AN INTERESTING CASE OF GIDDINESS

Dr. Purushothama K. R

Consultant Physician

Mallige Hospital

Dr. Mahanthesh Chiranthimath

Dr. Abhinay

Consultant Cardiologist

Mallige Hospital

By:Dr. Arjun.B.S

DNB Resident

Mallige Hospital

• 56 years male, right handed

• Bank Manager

• Residing in Bangalore

• H/O giddiness since 2 days, acute in onset, intermittent, like his head rotating around, usually on daily activity.

• H/O headache since 2 days, acute in onset, whole head, relieves on taking medications or rest.

• No H/O cold, cough, fever or tinnitus.

• No H/O vomiting, pain abdomen or loose stools

• No H/O chest pain, breathlessness or excessive perspiration.

• No H/O loss of consciousness, blurring of vision, seizures, localized weakness or bowel / bladder disturbance.

• No H/O imbalance, fall or trauma.

• No H/O diabetes mellitus / cerebrovascular accident / seizures / bronchial asthma / tuberculosis in the past.

• Detected hypertensive at a clinic and started on Losartan but came to our hospital as he did not get any relief.

• No addictive habits.

• General physical examination:• Moderately built and nourished.

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema.

• Temp: 98.6 F

• BMI: 23.66 Kg/M2

• Pulse: 80 beats per min, regular, normal volume

• BP: 180/110 mm of Hg in right upper limb

• SpO2: 98 % on room air

• GRBS: 557 mg/dL

• Systemic examination:• R.S- Vesicular breath sounds were heard bilaterally.

• C.V.S- normal first and second heart sounds. No murmurs.

• P.A- soft, no organomegaly, bowel sounds were audible.

• C.N.S- conscious, oriented and co-operative.

- No motor/ sensory deficit.

- No obvious nystagmus.

- No cerebellar signs.

- Gait normal.

• PT/INR- 15.8/1.08

• HbA1c- 13.40

• Urine routine- glucose +++

• CXR- Normal

• ECG- Normal

• CT Brain (Plain)- Normal

• Investigations:• Hb- 13.3 Gm%.• TC- 7480 cells/cumm.• DC- N: 57, L: 35, E: 02,

M: 06• PC- 3,06,000 cells/cumm.• ESR- 15 mm/hr.• B. Urea- 29 mg/dL.• S. Creatinine- 1.0 mg/dL.• S. Na+- 138 mEq/L• S. K+- 4.1 mEq/L• LFT- Normal.

• Provisional diagnosis:• Recently detected Hypertension

• Hypertensive emergency.

• Newly detected Diabetes Mellitus with severe hyperglycemia.

• Vertigo ? cause.

• Cerebrovascular accident: Vertebro-basilar insufficiency.

• Further investigations:• Triglycerides- 320 mg/dL.

• Total cholesterol- 168 mg/dL.

• LDL- 75 mg/dL.

• HDL- 29 mg/dL.

• VLDL- 64 mg/dL.

• 2-D ECHO- Normal

• Carotid and vertebral arterial doppler- Normal

• Next day:• B.P evaluation

• Left upper limb - 100/60 mm of Hg

• Right upper limb - 160/100 mm of Hg

• Bilateral lower limbs - 180/100 mm of Hg

• C T Aortography : Short segment ostio proximal, 80-90% acute thrombotic stenosis of left subclavian artery.

• Vascular surgeon and Cardiac opinion’s were taken.

• Received Heparin infusion for 5 days.

• Repeat CT Angiography showed no interval changes.

• Cardiologist review.

• Shifted to Cath lab.

• Coronary, renal and peripheral angiogram done.• Coronary and renal arteries- Normal.

• Left Subclavian artery - 90% stenosis at ostio proximal segment followed by subclavian angioplasty and stenting.

• Subclavian Stenosis

• Subclavian Stenosis Balloon and stent placement

• Subclavian Stenosis Balloon and stent placement

• Discharged home after 2 days with antiplatelets, anticoagulants, statins, anti-hypertensives and anti-diabetic medications.

• On regular follow up. Both upper limb BP: 130/80 mm of Hg.

• Final diagnosis:

➢ACUTE LEFT SUBCLAVIAN ARTERY THROMBOTIC STENOSIS

➢NEWLY DETECTED HYPERTENSION

➢NEWLY DETECTED DIABETES MELLITUS

➢DYSLIPIDEMIA

• Discussion:• Subclavian artery stenosis causes notable morbidity because it causes

symptomatic ischemic problems that affect the upper extremities, brain, andheart.

• Atherosclerosis is the most common cause.

• Other etiologies include arteritis, inflammation due to radiation exposure,compression syndromes, fibromuscular dysplasia, and neurofibromatosis.

• 2% of the population has subclavian artery stenosis.

• Often patients present during their sixth or seventh decades of life.

• Risk factors such as smoking, diabetes mellitus, hyperlipidemia, hypertension,lower-extremity peripheral arterial artery disease, and less common inheritedgenetic disorders such as inflammatory or Takayasu arteritis.

• Left subclavian artery is more likely to be affected than the right or innominatearteries.

• Upper extremity symptoms include arm claudication or muscle fatigue, rest pain,and finger necrosis.

• Neurologic issues include vertebrobasilar hypoperfusion including visualdisturbances, syncope, ataxia, vertigo, dysphasia, dysarthria, and facial sensorydeficits (Subclavian steal syndrome)

• In patients with internal mammary artery grafts as a result of coronary arterybypass graft surgery, the symptoms of ischemic heart disease, including anginapectoris, due to coronary-subclavian steal, predominate.

• On examination, patients can display: Unequal arm blood pressures, Absent orsignificantly diminished pulses, Neurologic and cardiac sequelae, Bruits, Ulcers,Gangrenous skin changes, Nail bed splinter hemorrhages.

Left Subclavian Artery stenosis

• Duplex ultrasound with color flow imaging is the noninvasive modality of choice in the evaluation of subclavian artery disease.

• Dampened or monophasic waveforms, turbulent color flow imaging, and increased velocities in the region of stenosis are characteristic findings of obstruction. Reversal of ipsilateral vertebral artery flow is seen in subclavian steal syndrome.

• CT angiography offers an excellent anatomic resolution, determines the length of the lesion as well as location. Its drawback, however, lies in the fact that it does not provide optimal information because of calcification.

• Digital subtraction angiography and fluoroscopy also do not quantify the degree of calcification.

• MR angiography can be misinterpreted as the reduced flow can be interpreted as exaggerated disease.

• The definite test is invasive angiography.

• References:• Shannon Caesar-Peterson1; Erion Qaja2; Treasure Island (FL): StatPearls Publishing; 2018 Jan-

.[PubMed]• Muraoka M, Nagata H, Hirata Y, Uike K, Terashi E, Morihana E, Ochiai M, Fujita Y, Kato K,

Yamamura K, Ohga S. High incidence of progressive stenosis in aberrant left subclavian artery with right aortic arch. Heart Vessels. 2018 Mar;33(3):309-315. [PubMed]

• Antón Vázquez V, Armario García P, García Sánchez SM, Martí Castillejos C. Subclavian steal syndrome: A forgotten aetiology of acute cerebral ischaemia. Neurologia. 2017 Sep 25; [PubMed]

• Przewlocki T, Wrotniak L, Kablak-Ziembicka A, Pieniazek P, Roslawiecka A, Rzeznik D, MisztalM, Zajdel W, Badacz R, Sokolowski A, Trystula M, Musialek P, Zmudka K. Determinants of long-term outcome in patients after percutaneous stent-assisted management of symptomatic subclavian or innominate artery stenosis or occlusion. EuroIntervention. 2017 Dec 20;13(11):1355-1364. [PubMed]

• Maciejewski DR, Tekieli Ł, Machnik R, Kabłak-Ziembicka A, Przewłocki T, Paluszek P, TrystułaM, Musiał R, Dzierwa K, Pieniążek P. Simultaneous vertebral and subclavian artery stenting. Postepy Kardiol Interwencyjnej. 2017;13(2):142-149. [PMC free article] [PubMed]

Thank you