ISSN 2005-7881 Journal of Neurosonology 2(Suppl. 1):25-30, 2010 TCD in Subclavian Steal Syndrome Soon-Tae Lee, M.D., Ph.D. Department of Neurology, Seoul National University Hospital, Seoul, South Korea Subclavian steal syndrome Left subclavian The siphoning of blood away from its proper cranial destination toward the ischemic arm When a high-grade stenosis of a subclavian artery occurs proximal to the VA origin. First reported by Reivich et al., NEJM, 1961, and named by Fisher, NEJM, 1961. Right subclavian Right innominate with carotid steal Journal of Neurosonology Volume 2 Suppl. 1, 2010 25
Journal of Neurosonology Vol. 2, Suppl. 1, 2010 Carotid basilar Carotid basilar ECA VA Double steal Classical symptoms of subclavian steal syndrome Causes of subclavian steal syndrome Headache TIA Arm claudication Atherosclerosis Arteritis (Takayasu s arteritis, Temporal arteritis) Congenital Vascular procedure Traumatic 26 신경초음파학회지제 2 권부록 1, 2010
이순태 TCD in Subclavian Steal Syndrome TFCA feature of SSS Stages of VA flow dynamics Von Reutern, Stroke, 1978 Flow dynamics TCD procedures Apply brachial pressure cuff to side of the abnormal VA flow (early systolic deceleration, retrograde flow) Inflate cuff to 20 mmhg above SBP and maintain for 3-5min Record VA flow before/during/following the release of cuff pressure Watch the augmentation of to and fro Von Reutern, Stroke, 1978 Video Resting BP cuff on BP cuff off Journal of Neurosonology Volume 2 Suppl. 1, 2010 27
Journal of Neurosonology Vol. 2, Suppl. 1, 2010 Rare neurologic deficits in subclavian steal syndrome SNUH case series Classification of clinical stages Vascular diagnosis Pts (n) Asymptomatic Lateralizing hemispheric Non-hemispheric Unilateral SSS 155 116 (74%) 32 (21%) 7 (5%) Unilateral SSS + CSS 32 24 (75%) 6 (19%) 2 (6%) Bilateral SSS 16 9 (56%) 5 (31%) 2 (13%) Unilateral SSS or bilateral SSS 121 60 (50%) 56 (46%) 5 (4%) + carotid disease Total 324 209 (64%) 99 (31%) 16 (5%) 2007.06~2010.06, total 4603 cases for TCD 16 SSS detected (0.35%) Early systolic deceleration or retrograde flow Reactive hyperemia test confirmation SSS: subclavian steal syndrome CSS: carotid steal syndrome Hennerici et al., Neurology, 1988 SNUH case series Symptoms of SSS Characteristics SSS (n=16) Age yr 70.8±8.6 (50~82) Male gender no. (%) 11 (68.8%) Medical history no. (%) Hypertension 9 (56.3) Diabetes mellitus 3 (18.8) Hyperlipidemia 5 (31.3) Current Smoking 7 (43.8) known CAD 1 (6.3) r/o arteritis 2 (12.5) Body-mass index (BMI) 23.6±2.3 Total cholesterol (mg/dl) 184.4±32.0 Total symptomatic SSS no. (%) 8 (50) Right SSS no. (%) 3 (18.8) Bilateral SSS no. (%) 1 (6.3) Proximal ICA stenosis no. (%) 5 (31.3) To and fro of BA flow no. (%) 2 (12.5) High f.v. of contralateral VA no. (%) 2 (12.5) High PI of contralateral VA no. (%) 9 (56.3) Stent placement 2 (12.5) Asymptomatic (8, 50%) Recurrent dizziness (6, 37.5%) stent 1 case Arm claudication (3, 18.8%) Headache (2, 12.5%) Angina (1, 6.3%) stent 1 case Multiple choice Effectiveness of TCD in detecting SSS 왜 MRA 에서는자주놓칠까? MRA 에서 subclavian stenosis 가존재함 MRA 판독에언급되지않고, 임상의사도인지하지못함 TCD 검사에서 SSS 진단됨 56.3% (9 cases) 28 신경초음파학회지제 2 권부록 1, 2010
이순태 TCD in Subclavian Steal Syndrome Case #1. missed SSS during TFCA/pICA stenting - F/74, Rt neck bruit Case #2. Stent placement in double steal - 67/M with dizziness Case #3. Asymptomatic does not mean benign. - 72/M, Rt weakness, Hx of CABG (9YA) Missed SSS and discharged. 5 months later: angina pectoris + transient drowsiness Æ Admitted to CCU via ER Stent to the SCA and relieved symptoms - SSS is critical in patients with CABG Case #4. looks like SSS in MRA, but normal in TCD Thyrocervical artery ITA (IMA) Journal of Neurosonology Volume 2 Suppl. 1, 2010 29
Journal of Neurosonology Vol. 2, Suppl. 1, 2010 Prognosis of asymptomatic SSS Therapeutic flow after TCD detects SSS TCD detected SSS Asymptomatic neck bruit, n=500 Angiography, Chest W/U SSS, n=45 4-year follow-up Benign? Yes No Complete occlusion? Medical treatment No stroke 3 dizzy spell 2 numbness in the arm No Endovascular tx (stenting) : 85~100% success 90% 3 year patency Yes Carotid-subclavian bypass : 94 % 5-year patency Bornstein and Norris, Lancet, 1986 Summary 1. Importance of TCD in the diagnosis of SSS 2. SSS can be benign only if the clinician is aware of it 30 신경초음파학회지제 2 권부록 1, 2010