Presenting an unusual case of subclavian artery steal syndrome with multifocal severe stenoses of posterior cerebral circulation.

Subclavian steal syndrome is a vascular disorder in which stenosis of the subclavian artery proximal to the vertebral artery origin causes altered vascular hemodynamics resulting in retrograde blood flow in the ipsilateral vertebral artery toward the upper extremity, distal to the subclavian artery narrowing to meet the hemodynamic demand of the upper extremity, especially during physical activities. This will often lead to symptomatic vertebrobasilar arteries.

A 78-year old male smoker (30 pack-year) presented with multiple transient episodes of horizontal and/or vertical diplopia, right hand and arm tingling, vertigo and vomiting while playing Golf, each episode lasted for 15-20 minutes before spontaneous symptom resolution since last year. He had intact neurological exam but diminished left brachial and radial pulses with negative CT and MRI brain for acute stroke, mass or hemorrhages.

However, CT Angiogram of head and neck reveled dense calcified plaque in the proximal left subclavian artery causing occlusion, in addition to a short segment occlusion in the proximal basilar artery and short segment severe stenoses in the distal V4 segment of the right vertebral artery  and distal basilar artery. MRA and duplex showed retrograde flow from the left vertebral artery compatible with left subclavian steal syndrome.

Patient was loaded with plavix 300mg and aspirin 325mg for symptomatic intracranial and extracranial stenoses as a result of left subclavian steal syndrome.

Plan to perform aortic arch and left arm angiogram with possible angioplasty and stenting of the left subclavian artery before consideration of left carotid to left vertebral artery bypass.

Although subclavian artery steal syndrome is an uncommon cause of posterior circulation neurovascular symptoms, early recognition and appropriate treatment including endovascular and/or bypass surgery is important to avoid major disabilities.