Shaking limb transient ischemic attacks: unusual presentation of carotid artery occlusive disease: report of two cases.

OBJECTIVE AND

IMPORTANCE

Shaking limb transient ischemic attacks (TIAs) represent a rare clinical syndrome that has been ascribed to focal cerebral ischemia attributable to insufficient brain perfusion, usually resulting from carotid artery occlusive disease. The techniques conventionally used to evaluate this condition are contrast angiography, carotid artery ultrasonography, and magnetic resonance angiography. Treatment consists of internal carotid artery (ICA) endarterectomy or, in the case of complete ICA occlusion, extracranial-intracranial bypass. In this report, two patients with shaking limb TIAs are presented. For one patient, preoperative evaluations included single-photon emission computed tomographic studies with acetazolamide vasodilator challenge; for the second patient, computed tomographic angiography was used to assess vascular anatomic features.

CLINICAL PRESENTATION: Two patients with severe carotid artery disease presented with brief, recurrent, shaking limb TIAs. Angiograms obtained for Patient 1 demonstrated complete ICA occlusion in association with severe external carotid artery stenosis, whereas preoperative single-photon emission computed tomographic scans revealed a lack of cerebrovascular reserve in response to acetazolamide challenge. Carotid artery duplex ultrasonography and computed tomographic angiography demonstrated severe stenosis of the ICA for Patient 2.

INTERVENTION: Patient 1 underwent a left external carotid artery endarterectomy. Patient 2 underwent a right ICA endarterectomy.

CONCLUSION

After surgery, the shaking limb episodes ceased for both patients. Postoperative single-photon emission computed tomographic scans for Patient 1 demonstrated increased cerebral blood flow in response to acetazolamide challenge. These data provide support for the concept that shaking limb TIAs are related to hemodynamic failure and that improvements in cerebral blood flow through conducting vessels can alleviate the condition.