Case report:

61-year-old lady with a history of diabetes, hypertension, and coronary heart disease presented to the ED with left-sided weakness and slurred speech of 1-day duration. The patient had intermittent episodes of weakness and trouble speaking for days prior in addition to transient intermittent episodes of shaking and weakness of her left leg that lasted for few seconds for the last couple of months. The patient was on Aspirin, Clopidogrel and Atorvastatin at home. NIHSS in the ED was 4.

CT head: right ACA sub-acute infarction. CTA head and neck: No large vessel disease.

Brain MRI: Diffusion positive infarct within the paramedian right frontal lobe.

Echocardiogram was unremarkable.

Hemoglobin A1c 5.6 and LDL of 54.

Digital Subtraction Angiography DSA showed right ACA A3 segment 90% stenosis. Intensive medial management was recommended.

As patient continued to have worsening in her symptoms, submaximal angioplasty of the right A3 ACA long segment lesion was done using balloon angioplasty.

Limb shaking TIA is typically secondary to significant MCA, ICA or rarely ACA stenosis. Diagnosis can be challenging and confused with focal seizures. Treatment with carotid endarterectomy or stenting is usually successful for most patients.

For intracranial atherosclerosis initial management is optimizing medical management. Our patient was symptomatic despite optimal medical therapy. Submaximal angioplasty was utilized to successfully restore blood flow with balloon angioplasty of the A3 segment of the right ACA.