION

This case report highlights the importance of accurate diagnosis and treatment, because treatment-related carotid artery occlusion can not only eliminate the attack, but also reduce the risk of future stroke.

Reduced contralateral cerebrovascular reserve in patients with unilateral steno-occlusive disease

The purpose of this study was to evaluate cerebrovascular reactivity (CVR) of major arterial vascular territories, particularly in the contralateral hemodynamically unaffected hemisphere, in patients with unilateral internal carotid artery (ICA) steno-occlusive disease compared to control subjects with risk factors for cerebrovascular disease.

METHODS

In this retrospective observational study, twenty-seven patients with right-sided unilateral ICA steno-occlusive disease (age range, 25 to 91 years; 17 males) and twenty-one patients with left-sided unilateral ICA steno-occlusive disease (age range, 24 to 83 years; 14 males) and 41 control subjects were studied. CVR was quantitated as the change in blood oxygen level dependent (BOLD) MRI signal (as a surrogate of cerebral blood flow), in response to a consistently applied step change in the arterial partial pressure of carbon dioxide (PaCO2). The CVR of each major arterial vascular territory was assessed in the ipsilateral hemodynamically affected hemisphere and compared to the corresponding territory in the contralateral hemisphere.

RESULTS

In patients, a significant reduction in CVR was observed in the ipsilateral anterior circulation compared to that of the corresponding territory on the contralateral side (0.027 ± 0.083 vs. 0.109 ± 0.066% BOLD change/​mm Hg, p < 0.0001) and to controls (0.195 ± 0.054% BOLD change/mm Hg, p < 0.0001). The CVR of the contralateral anterior circulation was reduced on average by 50% compared to controls (p < 0.0001).

CONCLUSIONS

The implication of these findings is that unilateral carotid stenosis affects the vascular reserve of both sides of the brain compared to control subjects. This indicates that the collateral blood flow support from the contralateral to the ipsilateral hemisphere comes at a cost of reduced reserve capacity in the contralateral hemisphere. The findings suggest that there may be a reduction in functional hyperemia associated with neuronal activation, not only affecting the hemisphere ipsilateral to an occlusion, but also the hemisphere contralateral to an occlusion. It remains to be determined if 'stealing' from the 'rich' to support the 'poor' has clinical consequences over the long term.

Limb-shaking transient ischemic attacks successfully treated with external carotid artery stenting

The external carotid artery (ECA) is one of the most important extracranial-to-intracranial sources of collateral circulation, contributing significantly to the cerebral blood flow especially when perfusion through the internal carotid artery (ICA) is compromised. Most of the endovascular studies so far have been dedicated to ICA, with little focus on the ECA. Limb-shaking transient ischemic attacks (TIAs) are a relatively rare manifestation of carotid artery disease that may present with repetitive shaking movements of the affected limbs. We report a case of an 80-year-old male with bilateral internal and contralateral external carotid artery occlusion who developed limb-shaking TIAs as a result of significant stenosis of the right ECA. Percutaneous revascularization of the ECA was performed by angioplasty and stenting. At the follow-up 12 months later, the patient remained neurologically intact with complete resolution of his symptoms. Stenting of the ECA should be considered as a reasonable alternative to conventional open repair especially in patients with contralateral carotid stenosis, insufficient circle of Willis, and significant comorbidities.