SHM Converge Scientific Abstract ePoster Gallery-Pirates of the Circulation: Theft in Uncharted Vessels

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This case describes a 47-year-old woman with hyperlipidemia, diabetes, and hypothyroidism who presented to the emergency department as a stroke alert after syncope with transient right-sided weakness and aphasia. Initial exam and labs were normal, and CT/CTA of the head and neck showed no acute stroke. Imaging did reveal critical left subclavian artery stenosis with near-total occlusion and an anomalous left vertebral artery arising directly from the aortic arch. Because of the vertebral artery variant, radiology and consulting teams initially felt subclavian steal physiology was unlikely.<br /><br />During hospitalization for further evaluation of syncope and hypotension, additional workup excluded other causes, including structural heart disease and endocrine abnormalities. MRI brain revealed an old left cerebellar infarct. More detailed history uncovered chronic vertigo, intermittent ataxia, visual symptoms, and occasional left arm fatigue, weakness, and paresthesias, especially with overhead activity. These findings suggested chronic vertebrobasilar insufficiency. Cerebral angiography then demonstrated retrograde flow in the left vertebral artery through the thyrocervical trunk into the left subclavian artery, confirming subclavian steal syndrome. The patient underwent stenting of the left subclavian artery and had significant improvement in her symptoms afterward.<br /><br />The key lesson is that anomalous vertebral artery anatomy does not rule out subclavian steal syndrome. Cerebral angiography remains the most reliable test to confirm steal physiology. The case also highlights the importance of careful clinical reassessment and avoiding cognitive errors such as anchoring and premature closure when imaging findings seem to contradict the diagnosis.

Asset Subtitle

Morgan Scott

Meta Tag

Author List Anthony Lile, Morgan Scott

Category Clinical Vignettes

Concept Subclavian Steal Syndrome

Concept Retrograde Vertebral Artery Flow

Concept Vertebrobasilar Insufficiency

Concept Subclavian Artery Stenosis

Concept CT Angiography

Distinguished Non-Finalist

Presenter Organization University of Kentucky College of Medicine

Presenting Author Morgan Scott

Track Adult

Keywords

subclavian steal syndrome

vertebrobasilar insufficiency

left subclavian artery stenosis

anomalous vertebral artery

cerebral angiography

retrograde vertebral flow

syncope

transient aphasia

cognitive bias

endovascular stenting

Subclavian Steal Syndrome

Retrograde Vertebral Artery Flow

Vertebrobasilar Insufficiency

Subclavian Artery Stenosis

CT Angiography