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Cerebral hemodynamic failure presenting as limb-shaking transient ischemic attacks.

Nedelmann M, Kolbe M, Angermueller D, Franzen W, Gizewski ER - Case Rep Neurol (2011)

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Justus Liebig University Giessen, Giessen, Germany.

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.

No MeSH data available.


Related in: MedlinePlus

Hyperventilation for 30 s followed by apnea for 30 s showed no relevant flow velocity changes in the M1 segment, reflecting exhausted reserve capacity.
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Figure 1: Hyperventilation for 30 s followed by apnea for 30 s showed no relevant flow velocity changes in the M1 segment, reflecting exhausted reserve capacity.

Mentions: A 64-year-old female patient was referred to our hospital because of TIA. Three years before presentation, a routine assessment of the brain-supplying arteries had led to the diagnosis of left ICA occlusion. On admission, the patient reported transient episodes occurring up to 10 times per day. The episodes affected the right arm and leg and mainly consisted of involuntary non-rhythmic shaking movements, limb weakness and speech problems that she referred to as a ‘mental block’. Sometimes the mental block was the leading symptom. The patient was responsive but appeared to be markedly slowed in her reactions. After 1–2 min, her clinical status normalized again. She reported that the episodes mainly occurred after standing up from a supine position or when walking. We observed these episodes on several occasions after the patient had been lying and was then asked to sit or stand up (online suppl. video; www.karger.com/doi/10.1159/000327683). An ultrasound examination revealed subtotal stenosis of the left extracranial ICA with extensive lumen narrowing in the whole extracranial segment. The B-mode finding was suggestive of a past arterial dissection. Doppler analysis showed pendular flow, indicating vessel patency with absent hemodynamic function. Transtemporal insonation demonstrated postocclusive flow in the left middle cerebral artery (MCA). Additionally, hyperventilation apnea testing indicated an exhausted cerebrovascular reserve (fig. 1). Moving the patient from a supine to a sitting position further resulted in a marked decline of MCA flow velocities. At the same time, the patient experienced typical limb-shaking symptoms, which resolved after 2 min. Flow velocities also returned to pretest values within 2 min (fig. 2). The A1 segment of the left anterior cerebral artery (ACA) was not detectable despite good insonation conditions, indicating poor collateral quality. High velocities were found in the right A1 and the left P2 segments, demonstrating collateral flow via leptomeningeal anastomoses. The results of the native and perfusion CT are shown in figure 3.


Cerebral hemodynamic failure presenting as limb-shaking transient ischemic attacks.

Nedelmann M, Kolbe M, Angermueller D, Franzen W, Gizewski ER - Case Rep Neurol (2011)

Hyperventilation for 30 s followed by apnea for 30 s showed no relevant flow velocity changes in the M1 segment, reflecting exhausted reserve capacity.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3094577&req=5

Figure 1: Hyperventilation for 30 s followed by apnea for 30 s showed no relevant flow velocity changes in the M1 segment, reflecting exhausted reserve capacity.
Mentions: A 64-year-old female patient was referred to our hospital because of TIA. Three years before presentation, a routine assessment of the brain-supplying arteries had led to the diagnosis of left ICA occlusion. On admission, the patient reported transient episodes occurring up to 10 times per day. The episodes affected the right arm and leg and mainly consisted of involuntary non-rhythmic shaking movements, limb weakness and speech problems that she referred to as a ‘mental block’. Sometimes the mental block was the leading symptom. The patient was responsive but appeared to be markedly slowed in her reactions. After 1–2 min, her clinical status normalized again. She reported that the episodes mainly occurred after standing up from a supine position or when walking. We observed these episodes on several occasions after the patient had been lying and was then asked to sit or stand up (online suppl. video; www.karger.com/doi/10.1159/000327683). An ultrasound examination revealed subtotal stenosis of the left extracranial ICA with extensive lumen narrowing in the whole extracranial segment. The B-mode finding was suggestive of a past arterial dissection. Doppler analysis showed pendular flow, indicating vessel patency with absent hemodynamic function. Transtemporal insonation demonstrated postocclusive flow in the left middle cerebral artery (MCA). Additionally, hyperventilation apnea testing indicated an exhausted cerebrovascular reserve (fig. 1). Moving the patient from a supine to a sitting position further resulted in a marked decline of MCA flow velocities. At the same time, the patient experienced typical limb-shaking symptoms, which resolved after 2 min. Flow velocities also returned to pretest values within 2 min (fig. 2). The A1 segment of the left anterior cerebral artery (ACA) was not detectable despite good insonation conditions, indicating poor collateral quality. High velocities were found in the right A1 and the left P2 segments, demonstrating collateral flow via leptomeningeal anastomoses. The results of the native and perfusion CT are shown in figure 3.

Bottom Line: 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.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Justus Liebig University Giessen, Giessen, Germany.

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.

No MeSH data available.


Related in: MedlinePlus