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Haasdijk EJ, Sadigh Y, Yildirim G, Dammers R, Volovici V. Limb-Shaking Transient Ischemic Attacks in Patients with Carotid Occlusion or Stenosis: A Systematic Review and Individual Patient Data Meta-Analysis. Neuroepidemiology 2024:1-10. [PMID: 38631313 DOI: 10.1159/000538977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/11/2024] [Indexed: 04/19/2024] Open
Abstract
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.
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Affiliation(s)
- Eva Joëlle Haasdijk
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands,
| | - Yasmin Sadigh
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Gizem Yildirim
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Pitton Rissardo J, Fornari Caprara AL. Limb-Shaking And Transient Ischemic Attack: A Systematic Review. Neurologist 2024; 29:126-132. [PMID: 37839077 DOI: 10.1097/nrl.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
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.
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Gonring D, Bartko J, Wehbe MR, Stoner M, Sandness D, Mix D. Limb shaking transient ischemic attack secondary to innominate artery stenosis. J Vasc Surg Cases Innov Tech 2023; 9:101277. [PMID: 37674589 PMCID: PMC10477680 DOI: 10.1016/j.jvscit.2023.101277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/08/2023] [Indexed: 09/08/2023] Open
Abstract
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.
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Affiliation(s)
- Dakota Gonring
- Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jonathan Bartko
- Department of Surgery, Case Western Reserve University, Cleveland, OH
| | - Mohammad Rachad Wehbe
- Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Michael Stoner
- Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - David Sandness
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Doran Mix
- Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Darıcı D, Gönül Öner Ö, Ertürk Çetin Ö, Zanapalıoğlu Ü, Önal Y, Karadeli HH. Limb-shaking transient ischemic attack misdiagnosed as focal seizure: A video case report. Epileptic Disord 2023; 25:567-570. [PMID: 36938896 DOI: 10.1002/epd2.20041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/01/2023] [Accepted: 03/03/2023] [Indexed: 03/21/2023]
Abstract
Content available: Video
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Affiliation(s)
- Didem Darıcı
- Department of Neurology, Istanbul Medeniyet University Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, Turkey
| | - Özge Gönül Öner
- Department of Neurology, Istanbul Medeniyet University Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, Turkey
| | - Özdem Ertürk Çetin
- Department of Neurology, Sancaktepe Sehit Prof. Dr. İlhan Varank Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ümit Zanapalıoğlu
- Department of Neurology, Sancaktepe Sehit Prof. Dr. İlhan Varank Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Yılmaz Önal
- Interventional Radiology Department, University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Hasan Hüseyin Karadeli
- Department of Neurology, Istanbul Medeniyet University Göztepe Prof. Dr. Süleyman Yalçın City Hospital, Istanbul, Turkey
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Handoko KA, Hamdan M, Kurniawan D, Fatimah E. Limb shaking movement as a rare manifestation of transient ischemic attacks caused by carotid stenosis disease: A case report. Radiol Case Rep 2023; 18:2412-2415. [PMID: 37214328 PMCID: PMC10193158 DOI: 10.1016/j.radcr.2023.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 05/24/2023] Open
Abstract
A limb shaking TIA is a less common form of TIA that manifests as involuntary movement and is frequently confused with focal motor epilepsy. A 64-year-old female presented with a 7-month history of episodic involuntary shaking movements affecting her left arm and leg before admission. These attacks primarily occurred after she rose from a sitting or lying down position to a standing position, and were relieved by simply returning to a sitting or lying position. A neurological examination revealed no motor or sensory deficits in either extremity. Her magnetic resonance angiogram (MRA) and carotid Doppler revealed right ICA stenosis in her brain. It is important to distinguish this limb shaking TIA from other conditions such as focal motor seizures. Importantly, early detection and treatment of the associated carotid artery occlusion can not only prevent the patient's TIA episode, but also lower the risk of future stroke.
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Kumar M, Khurana D, Ahuja CK, Kumar A, Singh B, Mohanty M. Simple CaroTID-VasC score to predict one-year risk of stroke in symptomatic carotid stenosis patients. J Neurol Sci 2023; 446:120578. [PMID: 36739782 DOI: 10.1016/j.jns.2023.120578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND A subset of extracranial symptomatic carotid stenosis (ESCS) patients may fare well on current optimal medical therapy (OMT), and surgery may be avoided in these patients. Therefore, we aimed to develop and validate a stroke risk prediction model to stratify the risk among ESCS patients. METHODS Adult ESCS patients who denied revascularization procedures were enrolled prospectively and prescribed OMT. Patients were followed-up for twelve months after assessing the clinical, imaging, and hemodynamics-based risk predictors at baseline. Cox regression analysis was performed on predictors which were significant in univariate analysis. Beta coefficients of significant predictors in Cox regression were used to generate a numeric score. The model was internally validated using bootstrapping. RESULTS A total of 20 (20.2%) out of 99 patients had event recurrence during the follow-up. Transient ischemic attack index event (P = 0.014), diabetes mellitus (P = 0.018), contralateral significant stenosis (P = 0.007), echolucent plaque (P = 0.011), and impaired vasomotor reactivity (P = 0.006) were significant predictors in Cox regression analysis. A points score (0-6) was derived from regression coefficients of the significant predictors. The area under ROC was 0.884 for the developed model and 0.832 for the bootstrapped model. Youden's index divided the score into low-risk (2.2%) and high-risk (35.8%) groups, and the difference in risk was significant (P < 0.001). CONCLUSIONS Most ESCS patients benefited from OMT, and the CaroTID-VasC score was effective in stratifying patients for risk of endpoint occurrence. The developed model may help identify high-risk subgroups of ESCS patients and assist the decision-making of carotid interventions.
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Affiliation(s)
- Mukesh Kumar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Chirag Kamal Ahuja
- Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Baljinder Singh
- Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Zhao Z, Qin J. Limb-shaking transient ischemic attack in posterior circulation ischemia: a case report. J Int Med Res 2022; 50:3000605221142361. [PMID: 36482679 PMCID: PMC9743026 DOI: 10.1177/03000605221142361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jie Qin
- Jie Qin, Department of Neurology, Tianjin Huanhu Hospital, 6 JiZhao Road, JinNan District, Tianjin 300350, China.
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Penn R, Harrar D, Sun LR. Seizures, Epilepsy, and Electroencephalography Findings in Pediatric Moyamoya Arteriopathy: A Scoping Review. Pediatr Neurol 2022; 142:95-103.e2. [PMID: 36577597 DOI: 10.1016/j.pediatrneurol.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/27/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Although seizures are known to occur in children with moyamoya arteriopathy, data regarding characteristics, prevalence, and predictive factors for their development are less established. This study aimed to systematically review literature addressing seizures, epilepsy, and electroencephalography findings in the pediatric moyamoya population. METHODS A scoping review was performed by searching PubMed and Ovid:Embase databases for articles that described seizures, epilepsy, and electroencephalography findings in patients aged 0 to 21 years with moyamoya arteriopathy. RESULTS The search yielded 43 total articles that addressed the following topics in childhood moyamoya: seizures as the presenting symptom, epilepsy characteristics and management, characteristic electroencephalography findings including rebuildup with discussion of proposed mechanisms, and potential predictive clinical factors for the development of seizures preoperatively and the persistence of epilepsy postoperatively. In the reviewed literature, 9% to 19% of children with moyamoya had epilepsy, with over half of the cases lacking radiographic evidence of ischemia. Young age was the most consistent clinical factor associated with both seizures as the presenting symptom and with moyamoya-related epilepsy. Multiple studies report that seizures, electroencephalographic background abnormalities, and the rebuildup phenomenon improve after successful revascularization surgery. CONCLUSIONS This scoping review provides a thorough investigation of the literature available to date on the clinical features of seizures in the pediatric moyamoya population. Literature on this topic is scarce and further studies assessing predictive factors for the development of epilepsy, prognosis as a result of having seizures, and seizure management in this population will help to fill existing knowledge gaps.
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Affiliation(s)
- Rachel Penn
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dana Harrar
- Children's National Hospital, Washington, District of Columbia
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Baltimore, Maryland.
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9
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Walls SP, Andre T, Adetunji A, Hama E. Transient Ischemic Attacks Shakes: A Case Report. Cureus 2022; 14:e28410. [PMID: 36171836 PMCID: PMC9509206 DOI: 10.7759/cureus.28410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/18/2022] Open
Abstract
Transient ischemic attack (TIA) shakes can present as epilepsy which could lead to misdiagnosis. When a patient present with neurological findings we must ensure our differentials remain broad. As a physician, we must ensure our role in analyzing the full clinical picture of our patients. We present the case of a 75-year-old man with multiple comorbidities who presented with limb shaking and seizure-like symptoms and who was found to have bilateral carotid stenosis. After finding bilateral carotid stenosis, it ultimately led to the diagnosis of “TIA Shakes.” Overall, this case re-emphasizes the importance of diagnosis and correctly managing our patients.
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10
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O'Dwyer M, Togher Z, Lim ST, Ryan M, Garcia-Gallardo A, O'Connell K, Tolan MJ. Brachiocephalic artery aneurysm plaque rupture, stroke & repair. Radiol Case Rep 2022; 17:1784-1788. [PMID: 35369543 PMCID: PMC8965028 DOI: 10.1016/j.radcr.2022.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 10/27/2022] Open
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Kitano T, Sakaguchi M, Okazaki S, Todo K, Mochizuki H. Real-time cerebral blood flow velocity during limb-shaking transient ischemic attacks. Acta Neurol Belg 2022; 123:635-636. [PMID: 35286621 DOI: 10.1007/s13760-022-01914-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
- Department of Neurology, Toyonaka Municipal Hospital, Osaka, Japan.
| | - Manabu Sakaguchi
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Ikeuchi Y, Ashida N, Nishihara M, Hosoda K. Successful multiple burr hole openings for limb-shaking transient ischemic attack due to moyamoya disease: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21401. [PMID: 35855188 PMCID: PMC9265226 DOI: 10.3171/case21401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/27/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Yusuke Ikeuchi
- Department of Neurosurgery, Nishi-Kobe Medical Center, Kobe, Japan
| | - Noriaki Ashida
- Department of Neurosurgery, Nishi-Kobe Medical Center, Kobe, Japan
| | | | - Kohkichi Hosoda
- Department of Neurosurgery, Nishi-Kobe Medical Center, Kobe, Japan
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Richardson TE, Beech P, Cloud GC. Limb-shaking TIA: a case of cerebral hypoperfusion in severe cerebrovascular disease in a young adult. BMC Neurol 2021; 21:260. [PMID: 34217237 PMCID: PMC8254341 DOI: 10.1186/s12883-021-02296-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Limb-shaking transient ischaemic attacks (TIAs) are an under recognised presentation of severe cerebrovascular disease resulting from cerebral hypoperfusion. Patients present with jerking, transitory limb movements precipitated by change in position or exercise that are often confused with seizure. Cerebral perfusion imaging studies are an important tool available to aid diagnosis. CASE PRESENTATION We present the case of a young female who developed limb-shaking TIA in the context of progressive severe intracranial atherosclerotic disease (ICAD). Previous cortical infarction raised suspicion for seizure as a cause of her symptoms. However, single photon emission CT (SPECT) with CT acetazolamide challenge identified severe left hemisphere cerebral hypoperfusion and a diagnosis of limb-shaking TIA was made. Symptoms improved with maximal medical management. CONCLUSIONS This case highlights the importance of cerebral perfusion imaging for diagnostic confirmation as well as therapeutic options available to alleviate symptoms and reduce stroke risk in patients with limb-shaking TIA.
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Affiliation(s)
| | - Paul Beech
- Department of Radiology, Alfred Hospital, Melbourne, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Australia
- Department of Clinical Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
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Tater P, Pandey S. Post-stroke Movement Disorders: Clinical Spectrum, Pathogenesis, and Management. Neurol India 2021; 69:272-283. [PMID: 33904435 DOI: 10.4103/0028-3886.314574] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Involuntary movements develop after 1-4% of strokes and they have been reported in patients with ischemic and hemorrhagic strokes affecting the basal ganglia, thalamus, and/or their connections. Hemichorea-hemiballism is the most common movement disorder following a stroke in adults while dystonia is most common in children. Tremor, myoclonus, asterixis, stereotypies, and vascular parkinsonism are other movement disorders seen following stroke. Some of them occur immediately after acute stroke, some can develop later, and others may have delayed onset progressive course. Proposed pathophysiological mechanisms include neuronal plasticity, functional diaschisis, and age-related differences in brain metabolism. There are no guidelines regarding the management of post-stroke movement disorders, mainly because of their heterogeneity.
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Affiliation(s)
- Priyanka Tater
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
| | - Sanjay Pandey
- Department of Neurology, Govind Ballabh Pant Postgraduate Institute of Medical Education and Research, New Delhi, India
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Frey J, Seachrist E. Clinical Reasoning: A 70-Year-Old Man With Right Arm and Leg Shaking. Neurology 2021; 96:1098-1101. [PMID: 33849992 DOI: 10.1212/wnl.0000000000012047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jessica Frey
- From the Department of Neurology, West Virginia University, Morgantown.
| | - Eric Seachrist
- From the Department of Neurology, West Virginia University, Morgantown
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Osteraas N. Neurologic complications of brady-arrhythmias. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:163-174. [PMID: 33632435 DOI: 10.1016/b978-0-12-819814-8.00006-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Brady-arrhythmias are responsible for both overt as well as subtle neurologic signs and symptoms, from the seemingly benign and nonspecific symptoms associated with presyncope, to sudden focal neurologic deficits. A brief background on nodal and infra-nodal brady-arrhythmias is provided, followed by extensive discussion regarding neurologic complications of brady-arrhythmias. The multiple mechanisms of and associations between Brady-arrhythmias and transient ischemic attacks and ischemic stroke are discussed. Controversial associations between brady-arrhythmias and neurologic disease are discussed as well, such as potential roles of brady-arrhythmias in cognitive impairment and sequelae of chronotropic incompetence; and the contribution of brady-arrhythmias to syncope and associated injuries to the nervous system. The chapter is written to stand on its own, with guidance toward other pertinent sections of this text where appropriate for further reading.
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Affiliation(s)
- Nicholas Osteraas
- Department of Neurologic Sciences, Rush University, Chicago, IL, United States.
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Vicente-Pascual M, Mauri-Capdevila G, Purroy F. A Less Frequent Etiology of Limb Shaking Syndrome: A Severe Middle Cerebral Artery Stenosis. J Stroke Cerebrovasc Dis 2021; 30:105629. [PMID: 33497937 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/15/2021] [Accepted: 01/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Limb Shaking Syndrome (LSS) is usually associated with internal carotid occlusion. There are few reported-cases in context of middle cerebral artery stenosis. METHODS We presented LSS in a patient with middle cerebral artery stenosis disease. RESULTS The patient was a 62-year-old man, smoker, with high blood pressure who suffered left hemifacial and limbs myoclonus. He was initially diagnosed with focal seizures and he started antiepileptic treatment. However, he repeated the episodes. The electroencephalogram showed no abnormalities, and a vascular study with ultrasounds and angio-MRI evidenced severe middle cerebral stenosis. Finally, a diagnosis of Limb Shaking Syndrome was established and he started antiplatelet and high dose lipid-lowering treatment. CONCLUSION Not all abnormal movements are due to epileptic seizures. When we evaluate a patient with vascular risk factors it is important to perform a complete vascular study to discard not only critical carotid stenosis but also intracranial disease.
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Affiliation(s)
- Mikel Vicente-Pascual
- Stroke Unit, Neurology Department.Hospital Universitari Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain.
| | - Gerard Mauri-Capdevila
- Stroke Unit, Neurology Department.Hospital Universitari Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain.
| | - Francisco Purroy
- Stroke Unit, Neurology Department.Hospital Universitari Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, 25198 Lleida, Spain.
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Tan CHN, Taneja M, Venketasubramanian N. Limb-Shaking Transient Ischemic Attacks in a Patient with Previous Bilateral Neck Irradiation: The Role of Collateral Flow. Case Rep Neurol 2020; 12:84-90. [PMID: 33505277 PMCID: PMC7802474 DOI: 10.1159/000505391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/11/2019] [Indexed: 10/17/2023] Open
Abstract
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.
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Affiliation(s)
- Chai-Hoon Nowel Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Manish Taneja
- Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore
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Han YY, Qi D, Chen XD, Song CJ. Limb-shaking transient ischemic attack with facial muscles involuntary twitch successfully treated with internal carotid artery stenting. Brain Behav 2020; 10:e01679. [PMID: 32472668 PMCID: PMC7375045 DOI: 10.1002/brb3.1679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Yuan-Yuan Han
- Department of Neurology, Suqian First Hospital, Suqian, China
| | - Dong Qi
- Department of Neurology, Suqian First Hospital, Suqian, China
| | - Xiao-Dong Chen
- Department of Neurology, Suqian First Hospital, Suqian, China
| | - Chun-Jie Song
- Department of Neurology, Suqian First Hospital, Suqian, China
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Lu J, Xia Q, Yang T, Qiang J, Liu X, Ye X, Wang R. Electroencephalographic features in pediatric patients with moyamoya disease in China. Chin Neurosurg J 2020; 6:3. [PMID: 32922932 PMCID: PMC7398412 DOI: 10.1186/s41016-019-0179-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/13/2019] [Indexed: 11/13/2022] Open
Abstract
Background Moyamoya disease (MMD) is a relatively important and common disease, especially in East Asian children. There are few reports about EEG in children with MMD in China till now. This study is aimed to analyze the electroencephalographic features of MMD in pediatric patients in China preliminarily. Methods Pediatric patients with MMD who were hospitalized in Peking University International Hospital and Beijing Tiantan Hospital from January 2016 to December 2018 were collected. Clinical and electroencephalography (EEG) findings were analyzed retrospectively. Results A total of 110 pediatric patients with MMD were involved, and 17 (15.5%) cases had a history of seizure or epilepsy. Ischemic stroke was associated with a 1.62-fold relative risk of seizure. A subset of 15 patients with complete EEG data was identified. Indications for EEG in patients with MMD included limb shaking, unilateral weakness, or generalized convulsion. Abnormal EEG was seen in 14 (93.3%) cases, with the most common findings being focal slowing 12 (80.0%), followed by epileptiform discharge 10 (66.7%), and diffuse slowing 9 (60.0%). “Re-build up” phenomenon on EEG was observed in one patient. Conclusions Seizure and abnormal background activity or epileptiform discharge on EEG were common in pediatric patients with MMD. EEG may play a role in differential diagnosis among the transient neurological events in MMD such as transient ischemic attack and seizure.
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Affiliation(s)
- Jia Lu
- Department of Neurology, Peking University International Hospital, No.1 Life Park Road, Changping District, Beijing, 102206 China
| | - Qing Xia
- Department of Neurology, Peking University International Hospital, No.1 Life Park Road, Changping District, Beijing, 102206 China
| | - Tuanfeng Yang
- Department of Neurology, Peking University International Hospital, No.1 Life Park Road, Changping District, Beijing, 102206 China
| | - Jun Qiang
- Department of Neurology, Peking University International Hospital, No.1 Life Park Road, Changping District, Beijing, 102206 China
| | - Xianzeng Liu
- Department of Neurology, Peking University International Hospital, No.1 Life Park Road, Changping District, Beijing, 102206 China
| | - Xun Ye
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 China.,Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100070 China
| | - Rong Wang
- Department of Neurosurgery, Peking University International Hospital, Beijing, 102206 China.,Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, 100070 China
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Limb shaking transient ischemic attacks: A follow-up of 28 patients. Rev Neurol (Paris) 2020; 176:587-591. [PMID: 31916976 DOI: 10.1016/j.neurol.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/12/2019] [Accepted: 12/17/2019] [Indexed: 11/21/2022]
Abstract
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.
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Muguruma K, Motoda A, Sugimoto T, Kitamura T. [A case of hemichorea caused by right internal carotid artery stenosis]. Rinsho Shinkeigaku 2019; 59:509-514. [PMID: 31341125 DOI: 10.5692/clinicalneurol.cn-001276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Demin DA, Belopasov VV, Asfandiiarova EV, Zhuravleva EN, Mintulaev IS, Nikolaeva EV. ['Stroke chameleons']. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:72-80. [PMID: 31156226 DOI: 10.17116/jnevro201911904172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diagnosis of acute stroke should be correct and early that allows physician planning the most effective treatment strategies (reperfusion therapy, undifferentiated (basic) treatment, early secondary prevention). However, stroke symptoms can be atypical and similar to some other (non-vascular) event. It can significantly complicate the clinical diagnosis of stroke and decrease the patient's chances for effective treatment. A stroke should be suspected in every patient with acute onset of neurological symptoms, especially when the patient has the 'vascular' risk factors. Furthermore it is important to remember that negative CT-scan data and/or MRI data do not exclude the presence of not only ischemic stroke but also hemorrhagic stroke. The article describes the main variants of strokes with atypical symptoms (strokes-chameleons), emphasizes the importance of careful clinical examination, provides supportive differential diagnostic criteria and discusses limitations of neuroimaging methods.
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Affiliation(s)
- D A Demin
- Federal Center for Cardiovascular Surgery, Astrakhan, Russia
| | - V V Belopasov
- Astrakhan State Medical University, Astrakhan, Russia
| | | | - E N Zhuravleva
- Alexandro-Mariinskay Regional Clinical Hospital, Astrakhan, Russia
| | - I S Mintulaev
- Alexandro-Mariinskay Regional Clinical Hospital, Astrakhan, Russia
| | - E V Nikolaeva
- Federal Center for Cardiovascular Surgery, Astrakhan, Russia
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Abstract
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.
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Positional Brain Single-Photon Emission Computed Tomography Findings in a Case of Limb-Shaking Syndrome. J Stroke Cerebrovasc Dis 2017; 27:1420-1422. [PMID: 29217363 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 09/27/2017] [Accepted: 10/31/2017] [Indexed: 11/22/2022] Open
Abstract
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.
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Internal Carotid Artery Stenosis Presenting with Limb Shaking TIA. Case Rep Neurol Med 2016; 2016:3656859. [PMID: 27840754 PMCID: PMC5093263 DOI: 10.1155/2016/3656859] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/04/2016] [Indexed: 01/10/2023] Open
Abstract
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.
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Ure RJ, Dhanju S, Lang AE, Fasano A. Unusual tremor syndromes: know in order to recognise. J Neurol Neurosurg Psychiatry 2016; 87:1191-1203. [PMID: 26985048 DOI: 10.1136/jnnp-2015-311693] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 02/28/2016] [Indexed: 11/04/2022]
Abstract
Tremor is a common neurological condition in clinical practice; yet, few syndromes are widely recognised and discussed in the literature. As a result, there is an overdiagnosis of well-known causes, such as essential tremor. Many important unusual syndromes should be considered in the differential diagnosis of patients with tremor. The objective of this review is to provide broad clinical information to aid in the recognition and treatment of various unusual tremor syndromes in the adult and paediatric populations. The review comprised of a comprehensive online search using PubMed, Ovid database and Google Scholar to identify the available literature for each unusual tremor syndrome. The review includes fragile X-associated tremor/ataxia syndrome, spinocerebellar ataxia type 12, tremors caused by autosomal recessive cerebellar ataxias, myorhythmia, isolated tongue tremor, Wilson's disease, slow orthostatic tremor, peripheral trauma-induced tremor, tardive tremor and rabbit syndrome, paroxysmal tremors (hereditary chin tremor, bilateral high-frequency synchronous discharges, head tremor, limb-shaking transient ischaemic attack), bobble-head doll syndrome, spasmus nutans and shuddering attacks. Rare tremors generally present with an action tremor and a variable combination of postural and kinetic components with resting tremors less frequently seen. The phenomenology of myorhythmia is still vague and a clinical definition is proposed. The recognition of these entities should facilitate the correct diagnosis and guide the physician to a prompt intervention.
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Affiliation(s)
- Robert J Ure
- Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Sanveer Dhanju
- Faculty of Science, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Anthony E Lang
- Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Joseph JR, Delavari N, Wilkinson DA, Roark C, Thompson BG. A Case of Complete Resolution of Hemiballismus After Carotid Endarterectomy. World Neurosurg 2016; 95:624.e5-624.e7. [DOI: 10.1016/j.wneu.2016.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/26/2022]
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Kwon DY. Movement Disorders Following Cerebrovascular Lesions: Etiology, Treatment Options and Prognosis. J Mov Disord 2016; 9:63-70. [PMID: 27240807 PMCID: PMC4886206 DOI: 10.14802/jmd.16008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/23/2016] [Accepted: 03/07/2016] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Do-Young Kwon
- Department of Neurology, Korea University College of Medicine, Ansan Hospital, Ansan, Korea
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Kassab A, Tremblay J, Poppe AY, Létourneau-Guillon L, Gallagher A, Nguyen DK. Cerebral hemodynamic changes during limb-shaking TIA: A near-infrared spectroscopy study. Neurology 2016; 86:1166-8. [PMID: 26896046 DOI: 10.1212/wnl.0000000000002505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/18/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ali Kassab
- From the Centre de Recherche du CHUM (A.K., D.K.N.), Centre de Recherche de l'Hôpital Sainte-Justine (J.T., A.G.), Hôpital Notre-Dame du CHUM (A.Y.P., L.L.-G., D.K.N.), and Centre de Recherche en Neuropsychologie et Cognition (A.G.), Université de Montréal (A.K., A.Y.P., D.K.N.), Canada.
| | - Julie Tremblay
- From the Centre de Recherche du CHUM (A.K., D.K.N.), Centre de Recherche de l'Hôpital Sainte-Justine (J.T., A.G.), Hôpital Notre-Dame du CHUM (A.Y.P., L.L.-G., D.K.N.), and Centre de Recherche en Neuropsychologie et Cognition (A.G.), Université de Montréal (A.K., A.Y.P., D.K.N.), Canada
| | - Alexandre Y Poppe
- From the Centre de Recherche du CHUM (A.K., D.K.N.), Centre de Recherche de l'Hôpital Sainte-Justine (J.T., A.G.), Hôpital Notre-Dame du CHUM (A.Y.P., L.L.-G., D.K.N.), and Centre de Recherche en Neuropsychologie et Cognition (A.G.), Université de Montréal (A.K., A.Y.P., D.K.N.), Canada
| | - Laurent Létourneau-Guillon
- From the Centre de Recherche du CHUM (A.K., D.K.N.), Centre de Recherche de l'Hôpital Sainte-Justine (J.T., A.G.), Hôpital Notre-Dame du CHUM (A.Y.P., L.L.-G., D.K.N.), and Centre de Recherche en Neuropsychologie et Cognition (A.G.), Université de Montréal (A.K., A.Y.P., D.K.N.), Canada
| | - Anne Gallagher
- From the Centre de Recherche du CHUM (A.K., D.K.N.), Centre de Recherche de l'Hôpital Sainte-Justine (J.T., A.G.), Hôpital Notre-Dame du CHUM (A.Y.P., L.L.-G., D.K.N.), and Centre de Recherche en Neuropsychologie et Cognition (A.G.), Université de Montréal (A.K., A.Y.P., D.K.N.), Canada
| | - Dang Khoa Nguyen
- From the Centre de Recherche du CHUM (A.K., D.K.N.), Centre de Recherche de l'Hôpital Sainte-Justine (J.T., A.G.), Hôpital Notre-Dame du CHUM (A.Y.P., L.L.-G., D.K.N.), and Centre de Recherche en Neuropsychologie et Cognition (A.G.), Université de Montréal (A.K., A.Y.P., D.K.N.), Canada
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Swinnen B, Schreurs A, Heye S, Lemmens R. Limb-shaking TIA during balloon test occlusion of the internal carotid artery. Acta Neurol Belg 2015; 115:449-51. [PMID: 25283769 DOI: 10.1007/s13760-014-0366-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 09/18/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Bart Swinnen
- Department of Neurology, University Hospitals Leuven, University of Leuven and VIB, Herestraat 49, 3000, Leuven, Belgium
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Frechette ES, Bell-Stephens TE, Steinberg GK, Fisher RS. Electroencephalographic features of moyamoya in adults. Clin Neurophysiol 2014; 126:481-5. [PMID: 25065300 DOI: 10.1016/j.clinph.2014.06.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 06/18/2014] [Accepted: 06/25/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Electroencephalography is useful for evaluating transient neurological events in the setting of moyamoya disease. METHODS EEG findings of adults with moyamoya seen at a large moyamoya referral center are summarized. Patients were identified by retrospective chart review. RESULTS EEGs were ordered after cerebral revascularization for altered mental status, aphasia, limb shaking, or facial twitching. Among the study population of 103 patients having EEGs, 24% of adults with moyamoya had a history of clinical seizures. Ischemic or hemorrhagic strokes were associated with a twofold relative risk of seizures. Overall, 90% of EEGs were abnormal, most commonly focally (78%), or diffusely slow (68%). Epileptiform EEG discharges were seen in 24%. Whereas hemispheres with an ischemic stroke had a 19% risk of epileptiform discharges and an 8% risk of seizures on EEG, hemispheres with hemorrhagic stroke had a 35% risk of epileptiform discharges and 19% risk of seizures on EEG. Focal amplitude attenuation was seen in 19%, breach rhythm in 15%, rhythmic delta in 14%, and electrographic seizures in 12%. CONCLUSIONS Seizures and epileptiform EEG changes are common in patients with moyamoya disease. SIGNIFICANCE Transient events in patients with moyamoya can result from seizures as well as ischemia.
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Affiliation(s)
- E S Frechette
- Fortanasce-Frechette Neurology Center, Arcadia, CA, United States. http://www.HealthyBrainMD.com
| | - T E Bell-Stephens
- Department of Neurosurgery, Stanford University School of Medicine, United States
| | - G K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, United States
| | - R S Fisher
- Department of Neurosurgery, Stanford University School of Medicine, United States; Department of Neurology and Neurological Sciences and Neurosurgery by Courtesy, Stanford University School of Medicine, United States.
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Abstract
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.
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Affiliation(s)
- Raja Mehanna
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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34
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Abstract
Limb shaking Transient Ischemic Attack is a rare manifestation of carotid-occlusive disease. The symptoms usually present with seizure like activity and often misdiagnosed as focal seizures. Only on careful history the important clinical clues-which may help in differentiating from seizure-are revealed: Lack of Jacksonian march or aura; precipitation by maneuvers that lead to carotid compression. We present the case of an elderly gentleman with recurrent limb shaking transient ischemic attacks that was initially diagnosed as a case of epilepsy. His symptoms responded to optimization of blood pressure. The case report highlights the importance of accurate diagnosis as the treatment of the associated carotid artery occlusion may not only abolish the attacks but also reduce the risk of future stroke.
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Affiliation(s)
- Abhijit Das
- Kessler Foundation Research Center, West Orange, USA
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36
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Béjot Y, Giroud M, Moreau T, Benatru I. Clinical Spectrum of Movement Disorders after Stroke in Childhood and Adulthood. Eur Neurol 2012; 68:59-64. [DOI: 10.1159/000336740] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/22/2012] [Indexed: 11/19/2022]
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Siniscalchi A, Gallelli L, Malferrari G, De Sarro G. Limb-shaking transient ischemic attack associated with focal electroencephalography slowing: case report. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2012; 5:3-5. [PMID: 22737258 PMCID: PMC3379906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Limb shaking is a rare form of transient ischemic attack (TIA) that can easily be confused with focal motor seizures. CASE We report a case of a 61-year-old man with rhythmic jerky movements of his left limb, without loss of awareness, that have occurred about once per month for the past four months, precipitated by standing up and extending the neck. The electroencephalography test showed right temporal slow activity, without epileptiform features. No evidence of a noteworthy structural lesion was found on magnetic resonance imaging of the brain. Doppler ultrasound and magnetic resonance angiography of the neck disclosed an 80% stenosis of the right internal carotid artery. The patient underwent an endarterectomy of the right internal carotid artery and remained asymptomatic in the 12-month follow-up period. DISCUSSION Both hypoperfusion and reduction of vasomotor reactivity to hypercapnia of corresponding cerebral territories, without the structural lesions of the brain, were observed in patients with limb-shaking syndrome (LSS). Electroencephalographic studies have failed to show epileptiform activity associated with LSS, although some patients have controlateral slow activity. In our patient, we observed a resolution of the attacks after endarterectomy of controlateral internal carotid artery, suggesting that a quick diagnosis of this form of TIA is important both to abolish the attacks and to reduce the risk of major stroke.
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Affiliation(s)
- Antonio Siniscalchi
- Department of Neuroscience, Neurology Division, “Annunziata” Hospital, Cosenza, Italy ‡ Regional delegate SINV
| | - Luca Gallelli
- Department of Experimental and Clinical Medicine, University Magna Grecia of Catanzaro, Clinical Pharmacology Operative Unit, Mater Domini University Hospital, Catanzaro, Italy
| | | | - Giovambattista De Sarro
- Department of Experimental and Clinical Medicine, University Magna Grecia of Catanzaro, Clinical Pharmacology Operative Unit, Mater Domini University Hospital, Catanzaro, Italy
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Guida D, Biraschi F, Francione G, Orzi F, Fantozzi LM. Hemichorea-hemiballism syndrome following a thrombo-embolic striatal infarction. Neurol Sci 2012; 34:599-601. [PMID: 22532104 DOI: 10.1007/s10072-012-1098-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 04/12/2012] [Indexed: 11/24/2022]
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Caplan JP, Binius T, Lennon VA, Pittock SJ, Rao MS. Pseudopseudoseizures: Conditions That May Mimic Psychogenic Non-Epileptic Seizures. PSYCHOSOMATICS 2011; 52:501-6. [DOI: 10.1016/j.psym.2011.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 08/05/2011] [Accepted: 08/08/2011] [Indexed: 02/07/2023]
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Nedelmann M, Kolbe M, Angermueller D, Franzen W, Gizewski ER. Cerebral hemodynamic failure presenting as limb-shaking transient ischemic attacks. Case Rep Neurol 2011; 3:97-102. [PMID: 21589846 PMCID: PMC3094577 DOI: 10.1159/000327683] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Limb-shaking transient ischemic attacks (TIA) may occur in patients with insufficient brain perfusion due to an underlying occlusive disease. We present the case of a 64-year-old patient who suffered from repetitive TIA presenting with shaking movements of the right-sided extremities and accompanying speech arrest. Symptoms are documented in the online supplementary video (www.karger.com/doi/10.1159/000327683). These episodes were frequently triggered in orthostatic situations. The diagnosis of limb-shaking TIA was established. The diagnostic workup revealed pseudo-occlusion of the left internal carotid artery, a poor intracranial collateral status and, as a consequence, an exhausted vasomotor reserve capacity. At ultrasound examination, symptoms were provoked by a change of the patient's position from supine to sitting. During evolvement of symptoms, a dramatic decrease of flow velocities in the left middle cerebral artery was observed. This case thus documents the magnitude and dynamics of perfusion failure in a rare manifestation of cerebral ischemic disease.
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Affiliation(s)
- Max Nedelmann
- Department of Neurology, Justus Liebig University Giessen, Giessen, Germany
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Ribacoba R, Menéndez-González M, Calleja S, Salas-Puig J, de la Vega V. Partial motor status epilepticus as a clinical manifestation of carotid stenosis. Int Arch Med 2010; 3:18. [PMID: 20815934 PMCID: PMC2942812 DOI: 10.1186/1755-7682-3-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 09/06/2010] [Indexed: 11/10/2022] Open
Abstract
Limb shaking (LS) is often confused with focal motor seizures. Distinguishing between both is crucial, because LS may represent an indicator of severe carotid occlusive disease and patients are at high risk of stroke. We report the case of a patient with occlusive carotid stenosis without definite stroke who develops partial motor status epilepticus (SE). Clinical, neuroimaging and electroencephalographic findings are provided. We conclude that focal motor seizures should be distinguished from LS based on clinical and electroencephalographic findings.
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Affiliation(s)
- Renée Ribacoba
- Service of Neurology, Hospital Universitario Central de Asturias, Oviedo, Astuias, Spain
| | | | - Sergio Calleja
- Service of Neurology, Hospital Universitario Central de Asturias, Oviedo, Astuias, Spain
| | - Javier Salas-Puig
- Service of Neurology, Hospital Universitario Central de Asturias, Oviedo, Astuias, Spain
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Maddula MP, Keegan BC. Limb Shaking as a Manifestation of Low-flow Transient Ischemic Attacks. INT J GERONTOL 2010. [DOI: 10.1016/s1873-9598(10)70022-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Braakman HM, Knippenberg SA, de Bondt BJ, Lodder J. An Unusual Cause of Transient Neurologic Deficits: Compression of the Carotid Artery by a Thyroid Cystic Nodule. J Stroke Cerebrovasc Dis 2010; 19:73-4. [DOI: 10.1016/j.jstrokecerebrovasdis.2009.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 02/02/2009] [Accepted: 02/11/2009] [Indexed: 11/29/2022] Open
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Treatment of limb-shaking TIAs with external carotid artery stenting. Clin Neurol Neurosurg 2009; 111:695-8. [PMID: 19559521 DOI: 10.1016/j.clineuro.2009.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 04/24/2009] [Accepted: 05/26/2009] [Indexed: 01/10/2023]
Abstract
Limb-shaking transient ischemic attacks (TIAs) occur when perfusion is reduced to the cortical territory associated with the transient movements. We present a case in which a patient with preexisting left internal carotid artery (ICA) occlusion developed limb-shaking TIAs secondary to severe stenosis of her left external carotid artery (ECA). After angioplasty and stenting of her left ECA, her symptoms resolved.
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Abstract
BACKGROUND AND PURPOSE We describe the clinical, diagnostic, and outcome features of a cohort of white patients with idiopathic moyamoya disease treated in a German institution. METHODS Our cohort included 21 white patients with moyamoya disease. Clinical and diagnostic features were obtained by retrospective chart review; follow-up information and outcome were obtained prospectively. We used the Kaplan-Meier methods to estimate stroke risk by treatment status. RESULTS The mean age at onset of symptoms was 31 years. The female predominance was 4.25:1. In our cohort, the initial symptom was a cerebral ischemic event in all patients. There was no patient with a hemorrhage at onset; only one patient experienced subarachnoidal hemorrhage in the further course of disease. The Kaplan-Meier risk for recurrent stroke was very high after the first ischemic event and smaller after angiographic diagnosis. The 5-year-Kaplan-Meier risk of recurrent stroke was 80.95% after the first ischemic event for all patients. Most subsequent ischemic events appeared in the first 2 years after symptom onset. Eleven patients (52.3%) underwent neurosurgical revascularizing procedures. After surgery, the Kaplan-Meier risk of perioperative or subsequent stroke was 27.27% within the first month and was stable thereafter. CONCLUSIONS Clinical features and course of moyamoya disease of whites analyzed in this German study are comparable to American results. Moyamoya disease in whites differs clearly from Asian moyamoya disease in timing of onset of vasculopathy and lower rate of hemorrhages.
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Affiliation(s)
- Markus Kraemer
- Department of Neurology, Alfried Krupp von Bohlen und Halbach Hospital, Essen, Germany.
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Silva DAD, Lee MP, Wong MC, Chang HM, Chen CLH. Limb-Shaking Transient Ischemic Attack with Distal Micro-Embolic Signals and Impaired Cerebrovascular Reactivity Using Transcranial Doppler. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2008. [DOI: 10.47102/annals-acadmedsg.v37n7p619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Switzer JA, Nichols FT. Are Limb-Shaking Transient Ischemic Attacks a Risk Factor for Postendarterectomy Hemorrhage? Case Report and Literature Review. J Neuroimaging 2008; 18:96-100. [DOI: 10.1111/j.1552-6569.2007.00172.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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