The Sistine Chapel and clothesline signs: a tale of two arteries

O sinal da Capela Sistina e sinal do varal: um conto sobre duas artérias

An 83-year-old woman presented sudden vertigo, drop attack, and transient dysarthria after head hyperextension to see the Sistine Chapel ceiling, in the Vatican. Transcranial doppler ultrasound (Figure 1) suggested proximal basilar stenosis, confirmed by arteriography (Figure 2). Case 2: A 77-year-old woman presented a 1-year history of transient vertigo after hanging clothes on a clothesline. Transcranial doppler ultrasound (Figure 3) revealed left subclavian artery steal phenomenon secondary to proximal subclavian artery stenosis, confirmed by arteriography (Figure 4). They received stenting and dual antiplatelet therapy. Transient ischemic symptomatology triggered by head/neck and arm movements demands vertebrobasilar and subclavian evaluation.¹–³

Figure 1
Transcranial Doppler show signs of segmental increase in flow velocity in the proximal basilar artery, compatible with basilar artery stenosis.

Figure 2
Brain arteriography showing severe stenosis in the proximal basilar artery (A). Postangioplasty control with stent in the proximal basilar artery (B).

Figure 3
Systolic flow reversal in the left vertebral artery at transcranial doppler ultrasound (arrow), compatible with grade 2 subclavian steal syndrome (intermittent or partial).

Figure 4
Cervical arteriography demonstrating a critical lesion in the origin of the left subclavian artery, promoting subclavian steal syndrome (A). Cervical arteriography after subclavian artery angioplasty with stent positioning (B) (C).

References

• ¹
  Go JA, Al Othman B, Kini A, Beaver HA, Lee AG. Vertebrobasilar ischemia (VBI) related neuro-ophthalmic syndromes after routine activities involving hyperextension or rotation of the neck (hairdresser syndrome). Eye (Lond) 2020;34(05):901–905
• ²
  Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352(25):2618–2626
• ³
  Kargiotis O, Siahos S, Safouris A, Feleskouras A, Magoufis G, Tsivgoulis G. Subclavian steal syndrome with or without arterial stenosis: A review. J Neuroimaging 2016;26(05):473–480

Publication Dates

• Publication in this collection
  28 Apr 2023
• Date of issue
  2022

History

• Received
  08 May 2022
• Accepted
  15 June 2022