Inducible limb-shaking transitory ischemic attacks: a video-documented case report and review of the literature.

BACKGROUND: Limb-shaking transient ischemic attack (TIA) is a well-recognized, but rare observation in contralateral carotid steno-occlusive disease. Consequently, most clinicians have not had the chance to witness an attack. CASE PRESENTATION: We present the story of a 64-year old gentleman with exercise-induced weakness associated with tremor in his right arm. His left internal carotid artery was occluded at the bifurcation. Administration of statin and antiplatelet did not relieve his symptoms, and his stereotypic, exercise-induced "limb-shaking" episodes persisted. He underwent successful extracranial to intracranial (EC-IC) bypass, which stopped his symptoms. The patient, however, returned to our department and reported that he was able to recreate his original symptoms by compressing the bypass graft manually. CONCLUSION: To our knowledge, this is the first case with video documentation of the clinical appearance of a limb-shaking TIA. We hope this case report will increase the physicians' understanding of the clinical nature of limb-shaking TIAs.

EC-IC bypass: the failure of a clinical trial? Applicability to PFO closure trials.

Extracranial-to-intracranial (EC-IC) bypass surgery was used to prevent stroke in patients with carotid occlusion and inadequate collateral flow. Because of inappropriate proliferation of EC-IC bypass, a randomized clinical trial was carried out. The failure of the trial may have been related to inappropriate patient selection and all eligible patients not being randomized. Subsequent study has identified criteria for patient selection and new trials are underway. The present patent foramen ovale closure trials share many of the same difficulties, including overuse of the procedure and interventionalists reluctant to randomize patients. If these trials are not properly done we will be in the same situation in 20 years that the EC-IC trialists are facing today. Improvements in patient selection criteria, randomization of all eligible patients, and better statistical parameters will increase the likelihood of future trials getting the correct answer the first time. The importance of carefully done observational trials should not be overlooked.