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Objective - Arterial steal syndromes are disorders characterized by the pathologic reversal of flow through adjacent collateral vessels in order to meet metabolic demands for organ systems in which native, antegrade flow is compromised. Etiologies are often secondary to occlusive process such as atherosclerosis. Several steal syndromes have been described with variable frequency. We present a rare case of mastication steal causing symptomatic vertebral-basilar arterial insufficiency related to carotid occlusive disease.
Methods - Case report
Results - A 56-year-old female developed recurrent episodes of transient vertigo and diplopia. She became consistently symptomatic during eating or oral presentations at work. Her physical exam demonstrated a normal neurological status, no cervical bruits, and normal pulses and brachial pressures in the upper extremity. Duplex ultrasound identified a left internal carotid artery without significant stenosis but an occluded external carotid artery (ECA) with flow reversal in the ipsilateral vertebral artery (VA). The contralateral right side was normal. Catheter-based-angiography revealed a dominant left VA with a large collateral communication to the ipsilateral external carotid system and reversal of flow via that vessel from the left VA to the left ECA. No intra-cerebral abnormalities were noted and the contralateral right carotid system was unremarkable.
The patient underwent revascularization of the left ECA through an eversion endarterectomy and re-implantation onto the common carotid artery. The ascending pharyngeal artery was identified as the predominant collateral vessel from VA and was ligated. Completion angiography revealed restoration of antegrade ECA flow and elimination of steal. The patient recovered with complete amelioration of her symptoms and remains symptom free 18 months later.
Conclusions – Mastication-induced vertebral steal is a rare phenomenon with only two cases previously reported in the literature. In those cases, patients had significant atherosclerotic disease involving multiple arteries of the head and neck. Our patient had a much more focal process involving only the external carotid artery and the ascending pharyngeal artery providing a collateral pathway. Clinical symptoms and imaging studies allow for accurate diagnosis and appropriate treatment of this syndrome.