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Enhanced leg exercise endurance with a high-carbohydrate diet and dihydroxyacetone and pyruvate.

The effects of dietary supplementation of dihydroxyacetone and pyruvate (DHAP) on metabolic responses and endurance capacity during leg exercise were determined in eight untrained males (20-30 yr). During the 7 days before exercise, a high-carbohydrate diet was consumed (70% carbohydrate, 18% protein, 12% fat; 35 kcal/kg body weight). One hundred grams of either Polycose (placebo) or dihydroxyacetone and pyruvate (treatment, 3:1) were substituted for a portion of carbohydrate. Dietary conditions were randomized, and subjects consumed each diet separated by 7-14 days. After each diet, cycle ergometer exercise (70% of peak oxygen consumption) was performed to exhaustion. Biopsy of the vastus lateralis muscle was obtained before and after exercise. Blood samples were drawn through radial artery and femoral vein catheters at rest, after 30 min of exercise, and at exercise termination. Leg endurance was 66 +/- 4 and 79 +/- 2 min after placebo and DHAP, respectively (P less than 0.01). Muscle glycogen at rest and exhaustion did not differ between diets. Whole leg arteriovenous glucose difference was greater (P less than 0.05) for DHAP than for placebo at rest (0.36 +/- 0.05 vs. 0.19 +/- 0.07 mM) and after 30 min of exercise (1.06 +/- 0.14 vs. 0.65 +/- 0.10 mM) but did not differ at exhaustion. Plasma free fatty acids, glycerol, and beta-hydroxybutyrate were similar during rest and exercise for both diets. Estimated total glucose oxidation during exercise was 165 +/- 17 and 203 +/- 15 g after placebo and DHAP, respectively (P less than 0.05). It is concluded that feeding of DHAP for 7 days in conjunction with a high carbohydrate diet enhances leg exercise endurance capacity by increasing glucose extraction by muscle.

Adult↗

Seven days of bed rest decrease insulin action on glucose uptake in leg and whole body.

Impaired glucose tolerance develops in normal humans after short-term bed rest. To elucidate the mechanism, insulin action on whole body glucose uptake rate (WBGUR) and leg glucose uptake rate (LGUR) was measured by sequential euglycemic clamp technique combined with femoral arterial and venous cannulation at insulin concentrations of 10 +/- 1, 18 +/- 1, 37 +/- 2, and 360 +/- 15 microU/ml. Studies were performed before (C) and after (BR) 7 days of strict bed rest. WBGUR was significantly lower after bed rest than before (5.5 +/- 0.4 and 7.2 +/- 0.8 mg.min-1.kg-1, respectively) when insulin was 37 microU/ml. LGUR was even more markedly depressed by bed rest, being 0.6 +/- 0.1, 0.9 +/- 0.2, and 2.8 +/- 0.4 mg.min-1.kg leg-1 (BR) compared with 0.9 +/- 0.1, 1.7 +/- 0.4, and 5.9 +/- 0.5 mg.min-1.kg leg-1 (C) (P less than 0.05) at the three lower insulin concentrations. At these insulin concentrations also, lactate release and glucose oxidation and glycogen storage estimated by indirect calorimetry were lower in the leg after bed rest. At the highest insulin dose WBGUR was similar on BR and C days, while LGUR was lower after bed rest. In conclusion, 7 days of bed rest decrease whole body insulin action, a fact that is explained by decreased insulin action in inactive muscle.

Adult↗

Effect of reduced hemoglobin concentration on leg oxygen uptake during maximal exercise in humans.

Maximum oxygen uptake (VO2max) is affected by hemoglobin concentration ([Hb]). Whether this is simply due to altered convection of O2 into the muscle microcirculation or also to [Hb]-dependent diffusive transport of O2 out of the muscle capillary is unknown in humans. To examine this, seven healthy volunteers performed four maximal cycle exercise bouts at sea level immediately after 8 wk at altitude (3,801 m, barometric pressure 485 Torr), a sojourn designed to increase [Hb]. The first two bouts were at ambient [Hb] of 15.9 +/- 0.7 g/100 ml breathing 21 or 12% O2 in random order. [Hb] was then decreased to a prealtitude level of 13.8 +/- 0.6 g/100 ml by venesection and isovolemic replacement with 5% albumin in 0.9% saline, and the exercise bouts were repeated. At whole body VO2max, PO2, PCO2, pH, and O2 saturation were measured in radial arterial and femoral venous blood. Femoral venous thermodilution blood flow was determined for calculation of leg VO2. Mean muscle capillary PO2 and muscle diffusing capacity (DO2) were computed by Bohr integration between measured arterial and femoral venous PO2. Averaged over both fractional concentrations of inspired O2, leg VO2 at maximum decreased by 17.7 +/- 4.3% as [Hb] was lowered while leg O2 delivery decreased by 17.5 +/- 2.6% and DO2 decreased by 10.7 +/- 2.7% (all P < 0.05). The relative contributions of decreases in leg O2 delivery and DO2 to the decrease in VO2max were computed to be 64 and 36%, respectively. These findings suggest that [Hb] is an important determinant of O2 diffusion rates into working muscle in humans. Possible mechanisms include 1) dependence of DO2 on intracapillary red blood cell spacing, 2) changes in the total rate of dissociation of O2 from [Hb], and 3) increased red blood cell flow heterogeneity as [Hb] is reduced.

Adolescent↗

Muscular blood flow response to submaximal leg exercise in normal subjects and in patients with heart failure.

Blood flow to working skeletal muscle is usually reduced during exercise in patients with congestive heart failure. An intrinsic impairment of skeletal muscle vasodilatory capacity has been suspected as a mechanism of this muscle underperfusion during maximal exercise, but its role during submaximal exercise remains unclear. Therefore, we studied by transcutaneous Doppler ultrasonography the arterial blood flow in the common femoral artery at rest and during a submaximal bicycle exercise in 12 normal subjects and in 30 patients with heart failure. Leg blood flow was lower in patients than in control subjects at rest [0.29 +/- 0.14 (SD) vs. 0.45 +/- 0.14 l/min, P < 0.01], at absolute powers and at the same relative power (2.17 +/- 1.06 vs. 4.39 +/- 1.4 l/min, P < 0.001). Because mean arterial pressure was maintained, leg vascular resistance was higher in patients than in control subjects at rest (407 +/- 187 vs. 247 +/- 71 mmHg.l-1.min, P < 0.01) and at the same relative power (73 +/- 49 vs. 31 +/- 13 mmHg.l-1.min, P < 0.01) but not at absolute powers. Although the magnitude of increase in leg blood flow corrected for power was similar in both groups (31 +/- 10 vs. 34 +/- 10 ml.min-1.W-1), the magnitude of decrease of leg vascular resistance corrected for power was higher in patients than in control subjects (5.9 +/- 3.3 vs. 1.9 +/- 0.94 mmHg.l-1.min.W-1, P < 0.001). These results suggest that the ability of skeletal muscle vascular resistance to decrease is not impaired and that intrinsic vascular abnormalities do not limit vasodilator response to submaximal exercise in patients with heart failure.

Adult↗

Measuring leg muscle and fat mass in humans: comparison of CT and dual-energy X-ray absorptiometry.

Dual-energy X-ray absorptiometry (DEXA) is reported to be inferior to computed tomography (CT) to measure changes in appendicular soft tissue composition. We compared CT- and DEXA-measured thigh muscle and fat mass to evaluate the random and systematic discrepancies between these two methods. Thigh skeletal muscle area (single-slice CT) was suboptimally (r(2) = 0.74, P < 0.0001) related to DEXA-measured thigh fat-free mass (FFM). In contrast, thigh muscle and adipose tissue volumes (multislice CT) were highly related to DEXA-measured thigh FFM and fat (both r(2) = 0.96, P < 0.0001). DEXA-measured leg fat was significantly less than multislice-CT-measured leg adipose tissue volume, whereas multislice-CT-measured leg muscle mass was less (P < 0.0001) than DEXA-measured leg FFM. The systematic discrepancies between the two approaches were consistent with the 10-15% nonfat components of adipose tissue. In conclusion, CT and DEXA measures of appendicular soft tissue are highly related. Systematic differences between DEXA and CT likely relate to the underlying principles of the techniques.

Absorptiometry, Photon↗

Is postexercise hypotension related to excess postexercise oxygen consumption through changes in leg blood flow?

After a single bout of aerobic exercise, oxygen consumption remains elevated above preexercise levels [excess postexercise oxygen consumption (EPOC)]. Similarly, skeletal muscle blood flow remains elevated for an extended period of time. This results in a postexercise hypotension. The purpose of this study was to explore the possibility of a causal link between EPOC, postexercise hypotension, and postexercise elevations in skeletal muscle blood flow by comparing the magnitude and duration of these postexercise phenomena. Sixteen healthy, normotensive, moderately active subjects (7 men and 9 woman, age 20-31 yr) were studied before and through 135 min after a 60-min bout of upright cycling at 60% of peak oxygen consumption. Resting and recovery VO2 were measured with a custom-built dilution hood and mass spectrometer-based metabolic system. Mean arterial pressure was measured via an automated blood pressure cuff, and femoral blood flow was measured using ultrasound. During the first hour postexercise, VO2 was increased by 11 +/- 2%, leg blood flow was increased by 51 +/- 18%, leg vascular conductance was increased by 56 +/- 19%, and mean arterial pressure was decreased by 2.2 +/- 1.0 mmHg (all P <0.05 vs. preexercise). At the end of the protocol, VO2 remained elevated by 4 +/- 2% (P <0.05), whereas leg blood flow, leg vascular conductance, and mean arterial pressure returned to preexercise levels (all P >0.7 vs. preexercise). Taken together, these data demonstrate that EPOC and the elevations in skeletal muscle blood flow underlying postexercise hypotension do not share a common time course. This suggests that there is no causal link between these two postexercise phenomena.

Adaptation, Physiological↗

High body mass index, dry scaly leg skin and atopic conditions are highly associated with keratosis pilaris.

BACKGROUND: In a previous study we have found that young patients with insulin-dependent diabetes mellitus had a higher prevalence of keratosis pilaris (KP) than healthy controls, with a high correlation with body mass index (BMI) and ichthyosiform skin changes of the legs. OBJECTIVES: To investigate whether BMI, dry scaly legs and atopic conditions could be associated with KP in a healthy population of adolescents. METHODS: A total of 202 Jewish adolescents chosen at random among students undergoing a routine medical examination at school participated in the study. The patients filled in a questionnaire for data on ethnic origin, the presence or history of allergic rhinitis, asthma or atopic dermatitis, the presence of thyroid disease, diabetes or dry skin. A similar questionnaire was sent to the family physician for verification. A general inspection of the skin was made for the presence of KP; the lower legs were also examined for dry scaly skin and ichthyosiform skin changes. RESULTS: KP was present in 33 examinees (16%). Factors significantly associated with were dry scaly skin (p < 0.001, odds ratio, OR = 31.3, with 95% confidence interval, CI, 6.4-153.7), BMI >25 (p < 0.001, OR = 4.9, with 95% CI 2.2-11.2) and atopy (p = 0.001, OR = 4.5, with 95% CI 1.8-11.1). CONCLUSION: It therefore appears that KP is associated with multiple factors, including high BMI, leg skin dryness and atopic conditions.

Adolescent↗

Effect of thoracic sympathectomy on arm and leg exercise capacity and on lung function.

BACKGROUND: Thoracic T(2-4) sympathectomy (TS) relieves palmar hyperhidrosis. These same roots innervate the heart and the lung. Thoracoscopic TS minimizes damage to the chest wall so that the effect of sympathectomy itself on these organs can be studied. We attempted to determine whether attenuated sympathetic output affects arm or leg exercise tolerance and lung function in young adults who underwent this operation. METHODS: Seven subjects, aged 17-30 years, had lung function tests (water spirometer, Godart, Holland), and leg and arm maximal exercise (CPX, MedGraphics, USA), before and 3-6 months after TS. RESULTS: After TS, resting and exercise heart rate and blood pressure were reduced. Baseline leg and arm peak O(2) uptake, 2.08 (0.6) and 1.44 (0.5) liters/min, respectively, were not different from the post-TS values, 2.06 (0.7) and 1.54 (0.5) liters/min (nonsignificant). Post-TS lung functions were not significantly reduced. CONCLUSION: Thoracoscopic T(2-4) sympathectomy does not lead to a clinically important fall in lung function and does not compromise arm or leg exercise capacity. Therefore, TS can be done safely in young subjects with palmar hyperhidrosis.

Adolescent↗

The beneficial toxicity paradox of antimicrobials in leg ulcer healing impaired by a polymicrobial flora: a proof-of-concept study.

BACKGROUND: Some of the views contrasting the beneficial and toxic effects of antimicrobials upon wound healing remain controversial. OBJECTIVE: To assess the clinical relevance of histological findings following antimicrobial applications on chronic leg ulcers. METHOD: The present study was performed in three parallel groups of 17 patients suffering from at least 2 similar chronic leg ulcers. Clinical planimetric assessments were performed before and after 3 and 6 weeks of treatment using hydrocolloid dressings. In addition, 1 ulcer in each patient received applications of povidone-iodine (PVP-I), silver sulfadiazine or chlorhexidine digluconate. Histological examinations were made at inclusion and after the 6-week therapy. Time to healing was also recorded. RESULTS: At entry in the study, fibroblasts, macrophages, neutrophils and vessels were abundant in the ulcers. In addition, focal necrotizing vasculitis was related to the microbiological load. Compared to the control lesions, both the healing rate and time to healing of the leg ulcers showed a modest improvement at the sites receiving silver sulfadiazine (2-7%) or chlorhexidine digluconate (-1 to 5%). By contrast, PVP-I increased significantly the healing rate (4-18%, p < 0.01), and time to healing was reduced by 2-9 weeks (p < 0.01). The 3 antimicrobials decreased the bacterial density, and the vascular margination and migration of inflammatory cells, thus abating the vasculitic changes. PVP-I applications did not alter the microvessels and did not significantly reduce the density in dendrocytes and fibroblasts. By contrast, both silver sulfadiazine and chorhexidine digluconate appeared to alter the superficial microsvasculature including the dendrocyte population. CONCLUSION: Although topical antimicrobials may apparently achieve almost similar activity on the bacterial load inside chronic leg ulcers, the toxicity upon host cells was different among these agents. PVP-I appeared to be an efficient compound in these respects exhibiting a positive and relevant clinical effect.

Anti-Infective Agents, Local↗

Topical effectiveness of molgramostim (GM-CSF) in sickle cell leg ulcers.

BACKGROUND: Leg ulcers are a frequently neglected, severe complication of sickle cell disease (SCD), responsible for significant altering quality of life. The management of leg ulcers remains disappointing. Local application of recombinant human granulocyte-macrophage colony-stimulating factor has been shown to be effective in several types of chronic wound healing. METHODS: We report 5 homozygous sickle cell patients with 14 leg ulcers lasting from 1 month to 6 years, treated with topical dripping of molgramostim solution. RESULTS: Healing was obtained for 9/14 ulcers, with no local or systemic adverse reactions. COMMENTS: Molgramostim solution appears to be an adequate therapy for SCD leg ulcers but a more conclusive evaluation will depend on larger series of patients and other types of formulations for topical applications could be even more effective in the future.

Administration, Topical↗

Unilateral impairment of leg blood flow in chronic stroke patients.

BACKGROUND: Previous studies comparing paretic limb blood flow with the unaffected limb have been contradictory and have often omitted comparisons of peak reactive hyperemic flow. Our objective was to perform bilateral measurements of resting and reactive hyperemic blood flow in the lower legs of chronic (>6 months) stroke patients. A secondary purpose was to determine the extent to which any unilateral changes in limb blood flow were a function of decreases in lean tissue mass on the affected side. We hypothesized that the chronic hemiparesis accompanying ischemic stroke creates an altered metabolic environment in the tissues of the affected side that ultimately impairs vasomotor function. METHODS: The study used a single-visit cross-sectional design. All tests were performed at the Baltimore VA Medical Center. Nineteen chronic hemiparetic stroke patients (15 male, 4 female) who had mild to moderate hemiparetic gait after ischemic stroke were recruited for observation. Bilateral measurements of resting and reactive hyperemic blood flow were made using venous occlusion strain gauge plethysmography. Paired t-tests were used for the between leg comparison. Regression analysis and analysis of covariance were utilized to determine the strength of the relationship between lower leg lean tissue mass and blood flow. RESULTS: Resting and reactive hyperemic blood flows were significantly reduced in the paretic compared with the non-paretic limb (32 and 35%, respectively, p < 0.001). Lean tissue mass was also significantly lower in the affected limb (p < 0.01). However, neither resting nor reactive hyperemic blood flows were significantly correlated with lower leg lean tissue mass by dual energy X-ray absorptiometry. The difference in blood flow between limbs remained after covarying for lean tissue mass. CONCLUSION: Hemiparesis causes impairments in vasomotor function under both resting and hyperemic conditions that are independent of the muscle atrophy on the affected side.

Absorptiometry, Photon↗

Wound teleconsultation in patients with chronic leg ulcers.

BACKGROUND: The treatment of chronic leg ulcers requires frequent assessments of local wound status and adjustment of therapy. The availability of reasonably priced photographic equipment and quick electronic transfer of high-quality digital images should make it possible that the assessment of wound status can be made by remote experts. OBJECTIVE: This study examines the feasibility of using teledermatology for wound assessment and therapeutic suggestions for patients with chronic leg ulcers. METHODS: One hundred ten chronic leg ulcers of different origins were examined in face-to-face consultations. The examining doctor assessed the wound, made therapeutic recommendations and took 1-4 photographs of the wound using a digital camera. The digital images and relevant clinical information were then transmitted via a web application to an expert in wound care, who provided an independent teledermatological assessment of wound status and therapeutic recommendations. RESULTS: In our study, a high accordance between direct consultations and electronic consultations was found in the assessment of chronic leg ulcers, especially for important features like slough (concordance: 84.6%), necrosis (concordance: 98.2%) and granulation tissue formation (concordance: 76.4%). Furthermore, the teledermatologist generally felt confident in recommending further treatment strategies and in planning further wound assessments via the internet. CONCLUSIONS: Our results suggest that teledermatology offers great potential for the future in chronic wound care. By reducing the need to travel long distances to the hospital or to consult a physician with expertise in wound care, wound teleconsultation might lower health care costs and improve the quality of life for patients with chronic wounds, while still maintaining a high quality of wound care.

Adult↗

Disturbed blood flow regulation in venous leg ulcers.

Microangiopathy of the skin has been recognized as an important factor in the development of skin diseases connected with chronic venous insufficiency (CVI). Here the relationship between postcapillary transmural pressure and precapillary vaso-constriction - we call it the postural feedback system - was examined in venous ulcers (n = 12) and compared to blood flow regulation in the inner ankle area of healthy controls (n = 12). Blood flow changes were measured by laser Doppler fluxmetry. Changes in the laser Doppler flux (LDF) minus the biological zero value were measured after 3 min of arterial occlusion, during 3 min of venous occlusion, while the leg was elevated and while it was lowered and expressed relative to the pretest resting value. In venous ulcers the LDF remained nearly unchanged after arterial occlusion (3 vs. 190%, p < 0.001), leg elevation caused an LDF decrease contrary to what was seen in the controls (-17 vs. +80%, p < 0.001), in the lowered leg an LDF decrease was found (-51 vs. -65%) and venous occlusion led to a profound reduction of flux (-78 vs. -84%). In severe CVI the precapillary arterioles seem to be dilated even with the leg at heart level. This finding means that the postural feedback system under resting conditions is upregulated, and 'luxus' hyperperfusion results. The upregulated postural feedback system contributes to the cutaneous microangiopathy due to chronic venous congestion.

Adult↗

Recombinant human erythropoietin induced rapid healing of a chronic leg ulcer in a patient with sickle cell disease.

A 23-year-old man with severe sickle cell disease and a chronic non-healing left leg ulcer was entered into a study in which he received hydroxyurea (HU) and recombinant human erythropoietin (r-HuEPO) in order to modify the severity of his disease. HU 20 mg/kg/day effectively prevented vaso-occlusive crises and improved hematological parameters, but the chronic leg ulcer and chronic mild bone pains remained. Six months later, r-HuEPO 600-800 IU/kg subcutaneously was added at weekly intervals. This led to a rapid and complete healing of the chronic leg ulcer, further improvement in hematological parameters and relief from chronic pains. We conclude that treatment with r-HuEPO may provide an effective therapy for chronic leg ulcers in patients with sickle cell disease.

Adult↗

Light exposure of the lower leg as a pathogenetic factor in the occurrence of malignant melanoma.

Of the 1,198 women and men studied in Mainz from 1966 to 1987 there was an approximately fivefold increase in the incidence of melanoma. Among the men melanomas on the trunk (59.9%) predominated, whereas among the women melanomas on the extremities (40.0%) were more common, especially on the lower leg (26.3%). Comparing the decades 1966-1976 and 1977-1987 there was a significant decrease in melanomas affecting women's lower legs (1966-1976: 33%,; 1977-1987: 24.2%). Fashion-dependent sun exposure of this body area might offer an explanation. It could be demonstrated that common stocking materials do not sufficiently protect against UV radiation (average permeability for UV light about 55%), therefore an intense sun exposure of the lower leg in the fifties and sixties (nylon stockings and knee-long skirts) and a less intense sun exposure in the seventies (skirts of all lengths and trousers) can be assumed. The difference in the incidence of women's melanomas on the lower leg in our two subgroups correlates indeed with the fashion-dependent insolation 10-20 years before tumour diagnosis.

Clothing↗

Effect of hydralazine on perfusion and metabolism in the leg during upright bicycle exercise in patients with heart failure.

The aerobic exercise capacity of patients with chronic heart failure is frequently impaired because of inadequate O2 transport to working skeletal muscle. To determine whether hydralazine improves O2 transport to working muscle, we examined the effect of intravenous hydralazine on blood flow (measured by thermodilution) and metabolism in the leg during maximal upright bicycle exercise in 10 patients with chronic heart failure. Hydralazine increased maximal exercise cardiac output (5.6 +/- 0.7 to 6.7 +/- 0.6 l/min; p less than .01) and decreased systemic O2 extraction (79 +/- 3% to 65 +/- 2%; p less than .01) but did not alter maximal O2 uptake (787 +/- 105 vs 779 +/- 82 ml/min). Leg blood flow at maximal exercise increased from 1.6 +/- 0.2 to 2.1 +/- 0.4 l/min (p less than .03); the proportion of cardiac output delivered to the leg remained unchanged (59 +/- 3% vs 57 +/- 9%). This increase in flow was associated with a decrease in O2 extraction in the leg (84 +/- 2% to 79 +/- 2%; p less than .01) and no change in peak femoral venous lactate (59.1 +/- 7.4 vs 54.1 +/- 5.3 mg/dl), suggesting that there is functional or anatomic shunting of the augmented limb flow rather than delivery to metabolizing muscle. These data suggest that hydralazine augments flow to the exercising limb in patients with heart failure but that this augmented flow does not increase oxygen availability within working muscle.

Aged↗

Amlodipine, enalapril, and dependent leg edema in essential hypertension.

Calcium channel blockers (CCBs) blunt postural skin vasoconstriction, an autoregulatory mechanism that minimizes gravitational increases in capillary pressure and avoids fluid extravasation when standing. To evaluate the dose-response relation between this pharmacological interference and dependent edema, a frequent side effect of CCBs during antihypertensive treatment, skin blood flow (laser Doppler flowmetry) at the dorsum of the foot, both supine and with the limb passively placed 50 cm below the heart level, and leg weight (Archimedes principle) were measured at baseline, during increasing doses of the dihydropyridine amlodipine (5 and 10 mg UID each for 2 weeks), and after drug withdrawal in 10 hypertensive men. Because angiotensin-converting enzyme inhibitors may attenuate ankle swelling by CCBs, those parameters were evaluated according to a similar design during amlodipine (10 mg UID) and enalapril (20 mg UID) combined (n=10). As a control, the effect of enalapril monotherapy (10 and 20 mg UID for 2 weeks each) was evaluated in a third series of patients (n=8). Amlodipine (5 mg UID) increased leg weight without modifying postural vasoconstriction (the percent skin blood flow decrease from horizontal to dependent position), which indicates that extravascular fluid shift was independent of postural skin vasoconstriction. At 10 mg UID, however, amlodipine blunted postural vasoconstriction and increased leg weight further, which suggests that skin blood flow autoregulation limited additional fluid transfer. Both parameters normalized after drug withdrawal. Enalapril per se did not affect cutaneous vasomotion or leg weight but reduced the amount of dependent fluid extravasation by the CCB despite a persistent antagonism for postural vasoconstrictor responses.

Adult↗

Ipsilateral leg weakness associated with carotid stenosis.

Ipsilateral motor or sensory symptoms associated with carotid occlusive diseases are rare. We report a 52-year-old man who presented with aphasia, right hemiparesis, mild left leg weakness, and bilateral Babinski's signs. During the previous 10 days, he had experienced three episodes of left leg numbness and incoordination that occurred either alone or in association with right arm and leg weakness. Computed tomography showed infarcts in the right frontoparietal (parasagittal), left frontal, and left parietal lobes. Cerebral angiography revealed 60% stenosis of the right internal carotid artery, 80% stenosis of the left internal carotid artery, absence of the A1 segment of the right anterior cerebral artery, filling of the right anterior cerebral artery from the left carotid circulation only, and a normal vertebrobasilar system. This report illustrates that leg weakness may occur ipsilateral to carotid disease if the contralateral anterior cerebral artery is supplied by the ipsilateral carotid artery.

Carotid Arteries↗