Limb-Shaking Transient Ischemic Attacks Masquerading as Focal Seizures

Limb shaking is a paroxysmal involuntary hyperkinetic movement that may be a presentation of severe unilateral steno-occlusive carotid disease. This unusual form of transient ischemic attack (TIA) is often misdiagnosed as focal motor seizures, especially with frequent repetition. We present a case of 67-year-old man with severe unilateral carotid stenosis leading to frequent left arm shaking TIAs. Initial work-up did not reveal any abnormalities, and anticonvulsant was started. He readmitted again after few days with left side mild hemiparesis. Cerebrovascular evaluation showed recent watershed infarction with significant stenosis in the ipsilateral internal carotid artery (ICA). The patient underwent stenting of the right ICA with weakness improvement and no more limb-shaking TIA on follow-up. In conclusion, early recognition of limb-shaking TIAs and differentiating it from focal motor seizures can facilitate identification of pre-occlusive carotid stenosis, allowing for appropriate interventions to prevent further TIAs or disabling stroke.

Keywords: carotid stenosis; focal seizures.; hypoperfusion; limb shaking; transient ischemic attacks.