An 83-year-old-lady presented with a short history of paroxysmal attacks of coarse jerking movements of the left arm, without any associated disturbance of consciousness, or other symptoms. The attacks lasted for a few minutes each time, and occurred two or three times per week. On direct questioning, she felt that the attacks often occurred as she stood up. She had a history of chronic stable angina and hypertension, and was taking aspirin, a beta blocker, an angiotensin converting enzyme inhibitor, and a nitrate preparation. She was otherwise in good health, and lived independently. The clinical examination was normal, although there was a significant postural drop of 40 mm Hg in her systolic blood pressure on standing up, but not accompanied by any symptoms.
It was felt that the differential diagnosis lay between focal epileptic seizures and carotid territory ‘shaking limb’ transient ischaemic attacks (TIAs), associated with low flow
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