Internal and Emergency Medicine

, Volume 12, Issue 5, pp 675–677 | Cite as

Limb-shaking TIA: on the borders of evidence-based medicine

  • Antonio Carolei
  • Pietro Amedeo ModestiEmail author

The case reported by Tiseo et al. [1] underlies the importance of considering and recognizing low cerebral perfusion among the possible causes of jerky unilateral hyperkinetic movements. In this case, the diagnostic difficulty lies in the fact that ischemic brain damage is a common cause of epilepsy in the elderly. A careful history and eyewitness description is crucial to the differentiation of seizures and psychogenic non-epileptic seizures [2].

A wide range of paroxysmal neurological events, linked with a dysfunction in the circuits connecting the cerebral cortex, thalamus, basal ganglia and cerebellum, can be associated with shaking or jerking movements [3, 4]. Any doctor who has managed patients with hyperkinetic involuntary movements knows that the etiological diagnosis of these disorders is a challenging issue that often, despite an extensive diagnostic workup, remains unsolved.

The time course of symptoms and some other elements of the history may provide important clues, and...


Celiac Disease Involuntary Movement Moyamoya Disease Carotid Artery Occlusion Paraneoplastic Neurological Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent



  1. 1.
    Tiseo C, Ornello R, Degan D, Notturno F (2017) Limb-shaking: not an exclusive epileptic origin. Intern Emerg Med. doi: 10.1007/s11739-017-1661-5
  2. 2.
    Hart YM (2012) All that shakes is not epilepsy. J R Coll Physicians Edinb. 42(2):151–154. doi: 10.4997/JRCPE.2012.213 PubMedGoogle Scholar
  3. 3.
    Abdo WF, van de Warrenburg BP, Burn DJ, Quinn NP, Bloem BR (2010) The clinical approach to movement disorders. Nat Rev Neurol. 6(1):29–37. doi: 10.1038/nrneurol.2009.196 CrossRefPubMedGoogle Scholar
  4. 4.
    Siniscalchi A, Gallelli L, Labate A, Malferrari G, Palleria C, Sarro GD (2012) Post-stroke movement disorders: clinical manifestations and pharmacological management. Curr Neuropharmacol 10(3):254–262. doi: 10.2174/157015912803217341 CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Mehanna R, Jankovic J (2013) Movement disorders in cerebrovascular disease. Lancet Neurol. 12(6):597–608. doi: 10.1016/s1474-4422(13)70057-7 CrossRefPubMedGoogle Scholar
  6. 6.
    Ghika-Schmid F, Ghika J, Regli F, Bogousslavsky J (1997) Hyperkinetic movement disorders during and after acute stroke: the Lausanne Stroke Registry. J Neurol Sci 146(2):109–116CrossRefPubMedGoogle Scholar
  7. 7.
    Im SH, Oh CW, Kwon OK, Cho BK, Chung YS, Han DH (2004) Involuntary movement induced by cerebral ischemia: pathogenesis and surgical outcome. J Neurosurg 100(5):877–882. doi: 10.3171/jns.2004.100.5.0877 CrossRefPubMedGoogle Scholar
  8. 8.
    Fisher CM (1962) Concerning recurrent transient cerebral ischemic attacks. Can Med Assoc J 86:1091–1099PubMedPubMedCentralGoogle Scholar
  9. 9.
    Thanvi B, Robinson T (2007) Complete occlusion of extracranial internal carotid artery: clinical features, pathophysiology, diagnosis and management. Postgrad Med J 83(976):95–99. doi: 10.1136/pgmj.2006.048041 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Carmo GA, Calderaro D, Gualandro DM, Casella IB, Yu PC, Marques AC, Caramelli B (2014) Carotid stenosis management: a review for the internist. Intern Emerg Med 9(2):133–142. doi: 10.1007/s11739-013-1005-z CrossRefPubMedGoogle Scholar
  11. 11.
    Fluri F, Engelter S, Lyrer P (2010) Extracranial-intracranial arterial bypass surgery for occlusive carotid artery disease. Cochrane Database Syst Rev (2):CD005953. doi: 10.1002/14651858.CD005953.pub2
  12. 12.
    Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP, Investigators C (2011) Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA 306(18):1983–1992. doi: 10.1001/jama.2011.1610 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Marshall RS, Festa JR, Cheung YK, Pavol MA, Derdeyn CP, Clarke WR, Videen TO, Grubb RL, Slane K, Powers WJ, Lazar RM, Investigators R (2014) Randomized evaluation of carotid occlusion and neurocognition (RECON) trial: main results. Neurology 82(9):744–751. doi: 10.1212/WNL.0000000000000167 CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ, Investigators ST (2011) Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med 365(11):993–1003. doi: 10.1056/NEJMoa1105335 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Banerjee C, Chimowitz MI (2017) Stroke caused by atherosclerosis of the major intracranial arteries. Circ Res 120(3):502–513. doi: 10.1161/circresaha.116.308441 CrossRefPubMedGoogle Scholar
  16. 16.
    Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, Levine SR, Chaturvedi S, Kasner SE, Benesch CG, Sila CA, Jovin TG, Romano JG, Symptomatic W-A (2005) Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med 352(13):1305–1316. doi: 10.1056/Nejmoa043033 CrossRefPubMedGoogle Scholar
  17. 17.
    Leira EC, Ajax T, Adams HP Jr (1997) Limb-shaking carotid transient ischemic attacks successfully treated with modification of the antihypertensive regimen. Arch Neurol 54(7):904–905CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2017

Authors and Affiliations

  1. 1.Department of Applied Clinical Sciences and Biotechnology University of L’AquilaL’AquilaItaly
  2. 2.Department of Experimental and Clinical MedicineUniversity of FlorenceFlorenceItaly

Personalised recommendations