Successful multiple burr hole openings for limb-shaking transient ischemic attack due to moyamoya disease: illustrative case

Abstract

BACKGROUND Limb-shaking transient ischemic attacks (LS-TIAs) are a rare form of TIAs that present as involuntary movements of the limbs and indicate severe cerebral hypoperfusion. LS-TIAs are often reported in patients with carotid artery stenosis but can also affect patients with intracranial artery stenosis and moyamoya disease (MMD). OBSERVATIONS A 72-year-old woman presented with repeated episodes of involuntary shaking movements of the right upper limb. Cerebral angiography revealed complete occlusion of the M1 segment of the left middle cerebral artery (MCA), and the left hemisphere was supplied by moyamoya vessels. She was treated with left direct revascularization without complications, and her involuntary movements subsided. However, she demonstrated involuntary shaking movements of the right lower limb 2 months postoperatively. Cerebral angiography revealed complete occlusion of the A1 segment of the left anterior cerebral artery (ACA). The multiple burr hole opening (MBHO) procedure was performed to improve perfusion in the left ACA territory and after 3 months, the patient’s symptoms resolved. LESSONS This case demonstrated that LS-TIAs can also develop as ischemic symptoms due to MMD. Moreover, instances of LS-TIA of the upper and lower limbs developed separately in the same patient. The patient’s symptoms improved with direct revascularization and MBHO.

Limb-Shaking And Transient Ischemic Attack

“…A total of 82 reports containing 161 cases that developed limb-shaking TIA from 25 countries were reported (Supplementary Material 2, Supplemental Digital Content 1, http://links.lww.com/NRL/A122). 6–87 The origin was European in 63 cases, Asian in 56, North American in 38, South American in 3, and 1 Australian. Figure 2 shows the number of articles published about limb-shaking TIA over time.…”

“…In 2009, Turtzo et al reported the second case treated with angioplasty and stenting, which had good outcomes 41 . In 2021, Ikeuchi et al described a case in which conservative, bypass, and synangiosis therapies failed 80 . The authors attempted multiple burr hole openings with improvement in motor symptoms.…”

“…41 In 2021, Ikeuchi et al described a case in which conservative, bypass, and synangiosis therapies failed. 80 The authors attempted multiple burr hole openings with improvement in motor symptoms.…”