A Case of Cerebral Infarction due to Right Anterior Cerebral Artery Stenosis Presenting with Suspected Limb-Shaking Syndrome Confined to the Left Lower Limb

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Cerebral infarction and limb-shaking syndrome due to right anterior cerebral artery stenosis (n=1). Intervention: Dual antiplatelet therapy (aspirin and prasugrel) and rehabilitation. Primary outcome: Recurrence of cerebral infarction or limb-shaking episodes and functional recovery.

Q: What does this research mean for the field?

Quantitative 123I-IMP SPECT can identify severe hemodynamic compromise and impaired cerebrovascular reserve in anterior cerebral artery stenosis presenting as isolated lower-limb limb-shaking syndrome. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Shinji Masuko; Yasufumi Kondo; Kanji Yamamoto

doi:10.3995/jstroke.11433

January 1, 2026NosotchuOpen Access

A Case of Cerebral Infarction due to Right Anterior Cerebral Artery Stenosis Presenting with Suspected Limb-Shaking Syndrome Confined to the Left Lower Limb

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Key result

Dual antiplatelet therapy prevents stroke recurrence in limb-shaking syndrome with impaired SPECT cerebrovascular reserve.

n=1

Why the study?

Limb shaking syndrome (LSS) is a rare subtype of transient ischemic attack usually associated with internal carotid artery lesions, and reports caused by anterior cerebral artery (ACA) stenosis are extremely scarce.

Key Points

To describe an unusual case of limb-shaking syndrome confined to the lower extremity resulting from right anterior cerebral artery stenosis rather than typical carotid artery pathology.
Clinical, electrophysiological, and neuroimaging evaluation of an 85-year-old female presenting with recurrent 1- to 2-minute involuntary left lower limb movements followed by weakness.
Diagnostic workup included brain MRI DWI, head and neck MRA, routine electroencephalography, and quantitative 123I-iodoamphetamine SPECT with acetazolamide challenge.
Brain MRI revealed right anterior cerebral artery territory infarctions and MRA showed bilateral ACA stenosis without internal carotid artery disease, while EEG displayed no epileptiform discharges.
SPECT demonstrated resting cerebral blood flow of 26.9 ml/100 g/min in the right ACA region (a 13.2% reduction compared to the left) and an exhausted cerebrovascular reserve of 4.8% versus 58.4% in the left ACA.
Management with dual antiplatelet therapy (aspirin 100 mg/day and prasugrel 3.75 mg/day), fluid loading, and antihypertensive withdrawal resulted in no stroke recurrence and improved Functional Independence Measure walking score from 1 to 4.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

An 85-year-old woman presenting with recurrent involuntary shaking and subsequent paresis of the left lower limb due to right anterior cerebral artery stenosis and cerebral infarction, followed through hospital day 33.

I

Intervention

Dual antiplatelet therapy with aspirin 100 mg/day and prasugrel 3.75 mg/day, intravenous fluid loading, discontinuation of prior antihypertensive medications (bisoprolol fumarate, sacubitril/valsartan, indapamide), and rehabilitation; diagnostic cerebral perfusion evaluation with 123I-iodoamphetamine SPECT using the RAMDA method with acetazolamide challenge.

O

Outcome

Recurrence of cerebral infarction and functional recovery (Functional Independence Measure [FIM] gait score) up to hospital discharge on day 33hard clinical

This case report highlights that anterior cerebral artery stenosis can present with limb-shaking syndrome confined to the lower limb as a prodrome to cerebral infarction, and demonstrates the utility of quantitative SPECT perfusion imaging in identifying the underlying hemodynamic ischemia.

Limitations

Single patient case report
Lack of follow-up SPECT imaging to confirm post-treatment improvements in cerebral blood flow and cerebrovascular reserve
Ictal electroencephalography (EEG) could not be recorded during the involuntary movement episodes
Epileptic seizures could not be completely ruled out because some episodes occurred during complete sleep without clear hemodynamic triggers
Follow-up SPECT after treatment was not performed to confirm improvement in cerebral blood flow and cerebrovascular reserve

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Answers are grounded in this paper and cite their sources.

Implication

SPECT may aid ACA stenosis diagnosis in limb-shaking syndrome; leaves open its role beyond single-case reports.

Abstract

Limb shaking syndrome（LSS）は高度脳低灌流によって引き起こされる一過性脳虚血発作の稀な病型で，多くは内頚動脈病変に伴うが，前大脳動脈（anterior cerebral artery: ACA）狭窄による報告は極めて少ない．本報告では1～2分で自然軽快する左下肢の反復性不随意運動で発症し，その後同下肢の脱力が出現した85歳の女性例を報告する．MRI DWIでACA領域の梗塞を認め，MRAでは両側ACA狭窄を認めたが内頚動脈狭窄を認めなかった．脳波異常はなく，123I-iodoamphetamine single-photon emission computed tomography（SPECT）では右ACA領域の安静時血流低下および脳血管予備能低下を認め，ACA狭窄に伴うLSSが疑われた．抗血小板薬による治療を行い，脳梗塞の再発はなく経過した．本症例はACA狭窄による脳梗塞前駆症状としてのLSSが疑われる際の早期診断・治療において，脳循環評価の有用性を示唆する．

Discussion

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Cite This Study

Masuko et al. (2026) conducted a case report in Cerebral infarction and limb-shaking syndrome due to right anterior cerebral artery stenosis (n=1). Dual antiplatelet therapy (aspirin and prasugrel) and rehabilitation was evaluated on Recurrence of cerebral infarction or limb-shaking episodes and functional recovery. 123I-IMP SPECT identified impaired right ACA cerebrovascular reserve (4.8% vs 58.4%) in an 85-year-old woman with limb-shaking syndrome who had no stroke recurrence on aspirin and prasugrel.

synapsesocial.com/papers/6af0e999de503f3774140a6e https://doi.org/10.3995/jstroke.11433

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A Case of Cerebral Infarction due to Right Anterior Cerebral Artery Stenosis Presenting with Suspected Limb-Shaking Syndrome Confined to the Left Lower Limb

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

A Case of Cerebral Infarction due to Right Anterior Cerebral Artery Stenosis Presenting with Suspected Limb-Shaking Syndrome Confined to the Left Lower Limb

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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