Centrifugal Cerebral Ischemia
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Abstract:
Eighteen of twenty patients with subclavian or innominate artery obstruction experienced episodes of transient cerebral arterial insufficiency; one patient suffered acute stroke and coma; all patients had angiographic evidence of subclavian or innominate artery obstruction; and most were shown to have retrograde flow in a vertebral artery. Two clinical patterns were apparent by arteriographic studies. Six patients had single lesions of a subclavian artery resulting in centrifugal cerebral ischemia. A second group of 14 patients had other significant lesions of either the carotid or vertebral-basilar arterial systems. Carotid-subclavian bypass or aorto-subclavian bypass are the preferred methods of reconstruction of subclavian obstructions. Of these two approaches, the extrathoracic procedure is preferable.Keywords:
Subclavian steal syndrome
Coma (optics)
Vertebrobasilar insufficiency
Subclavian "steal", when blood siphons from one vertebral artery to the other, has been suggested as a cause of brain stem ischaemia and stroke. We investigated 33 patients using transcranial Doppler to determine the direction and velocity of basilar blood flow. All patients had severe subclavian stenosis with reversed vertebral blood flow in the ipsilateral artery previously demonstrated by extracranial Doppler. Basilar flow was normal in direction in all cases, but its velocity was significantly increased (p less than 0.0008) compared to age- and sex-matched controls. These findings, in conjunction with previous observations using extracranial Doppler techniques, suggest that subclavian steal is little more than a harmless haemodynamic phenomenon.
Subclavian steal syndrome
Vertebrobasilar insufficiency
Transcranial Doppler
Left subclavian artery
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A significant subclavian or innominate artery obliteration may cause reversal of flow in the ipsilateral vertebral artery causing vertebro-basilar ischaemia with cerebral symptoms, called the subclavian steal syndrome. Until recently, angiography was the only method of diagnosing a subclavian steal. In the present study, a non-invasive technique (Directional Doppler ultrasound) was used to determine the direction of flow in the vertebral arteries. The study was carried out on 22 patients referred with suspected subclavian could be identified bilaterally by the Doppler ultrasound technique, which also revealed unilateral retrograde in twenty and bilateral antegrade (= normal) vertebral artery blood flow in two patients. These findings were verified in all patients by aorto-cervical angiography. Seven of the patients then had their subclavian or innominate artery reconstructed. Postoperatively a new Directional Doppler ultrasound examination then showed bilateral normal (= antegrade) vertebral artery blood flow. The used non-invasive technique is shown to have high reliability and may be used to screen patients suspected of having subclavian steal pre-angiographically and preoperatively. The method is also of value for the post-operative control.
Subclavian steal syndrome
Vertebrobasilar insufficiency
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Intraoperative vertebral artery blood flow was measured in two patients with symptomatic subclavian steal syndrome, before and after proximal end-to-side vertebral to common carotid artery transposition. This confirmed retrograde flow in the vertebral artery before transposition, and antegrade flow after transposition. The measured flow rates were compared to values in other series involving different operative procedures for correction of symptomatic subclavian steal. The greatest mean antegrade flow rates in the vertebral artery were restored by proximal end-to-side vertebral to common carotid artery transposition.
Subclavian steal syndrome
Transposition (logic)
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Subclavian steal syndrome
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The classical subclavian steal syndrome is a larcenous vertebrobasilar insufficiency, secondary to retrograde flow in the vertebral artery. The authors present their experience with an unusual variant of subclavian steal in which the ipsilateral vertebral artery was completely or partially occluded, or arose from the aortic arch. These patients had symptoms typical of vertebrobasilar insufficiency--dizziness or brain stem transient ischemic attacks--despite steal through relatively small cervical collaterals to the obstructed subclavian artery. Physical findings of diminished pulses and blood pressure in the involved upper extremity are similar to those in the common form of subclavian steal. The alternate collaterals found in these patients are documented by angiography and other potential collaterals are reviewed. All three symptomatic patients were treated successfully by carotid-subclavian bypass or anastomosis of the subclavian to the common carotid artery. They have remained asymptomatic for 1 1/2 to 3 years following operation. The potential for development of subclavian steal in the absence of a vertebral artery to provide collateral flow adds another reason for abandoning vertebral artery ligation as an alternative treatment for the subclavian steal syndrome.
Subclavian steal syndrome
Vertebrobasilar insufficiency
Occipital artery
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DESCRIBED originally by Contorni1 in 1960 and christened by the editors of this journal,2 the subclavian-steal syndrome has since become a well established clinical entity.3 , 4 It is associated with occlusion of the subclavian artery proximal to the origin of the vertebral. The syndrome is characterized by diversion of blood from the opposite vertebral artery into the obstructed side, with resultant perfusion of the distal subclavian bed with blood that was intended for cerebral circulation. The symptoms are reminiscent of basilar-artery insufficiency and may be precipitated by exertion of the involved extremity.5 The occlusion is usually caused by degenerative vascular disease, . . .
Subclavian steal syndrome
Vertebrobasilar insufficiency
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Five patients with subclavian artery stenosis, reversed vertebral artery blood flow, and basilar arterial insufficiency have been described. Four patients were successfully treated by arterial reconstruction. Serial angiography demonstrated in each case a stenosis of the subclavian artery proximal to the origin of the vertebral artery, with delayed retrograde flow through this vertebral artery to the subclavian artery distally.
Subclavian steal syndrome
Vertebrobasilar insufficiency
Left subclavian artery
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By means of ultrasound Doppler sonography it is shown that a proximal subclavian stenosis does not necessarily influence the blood flow of the vertebral artery in a subclavian steal syndrome (permanent retrograde flow in the vertebral artery) as is characteristic for subclavian occlusion. Depending on the peripheral resistance in the cranial and brachial circulation, the vertebral artery competes with the brachial artery for the poststenotic flow. Thus, a reduction of the vertebral flow during hyperemia within the brachial artery ststem, alternating vertebral flow, or a temporary steal syndrome may result in stenosis. Obviously the relation of the flow resistance may also change within one pulse beat, so that in the vertebral artery a characteristic flow pulse, i.e., an alternating flow, is detected with opposite direction in systole and diastole.
Subclavian steal syndrome
Brachial artery
Cardiac cycle
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Subclavian steal syndrome is a relatively rare condition that results from occlusion of the subclavian artery proximal to the origin of the vertebral artery.This causes a reversal in the direction of the blood flow in the vertebral artery, leading to symptoms of vertebrobasilar insufficiency.In this article, we report a case of subclavian steal syndrome in an elderly female, who was investigated with Doppler and CT angiography in our department.
Subclavian steal syndrome
Vertebrobasilar insufficiency
Left subclavian artery
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ABSTRACT: Subclavian “steal”, when blood siphons from one vertebral artery to the other, has been suggested as a cause of brain stem ischaemia and stroke. We investigated 33 patients using transcranial Doppler to determine the direction and velocity of basilar blood flow. All patients had severe subclavian stenosis with reversed vertebral blood flow in the ipsilateral artery previously demonstrated by extracranial Doppler. Basilar flow was normal in direction in all cases, but its velocity was significantly increased (p<0.0008) compared to age- and sex-matched controls. These findings, in conjunction with previous observations using extracranial Doppler techniques, suggest that subclavian steal is little more than a harmless haemodynamic phenomenon.
Subclavian steal syndrome
Vertebrobasilar insufficiency
Transcranial Doppler
Left subclavian artery
Cite
Citations (20)