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Subclavian Steal Syndrome: Diagnosis with Perfusion Metrics from Contrast-enhanced MR Angiographic Bolus-timing Examination—Initial Experience¹

¹ From the Department of Radiology, New York University School of Medicine, 550 First Ave, New York, NY 10016. Received April 20, 2004; revision requested June 29; revision received July 23; accepted August 20. Address correspondence to C.W. (e-mail: cw262@med.nyu.edu).

View larger version (114K): [in a new window]   Figure 1a. Left-sided subclavian steal in 67-year-old woman. (a) Thin maximum intensity projection coronal image from three-dimensional contrast-enhanced MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery. (b) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow. (c) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed below the volume of interest, shows normal signal intensity of blood flowing in the internal jugular veins (arrowheads). As expected, there is no signal in the right vertebral artery (long arrow), whereas signal in the left vertebral artery (short arrow) indicates retrograde flow. Note that the signal in the left vertebral artery is weaker than that in the right vertebral artery in b. (d) Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in the neck vessels, acquired at the time of peak signal intensity in the right vertebral artery (t = 16 seconds), shows no contrast enhancement of the left vertebral artery (short arrow), while both common carotid arteries (arrowheads) and the right vertebral artery (long arrow) are enhanced. (e) Transverse image from bolus-timing examination in the neck vessels, obtained 2 seconds later than d (t = 18 seconds), shows delayed contrast enhancement in the left vertebral artery (short arrow) and residual enhancement in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). Note that the left vertebral artery is enhanced to a lesser degree than is the right vertebral artery in d. (f) Signal intensity-time curve for vertebral artery enhancement, derived from bolus-timing examination, shows 2-second delay in peak arterial enhancement in the left vertebral artery (LVA) (t = 18 seconds) compared with that in the right vertebral artery (RVA) (t = 16 seconds). Peak signal intensity in the left vertebral artery is also decreased (parvus tardus) when compared with that in the right vertebral artery in c and e.

View larger version (122K): [in a new window]   Figure 1b. Left-sided subclavian steal in 67-year-old woman. (a) Thin maximum intensity projection coronal image from three-dimensional contrast-enhanced MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery. (b) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow. (c) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed below the volume of interest, shows normal signal intensity of blood flowing in the internal jugular veins (arrowheads). As expected, there is no signal in the right vertebral artery (long arrow), whereas signal in the left vertebral artery (short arrow) indicates retrograde flow. Note that the signal in the left vertebral artery is weaker than that in the right vertebral artery in b. (d) Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in the neck vessels, acquired at the time of peak signal intensity in the right vertebral artery (t = 16 seconds), shows no contrast enhancement of the left vertebral artery (short arrow), while both common carotid arteries (arrowheads) and the right vertebral artery (long arrow) are enhanced. (e) Transverse image from bolus-timing examination in the neck vessels, obtained 2 seconds later than d (t = 18 seconds), shows delayed contrast enhancement in the left vertebral artery (short arrow) and residual enhancement in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). Note that the left vertebral artery is enhanced to a lesser degree than is the right vertebral artery in d. (f) Signal intensity-time curve for vertebral artery enhancement, derived from bolus-timing examination, shows 2-second delay in peak arterial enhancement in the left vertebral artery (LVA) (t = 18 seconds) compared with that in the right vertebral artery (RVA) (t = 16 seconds). Peak signal intensity in the left vertebral artery is also decreased (parvus tardus) when compared with that in the right vertebral artery in c and e.

View larger version (140K): [in a new window]   Figure 1c. Left-sided subclavian steal in 67-year-old woman. (a) Thin maximum intensity projection coronal image from three-dimensional contrast-enhanced MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery. (b) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow. (c) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed below the volume of interest, shows normal signal intensity of blood flowing in the internal jugular veins (arrowheads). As expected, there is no signal in the right vertebral artery (long arrow), whereas signal in the left vertebral artery (short arrow) indicates retrograde flow. Note that the signal in the left vertebral artery is weaker than that in the right vertebral artery in b. (d) Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in the neck vessels, acquired at the time of peak signal intensity in the right vertebral artery (t = 16 seconds), shows no contrast enhancement of the left vertebral artery (short arrow), while both common carotid arteries (arrowheads) and the right vertebral artery (long arrow) are enhanced. (e) Transverse image from bolus-timing examination in the neck vessels, obtained 2 seconds later than d (t = 18 seconds), shows delayed contrast enhancement in the left vertebral artery (short arrow) and residual enhancement in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). Note that the left vertebral artery is enhanced to a lesser degree than is the right vertebral artery in d. (f) Signal intensity-time curve for vertebral artery enhancement, derived from bolus-timing examination, shows 2-second delay in peak arterial enhancement in the left vertebral artery (LVA) (t = 18 seconds) compared with that in the right vertebral artery (RVA) (t = 16 seconds). Peak signal intensity in the left vertebral artery is also decreased (parvus tardus) when compared with that in the right vertebral artery in c and e.

View larger version (133K): [in a new window]   Figure 1d. Left-sided subclavian steal in 67-year-old woman. (a) Thin maximum intensity projection coronal image from three-dimensional contrast-enhanced MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery. (b) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow. (c) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed below the volume of interest, shows normal signal intensity of blood flowing in the internal jugular veins (arrowheads). As expected, there is no signal in the right vertebral artery (long arrow), whereas signal in the left vertebral artery (short arrow) indicates retrograde flow. Note that the signal in the left vertebral artery is weaker than that in the right vertebral artery in b. (d) Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in the neck vessels, acquired at the time of peak signal intensity in the right vertebral artery (t = 16 seconds), shows no contrast enhancement of the left vertebral artery (short arrow), while both common carotid arteries (arrowheads) and the right vertebral artery (long arrow) are enhanced. (e) Transverse image from bolus-timing examination in the neck vessels, obtained 2 seconds later than d (t = 18 seconds), shows delayed contrast enhancement in the left vertebral artery (short arrow) and residual enhancement in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). Note that the left vertebral artery is enhanced to a lesser degree than is the right vertebral artery in d. (f) Signal intensity-time curve for vertebral artery enhancement, derived from bolus-timing examination, shows 2-second delay in peak arterial enhancement in the left vertebral artery (LVA) (t = 18 seconds) compared with that in the right vertebral artery (RVA) (t = 16 seconds). Peak signal intensity in the left vertebral artery is also decreased (parvus tardus) when compared with that in the right vertebral artery in c and e.

View larger version (131K): [in a new window]   Figure 1e. Left-sided subclavian steal in 67-year-old woman. (a) Thin maximum intensity projection coronal image from three-dimensional contrast-enhanced MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery. (b) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow. (c) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed below the volume of interest, shows normal signal intensity of blood flowing in the internal jugular veins (arrowheads). As expected, there is no signal in the right vertebral artery (long arrow), whereas signal in the left vertebral artery (short arrow) indicates retrograde flow. Note that the signal in the left vertebral artery is weaker than that in the right vertebral artery in b. (d) Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in the neck vessels, acquired at the time of peak signal intensity in the right vertebral artery (t = 16 seconds), shows no contrast enhancement of the left vertebral artery (short arrow), while both common carotid arteries (arrowheads) and the right vertebral artery (long arrow) are enhanced. (e) Transverse image from bolus-timing examination in the neck vessels, obtained 2 seconds later than d (t = 18 seconds), shows delayed contrast enhancement in the left vertebral artery (short arrow) and residual enhancement in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). Note that the left vertebral artery is enhanced to a lesser degree than is the right vertebral artery in d. (f) Signal intensity-time curve for vertebral artery enhancement, derived from bolus-timing examination, shows 2-second delay in peak arterial enhancement in the left vertebral artery (LVA) (t = 18 seconds) compared with that in the right vertebral artery (RVA) (t = 16 seconds). Peak signal intensity in the left vertebral artery is also decreased (parvus tardus) when compared with that in the right vertebral artery in c and e.

View larger version (18K): [in a new window]   Figure 1f. Left-sided subclavian steal in 67-year-old woman. (a) Thin maximum intensity projection coronal image from three-dimensional contrast-enhanced MR angiography of aortic arch and great vessels demonstrates occlusion (arrow) of the proximal left subclavian artery and a normal-appearing left vertebral artery (arrowhead) that originates from the left subclavian artery. (b) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed above the volume of interest, shows normal signal intensity in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). There is no signal in the left vertebral artery (short arrow), a finding that indicates either occlusion or retrograde flow. (c) Transverse image from two-dimensional time-of-flight MR angiography (27/6.5; flip angle, 35°) of the neck vessels, with a presaturation band placed below the volume of interest, shows normal signal intensity of blood flowing in the internal jugular veins (arrowheads). As expected, there is no signal in the right vertebral artery (long arrow), whereas signal in the left vertebral artery (short arrow) indicates retrograde flow. Note that the signal in the left vertebral artery is weaker than that in the right vertebral artery in b. (d) Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in the neck vessels, acquired at the time of peak signal intensity in the right vertebral artery (t = 16 seconds), shows no contrast enhancement of the left vertebral artery (short arrow), while both common carotid arteries (arrowheads) and the right vertebral artery (long arrow) are enhanced. (e) Transverse image from bolus-timing examination in the neck vessels, obtained 2 seconds later than d (t = 18 seconds), shows delayed contrast enhancement in the left vertebral artery (short arrow) and residual enhancement in the common carotid arteries (arrowheads) and right vertebral artery (long arrow). Note that the left vertebral artery is enhanced to a lesser degree than is the right vertebral artery in d. (f) Signal intensity-time curve for vertebral artery enhancement, derived from bolus-timing examination, shows 2-second delay in peak arterial enhancement in the left vertebral artery (LVA) (t = 18 seconds) compared with that in the right vertebral artery (RVA) (t = 16 seconds). Peak signal intensity in the left vertebral artery is also decreased (parvus tardus) when compared with that in the right vertebral artery in c and e.

View larger version (105K): [in a new window]   Figure 2. Transverse image from bolus-timing examination (500/1.8/260; flip angle, 20°) in a 53-year-old man with normal blood flow through the aortic arch and great vessels demonstrates simultaneous peak enhancement bilaterally of common carotid arteries (arrowheads) and vertebral arteries (arrows).