CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
e12
AFRICA
Case Report
Unexpected preserved brain perfusion imaging despite
severe and diffuse atherosclerosis of supra-aortic trunks
GIUSEPPE GARGIULO, FABIO TORTORA, MARIO CIRILLO, CINZIA PERRINO, GABRIELE GIACOMO
SCHIATTARELLA, BRUNO TRIMARCO, GIOVANNI ESPOSITO
Abstract
We report an unusual case of a patient whose whole cerebral
circulation was supported by poor vicariate collaterals and
a severely atherosclerotic right vertebral artery, with no
brain perfusion abnormalities. Our belief is that despite
the brain imaging and the absence of symptoms, because
of his critical vascular disease and the paucity of data from
large randomised clinical trials on vertebro-basilar revascu-
larisation, the case required an extremely cautious approach
regarding any kind of revascularisation.An accurate imaging
analysis together with clinical features allowed us to decide
on a strategy based on optimal medical therapy and careful
clinical monitoring.
Keywords:
brain perfusion, atherosclerosis, supra-aortic trunks,
imaging
Submitted 17/11/12, accepted 5/3/13
Cardiovasc J Afr
2013;
24
: e12–e14
DOI: 10.5830/CVJA-2013-009
Case report
A 61-year-old man was admitted to our department for routine
cardiological evaluation. He suffered from hypertension,
dyslipidaemia, diffuse atherosclerosis with a history of coronary
artery bypass graft in 2001 (saphenous vein grafts for a
triple-vessel coronary artery disease), percutaneous transluminal
coronary angioplasty (PTCA) with stent implantation in the right
coronary artery and intermediate branch in 2006, and a history
of symptomatic lower extremity arterial disease treated by PTA,
with stent implantation on the left external iliac artery in 2009.
He was also a heavy smoker.
He had no severe clinical conditions, being asymptomatic
for cerebrovascular symptoms and upper extremity claudication,
and with normal blood parameters. Arterial blood pressure was
110/70 mmHg on the right arm and 90/60 mmHg on the left
arm, suggesting a possible subclavian steal syndrome. Echo
colour Doppler of the supra-aortic trunks (SATs) confirmed this
hypothesis.
SATs angiography and magnetic resonance angiography
(MRA) were then performed, revealing: (1) a significant
stenosis of the brachiocephalic artery (BA) at its origin, with
a post-stenotic dilatation; (2) a significant stenosis of the right
subclavian artery (SA) in its middle tract, beyond the origin of
the vertebral artery (VA); (3) a significant stenosis of the right
VA at its origin; (4) a proximal occlusion of the right internal
carotid artery (ICA); (5) a significant ostial stenosis of the left
common carotid artery (CCA); (6) a proximal occlusion of
the left ICA; (7) a proximal occlusion of the left SA up to the
VA origin; and (8) a sub-occlusive stenosis of the left VA at its
origin, with a subclavian steal (Fig. 1A). Therefore, the only
patent vessel for brain perfusion was the diseased right VA. A
well-developed collateral circulation at the Willis circle was also
demonstrated secondary to an arterial flow through the right
vertebral artery and a hypertrophic compensation bilaterally of
the external carotid artery (Fig. 1B).
Surprisingly, cerebrovascular magnetic resonance imaging
(MRI) demonstrated regular morphology and appearance
of brain parenchyma (Fig. 2A), and regular perfusion with
dynamic susceptibility contrast-enhanced MRI (DSCe-MRI)
in both anterior and posterior circulation, despite the critical
atherosclerotic involvement of the supra-aortic trunks (Fig.
2B). Importantly, coronary–subclavian steal syndrome and
myocardial ischaemia
1
did not occur in this patient because of
the presence of three venous grafts in the coronary arteries rather
than a left internal mammary artery anasthomosis.
Based on the brain imaging results, the absence of
symptoms, and the paucity of data from large randomised
clinical trials on vertebro-basilar revascularisation, cerebro-
vascular revascularisation was excluded. Maximal medical
therapy was indicated with aspirin, clopidogrel (we also checked
the patient’s sensitivity to clopidogrel by light transmittance
aggregometry, resulting in a positive response), rosuvastatin,
ramipril and bisoprolol. Furthermore
,
smoking cessation was
strongly suggested.
Follow-up visits were performed focusing on accurate
anamnesis and physical examinations to search for new signs
and symptoms of ischaemia (such as fugax amaurosis, aphasia,
Division of Cardiology, Department of Clinical Medicine,
Cardiovascular Sciences and Immunology, Federico II
University, Naples, Italy
GIUSEPPE GARGIULO, MD
CINZIA PERRINO, MD, PhD
GABRIELE GIACOMO SCHIATTARELLA, MD
BRUNO TRIMARCO, MD
GIOVANNI ESPOSITO, MD, PhD,
Division of Neuroradiology, Department of Neurological
Sciences, Second University, Naples, Italy
FABIO TORTORA, MD
MARIO CIRILLO, MD
