Limb-shaking Transient Ischemic Attack (TIA) is a very rare presentation of cerebral arterial occlusion. It presents as involuntary abnormal movements that occur in one or more limbs usually triggered by orthostasis and cerebral hypoperfusion. This has been described in unilateral or bilateral carotid artery occlusions but to the best of our knowledge, this is the first case of Limb-Shaking TIA secondary to bilateral anterior cerebral artery (ACA) occlusions.

This is a 76-year-old male with significant cardiovascular comorbidities who presented with three months of recurrent falls preceded by 30 seconds of weakness and shaking of bilateral legs. He did not have any prodromal symptoms or loss of awareness associated with these episodes that occurred several times per day. After a few minutes of being in the ground, he would regain complete strength and would be able to stand up independently. He was found to have orthostatic hypotension during these episodes. Vascular imaging showed a complex anatomy of the anterior cerebral arteries, with fusiform dilation of the right A2 segment, a thrombosed right A3 segment and stenosed left ACA. MRI of the brain did not show diffusion restriction consistent with ischemic injury. He was also found to have lumbar spinal stenosis which was thought to contribute to the weakness. He was started on dual antiplatelet therapy and high intensity statins. His symptoms responded to hydration and careful ambulation with compression stockings.

Bilateral limb-shaking TIAs are a very unusual presentation of cerebral hypoperfusion. They are often misdiagnosed as focal seizures with preserved awareness or even movement disorders such as myoclonus. It is important to identify triggers such as orthostatic hypotension that can be often be reproduced at bedside. Management involves careful blood pressure control, avoidance of precipitating factors and consideration of revascularization if applicable.