Limb-shaking transient ischaemic attacks in patients with internal carotid artery occlusion: a case-control study

Hemodynamic Stroke: Emerging Concepts, Risk Estimation, and Treatment

Ischemic stroke can arise from the sudden occlusion of a brain-feeding artery by a clot (embolic), or local thrombosis. Hemodynamic stroke occurs when blood flow does not sufficiently meet the metabolic demand of a brain region at a certain time. This discrepancy between demand and supply can occur with cerebropetal arterial occlusion or high-grade stenosis but also arises with systemic conditions reducing blood pressure. Treatment of hemodynamic stroke is targeted toward increasing blood flow to the affected area by either systemically or locally enhancing perfusion. Thus, blood pressure is often maintained above normal values, and extra-intracranial flow augmentation bypass surgery is increasingly considered. Still, current evidence supporting the superiority of pressure or flow increase over conservative measures is limited. However, methods assessing hemodynamic impairment and identifying patients at risk of hemodynamic stroke are rapidly evolving. Sophisticated models incorporating clinical and imaging factors have been suggested to aid patient selection. In this narrative review, we provide current state-of-the-art knowledge about hemodynamic stroke, tools for assessment, and treatment options.

Limb-Shaking Transient Ischemic Attacks in Patients with Carotid Occlusion or Stenosis: A Systematic Review and Individual Patient Data Meta-Analysis

BACKGROUND

Limb-shaking transient ischemic attack (LSTIA) is a rare neurological condition which presents with involuntary jerky movements of the arm or leg, often because of carotid stenosis or occlusion. Due to the rarity of the condition, the epidemiology of LSTIA is poorly understood and the disease is frequently misdiagnosed. There is no standard treatment to date. The purpose of this study was to provide an overview of the epidemiology of LSTIA and its current treatment options.

METHODS

Embase, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials for randomized controlled trials, and Google Scholar were searched from database inception to December 30, 2023 for articles containing information on the epidemiology and treatment of LSTIA. An individual patient data meta-analysis (IPD-MA) was performed using data extracted from the included articles. Inclusion criteria were description of both the epidemiology and treatment of LSTIA in patients over the age of 18 with carotid stenosis/occlusion, confirmed by radiographic imaging. Exclusion criteria were studies focusing on pediatrics, no epidemiological data, internal carotid artery (ICA) stenosis/occlusion not radiologically confirmed, full text unavailable, full text not in English or Dutch, and non-original articles.

RESULTS

Of the 8,855 articles screened, 55 articles containing 251 patients were included. Fifty articles harboring 81 patients were included in the IPD-MA, and 7 articles harboring 187 patients were included in the cohort analysis. The results of the IPD-MA showed that LSTIA was caused by unilateral ICA stenosis/occlusion in 29 patients (36%) and most often from bilateral ICA stenosis/occlusion in 52 patients (64%). Limb-shaking was unilateral in 66 patients (83%) and was accompanied by weakness in 27 patients (33%). The intervention with the highest success rate was endovascular intervention (carotid stenting or balloon angioplasty), as all 10 patients remained asymptomatic after treatment. The cohort analysis showed that LSTIA can be caused by both unilateral and bilateral carotid stenosis or occlusion. The prevalence within cohorts of TIA patients of LSTIA varied considerably from 3.5 to 29%.

CONCLUSION

A large international clinical registry is warranted to gain a better understanding of the epidemiology of LSTIA. There is insufficient evidence available to suggest a standard treatment.

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.

Limb shaking transient ischemic attack secondary to innominate artery stenosis

Limb shaking transient ischemic attack is a rare disease manifestation typically caused by carotid stenosis but rarely caused by flow-limiting lesions involving more proximal vasculature. We demonstrate a case of limb shaking transient ischemic attack secondary to innominate stenosis in a 69-year-old woman who presented after a left leg shaking spell that caused her to fall and fracture her ipsilateral tibia. She did not experience changes in mentation and did not show any evidence of a postictal period. After receiving a comprehensive workup, she successfully underwent revascularization with innominate artery stenting. Continuous retrograde aspiration with the Enroute system (Silk Road Medical) and carotid clamping were used for embolic protection.

Limb-shaking transient ischemic attack in posterior circulation ischemia: a case report

Limb-shaking transient ischemic attack (LS-TIA) is a rare clinical manifestation of steno-occlusive carotid lesions. Reports of LS-TIA caused by posterior circulation ischemia are rare. Here, the case of a 56-year-old male patient with a history of epilepsy, who presented with dizziness, nausea and vomiting, is reported. Initial brain magnetic resonance imaging (MRI) indicated no signs of acute ischemia, and the patient's symptoms had not relieved despite drug administration to treat dizziness. During a vestibular function test on the next day, he developed sudden left-limb shaking without disturbance of consciousness or facial twitching. Considering a seizure, an anti-epileptic drug was administered, but no improvement was observed. Eight hours later, the patient experienced left-limb paralysis, and re-examination of the MRI indicated brainstem infarction. The patient recovered well with antiplatelet and antiatherosclerotic therapy. While LS-TIA is a rare manifestation of TIA of the carotid arterial system, posterior circulation ischemia may also manifest as LS-TIA. If a patient presents with limb shaking due to postural changes despite a history of epilepsy, LS-TIA should be highly suspected.

Evaluation of the Patient With Paroxysmal Spells Mimicking Epileptic Seizures

BACKGROUND

The diagnostic issue of paroxysmal spells, including epileptic seizure (ES) mimics, is one that neurologists frequently encounter. This review provides an up-to-date overview of the most common causes of ES mimics encountered in the outpatient setting.

REVIEW SUMMARY

Paroxysmal spells are characterized by changes in awareness, attention, perception, or abnormal movements. These can be broadly classified as ES and nonepileptic spells (NES). NES mimics ES but are distinguished by their symptomatology and lack of epileptiform activity on electroencephalography. NES may have psychological or physiological underpinnings. Psychogenic non-ES are the most common mimics of ES. Physiological causes of NES include syncope, cerebrovascular, movement, and sleep-related disorders.

CONCLUSIONS

Distinguishing NES from ES at times may be challenging even to the most experienced clinicians. However, detailed history with an emphasis on the clinical clues, including taking a moment-by-moment history of the event from the patient and observers and physical examination, helps create an appropriate differential diagnosis to guide further diagnostic testing. An accurate diagnosis of NES prevents iatrogenic harm, including unnecessary exposure to antiseizure medications and overuse of health care resources. It also allows for the correct specialist referral and appropriate treatment.

Stepwise improvement in limb shaking achieved by staged angioplasty for severe carotid stenosis

Cerebral hyperperfusion syndrome is a rare but severe complication of carotid artery stenting or carotid endarterectomy. Staged angioplasty is reportedly an effective strategy to avoid cerebral hyperperfusion syndrome. We encountered a case of internal carotid artery stenosis with a rare clinical presentation of limb shaking that was successfully improved by staged angioplasty. To our knowledge, there are no reported cases of limb shaking treated with staged angioplasty.A 76-year-old woman presented with continuous chorea in her left lower limb and shoulder. Medical examination revealed a tiny cerebral infarction in the right corona radiata and severe right internal carotid artery stenosis. Angiography showed near occlusion of the right internal carotid artery. Staged angioplasty was performed to avoid the risk of cerebral hyperperfusion syndrome. The first angioplasty resulted in an expanded diameter of 2.5 mm and was followed by definitive carotid artery stenting using a closed-cell stent 3.5 weeks later. Limb shaking improved in a stepwise manner along with an improvement in internal carotid artery stenosis and distal flow state with no signs of cerebral hyperperfusion syndrome. Patients with internal carotid artery stenosis or occlusion presenting with limb shaking have been suggested to have impaired cerebrovascular reactivity, which is also thought to be a risk factor for cerebral hyperperfusion syndrome. The stepwise improvement in limb shaking observed in this case supports the idea that the pathophysiology of limb shaking is related to cerebral haemodynamic impairment. Measures to prevent cerebral hyperperfusion syndrome, including staged angioplasty, should be actively considered in patients with limb shaking because the symptoms themselves suggest severe hypoperfusion.

Internal carotid artery occlusion related to poorly controlled rheumatoid arthritis presenting with continuous hand shaking: A case report and literature review

RATIONALE

Limb-shaking syndrome is a special manifestation of transient ischemic attack, resulting from internal carotid artery (ICA) occlusion. Extra-articular manifestations of rheumatoid arthritis (RA) are likely to occur in patients with severe or active RA. RA may accelerate atherosclerotic processes through inflammation. Here, we present a case of ICA occlusion related to poorly controlled RA that presented with continuous hand shaking.

PATIENT CONCERNS

A 73-year-old man with a history of poorly controlled RA developed total occlusion of the right ICA in recent 4 months. He presented with 2 days of continuous and rhythmic left-hand shaking before admission.

DIAGNOSIS

The patient was suspected to have transient ischemic attack resulting from ICA occlusion.

INTERVENTIONS

Antiplatelets and antiepileptic drugs were used for continuous nonepileptic focal myoclonus. A disease-modifying antirheumatic drug-based regimen for RA was developed to prevent further atherosclerosis.

OUTCOMES

Following the initial intervention, continuous hand shaking subsided on hospital day 7. Prednisolone was titrated as an active RA control. At the 6-month follow-up visit, neither painful wrist swelling nor recurrent shaking of the hand was noted.

LESSONS

Continuous hand shaking (nonepileptic focal myoclonus) can be the initial presentation of ICA occlusion in patients with poorly controlled RA. Every patient with RA should be treated aggressively with anti-rheumatic agents since RA is an independent risk factor for stroke. Additionally, every patient with RA should be surveyed for ICA stenosis, especially in those with poor control.

Preoperative clinical symptomatology and stroke burden in pediatric moyamoya angiopathy: Defining associated risk variables

OBJECTIVE

To evaluate the preoperative clinical and magnetic resonance imaging and angiography (MRI-MRA) characteristics in pediatric moyamoya patients.

METHODS

Analysis included 100 children with moyamoya angiopathy referred to our moyamoya center for preoperative evaluation. Clinical symptoms, neurological status using Pediatric Stroke Outcome Measurement (PSOM) and degree of disability on modified Rankin scale score (mRS) were evaluated. MRI-MRA evaluation included the assessment of ischemic lesions and involvement of posterior circulation. Data were analyzed for moyamoya disease (MMD), moyamoya syndrome (MMS) and age at disease onset.

RESULTS

Stroke was a common presentation in both MMD and MMS patients. TIAs and headaches/migraine were more frequent in MMD. There was no evidence of a difference in stroke burden on MRI as well as in PCA involvement between the two subgroups. Children <2 years had higher odds of having a stroke (OR 15.5, 95% CI 3.8-62.4, p < 0.001), recurrent stroke (OR 11.8, 95%CI 2.9-46.7, p < 0.001) and unfavorable mRS (≥2) (OR 4.2, 95% CI 1.3-13.7, p = 0.01) when compared to those >5 years of age. There was some evidence of association of PCA involvement with recurrent strokes (OR 3.1, CI 1.0-9.6, p = 0.05), a poor PSOM (OR 3.0, 95% CI 1.1-8.2, p = 0.04) and mRS (OR 3.1, 95% CI 1.2-8.3, p = 0.02).

CONCLUSION

Stroke seems to be a common presentation in both MMD and MMS patients. Early age at symptom onset and involvement of posterior circulation seem to be important risk factors for a high stroke burden and an unfavorable PSOM and mRS.

Estenosis bilateral de carótidas internas manifestado por síndrome de Limb-Shaking

El síndrome de limb-shaking o sacudida de extremidades como presentación de un ataque isquémico transitorio es raro y suele asociarse con estenosis de las arterias carótidas internas. El principal diagnóstico diferencial es con crisis convulsivas. Presentamos el caso de un paciente con estenosis carotídea intracraneal bilateral que presentó sacudidas en extremidades y tuvo mejoría clínica satisfactoria tras un procedimiento con stent.

Current challenges in the pathophysiology, diagnosis, and treatment of paroxysmal movement disorders

INTRODUCTION

Paroxysmal movement disorders mostly comprise paroxysmal dyskinesia and episodic ataxia, and can be the consequence of a genetic disorder or symptomatic of an acquired disease.

AREAS COVERED

In this review, the authors focused on certain hot-topic issues in the field: the respective contribution of the cerebellum and striatum to the generation of paroxysmal dyskinesia, the importance of striatal cAMP turnover in the pathogenesis of paroxysmal dyskinesia, the treatable causes of paroxysmal movement disorders not to be missed, with a special emphasis on the treatment strategy to bypass the glucose transport defect in paroxysmal movement disorders due to GLUT1 deficiency, and functional paroxysmal movement disorders.

EXPERT OPINION

Treatment of genetic causes of paroxysmal movement disorders is evolving towards precision medicine with targeted gene-specific therapy. Alteration of the cerebellar output and modulation of the striatal cAMP turnover offer new perspectives for experimental therapeutics, at least for paroxysmal movement disorders due to selected causes. Further characterization of cell-specific molecular pathways or network dysfunctions that are critically involved in the pathogenesis of paroxysmal movement disorders will likely result in the identification of new biomarkers and testing of innovative-targeted therapeutics.

Limb-Shaking Transient Ischemic Attacks in a Patient with Previous Bilateral Neck Irradiation: The Role of Collateral Flow

Nasopharyngeal carcinoma (NPC) is commonly treated with bilateral neck radiation, which is closely associated with the complication of carotid-occlusive disease. This leads to cerebral hemodynamic compromise and possible ischemic stroke. Another manifestation is limb-shaking transient ischemic attacks (LS-TIAs), characterized by rhythmic jerks which can be easily mistaken as a focal motor seizure. We describe a case of unilateral LS-TIAs from bilateral carotid occlusion that resolved with contralateral carotid revascularization. Our patient is a 65-year-old gentleman who had no significant co-morbidities other than a past history of bilateral neck irradiation for NPC 8 years before. He presented with left-sided limb weakness and subsequently left-sided limb involuntary movements whenever he sat up or stood. His symptoms did not respond to anti-epileptic therapy. Clinical and neurological examination was significant for a left pronator drift and weak left finger abduction. Computed tomography and magnetic resonance imaging of the brain revealed infarcts in the right periventricular and watershed areas; MR angiogram showed bilateral internal carotid artery occlusion. Single photon emission computed tomography showed reduced blood flow in the right frontal, temporal, and parietal regions, that reduced further after acetazolamide challenge. He was diagnosed as having LS-TIA secondary to carotid-occlusive disease. Attempts at endovascular opening the right internal carotid artery failed. Following successful left carotid angioplasty and stenting, his symptoms gradually resolved. The left internal carotid artery remained patent at the 3-month follow-up; the right side remained occluded. Our case supports the hypothesis that LS-TIAs are due to hemodynamic compromise and may respond to improved collateral cerebral blood flow.

Limb shaking transient ischemic attacks: A follow-up of 28 patients

BACKGROUND

Limb shaking transient ischemic attack (LSTIA) is an uncommon picture of carotid-occlusive disease. The symptoms are a seizure like activity and misdiagnosed as partial motor seizures. We here present a series of patients in our registry who had limb-shaking activities and their long-term outcome after treatment of their disease.

METHODS

A total of 28 patients with limb shaking symptoms were recruited among 798 patients with TIA in our stroke registry. Risk factors and etiology of LSTIA were examined within hospitalization. After the initiaition of treatment patients were followed for a median of 6months.

RESULTS

Limb-shaking was observed mainly on the hand-arms (46%), and secondly on the legs (39%). We found five different DWI lesion patterns in patients with LSTIA, including unilateral or bilateral either cortical or borderzone ischemic hyperintensities. Carotid endarterectomy was performed in 9 (32%) patients and carotid angioplasty-stent (CAS) in 10 (36%), and after 6-months of follow-up none of the patients had LSTIA. Limb shaking continued only in a patient with chronic carotid occlusion who received only conservative treatment.

CONCLUSIONS

Limb shaking TIA point to carotid artery disease in the majority of patients and vertebrobasilar artery disease in one third. Fast and timely treatment with either surgical or CAS eliminates the attacks and also reduce their risk of stroke.

The spectrum of paroxysmal dyskinesias

Paroxysmal dyskinesias (PxD) comprise a group of heterogeneous syndromes characterized by recurrent attacks of mainly dystonia and/or chorea, without loss of consciousness. PxD have been classified according to their triggers and duration as paroxysmal kinesigenic dyskinesia, paroxysmal nonkinesigenic dyskinesia and paroxysmal exertion-induced dyskinesia. Of note, the spectrum of genetic and nongenetic conditions underlying PxD is continuously increasing, but not always a phenotype–etiology correlation exists. This creates a challenge in the diagnostic work-up, increased by the fact that most of these episodes are unwitnessed. Furthermore, other paroxysmal disorders, included those of psychogenic origin, should be considered in the differential diagnosis. In this review, some key points for the diagnosis are provided, as well as the appropriate treatment and future approaches discussed.

Postictal syndrome: The forgotten continent. An overview of the clinical, biochemical and imaging features

Postictal syndrome (PIS) encompasses the clinical, biological, electroencephalographic (EEG) and magnetic resonance imaging (MRI) signs that follow the termination of a seizure. These signs occur as soon as the epileptic discharge ends, but might remain for a substantially long period of time, making them amenable to clinical observation. As a direct consequence, neurologists and intensivists are more frequently attending patients with PIS than during their seizure. Moreover, careful PIS documentation may help physicians to diagnose epileptic seizure from other non-epileptic disorders. Careful analysis of PIS could also be helpful to better characterize the seizure (seizure subtypes, and to some extent, the localization and/or lateralization of the seizure). This article aims to review the main clinical, biological, EEG and MRI components of PIS, discuss differential diagnoses and propose a general clinical attitude, based on the acronym "WAITTT": W for "Watch", to monitor and investigate PIS in order to provide relevant information on seizure, AIT for "Avoid Inappropriate Treatment", to underscore the risk carrying out unnecessary drug injections and intensive care procedures in the setting of a self-limited symptomatology, and TT for "Take Time", to keep in mind that time remains the clinician's best ally for treating patients with PIS.

Rare Phenomenon of Limb-shaking TIA, Resolved With Intracranial Wingspan Stenting

OBJECTIVE

Illustrates the importance of differentiating limb-shaking transient ischemic attack (LS-TIA) from focal seizures and carefully selecting patients for intracranial stenting.

BACKGROUND

LS-TIA is associated with severe carotid stenosis or occlusion, often precipitated by cerebral hypoperfusion. A case study of 313 patients with symptomatic intracranial artery stenosis/occlusion reported 11% with LS-TIA. In our literature search, we did not find any other cases of successful treatment of LS-TIA with an intracranial Wingspan stent.

DESIGN/METHODS

A 66-year-old woman with a history of atrial fibrillation on anticoagulation, hypertension, hyperlipidemia and left middle cerebral artery (MCA) stroke followed by a left internal carotid artery (ICA) endarterectomy presented with transient repetitive involuntary movements (TRIMs) over her right upper and lower limbs. She described episodes of numbness followed by TRIMs over the right side of her body lasting for 1 to 2 minutes. TRIMs occurred only while standing and usually resolved on sitting or lying down.

RESULTS

Conventional angiogram showed severe stenosis of left supraclinoid ICA and proximal MCA. Brain single photon emission computed tomography scan showed impaired vascular reserve in the left MCA territory. An ambulatory electroencephalogram captured TRIMs without epileptiform discharges. She continued to have symptoms with no improvement over a period of 3 months on maximal medical management. She underwent successful endovascular treatment with the Wingspan stent system in the left M1 segment and terminal ICA. Following the revascularization procedure, her symptoms resolved.

CONCLUSIONS

It is vitally important to differentiate LS-TIA from focal seizures. This is the first documented case report of complete resolution of LS-TIA symptoms following an intracranial Wingspan stenting.

Predictors of poor cerebral collaterals and cerebrovascular reserve in patients with chronic total carotid occlusion

BACKGROUND

This study aims to investigate the relationship between cerebrovascular reserve (CVR) capacity, as measured by single-photon emission computed tomography (SPECT) and collateral blood flow, according to a transcranial colour-coded duplex(TCCD), in patients with symptomatic total carotid occlusion (TCO). Additionally, the study aims to determine whether vascular risk factors have an effect on collateral blood flow, as well as on the CVR.

METHODS

Thirty-four patients with chronic TCO, diagnosed by carotid duplex scanning and confirmed by other vascular imaging modalities, who had ischaemic symptoms either as stroke or transient ischaemic attack, were subjected to clinical assessment, SPECT under dipyridamole stress, and grading of cerebral collateral blood flow using TCCD. Demographics and vascular risk factors were correlated with SPECT and TCCD findings.

RESULTS

CVR showed a significant positive correlation with the intensity of collaterals with P value <0.001 and a Spearman correlation coefficient of 0.686. Hypertension was the only predictor of poor collaterals (p value =0.049; OR =11.5 with 95% CI 1.01-131.16).Smoking was predictive of poor CVR as measured by qualitative SPECT (p value =0.02; OR =13.2 with 95% CI 1.4-120.6).

CONCLUSION

Cerebral collaterals have an important role in the maintenance of CVR in patients with TCO. Preventive measures should be directed towards hypertension and smoking to preserve cerebral collateral patency and consequently improve CVR in patients with TCO.

Differentiating motor phenomena in tilt-induced syncope and convulsive seizures

Objective

We assessed motor phenomena in syncope and convulsive seizures to aid differential diagnosis and understand the pathophysiologic correlates.

Methods

We studied video-EEG recordings of tilt-induced syncope and convulsive seizures in participants aged 15 years and older. Syncope was defined as (1) loss of consciousness (video-assessed), (2) circulatory changes (accelerating blood pressure decrease with or without bradycardia/asystole), and (3) EEG changes (“slow” or “slow-flat-slow”). We assessed myoclonic jerks and tonic postures of the arms and noted time of occurrence, laterality, synchrony, and rhythmicity (mean consecutive differences of interclonic intervals).

Results

Video-EEG records of 65 syncope cases and 50 convulsive seizures were included. In syncope, postures occurred in 42 cases (65%) and jerks in 33 (51%). Fewer jerks occurred in syncope (median 2, range 1–19) compared to convulsive seizures (median 48, range 20–191; p < 0.001). Jerks were more rhythmic in seizures compared to syncope (p < 0.001). Atonia was seen in all syncope cases, while this was not observed in any seizure. Jerks predominantly occurred during the slow and postures during the flat EEG phase.

Conclusions

Jerks and tonic postures were common in syncope, but semiology differed from convulsive seizures. The lack of overlap in the number of jerks suggests that less than 10 indicates syncope and more than 20 a convulsive seizure: the “10/20 rule.” Loss of tone strongly favors syncope. The EEG correlates imply that jerks in syncope are likely of cortical origin, whereas tonic postures may result from brainstem disinhibition.

[Rare tremor syndromes]

BACKGROUND

There is a group of uncommon sporadic tremor syndromes, which are only partially taken into account in the current classification of tremor. Their knowledge is of diagnostic and therapeutic relevance and they should be considered in the differential diagnosis of frequent tremor syndromes.

OBJECTIVE

Differential diagnostics and treatment of uncommon tremor syndromes.

METHOD

Literature search (PubMed, Google Scholar).

RESULTS

Holmes tremor, myorhythmia, palatal tremor, limb-shaking transient ischemic attack (TIA), tardive tremor, neuropathic tremor, tremor induced by peripheral trauma and orthostatic tremor syndrome are described.

CONCLUSION

Uncommon sporadic tremor syndromes are mainly symptomatic with various underlying neurological or systemic pathologies. Their recognition accelerates the diagnostic process and has therapeutic relevance.

Positional Brain Single-Photon Emission Computed Tomography Findings in a Case of Limb-Shaking Syndrome

An 84-year-old man, who presented lower limbs limb-shaking syndrome at orthostatism lasting a few seconds, was referred in our stroke unit. Magnetic resonance imaging showed an acute infarction in the right thalamus and the insular cortex, left extracranial carotid stenosis at 80%, and low flow in the right middle cerebral artery but did not explain limb-shaking syndrome symptomatology. We performed comparative positional brain perfusion single-photon emission computed tomography (SPECT), in the upright and in the supine position, to explore and localize hypoperfusion-endangered brain structures that may be involved in the presenting symptoms. Brain perfusion SPECT showed deep hypoperfusion in bilateral carotid territories in the upright position in favor of a hemodynamic mechanism, on which blood pressure was maintained higher to avoid hypoperfusion and the patient remained supine for a longer period of time than in the usual support. Late postoperative brain perfusion SPECT after left endarterectomy did not show significant abnormalities. Limb-shaking syndrome may be related to a transient decrease in blood pressure and cerebral blood flow caused by postural changes. Positional brain perfusion SPECT seems to be helpful to improve clinical care. Positional brain perfusion SPECT should be discussed in the acute phase of stroke and if there are involuntary movements.

Limb-Shaking Transient Ischemic Attack Induced by Middle Cerebral Artery Dissection after Lung Surgery

We report a case of limb-shaking transient ischemic attack (TIA) caused by a dissection of the middle cerebral artery (MCA) following lung surgery under general anesthesia. An 81-year-old male patient who underwent lobectomy for lung cancer suddenly developed transient shaking movements of the neck and the left upper distal limb on postoperative day 1. On the basis of the double-barrel appearance of the right M1 segment of the MCA, a diagnosis of MCA dissection was made. Physicians should be aware that limb-shaking TIA is sometimes caused by MCA dissection and could be precipitated by any condition, including lung surgery under general anesthesia.

Resting-state Functional Magnetic Resonance Imaging Analysis of Brain Functional Activity in Rats with Ischemic Stroke Treated by Electro-acupuncture

OBJECTIVE

To evaluate whether electro-acupuncture (EA) treatment at acupoints of Zusanli (ST 36) and Quchi (LI 11) could reduce motor impairments and enhance brain functional recovery in rats with ischemic stroke.

MATERIALS AND METHODS

A rat model of middle cerebral artery occlusion (MCAO) was established. EA at ST 36 and LI 11was started at 24 hours (MCAO + EA group) after ischemic stroke. The nontreatment (MCAO) and sham-operated control (SC) groups were included as controls. The neurologic deficits of all groups were assessed by Zea Longa scores and the modified neurologic severity scores on 24 hours and 8 days after MCAO. To further investigate the effect of EA on infract volume and brain function, magnetic resonance imaging was used to estimate the brain lesion and brain neural activities of each group at 8 days after ischemic stroke.

RESULTS

Within 1 week after EA treatment, the neurologic deficits were significantly alleviated, and the cerebral infarctions were improved, including visual cortex, motor cortex, striatum, dorsal thalamus, and hippocampus. Furthermore, whole brain neural activities of auditory cortex, lateral nucleus group of dorsal thalamus, hippocampus, motor cortex, orbital cortex, sensory cortex, and striatum were decreased in MCAO group, whereas that of brain neural activities were increased after EA treatment, suggesting these brain regions are in accordance with the brain structure analysis.

CONCLUSION

EA at ST 36 and LI 11 could enhance the neural activity of motor function-related brain regions, including motor cortex, dorsal thalamus, and striatum in rats, which is a potential treatment for ischemia stroke.

Cerebral misery perfusion due to carotid occlusive disease

Purpose

Cerebral misery perfusion (CMP) is a condition where cerebral autoregulatory capacity is exhausted, and cerebral blood supply in insufficient to meet metabolic demand.

We present an educational review of this important condition, which has a range of clinical manifestations.

Method

A non-systematic review of published literature was undertaken on CMP and major cerebral artery occlusive disease, using Pubmed and Sciencedirect.

Findings

Patients with CMP may present with strokes in watershed territories, collapses and transient ischaemic attacks or episodic movements associated with an orthostatic component. While positron emission tomography is the gold standard investigation for misery perfusion, advanced MRI is being increasingly used as an alternative investigation modality. The presence of CMP increases the risk of strokes. In addition to the devastating effect of stroke, there is accumulating evidence of impaired cognition and quality of life with carotid occlusive disease (COD) and misery perfusion. The evidence for revascularisation in the setting of complete carotid occlusion is weak. Medical management constitutes careful blood pressure management while addressing other vascular risk factors.

Discussion

The evidence for the management of patients with COD and CMP is discussed, together with recommendations based on our local experience. In this review, we focus on misery perfusion due to COD.

Conclusion

Patients with CMP and COD may present with a wide-ranging clinical phenotype and therefore to many specialties. Early identification of patients with misery perfusion may allow appropriate management and focus on strategies to maintain or improve cerebral blood flow, while avoiding potentially harmful treatment.

Internal Carotid Artery Stenosis Presenting with Limb Shaking TIA

Internal carotid artery (ICA) stenosis may lead to a wide range of clinical symptoms. We describe the case of a 66-year-old female who experienced a transient ischemic attack (TIA) with episodes of limb shaking caused by ICA stenosis. After epilepsy had been suspected and ruled out, studies of her left ICA showed extensive blockage as a result of atherosclerosis. Magnetic resonance angiography (MRA) revealed total occlusion of the left ICA and the patient was eventually medically managed due to the strong possibility of surgical complications. We reported this patient's clinical course to shed light on a rare manifestation of carotid stenosis that may be confused with other diagnoses if not closely scrutinized.

Movement Disorders Following Cerebrovascular Lesions: Etiology, Treatment Options and Prognosis

Post-stroke movement disorders are uncommon, but comprise an important part of secondary movement disorders. These exert variable and heterogeneous clinical courses according to the stroke lesion and its temporal relationships. Moreover, the predominant stroke symptoms hinder a proper diagnosis in clinical practice. This article describes the etiology, treatment options and prognosis of post-stroke movement disorders.

The Vulnerability of Vessels Involved in the Role of Embolism and Hypoperfusion in the Mechanisms of Ischemic Cerebrovascular Diseases

Accurate definition and better understanding of the mechanisms of stroke are crucial as this will guide the effective care and therapy. In this paper, we review the previous basic and clinical researches on the causes or mechanisms of ischemic cerebrovascular diseases (ICVD) and interpret the correlation between embolism and hypoperfusion based on vascular stenosis and arterial intimal lesions. It was suggested that if there is no embolus (dynamic or in situ emboli), there might be no cerebral infarction. Three kinds of different clinical outcomes of TIA were theoretically interpreted based on its mechanisms. We suppose that there is a correlation between embolism and hypoperfusion, and which mechanisms (hypoperfusion or hypoperfusion induced microemboli) playing the dominant role in each type of ICVD depends on the unique background of arterial intimal lesions (the vulnerability of vessels). That is to say, the vulnerability of vessels is involved in the role of embolism and hypoperfusion in the mechanisms of ischemic cerebrovascular diseases. This inference might enrich and provide better understandings for the underlying etiologies of ischemic cerebrovascular events.

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

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.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0601-8) contains supplementary material, which is available to authorized users.

Statin treatment reduces the risk of poststroke seizures

OBJECTIVE

To examine the potential efficacy of statin treatment in reducing the risk of poststroke seizures.

METHODS

In this cohort study, patients with a first-ever ischemic stroke and no history of epilepsy before stroke were enrolled. After a mean follow-up period of 2.5 years, a follow-up assessment was performed to identify poststroke epilepsy. Logistic regression and Cox regression analyses were used to assess the relationship between statin use and poststroke early-onset seizures or poststroke epilepsy.

RESULTS

Of 1,832 enrolled patients, 63 (3.4%) patients had poststroke early-onset seizures and 91 (5.0%) patients had poststroke epilepsy. Statin use was associated with a lower risk of poststroke early-onset seizures (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.20-0.60, p < 0.001), and this reduced risk was seen mainly in patients who used a statin only in the acute phase (OR 0.36, 95% CI 0.20-0.62, p < 0.001). No significant association was found between statin use and poststroke epilepsy (OR 0.81, 95% CI 0.52-1.26, p = 0.349). In 63 patients who presented with early-onset seizures, statin use was associated with reduced risk of poststroke epilepsy (OR 0.34, 95% CI 0.13-0.88, p = 0.026).

CONCLUSIONS

Statin use, especially in the acute phase, may reduce the risk of poststroke early-onset seizures. In addition, statin treatment may prevent the progression of initial poststroke seizure-induced neurodegeneration into chronic epilepsy. Because of the observational nature of the study, more studies are needed to confirm the results.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in patients with a first-ever ischemic stroke, the early use of statins reduces the risk of early poststroke seizures.

Transient ischaemic attacks: mimics and chameleons

Suspected transient ischaemic attack (TIA) is a common diagnostic challenge for physicians in neurology, stroke, general medicine and primary care. It is essential to identify TIAs promptly because of the very high early risk of ischaemic stroke, requiring urgent investigation and preventive treatment. On the other hand, it is also important to identify TIA ‘mimics’, to avoid unnecessary and expensive investigations, incorrect diagnostic labelling and inappropriate long-term prevention treatment. Although the pathophysiology of ischaemic stroke and TIA is identical, and both require rapid and accurate diagnosis, the differential diagnosis differs for TIA owing to the transience of symptoms. For TIA the diagnostic challenge is greater, and the ‘mimic’ rate higher (and more varied), because there is no definitive diagnostic test. TIA heralds a high risk of early ischaemic stroke, and in many cases the stroke can be prevented if the cause is identified, hence the widespread dissemination of guidelines including rapid assessment and risk tools like the ABCD2 score. However, these guidelines do not emphasise the substantial challenges in making the correct diagnosis in patients with transient neurological symptoms. In this article we will mainly consider the common TIA mimics, but also briefly mention the rather less common situations where TIAs can look like something else (‘chameleons’).

A case of isolated middle cerebral artery stenosis with hemichorea and moyamoya pattern collateralization

Isolated middle cerebral artery (MCA) stenosis in young patients with no other medical condition may be a unique pathologic entity with a benign long-term course. Generally, moyamoya disease shows a progression of stenosis from internal cerebral artery (ICA) to other intracranial vessel. A 26-year-old woman was admitted for choreic movements of the right arm and leg. Brain magnetic resonance imaging showed no stroke. Conventional angiography revealed 48% stenosis of the left M1 without ICA stenosis. Single photon emission computed tomography revealed perfusion asymmetry after acetazolamide injection, suggesting decreased uptake in the left basal ganglia and the cerebral cortex. Her hemichorea was mildly decreased with risperidone. One year later, follow-up angiography showed complete occlusion of the left M1 with neovascularization suggestive of moyamoya disease. The patient underwent bypass surgery and her hemichorea disappeared. This may be an atypical presentation of moyamoya disease. The bypass surgery was an effective measure for restoring the vascular insufficiency and, resultantly, controlling her hemichorea.

Movement disorders in cerebrovascular disease

Movement disorders can occur as primary (idiopathic) or genetic disease, as a manifestation of an underlying neurodegenerative disorder, or secondary to a wide range of neurological or systemic diseases. Cerebrovascular diseases represent up to 22% of secondary movement disorders, and involuntary movements develop after 1-4% of strokes. Post-stroke movement disorders can manifest in parkinsonism or a wide range of hyperkinetic movement disorders including chorea, ballism, athetosis, dystonia, tremor, myoclonus, stereotypies, and akathisia. Some of these disorders occur immediately after acute stroke, whereas others can develop later, and yet others represent delayed-onset progressive movement disorders. These movement disorders have been encountered in patients with ischaemic and haemorrhagic strokes, subarachnoid haemorrhage, cerebrovascular malformations, and dural arteriovenous fistula affecting the basal ganglia, their connections, or both.

Matched case-control studies: a review of reported statistical methodology

BACKGROUND

Case-control studies are a common and efficient means of studying rare diseases or illnesses with long latency periods. Matching of cases and controls is frequently employed to control the effects of known potential confounding variables. The analysis of matched data requires specific statistical methods.

METHODS

The objective of this study was to determine the proportion of published, peer-reviewed matched case-control studies that used statistical methods appropriate for matched data. Using a comprehensive set of search criteria we identified 37 matched case-control studies for detailed analysis.

RESULTS

Among these 37 articles, only 16 studies were analyzed with proper statistical techniques (43%). Studies that were properly analyzed were more likely to have included case patients with cancer and cardiovascular disease compared to those that did not use proper statistics (10/16 or 63%, versus 5/21 or 24%, P = 0.02). They were also more likely to have matched multiple controls for each case (14/16 or 88%, versus 13/21 or 62%, P = 0.08). In addition, studies with properly analyzed data were more likely to have been published in a journal with an impact factor listed in the top 100 according to the Journal Citation Reports index (12/16 or 69%, versus 1/21 or 5%, P ≤ 0.0001).

CONCLUSION

The findings of this study raise concern that the majority of matched case-control studies report results that are derived from improper statistical analyses. This may lead to errors in estimating the relationship between a disease and exposure, as well as the incorrect adaptation of emerging medical literature.