Introduction:

The proximal subclavian stenosis associated with subclavian steal syndrome is frequently secondary to atherosclerotic arterial disease. It can be completely asymptomatic or present symptoms of superior ipsilateral arm ischemia or transitory posterior-circulation cerebral ischemia. The final diagnosis is imagiological. However, the alterations to the physical examination (PhE) are extremely suggestive, namely, arterial pressure discrepancy between the two superior arms.

Case description:

A 69-year-old woman, with hypertension, diabetes mellitus type 2, dyslipidaemia, and obesity, has gone to the medical appointment with dizziness, headache and a decrease in blood pressure which had two months of evolution. She decided to suspend the antihypertensive treatment by herself. She also referred to a previous headache episode, sudden dysarthria, and a ‘tied tongue’ sensation, which let her go to emergency care. In urgency care, when she was observed, no objective alterations were found. During the family physician appointment, PhE showed a blood pressure 108/75mmHg, which was evaluated on the superior left arm. Due to the various atherosclerosis risk factors and the previous episode suggestive of AIT, complementary diagnostic exams were made, including carotid and vertebral doppler ultrasonography, which showed a retrograde flow from the left vertebral artery that suggests proximal left subclavian stenosis. Consequently, a detailed PhE revealed a blood pressure discrepancy between the two superior arms (108/79mmHg on the left and 170/81mmHg on the right). The woman was recommended to retake antihypertensive medicines, to control the multiple atherosclerosis risk factors and she was tracked to a vascular surgery appointment.

Comments:

In this clinical case the BP values were, apparently, decreased. However, after an evaluation in both superior arms, it was revealed that the patient presented uncontrolled grade 2 hypertension. The authors really want to alert for the importance of keeping the good semiological practice of BP determination, in both arms, even though the multitasking daily routines.

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