International Journal of Gerontology | March 2010 | Vol 4 | No 1 47

Introduction
Transient ischemic attacks usually present with motor
and/or sensory deficit or with visual loss. Involuntary
hyperkinetic movements of the limbs are not generally
regarded to be a feature of cerebral ischemic episodes.
Moreover, carotid occlusive disease is not generally con-
sidered in the differential diagnosis when patients pres-
ent with such movement disorders. Because damage
from cerebral ischemia is the most common cause of
symptomatic epilepsy in the elderly
1
, this diagnosis is
most often suspected when encountering such stereo-
typical movements.
In 1962, however, Fisher
2
described a syndrome of
transient limb shaking associated with contralateral
carotid stenosis. Since then, this phenomenon has been
reported in over 50 cases worldwide
39
. Early recogni-
tion of this unusual form of transient ischemic attack
is important, as these patients with severe occlusive
carotid disease are at high risk of stroke
10
.
Case Reports
Case 1
A 76-year-old woman presented with a 1-day history
of transient left-sided weakness and slurred speech.
She had been started on bendroflumethiazide for
hypertension a few days previously. Prior to this, she
had noticed intermittent jerking of her left arm upon
standing; this was after she had commenced taking an
angiotensin-converting enzyme inhibitor. The antihyper-
tensive treatment was part of her secondary prevention
LIMB SHAKING AS A MANIFESTATION OF LOW-FLOW
TRANSIENT ISCHEMIC ATTACKS
Mohana P. Maddula*, Breffni C. Keegan
Erne Hospital, Northern Ireland, United Kingdom.
SUMMARY
Limb shaking presenting as rhythmic involuntary hyperkinetic movements may represent as severe bilateral
occlusive carotid disease. This unusual form of transient ischemic attack is often misdiagnosed as focal motor
seizures. However, careful assessment reveals a lack of usual seizure characteristics such as a jacksonian march
or facial involvement. The movements also appear to be precipitated by activities that lower blood pressure.
We present two cases of patients with severe bilateral carotid stenosis leading to limb-shaking transient
ischemic attacks. There was complete stenosis in the internal carotid artery (ICA) contralateral to the jerking
limb, combined with significant stenosis in the ipsilateral ICA. Cerebral perfusion on the occluded ICA side was
maintained through collateral circulation from the opposite ICA and posterior circulation. When blood pres-
sure was lowered orthostatically or by medication, the resulting cerebral hypoperfusion manifested as limb
jerking. Recognition of limb shaking as a rare form of transient ischemic attack and differentiating it from focal
motor epilepsy can facilitate early identification of critical carotid stenosis, allowing for appropriate interven-
tions and thus reducing the risk of a disabling stroke. We recommend that clinicians should consider carotid
disease in elderly patients presenting with orthostatic or episodic movement disorders. [International Journal
of Gerontology 2010; 4(1): 4750]
Key Words: carotid stenosis, limb jerking, limb shaking, low-flow transient ischemic attacks
*Correspondence to: Dr Mohana P. Maddula, Erne
Hospital, Cornagrade Road, Enniskillen BT74 6AY,
Northern Ireland, United Kingdom.
E-mail: mmaddula@doctors.org.uk
Accepted: December 14, 2009
CASE REPORT
2010 Taiwan Society of Geriatric Emergency & Critical Care Medicine.
regime following an episode of left-sided hemiparesis
immediately after an aortic valve replacement some
2 months previously.
Her medical history was remarkable for ischemic
heart disease and hypertension, and she had been
warfarinized because of her prosthetic valve. On initial
examination, she had left hemiparesis that resolved
a few hours later, and auscultation revealed a systolic
flow murmur. Her international normalized ratio was
subtherapeutic on presentation at 1.9, and her brain
computed tomography showed only an old right fron-
toparietal infarct. Carotid Doppler and computed tomog-
raphy carotid angiography demonstrated complete
right internal carotid artery (ICA) occlusion with a 60%
stenosis of the left ICA (Figures 1 and 2). Posterior cir-
culation was patent, and an echocardiogram did not
reveal any vegetation.
Initial treatment comprised heparin infusion and
withdrawal of bendroflumethiazide, with gradual res-
olution of her symptoms. She was referred to our local
vascular surgeons given her symptomatic left ICA, but
no surgery was planned at the time of writing. She was
managed conservatively, with a reduction in antihyper-
tensive treatment resulting in good symptom control.
Case 2
A 69-year-old man presented with intermittent jerking
of the left arm and leg upon standing up. Each jerking
episode lasted about 30 seconds, and would resolve
once the patient sat down. His symptoms were partic-
ularly bad whilst on holiday in a warm climate, and he
described a particular episode of his left leg giving way
when he alighted from a hot bus. Further exacerbation
of the jerking episodes followed after the introduction
of an angiotensin-converting enzyme inhibitor, and con-
tinued when treatment was switched to an angiotensin
II antagonist. Frequency of these episodes declined fol-
lowing the withdrawal of these agents.
Past medical history included a right temporal lobe
infarct 8 years previously, ischemic heart disease, spinal
stenosis, and a colonic resection for carcinoma. He was
on several antihypertensive medications and had a
noticeable postural drop. Examination was unremark-
able except for left central facial palsy. Carotid ultra-
sound revealed complete stenosis of his right ICA, with
70% stenosis on the left side (Figure 3). He had also un-
dergone neurosurgical review regarding potential inter-
vention for his symptomatic left ICA stenosis, and again
a conservative approach was adopted.
International Journal of Gerontology | March 2010 | Vol 4 | No 1 48

M.P. Maddula, B.C. Keegan
Figure 1. Computed tomography angiogram showing complete
right internal carotid artery occlusion.
Figure 2. Partial stenosis of the left internal carotid artery.
Figure 3. Doppler scan of the left internal carotid artery
indicating a 70% stenosis.
Discussion
The jerking movements in limb-shaking transient is-
chemic attacks can be easily mistaken for focal motor
epilepsy. The absence of a jacksonian march and the
precipitation of jerking with postural changes (lower-
ing of blood pressure) are some features that can
be used to distinguish this phenomenon from focal
seizures
6
. Facial muscles are not usually affected, and
there is a reported preferential involvement of upper
limbs. No epileptic discharge is evident on electroen-
cephalography, and no improvement is demonstrated
with anticonvulsant therapy
35
.
The underlying mechanism is speculated to be due
to transient focal hemodynamic failure. Cerebral hypo-
perfusion above the carotid narrowing in the hemi-
sphere contralateral to the side of limb jerking has been
described
11
, with loss of cerebral vasoreactivity to hy-
percapnia in this territory similarly demonstrated
12
.
In our two cases, the ICA contralateral to the jerk-
ing limb was completely occluded. In addition, there
was significant stenosis in the ipsilateral ICA. To attrib-
ute the recurrent limb-jerking events to embolic events,
these emboli would need to travel up the partially
stenosed ICA ipsilateral to the jerking limb, recurrently
crossing over at the circle of Willis, to lodge only in the
hemisphere contralateral to the jerking limb.
A more likely mechanism is cerebral hypoperfu-
sion in the hemisphere contralateral to the jerking
limb. Cerebral perfusion is maintained through collat-
eral circulation from the partially occluded ICA and
posterior arteries. Perfusion is compromised, however,
when blood pressure is lowered orthostatically or by
medication. The resulting cerebral hypoperfusion mani-
fests as limb jerking on the contralateral side, which may
resolve upon sitting or lying down. Although a reduction
of blood pressure through postural changes appears
to decrease cerebral perfusion, orthostatic hypoten-
sion does not seem compulsory for the development
of limb jerking
12
.
Management is aimed at improving/maintaining
cerebral perfusion through careful blood pressure
control and surgical revascularization. In the absence
of cardiac or renal disease, blood pressure may even be
allowed to rise, leading to an improvement in symp-
toms
2
. Addressing other stroke risk factors with choles-
terol lowering and antiplatelet agents is also beneficial.
Alternatively, surgical revascularization can be con-
sidered if comorbidities do not contribute to increases
in blood pressure. Carotid endarterectomy can improve
symptoms and lower stroke risk in the context of in-
complete carotid stenosis
3,11
. For complete carotid steno-
sis, however, extracranialintracranial bypass surgery
is suggested, and can lead to a resolution of symptoms
but does not reduce the risk of a future stroke
3,13
. Suc-
cessful resolution of symptoms has also been achieved
with carotid artery stenting
14
.
Carotid surgery, however, is not without risk. A much
higher incidence of postoperative intracerebral hem-
orrhage following carotid endarterectomy has been
reported in patients with limb shaking because of se-
vere carotid stenosis (23%), compared with an overall
risk of about 0.5% following carotid endarterectomy in
general. A reperfusion syndrome due to the combina-
tion of an increase in cerebral blood flow with the asso-
ciated loss of vasomotor reactivity above the stenosis
is likely to contribute to the higher risk of bleeding.
Accordingly, use of transcranial Doppler ultrasound
has been recommended to help assess cerebral perfu-
sion prior to surgery
15
.
In conclusion, limb-jerking transient ischemic attacks
are a rare presentation of carotid occlusive disease. It
is important to recognize this phenomenon correctly
and differentiate it from focal motor epilepsy. This
should facilitate early identification of critical carotid
stenosis, allowing for appropriate interventions and
thus reducing the risk of a disabling stroke. We recom-
mend that clinicians should consider carotid disease in
elderly patients presenting with orthostatic or episodic
movement disorders.
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M.P. Maddula, B.C. Keegan