Ital. J. Neurol. Sci. 2: 239-241, 1983

Bilateral TIAs and unilateral
seizures due to orthostatic
hypotension. A case report.
Landi G.*, Perrone P.**, Guidotti M.*
*Clinica Neurologica 11, Universitgt degfi Studi di Milano
** Divisione di Neurologia, Ospedale Civile di Busto Arsizio

After a reversible right hemispheric stroke, a patient with bilateral carotid
occlusion developed left motor seizures and bilateral TIAs, both triggered by
orthostatic hypotension.
A CT-scan showed a right frontal hypodense area.
Hemodynamic factors may cause focal seizures in patients with cortical
lesions.
Key-Words: TIA - - orthostatic hypotension

Introduction
Although partial seizures are relatively frequent
in cerebrovascular patients [1], they are not
regarded as TIAs in the absence of other symptoms [2]. Actually, most of these fits are due to
the presence of epileptogenic lesions of the brain
parenchyma. However, in patients with stenosis
or thrombosis of the carotid artery, a hemodynamic [3] or embolic [4] pathogenesis has been
suggested. We report the case of a patient with
pre-existing cortical lesion that supports this
possibility.

Case Report
A 60-year-old man suddenly developed a left
hemiparesis which resolved completely within a
week. He was hypertensive and was treated with
alpha-methyldopa 250 mg bid. Ten months later
he began to have focal motor seizures which
started from the left hand spreading to the ipsilateral limbs. The seizures occurred several
times a month, always when the patient was
standing; treatment with diphenylhydantoin
did not reduce their frequency, despite a serum
level of 14.5 mcg/ml.
After one year the patient began to present also

TIAs, sometimes with aphasia and right hemiparesis, at other times with left hemiparesis.
They too developed only when the patient was
standing.
On admission, neurological examination was
negative. An EEG showed diffuse slowing with
rhythmic sharp waves on the right hemisphere.
A CT-scan (Fig. 1.) demonstrated a right frontal
hypodense area involving the cortex and the
white matter. Cerebral angiography revealed
thrombosis of both internal carotid arteries near
the origin, a 50% stenosis of the right external
and a 30% stenosis of the left common carotid
arteries.
Methyldopa and diphenylhydantoin were stopped and aspirin and phenobarbital (200 mg/
day) were administered. Blood pressure (BP)
ranged from 170/100 to 250/120; however, in
the standing position a BP of 90/50 - - 100/60
was sometimes reported. During his hospital
stay the patient had several episodes both of
TIA and of left motor seizures, occurring either
when he passed from the recumbent to the
standing position, or when he was already standing. During four TIAs and two focal seizures the
BP was taken, and it was always lower than
100/70.
Without any hypotensive treatment, the BP pro239

The Italian Journal of Neurological Sciences

one T I A with left hemiparesis lasting 6 hours.
Seizures did not recur.
Comment

Fig. 1. CT-scan of the right frontal hypodense
area.

gressively became normal, and no further hypotensive episodes occurred. Phenobarbital was
continued, with a serum level of 22 mcg/ml.
During the following year the patient had only

In our patient marked decreases of the BP, probably caused by loss of baroceptor mechanisms
and by antihypertensive therapy, triggered both
focal seizures and episodes of right and left
hemiparesis. His symptoms disappeared as soon
as orthostatic hypotension improved. Although
focal inhibitory seizures may mimic the clinical
appearance of TIAs [5], the occurrence of bilateral attacks of transient neurological dysfunction in a patient with thrombosis of both internal carotid arteries pointed to focal ischemia as
the pathogenetic mechanism.
However, focal seizures involved only the left
limbs, thus raising the possibility that hypotension was sufficient to cause TIAs, but the additional presence of a structurally abnormal cortical area was necessary to trigger epileptic discharges, as already suggested by other authors
[3, 6].
In this case, although both kinds of episodes
were due to transient focal ischemia, partial seizures should be distinguished from TIAs which
do not require a permanent pathological substraturn.

Riassunto
Dopo un attacco L~chemico reversibile in emisfero destro, un paziente con occlusione carotictea bilaterale
present6 crisi epilettiche focali motorie agli arti di sinistra e TIA bilaterali, entrambi scatenati da
ipotensione ortostatica.
Una TA C dimostr6 un'area ipodensa frontale destra.
Fattori emodinamici possono provocare crisi epilettiche focali in pazienti con lesioni corticali.

Address reprint requests to: Dr. Gianluca Landi
Clinica Neurologia II Universit/i degli Studi di Milano
Ospedale Policlinico
Via F. Sforza 35 20122 Milano
240

Landi: Bilateral Tias and orthostatic hypotension

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1974.
[3] RILEY TL., FRIEDMAN JM,: Stroke, orthostatic
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[4]

JOYEUXO., AIMARDG., GOUTELLEA., COUVJON
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[6] DODGE P.R., RICHA~SON EP., VlC'rOR M.:
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Brain 77, 610-638, 1959.

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