Orthostatic limb shaking from carotid hypoperfusion

Limb shaking and other involuntary episodic movements may be a concomitant of carotid artery occlusive disease.1-3 The possibility that limb shaking can be caused by cerebral ischemia has been supported by reports of patients in whom there was no response to antiepileptic medications and an absence of epileptiform activity on ictal and interictal encephalogram, but in whom there was abnormality of cerebral blood flow. In several instances, symptoms improved after treatment with antiplatelet agents or avoiding iatrogenic hypotension.2-4 We present a patient with this unusual syndrome that was initially treated as a seizure who eventually responded to an uncommon type of endarterectomy. A 66-year-old right-handed man with a history of hypercholesterolemia, coronary artery bypass graft surgery, and pacemaker insertion for sick sinus syndrome was referred for evaluation of recurrent left-sided involuntary movement. His spells began 14 months before presentation. He repeatedly dropped keys from his hand when getting out of his car. He noted clumsiness and tremorlike motion …