PMC3368357_01
Multimodality imaging demonstrating stenoocclusive disease of intracranial and extracranial arteries. (a) CT angiogram chest demonstrating complete occlusion of left subclavian artery (arrow) with distal filling from left VA (arrowhead). Remainder of VA is out of plane of view, but patent distally. (b) MR Angiogram of abdomen demonstrating bilateral renal artery stenoses (arrows). (c) Time-of-flight MR angiogram of head showing absence of bilateral MCA vessels and decreased flow of both ICAs. The posterior circulation is relatively plethoric. (d) Conventional angiogram of the right ICA (AP projection) showing typical moyamoya appearance of intracranial occlusion of supraclinoid ICA (arrow) with reconstitution of the MCA via multiple small moyamoya collaterals (arrowhead). (e) Right subclavian digital subtraction angiogram demonstrating high-grade (>70%) right VA stenosis (arrow).
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This was confirmed on CT angiogram which demonstrated complete occlusion of the left subclavian artery proximal to the vertebral artery (VA) origin with a patent left vertebral and distal subclavian artery (Figure 1(a)). MR angiography confirmed the above arterial stenoses (Figure 1(c)), while MRI demonstrated multiple chronic watershed cerebral infarcts. Conventional angiogram also demonstrated bilateral supraclinoid ICA occlusions with moyamoya-type collaterals (Figure 1(d)), high-grade (70%) right VA stenosis (Figure 1(e)), and left subclavian artery occlusion. MR angiogram of her chest and abdomen demonstrated mild wall thickening of the aortic arch and abdominal aorta, 50% bilateral renal artery stenoses (Figure 1(b)), superior mesenteric artery stenosis, and right common iliac artery stenosis (not shown).