Subclavian Steal Syndrome with or without Arterial Stenosis: A Review

The subclavian‐vertebral artery steal syndrome (SSS) is the hemodynamic phenomenon of blood flow reversal in the vertebral artery due to significant stenosis or occlusion of the proximal subclavian artery or the innominate artery. Occasionally, SSS is diagnosed in patients not harboring arterial stenosis. With the exception of arterial congenital malformations, the limited case reports of SSS with intact subclavian artery are attributed to dialysis arteriovenous fistulas (AVFs). Interestingly, these cases are more frequently symptomatic than those with the classical atherosclerotic SSS forms. On the other hand, the disclosure of SSS due to subclavian/innominate artery atherosclerotic stenosis, even in the absence of accompanying symptoms, should prompt a thorough cardiovascular work‐up for the early detection of coexisting coronary, carotid, or peripheral artery disease. Herein, we review the incidence, clinical presentation, sonographic findings, and therapeutic interventions related to SSS with and without subclavian/innominate artery stenosis. We also review the currently available data in the literature regarding the association of SSS and dialysis AVF. In addition, we present a patient with bilateral symptomatic SSS as the result of an arteriovenous graft (AVG) that was introduced after the preexisting AVF in the contralateral arm became nonfunctional. SSS due to subclavian or innominate artery stenosis/occlusion is rarely symptomatic warranting interventional treatment. In contrast, when it is attributed to AVF, surgical correction is frequently necessary.     

血管内介入治疗锁骨下动脉盗血综合征临床研究

目的探讨应用血管内介入治疗锁骨下动脉盗血综合征的有效性和安全性。方法回顾性分析53例经血管内介入的锁骨下动脉盗血综合征患者的临床资料,从手术成功率、手术并发症及术后随访情况观察血管内介入治疗的有效性和安全性。结果 45/53例(84.90%)锁骨下动脉狭窄患者和8/53例(15.09%)完全锁骨下动脉闭塞患者均成功进行了血管内介入治疗,术后症状明显缓解。53例患者中发生手术并发症5次(9.43%),但未出现神经功能缺损和危及生命的手术并发症。锁骨下动脉闭塞的手术并发症发生率(37.50%)较锁骨下动脉狭窄(4.44%)显著升高(P0.05)。随访50/53例患者,随访率94.34%,平均随访时间(18.6±1.2)个月。1例患者术后12个月再狭窄率超过90%,行二次球囊成型;其余患者预后良好。结论应用血管内介入治疗锁骨下动脉盗血综合征具有微创、安全、高效优点,可作为首选治疗方法。     

Pitfall of Electron Beam Computed Tomography Angiography in Diagnosis of Subclavian Steal Syndrome

A patient presented with vertebrobasilar insufficiency during exertion. Vertebral duplex and transcranial Doppler ultrasonography showed reversal of flow in both intracranial and extracranial vertebral and basilar arteries, suggesting bilateral subclavian and vertebrobasilar steal. Electron beam computed tomography angiography (CTA) showed no evidence of subclavian artery stenosis including normal vertebral artery origin on both sides. However, digital subtraction angiography revealed complete occlusion of both subclavian arteries with retrograde flow from both vertebral and basilar arteries to reconstitute both subclavian arteries. This false-negative finding on CTA in detection of subclavian steal syndrome (SSS) is due to inappropriate contrast administration technique and postprocessing method, inability to differentiate flow direction, and lack of hemodynamic time sequences. This study demonstrates a pitfall of CTA in diagnosis of SSS compared to more reliable hemodynamic information obtained by duplex and transcranial Doppler ultrasonography, and digital subtraction angiography.     

Variant of Subclavian Steal in the Setting of Ipsilateral Common Carotid Artery Occlusion: Case Report

Subclavian steal is a well-described angiographic finding and clinical syndrome that rarely results in vertebrobasilar ischemic symptoms. In classic subclavian steal, left subclavian artery (SA) stenosis occurs proximal to the left vertebral artery (VA) origin. We report a symptomatic variant of this syndrome that occurred in the setting of left common carotid artery occlusion and anomalous origin of the left VA directly from the aortic arch. The steal and symptoms resolved after stenting of the left SA stenosis.     

锁骨下动脉闭塞血管内再通治疗的可行性分析

目的 探讨慢性锁骨下动脉闭塞血管内再通治疗的可行性、安全性与有效性.方法 回顾性分析2014年1月-2018年6月首都医科大学附属北京天坛医院神经介入中心收治的慢性锁骨下动脉完全闭塞且存在病变侧上肢远端肢体乏力等缺血症状或明确诊断为锁骨下动脉盗血综合征(subclavian steal syndrome,SSS)患者的...     

Subclavian Steal Syndrome Like Appearance Resulting from a Vertebral Artery Origin Stenosis: A Case Report

Partial steal has been regarded as a classic ultrasound appearance of subclavian steal syndrome. We report a case with the vertebral artery origin stenosis and intact subclavian artery, which showed the similar partial steal ultrasound features. The following computerized tomography angiography confirmed the stenosis. Therefore, when an alternating flow in the vertebral artery is detected, the investigation of its origin must be performed besides the ipsilateral subclavian artery.     

锁骨下动脉盗血综合征5例临床分析和文献复习

目的：通过全脑血管造影观察锁骨下动脉盗血综合征（SSS）患者的颅外侧支循环代偿模式及血管内支架治疗的疗效。方法：通过全脑血管造影对5例SSS患者的颅外侧支循环代偿模式进行观察,行血管内支架治疗并随访2～13个月,观察术后疗效并复习相关文献。结果：5例患者共置入6枚支架。颅外侧支循环代偿途径中,出现枕动脉与椎动脉肌支吻合血管开放4例,无吻合1例;吻合后向颅内供血1例,双向供血1例,向颅外供血2例,其中1例同时伴后交通动脉开放前循环向后循环供血;1例锁骨下次全闭塞患者因术中多次行球囊扩张而术后并发非感染性动脉内膜炎。结论：血管内支架治疗锁骨下动脉盗血综合征安全有效,在颅外侧支循环代偿途径中,枕动脉与椎动脉肌支间吻合发挥重要作用,且有多种不同代偿模式,重度狭窄行血管成形术时应警惕非感染性动脉内膜炎的发生。     

Stenosis and occlusion of the subclavian artery: ultrasonographic and clinical findings

Summary Continuous-wave (CW) Doppler sonography has proved to be a reliable tool both to detect subclavian stenosis or occulusion and to detect reversal of blood flow in the vertebral artery. This method is entirely atraumatic and in contrast to angiography allows investigation of asymptomatic patients and provides more representative data for epidemiological studies. The incidence of subclavian stenosis or occlusion was 1.15% among the 23,500 patients examined in our department between 1978 and 1985. Of the 272 patients with unilateral or bilateral subclavian stenosis or occlusion, 54% were asymptomatic with no subjective complaints and were normal upon neurological examination; 29% reported vertebrobasilar transient ischaemic attacks (TIAs), with or without concomitant TIAs or infarction in the vascular territory of the carotid arteries; and 17% complained of symptoms exclusively referring to the region of carotid blood supply. Reversal of blood flow in the ipsilateral vertebral artery was detected in 152 patients (56%). The incidence of neurological symptoms within this group was double that found in patients without steal. None of the patients suffered from permanent vertebrobasilar damage. In most cases, subclavian artery disease was due to atherosclerosis. For 13 patients an inflammatory, iatrogenic, traumatic, or congenital aetiology could be assumed. The marked preponderance of left-sided subclavian stenosis or occlusion, reported by others, could be confirmed among our patients, but was less pronounced for tight stenoses than for occlusions. Mild-to-moderate subclavian stenoses were about equally distributed on each side.     

经皮血管内成形术治疗锁骨下动脉盗血综合征的疗效观察

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蛛网膜下腔出血对ICP、rCBF及死亡率影响的实验研究

目的 :研究不同严重程度SAH对颅内压 (ICP) ,脑灌注压 (CPP) ,局部脑血流量 (rCBF)及死亡率的影响。方法 :建立一种新的大鼠颈总动脉 视交叉前池体外转流蛛网膜下腔可控制性出血动物模型 ,比较出血 3 0 ,60 ,90s及重复 3 0s 3次出血后上述指标的变化。结果 :SAH后ICP急剧上升至接近平均动脉压水平 ,当ICP超过 6kPa(80mmHg)即可引起部分动物呼吸抑制而死亡 ;60s和 90s出血组ICP水平相差未具显著性 ,提示在此期间内出血可能趋向停止 ;SAH后rCBF立即受到大幅抑制 ,其后恢复程度与SAH严重程度呈反比。结论 :SAH后ICP剧升引起呼吸功能衰竭是死亡的主要原因 ;SAH后普遍存在脑微循环障碍 ,故应及早开始脑缺血的治疗     

Pathology of the arteries in the central nervous system with special reference to their dilatation: Blood flow

Arteries that belong to the central nervous system (CNS) have thick and monotonous internal elastic lamina (IEL), Willis ring, and no collateral branch to the systemic circulation. These characteristics suggest that the circulation of the CNS is constant. In order to know how flow controls the arterial configuration of the CNS, flow of the vertebral and basilar arteries was increased experimentally using eight adult male Japanese white rabbits. Flow increase was induced by the simple ligation of the bilateral common carotid arteries (ligation group, n = 4) or by the ligation of the bilateral common carotid arteries at 1 week after arteriovenous fistula (AVF) between the left common carotid artery and the left external jugular vein (ligation plus AVF group, n = 4). Cineangiography revealed distinct flow increase in the ligation group at 5 weeks after ligation and in the ligation plus AVF group at 5 weeks after AVF (4 weeks after ligation). Vertebral and basilar arteries were remarkably dilated and elongated. Histopathologically, severe disruption of the IEL and focal thinning of the media were distinct. Endothelial cells were preserved and there was no inflammatory cell infiltration. These morphological features are consistent with increased flow‐induced adaptive remodeling. It is suggested that the constancy of the flow may give the arterial tree of the CNS these morphological characterizations.     

动脉-动脉栓塞性缺血性卒中患者晨峰血压与颈动脉溃疡斑块的相关性研究

【摘要】 目的 在动脉-动脉栓塞性缺血性卒中患者中,探讨晨峰高血压与颈动脉溃疡斑块的相关性。 方法 连续入组120例经中国缺血性卒中亚型（Chinese Ischemic Stroke Subclassification,CISS）分型诊断为动脉-动脉栓塞性缺血性卒中患者,利用24 h动态血压监测以及颈动脉彩超分别监测晨峰血压及颈动脉溃疡斑块。利用Logistic回归模型,研究晨峰血压与颈动脉溃疡斑块的相关性。 结果 120例缺血性卒中患者的平均年龄为（62.6±12.8）岁,女性占36.8%。晨峰高血压组（n=48）溃疡斑块的检出率与无晨峰高血压组（n=72）相比,差异无显著性（31.3％ vs 30.6％,P=0.84）。进一步将溃疡斑块按照检出部位（出现在卒中病灶同侧颈动脉或对侧颈动脉）进行分类发现,晨峰高血压组病灶同侧溃疡斑块的检出率明显高于无晨峰高血压组（27.1% vs 19.4%,P=0.008）。多因素分析的结果显示,在调整了年龄、性别之后,晨峰高血压与病灶同侧溃疡斑块的相关性具有统计学意义[优势比（odds ratio,OR）：1.42;95%可信区间（confidence interval,CI）：1.09～4.22）］;进一步校正其他危险因素之后,两者相关性仍存在（OR 1.23;95%CI 1.02～3.46）。 结论 在动脉-动脉栓塞性缺血性卒中患者中,晨峰高血压与卒中病灶同侧颈动脉溃疡斑块的检出率具有相关性,提示过高的晨峰血压可能是颈动脉溃疡斑块脱落导致动脉-动脉栓塞型缺血性卒中发病的危险因素。     

On the Severity of Carpal Tunnel Syndrome: Diabetes or Metabolic Syndrome

Background and Purpose

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Although its etiology is unknown, certain conditions are commonly associated with CTS, such as obesity, arthritis, hypothyroidism, diabetes mellitus, trauma, mass lesions, amyloidosis, and sarcoidosis. We aimed to determine the association between metabolic syndrome and CTS, and we compared the severity of CTS between patients with diabetes (and no concomitant metabolic syndrome) and patients with metabolic syndrome.

Methods

Two hundred patients with a clinically and electrophysiological confirmed diagnosis of CTS were included in the study. Their demographic characteristics and severity of CTS were analyzed according to the presence or the absence of metabolic syndrome. Differences in the electrophysiological findings were evaluated between the following four groups: 1) metabolic syndrome alone (n=52), 2) diabetes alone (n=20), 3) combined metabolic syndrome and diabetes (n=44), and 4) no metabolic syndrome or diabetes (n=84).

Results

CTS was more severe in the patients with metabolic syndrome than those without this syndrome. The electrophysiological findings were worse in patients with metabolic syndrome alone than in those with diabetes alone and those without diabetes and metabolic syndrome.

Conclusions

CTS appears to be more severe in patients with metabolic syndrome than patients with diabetes. Diabetes is one of the well-known risk factors for CTS, but other components of metabolic syndrome may have a greater effect on the severity of CTS.     

阻塞性睡眠呼吸暂停低通气综合征与高血压之间关系的研究进展

【摘要】 阻塞性睡眠呼吸暂停低通气综合征与高血压关系密切,可能是某些继发性高血压的主要病因之一,对合并阻塞性睡眠呼吸暂停低通气综合征的高血压患者采取综合性治疗对控制高血压及心脑血管病可能有益处。     

Effect of Pretreatment Blood Pressure on Outcomes in Thrombolysed Acute Ischemic Stroke Patients: A Systematic Review and Meta-analysis

Background

Blood pressure (BP) is an important determinant of functional outcome in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (IV-tPA). Current guidelines recommend a BP target of 185/110 mmHg before IV-tPA bolus and maintaining it at less than 180/105 mmHg for the first 24 hours. However, the effect of blood pressure on various outcome measures after systemic thrombolysis remains unclear.

The hemimedullary syndrome: case report and review of the literature

Summary Hemi-infarction of the medulla causes the clinical constellation of symptoms and signs of both the lateral and medial medullary syndromes and nearly always results from occlusion of an intracranial vertebral artery. In the case reported here, with a clinical diagnosis of hemimedullary syndrome, the expected infarction was imaged by magnetic resonance. A review of the literature confirms that the hemimedullary syndrome, in which both medial and lateral syndromes occur simultaneously, is extremely rare, since it yielded only two previous cases with adequate anatomical confirmation.