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

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] [2] [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