Alternating paroxysmal hemiballism-hemichorea in bilateral internal carotid artery stenosis

Limb-Shaking And Transient Ischemic Attack: A Systematic Review

BACKGROUND

Limb-shaking is one of the transient ischemic attacks (TIA) 'chameleons.' This literature review aims to evaluate the clinical, epidemiological profile, pathologic mechanisms, and management of limb-shaking TIA.

REVIEW SUMMARY

Relevant reports in Medline's (PubMed) database were identified and assessed by 2 reviewers without language restriction from 1985 to 2022. A total of 82 reports containing 161 cases that developed limb-shaking TIA were reported. The mean and median age were 61.36 (SD: 15.29) and 62 years (range: 4-93 y). Most of the individuals affected were males (64.34%). Limb-shaking was reported as unilateral in 83.33% of the patients. Limb-shaking presented with other neurological deficits in 44.33% of the individuals, in which the most common concurrent neurological deficit was the weakness of at least 1 limb. A recurrence of the "shaking" phenomenon was observed in 83 individuals. A trigger of limb-shaking was reported in 69 cases, and the most common was changing body position. The internal carotid artery was the most frequent vessel involved in limb-shaking. A chronically occluded internal carotid artery was observed in 42 individuals. Hypertension was the most common comorbidity. The management was conservative in 42.30% of the cases. The most frequent misdiagnoses were seizures. A full recovery was achieved in 56.60% of the individuals.

CONCLUSIONS

Limb-shaking TIA could be defined as involuntary, rhythmic, brief (<5 min), recurrent, jerky movement usually precipitated by activities that may reduce cerebral blood flow. The "shaking" phenomenon was primarily described as a manifestation of symptomatic complete internal carotid artery obstruction.

Transient Hemichorea-hemiballism Induced by a Combination of Postprandial Hypotension and Severe Stenosis of the Innominate Artery Concomitant with Left Carotid Occlusion

Hemichorea-hemiballism (HCHB) due to transient ischemic attacks (TIAs) is rare. An 83-year-old woman had repeated episodes of right-sided HCHB for 3 months. Magnetic resonance (MR) angiography demonstrated occlusion of the left carotid and middle cerebral arteries and severe stenosis of the innominate artery, and 24-hour ambulatory blood pressure monitoring showed a blood pressure decrease of >20 mmHg after each meal. We speculated that HCHB developed as TIAs due to hemodynamic failure in the left cerebral hemisphere, caused by a combination of severe stenosis of the innominate artery concomitant with occlusion of the left carotid and middle cerebral arteries as well as postprandial hypotension.

Successful multiple burr hole openings for limb-shaking transient ischemic attack due to moyamoya disease: illustrative case

BACKGROUND

Limb-shaking transient ischemic attacks (LS-TIAs) are a rare form of TIAs that present as involuntary movements of the limbs and indicate severe cerebral hypoperfusion. LS-TIAs are often reported in patients with carotid artery stenosis but can also affect patients with intracranial artery stenosis and moyamoya disease (MMD).

OBSERVATIONS

A 72-year-old woman presented with repeated episodes of involuntary shaking movements of the right upper limb. Cerebral angiography revealed complete occlusion of the M1 segment of the left middle cerebral artery (MCA), and the left hemisphere was supplied by moyamoya vessels. She was treated with left direct revascularization without complications, and her involuntary movements subsided. However, she demonstrated involuntary shaking movements of the right lower limb 2 months postoperatively. Cerebral angiography revealed complete occlusion of the A1 segment of the left anterior cerebral artery (ACA). The multiple burr hole opening (MBHO) procedure was performed to improve perfusion in the left ACA territory and after 3 months, the patient’s symptoms resolved.

LESSONS

This case demonstrated that LS-TIAs can also develop as ischemic symptoms due to MMD. Moreover, instances of LS-TIA of the upper and lower limbs developed separately in the same patient. The patient’s symptoms improved with direct revascularization and MBHO.

A case of hemichorea in RNF213-related vasculopathy

Background

Internal carotid artery (ICA) stenosis has been recently reported to cause hemichorea, mainly in East Asia. The East Asian-specific p.R4810K variant of RNF213, a susceptibility gene for moyamoya disease (MMD), accounts for up to 25% of sporadic ischemic stroke with ICA stenosis cases in East Asia. However, as RNF213-related vasculopathy does not meet the diagnostic criteria for MMD, the creation of a new disease category has been suggested. Here, we report the first case of hemichorea in RNF213-related vasculopathy.

Case presentation

An 81-year-old woman was admitted to our hospital with choreic movements in the periphery of the right extremities at rest. Though head magnetic resonance imaging showed no fresh or old cerebral infarction, ¹²³I-iodoamphetamine-single photon emission computed tomography showed cerebral blood flow of < 80% in the anterior territory of the left middle cerebral artery (MCA) in a resting state and cerebrovascular reactivity of < 10% in the broader area supplied by the left MCA after acetazolamide challenge. Head magnetic resonance angiography and digital subtraction angiography revealed left ICA C1 portion stenosis with compromised collateral vessels. Involuntary movements resolved with haloperidol administration within 3 days, without apparent recurrence from continuation of the medication for a year. Genetic testing revealed the presence of the heterozygous RNF213 p.R4810K variant.

Conclusions

Chorea is thought to be caused by damage to circuitry connecting the basal ganglia with the cerebral cortex, as found in cases of MMD, which possess aberrant vessels in the basal ganglia. However, aberrant vessels and cerebral infarctions were not observed in the basal ganglia in the current case, decreasing the likelihood of a role in chorea. Alternatively, as RNF213 regulates vascular endothelial function and angiogenesis, dysregulation may impair the neurovascular unit and damage basal ganglia circuitry, contributing to the development of chorea. This case may renew interest in the concept of RNF213-related vasculopathy and the pathophysiological mechanisms behind chorea in ICA stenosis.

[A case of hemichorea caused by right internal carotid artery stenosis]

This is a case of a 71 years old man. Hemichorea appeared in the left half of his body in the middle of November, 2014. Minute hyperintense areas in the white matter near the posterior horn of the right lateral ventricle and in the right parasagittal frontal cortex was shown in MRI diffusion weighted image. Severe stenosis was seen in the right internal carotid artery, and reduction in cerebral blood flow of the right cerebral hemisphere including the basal ganglia was shown in single photon emission computed tomography (SPECT). After having carotid endarterectomy of the right internal carotid artery in January, 2015, hemichorea disappeared, and the cerebral blood flow of the right cerebral hemisphere improved. It is known that hemichorea is caused by the infarction of the basal ganglia. In recent years, some hemichorea cases are reported around East Asia caused by internal carotid artery stenosis with reduction in cerebral blood flow.

Paroxysmal movement disorders: An update

Paroxysmal movement disorders comprise both paroxysmal dyskinesia, characterized by attacks of dystonic and/or choreic movements, and episodic ataxia, defined by attacks of cerebellar ataxia. They may be primary (familial or sporadic) or secondary to an underlying cause. They can be classified according to their phenomenology (kinesigenic, non-kinesigenic or exercise-induced) or their genetic cause. The main genes involved in primary paroxysmal movement disorders include PRRT2, PNKD, SLC2A1, ATP1A3, GCH1, PARK2, ADCY5, CACNA1A and KCNA1. Many cases remain genetically undiagnosed, thereby suggesting that additional culprit genes remain to be discovered. The present report is a general overview that aims to help clinicians diagnose and treat patients with paroxysmal movement disorders.

Acute hemichorea as an unusual presentation of internal carotid artery stenosis

Involuntary movement associated with deep watershed ischemic lesions has been rarely reported. A 67-year-old woman presented with acute hemichorea on the left side. Magnetic resonance imaging showed acute infarcts in the anterior border zone. On perfusion studies, impaired cerebral blood flow was observed on the subcortical region sparing the basal ganglia. Cerebral angiogram confirmed severe stenosis in the right internal carotid artery. Her hemichorea gradually improved along with normalization of perfusion after carotid artery stenting with angioplasty. We suggest that impaired cerebral blood flow in critical watershed territories may be an important contributing factor in hemichorea associated with carotid occlusive disease.

Prognostic relevance of limb shaking in symptomatic carotid artery occlusion

BACKGROUND

Internal carotid artery (ICA) occlusion, present in up to 15% of stroke patients, may cause low-flow transient ischemic attacks (TIAs) like limb shaking (LS) or retinal claudication (RC). Reliable data on the frequency of these phenomena and their potential prognostic relevance are still sparse.

AIMS

To provide more data about the frequency of low-flow TIA and investigate their influence on outcome.

MATERIAL AND METHODS

Medical records of 260 consecutive patients with symptomatic ICA occlusion were carefully reviewed (survey period: January 2000 to December 2006). Baseline stroke severity and outcome at 90 days and in the long term were assessed. All patients were specifically questioned about symptoms of LS and RC, were exposed to bright light (pupillary testing) and carefully watched during testing of posture/gait and early mobilization.

RESULTS

LS, RC or both occurred in 28.6, 9.5 and 2.7%, respectively, of patients eligible for a thorough assessment of low-flow TIAs (n = 147). An adverse outcome was more likely in patients with LS than in those without at day 90 (modified Ranking Scale ≥4, 45.2 vs. 21.9%, p = 0.005) and in the long term (median, 37 months) (52.7 vs. 23.1%, p < 0.001). In a multivariable analysis, prognostic relevance was found to be independent of baseline stroke severity (National Institutes of Health Stroke Scale). There was also a tendency towards higher rates of recurrent stroke and TIA in limb shakers. RC had no prognostic relevance regarding functional outcome and recurrent events.

CONCLUSION

In patients with ICA occlusion, RC and LS are more common than previously assumed. The presence of LS is associated with a worse outcome independent of initial stroke severity and patient characteristics.

Hemichorea due to hemodynamic ischemia associated with extracranial carotid artery stenosis. Report of two cases

In this paper the authors describe two patients with recurrent hemiparesis and limb shaking that gradually progressed to hemichorea. Cerebral angiography confirmed severe unilateral internal carotid artery stenosis (95%) contralateral to the hemichorea. The cerebral blood flow, assessed using N-isopropyl-p-(iodine-123) iodoamphetamine single-photon emission computed tomography (SPECT), disclosed markedly decreased vascular reserves in both patients. After carotid endarterectomy was performed, the hemichorea gradually subsided and SPECT confirmed increased cerebral perfusion. The results in these cases indicate that surgical revascularization is effective for hemichorea due to cerebral ischemia with reduced vascular reserve.

Angioplasty of Middle Cerebral Artery Stenosis Improves Recurrent Hemichorea Caused by Basal Ganglia Hypoperfusion

We report a case of intermittent hemichorea associated with severe stenosis in the proximal M1 portion of the middle cerebral artery. The movements disappeared after transluminal angioplasty and stenting with restoration of perfusion in the basal ganglia.

Resolution of Hemiballism after Carotid Endarterectomy: Case Report

A 74-year-old man presented with a 3-week history of involuntary left-sided upper and lower extremity shaking without any focal neurologic deficit. Bilateral carotid artery duplex demonstrated severe stenosis of the right internal carotid artery and moderate stenosis of the left internal carotid artery. A right carotid endarterectomy was performed without complications and resulted in elimination of the left-sided involuntary movements postoperatively.

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.