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Thromboembolism of the subclavian artery to the vertebral artery with haemorrhagic transformation - A case report

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We report on the case of a 56-year-old male patient who, after fainting, regained consciousness in hospital in a confused state complaining of pain in the left arm. In the physical examination, the arm was seen to be cold and without pulse, so an arteriography was performed which identified an aneurysm of the subclavian artery with distal embolus of the upper limb. He was submitted to embolectomy of the limb but evolved with degeneration of the neurological state and so was transferred to a university hospital which confirmed the presence of thromboembolism of the vertebral artery. The upper limb had signs of distal ischaemia, so anticoagulation with heparin was initiated. The patient presented with further deterioration of the neurological condition and a transformation from ischaemic to hemorrhagic stroke was confirmed. Key words: subclavian artery aneurysm, vertebral artery, thromboembolism, haemorrhage
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Acta Angiol
Vol. 16, No. 3, pp. 135–137
Copyright © 2010 Via Medica
ISSN 1234–950X
www.angiologia.pl
135
CASE REPORT
Thromboembolism of the subclavian artery to the
vertebral artery with haemorrhagic transformation
— a case report
José Maria Pereira de Godoy1, Guilherme de Lima Palini2, Carlos Eduardo Dall’Aglio Rocha3,
Marcio Luiz Tostes dos Santos3
1Department of Cardiology and Cardiovascular Surgery, Medicine School of São Jose do Rio Preto-FAMERP
and Researcher CNPq (National Council for Research and Development), Brazil
2Physician of Service Vascular Surgery in Medicine School of São Jose do Rio Preto-FAMERP
3Department of Neurosurgery in Medicine School of São Jose do Rio Preto-FAMERP
Abstract
We report on the case of a 56-year-old male patient who, after fainting, regained consciousness in hospital
in a confused state complaining of pain in the left arm. In the physical examination, the arm was seen to be
cold and without pulse, so an arteriography was performed which identified an aneurysm of the subclavian
artery with distal embolus of the upper limb. He was submitted to embolectomy of the limb but evolved
with degeneration of the neurological state and so was transferred to a university hospital which confirmed
the presence of thromboembolism of the vertebral artery. The upper limb had signs of distal ischaemia, so
anticoagulation with heparin was initiated. The patient presented with further deterioration of the neurological
condition and a transformation from ischaemic to hemorrhagic stroke was confirmed.
Key words: subclavian artery aneurysm, vertebral artery, thromboembolism, haemorrhage
Acta Angiol 2010; 16, 3: 135–137
Address for correspondence:
Jose Maria Pereira de Godoy
Rua Floriano Peixoto, 2950
15010–020 São José do Rio Preto, SP – Brazil
e-mail: godoyjmp@riopreto.com.br
Introduction
Subclavian artery aneurysms are relatively rare; there
are few cases of aneurysms at the subclavian-vertebral
junction mentioned in the literature [1, 2]. One of the
possible complications is thromboembolism to the ver-
tebral artery. These aneurysms may be symptomatic [1,
2] or asymptomatic [3].
The objective of the current study is to report the
case of thromboembolism of an aneurysm at the subcla-
vian-vertebral artery junction as the first manifestation
of disease that evolved into a stroke that transformed
from ischaemic to haemorrhagic with the use of anti-
coagulation.
Case report
The case of a 56-year-old male patient is reported,
who, after fainting, regained consciousness in hospital
in a confused state complaining of pain in the left arm.
In the physical examination, the arm was seen to be
cold and without pulse, so an arteriography was per-
formed, which identified an aneurysm of the subclavian
artery with distal embolus of the upper limb (Figures 1
and 2). He was submitted to embolectomy of the limb
but evolved with a degeneration of the neurological
state and so was transferred to a university hospital,
which confirmed the presence of thromboembolism
of the vertebral artery (Figure 3) and occlusion of the
136
Acta Angiol, 2010, Vol. 16, No. 3
www.angiologia.pl
subclavian and axillary arteries. The limb evolved with
distal ischaemia, and anticoagulation therapy was ad-
ministered using heparin. The patient presented with
further deterioration of the neurological condition and
a transformation from ischaemic to haemorrhagic stroke
was confirmed (Figure 4).
Discussion
The current case illustrates the possibility of neuro-
logical compromise due to a subclavian artery aneurysm.
Fainting followed by pain in the arm associated with the
disappearance of the arterial pulse of the limb was indica-
tive of a vascular problem. The first procedure by the
vascular surgeon was embolectomy, but the neurological
symptoms of the patient were not taken into account.
This case serves as a warning of the possibility of emboli
Figure 1. Aneurysm of the subclavian artery
Figure 2. Embolus in the axillary artery
Figure 3. Occlusion of the vertebral artery
Figure 4. Axial T2 FLAIR magnetic resonance with heterogenicity signal compatible with ischaemic stroke transforming
to hemorrhagic stroke
137
Thromboembolism of the subclavian artery to the vertebral artery, Godoy et al.
www.angiologia.pl
References
1. Suzukawa K, Suzuki H, Fujii T (2004) A case of a subcla-
vian-vertebral junction arterial aneurysm with brain stem
thromboembolism. No Shinkei Geka, 32: 1151–1155.
2. Gardner MA, Pathare HP (2001) Aneurysms of an aberrant
right subclavian artery: report of two cases. Heart Lung
Circ, 10: 154–157.
3. Schellhammer F, Wobker G, Turowski B (2005) Asymp-
tomatic aneurysm of the subclavian vein. Acta Radiol, 46:
366–367.
of the subclavian artery migrating to the vertebral artery.
The deterioration in the mental state led to a cerebral
arteriography being performed, which confirmed brain
embolisation. Despite of the rarity of this, subclavian
aneurysms should be considered a factor as a source of
emboligenic conditions of the vertebral artery. The case
also illustrates the possibility of ischaemic strokes trans-
forming into haemorrhagic strokes.
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